We fit a power law distribution to US foodborne disease outbreaks to assess underdetection and underreporting. We predicted that 788 fewer than expected small outbreaks were identified annually during 1998-2017 and 365 fewer during 2018-2019, after whole-genome sequencing was implemented. Power law can help assess effectiveness of public health interventions.

Each year, infections from major foodborne pathogens are responsible for an estimated 9.4 million illnesses, 56,000 hospitalizations, and 1,350 deaths in the United States (1). To evaluate progress toward prevention of enteric infections in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) conducts surveillance for laboratory-diagnosed infections caused by eight pathogens transmitted commonly through food at 10 U.S. sites. During 2020-2021, FoodNet detected decreases in many infections that were due to behavioral modifications, public health interventions, and changes in health care-seeking and testing practices during the COVID-19 pandemic. This report presents preliminary estimates of pathogen-specific annual incidences during 2022, compared with average annual incidences during 2016-2018, the reference period for the U.S. Department of Health and Human Services' Healthy People 2030 targets (2). Many pandemic interventions ended by 2022, resulting in a resumption of outbreaks, international travel, and other factors leading to enteric infections. During 2022, annual incidences of illnesses caused by the pathogens Campylobacter, Salmonella, Shigella, and Listeria were similar to average annual incidences during 2016-2018; however, incidences of Shiga toxin-producing Escherichia coli (STEC), Yersinia, Vibrio, and Cyclospora illnesses were higher. Increasing culture-independent diagnostic test (CIDT) usage likely contributed to increased detection by identifying infections that would have remained undetected before widespread CIDT usage. Reducing pathogen contamination during poultry slaughter and processing of leafy greens requires collaboration among food growers and processors, retail stores, restaurants, and regulators.

To evaluate progress toward prevention of enteric infections in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) conducts active population-based surveillance for laboratory-diagnosed infections caused by Campylobacter, Cyclospora, Listeria, Salmonella, Shiga toxin-producing Escherichia coli (STEC), Shigella, Vibrio, and Yersinia at 10 U.S. sites. This report summarizes preliminary 2021 data and describes changes in annual incidence compared with the average annual incidence for 2016-2018, the reference period for the U.S. Department of Health and Human Services' (HHS) Healthy People 2030 goals for some pathogens (1). During 2021, the incidence of infections caused by Salmonella decreased, incidence of infections caused by Cyclospora, Yersinia, and Vibrio increased, and incidence of infections caused by other pathogens did not change. As in 2020, behavioral modifications and public health interventions implemented to control the COVID-19 pandemic might have decreased transmission of enteric infections (2). Other factors (e.g., increased use of telemedicine and continued increase in use of culture-independent diagnostic tests [CIDTs]) might have altered their detection or reporting (2). Much work remains to achieve HHS Healthy People 2030 goals, particularly for Salmonella infections, which are frequently attributed to poultry products and produce, and Campylobacter infections, which are frequently attributed to chicken products (3).

The COVID-19 pandemic has disproportionately affected people with diabetes, who are at increased risk of severe COVID-19.* Increases in the number of type 1 diabetes diagnoses (1,2) and increased frequency and severity of diabetic ketoacidosis (DKA) at the time of diabetes diagnosis (3) have been reported in European pediatric populations during the COVID-19 pandemic. In adults, diabetes might be a long-term consequence of SARS-CoV-2 infection (4-7). To evaluate the risk for any new diabetes diagnosis (type 1, type 2, or other diabetes) >30 days(†) after acute infection with SARS-CoV-2 (the virus that causes COVID-19), CDC estimated diabetes incidence among patients aged <18 years (patients) with diagnosed COVID-19 from retrospective cohorts constructed using IQVIA health care claims data from March 1, 2020, through February 26, 2021, and compared it with incidence among patients matched by age and sex 1) who did not receive a COVID-19 diagnosis during the pandemic, or 2) who received a prepandemic non-COVID-19 acute respiratory infection (ARI) diagnosis. Analyses were replicated using a second data source (HealthVerity; March 1, 2020-June 28, 2021) that included patients who had any health care encounter possibly related to COVID-19. Among these patients, diabetes incidence was significantly higher among those with COVID-19 than among those 1) without COVID-19 in both databases (IQVIA: hazard ratio [HR] = 2.66, 95% CI = 1.98-3.56; HealthVerity: HR = 1.31, 95% CI = 1.20-1.44) and 2) with non-COVID-19 ARI in the prepandemic period (IQVIA, HR = 2.16, 95% CI = 1.64-2.86). The observed increased risk for diabetes among persons aged <18 years who had COVID-19 highlights the importance of COVID-19 prevention strategies, including vaccination, for all eligible persons in this age group,(§) in addition to chronic disease prevention and management. The mechanism of how SARS-CoV-2 might lead to incident diabetes is likely complex and could differ by type 1 and type 2 diabetes. Monitoring for long-term consequences, including signs of new diabetes, following SARS-CoV-2 infection is important in this age group.

