The RUsick2 Foodborne Disease Forum for syndromic surveillance.The RUsick2 Foodborne Disease Forum at the National Food Safety and Toxicology toxicology, study of poisons, or toxins, from the standpoint of detection, isolation, identification, and determination of their effects on the human body. Toxicology may be considered the branch of pharmacology devoted to the study of the poisonous effects of drugs. Center increased reporting of foodborne diseases to more than four times the rate seen in the previous 2 years. Since November 2002, the Forum has allowed pilot-area residents with sudden-onset vomiting vomiting, ejection of food and other matter from the stomach through the mouth, often preceded by nausea. The process is initiated by stimulation of the vomiting center of the brain by nerve impulses from the gastrointestinal tract or other part of the body. or diarrhea to share and compare information regarding what theyareand did before becoming sick. The purpose is to identify a common food source, perhaps resulting in identifying a cluster of persons who are the same contaminated contaminated, v 1. made radioactive by the addition of small quantities of radioactive material. 2. made contaminated by adding infective or radiographic materials. 3. an infective surface or object. food item. Such information can assist health departments in detecting foodborne outbreaks while the possibility for intervention remains. ********** Foodborne infection is the cause of approximately 76 million gastrointestinal illnesses and approximately 5,000 deaths each year in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. (1), but causes are rarely identified. Nationally, an estimated 1%-2% of cases are reported annually (2). Given that two of three reported casesarerequired to recognize and define a common source outbreak common source outbreak Epidemiology An outbreak that results from a group of persons being exposed to a common pathogen or toxin Public health A mass infection from a single contaminated source , many small- and moderate-sized outbreaks escape detection. Table 1 depicts the results of a binomial binomial (bī'nō`mēəl), polynomial expression (see polynomial) containing two terms, for example, x+y. The binomial theorem, or binomial formula, gives the expansion of the nth power of a binomial (x+ analysis of outbreaks of various sizes, given an assumed 2% reporting. For example, with 2% reporting, an outbreak of 75 cases would have a 44% chance of having two or more cases reported and a 19% chance of having three or more cases reported. Many outbreaks are never detected, and many reported cases seen as sporadic and isolated may in fact be part of small, undetected outbreaks. Current laboratory-based surveillance will likely not substantially increase the percentage of routine gastroenteritis gastroenteritis: see enteritis. gastroenteritis Acute infectious syndrome of the stomach lining and intestines. Symptoms include diarrhea, vomiting, and abdominal cramps. cases that provide samples for culturing. Health insurance organizations are not expected to increase the numbers of fecal fecal /fe·cal/ (fe´k'l) pertaining to or of the nature of feces. fe·cal adj. Relating to or composed of feces. fecal pertaining to or of the nature of feces. samples submitted and cultured for uncomplicated cases of gastroenteritis, since culture results do not usually influence the medical management of individual cases. A second problem is the time delay inherent in current laboratory-based passive surveillance. On the basis of a 2000 survey of reported cases of foodborne illness A foodborne illness (also foodborne disease) is any illness resulting from the consumption of food. Although foodborne illness is commonly called food poisoning, this is often a misnomer. , 263 Michigan hospital laboratories (response rate 91%) averaged a delay of 12.3 days between specimen collection and scrotyping. In addition, a mean delay of 35 days occurred between symptom onset and completion of the case investigation form by the local health department (Michigan Department of Community Health, unpub. data). Given the short duration of most foodborne outbreaks, health department investigations are often a matter of documenting past events, with no real opportunity to quickly identify and remove contaminated food items to prevent further exposure. A third constraint of current surveillance is that it is based almost entirely on paper forms or individual telephone reports to local health departments. This system can manage sporadic cases and small outbreaks, but larger outbreaks would quickly overrun 1. overrun - A frequent consequence of data arriving faster than it can be consumed, especially in serial line communications. For example, at 9600 baud there is almost exactly one character per millisecond, so if a silo can hold only two characters and the machine takes the capacity of most local health departments. The inability to adequately investigate large outbreaks is especially important given the potential for intentional contamination of food supplies as an act of bioterrorism bi·o·ter·ror·ism n. The use of biological agents, such as pathogenic organisms or agricultural pests, for terrorist purposes. Bioterrorism