outreak alert! 2014

OUTBREAK ALERT! 2014

A REVIEW OF FOODBORNE ILLNESS IN AMERICA FROM 2002-2011

CENTER FOR SCIENCE IN THE PUBLIC INTEREST

APRIL 2014


Contents

Introduction ______________________________________________________________________________________________ 1

Findings ___________________________________________________________________________________________________ 2

Methodology ____________________________________________________________________________________________ 12

Appendix ________________________________________________________________________________________________ 14

References ______________________________________________________________________________________________ 15

Outbreak Alert! 2014 was researched and written by Caroline Smith DeWaal, J.D., and Marcus Glassman, M.S.

We gratefully acknowledge the assistance of Susan Grooters, M.P.H., and Michael F. Jacobson, Ph.D., in

preparing this report. We also thank those working in state and federal public health agencies who

provided information and inspiration for this report, and dedicate this edition of Outbreak Alert! in memory

of Bill Keene.

The Center for Science in the Public Interest (CSPI) is a non-profit organization based in Washington, DC.

Since 1971, CSPI has been working to improve the public’s health, largely through its work on nutrition and

food safety issues. CSPI is supported primarily by the over 900,000 subscribers to its Nutrition Action

Healthletter and by foundation grants. CSPI does not accept government or industry funding.

1220 L Street N.W., Suite 300

Washington, DC 20005

Tel 202.332.9110

www.cspinet.org

Copyright © 2014 by the Center for Science in the Public Interest; Sixteenth Edition, April 2014.

Cover: “Collection of foods including chicken, vegetables and milk” used with permission from Microsoft.


Page 1

Introduction

This report aims to help public health officials, policy makers, and consumers better understand the causes

and the burden of foodborne disease in the United States. Every year, one in six Americans—48 million

people—contracts an illness from contaminated food. Of those, 128,000 are hospitalized and 3,000 die.1

While the vast majority of foodborne illnesses are isolated cases, this report analyzes outbreaks—clusters of

two or more illnesses resulting from the same contaminated food source—because outbreaks provide the

most complete foodborne illness information.2 This report analyzes the most recent 10 years of outbreak

data available from the Centers for Disease Control and Prevention (CDC), covering 2002-2011. This

analysis can be used to identify food safety trends and can highlight gaps and essential improvements in

food safety control programs at the industry, government, and consumer levels.

State and local health departments are the front-line investigators of foodborne outbreaks. Those agencies

investigate and report information on outbreaks in their states to the CDC, the federal agency responsible

for tracking and reporting foodborne and emerging diseases. This reporting system, however, is far from

perfect. Many, perhaps most, outbreaks are never reported or fully investigated for a number of reasons.

Often, foodborne illnesses do not require a physician’s assistance to treat, and are therefore never reported.3

Many state and local health departments are understaffed and underfunded, which leaves them unable to

fully investigate all reported outbreaks. Clinical trends, such as a move away from culture-dependent

diagnostics, leave public health investigators with fewer laboratory samples to investigate. Finally, in many

cases, states are not required to report foodborne outbreaks to CDC.

For this report, the Center for Science in the Public Interest (CSPI) analyzed 10,409 foodborne disease

outbreaks reported to CDC that occurred between 2002 and 2011. Of those reported outbreaks, 3,933

outbreaks—responsible for 98,399 illnesses—were fully solved. “Solved” outbreaks are those where both

the contaminated food and the pathogen were identified.

The Worst Outbreaks of the Decade

In May 2006, California State Prisons served Campylobacter-contaminated pasteurized milk to

inmates. As a consequence, 1,644 inmates contracted clinical gastroenteritis in the decade’s largest

single-source outbreak.

In April 2008, Salmonella Typhimurium-contaminated jalapen o and serrano peppers and pepper

products (e.g., salsa) sickened 1,535 people in 42 states. Of those, 308 people required

hospitalization and 2 died in the decade’s largest multi-state outbreak.

In 2011, Listeria-contaminated cantaloupe produced by Colorado-based Jensen Farms sickened 148

people in 28 states. Of those sickened, 30 people died: a death rate of 21 percent. This outbreak had

the highest death-rate of any outbreak of the decade, and was the deadliest recorded outbreak

since 1990.


Page 2

Findings

FINDING I OUTBREAK REPORTING HAS DECREASED 42 PERCENT SINCE 2002

Foodborne illness outbreaks, as reported by CDC, appear to have decreased by 42 percent from 2002 to

2011. Nonetheless, foodborne outbreaks remain a pressing public health concern (Figure 1). Those data

include all outbreaks reported by CDC, including those without an identified pathogen or food vehicle.

