FoodChain-Lab: A Trace-Back and Trace-Forward Tool Developed and Applied during Food-Borne Disease Outbreak Investigations in Germany and Europe

Intersectoral collaboration in a One Health approach: Lessons learned from a country-level simulation exercise

Intersectoral collaboration is an essential component of the One Health (OH) approach, which recognises the interconnectedness of the health of humans, animals, and the environment. The OH European Joint Programme (OHEJP) developed a national foodborne outbreak table-top simulation exercise (SimEx) to practice OH capacity and interoperability across the public health, animal health, and food safety sectors, improving OH preparedness for future disease outbreaks. The Portuguese OHEJP SimEx highlighted strengths and weaknesses regarding the roles and functions of available systems, the constraints of existing legislation, the importance of harmonisation and data sharing, and the creation of common main messages adapted to each target sector. However, there is still a long way to go to ensure cooperation among the Public Health, Animal Health, and Food Safety sectors, as a OH approach relies not only on the awareness of "field experts" but also on political and organisational willingness and commitment.

Field Epidemiology: Fit for the future

In recent years, field epidemiologists have embraced rapidly evolving digital tools, data sources and technologies, and collaborated with an ever-growing field of scientific specialisms. The COVID-19 pandemic put field epidemiology under unprecedented demand and scrutiny. As the COVID-19 emergency recedes, it is timely to reflect on the core values of our profession and the unique challenges and opportunities that lie ahead. In November 2022, alumni of the European Programme for Intervention Epidemiology Training (EPIET) and the European Public Health Microbiology (EUPHEM) training programme celebrated 25 years of EPIET, and the present and future of field epidemiology was discussed. The output was recorded and qualitatively analysed. This Perspective reflects the authors' interpretation of the discussion. We should reaffirm our commitment to field epidemiology's core strengths: competence and rigour in epidemiology, surveillance, outbreak investigation and applied research, leading to timely and actionable evidence for public health. Our future success will be defined by an ability to adapt, collaborate, harness innovation, communicate and, ultimately, by our tangible impact on protecting and improving health.

Usefulness of linked data for infectious disease events: a systematic review

Surveillance is a key public health function to enable early detection of infectious disease events and inform public health action. Data linkage may improve the depth of data for response to infectious disease events. This study aimed to describe the uses of linked data for infectious disease events. A systematic review was conducted using Pubmed, CINAHL and Web of Science. Studies were included if they used data linkage for an acute infectious disease event (e.g. outbreak of disease). We summarised the event, study aims and designs; data sets; linkage methods; outcomes reported; and benefits and limitations. Fifty-four studies were included. Uses of linkage for infectious disease events included assessment of severity of disease and risk factors; improved case finding and contact tracing; and vaccine uptake, safety and effectiveness. The ability to conduct larger scale population level studies was identified as a benefit, in particular for rarer exposures, risk factors or outcomes. Limitations included timeliness, data quality and inability to collect additional variables. This review demonstrated multiple uses of data linkage for infectious disease events. As infectious disease events occur without warning, there is a need to establish pre-approved protocols and the infrastructure for data-linkage to enhance information available during an event.

Economic and value chain analysis to support an investigation and risk mitigation efforts on Marek's disease in layers in the southern part of Thailand

Background and Aim

Marek's disease (MD) is a common lymphoproliferative disease affecting chickens and causing economic losses in commercial poultry. The MD outbreak was noticed in the southern part of Thailand in 2019. The suspected cases were found with an abnormal number of cases of layers dying with clinical signs, for example, weakness and emaciation, with evidence of MD gross lesions. This study aimed to raise awareness of the MD outbreak through value chain analysis (VCA), identifying associated possible risk factors, and estimating the associated economic impact.

Materials and Methods

Value chain analysis, including seasonal calendar, value chain diagram, and layer movement mapping of the layer industry, was conducted. High-risk stakeholders were identified on the basis of risk practices and interactions between stakeholders. A case-control study was conducted to determine risk factors associated with the MD outbreak on layer farms, and partial budget analysis was used to estimate economic losses associated with MD.

Results

The value chain diagram showed the linkages between stakeholders, including estimation of the percentage of products moved from one stakeholder group to another and the negotiated price. Fourteen out of 35 layer farms were case farms. Farm size and source of birds were significantly associated with the MD outbreak. The MD outbreak caused total economic losses of 295,823 USD. Farms that slaughtered infected birds with additional revenues incurred losses of 140,930 USD, whereas farms that culled infected birds without additional revenue returned incurred losses of 1995 USD.

