Surveillance for Foodborne-Disease Outbreaks - Centers for Disease ...

Morbidity and Mortality Weekly Report Surveillance Summaries

November 10, 2006 / Vol. 55 / No. SS-10

Surveillance for Foodborne-Disease Outbreaks — United States, 1998–2002

depar tment of health and human ser vices department services Centers for Disease Control and Prevention

MMWR CONTENTS The MMWR series of publications is published by the Coordinating Center for Health Information and Service, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Suggested Citation: Centers for Disease Control and Prevention.

Introduction ........................................................................ 2 Methods .............................................................................. 2 Results ................................................................................. 3

[Title]. Surveillance Summaries, [Date]. MMWR 2006;55(No. SS-#).

Discussion ........................................................................... 4

Centers for Disease Control and Prevention Julie L. Gerberding, MD, MPH Director Tanja Popovic, MD, PhD (Acting) Chief Science Officer James W. Stephens, PhD (Acting) Associate Director for Science Steven L. Solomon, MD Director, Coordinating Center for Health Information and Service Jay M. Bernhardt, PhD, MPH Director, National Center for Health Marketing Judith R. Aguilar (Acting) Director, Division of Health Information Dissemination (Proposed)

Acknowledgments ............................................................... 6

Editorial and Production Staff Eric E. Mast, MD, MPH (Acting) Editor, MMWR Series Suzanne M. Hewitt, MPA Managing Editor, MMWR Series Teresa F. Rutledge Lead Technical Writer-Editor David C. Johnson Project Editor Beverly J. Holland Lead Visual Information Specialist Lynda G. Cupell Malbea A. LaPete Visual Information Specialists Quang M. Doan, MBA Erica R. Shaver Information Technology Specialists Editorial Board William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN David W. Fleming, MD, Seattle, WA William E. Halperin, MD, DrPH, MPH, Newark, NJ Margaret A. Hamburg, MD, Washington, DC King K. Holmes, MD, PhD, Seattle, WA Deborah Holtzman, PhD, Atlanta, GA John K. Iglehart, Bethesda, MD Dennis G. Maki, MD, Madison, WI Sue Mallonee, MPH, Oklahoma City, OK Stanley A. Plotkin, MD, Doylestown, PA Patricia Quinlisk, MD, MPH, Des Moines, IA Patrick L. Remington, MD, MPH, Madison, WI Barbara K. Rimer, DrPH, Chapel Hill, NC John V. Rullan, MD, MPH, San Juan, PR Anne Schuchat, MD, Atlanta, GA Dixie E. Snider, MD, MPH, Atlanta, GA John W. Ward, MD, Atlanta, GA

References .......................................................................... 6 Appendix A. ...................................................................... 35 Appendix B. ....................................................................... 38

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Surveillance Summaries

Surveillance for Foodborne-Disease Outbreaks — United States, 1998–2002 Michael Lynch, MD John Painter, DVM Rachel Woodruff, MPH Christopher Braden, MD Division of Foodborne, Bacterial, and Mycotic Diseases National Center for Zoonotic, Vector-Borne, and Enteric Diseases (proposed)

Abstract Problem/Condition: Since 1973, CDC has maintained a collaborative surveillance program for collection and periodic reporting of data on the occurrence and causes of foodborne-disease outbreaks (FBDOs) in the United States. Reporting Period Covered: 1998–2002. Description of System: The Foodborne Disease Outbreak Surveillance System reviews data on FBDOs, defined as the occurrence of two or more cases of a similar illness resulting from the ingestion of a common food. State and local public health departments have primary responsibility for identifying and investigating FBDOs. State, local, and territorial health departments use a standard form to report these outbreaks to CDC. In 1998, CDC implemented enhanced surveillance for FBDOs by increasing communication with state, local, and territorial health departments and revising the outbreak report form. Since 2001, reports of FBDOs are submitted through a web application on the Internet called the electronic Foodborne Outbreak Reporting System (eFORS). Results: During 1998–2002, a total of 6,647 outbreaks of foodborne disease were reported (1,314 in 1998, 1,343 in 1999, 1,417 in 2000, 1,243 in 2001, and 1,330 in 2002). These outbreaks caused a reported 128,370 persons to become ill. Among 2,167 (33%) outbreaks for which the etiology was determined, bacterial pathogens caused the largest percentage of outbreaks (55%) and the largest percentage of cases (55%). Among bacterial pathogens, Salmonella serotype Enteritidis accounted for the largest number of outbreaks and outbreak-related cases; Listeria monocytogenes accounted for the majority of deaths of any pathogen. Viral pathogens, predominantly norovirus, caused 33% of outbreaks and 41% of cases; the proportion of outbreaks attributed to viral agents increased from 16% in 1998 to 42% in 2002. Chemical agents caused 10% of outbreaks and 2% of cases, and parasites caused 1% of outbreaks and 1% of cases. Interpretation: Following implementation of measures to enhance outbreak surveillance, the annual number of FBDOs reported to CDC increased during this period compared with previous years. Viral pathogens accounted for an increased proportion of outbreaks each year during this reporting period and a higher proportion of outbreaks of known etiology during this reporting period than preceding reporting periods, probably reflecting the increased availability of improved viral diagnostic tests. S. Enteritidis continued to be a major cause of illness and L. monocytogenes was a major cause of death. In addition, multistate outbreaks caused by contaminated produce and outbreaks caused by Escherichia coli O157:H7 remained prominent. Public Health Actions: Methods to detect FBDOs are improving, and several changes to improve the ease and timeliness of reporting FBDO data have been implemented (e.g., a revised form to simplify FBDO reporting by state health departments and improved electronic reporting methods). State and local health departments continue to investigate and report FBDOs as part of efforts to better understand and define the epidemiology of foodborne disease in the United States. At the regional and national levels, surveillance data provide an indication of the etiologic agents, vehicles of transmisCorresponding author: Michael Lynch, MD, Division of Foodborne, Bacterial, sion, and contributing factors associated with and Mycotic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (proposed), 1600 Clifton Road, NE, MS A-38, Atlanta, GA 30333. FBDOs and help direct public health actions to Telephone: 404-639-2206; Fax: 404-639-2205; E-mail: [email protected]. reduce illness and death caused by FBDOs.

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Introduction The reporting of foodborne and waterborne diseases in the United States began approximately 80 years ago when state and territorial health officers, concerned about the high morbidity and mortality caused by typhoid fever and infantile diarrhea, recommended that cases of “enteric fever” be investigated and reported. The purpose of investigating and reporting these cases was to obtain information about the role of food, milk, and water in outbreaks of intestinal illness as the basis for public health action. Beginning in 1925, the U.S. Public Health Service (PHS) published summaries of outbreaks of gastrointestinal illness attributed to milk (1). In 1938, PHS added summaries of outbreaks caused by all foods. These early surveillance efforts led to the enactment of important public health measures (e.g., the Pasteurized Milk Ordinance) that resulted in decreased incidence of enteric diseases, particularly those transmitted by milk and water (2). During 1951–1960, the National Office of Vital Statistics reviewed reports of outbreaks of foodborne illness and published annual summaries in Public Health Reports. In 1961, CDC assumed responsibility for publishing reports about foodborne illness. During 1961–1965, CDC stopped publishing annual reviews but reported pertinent statistics and detailed individual investigations in MMWR. The current system of surveillance for outbreaks of foodborne and waterborne diseases began in 1966, when reports of enteric disease outbreaks attributed to microbial or chemical contamination of food or water were incorporated into an annual summary. Since 1966, the quality of investigative reports has improved greatly, with more active participation by state and federal epidemiologists in outbreak investigations. Outbreaks of waterborne diseases and foodborne diseases have been reported in separate annual summaries since 1978 because of increased interest and activity in surveillance for waterborne diseases. Previous summaries of data reported to the Foodborne Disease Outbreak Surveillance System were published for 1983–1987 (3), 1988–1992 (4), and 1993–1997 (5). Outbreak surveillance has served three purposes: • Disease prevention and control. The investigation of foodborne disease outbreaks leads to prevention and control measures in the food industry. Public health officials identify critical control points in the path from farm to table that can be monitored to reduce contamination by foodborne pathogens. Changes at all levels of food production (e.g., farm, slaughterhouse, and production plant) have contributed to less contamination in the food supply. Summarizing these investigations illustrates the burden of the outbreaks and the efforts needed to control them.

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• Knowledge of disease causation. Outbreak investigations are a critical means of identifying new and emerging pathogens and maintaining awareness about ongoing problems. However, the pathogen is not identified in many outbreaks because of delayed or incomplete laboratory investigation, inadequate laboratory capacity, or inability to recognize a pathogen as a cause of foodborne disease. Prompt and thorough investigations of foodborne outbreaks aid in the timely identification of etiologic agents and lead to appropriate prevention and control measures. Summarizing the results provides an index of the relative importance and impact of specific pathogens. • Administrative guidance. By analyzing several years of data on foodborne disease outbreaks, public health authorities can monitor trends over time in the prevalence of outbreaks caused by specific etiologic agents, the food that is the vehicle for the agent, and common errors in food handling. This information provides the basis for regulatory and other changes to improve food safety. Analysis of specific subsets of outbreaks can illustrate the challenges associated with specific pathogens, food vehicles, and settings and has helped define linkages between specific pathogens and foods. This report summarizes epidemiologic data on FBDOs reported to CDC during 1998–2002.

Methods Sources of Data for the Foodborne Disease Outbreak Surveillance System Agencies use a standard form (CDC form 52.13, Investigation of a Foodborne Outbreak) to report FBDOs to CDC. In 1998, CDC increased communication with state, local, and territorial health departments to enhance surveillance for FBDOs, including formal confirmation procedures to finalize reports from each state each year. This led to a substantial increase in the number of reports, resulting in a surveillance discontinuity during 1997–1998. A revised form became effective in 1999. The revised form expanded the range of food items, places, and contributing factors that could be reported. In 2001, state, local, and territorial health departments began submitting reports through a web-based version of this form. This web-based outbreak surveillance system is called the Electronic Foodborne Outbreak Reporting System (eFORS). This report summarizes data collected with both the paper and web-based forms (Appendix A). The majority of reports are submitted by state, local, and territorial health departments; however, they also can be submitted by federal agencies and

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other sources. Reporting officials use published criteria to determine whether a specific etiologic agent has been confirmed for an outbreak (Appendix B) and submit reasons that reported food vehicles were implicated. Implicated food vehicles for all reasons are included in this report.

Definition of Terms An FBDO is defined as the occurrence of two or more cases of a similar illness resulting from the ingestion of a food in common. Laboratory or clinical guidelines for confirming an etiology of a FBDO outbreak vary for bacterial, chemical, parasitic, and viral agents (Appendix B). An outbreak in which more than one etiologic agent was confirmed is categorized as attributable to multiple etiologies. Food vehicles identified in outbreak investigations that can be classified into a single commodity are classified into one of 12 major food commodity categories. Some reported food vehicles cannot be categorized in a single commodity category and are listed as unclassifiable. Outbreaks in which more than one implicated food is reported or the implicated food contains ingredients from multiple commodities are classified as attributable to complex food vehicles.

Exclusions from and Limitations of the Surveillance System The findings in this report are subject to at least four limitations. First, several types of outbreaks are excluded from the Foodborne Disease Outbreak Surveillance System, such as outbreaks that occur on cruise ships (these are summarized and published periodically in scientific publications) (6); outbreaks in which the food was eaten outside the United States, even if the illness occurred within the United States; and outbreaks that are traced to water intended for drinking (these are reported to the Waterborne Disease Outbreak Reporting System). In addition, FBDOs are excluded from the surveillance system if the route of transmission from the contaminated food to the infected persons is indirect. For example, in 1988, chitterlings (pig intestines) were the ultimate source of a cluster of Yersinia enterocolitica infections among several infants; however, this outbreak was not included because the infants did not eat the chitterlings (7). Similarly, outbreaks that occur as result of direct contact with animals are excluded. Second, for many reports, information on certain aspects of the outbreak, such as the etiology, the implicated food vehicle, or the factors that might have contributed to the outbreak, is missing or incomplete. The category of “unknown etiology” is broad. Outbreaks with some etiologic information might not meet guidelines for confirmation and are pre-

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sented in this report as “unknown etiology.” Clinical and descriptive epidemiologic information that suggests etiologic categories for outbreaks of unknown etiology have not been used in this report (8). Third, food vehicles are reported by investigating agencies as individual food items in varying levels of details (e.g., milk, 2% milk, pasteurized 2% milk). A particular reported food item with multiple ingredients could be classified under several food commodity categories; however, in this surveillance summary, the reported food item for each outbreak is classified under only one food commodity category. Food items that cannot be classified under one food commodity category are counted as unclassifiable. As a result, the reported number of outbreaks attributed to one food vehicle category might not include all outbreaks attributable to a particular food ingredient in that food. Finally, no standard criteria exist for classifying a death as being FBDO-related. This determination is made by the reporting agency.

