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Reading_05 - WATURES Food-Related Illness and Death in the...

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Unformatted text preview: WATURES Food-Related Illness and Death in the United States To better quantily the impact of loodbome diseases on health in the l'nited States. we compiled and analyzed information from multiple surveillance systems and other sources. We estimate that loodhorne diseases cause approximately 76 million illnesses. 323.000 hospitalizations. and 3,000 deaths in the United States each year. Known pathogens account for an estimated 14 million ill- nesses, 60,000 hospitalizations. and IBM deaths. Three pathogens, Salmonella, listaia, and Toxoplasnia, are responsible for 1,500 deaths each year, more than 75% of those caused by ltnown pathogens while unknown agents account for the remaining 62 million illnesses. 265.000 hospitalizations. and 3.200 deaths. Overall. loodborne diseases appear to cause more illnesses but fewer deaths than previously estimated. Editor‘s note This paper \tth otigiiitillt pith- lished in imaging Infectious Diseases till)! lM‘ National ( enter [or lrllt‘tllt'lh Dixetixes of the (enters {or Dixetiset ontiol tllltl l'tt'tt'niioii The format of the pupa theretoie mites iioni "tnmill lotiinal ol l‘lH‘ll‘ttnlltt‘llldl llealtli stile in [7.10. ovei itlt‘ references tittonipuninl the paper. as did (l \i'\ err-page tippentht tlest tih- ing the methods and assumptions hehind the ctuthois' pathogen-speciln t'\lHllillt'\ these soiitees were not reprinted In lllh l.\\lti' of the Joumal because of sprite limitations l'pon request. however. thev me tiittiluhle iioni NHM Sc'nttt' te'piesetttitlivi's in tin” oi niittl Introduction “me than 200 known diseases are transmit- ted through food tlt. lhe cattses of food- horne illness include viruses. bacteria. para- sites. toxtns. metals. and prions. and the svinptoins ol loodhorne illness range from nuld gastroenteritis to hie—threatening nett- iologic. hepatic. and renalsvndromes. In the l'inted States. loodliorne diseases have been estimated to cause 6 million to Hi million illnesses and up to 9.000 deaths each year (2- 5). However. ongoing changes in the food supply. the identilieatioti ol new loodhorne diseases. and the availability of new surveil- ’aul 5. .\lead Laurence Slutsker \'ante Diet] Linda [3. MtCaig Joseph S. lll’t‘St‘t‘ Craig Shapiro Patricia M. (iriffin and Robert V. Tauxe lance data have made these ligures obsolete. New. more accurate estimates are needed to gutde prevention ellorts and assess the dice- tivenes’s’ ol lood saletv regulations. Surveillance ol loodhorne illness is coni- plicated by several lactors. The first is under- reporting. Although loodhorne illness-es can be severe or even fatal. milder cases are olten not detected through routine surveillance Second. many pathogens transmitted through food are also spread through water or from person to person. thtts obscuring the role of loodborne transmission Finallv. some proportion of ioodhorne illness is caused hv pathogens or agents that have not yet been tdeiitilied and thus cannot be diagnosed. The importance of this final factor cannot he overstated. Many oi the pathogens ol greatest concern today (e.g.. (Tunipvlohattei ieiuni. Fscherichia mli OISHIT. Listeria nionoevto- genes, (fytlosponi ttiH'ldnt‘llslsl were not ret- ognizecl as causes ol loodhorne illness iust 20 vears ago. in this article. we report new estimates ol illnesses. hospitalizations. and deaths due to loodbomc diseases in the l'nited States To ensure their validity. these estimates have been derived by ustng data from multiple sources. including the neva established Foodhorne Diseases .'