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Online foodborne illness surveillance and visitor data entry patterns:
Building and strengthening public health infrastructure
Holly Wethington, MSPhD Candidate, Sociology
National Food Safety & Toxicology CenterMichigan State University
American Public Health Association Annual Meeting Washington DCNovember 2004
Foodborne Disease Epidemiology
Changes in demographics, food preferences, food distribution systems, microbial adaptationNewly identified pathogens have emerged in the USImmunosuppressed population increasing$23 billion dollar annual cost (Hedberg, MacDonald, and Shapiro, 1994)
76 million illnesses, 320,000 hospitalizations, and 5,000 deaths annually (Mead et al., 1999)
© Nature publishing group 2003
Current Foodborne Disease Surveillance
3 main purposes of surveillance (Olsen et al., 2000):
– disease prevention and control, – knowledge of disease causation, – administrative guidance
Limitations (Olsen et al. 2000):
1. not all outbreaks are included (e.g. cruise, water)
2. outbreaks not included if indirect route of transmission
3. determining a causal food vehicle is problematic
4. deficiency in standard criteria for classifying a death as foodborne disease related
© Dennis Kunkel Microscopy, Inc.
Burden of Illness Pyramid. (CDC, FoodNet Data Sources)
Burden of Illness
The current system requires laboratory confirmation
Underreporting remains a problem:– Estimated 1-2% incident
report rate (CD Summary, 1998)
One MI survey found a mean 35 day interval between onset date and report completion: – no opportunity for
preventive efforts
No surge capacity
Culture-confirmed case
Reported to Health Department/CDC
Lab tests for organism
Exposure in the general population
Person becomes ill
Person seeks care
Specimen obtained
RUsick2 Foodborne Disease ForumWe designed a syndromic surveillance system to augment existing laboratory-based surveillanceOvercomes several limitations:– Can increase rate of reporting so that small and
medium sized outbreaks no longer escape detection– Can hasten investigation so preventive measures can
occur– Capacity in event of large outbreak
Original RUsick2 operated from November 2002 - October 2004Enabled people who suspected food poisoning to come to our website, report their illness, and see if others became sick from the same food from the same place around the same time.
Several pages of data inputOutput reports towards the end:– displayed percentages of other RUsick2 visitors that
entered the same symptom or food item or food source
– kept personal information confidential from other RUsick2 visitors
– kept full names of food establishments confidential from other RUsick2 visitors
– output intended to motivate people coming to the web site
Password given so visitors could return and modify their report or view reports at a later date
RUsick2 Foodborne Disease Forum
Methods
Pilot counties; nationwide
Data input section (follows CDC’s Standard Foodborne Illness Questionnaire)
The individual goes through several entry levels as shown on the right
DATA COLLECTED1: Case ID assigned2: Personal Characteristics (age, gender)3: County, city4: Symptoms 5: Identifiers (name, email, phone)6: Suspected Foods and Food Sources 7: Suspected Food(s) 8: Suspected Food Source(s)9: Non-food Exposures 10: Four Day Food History11: Food Sources12: Contact Information (last name, address)13: First Summary Report (tallies on other
visitors who reported eating the same foods)14: Source Matching (asked to match up which
foods came from which food sources)15: Match foods to food sources16: Second Summary Report (can view reports)17: Comparison Report (compare target period to
comparison period)
Designed so people could leave at any point, different “options” for period of time spent on the websiteNov. 1, 2002 - Dec. 1, 2003Entry Level 4 (Symptoms & Onset date entered)3,693 visitors total; 2,044 reached at least level 4
RUsick2 Visitors by Entry Level
564
10411171143915241604
204421482261
2711
3693
1113903
589729 714
0
500
1000
1500
2000
2500
3000
3500
4000
Entry Level
No.
RU
sick
2 Vi
sito
rs
Key Entry Levels: 4 = Symptoms5 = Personal Identifiers7 = Suspected Foods10 = Food History13 = 1st Summary Report14 = Food Sources Matching
Results (restricted to Entry Level 4 and beyond; n=2,044)
18.3% from pilot counties
11.7% from MI, not pilot counties
70% outside MI
60% female
Mean age = 36 years (SD=14.24y)
Median age = 34 years
17% >50 years
6% >60 years
Results (restricted to Entry Level 4 and beyond; n=2,044)
13.5% sought medical attentionMean no. food items = 9.97 (SD=7.81)– Greater number than telephone reports
(mean = 4.4; n=87)Mean no. food sources = 1.81 (SD=1.24)– Slightly greater number than telephone
reports (mean = 1.65; n=87)59%: email address54%: at least one phone number61%: willing to leave some sort of contact information
Discussion
Gender breakdown consistent with literatureMedian age not surprisingThe percentage that sought healthcare was smallGeographic location: mostly outside of MINearly 2/3 were willing to leave contact infoOnline food history reports were more complete than telephone reports
Limitations of RUsick2
Web-based – Excluded those
without web accessDifficult to convince individuals to report foodborne illness.Difficult to identify clusters because low rate of participation due to minimal national advertising
Online food histories more complete than telephone food historiesCan save LHD timeThe pilot test found that it can increase the rate of reporting 4 fold in a geographic location if well advertised
Strengths of RUsick2
The “new and improved” RUsick2 …
a conduit to the health dept. reporting system
a website for people to create their own report to be given to LHD
gives instructions and links for visitors to contact their local health department
does not offer any output reports
helps people remember their food histories without any time pressure– Visitors still given a password to
modify their report
Online reporting to health departments has potential
Electronic reporting lessens the amount of time LHD employees need to stay on the phone with individuals trying to remember what they ate
Electronic reporting has better capacity in the event of a large outbreak
Conclusions
© 2000 Transportation Steering Committee. http://www.baltometro.org
Thank you!Thank you!
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