Outbreaks with incomplete data provide only limited insight into the cause of foodborne illness. For this

report, in-depth analysis was only performed on those outbreaks with both an identified food vehicle and

contaminant (Finding II).

0

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Figure. 1 Total Outbreaks Reported to CDC, 2002-2011


Page 3

FINDING II INCOMPLETE INVESTIGATIONS CONTRIBUTED TO DECLINES IN THE REPORTING OF SOLVED OUTBREAKS

To develop risk-based interventions and design the most effective and efficient food safety hazard controls,

robust outbreak data are critically important. The best outbreak data come from solved outbreaks, where

both the contaminated food and pathogen are identified. Unfortunately, the majority of outbreaks reported

to and published by the CDC between the years 2002 and 2011 were only partially investigated. During this

decade, between 57 and 68 percent of all outbreaks reported annually to CDC lacked necessary information,

such as the contaminated food or contaminant (Figure 2).

The declines in complete and incomplete reporting between 2002 and 2011 may be due, in part, to falling

budgets for public health departments in the latter half of the study period.4,5 Many health departments are

underfunded, understaffed, and overwhelmed by the volume of illness reports, foodborne and otherwise.

The recession at the end of the decade can be blamed for many states’ funding cuts, while influenza

pandemics and post-9/11 bioterrorism investments also impacted public health agencies’ budgets and may

have diverted attention away from foodborne illness investigations. Importantly, outbreak reporting rates

may also be down due to the increased use of culture-independent diagnostic testing by healthcare

providers. Such diagnostic tests are used to quickly diagnose foodborne illness in patients, but, unlike

traditional tests, do so without first growing bacterial samples in a laboratory. Without live bacteria to

study and compare, it is difficult for health departments to identify whether illnesses are linked, a necessary

step to identifying outbreaks.6

566 454 512 424 459 379 365 237 292 245

755 640 817 544 809 719 667 438 566 521

0%

20%

40%

60%

80%

100%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Ou

tbre

aks

Figure 2. Foodborne Illness Outbreaks Reported to CDC, 2002-2011

N=10,409

Solved Unsolved


Page 4

FINDING III RESTAURANTS ARE THE MOST FREQUENT LOCATION FOR OUTBREAKS, RESPONSIBLE FOR TWICE AS MANY OUTBREAKS AS PRIVATE HOMES

CSPI analyzed the locations where outbreak-associated contaminated foods were eaten. Not all outbreaks

analyzed for this report had location information, but among those that did, the largest numbers were

caused by foods eaten at restaurants, nearly twice the number caused by foods eaten at home. Outbreaks

with the largest average number of illnesses occurred in group settings, such as prisons, catered events,

schools, elderly care centers, and religious organization-sponsored meals. Outbreaks with the smallest

average numbers of illnesses were associated with foods eaten in private homes and restaurants. (Table 1)

TABLE 1

LOCATION OUTBREAKS ILLNESSES AVERAGE

OUTBREAK SIZE

Restaurant 1,610 28,570 18

Private Home 893 12,980 15

Workplace 313 7,643 24

Banquet Hall/

Catered Event 224 10,035 45

Religious/Social Club 144 5,607 39

School 138 5,557 40

Camping/Picnic/Farm 126 4,120 33

Other 97 3,758 39

Prison or Jail 66 9,522 144

Sick/Elderly/Youth Service

57 2,344 41

Foster Farms:

The largest outbreaks of 2013 were associated with Salmonella Heidelberg-contaminated chicken

produced by California-based Foster Farms. In March of 2013, the CDC documented an outbreak—

ongoing since the fall of 2012—associated with Foster Farms’ chicken. In total, 134 people in 13 states

were sickened and 33 required hospitalization for their illnesses. In October 2013, Foster Farms was

implicated a second time in an outbreak of Salmonella Heidelberg in raw chicken, this time sickening

481 people in 25 states. Moreover, some of the strains of S. Heidelberg implicated in the outbreak were

antibiotic resistant. Implicated strains were highly virulent, with a hospitalization rate was 38 percent,

over 50 percent higher than the norm for Salmonella.