How Data Are Presented In this report, 1998–2002 data on foodborne-disease outbreaks are presented as follows: • Reported outbreak reports, by years, 1993–2002 (Figure 1). • Outbreaks, by state, for each of the 5 years (Figures 2–6). • Outbreaks, cases, and deaths, by etiology, for the 5-year period combined (Table 1). • Outbreaks, cases, and deaths, by etiology, for each of the 5 years (Tables 2–6). • Outbreaks, by etiology and month of occurrence, for the 5-year period combined (Table 7). • Outbreaks, by etiology and place where food was eaten, for the 5-year period combined (Table 8). • Outbreaks, cases, and deaths, by vehicle of transmission, for each of the 5 years (Tables 9–13). • Outbreaks, by etiology and vehicle of transmission, for each of the 5 years (Tables 14–18). • Outbreaks, by etiology and contributing factors, for the 5-year period combined (Table 19).

Results During 1998–2002, the annual number of reported outbreaks ranged from 1,243 to 1,417 (Tables 2–6). The average annual number of outbreaks reported during this period (1,329) was substantially greater than the average annual number of outbreaks reported during 1993–1997 (550) (Figure 1). The average number of cases per outbreak during 1998–

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2002 (19) was lower than the average number of cases per outbreak during 1993–1997 (31). During 1998–2002, a total of 2,167 (33%) of the 6,647 outbreaks reported to CDC had a known etiology; these outbreaks accounted for 68,981 (54%) of 128,370 illnesses (Table 1). Of the 2,167 outbreaks with a known etiology, 55% (55% of illnesses) were caused by bacterial pathogens, 33% (41% of illnesses) by viruses, 10% (2% of illnesses) by chemical agents, and 1% (1% of illnesses) by parasites. The proportion of outbreaks with known etiology attributable to viruses increased from 16% in 1998 to 42% in 2002. In the majority (67%) of outbreaks, the etiology was not determined. However, the proportion of outbreaks for which an etiology was determined increased during the reporting period, from 28% in 1998 to 37% in 2002. Local investigators might report factors they believe contributed to the outbreak. These factors are grouped into those that investigators believed led to contamination of the food, those that allowed proliferation of the pathogen in the food, and those that contributed to survival of the pathogen in the food. During 1998–2002, at least one contributing factor was reported in 3,072 (46%) outbreaks. The most commonly reported contamination factor that contributed to FBDOs was “bare-handed contact by handler/worker/preparer” (Table 19). For outbreaks caused by bacterial pathogens “raw product/ ingredient contaminated by pathogens from animal or environment” was the most commonly reported contamination factor. The most commonly reported proliferation factor was “allowing foods to remain at room or warm outdoor temperature for several hours”; the most common survivability factor was “insufficient time and/or temperature during initial cooking/heat processing.” In the majority of foodborne outbreaks during this period, food was eaten outside the home (Table 8). Restaurants were the most commonly reported place where food was eaten. Many outbreaks caused by Salmonella or norovirus occurred at a school or nursing home. In outbreaks caused by ciguatoxin and L. monocytogenes, food was more commonly reported to have been eaten at a private home. During this period, notable outbreaks were reported that were caused by ground beef contaminated with E. coli O157:H7 (9) and fresh produce contaminated with Salmonella, E. coli O157:H7, Cyclospora cayetanensis, or hepatitis A (Tables 14–18). Multidrug-resistant strains of Salmonella caused outbreaks linked to unpasteurized milk and ground beef. A large multistate outbreak of listeriosis caused by contaminated deli meat led to one of the largest food recalls in the United States (10). Scombrotoxin (fish-derived histaminic agent) caused the majority of outbreaks attributable to a chemical etiology. The majority of these outbreaks was associated with tuna, although several were associated with

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nonscombroidae fish, including 10 outbreaks associated with escolar. Unexpected vehicles of transmission (e.g., dry cereal [11], parsley [12], and mangoes [13]) also were reported. During 1998–2002, norovirus caused 657 (30%) of the 2,167 FBDOs with a known etiology and 39% of all outbreakrelated cases in these outbreaks. S. Enteritidis, the most frequently reported bacterial cause of FBDOs, caused 204 outbreaks, accounting for 9% of outbreaks for which an etiology was determined. Eggs caused more S. Enteritidis outbreaks than any other food vehicle. L. monocytogenes resulted in 38 outbreak-related deaths among 256 cases, more deaths, and a higher case-fatality rate (15%) than any other pathogen.

Discussion Foodborne-Disease Outbreaks, 1998–2002 The annual number of FBDOs reported to CDC increased during this period compared with previous years, following implementation of measures to enhance outbreak surveillance (3–5). Certain observations suggest that the increase in outbreak reports probably represents the effect of enhanced surveillance rather than a true increase in the occurrence of FBDOs. First, after a marked increase during 1997–1998 with implementation of enhanced surveillance, the number of reported outbreaks remained within a relatively narrow range. Second, the number of cases of foodborne infections identified through routine surveillance, of which outbreak cases are a part, decreased or remained stable during this period (14). Finally, the average size of reported outbreaks during 1998– 2002 was smaller than the average size of outbreaks during 1993–1997, indicating that a substantial portion of the increase in reported outbreaks might be caused by smaller outbreaks that were not reported in previous years. Because of this increased reporting, comparisons of the number of reported FBDOs attributable to a specific etiology or vehicle of transmission between this period and previous reporting periods are difficult to make. Comparisons of the proportion of FBDOs related to specific causes are less likely to be influenced by the effect of enhanced surveillance but should be made with caution. As in previous years, bacterial pathogens caused the majority of outbreaks and infections among outbreaks with a known etiology (3–5). Viral pathogens accounted for a much greater proportion of outbreaks and infections than in previous years, probably because of the increased availability of methods to diagnose viral agents. Although 67% of reported FBDOs during 1998–2002 were of unknown etiology, the propor-

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tion of outbreaks of unknown etiology decreased during 1998– 2002. Much of this decrease is attributed to increased norovirus diagnostic capacity in state health department laboratories (15) and improved strategies to obtain diagnostic specimens (16). With continued improvements in epidemiologic and laboratory investigations, the proportion of outbreaks of unknown etiology might decrease further. Of FBDOs with a known etiology, multistate outbreaks caused by contaminated produce and outbreaks caused by E. coli O157:H7 remained prominent. Investigation of several multistate outbreaks attributed to L. monocytogenes, detected by linking information from molecular subtyping of isolates from several states, led to recalls of implicated products (10,17,18). Although S. Enteritidis continued to be a major cause of illness and death, it caused a much smaller proportion of outbreaks for which an etiology was known than in the past. The decrease in outbreaks attributed to S. Enteritidis parallels the decrease in S. Enteritidis infections reported to the National Salmonella Surveillance System and might reflect the role of Egg Quality Assurance Programs and other public health interventions in reducing the incidence of S. Enteritidis infection (19). Persons can decrease their risk for egg-associated infections caused by S. Enteritidis by not eating raw or undercooked eggs. Nursing homes, hospitals, and commercial kitchens should use pasteurized egg products for all recipes requiring pooled or lightly cooked eggs (20).

Interpretation of Data from the Foodborne Disease Outbreak Surveillance System Foodborne diseases cause an estimated 76 million illnesses and 5,000 deaths in the United States each year (21). Although foodborne diseases are common, only a fraction of these illnesses are routinely reported to CDC because a complex chain of events must occur before a foodborne infection is reported; a break at any point in the chain will result in a case not being reported. In addition, the majority of reported foodborne illnesses are sporadic; only a small number are identified as being part of an outbreak and reported through the Foodborne Disease Outbreak Surveillance System. For example, Salmonella infection causes an estimated 1.4 million foodborne illnesses annually (22). However, during 1998–2002, a total of 164,044 Salmonella infections (approximately 32,000 annually) were reported through the National Salmonella Surveillance System (23–27), which is a passive, public health laboratory-based system. During the same period, 585 recognized outbreaks of Salmonella infection resulting in 16,821 illnesses were reported through the Foodborne Disease Outbreak Surveillance System, not all of which were necessarily

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culture-confirmed. Therefore, the system represents only a fraction of the burden of foodborne disease. The number of outbreaks summarized in this report represents a small proportion of the outbreaks that actually occurred during the surveillance period. Some outbreaks are never recognized, and those that are recognized frequently go unreported. The likelihood that public health authorities are alerted about an outbreak depends on many factors, including its size and the severity of illnesses; consumer and physician awareness, interest, and motivation to report the incident; and the resources and disease surveillance activities of state and local public health and environmental agencies. Outbreaks that are most likely to be brought to the attention of public health authorities include those that are large, interstate, or restaurant-associated or that can cause serious illness, hospitalization, or death. The degree of underreporting might vary by etiology; therefore, this report provides limited information about the absolute or relative incidence of foodbornedisease outbreaks related to specific causes. For example, foodborne diseases characterized by short incubation periods (e.g., those caused by a chemical agent or staphylococcal enterotoxin) are more likely to be recognized as common source FBDOs than are diseases with longer incubation periods (e.g., hepatitis A). Outbreaks involving less commonly identified pathogens (e.g., Bacillus cereus, enterotoxigenic E. coli, or Giardia intestinalis) are less likely to have a confirmed etiology because these organisms are not always considered in clinical, epidemiologic, and laboratory investigations of FBDOs. The objective of this report is to present simple analyses of the data on outbreaks of foodborne disease reported during 1998–2002. These data will continue to be analyzed in detail, along with other relevant data, to answer specific questions of public health importance, and findings will be published in the scientific literature. Specifically, a more detailed analysis of outbreak data to estimate the attribution of illness to specific food commodities would take into account the burden of illness attributed to specific etiologies and the attributable portion of those illnesses caused by particular food commodities. The simple frequencies of outbreaks caused by certain food commodities presented here do not, by themselves, provide a good measure of the burden of illness associated with one food commodity compared with another.

Future Directions Methods to detect FBDOs continue to improve. For example, two tools that have enhanced detection of FBDOs are the Statistical Outbreak Detection Algorithm (SODA) and the National Molecular Subtyping Network for Foodborne Disease Surveillance (PulseNet). SODA applies a statistical

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algorithm to data reported through CDC’s National Salmonella, Shigella, and E. coli Surveillance Systems to identify substantial increases over a historical baseline for any given serotype (28). This technology can be used to help identify clusters or outbreaks. PulseNet is a national network of public health laboratories that perform pulsed-field gel electrophoresis (PFGE) analysis on bacteria that might be foodborne (29). PulseNet was initiated in four states in 1996 and reached full participation of all 50 states and several large cities by 2001. This network permits rapid comparison of PFGE patterns through an electronic database at CDC; closely related PFGE patterns suggest a common source. PulseNet has helped in the detection and investigation of outbreaks, particularly those that involve multiple states. An assessment of the impact of introducing PulseNet PFGE subtyping in one state indicated that it increased the number of detected outbreaks of E. coli O157:H7 by 40% (30). Several changes have improved the ease and timeliness of reporting. In October 1999, CDC issued a revised FBDO reporting form to simplify reporting by state health departments. In addition, eFORS was implemented in 2001 to help improve the timeliness of foodborne disease outbreak reporting. Upcoming versions of eFORS will include an automated search algorithm for more ready access to foodborne outbreak surveillance data. An annual listing of foodborne disease outbreaks reported to CDC is available at http://www.cdc.gov/ foodborneoutbreaks/outbreak_data.htm. The investigation and reporting of FBDOs by state and local health departments are important steps in efforts to better understand and define the epidemiology of foodborne disease in the United States. At the regional and national levels, surveillance data provide an indication of the etiologic agents, vehicles of transmission, and contributing factors associated with FBDOs and help direct public health actions. Acknowledgments

The authors would like to thank all State and Territorial Epidemiologists and, in particular, members of the Foodborne Disease Outbreak reporting network, who contributed reports of foodborne outbreak investigations included in this summary. References 1. Public Health Service. Annual report of the Surgeon General on the Public Health Service of the United States for the fiscal year 1924– 1925. Washington, DC: Government Printing Office; 1925:34–5. 2. Potter ME, Kaufmann AF, Blake PA, Feldman RA. Unpasteurized milk: the hazards of a health fetish. JAMA 1984;252:2048–52. 3. CDC. Foodborne-disease outbreaks, 5-year summary, 1983–1987. In: Surveillance Summaries,. MMWR 1990;39(No. SS-1). 4. CDC. Surveillance for foodborne-disease outbreaks—United States, 1988–1992. In: Surveillance Summaries, MMWR 1996;45(No. SS-5).