\Clt\‘(‘ Surveillance Network tFoodNet). The figures presented Manh 2000 - Environmental Health 9 include estimates for specific known pathogens. as well as overall estimates for all causes of foodborne illness. known. unknown. infectious. and noninfectious. Data Sources Data sources for this analysis include the 00' Foodborne Diseases Active Surveillance wz Network (Foothetl (oi, the National 003 Notiliable Disease Surveillance System (7). W the Public Health laboratory lnfonnation “5.0 W M System t8). the Gulf Coast States Vibrio “5' B i Surveillance System (9*. the Foodborne ' , . Disease Outbreak Surveillance System (10}. MRI-“5’3 W m the National Ambulatory Medical Care 005.0 Survey ill). the National Hospital 00$...”53 Ambulatory Medical Care Survey (ll-H). m M the National Hospital Discharge Survey US), the National Vllfll Statistics System ( lb). and selected published studies. [Established In [9%, FoodNet is a collabo- rative effort by the Centers for Disease Control and Prevention. the US. Department of Agriculture. the CS Food and Drug Administration. and selected state health departments. Foodth conducts active stir- veillance for seven bacterial and two parasitic foodbome diseases within a defined popula- tion of 20.5 million Americans to), Additional surveys conducted within the FoodNet catchment area provide informa- tion on the frequency of diarrhea in the gen- cral population. the proportion of ill persons seeking care. and the frequency of stool cul- turing by physicians and laboratories for selected foodbome pathogens. The National Notifiable Disease Surveillance System (7) and the Public M07 Health laboratory Information System (8) “69,000,. collect passive national surveillance data for a m, wide range of diseases reported by physicians s” 9 and laboratones. The Gulf Coast States V'ibrio ' Surveillance System collects reports of Vibno infections from selected states (9). and the 00” (Sindhi: 007.0. 0011-0073 000.00. 000.09 Other Protozoa! Intestinal Infections ttise. Botandiia' ' mli int:ka E. at Enterotaiguk E. «if Emmian E. (of Enmhemrrtiagk E. ali We»! l'em'tu'a Misc. Bacterial loath: 000.0l 000.01 000.03 000.04 000.43 000.64 000.4l-2. W01”. 000.5 000.“ 000.62 000.63 000.64 000.65 000.66 Foodborne Disease Outbreak Surveillance System receives data from all states on recog- nized foodborne illness outbreaks (defined as two or more cases of a similar Illness result- ing from ingestion of a common food) (10). As components of the National Health Care Survey. the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey measure health care use in various clinical settings. including physician offices and hos- pital emergency and outpatient departments (ll-l4). These surveys collect information 10 Environmental Health ' March Ml) on patient characteristics. patient symptoms or reasons for visit. provider diagnosis. and whether the patient was hospitalized. Up to three symptoms are recorded usrng a stan- dard classification (17). and up to three provider diagnoses are recorded according to the lntemational Classification of Diseases. 9th Revision. Clinical Modifications thD-9- CM) (18) (Table l). The National Hospital Discharge Survey. another component of the National Health Care Survey. is a representative annual sam- ple of discharge records from approximately 475 nonfederal short-stay hospitals ( l 5). The information collected includes up to seven princtpal discharge diagnoses classified by ICI).9-(IM codes (18). Because these data include information on condition at dis. charge, they can be used as a source of infor- mation on in-hospital deaths, Additional information on food—related deaths was obtained from the National Vital Statistics System. which collects death cenificate data on causes of death classified by 3- or 'i-dlgll lCD-9 codes (16). lti addition to information front these for- mal surveillance systems, we used data from two pttblished population-based studies. The Tecumseh study was conducted from 1965 through 1971 in 850 households in Tecumseh. Michigan. with an emphasis on households with young children (19). Households were telephoned weekly to iden- tify incident cases of self-defined diarrhea. vomiting. nausa. or stomach upset. The Cleveland study was conducted among a selected group of 86 families followed from 1948 through 