Page 5

FINDING IV FDA-REGULATED FOODS WERE IMPLICATED IN TWO-THIRDS OF SOLVED OUTBREAKS

CSPI classifies the foods implicated in each solved outbreak into one

of 13 consumer-focused categories and 37 sub-categories

(Appendix). The classification system is designed to group foods in

a way that is recognizable by consumers, as well as useful to

researchers and public health professionals. Categories are further

sorted by the regulatory agency responsible for each category’s food

safety oversight: either the United States Department of Agriculture

(USDA) for meat and poultry products, or the Food and Drug

Administration (FDA) for produce, seafood, and many processed

foods. An outbreak caused by foods regulated by both the FDA and

USDA is categorized as “Both.” Between 2002 and 2011, FDA-

regulated foods were responsible for 66.5 percent of outbreaks

analyzed by CSPI, USDA-regulated foods were responsible for 26 percent of outbreaks, and 7.5 percent of

outbreaks were caused by multi-ingredient foods regulated by both USDA and FDA (Figure 3).

FDA66.5%

USDA26.0%

Both Agencies7.5%

Figure 3. Outbreaks Linked to FDA- and USDA-Regulated Foods, 2002-2011

CSPI’s 13 categories include produce,

seafood, dairy, breads and bakery, eggs,

beverages, game, luncheon and other

meats, beef, poultry, pork, and multi-

ingredient foods with and without

meat. Multi-ingredient foods include

salads, sandwiches, sauces and

dressing, rice and beans, pasta dishes,

ethnic foods, and dried spices.


Page 6

FINDING V THE NUMBER OF PRODUCE OUTBREAKS SURPASSED ALL OTHER CATEGORIES; MOST FOOD CATEGORIES SAW DECLINES IN OUTBREAKS THROUGHOUT THE DECADE

The Produce category was the top category for outbreaks, with 667 outbreaks (17 percent of total

outbreaks) and 23,748 illnesses (24 percent of total illnesses). Produce, along with the Seafood, Poultry, and

Beef categories, were responsible for the largest number of solved foodborne illnesses during the past

decade (Figure 4). Those four categories were together linked to half of all attributed outbreaks (51

percent) and illnesses (48 percent). Seafood was responsible for the second-most outbreaks (602), but

relatively few illnesses due to the small size of an average seafood outbreak (5,317 illnesses, 8.8 illnesses

per outbreak). Outbreaks associated with meat categories include Poultry (413 outbreaks and 11,333

illnesses), Beef (324 outbreaks and 6,719 illnesses), Pork (164 outbreaks and 3,660 illnesses), and

Luncheon and Other Meats (122 outbreaks and 3,716 illnesses) (Figure 4).

The 2002-2011 results also show changes in outbreak reporting in several food categories. The annual

number of outbreaks associated with Produce, Seafood, Pork, and Poultry declined across the decade, but

reports increased slightly since 2009; outbreaks associated with Dairy products rose over the decade, while

the number of annual Beef outbreaks fell across the decade (Figure 4).

Reporting was at a low point for many categories in 2009. That year was the height of the recent recession,

and a time when many public health agencies saw budgets cut.7 A financially taxing H1N1 influenza

outbreak also occurred in 2009, which diverted many public health resources away from activities like

foodborne outbreak reporting.

The increase in Dairy-associated outbreaks over the decade could be due to the increased popularity of

unpasteurized dairy products, like queso fresco and raw milk.5 The spike in Produce illnesses in 2008 was

due to one large multi-state outbreak in jalapen o and serrano peppers that sickened over 1,500 people. The

spike in Dairy illnesses in 2006 was due to a Campylobacter outbreak in pasteurized milk served in prisons

that sickened 1,644 inmates.

Antibiotic Resistance:

In the United States, 73 percent of the antibiotics useful in human medicine are sold for use in food

animal production. Those antibiotics help animals to survive factory farming conditions and to grow

faster on less feed. The excessive use of antibiotics on farms, however, also leads to constant

environmental selection pressure on the bacteria that live in and around the animals, leading to

antibiotic resistance. Antibiotic-resistant bacteria may not respond to traditional antibiotics. If a human

is infected by one of those resistant bacteria, physicians may need to resort to drugs that have greater

side effects and are more expensive—or physicians may be left with no treatment options at all.


Page 7

Figure 4. Foodborne Illness Outbreaks in Different Commodities,

2002-2011

FDA Foods USDA Foods

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Page 8

FINDING VI OVER THE DECADE, PRODUCE SICKENED MORE PEOPLE THAN ANY OTHER SINGLE CATEGORY

Among CSPI’s specific food categories, Produce was linked to the greatest number of outbreaks, followed

closely by Seafood. Produce was also responsible for the greatest number of illnesses, more than double

that attributed to Poultry (Figure 5a). When the average sizes of outbreaks are considered, Produce caused

the largest average number of illnesses per outbreak, while Seafood outbreaks were the smallest, on average

(Figure 5b).


