Using the Electronic Foodborne Outbreak Reporting System (eFORS) to Improve Foodborne Outbreak Surveillance, Investigations, and Program Evaluation
Middaugh, John P., Hammond, Roberta M., Eisenstein, Leah, Lazensky, Rebecca, Journal of Environmental Health
Developing surveillance for foodborne outbreaks in the U.S. has posed a formidable challenge (Mead et al., 1999). Surveys have identified several reasons for chronic underreporting of FBDOs, including a lack in capacity for conducting FBDO investigations at the state and local level and delays in reporting outbreaks to public health officials (Hedberg et al., 2008; Hoffman et al., 2005; Mead et al., 1999).
The increasing globalization of the nation's food supply, identification of new foodborne diseases, improvements in laboratory technology and diagnostics, recognition of nationwide FBDOs due to mass distribution of commercial foods, and concerns over bioterrorism have galvanized increased efforts to improve surveillance, investigation, and evaluation of FBDOs. The Centers for Disease Control and Prevention (CDC) have been a leader in this effort, implementing the Foodborne Diseases Active Surveillance Network (FoodNet) and PulseNet (Pinner, Rebmann, Schuchat, & Hughes 2003; Swaminatha, Barrett, Hunter, Tauxe, & CDC PulseNet Task Force, 2001). In 2001, CDC implemented a web-based outbreak surveillance system, the Electronic Foodborne Outbreak Reporting System (eFORS) (Centers for Disease Control and Prevention [CDC], 2000). CDC periodically publishes surveillance summaries as special supplements of the Morbidity and Mortality Weekly Report (CDC, 2000, 2006).
In the fall of 2006, a news reporter obtained a copy of the eFORS database from CDC and conducted his own analysis of the data. Based on his findings, he interviewed health department representatives from several states, including Florida, and published a story in the national media (Hargrove, 2006). He reported that Florida ranked 49th in the nation in determining the cause of FBDOs, and ranked first in the nation in the number of FBDOs. His conclusions were widely reported in the Florida media (Editorial Board, 2007; Torres, 2007) and stimulated an examination of Florida's experience with FBDOs (CDC, 2006).
CDC receives reports of FBDOs due to bacteria, viruses, parasites, and chemicals from all 50 states and the Republics of Palau and Guam. Agencies use a standard form (CDC form 52.13, Investigation of a Foodborne Outbreak) to report to CDC. Starting in 2001, these reports were submitted through a web-based version of this form. The eFORS national database now contains records from 1998 to the present, with an average of 1,200 FBDOs each year (CDC, 2006).
In 2007, the Florida Department of Health (FDOH) initiated a review of Florida and national FBDOs using the eFORS database. Records for FBDOs reported by all U.S. states and accepted by eFORS for the period from 2000 to 2005 were obtained for Florida (N = 1,198) and the United States (N = 7,288). Microsoft Access 2003 and SAS 9.1 were used to stratify FBDOs by size and compare Florida to the U.S.
An FBDO is defined as the occurrence of two or more cases of a similar illness resulting from the ingestion of a food in common. Laboratory or clinical guidelines for confirming an etiology of an FBDO vary for bacterial, chemical, parasitic, and viral agents (CDC, 2006). Detailed descriptions of exclusions from and limitations to the surveillance system have been published (CDC, 2006).
Florida reported the largest number of FBDOs in the U.S. over the six-year study period when compared to other states, and ranked second in the average annual FBDOs per one million population. The state reported 1,198 FBDOs, contributing 16.4% of the total U.S. FBDOs, though it accounted for only 5.8% of the U.S. population (Table 1).
The majority (85%) of Florida's FBDOs were "small" outbreaks involving fewer than 10 cases per FBDO, compared to 57.3% of U.S. FBDOs (Table 2). This difference was primarily due to the large proportion of Florida FBDOs involving only two cases per outbreak. …