Infectious disease is recognized as the greatest threat to the endangered chimpanzees made famous by the groundbreaking work of Dr. Jane Goodall at Gombe National Park (GNP), Tanzania. The permeable boundary of this small protected area allows for regular wildlife-human and wildlife-domestic animal overlap, which may facilitate cross-species transmission of pathogens and antimicrobial resistance. Few studies have examined the prevalence of antimicrobial resistance in wild ape populations. We used molecular techniques to investigate the presence of genes conferring resistance to sulfonamides (often used to treat diarrheal illness in human settings in this region) and tetracycline (used in the past-though much less so now) in fecal specimens from humans, domestic animals, chimpanzees, and baboons in and around GNP. We also tested stream water used by these groups. Sulfonamide resistance was common in humans (74%), non-human primates (43%), and domestic animals (17%). Tetracycline resistance was less common in all groups: humans (14%), non-human primates (3%), and domestic animals (6%). Sul resistance genes were detected from 4/22 (18%) of streams sampled. Differences in sul gene frequencies did not vary by location in humans nor in chimpanzees.

Hypothesis generation is a critical, but challenging, step in a foodborne outbreak investigation. The pathogens that contaminate food have many diverse reservoirs, resulting in seemingly limitless potential vehicles. Identifying a vehicle is particularly challenging for clusters detected through national pathogen-specific surveillance, as cases can be geographically dispersed and lack an obvious epidemiological link. Moreover, state and local health departments may have limited resources to dedicate to cluster and outbreak investigations. These challenges underscore the importance of hypothesis generation during an outbreak investigation. In this review, we present a framework for hypothesis generation focusing on three primary sources of information, typically used in combination: (1) known sources of the pathogen causing illness; (2) person, place, and time characteristics of cases associated with the outbreak (descriptive data); and (3) case exposure assessment. Hypothesis generation can narrow the list of potential food vehicles and focus subsequent epidemiologic, laboratory, environmental, and traceback efforts, ensuring that time and resources are used more efficiently and increasing the likelihood of rapidly and conclusively implicating the contaminated food vehicle.

Attending the IAFP conference has been an annual highlight for the past decade, and a time for learning and sharing for more and more of my colleagues at CDC. It is an honor and a pleasure to join you here now, and to honor the formative contributions of John H Silliker to the field of food safety. | | When I first came to CDC to start a two year fellowship in field epidemiology and joined the small excited group that just 6 months before had identified E. coli O157 as a human pathogen, there were many questions in the air. One of the most interesting and persistent was around the first efforts towards molecular epidemiology. How could the new laboratory tools of molecular subtyping help solve epidemiological problems? Back then we tried plasmid profiles and satisfied ourselves that they could sometimes help us solve outbreaks. When a staff position was offered at CDC, I was fortunate to be able to start a career working in that same group for what has become several exciting decades.

