Fishing for Answers: Struggles of Investigating an Unsolved ......2016L-6034 2016L-6036 2015L-6883...
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National Center for Emerging and Zoonotic Infectious Diseases Fishing for Answers: Struggles of Investigating an Unsolved Outbreak of Listeriosis Among a Majority of Patients of Eastern European Background Amanda Conrad, MPH Assessment Epidemiologist Outbreak Response Team Outbreak Response and Prevention Branch Centers for Disease Control and Prevention InFORM 2017 November 8, 2017
Transcript of Fishing for Answers: Struggles of Investigating an Unsolved ......2016L-6034 2016L-6036 2015L-6883...
National Center for Emerging and Zoonotic Infectious Diseases
Fishing for Answers: Struggles of Investigating an Unsolved Outbreak of Listeriosis Among a Majority of Patients of Eastern European Background
Amanda Conrad, MPH
Assessment Epidemiologist
Outbreak Response Team
Outbreak Response and Prevention Branch
Centers for Disease Control and Prevention
InFORM 2017
November 8, 2017
Cluster Summary
Cluster of 38 cases from 10 states: CA (6), IL (12), IN, ME, MA (2), MD (3), NJ, NYC (4), OH (2), and PA (6)
3 different Listeria monocytogenes strains based on wgMLST and PFGE results
20 patients with available information reported Eastern European background
33 patients shopped Russian or Eastern European stores
Food and environmental testing yielded 3 environmental swabs and 1 leftover product with strains matching clinical isolates
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1
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3
4
5
6
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2015 2016 2017
Cas
es
(N)
Isolation date
Strain 1 Strain 2 Strain 3
Patients infected with the outbreak strain of Listeria monocytogenes by isolation date and patient isolate WGS strain n=38*
*Two cases from a single mother infant pair where only the infant’s isolate was sequenced. Mother’s isolate not included in this figure but is assumed to be strain 3.
12/11 Cluster 1 Detected 1/28
Cluster 2 Detected 2/12Clusters combined
2/24Investigation
Closed
Challenge 1: Food Exposures
Lack of knowledge of Eastern European-style foods and food terminology
Limited exposures that could be considered culturally-specific on Listeria Initiative (LI) questionnaire
Difficult to determine which food items were uncommon among patients
No background rates for comparison for items like herring and caviar from the LI or the FoodNet Population Survey
Supplemental questionnaires were created at various points in the investigation as more items of interest became available
Patients reported similar foods but brand information was lacking and foods were purchased ready-to-eat or at the deli counter making us suspicious of cross-contamination within store or deli locations
Challenge 2. Whole Genome Sequencing
wgMLST (<All Characters>)
100
95
90
85
80
75
70
65
60
55
50
45
40
35
Key
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Modified date
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CalculationStatusRunIdscdc_id
2015L-6874
2015L-6908
2015L-6944
2015L-6873
2015L-6897
2015L-6933
2016L-6034
2016L-6036
2015L-6883
2016L-6018
2016L-6040
2015L-6949
2016L-6033
2016L-6037
Id
PNUSAL001931
PNUSAL001961
PNUSAL002003
PNUSAL001930
PNUSAL001957
PNUSAL001979
PNUSAL002019
PNUSAL002029
PNUSAL001943
PNUSAL002014
PNUSAL002036
PNUSAL002007
PNUSAL002028
PNUSAL002033
State ID
IL___150296
PA___M15016774-1
IL___150356
IL___150294
IL___150306
IL___150334
PA___M16000362-1
IN___16REF0130
OH___2015008862
NYC__nyc16-200477720
OH___2016000554
PA___M16000010-1
NYC__nyc16-200479727
MA___16EN0475
PFGE-AscI-pattern
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0016
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
PFGE-ApaI-pattern
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1600
GX6A12.1600
GX6A12.0112
GX6A12.1600
GX6A12.1600
Outbreak
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
Serotype
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
SourceCountry
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SourceState
IL
PA
IL
IL
IL
IL
PA
IN
OH
NY
OH
PA
NY
ME
PatientAge
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PatientSex
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SourceType
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SourceSite
Blood
Blood
Blood
Blood
Blood
Blood
Blood
Ascites Fluid
Blood
CSF
Blood
Blood
Blood
Other
IsolatDate
2015-11-24
2015-12-03
2015-12-29
2015-11-25
2015-12-02
2015-12-19
2015-12-28
2016-01-02
2015-11-27
2015-12-30
2016-01-11
2015-12-22
2016-01-04
2016-01-15
5[1-9]
5[3-6]9[1-1904]
ILPAILILILILPAINOH
NYCOHPANYCMA
Cluster 1
Cluster 2
Challenge 3: Combine clusters?
