Highlights and Successes
In a quaint town along the South Carolina coast, an otherwise healthy 5 month old girl began to show signs of getting sick. After a few days of diarrhea, her condition worsened, and she started having blood in her stools. Her parents immediately took her to their pediatrician, where a stool sample revealed a Salmonella infection.
Around the same time, an 8 month old boy from a neighboring town fell ill with vomiting, fever, and diarrhea. His mom took him to the doctor to find out what was going on. Turns out, this little boy was also sick with a Salmonella infection.
Infants and other young children have developing immune systems and are more likely to get sick from a Salmonella infection.
The laboratory results from the little girl and boy were reported to the State of South Carolina. In the course of interviewing the cases, an investigator from South Carolina’s FoodCORE Team discovered that they both attended the same nursery. She worked quickly to determine if any other infants from that nursery were ill. The investigator found three more infants from the same classroom were sick. Additional laboratory testing by the South Carolina Bureau of Labs using pulsed field gel electrophoresis, or “DNA fingerprinting” confirmed that the original cases were related because they had an identical strain of Salmonella bacteria.
The FoodCORE investigator collaborated with a multidisciplinary team, including a regional epidemiologist and an environmental health inspector, who jointly visited the nursery. The visit included a review of formula preparation, diaper changing and handwashing procedures. Despite this combined approach, the source of the Salmonella infection was not ultimately found. However, recommendations were made and are now being followed to improve overall hygiene practices. Such recommendations included carefully washing hands with soap and water between diaper changes.
Thanks to the disease detectives’ swift investigative collaboration with local and state partners, the outbreak was stopped quickly. Fortunately, all five of the sick infants recovered from their illnesses and are now healthy.
Click here to view Stopping a Salmonella Outbreak among Infants in a Nursery [PDF - 1 page].
Imagine 8-year-old Susie* is enjoying her summer break when she suddenly becomes sick with stomach cramps and vomiting. Within hours, other members of her family also start getting sick with similar symptoms. Little do they know, there was a virus in the lake they swam at yesterday that has made them and hundreds of other swimmers sick.
In the summer of 2012, a Wisconsin lake was the site of an outbreak of gastrointestinal illnesses. Local public health officials at the Jackson County Health Department were quickly notified of these illnesses and started to investigate the situation. Early on, officials found that many of the sick people had been at the same outdoor recreation area the day before they got ill. They felt an urgency to rapidly identify a cause so they could keep more people from getting sick.
Disease detectives from the FoodCORE-funded Surveillance and Outbreak Support (SOS) Team at the Wisconsin Division of Public Health traveled to Jackson County to support the investigation. They helped the local health officials to quickly interview and analyze the data from nearly 300 people. They determined that exposure to lake water at the recreation area was the most likely cause of illnesses. It turns out, norovirus in the lake water had caused Susie and others to get sick—mystery solved.
This successful investigation identified a large waterborne norovirus outbreak and will lead to improvements at the lake, such as installing more hand hygiene stations and increasing staffing, to help prevent this type of outbreak from happening again.
*Susie is not a real person, but she represents one of the hundreds of vacationers who really did get sick.
“Because we have a small staff at our local health department, the added resources and expertise provided by the SOS Team were critical to helping us manage the outbreak and identify the water as the source of the infections.”
Jackson County Health Officer
Click here to view Wisconsin’s Public Health Sleuths Take to the Lake [PDF - 1 page] .
Nearly 50 people attended the 2013 FoodCORE Vision Meeting in Atlanta on May 15-16, 2013. There were productive discussions about a variety of topics. The FoodCORE centers were able to develop group consensus about ongoing and upcoming projects, including model practices, metrics reporting and collaborating with partners. At the end of the meeting, all centers had the opportunity to network and have smaller group discussions about their projects and plans. The participants will have another opportunity to meet at the 2013 InFORM Meeting and share their accomplishments.