of biowarfare. Examining these three limitations evolved into a plan to implement a syndromic surveillance forum in which clusters of foodborne disease could be quickly identified for further investigation. This system would act as a method to augment existing laboratory-based surveillance and would identify clusters of persons with suspected foodborne disease that warrant further investigation by health departments. The RUsick2 Forum The RUsick2 Forum was developed by epidemiologists from the Michigan Department of Community Health, the Michigan Department of Agriculture, the University of Michigan (body, education) University of Michigan - A large cosmopolitan university in the Midwest USA. Over 50000 students are enrolled at the University of Michigan's three campuses. The students come from 50 states and over 100 foreign countries. , Lansing-area health departments, and Michigan State University Michigan State University, at East Lansing; land-grant and state supported; coeducational; chartered 1855. It opened in 1857 as Michigan Agricultural College, the first state agricultural college. . All were brought together under the auspices of the National Food Safety and Toxicology Center at Michigan State University. Data Input A Web site (www.RUsick2.msu.edu) was developed to record information on symptoms, time of illness onset, a 4-day preillness food history, food sources, and other information regarding nonfoodborne sources of common gastrointestinal illness. Visitors can potentially view 22 screens, most of which are data input screens with a few displaying other visitors' data (no personal identifiers are viewed by RUsick2 visitors). The Forum allows visitors to return multiple times to modify their data if they recall more about what food they consumed and where they purchased it. The Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ) Standard Foodborne Questionnaire and other foodborne questionnaires were emulated in creating the data input screens (3). The food list currently contains 54 food items, divided into the following categories: popular main courses, meats/poultry/fish, dairy and eggs, raw fruit, raw vegetables, prepared fruit or vegetables, salad items/side dishes, grains and starches starch n. 1. A naturally abundant nutrient carbohydrate, (C6H10O5)n, found chiefly in the seeds, fruits, tubers, roots, and stem pith of plants, notably in corn, potatoes, wheat, and rice, and , and beverages. Figure 1 displays an abbreviated version of this data entry screen. [FIGURE 1 OMITTED] A section concerning nonfood non·food adj. Of, relating to, or being something that is not food but is sold in a supermarket, as housewares or stationery. exposures was incorporated to gather information regarding exposure to animals, sick persons, patients in a healthcare setting, commercial food preparation, young children, private well water, and swimming (lake/river or swimming pool). The Forum is unlike most Web-based forums in that it is structured and does not allow narrative testimony. As with written or telephone reporting, persons generally have a difficult time remembering what they consumed during the several days before becoming ill. Computer technology does not enhance memory, but it allows the reporter to recall data at his own pace and return to the Web site to add or modify data after consulting friends, family, calendars, checkbooks, and credit-card records. A follow-up survey is being conducted of all visitors to the Web site. Virtually all modifications to the program instituted after November 2002 shortened and simplified the program. We intend to continue modifying the program to meet the requests of RUsick2 visitors. Moreover, focus groups are planned for the future to further increase usability. Information Retrieval information retrieval Recovery of information, especially in a database stored in a computer. Two main approaches are matching words in the query against the database index (keyword searching) and traversing the database using hypertext or hypermedia links. As the visitor proceeds through the program entering data regarding symptoms, food items eaten, and food sources, increasingly specific comparisons with other users' data are available. The objective is to help each visitor determine what he might have in common with other persons, including symptoms, time of illness onset, and consumption of the same food item from the same food source. The summary report is a univariate descriptive analysis showing the number and percentage of past visitors who reported the same risk factors (foods, food sources, nonfood exposures) as the current visitor, who can use the summary report to select individual reports for viewing. A comparison report analyzes the visitor's risk factors during an adjustable "target" period of onset dates, compared to an adjustable historic "comparison" period. Subsequent retrievals can be restricted on the basis of risk factors, and data can be viewed as a case report or output in a format accessible by most spreadsheet, database, and statistical programs. Figure 2 shows an example of the comparison report. [FIGURE 2 OMITTED] Visitors may choose to enter their data and leave the investigation to the health departments to determine