Cluster 1 • Rare PFGE pattern combinations
• Cases in IL (5), IN, OH, PA (2)
Cluster 2• PFGE pattern combinations new to the
database
• Cases in ME, MA, NYC (2), OH, PA (2)
• OH patients receive meals from the same meal delivery service
• PA patients shop at the same grocery store location
Challenge 4. Whole Genome Sequencing…AgainwgMLST (<All Characters>)
100
95908580757065605550454035
Key
IL___150296
PA___M15016774-1
IL___150356
IL___150294
IL___150306
OH___2015008862
PA___M16000362-1
IL___150334
IL___150681
IN___16REF0130
IL___150471
IL___150910
LAC__M27535
IL___151055
NYC__nyc16-200579813
LAC__M27654
NJ___161816
IL___151046
CA___M16X06023
MD___MDA16101368
CAOC_SB162000168
MD___MDA16002925
MD___MDA16076533
IL___150856
MA___16EN1147
CA___M16X04657
NYC__nyc16-200491016
NYC__nyc16-200488253
MA___16EN1283
MA___16EN1279
MA___16EN1281
CA___M16X01836
IL___150505
NYC__nyc16-200479727
NYC__nyc16-200477720
OH___2016000554
PA___M16001102-1
PA___M16000010-1
MA___16EN0475
MA___16EN0480
PA___M16002259-1
Modified date
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cdc_id
2015L-6874
2015L-6908
2015L-6944
2015L-6873
2015L-6897
2015L-6883
2016L-6034
2015L-6933
2016L-6164
2016L-6036
2016L-6087
2016L-6426
2016L-6431
2016L-6622
2016L-6541
2016L-6430
2016L-6558
2016L-6613
2016L-6669
2016L-6650
2016L-6547
2016L-6408
2016L-6077
2016L-6632
2016L-6088
2016L-6072
2016L-6201
2016L-6101
2016L-6033
2016L-6018
2016L-6040
2016L-6059
2015L-6949
2016L-6037
2016L-6048
2016L-6079
WGS_id
PNUSAL001931
PNUSAL001961
PNUSAL002003
PNUSAL001930
PNUSAL001957
PNUSAL001943
PNUSAL002019
PNUSAL001979
PNUSAL002171
PNUSAL002029
PNUSAL002071
PNUSAL002442
PNUSAL002453
PNUSAL002685
PNUSAL002585
PNUSAL002452
PNUSAL002597
PNUSAL002660
PNUSAL002648
PNUSAL002494
PNUSAL002503
CFSAN058711
PNUSAL002317
PNUSAL002422
PNUSAL002059
PNUSAL002482
PNUSAL002072
PNUSAL000650
FDA00009952
FDA00009950
FDA00009951
PNUSAL002176
PNUSAL002091
PNUSAL002028
PNUSAL002014
PNUSAL002036
PNUSAL000863
PNUSAL002007
PNUSAL002033
PNUSAL002043
PNUSAL002061
PFGE-AscI-pattern
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0016
GX6A16.0016
GX6A16.0002
GX6A16.0002
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
PFGE-ApaI-pattern
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1085
GX6A12.1085
GX6A12.1085
GX6A12.1085
GX6A12.1085
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.0112
GX6A12.1600
GX6A12.0851
GX6A12.0851
Outbreak
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
Serotype
4b
4b
4b
4b
4b
4b
4b
4b
4b
4b
4b
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
4 incomplete
not typed
not typed
1/2b
not typed
1/2b
not typed
not typed
not typed
not typed
1/2b
1/2b
1/2b
1/2b
1/2b
1/2b
4b
1/2b
1/2b
1/2b
IsolatDate
2015-11-24
2015-12-03
2015-12-29
2015-11-25
2015-12-02
2015-11-27
2015-12-28
2015-12-19
2016-04-17
2016-01-02
2016-02-03
2016-08-15
2016-08-10
2016-11-03
