The Ohio Department of Health released this video to show the advantages of social distancing:
That’s a lot of balls and mousetraps to setup.
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New Lab Matters: When the water comes, be prepared
According to a study by the National Center for Atmospheric Research, the volume of rainfall from storms will rise by as much as 80% in North America by the end of the century. Not only do storms and floods threaten public health laboratory facilities, but receding floodwaters pose serious public health risks. As our feature article shows, the best weapon in a public health laboratory’s arsenal is preparation for inundation…from any source.
Here are just a few of this issue’s highlights:
- Preparing for the Super Bowl: Minnesota Gets Ahead of the Game
- Louisville Expands Arbovirus Surveillance, Streamlines Mosquito Testing
- NBS Programs Get “Building Blocks” to Implement Electronic Data Exchange
- A New Beginning: PulseNet Middle East Reinvigorated
- Syphilis Rising: APHL’s Efforts to Address Another Historic Foe
- 100 Faces of Excellence in Missouri
- Monitoring Environmental Conditions in the Buckeye State
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PulseNet key to solving 2010 E. coli outbreak linked to lettuce
by Kim Krisberg
On April 22, 2010, federal public health officials notified the New York State Department of Health of two E. coli clusters at colleges in Michigan and Ohio. The very next day, the New York agency got word of an illness cluster in its own state with symptoms similar to the neighboring outbreaks.
Fortunately, that initial notification came via PulseNet, the national molecular subtyping network for foodborne disease surveillance, which allows public health scientists and investigators to rapidly identify foodborne illness outbreaks. That meant staff at the New York State public health laboratory, officially known as the Wadsworth Center, had easy access to Michigan’s and Ohio’s laboratory findings, which allowed immediate testing to begin to discover whether the New York illnesses were connected to the larger outbreak. Just a handful of days later, the New York lab had an answer — DNA fingerprints from patient specimens in Michigan, Ohio and New York were a match. The E. coli O145 outbreak had spread to New York.
“It was invaluable for us,” said Madhu Anand, DrPH, deputy director of the Regional Epidemiology and Investigations Program in the department’s Bureau of Communicable Disease Control, of PulseNet, which celebrated its 20th anniversary last year. “PulseNet was critical at every stage of this investigation.”
Just a few days following identification of the initial New York illness cluster, which occurred at a college in western New York, public health staff got word about a cluster of hemolytic uremic syndrome (HUS) illnesses in a school district just north of New York City. HUS is a potentially life-threatening complication associated with Shiga toxin-producing E. coli infection. Public health workers began active surveillance in the district, Anand said, finding multiple cases that matched the profile of cases connected to the E. coli outbreak.
Around this same time, CDC announced that epidemiologic and traceback investigations in Michigan and Ohio pointed to shredded romaine lettuce from a single distributor as the culprit. In response, the New York State Department of Health worked with local public health to collect any leftover lettuce from the college. The college didn’t have any leftovers, said David Nicholas, MPH, research scientist and epidemiologist in the state’s Bureau of Community Environmental Health and Food Protection, but it did have an invoice, which showed the same distributor identified in Ohio and Michigan. Public health staff also sought out lettuce leftovers in the affected school district, and they found plenty.
On April 28, 2010, the Wadsworth Center received more than 150 pounds of shredded lettuce from the school district — or what Nicholas described as a “Honda full of lettuce.” Lab staff got to work testing portions of the entire lot, which were divided into two-pound bags, reported Nellie Dumas, associate director of the Wadsworth Center’s Bacteriology Laboratory. However, one of the two-pound bags was stamped with an expiration date indicating it could have been among the same batch of shredded lettuce that the sickened children had eaten. That expiration date led lab staff to test the entire two pounds of lettuce, Dumas said.
In testing that particular bag of lettuce, laboratorians were able to isolate E. coli O145, which was then tested by pulsed-field gel electrophoresis (PFGE) to obtain a DNA fingerprint. The DNA fingerprint matched the outbreak strains identified in Ohio and Michigan. The Wadsworth findings were then uploaded to PulseNet, helping to confirm that shredded lettuce was indeed the source of the outbreak, said Deborah Baker, research scientist in the Wadsworth Center Bacteriology Laboratory.
“PulseNet was vitally important because it allowed states to instantly share subtyping information,” Baker said. “As soon as we have a PFGE pattern, we can immediately go into the database and see what’s happening in other states.”
Overall, according to Anand, New York state was home to six confirmed cases and one probable case of E. coli O145 connected to multistate outbreak traced back to shredded lettuce. All six confirmed patients had to be hospitalized and four developed HUS. Nationwide, according to CDC, 26 confirmed and seven probable cases of illness were connected to the E. coli outbreak in five states: Michigan, New York, Ohio, Tennessee and Pennsylvania. (The cases in Tennessee and Pennsylvania were identified in retrospect using PulseNet data.) Among the 30 E. coli patients with available information, 40 percent became so sick they had to be hospitalized. Thankfully, no deaths occurred.
