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![Page 1: Listeriosis in the United States Frederick J Angulo, DVM, PhD Enteric Diseases Epidemiology Branch Division of Foodborne, Bacterial and Mycotic Diseases.](https://reader035.fdocuments.net/reader035/viewer/2022062719/56649eeb5503460f94bfcc81/html5/thumbnails/1.jpg)
Listeriosis in the United States
Frederick J Angulo, DVM, PhDEnteric Diseases Epidemiology Branch
Division of Foodborne, Bacterial and Mycotic DiseasesCenters for Disease Control and Prevention
June 23, 2009
Unpublished data in this presentation is preliminary
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Listeriosis
1. Clinical characteristics2. Human health burden3. Trends in incidence4. Sources5. Conclusions
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1. Clinical characteristics
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1. Clinical characteristics
Pregnancy-associated infection
Non-pregnancy-associated infection
- Immune compromised- Previously healthy
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Pregnancy-associated infection
• Pregnant woman may have fever, or not have a defined illness
• Spread to the fetus- Sepsis, miscarriage, stillbirth
• Spread to the newborn baby- Meningitis
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Non-pregnancy-associated infection
• Immune compromised (malignancy, organ transplant, immunosuppressive medications, HIV/AIDS)
- Invasive disease (Sepsis, meningitis, encephalitis)
• Previously healthy
- Most often asymptomatic
- Diarrheal illness, rarely invasive
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Clinical outcomes of 169 laboratory-confirmed cases in the FoodNet, 2000-2003
28 (17%) pregnancy-associated cases• All invasive infections• 18 (65%) hospitalized• 7 (25%) associated with stillbirth
141 (83%) non-pregnancy-associated cases• All invasive infections
– 108 (76%) immune compromised– 33 (24%) previously healthy
• 131 (92%) hospitalized• 22 (15%) died
Overall hospitalization rate 82%Overall mortality 17%
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2. Human health burden
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Estimated annual human health burden of selected foodborne diseases,
United States
Pathogen Illnesses Deaths Case-fatality rate
Campylobacter 2,453,926 124 0.1%
Salmonella 1,412,498 582 0.8%
E. coli O157:H7 73,480 61 0.8%
Listeria 2,518 504 20.0%
Mead P, et al, Emerging Infectious Diseases, 1999
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Incidence of invasive laboratory-confirmed Listeria infection in different population
groups, FoodNet (1996-2003)
4 per million persons in general population
•2 per million among White, non Hispanic•2 per million among African-Americans•4 per million among Asians
2 per million among non-Hispanic7 per million among Hispanics
Voetsch A, et al, Clinical Infectious Diseases, 2007
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Incidence of invasive laboratory-confirmed Listeria infection in different
population groups, FoodNet (1996-2003)
Among infants•Incidence rate 12 fold higher among Hispanics than among non Hispanics
Among women of childbearing age•Incidence rate 11 fold higher among Hispanics than among non-Hispanics
Voetsch A, et al, Clinical Infectious Diseases, 2007
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3. Trends in incidence
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Early timeline: establishing surveillance
1985: Large California outbreak: 142 cases with 40 deaths due to Mexican style soft cheese, queso fresco
1986: Active surveillance began in sentinel locations
1989: Associated with turkey hot dog – industry efforts to control
1996: Active surveillance incorporated into FoodNet (with support of USDA-FSIS and FDA-CSFAN)
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012
34567
89
10
'86 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07
Year
Cas
es p
er m
illio
n po
pula
tion
Active surveillanc
Trend in incidence of laboratory-confirmed Listeria infection in sentinel sites in the United States, 1986-2008
FoodNet began
New regulatory policies,Industry efforts
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FoodNet Sites, 2009
~ 46 million persons (15% of U.S. population)
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National Health objectives for the incidence of laboratory-confirmed Listeria infection
Healthy People 2010 National Health Objective was a 50% reduction in the incidence of laboratory-confirmed Listeria infections
-Baseline 1996-1998- Goal: incidence of 2.4 cases per 100,000 population in 2010
Presidential Initiative accelerated National Health Objective to 2005
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1.0
0.9
0.8
0.7
0.6
0.5
0.4
2.0
1996-1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Rel
ati
ve
rate
(lo
g s
cale
)
36% (20% to 49%)
