Group grades states for foodborne illness outbreak reporting

Jan 19, 2011 (CIDRAP News) – The Center for Science in the Public Interest (CSPI) today released its first report on how well states perform at reporting foodborne disease outbreaks, which they say varies greatly, with seven states earning A grades and 14 getting Fs.

The CSPI, a food safety watchdog based in Washington, DC, said it released the report to help clarify foodborne illness problems and develop better strategies for minimizing them. The 66-page report, titled "All Over the Map," appears on the group's Web site. Food safety experts have often said that states vary in their capacity to identify and respond to foodborne illness outbreaks, but the CSPI's report is the first to systematically look at each state.

The CSPI based its letter grade and outbreak profile for each state on its analysis of two databases, which cover a 10-year span. One is the CSPI's own outbreak database and the other is the US Centers for Disease Control and Prevention's (CDC's) OutbreakNet Foodborne Outbreak Online Database, which launched in September 2009.

Even though new tools such as PulseNet have made it easier to link illness clusters that occur in different states, the hard work of outbreak investigations is still done largely at the local level, where public health officials—often with a number of additional job responsibilities—are tasked with interviewing sick patients and identifying a common food source.

The group compared the nation's outbreak identification and reporting system to a house of cards. "At each step in this inherently passive process, a single moment of inaction—a single missed opportunity to follow up—can result in an aborted investigation and another outbreak uncounted," CSPI said in its findings.

For benchmarks the CSPI used Oregon and Minnesota, two states that it says are known for excellent laboratory facilities and public health departments that quickly interview patients whose illnesses are suspected to be linked to an outbreak.

Each state's grade was based on how many outbreaks it reported each year per million people. States with higher outbreak numbers received higher grades. Oregon and Minnesota reported nine and eight outbreaks per million people per year, respectively, receiving A grades. Other states that received the highest grade were Florida, Hawaii, Maryland, Washington, and Wyoming.

Fourteen states reported only one foodborne illness outbreak per million people per year, which earned them Fs in the CSPI's report. The group includes Arizona, Arkansas, Indiana, Kentucky, Louisiana, Mississippi, Missouri, Nebraska, Nevada, New Mexico, Oklahoma, South Carolina, Texas, and West Virginia.

Grades should not be used to compare states, the CSPI cautioned, because state budgets and staffing can vary substantially, as do climate and geography, two factors that can influence the risk of foodborne illness outbreaks.

The CSPI said it may seem counterintuitive to give higher grades to states with more outbreaks, but the pattern shows those states are most likely to have robust disease detection and reporting systems. It added that the lowest scores might point to funding gaps for public health activities, such as outbreak response teams.

Caroline Smith DeWaal, the CSPI's food safety director, said in the press release that aggressively investigating outbreaks and reporting them to the CDC can help pinpoint the foods responsible for outbreaks. "But when states aren't detecting outbreaks, interviewing victims, identifying suspect food sources, or connecting with federal officials, outbreaks can grow larger and more frequent, putting more people at risk," she said.

Analysis of the outbreak data revealed that the percentage of solved outbreaks, those having both an identified food and an identified pathogen, s declined from 44% in 2001 to 34% in 2007, which the CSPI called a troubling trend.

However, the group added that food safety legislation signed by President Barack Obama early this month requires the US Food and Drug Administration (FDA) and CDC to boost coordination between federal, state, and local surveillance systems and improve epidemiological tools for states to use. It said the law also requires the government to designate five state health departments as regional Centers of Excellence that can help public health officials respond to outbreaks.

In its list of recommendations, the CSPI said people at many different levels have a role to play in improving the outbreak response system. For example, lawmakers can better fund public health budgets, the CDC can develop a curriculum to teach better investigation and epidemiologic practices, and consumers can report suspected infections to their doctors.

Dr Craig Hedberg, a food safety expert at the University of Minnesota in Minneapolis, reviewed the CSPI's executive summary and recommendations before the report was published. He told CIDRAP News that CSPI's analysis is an important effort that could help stimulate improved practices.

"It is really the first time there has been a systematic look at outbreak reporting by state. Like every first step, there is room to improve the assessment, but I think it gets the discussion started," Hedberg said.

Another variable that the CSPI could use to measure outbreak performance is consistency, according to Hedberg. He said among several states that received A grades, outbreak reports became fewer over the second half of the 10-year time period. Patterns would have to be analyzed on a state-by-state basis, he said, because a drop-off could suggest worrisome resource constraints or more stringent criteria for reporting, which would be a sign of improved investigation practices.

In further analysis, the CSPI could use the assessment to distinguish which kind of surveillance system initially detected the outbreak, another factor that can vary from state to state, Hedberg said. He said multistate outbreaks are typically detected through pathogen-specific surveillance tools such as PulseNet, but about 75% of all outbreaks are linked to events or establishments and are detected through consumer complaints or medical providers.

He said one problem with grading surveillance data is that it doesn't account for year-to-year fluctuations in foodborne illness outbreaks. For example, he pointed out that 2006 and 2007 were active years for norovirus transmission, with several states recording record numbers of outbreaks.

"A drop in the number of outbreaks coinciding with the return to a more 'normal' occurrence of norovirus could be interpreted as a drop in performance of the health department rather than the real change in the occurrence of disease," Hedberg said. "This type of tracking system could help us understand underlying fluctuations in disease occurrence, but it would take some time to figure out."

See also:

Jan 19 CSPI press release

Jan 19 CSPI state outbreak reporting review

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