A May 10, 2010 news release from the U.S Food and Drug Administration linked the contaminated shredded lettuce back to Freshway Foods in Ohio. The company issued a voluntary recall.
“For 20 years, PulseNet has helped us find the sources of these horrific illnesses,” said Dumas, associate director of the Wadsworth Center Bacteriology Laboratory. “It’s total teamwork.”
According to CDC, PulseNet identifies about 1,500 clusters of foodborne illness every year, about 250 clusters that cross state lines, and about 30 multistate outbreaks traced back to a food source. A recent economic evaluation of PulseNet found that every year, the laboratory network prevents more than 266,500 illnesses from Salmonella, nearly 9,500 illnesses from E. coli and 56 from Listeria. That translates into $507 million in reduced medical and productivity costs.
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With PulseNet, handful of E. coli cases reveal multistate outbreak, prompt huge recall
By Kim Krisberg
In 2014, two Ohio residents living more than 100 miles apart were diagnosed with an E. coli infection. Twenty years ago, the two cases might have been chalked up to coincidence — after all, tens of millions of Americans experience foodborne illness every year.
But thanks to a nationwide lab network known as PulseNet, public health officials could compare the genetic patterns of the Ohio cases to foodborne illness cases across the country, eventually detecting a multistate foodborne illness outbreak that led to the recall of 1.8 million pounds of ground beef products. Overall, 12 people across Ohio, Michigan, Massachusetts and Missouri were diagnosed with outbreak strains of Shiga toxin-producing Escherichia coli O157:H7, or STEC O157:H7, and more than half of those sickened had to be hospitalized.
“Without PulseNet, we may have never recognized this as a multistate outbreak,” said Scott Nowicki, MPH, epidemiologist at the Ohio Department of Health.
Several key activities came together in late spring 2014 that enabled public health officials in Ohio and Michigan to detect and contain the outbreak fairly quickly. First, after the Ohio Public Health Laboratory confirmed the initial two cases of STEC O157:H7, student interviewers with Ohio’s FoodCORE team — a Centers for Disease Control and Prevention-funded effort to strengthen state and local foodborne illness outbreak response — set out to interview the patients. It turned out both patients, who lived more than 100 miles apart, said they had eaten at the same local chain restaurant that specializes in serving undercooked hamburgers. It was a strong signal that undercooked beef, as opposed to contaminated produce, was the culprit, Nowicki said.
On the same day as the FoodCORE interviews, the Ohio Public Health Laboratory uploaded its test results for the local STEC O157:H7 cases to PulseNet. Previously, the lab, which routinely receives specimens of public health importance from health providers around the state, received isolates connected to the STEC O157:H7 patients. Lab staff then performed pulsed-field gel electrophoresis, or PFGE, to determine the sample’s DNA fingerprint pattern. They posted the fingerprint patterns to PulseNet and quickly noticed their PFGE results matched two isolates in Michigan.
In addition to a match, the PFGE pattern was also relatively uncommon, which was another strong signal of an outbreak rather than a string of isolated cases, said Eric Brandt, a laboratory scientist at the Ohio Department of Health, Bureau of Public Health Laboratory.
With the matching PFGE results, epidemiologists in Ohio and Michigan began comparing notes, finding that patients in both states reported eating at restaurants that serve undercooked beef. In particular, 92% of the 12 ill persons identified in the outbreak reported eating ground beef at such a restaurant before they became sick, and 73% said they may have eaten hamburger prepared rare, medium rare or undercooked.
From there, an intensive local, state and federal traceback investigation ensued, eventually tracing the ground beef at the restaurants where the STEC O157:H7 patients had eaten to the Wolverine Packing Company in Detroit. In May 2014, the meatpacking company recalled about 1.8 million pounds of ground beef that may have been contaminated with the pathogen. During the outbreak, five people were sickened in Ohio, five in Michigan, one in Massachusetts and one in Missouri. While seven of those people had to be hospitalized, none developed hemolytic uremic syndrome, a potentially life-threatening complication associated with STEC O157:H7 infection.
Nowicki noted that before PulseNet, it often took many more cases of foodborne illness for public health officials to recognize an outbreak and begin efforts to identify the source and prevent further disease. Indeed, he said the 2014 STEC O157:H7 outbreak is the perfect example of how PulseNet can quickly connect a small handful of seemingly isolated dots to reveal the outbreak lurking beneath.