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5. CDC. Surveillance for foodborne-disease outbreaks—United States, 1993–1997. In: Surveillance Summaries, MMWR 2000;49(No. SS-1). 6. Koo D, Maloney K, Tauxe R. Epidemiology of diarrheal disease outbreaks on cruise ships, 1986 through 1993. JAMA 1996;275:545–7. 7. Lee LA, Taylor J, Carter GP, et al. Yersinia enterocolitica O:3: an emerging cause of pediatric gastroenteritis in the United States. J Infect Dis 1991;163:660–3. 8. Hall J, Goulding J, Bean N, et al. Epidemiologic profiling: evaluating foodborne outbreaks for which no pathogen was isolated by routine laboratory testing: United States, 1982–9. Epi and Infect 2001;127:381–7. 9. CDC. Multistate outbreak of Escherichia coli O157:H7 infections associated with eating ground beef—United States, June–July, 2002. MMWR 2002;51:637–9. 10. CDC. Outbreak of listeriosis—Northeastern United States, 2002. MMWR 2002;51:950–1. 11. CDC. Multistate outbreak of Salmonella Serotype Agona infections linked to toasted oats cereal—United States, April–May 1998. MMWR 1998;47:462–4. 12. CDC. Outbreaks of Shigella sonnei infection associated with eating fresh parsley—United States and Canada, July–August, 1998. MMWR 1999;48:285–9. 13. Sivapalasingham S, Barret E, Kimura A, et al. A multistate outbreak of Salmonella enterica Serotype Newport infection linked to mango consumption: impact of water-dip disinfestation technology. Clin Infect Dis 2003;37:1585–90. 14. CDC. Summary of notifiable diseases, United States, 2002. MMWR 2002;51:1–84. 15. Widdowson M, Sulka A, Bulens S, et al. Norovirus and foodborne disease, United States, 1991–2000. Emerg Infect Dis 2005;11:95–102. 16. Jones T, Bulens S, Gettner S, et al. Use of stool collection kits delivered to patients can improve confirmation of etiology in foodborne disease outbreaks. Clin Infect Dis 2004;39:1454–9. 17. CDC. Multistate outbreak of listeriosis—United States, 1998. MMWR 1998; 47:1085–6. 18. CDC. Multistate outbreak of listeriosis, United States, 2000. MMWR 2000;49:1129–30. 19. Mumma G, Griffin P, Meltzer M, Braden C, Tauxe RV. Egg quality assurance programs and egg-associated Salmonella Enteritidis infections, United States. Emerg Infect Dis 2004;10:279–82. 20. Levine WC, Smart JF, Archer DL, Bean NH, Tauxe RV. Foodborne disease outbreaks in nursing homes, 1975 through 1987. JAMA 1991;266:2105–9. 21. Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis 1999;5:607–25. 22. Voetsch AC, Van Gilder TJ, AnguloFJ, et al. FoodNet estimate of the burden of illness caused by nontyphoidal Salmonella infections in the United States. Clin Infect Dis 2004;38:127–34. 23. CDC. Salmonella surveillance: annual tabulation summary, 1998. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 1994. 24. CDC. Salmonella surveillance: annual tabulation summary, 1999. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 1995. 25. CDC. Salmonella surveillance: annual tabulation summary, 2000. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 1996.

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26. CDC. Salmonella surveillance: annual tabulation summary, 2001. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 1997. 27. CDC. Salmonella surveillance: annual tabulation summary, 2002. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 1998. 28. Hutwagner LC, Maloney EK, Bean NH, Slutsker L, Martin SM. Using laboratory-based surveillance data for prevention: an algorithm for detecting Salmonella outbreaks. Emerg Infect Dis 1997;3:395–400.

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29. Swaminathan B, Barrett TJ, Hunter SB, Tauxe RV. PulseNet: the molecular subtyping network for foodborne disease surveillance—United States. Emerg Infect Dis 2001;7:382–9. 30. Bender J, Hedberg C, Besser J, et al. Surveillance for Escherichia coli O157:H7 infections in Minnesota by molecular subtyping. N Engl J Med 1997;337:388–94.

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FIGURE 1. Number of reported foodborne-disease outbreaks, 1993–2002 1,600

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1,200

Number

FIGURE 2. Number of reported foodborne-disease outbreaks, by state — United States,* 1998

Enhanced surveillance

Paper forms Web-based (eFORS*)

1,400

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* Electronic Foodborne Outbreak Reporting System.

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0 0 0

39

5

1

3 2 208 3

50

60

7

24 91

13

20 1

1

1

8

GU PR VI

13 0 0


6

15

32 4

6 3

7 1 11 63 16 3 10 0 3

13

1

3 12

CT DE DC MD MA NH NJ RI VT

47

14

53

29

13 224 46



6


Vol. 55 / SS-10


9

TABLE 1. Number of reported foodborne-disease outbreaks, cases, and deaths, by etiology — United States, 1998-2002 Outbreaks Etiology Bacterial Bacillus cereus Brucella Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli* Listeria monocytogenes Salmonella Shigella Staphylococcus aureus Streptococcus Vibrio cholerae† Vibrio parahemolyticus Vibrio, other Yersinia enterocolitica Other bacterial Total bacterial Chemical Ciguatoxin Heavy metals Mushroom toxin Scombrotoxin Shellfish toxin Other chemical Total chemical Parasitic Anisakis Cryptosporidium parvum Cyclospora cayetanensis Giardia intestinalis Trichinella spiralis Total parasitic Viral Astrovirus Hepatitis A Norovirus Rotavirus Total viral Multiple etiologies

Cases

No.

(%)

No.

37 1 61 12 130 140 11 585 67 101 1 3 25 1 8 1 1,184

(0.6) (0.0) (0.9) (0.2) (2.0) (2.1) (0.2) (8.8) (1.0) (1.5) (0.0) (0.0) (0.4) (0.0) (0.1) (0.0) (17.8)

84 2 2 118 5 10 221

Deaths

(%)

No.

(%)

571 4 1,440 52 6,724 4,854 256 16,821 3,677 2,766 4 12 613 2 87 4 37,887

(0.4) (0.0) (1.1) (0.0) (5.2) (3.8) (0.2) (13.1) (2.9) (2.2) (0.0) (0.0) (0.5) (0.0) (0.1) (0.0) (29.5)

0 0 0 1 4 4 38 20 1 2 0 0 0 0 0 0 70

(0.0) (0.0) (0.0) (1.1) (4.5) (4.5) (43.2) (22.7) (1.1) (2.3) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (79.5)

(1.3) (0.0) (0.0) (1.8) (0.1) (0.2) (3.3)

315 23 6 463 36 297 1,140

(0.2) (0.0) (0.0) (0.4) (0.0) (0.2) (0.9)

1 0 0 0 0 0 1

(1.1) (0.0) (0.0) (0.0) (0.0) (0.0) (1.1)

1 4 9 3 6 23

(0.0) (0.1) (0.1) (0.0) (0.1) (0.3)

14 139 325 119 33 630

(0.0) (0.1) (0.3) (0.1) (0.0) (0.5)

0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

1 50 657 1 709

(0.0) (0.8) (9.9) (0.0) (10.7)

14 981 27,171 108 28,274

(0.0) (0.8) (21.2) (0.1) (22.0)

0 4 1 0 5

(0.0) (4.5) (1.1) (0.0) (5.7)

30

(0.5)

1,050

(0.8)

0

(0.0)

2,167 4,480

(32.6) (67.4)

68,981 59,389

(53.7) (46.2)

76 12

(86.4) (13.6)

Total 1998–2002 6,647 (100.0) 128,370 * Enterohemorrhagic (132 outbreaks), Enterotoxigenic (7), Enteroaggregative (1) † Serotype O1 (1 outbreak), Serotype non-O1, non-O139 (1), serotype unspecified (1)

(100.0)

88

(100.0)

Confirmed etiology Unknown etiology

10

MMWR

November 10, 2006

TABLE 2. Number of reported foodborne-disease outbreaks, cases, and deaths, by etiology — United States, 1998 Outbreaks

Cases

Etiology

No.

(%)

No.

Bacterial Bacillus cereus Brucella Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Listeria monocytogenes Salmonella Shigella Staphylococcus aureus Streptococcus Vibrio cholerae Vibrio parahemolyticus Vibrio, other Yersinia enterocolitica Other bacterial Total bacterial

10 0 12 3 24 32 2 125 17 15 1 1 13 1 1 1 258

(0.8) (0.0) (0.9) (0.2) (1.8) (2.4) (0.2) (9.5) (1.3) (1.1) (0.1) (0.1) (1.0) (0.1) (0.1) (0.1) (19.6)

16 0 1 27 1 3 48

Chemical Ciguatoxin Heavy metals Mushroom toxin Scombrotoxin Shellfish toxin Other chemical Total chemical Parasitic Anisakis Cryptosporidium parvum Cyclospora cayetanensis Giardia intestinalis Trichinella spiralis Total parasitic Viral Astrovirus Hepatitis A Norovirus Rotavirus Total viral Multiple etiologies Confirmed etiology Unknown etiology Total 1998

Deaths

(%)

No.

(%)

213 0 483 8 1,328 1,613 105 2,731 1,266 615 4 6 532 2 9 4 8,919

(0.8) (0.0) (1.8) (0.0) (4.9) (5.9) (0.4) (10.0) (4.6) (2.3) (0.0) (0.0) (2.0) (0.0) (0.0) (0.0) (32.7)

0 0 0 0 0 0 21 6 0 0 0 0 0 0 0 0 27

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (65.6) (18.8) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (84.4)

(1.2) (0.0) (0.1) (2.1) (0.1) (0.2) (3.7)

73 0 2 124 6 124 329

(0.3) (0.0) (0.0) (0.5) (0.0) (0.5) (1.2)

0 0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

0 1 1 1 0 4

(0.0) (0.1) (0.1) (0.1) (0.0) (0.3)

0 88 17 3 0 116

(0.0) (0.3) (0.1) (0.0) (0.0) (0.4)

0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

0 13 47 0 60

(0.0) (1.0) (3.6) (0.0) (4.6)

0 293 2,563 0 2,856

(0.0) (1.1) (9.4) (0.0) (10.5)

0 1 0 0 1

(0.0) (3.1) (0.0) (0.0) (3.1)

2

(0.2)

31

(0.1)

0

(0.0)

372 942

(28.3) (71.7)

12,251 15,007

(44.9) (55.1)

28 4

(87.5) (12.5)

1,314

(100.0)

27,258

(100.0)

32

(100.0)

Vol. 55 / SS-10


11


Cases

No.

(%)

No.