1957 (20). A family member recorded occunences of gastrointestinal ill- nesses and associated symptoms on a month- ly tally sheet. Both studies also collected information on extraintestinal illnesses (e.g.. respiratory illness). Other studies with simi- lar designs were not included in our analysis. either because they were relatively small or because they did not provide information on the desired endpoints. The Study Food-Related Illness and Death from Known Pathogens Total Cases To estimate the total number of foodbome illnesses caused by known pathogens. we determined the number of reported cases for each pathogen. adjusted the figures to account for underreponing. and estimated the proportion of illnesses specifically attrib- utable to foodbome transmission. Although data from various periods were used. adjust- ments for changes in population size had minimal effect on the final estimates and were therefore omitted. Cases may be reported in association with documented foodbome outbreaks. through passive surveillance systems (e.g.. the National Notifiable Disease Surveillance System. the Public Health Laboratory lnforrnation System). or through active sur- veillance systems (e.g.. FoodNet). Sporadic illness caused by some pathogens (e.g.. Bacillus ccretts. Clostridium perjringens. Staphylococcus auretts) is not reportable through passive or active systems; hence. the only cases reported are those related to out- breaks. For these pathogens. we have assumed that if diagnosed sporadic cases were reported. the total number would be 10 times the number of outbreak-related cases. This multiplier is based on experience with pathogens for which data are available on both sporadic and outbreak-associated cases (e.g.. reported cases of Salmonella or Shigella. Table 2). For all pathogens. the number of outbreak-related cases was calculated as the average annual number of such cases report- ed to CDC from 1983 to 1992. the most recent years for which published outbreak data are available. For pathogens also under passive surveillance. we used the average number of cases reported to CDC from 1992 through 1997. and for pathogens under active surveillance through FoodNet. we used the average rate observed for the sur- veillance population from l996'to 1997 and applied this to the total 1997 U.S. population (with some modification for E. coli 0157:H7; Appendix). Irrespective of the surveillance system. many cases of foodbome illness are not reported because the ill person does not seek medical care. the health-care provider does not obtain a specimen for diagnosis. the lair oratory does not perform the necessary diag- nostic test. or the illness or laboratory find- ings are not communicated to public health officials. Therefore. to calculate the total number of illnesses caused by each pathogen. it is necessary to account for underreponing. i.e.. the difference between the number of reported cases and the num- ber of cases that actually occur in the com- munity. For Salmonella. a pathogen that typ« ically causes nonbloody diarrhea. the degree of underreponing has been estimated at ~38 fold (Voetsch. manuscript in preparation) (21). For E. coli 01572H7. a pathogen that typically causes bloody diarrhea. the degree of underreponing has been estimated at ~20 fold (22). Because similar information is not available for most other pathogens. we used a factor of 38 for pathogens that cause pri- marily nonbloody diarrhea (e.g.. Salmonella. Campylobacter) and 20 for pathogens that cause bloody diarrhea (e.g.. E. coli OlS7:H7. Shigella). For pathogens that typically cause severe illness (i.e.. Clostridium botulinum. Listeria monocytogerrcs). we arbitrarily used a far lower multiplier of 2. on the assumption that most cases come to medical attention. Details of the calculations for each specific pathogen and rationale are provided in the Appendix. Where information from both active and passive reporting was available. we used the figure from active surveillance when estimating the total