Food Safety: CDC Is Working to Address Limitations in Several of 
Its  Foodborne Disease Surveillance Systems (07-SEP-01, 	 
GAO-01-973).							 
								 
Foodborne disease in the United States annually causes an	 
estimated 76 million illnesses, 325,000 hospitalizations, and	 
about 5,000 deaths, according to the Centers for Disease Control 
and Prevention (CDC). Surveillance is public health officials'	 
most important tool for detecting and monitoring both existing	 
and emerging foodborne diseases. In the United States,		 
surveillance for foodborne disease is also used to identify	 
outbreaks--two or more cases of a similar illness that result	 
from ingestion of a common food--and their causes. CDC has 18	 
surveillance systems that include information on foodborne	 
diseases used to detect cases or outbreaks of foodborne disease, 
pinpoint their cause, recognize trends, and develop effective	 
prevention and control measures. Four principal systems, the	 
Foodborne Disease Outbreak Surveillance System, PulseNet,	 
FoodNet, and the Surveillance Outbreak Detection Algorithm, focus
on foodborne diseases and cover more than one pathogen. While	 
CDC's systems have contributed to food safety, the usefulness of 
several of these surveillance systems is impaired both by CDC's  
untimely release of surveillance data and by gaps in the data	 
collection. CDC is providing funds to state and local health	 
departments that are designed to address their staffing and	 
technology limits to help the states provide CDC with more	 
complete information. CDC officials have entered into a 	 
cooperative agreement with the Association of Public Health	 
Laboratories to assess the states' capability and capacity to	 
address public health issues, including foodborne disease. CDC	 
consults annually with the Council of State and Territorial	 
Epidemiologists to encourage more standardized reporting among	 
states. 							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-01-973 					        
    ACCNO:   A01563						        
  TITLE:     Food Safety: CDC Is Working to Address Limitations in    
Several of Its	Foodborne Disease Surveillance Systems		 
     DATE:   09/07/2001 
  SUBJECT:   Contaminated foods 				 
	     Data collection					 
	     Federal/state relations				 
	     Health hazards					 
	     Reporting requirements				 
	     CDC Botulism Surveillance System			 
	     CDC Ceutzfeldt-Jakob Disease			 
	     Surveillance Program				 								 
	     CDC Emerging Infections Program			 
	     CDC Epidemiology and Laboratory Capacity		 
	     Program						 								 
	     CDC Escherichia coli Outbreak			 
	     Surveillance System				 								 
	     CDC Foodborne Disease Outbreak			 
	     Surveillance System				 								 
	     CDC FoodNet					 
	     CDC National Antimicrobial Resistance		 
	     Monitoring System					 								 
	     CDC National Electronic Disease			 
	     Surveillance System				 
             CDC National Electronic                             
	     Telecommunications System for			 
	     Surveillance					                                                                 
	     CDC National Giardiasis Surveillance		 
	     System						 								 
	     CDC National Notifiable Diseases			 
	     Surveillance System				 								 
	     CDC National Salmonella Surveillance		 
	     System						                                                                 
	     CDC National Shigella Surveillance 		 
	     System						 								 
	     CDC PulseNet					 
	     CDC Salmonella Enteritidis Outbreak		 
	     Surveillance System				 								 
	     CDC Surveillance Outbreak Detection		 
	     Algorithm						 								 
	     CDC Trichinellosis Surveillance System		 
	     CDC Typhoid Fever Surveillance System		 
	     CDC Vibrio Surveillance System			 
	     CDC Viral Hepatitis Surveillance Program		 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Testimony.                                               **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-01-973
     
Report to the Chairman, Committee on Agriculture, Nutrition, and Forestry,
U. S. Senate

United States General Accounting Office

GAO

September 2001 FOOD SAFETY CDC Is Working to Address Limitations in Several
of Its Foodborne Disease Surveillance Systems

GAO- 01- 973

Page i GAO- 01- 973 Food Safety Surveillance Letter 1

Results in Brief 2 Background 4 CDC Foodborne Disease Surveillance Systems
Provide National

Data Needed to Prevent and Control the Spread of Foodborne Disease 8 Delayed
Reporting and Incomplete Data Limit CDC?s Surveillance

Systems, but CDC Is Working to Address These Problems 13 Agency Comments 17
Scope and Methodology 17

Appendix I Questionnaire Results 20

Appendix II Major Foodborne Pathogens Under Surveillance by the Centers for
Disease Control and Prevention 37

Appendix III CDC?s Surveillance Systems for Foodborne Disease 39 Botulism
Surveillance System 39 CaliciNet 40 Creutzfeldt- Jakob Disease Surveillance
Program 41 Epidemic Information Exchange (Epi- X) 42

Escherichia Coli O157: H7 Outbreak Surveillance System 43 Foodborne Disease
Outbreak Surveillance System 44 FoodNet 45 National Antimicrobial Resistance
Monitoring System- Enteric

Bacteria 47 National Giardiasis Surveillance System 48 National Notifiable
Diseases Surveillance System 49 National Salmonella Surveillance System 50
National Shigella Surveillance System 51 PulseNet 52

Salmonella Enteritidis Outbreak Surveillance System 53 Sentinel Counties
Study of Viral Hepatitis 54 Surveillance Outbreak Detection Algorithm 55
Trichinellosis Surveillance System 56 Typhoid Fever Surveillance System 57

Vibrio Surveillance System 58 Viral Hepatitis Surveillance Program 59
Contents

Page ii GAO- 01- 973 Food Safety Surveillance Appendix IV Comments From the
Centers for Disease Control 60

Appendix V GAO Contacts and Staff Acknowledgments 62

Table

Table 1: Conditions That Could Hinder Detection and Investigation of
Foodborne Disease Outbreaks 16

Figure

Figure 1: Levels of Disease Reporting 7

Abbreviations

CDC Centers for Disease Control and Prevention GAO General Accounting Office
USDA United States Department of Agriculture

Page 1 GAO- 01- 973 Food Safety Surveillance

September 7, 2001 The Honorable Tom Harkin Chairman Committee on
Agriculture, Nutrition, and Forestry United States Senate

Dear Mr. Chairman: Foodborne disease in the United States annually causes an
estimated 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths,
according to the Centers for Disease Control and Prevention (CDC). The
effects of these diseases range from mild gastroenteritis to life-
threatening damage to the kidneys, heart, and nervous system. The U. S.
Department of Agriculture (USDA) estimates that five major foodborne
diseases alone cost the nation at least $6.9 billion each year in medical
treatments, productivity losses, and premature deaths.

Surveillance is public health officials? most important tool for detecting
and monitoring both existing and emerging foodborne diseases. Without
adequate surveillance systems, local, state, and federal officials cannot
gauge the impact of existing foodborne diseases and may not recognize new
diseases until many people have been affected. These officials rely on
surveillance data to focus their staff and financial resources on preventing
and controlling the foodborne diseases that most threaten public health.
Health officials also use surveillance data to monitor and evaluate the
effectiveness of prevention and control programs.

In the United States, surveillance for foodborne disease is also used to
identify outbreaks- two or more cases of a similar illness that result from
ingestion of a common food- and their causes. Nearly all of CDC?s
surveillance systems are passive, which means they rely on physicians,
laboratory and hospital staff, and others to take the initiative in
reporting data to health departments. However, for FoodNet, one of CDC?s
principal foodborne disease surveillance systems, the reverse occurs. In
this system- referred to as an active system- public health officials take
the initiative to periodically contact laboratory officials to gather data
instead of passively waiting to receive data from laboratories and others.
Compared to a passive system, an active surveillance system produces more
complete information but is more costly to use for data collection
activities.

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 01- 973 Food Safety Surveillance

Responsibility for surveillance of foodborne diseases rests primarily with
local and state health departments, although the federal government also has
an important role. At the local level, health care providers identify cases
of foodborne disease. Typically, these local officials report cases of
certain diseases to state health departments. Both local and state health
departments investigate outbreaks. State health departments voluntarily
report those individual cases and outbreaks to CDC, which is part of the
Department of Health and Human Services.

CDC, as the central control point for collection of such data at the
national level, collects this data through two electronic information
systems and other information sources, such as paper forms, in order to
analyze and summarize foodborne disease information on a national basis.
Surveillance information can be used to detect outbreaks and to confirm that
the ensuing intervention is effective. For example, in 1996, public health
officials used surveillance data to detect an outbreak associated with
Escherichia coli (E. coli) O157: H7, which made 66 people ill and killed 1
after they drank unpasteurized apple juice. Surveillance triggered an
outbreak investigation, and as a result, the juice responsible for the
outbreak was recalled from all retail outlets.

However, the capabilities of any foodborne disease surveillance system are
limited. Surveillance systems can detect only a fraction of disease cases
because not all people who contract foodborne diseases actually seek
treatment, are properly diagnosed, have their diagnoses confirmed through
laboratory analysis, and then have their cases reported through the
surveillance systems.

In this context, you asked us to (1) describe CDC?s foodborne disease
surveillance systems and (2) identify limitations of these systems, as well
as any initiatives designed to address them. To accomplish these objectives,
we examined CDC?s surveillance systems and sent questionnaires to public
health officials in all 50 states, the District of Columbia, and New York
City to determine their level of participation in and opinions about the
systems. Appendix I contains the questionnaire, which addressed those
surveillance systems that focus on foodborne disease and cover more than one
pathogen. It also addressed CDC?s two primary databases that support these
systems.

