CDC Telebriefing: CDC data show limited progress in reducing foodborne infections in 2013

OPERATOR: Welcome, and thank you for standing by. At this time, all participants are in a listen-only mode. During the question-and-answer session of today's call, you may press star-one to ask a question. Today's conference is being recorded. And at this time I’ll turn the call over Mr. Benjamin Haynes, you may begin, sir.

BENJAMIN HAYNES: Thank you, Shirley. I want to thank you all for joining us today for this telebriefing on a report that the CDC is releasing on incidents and trends of foodborne disease. With us are three principals to discuss this issue. We have Dr. Robert Tauxe, Deputy Director of CDC's Division of Foodborne, Waterborne and Environmental Diseases. He’s joined by David Goldman, Assistant Administrator, Office of Public Health Science of the Department of Agriculture, Food Safety Inspections Service, and Dr. Steve Ostroff, Acting Chief Scientist of the Food and Drug Administration. Each will provide brief opening remarks, and we will move to questions and answers. I will turn it over to Dr. Tauxe at this time.

ROBERT TAUXE: Thank you very much, Ben, and thank you all for being on the line with us this afternoon. I'm very glad to be here today with you and with our colleagues from the Department Of Agriculture's Food Safety and Inspection Service and the Food and Drug Administration. For many years, we have worked together to track and prevent foodborne illness, commonly referred to as food poisoning here in the United States. CDC is uniquely tasked with monitoring human infections at the national level. We work to link those illnesses to contaminated food and to other sources. We estimate that each year one in six people in the United States gets sick from eating contaminated food. Our ability to systematically track and assess foodborne disease trends is critical for food safety. Following which pathogens are increasing, decreasing, or staying the same is accomplished through Foodnet, our foodborne disease active surveillance network, which tracks nine infections transmitted commonly through foods. Foodnet is actually a powerful collaboration of CDC, ten state health departments, the USDA and FDA. And since 1996, these partners in food safety have produced these reports for our other partners who rely on this network to show progress and to identify areas of concern. The network's annual tracking allows identification of changes over the short term and over the longer term. Data collected by Foodnet are used as a foundation for estimating foodborne illness and to inform and guide subsequent policy and prevention efforts that are based on them. These data are used by public health, by regulators, by the food industry, and by consumers it track progress and guide further effort. Today's report in our MMWR journal at CDC summarizes the 2013 data. And the news is mixed. Some improvements were made, but substantial more work is needed. Foodnet identified just over 19,000 infections, 4,200 hospitalizations, and 80 deaths among 48 million residents of ten states. This represents about 15 percent of the total U.S. population. And what can we say by looking at these data in more detail? We see that the most frequent cause of these infections was salmonella, which accounted for 38 percent of the reported infections. Campylobacter was second with 35 percent. And vibrio caused about 1 percent of infections. You can see that the incident of infection caused by nearly all the germs tracked was highest among either children aged less than 5 years or among older adults age 65 years and older. We also can look at how the rates have changed both in the short and the longer term. For the short-term change, we compared these 2013 rate with rates in the preceding three years: The period 2010 to 2012. For longer term change, we compare these 2013 rates again with the baseline period of 2006 to 2008. And we can also go back to the very beginning of Foodnet in 1996 for the longest term look. So to look at salmonella in the short term, so in 2013 the rate of salmonella infections dropped by about nine percent compared with the previous three years. This decline brings salmonella down to the rate we saw back in 2006 to 2008 baseline. And -- however, this incidence rate of 15 per 100,000 people is still well above our national goal of 11.4 cases per 100,000 people which we hope to reach by the year 2020. The incidence of infections with the most common subtype of salmonella called enteritidis has increased in the last three years particularly. And some of the recent decrease in salmonella may be due to stopping a large outbreak in 2010 which was tied to eggs in salmonella and derivatives and by subsequent control measures that were put in place by the FDA across the egg industry. Meanwhile, campylobacter infections which are often linked to chicken show a somewhat different picture. They have risen 13 percent in the longer term since 2006 to 2008, and they have not changed much recently at all. Vibrio infections, which are often linked to eating raw shellfish, continue to increase as they have in the past, and were at the highest level observed since our tracking began in 1996. However, the rates of infection caused by vibrio vulnificus, which is the most severe strain, have not increased particularly in recent years. And E. coli infections continue to inch up, and the progress that had been noted since 2006 to 2008 in past years has stalled. Still, the E. coli infections are 30 percent lower than they were back in 1996. The rates of the other foodborne infections tracked haven't changed much. In looking at these results, we keep current and future challenges to tracking foodborne disease in mind. Our Foodnet and other CDC surveillance systems rely on the diagnoses that are made in clinical laboratories. And diagnostic practices, the tests that are used in those laboratories, are changing. You may be familiar with the rapid strep test that doctors now use to diagnose strep throats faster than it can done by culturing a throat swab. And now, other new culture-independent diagnostic tests like the rapid strep test are starting to be used by clinical laboratories to diagnose other infections. These tests do not by themselves isolate a living germ in a laboratory culture that can be further studied. For many years, public health surveillance and outbreak detection has depended on those living cultures. So this trend will challenge our ability in public health in the future to identify cases, monitor trends, detect outbreaks, and characterize pathogens. We are further evaluating the use of these diagnostic tests and their effect on laboratory-based surveillance. We've -- we find now in the tracking we're doing in Foodnet that so far these tests are mostly being used for campylobacter and s-tech, but not yet for salmonella. We will have a more detailed report later on this issue, sometime later this year. So in addition to evaluating the effect of a changing laboratory landscape, CDC and its public health partners are taking advantage of new technologies to better understand foodborne infections. Current efforts underway include the use of advanced molecular diagnostics such as whole genome sequencing, for examining listeria which is known to affect our most vulnerable populations. In fact, we have combined FDA, USDA, and NIH projects launched this year to examine listeria whole genome sequence and how it can be used for surveillance. We're also enhancing our testing and understanding of anti-microbial-resistant infections which we know have more severe outcomes. CDC's new initiative to detect and protect against drug-resistant salmonella could greatly increase our ability to test drug-resistant salmonella infections in the future. CDC and our colleagues at FDA and USDA are active and alert, and we keep working together to measure our progress, to identify risk factors, and to create solutions for our continuously evolving food safety system. This is a critical time for food safety. And we are especially encouraged by the convergence of efforts aimed at decreasing salmonella infections so that the modest declines we've seen in the last few years can continue and salmonella can continue to decrease. I now will turn the floor over to Dr. David Goldman, Assistant Administrator for the Office of Public Health Science in the USDA's Food Safety and Inspection Service. And he will be followed by Dr. Stephen Ostroff, Acting Chief Scientist at the Food and Drug Administration. Dr. Goldman?