whether a cluster exists. They may also view a descriptive table of recent reports and see whether the source they originally suspected was mentioned by other Forum visitors. Persons who are satisfied that theyarenot part of an outbreak may leave the Forum without requesting further output. Those who see common exposures may pursue more sophisticated output. At any time in the process, Forum visitors can request the aid of their health department. The Forum does not investigate outbreaks or replace the current systems used by local health departments. Rather, the Forum increases reporting of foodborne illness and makes identifying suspicious clusters that may warrant further investigation possible. By collecting numerous variables, the Forum delivers information on a large number of risk factors to local health departments to assist in an investigation. A moderator moderator - A person, or small group of people, who manages a moderated mailing list or Usenet newsgroup. Moderators are responsible for determining which email submissions are passed on to the list or newsgroup. views each report after it is entered and conducts appropriate follow-up. For example, if a report from outside the three-county pilot area is entered, the moderator will alert the proper health department that a report from their jurisdiction has been entered. Like most Web-based forums, the moderator also reviews data for reasonableness, profanity Irreverence towards sacred things; particularly, an irreverent or blasphemous use of the name of God. Vulgar, irreverent, or coarse language. The use of certain profane or obscene language on the radio or television is a federal offense, but in other situations, profanity , or other infringements of posted Forum rules. Records can be excluded from analysis, and each health department may similarly reject records. Health Departments RUsick2 visitors cannot retrieve other visitors' personal identifiers, narrative testimony, or names of restaurants, stores, or other food sources. In contrast, health departments have access to all data fields for visitors who report being residents of their jurisdiction. Local health departments in the three-county pilot area around Lansing, Michigan “Lansing” redirects here. For other uses, see Lansing (disambiguation). Lansing is the capital city of the U.S. state of Michigan, and the state's sixth largest city. , were involved in developing the Forum and have helped design methods by which local health departments can monitor the Forum. During the pilot phase, local health departments have had password access to the database to check reports from their residents. After expansion of the Forum, counties with less activity will be able to request automatic email notification from the Forum's computer. Phantom Outbreaks Several features of the Forum are designed to prevent phantom outbreaks caused by the power of suggestion. Visitors cannot implicate im·pli·cate tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates 1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot. 2. any particular food item or exposure. Second, visitors enter data before being given the opportunity to view output that might influence their own reports. (While visitors may modify their responses on subsequent visits to the Forum, very few do.) Third, each visitor only views output for food sources, foods, and other risk factors they have already indicated in earlier data entry screens. Fourth, food stores, restaurants, and other food sources are identified to Forum visitors only by abbreviations, which may not be specific to particular establishments. Abbreviations are sufficient to identify suspicious clusters, but only health departments see the entire names of commercial establishments. Finally, suspicious clusters must be investigated by the local health department to determine if clusters are due to foodborne outbreaks, chance, confounding confounding when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies. confounding factor , pranks, or normal changes in diet. Pilot Test The Forum is being pilot tested in the tri-county area of Clinton, Eaton, and Ingham counties, which make up the Greater Lansing, Michigan area. The Forum was implemented in November 2002, involving three local health departments: the Barry-Eaton District Health Department, the Ingham County Health Department, and the Mid-Michigan District Health Department. For comparison purposes, we evaluated previous foodborne illness reports from the population of these counties for the years 2000 and 2001 (4-6). Publicity The target population was 450,000 residents living in the three pilot counties. The percentage of this population that has Internet access See how to access the Internet. is unknown, but an estimated 51.2% of all Michigan households had Internet access in 2001 (7). This percentage does not include persons who may have access at work, school, or public libraries. Advertisements were published five times a week in the area's daily newspaper (The Lansing State Journal The Lansing State Journal is a daily newspaper published in Lansing, Michigan owned by Gannett. History The paper was started as the Lansing Republican on April 28, 1855. ). Fliers and brochures were