7 0 5 1 22 28 5 111 14 19 0 1 3 0 1 0 217

(0.5) (0.0) (0.4) (0.1) (1.6) (2.1) (0.4) (8.3) (1.0) (1.4) (0.0) (0.1) (0.2) (0.0) (0.1) (0.0) (16.2)

194 0 85 3 1,166 842 28 3,463 221 353 0 2 14 0 32 0 6,403

(0.8) (0.0) (0.3) (0.0) (4.7) (3.4) (0.1) (13.9) (0.9) (1.4) (0.0) (0.0) (0.1) (0.0) (0.1) (0.0) (25.7)

0 0 0 0 1 0 2 2 0 0 0 0 0 0 0 0 5

(0.0) (0.0) (0.0) (0.0) (10.0) (0.0) (20.0) (20.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (50.0)

12 1 0 21 0 1 35

(0.9) (0.1) (0.0) (1.6) (0.0) (0.1) (2.6)

47 2 0 67 0 2 118

(0.2) (0.0) (0.0) (0.3) (0.0) (0.0) (0.5)

1 0 0 0 0 0 1

(10.0) (0.0) (0.0) (0.0) (0.0) (0.0) (10.0)

1 0 2 0 0 3

(0.1) (0.0) (0.1) (0.0) (0.0) (0.2)

14 0 153 0 0 167

(0.1) (0.0) (0.6) (0.0) (0.0) (0.7)

0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

0 12 98 0 110

(0.0) (0.9) (7.3) (0.0) (8.2)

0 387 4,745 0 5,132

(0.0) (1.6) (19.1) (0.0) (20.6)

0 0 1 0 1

(0.0) (0.0) (10.0) (0.0) (10.0)


(%)

Deaths

Etiology

No.

(%)

5

(0.4)

267

(1.1)

0

(0.0)

370 973

(27.6) (72.4)

12,087 12,807

(48.6) (51.4)

7 3

(70.0) (30.0)

1,343

(100.0)

24,894

(100.0)

10

(100.0)

12

MMWR

November 10, 2006


Cases

Etiology

No.

(%)

No.


8 0 15 2 22 32 2 127 12 23 0 0 4 0 0 0 247

(0.6) (0.0) (1.1) (0.1) (1.6) (2.3) (0.1) (9.0) (0.8) (1.6) (0.0) (0.0) (0.3) (0.0) (0.0) (0.0) (17.4)

12 1 0 20 3 2 38


Deaths

(%)

No.

(%)

61 0 205 5 791 1,392 41 2,850 866 657 0 0 37 0 0 0 6,905

(0.2) (0.0) (0.8) (0.0) (3.0) (5.3) (0.2) (10.9) (3.3) (2.5) (0.0) (0.0) (0.1) (0.0) (0.0) (0.0) (26.4)

0 0 0 1 0 2 7 2 1 2 0 0 0 0 0 0 15

(0.0) (0.0) (0.0) (4.8) (0.0) (9.5) (33.3) (9.5) (4.8) (9.5) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (71.4)

(0.8) (0.1) (0.0) (1.4) (0.2) (0.1) (2.7)

46 21 0 81 9 36 193

(0.2) (0.1) (0.0) (0.3) (0.0) (0.1) (0.7)

0 0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

0 1 2 1 2 6

(0.0) (0.1) (0.1) (0.1) (0.1) (0.4)

0 8 73 82 6 169

(0.0) (0.0) (0.3) (0.3) (0.0) (0.6)

0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

0 12 163 1 176

(0.0) (0.8) (11.5) (0.1) (12.4)

0 135 6,969 108 7,212

(0.0) (0.5) (26.7) (0.4) (27.6)

0 1 0 0 1

(0.0) (4.8) (0.0) (0.0) (4.8)

3

(0.2)

22

(0.1)

0

(0.0)

470 947

(33.2) (66.8)

14,501 11,621

(55.5) (44.5)

16 5

(76.2) (23.8)

1,417

(100.0)

26,122

(100.0)

21

(100.0)

Vol. 55 / SS-10


13


Cases

Etiology

No.

(%)

No.


5 1 16 3 31 22 1 111 15 23 0 1 3 0 3 0 235

(0.4) (0.1) (1.3) (0.2) (2.5) (1.8) (0.1) (8.9) (1.2) (1.9) (0.0) (0.1) (0.2) (0.0) (0.2) (0.0) (18.9)

24 0 0 29 0 1 54


Deaths

(%)

No.

(%)

61 4 317 22 1,232 521 28 3,141 1,006 646 0 4 19 0 33 0 7,034

(0.2) (0.0) (1.3) (0.1) (4.9) (2.1) (0.1) (12.5) (4.0) (2.6) (0.0) (0.0) (0.1) (0.0) (0.1) (0.0) (28.0)

0 0 0 0 3 0 0 7 0 0 0 0 0 0 0 0 10

(0.0) (0.0) (0.0) (0.0) (27.3) (0.0) (0.0) (63.6) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (90.9)

(1.9) (0.0) (0.0) (2.3) (0.0) (0.1) (4.3)

81 0 0 132 0 15 228

(0.3) (0.0) (0.0) (0.5) (0.0) (0.1) (0.9)

0 0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

0 0 2 1 2 5

(0.0) (0.0) (0.2) (0.1) (0.2) (0.4)

0 0 42 34 14 90

(0.0) (0.0) (0.2) (0.1) (0.1) (0.4)

0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

0 6 150 0 156

(0.0) (0.5) (12.1) (0.0) (12.6)

0 116 6,335 0 6,451

(0.0) (0.5) (25.2) (0.0) (25.7)

0 1 0 0 1

(0.0) (9.1) (0.0) (0.0) (9.1)

9

(0.7)

190

(0.8)

0

(0.0)

459 784

(36.9) (63.1)

13,993 11,137

(55.7) (44.3)

11 0

(100.0) (0.0)

1,243

(100.0)

25,130

(100.0)

11

(100.0)

14

MMWR

November 10, 2006


Cases

Etiology

No.

(%)

No.


7 0 13 3 31 26 1 111 9 21 0 0 2 0 3 0 227

(0.5) (0.0) (1.0) (0.2) (2.3) (2.0) (0.1) (8.3) (0.7) (1.6) (0.0) (0.0) (0.2) (0.0) (0.2) (0.0) (17.1)

20 0 1 21 1 3 46

Chemical Ciguatoxin Heavy metals Mushroom toxin Scombrotoxin Shellfish toxin Other chemical Total chemical Parasitic Anisakis Cryptosporidium parvum Cyclospora cayetanensis Giardia intestinalis Trichinella spiralis Total parasitic Viral Astrovirus Hepatitis A Norovirus Rotavirus Total viral

Deaths

(%)

No.

(%)

42 0 350 14 2,207 486 54 4,636 318 495 0 0 11 0 13 0 8,626

(0.2) (0.0) (1.4) (0.1) (8.8) (1.9) (0.2) (18.6) (1.3) (2.0) (0.0) (0.0) (0.0) (0.0) (0.1) (0.0) (34.6)

0 0 0 0 0 2 8 3 0 0 0 0 0 0 0 0 13

(0.0) (0.0) (0.0) (0.0) (0.0) (14.3) (57.1) (21.4) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (92.9)

(1.5) (0.0) (0.1) (1.6) (0.1) (0.2) (3.5)

68 0 4 59 21 120 272

(0.3) (0.0) (0.0) (0.2) (0.1) (0.5) (1.1)

0 0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

0 2 2 0 1 5

(0.0) (0.2) (0.2) (0.0) (0.1) (0.4)

0 43 40 0 5 88

(0.0) (0.2) (0.2) (0.0) (0.0) (0.4)

0 0 0 0 0 0

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

1 7 199 0 207

(0.1) (0.5) (15.0) (0.0) (15.6)

14 50 6,559 0 6,623

(0.1) (0.2) (26.3) (0.0) (26.5)

0 1 0 0 1

(0.0) (7.1) (0.0) (0.0) (7.1)

Multiple etiologies

11

(0.8)

540

(2.2)

0

(0.0)


496 834

(37.3) (62.7)

16,149 8,817

(64.7) (35.3)

14 0

(100.0) (0.0)

1,330

(100.0)

24,966

(100.0)

14

(100.0)

Total 2002

Vol. 55 / SS-10


15

TABLE 7. Number of reported foodborne-disease outbreaks, by etiology and month of occurrence — United States, 1998–2002 Month of occurrence Etiology

Jan

Feb

Mar

Apr

May

Jun

Jul


3 — 4 3 3 — — 32 8 4 — 1 1 — 2 — 61

3 — 5 — 9 1 — 22 3 6 — — — — 1 — 50

2 — 5 — 6 3 — 31 2 9 1 — 1 — — — 60

5 — 4 1 17 8 — 43 5 8 — — 2 — — — 93

5 — 7 — 14 19 1 50 4 11 — — 2 — — 1 114

7 — 13 1 8 18 1 88 11 13 — 1 8 — — — 169

Chemical Ciguatoxin Heavy metals Mushroom toxin Scombrotoxin Shellfish toxin Other chemical Total chemical

4 — — 7 1 — 12

2 — — 6 — — 8

4 — — 5 — 1 10

8 1 — 14 — — 23

12 — — 11 — 4 27

Parasitic Anisakis Cryptosporidium parvum Cyclospora cayetanensis Giardia intestinalis Trichinella spiralis Total parasitic

— — 3 — — 3

1 — — — — 1

— — — — — 0

— 1 — 1 1 3

Viral Astrovirus Hepatitis A Norovirus Rotavirus Total viral

1 4 46 — 51

— 2 51 — 53

— 9 64 1 74

— 4 60 — 64

Multiple etiologies

Aug

Sep

Oct

Nov

Dec

Total

4 1 3 3 8 24 1 80 3 5 — — 5 — — — 137

3 — 9 1 11 21 2 76 6 7 — — 5 — — — 141

1 — 4 1 8 15 1 61 11 9 — 1 1 — 1 — 114

1 — 1 1 13 19 2 33 6 13 — — — — — — 89

1 — 5 — 15 10 1 39 5 6 — — — 1 3 — 86

2 — 1 1 18 2 2 30 3 10 — — — — 1 — 70

37 1 61 12 130 140 11 585 67 101 1 3 25 1 8 1 1,184

6 — — 12 — — 18

17 — 1 11 — — 29

6 — — 12 3 1 22

10 — — 10 — — 20

8 — 1 12 1 1 23

5 — — 7 — 1 13

2 1 — 11 — 2 16

84 2 2 118 5 10 221

— — 3 — 1 4

— — 2 — — 2

— — 1 — — 1

— — — 1 2 3

— 2 — — 1 3

— 1 — 1 — 2

— — — — 1 1

— — — — — 0

1 4 9 3 6 23

— — 70 — 70

— 5 49 — 54

— 3 43 — 46

— 3 42 — 45

— 4 28 — 32

— 10 47 — 57

— 2 66 — 68

— 4 91 — 95

1 50 657 1 709

1

2

1

5

3

1

3

5

3

4

2

—

30


128 329

114 355

145 422

188 425

218 462

244 394

216 349

216 334

172 267

175 316

170 377

181 450

2,167 4,480

Total 1998–2002

457

469

567

613

680

638

565

550

439

491

547

631

6,647

16

MMWR

November 10, 2006

TABLE 8. Number of reported foodborne-disease outbreaks, by etiology and place where food was eaten* — United States, 1998–2002 Place where food was eaten Etiology Bacterial Bacillus cereus Brucella Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Listeria monocytogenes Salmonella Shigella Staphylococcus aureus Streptococcus Vibrio cholerae Vibrio parahaemolyticus Vibrio, other Yersinia enterocolitica Other bacterial Total bacterial Chemical Ciguatoxin Heavy metals Mushroom toxin Scombrotoxin Shellfish toxin Other chemical Total chemical Parasitic Anisakis Cryptosporidium parvum Cyclospora cayetanensis Giardia intestinalis Trichinella spiralis Total parasitic Viral Astrovirus Hepatitis A Norovirus Rotavirus Total viral Multiple etiologies Confirmed etiology Unknown etiology

Private residence

Restaurant or Delicatessen

Grocery

School

Daycare center

Workplace cafeteria

Picnic

Church

Camp

7 1 16 10 15 40 9 169 10 20 — 1 4 — 4 — 306

13 — 25 — 36 41 2 271 39 26 — 2 17 — 1 — 473

— — — — — 1 2 2 — 1 1 — — — — — 7

2 — 2 — 11 9 — 21 5 10 — — — — — — 60

— — — — — 2 — 5 2 2 — — — — — — 11

2 — — 1 10 2 — 7 — 8 — — — — 1 — 31

— — 1 — 2 7 — 12 3 4 — — — — — — 29

— — 1 1 6 5 — 20 2 9 — — — — — — 44

— — 2 — 1 6 — 9 — 3 — — — — — — 21

73 1 2 14 4 2 96

7 — — 84 — 3 94

— — — 2 — — 2

— 1 — 1 — 2 4

— — — — — — —

— — — 3 — 1 4

1 — — — — — 1

— — — — — — 0

2 — — — — — 2

1 2 2 1 3 9

— — 2 1 — 3

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — 1 1

— — — — — —

— — — — 1 1

— 5 83 — 88

1 29 279 — 309

— — — — —

— 2 51 1 54

— 1 1 — 2

— 3 30 — 33

— 2 11 — 13

— — 17 — 17

— — 12 — 12

7

8

1

2

1

—

2

—

1

506 791

887 2,447

10 6

120 165

14 10

68 133

46 45

61 54

37 29

3,334

16

285

24

201

91

115

66

Total 1998–2002 1,297 * More than one place might be reported per outbreak.