DAVID GOLDMAN: Thank you very much, Dr. Tauxe and thank you to all of you who joined on the phone today to hear our discussion about this year's MMWR Foodnet report. As you know, FSIS has collaborated with the FDA since the inception of Foodnet to assist in compiling the data and reporting the annual data. And I’m happy to have this opportunity to discuss the results with you. Our mission at FSIS is to ensure that meat, poultry, and processed egg products are safe, wholesome, and accurately labeled. This report speaks directly to that mission as it helps us to evaluate our collective efforts in fighting foodborne illness, as well as identifying areas that may need improvement. This report guides us in aligning our policies and priorities with the pathogens that cause illnesses to best protect the safety of the American public. As noted in this year's report, salmonella illnesses continue to cause a significant proportion of illness, and although the rate has dropped compared to the three most recent years by nine percent, the overall rate of salmonellosis has not substantially declined since the inception of Foodnet. Therefore, FSIS remains focused on this troubling pathogen. I would like to spend a couple of minutes pointing out some of the agency's most recent actions to prevent salmonella contamination in the products that we regulate and, thereby, prevent salmonella illnesses. Just this past December, FSIS released a comprehensive strategy to reduce salmonella contamination in meat and poultry products. This salmonella action plan which is found on our website identifies modernizing the outdated poultry and slaughter inspection system as a top priority and aims to focus our inspectors' duties solely on food safety tasks. This plan also calls for enhancing salmonella sampling and testing programs, ensuring that the best scientific technology is -- that is available is utilized and addresses emerging trends in foodborne illness. FSIS will take several actions to drive innovation that will result in lower salmonella contamination rates, including the following: We intend to establish new performance standards for poultry products, in particular, for poultry parts as well as for common or ground poultry, chicken and turkey. And all these standards will be aimed at achieving the Healthy People 2020 targets for reductions in salmonella. In addition, I’ll note that although this salmonella action plan is obviously focused on reducing salmonella contamination, because poultry is known to contribute to campylobacteriosis, we will also address campylobacter in these performance standards. We also will be developing new strategies for inspection for raw meat and poultry products, as mentioned above. We will also be addressing all potential sources of salmonella in the production environment. And finally, we'll be focusing the agency's education and outreach tools on salmonella. While salmonella-positive samples in young chickens have dropped over 75 percent since 2006, unfortunately this has not translated into significant changes in salmonellosis, thus our continuing efforts at reducing salmonella contamination. While we hope that all of these steps just outlined are headed in the right direction, this report reminds us that there is more work to be done. And so we remain committed to our mission to prevent foodborne illness, and we appreciate the findings of this report, as it will help us in guiding our mission. I look forward to answering any of your questions after these initial remarks. And at this time, I will turn the briefing over to Dr. Ostroff.