distributed to 450 Lansing-area physicians in October 2002 with a letter explaining the project. Local television channels featured the project on various newscasts. In addition, three newspaper articles about the project appeared in the daily newspaper (8-10), two articles appeared in the university's independent student newspaper (11,12), and one article ran in a smaller weekly paper (a subsidiary of the area's largest newspaper) and a local township paper (13,14). Articles have been printed in various health departments' newsletters and other university-related publications. A student employee worked 2 days per week visiting private physicians' offices, urgent care offices, emergency rooms, and pharmacies to distribute fliers and brochures and to ask clinic nurses to recommend the Forum to patients with suspected foodborne illness. The Forum has been described at local grand-rounds meetings for internal medicine, emergency medicine, pediatrics, and family practice. Publicity given to this project may have influenced the results. The Forum was well advertised in the three-county pilot area. Reports could have increased as a result of advertising, regardless of mode of reporting, However, one local health department involved in the pilot project stated that the number of traditional reports had not increased since the outset of the RUsick2 Forum. Illness Reporting Table 2 depicts the Michigan Department of Agriculture data collected for 2000 and 2001 by year, month, and county. From these data, we predicted that approximately 22 reports would have been expected during the comparable months of 2002 and 2003. The RUsick2 dataaredisplayed by month and county in Table 3 and show that 93 reports were obtained with the Web-based system. From November 2002 (the time the Forum was implemented) until February 2003, a total of 93 reports to the RUsick2 Forum reached at least the entry level of reporting (which begins by identifying foods consumed). In the first 17 weeks of the program, an average of 5.37 cases were reported each week. Based on the previous years' reports, we calculated an expected number of 1.31 cases per week; hence, the ratio of reported cases to expected reports (5.37/1.31) was 4.10. Figure 3 shows the weekly average of foodborne complaints reported to the Forum from the three pilot counties during the first 17 weeks of operation. Also shown on this graph is the weekly average number of foodborne disease complaints reported to the state of Michigan during the corresponding months of January, February, November, and December 2000-2001. Approximately 22 reports would have been expected during the 17-week period, based on reports from previous years. However, 93 reports were received during the first 17 weeks of operation, more than a fourfold fourfold Adjective 1. having four times as many or as much 2. composed of four parts Adverb by four times as many or as much Adj. 1. increase in reporting. [FIGURE 3 OMITTED] Local health departments monitored reports to the Forum and contacted reporting persons by telephone or email to verify the accuracy of the report and authenticate (1) To verify (guarantee) the identity of a person or company. To ensure that the individual or organization is really who it says it is. See authentication and digital certificate. (2) To verify (guarantee) that data has not been altered. the complaint. Contacts usually required a few minutes. Reports delivered from the Forum to local health departments were treated as traditional reports. The Forum identified two foodborne outbreaks that would likely not have been identified. One fictitious Based upon a fabrication or pretense. A fictitious name is an assumed name that differs from an individual's actual name. A fictitious action is a lawsuit brought not for the adjudication of an actual controversy between the parties but merely for the purpose of report was identified and rejected. Future Development Similar to other Web-based forums, RUsick2 allows persons with a common health problem to examine one another's information. In an attempt to determine if they share any common exposures, visitors can view risk factors such as food histories, food sources, and other exposures entered by previous visitors. The Rusick2 Forum acts as a "front end" to existing surveillance by increasing reporting and identifying suspicious clusters that warrant a full investigation. The Forum has recently been adapted for national usage so that the technical aspects of data entry and information retrieval will function identically for residents of all states. The publicity campaign conducted in the pilot counties will be too expensive to reproduce on a national level, so the Forum will only gain national prominence if local health departments and consumer advocacy groups use and publicize pub·li·cize tr.v. pub·li·cized, pub·li·ciz·ing, pub·li·ciz·es To give publicity to. publicize or -cise Verb [-cizing, -cized] the Web site. The input screens of this program are easily modifiable or removable. For example, the symptoms screen can be altered to include symptoms specific to a non-foodborne disease, or the food history screens can be deleted entirely. Thus, this program could be adapted for use in other disease outbreaks.