2016-07-06
2016-08-11
2016-09-28
2016-10-30
2016-10-15
2016-09-04
2016-07-18
2016-07-05
2016-07-17
2016-02-09
2016-08-10
2016-02-13
2016-02-05
2016-02-19
2016-02-19
2016-02-19
2016-04-10
2016-02-16
2016-01-04
2015-12-30
2016-01-11
2016-01-21
2015-12-22
2016-01-15
2016-01-19
2016-02-09
ReceivedDate
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PulseNet_UploadDate
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SourceType
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SourceSite
Blood
Blood
Blood
Blood
Blood
Blood
Blood
Blood
Ascites Fluid
Blood
Referred Culture
Blood
Liver abscess drainage
Blood
Blood
Blood
Blood
Blood
Blood
BLOOD
Blood
Blood
Blood
Blood
Blood
Blood
Environmental Swab
Environmental Swab
Environmental Swab
Blood
CSF
Blood
CSF
Blood
Blood
Blood
Other
Blood
Blood
10[2-18]
6[1-10]
3[0-6]
16[0-34]
>1900
Strain 1
Strain 2
Strain 3
Challenge 5: Changing Demographics
New states included in the investigation • California (strains 2 and 3)
• Maryland (strain 2)
• New Jersey (strain 2)
Cases that weren’t Eastern European• Vietnamese (n=2, both strain 2)
• Hispanic (n=1, strain 1)
wgMLST (<All Characters>)
100
95
90
85
80
75
70
65
60
55
50
45
40
35 Key
IL___150296
PA___M15016774-1
IL___150356
IL___150294
IL___150306
OH___2015008862
PA___M16000362-1
IL___150334
IL___150681
IN___16REF0130
IL___150471
IL___150910
LAC__M27535
IL___151055
NYC__nyc16-200579813
LAC__M27654
NJ___161816
IL___151046
CA___M16X06023
MD___MDA16101368
CAOC_SB162000168
MD___MDA16002925
MD___MDA16076533
IL___150856
MA___16EN1147
CA___M16X04657
NYC__nyc16-200491016
NYC__nyc16-200488253
MA___16EN1283
MA___16EN1279
MA___16EN1281
CA___M16X01836
IL___150505
NYC__nyc16-200479727
NYC__nyc16-200477720
OH___2016000554
PA___M16001102-1
PA___M16000010-1
MA___16EN0475
MA___16EN0480
PA___M16002259-1
Modified date
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cdc_id
2015L-6874
2015L-6908
2015L-6944
2015L-6873
2015L-6897
2015L-6883
2016L-6034
2015L-6933
2016L-6164
2016L-6036
2016L-6087
2016L-6426
2016L-6431
2016L-6622
2016L-6541
2016L-6430
2016L-6558
2016L-6613
2016L-6669
2016L-6650
2016L-6547
2016L-6408
2016L-6077
2016L-6632
2016L-6088
2016L-6072
2016L-6201
2016L-6101
2016L-6033
2016L-6018
2016L-6040
2016L-6059
2015L-6949
2016L-6037
2016L-6048
2016L-6079
WGS_id
PNUSAL001931
PNUSAL001961
PNUSAL002003
PNUSAL001930
PNUSAL001957
PNUSAL001943
PNUSAL002019
PNUSAL001979
PNUSAL002171
PNUSAL002029
PNUSAL002071
PNUSAL002442
PNUSAL002453
PNUSAL002685
PNUSAL002585
PNUSAL002452
PNUSAL002597
PNUSAL002660
PNUSAL002648
PNUSAL002494
PNUSAL002503
CFSAN058711
PNUSAL002317
PNUSAL002422
PNUSAL002059
PNUSAL002482
PNUSAL002072
PNUSAL000650
FDA00009952
FDA00009950
FDA00009951
PNUSAL002176
PNUSAL002091
PNUSAL002028
PNUSAL002014
PNUSAL002036
PNUSAL000863
PNUSAL002007
PNUSAL002033
PNUSAL002043
PNUSAL002061
PFGE-AscI-pattern
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0002
