VOLUME 1, ISSUE 1 FOODNETFOODNET NEWNEWSS EMERGING EMERGING

FALL 2007 PROGRAM PROGRAM INFECTIONS

INSIDE THIS ISSUE: Burden and Trends in Campylobacter

FEATURE 1 Campylobacter is a common (particularly cats and puppies). testing of poultry meat from ARTICLE:BURDEN bacterial pathogen in the Illness usually occurs 2-5 days retail stores. FoodNet has also AND TRENDS IN United States; it is estimated after exposure. Outbreaks of conducted two case-control CAMPYLOBACTER that there are 2.5 million infec- Campylobacter are rare; how- studies to help understand risk SPORADIC 2 tions every year resulting in ever, many outbreaks are factors for sporadic disease CAMPYLOBACTER 13,000 hospitalizations and caused by the consumption of (see summary of Sporadic Cam- INFECTIONS IN 124 deaths1. Persons with unpasteurized milk. pylobacter Infections in Infants INFANTS Campylobacter typically experi- on pg. 2) ence fever, abdominal cramps Campylobacter infections FSIS HELPS 2 and diarrhea which may be are not nationally notifiable, Continued active surveillance CONSUMERS BE and prior to the establishment coupled with the work of part- FOOD SAFE bloody. Although most persons recover in about a week, per- of FoodNet in 1996, there were ner agencies to understand the no precise estimates of the rates of contamination on meat FSIS: A TEAM 3 sons with weakened immune PLAYER IN systems may suffer complica- burden of this important patho- and poultry products will help PREVENTING tions such as a bloodstream gen in the U.S. Using data from us to gain a better understand- FOODBORNE FoodNet, national goals were ing of the overall burden of ILLNESS or Guillan-Barre syn- drome (a temporary paralysis established for a 50% reduction Campylobacter and enable the CAMPYLOBACTER 3 that can last several weeks and in the 1996 of infec- implementation of effect pre- OUTBREAKS usually requires intensive care). tions by 2010 (goal of 12.3 vention and control measures. Anyone can get a Campylobac- cases per 100,000 per- For more information on Cam- 3 CHRO/BURDEN OF 4 ter infection, but children <5 sons ).We are close to meeting pylobacter, visit: http:// ILLNESS UPDATES years and young adults are this goal; compared to a base- www.cdc.gov/ncidod/dbmd/ known to be at a higher risk; line period of 1996-1998, the diseaseinfo/ RECENTLY 4 males are more likely to be- incidence of Campylobacter campylobacter_g.htm. PRESENTED has declined by 30%. In 2006, ABSTRACTS come infected than females. —Mary Patrick, CDC FoodNet Although there are many spe- the incidence was 12.7 per cies of Campylobacter, the ma- 100,000 persons, with the jority of human illness is caused highest rate in California and 1Mead et al. Food-Related Illness and Death in 2 by Campylobacter jejuni and lowest in Tennessee . Several the United States. EID Vol 5, Sep 1999. most cases occur in the sum- efforts are underway in Food- 2Preliminary FoodNet Data on the Incidence of Net to attempt to explain these Infection with Pathogens Transmitted Com- mer months. Campylobacter is monly Through Food --- 10 States, 2006. spread through the consump- regional differences in Campy- MMWR. April 13, 2007 / 56(14);336-339. lobacter rates; including a sur- tion of contaminated food 3 http://www.cdc.gov/nchs/about/otheract/ (typically poultry), water or con- vey of clinical laboratories re- hpdata2010/abouthp.htm garding testing practices, and SAFER·HEALTHIER·PEOPLE™ tact with infected animals