Early in a foodborne disease outbreak investigation, illness incubation periods can help focus case interviews, case definitions, clinical and environmental evaluations and predict an aetiology. Data describing incubation periods are limited. We examined foodborne disease outbreaks from laboratory-confirmed, single aetiology, enteric bacterial and viral pathogens reported to United States foodborne disease outbreak surveillance from 1998-2013. We grouped pathogens by clinical presentation and analysed the reported median incubation period among all illnesses from the implicated pathogen for each outbreak as the outbreak incubation period. Outbreaks from preformed bacterial toxins (Staphylococcus aureus, Bacillus cereus and Clostridium perfringens) had the shortest outbreak incubation periods (4-10 h medians), distinct from that of Vibrio parahaemolyticus (17 h median). Norovirus, salmonella and shigella had longer but similar outbreak incubation periods (32-45 h medians); campylobacter and Shiga toxin-producing Escherichia coli had the longest among bacteria (62-87 h medians); hepatitis A had the longest overall (672 h median). Our results can help guide diagnostic and investigative strategies early in an outbreak investigation to suggest or rule out specific etiologies or, when the pathogen is known, the likely timeframe for exposure. They also point to possible differences in pathogenesis among pathogens causing broadly similar syndromes.

The US Food Safety Modernization Act (FSMA) gives food safety regulators increased authority to require implementation of safety measures to reduce the contamination of produce. To evaluate the future impact of FSMA on food safety, a better understanding is needed regarding outbreaks attributed to the consumption of raw produce. Data reported to the US Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System during 1998-2013 were analysed. During 1998-2013, there were 972 raw produce outbreaks reported resulting in 34 674 outbreak-associated illnesses, 2315 hospitalisations, and 72 deaths. Overall, the total number of foodborne outbreaks reported decreased by 38% during the study period and the number of raw produce outbreaks decreased 19% during the same period; however, the percentage of outbreaks attributed to raw produce among outbreaks with a food reported increased from 8% during 1998-2001 to 16% during 2010-2013. Raw produce outbreaks were most commonly attributed to vegetable row crops (38% of outbreaks), fruits (35%) and seeded vegetables (11%). The most common aetiologic agents identified were norovirus (54% of outbreaks), Salmonella enterica (21%) and Shiga toxin-producing Escherichia coli (10%). Food-handling errors were reported in 39% of outbreaks. The proportion of all foodborne outbreaks attributable to raw produce has been increasing. Evaluation of safety measures to address the contamination on farms, during processing and food preparation, should take into account the trends occurring before FSMA implementation.

During 2006-2014, a total of 15 multistate outbreaks of turtle-associated salmonellosis in humans were reported in the United States. Exposure to small pet turtles has long been recognized as a source of human salmonellosis. The risk to public health has persisted and may be increasing. Turtles are a popular reptilian pet among children, and numerous risky behaviors for the zoonotic transmission of Salmonella bacteria to children have been reported in recent outbreaks. Despite a long-standing federal ban against the sale and distribution of turtles <4 in (<10.16 cm) long, these small reptiles can be readily acquired through multiple venues and continue to be the main source of turtle-associated salmonellosis in children. Enhanced efforts are needed to minimize the disease risk associated with small turtle exposure. Prevention will require novel partnerships and a comprehensive One Health approach involving human, animal, and environmental health.

Listeria monocytogenes is a foodborne pathogen that can cause bacteraemia, meningitis, and complications during pregnancy. In July 2012, molecular subtyping identified indistinguishable L. monocytogenes isolates from six patients and two samples of different cut and repackaged cheeses. A multistate outbreak investigation was initiated. Initial analyses identified an association between eating soft cheese and outbreak-related illness (odds ratio 17.3, 95% confidence interval 2.0-825.7) but no common brand. Cheese inventory data from locations where patients bought cheese and an additional location where repackaged cheese yielded the outbreak strain were compared to identify cheeses for microbiological sampling. Intact packages of imported ricotta salata yielded the outbreak strain. Fourteen jurisdictions reported 22 cases from March-October 2012, including four deaths and a fetal loss. Six patients ultimately reported eating ricotta salata; another reported eating cheese likely cut with equipment also used for contaminated ricotta salata, and nine more reported eating other cheeses that might also have been cross-contaminated. An FDA import alert and US and international recalls followed. Epidemiology-directed microbiological testing of suspect cheeses helped identify the outbreak source. Cross-contamination of cheese highlights the importance of using validated disinfectant protocols and routine cleaning and sanitizing after cutting each block or wheel.

