Epidemiologic Principles and Food Safety

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To my mother, Miriam

3
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Library of Congress Cataloging-in-Publication Data

Epidemiologic principles and food safety / edited by Tamar Lasky.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-19-517263-8
1. Food—Safety measures. 2. Epidemiology. 3. Food supply. 4. Food—Toxicology.
I. Lasky, Tamar.
[DNLM: 1. Food Contamination—prevention & control. 2. Epidemiologic Studies.
3. Food Handling—methods. WA 701 E64 2006]
RA1258.E65 2006
363.19'26—dc22 2006021979

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
FOREWORD

Food is much more than personal fuel—food creates community. We welcome

friends and family into our homes with a meal. We celebrate important occa-
sions with feasts. We carry food to those in mourning. We receive food as
daily comfort. We don’t think of food as a risk.
But there is risk.
When we consider factors that spread disease, ticks or rats spring to mind
more quickly than scrambled eggs or a juicy hamburger. What could be more
wholesome than those fresh sprouts at the salad bar? But foods bring risk, as
this book bluntly reminds us. In the United States alone, millions are diag-
nosed each year with food poisoning, with 325,000 affected so severely that
they require hospitalization. (Many thousands of others probably go undiag-
nosed.) While treatments are usually effective, food poisoning in the United
States kills more than a thousand people annually.
The problems of food safety are not only serious—they are growing. Two
crucial factors in this unfolding story are the increasingly industrialized pro-
duction of food and the emergence of new infectious agents.
“Industrialization” of foods refers to a range of innovations in food pro-
duction, preservation, and transportation that radically changed eating habits
during the twentieth century. For the first time in human history, seasonal foods
vi Foreword

became available year-round. Commercially prepared foods took precedence

over home-made. Food of all sorts became cheap.
As the industrialization of food continues to expand in the twenty-first cen-
tury, new problems are emerging. Consider the complex networks by which
food is distributed. The contamination of a prepared food in one factory can
sicken hundreds of people in widely separated areas, concealing both the
outbreak and its source. Globalization and the expansion of world trade fur-
ther complicate epidemiologic detective work—an outbreak of food poison-
ing in Canada may trace back to an abattoir in Argentina or a greenhouse in
South Africa.
A second major factor in food safety has been the emergence of new infec-
tious diseases. Diseases carried by foods are part of a larger picture of emerg-
ing infections. Among the emerging food-borne infectious agents, the prion
may be the most fascinating. Prions are the cause of such diseases as scrapie
and bovine spongiform encephalopathy (“mad cow” disease). While prions
are not life forms by conventional definition, they slowly catalyze lethal re-
actions in our food animals—and in us. Epidemiologists made some of the
key observations on the infectious nature of prion diseases, and the tools of
epidemiology will be necessary to monitor the future impact of these diseases.
Infectious agents are not our only worry. With industrialization comes an
increased reliance on pesticides, leading to more pesticide exposures for those
handling and eating food, with the potential for producing subtle and long-
term problems. The ubiquity and chronic nature of pesticide exposures, to-
gether with their potential to produce diverse health effects, make their study
by epidemiologists particularly challenging.
In coming to grips with new problems, epidemiologists have the advantage
of new tools. Better integration and monitoring of medical information sys-
tems allow earlier detection of suspicious clusters of acute infections. Once
identified, such clusters can be traced with molecular genetic assays that al-
low the “fingerprinting” of specific strains of organisms, and thus the precise
identification of cases. Once an outbreak has been identified, public health
actions may be required that cross national borders. The swift international
response to the SARS (severe acute respiratory syndrome) epidemic has shown
that effective cross-border interventions are possible.
Meanwhile, the public is becoming more aware of the emerging problems
of food-borne diseases and the hidden costs of our cheap food. The essays of
Wendell Berry bear witness to the ecologic virtues embodied in the small farm
and lost with industrialized farming. Community farmers’ markets are thriv-
ing as people rediscover the benefits of locally grown foods. Even so, these
are small drops compared with the vast ocean of agribusiness. The spectrum
of food-borne illnesses is increasingly complex, and the economic and social
consequences are ever more far-reaching.
 Foreword vii

In this volume, experts from a range of disciplines address the problems of

food safety in a scholarly and informative way. Chapters address how food
safety has evolved over the years, the various ways in which food can become
contaminated, and the use of epidemiologic methods to understand and con-
trol food-borne illness. With an insider’s understanding of how the U.S. pub-
lic health system works to prevent food-borne illness, this book is directed
toward those with an interest in public health. Make no mistake: this topic
should be compelling to anyone who eats.