STEPHEN OSTROFF: Thank you very much, and good afternoon. All of us at FDA want to extend our thanks to CDC for their continuing work on the Foodnet system. This system is and has been a critical metric for gauging the progress in reducing foodborne illnesses due to the major foodborne pathogens. Foodnet is also a great illustration of the collaborative efforts between CDC, USDA, and FDA to address foodborne disease as well as the ten participating state health departments. The 2013 Foodnet data released today show that we continue to have a lot of work ahead of us to begin to see the incidence of these foodborne diseases decline. Although some small changes in the annual rates are seen this year, the overall levels are essentially unchanged, and the number of identified infections remains high across several of the critical Foodnet pathogens. The findings taken as a whole reinforce the importance of moving forward with preventive measures that will help ensure food safety at every stage of production from the farm to the consumer. In the past, FDA has addressed specific foods such as seafood and juice through mandatory hazard analysis and critical control programs, also known as HACCP. However, the Food Safety Modernization Act, which was signed into law in 2011, addresses food safety across the board and is meant to move the food safety system from a reactive mode to a preventive posture. As those of you who follow FSMA know, we are making progress in its implementation. To date, FDA has issued seven proposed rules that address the requirements of FSMA including the safety of produce, imported foods, human and animal foods produced by facilities, and food-storing transportation. Once the rules are finalized and fully implemented, the new system will help to prevent infection from major pathogens such as salmonella, listeria, and pathogenic E. coli. And the impact will hopefully be seen in future Foodnet reports. Other activities such as the Shell Egg Life Safety Rule are already underway to help drive infections related to eggs down. Today virtually all eggs are produced under FDA's rule which was issued in 2009 and implemented in full by 2012 to prevent the contamination of eggs with salmonella enteritidis. The rule requires preventive measures in poultry houses during egg production and requires refrigeration during storage and transportation. To date we have conducted just over 1,000 inspections of egg producers to verify compliance with this rule. With the Shell Egg rule in place, we hope to avoid outbreaks such as the one in 2010 that was tied to eggs which was mentioned previously by Dr. Tauxe which helped to push the salmonella rate up in that particular year. And that we will now continue to see declines in the bird and egg-associated salmonellosis. As for vibrio, which was also mentioned, we are concerned about the increase in infection identified by the CDC to the highest level yet seen in Foodnet. However, we are gratified that infections due to vibrio vulificus, which is associated with the most severe form of vibrio disease, has remained low and steady. We worked through the National Shellfish Sanitation Program, or NSSP, on the safety of molluscan shellfish in interstate commerce. The NSSP is a cooperative program that involves the FDA, CDC, NOAA, EPA, state regulatory agencies, academic partners, and the shellfish industry. These entities work together to adopt and implement strict controls on the growing, harvesting, processing, packaging, and transport of molluscan shellfish so that the risk of foodborne illness is minimized. FDA has increased its efforts to evaluate the implementation of state vibrio control plans. In addition, we have increased our work with partners to better understand the root forces of vibrio illness so that the existing controls can be adapted to prevent infections. We are currently working to determine which harvest areas, climactic factors, and circumstances may be most closely associated with illness. The more we understand the most important factors in determining product safety, the more that can be done to ensure safety of these products. These initiatives in conjunction with our food safety programs at retail settings and consumer education in the home illustrate the sustained and across-the-board efforts which are necessary to impact the occurrence of foodborne illness. By focusing on prevention and addressing hazards from farm to table, we at FDA believe that we can reduce foodborne illness and maintain public confidence in our food supply. So with that, I will turn it back over to Benjamin so that we can move on to the question-and-answer period. Thank you.