In March 2014 the World Health Organization was notified of an outbreak of Ebola virus disease (EVD) in the forest region of Guinea. As of May 2015, the outbreak had become the most devastating EVD epidemic in history with more than 27,000 cases and more than 11,000 deaths. The introduction of EVD into noncontiguous countries, including the United States, from infected travelers highlights the importance of preparedness of all health care providers. Early identification and rapid isolation of patients suspected with EVD is critical to limiting the spread of Ebola virus. Additionally, enhanced understanding of EVD case definitions, clinical presentation, treatment procedures, and infection control strategies will improve the ability of health care workers to provide safe care for patients with EVD.

The cholera epidemic in Haiti entered its fourth year on 21 October 2013. This unexpected catastrophe appeared in a rural area, spreading rapidly to all departments within a month, and 5% of the population was reported with cholera in the first year.1 It has persisted, with lower case counts reported each year (national data, accessed 30 July 2013 at: http://mspp.gouv.ht/site/index.php#). Rapid case reporting to public health surveillance provided a detailed picture, guided mobilization of resources to treat and prevent the illness, identified areas for more detailed investigation, and documented the decrease in case mortality that followed improved treatment. As part of that surveillance, microbiological studies showed the epidemic strain of Vibrio cholerae O1 belongs to a lineage of atypical El Tor stains that arose in the 1990s and is now the predominant strain circulating in Asia and Africa.

After a series of outbreaks associated with sprouts in the mid-1990s, the U.S. Food and Drug Administration (FDA) published guidelines in 1999 for sprouts producers to reduce the risk of contamination. The recommendations included treating seeds with an antimicrobial agent such as calcium hypochlorite solution and testing spent irrigation water for pathogens. From 1998 through 2010, 33 outbreaks from seed and bean sprouts were documented in the United States, affecting 1330 reported persons. Twenty-eight outbreaks were caused by Salmonella, four by Shiga toxin-producing Escherichia coli, and one by Listeria. In 15 of the 18 outbreaks with information available, growers had not followed key FDA guidelines. In three outbreaks, however, the implicated sprouts were produced by firms that appeared to have implemented key FDA guidelines. Although seed chlorination, if consistently applied, reduces pathogen burden on sprouts, it does not eliminate the risk of human infection. Further seed and sprouts disinfection technologies, some recently developed, will be needed to enhance sprouts safety and reduce human disease. Improved seed production practices could also decrease pathogen burden but, because seeds are a globally distributed commodity, will require international cooperation.

A polyphasic study was undertaken to determine the taxonomic position of 13 Campylobacter fetus-like strains from humans (n=8) and reptiles (n=5). The results of matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) and genomic data from sap analysis, 16S rRNA and hsp60 sequence comparison, pulsed- field gel electrophoresis (PFGE), amplified fragment length polymorphism (AFLP) analysis, DNA-DNA hybridization and whole genome sequencing demonstrate that these strains are closely related to C. fetus but clearly differentiated from the present C. fetus subspecies. Therefore this unique cluster of 13 strains represents a novel subspecies within the species C. fetus, for which the name Campylobacter fetus subsp. testudinum subsp. nov. is proposed, with strain 03-427T (=ATCC BAA-2539T = LMG 27499T) as the type strain. Although this novel taxon cannot be differentiated from C. fetus subsp. fetus and C. fetus subsp. venerealis using conventional phenotypic tests, MALDI-TOF MS analysis revealed the presence of multiple phenotypic biomarkers which distinguish C. fetus subsp. testudinum from the present C. fetus subspecies.