Page 9

FINDING VII POUND-FOR-POUND, SEAFOOD IS THE RISKIEST FOOD, FOLLOWED BY POULTRY; FRUIT AND DAIRY ARE THE SAFEST FOODS

Although Produce is responsible for the greatest overall numbers of outbreaks and illnesses, pound-for-

pound, Produce—and especially fruit—are among the safest foods to eat. When illnesses are considered

together with consumption rates, red meats (Beef and Pork), Poultry, and Seafood products are far more

likely to cause illness than fruits and vegetables. When the risk of illness-per-pound consumed was

analyzed, Poultry products topped Beef and Pork. Seafood was by far the most hazardous food (Figure 6).8

Note, however, that the number of Seafood-related outbreaks generally declined over the decade, except in

2010 and 2011 (Figure 4).

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0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0

Seafood

Poultry

Beef

Eggs

Vegetables

Pork

Fruit

Dairy

Number of illnesses relative to those caused by DairyThe yearly average number of illnesses linked to Dairy outbreaks serves as baseline

Figure 6. Relative Rates of Illness by Food Category Adjusted for Consumption, 2002-2011


Page 10

FINDING VIII THE MOST COMMON CONTAMINANTS ARE…

Among USDA-regulated products, the most commonly identified pathogens were Salmonella species (spp.)

in Poultry products; Clostridium perfringens and E. coli O157:H7 in Beef; Salmonella spp. and Staphylococcus

aureus in Pork; and Salmonella spp., Clostridium perfringens and Norovirus in Luncheon and Other Meats

(Figure 7a).

0%

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30%

40%

50%

60%

70%

80%

90%

100%

Poultry Beef Pork Luncheon/DeliMeats

Figure 7a. Pathogens Identified in Outbreaks From USDA-Regulated Foods, 2002-2011

N=1,023

Staphylococcus

Salmonella

Norovirus

Other

E. coli O157:H7

Clostridium

Campylobacter

Bacillus


Page 11

The most commonly identified causes of foodborne illness in FDA-regulated foods were Norovirus and

Salmonella spp. in Produce; Scrombrotoxin and Ciguatoxin in Seafood; Campylobacter in Dairy; and

Salmonella spp. in Eggs (Figure 7b).

For Seafood, 18 percent of outbreaks are due to shellfish. For Produce, 51 percent of outbreaks are due to

mixed-ingredient Produce dishes, like salads; for Eggs, 70 percent of outbreaks are attributed to mixed-

ingredient Egg dishes, like omelets. Within Dairy, 51 percent of outbreaks are associated with milk, and

within milk, 70 percent of outbreaks are due to unpasteurized milk.

0%

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Produce Seafood Dairy Eggs

Figure 7b. Pathogens and Toxins Identified in Outbreaks in FDA-Regulated Foods, 2002-2010

N=2,616

Scrombrotoxin

Ciguatoxin

Staphylococcus

Salmonella

Norovirus

E. coli

Clostridium

Campylobacter

Bacillus

Unpasteurized (Raw) Milk:

Unpasteurized, or raw, milk is an urgent public health risk. Of those outbreaks in the CSPI database

associated with milk, 70 percent are due to unpasteurized milk. Although a majority of Americans drink

milk, according to FDA, raw milk is consumed by less than one percent of the population. This

overwhelming dominance of outbreaks associated with unpasteurized milk—70 percent of all milk

outbreaks suffered by less than one percent of the population—helps to illustrate how risky

unpasteurized dairy can be.


Page 12

Methodology

CSPI maintains a database of foodborne illness outbreaks that occurred from 1990 through 2011. The

database includes 7,461 unique and solved outbreaks responsible for 211,726 cases of illness. The

outbreaks in CSPI’s database—those that were reported by public health officials with both an identified

pathogen and contaminated food—include only a small fraction of total foodborne illnesses, but provide the

most useful information for attribution analysis. The database is compiled largely from the CDC’s

Foodborne Outbreak Online Database (FOOD), which CDC first made publicly available in 2001. FOOD

currently provides CDC’s outbreak data from 1998 to 2011 to the public.9 Prior to FOOD’s launch in 2001,

CSPI obtained CDC outbreak data through Freedom of Information Act requests, and supplemented its

database with data from state health department reports, CDC’s Foodborne Outbreak Response and

Surveillance Unit reports, and peer-reviewed journal articles. Today, data from non-CDC sources constitute

less than one percent of the total CSPI database and essentially none (0.002%) of the data analyzed for this

report.10 For this report, CSPI analyzed the most recent 10 years of solved outbreak data: 3,933 outbreaks

and 98,399 illnesses that occurred between 2002 and 2011.