BENJAMIN HAYNES: Thank you, Dr. Ostroff. Shirley, we are ready for questions.

OPERATOR: Thank you, at this time, if you would like to ask a question, please press star-one and record your name clearly. To withdraw your question, you may press star-two. Again, star-one to ask a question. And one moment, please, for our first question. Our first question comes from Maryn McKenna with Wired. You may ask your question.

MARYN MCKENNA: Hi, thank you all for doing this call. I have two questions. And they both have to do with salmonella. So looking at the text of the MMWR, you point out that the -- that for whole chickens, the rate of contamination with salmonella was 3.9 percent. But that actually the kind of chicken that most people buy is parts of chicken, not whole chickens. And that the rate on that is several times higher. So could you talk for a minute about why there's such a discrepancy and why the standard has been for whole chickens if people don't buy whole chickens. It sounds like the policies were directed at the wrong food type.

DAVID GOLDMAN: Yeah, this is Dr. Goldman at FSIS. Thank you for the question. I'll try to explain briefly and answer here. The testing of chicken carcasses has been part of the agency's practice for many, many years and was based on some baseline sampling that was done in the mid '90s. So the performance standard that was initially set had to do with whole carcasses. The agency did conduct a baseline for chicken parts, as you referred to the kinds of chicken that are most commonly purchased by consumers, about two and a half, three years ago. And as a consequence of the data from that report which is posted on our website, we are in the process, as I mentioned, of developing performance standards for chicken parts, understanding that this is the most commonly purchased chicken commodity. And so we are attempting now to address this hazard of salmonella in chicken parts through performance standards, which we feel will translate into lower contamination rates and fewer illnesses attributable to those purchases.

MARYN MCKENNA: So I’m sorry, for clarification, those performance standards have not been achieved yet? They're in process or under discussion?

DAVID GOLDMAN: Those performance standards are under development, and we hope will be published as a proposal within the next few months.

MARYN MCKENNA: Can I ask my follow-up question?

BENJAMIN HAYNES: Yes, go ahead.

MARYN MCKENNA: Thanks. So Dr. Goldman, can you relate this problem of salmonella contamination on chickens, particularly on chicken parts, to the FSIS proposal for changing meat inspection? Particularly speeding up inspection lines and substituting private -- privatized inspectors for the USDA inspectors?

DAVID GOLDMAN: This is Dr. Goldman again. We can follow up with you separately about that, but I will say that the modernization of poultry inspections you referred to has to do with slaughter plants. And this proposal for performance standards for performance standards for chicken parts is for companies that cut up chickens. And some of them are slaughter plants, but this is further in the process. So they're really separate issues.

OPERATOR: thank you. Our next question comes from Mike Stobbe with the Associated Press. You may ask your question.

MIKE STOBBE: Hi, thank you for taking my call. I had a question for Dr. Tauxe and one for Dr. Ostroff. Dr. Tauxe could you -- I’m sorry, I just wasn't clear -- in terms of -- these are about vibrio – vibrio, the increase from 2010 to 2012 period to 2013, I believe that was the 32 percent increase. I see in the figure a general trend line for vibrio, but I didn't know, could you also say what the percentage increase was from 2006, 2008 to 2013 and also from 1996 to 2013 for vibrio? Then I had a question for Dr. Ostroff after.

ROBERT TAUXE: Yes, thank you, Mike, for the question. It's been -- vibrio infections have been increasing over the years quite a lot actually. And as you say, if we compare it with the previous three years, it's 32 percent. If we go back and compare it with the longer term baseline back in 2006, 2008, it's a 75 percent increase. Go back all the way to the beginning, 1996 through 1998 baseline, infections were up 168 percent. We know that it's confusing to have several different comparison timeframes, short, longer term, and very long term like this. And it's important when looking at our graphs or at our tables, it should be -- it should be indicated very clearly them which -- which time frame we're referring to. But for vibrio, the story has been one of a pretty consistent increase for all three.

MIKE STOBBE: Great. Thank you, doctor. And for Dr. Ostroff, could you elaborate just a little bit on what you were saying about what may be in the works regarding vibrio? I think you were talking about looking at harvest areas which were most closely associated with illness. But are you all talking about identifying harvest areas and then pushing for pressure treatment or some other treatment of oysters and other shellfish from those areas? What exactly are you all contemplating?