Vol. 55 / SS-10


17

TABLE 8. (Continued) Number of reported foodborne-disease outbreaks, by etiology and place where food was eaten* — United States, 1998–2002 Place where food was eaten Fair or festival

Hospital

Nursing home

Prison

Bacterial Bacillus cereus Brucella Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Listeria monocytogenes Salmonella Shigella Staphylococcus aureus Streptococcus Vibrio cholerae Vibrio parahaemolyticus Vibrio, other Yersinia enterocolitica Other bacterial Total bacterial

— — 1 — — 3 — 7 — 4 — — — — — — 15

— — — — 4 — 2 4 — 1 — — — — — — 11

— — — — — 1 1 19 — 1 — — — — — — 22


— — — — — — —

— — — 1 — — 1


— — — — — —


— — 5 — 5

Etiology

Other

Known place

Unknown place

— — 1 — 10 7 — 10 — 1 — — — — — — 29

8 — 13 — 33 20 2 68 4 18 — — 2 — 1 — 169

33 1 57 11 125 127 11 540 64 96 1 3 23 — 7 — 1,099

4 — 4 1 5 13 — 45 3 5 — — 2 1 1 1 85

37 1 61 12 130 140 11 585 67 101 1 3 25 1 8 1 1,184

— — — 1 — — 1

— — — — — — —

2 — — 8 1 1 12

82 2 2 113 4 9 212

2 — — 5 1 1 9

84 2 2 118 5 10 221

— — — — — —

— — — — — —

— — — — — —

— 2 4 1 3 10

1 4 7 3 6 21

— — 2 — — 2

1 4 9 3 6 23

— — 7 — 7

— — 21 — 21

— — 6 — 6

— 4 148 — 152

1 42 636 1 680

— 8 21 — 29

1 50 657 1 709

Total

Multiple etiologies

1

—

1

4

3

29

1

30


21 23

19 32

45 23

39 20

346 576

2,041 4,222

126 258

2,167 4,480

51

68

59

922

6,263

384

6,647

Total 1998-2002 44 * More than one place might be reported per outbreak.

18

MMWR

November 10, 2006

TABLE 9. Number of reported foodborne-disease outbreaks, cases, and deaths, by vehicle of transmission — United States, 1998 Outbreaks

Cases

Vehicle of transmission

No.

(%)

No.

Beef Dairy Eggs Game Pork Poultry Vegetables Fruits and nuts Grains Oils and sugars Finfish Shellfish Unclassifiable vehicle Complex vehicle Known vehicle Unknown vehicle

26 18 7 2 29 62 27 17 9 1 69 38 41 432 778 536

(2.0) (1.4) (0.5) (0.2) (2.2) (4.7) (2.1) (1.3) (0.7) (0.1) (5.3) (2.9) (3.1) (32.9) (59.2) (40.8)

1,314

(100.0)

Total 1998

Deaths

(%)

No.

(%)

805 492 48 13 610 876 1,299 586 306 4 493 880 632 10,851 17,895 9,363

(3.0) (1.8) (0.2) (0.0) (2.2) (3.2) (4.8) (2.1) (1.1) (0.0) (1.8) (3.2) (2.3) (39.8) (65.7) (34.3)

0 0 0 0 0 0 2 0 0 0 0 0 2 23 27 5

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (6.3) (0.0) (0.0) (0.0) (0.0) (0.0) (6.3) (71.9) (84.4) (15.6)

27,258

(100.0)

32

(100.0)


Cases

No.

(%)

No.


62 15 25 0 26 74 43 19 19 5 64 28 37 372 789 554

(4.6) (1.1) (1.9) (0.0) (1.9) (5.5) (3.2) (1.4) (1.4) (0.4) (4.8) (2.1) (2.8) (27.7) (58.7) (41.3)

1,332 199 762 0 559 947 1,273 629 139 135 322 253 1,513 7,189 15,252 9,642

(5.4) (0.8) (3.1) (0.0) (2.2) (3.8) (5.1) (2.5) (0.6) (0.5) (1.3) (1.0) (6.1) (28.9) (61.3) (38.7)

0 0 0 0 0 0 0 0 0 0 1 0 0 5 6 4

(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (10.0) (0.0) (0.0) (50.0) (60.0) (40.0)

1,343

(100.0)

24,894

(100.0)

10

(100.0)

Total 1999

(%)

Deaths


No.

(%)


Cases


No.

(%)

No.


43 22 25 0 27 61 41 21 28 1 63 25 51 455 863 554

(3.0) (1.6) (1.8) (0.0) (1.9) (4.3) (2.9) (1.5) (2.0) (0.1) (4.4) (1.8) (3.5) (32.1) (60.9) (39.1)

1,417

(100.0)

Total 2000

Deaths

(%)

No.

(%)

696 300 620 0 610 829 872 1,527 434 27 267 134 959 9,525 16,800 9,322

(2.7) (1.1) (2.4) (0.0) (2.3) (3.2) (3.3) (5.8) (1.7) (0.1) (1.0) (0.5) (3.6) (36.5) (64.3) (35.7)

1 0 0 0 0 7 2 1 0 0 0 0 0 9 20 1

(4.8) (0.0) (0.0) (0.0) (0.0) (33.3) (9.5) (4.8) (0.0) (0.0) (0.0) (0.0) (0.0) (42.9) (95.2) (4.8)

26,122

(100.0)

21

(100.0)

Vol. 55 / SS-10


19


Cases

No.

(%)

No.


33 21 12 5 30 73 37 21 11 4 75 33 51 384 790 453

(2.6) (1.7) (1.0) (0.4) (2.4) (5.9) (3.0) (1.7) (0.9) (0.3) (6.0) (2.7) (4.1) (31.0) (63.6) (36.4)

525 536 465 45 560 1,010 1,997 585 92 95 330 291 1,182 8,112 15,825 9,305

(2.1) (2.1) (1.9) (0.2) (2.2) (4.0) (7.9) (2.3) (0.4) (0.4) (1.3) (1.2) (4.7) (32.3) (63.0) (37.0)

1 0 0 0 0 0 0 2 0 0 0 0 1 1 5 6

(9.1) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (18.2) (0.0) (0.0) (0.0) (0.0) (9.1) (9.1) (45.5) (54.5)

1,243

(100.0)

25,130

(100.0)

11

(100.0)

Total 2001

(%)

Deaths


No.

(%)


Cases


No.

(%)

No.


44 16 14 3 26 75 44 9 14 1 66 27 52 436 827 503

(3.3) (1.2) (1.1) (0.2) (2.0) (5.6) (3.3) (0.7) (1.1) (0.1) (5.0) (2.0) (3.9) (32.8) (62.2) (37.8)

1330

(100.0)

Total 2002

Deaths

(%)

No.

(%)

831 704 317 33 360 1325 1596 169 177 4 280 200 1049 9369 16414 8552

(3.3) (2.8) (1.3) (0.1) (1.4) (5.3) (6.4) (0.7) (0.7) (0.0) (1.1) (0.8) (4.2) (37.5) (65.7) (34.3)

3 0 0 0 0 8 0 0 0 0 0 0 0 1 12 2

(21.4) (0.0) (0.0) (0.0) (0.0) (57.1) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (7.1) (85.7) (14.3)

24966

(100.0)

14

(100.0)

20

MMWR

November 10, 2006

TABLE 14. Number of reported foodborne-disease outbreaks, by etiology and vehicle of transmission — United States, 1998 Vehicle of transmission Etiology

Fruits and nuts

Beef

Dairy

Eggs

Game

Pork

Poultry

Vegetables


Grains

— — — — 4 1 — — — 1 — — — — — — 6

— — 2 — — 2 — 3 — — — — — — — — 7

— — — — — — — 3 — — — — — — — — 3

— — — — — — — 1 — — — — — — — — 1

— — — — 3 — — 2 — 2 — — — — — — 7

— — 1 — 2 — — 6 1 1 1 — 1 — — — 13

— — 1 — — 2 — 3 1 — — — — — — — 7

— — — — — 1 — 1 — — — — — — — — 2

— — — — — — — 2 — — — — — — — — 2


— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — 1 — — 1 2

— — — — — — —

— — — — — — —


— — — — — —

— — — — — —

— — — — — —

— — — — 1 1

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —


— — — — —

— — 1 — 1

— — — — —

— — — — —

— — 1 — 1

— — — — —

— — 1 — 1

— 2 2 — 4

— — — — —

Multiple etiologies

—

—

—

—

—

—

—

—

—


6 20

8 10

3 4

2 —

8 21

13 49

10 17

6 11

2 7

Total 1998

26

18

7

2

29

62

27

17

9

Vol. 55 / SS-10


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TABLE 14. (Continued) Number of reported foodborne-disease outbreaks, by etiology and vehicle of transmission — United States, 1998 Vehicle of transmission Oils and sugars