CDC has 20 surveillance systems that include information on foodborne
diseases. These systems are used to detect cases or outbreaks of foodborne
disease, pinpoint their cause, recognize trends, and develop effective
prevention and control measures. Of these, four principal Results in Brief

Page 3 GAO- 01- 973 Food Safety Surveillance

systems focus on foodborne diseases and cover more than one pathogen. The
first such system, the Foodborne Disease Outbreak Surveillance System,
collects information nationwide about the incidence and cause of foodborne
outbreaks. This system relies on local health officials to take the
initiative to report outbreaks to CDC through state public health officials.
CDC and others use this system to maintain an awareness of ongoing problems,
among other things. The second system, FoodNet, actively collects
information in nine geographic areas on nine foodborne pathogens, hemolytic
uremic syndrome (a serious complication of E. coli

O157: H7 infection), Guillain- Barre syndrome (a serious complication of

Campylobacter infection), and toxoplasmosis. Public health officials who
participate in FoodNet receive funds from CDC to systematically contact
laboratories in their geographical areas and solicit incidence data. As a
result of this active solicitation, FoodNet provides more accurate estimates
of the occurrence of foodborne diseases than is otherwise available. The
third system, PulseNet, is used to identify whether separate cases of
illness likely originate from a common source. Using this system, public
health officials in 46 state and 2 local public health laboratories and in
the food safety laboratories of both the USDA and the Food and Drug
Administration submit to CDC genetic patterns of bacteria isolated from
patients and/ or contaminated food. The officials can then rapidly compare
the new patterns to other patterns already in the PulseNet database. Matches
may indicate an outbreak. The fourth system, the Surveillance Outbreak
Detection Algorithm, uses statistical analysis to compare current data
against a historical baseline in order to detect unusual increases in the
incidence of two pathogens- Salmonella and Shigella. Such increases may
indicate an outbreak. CDC?s 16 other surveillance systems either collect
data about a variety of diseases, only some of which are foodborne, or focus
exclusively on a single foodborne disease. Collectively these systems
provide information aimed at detecting and controlling the spread of
foodborne disease.

While CDC?s systems have contributed to food safety, the usefulness of
several of these surveillance systems is impaired both by CDC?s untimely
release of surveillance data and by gaps in the data collected. Twenty- six
survey respondents said that delays in publishing data from the Foodborne
Disease Outbreak Surveillance System diminished the usefulness of this
system. Many also said that more rapid release of data from FoodNet,
PulseNet, and the Surveillance Outbreak Detection Algorithm would make these
systems more useful. CDC officials attributed the delays in part to staffing
shortages at CDC and to the sometimes untimely reporting of surveillance
data by state and local health officials. To address these problems, CDC has
hired additional staff and is training state and local

Page 4 GAO- 01- 973 Food Safety Surveillance

health officials about the reporting needs of both state health departments
and CDC. Concerning gaps in data collection, survey respondents said that
the problem is caused, in part, by shortages of trained epidemiologists at
state and local health departments and by deficiencies in state laboratory
capabilities. Another contributing factor is that each state decides which
diseases it will track and which ones it will not. For example, while 32
survey respondents indicated that health providers in their states are
required to notify state or local health departments about cases of
cyclosporiasis- infection with Cyclospora, a parasite that causes diarrhea,
stomach cramps, and nausea- 19 said notification was not required. To help
the states provide CDC with more complete information, CDC is providing
funds to state and local health departments that are designed to address
their staffing and technology limitations. Additionally, CDC officials told
us they have entered into cooperative agreements with the Council of State
and Territorial Epidemiologists and the Association of Public Health
Laboratories to encourage more standardized reporting among states and to
assess the states? capability and capacity to address public health issues,
including foodborne disease. CDC?s actions represent a good first step
toward providing public health officials with more timely and complete
surveillance data.

In commenting on a draft of this report, CDC officials generally agreed with
the overall message of the report and provided technical comments, which we
incorporated as appropriate.

Surveillance of foodborne diseases allows public health officials to
recognize trends, detect outbreaks, pinpoint the causes of these outbreaks,
and develop effective prevention and control measures. Such surveillance
presents a complex challenge. Many foods today are imported, prepared and/
or eaten outside the home, and widely distributed after processing. As a
result, an outbreak of foodborne disease can involve people in different
localities, states, and even countries. The number and diversity of
foodborne diseases further complicate surveillance. Although many of the
more well- known foodborne pathogens are bacteria, such as E. coli

O157: H7 and Salmonella, foodborne diseases are caused by a variety of other
pathogens, including viruses, parasites, and toxins. Some of these diseases
also can be transmitted by nonfood sources, such as through water or through
person- to- person contact. Appendix II describes the major foodborne
diseases currently under national surveillance.

The surveillance process usually begins when a person with a foodborne
disease seeks medical care. To help determine the cause of the patient?s
illness, a physician may rely on a laboratory test, which could be
Background

Page 5 GAO- 01- 973 Food Safety Surveillance

performed in the physician?s own office, a hospital, an independent clinical
laboratory, or a public health laboratory. If the test shows that the
patient is ill with a disease (including a foodborne disease) that must be
reported under state law, or if the physician diagnoses the disease without
the use of a test, the cases are usually reported to the local health
department. Health department staff collect these reports, check them for
completeness, contact health- care professionals to obtain missing
information or clarify unclear responses, and forward them to state health
agencies. Staff resources devoted to disease reporting vary with the overall
size and mission of the health department. Because nearly half of local
health agencies have jurisdiction over a population of fewer than 25,000,
many cannot support a large, specialized staff to work on disease reporting.

The states have principal responsibility for protecting the public?s health
and therefore take the lead in conducting surveillance. In state health
departments, epidemiologists analyze the data reported and decide when and
how to supplement passive reporting with active surveillance methods,
conduct outbreak and other disease investigations, and design and evaluate
disease prevention and control efforts. They also transmit state data to
CDC, providing routine reporting on selected diseases.

Surveillance data are transmitted to CDC both electronically and using
paper- based systems. Information about individual cases of disease is
reported through two electronic systems. The National Electronic
Telecommunications System for Surveillance collects data submitted by
epidemiologists about patient demographics and residences, suspected or
confirmed diagnoses, and the dates of disease onset. In contrast, the second
system, the Public Health Laboratory Information System, collects more
definitive data from public health laboratory officials on pathogens
identified by laboratory tests. 1 Both systems also offer disease- specific
reporting options that states may use to report additional data to CDC. For
some surveillance systems, such as the Viral Hepatitis Surveillance Program,
data are submitted to CDC both electronically and using paper forms. For
other surveillance systems, such as the Foodborne Disease

1 The Public Health Laboratory Information System is a national electronic
laboratory reporting system that rapidly collects and transmits information
about laboratory confirmed isolates from all 50 state public health
laboratories. This system provides electronic laboratory data reporting for
20 pathogens or other conditions, including the National Salmonella and
Shigella Surveillance Systems, and provides data transmission for FoodNet.

Page 6 GAO- 01- 973 Food Safety Surveillance

Outbreak Surveillance System, the data are submitted primarily through paper
reporting. CDC officials told us they have an ongoing effort to integrate
public heath information collected through these and other systems. They
estimate this effort will take several years to complete.

Federal participation in the foodborne disease surveillance network focuses
on CDC activities- particularly those of the National Center for Infectious
Diseases. CDC analyzes the data furnished by states to (1) monitor national
health trends, (2) formulate and implement prevention strategies, (3)
evaluate state and federal disease prevention efforts, and (4) identify
outbreaks that affect multiple jurisdictions, such as more than one state.
CDC routinely provides public health officials, medical personnel, and
others information on disease trends and analyses of outbreaks.

In fiscal year 2000, CDC?s budget for foodborne disease surveillance through
the Food Safety Initiative was $29 million. In order to maximize the
effectiveness of its surveillance efforts, CDC works with the Council of
State and Territorial Epidemiologists, a professional association of public
health epidemiologists from each U. S. state and territory. They are
responsible for monitoring trends in health and health problems and devising
prevention programs that promote the entire community?s health. The council
is currently in its eighth year of a cooperative agreement with the CDC and
has approximately 15 separate activities on which they work collaboratively
with the CDC. CDC also works with the Association of Public Health
Laboratories, which links local, state, national, and global health leaders
in order to promote the highest quality laboratory practices worldwide.

However, regardless of the completeness and comprehensiveness of a
surveillance system, it can generally detect only a fraction of disease
cases- the tip of the iceberg, at best, as shown in figure 1.

Page 7 GAO- 01- 973 Food Safety Surveillance

Figure 1: Levels of Disease Reporting

Source: CDC.

Very few people who contract foodborne diseases actually seek treatment, are
properly diagnosed, have their diagnoses confirmed through laboratory
analysis, and then have their cases reported through the surveillance
systems. For example, a recent CDC- sponsored study estimated that 340
million annual episodes of acute diarrheal illness occurred in the United
States, but only 7 percent of people who were ill sought treatment. The
study further estimated that physicians requested laboratory testing of a
stool culture for only 22 percent of those patients who sought treatment,
which produced about 6 million test results that could be reported.

Although federal participation in foodborne disease surveillance focuses on
CDC activities, two other federal agencies have a key role in the wider
arena of food safety and use surveillance information in their programs.
USDA?s Food Safety and Inspection Service is responsible for ensuring

Reported to CDC Laboratory confirmed case

Lab test for organism Specimen obtained Person seeks care Person becomes ill
Exposure in the general population

Reported to health department

Page 8 GAO- 01- 973 Food Safety Surveillance

that meat, poultry, and processed egg products moving in interstate and
foreign commerce are safe. This agency primarily carries out its
responsibilities through inspections at meat, poultry, and egg processing
plants to ensure that these products are safe, wholesome, and accurately
labeled. In addition, the Food and Drug Administration in the Department of
Health and Human Services is responsible for ensuring that all other
domestic and imported food products are safe. Unlike the USDA, the Food and
Drug Administration, by and large, conducts post- market surveillance
through domestic inspections and testing of products already in commerce to
assure that foods are safe and comply with appropriate standards. This is
especially true for imported foods where the surveillance program is
primarily post- market testing, because the Federal Food, Drug and Cosmetic
Act does not provide explicit inspection authority outside the United
States. In addition to their other duties, these two agencies work to remove
from the market foods that are implicated in foodborne disease outbreaks.