WHAT IS FOODNET? STATE SPOTLIGHT: GUILLAIN-BARRÉ IN OREGON

The Foodborne Diseases Active Surveillance Net- Hospital discharge data from 1997 and 2003 were used to determine the burden and the pro- work (FoodNet) is the principal foodborne disease portion of Guillain-Barré Syndrome (GBS) and the proportion attributable to campylobacteriosis component of CDC’s Emerging Infections Program. in Oregon. Campylobacter associated cases decreased from 1997 to 2003 (7% vs. 3%). The FoodNet is a collaborative project of the CDC, ten average incidence of GBS was 1.25/100,000. The incidence of GBS decreased corresponding sites (CA, CO, CT, GA, MD, MN, NM, NY, OR, TN), the U.S. Department of Agriculture (USDA), and the Food to the decline in campylobacteriosis1. and Drug Administration (FDA). —Beletshachew Shiferaw, Oregon FoodNet Centers for Disease Control and Prevention 1Shiferaw et al. Use of Hospital Discharge Data to Assess the Incidence of Guillain-Barré Syndrome. Sub- 1600 Clifton Road NE, MS D-63 mitted to Neuroepidemiology, Fall 2007. Atlanta, Georgia 30333 FOODNET NEWS Page 2

Sporadic Campylobacter Infection in Infants

Infants have a higher risk of catching foodborne pylobacter and 928 healthy infants. Parents or CAMPYLOBACTER: illness than older children or adults. However, guardians were interviewed by telephone about STRATEGIES FOR findings from a recent study1 conducted by Food- various environmental and dietary exposures the Net describe several ways to reduce your infant’s infant may have had in the five days before illness PREVENTION risk of contracting the most common bacterial or interview. in the United States. x For young infants, breastfeeding is the best way to When compared to healthy infants of the same prevent illness and is encouraged for this and a Campylobacter infection has been linked to the age, infants 0-6 months old with Campylobacter variety of health reasons. consumption of unpasteurized (raw) milk and poul- infection were less likely to have been breastfed, try, untreated water, contact with pets, especially and more likely to have drunk well water or to have x Frequently wash your hands with soap and warm water or using an alcohol-based hand sanitizer, those with diarrhea, and exposure to farms or farm ridden in a shopping cart next to meat or poultry in but especially before preparing food or bottles for animals. However, because of their limited diets the five-days before illness or interview. For infants infants. and behavioral factors such as frequent hand-to- 7-11 months old, infants with Campylobacter infec- mouth contact, the sources of infection among tion were more likely to have visited or lived on a x Pacifiers, teething rings and toys that fall to the infants may differ from those of older age groups. farm, to have contact with a pet with diarrhea in floor should be cleaned with soap and water. the home, and to have eaten fruits and vegetables FoodNet conducted a study of sporadic (non- prepared in the home. Campylobacter infection x Purified water should be used for drinking, brush- outbreak) laboratory-confirmed Campylobacter ing teeth, and mixing infant formula and foods. was associated with travel outside the U.S. in in- cases occurring in children under the age of one fants of all ages, though international travel was year to investigate the potential sources of infec- x Fresh fruits and vegetables should be cooked or uncommon, suggesting that most infections in tion in infants residing in Connecticut, Minnesota, washed well and peeled before eating. infants in the U.S. are acquired domestically1. Oregon, and selected counties in California, Colo- x Use a disinfecting hand wipe to clean parts of rado, Georgia, New York and Tennessee. The study —Bridget Anderson, New York FoodNet shopping carts an infant may touch and place raw area covered a population of approximately 35.2 1Summary of Fullerton et al. Sporadic Campylobacter Infections in meat and chicken out of reach of infants. million persons (12.1% of the U.S. population), Infants: A Population-Based Surveillance Case-Control Study in Eight including approximately 450,000 infants. FoodNet Sites. PIDJ; 2007 Vol 26(1): 19-24. x For more information regarding Campylobacter infection, please contact your local health depart- The study involved 123 infants infected with Cam- ment or visit the CDC website at www.cdc.gov.