Shellfish

Unclassifiable vehicle

Finfish

Complex vehicle

Known vehicle

Unknown vehicle


Total

— — — — — — — — — — — — — — — — —

— — — 2 — — — 1 1 — — — — — — — 4

1 — 1 — — — — 1 — — — 1 11 1 — — 16

— — — — — — — 4 — — — — — — — — 4

7 — 2 1 12 12 2 35 4 9 — — — — 1 1 86

8 — 7 3 21 18 2 62 7 13 1 1 12 1 1 1 158

2 — 5 — 3 14 — 63 10 2 — — 1 — — — 100

10 — 12 3 24 32 2 125 17 15 1 1 13 1 1 1 258


— — — — — — —

16 — — 27 — 1 44

— — — — 1 — 1

— — — — — — —

— — — — — 1 1

16 — 1 27 1 3 48

— — — — — — —

16 — 1 27 1 3 48


— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — 1 — 1

— — — 1 1 2

— 1 1 — — 2

— — — — 1 1


— — — — —

— — — — —

— — 1 — 1

— — 3 — 3

— — 17 — 17

— 2 26 — 28

— 11 21 — 32

— 13 47 — 60

Etiology

Multiple etiologies

—

—

—

—

1

1

1

2


— 1

48 21

18 20

6 35

107 325

237 541

135 401

372 942

1

69

38

41

432

778

536

1,314

Total 1998

22

MMWR

November 10, 2006


Fruits and nuts

Beef

Dairy

Eggs

Game

Pork

Poultry

Vegetables


Grains

— — — — 4 12 1 3 — 2 — — — — — — 22

— — 1 — — — — 2 — — — — — — — — 3

— — — — 1 — — 19 1 — — — — — — — 21

— — — — — — — — — — — — — — — — 0

— — — — — — — 3 — 6 — — — — 1 — 10

— — 1 — 3 — — 15 — — — — — — — — 19

— — — — 1 5 — 7 — 1 — — — — — — 14

— — — — — — — 5 — — — — — — — — 5

3 — — — — — — — — — — — — — — — 3


— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —


— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — 1 — — 1

— — 1 — — 1

— — — — — —


— — 5 — 5

— — 2 — 2

— — — — —

— — — — —

— — 1 — 1

— — 2 — 2

— — 3 — 3

— — 5 — 5

— — — — —

Multiple etiologies

—

—

—

—

—

1

—

—

1


27 35

5 10

21 4

— —

11 15

22 52

18 25

11 8

4 15

Total 1999

62

15

25

—

26

74

43

19

19

Vol. 55 / SS-10


23


Shellfish


Finfish

Complex vehicle

Known vehicle

Unknown vehicle


Total

— — — — — — — — — — — — — — — — —

— — — — — — — — — — — — — — — — —

— — — — — — — — — — — 1 3 — — — 4

— — — — — 1 — 1 — — — — — — — — 2

3 — — 1 12 3 3 21 7 7 — — — — — — 57

6 — 2 1 21 21 4 76 8 16 — 1 3 — 1 — 160

1 — 3 — 1 7 1 35 6 3 — — — — — — 57

7 — 5 1 22 28 5 111 14 19 — 1 3 — 1 — 217


— — — — — 1 1

12 — — 20 — — 32

— — — — — — —

— — — — — — —

— 1 — 1 — — 2

12 1 — 21 — 1 35

— — — — — — —

12 1 — 21 — 1 35


— — — — — —

1 — — — — 1

— — — — — —

— — — — — —

— — — — — —

1 — 2 — — 3

— — — — — —

1 — 2 — — 3


— — 1 — 1

— — — — —

— — 2 — 2

— 1 3 — 4

— 5 29 — 34

— 6 53 — 59

— 6 45 — 51

— 12 98 — 110

Etiology

Multiple etiologies

—

—

—

1

—

3

2

5


2 3

33 31

6 22

7 30

93 279

260 529

110 444

370 973

Total 1999

5

64

28

37

372

789

554

1,343

24

MMWR

November 10, 2006


Fruits and nuts

Beef

Dairy

Eggs

Game

Pork

Poultry

Vegetables


Grains

— — — — 3 11 — 1 — 2 — — — — — — 17

— — 10 — — — 1 — — — — — — — — — 11

— — — — — — — 19 — — — — — — — — 19

— — — — — — — — — — — — — — — — —

— — — — 2 — — 4 1 3 — — — — — — 10

— — — — 4 2 1 12 — 2 — — — — — — 21

— — 1 2 — 1 — 4 — 1 — — — — — — 9

— — — — — 2 — 3 — — — — — — — — 5

2 — — — 1 — — — — 1 — — — — — — 4


— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— 1 — — — — 1

— — — — — — —


— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — 1 — — 1

— — — — — —


— — 1 — 1

— — — — —

— — — — —

— — — — —

— — 2 — 2

— — 1 — 1

— 1 8 — 9

— 1 6 — 7

— — — — —

Multiple etiologies

—

—

—

—

1

—

—

—

2


18 25

11 11

19 6

— —

13 14

22 39

18 23

14 7

6 22

Total 2000

43

22

25

—

27

61

41

21

28

Vol. 55 / SS-10


25


Shellfish


Finfish

Complex vehicle

Known vehicle

Unknown vehicle


Total

— — — — — — — — — — — — — — — — —

1 — — — — — — 2 — — — — — — — — 3

— — — — — — — — — — — — 3 — — — 3

— — — — 1 2 — 4 2 1 — — — — — — 10

3 — — — 9 4 — 37 6 9 — — 1 — — — 69

6 — 11 2 20 22 2 86 9 19 — — 4 — — — 181

2 — 4 — 2 10 — 41 3 4 — — — — — — 66

8 — 15 2 22 32 2 127 12 23 — — 4 — — — 247


— — — — — — —

12 — — 20 — — 32

— — — — 3 — 3

— — — — — — —

— — — — — 2 2

12 1 — 20 3 2 38

— — — — — — —

12 1 — 20 3 2 38


— — — — — —

— — — — — —

— — — — — —

— — — 1 — 1

— 1 1 — 2 4

— 1 2 1 2 6

— — — — — —

— 1 2 1 2 6


— — — — —

— — 1 — 1

— 1 2 — 3

— 1 4 1 6

— 5 49 — 54

— 9 74 1 84

— 3 89 — 92

— 12 163 1 176

Etiology

Multiple etiologies

—

—

—

—

—

3

—

3


— 1

36 27

9 16

17 34

129 326

312 551

158 396

470 947

1

63

25

51

455

863

554

1,417

Total 2000

26

MMWR

November 10, 2006


Fruits and nuts

Beef

Dairy

Eggs

Game

Pork

Poultry

Vegetables


Grains

— — — — 10 — — 1 1 — — — — — — — 12

— 1 2 — — 1 — 4 — — — — — — — — 8

— — — — — — — 10 — — — — — — — — 10

— — 1 1 — — — — — — — — — — — — 2

— — — — — — — 5 — 6 — — — — 2 — 13

— — 2 — 4 — 1 9 1 2 — — — — — — 19

1 — — — 1 1 — 3 2 — — — — — — — 8

— — 1 — — 1 — 6 — — — — — — — — 8

— — — — — — — — — — — — — — — — —


— — — — — — —

— — — — — — —

— — — — — — —

— — — — — 1 1

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —


— — — — —

— — — — —

— — — — —

— — — 1 1

— — — — —

— — — — —

— 1 — — 1

— — — — —

— — — — —


— — — — —

— 1 2 — 3

— — — — —

— — 1 — 1

— — 1 — 1

— — 3 — 3

— 1 7 — 8

— — 5 — 5

— — 1 — 1

Multiple etiologies

1

—

—

—

1

1

—

—

—


13 20

11 10

10 2

5 —

15 15

23 50

17 20

13 8

1 10

Total 2001

33

21

12

5

30

73

37

21

11

Vol. 55 / SS-10


27


Shellfish


Finfish

Complex vehicle

Known vehicle

Unknown vehicle


Total

— — — — — — — — — — — — — — — — —

— — — 1 — — — — — — — — — — — — 1

— — — — — — — 1 2 — — 1 1 — — — 5

— — — — — 1 — 8 — — — — — — — — 9

4 — 5 1 11 6 — 30 4 14 — — 2 — — — 77

5 1 11 3 26 10 1 77 10 22 — 1 3 — 2 — 172

— — 5 — 5 12 — 34 5 1 — — — — 1 — 63

5 1 16 3 31 22 1 111 15 23 — 1 3 — 3 — 235


— — — — — — —

24 — — 29 — — 53

— — — — — — —

— — — — — — —

— — — — — — —

24 — — 29 — 1 54

— — — — — — —

24 — — 29 — 1 54


— — — — —

— — — — —

— — — — —

— — — — —

— — — 1 1

— 1 — 2 3

— 1 1 — 2

— 2 1 2 5


— — 1 — 1

— — 1 — 1

— — 8 — 8

— 2 10 — 12

— — 40 — 40

— 4 80 — 84

— 2 70 — 72

— 6 150 — 156

Multiple etiologies

—

—

—

—

4

7

2

9


1 3

55 20

13 20

21 30

122 262

321 470

139 314

459 784

Total 2001

4

75

33

51

384

791

453

1,243

Etiology

28

MMWR

November 10, 2006


Fruits and nuts

Beef

Dairy

Eggs

Game

Pork

Poultry

Vegetables


Grains

— — — — 8 6 — 4 — 1 — — — — — — 19

— — 4 — — — — 2 — — — — — — — — 6

— — — — 1 — — 6 — — — — — — — — 7

— — — — — — — 2 — — — — — — — — 2

— — — — 2 — — 3 — 4 — — — — 1 — 10

2 — 2 — 5 — 1 8 — 2 — — — — — — 20

— — 1 — — 3 — 8 1 — — — — — — — 13

— — — — — — — 3 — — — — — — — — 3

1 — — — — 1 — 1 — — — — — — — — 3


— — — — — — —

— — — — — 1 1

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — 1 1

— — 1 — — — 1

— — — — — — —

— — — — — — —


— — — — — —

— — — — — —

— — — — — —

— — — — 1 1

— — — — — —

— — — — — —

— — — — — —

— — 1 — — 1

— — — — — —


— — 4 — 4

— — 2 — 2

— — — — —

— — — — —

— — — — —

— — 2 — 2

— — 11 — 11

— — 1 — 1

— — — — —

Multiple etiologies

1

—

—

—

1

—

—

—

—


24 20

9 7

7 7

3 —

11 15

23 52

25 19

5 4

3 11

Total 2002

44

16

14

3

26

75

44

9

14

Vol. 55 / SS-10


29


Shellfish


Finfish

Complex vehicle

Known vehicle

Unknown vehicle


Total

— — — — — — — — — — — — — — — — —

— — — 2 — — — 1 — — — — — — — — 3

— — — — — — — — — — — — 2 — — — 2

— — — — — 3 — 3 — — — — — — 1 — 7

4 — 4 1 13 7 — 34 2 13 — — — — — — 78

7 — 11 3 29 20 1 75 3 20 — — 2 — 2 — 173

— — 2 — 2 6 — 36 6 1 — — — — 1 — 54

7 — 13 3 31 26 1 111 9 21 — — 2 — 3 — 227


— — — — — — —

20 — — 21 1 — 42

— — — — — — —

— — — — — 1 1

— — — — — — —

20 — 1 21 1 3 46

— — — — — — —

20 — 1 21 1 3 46


— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — 1 — — 1

— — 2 — 1 3

— 2 — — — 2

— 2 2 — 1 5


— — — — —

— — — — —

— — 2 — 2

— — 10 — 10

— 1 62 — 63

— 1 94 — 95

1 6 105 — 112

1 7 199 — 207

Multiple etiologies

—

—

—

—

5

7

4

11


— 1

45 21

4 23

18 34

147 289

324 503

172 331

496 834

1

66

27

52

436

827

503

1,330

Etiology

Total 2002

30

MMWR

November 10, 2006

TABLE 19. Number of reported foodborne-disease outbreaks, by etiology and contributing factors*,† — United States, 1998–2002 Contamination factors Etiology

C1

C2

C3

C4

C5

C6

C7

C8

— — — — — — — 1 — — — — 1 — — — 2

— — — — — 1 — — — — — — — — — — 1

— — — — — — — — — — — — — — — — —

— — — — — — — — — — — — — — — — —

— — — — — — — 4 — — — — — — — — 4

3 1 18 5 14 33 1 97 1 — — — 7 — — — 180

— — 7 1 1 4 1 42 — — — 1 4 — — — 61

— — — — — 1 — 3 — — — 1 2 — — — 7

— — 10 — 5 14 — 85 1 1 — — 2 — 2 — 120

54 — 1 43 4 — 102

— — — — — — —

— 1 — — — 5 6

— — — — — — —

— — — — — — —

— 1 — 1 — — 2

— — — 1 — — 1

4 — — — — — 4

— — — 1 — — 1


— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— 1 5 — 1 7

— 1 3 — 3 7

— — — — — —

— — — — — —


— — — — —

— — — — —

— — — — —

— — — — —

— 1 1 — 2

— — 21 — 21

— 1 18 — 19

— — 3 — 3

— 1 9 — 10

Multiple etiologies

—

—

—

—

—

2

3

1

—

104 42

1 1

6 20

— 3

6 7

212 133

91 38

15 10

131 251

26

3

13

345

129

25

382

Bacterial Bacillus cereus Brucella Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Listeria monocytogenes Salmonella Shigella Staphylococcus aureus Streptococcus Vibrio cholerae Vibrio parahaemolyticus Vibrio, other Yersinia enterocolitica Other bacterial Total bacterial Chemical Ciguatoxin Heavy metals Mushroom toxin Scombrotoxin Shellfish toxin Other chemical Total chemical


Total 1998–2002 146 2 * More than one contributing factor might be reported per outbreak † See Appendix A for description of each factor.