†The position of each line indicates only the relative change in the incidence of that pathogen compared with the years 1996-1998. The actual incidences of these infections can differ
FIGURE. Relative rates compared with 1996-1998 period of laboratory-diagnosed cases of infection with Listeria, by year. Foodborne Diseases Active Surveillance Network, 1996-2008†
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Trend in incidence of laboratory-confirmed Listeria infection
• No change in Listeria infections in 2008 compared with previous 3 years
• National Health objective for 2005 was 0.24 cases/100,000 persons
• 2004: 0.27 cases/100,000 persons
• 2005: 0.30 cases/100,000 persons
• 2006: 0.31 cases/100,000 persons
• 2007: 0.27 cases/100,000 persons
• 2008: 0.29 cases/100,000 persons
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FIGURE 1. Percent change in incidence of laboratory confirmed bacterial and parasitic infections in 2008 compared with 2005-2007, by pathogen - Foodborne Diseases Active Surveillance Network, United States
-100
-80
-60
-40
-20
0
20
40
60
80
100
Campylobacter Listeria Salmonella Shigella STEC O157 Vibrio Yersinia Cryptosporidium
No change
Incr
ea
seD
ecr
ea
se
% c
han
ge*
Percent change estimate
95% confidence interval
STEC† O157
Pathogen
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Trend in incidence of laboratory-confirmed Listeria
Incidence has declined from 1989- Two periods of greatest decline
1989 to 19931997 to 2001
In 2009, the incidence was 36% below the incidence from the 1996-1998 FoodNet baseline
- We did NOT meet the National Health Objective of a 50% reduction by 2005
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4. Sources
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Sources of laboratory-confirmed Listeria infections
Source attribution: the partitioning of the human health burden to specific sources
-Attribution may conducted at different places from farm-to-table
“Point of consumption” attribution-Case-control studies of sporadic infections-Outbreak investigations
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Sources of laboratory-confirmed Listeria infections
Determining the source is difficult-geographically dispersed-Incubation period of up to 30 days makes remembering food eaten difficult
Case-control studies-Selection of controls difficult
Outbreaks- Delays common
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Case-control studies of sporadic infections
1986-87 (Schwartz B, et al. Lancet 1988)• Uncooked or non-reheated hot dogs
1988-90 (Schuchat A, et al. JAMA 1992)• Soft cheeses and food purchased at retail (deli
counters)
2000-03 FoodNet (Varma J, Clinical Infectious Diseases 2007)• Hummus and melons purchased at retail (grocery
stores)
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Recent timeline: improving outbreak detection and response
1998: PulseNet began routine PFGE of Listeria
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012
34567
89
10
'86 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07
Year
Cas
es p
er m
illio
n po
pula
tion
Active surveillanc
Trend in incidence of laboratory-confirmed cases of listeriosis in sentinel sites in the United States, 1986-2008
FoodNet began
PulseNet began
subtyping
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PulseNet molecular fingerprinting networkPFGE
patterns
National database
Participating laboratories
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012
34567
89
10
'86 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07
Year
Cas
es p
er m
illio
n po
pula
tion
Active surveillanc
Trend in incidence of laboratory-confirmed cases of listeriosis in sentinel sites in the United States, 1986-2008
Hot dog
PulseNet began
subtyping
Turkey deli meat
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108 cases in 24 states, 13 were perinatal
14 deaths (all adults), 4 miscarriages
Epidemiological investigation implicated eating hot dogs from Plant A
Hot dog-associated outbreak 1998-1999
12
Nu
mb
er o
f P
atie
nts
Death or miscarriage
6/27 8/2 9/6 10/1111/1512/20 1/24 2/27 4/30123456789
1011
Date
Recall Survived
PlantConstruction
Mead P, et al. Epidemiology and Infection 2006 134:744-751
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Turkey deli meat-associated outbreak, 2002
54 patients in 9 states • 42 non-pregnant adults• 8 deaths, 3 miscarriages/stillbirths
Outbreak was caused by turkey deli meat
Post-processing contamination likely
USDA-FSIS issued new microbial sampling policy• Increased environmental testing
• Can base recall on testing of food contact surfaces
Gottlieb S, et. al. Clinical Infectious Diseases 2006 42:29-36
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Recent timeline: improving outbreak detection and response
1998: PulseNet began routine PFGE of Listeria
2001: Became nationally notifiable
2004: Began Listeria Initiative