CDC conducts surveillance of foodborne diseases through 20 systems. Four of
these- the Foodborne Disease Outbreak Surveillance System, FoodNet,
PulseNet, and the Surveillance Outbreak Detection Algorithm- focus on
foodborne diseases and cover multiple pathogens. The other 16 either collect
data about a variety of diseases, only some of which are foodborne, or focus
exclusively on a single foodborne disease. Collectively, these systems
provide information to detect and control the spread of foodborne disease.

The Foodborne Disease Outbreak Surveillance System collects nationwide
information about the occurrence and causes of foodborne outbreaks. This
system relies on local health officials to correctly identify, investigate,
and report outbreaks to CDC through state public health officials. CDC uses
the system to, among other things, compile and periodically report national
outbreak data. In 1997, the latest year for which published data are
available, states and U. S. territories reported 806 outbreaks to CDC
through this system. Furthermore, information from this system can serve as
a basis for regulatory and other changes to improve food safety. For
example, data from the Foodborne Disease Outbreak Surveillance System has
played an important role in documenting the importance of shell eggs as a
source of human infection with Salmonella Enteritidis. In response to this
data and other reports pointing out the dangers posed by improperly handled
eggs, government agencies and the egg industry have taken steps to reduce
Salmonella contamination of eggs. These steps include refrigerating eggs
during transport from the producer to the consumer, identifying and removing
infected laying flocks, diverting eggs from CDC Foodborne

Disease Surveillance Systems Provide National Data Needed to Prevent and
Control the Spread of Foodborne Disease

Page 9 GAO- 01- 973 Food Safety Surveillance

infected flocks to pasteurization facilities, and increasing on- farm
quality assurance and sanitation measures. CDC has advised state health
departments, hospitals, and nursing homes of specific measures to reduce

Salmonella Enteritidis infection, and the USDA tests the breeder flocks that
produce egg- laying chickens to ensure that they are free of

Salmonella Enteritidis. The Food and Drug Administration has amended its
regulations, which now require that all shell eggs in retail establishments
be held at a temperature of 45 degrees Fahrenheit or lower and that all egg
cartons carry safe- handling instructions to inform consumers about proper
storage and cooking of eggs.

FoodNet is a surveillance system operating in nine sites selected by CDC on
the basis of their capability to conduct active surveillance and because of
their geographic location. FoodNet produces a more stable and accurate
national estimate than is otherwise available of the frequency and sources
of nine foodborne pathogens, hemolytic uremic syndrome (a serious
complication of E. coli O157: H7 infection), Guillain- Barre syndrome (a
serious complication of Campylobacter infection), and toxoplasmosis. These
improved estimates result from the use of active surveillance and additional
studies that are not characteristic of CDC?s other foodborne surveillance
systems. Public health departments who participate in FoodNet receive funds
from CDC to systematically contact laboratories in their geographical areas
and solicit incidence data. 2 In 1999, state officials participating in
FoodNet contacted each of the more than 300 clinical labs within the FoodNet
areas on a regular basis. 3 FoodNet studies include various ?case control?
studies, which are used to determine factors, such as food preparation or
handling practices, that affect the risk of infection by pathogens covered
by the system. The studies also examine the association between infections
and specific foods. In addition, public health officials that participate in
FoodNet conduct surveys to identify physician and lab practices that may
limit the identification of foodborne diseases.

PulseNet is a nationwide network of public health laboratories that perform
DNA ?fingerprinting? on four types of foodborne bacteria in order to
identify and investigate potential outbreaks. The four bacteria

2 Funding for FoodNet comes not only from CDC but also from the Food and
Drug Administration and the USDA. 3 Throughout this report, we use 1999 as
the reference year because it is the most recent year for which surveillance
data are consistently available.

Page 10 GAO- 01- 973 Food Safety Surveillance

fingerprinted by PulseNet- Salmonella, E. coli O157: H7, Listeria, and

Shigella- were selected because of their public health importance and the
availability of specific ?fingerprinting? methods for the pathogens. These
four bacteria are either common or have severe symptoms, or both. Public
health officials in 46 state and 2 local public health laboratories as well
as the food safety laboratories of the USDA and the Food and Drug
Administration submit ?fingerprint? patterns of bacteria isolated from
patients and/ or contaminated food to the PulseNet database. The PulseNet
network permits rapid comparison of the patterns in the database. Matches
may indicate an outbreak. Similar patterns in samples taken from different
patients suggest that the bacteria come from a common source, for example, a
widely distributed contaminated food product. In addition, strains isolated
from food products can be compared with those isolated from ill persons to
provide evidence that a specific food caused the disease. By identifying
these connections, PulseNet provides critical data for identifying and
controlling the source of an outbreak, thus reducing the burden of foodborne
disease for the pathogens within the scope of this network. Thirty survey
respondents told us that, in the last 3 years, PulseNet had identified a
cluster of cases in their state that turned out to be a previously unknown
outbreak. In addition, 42 respondents reported that PulseNet helped their
state detect and investigate outbreaks of E. coli

O157: H7, Salmonella, Listeria, and/ or Shigella. Twenty- five of these said
that PulseNet greatly helped in this area. In 2000, over 17,000 patterns
were submitted to the PulseNet database, and 105 potential outbreaks were
identified and investigated.

Another system that CDC uses to detect potential foodborne outbreaks is the
Surveillance Outbreak Detection Algorithm. In contrast to PulseNet, which
uses advanced technology to compare bacterial DNA, the Surveillance Outbreak
Detection Algorithm uses statistical analysis to compare currently reported
incidence of two common pathogens,

Salmonella and Shigella, to a historical baseline in order to detect unusual
increases in a specific serotype, such as Salmonella Enteritidis. Such
increases may indicate an outbreak. CDC selected Salmonella and

Shigella because there are many different serotypes of these organisms, and
tracking and comparing the frequency of each serotype was a task well suited
for computer analysis. In addition, baseline data for these two pathogens
were already available through the National Salmonella

Surveillance System and the National Shigella Surveillance System, described
below and in appendix III. Beginning in 2002, CDC plans to expand the system
to include E. coli O157: H7. Twenty- five of the states that we surveyed
told us that in their state, at least once in the last 3 years

Page 11 GAO- 01- 973 Food Safety Surveillance

the Surveillance Outbreak Detection Algorithm had identified a cluster of
cases in their state that turned out to be a previously unknown outbreak.

In addition to these 4 systems, CDC also has the following 16 systems that
either collect information about a number of diseases, only some of which
are foodborne, or focus solely on one disease:

 The Botulism Surveillance System is a national system designed to collect
information about all types of botulism, including foodborne. Because every
case of foodborne botulism is considered a public health emergency, CDC
maintains intensive surveillance for botulism in the United States.

 The CaliciNet is a network of public health laboratories that perform
genetic ?fingerprinting? for foodborne viruses, allowing rapid
identification and comparison of strains.

 The Creutzfeldt- Jakob Disease Surveillance Program monitors the
occurrence of this disease through periodic review of national cause-
ofdeath data. Surveillance for this disease was enhanced in 1996 to monitor
for the possible occurrence of new variant Creutzfeldt- Jakob Disease after
this new form of the disease was reported to have possibly resulted from
consumption of cattle products contaminated with bovine spongiform
encephalopathy (also known as ?mad cow? disease).

 The Epidemic Information Exchange (Epi- X) is a secure Web- based
communications network that allows local, state, and federal public health
officials to share and discuss outbreak data on a real- time basis. This
system can immediately notify health officials of urgent public health
events so that they can take appropriate actions.

 The Escherichia coli O157: H7 Outbreak Surveillance System is a national
system established to collect detailed information about risk factors and
vehicles of transmission for E. coli infection and is used to inform the
public about new vehicles of transmission.

 The National Antimicrobial Resistance Monitoring System is used to monitor
the antimicrobial resistance of certain bacteria that are under surveillance
through other systems. The system currently operates in 17 sites throughout
the United States.

 The National Giardiasis Surveillance System includes data from
participating states about reported cases of giardiasis- a condition caused
by a parasite found in contaminated water or food such as fruits and
vegetables. This system began in 1992, when the Council of State and
Territorial Epidemiologists assigned giardiasis a code that enabled states
to begin voluntarily reporting surveillance data on this disease to CDC
electronically.

 The National Notifiable Diseases Surveillance System is a national system
that collects information about 58 diseases, most of which are not

Page 12 GAO- 01- 973 Food Safety Surveillance

considered foodborne, about which regular, frequent, and timely information
is considered necessary for their prevention and control. Data from the
system are used to analyze disease trends and determine relative disease
burdens on a national basis.

 The National Salmonella Surveillance System is a national system that
collects information on the isolates of Salmonella that are serotyped in
state public health laboratories, as well as the isolates from food and
animals. This system tracks the frequency of more than 500 specific
serotypes to determine trends, detect outbreaks, and focus interventions.
The system can detect outbreaks either locally or spread out over several
jurisdictions.

 The National Shigella Surveillance System is a national system that
collects information on the isolates of Shigella that are serotyped in state
public health laboratories. This system tracks the frequency of more than 40
specific serotypes to determine trends, detect outbreaks, and focus
interventions. The system can detect outbreaks either locally or spread out
over several jurisdictions.