FSIS Helps Consumers Be Food Safe

Salmonella, prevalent foodborne pathogens found in poultry, are easily destroyed by cooking all poul- The United States Department of Agriculture’s Food try to a safe minimum internal temperature of Safety and Inspection Service (FSIS) helps to edu- 165˚F. FSIS recommends that a food thermome- cate consumers on safe food handling practices to ter be inserted in the thickest areas of the product protect them from contracting a foodborne illness. without touching bone, to ensure the product is Through its national consumer-oriented campaigns cooked to a safe minimum internal temperature. and programs, such as Be Food Safe and Is It Done For whole turkey, check the internal temperature in Yet?, FSIS promotes the science-based and simple the innermost part of the thigh and wing and in the messages of Clean, Separate, Cook and Chill devel- thickest part of the breast. oped by the Partnership for Food Safety Education to help consumers prevent foodborne illness. Additionally, FSIS encourages you to access its virtual food safety representative, Ask Karen, avail- x Clean: Wash hands and surfaces often able 24/7, at www.AskKaren.gov, its Web site at http://www.fsis.usda.gov/Fact_Sheets, or call its Meat and Poultry Hotline at 1-888-MPHotline (1- Separate: Don’t cross-contaminate x 888-674-6854) Monday through Friday from 10A to 4P, excluding all holidays, except Thanksgiving x Cook: Cook to proper temperature Day, when it is available 8AM to 2PM. x Chill: Refrigerate promptly Accessing and applying this valuable safe food handling information will help you to prepare your With the holiday season quickly approaching, know- meat, poultry, and egg products safely; thus, help- ing how to prepare your meat, poultry, and egg ing you be food safe all year round. products safely is critical to helping you be food safe. Science tells us that Campylobacter and —Janice Adams King, USDA-FSIS VOLUME 5, ISSUE 1 Page 3 FSIS: A Team Player in Preventing Foodborne Illness

Like a first down, enforcing regulations, identifying and federal agencies, and academia to better understand line studies underway in the fall of 2007. These base- implementing science-based strategies to keep our existing and emerging foodborne pathogens, develop line studies will help establish a microbiological per- food safe, and educating the public about foodborne and implement food safety campaigns and educa- formance standard for Campylobacter. illness and safe food handling behaviors is an ongoing tional initiatives, as well as programs, policies and FSIS is working very hard to ensure that the industry is process in helping us score a touchdown – hence, procedures, such as the Hazard Analysis and Critical effectively addressing the occurrence of Salmonella on achieving the goal of reducing pathogens in foods and Control Point (HACCP) system and laboratory testing poultry products. Many of the interventions that are preventing foodborne illness. programs to help ensure the safety of its regulated effective against Salmonella are also effective against products. The United States Department of Agriculture’s Food Campylobacter. This effort has undoubtedly contrib- Safety and Inspection Service (FSIS) ensures that Recognizing that poultry can be contaminated with uted to the reduction in human illnesses attributable meat, poultry, and egg products sold in interstate Campylobacter and that this pathogen presents public to Campylobacter. commerce are safe, wholesome, and correctly labeled health challenges, FSIS sought advice from the Na- and packaged. FSIS enforces food safety laws, regula- tional Advisory Committee on Microbiological Criteria tions, policies, and programs year-round to reduce for Foods (NACMCF) on the applicability of various For more information about the work of FSIS, visit: pathogens in meat, poultry, and egg products. Campylobacter food testing methodologies. FSIS used http://www.fsis.usda.gov/. the NACMCF recommendations (http:// Never working in isolation, and always part of a team, —Janice Adams-King, USDA-FSIS www.fsis.usda.gov/About_FSIS/NACMCF/index.asp) FSIS partners with the food industry, state and other as the basis of the new FSIS broiler and turkey base-