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Listeria Initiative
All isolates are fingerprinted in PulseNet
Encourage states to use a standard case interview form
Monitoring for clusters
Immediate analysis of clusters using case-control study design• Cases: serotype/genotype matched
• Controls: patients with non-matching isolates
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012
34567
89
10
'86 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07
Year
Cas
es p
er m
illio
n po
pula
tion
Active surveillanc
Trend in incidence of laboratory-confirmed cases of listeriosis in sentinel sites in the United States, 1986-2008
Hot dog
PulseNet began
subtypingNationallynotifiable Listeria
Iniatitve
Turkey deli meat
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Lm Outbreaks reported to CDC Foodborne Outbreak Reporting System, 1978-2007
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Outbreaks of Listeria monocytogenes Infections Reported to eFORS, 1998-2007
Year State Serotype Ill Food
1998 ML 4b 108 hot dog
1999 MN 5 deli meat
1999 NY 6 food not reported
1999 NY 1/2a 4 hot dog
1999 FL 2 deli meat: turkey; ham; roast beef
1999 ML 1/2a 11 pate
2000 ML 1/2a 29 deli meat, sliced turkey
2000 NC 4b 12 queso fresco
2001 CA 28 sandwich, deli
2002 ML 4b 54 deli meat, sliced turkey
2003 NY 3 food not reported
2003 TX 4b 12 queso fresco, unpasteurized
2005 NY 4b 6 food not reported
2005 NY 1/2b 3 grilled chicken
2005 ML 1/2a 13 deli meat, sliced turkey
2005 TX 4b 12 queso fresco
2006 OR 4b 2 food not reported
2006 MN 2 taco or nacho salad
2006 OR 3 cheese
2006 OH 3b 3 ham
2007 MA 4b 4 pasteurized milk
21 OutbreaksDeli meat = 7Cheese = 4Hot dogs = 2Pate = 1Salad = 1Chicken = 1Milk = 1
Not reported = 4
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Selected recent outbreaks:(1) February 2008
• Routine testing of chicken salad at retail yielded Listeria; product recalled
• Patient’s PFGE pattern matched that of the recalled chicken products (patient died)
• Prompt interview of patient’s family– Patient ate chicken salad from same plant but on
list of recalled products– Recall expanded
• Listeria isolated at the plant; plant temporarily closed
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Selected recent outbreaks: (2) August-September 2008
• Outbreak in NYC hospital: 5 persons hospitalized for other reasons (immune suppressed), becam infected with Listeria of same PFGE pattern; 3 patients die
• Outbreak caused by tuna salad contaminated in the hospital’s kitchen
• Listeria same PFGE isolated from kitchen–Immune suppressed patients not on special
diet (survey of NY city hospitals finds similar in other hospitals)
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Selected recent outbreaks: (3) October 2008-March 2009
Rapid patient interviews identifies Mexican style soft cheese in common (when have only 3 cases)
Although outbreak lasts six months, identification of source was rapid• 8 patients – all Hispanic ethnicity; 7/8 pregnant
(all stillborn)• Traced to commercially-produced, pasteurized
Mexican-style soft cheese• Listeria with same PFGE isolated from
patients, cheese, and plant: plant closed
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Selected recent outbreaks: (4) March 2008 – March 2009
Prolonged outbreak: No common exposures identified using rapid interviews• 20 patients in 7 states• Hypothesis interviews identifies alfalfa sprouts eaten
by couple cases• Case-control study implicated alfalfa sprouts• Outbreak caused by alfalfa sprouts produced at a
single grower• Listeria of same PFGE pattern isolated from
patients, sprouts, and sprouting facility: facility closed
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Sources
For last two decades outbreaks most often caused by:
• Processed ready-to-eat meats, especially turkey and hot dogs
• Typically contaminated after initial processing
• Locus of contamination in the processing plant
• Fresh soft cheeses made with raw milk
• Recent outbreak associated with alfalfa sprouts
Sporadic cases associated with:
• Unreheated hot dogs, undercooked poultry
• Foods from a deli, soft cheeses
• Hummus, sliced melons
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5. Conclusions
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BURDEN• Mortality is high (about 20%)
• Highest incidence in Hispanics
TREND• Overall incidence has declined from 8 per million to 2.9 per million
in the last two decade
• Little change since 2002: did NOT meet National Goal
SOURCE• Enhanced surveillance leading to more outbreaks
• Novel foods continue to be identified: Produce identified for first time
Targeted efforts to reduce contamination have been followed by declines in incidence of human illness
General conclusions from the epidemiological data
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Thank you
The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention