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Volume 17, Number 7—July 2011
Letter

Foodborne Illness Acquired in the United States

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To the Editor: The updated estimates of foodborne illness in the United States reported by Scallan et al. probably overestimate the occurrence of illness caused by unspecified agents because they did not account for the apparent sensitivity of the population survey to the occurrence of norovirus (1,2). The number of illnesses attributed to unspecified agents was derived from the simultaneous processes of extrapolation and subtraction: extrapolation from the population survey to create a base of diarrheal illnesses and subtraction of known agents from this base. Scallan et al. averaged illness rates from 3 successive population surveys to come up with a rate of 0.6 episodes of acute gastroenteritis per person per year. However, the individual rates were 0.49 (2000–2001), 0.54 (2002–2003), and 0.73 (2006–2007). The 2006–2007 survey was conducted at the time of widespread norovirus activity. The estimated rate of population illness was strongly correlated with the number of confirmed and suspected norovirus outbreaks reported to the Centers for Disease Control and Prevention Foodborne Disease Outbreak Surveillance System during each of the survey periods (300, 371, and 491, respectively; R2 = 0.97, p<0.0001). No other known agents were correlated with the population survey rates, and the total numbers of outbreaks were inversely correlated with the population survey data.

The strength of the correlation between norovirus outbreaks and survey results suggests that the population survey is sensitive to norovirus activity and that norovirus may account for much of what is considered to be unspecified. The fact that the highest observed population rate was ≈50% greater than the lowest rate suggests that annual variation in norovirus activity may account for a considerable proportion of what otherwise seems to be unspecified. More thorough and timely investigation and reporting of outbreaks could facilitate the development of models to evaluate the number of illnesses and update them annually.

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Craig W. Hedberg
Author affiliation: Author affiliation: University of Minnesota, Minneapolis, Minnesota, USA

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References

  1. Scallan  E, Hoekstra  RM, Angulo  FJ, Tauxe  RV, Widdowson  MA, Roy  SL, Foodborne illness acquired in the United States—major pathogens. Emerg Infect Dis. 2011;17:715.PubMed
  2. Scallan  E, Griffin  PM, Angulo  FJ, Tauxe  RV, Hoekstra  RM. Foodborne illness acquired in the United States—unspecified agents. Emerg Infect Dis. 2011;17:1622.PubMed

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DOI: 10.3201/eid1707.110019

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To the Editor: The report by Scallan et al. provides a valuable update regarding estimated annual illnesses, hospitalizations, and deaths caused by recognized foodborne pathogens, most of which cause diarrheal disease, in the United States (1). However, absent from this study, and from most previous reviews of foodborne illness, was attention to possible extraintestinal disease, especially antimicrobial drug–resistant infections caused by food-source Escherichia coli and associated resistance elements.

A growing body of molecular and epidemiologic evidence suggests that a substantial fraction of extraintestinal E. coli infections in humans, particularly those involving antimicrobial drug–resistant strains, might be caused by E. coli from food animals (2). Extraintestinal pathogenic and antimicrobial drug–resistant E. coli commonly contaminate retail meat products (3,4); rates of contamination and resistance associated with “no antibiotics” production methods, labeling, and markets are lower (4). In a study of women with acute urinary tract infection, frequent consumption of chicken and pork was associated with isolation of antimicrobial drug–resistant E. coli from urine (5).

Extraintestinal E. coli infections, which include urinary tract infections and sepsis, are more common and result in more hospitalizations and deaths than do infections caused by the classic foodborne pathogens. For example, each year in the United States, an estimated 40,000 deaths are associated with sepsis caused by extraintestinal E. coli infection (6); only <1,400 deaths are caused by all major classic foodborne pathogens combined (1). Therefore, if even a modest fraction (e.g., 5%–10%) of all extraintestinal E. coli infections in humans are of foodborne origin—which seems highly plausible, considering the molecular evidence (2)—the extent of associated disease may equal or exceed that attributable to the classic foodborne pathogens as estimated by Scallan et al. Greater recognition of this possibility by the public health system is needed so that appropriate attention can be devoted to this neglected, invisible foodborne disease threat.

References

  1. Scallan  E, Hoekstra  R, Angulo  FJ, Tause  RV, Widdowson  M-A, Roy  SL, Foodborne illness acquired in the United States—major pathogens. Emerg Infect Dis. 2011;17:715.PubMed
  2. Johnson  JR, Sannes  MR, Croy  C, Johnston  B, Clabots  C, Kuskowski  MA, Antimicrobial drug–resistant Escherichia coli isolates from humans and poultry products, Minnesota and Wisconsin, 2002–2004. Emerg Infect Dis. 2007;13:83846. DOIPubMed
  3. Johnson  JR, McCabe  JS, White  DG, Johnston  B, Kuskowski  MA, McDermott  P. Molecular analysis of Escherichia coli from retail meats (2002–2004) from the United States National Antimicrobial Resistance Monitoring System (NARMS). Clin Infect Dis. 2009;49:195201. DOIPubMed
  4. Johnson  JR, Kuskowski  MA, Smith  K, O’Bryan  TT, Tatini  S. Antimicrobial-resistant and extraintestinal pathogenic Escherichia coli in retail foods. J Infect Dis. 2005;191:10409. DOIPubMed
  5. Manges  AR, Smith  SP, Lau  BJ, Nuval  CJ, Eisenberg  JN, Dietrich  PS, Retail meat consumption and the acquisition of antimicrobial resistant Escherichia coli causing urinary tract infections: a case–control study. Foodborne Pathog Dis. 2007;4:41931. DOIPubMed
  6. Russo  TA, Johnson  JR. Medical and economic impact of extraintestinal infections due to Escherichia coli: focus on an increasingly important endemic problem. Microbes Infect. 2003;5:44956. DOIPubMed
  7. Hedberg  CW. Foodborne illness acquired in the United States [letter]. Emerg Infect Dis. 2011;17:1338. DOIPubMed
  8. Johnson  JR. Foodborne illness acquired in the United States [letter]. Emerg Infect Dis. 2011;17:13389. DOIPubMed
  9. Scallan  E, Hoekstra  RM, Angulo  FJ, Tauxe  RV, Widdowson  MA, Roy  SL, Foodborne illness acquired in the United States—major pathogens. Emerg Infect Dis. 2011;17:715.PubMed
  10. Scallan  E, Griffin  PM, Angulo  FJ, Tauxe  RV, Hoekstra  RM. Foodborne illness acquired in the United States—unspecified agents. Emerg Infect Dis. 2011;17:1622.PubMed
  11. Manges  AR, Smith  SP, Lau  BJ, Nuval  CJ, Eisenberg  JN, Dietrich  PS, Retail meat consumption and the acquisition of antimicrobial resistant Escherichia coli causing urinary tract infections: a case–control study. Foodborne Pathog Dis. 2007;4:41931. DOIPubMed
  12. Widdowson  MA, Cramer  EH, Hadley  L, Bresee  JS, Beard  RS, Bulens  SN, Outbreaks of acute gastroenteritis on cruise ships and on land: identification of a predominant circulating strain of norovirus—United States, 2002. J Infect Dis. 2004;190:2736. DOIPubMed

Table of Contents – Volume 17, Number 7—July 2011

Page created: August 26, 2011
Page updated: August 26, 2011
Page reviewed: August 26, 2011
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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