GX6A16.0016
GX6A16.0016
GX6A16.0002
GX6A16.0002
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0016
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
GX6A16.0259
PFGE-ApaI-pattern
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1644
GX6A12.1085
GX6A12.1085
GX6A12.1085
GX6A12.1085
GX6A12.1085
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.1600
GX6A12.0112
GX6A12.1600
GX6A12.0851
GX6A12.0851
Outbreak
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
1512ILGX6-1
Serotype
4b
4b
4b
4b
4b
4b
4b
4b
4b
4b
4b
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
not typed
4 incomplete
not typed
not typed
1/2b
not typed
1/2b
not typed
not typed
not typed
not typed
1/2b
1/2b
1/2b
1/2b
1/2b
1/2b
4b
1/2b
1/2b
1/2b
IsolatDate
2015-11-24
2015-12-03
2015-12-29
2015-11-25
2015-12-02
2015-11-27
2015-12-28
2015-12-19
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2016-02-09
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SourceSite
Blood
Blood
Blood
Blood
Blood
Blood
Blood
Blood
Ascites Fluid
Blood
Referred Culture
Blood
Liver abscess drainage
Blood
Blood
Blood
Blood
Blood
Blood
BLOOD
Blood
Blood
Blood
Blood
Blood
Blood
Environmental Swab
Environmental Swab
Environmental Swab
Blood
CSF
Blood
CSF
Blood
Blood
Blood
Other
Blood
Blood
10[2-18]
6[1-10]
3[0-6]
16[0-34]
>1900
Strain 1
Strain 2
Strain 3
Challenge 5 : Burnout
Investigation length leads to burnout• Cluster closed in July, 2016 and reopened in September, 2017
• Hard to maintain engagement when efforts seem fruitless
Rollercoaster of events • Environmental and food sampling at stores and food producers of interest yielded
Listeria monocytogenes
• Isolates did not match cases or were from store environments subject to cross-contamination
Successes
States were able to share experiences and lessons learned with each other throughout each stage of the investigation
Development of a more comprehensive supplemental questionnaire for Eastern European foods that can be used in future investigations
Emphasized the importance of home visits with patients and retail inspections where product was purchased
Acknowledgements
California Department of Public Health
Illinois Department of Public Health
Indiana State Department of Health
Maine Center for Disease Control and Prevention
Massachusetts Department of Public Health
Maryland Department of Health & Mental Hygiene
New Jersey Department of Health NYC Department of Health and Mental
Hygiene New York State Department of Health
Ohio Department of Health Pennsylvania Department of Health Philadelphia Department of Public
Health
CDCKatherine Marshall
Steven Stroika
Zuzana Kucerova
Alexandr Surin
Katie Roache
Laura Gieraltowski
Matt Wise
FDA
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Thank you!
For more details on the investigation please stop by the poster session this evening!
An Unsolved Listeriosis Cluster Among Patients of Eastern European Background, 2015-2016
The Hunt for the Red Herring
Vasudha Reddy, HaeNa Waechter, Michelle Boyle, Emily Harvey, Yvette Khachadourian, Amanda Conrad
Listeriosis surveillance
• Health departments have timely and complete surveillance
• Rapid and complete hypothesis generating interviews• Complete questionnaires forwarded to CDC
• Follow-up to ensure that isolates are forwarded to PHLs
• Rapid PFGE and WGS is performed at PHLs or CDC
• Outbreak investigations are challenging• Difficult to obtain food histories simply over the phone (long incubation
period and patients are very ill)• Alternate approaches to collect data are often necessary
Hypothesis Generation
• Cases are interviewed with standard form that mostly covers previously implicated foods
• Ethnic link among the cases identified early on• Ethnic groups live in the same area and there are many stores that target
products from those groups
• People travel to these neighborhoods to shop for ethnic foods
• Developed an Eastern European supplemental form with the help of knowledgeable staff
• Arranged to do home visits
Field Visits
•Home visits • Re-interviewed patients if possible• Took photos of remaining ready-to-eat food in the home• Collected food for testing
•Retail establishment visits
Maryland• Local outbreak identified 9/9/2016
• Onset 7/1/2016-8/28/2016
• 3 cases from same county with matching PFGE and highly related WGS
• All Eastern European
• Home visit• Collected frozen food for testing (samples were positive for Lm
outbreak strain)
• Prompted testing at place of purchase
• Shopping excursion with 1 of the cases• 2 state and 1 local health epidemiologist
• Purchased products likely consumed before onset
• Photographed as many products as possible
• retail samples positive for Listeria species, not monocytogenes
Massachusetts
• Local cluster identified 2/1/2016• 2 MA cases and 1 ME case shopped at same Eastern
European Market in MA
• Obtained detailed food histories with the help of the hospital IP as an interpreter
• Shopping dates and last 4 digits of credit card• Establishment identified specific items purchased
• Market visits• Positive food and environmental samples
• Required the establishment to cease all food operations and hire a professional cleaning company
Store D
New York City
• Local cluster identified 1/19/2016• 4 cases with onset 12/24/2015-2/12/2016
• Visited homes with Russian speaking environmental health colleagues• Food samples obtained from patient’s home
• Obtained shopper card numbers that were available
• Requested shopper card records from Store E• Management refused to provide records
• NYC DOHMH general counsel served subpoena to market and records were released
Store E
Pennsylvania
• 6 cases with onset date 11/20/2015 to 2/8/2016• Interviewed with focused questionnaire
• Obtained receipts directly from patients or stores
• Inspected two Eastern European markets in Philadelphia that cases identified • Obtained shopper card records
• Collected food samples and environmental swabs
Food Items of Interest
* Includes but not limited to store prepared salads (e.g., Olivier, potato, cabbage, cucumber, artichoke, or eggplant), kholodets, and pelmeni.
† Denominator data unavailable because cases may not have been specifically asked or details were provided by questionnaires and shopper card records.
Food Item Cases, N (%)
Smoked fish 11/30 (37)
Herring 12/18 (67)
Ready-to-eat food prepared in store* 17/30 (57)
Cheese 30/34 (88)
Farmer’s, tvorog, or cottage cheese 19†
Deli-sliced cheese 6†
Deli meat 28/31 (90)
Tongue or organ meat 6†
Deli-sliced meat 10†
Challenges
• Long incubation period
• Obtaining accurate product and information and descriptions
• Cooperation of case patients
• Language (communication and labeling of products)
• Definitive source not identified• Possible cross contamination of ready-to-eat foods
Successes
• Strong communication and coordination across local, state, and federal colleagues
• Ability to collect good information through field visits to help guide food and environmental sampling and testing
• Responding immediately to any single case or cluster identified among Eastern Europeans regardless of subtyping• 3 new cases in NYC reported in October 2017
Conclusion
• Illustrates the importance of working closely with lab, epi, and environmental health colleagues at local, state, and federal level
•Visiting homes and obtaining purchase records as soon as possible is important
•Necessary to provide more education to food retail and processing firms to prevent Lm contamination is necessary
Thank you to all Epidemiology, Laboratory, and Environmental Health colleagues who worked on these investigations
• California Department of Health
• Illinois Department of Health
• Indiana Department of Health
• Maine Department of Health
• Massachusetts Department of Health
• Maryland Department of Health & Mental Hygiene
• New Jersey Department of Health
• NYC Department of Health and Mental Hygiene
• New York State Department of Health
• Ohio Department of Health
• Pennsylvania Department of Health
• Philadelphia Department of Health
• CDC
• FDA
Thank you!