Campylobacter fetus can cause intestinal illness and, occasionally, severe systemic infections. Infections mainly affect persons at higher risk, including elderly and immunocompromised individuals and those with occupational exposure to infected animals. Outbreaks are infrequent but have provided insight into sources. Source attribution of sporadic cases through case-control interviews has not been reported. The reservoirs for C. fetus are mainly cattle and sheep. Products from these animals are suspected as sources for human infections. Campylobacter fetus is rarely isolated from food, albeit selective isolation methods used in food microbiology are not suited for its detection. We hypothesize that the general population is regularly exposed to C. fetus through foods of animal origin, cross-contaminated foodstuffs, and perhaps other, as yet unidentified, routes. Campylobacter fetus infection should be suspected particularly in patients with nonspecific febrile illness who are immunocompromised or who may have been occupationally exposed to ruminants.

From August to September 2008, the Centers for Disease Control and Prevention (CDC) assisted the Alaska Division of Public Health with an outbreak investigation of campylobacteriosis occurring among the residents of Southcentral Alaska. During the investigation, pulsed-field gel electrophoresis (PFGE) of Campylobacter jejuni isolates from human, raw pea and wild bird fecal samples confirmed the epidemiologic link between illness and the consumption of raw peas contaminated by Sandhill cranes from 15 of 43 epidemiologically-linked human isolates. However, an association between the remaining epidemiologically-linked human infections and the pea and wild bird isolates was not established. To better understand the molecular epidemiology of the outbreak, C. jejuni isolates (n=130; 59 humans, 40 peas and 31 wild birds) were further characterized by multi-locus sequence typing (MLST). Here, we present the molecular evidence to demonstrate the association of many more human C. jejuni infections associated with the outbreak with raw peas and wild bird feces. Among all sequence types (STs) identified, 26 (67%) of 39 were novel and exclusive to the outbreak. Five clusters of overlapping STs (n=32 isolates; 17 humans, 2 peas and 13 wild birds) were identified. In particular, Cluster E (n=7 isolates, ST-5049) consisted of isolates from humans, peas and wild birds. Novel STs clustered closely with isolates typically associated with wild birds and the environment, but distinct from lineages commonly seen in human infections. Novel STs and alleles recovered from human outbreak isolates allowed additional infections caused by these rare genotypes to be attributed to the contaminated raw peas.

Timely, accurate, and representative data on disease occurrence are the foundation for effective, targeted prevention and control. In recent years, the achievements of disease-specific programs in Africa, including the President's Emergency Plan for AIDS Relief, the President's Malaria Initiative, and campaigns to eradicate Guinea worm and polio, have demonstrated the power of enhanced surveillance closely coupled with prevention and control measures. Broadly-based programs for strengthening public health capacity, such as the Integrated Diseases Surveillance and Response program [1], the Field Epidemiology and Laboratory Training Program [2], the African Field Epidemiology Network [3], and the EPIVAC Field Vaccinology Training Program [4], combined with new international health regulations adopted in 2005 and fully implemented in 2012 [5], have provided new resources and lent new impetus to improved surveillance, investigation, and reporting for many diseases, including cholera.

We investigated an outbreak of 396 Salmonella enterica serotype I 4,5,12:i:- infections to determine the source. After 7 weeks of extensive hypothesis-generation interviews, no refined hypothesis was formed. Nevertheless, a case-control study was initiated. Subsequently, an iterative hypothesis-generation approach used by a single interviewing team identified brand A not-ready-to-eat frozen pot pies as a likely vehicle. The case-control study, modified to assess this new hypothesis, along with product testing indicated that the turkey variety of pot pies was responsible. Review of product labels identified inconsistent language regarding preparation, and the cooking instructions included undefined microwave wattage categories. Surveys found that most patients did not follow the product's cooking instructions and did not know their oven's wattage. The manufacturer voluntarily recalled pot pies and improved the product's cooking instructions. This investigation highlights the value of careful hypothesis-generation and the risks posed by frozen not-ready-to-eat microwavable foods.