In addition to participants from each of the FoodCORE centers, attendees also included colleagues from —
- CDC's National Center for Emerging and Zoonotic Infectious Diseases, including four branches within the Division of Foodborne, Waterborne, and Environmental Diseases (Outbreak Response and Prevention Branch, Enteric Disease Epidemiology Branch, Enteric Disease Laboratory Branch); and the Epidemiology and Laboratory Capacity for Infectious Diseases program within the Division of Preparedness and Emerging Infections.
- CDC's National Center for Immunization and Respiratory Diseases.
- CDC's National Center for Environmental Health.
- U.S. Department of Agriculture's Food Safety and Inspection Services.
- U.S. Food and Drug Administration, including the Rapid Response Teams and European Food Safety Authority Liason.
"It was apparent at the 2013 Vision Meeting that FoodCORE centers have successfully tailored their activities to enhance their state and local epidemiologic, laboratory, and environmental health responses to foodborne outbreaks. Through the development and use of standardized metrics and model practices based on real world experience, FoodCORE provides others with valuable resources to consider."
– Kristin G. Holt
Liaison to CDC, U.S. Department of Agriculture's Food Safety and Inspection Service
Click here to view Spotlight on the 2013 Vision Meeting [PDF - 780 KB]
In 2012, CDC scientists monitored between 16 and 57 potential food poisoning clusters each week and investigated more than 200 multistate clusters nationwide. Two of CDC’s food safety programs partner with 15 jurisdictions to get ahead of stubborn foodborne outbreaks: FoodCORE and FoodNet.
What is the difference between FoodCORE and FoodNet?
FoodCORE is one of the newest and most promising programs at CDC. Seven FoodCORE centers, covering about 14% of the US population, work together to develop new and better methods to detect, investigate, respond to, and control multistate outbreaks of foodborne diseases.
FoodNet, established in 1996, is an active population- based surveillance system that collects information in 10 states and covers 15% of the US population. It estimates the number of foodborne illnesses, monitors trends in incidence of specific foodborne illnesses over time, attributes illnesses to specific foods and settings, and disseminates this information. One of the states where these two programs overlap is in Connecticut.
How do FoodCORE and FoodNet work together in Connecticut?
FoodCORE and FoodNet work together seamlessly and they complement each other’s missions. Since becoming a FoodCORE center in January 2012, Connecticut has been able to quickly and easily acquaint itself with the program. In part, this is a result of the existing infrastructure already in place through FoodNet and a 17-year collaborative effort between the Connecticut Department of Public Health (DPH) and Yale School of Public Health.
Quyen Phan, an epidemiologist with the Connecticut DPH, commented that “the existing partnership between DPH and Yale paved the way for rapid formation of a student interview team composed of Yale public health students. After our first year, we have seen over 80% of Salmonella cases interviewed compared with about 50% in previous years.”
FoodCORE and FoodNet enhance foodborne disease surveillance and outbreak detection and response in Connecticut by working cohesively without duplicating or replicating efforts. FoodNet Program Coordinator Sharon Hurd made the observation that “if not for FoodNet, FoodCORE might not have thrived in its first year as it has; conversely, if not for FoodCORE, FoodNet might not have continued to make the strides that it is known for in Connecticut.” These programs are now intertwined and will undoubtedly continue to serve one another to protect the health of Connecticut’s residents.
In the summer of 2012, public health officials in Tennessee were notified that a group of volunteers were sick with gastroenteritis. The volunteers were from multiple states and had traveled to Tennessee to work on a farm. Tennessee officials collaborated with several other states to figure out what caused the illness. They used an online survey to collect information, but after a couple days only a few volunteers had responded.
FoodCORE interviewers were determined to help collect more information and called about 60 volunteers who did not answer the online survey. At the same time, laboratorians tested samples from the sick people, which came back positive for a parasite called Cryptosporidium.
FoodCORE’s direct outreach to the remaining volunteers provided the critical information needed to help solve the outbreak. Using these responses, public health officials determined that the volunteers got sick through their contact with calves while working in the barn, and not from something they ate. The barn owner conducted an extensive clean-up, and Tennessee officials shared educational information about the risks of human illness due to contact with animals and their environments. All the sick volunteers returned to their homes and recovered fully from their illness.
"Our FoodCORE interviewers contacted the volunteers, and conducted phone surveys to gather more information. This was no easy task, and without FoodCORE's help, we would not have been able to identify the source of the outbreak as quickly."
- Ellyn Marder
CDC/CSTE Applied Epidemiology Fellow, Tennessee Department of Health
FoodCORE + U
It’s hard to imagine that simply having students talk with patients about chicken livers, raw milk, and sprouts could help protect our food supply and save lives, but it’s true. These students have become integral in identifying the culprits in outbreaks of foodborne illness across the country.
“U” niversity partnerships—at the core of FoodCORE
Student interviewers are a vital part of Foodborne Diseases Centers for Outbreak Response Enhancement, or FoodCORE, which is a program of centers that work together to develop better ways to investigate and respond to outbreaks of foodborne diseases. FoodCORE students quickly interview patients who became sick after eating contaminated food. Six out of seven FoodCORE centers hire students from nearby universities and schools of public health and train them to interview patients.
“It is very rewarding to be a part of the connection between students and the FoodCORE program. FoodCORE closes the gap between academia and the real world by providing students with valuable experiences. Students are graduating with a deeper understanding of foodborne outbreak response as well as credible references and potential job offers.”
– Amy Woron
Molecular Biologist, Tennessee State Public Health Laboratory
Adjunct Professor, Tennessee State University
You ate what?
During the interviews, students ask the patients what foods they ate before they got sick. Students often conduct interviews after regular working hours and on weekends, when patients are easier to reach.
FoodCORE program coordinators have been pleased with the students’ contributions. “The students are doing real world public health, helping prevent the spread of disease. They bring a superior level of enthusiasm to their interviews,” said Sharon Hurd, FoodCORE-Connecticut Program Coordinator.
Since 2009, more than 64 students from 15 universities have been involved in this program. The program has had many benefits:
- Public health investigators have been able to get faster and more complete food histories, which are essential for responding to a foodborne outbreak.
- Staff at FoodCORE centers have formed vital working relationships with staff at nearby colleges and universities.
- Students gain experiences that prepare them for careers in public health.
Several student interviewers have gone on to work in public health. For example, one student is now FoodCORE-Wisconsin’s student team coordinator. Another student, who worked for FoodCORE-New York City’s team, joined CDC as an epidemiologist. A student who worked in Utah’s FoodCORE center said the experience helped him see face-to-face the people affected by disease outbreaks:
“In epidemiology, it’s easy to get lost in the numbers and statistics related to the investigation of a disease. In reality, they aren’t just numbers, they’re people, and those of us in public health have committed our lives to protecting people,” said Randy Leggett, former FoodCORE-Utah student interviewer. “I am grateful for the opportunity I had as a FoodCORE student interviewer. The experience taught me about real world enteric disease investigations and reaffirmed my dedication to public health.”
Patients who are interviewed by students might wonder, “Why is this student asking me what I ate?” The answer is simple: That student is helping to protect our food supply and save lives.
Click here to view FoodCORE + U [PDF - 1.08 MB]
Ohio Uses Social Media to Help Protect People from Norovirus
Norovirus spreads quickly, but public health experts in Ohio are even faster. FoodCORE funding has allowed Ohio’s public health laboratory to test for norovirus more frequently, which helps to confirm local outbreaks faster. In the first three months of 2012, the Ohio Department of Health confirmed that 76 outbreaks were caused by norovirus. This compares with the same three-month period in 2011, which had 35 confirmed norovirus outbreaks reported; the five-year average (2007–2011) for this three-month period was 30 confirmed norovirus outbreaks.
Public health experts reacted quickly to create a norovirus web page and use social media to teach people how to protect themselves from norovirus infection. Many people visited the web page through a mobile Facebook app. Prevention tips were also posted on the Department of Health’s Facebook and Twitter pages. The Department of Health’s social network is popular, reaching a total network of more than 400,000 Facebook users when friends of fans are included. There are 1,360 followers on Twitter. “Getting the word out using social media is a modern way to share disease prevention messages, especially about the importance of hand washing in reducing the spread of norovirus,” said Kim Quinn, Chief of the Outbreak Response and Bioterrorism Investigation Team. The best ways to help prevent the spread of norovirus are to practice proper hand washing, disinfect surfaces, and avoid caring for others or preparing food when sick.
For more information about the Ohio Department of Health’s norovirus web page, please visit: http://www.odh.ohio.gov/features/odhfeatures/norovirus.aspx
Click here to view Ohio Uses Social Media to Help Protect People from Norovirus [PDF - 347 KB]
Helping Solve Salmonella Outbreak Mysteries
Foodborne Diseases Centers for Outbreak Response Enhancement (FoodCORE) played a key role in solving a 2012 multistate outbreak of Salmonella Bareilly and Nchanga infections. This outbreak was quickly detected by PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that perform molecular surveillance of foodborne infections. The outbreak was widespread, with 425 ill people identified in 28 states and the District of Columbia; 55 people were hospitalized.
Ill persons were identified by five of seven FoodCORE centers. These centers contributed critical evidence to accelerate the investigation. State and local public health epidemiologists, public health nurses, and student interview teams in the centers rapidly interviewed ill people to determine their food history and quickly identified restaurants where they ate. Multiple people reported eating sushi the week before they became sick. This information was crucial to identifying which foods to test and trace back. Using interview information as well as their centers’ enhanced capabilities, environmental health specialists and laboratory personnel collected and tested food samples.
The participating FoodCORE centers worked together with other involved health departments and regulatory partners to pinpoint frozen raw scraped ground tuna as the likely source of contamination. They were among the first to identify the outbreak strains in the contaminated food. The product was recalled, which likely prevented additional illnesses.
Click here to view Helping Solve Salmonella Outbreak Mysteries [PDF - 769 KB]
New York City's "Team Salmonella" Successful in Solving an Outbreak
In August 2011, public health officials began an investigation into a Salmonella outbreak in which many cases resided in New York. An in-depth investigation was conducted by the New York City Department of Mental Health and Hygiene (NYCDOHMH), who is a partner in the FoodCORE project. With FoodCORE funding, NYCDOHMH is able to maintain a staff of trained student interviewers, aptly named "Team Salmonella." These students helped conduct the enhanced epidemiologic investigation among the Salmonella cases in New York City.
While the investigation was a team effort, it would not have been solved without the dedication of two students in particular, who were discussing the outbreak and the results of their interviews. These students came up with the theory that chicken livers, not specifically asked on the questionnaire, might be the cause of the outbreak. Students, FoodCORE staff, and other NYCDOHMH staff visited specialty stores where cases shopped in order to learn more about the food items available, and specifically how chicken livers were being prepared.
Suspect food items were collected for testing and the outbreak strain was found in "kosher broiled chicken liver" products. As a result, the contaminated products were recalled from grocery stores on November 8, 2011 and additional illnesses were prevented.
For over 2 years, public health officials in Utah struggled with a Salmonella outbreak linked to queso fresco. But by using FoodCORE resources to conduct an investigation training exercise, interdisciplinary teams identified the outbreak strain of Salmonella in queso fresco and determined who produced the cheese, thus solving the food safety mystery. Currently, Utah's officials are working with regulatory and law enforcement partners to take action against the distributor to prevent future illnesses.
Click here to view Utah Solves a Two-year Outbreak Mystery [PDF - 844 KB]