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Chapter 7 : Investigation of Enteric Disease Outbreaks

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Abstract:

This chapter talks about acute gastroenteritis and other foodborne diseases that can be caused by bacteria, viruses, protozoa, fungi, helminths, prions, and biological or environmental toxins. Many foodborne and waterborne diseases are self-limited and characterized by gastrointestinal symptoms such as vomiting and diarrhea. In a few situations, such as mushroom poisoning, ciguatera fish poisoning, or other chemical intoxications, it is sufficient to document the clinical syndrome among affected persons. can also be problematic because the organism may not be viable in stool or food samples, and most laboratories cannot test for enterotoxin. Enteric disease surveillance is generally the province of public health agencies. Surveillance includes the collection and analysis of information about disease occurrence and leads to taking considered action based upon those data. Disease surveillance often is based on mandatory reporting laws, whereby diagnostic laboratories or clinicians are required to notify public health agencies about individuals with specified conditions, e.g., salmonellosis or hepatitis A, as well as unusual clusters of illness. In recent years, however, public health officials and the public have become increasingly concerned that the food supply system is a potential target of intentional acts of contamination, sabotage, or terrorism. Summary information about foodborne and waterborne outbreak investigations is typically reported to the CDC, which periodically summarizes these data. It should be emphasized that the quality of these data is highly variable, which complicates one's ability to summarize them meaningfully.

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7

Key Concept Ranking

Restriction Fragment Length Polymorphism
0.5058634
Viruses
0.41679552
Food Safety
0.40796062
Reverse Transcriptase PCR
0.40088728
0.5058634
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Figures

Image of FIGURE 1
FIGURE 1

Etiology of foodborne outbreaks, United States, 2001 to 2006 ( = 7,165). Data are from reference .

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
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Image of FIGURE 2
FIGURE 2

Etiology of drinking-water-associated outbreaks of gastroenteritis, United States, 2001 to 2006 ( = 36). Data are from references , and .

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
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Image of FIGURE 3
FIGURE 3

Etiology of recreational-water-associated outbreaks of gastroenteritis, United States, 2001 to 2006 ( =108). Data are from references , and .

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
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Image of FIGURE 4
FIGURE 4

Epidemic curve of serovar Typhimurium by PFGE pattern, Minnesota, 1995. Molecular subtyping allowed investigators to recognize three concurrent outbreaks caused by different strains and associated with different restaurants. Adapted from reference .

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
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Image of FIGURE 5
FIGURE 5

Epidemic curve of a hypothetical point source salmonellosis outbreak with onset on the 10th day of the month.

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
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FIGURE 6

Epidemic curve of an O157:H7 outbreak associated with nationally distributed bagged spinach, 2006.

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
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References

