In the 21st in a series of assessments of Healthy People 2010,
Senior Executive Advisor to the Assistant Secretary for Health Larry Fields chaired
a focus area Progress Review on Food Safety. Dr. Fields noted that food supplies in
the United States are generally maintained at such high levels of safety that citizens
seldom give much thought to the subject. Food safety rarely becomes a public issue,
except on occasions when outbreaks of foodborne illness make headline news. However,
the problem is ongoing and has serious dimensions. Foodborne infections are estimated
to cause approximately 76 million illnesses each year in the United States, resulting
in approximately 325,000 hospitalizations and 5,000 deaths annually. In conducting
the review, Dr. Fields was assisted by staff of the co-lead agencies for this Healthy
People 2010 focus area, the Food and Drug Administration (FDA) and the Food Safety
and Inspection Service (FSIS) of the Department of Agriculture (USDA). Also participating
were representatives of other Department of Health and Human Services (HHS) offices
and agencies.
The complete text for the Food Safety focus area of Healthy People 2010 is
available at www.healthypeople.gov/
document/html/volume1/10food.htm. The Progress Review materials on challenges
and strategies for reaching the objectives of the focus area can be found at the FDA
Web sites www.cfsan.fda.gov/~dms/hp2010.html
and www.cfsan.fda.gov/~dms/hp2010ed.html.
The meeting agenda, tabulated data for all focus area objectives, charts, and other
materials used in the Progress Review are at www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/
fa10-food.htm.
Data Trends
Richard Klein of the National Center for Health Statistics/Centers for Disease Control
and Prevention (CDC) provided a summation of progress achieved in meeting the targets
of selected objectives in the Food Safety focus area. Mr. Klein characterized the consequences
of most foodborne infections as high morbidity and lower mortality, with an estimated
annual burden in costs of $23 billion. Of all infections caused by the key foodborne
pathogens tracked by Healthy People 2010, Campylobacter and Salmonella
species combined account for the majority of all cases. From 1997 to 2002, the crude
incidence of laboratory-confirmed Campylobacter spp. infections decreased
from 24.6 to 13.3 cases per 100,000 population. The 2010 target is 12.3 cases per 100,000
(Obj. 10-1a). Over the same period, the crude incidence of laboratory-confirmed Salmonella
spp. infections increased from 13.6 to 16.2 cases per 100,000. The target is 6.8 cases
per 100,000 (Obj. 10-1d). The crude incidence of laboratory-confirmed Listeria
monocytogenes declined over the 5-year period from 0.47 to 0.26 cases per 100,000,
almost achieving the target of 0.25 cases per 100,000 (Obj. 10-1c). The crude incidence
of laboratory-confirmed Escherichia coli O157:H7 (Obj. 10-1b) showed no clear
trend during this period, reaching 1.7 cases per 100,000 in 2002 (target, 1.0 cases
per 100,000). Cases of postdiarrheal hemolytic uremic syndrome (HUS) per 100,000 population
younger than 5 years increased from 1.36 per 100,000 in 1997 to 1.91 per 100,000 in
2002. A target has not been officially established (Obj. 10-1f).
Increases in the number of outbreaks (i.e., two or more cases of the same illness
resulting from ingestion of the same food) could reflect enhanced reporting of smaller
outbreaks, not a true increase in outbreak frequency. The number of outbreaks of E.
coli O157:H7 increased from 22 in 1997 to 69 in 2000, then decreased to 38 in
2002. The 2010 target is 11 outbreaks (Obj. 10-2a). During that 6-year period, outbreaks
of Salmonella serotype Enteritidis increased from 44 in 1997 to 50 in 2000,
then decreased to 29 in 2002. The target is 22 outbreaks (Obj. 10-2b).
Year 2010 targets for the proportion of human isolates of non-typhi Salmonella
spp. that are resistant to antimicrobial drugs were set at no increase from the 1997
baselines. Two antibiotics surpassed their 2010 targets in 2002: (1) 1 percent of isolates
were found resistant to gentamicin, which was targeted at no increase over 3 percent
(Obj. 10-3c), and (2) 13 percent of isolates were found resistant to ampicillin, which
was targeted at no increase over 18 percent (Obj. 10-3d). In 2002, the proportion of
non-typhi Salmonella spp. isolates from humans that were fluoroquinolone-resistant
was 0.1 percent (Obj. 10-3a). The proportion of such isolates that were third-generation
cephalosporin-resistant was 0.2 percent in 2002 (Obj. 10-3b). The targets for both
are 0.0 percent.
The proportion of adult consumers who follow key food safety practices moved toward
the 79-percent target, increasing from 73 percent in 1998 to 75 percent in 2001 (Obj.
10-5). Slight improvements in food safety practices were recorded for every population
group for which data were available, including blacks, whites, females, males, and
people grouped according to three levels of educational attainment. In 1998, FDA conducted
a study that focused on direct observations of 42 data items concerning food safety
practices and employee behaviors as factors in the control of foodborne illness within
selected institutional foodservice, restaurant, and retail food store facility types.
When the results for the 42 data items were combined, the overall in-compliance percentage
of observations ranged from 60 to 83 percent among the 9 facility types selected, based
on the 1997 FDA Food Code provisions (Obj. 10-6).
Key Challenges and Current Strategies
In the presentations that followed the data overview, the principal themes were introduced
by representatives of the two co-lead agencies: Robert Brackett, Director of FDA’s
Center for Food Safety and Applied Nutrition, and Karen Hulebak, FSIS Deputy Administrator.
With the aid of briefing materials provided to Dr. Fields, these agency representatives
and other participants in the review identified a number of obstacles to achieving
the objectives and discussed activities under way to meet these challenges, including
the following:
In the United States, about 81 percent of cases of foodborne illness and 64 percent
of deaths from such illness cannot be ascribed to an identified pathogen. To some extent,
the inability to ascribe such illnesses to specific pathogens is caused by inadequate detection methods. In addition, some pathogens currently recognized as
causes
of foodborne illness were unknown 20 years ago, and the likelihood is that others will
be identified in the future.
Research indicates the expected number of deaths from anaphylaxis caused by
food allergies to be around 125 annually, but death certificates currently show only
about 20 such deaths a year, a likely underreporting.
New challenges to the safety of the nation’s food supply include microbiological
contaminants, such as Enterobacter sakazakii, and hazardous chemicals, including
methyl mercury, polychlorinated biphenyls (PCBs), dioxins, acrylamide, and furans.
Small-scale producers in the United States account for only 10 percent of the food
supply but 90 percent of the outbreaks of foodborne illness.
Produce has become an increasing source of foodborne illnesses, with more than
1,000 such cases reported in 2003. Included were Salmonella and Shigella
from different types of melons, E. coli O157:H7 from pre-cut lettuce and
pre-cut spinach, and hepatitis A virus from green onions. FDA has developed the Produce
Initiative to address the problem.
Established in 1996, the Foodborne Diseases Active Surveillance Network (FoodNet)
conducts laboratory-based surveillance of sporadic cases of foodborne disease to identify
their sources, burden, and severity. FoodNet is a collaborative activity of FDA, FSIS,
CDC, and 10 states.
The Electronic Foodborne Outbreak Reporting System (EFORS) is CDC’s new
Internet-based system through which state health departments can report outbreaks of
foodborne disease.
Since 1997, the Hazard Analysis and Critical Control Points (HACCP) system
of inspection
has been implemented by FDA and FSIS regulations covering the production of seafood,
meat, poultry, and juice products. HACCP is an internationally recognized scientific
approach to producing safer food by anticipating how biological, chemical, or physical
hazards are most likely to occur and by installing appropriate measures to prevent
their occurrence.
FDA will publish proposed rules to introduce measures for reducing Salmonella
Enteritidis in shell eggs, which continue to be a source of infections. A standard
protocol, soon to be released, can be used by field personnel when investigating
Salmonella Enteritidis outbreaks attributed to egg consumption. FDA also
is encouraging states to adopt the safe egg handling and preparation provisions in
the agency’s 2001 Food Code.
FSIS introduced an educational campaign
designed to reach millions of consumers with
food safety messages. The campaign’s centerpiece
is the Food Safety Mobile, which travels the country disseminating food safety information
and developing partnerships at the local level. In 2003, the Food Safety Mobile visited
28 states and participated in almost 90 events.
In April 2004, FDA, CDC, FSIS, the American Medical Association, and the American
Nurses Association-American Nurses Foundation collaboratively produced and released
Diagnosis and Management of Foodborne Illnesses, A Primer for Physicians and
Other Healthcare Professionals as an educational resource to assist primary
care physicians and others in recognizing, diagnosing, and treating foodborne illness.
The National Antimicrobial Resistance Monitoring System (NARMS) was established
in 1996 in response to concerns about increased antimicrobial resistance in humans
and food animals. NARMS is a collaborative program between FDA, CDC, and USDA to monitor
trends over time in antimicrobial susceptibilities of foodborne enteric organisms.
An initiative proposed by USDA will follow antimicrobial resistance from farm to table,
providing more complete data.
Approaches for Consideration
Participants in the review made the following suggestions for steps to enable further
progress toward achievement of the objectives for the Food Safety focus area:
Urge states to make training in food safety a part
of the curricula of school science classes.
Inasmuch as there has been a fivefold or sixfold increase in imported food
products in recent years, increase efforts to include foreign producers as targets
for educational messages and training courses on maintaining the safety of food supplies.
Seek to reduce reluctance on the part of many healthcare professionals to providing
food safety advice to their patients.
Intensify efforts to assess the illness burden of specific viruses and parasites
that are suspected
to be sources of foodborne disease but are not currently identified and tracked as
such.
Integrate the protection of food supplies more thoroughly into planning for
measures to ensure homeland security.
When appropriate, incorporate advice about
good nutrition into public messages about food safety practices.
Take additional steps to protect the health of groups at greatest risk of morbidity
and mortality from Listeria monocytogenes, including pregnant women and
their fetuses, newborns, the elderly, diabetics, and those with compromised immune
systems.
Counter underreporting of deaths from anaphylaxis caused by food allergies
by outreach to increase the familiarity of medical examiners with the ICD-10 classification
system and its use of new codes.
Explore innovative approaches to effecting
desirable behavior changes in employees of retail food and food service establishments.
Contacts for information about Healthy People 2010 focus area 10—Food
Safety :
- Office of Disease Prevention and Health Promotion (coordinator of the Progress
Reviews)—Ellis Davis (liaison to the focus area 10 workgroup), edavis@osophs.dhhs.gov
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Cristina V. Beato, M.D.
Acting Assistant Secretary for Health
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