Spotlight on Resistance

Campylobacter is the most common cause of bacterial gastroenteritis in the U.S., causing approximately 2.5 million infections each year1,2 . Although most infections are self-limited, characterized by diarrhea, fever, and abdominal cramps, treatment is essential for severe illness. Ciprofloxacin, a fluoroquinolone, is one of the most common antimicrobial agents prescribed for treatment of Campylobacter infections in humans1,3. Poultry is a major source of human Campylobacter infections and has been identified as a possible reservoir for antimicrobial-resistant infections2. Campylobacter surveillance was initiated in FoodNet as a part of the National Monitoring System (NARMS) in 1997. NARMS tests a proportion of Campylobacter isolates obtained from FoodNet sites for resistance to com- mon antimicrobial agents, including fluoroquinolones. The of ciprofloxacin-resistant Campylobacter increased from 13% (28/217) in 1997 to 19% (66/347) in 20044. In the U.S. fluoroquinolones were approved for use in poultry in 19952. In 2000, prompted by surveillance data from FoodNet and NARMS, FDA began steps to withdrawal the use of fluoroquinolones in poultry. Following a series of legal hearings, the FDA commissioner prohibited the use of the fluoroquinolone, enrofloxacin, in poultry1. Antimicrobial resistance surveillance continues to emphasize the importance of judicious use of antimicrobial agents in food animals.

—Sharon Greene, CDC NARMS

1Nelson JM, Chiller TM, Powers JH, Angulo FJ. 2007. Fluoroquinolone-Resistant Campylobacter Species and the Withdrawl of Fluorquinolones from Use in Poultry: A Public Health Success Story. CID 44:977-980; 2Smith KE, BesserJM, Hedberg CW, Leano FT, Bender JB, Wicklund JH. 1999. Quinolone-Resistant Campylobacter jejuni infections is Minnesota, 1992-1998. N Engl J Med 340(20): 1525-1532; 3Gupta A, Nelson HM, Barrett TJ, Tauxe RV, Rossiter SP, Friedman CR. 2004. Antimicrobial resistance among Campylobacter strains, United States. 1997-2001. EID 10(6): 1102-1109; 4Centers for Disease Control and Prevention. 2007. National Antimicrobial Resistance Monitoring System (NARMS): Human Isolates Final Report, 2004. Atlanta, Georgia: U.S. Department of Health and Human Services.

Campylobacter Outbreaks

Outbreaks of Campylobacter are rare. Only 23 out- ducted a case-control study and an environmental indicated contamination with multiple fecal microbes, breaks of Campylobacter were reported from FoodNet investigation. A case was defined as diarrhea in a including Escherichia coli, C. jejuni, Salmonella spe- sites between 2000 and 2006. Of 17, 142 cases person who traveled to the island during the period cies, and Giardia species. Irregularities in sewage reported to FoodNet (2004-2006), only 82 (0.5%) from May 1 through September 30, 2004 and became disposal practices that could have contaminated the were outbreak-associated. The following abstract ill within 2 weeks after the visit. Healthy travel com- underground aquifer were noted. describes a recent outbreak of Campylobacter that panions served as matched control subjects. We also Conclusions: The combined epidemiological and envi- was linked to contamination of a municipal water performed an environmental assessment and exten- ronmental investigation indicated that sewage- source. sive testing of island water sources. contaminated ground water was the likely sources of Background: The implementation of treated municipal Results: Among the 1450 persons reporting illness, this large outbreak. Long-term changes to the island’s water systems in the 20th century led to a dramatic Campylobacter jejuni, norovirus, Giardia intestinalis, water supply and sewage management infrastructure decrease in waterborne disease in the United States. and Salmonella enterica serotype Typhimurium were are needed.1 However, communities with deficient water systems identified in 16, 9, 3, and 1 persons, respectively. We -Abstract by Ciarra O’Reilly et al. still experience waterborne outbreaks. In August interviewed 100 case patients and 117 matched 2004, we investigated an outbreak of gastroenteritis control subjects. Case patients were more likely to 1O’Reilly et al. A Waterborne Outbreak of Gastroenteritis with on South Bass Island, Ohio, an island of 900 residents drink water on the island than control subjects (68% Multiple Etiologies Among Resort Island Visitors and Residents: Ohio 2004. CID 2007; Vol 44(4): 506-512. that is visited by >500,000 persons each year. vs. 35%; matched odds ratio, 4.3; 95% confidence interval, 2.2-9.3). Sampling of ground water wells Methods: To identify the sources of illness, we con- CHRO Update

The 14th International Workshop on Campylo- in England by C.C. Tam et al. found that, com- bacter in Danish broiler meat. The strategy bacter, Helicobacter and Related Organisms pared to those who normally consume focused on reducing infection at the farm (CHRO 2007) was held in Rotterdam, the chicken, non-habitual chicken eaters had a level, reducing the concentration of Campylo- Netherlands, on September 2-5. greater risk of infection when consuming bacter on the chicken meat, and educating commercially-prepared chicken in the previ- the consumers. There were a number of presentations on ous five days. multilocus sequence typing (MLST). In the FoodNet presented three posters at the con- United Kingdom, W. F. Sopwith et al. reported A quantitative risk model for C. jejuni and C. ference (see recently presented abstracts that sequence types (ST) ST-21, ST-257 and coli developed by R. J. Lake et al. indicates below). Pat McDermott from FDA gave an oral ST-45 were the most common clonal com- that poultry is an important vehicle for campy- presentation on the NARMS Retail Foods plexes in humans. N. French reported that lobacteriosis in New Zealand. Study. Conference abstracts are available at the most common human STs in New Zea- http://www.chro2007.nl/. land (ST-474 and ST-190) are both are inter- B. Borck et al. reported that a risk manage- nationally rare and found almost exclusively ment strategy in Denmark has had a signifi- —Elaine Scallan, CDC FoodNet in humans and poultry. A case-control study cant impact on the occurrence of Campylo-

Burden of Illness Update

The 4th Annual Meeting of the International typing (MLST) for tracing the sources of C. will establish a working group to review meth- Collaboration on Enteric Disease Burden of jejuni infection in the UK, indicating that the ods to estimate the burden of GBS interna- Illness Studies was held as a satellite meet- most sequence types in humans are from tionally. The International Campylobacter ing to CHRO 2007 on September 1-2. The meat sources. Irving Nachamkin from the Laboratory Survey Working Group presented second day of the meeting focused on Cam- University of Pennsylvania gave an overview preliminary results from FoodNet sites, Can- pylobacter. of Guillain-Barré Syndrome (GBS) and de- ada and New Zealand. scribed patterns of GBS among children in Donald Campbell from the New Zealand Food For additional information or to join the Inter- Mexico. Approaches to estimating the burden Safety Authority presented New Zealand’s national Collaboration please email: of GBS attributable to Campylobacter were strategy for the management of Campylobac- [email protected]. presented with examples from the United ter. Daniel Wilson from Lancaster University Kingdom and the Tennessee and Oregon —Elaine Scallan, CDC FoodNet described the use of multilocus sequence FoodNet sites. The international collaboration RECENTLY PRESENTED ABSTRACTS ON CAMPYLOBACTER

x L. Demma, Campylobacter species in FoodNet and NARMS 1997-1004: is the incidence of Campylobacter coli infection increasing?

x L. Demma, Clinical laboratory practices for the isolation and identification of Campylobacter in FoodNet sites and correla- tion with geographic variation.

x E. Ailes, and Trends in Incidence of Sporadic Campylobacter in the United States, FoodNet 1996-2006

x M. Patrick, Trends in incidence of Campylobacter infections: effect of age and gender, FoodNet, 1996-2006.

ADDITIONAL CAMPYLOBACTER RESOURCES

x http://www.fightbac.org

x http://www.fsis.usda.gov/Fact_Sheets/Campylobacter_Questions_and_Answers/index.asp

x http://www.cdc.gov/ncidod/dbmd/diseaseinfo/campylobacter_g.htm

For more information about this newsletter please contact: [email protected]