 The Salmonella Enteritidis Outbreak Surveillance System is a national
system designed to track these outbreaks and to collect information on
implicated food items and the results of traceback investigations conducted
by local agencies and the Food and Drug Administration.

 The Sentinel Counties Study of Viral Hepatitis is carried out in six U. S.
counties to elicit more detailed information on individual hepatitis cases
and collect samples for further analyses.

 The Trichinellosis Surveillance System is a national surveillance system
used to monitor long- term trends for this disease.

 The Typhoid Fever Surveillance System is a national surveillance system
for monitoring long- term trends in the epidemiology of typhoid fever in the
United States. The system provides information about risk factors that is
used in making vaccine recommendations.

 The Vibrio Surveillance System is composed of two parts: a national system
used for reporting cases of Vibrio cholerae (cholera), and another system,
which is more geographically limited, that is used for reporting all

Vibrio infections. All cases reported to this system are confirmed through
laboratory tests by the relevant state or CDC. Surveillance data for this
system are used to identify environmental risk factors, retail food outlets
where high- risk exposures occur, and target groups that may benefit from
consumer education.

 The Viral Hepatitis Surveillance Program is a national system designed to
collect information about acute cases of viral hepatitis: hepatitis A;
hepatitis B; and non- A, non- B hepatitis (including hepatitis C). States
report basic demographic information for each case, as well as other
factors, such as risk- factor information. These data are essential for

Page 13 GAO- 01- 973 Food Safety Surveillance

monitoring trends in the characteristics of the various types of viral
hepatitis.

Collectively, these surveillance systems provide crucial national data
needed to detect and control the spread of foodborne disease. More detailed
information about these systems is contained in appendix III, in
alphabetical order by system.

Public health officials that we contacted said that both untimely release of
surveillance data by CDC and the gaps in some of CDC?s data limit the
surveillance systems? usefulness. Some of these problems have resulted from
staff shortages at CDC, while others have been caused by shortages of
trained epidemiologists and laboratory personnel at state and local health
departments. Another contributing factor is that each state decides which
diseases it will track and which ones it will not. Therefore, the diseases
that are reported to CDC vary from one state to another. In response to
these problems, CDC has taken action to address its staff deficiencies and
to assist state and local health officials to improve their data collection
and reporting abilities. CDC?s actions represent a good first step toward
providing public health officials with more timely and complete surveillance
data.

Delayed dissemination of information from CDC?s foodborne disease
surveillance systems has impaired the usefulness of the data. For example,
for the Foodborne Disease Outbreak Surveillance System, CDC did not publish
outbreak data for the years 1993- 1997 until March 2000. CDC officials told
us that the late publication of the March 2000 outbreak report was due in
part to staff shortages. As of June 2001, data from 1997 was the most recent
available from this system. Officials from both the Food and Drug
Administration and USDA?s Food Safety and Inspection Service told us that
this delay limited the data?s usefulness. In addition, of the 52 respondents
to our survey, 26 said that the 3- year lag between the end of the reporting
period and the publication of CDC?s March 2000 report diminished the
usefulness of the report to their state. Of the 43 survey respondents that
used this report, nearly all said that the outbreak data was used as a
source of information about foodborne disease trends or to determine
associations between pathogens and food.

Many survey respondents also told us that more rapid reporting or release of
data from FoodNet, PulseNet, and the Surveillance Outbreak Detection
Algorithm would improve the systems? usefulness. For FoodNet, CDC publishes
surveillance results annually. However, as of June 2001, CDC had not
published any detailed results from its case control studies about Delayed
Reporting

and Incomplete Data Limit CDC?s Surveillance Systems, but CDC Is Working to
Address These Problems

Delayed Reporting

Page 14 GAO- 01- 973 Food Safety Surveillance

the proportion of foodborne disease caused by specific foods or food
preparation and handling practices, even though FoodNet has been operational
since 1995. CDC officials told us that they had submitted the results of
these surveys and studies to professional journals, but the results were
never published. For PulseNet, nearly half of the survey respondents said
that more rapid analysis of data and more rapid reporting of identified
clusters would make the system more useful. In addition, 33 of the
respondents said that direct access to the PulseNet database would make the
system more useful. For the Surveillance Outbreak Detection Algorithm, 25 of
the respondents said that more rapid analysis of state, regional, and
national data by CDC would make that system more useful. In addition, 20
respondents said more rapid reporting of clusters by CDC would make the
system more useful.

CDC officials told us that the late publication of the March 2000 outbreak
report was due in part to staff shortages. CDC took action to address this
problem when the agency hired four new staff between June 2000 and September
2000 to take on the responsibilities of collecting, verifying, coding,
processing, and summarizing the outbreak data in addition to other duties.
In the future, CDC plans to release outbreak data annually beginning with
1998 data, instead of aggregating these data over several years. CDC is
currently compiling 2001 outbreak data and intends to publish it by the end
of 2002. In addition, CDC is developing a system, called the Electronic
Foodborne Outbreak Reporting System, which will allow states to
electronically transmit reports of foodborne disease outbreaks. Thirty- six
survey respondents indicated that this system would increase the timeliness
of their initial outbreak reports to CDC. Finally, in November 2000 CDC
introduced an electronic bulletin board, known as Epi- X, which allows
local, state, and federal public health officials to share outbreak data on
a real- time basis. This system can automatically notify health officials of
urgent public health events so that they can take appropriate actions.

CDC also has plans to provide more rapid reporting or release of data from
FoodNet and PulseNet. For FoodNet, CDC officials said they plan to publish
by the end of 2001 a number of case control study results that were
previously unavailable. For PulseNet, CDC told us it has developed new
software that, effective June 30, 2001, gives all participating certified
laboratories direct access to the PulseNet database. This allows state
officials to query the PulseNet database directly instead of waiting for CDC
to send them notice of a new pattern.

Page 15 GAO- 01- 973 Food Safety Surveillance

However, CDC?s ability to disseminate surveillance data in a timely fashion
also depends in part on the timeliness of state and local officials?
submittal of the data. For example, for the Foodborne Disease Outbreak
Surveillance System, 24 of the survey respondents said they did not report
any outbreak data for 2000 until the end of the year or even later. Thus,
data could be over a year old before it gets reported to CDC. Similarly, CDC
officials also told us that for the Surveillance Outbreak Detection
Algorithm, some states report information only quarterly, which is too late
to allow CDC to provide early detection of an ongoing outbreak. Because
responsibility for surveillance of foodborne diseases rests primarily with
the states, states? reporting of data to CDC is voluntary. To assist in
overcoming this problem, CDC is developing a new program known as the
National Electronic Disease Surveillance System. This system is intended to
facilitate the ready exchange of data between local and state health
departments, among states, and among states and CDC. While this may not
overcome delayed reporting by the states, it should make information more
readily available. In addition, through their Epidemic Intelligence Service
program, CDC is training medical doctors, researchers, and scientists, who
serve in 2- year assignments, about the needs of both state health
departments and CDC. Agency officials said that they hope graduates from the
program will understand the value of sharing information in a timely manner
and help speed the flow of information into CDC.

The completeness of CDC?s data is dependent in large part on the submissions
from state and local health officials, which often do not report all cases
or all information requested about individual cases. For example, 17 survey
respondents told us that not all of the outbreaks in their states were
reported to the Foodborne Disease Outbreak Surveillance System. Moreover,
for those outbreaks that were reported, 25 survey respondents said the
responsible pathogen was identified in only half or fewer of their reports
submitted to CDC. Further, as regards the contaminated food item that caused
the outbreaks, 28 survey respondents said they identified and reported the
responsible food item in half or fewer of their reports. According to FDA
and FSIS officials, identifying the responsible pathogen and the
contaminated food item is critical for understanding and controlling
foodborne disease, and for tracing the cause of the contaminant to its
original source.

Survey respondents cited several reasons for the gaps in outbreak
information sent to CDC. Table 1 summarizes some of the major reasons.
Incomplete Data

Page 16 GAO- 01- 973 Food Safety Surveillance

Table 1: Conditions That Could Hinder Detection and Investigation of
Foodborne Disease Outbreaks Conditions True in our

state Not true in our state Total

respondents

There are not enough trained epidemiologists at the local level to
investigate outbreaks. 44 6 50 Workload and priorities at local level
discourage investigation of outbreaks. 36 15 51 There is local resistance to
linking a business name with foodborne disease. 32 19 51 There are not
enough trained epidemiologists at the state level to investigate outbreaks.
32 19 51 State labs do not have capability to analyze specimens for a full
range of pathogens (e. g., viruses). 31 20 51 Foodborne disease has much
lower priority for resources compared to other public health issues. 26 24
50 Local health departments do not always inform the state about outbreaks.
26 23 49

Source: GAO survey.

As the table shows, the majority of the respondents said shortages of
personnel and capacity in state and local health departments, among other
things, hinder their ability to detect and investigate foodborne disease
outbreaks. A complete listing of conditions that could hinder state and
local public health officials is included in our questionnaire results,
contained in appendix I.

Another cause of incomplete data submissions to the Foodborne Disease
Outbreak Surveillance System, as well as to other systems, is the lack of
standard disease reporting requirements among states. Each state has a
separate list of ?reportable? diseases that must be reported to the state
health department. The lists vary greatly from state to state because of
differences in the extent to which the diseases occur. For example, while 32
survey respondents indicated that health providers in their state are
required to notify state or local health departments about cases of
cyclosporiasis, 19 said notification was not required. (See app. I for more
information on state reporting requirements for a number of foodborne
pathogens.) Although states can forward data to CDC about diseases that are
not reportable, overall data about such diseases are often incomplete
because of deficiencies in reporting by physicians and labs.