“For identifying outbreaks,” Nowicki said, “PulseNet is invaluable.”
Brandt agreed, adding that “these very sporadic cases that cross state lines…those would have been much more difficult to detect in the pre-PulseNet days.” He also said that PulseNet, which celebrated its 20th anniversary this year, is “fundamental” to the Ohio Public Health Laboratory’s foodborne illness capacity, providing the lab’s primary infrastructure for cluster detection, bacterial subtyping, training, instrumentation and much more.
“PulseNet is crucial,” said Brandt, who’s spent most of his career working with PulseNet. “I can’t even imagine what it was like before.”
According to CDC, PulseNet identifies about 1,500 clusters of foodborne illness every year, about 250 clusters that cross state lines, and about 30 multistate outbreaks traced back to a food source. A recent economic evaluation of PulseNet found that every year, the laboratory network prevents more than 266,500 illnesses from Salmonella, nearly 9,500 illnesses from E. coli and 56 from Listeria. That translates into $507 million in reduced medical and productivity costs.
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Random dog food sample proved critical in solving human illness outbreak
As part of Michigan’s routine pet food surveillance program, microbiologists in the Michigan Department of Agriculture and Rural Development (MDARD) Laboratory Division were used to testing random samples of dog food. While they rarely found anything unusual or harmful, they continued this testing. On April 2, 2012 the importance of their work was made abundantly clear.
In the MDARD microbiology lab, the unopened bag of dry dog food which was selected at random from a store shelf, looked like so many others. Such samples usually tested negative for contaminants and foodborne pathogens, but this one tested positive for Salmonella Infantis. The MDARD team recovered an isolate from the sample and sent it to the state’s PulseNet lab at the Michigan Department of Health and Human Services (MDHHS), Bureau of Laboratories.
There, scientists performed pulsed-field gel electrophoresis (PFGE) testing on the sample and promptly uploaded their findings to the PulseNet database. Once the data was entered on April 10, lab scientists noticed that the PFGE pattern from the contaminated dog food matched PFGE patterns from human illnesses in the US and Canada. These human cases were previously unsolved; the random sample of contaminated dog food was the smoking gun in over 50 human cases. They forwarded the information to state epidemiologists who promptly initiated an investigation.
Human illness from pet food isn’t uncommon. No, it doesn’t mean someone ate dog food. When humans handle pet food, any contaminants can be left on their hands. From there it’s easy to spread those potentially-harmful pathogens to other surfaces or unwittingly ingest it. It’s important to wash hands after handling pet food and thoroughly clean any surfaces where the food may have been.
In response to the discovery that previously unsolved human cases of Salmonella may be linked to the contaminated pet food, every key player was contacted. MDHHS reached out to MDARD’s Rapid Response Team, the Food and Drug Administration’s (FDA) Detroit District Office, the Public Health Agency of Canada, and notified PETNet, the FDA’s pet-food tracking system. The dog food manufacturer was also contacted to inform them of the findings. Because the manufacturing facility listed on the bag was said to be in Missouri, the Missouri Department of Agriculture was also contacted. It was later discovered that the factory where this food was made was in Gaston, South Carolina, so the South Carolina Department of Agriculture was eventually contacted as well.
As the scope of the investigation widened, state agriculture laboratories, public health teams, and CDC and FDA scientists joined Michigan’s epidemiologists and laboratory scientists in responding to the outbreak. They collaborated closely to conduct trace-back investigations of the implicated products, implement recalls and limit additional exposures by informing the public of the health risks associated with the products.
On April 20, scientists at the Ohio Department of Agriculture isolated the outbreak strain from an opened bag of dog food collected from the home of a case-patient. And on April 30, MDARD and FDA scientists isolated the outbreak strain from dog food samples collected from the SC facility.
With a clear link between the contaminated food and human illnesses established, the pet food company issued a national recall of the implicated brand of dog food. As the Departments of Agriculture in South Carolina and Ohio identified other contaminated pet foods manufactured by the firm, this recall was expanded eight times to include 17 brands representing approximately 30,000 tons of dry dog and cat food, all produced at the South Carolina facility.
Ultimately 53 human illnesses in 21 states and two Canadian provinces were connected to the outbreak. Ten of these cases required hospitalization. In addition, 37 animals were sickened, and there were numerous complaints of illnesses that met the case definition.
However, the effects could have been far worse as 30,000 tons of contaminated pet chow could have caused innumerable cases of human and pet illness if distributed. But thanks to Michigan’s routine pet food sampling program, clear PFGE data entered into PulseNet and strong collaboration among public health partners, the spread of disease was halted.
More on this outbreak: Notes from the Field: Human Salmonella Infantis Infections Linked to Dry Dog Food — United States and Canada, 2012
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