CSPI categorizes outbreaks by the contaminated food or ingredient and by the federal agency responsible

for regulatory oversight of that food. Outbreaks attributed to meats and poultry products are assigned to

the USDA, while outbreaks attributed to produce, seafood, and meat-free multi-ingredient dishes are

assigned to the FDA. CSPI uses a ‘Both’ category for outbreaks attributed to meat-containing multi-

ingredient dishes, or other situations where an outbreak was linked to multiple foods under the jurisdiction

of both the USDA and FDA. CSPI’s categorization approach is unique in its ability to be easily utilized by

both consumers and regulatory agencies, and has been used by the Food Safety Research Consortium and

University of Florida’s Emerging Pathogens Institute.11 CSPI regularly provides its database and outbreak

analysis to the World Health Organization for risk assessment purposes.

Imported Foods:

In addition to publishing retrospective trends in outbreak reporting, CSPI monitors reports of outbreaks

continuously—especially large outbreaks and those caused by imported foods and antibiotic-resistant

bacteria. For example, in 2012 and 2013, imported foods were implicated in numerous outbreaks,

including:

An outbreak due to Salmonella Saintpaul in imported cucumbers sickened 84 people in 18 states.

An outbreak due to Salmonella Montevideo and Salmonella Mbandaka in contaminated tahini

sesame paste sickened 16 people in 9 states.

An outbreak of Hepatitis A due to contaminated frozen pomegranate seeds sickened 162 people

in 10 states.

An outbreak due to Salmonella Bareilly and Salmonella Nchanga in contaminated raw tuna

scrape from India sickened 425 people in 28 states and hospitalizing 55.


Page 13

DATA COLLECTION

CDC’s Foodborne Outbreak Online Database (FOOD) is the product of a large and dynamic network of

nationwide outbreak surveillance systems. State agencies can modify their past outbreak reports at any

time as new information becomes available, even years after an outbreak has occurred.12 Because of this,

previously published CDC data are subject to change. This report includes one year (2011) of new data and

numerous updated outbreak reports from past years that update our previous Outbreak Alert! 2001-2010

published in March 2013.13 The data used in this report was downloaded from FOOD on May 16, 2013.

ANALYSIS

Incidents of foodborne illness are only included in the CSPI database if they meet CDC’s definition of an

outbreak and have an identified pathogen and contaminated food. Outbreak reports that meet CSPI’s

inclusion criteria are further evaluated to determine whether they represent new outbreaks, or updates to

previously published outbreaks. The CSPI database excludes sporadic cases of foodborne illness (individual

illnesses not linked to an outbreak), outbreaks with no identified pathogen, outbreaks with no identified

contaminated food, and outbreaks linked to water or ice.14 Relative rates of foodborne illnesses were

calculated using loss-adjusted per-capita consumption data from the USDA Economic Research Service for

each food group, and population data from the U.S. Census Bureau.


Page 14

Appendix: Summary of Solved Foodborne Outbreaks and Illnesses by Food Categories, 2002-2011

FDA-Regulated Foods USDA-Regulated Foods

Category Outbreaks Illnesses Category Outbreaks Illnesses

Produce 667 23,748 Poultry 413 11,333

Fruits 98 3,608 Chicken 171 4,444

Vegetables 230 10,806 Turkey 76 3,059

Produce Dishes 339 9,333 Poultry Dishes 163 3,818

Seafood 602 5,317 Other Poultry 3 12

Finfish 335 2,183 Beef 324 6,719

Molluscan Shellfish 108 1,541 Ground Beef 130 2,220

Seafood Dishes 98 1,083 Beef Dishes 62 1,743

Other Seafood 41 510 Other Beef 132 2,756

Dairy 202 4,920 Pork 164 3,660

Cheese 59 1,050 Ham 21 399

Ice Cream 26 411 Pork Dishes 30 785

Milk 104 3,261 Other Pork 113 2,476

Other Dairy 13 198 Luncheon & Other Meats 122 3,716

Breads & Bakery 141 3,203 Luncheon 32 928

Bakery 120 2,881 Meat Dishes 15 488

Breads & Bakery 21 322 Other Meats 75 2,300

Eggs 107 2,588

Eggs 32 628 USDA Total 1,023 26,811

Egg Dishes 75 1,960

Beverages 54 1,972 Multi-Ingredient (Meat)

