8 • CID 2004:39 (1 July) • EDITORIAL COMMENTARY

E D I T O R I A L C O M M E N T A R Y

Foodborne Disease: The More Things Change,the More They Stay the Same

Michael T. OsterholmCenter for Infectious Disease Research and Policy, School of Public Health, University of Minnesota, Minneapolis

(See the article by Jay et al. on pages 1–7)

The more things change, the more they stay the same.

Alphonse Karr

Received 16 March 2004; accepted 16 March 2004;electronically published 11 June 2004.

Reprints or correspondence: Michael T. Osterholm, Centerfor Infectious Diseases Research and Policy, School of PublicHealth, University of Minnesota, 420 Delaware St. SE, MMC263, Rm. C-315, Minneapolis, MN 55455 (mto@umn.edu).

Clinical Infectious Diseases 2004; 39:8–10� 2004 by the Infectious Diseases Society of America. Allrights reserved.1058-4838/2004/3901-0002$15.00

Despite efforts by the public health com-

munity and the food production and ser-

vice industries, Escherichia coli O157:H7

remains an important foodborne patho-

gen in the United States. The article by

Jay et al. [1] detailing a multistate outbreak

of E. coli O157:H7 caused by the con-

sumption of contaminated beef tacos is

another unfortunate story in the book on

foodborne disease [1]. The source of the

contamination was precooked ground

beef, a supposedly safe product that my

colleagues and I [2] had previously dem-

onstrated 14 years ago is a source for E

.coli O157:H7 infection.

In 1996, the Centers for Disease Control

and Prevention (CDC) Emerging Infec-

tions Program established the foodborne

disease active surveillance network (Food-

Net) to follow trends of specific foodborne

infections by using laboratory-based sur-

veillance for culture-confirmed illnesses

caused by several enteric pathogens com-

monly transmitted through food. One of

the pathogens surveyed was E. coli O157:

H7 [3]. Recent analysis of the FoodNet

data of 1996–2002 found that the inci-

dence of E. coli O157:H7 infection did not

significantly change at the FoodNet sites,

despite implementation of several major

control measures, including initiation of

the pathogen reduction/hazard analysis

critical point systems regulations for meat

and poultry slaughterhouses and process-

ing plants sponsored by the US Depart-

ment of Agriculture (USDA) Food Safety

Inspection Service. These national sur-

veillance data, as well as the continued oc-

currence of outbreaks of Salmonella and

E. coli O157:H7 infections associated with

ground beef consumption, give us reason

to reconsider further steps needed to re-

duce the burden of disease associated with

pathogens transmitted through meat and

poultry.

The outbreak investigation reported by

Jay et al. [1] and our ongoing collection

of foodborne disease surveillance data il-

lustrate 2 very important lessons. First,

there will be only limited gains in reducing

the incidence of meat- and poultry-related

foodborne illnesses until the implemen-

tation of food irradiation becomes stan-

dard. Second, most foodborne disease

outbreak investigations are initiated “after

the fact” and have little real-time public

health impact for preventing additional

cases of illness; the investigation by Jay et

al. [1], although comprehensive and

thoughtful, offers no exception.

It is disappointing that Jay et al. [1] did

not mention the use of food irradiation

in their discussion of ways in which similar

outbreaks can be prevented in the future.

Because of the support for food irradiation

by the federal food-safety agencies in the

United States, which include the CDC, the

US Food and Drug Administration, and

the USDA, public health officials should

use every opportunity to promote this im-

portant technology, particularly in the

context of foodborne outbreaks. Food ir-

radiation has the potential to dramatically

decrease the incidence of foodborne dis-

ease and is widely supported by interna-

tional and national medical, scientific, and

public health organizations, as well as

groups in the food processing industry

(table 1) [4]. The CDC has determined

that if even 50% of meat and poultry con-

sumed in the United States were irradi-

ated, the potential impact on foodborne

EDITORIAL COMMENTARY • CID 2004:39 (1 July) • 9

Table 1. Selected organizations that support the safety offood irradiation.

Organization

US government agenciesDepartment of AgricultureDepartment of Health and Human Services

Food and Drug AdministrationCenters for Disease Control and Prevention

Scientific and health-related organizationsUnited States

American Academy of PediatricsAmerican Dietetic AssociationAmerican Medical AssociationAmerican Veterinary Medical AssociationCouncil for Agricultural Science and TechnologyCouncil of State and Territorial EpidemiologistsInfectious Diseases Society of AmericaNational Association of State Departments of Agriculture

InternationalCodex Alimentarius CommissionFood and Agriculture Organization of the United NationsInternational Atomic Energy AgencyScientific Committee for Food of the European UnionWorld Health Organization

Food processing, food service, and related groupsAmerican Meat InstituteInstitute of Food TechnologistsFood Marketing InstituteGrocery Manufacturers of America

disease would be a reduction of 900,000

cases and the elimination of 352 deaths

each year [5]. Unfortunately, !0.002% of

fruits, vegetables, meats, and poultry are

currently irradiated in the United States

[6]. My colleagues and I have recently de-

tailed the role of irradiation in food safety

and the potential barriers that cause it to

be largely unused [4]. The bottom line

messages are that (1) health and public

health professionals are largely unaware of

the benefits of food irradiation, (2) there

is an enormous body of data demonstrat-

ing the safety of this process, and (3) we

must detail specific steps necessary to re-

alize its potential benefits as a widely used

food safety technology.

Commercial use of irradiation for meats

and poultry is conceptually similar to milk

pasteurization. It uses high-energy irra-

diation in any of 3 approved forms: g rays,

radiography, and electron beam. Pasteur-

ization by irradiation is not intended to

eliminate all bacteria in meat and poultry,

but rather to eliminate a large proportion

of pathogenic organisms. Thus, irradia-

tion does not eliminate the need for es-

tablished safe food handling and cooking

practices, but it will reduce the dangers of

primary and cross-contamination. Cur-

rently in the United States, irradiation is

approved for insect disinfestation, shelf-

life extension, pathogen and parasite con-

trol, and sprout inhibition. Foods that

have been approved for irradiation include

red meat, poultry, pork, fruits and vege-

tables, aromatic spices, seeds, herbs and

seasonings, enzyme preparations, eggs,

and wheat.

Without a technology like irradiation,

even with other recent efforts by the meat

and poultry processing industries, it is im-

possible to eliminate all contamination of

these products, particularly in the slaugh-

terhouse environment. In 2003, the USDA

Food Safety and Inspection Service found

that 0.32% of ground beef samples were

contaminated with E. coli O157:H7 [7].

Because the United States produces ∼3.6

billion kg of ground beef annually, even

this exceedingly low level of contamina-

tion means that an estimated 11.6 million

kg of E. coli O157:H7–contaminated

ground beef will be produced each year.

Until the use of irradiation as a food safety

technology for food products like ground

beef is taken seriously in the United States,

there will continue to be reports of out-

breaks similar to those discussed by Jay et

al. [1].

Finally, although I applaud the com-

prehensive nature of outbreak investiga-

tion conducted by Jay et al. [1], it high-

lights a major shortcoming of many

similar foodborne disease investigations

reported recently: too little, too late. De-

spite the occurrence of cases of illness in

early November 1999, an investigation-re-

lated case-control study to identify risk

factors was not initiated until early De-

cember 1999. The subsequent trace-back

studies of implicated food products nec-

essarily did not start until weeks after the

start of the case-control study. So, despite

the relatively timely use of PFGE for sur-

veillance-based analysis of isolates of E. coli

O157:H7 recovered from patients, the im-

plicated food product (i.e., undercooked

precooked ground beef) had cleared

through the food distribution system be-

fore investigators could identify it. This is

typical for most food commodity–related

outbreaks today, particularly those involv-

ing perishable items such as fresh produce.

Although such outbreak investigations can

be very instructive in discovering defi-

ciencies in the safety of a given commodity

or food process and provide guidance

for preventing future outbreaks, rarely do

such investigations actually allow for

meaningful removal of the implicated

item from the market or make possible

specific warning to consumers. The out-

come of this investigation was no

different.

10 • CID 2004:39 (1 July) • EDITORIAL COMMENTARY

So, we are really left with the fact that

we must only consider these important

investigations largely as lessons for the fu-

ture, not as “smoke alarms” capable of

early warning and cause for immediate

prevention. This concept brings us full cir-

cle; we must begin to use food irradiation

if we are really to make a difference in

food safety.

References

1. Jay MT, Garrett V, Mohle-Boetani JC, et al. Amultistate outbreak of Escherichia coli O157:H7

infection linked to consumption of beef tacosat a fast-food restaurant chain. Clin Infect Dis2004; 38:1–7 (in this issue).

2. Belongia EA, MacDonald KL, Parham GL, etal. An outbreak of Escherichia coli O57:H7 co-litis associated with consumption of precookedmeat patties. J Infect Dis 1991; 164:338–43.

3. Nelson JM, Vugio DJ, Cronquist AB, et al. In-cidence of foodborne illness in the UnitedStates, FoodNet 2002. In: Program and ab-stracts of the International Conference onEmerging Infectious Diseases (Atlanta). At-lanta: Centers for Disease Control and Preven-tion, 2004:194.

4. Osterholm MT, Norgren AP. The role of irra-diation in food safety. N Engl J Med 2004; 350:1898–901.

5. Tauxe RV. Food safety and irradiation: pro-

tecting the public from foodborne infections.Emerg Infect Dis 2001; 7:516–21.

6. US General Accounting Office (GAO). Foodirradiation: available research indicates thatbenefits outweigh risks. Publication no. GAO/RCED-00-217. Washington, DC: GAO, 2000.

7. Roybal J. Beef industry logs successful week inE. coli O157:H7 battle. BEEF Magazine’s Cow-Calf Weekly. 26 September 2003. Available at:http://enews.primediabusiness.com/enews/beef/cowcalf_weekly/current- a030926_4. Accessed30 September 2003.