Allen J. Wilcox
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PREFACE

Epidemiology has long played a critical role in investigating outbreaks of food-

borne illness and in identifying the microbial pathogens associated with such
illness. In the past, epidemiologists were the detectives who would track down
the guilty culprit—the food vehicle carrying the pathogen, as well as the fate-
ful errors that resulted in contamination or multiplication of pathogens. Today,
epidemiologists continue to investigate food-borne outbreaks, but epidemi-
ologists also have a role in policy formation and outbreak prevention. By ac-
cumulating information across outbreaks, and for cases of food-borne illness
not associated with a specific outbreak, epidemiologists can apply methods
developed for the study of chronic diseases (e.g., heart disease or cancer) to
identify points for intervention, inform risk assessors and policy makers, iden-
tify risk factors, and assess the contribution of steps along the farm-to-table
continuum to the overall burden of food-borne disease.
Although epidemiologists working in food safety are primarily concerned
with infectious agents, and must draw on methods developed within infec-
tious disease epidemiology, they also must often draw on methods developed
within chronic disease epidemiology. This intertwining of two strands of epi-
demiology may require the reader to adapt methods that are not yet available
at the time of this writing. In this book, we have attempted to identify areas
that provide a challenge to epidemiology, areas in which more methodologic
x Preface

research is required to more fully benefit from the application of epidemiologic

principles. In these areas, epidemiologic ideas are being applied in new ways,
for example, surveillance for outbreaks, where the unit is not an individual but
an entire outbreak, or case–control studies of unrelated cases (sometimes termed
“sporadic”) of an infectious illnesses caused by a specific pathogen. These new
applications push at the edges of the current methodology and will require growth
and development of epidemiologic thinking to meet the needs of food safety
scientists.
This book should introduce the reader to some of the key concepts appli-
cable to epidemiology in the food safety context, and should also introduce
the reader to key disciplines relevant to any discussion regarding the mainte-
nance of a safe food supply. Epidemiologists unfamiliar with food safety is-
sues will gain a broad understanding of the outbreak investigation, economic
and policy concerns, and points of intervention along the farm-to-table con-
tinuum: from the farm, through processing, to preparation and consumption.
Food scientists unfamiliar with epidemiology will gain knowledge of key
epidemiologic principles applied to food safety, such as surveillance and de-
scriptive epidemiology, methodology for estimating data points required in
risk assessment, and study designs for testing hypotheses regarding factors
contributing to the overall occurrence of food-borne illness.
More than in any other field in epidemiology, food safety activities take
place within government agencies at the local, state, national, and international
levels. One consequence is that definitions, perspectives, and methodologies
become consolidated within a particular government agency and, being part
of government, become established in law. Food scientists from different
agencies and levels of government may work with different definitions and
concepts, and there is very little opportunity to exchange ideas or modify sci-
entific thinking within the bureaucratic structure of a specific agency. In this
book, scientists have attempted to describe issues and principles in a generic
form that can be applied within or outside the United States, Canada, Europe,
and the world and can be useful to government at local, state, and national
levels. By attempting to be generic, it may contradict policies or procedures
of specific government entities, and this might lead to a sense of disconnect
for some readers. Those in specific government agencies need to follow their
agency’s approach; however, general scientific discussions need to move
beyond the mission and constraints of specific government agencies. Thus,
this book will be useful for general discussions but is not meant to be a manual
or guide book for any specific government agency or activity. Similarly, the
majority of examples in the book are drawn from the United States, but we
have attempted to bring in examples of food safety epidemiology from Canada,
the United Kingdom, Denmark, and other countries, as well as the interna-
tional activities promoted by the World Health Organization. Again, we aimed
 Preface xi

to produce a book with applications to various settings but do not fully de-
scribe any specific national approach.
One word about Internet resources—as with many other areas, the Internet
provides a range of resources for food safety scientists, from descriptions of
pathogens and their symptoms, to access to the most recent recall informa-
tion, statistics, legislation, data collection forms, and more. We have avoided
providing an extensive number of web addresses because these addresses
change rapidly, but any scientist, professor, student, or reader will need to use
this book in combination with resources available on the web and will need
to individualize their approach to the many Internet resources available. The
focus of this book is on generic principles that will apply in the next 10–15
years or longer. We have also avoided providing tables or charts of materials
that are readily available on the Internet and more easily updated on the Internet
than in a book (e.g., lists of pathogens and symptoms).
Finally, this book contains very little about intentional contamination of the
food supply or bioterrorism. Although maintenance of a safe food supply in-
cludes protection from intentional tampering, biosecurity draws on content
and methodology from security, criminal, law enforcement, and similar fields,
very much beyond the scope of this book. Although intentional contamination
of food may result in outbreaks that appear similar to accidental contamina-
tion, and epidemiologists may be the first to investigate outbreaks of inten-
tional contamination, resolution of the outbreak and prevention of future breaks
in security fall on those specially trained in bioterrorism prevention. Epide-
miologists and public health workers may be in a unique position to partici-
pate in surveillance for bioterrorism, but this is a specialized activity that
requires in-depth discussion in a context outside this book.
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ACKNOWLEDGMENTS