Fresh salsa and guacamole often contain diced raw produce, are often made in large batches, and are often poorly refrigerated, which may make them prone to contamination that can cause foodborne illness. The safety of salsa and guacamole is increasingly important as these foods gain popularity. Since 1973, local, state, and territorial health departments have voluntarily reported foodborne disease outbreaks to the Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System (FDOSS) using a standard reporting form. FDOSS used paper-based reporting for 1973-1997 and switched to electronic reporting for 1998-2008. We reviewed all reports of outbreaks during 1973-2008 in which salsa or guacamole was reported as a vehicle. We found 136 outbreaks in which salsa or guacamole was reported as a possible vehicle, which resulted in 5,658 illnesses. Of these 136 salsa- or guacamole-associated (SGA) outbreaks additional possible food vehicles were reported for 33 (24%) outbreaks. There were no SGA outbreaks reported before 1984. Among reported outbreaks, most were caused by norovirus (24%), nontyphoidal Salmonella (19%), and Shigella (7%). Eighty-four percent of outbreaks were caused by foods prepared in restaurants or delis; of these, 19% reported ill foodworkers, and 29% reported improper storage as possible contributing factors. Among all foodborne disease outbreaks with a reported food vehicle during 1984-1997, 26 (0.9%) of 2,966 outbreaks were SGA, and during 1998-2008, 110 (1.4%) of 7,738 outbreaks were SGA. The number of reported foodborne disease outbreaks attributable to salsa or guacamole increased in the United States from 1984 to 2008, especially in later years, and especially in restaurants. Fresh salsa and guacamole require careful preparation and storage. Focused prevention strategies should reduce the risk of illness and ensure that these foods are enjoyed safely.

Each year, >9 million foodborne illnesses are estimated to be caused by major pathogens acquired in the United States. Preventing these illnesses is challenging because resources are limited and linking individual illnesses to a particular food is rarely possible except during an outbreak. We developed a method of attributing illnesses to food commodities that uses data from outbreaks associated with both simple and complex foods. Using data from outbreak-associated illnesses for 1998-2008, we estimated annual US foodborne illnesses, hospitalizations, and deaths attributable to each of 17 food commodities. We attributed 46% of illnesses to produce and found that more deaths were attributed to poultry than to any other commodity. To the extent that these estimates reflect the commodities causing all foodborne illness, they indicate that efforts are particularly needed to prevent contamination of produce and poultry. Methods to incorporate data from other sources are needed to improve attribution estimates for some commodities and agents.

Organisms, including Vibrio cholerae, can be transferred between harbors in the ballast water of ships. Zones in the Caribbean region where distance from shore and water depth meet International Maritime Organization guidelines for ballast water exchange are extremely limited. Use of ballast water treatment systems could mitigate the risk for organism transfer.

SUMMARY: The emergence of epidemic cholera in post-earthquake Haiti portended a public health disaster of uncertain magnitude. In order to coordinate relief efforts in an environment with limited healthcare infrastructure and stretched resources, timely and realistic projections of the extent of the cholera outbreak were crucial. Projections were shared with Government and partner organizations beginning 5 days after the first reported case and were updated using progressively more advanced methods as more surveillance data became available. The first projection estimated that 105,000 cholera cases would occur in the first year. Subsequent projections using different methods estimated up to 652,000 cases and 163,000-247,000 hospitalizations during the first year. Current surveillance data show these projections to have provided reasonable approximations of the observed epidemic. Providing the real-time projections allowed Haitian ministries and external aid organizations to better plan and implement response measures during the evolving epidemic.

SUMMARY: Campylobacter is a common but decreasing cause of foodborne infections in the USA. Outbreaks are uncommon and have historically differed from sporadic cases in seasonality and contamination source. We reviewed reported outbreaks of campylobacteriosis. From 1997 to 2008, 262 outbreaks were reported, with 9135 illnesses, 159 hospitalizations, and three deaths. The annual mean was 16 outbreaks for 1997-2002, and 28 outbreaks for 2003-2008. Almost half occurred in warmer months. Foodborne transmission was reported in 225 (86%) outbreaks, water in 24 (9%), and animal contact in seven (3%). Dairy products were implicated in 65 (29%) foodborne outbreaks, poultry in 25 (11%), and produce in 12 (5%). Reported outbreaks increased during a period of declining overall incidence, and seasonality of outbreaks resembled that of sporadic infections. Unlike sporadic illnesses, which are primarily attributed to poultry, dairy products are the most common vehicle identified for outbreaks.