To improve local and state health officials? ability to respond to a broad
range of public health issues relating to infectious diseases, which include
foodborne outbreaks, CDC provides funding to state and local health
departments through its Emerging Infections Programs and its

Page 17 GAO- 01- 973 Food Safety Surveillance

Epidemiology and Laboratory Capacity program. Funding for these two programs
has increased from $900,000 in 1994 to approximately $50 million in 2001.
These programs are designed to address staffing or technology shortages, or
both, and will help the states provide CDC with more complete information.
For example, states have received grants to significantly increase the
capacity of their laboratories. According to CDC officials, now nearly every
state has properly trained staff able to use PulseNet technology.

To encourage more standardized reporting among the states, CDC consults
annually with the Council of State and Territorial Epidemiologists to
determine which infectious diseases, including foodborne diseases, are
important enough to merit routine reporting to CDC. Officials from CDC told
us they have also entered into cooperative agreements with the council and
with the Association of Public Health Laboratories to assess the states?
capability and capacity to address public health issues, including foodborne
diseases.

In commenting on a draft of this report, CDC officials generally agreed with
the overall message of the report and provided technical comments to ensure
completeness and accuracy. We incorporated these comments into our report as
appropriate. CDC comments are presented in appendix IV.

To describe CDC?s foodborne disease surveillance systems, we obtained
information from CDC on the systems used most often in conducting foodborne
disease surveillance activities. We examined each of these systems to
identify their use and how they operate. We also discussed the systems? use
and operation with officials from the Food and Drug Administration, USDA?s
Food Safety and Inspection Service, the Council of State and Territorial
Epidemiologists, the Association of Public Health Laboratories, the National
Pork Producers Council, the American Meat Institute, the National Broilers
Council, and the Center for Science in the Public Interest. As a result of
our initial work, we then directed the remainder of our review effort to
four surveillance systems that focus on foodborne disease and that cover
more than one pathogen. These four systems were the Foodborne Disease
Outbreak Surveillance System, FoodNet, PulseNet, and the Surveillance
Outbreak Detection Algorithm. We reviewed extensive literature about each of
these four systems and examined the systems? input and reporting
documentation. Agency Comments

Scope and Methodology

Page 18 GAO- 01- 973 Food Safety Surveillance

To identify limitations of these surveillance systems, we sent mail- back
questionnaires to officials in the 50 state health departments, as well as
in the District of Columbia, and New York City. 4 We pretested this survey
in three states to ensure that our questions were clear, unbiased, and
precise, and that responding to the survey did not place an undue burden on
the health departments. We received completed questionnaires from 100
percent of those surveyed. We discussed limitations identified in the survey
with CDC and other federal and state public health officials and with other
groups that use foodborne disease surveillance systems. To identify
initiatives designed to address these limitations, we met with CDC officials
responsible for the surveillance systems and discussed actions they have
taken or plan to take to address the limitations.

We conducted our review from August 2000 through July 2001 in accordance
with generally accepted government auditing standards.

As agreed with your offices, unless you publicly announce the contents of
this report earlier, we plan no further distribution of it until 30 days
from the date of this letter. We will then send copies to the congressional
committees with jurisdiction over food safety issues; the Secretary of
Health and Human Services; the Director, Office of Management and Budget;
and other interested parties. We will also provide copies to others on
request.

4 We added New York City because CDC officials told us that sometimes the
city?s public health department reports data directly to CDC.

Page 19 GAO- 01- 973 Food Safety Surveillance

If you or your staff have any questions about this report, please call me on
(202) 512- 3841. Key contributors to this report are listed in appendix V.

Sincerely yours, Lawrence J. Dyckman Director, Natural Resources

and Environment

Appendix I: Questionnaire Results Page 20 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results

Appendix I: Questionnaire Results Page 21 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 22 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 23 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 24 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 25 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 26 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 27 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 28 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 29 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 30 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 31 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 32 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 33 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 34 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 35 GAO- 01- 973 Food Safety
Surveillance

Appendix I: Questionnaire Results Page 36 GAO- 01- 973 Food Safety
Surveillance

Appendix II: Major Foodborne Pathogens Under Surveillance by the Centers for
Disease Control and Prevention

Page 37 GAO- 01- 973 Food Safety Surveillance

Pathogen Incubation period Common symptoms Transmission Associated foods

Bacterial

Campylobacter 2 to 5 days Fever, abdominal cramps, diarrhea (often bloody)

Consumption of contaminated food or water; contact with infected animals

Raw or undercooked poultry meat, unpasteurized milk

Clostridium botulinum

(Botulism) 18 to 36 hours; can

be 6 hours to 10 days

Double vision, drooping eyelids, slurred speech, difficulty swallowing and
other signs of muscle paralysis

Ingestion of contaminated food product; infected wounds

Home- canned foods with low acid content, such as green beans, beets and
corn; chopped garlic in oil; chili peppers

Escherichia coli O157: H7 1 to 10 days; usually 3 to 4 days Bloody diarrhea,

abdominal cramps, little or no fever

Consumption of contaminated food, swimming in contaminated water, person to
person contact

Ground beef, salami, lettuce, unpasteurized milk, juice

Listeria monocytogenes 2 to 8 weeks Fever, muscle aches; sometimes nausea
and/ or diarrhea

Consumption of contaminated food Hot dogs and

packaged meats; soft cheeses

Salmonella

non- typhoidal Usually 12 to 72

hours; can be up to 7 days

Abdominal cramps, fever, diarrhea; sometimes nausea and vomiting

Consumption of contaminated food or water; contact with infected animals

Beef, poultry, milk, eggs, and produce

Salmonella typhi (Typhoid Fever)

1 to 3 weeks Sustained high fever, weakness, stomach pains, headache, or
loss of appetite

Contaminated drinking water or food Risk is very low in

the United States

Shigella 12 to 72 hours Watery or bloody diarrhea, abdominal pain, fever,
malaise

Most commonly from person to person, but can be transmitted by food and
water

Fresh produce, salads, foods with hand preparation

Vibrio

non- cholera, including Vibrio

vulnificus

4 hours to 4 days; average of 15 hours

Diarrhea, abdominal pain, nausea, vomiting; sometimes fever

Ingestion of contaminated seafood or exposure of an open wound to seawater

Contaminated seafood, such as raw oysters

Vibrio cholerae

(Cholera) 6 hours to 5 days Profuse watery

diarrhea, vomiting, circulatory collapse, shock

Contaminated drinking water or food Undercooked

shellfish; virtually no cases in the United States

Yersinia enterocolitica 4 to 7 days Fever, abdominal pain, diarrhea (often
bloody) Contaminated food or

drinking water; contact with infected animals

Raw or undercooked pork, unpasteurized milk Parasitic

Cryptosporidium 2 to 10 days Diarrhea (usually watery), stomach cramps,
upset stomach, slight fever

Contaminated water or food; contact with infected items, such as toys and
bathroom fixtures

Any food contaminated by an ill food handler

Appendix II: Major Foodborne Pathogens Under Surveillance by the Centers for
Disease Control and Prevention

Appendix II: Major Foodborne Pathogens Under Surveillance by the Centers for
Disease Control and Prevention

Page 38 GAO- 01- 973 Food Safety Surveillance

Pathogen Incubation period Common symptoms Transmission Associated foods

Cyclospora 1 to 14 days Diarrhea (usually watery), loss of appetite,
substantial loss of weight, stomach cramps, nausea, vomiting, fatigue

Contaminated food or drinking water Various types of

fresh produce, including imported raspberries

Giardia 1 to 2 weeks Diarrhea (usually watery) and stomach cramps

Contaminated water, food, or surfaces Fruits and

vegetables Toxoplasma 5 to 23 days Flu- like illness;

congenital infection causes neurological and ocular disease

Consumption of raw or undercooked meat; ingestion of the organism after
contact with cat feces or soil contaminated with cat feces

Undercooked meat, especially pork, lamb, and wild game meat; contaminated
fruits and vegetables

Trichinella 1 to 2 days for initial symptoms; others begin 2 to 8 weeks
after infection

Nausea, diarrhea, vomiting, fatigue, fever, abdominal discomfort

Consumption of raw or undercooked meat Undercooked pork

or wild game; infection is relatively rare in the United States Viral
Hepatitis A 15 to 50 days, with

an average of 28 days

Fever, fatigue, loss of appetite, nausea, abdominal cramps, dark urine,
jaundice

Person- to- person or by contaminated food or water (fecal- oral)

Contaminated foods eaten uncooked or foods contaminated after cooking
?Norwalk- like? virus 12 to 48 hours Vomiting, non- bloody

diarrhea, nausea, abdominal pain, fever

Contaminated food or water; person to person; contact with a contaminated
item (fecal- oral)

Shellfish, salads, sandwiches, ready to- eat foods with bare- hand contact

Other New variant Creutzfeldt- Jakob disease Multiple years Prominent
behavior

changes, neurological abnormalities, dementia

Consumption of contaminated meat Beef and beef

products that include brain or nerve tissue; no documented cases in the
United States

Source: GAO?s presentation of disease data.

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 39 GAO- 01- 973 Food Safety Surveillance

The Botulism Surveillance System was established in 1973 to collect detailed
information about all types of botulism- foodborne, wound, infant, and child
or adult. Because every case of foodborne botulism is considered a public
health emergency, CDC maintains intensive surveillance for botulism in the
United States. All states except California and Alaska must contact CDC when
a case of botulism is suspected, because CDC is the main source of the
antitoxin used to treat botulism. As a result, most cases of botulism are
reported to CDC immediately. CDC officials follow up on these cases to
collect demographic information about the affected individuals, as well as
additional information about which foods were involved and their handling
and preparation. This information is especially important because the
hazardous food may still be available.

Geographic Scope: National.

Pathogen: Clostridium botulinum.

Cases Reported: In 1999, a total of 174 cases were reported to this system,
of which 26 were foodborne.

Data Sources: Data are initially collected using three main sources: CDC
clinical consultation reports, National Electronic Telecommunications
Surveillance System reports, and pharmacy antitoxin release reports. Data
collected from these sources are compiled and considered to be unconfirmed
Clostridium botulinum cases. Following the compilation of this data, states
are asked to verify the list of cases reported, and the list is then
compared to laboratory data. From this two- step process,
laboratoryconfirmed and epidemiologically linked cases are ascertained.
Appendix III: CDC?s Surveillance Systems for

Foodborne Disease Botulism Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 40 GAO- 01- 973 Food Safety Surveillance

CaliciNet, an initiative currently under development, is a network of public
health laboratories that uses DNA sequence analysis for ?fingerprinting? of
foodborne viruses. The network permits rapid comparison of the genetic
patterns of foodborne caliciviruses through an electronic sequence database
at CDC. Laboratories participating in CaliciNet detect ?Norwalklike?

viruses in samples from patients involved in outbreaks of gastroenteritis.
Depending on the capabilities in the laboratory, amplification products from
positive samples are sequenced locally, sent to a contract laboratory for
sequencing, or sent to CDC for confirmatory testing and sequencing.
Comparison of newly identified sequences with those in the database may help
public health laboratories to identify cases with a common source.

Geographic Scope: Thirteen state health departments (California, Florida,
Idaho, Iowa, Maryland, Michigan, Minnesota, Missouri, New York, Oregon,
Virginia, Washington, and Wisconsin) and the Los Angeles County health
department are currently submitting samples for confirmatory testing and
genetic analysis. Ten other state health departments (Colorado, Connecticut,
Illinois, Nevada, New Hampshire, New Mexico, Ohio, Rhode Island, South
Carolina, and Tennessee) are currently undergoing proficiency testing.

Pathogens: ?Norwalk- like? viruses and ?Sapporo- like? viruses.

Cases Reported: In 1999, 94 specimens from 9 states were submitted for
confirmatory testing and genetic analysis at CDC.

Data Sources: State public health laboratories submit samples to CDC for
confirmatory testing and genetic analysis, or sequences are transmitted
electronically. CaliciNet

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 41 GAO- 01- 973 Food Safety Surveillance

CDC monitors the occurrence of Creutzfeldt- Jakob disease through periodic
review of national multiple- cause- of- death data. Surveillance for this
disease was enhanced in 1996 to monitor for the possible occurrence of new
variant Creutzfeldt- Jakob disease after this new form of the disease was
reported to have possibly resulted from consumption of cattle products
contaminated with bovine spongiform encephalopathy (also known as ?mad cow?
disease).

One enhancement focused on striking differences in the age distribution of
new variant Creutzfeldt- Jakob disease cases, for which the median age at
death is 28 years, from that of sporadic cases of Creutzfeldt- Jakob disease
in the United States, for which the median age at death is 68 years. This
enhancement included an ongoing review of the clinical and pathologic
records of U. S. victims of Creutzfeldt- Jakob disease under 55 years of
age.

In addition, in collaboration with the American Association of
Neuropathologists, CDC established a National Prion Disease Pathology
Surveillance Center to facilitate neuropathologic evaluation of patients
suspected of having Creutzfeldt- Jakob disease or other diseases caused by
prions.

Geographic Scope: National.

Pathogens: The agents of Creutzfeldt- Jakob disease and the new variant form
of Creutzfeldt- Jakob are believed to be prions.

Cases Reported: Between January 1979 and June 2001, over 5, 000 U. S. cases
of Creutzfeldt- Jakob disease were reported; no evidence of the occurrence
of new variant Creutzfeldt- Jakob disease in the United States was detected.

Data Sources: National multiple- cause- of- death data are compiled by the
National Center for Health Statistics. Physicians, pathologists, other
health care workers, and state and local health departments report suspected
cases of prion diseases. Creutzfeldt- Jakob

Disease Surveillance Program

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 42 GAO- 01- 973 Food Safety Surveillance

The Epidemic Information Exchange, known as Epi- X, is a secure, Webbased
communications network for public health officials that simplifies and
expedites the exchange of routine and emergency public health information
among state and local health departments, CDC, and the U. S. military. CDC
recognized that the public health profession had a need for rapid
communication, research, and response to widespread food and food- product
contamination. After consulting with more than 300 health officials, CDC
developed this new system, which enables federal, state, and local
epidemiologists, laboratory staff, and other health professionals to quickly
notify colleagues of disease outbreaks as they are identified and
investigated. The system allows users to compare information on current and
past outbreaks through an easily searchable database, discuss a response to
the outbreak with colleagues through e- mail, Internet, and
telecommunications capabilities, and request epidemiological assistance from
CDC on- line. Epi- X is endorsed by the Council of State and Territorial
Epidemiologists.

Geographic Scope: National.

Pathogens: Any pathogen, including bacteria, chemicals, parasites, and
viruses (also products or devices).

Cases Reported: From November 2000 through August 2001, 153 outbreaks were
reported, including 37 foodborne outbreaks. Two health alerts related to
foodborne outbreaks of food contamination were issued; over 85 percent of
Epi- X users were notified within 30 minutes.

Data Sources: CDC and state and local public health officials submit
encrypted reports to CDC. At CDC, reports are decrypted, reviewed for
accuracy and quality, and posted within 48 hours after they are received.
Epidemic Information

Exchange (Epi- X)

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 43 GAO- 01- 973 Food Safety Surveillance

The Escherichia coli (E. coli) O157: H7 Outbreak Surveillance System began
in 1982, after the first recognized outbreak of this pathogen, and was
established to collect detailed information about risk factors and vehicles
of transmission for E. coli infection. State health departments are
encouraged to report any outbreak of E. coli O157: H7 infection in their
state to CDC. Data are collected on outbreaks caused by all sources
including food, recreational water, drinking water, animal contact, and
person- to- person transmission. E. coli O157: H7 infections can be quite
serious and may result in death. Therefore, public health officials at CDC
follow up with state health departments on reported outbreaks of E. coli

infection to determine their cause and prevent additional spread. Data from
this surveillance system are used to inform the public about new vehicles of
transmission.

Geographic Scope: National.

Pathogen: E. coli O157: H7.

Cases Reported: In 1999, 38 confirmed outbreaks (causing 1,897 illnesses)
were reported to CDC.

Data Sources: Outbreaks of E. coli O157: H7 infection are reported to CDC
through several sources including PulseNet; the Foodborne Outbreak
Listserve, through which state and local health departments can share
information about confirmed and potential outbreaks; Epi- X; U. S.
Department of Agriculture and Food and Drug Administration contacts; and
state health department contacts.

Escherichia Coli

O157: H7 Outbreak Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 44 GAO- 01- 973 Food Safety Surveillance

CDC created the Foodborne Disease Outbreak Surveillance System in 1973 to
collect data about cases of foodborne disease that are contracted by two or
more patients as a result of ingesting a common food. In the event of such
an outbreak, state and local public health department officials provide data
to the system about the pathogen that caused the outbreak, the contaminated
food that was involved, and contributing factors associated with foodborne
disease outbreaks. The data help focus public health actions intended to
reduce illnesses and deaths caused by foodborne disease outbreaks. Trend
analysis of the data shows whether outbreaks occur seasonally and whether
certain foods are more likely to contain pathogens. It also helps public
health officials identify critical control points in the path from farm to
table that can be monitored to reduce food contamination. However, the data
from this system do not always identify the pathogen responsible for a given
outbreak; such identification may be hampered by delayed or incomplete
laboratory investigation, inadequate laboratory capacity, or inability to
recognize a particular pathogen as a cause of foodborne disease.

Geographic Scope: All 50 states, the District of Columbia, Guam, Puerto
Rico, and the U. S. Virgin Islands.

Pathogens: Any pathogen, including bacteria, chemicals, parasites, and
viruses.

Cases Reported: In 1997, 806 outbreaks were reported to CDC through this
system.

Data Sources: State and local public health officials submit this data to
CDC using a paper form. CDC has also been piloting electronic reporting of
outbreaks using a system called the Electronic Foodborne Outbreak Reporting
System. Foodborne Disease

Outbreak Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 45 GAO- 01- 973 Food Safety Surveillance

The Foodborne Diseases Active Surveillance Network, also known as FoodNet,
is a collaborative project of the CDC, the USDA, the Food and Drug
Administration, and nine sites that gathers information about nine foodborne
pathogens, two syndromes, and toxoplasmosis. A significant distinction
between FoodNet and other foodborne surveillance systems is that FoodNet
participants actively and routinely contact the clinical laboratories in
their areas to collect information about the number of cases of each disease
covered by this system. For other systems, state and local reporting
practices to CDC may not be consistent from state to state.

In addition to the active surveillance efforts, FoodNet participants conduct
studies and surveys of the physicians, laboratories, and populations within
the nine sites. Case control studies are used to determine risk factors,
such as food preparation or handling practices, for acquiring infections
from the pathogens covered by the system, as well as the association between
these infections and specific foods. These studies have been conducted for
E. coli O157: H7, Salmonella, Campylobacter, and others. CDC also collects
information through population surveys, in which individuals who live in a
FoodNet catchment area and were not part of a case control study are
surveyed about their consumption of certain foods and how often they see a
physician. To determine which tests are typically performed at laboratories
in FoodNet areas, CDC administers laboratory surveys. Finally, state
officials in the FoodNet areas have administered two physician surveys. The
first survey asked physicians to describe actions they take when seeing a
patient with a possible foodborne illness, while the second asked how they
educate patients about foodborne diseases. FoodNet data can also test the
efficacy of interventions designed to reduce the incidence of foodborne
pathogens.

Geographic Scope: Nine sites consisting of parts or all of the states of
California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York,
Oregon, and Tennessee.

Pathogens: Nine pathogens- Campylobacter, Cryptosporidium, Cyclospora, E.
coli O157: H7, Listeria monocytogenes, Salmonella, Shigella, Vibrio,
Yersinia enterocolitica- and hemolytic uremic syndrome (a serious
complication of E. coli O157: H7 infection), GuillainBarre syndrome (a
serious complication of Campylobacter infection), and toxoplasmosis.

Cases Reported: The number of cases varies by pathogen. FoodNet

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 46 GAO- 01- 973 Food Safety Surveillance Data Sources: State public
health officials submit lab- confirmed case

data to CDC using the Public Health Laboratory Information System.

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 47 GAO- 01- 973 Food Safety Surveillance

The National Antimicrobial Resistance Monitoring System for Enteric Bacteria
began in 1996 as a collaborative effort among CDC, the Food and Drug
Administration, and USDA. Its purpose is to monitor the resistance of human
enteric (intestinal) bacteria. Participating health departments forward some
portion of their isolates for six types of bacteria to CDC for
susceptibility testing. Susceptibility testing involves determining the
sensitivity of the bacteria toward 17 antimicrobial agents that inhibit
their growth. Campylobacter isolates are submitted only by the FoodNet sites
and are tested against 8 antimicrobial agents instead of 17. Because these
data have been collected continually since 1996, trend analyses are
possible. This can provide useful information about patterns of emerging
resistance, which in turn can guide mitigation efforts.

Geographic Scope: Seventeen state and local public health laboratories in
California, Colorado, Connecticut, Florida, Georgia, Kansas, Los Angeles
County, Maryland, Minnesota, Massachusetts, New Jersey, New York City, New
York, Oregon, Tennessee, Washington, and West Virginia participate in this
system.

Pathogens: Campylobacter, Enterococcus, E. coli O157: H7, Salmonella

non- typhoidal, Salmonella typhi, and Shigella.

Cases Reported: The number of cases varies by pathogen.

Data Sources: Participating health departments submit isolates of human
bacteria to CDC for testing. National

Antimicrobial Resistance Monitoring System- Enteric Bacteria

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 48 GAO- 01- 973 Food Safety Surveillance

The National Giardiasis Surveillance System began in 1992 when the Council
of State and Territorial Epidemiologists assigned giardiasis a code that
enabled states to voluntarily report giardiasis cases to CDC electronically.
For each case, basic information is collected, such as the age, sex, and
race of the patient, as well as the place and time of infection. This
surveillance system provides data used to educate public health
practitioners and health- care providers about the scope and magnitude of
giardiasis in the United States. The data can also be used to establish
research priorities and to plan future prevention efforts. In June 2001, the
Council of State and Territorial Epidemiologists voted to add giardiasis to
the list of Nationally Notifiable Diseases.

Geographic Scope: Forty- three states, the District of Columbia, New York
City, Guam, and Puerto Rico.

Pathogen: Giardia intestinalis (also known as Giardia lamblia).

Cases Reported: In 1999, over 23,000 cases of giardiasis were reported to
CDC through this system.

Data Sources: State officials report this data to CDC using the National
Electronic Telecommunication System for Surveillance. National Giardiasis

Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 49 GAO- 01- 973 Food Safety Surveillance

The National Notifiable Diseases Surveillance System collects information
about 58 diseases designated as nationally notifiable- that is, diseases
about which regular, frequent, and timely information regarding individual
cases is considered necessary for their prevention and control. The first
annual report on notifiable diseases was published in 1912 for 10 diseases.
CDC assumed responsibility for the collection and publication of this data
in 1961. The list of nationally notifiable diseases is revised periodically
to include emerging pathogens and to delete those whose incidence has
declined significantly. CDC also publishes provisional figures for some of
these diseases weekly.

Policies for reporting notifiable disease cases can vary by disease or
reporting jurisdiction, depending on case status classification (i. e.,
confirmed, probable, or suspect). Reporting of diseases is mandated by
legislation or regulation only at the state and local level. Thus, the list
of diseases considered notifiable varies slightly by state. Public health
officials report basic information for each case, such as age, sex, and race
of the patient, as well as the place and time of infection. The data
reported in the annual summaries for this system are useful for analyzing
disease trends and determining relative disease burdens.

Geographic Scope: National.

Pathogens/ Diseases: Botulism, cholera, cryptosporidiosis, cyclosporiasis,
E. coli, hepatitis A, listeriosis, salmonellosis, shigellosis, trichinosis,
and typhoid fever (also 47 other pathogens or diseases, which are not
considered to be foodborne).

Number of Cases Reported: The number of cases varies by disease.

Data Sources: Health departments in the 50 states, 5 territories, New York
City, and the District of Columbia report case information for this system
to CDC using the National Electronic Telecommunications System for
Surveillance. National Notifiable

Diseases Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 50 GAO- 01- 973 Food Safety Surveillance

The National Salmonella Surveillance System began in 1962 when the Council
of State and Territorial Epidemiologists and the Association of Public
Health Laboratories agreed that state public health laboratories would
routinely test samples of Salmonella to determine their serotype and report
the results to CDC. For many years these reports were submitted as paper
forms, but for the last 10 years, reporting has been electronic. In addition
to the specific serotype, the reports include the age, sex, and county of
residence of the person from whom the sample was isolated, the clinical
source (such as stool, blood, or abscess), and the date the sample was
received in the state laboratory. CDC maintains the national reference
laboratory for Salmonella and provides the laboratory reagents and training
needed to determine the serotypes. These data are used to identify long-
term trends and specific populations at risk for infection, detect and
investigate outbreaks, and monitor the effectiveness of prevention efforts.

Geographic Scope: All 50 states, New York City, and Guam.

Pathogens: Salmonella enterica.

Cases Reported: In 1999, approximately 32,750 cases were reported to CDC
through this system.

Data Sources: State health officials report these data to CDC using the
Public Health Laboratory Information System. National Salmonella

Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 51 GAO- 01- 973 Food Safety Surveillance

The National Shigella Surveillance System began in 1963 when the Council of
State and Territorial Epidemiologists and the Association of Public Health
Laboratories agreed that state public health laboratories would routinely
test samples of Shigella to determine their serotype and report the results
to CDC. For many years these reports were submitted as paper forms, but for
the last 10 years, reporting has been electronic. In addition to the
specific serotype, the reports include the age, sex, and county of residence
of the person from whom the sample was isolated, the clinical source (such
as stool, blood, or abscess), and the date the sample was received in the
state laboratory. CDC maintains the national reference laboratory for
Shigella and provides the laboratory reagents and training needed to
determine the serotypes. These data are used to identify longterm trends and
specific populations at risk for infection, detect and investigate
outbreaks, and monitor the effectiveness of prevention efforts.

Geographic Scope: All 50 states, New York City, and Guam.

Pathogen: Shigella species.

Cases Reported: In 1999, approximately 12,000 cases were reported to CDC
through this system.

Data Sources: State health officials report these data to CDC using the
Public Health Laboratory Information System. National Shigella

Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 52 GAO- 01- 973 Food Safety Surveillance

PulseNet is a national network of public health laboratories that, since
1996, has been using standardized methods to perform genetic

?fingerprinting? of four types of foodborne bacteria. The network permits
rapid comparison of the bacteria?s genetic patterns through an electronic
database at CDC. Laboratories participating in PulseNet use a method called
pulsed- field gel electrophoresis to identify the genetic patterns in
bacterial pathogens isolated from patients and from suspected food items.
Once the patterns are generated, they are entered into an electronic
database of patterns at the state or local health department and transmitted
to CDC where they are filed in the PulseNet database. If patterns submitted
by laboratories during a defined time period are found to match, CDC will
alert the laboratory officials of the match so that a timely investigation
can be performed.

PulseNet can help public health authorities recognize when cases of
foodborne illness occurring at the same time in geographically separate
locales are caused by the same strain of bacteria and may be due to a common
exposure, such as a food item. An epidemiologic investigation of those cases
can then determine what they have in common. If a bacterial pathogen is
isolated from a suspected food, the pathogen?s genetic pattern can be
quickly compared with the patterns of pathogens isolated from patients.
Matching patterns can indicate possible nationwide outbreaks and lead to
public health actions such as epidemiologic investigations, product recalls,
and long- term prevention measures.

Geographic Scope: 46 state and 2 local public health laboratories- New York
City and Los Angeles County- and the food safety laboratories of the Food
and Drug Administration and USDA.

Pathogens: E. coli O157: H7, Salmonella, Listeria, and Shigella.

Cases Reported: In 2000, over 17,000 patterns were submitted to the CDC
PulseNet database, and 105 potential outbreaks were investigated by state
and local officials.

Data Sources: State public health laboratories submit patterns to CDC
electronically. PulseNet

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 53 GAO- 01- 973 Food Safety Surveillance

The Salmonella Enteritidis Outbreak Surveillance System began in 1985. This
passive system collects reports of outbreaks as they occur throughout the
calendar year. States are encouraged to report any outbreak of

Salmonella Enteritidis infection in their state to CDC. The surveillance
system tracks morbidity and mortality associated with outbreaks and collects
information on implicated food items and on the results of traceback
investigations conducted by local agencies and the Food and Drug
Administration. Surveillance data have been used to identify risk factors
for Salmonella Enteritidis infection, contaminated food items, and groups
that may benefit from education.