Conclusion

The VCA provided a better understanding of the layer and egg businesses in South Thailand and guided the development of questionnaires for outbreak investigation. The potential risk factor findings suggested the need for further exploration of the source of the MD outbreak.

Introducing the Rapid Alert Supply Network Extractor (RASNEX) tool to mine supply chain information from food and feed contamination notifications in Europe

Background

During food or feed contamination events, it is of utmost importance to ensure their rapid resolution to minimize impact on human health, animal health and finances. The existing Rapid Alert System for Food and Feed (RASFF) is used by the European Commission, national competent authorities of member countries and the European Food Safety Authority to report information on any direct or indirect human health risk arising from food or feed, or serious risks to animal health or the environment in relation to feed. Nevertheless, no methods exist to to collectively evaluate this vast source of supply chain information.

Methods

To aid in the extraction, evaluation and visualization of the data in RASFF notifications, we present the Rapid Alert Supply Network Extractor (RASNEX) open-source tool available from https://doi.org/10.5281/zenodo.4322555 freely. Among RASNEX’s functions is the graphical mapping of food and feed supply chain operators implicated in contamination events. RASNEX can be used during ongoing events as a support tool for risk analysis using RASFF notifications as input.

Results

In a first use case, we showcase the functionality of RASNEX with the RASFF notification on a 2017/2018 contamination event in eggs caused by the illegal use of fipronil. The information in this RASFF notification is used to visualize nine different flows of main and related food products. In a second use case, we combine RASFF notifications from different types of food safety hazards (Salmonella spp., fipronil and others) to obtain wider coverage of the visualized egg supply network compared to the first use case. Actors in the egg supply chain were identified mainly for Italy, Poland and Benelux. Other countries (although involved in the egg supply chain) were underrepresented.

Conclusions

We hypothesize that biases may be caused by inconsistent RASFF reporting behaviors by its members. These inconsistencies may be counteracted by implementing standardized decision-making tools to harmonize decisions whether to launch a RASFF notification, in turn resulting in a more uniform future coverage across European food and feed supply chains with RASNEX.

Utility of whole-genome sequencing during an investigation of multiple foodborne outbreaks of Shigella sonnei

In April 2018, Public Health England was notified of cases of Shigella sonnei who had eaten food from three different catering outlets in England. The outbreaks were initially investigated as separate events, but whole-genome sequencing (WGS) showed they were caused by the same strain. The investigation included analyses of epidemiological data, the food chain and microbiological examination of food samples. WGS was used to determine the phylogenetic relatedness and antimicrobial resistance profile of the outbreak strain. Ultimately, 33 cases were linked to this outbreak; the majority had eaten food from seven outlets specialising in Indian or Middle Eastern cuisine. Five outlets were linked to two or more cases, all of which used fresh coriander although a shared supplier was not identified. An investigation at one of the venues recorded that 86% of cases reported eating dishes with coriander as an ingredient or garnish. Four cases were admitted to hospital and one had evidence of treatment failure with ciprofloxacin. Phylogenetic analysis showed that the outbreak strain was part of a wider multidrug-resistant clade associated with travel to Pakistan. Poor hygiene practices during cultivation, distribution or preparation of fresh produce are likely contributing factors.

Emerging Applications of Machine Learning in Food Safety

Food safety continues to threaten public health. Machine learning holds potential in leveraging large, emerging data sets to improve the safety of the food supply and mitigate the impact of food safety incidents. Foodborne pathogen genomes and novel data streams, including text, transactional, and trade data, have seen emerging applications enabled by a machine learning approach, such as prediction of antibiotic resistance, source attribution of pathogens, and foodborne outbreak detection and risk assessment. In this article, we provide a gentle introduction to machine learning in the context of food safety and an overview of recent developments and applications. With many of these applications still in their nascence, general and domain-specific pitfalls and challenges associated with machine learning have begun to be recognized and addressed, which are critical to prospective use and future deployment of large data sets and their associated machine learning models for food safety applications.

Knowledge, attitude and practices of environmental health practitioners conducting food-borne disease outbreak investigation at a local municipality in Gauteng province, South Africa

Background

Food-borne disease (FBD) outbreaks are a common occurrence that is either not investigated or poorly investigated. According to anecdote evidence, this is because of non-uniformity to environmental health practices in South Africa.

Aim

This study aimed to determine and describe the knowledge, attitude and practices (KAP) of environmental health practitioners (EHPs) when conducting outbreak investigations of FBD at a local municipality.

Setting

This study was conducted in three sub-districts of Ekurhuleni Metropolitan Municipality (EMM), one of five municipalities in Gauteng province, South Africa.

Methods

A descriptive cross-sectional study was conducted to collect data using a semi-structured questionnaire. Data collected were analysed using IBM Statistical Package for the Social Sciences. Continuous variables were compared using analysis of variances, and correlation was used to determine any association.

Results

Knowledge responses were scored out of 9. Open-ended questions were themed into five items (support, guidelines, resources, training and specialisation). Sixty-one (76.3%) participants were randomly selected to participate in the study. There were more female participants (55.7%) than male participants, and the mean age was 30.9 years. The participants’ knowledge scores ranged from 1 to 9. There were 17 (27.9%) participants who have conducted FBD outbreak investigation. Twenty-six (42.6%) believed that they were properly trained to conduct FBD outbreak investigations. Age was associated with position (p = 0.000) and qualification (p = 0.033).

Conclusion

The results indicated that there are gaps and challenges in the knowledge, while the practices were not consistent amongst environmental health practitioners. However, the attitude of EHPs was positive with regard to their role in FBD outbreak investigations.

Refinement of dietary exposure assessment using origin-related scenarios

Global sourcing of food may lead to variability in concentrations of contaminants or pesticide residues. It would be important to incorporate origin influences in dietary exposure assessment. To characterise uncertainties, substance concentrations from GFM (German Food Monitoring), chosen based on the highest CV (coefficient of variation), and food consumption from NVS II (German National Nutrition Survey II) were combined in standard scenarios. Averages or higher percentiles of non-grouped concentrations were used. Additional origin-related scenarios used concentrations grouped by origin. For bromide in tomatoes the most conservative origin-related scenario for Italian tomatoes resulted in the highest exposure of 0.015 mg/d/kg BW. The impact of origin was not covered by the conservative standard scenario (0.006 mg/d/kg BW). For ethephon in pineapples and aluminium in kiwifruits, the highest intake estimates were obtained with the conservative standard scenario resulting in 0.895 μg/d/kg BW and 0.023 mg/week/kg BW, respectively. In these two cases, standard scenarios cover origin influences but the conservative origin-related scenario based on origins with higher concentrations identifies lower exposures of 0.835 μg/d/kg BW for ethephon from African pineapples and 0.014 mg/week/kg BW for aluminium from non-EU kiwifruits. Hence, the inclusion of origin information can refine exposure assessment.

Hepatitis A outbreak linked to imported frozen strawberries by sequencing, Sweden and Austria, June to September 2018

Between June–September 2018, 20 hepatitis A cases were notified in six counties in Sweden. Combined epidemiological and microbiological investigations identified imported frozen strawberries produced in Poland as the source of the outbreak. Sequence analysis confirmed the outbreak strain IB in the strawberries with 100 % identity and the respective batch was withdrawn. Sharing the sequence information internationally led to the identification of 14 additional cases in Austria, linked to strawberries from the same producer.

Unrecognised Outbreak: Human parainfluenza virus infections in a pediatric oncology unit. A new diagnostic PCR and virus monitoring system may allow early detection of future outbreaks

Background: Human parainfluenza viruses (HPIVs) are significant causes of both upper and lower respiratory tract infections with type 3 (HPIV3) causing the most severe disease in the immunocompromised cohorts.  The objective of this study was to analyse the epidemiological nature of a cluster of cases of HPIV3 in a pediatric oncology unit of a major teaching hospital. Methods: In order to determine whether the activity observed represented a deviation from the norm, seasonal trends of HPIV3 in the surrounding geographical area as well as on the ward in question were analysed.  The genetic link between cases was established by the phylogenetic analysis of the non-coding hypervariable region between the M (Matrix) and F (fusion) genes of HPIV3. The 15 cases involved and 15 unrelated cases were sequenced.  Transmission routes were subsequently inferred and visualized using Konstanz Information Miner (KNIME) 3.3.2. Results: Of the 15 cases identified, 14 were attributed to a point source outbreak. Two out of 14 outbreak cases were found to differ by a single mutation A182C. The outbreak strain was also seen in 1 out of 15 unrelated cases, indicating that it was introduced from the community. Transmission modeling was not able to link all the cases and establish a conclusive chain of transmission. No staff were tested during the outbreak period. No deaths occurred as a result of the outbreak. Conclusion: A point source outbreak of HPIV3 was recognized post factum on an oncology pediatric unit in a major teaching hospital. This raised concern about the possibility of a future more serious outbreak. Weaknesses in existing systems were identified and a new dedicated respiratory virus monitoring system introduced.  Pediatric oncology units require sophisticated systems for early identification of potentially life-threatening viral outbreaks.