BACKGROUND: In the United States, considerable geographic variation in the rates of culture-confirmed Campylobacter infection has been consistently observed among sites participating in the Foodborne Diseases Active Surveillance Network (FoodNet). METHODS: We used data from the FoodNet Population Surveys and a FoodNet case-control study of sporadic infection to examine whether differences in medical care seeking, medical practices, or risk factors contributed to geographic variation in incidence. RESULTS: We found differences across the FoodNet sites in the proportion of persons seeking medical care for an acute campylobacteriosis-like illness (range, 24.9%-43.5%) and in the proportion of ill persons who submitted a stool sample (range, 18.6%-40.7%), but these differences were not statistically significant. We found no evidence of geographic effect modification of previously identified risk factors for campylobacteriosis in the case-control study analysis. The prevalence of some exposures varied among control subjects in the FoodNet sites, including the proportion of controls reporting eating chicken at a commercial eating establishment (18.2%-46.1%); contact with animal stool (8.9%-30.9%); drinking water from a lake, river, or stream (0%-5.1%); and contact with a farm animal (2.1%-12.7%). However, these differences do not fully explain the geographic variation in campylobacteriosis. CONCLUSIONS: Future studies that quantify Campylobacter contamination in poultry or variation in host immunity may be useful in identifying sources of this geographic variation in incidence.

This report presents the main findings from an international workshop on Shiga toxin-producing Escherichia coli (STEC), held on 28-29 November 2011, organized by the Robert Koch Institute. The workshop assembled over 100 experts in clinical medicine, epidemiology, public health, microbiology, food safety, and environmental science from various countries.

Epidemic-assistance investigations (Epi-Aids) in response to outbreaks of foodborne and other enteric pathogens have identified novel pathogens, clinical syndromes, and sequelae; described new reservoirs and vehicles of transmission; evaluated existing prevention strategies; and identified deficiencies in the food safety systems on local, national, and international levels. Since the first Epi-Aid was issued in 1946, approximately 23% (1,023 of 4,484 for which investigations were initiated) of all Epi-Aids have been related to foodborne or other enteric diseases. Epi-Aid results have yielded valuable insights into the epidemiology of these pathogens and have molded prevention strategies for detecting, responding to, and preventing future outbreaks. New challenges, brought about in part by centralization and globalization of the food supply, will continue to emerge. The need for Epi-Aids of such outbreaks undoubtedly will persist as an integral part of future public health response efforts, prevention strategies, and training programs.

During the 2010 cholera outbreak in Haiti, water and seafood samples were collected to detect Vibrio cholerae. The outbreak strain of toxigenic V. cholerae O1 serotype Ogawa was isolated from freshwater and seafood samples. The cholera toxin gene was detected in harbor water samples.

After epidemic cholera emerged in Haiti in October 2010, the disease spread rapidly in a country devastated by an earthquake earlier that year, in a population with a high proportion of infant deaths, poor nutrition, and frequent infectious diseases such as HIV infection, tuberculosis, and malaria. Many nations, multinational agencies, and nongovernmental organizations rapidly mobilized to assist Haiti. The US government provided emergency response through the Office of Foreign Disaster Assistance of the US Agency for International Development and the Centers for Disease Control and Prevention. This report summarizes the participation by the Centers and its partners. The efforts needed to reduce the spread of the epidemic and prevent deaths highlight the need for safe drinking water and basic medical care in such difficult circumstances and the need for rebuilding water, sanitation, and public health systems to prevent future epidemics.

When epidemic cholera appeared in Haiti in October 2010, the medical community there had virtually no experience with the disease and needed rapid training as the epidemic spread throughout the country. We developed a set of training materials specific to Haiti and launched a cascading training effort. Through a training-of-trainers course in November 14-15, 2010, and department-level training conducted in French and Creole over the following 3 weeks, 521 persons were trained and equipped to further train staff at the institutions where they worked. After the training, the hospitalized cholera patients' case-fatality rate dropped from 4% to 2% by mid-December and was 1% by January 2011. Continuing in-service training, monitoring and evaluation, and integration of cholera management into regular clinical training will help sustain this success.