Geographic Scope: National.

Pathogen: Salmonella Enteritidis.

Outbreaks Reported: In 1999, 44 confirmed outbreaks of Salmonella

Enteritidis were reported, affecting U. S. residents in 17 states.

Data Sources: Outbreaks of Salmonella Enteritidis infection are reported by
each state throughout the calendar year. Detailed information is maintained
about the details of the outbreak. States are requested to verify all data,
checking accuracy and completeness at the end of each year.

Salmonella Enteritidis Outbreak Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 54 GAO- 01- 973 Food Safety Surveillance

The Sentinel Counties Study of Viral Hepatitis began in 1979 to collect more
detailed information on risk factors for cases of acute viral hepatitis and
to detect newly emerging viruses. Under contracts with CDC, county health
departments collect data for each reported case and a serum sample for each
reported case and report the information to CDC. In recent years, data from
this system have been used to better characterize hepatitis A epidemiology
and to develop molecular subtyping techniques.

Geographic Scope: Six counties- Pinellas, Florida; Jefferson, Alabama;
Denver, Colorado; Pierce, Washington; Multnomah, Oregon; and San Francisco,
California.

Pathogens: Hepatitis A; hepatitis B; and non- A, non- B hepatitis (including
hepatitis C).

Cases Reported: In 1999, 240 cases of hepatitis A, 134 cases of hepatitis B,
and 32 cases of non- A, non- B hepatitis (including hepatitis C) were
reported to CDC through this system.

Data Sources: Participating county health departments submit paper forms and
serologic specimens to CDC for each case. Sentinel Counties

Study of Viral Hepatitis

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 55 GAO- 01- 973 Food Safety Surveillance

The Surveillance Outbreak Detection Algorithm was designed to detect unusual
clusters of cases of a foodborne disease that indicate a potential outbreak.
The algorithm was first used in 1996 for Salmonella cases. The algorithm
compares, by serotype, the number of cases reported through the Public
Health Laboratory Information System during a given week with a 5- year
historical baseline for that serotype and week to detect unusual increases
from the baseline. The weekly comparisons are done on a national, regional,
and state basis. If they detect any unusual clusters, CDC notifies the
affected state( s) by fax.

The Surveillance Outbreak Detection Algorithm is useful for identifying
multistate outbreaks, especially where individual cases may be quite
diffuse. The software also has an interface with which any user can easily
generate basic statistical information. The interface also produces graphs
and maps to facilitate identification of trends or anomalies. State health
departments have access to a limited version of the algorithm via the Public
Health Laboratory Information System.

Geographic Scope: National.

Pathogens: Salmonella and Shigella.

Cases Reported: Using the algorithm, CDC officials identified 133 potential
Salmonella outbreaks in 1999 and 273 in 2000.

Data Sources: The algorithm is run on a database of lab- confirmed cases
submitted to CDC through the Public Health Laboratory Information System.
Surveillance Outbreak

Detection Algorithm

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 56 GAO- 01- 973 Food Safety Surveillance

The Trichinellosis (Trichinosis) Surveillance System was created in 1947,
when the U. S. Public Health Service began collecting statistics on cases of
infection at the national level. In 1965, trichinellosis was included among
the notifiable diseases that physicians report weekly to state health
departments and to CDC through the National Morbidity Reporting System. A
standardized surveillance form was developed to collect detailed information
for each case.

Geographic Scope: National.

Pathogen: Trichinella spp.

Cases Reported: In 1999, 12 cases were reported to CDC through this system.

Data Sources: Trichinellosis is reported to CDC through the National
Notifiable Diseases Surveillance System. Trichinellosis

Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 57 GAO- 01- 973 Food Safety Surveillance

The Typhoid Fever Surveillance System was established in 1962 to collect
detailed information about all cases of Salmonella typhi. State health
department officials are asked to complete a typhoid fever surveillance
report form when a laboratory confirms a case of typhoid fever. The form
collects demographic information about each case, as well as information
about patients? international travel and vaccination history, and the
antibiotic susceptibility of isolates. This information is especially
important for developing travel advisories, vaccination recommendations, and
treatment guidelines.

Geographic Scope: National.

Pathogen: Salmonella typhi.

Cases Reported: In 1999, 115 cases were reported to this system.

Data Sources: Local or state health department officials complete the
typhoid fever surveillance report forms and submit them to CDC?s Foodborne
and Diarrheal Diseases Branch. In addition, cases of laboratory- confirmed
Salmonella typhi infection are reported to CDC through the Public Health
Laboratory Information System as part of the National Salmonella
Surveillance System, accompanied by limited information on patient age and
sex, and on the clinical source of the isolate. Typhoid Fever

Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 58 GAO- 01- 973 Food Safety Surveillance

The Vibrio Surveillance System began in 1988 and is composed of two parts.
One is a national passive system for reporting cases of toxigenic

Vibrio cholerae infection (cholera), and the other is a more active system
that covers all types of Vibrio infections in a more limited geographic
area. For the active system, investigators use a standardized form to
collect clinical data, information about patients? underlying illnesses, and
epidemiologic data about patients? seafood consumption and exposure to
seawater for the week preceding illness. Surveillance data have been used to
identify environmental risk factors, retail food outlets where high- risk
exposures occur, and groups that may benefit from consumer education.

Geographic Scope: National for the cholera portion of the system; the non-
cholera portion of the system initially included only the Gulf Coast states
of Alabama, Florida, Louisiana, and Texas but is open to all states and has
expanded to include, among others, the FoodNet sites and states along both
the East and West coasts.

Pathogen: Toxigenic Vibrio cholerae; Vibrio spp.

Cases Reported: In 2000, four cases of Vibrio cholerae and 295 laboratory-
confirmed cases of other types of Vibrio infections were reported to CDC
through this system.

Data Sources: State health departments report cases of Vibrio cholerae

to CDC, and isolates are confirmed at the CDC reference laboratory; for
other types of Vibrio infection, state health departments collect and report
data throughout the year using CDC?s Vibrio Surveillance Report form. 1

1 To enhance the accuracy and completeness of reporting, CDC requests that
participating states verify the information reported twice a year.

Vibrio Surveillance System

Appendix III: CDC?s Surveillance Systems for Foodborne Disease

Page 59 GAO- 01- 973 Food Safety Surveillance

The Viral Hepatitis Surveillance Program was created in 1961 to collect
demographic, clinical, serologic, and risk- factor information on cases of
acute viral hepatitis. The data collected through the program are essential
for monitoring trends in the epidemiologic characteristics of the various
types of viral hepatitis. These data are also valuable for monitoring the
effectiveness of prevention programs.

Pathogens: Hepatitis A; hepatitis B; non- A, non- B hepatitis (including
hepatitis C).

Geographic Scope: National.

Number of Cases Reported: In 1999, 17,047 cases of hepatitis A, 7,694 cases
of hepatitis B, and 3,111 cases of non- A, non- B hepatitis were reported
through National Electronic Telecommunication Surveillance System.
Information about risk factors was reported through the Viral Hepatitis
Surveillance Program for approximately 33 percent of these cases.

Source of Data: States report this information to CDC through the extended-
record capability of the National Electronic Telecommunication Surveillance
System or by submitting a paper form with this information. Viral Hepatitis

Surveillance Program

Appendix IV: Comments From the Centers for Disease Control Page 60 GAO- 01-
973 Food Safety Surveillance

Appendix IV: Comments From the Centers for Disease Control

Appendix IV: Comments From the Centers for Disease Control Page 61 GAO- 01-
973 Food Safety Surveillance

Appendix V: GAO Contacts and Staff Acknowledgments Page 62 GAO- 01- 973 Food
Safety Surveillance

Lawrence J. Dyckman, (202) 512- 3841 Robert C. Summers, (404) 679- 1839

In addition to those named above, Carolyn Boyce, Cathy Helm, Natalie Herzog,
Cynthia Norris, Paul Pansini, and Stuart Ryba made key contributions to this
report. Appendix V: GAO Contacts and Staff

Acknowledgments GAO Contacts Staff Acknowledgments

(150187)

The first copy of each GAO report is free. Additional copies of reports are
$2 each. A check or money order should be made out to the Superintendent of
Documents. VISA and MasterCard credit cards are also accepted.

Orders for 100 or more copies to be mailed to a single address are
discounted 25 percent.

Orders by mail:

U. S. General Accounting Office P. O. Box 37050 Washington, DC 20013

Orders by visiting:

Room 1100 700 4 th St., NW (corner of 4 th and G Sts. NW) Washington, DC
20013

Orders by phone:

(202) 512- 6000 fax: (202) 512- 6061 TDD (202) 512- 2537

Each day, GAO issues a list of newly available reports and testimony. To
receive facsimile copies of the daily list or any list from the past 30
days, please call (202) 512- 6000 using a touchtone phone. A recorded menu
will provide information on how to obtain these lists.

Orders by Internet

For information on how to access GAO reports on the Internet, send an e-
mail message with ?info? in the body to:

Info@ www. gao. gov or visit GAO?s World Wide Web home page at: http:// www.
gao. gov

Contact one:

 Web site: http:// www. gao. gov/ fraudnet/ fraudnet. htm

 E- mail: fraudnet@ gao. gov

 1- 800- 424- 5454 (automated answering system) Ordering Information

To Report Fraud, Waste, and Abuse in Federal Programs
*** End of document. ***