STEPHEN OSTROFF: Well, as I mentioned, the National Shellfish Sanitation Program is a program that's been ongoing for a number of years. It is a collaborative and cooperative program that is done in association with the Interstate Shellfish Sanitation Commission which develops policies, and then the National Shellfish Sanitation Program does the implementation. And together these entities, with FDA and the other partner agencies, have been looking at the circumstances of vibrio, and in particular, some of the changes that have occurred in recent years. There have been in the past couple of years implementing recommendations that have been approved by the Interstate Shellfish Sanitation Conference to address vibrio, parahaemolyticus, in particular, first in oysters and then in clams. And part of this is to examine the situations and circumstances that may be associated with the proliferation of the organism. I think as was mentioned in the report, you know, there have been some change in the occurrence of vibrio, especially, you know, the strain that traditionally has been associated with the pacific northwest now being seen on the Atlantic coast. Certainly that is associated with some of the increases that were noted. And efforts are underway to look closely at those circumstances, identify measures that could potentially be used to identify problem areas as well as procedures that could be used to decrease the occurrence of the organism in the various types of molluscan and shellfish.

OPERATOR: Thank you. This next question comes from Philip Brasher with Congressional Quarterly. You may ask your question.

PHILIP BRASHER: Dr. Goldman, I believe you referred to the—talked about the salmonella performance standards that you have developed for poultry parts and I think also for ground poultry. I believe you said that that was -- would address campylobacter, as well. Could you talk about how you will address campylobacter.

DAVID GOLDMAN: Yes, thank you for the question. Because when we did the data collection for poultry parts, chicken parts in particular, and actually to clarify we're not talking about cut-up turkey parts. But for chicken parts and then for ground turkey and ground chicken, we sampled and tested for both salmonella and campylobacter. So because we have that data for campylobacter contamination in chicken parts as well as ground chicken and ground turkey, we're able to take the same risk assessment approach and target the performance standards to Healthy People 2020 target. So we will do the same for campylobacter where it's feasible to do so as we are with salmonella.

PHILIP BRASHER: So just to be clear, will you have a performance standard for campylobacter? I'm not clear exactly.

DAVID GOLDMAN: We’re still in the process of developing all of these standards, and we're still in the process of determining whether the data would support a performance standard for campylobacter.

OPERATOR: Our next question comes from Bill Thompson with Politico. You may ask your question.

BILL THOMPSON: Yeah. Hi. Thanks. Just a small thing I guess. The report starts off by saying that there was a total of 19,000 -- about 19,000 infections, 4,000 total hospitalizations, and 80 deaths in 2013. Can you give me some numbers to compare this to? Were there more deaths in 2013 than 2012? Just some reference of comparison. It might be in here, and I’m just not seeing it. Thanks.

ROBERT TAUXE: Right. This is Dr. Tauxe at CDC. I think that the overall number of infections and the overall number of hospitalizations have not changed dramatically year to year. And it's a very good question of whether there are any trends that we could discern and, say, in hospitalizations or in deaths. We're in the process of looking systematically at the numbers over time to see whether we can look at trends in hospitalizations and deaths the same way that we look at trends in cases. If we just look back at last year, there were -- there were 68 deaths last year, there were 80 this year. So several more deaths this year. But not a -- not a particular change.

BILL THOMPSON: Thank you.

OPERATOR: thank you. Our next question comes from Lynne Terry with the Oregonian. You may ask your question.

LYNNE TERRY: Thanks for taking my call. That last question took care of one of them. But I wanted to follow up on -- I have two actually on campylobacter. And so Dr. Goldman, you were saying how you're looking at -- you've done a baseline on campylobacter and possibly thinking of coming up with performance standards. But you're not sure whether you will or not. Why not? Campylobacter is very prevalent in poultry. And you know, infections are going up. So why not?

DAVID GOLDMAN: Thank you for the question. I didn't say we wouldn't establish standards. We're looking at the data now to determine in which products standards are supportive based on the baseline data, the data collection that I mentioned for chicken parts a couple years ago and the current data collection for common turkey and chicken that's underway now.

LYNNE TERRY: But what would be the problem? When you say standards are supportable, could you translate that for me? Are you saying that you don't know if industry could bring them down, or -- not quite sure what that means.

DAVID GOLDMAN: Well, let me give you an example or try to give you a quick example. If -- if the prevalence of any pathogen is so low in a product, then there may be other regular story options or policy options that the agency would have available to it other than setting performance standards. So if it's already very, very low, then there may be other options to consider.