C9

Vol. 55 / SS-10


31

TABLE 19. (Continued) Number of reported foodborne-disease outbreaks, by etiology and contributing factors*,† — United States, 1998–2002 Contamination factors

C10

C11

C12

C13

C14

C15

Outbreaks in which contamination factor reported


1 — 5 — 8 12 — 37 12 17 — — 2 — — — 94

1 — 2 — 2 1 — 4 3 5 — — 1 — — — 19

1 — 1 — 2 6 — 64 16 30 1 — 1 — — — 122

3 — 13 1 12 8 1 82 5 9 — — 4 — 3 1 142

2 — 3 — 6 3 — 17 2 5 — — 1 — — — 39

— — 3 1 11 3 3 23 3 6 — — — — — — 53

10 1 39 7 41 60 6 260 25 50 1 2 14 — 4 1 521


— — — — — — —

— — — 1 — — 1

— — — — — — —

— — — 1 — — 1

— — — 2 — 1 3

— — — 9 — 1 10

58 2 1 55 4 6 126


— — — — 1 — 1

— — — — — — —

— — — — 2 — 2

— — — — 1 — 1

— — — — 1 — 1

— 1 — 1 — — 2

— 1 1 6 2 4 14

— 13 129 — 142

— 4 30 — 34

— 16 202 — 218

— 1 40 — 41

— — 7 — 7

— 3 28 — 31

— 25 312 — 337

Etiology

Viral Astrovirus Hepatitis A Norovirus Rotavirus Total viral Multiple etiologies Confirmed etiology Unknown etiology

2

1

7

6

2

4

14

239 526

55 132

349 251

191 477

52 122

100 191

1,012 1,365

600

668

174

291

2,377

Total 1998–2002 765 187 * More than one contributing factor might be reported per outbreak. † See Appendix A for description of each factor.

32

MMWR

November 10, 2006

TABLE 19. (Continued) Number of reported foodborne-disease outbreaks, by etiology and contributing factors*,† — United States, 1998–2002 Proliferation factors Etiology

P1

P2

P3

P4

P5

P6

P7

P8

16 — 6 7 53 12 — 110 3 42 — — 5 — — 1 255

1 — 1 — 50 2 — 26 1 17 — — — — — — 98

4 — 4 — 20 7 1 53 5 13 — — — — — — 107

4 — — 1 27 3 — 33 1 17 — — 2 — — — 88

— — — — — — — 3 — 1 — — — — — — 4

3 — 1 — 39 6 — 28 — 15 1 — — — — — 93

— — — 3 — — — — — — — — — — — — 3

— — — — — — — 1 — 1 — — — — — — 2


— — — 21 — — 21

— — — — — — —

— — — 18 — — 18

— — — 1 — — 1

— — — — — — —

— — — — — — —

— — — — — — —

— — — — — — —


— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —


— — 17 — 17

— — 4 — 4

— — 8 — 8

— — 3 — 3

— — — — —

— — 6 — 6

— — 1 — 1

— — — — —

9

4

3

2

—

3

—

—

296 589

102 224

136 432

93 159

4 15

100 219

4 1

2 —

571

254

19

322

5

2


Multiple etiologies Confirmed etiology Unknown etiology


Vol. 55 / SS-10


33

TABLE 19. (Continued) Number of reported foodborne-disease outbreaks, by etiology and contributing factors*,† — United States, 1998–2002 Proliferation factors

Etiology

P9

P10

P11

P12

Outbreaks in which proliferation factor reported


— — — — 4 — — 4 — 3 — — — — — — 11

— — — 1 — — 1 — — — — — — — — — 2

— — 1 — — — — — — — — — — — — — 1

— 1 4 1 5 3 — 25 3 1 — — — — 1 — 44

21 1 14 11 103 24 2 186 10 63 1 — 6 — 1 1 444


— — — — — — —

— — — — — — —

— — — — — — —

— — — 3 — — 3

— — — 31 — — 31


— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — — —


— — — — —

— — — — —

— — — — —

— 1 1 — 2

— 1 28 — 29

Multiple etiologies

1

—

—

—

13


11 41

2 —

1 4

50 40

511 1,133

2

5

90

1,657

Total 1998–2002 53 * More than one contributing factor might be reported per outbreak. † See Appendix A for description of each factor.

34

MMWR

November 10, 2006

TABLE 19. (Continued) Number of reported foodborne-disease outbreaks by etiology, and contributing factors*,† — United States, 1998–2002 Survival factors

Outbreaks in which any contributing factor reported

S1

S2

S3

S4

S5

Outbreaks in which survival factor reported

— — 15 5 33 20 1 104 — 8 — — 3 — — — 189

3 — — 1 41 2 — 23 — 14 — — — — — — 84

— — — 2 — — — 1 — — — — — — — — 3

— — 1 — 5 3 — 5 — 2 — — — — — — 16

1 1 6 4 4 4 — 21 4 8 — — 1 — 1 — 55

4 1 21 10 61 27 1 139 4 28 — — 4 — 1 — 301

24 1 39 12 102 68 6 326 27 73 1 2 15 — 4 1 695

37 1 61 12 130 140 11 585 67 101 1 3 25 1 8 1 1,184


— — — 1 — — 1

— — — — — — —

— — — — — — —

— — — — — — —

— — — 3 — — 3

— — — 4 — — 4

58 2 1 74 4 6 145

84 2 2 118 5 10 221


— — — — 3 3

— — — — — —

— — — — — —

— — — — — —

— — — — — —

— — — — 3 3

1 1 6 2 5 15

1 4 9 3 6 23


— — 5 — 5

— — 4 — 4

— — — — —

— — — — —

— — 10 — 10

— — 18 — 18

— 25 319 — 344

1 50 657 1 709

4

1

—

1

1

6

20

30

198 171

88 161

3 2

16 16

69 74

327 369

1,238 1,834

2,167 4,480

5

33

144

702

3,072

6,647

Etiology Bacterial Bacillus cereus Brucella Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Listeria monocytogenes Salmonella Shigella Staphylococcus aureus Streptococcus Vibrio cholerae Vibrio parahaemolyticus Vibrio, other Yersinia enterocolitica Other bacterial Total bacterial

Multiple etiologies Confirmed etiology Unknown etiology


Total

Vol. 55 / SS-10


35

APPENDIX A. CDC form 52.13 Investigation of a Foodborne Outbreak* Electronic Foodborne Outbreak Reporting System

CDC Use Only

Investigation of a Foodborne Outbreak This form is used to report foodborne disease outbreak investigations to CDC. A foodborne outbreak is defined as the occurrence of two or more cases of a similar illness resulting from the ingestion of a common food in the United States. This form has two parts: Part 1 asks for the minimum data needed and Part 2 asks for additional information. For this investigation to be counted in the CDC annual summary, Part 1 must be completed. We encourage you to complete as much as possible of Part 1 and Park 2 as you can.

State Use Only

Part 1: Required Information 1. Location of Exposure State: ___ ___ Multi-state exposure Other State:

2. Dates:

3. Numbers of Cases Exposed: __ __/__ __/__ __ __ __

Date first case became ill:

Month

Month

Month

4. Approximate Percentage of Total Cases in Each Age Group: 50 yrs ____%

Year

__ __/__ __/__ __ __ __

Date of last known exposure:

Lab-confirmed cases:

Year

__ __/__ __/__ __ __ __

Date of first known exposure: Country: _________________ Multi-county exposure Other Countries:

Day

eggs

Investigation at factory or production plant Investigation at original source (farm, marine estuary, etc) Environment / food sample cultures

Reason(s) Suspected (see below)

Method of Preparation (see list on page 2)

4

M1

1.) 2.) 3.)

Food vehicle could not be determined Reason Suspected (Choose all that apply): 1 Statistical evidence from epidemiological investigation 2 Laboratory evidence (e.g., identification of agent in food) 3 Compelling supportive information

4 5

Other data (e.g., same phage type found on farm that supplied eggs) Specific evidence lacking but prior experience makes it likely source

8. Etiology: (Name the bacteria, virus, parasite, or toxin. If available, include serotype and other characteristics such as phage type, virulence factors, molecular fingerprinting, antibiogram, metabolic profile.) Confirmation criteria available at http://www.cdc.gov/ncidod/dbmd/outbreak/ or MMWR2000/Vol 49/SS-1/Appendix B Etiology

Serotype (if available)

1.)

Confirmed Suspected

2.)

Confirmed Suspected

3.)

Confirmed Suspected

Other characteristics (if available)

Etiology undetermined Isolated / Identified from: (Check all that apply:)

Patient specimen(s) Food specimen(s)

Environment specimen(s) Food Worker specimen(s)

This questionnaire is authorized by law (Public Health Act, 42 USC §241). Although response to the questions asked is voluntary, cooperation of the patient is necessary to the study and control of disease. Public reporting burden for this collection of information is estimated to average 15 minutes per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to PHS Reports Clearance Officer; Rm 721-H, Humphrey Bg; 20 Independence Ave, SW; Washington, DC 20201; ATTN: PRA, and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503. CDC 52.13 REV 8/2001

1

* This form is used to collect data for this report. Foodborne outbreak reporting is conducted through a web application. A revised form that reflects recent upgrades to this web application became effective November, 2005. Additional information is available at http://www.cdc.gov/foodborneoutbreaks or CDC’s Enteric Diseases Epidemiology Branch (proposed), telephone 404-639-2206.

36

MMWR

November 10, 2006

9. Contributing Factors**: (See list on page 3, check all that apply)

10. Agency reporting this outbreak:

Contributing factors unknown

________________________________ Contamination Factor: C7

C8

Contact Person:

C1

C2

C3

C4

C5

C6

C10

C11

C12

C13

C14

C15 (describe in Comments)

C9 N/A

NAME: _________________________ TITLE: __________________________ PHONE NO: _____________________ FAX NO: ________________________ E-MAIL: _________________________

Proliferation/Amplification Factor (bacterial outbreaks only): P1

P2

P3

P10

P11

P12 (describe in Comments)

P4

P5

P6

P7

P8

P9

N/A

Survival Factor (microbial outbreaks only): S1

S2

S3

S4

Date of completion of this form:

S5 (describe in Comments)

N/A

__ __/__ __/__ __ __ __ Month Day

Was food-worker implicated as the source of contamination? Ye s No If yes, please check only one of following:

Year

Initial Report Updated Report Final Report Additional data suggests this is not a foodborne outbreak

laboratory and epidemiologic evidence epidemiologic evidence (w/o lab confirmation) lab evidence (w/o epidemiologic evidence) prior experience makes this the likely source (please explain in Comments)

Part 2: Additional Information (Please complete as much as possible) 12. Incubation Period:

11. Numbers of: OUTCOME/SYMPTOM

Cases with Outcome / Symptom

Total cases for whom you have information available

Healthcare Provider Visit Hospitalization Death

13. Duration of Acute Illness Among Those Who Recovered:

(circle appropriate units) Shortest: _______ (Hours, days) Longest: _______ (Hours, days) Median: _______ (Hours, days) Unknown

(circle appropriate units) Shortest: _______ (Hours, days) Longest: _______ (Hours, days) Median: _______ (Hours, days) Unknown

Vomiting Diarrhea

Use the following terms, if appropriate, to describe other common characteristics of cases:

Bloody Stools

anaphylaxis arthralgia bradycardia bullous skin lesions cough coma descending paralysis

Fever Abdominal Cramps

diplopia flushing headache hemolytic uremic syndrome (HUS) hypotension itching jaundice lethargy

myalgia paresthesia septicemia sore throat tachycardia thromobocytopenia temperature reversal urticaria wheezing

14. If Cohort Investigation Conducted: Event-specific Attack Rate = _______________ / _____________________________________ x 100 = ___________% # ill total

# of persons for whom you have illness info.

16. Where was Food Eaten? (Check all that apply)

15. Where was Food Prepared? (Check all that apply) Restaurant or deli Day care center School Church, temple, etc Camp Caterer Grocery Store Hospital Workplace cafeteria

Nursing home Prison, jail Private home Picnic Fair, festival, other temporary/ mobile services Contaminated food imported into U.S. Commercial product, served without further preparation Other (please describe) ______________________________________

17. Other Available Info: Unpublished agency report (please attach) Epi-Aid Publication (please reference) _________________________ Not available

Restaurant or deli Day care center School Church, temple, etc. Camp Grocery Store Hospital Workplace cafeteria