Please stop by our posters (P-069 and P-070)for more details on the investigation!
Environmental AssessmentsL. monocytogenes
Eastern European Foods
D’Ann L. Williams, DrPH – Maryland Department of HealthBrandi Hopkins, MPH – Massachusetts Department of Public Health
David Nicholas, MPH - New York State Department of Health
November, 2017
Outline• MA/MD/NY investigations
• Environmental investigation and samples collected
– Retail
– Leftover product sampling
– Swabbing
• Laboratory results
• Actions
• Challenges
• Opportunities
MD/MA/NY Investigations
• Eleven environmental assessments
• Two in Massachusetts
• 1 retail establishment
• 2 rounds of sampling
• Six in NY
• 5 retail firms
• 1 home
• Three in MD
• 2 retail locations
• 1 home location
– No specific food item in common
Retail Sampling
93 retail food samples collected
• MA – 51 samples collected
• NY – 12 samples, 3 firms
• MD – 30 samples, 2 firms
– Deli meats
– Store produced salads
– Cheeses, dairy, butter
– Canned fish
– Caviar
– Smoked and salted fish
Leftover Product Sampling
• 15 home food remnant samples
– 5 MD and 10 NY
– Deli meats, cheese
– L.M strain identified in only 1 sample (MD)
Environmental Swabbing98 environmental swabs collected
• MA – 68
• MD – 30
• Focus areas– Slicers
– Deli cases, refrigerators
– Condensation pan
– Cutting boards
– Handles and knobs
• 10 positive for L. spp
• 14 positive for LM
– 3 related to outbreak strain (MA)
Actions
• Facility inspection LHD/State
• Provided FDA/USDA Listeria guidance documents
• Require thorough cleaning of facility, equipment
• Discard defective, heavily soiled equipment
• Remove uncleanable, unapproved surfaces
• Reinspection
• Resampling before clearance for reopening
Orkopina.com
Challenges
• Time frame between consumption, onset, report, investigation
• Response
• Poor recall, food history
• Cooperation of case patients
• Cooperation of firms
• Language (communications and labeling)
• Product descriptions/imports
• Documentation for source and sales
• Listeria spp. vs Listeria monocytogenes
• Lab results
• Remediation and facility clearance
• Risk communication and education
Opportunities
• Investigation participation and knowledge and experience
• Identification of product and reservoir of outbreak strain
• Add to current knowledge about reservoirs and potential future sampling directions
• Sampling proficiency
• Risk Communication and Food Safety Education for food supply firms and regulators
• Networking with other agencies
Additional Comments
• Recurring clusters and outbreaks require quick response to and require a seamless collaboration between RRT, EPI and the Labs
• Difficult to connect clinical with environmental samples
• Lab research indicate that Listeria may be present in “communities”, what determines survival, reservoirs, product vulnerability, collection efficiency
• Laboratory enrichment can cause interference by non-pathogenic species preventing L. mono detection
• Laboratory results may be difficult to interpret, required regulatory actions are unclear
• Educate retail and processing firms on preventative measures given the increasing number of foodborne reservoirs
Questions/Comments
D’Ann L. Williams
410-767-2633
Brandi Hopkins
David C. Nicholas
Acknowledgements
• Maryland Department of Health
– Baltimore County Health Department
• Massachusetts Department of Public Health
– Newton Health Department
• New York City Department of Health and Mental Hygiene
• New York State Department of Health
• New York State Department of Agriculture and Markets
• CDC
• FDA
Outbreaks with unknown etiology –
all for nothing?
