Food Safety: CDC Could Further Strengthen Its Efforts to Identify and Respond to Foodborne Illnesses
Fast Facts
The Centers for Disease Control and Prevention estimates that 1 in 6 people in the U.S. get food poisoning each year—leading to 128,000 hospital stays and 3,000 deaths. CDC has seen an increase in foodborne illness outbreaks that span multiple states in recent years.
CDC has developed tools to identify possible multistate outbreaks, investigate their cause, and communicate about them to the public. But it needs to balance the need to communicate quickly against the need to provide accurate and specific information.
Our recommendations include that CDC publicize its decision-making process for communicating about multistate outbreaks.
In 2019, Listeria (illustrated below) in mushrooms, hard-boiled eggs, deli-sliced meats and cheeses, and other foods was linked to multistate foodborne illness outbreaks.
Highlights
What GAO Found
The roles and responsibilities of the Centers for Disease Control and Prevention (CDC) during a multistate foodborne illness outbreak include analyzing federal foodborne illness surveillance networks to identify outbreaks, leading investigations to determine the food causing the outbreak, and communicating with the public. CDC also works to build and maintain federal, state, territorial, and local capacity to respond to foodborne illness outbreaks by awarding funds to state and local public health agencies and through other initiatives.
In identifying and responding to multistate foodborne illness outbreaks, CDC faces challenges related to clinical methods and communication, and it has taken some steps to respond to these challenges. One challenge stems from the increasing clinical use of culture-independent diagnostic tests (CIDTs). CIDTs diagnose foodborne illnesses faster and cheaper than traditional methods, but because they do not create DNA fingerprints that can specify a pathogen, they may reduce CDC's ability to identify an outbreak. A CDC working group recommended in May 2018 that CDC develop a plan to respond to the increasing use of CIDTs. By developing a plan, CDC will have greater assurance of continued access to necessary information. CDC also faces a challenge in balancing the competing needs for timeliness and accuracy in its outbreak communications while maintaining public trust. CDC has an internal framework to guide its communications decisions during outbreaks, and it recognizes that stakeholders would like more transparency about these decisions. By making its framework publicly available, CDC could better foster public trust in its information and guidance during outbreaks.
CDC has taken steps to evaluate its performance in identifying and responding to multistate outbreaks. Specifically, CDC has developed general strategic goals (see fig.) and taken initial steps to develop performance measures. However, CDC has not yet established other elements of a performance assessment system—an important component of effective program management.
CDC's Use of Elements of Program Performance Assessment Systems
In particular, CDC has not set specific performance goals, used performance measures to track progress, or conducted a program evaluation of its multistate foodborne illness outbreak investigation efforts. By implementing all elements of a performance assessment system, CDC could better assess its progress toward meeting its goals, identify potentially underperforming areas, and use that information to improve its performance.
Why GAO Did This Study
CDC has estimated that each year, one in six people in the United States gets a foodborne illness, 128,000 are hospitalized, and 3,000 die. CDC data show increases in the number of reported multistate foodborne illness outbreaks—groups of two or more linked cases in multiple states—in recent years. Such outbreaks are responsible for a disproportionate number of hospitalizations and deaths, compared with single-state outbreaks.
GAO was asked to review CDC's response to multistate foodborne illness outbreaks. This report examines (1) CDC's roles and responsibilities, (2) challenges that CDC faces and the extent to which it has addressed these challenges, and (3) the extent to which CDC evaluates its performance. GAO reviewed agency documents and data; conducted site visits and case studies; and interviewed federal, state, and local public health officials, as well as representatives of stakeholder groups.
Recommendations
GAO is recommending that CDC (1) develop a plan to respond to the increasing use of CIDTs, (2) make publicly available its decision-making framework for communicating about multistate foodborne illness outbreaks, and (3) implement all the elements of a performance assessment system. CDC concurred with all three recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Centers for Disease Control and Prevention | The Director of the Centers for Disease Control and Prevention should develop a plan for addressing risks that the increasing use of culture-independent diagnostic tests poses to CDC's continued ability to identify foodborne illness outbreaks. (Recommendation 1) |
CDC developed a plan to address the increasing use of culture-independent diagnostic tests through a cooperative agreement with the Association of Public Health Laboratories. This plan discusses several potential approaches to address this issue, such as highly multiplex amplicon sequencing, shotgun metagenomics, and the development of protocols for expedited low-cost isolate recovery from patient specimens for clinical and public health partners. CDC finalized the action plan in August 2021.
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| Centers for Disease Control and Prevention | The Director of the Centers for Disease Control and Prevention should make publicly available CDC's decision-making process for communicating about multistate foodborne illness outbreaks, including the scenarios it considers to aid in decision-making. (Recommendation 2) |
As of February 2022, CDC has updated its webpage content regarding the public communications framework for multistate outbreaks. This new content augments previous webpage information describing multistate outbreak communications and describes various methods of communication CDC will use based on how serious the outbreak is and how much information CDC has about what food is causing the outbreak. This new material satisfies the recommendation.
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| Centers for Disease Control and Prevention | The Director of the Centers for Disease Control and Prevention should implement a program performance assessment system for its multistate foodborne illness outbreak investigations, including setting performance goals, assessing progress toward achieving those goals with performance measures, and conducting program evaluations. (Recommendation 3) |
CDC has set performance goals and objectives related to managing foodborne, waterborne, and environmentally transmitted infections and incorporated them into its strategic plan. As part of its efforts to assess progress toward achieving those goals, CDC completed development of an internal dashboard in May 2023 that displays overall performance indicators for multistate outbreaks (solve rate, time to vehicle identification, and proportion with a public outbreak notice), as well as process indicators for inputs and three investigation phases (triage, investigation, and control). To evaluate the program, CDC monitors the indicators annually to determine the overall health of the epidemiologic and laboratory aspects of multistate foodborne outbreak response infrastructure in the U.S., as well as on an ongoing basis to identify potential changes in response effectiveness or in data quality or capture. While the indicators do not affect how CDC manages any individual outbreak investigation, CDC considers the indicators as part of the overall strategic management of their foodborne disease portfolio. As a result of these actions, we are closing this recommendation as implemented.
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