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1. Bender, J. B.,, C. W. Hedberg,, D. J. Boxrud,, J. M. Besser,, J. H. Wicklund,, K. E. Smith,, and M. T. Osterholm. 2001. Use of molecular subtyping in surveillance for Salmonella enterica serotype Typhimurium. N. Engl. J. Med. 344:189195.
2. Blackburn, B. G.,, G. F. Craun,, J. S. Yoder, et al. 2004. Surveillance for waterborne disease outbreaks associated with drinking water, United States, 2001-2002. MMWR Surveill. Summ. 53:2345.
3.Centers for Disease Control. 1992. Principles of Epidemiology. An Introduction to Applied Epidemiology and Biostatistics. U.S. Department of Health and Human Services, Atlanta, GA.
4.Centers for Disease Control and Prevention. 2000. Surveillance for foodborne-disease outbreaks—United States, 1993-1997. MMWR Morb. Mortal. Wkly. Rep. 49(SS-1):162.
5.Centers for Disease Control and Prevention. 2004. Diagnosis and management of foodborne illnesses. A primer for physicians. MMWR Morb. Mortal. Wkly. Rep. 53:133.
6.Centers for Disease Control and Prevention. 2006. Surveillance for foodborne-disease outbreaks—United States, 1998-2002. MMWR Morb. Mortal. Wkly. Rep. 55(SS10):134.
7.Centers for Disease Control and Prevention. 2009. Surveillance for foodborne disease outbreaks—United States, 2006. MMWR Morb. Mortal. Wkly. Rep. 58:609615.
8.Council to Improve Foodborne Outbreak Response (CIFOR). 2009. Guidelines for Foodborne Outbreak Response. Council of State and Territorial Epidemiologists, Atlanta, GA.
9. Dziuban, E. J.,, J. L. Liang,, G. F. Craun, et al. 2006. Surveillance for waterborne disease and outbreaks associated with recreational water—United States, 2003-2004. MMWR Morb. Mortal. Wkly. Rep. 55:130.
10. Gregg, M. B. (ed.). 2002. Field Epidemiology. Oxford University Press, New York, NY.
11.International Association of Milk Food and Environmental Sanitarians, Inc. 1999. Procedures To Investigate Foodborne Illness. International Association of Milk Food and Environmental Sanitarians, Inc., Des Moines, IA..
12. Jones, T. F.,, B. Imhoff,, M. Samuel,, P. Mshar,, K. Gibbs McCombs,, M. Hawkins,, V. Deneen,, M. Cambridge,, and S. J. Olsen. 2004. Limitations to successful investigation and reporting of foodborne outbreaks: an analysis of foodborne disease outbreaks in FoodNet catchment areas, 1998-1999. Clin. Infect. Dis. 38:S297S302.
13. Keene, W. E.,, J. M. McAnulty,, F. C. Hoesly,, L. P. Williams, Jr.,, K. Hedberg,, G. L. Oxman,, T. J. Barrett,, M. A. Pfaller,, and D. W. Fleming. 1994. A swimmingassociated outbreak of hemorrhagic colitis caused by Escherichia coli O157:H7 and Shigella sonnei. N. Engl. J. Med. 331:579584.
14. Liang, J. L.,, E. J. Dziuban,, and G. F. Craun. 2006. Surveillance for waterborne disease and outbreaks associated with drinking water and water not intended for drinking—United States, 2003-2004. MMWR Surveill. Summ. 55:130.
15. Mead, P. S.,, L. Slutsker,, V. Dietz,, L. F. McCaig,, J. S. Bresee,, C. Shapiro,, P. M. Griffin,, and R. V. Tauxe. 1999. Food-related illness and death in the United States. Emerg. Infect. Dis. 5:607625.
16. Rothman, K. J.,, and K. Greenland (ed.). 1998. Modern Epidemiology. Lippincott-Raven, Philadelphia, PA.
17. Selvin, S. 2004. Statistical Analysis of Epidemiologic Data. Oxford University Press, New York, NY..
18. Vestergaard, L. S.,, K. E. Olsen,, R. Stensvold, et al. 2007. Outbreak of severe gastroenteritis with multiple aetiologies caused by contaminated drinking water in Denmark, January 2007. Eur. Surveill. 12:EO70329.
19.World Health Organization. 2005. Burden of Disease and Cost-Effectiveness Estimates. WHO, Geneva, Switzerland.
20.World Health Organization. 2005. The World Health Report 2005—Making Every Child and Mother Count. WHO, Geneva, Switzerland.
21.World Health Organization. 2008. Foodborne Disease Outbreaks: Guidelines for Investigation and Control. World Health Organization, Geneva, Switzerland.
22. Yoder, J. S.,, B. G. Blackburn,, and G. F. Craun. 2004. Surveillance for waterborne disease outbreaks associated with recreational water—United States, 2001-2002. MMWR Surveill. Summ. 53:122.
23. Yoder, J. S.,, M. C. Hlavsa,, and G. F. Craun. 2008. Surveillance for waterborne disease and outbreaks associated with recreational water use and other aquatic facility-associated health events—United States, 2005-2006. MMWR Surveill. Summ. 57:129.
24. Yoder, J. S.,, V. Roberts,, and G. F. Craun. 2008. Surveillance for waterborne disease and outbreaks associated with drinking water and water not intended for drinking—United States, 2005-2006. MMWR Surveill. Summ. 57:3962.

Tables

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TABLE 1

Enteric and other potential foodborne diseases and conditions designated as notifiable at the national level in the United States, 2009

Adapted from http://www.cdc.gov/ncphi/disss/nndss/PHS/infdis.htm.

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
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TABLE 2

Roles of selected government agencies in responding to possible foodborne or waterborne disease outbreaks in the United States

This table provides a general outline of typical responsibilities for different agencies involved in investigating food- and waterborne outbreaks. All states have unique food and water safety laws, policies, and organizational structures that will affect investigations, and many other agencies and organizations may play important roles in certain situations. Additional information is available at the “Gateway to Government Food Safety Information” (http://www.foodsafety.gov/) and the Environmental Protection Agency website (http://www.epa.gov/ebtpages/water.html).

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
Generic image for table
TABLE 3

Typical characteristics of foodborne and waterborne disease outbreaks and guidelines for confirmation

Adapted from references , and .

Vehicles noted include examples from reported outbreaks and other commonly contaminated foods or sources.

Incubation periods can vary substantially within, and sometimes outside, published “typical” ranges.

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
Generic image for table
TABLE 4

Guidelines for collection and handling of stool specimens during a foodborne or waterborne disease outbreak investigation

Adapted from reference .

Wrap the packaged samples in sealed, waterproof containers (i.e., plastic bags). Label each specimen container in a waterproof manner. Batch the collection and send in overnight mail to arrive at the testing laboratory on a weekday during business hours unless other arrangements have been made in advance with the testing laboratory. Contact the testing laboratory before shipping, and give the testing laboratory as much advance notice as possible so that testing can begin as soon as samples arrive. When etiology is unclear and syndrome is nonspecific, consider collecting all four types of specimens.

For more detailed instructions on how to collect specimens for specific parasites, please go to http://www.dpd.cdc.gov/dpdx/.

For more detailed instructions on how to collect specimens for viral testing, please go to http://www.cdc.gov/mmwr/PDF/RR/RR5009.pdf.

The containers have been tested for the presence of the chemical of interest before use.

Unused specimen collection containers that have been brought in to the field and subjected to the same field conditions as the used containers. These containers are then tested for trace amounts of the chemical of interest.

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
Generic image for table
TABLE 5

Steps of an outbreak investigation

Adapted from references and .

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
Generic image for table
TABLE 6

Potential clues that might increase suspicion that intentional contamination is the cause of a foodborne or waterborne disease outbreak

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7
Generic image for table
TABLE 7

Recommended components of an outbreak investigation summary report

Citation: Jones T, Keene W. 2011. Investigation of Enteric Disease Outbreaks, p 85-99. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch7

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