number of cases. Having estimated the number of cases caused by each pathogen. the final step was to estimate for each the percentage of illness attributable to foodbome transmission. The total number of cases was then multiplied by this percentage to derive the total number of illnesses attributable to foodbome transmis- sion. The rationale for each estimate is pre- sented in the Appendix; although precise percentages are generally difficult to justify. in most instances there is ample support for the approximate value used. Results are presented in Tables 2 and 3. Known pathogens account for an estimated 38.6 million illnesses each year. including 5.2 million (13%) due to bacteria. 2.5 mil- lion (7%) due to parasites. and 30.9 million (80%) due to viruses (Table 2). Overall. foodbome transmission accounts for 13.8 million of the 38.6 million illnesses (Table 3). Excluding illness caused by Listeria. Toxoplasma. and hepatitis A virus (three pathogens that typically cause nongastroin- teStinal illness). 38.3 million cases of acute gastroenteritis are caused by known pathogens. and 13.6 million (36%) of these are attributable to foodbome transmission. Among all illnesses attributable to foodbome transmission. 30% are caused by bacteria. 3% by parasites. and 67% by viruses. Hospitalizations To estimate the number of hospitalizations due to foodbome transmission. we calculat- ed for each pathogen the expected number of hospitalizations among reported cues by multiplying the number of reported cases by pathogen-specific hospitalization rates from FoodNet data (23.24). reported outbreaks (10.25). or other published studies (Appendix). Not all illnesses resulting in hospitalization are diagnosed or reported. Health-care providers may not order the nec- essary diagnostic tests. patients may have already taken antibiotics that interfere with diagnostic testing. or the condition leading to hospitalization may be a sequela that develops well after resolution of the actual infection (e.g.. Campylobacter-associated Guillain-Barré syndrome). Therefore. to account for underreponing. we doubled the number of hospitalizations among reported cases to derive for each pathogen an estimate of the total number of hospitalizations. Finally. we multiplied this figure by the pro- portion of infections attributable to food- bome transmission. Because of gaps in the available data. this approach could not be used for some parasitic.and viral diseases (Appendix). Overall. the pathogens listed in Table 2 cause an estimated 181.177 hospitalizations each year. of which 60.854 are attributable to foodbome transmission (Table 3). Excluding hospitalizations for infection with Listeria. March 2000 - Environmental Health 1 1 Reported and Estimateda Illnesses. Frequency of Foodborne Transmission, and Hospitalization ‘ and Case-Fatality Rates for Known Foodborne Pathogens, United States 1 Estimated RWWW“ C3595 °/o Case Total by SU'Veillance TYPE Foodborne Hospitalization Fatality 1 Disease or Agent Cases Active PJSSiVe Outbreak Transmission Rate Rate ‘ Bacterial i Baal/us (mus 27.360 720 72 IM 0.006 0.0000 \ Botulism. Foodbome 58 29 I00 0.800 0.0769 Brute/la spp. [.554 Ill 50 0.550 0.0500 Campy/abort" spp. 2.453. 926 64.5 77 37.496 I46 80 0. l 02 0.00 I 0 (lasmdium perfringent 248.520 6.540 654 I00 0.003 0.0005 Escherichia coll 0|57:ll7 73.480 3.674 2.725 500 85 0.295 0.0083 5. coll. Non-0l57 STE( 36.740 [.837 85 0.295 0.0083 E. (all. Entetotoxigenic 79.420 2.090 209 70 0.005 0.000l E. (oli. Other Diarrheogenit 79.420 2,090 30 0.005 0.000l ; Listeria monocyrogenes 2.5/8 [.259 373 99 0.922 0.2000 ‘ Salmonella Typhib 824 4l2 80 0.750 0.0040 Salmonella. Nontyphoidal /.4IZ.498 37,I7I 37.842 3.640 95 MN 0.0078 ‘ Shigella spp. 448.240 22.4/2 l7.324 L476 20 0.l39 0.00I6 3 Staphylococcus Food Poisoning l85.060 4.870 487 [00 0.l80 0.0002 i Streptotottus. Foodborne 50, 920 l. 340 I 34 [00 0| 33 0.0000 1 l’ibn‘o cholene. loxigenit 54 27 90 0.340 0.0060 9. vulnilicus 94 47 50 MW 0.3900 Vibn'o. Othei 7.880 393 I ll 65 0. I 26 0.0250 lemma enterotolilia 96.368 2.536 90 0.242 0.0005 1 Subtotal 5.204.934 ’ Parasitic Cryptospofidium parvum 300.000 6.630 2.788 M 0.l50 0.005 ‘ [ydospora ayennemi: 10,204 420 90 90 0.020 0.0005 Glardi'a lamb/i: 2.000.000 707.000 22.907 I0 n/a n/a loxoplaima gondii 225.000 |5.000 50 n/a n/a Iridiinella spiral/'5 52 26 |00 0.08I 0.003 . Subtotal 2.54l.3l6 } Viral Norwalk-lilte Viruses 23,000,000 40 n/a n/a Rouvirus 3,900,000 I nla n/a Astrovirus 3,900,000 7 n/a 01: l Hepatitis A 83.397 27.797 5 0| 30 0.0030 i Subtotal 30,003,391 Grand Total 38,629.64! 