Juices 17 861 Category Outbreaks Illnesses

Other Beverages 43 1,880 Both (FDA & USDA) 294 9,508

Game 11 92

Multi-Ingredient 832 21,623 Percent of Total Outbreaks

Salads 160 5,138 Both 7.5%

Sandwiches 126 2,534 FDA 66.5%

Sauces/Dressing/Oils 43 1,159 USDA 26.0%

Rice/Beans/Stuffing/

Pasta Dishes 151 2,979 Total 100%

Ethnic Foods 200 4,409

Nuts/Dried Spices 14 2,089 Total Outbreaks 3,933

Other Foods 138 3,315 Total Illnesses 98,399

FDA Total 2,616 63,463


Page 15

References

1 Centers for Disease Control and Prevention. Estimates of Foodborne Illness in the United States http://www.cdc.gov/foodborneburden. Accessed February 7, 2014. 2 Centers for Disease Control and Prevention. February 2011. CDC Estimates of Foodborne Illness in the United States: CDC 2011 Estimates. February 2011. http://cdc.gov/foodborneburden/PDFs/FACTSHEET_A_FINDINGS_updated4-13.pdf. Accessed February 7, 2014. 3 Lynch M, Painter J, Woodruff R, Braden C. Surveillance for Foodborne Disease Outbreaks – United States, 1998-2002. MMWR 2006; 55 (SS10): 1-34. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5510a1.htm. Accessed February 7, 2014. 4 Trust for America’s Health. April 2013. Investing in America’s Health: A State-by-State Look at Public Health Funding and Key Health Facts. 5 Centers for Disease Control and Prevention. Surveillance for Foodborne Disease Outbreaks – United States, 2009-2010. MMWR 2013;62:41-47. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6203a1.htm?s_cid=mm6203a1_w. Accessed February 7, 2014. 6 Nuzzo, JB, et al. March 2013. When Good Food Goes Bad: Strengthening the US Response to Foodborne Disease Outbreaks. Center for Biosecurity of UPMC. 7 National Association of County & City Health Officials. August 2011. 2010 National Profile of Local Health Departments. http://www.naccho.org/topics/infrastructure/profile/resources/2010report/upload/2010_Profile_main_report-web.pdf Accessed February 7, 2014. 8 Calculations for the relative rates of illness used the following data sources:

USDA-Economic Research Service. Pounds/year per capita consumption data adjusted for loss. February 1, 2013 update. http://www.ers.usda.gov/data-products/food-availability-%28per-capita%29-data-system.aspx#26705. Accessed February 7, 2014.

U.S. Census Bureau annual estimated population data. http://www.census.gov/popest/data/historical/2000s/index.html. Accessed February 7, 2014.

Center for Science in the Public Interest (CSPI) “Outbreak Alert” Database. http://www.cspinet.org/foodsafety/outbreak/pathogen.php. Accessed February 7, 2014.

9 Centers for Disease Control and Prevention. Foodborne Outbreak Online Database (FOOD). http://wwwn.cdc.gov/foodborneoutbreaks/. Downloaded May 6, 2013. 10 Prior to 2001, CDC data were unpublished, and obtained by CSPI via Freedom of Information Act requests, or identified from scientific articles, federal government publications, state health department postings, and newspaper reports verified by public health officials. 11 Batz MB, Hoffmann S, Morris, JG. 2011. Ranking the Risks: The 10 Pathogen-Food Combinations with the Greatest Burden on Public Health. University of Florida Emerging Pathogens Institute. 12 Centers for Disease Control and Prevention. Foodborne Illness: Frequently Asked Questions. http://www.cdc.gov/foodborneburden/questions-and-answers.html. Accessed February 7, 2014. 13 DeWaal CS, Glassman M. March 2013. Outbreak Alert! 2001-2010. Center for Science in the Public Interest. 14 DeWaal CS, Hicks G, Barlow K, Alderton L, Vegosen L. 2006. Foods Associated with Foodborne Illness Outbreaks from 1990 through 2003. Food Protection Trends, 26(7): 466-473.

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