Brooke M. Whitney, PhDFDA Coordinated Outbreak Response & Evaluation Network
Response Team 1
November 8, 2017
40
CORE Response Timeline
January 15, 2016
•CORE Signals began evaluating
•7 cases in 4 states
January 21, 2016
•Transferred to CORE Response Team 1
•The initial signal was for deli products, specifically cheese and fish
•Cases were of Eastern European background
May 4, 2016
•CORE Response activities end
•Source remained unknown
•23 cases (22 hospitalized, 2 fetal losses, and 1 death) in 7 states
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015 2016
CORE Response
41
Response Activities
Multiple State Samples
•One state sample matched by PFGE and WGS to one outbreak strain
•Sample from a retail location
Three FDA firm investigations
•Listeria monocytogenes identified at two firms during response
•No PFGE or WGS link to clinical cases, but laboratory links to other firms identified
Three product recalls
•Occurred as a result of FDA investigations
•None definitively linked to the outbreak
Import Alert
•Additional firm added to an import alert
•Not definitively linked to the outbreak
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015 2016
CORE Response
42
FDA Visits
During response
• FDA visited firms linked to the outbreak through traceback evidence (4 firms)
After outbreak response ended
• FDA continued to visit firms that were identified by links to firms of interest
• Other firms according to previously planned assignments
The following firms mentioned are related by product type and geography to the outbreak, but the available evidence does not
support that they’re directly related to the outbreak.
43
Manufacturer G
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015 2016
CORE Response
October 2015 Warning Letter
• Related to seafood HACCP violations
• Issued prior to Response timeframe
December 2016 Recall
• Various RTE herring products
• Issued after Response timeframe
• Result of environmental sampling at the firm
• Listeria monocytogenes identified at firm
44
Manufacturer F
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015 2016
CORE Response
July 2016 Recall
• Recall of herring salads
• Due to FDA identifying Listeria monocytogenes at the firm
September 2016
• FDA suspended firm’s food facility registration
• “Widespread and persistent Listeriacontamination”
• FDA Form 483 publicly available
45
Manufacturer D
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015 2016
CORE Response
September 2016 Recall
• Smoked salmon recalled
• FDA identified Listeria monocytogenes at the firm
46
Distributor A
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015 2016
CORE Response
April 2016 Recall
• Product tested positive for Listeria monocytogenes
• Imported herring products
• Foreign firm added to Import Alert 16-39
November 2016 Recall
• Product tested positive for Listeria monocytogenes
• Imported fish products (not herring)
• Foreign firm added to Import Alert 16-39
47
Summary
• No definitive vehicle identified related to clinical clusters.
• Several firms of interest were identified for FDA follow-up.
• Multiple FDA actions were taken to protect public health;
including, but not limited to:
– Multiple firm investigations
– 7 recalls
– 2 firms added to Import Alert 16-39
– 1 Suspension of registration
48
Acknowledgements
• FDA Office of Regulatory Affairs (ORA)– Office of Food & Feed Operations
– Division of Import Operations
– Office of Regulatory Science
– Philadelphia District Office
– Detroit District Office
– Cincinnati District Office
– Chicago District Office
– New York District Office
– New England District Office
• FDA Center for Food Safety and Applied Nutrition (CFSAN)– Office of Compliance
– Office of Food Safety
– Office of Analytics and Outreach
– Office of Regulatory Science
– Office of Applied Research and Safety Assessment
• Centers for Disease Control and Prevention– Division of Foodborne, Waterborne, and
Environmental Diseases
• State and Local Partners– Pennsylvania Department of Agriculture
– New York Department of Agriculture and Markets
– New York State Department of Health
– New York City Department of Health and Mental Hygiene
– Massachusetts Department of Health
• FDA Coordinated Outbreak Response and Evaluation Network