1Number; In «talus in estimates; others are measured. b>707. ol (am atqmred abmd. 12 lm lini‘nu'l‘ln. lit-.allh - \ltinlt Ill" WBLE if* i—_' ‘ Estimated Illnesses. Hospitalizations. and Deaths Caused by Known Foodborne Pathogens, United States Illnesses Hospitalizations °/. 0! Total ' °/. 0! Total ' 7 ' 73/; of Total ' Disease or Agent Total Foodbome FOOdbOI'M 1 Total Foodborne FOOdbON‘Ie Total Foodborne FOOdbOme Bacterial Baal/u: (mus 27.360 27.360 0.2 8 8 0.0 0 0 0.0 Botulism. loodborne 58 58 0.0 46 46 0| 4 4 0.2 Brucella spp. L554 777 0.0 I22 6| 0| || 6 0.3 | Campy/063cm spp. 2.453.926 |.963.|4l l4.2 l3.|74 |0.539 I73 I24 99 5.5 1 (lostnd/um perfiingem 248.520 248.520 |.8 4| 4| 0| 7 7 0.4 ‘ [schen'rhia (all 0|571||7 73.480 62.458 0.5 2.l68 L843 3.0 6| 52 2.9 6. (all. Non-0|57 STEC 36.740 3|.229 0.2 L084 92| |.5 30 26 l.4 [. (all. Enterotoxigenic 79.420 55.594 0.4 2| l5 0.0 0 0 0.0 E. (all; Other Dianlieogenic 79.420 23.826 0.2 2| 6 0.0 0 0 0.0 ‘ listed: monoqtogene: 2.5l8 2.493 0.0 2.322 2.298 3.8 504 499 27.6 1 Salmoner Typhi 824 659 0.0 6|8 494 0.8 3 3 0| Salmonella. Nontyphoidal |.4l2.498 |.34l.873 9.7 l6.430 l5.608 25.6 582 553 30.6 | Shigella spp. 448.240 89.648 0.6 6.23l L246 2.0 70 I4 0.8 ‘ Stair/locum: Food Pointing |85.060 |85.060 L3 L753 L753 2.9 2 2 0| Streptococcus. Foodborne 50.920 50.920 0.4 358 358 0.6 0 0 0.0 l’lbrlo (ho/em. Toxigenic 54 49 0.0 l8 l7 0.0 0 0 0.0 1 V. vulnificus 94 47 0.0 86 43 0| 37 I8 |.0 Vibn'o. Othet 7.880 5.|22 0.0 99 65 0| 20 I3 0.7 1 ‘ Yminia enterwolirita 96.368 86.73l 0.6 L228 |.|05 L8 3 2 0| Subtotal 5.204.934 4.|75.565 30.2 45.826 36.466 59.9 L458 L297 7|.7 Parasitic Cryptosporidium panum 300.000 30.000 0.2 L989 I99 0.3 66 7 0.4 (ydospora (ayeranensis l6.264 H.638 0.| I7 l5 0.0 0 0 0.0 Giardia lamb/i2 2.000.000 200.000 H 5.000 500 0.8 W | 0.l Iaxoplasma gondii 225.000 “2.500 0.8 5.000 2.500 4.| 750 375 20.7 i lrkhinella spin/is 52 52 0.0 4 4 0.0 0 0 0.0 ‘ Subtotal 2.54l.3l6 357.|90 2.6 |2.0|0 3.2l9 5.3 827 383 2|.2 Viral Norwalk-like Viruses 23.000.000 9.200.000 66.6 50.000 20.000 32.9 3l0 |24 6.9 Rouvirus 3.900000 39.000 0.3 50.000 500 0.8 30 0 0.0 Astwvirus 3.900.000 39.000 0.3 |2.500 |25 0.2 l0 0 0.0 Hepatitis A 83.39l 4.|70 0.0 |0.84| 90 0.9 83 4 0.2 Subtotal 30.833.39l 9.282.|70 67.2 |23.34| 2|.l67 34.8 433 I29 7.l Grand Total 38,619.64I I3,8|4.924 |00.0 I8l.|77 60.854 l00.0 2.7I8 |.809 l00.0 lovopliisiittr and hepatitis .1\ virus. “8013 hospitalizations for acute gastroenteritis are caused bv ktiowii pathogens. of which 33.3l.’ 04%) are attributable to loodborne transmission Overall, bacterial pathogens account for 60“» of hospitalizations attribut- able to loodborne transmission. parasites for 3%. and viruses for 34%. Deaths like illnesses and hospitalizations. deaths are also underreported. l’recise information on food-related deallis Is espectallv dilliciill to ohtain because pathogen-specilic surveil- lance svstems rarelv collect inlorinatioii on illness outcome. and outcome-specilie stir- veillance systems leg. death certilieatesl grosslv underreport manv pathogen-specific conditions. To estimate the number of deaths due to bac terial pathogens. we used the same approach described for hospitalizations: first calculating the iitiiiiber ol deaths among reported cases. then doubling this figure to account lor unreported deaths. and liiiall) niiiltiplving bv the percentage ol infections attributable to...
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