Hepatitis E virus: zoonotic and foodborne transmission in developed countries

Hepatitis E virus (HEV), together with hepatitis A virus, transmits via the fecal–oral route. The number of domestic hepatitis E cases among Europeans has grown alarmingly during the past 5 years. Surveillance studies suggest that the number of foodborne HEV infections is increasing most rapidly. Zoonotic HEV genotype HEV-3 is prevalent among pigs and wild boars in Europe and many developed countries, whereas zoonotic genotype HEV-4 is more common in pigs in some Asian countries. This review presents the most recent data about possible foodborne transmission of HEV via pigs and other production animals and about the presence of HEV in high-risk foods, such as ready-to-eat meat products. Possible solutions about how to tackle this problem are discussed here.

Novel application of the matched case-control design to compare food supply chains during an Escherichia coli O157 outbreak, United Kingdom, 2016

There is a need for innovative methods to investigate outbreaks of food-borne infection linked to produce with a complex distribution network. The investigation of a large outbreak of Escherichia coli O157 PT34 infection in the United Kingdom in 2016 indicated that catering venues associated with multiple cases had used salad leaves sourced from one supplier. Our aim was to investigate whether catering venues linked to cases were more likely to have used salad leaves from this supplier. We conducted a matched case-control study, with catering venues as the units of analysis. We compared venues linked to cases to those without known linked cases. We included 43 study pairs and obtained information on salad leaf products received by each venue. The odds of a case venue being supplied with salad leaves by Supplier A were 7.67 times (95% confidence interval: 2.30-25.53) those of control venues. This association provided statistical evidence to support the findings of the other epidemiological investigations undertaken for this outbreak. This is a novel approach which is labour-intensive but which addresses the challenge of investigating exposures to food across a complex distribution network.

National outbreak of Shiga toxin-producing Escherichia coli O157:H7 linked to mixed salad leaves, United Kingdom, 2016

We investigated a large outbreak of Escherichia coli O157 in the United Kingdom (UK) with 165 cases between 31 May and 29 July 2016. No linked cases were reported in other countries. Cases were predominately female (n = 128) and adult (n = 150), 66 attended hospital and nine had features of haemorrhagic uraemic syndrome. A series of epidemiological studies (case-control, case-case, ingredients-based and venue-based studies) and supply chain investigations implicated mixed salad leaves from Supplier A as the likely outbreak vehicle. Whole genome sequencing (WGS) indicated a link with strains from the Mediterranean and informed the outbreak control team to request that Supplier A cease distributing salad leaves imported from Italy. Microbiological tests of samples of salad leaves from Supplier A were negative. We were unable to confirm the source of contamination or the contaminated constituent leaf although our evidence pointed to red batavia received from Italy as the most likely vehicle. Variations in Shiga toxin-producing E.coli surveillance and diagnosis may have prevented detection of cases outside the UK and highlights a need for greater standardisation. WGS was useful in targeting investigations, but greater coverage across Europe is needed to maximise its potential.

Foodborne parasites: Outbreaks and outbreak investigations. A meeting report from the European network for foodborne parasites (Euro-FBP)

Foodborne parasites (FBP) are a neglected topic in food safety, due to lack of awareness of their importance for public health, their biological diversity, and, for many FBP, lack of standardized detection methods, which complicates identification of the infection vehicle. The COST Action FA1408, A European Network for Foodborne Parasites (Euro-FBP), aims to limit the impact of FBP on public health by facilitating multidisciplinary cooperation and partnership among researchers, and between researchers and stakeholders. Outbreaks represent a common topic overarching specialization in one or more FBP, thus providing a platform for knowledge exchange. This report summarizes the outcomes of a meeting within the Euro-FBP consortium entitled 'Outbreaks and Outbreak Investigations'. Recent and historical outbreaks of trichinellosis, opisthorchiasis, and cryptosporidiosis were used as examples to underline the complexity of the topic, the different foods implicated and their traceability, and the lack of standardized detection methods for some parasites. Possible solutions to overcome current limitations were also illustrated. The meeting provided an opportunity to learn from recent advances in the study of bacterial foodborne outbreaks, with an emphasis on genome analysis.