Table 1. Simulated binomial data, assuming 2% of cases
reported
Size of outbreak 2 or more reports 3 or more reports
25 9% 1%
50 26% 8%
75 44% 19%
Table 2. Foodborne disease reports in Michigan by county, month,
and year (a)
County Y Jan Feb Nov Dec
Ingham 2000 9 4 4 3
2001 1 2 0 4
Clinton 2000 0 0 0 0
2001 0 0 0 0
Eaton 2000 1 2 3 1
2001 4 4 1 2
Total 15 12 8 10
No. wk/m 4.42 4.00 4.29 4.42
2000-2001 average/wk 1.70 1.50 0.93 1.13
(a) Source: Michigan Deparunenl of Agriculture, unpub. data.
Table 3. RUsick2 visits by county. month, and year
County Y Nov Dec Jan Feb
Ingham 2002 15 13 -- --
2003 -- -- 25 9
Clinton 2002 0 1 -- --
2003 -- -- 1 3
Eaton 2002 7 7 -- --
2003 -- -- 12 3
Total 22 21 38 12
No. wk/m 4.29 4.42 4.42 4.00
Average/wk 5.13 4.75 8.60 3.00
Acknowledgment acknowledgment, in law, formal declaration or admission by a person who executed an instrument (e.g., a will or a deed) that the instrument is his. The acknowledgment is made before a court, a notary public, or any other authorized person. This project was funded through the Michigan Life Sciences Corridor The Michigan Life Sciences Corridor (MLSC) is a $1 billion biotechnology initiative in the U.S. state of Michigan. It started in 1999 with money from the state's settlement with the tobacco industry. , the United States Department of Agriculture United States Department of Agriculture (USDA), n.pr established in 1862, USDA is responsible for the safety of meat, poultry, and egg products. It conducts ongoing research in areas from human nutrition to new crop technologies and also helps ensure open , and the Michigan Department of Community Health. References (1.) Mead PS, Slutsker L, Dictz V, McCaig LF, Bresee JS, Shapiro C, et al. Food-related illness and death in the United States. Emerg Infect infect /in·fect/ (in-fekt´) 1. to invade and produce infection in. 2. to transmit a pathogen or disease to. in·fect v. 1. Dis 1999;5:607-25. 2. Food practices and diarrheal diseases: vox populi vox populi Voice of the people Sociology A language, as spoken, which includes slang and jargon. See Jargon, Slang. . CD Summary [newsletter on the Internet]. Center for Disease Prevention and Epidemiology, Oregon Health Division. 1998 Nov 24; 47(24). Available from: http://www.dhs.state.or.us/publichealth/cdsummary/1998/ohd4724.pdf (3.) Centers for Disease Control and Prevention. Standard foodborne disease outbreak case questionnaire. 2002 Mar [cited 2003 Mar 21]. Available from: http://www.cdc.gov/foodborneoutbreaks/standardquestionnaire.htm (4.) U.S. Ccnsus Bureau. State and county quickfacts: Clinton county
(5.) U.S. Census Bureau Noun 1. Census Bureau - the bureau of the Commerce Department responsible for taking the census; provides demographic information and analyses about the population of the United States Bureau of the Census . State and county quickfacts: Eaton county. 2002 Sept [cited 2002 Nov 15]. Available from: http://quickfacts.census.gov/qfd/states/26/26045.html (6.) U.S. Census Bureau. State and county quickfacts: Ingham county. 2002 Sept [cited 2002 Nov 15]. Available from: http://quickfacts.census.gov/qfd/states/26/26065.html (7.) U.S. Department of Commerce. Economics and Statistics Administration The Economics and Statistics Administration (ESA) is an agency in the United States Department of Commerce that produces, analyzes and disseminates national economic and demographic data. : National Telecommunications and Information Administration The National Telecommunications and Information Administration (NTIA) is an agency of the United States Department of Commerce that serves as the President's principal adviser on telecommunications policies pertaining to the United States' economic and technological . A nation online: How Americans are expanding their use of the internet [online]. 2002 Feb [cited 2002 Dec 2]. Available from: http://www.ntia.doc.gov/ntiahome/dn/nation_online.pdf (8.) Terlep S. MSU develops unique method to track food-poisoning cases: system will let people report sickness online. The Lansing State Journal 2002 May 20; Sect. A:1, A:5. (9.) Harrison S Harrison, town (1990 pop. 13,425), Hudson co., NE N.J., an industrial suburb on the Passaic River opposite Newark; inc. 1869. The town has several foundries. Its manufactures include plastics, paperboard, and metal products. . Wcb site lets users report food poisoning food poisoning, acute illness following the eating of foods contaminated by bacteria, bacterial toxins, natural poisons, or harmful chemical substances. It was once customary to classify all such illnesses as "ptomaine poisoning," but it was later discovered that . The Lansing State Journal 2002 Nov 4; Sect. B:1. (10. Trout S. More food ailments reported online. The Lansing State Journal 2003 Jan 5; Sect. B:I. (11.) Byrne K. Web site to aid food poisoning reporting. The State News 2002 May 22; 3. (12.) Korneffel S. Group sets up web site on contaminated foods. The State News 2002 Nov 26; 7. (13.) Miller M. Got the dry heaves heaves, chronic pulmonary emphysema in horses. Heaves is characterized by the disruption of normal lung tissue with resultant loss of the lung's elastic recoil. A forced expiratory effort is needed to empty the lungs of air. ? Tell us please. NOISE 2003 Feb 5. (14.) Michigan State University asks Lansing area: RUsick2? The Ingham County Community News 2003 Jan 12; 18. Holly Wethington * and Paul Bartlett * * Michigan State University, East Lansing, Michigan East Lansing is a city in the U.S. state of Michigan. The city is located directly east of Lansing, Michigan, the state's capital. Most of the city is within Ingham County, though a small portion lies in Clinton County. , USA Ms. Wethington is a graduate research assistant at the National Food Safety and Toxicology Center at Michigan State University. Her primary research interests are factors increasing foodborne illness reporting and electronic reporting. Dr. Bartlett is a professor at the National Food Safety and Toxicology Center and the College of Veterinary Medicine veterinary medicine, diagnosis and treatment of diseases of animals. An early interest in animal diseases is found in ancient Greek writings on medicine. Veterinary medicine began to achieve the stature of a science with the organization of the first school in the at Michigan State University. His primary research interests are veterinary preventive medicine preventive medicine, branch of medicine dealing with the prevention of disease and the maintenance of good health practices. Until recently preventive medicine was largely the domain of the U.S. , food safety, antimicrobial antimicrobial /an·ti·mi·cro·bi·al/ (-mi-kro´be-al) 1. killing microorganisms or suppressing their multiplication or growth. 2. an agent with such effects. resistance, dairy management, corporate and government veterinary practice, and veterinary public health. Address for correspondence: Holly Wethington, 165 Food Safety & Toxicology Building, Michigan State University, East Lansing East Lansing, city (1990 pop. 50,677), Ingham co., S central Mich., a suburb of Lansing, on the Red Cedar River; inc. 1907. The city was first known as College Park, but was renamed when it was incorporated. , MI 48824, USA; fax: 517-432-2310; email: ffmod@cvm.msu.edu |
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