Nursing Home Prison, jail Private home Picnic Fair, festival, temporary/ mobile service Other (please describe) ____________________

18. Remarks: Briefly describe important aspects of the outbreak not covered above (e.g., restaurant closure, product recall, immunoglobin administration, economic impact, etc)

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

State Health Departments: If you have not entered this information into EFORS (Electronic Foodborne Outbreak Reporting System), please send this document to the Foodborne and Diarrheal Disease Branch, Centers for Disease Control and Prevention, 1600 Clifton Road Mailstop A-38, Atlanta, GA 30333, Phone: 404-639-2206, Fax: 404-639-2205 CDC 52.13 REV 8/2001

2

Vol. 55 / SS-10


**Contributing factor definitions: Contamination Factors: C1 -Toxic substance part of tissue (e.g., ciguatera) C2 -Poisonous substance intentionally added (e.g., cyanide or phenolphthalein added to cause illness) C3 -Poisonous or physical substance accidentally/incidentally added (e.g., sanitizer or cleaning compound) C4 -Addition of excessive quantities of ingredients that are toxic under these situations (e.g., niacin poisoning in bread) C5 - Toxic container or pipelines (e.g., galvanized containers with acid food, copper pipe with carbonated beverages) C6 -Raw product/ingredient contaminated by pathogens from animal or environment (e.g., Salmonella enteriditis in egg, Norwalk in shellfish, E. coli in sprouts) C7 -Ingestion of contaminated raw products (e.g., raw shellfish, produce, eggs) C8 -Obtaining foods from polluted sources (e.g., shellfish) C9 -Cross-contamination from raw ingredient of animal origin (e.g., raw poultry on the cutting board) C10 - Bare-handed contact by handler/worker/preparer (e.g., with ready-to-eat food) C11 - Glove-handed contact by handler/worker/preparer (e.g., with ready-to-eat food) C12 - Handling by an infected person or carrier of pathogen (e.g., Staphylococcus spp., Salmonella spp., Norwalk agent) C13 - Inadequate cleaning of processing/preparation equipment/utensils B leads to contamination of vehicle (e.g., cutting boards) C14 - Storage in contaminated environment B leads to contamination of vehicle (e.g., store room, refrigerator) C15 - Other source of contamination (please describe in Comments) Proliferation Factors: P1 - Allowing foods to remain at room or warm outdoor temperature for several hours (e.g., during preparation or holding for service) P2 - Slow cooling (e.g., deep containers or large roasts) P3 - Inadequate cold-holding temperatures (e.g., refrigerator inadequate/not working, iced holding inadequate) P4 - Preparing foods a half day or more before serving (e.g., banquet preparation a day in advance) P5 - Prolonged cold storage for several weeks (e.g., permits slow growth of psychrophilic pathogens) P6 - Insufficient time and/or temperature during hot holding (e.g., malfunctioning equipment, too large a mass of food) P7 - Insufficient acidification (e.g., home canned foods) P8 - Insufficiently low water activity (e.g., smoked/salted fish) P9 - Inadequate thawing of frozen products (e.g., room thawing) P10 - Anaerobic packaging/Modified atmosphere (e.g., vacuum packed fish, salad in gas flushed bag) P11 - Inadequate fermentation (e.g., processed meat, cheese) P12 - Other situations that promote or allow microbial growth or toxic production (please describe in Comments) Survival Factors: S1 - Insufficient time and/or temperature during initial cooking/heat processing (e.g., roasted meats/poultry, canned foods, pasteurization) S2 - Insufficient time and/or temperature during reheating (e.g., sauces, roasts) S3 - Inadequate acidification (e.g., mayonnaise, tomatoes canned) S4 - Insufficient thawing, followed by insufficient cooking (e.g., frozen turkey) S5 - Other process failures that permit the agent to survive (please describe in Comments)

CDC 52.13 REV 8/2001

3

37

38

MMWR

November 10, 2006

APPENDIX B. Guidelines for Confirmation of Foodborne-Disease Outbreaks A foodborne disease outbreak (FBDO) is defined as an incident in which two or more persons experience a similar illness resulting from the ingestion of a common food.* The following table provides information about incubation periods, clinical syndromes, and criteria for confirming the etiology once an FBDO has been identified. The information on incubation periods and clinical syndromes is provided as a guideline and should not be included in the confirmation criteria. These guidelines might not include all etiologic agents and diagnostic tests. FBDOs should be reported to the Foodborne and Diarrheal Diseases Branch at CDC through the Electronic

Foodborne Outbreak Reporting System (eFORS) using the web-based Form 52.13, Investigation of a Foodborne Outbreak, which was updated in October 1999. Provision of other documents describing the outbreak investigation also is encouraged. For information about collecting laboratory specimens and for additional information on viral agents, refer to other CDC publications (i.e., Recommendations for collection of laboratory specimens associated with outbreaks of gastroenteritis. MMWR 1990;39[No. RR-14] and Viral agents of gastroenteritis: public health importance and outbreak management. MMWR 1990;39[No. RR-5]).

* Before 1992, three exceptions existed to this definition; only one case of botulism, marine-toxin intoxication, or chemical intoxication was required to constitute an FBDO if the etiology was confirmed. The definition was changed in 1992 to require two or more cases to constitute an outbreak.

TABLE. Guidelines for confirmation of foodborne-disease outbreaks Etiologic agent

Incubation period

Clinical syndrome

Confirmation

Bacterial 1. Bacillus cereus a. Vomiting toxin

b. Diarrheal toxin

1–6 hrs

Vomiting; some patients with diarrhea; fever uncommon

Isolation of organism from stool of two or more ill persons and not from stool of control patients OR Isolation of 105 organisms/g from epidemiologically implicated food, provided specimen is properly handled

6–24 hrs

Diarrhea, abdominal cramps, and vomiting in some patients; fever uncommon

Isolation of organism from stool of two or more ill persons and not from stool of control patients OR Isolation of 105 organisms/g from epidemiologically implicated food, provided specimen is properly handled

2. Brucella

Several days to several months; Weakness, fever, headache, sweats, usually >30 days chills, arthralgia, weight loss, and splenomegaly

Two or more ill persons and isolation of organism in culture of blood or bone marrow; greater than fourfold increase in standard agglutination titer (SAT) over several weeks, or single SAT 1:160 in person who has compatible clinical symptoms and history of exposure

3. Campylobacter jejuni/coli

2–10 days; usually 2–5 days

Isolation of organism from clinical specimens from two or more ill persons OR Isolation of organism from epidemiologically implicated food

Diarrhea (often bloody), abdominal pain, and fever

Vol. 55 / SS-10


39

TABLE. (Continued) Guidelines for confirmation of foodborne-disease outbreaks Etiologic agent Bacterial 4. Clostridium botulinum

Incubation period

Clinical syndrome

Confirmation

2 hours–8 days; usually 12–48 hrs

Illness of variable severity; common symptoms are diplopia, blurred vision, and bulbar weakness; paralysis, which is usually descending and bilateral, might progress rapidly

Detection of botulinum toxin in serum, stool, gastric contents, or implicated food OR Isolation of organism from stool or intestine

6–24 hrs

Diarrhea and abdominal cramps; vomiting and fever uncommon

Isolation of 106 organisms/g from stool of two or more ill persons, provided specimen is properly handled OR Demonstration of enterotoxin in the stool of two or more ill persons OR Isolation of 105 organisms/g from epidemiologically implicated food, provided specimen is properly handled


Diarrhea (often bloody), abdominal cramps (often severe), and little or no fever

Isolation of E. coli O157:H7 or other Shiga-like toxin-producing E. coli from clinical specimen from two or more ill persons OR Isolation of E. coli O157:H7 or other Shiga-like toxin-producing E. coli from epidemiologically implicated food

b. Enterotoxigenic (ETEC)

6–48 hours

Diarrhea, abdominal cramps, and nausea; vomiting and fever less common

Isolation of organism of same serotype, demonstrated to produce heat-stable (ST) and/or heat-labile (LT) enterotoxin, from stool of two or more ill persons

c. Enteropathogenic (EPEC)

Variable

Diarrhea, fever, and abdominal cramps

Isolation of organism of same enteropathogenic serotype from stool of two or more ill persons

d. Enteroinvasive (EIEC)

Variable

Diarrhea (might be bloody), fever, and abdominal cramps

2–6 weeks

Meningitis, neonatal sepsis, and fever

Isolation of organism from normally sterile site

Unknown

Diarrhea, abdominal cramps, and fever

Isolation of organism of same serotype from stool of two or more ill persons exposed to food that is epidemiologically implicated or from which organism of same serotype has been isolated

8. Nontyphoidal Salmonella

6 hrs–10 days; usually 6–48 hours

Diarrhea, often with fever and abdominal cramps

Isolation of organism of same serotype from clinical specimens from two or more ill persons OR Isolation of organism from epidemiologically implicated food

9. Salmonella Typhi


Fever, anorexia, malaise, headache, and myalgia; sometimes diarrhea or constipation

Isolation of organism from clinical specimens from two or more ill persons OR Isolation of organism from epidemiologically implicated food

5. Clostridium perfringens

6. Escherichia coli a. Enterohemorrhagic (E. coli O157:H7 and others)

7. Listeria monocytogenes a. Invasive disease b. Diarrheal disease

Isolation of same enteroinvasive serotype from stool of two or more ill persons

40

MMWR

November 10, 2006

TABLE. (Continued) Guidelines for confirmation of foodborne-disease outbreaks Etiologic agent Bacterial 10. Shigella spp.

Incubation period

Clinical syndrome

Confirmation

12 hours–6 days; usually 2–4 days

Diarrhea (often bloody), often accompanied by fever and abdominal cramps

Isolation of organism of same serotype from clinical specimens from two or more ill persons OR Isolation of organism from epidemiologically implicated food

11. Staphylococcus aureus

30 minutes–8 hours; usually 2–4 hours

Vomiting and diarrhea

Isolation of organism of same phage type from stool or vomitus of two or more ill persons OR Detection of enterotoxin in epidemiologically implicated food OR Isolation of 105 organisms/g from epidemiologically implicated food, provided specimen is properly handled

12. Streptococcus, group A

1–4 days

Fever, pharyngitis, scarlet fever, and upper-respiratory infection

Isolation of organism of same M- or Ttype from throats of two or more ill persons OR Isolation of organism of same M- or Ttype from epidemiologically implicated food

13. Vibrio cholerae a. O1 or O139

1–5 days

Watery diarrhea, often accompanied by vomiting

Isolation of toxigenic organism from stool or vomitus of two or more ill persons OR Significant rise in vibriocidal, bacterialagglutinating, or antitoxin antibodies in acute- and early convalescent-phase sera among persons not recently vaccinated OR Isolation of toxigenic organism from epidemiologically implicated food

1–5 days

Watery diarrhea

Isolation of organism of same serotype from stool of two or more ill persons

14. Vibrio parahaemolyticus

4–30 hours

Diarrhea

Isolation of Kanagawa-positive organism from stool of two or more ill persons OR Isolation of 105 Kanagawa-positive organisms/g from epidemiologically implicated food, provided specimen is properly handled

15. Yersinia enterocolitica


Diarrhea and abdominal pain (often severe)

Isolation of organism from clinical specimen from two or more ill persons OR Isolation of pathogenic strain of organism from epidemiologically implicated food

b. non-O1 and non-O139

Vol. 55 / SS-10


41

TABLE. (Continued) Guidelines for confirmation of foodborne-disease outbreaks Etiologic agent Chemical 1. Marine toxins a. Ciguatoxin

Incubation period

Clinical syndrome

Confirmation

1–48 hours; usually 2–8 hours

Usually gastrointestinal symptoms, followed by neurologic symptoms (including paresthesia of lips, tongue, throat, or extremities) and reversal of hot and cold sensation

Demonstration of ciguatoxin in epidemiologically implicated fish OR Clinical syndrome among persons who have eaten a type of fish previously associated with ciguatera fish poisoning (e.g., snapper, grouper, or barracuda)

b. Scombroid toxin (histamine)

1 minute–3 hours; usually

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