I am always grateful for having received a liberal arts education at Grinnell

College in Iowa, where I was encouraged to explore different disciplines and to
apply the highest standards of scholarship to all questions. I was equally fortu-
nate in the graduate training that I received in the Department of Epidemiology
at the School of Public Health at the University of North Carolina–Chapel Hill.
The department was a nurturing environment that fostered scientific excellence
as well as awareness of the social context for so many health issues.
Ruth Etzel opened the field of food safety to me by bringing me to the Food
Safety and Inspection Service at the U.S. Department of Agriculture. She in-
troduced me to the many issues related to food safety and, in particular, the
federal government’s role and responsibilities. Allan Wilcox responded to my
interest by suggesting the symposium on food safety held at the EpiCongress
2000 and further encouraged me to put my thoughts on paper by asking me to
write a commentary for the journal Epidemiology. The ideas first put forth in
that essay developed into this book. I also thank the MPH students from George
Washington University who worked with me while I was at the Department
of Agriculture. In particular, Wenyu Sun and Rekha Holtry did work that used
descriptive epidemiology to explore new questions in food safety.
The scientists who contributed chapters to this book were generous with
their time, patience, and expertise, writing and rewriting chapters, explaining
xiv Acknowledgments

concepts to me when necessary, writing more when asked, suffering edits and
cuts, and maintaining energy and interest over the three years of writing this
book. Each is an expert in their area, and each permitted their areas of exper-
tise to be condensed into a single chapter, painfully omitting many fine points
and details.
Jeffrey House, at Oxford University Press, enthusiastically encouraged me
to proceed with the book, and Carrie Pedersen carried on the work begun by
Jeffrey, with professionalism and genuine interest. She was assisted by Regan
Hofmann and others in production of this book.
My children, Daphne and David, used reverse psychology to encourage me
to write this book. Although they both learned to pronounce “bovine spongi-
form encephalopathy” relatively early in life, they have found the subject rather
unglamorous. I thank them for reminding me of the world outside of public
health and food safety, and the need to keep in perspective concerns about
food safety.
CONTENTS

Foreword—v
Allen J. Wilcox
Contributors—xvii
1. Introduction and Background—3
Tamar Lasky
2. Infectious Agents—18
A. Mahdi Saeed and Ritha Naji
3. Surveillance and Description—40
Luenda E. Charles and Tamar Lasky
4. Vehicles, Sources, Risk Factors, and Causes—64
Tamar Lasky
5. Food as Exposure: Measuring Dietary Intake and Consumption Patterns—76
Nga L. Tran and Leila Barraj
6. Managing a Food-Borne Outbreak—96
Tamar Lasky
7. Epidemiologic Study Designs—122
Tamar Lasky
xvi Contents

8. Data Quality—139
Tamar Lasky
9. Risk Assessment—160
Steven A. Anderson and Sherri B. Dennis
10. Food Production and Processing—177
James C. Kile
11. Food Handling and Preparation—197
Charles Higgins
12. The Economic Context—216
Tanya Roberts
13. The Regulatory Environment—230
Sean Altekruse
Index—245
CONTRIBUTORS

Captain Sean Altekruse, DVM, Luenda E. Charles, PhD, MPH

MPH, PhD Centers for Disease Control and
U.S. Public Health Service Prevention
Assigned to Food Safety and Inspec- National Institute for Occupational
tion Service Safety and Health
U.S. Department of Agriculture Morgantown, WV
Washington, DC
Sherri B. Dennis, PhD
Center for Food Safety and Applied
Steven A. Anderson, PhD, MPP Nutrition
Center for Biologics Evaluation and U.S. Food and Drug Administration
Research Washington, DC
U.S. Food and Drug Administration
Rockville, MD Captain Charles Higgins, MSEH,
REHS
U.S. Public Health Service
Leila Barraj, DsC Assigned to National Park Service,
Exponent, Inc. U.S. Department of the Interior
Washington, DC Washington, DC

xvii