An outbreak of Shiga toxin-producing Escherichia coli O157:H7 associated with contaminated salad leaves: epidemiological, genomic and food trace back investigations

In August 2015, Public Health England detected an outbreak of Shiga toxin-producing Escherichia coli (STEC) serotype O157:H7 caused by contaminated salad leaves in a mixed leaf prepacked salad product from a national retailer. The implicated leaves were cultivated at five different farms and the zoonotic source of the outbreak strain was not determined. In March 2016, additional isolates from new cases were identified that shared a recent common ancestor with the outbreak strain. A case-case study involving the cases identified in 2016 revealed that ovine exposures were associated with illness (n = 16; AOR 8·24; 95% CI 1·55-39·74). By mapping the recent movement of sheep and lambs across the United Kingdom, epidemiological links were established between the cases reporting ovine exposures. Given the close phylogenetic relationship between the outbreak strain and the isolates from cases with ovine exposures, it is plausible that ovine faeces may have contaminated the salad leaves via untreated irrigation water or run-off from fields nearby. Timely and targeted veterinary and environmental sampling should be considered during foodborne outbreaks of STEC, particularly where ready to eat vegetables and salads are implicated.

Two consecutive large outbreaks of Salmonella Muenchen linked to pig farming in Germany, 2013 to 2014: Is something missing in our regulatory framework?

In 2013, raw pork was the suspected vehicle of a large outbreak (n = 203 cases) of Salmonella Muenchen in the German federal state of Saxony. In 2014, we investigated an outbreak (n = 247 cases) caused by the same serovar affecting Saxony and three further federal states in the eastern part of Germany. Evidence from epidemiological, microbiological and trace-back investigations strongly implicated different raw pork products as outbreak vehicles. Trace-back analysis of S. Muenchen-contaminated raw pork sausages narrowed the possible source down to 54 pig farms, and S. Muenchen was detected in three of them, which traded animals with each other. One of these farms had already been the suspected source of the 2013 outbreak. S. Muenchen isolates from stool of patients in 2013 and 2014 as well as from food and environmental surface swabs of the three pig farms shared indistinguishable pulsed-field gel electrophoresis patterns. Our results indicate a common source of both outbreaks in the primary production of pigs. Current European regulations do not make provisions for Salmonella control measures on pig farms that have been involved in human disease outbreaks. In order to prevent future outbreaks, legislators should consider tightening regulations for Salmonella control in causative primary production settings.

Mathematical aspects of nutrition systems projecting for dietary therapy

The mathematical toolkit created and used for the design of durable nutrition systems aimed at the prevention and therapy of the diseases caused by calcium deficiency is analyzed. In particular, these are: the complex of mathematical models of the expendable diets and methods of the ingredients content optimization in them, mathematical model of daily diets optimization, and formalizationed method of fast and light determination of a diet’s biological value.The ways for the improvement of the developed mathematical toolkit aimed at the creation of the nutrition systems with higher level of both nutrients balance and provision of daily needs in them on the basis of using unconventional floury products enriched with the deficient nutrients, functionals for balancing the connected groups of nutrients are determined, as well as the introduction of aggregated restrictions on these groups of nutrients to the models (both products and rations).

Food Safety Crisis Management-A Comparison between Germany and the Netherlands

In order to prevent food safety incidents from becoming a crisis, a good crisis management structure is essential. The aim of the current study was to compare and evaluate the national food incident response plans of 2 neighboring EU Member States: Germany and the Netherlands. This revealed that the structure of these plans is comparable, starting with initial alerting, assessment of the problem, upscaling, an execution phase and finally an evaluation of the crisis management. However, the German communication structure is more complex than the Dutch one and cross-border communication between both countries is currently limited. In general, the presence of national response plans does not guarantee a good and swift response to a food safety incident as this is often hampered by difficulties in tracing the source of the problem as well as difficulties in communication between organizations involved in crisis management. A timely detection can be improved through the development of fast screening and detecting systems and through combining various data sources using computer software systems. Mutual cooperation and communication can be improved through joint exercises or projects. This will help to streamline communication toward consumers and trade partners. Such communication should be transparent relaying not only the facts but also the uncertainties in a crisis in order to gain consumer trust and safeguard international trade.