Weekly Report

Outbffraka of Saimonet/a Serotype Enteritidis Infection Assccieied wiih Eating Raw oi Undercooked Shell Eflfl®—United States, 19&S-1998 Prevaknc* of Selected Risk Factors (or Chronic. Disease and Injury Among Annericen Indiens end Alssks Natives — United States. 1995-1998 National Child Psssenoer Safety Week -February 13-19.20ÄI

Outbreaks of Salmonella Serotype Enteritidis Infection Associated with Eating Raw or Undercooked Shell Eggs — United States, 1996-1998

During the 1980s and 1990s, Salmoneite serotype Enteritidis (SE) emerged as an important cause of human illness in the United States. The rate of SE isolates reported to CDC increased from 0.6 per 100,000 population in 1976 to 3-6 per 100,000 in 1996 (Figure i). Case-control studies of sporadic infections and outbreak investigations found that this increase was associated with eating raw or undercooked shell eggs (7). From 1996 to 1998, the rate of culture-confirmed SE cases reported to CDC declined to 2,2 per 100,000; however, outbreaks of illness caused by SE continue to occur. This re port describes fourSE outbreaks during 1996-1998 associated with eating raw or undercooked shell eggs and discusses measures that may be contributing to the decline in culture-confirmed SE cases.

Los Angeles County, California

In August 1997, the Los Angeles County Department of Health Services (LACDHS) received reports of gastrointestinal illness in members of a Girl Scout troop and some of their parents. The ill persons had eaten food prepared in a private residence by the scouts. Stool cultures taken from 12 ill persons yielded SE; selected isolates tested were phage type 4,

An investigation by LACDHS found that of 17 persons at the dinner, 13 had gastrointestinal illness consistent with salmonellosis. Cheesecake served at the dinner was associated with illness; all 13 ill persons and two well persons ate the cheesecake (attack rate=87%; relative risk [RR]=undefined; p=0.04). The cheesecake contained raw egg whites and egg yolks that were cooked in a double boiler until slightly thickened. California Department of Health Services and Department of Food and Agriculture investigated the farm that supplied the eggs and found SE contamination. Of 476 environmental cultures taken from manure, feed, and water, 21 (4.4%) yielded SE; all positive cultures were from manure. Nineteen isolates were phage type 4, and two were phage type 7. SE also was isolated from one (0.5%) of 200 pooled egg samples obtained at the farm. On the basis of these findings, the layer flock was depopulated to prevent further SE cases.


Infectious disease surveillance both nationally and worldwide is one of the most important aspects of disease prevention.

Figure 20.8 Morbidity and Mortality Weekly Report A publication of the Centers for Disease Control and Prevention.

Chapter 20 Epidemiology

Table 20.2 Notifiable Infectious Diseases

Individual states and territories require physicians to report cases of these notifiable diseases. In turn, the number of cases is reported to the CDC, where they are collated and published in the MMWR.

• Brucellosis

• Chancroid

• Hemolytic uremic syndrome, post-diarrheal

• Hepatitis, viral, acute

• HIV infection

• Legionellosis (Legionnaires' disease)

• Listeriosis

• Lyme disease

• Rubella, congenital syndrome

• Salmonellosis

• Shigellosis

• Streptococcal disease, invasive, group A

• Streptococcal toxic shock syndrome

• Chlamydia trachomatis, genital infections

• Cholera

• Streptococcus pneumoniae, drug-resistant, invasive disease

• Coccidioidomycosis

• Cryptosporidiosis

• Cyclosporiasis

• Diphtheria

• Meningococcal disease

• Pertussis

• Streptococcus pneumoniae, invasive in children <5 years

• Syphilis, congenital

• Tetanus

• Encephalitis, arboviral

• Plague

• Toxic shock syndrome

• Enterohemorrhagic Escherichia coli

• Poliomyelitis, paralytic

• Trichinosis

• Giardiasis

• Psittacosis

• Tuberculosis

• Gonorrhea

• Q fever

• Tularemia

• Haemophilus influenzae, invasive disease

• Rabies, animal and human

• Typhoid fever

• Hansen's disease (leprosy)

• Rocky Mountain spotted fever

• Varicella (deaths only)

• Hantavirus pulmonary syndrome

• Rubella

• Yellow fever

Typically they are diseases of relatively high incidence or otherwise a potential danger to public health. The data collected by the CDC are published in the MMWR along with historical numbers to reflect any trends. Potentially significant case reports, such as the 1981 report of a cluster of opportunistic infections in young gay men that heralded the AIDS epidemic, and the 1995 report on the Ebola outbreak in Zaire, are also included in the MMWR.. This publication is an invaluable aid to physicians, public health agencies, teachers, students, and anyone else studying infectious disease or public health. In fact, many of the epidemiological charts and stories in this textbook are extracted from the MMWR.

The CDC also conducts research relating to infectious diseases and can dispatch teams worldwide to assist with identifying and controlling epidemics. In addition, the CDC provides refresher courses that update the knowledge of laboratory and infection control personnel.

Public Health Departments

Each state has a public health laboratory that is involved in infection surveillance and control as well as other health-related activities. Individual states have the authority to mandate which diseases must be reported by physicians to the state laboratory. The prompt response of health authorities in Washington State that led to the cessation ofthe 1993 outbreak of Escherichia coli O157:H7 caused by contaminated hamburger patties was partly because Washington then was one of the few states with surveillance and reporting measures for the organism. The epidemic had actually started in other states but had gone unrecognized.

State laboratories also examine specimens and cultures submitted by physicians, local health departments, hospital laboratories, and others. They also deal with environmental health matters, testing water supplies for potential pathogens, giving advice on laboratory safety and design, and assisting in handling outbreaks of infectious disease. Additional programs enhance the reliability

20.4 Trends in Disease 497

of laboratories in the state and ensure that they meet standards for certification. These laboratories are often tested for their reliability by seeing if they can correctly identify known pathogens.

Other Components of the Public Health Network

The public health network also includes public schools, which report absentee rates, and hospital laboratories, which report on the isolation of pathogens that have epidemiological significance for the community. In conjunction with these local activities, the news media alert the general public of the presence of infectious disease.

Worldwide Disease Surveillance

The World Health Organization (WHO) is an international agency devoted to achieving the highest possible level of health for all peoples. An agency of the United Nations, the WHO has 191 member countries. It has four main functions: (1) to provide worldwide guidance in the field of health; (2) to set global standards for health; (3) to cooperatively strengthen national health programs; and (4) to develop and transfer appropriate health technology. To accomplish its goals, the WHO provides education and technical assistance to member countries. One of their most recent successes has been the establishment of truces between various factions in war-torn countries in order to allow vaccination efforts to proceed.

The WHO disseminates information through a series of periodicals and books. For example, the Weekly Epidemiological Record reports timely information about epidemics of public health importance, particularly those of global concern.

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