LYNNE TERRY: Okay. I don't want to belabor this. I know that tests in Oregon have shown that, you know,one-third of the chicken was contaminated. But Dr. Tauxe, I wanted to ask you, follow up a little bit on the test you were talking about. You are expressing some concern about those, the tests in laboratories. Are you worried that in the future the ability of the CDC and your federal partners will be hampered in terms of being able to pinpoint epidemics -- not epidemics, but outbreaks because of changes in the use of tests? Could you just elaborate a little bit.

ROBERT TAUXE: Yes, thank you for the question, Lynne. Here's -- here's the concern -- and we view this both as a challenge and an opportunity. The concern is that the rapid tests that have started to be used particularly for E. coli and for campylobacter mean that diagnosis can happen much quicker which is a good thing for the patient. But unless they -- the patient is also cultured for the organism if the test is positive, we don't get the isolate, we don't get the living strain of the bacteria out in the laboratory on a petri dish, say. And we have depended in the past on isolating that strain, on getting that bacteria to grow on a petri dish in order to confirm the case so that we know we're counting a case of real infection. And also then we take that strain and do DNA profiling on it and other tests which we use in our Pulsenet network to look for outbreaks. If we don't have a strain, if we don't have the living germ, we won't have, at least for the short term, we won't be able to use that system to find outbreaks. And we won't have the confirmation that it truly is a case. Now, there are a number of tests that are being developed and approved and that we think are going to be coming in to use. And we in public health are thinking and working on this problem with a number of partners. And I think Foodnet is going to be an important place to look at whether these are having an impact to adjust numbers for them, to decide which tests look like, well, we should just count those as positive says because the tests are the same, whenever they're cultured and we find that same organism so the tests are as good as culture, and for introducing new methods that are going to let us keep Pulsenet going for the long term. I think we're just starting down the road of a serious and important transformation of microbiology. The whole science microbiology is going digital, is going into the DNA sequence-based testing. And public health needs to go there, too. It's going to take some years for us to get there, but we're starting down the road. And Foodnet is going to be an important field laboratory place to look at the impact and to evaluate the new strategies.

LYNNE TERRY: Thank you very much.

OPERATOR: Thank you. Our final question comes from Michael Smith with Medpage Today. You may ask your question.

MICHAEL SMITH: Yes, thank you. I just have technical questions. One of them was partly answered. My first question is I’m assuming that the percent comparison that you're giving are to-- sort of the average of the three-year period in the comparative.

ROBERT TAUXE: Yes, that's correct. It's a comparison of the rate, say, in 2013, the number of cases per 100,000 people in 2013 versus the rate averaged over a three-year period.

MICHAEL SMITH: The other question, part of it was answered for me, and that is the sort of comparative numbers. You said you gave comparatives for deaths in 2012, but not for the other two factors. Number of cases and number of hospital admissions. I'd like to have those if that's possible.

ROBERT TAUXE: Let’s see. We -- perhaps we can look those up. But we also have -- all of the previous year's data back to 1996 are on our website, and that's the place to go and get earlier data. I don't know if we have the rest of those numbers here. I don't think we have them here in this room.

MICHAEL SMITH: Okay. I'll have a look at that. That's on CDC's website.

ROBERT TAUXE: Yes. CDC.gov/Foodnet.

MICHAEL SMITH: Okay, thank you.

OPERATOR: thank you very much. I'll turn the call back over to the speakers.

ROBERT TAUXE: Well, I thank everyone for your time here with us today and your interest and I consider all of you important partners in translating the scientific messages to the public. It is the consumer concern with food safety that at the end of the day propels a lot of what we do. We want the public health to understand -- we want the public to understand what we're doing, and we want them to have confidence that we're trying to address this problem. Reducing foodborne illness is not easy. It requires strong actions to control the known risks. It requires the investment of resources and talent to discover new and risky combinations of food and germs and then to do something about it. CDC's Foodnet continues to prove itself, I think, as a trusted and essential resource for the surveillance and investigation of foodborne diseases in the United States. The report being released today says that more work needs to be done. And it reminds us of the human health impact these diseases have. Thanks to my colleagues in the other agencies for participating, and thanks to you all for joining us this afternoon.

OPERATOR: Thank you and this does conclude today's conference. We thank you for your participation. At this time, you may disconnect your lines.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES