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Communicable Diseases Intelligence Volume 33 No 4 - December 2009 /
Monitoring the incidence and causes of diseases potentially transmitted by food in Australia: Annual report of the OzFoodNet Network, 2008
OzFoodNet conducts surveillance on foodborne disease to investigate, describe and understand foodborne disease at the national level to provide better evidence of how to prevent foodborne illness. This page contains the annual report for 2008.
Page last updated: 22 February 2010
A print friendly PDF version is available from this Communicable Diseases Intelligence issue's table of contents.
Introduction | Methods | Results | Discussion | Acknowledgements | References
The OzFoodNet Working Group
In 2008, OzFoodNet sites reported 25,260 notifications of 9 diseases or conditions that are commonly transmitted by food. The most frequently notified infections were Campylobacter (15,535 notifications) and Salmonella (8,310 notifications). Public health authorities provided complete serotype and phage type information on 94% of all Salmonella infections in 2008. The most common Salmonella serotype notified in Australia during 2008 was Salmonella Typhimurium, and the most common phage type was S. Typhimurium 135. During 2008, OzFoodNet sites reported 1,545 outbreaks of gastrointestinal illness; affecting 25,555 people and resulting in 691 people being hospitalised. There were 99 deaths during these outbreaks. The majority (83%, 1,276/1,545) of outbreaks were due to personto-person spread, but 7% (104/1,545) were transmitted by contaminated food. Foodborne outbreaks affected 1,454 persons including 96 hospitalisations. Eleven deaths were reported during these outbreaks. For these foodborne outbreaks, Salmonella was the most common aetiological agent and restaurants were the most common setting where foods were prepared. Twenty of these foodborne outbreaks were related to the consumption of eggs; the majority (n=18) of these outbreaks were due to various phage types of S. Typhimurium. This report summarises the incidence of disease potentially transmitted by food in Australia and details outbreaks associated with various food vehicles in 2008. These data assist agencies to identify emerging disease, develop food safety policies, and prevent foodborne illness. Commun Dis Intell 2009;33(4):389–413.
In Australia, an estimated 5.4 million cases of foodborne disease occur annually, costing an estimated $1.2 billion dollars per year.1 Many of these illnesses are preventable by appropriate interventions and surveillance helps to identify control measures.2 Health departments conduct surveillance for foodborne diseases and diseases potentially transmitted by food to monitor trends in illness, detect outbreaks, inform preventative measures and to evaluate the efficacy of intervention efforts.3,4
In Australia, state and territory health departments conduct surveillance for between 10 and 15 different diseases that may be transmitted through food. Most of these diseases are transmitted by the faecal–oral route and as such may also be transmitted by contact with infected animals or people, or through consumption of contaminated water. In addition, health departments collect summary data on all outbreaks of foodborne diseases, which provides robust surveillance information on contaminated foods causing illness in Australia.
Most foodborne diseases manifest as mild self-limiting gastroenteritis, with only around 20% of affected people seeking medical attention. Consequently, surveillance data collected by health departments underestimate the true burden of disease. In Australia, for every case of salmonellosis notified to a health department there are an estimated 7 infections that occur in the community, while there are approximately 10 and 8 cases in the community for every notified case of campylobacteriosis and infection with Shiga-toxin producing Escherichia coli (STEC), respectively.5,6
The Australian Government established OzFoodNet—Australia's enhanced foodborne disease surveillance system—in 2000 to improve national surveillance and conduct applied research into the causes of foodborne illness.7 OzFoodNet aggregates and analyses national information on the incidence of diseases caused by pathogens commonly transmitted by food, as well as foodborne disease outbreaks. The OzFoodNet network includes collaborators from the National Centre for Epidemiology and Population Health at the Australian National University, the Public Health Laboratory Network, Food Standards Australia New Zealand (FSANZ), and the Department of Agriculture Fisheries and Forestry. OzFoodNet is a member of the Communicable Diseases Network Australia, which is Australia's peak body for communicable disease control.8 This is the 8th annual report for the OzFoodNet network and summarises 2008 surveillance data, which includes a comparison with data from previous years.
Population under surveillance
In 2008, the network covered the whole of the Australian population, which was estimated to be 21,373,998 persons.9
Notified infections
All Australian states and territories have public health legislation requiring doctors and pathology laboratories to notify cases of infectious diseases that are important to public health. State and territory health departments record details of notified patients on surveillance databases. These surveillance datasets are aggregated into a national database—the National Notifiable Diseases Surveillance System (NNDSS)—under the auspices of the National Health Security Act 2007 and the National Health Securities Agreement 2008. OzFoodNet aggregated and analysed data from NNDSS and enhanced surveillance data from OzFoodNet sites on the following 9 diseases or conditions, a proportion of which are commonly transmitted by food:
non-typhoidal Salmonella infections;
Campylobacter infections (except in New South Wales);
Listeria infections;
Shigella infections;
Salmonella Typhi;
STEC infections; and
haemolytic uraemic syndrome (HUS).
Data for this report were extracted from NNDSS in July 2009 and were analysed by the date of diagnosis within the reporting period 1 January to 31 December 2008. Date of diagnosis was derived from the earliest date supplied from the date of onset of the case's illness, the date a specimen was collected or the date that a health department received the notification. Estimated resident populations for each state or territory as at June 2008 were used to calculate rates of notified infections.
Enhanced surveillance
OzFoodNet sites collected supplementary data on infections commonly transmitted by foods. Information on travel status was collected for cases of Salmonella Enteritidis, hepatitis A and typhoid. We compared the incidence of infection in returned travellers with the number of travellers to that region using customs data derived from incoming passenger cards.10 The field 'country where you spent the most time abroad' was used as the numerator.
To examine the quality of surveillance data collected across Australia, OzFoodNet sites provided data on the completeness of serotype and phage type for Salmonella notifications. Data from Western Australia were excluded from the analysis, as isolates have not been routinely sent for phage typing since June 2007. To assess completeness, data were analysed using the date a notification was received by the health department.
OzFoodNet sites supplied data on listeriosis cases, which included whether a case was materno–foetal or not, and whether the case died. Many cases have severe chronic illnesses prior to their Listeria infection so it is difficult to determine if listeriosis is the cause of death for fatal cases, or one of many contributing factors. We did not validate deaths and all cases reported to have died were considered a listeriosis fatality. Maternofoetal pairs (mother and neonate) were counted as a single case with the mother being counted as the primary case. This affects age-specific notification rates for listeriosis and the proportion of reported cases that were female.
Gastrointestinal and foodborne disease outbreaks
OzFoodNet sites collected summary information on gastrointestinal and foodborne disease outbreaks that occurred in Australia during 2008. An outbreak of foodborne disease was defined as two or more people with a particular infection or illness whose common exposure was associated with a specific food or meal. A cluster was defined as an increase in infections that were epidemiologically related in time, place or person where investigators were unable to implicate a vehicle or determine a mode of transmission.
For foodborne and suspected foodborne outbreaks, the summary information collected on each outbreak included the setting where the outbreak occurred, where food was prepared, the month the outbreak occurred, the aetiological agent, the number of persons affected, the type of investigation conducted, the level of evidence obtained, and the food vehicle responsible for the outbreak. To summarise the data, outbreaks were categorised by aetiological agents, food vehicles and settings where the implicated food was prepared. Data on outbreaks due to waterborne transmission and data from clusters investigated by jurisdictional health departments were also summarised. The number of outbreaks and documented causes reported here may vary from summaries previously published by individual jurisdictions as these can take time to finalise.
We used Microsoft Excel and Stata version 10.1 for all analyses. Where appropriate we compared proportions using χ2 tests.
Rates of notified infections
In 2008, OzFoodNet sites reported 25,260 notifications of 9 diseases or conditions that are commonly transmitted by food (Table 1), similar to the mean of 25,054 notifications per year for the previous 5 years (2003–2007). There were no cases of botulism in 2008.
Table 1: Number of notified cases, crude rate and 5-year mean (2003–2007) rate per 100,000 population of diseases or infections commonly transmitted by food, Australia, 2008, by disease and state or territory
Salmonella Notified cases, 2008
Rate 2008
Mean rate, 2003–2007
Campylobacter* Notified cases, 2008
Listeria Notified cases, 2008
Shigella Notified cases, 2008
Typhoid Notified cases, 2008
Hepatitis A Notified cases, 2008
Shiga toxin-producing Escherichia coli Notified cases, 2008
Haemolytic uraemic syndrome Notified cases, 2008
* Campylobacter is not a notifiable disease in New South Wales.
In 2008, OzFoodNet sites reported 8,310 cases of Salmonella infection, a rate of 39 cases per 100,000 population (Table 1). Notification rates among jurisdictions ranged from 31 cases per 100,000 population in Victoria to 226 cases per 100,000 population in the Northern Territory, which usually has the highest rate of salmonellosis. Approximately half (49%) of Salmonella notifications were in males. The highest age-specific rate of Salmonella infection was 300 cases per 100,000 population in children aged 0–4 years (Figure 1). The notification rate increased dramatically in children aged 2 years or under, with rates in children aged 3 or 4 years being similar to the 5–9 year age group.
Figure 1: Salmonellosis notifications, Australia, 2008, by age group and sex
Nationally during 2008, the most commonly notified Salmonella serotype was S. Typhimurium, which was responsible for approximately 42% of all notified infections (Tables 2 and 3). During 2008, S. Typhimurium phage types 135, 44, 170/108 and 9 were commonly reported, representing four of the top 5 infections nationally. All serotypes in the Northern Territory exceeded 12 cases per 100,000 population, with Salmonella Ball being the highest at 20 cases per 100,000 population. Tasmania recorded a high rate for S. Mississippi notifications, which was 14.9 cases per 100,000 population. S. Mississippi is endemic in Tasmania and is thought to be transmitted from exposure to environments and drinking water that have been contaminated by native animals.11
Table 2: Numbers, rates and proportions of the top 5 Salmonella infections, Australia (excluding Western Australia), 2007 to 2008,* by OzFoodNet site
OzFoodNet site
Sero/phage type
2008/2007 ratio§
Rate†
(%)‡
Australian Capital Territory S. Typhimurium 44
S. Typhimurium 9
S. Typhimurium 135
S. Typhimurium 170/108
S. Infantis
New South Wales S. Typhimurium 135
S. Typhimurium 44
S. Birkenhead
Northern Territory S. Ball
S. Saintpaul
S. Weltevreden
S. Virchow 8
S. Lansing
Queensland S. Typhimurium 135
S. Aberdeen
South Australia S. Typhimurium 135
Tasmania S. Mississippi
S. Enteritidis 6a
Victoria S. Typhimurium 135
S. Stanley
*	Where there were multiple 5th ranking Salmonella types all data have been shown; Western Australia data not included due to incomplete phage typing of S. Typhimurium, S. Enteritidis, and S. Virchow in 2008.
†	Rate per 100,000 population.
‡	Proportion of total Salmonella notified for this jurisdiction in 2008.
§ Ratio of the number of cases in 2008 compared to the number in 2007.
Table 3: Numbers, rates, and proportions of top 5 Salmonella infections, Western Australia, 2007 to 2008
2008/2007 ratio‡
(%)†
Western Australia S. Typhimurium
S. Enteritidis
S. Chester
S. Kiambu
S. Muenchen
*	Rate per 100,000 population.
†	Proportion of total Salmonella notified for this jurisdiction in 2008.
‡	Ratio of the number of cases in 2008 compared to the number in 2007.
Salmonella Enteritidis
Salmonella Enteritidis is a globally important Salmonella serotype that can infect the internal contents of eggs, but is not endemic in Australian egg layer flocks. To monitor the emergence of this strain in Australia, OzFoodNet conducts enhanced surveillance of locally-acquired infections of S. Enteritidis. The majority of cases in Australia are associated with overseas travel.
During 2008, OzFoodNet sites reported 511 cases of S. Enteritidis infection (Table 4). Of those cases where travel status was reported, 83% (399/480) had travelled overseas and cases often reported visiting several countries. A travel history could not be obtained for 6% (31/511) of cases in 2008, compared with 18% of cases (73/396) in 2007 and 24% (72/305) of cases in 2006.
Table 4: Number of Salmonella Enteritidis infections, Australia, 2008, by travel history and state or territory
History of overseas travel
Of the cases that were known to have been acquired overseas, 80% (321/399) reported travel to South East Asia. This compares with only 13% (714,000 of 5,551,600) of returning travellers coming from South East Asia in 2008 (relative risk [RR] 28, 95% confidence interval [CI] 22–36).10 Similar to previous years, the most common country of acquisition for overseas-acquired cases was Indonesia, with 43% (173/399) of cases reporting travel there, while comprising only 2% (94,000 of 5,551,600) of travel undertaken in 2008 (RR 44, 95% CI 36–54). Thailand was the 2nd most common country of acquisition with 16% (63/399) of all notifications that were known to have been acquired overseas, followed by Malaysia with 10% (40/399) and Singapore with 6% (25/399). The most common infecting phage types amongst overseas-acquired cases were 6a (17.5%) and 1 (11.3%) (Table 5).
Table 5: Number and percentage of each phage type for of overseas-acquired cases of Salmonella Enteritidis, Australia, 2008
Phage type
Reactions do not conform
Untypable
21b var
Other phage types
No phage type was provided
*	The number of overseas-acquired cases with no phage type available includes 123 cases from Western Australia, where phage typing ceased in June 2007.
All states and territories except the Australian Capital Territory reported locally acquired S. Enteritidis cases in 2008. In total, 16% (81/511) of S. Enteritidis infections were locally-acquired, which was higher than previous years. There was an average of 44 locally-acquired cases per year between 2003 and 2007. In 2008, 30% (24/81) of locally-acquired infections were due to S. Enteritidis 26, while 16% (13/81) were due to S. Enteritidis 6a. No phage type was recorded for 22% (18/81) of locally-acquired cases, the majority of which were reported from New South Wales. Queensland reported 90% (19/21) of S. Enteritidis 26 cases with infections occurring throughout the year, except during winter months. In contrast, S. Enteritidis 6a occurred mainly in the last half of 2008 and affected 3 jurisdictions; Queensland, New South Wales and Tasmania.
Completeness of Salmonella serotyping and phage typing
Overall, 94% (6,983/7,464) of Salmonella notifications on state and territory databases contained information about serotype and/or phage type (excluding Western Australia). In Australia, 6 serotypes are routinely phage typed: Bovismorbificans; Enteritidis; Hadar; Heidelberg; Typhimurium; and Virchow. In 2008, phage typing was greater than 90% complete for serotypes Typhimurium, Virchow and Enteritidis (Table 6). There was an overall decline in the percentage of notifications with phage type reported in 2008 compared with previous years, with 94.1% containing complete information on phage type during 2008 (excluding Western Australia where routine phage typing ceased after June 2007).
Table 6: Percentage of Salmonella notifications for 6 serotypes notified to state and territory health departments with phage type information available, Australia,* 2003 to 2008
Salmonella serotype
S. Bovismorbificans
S. Hadar
S. Heidelberg
S. Typhimurium
S. Virchow
*	2007 to 2008 data excluding Western Australia, where phage typing ceased in June 2007.
In 2008, OzFoodNet sites (excluding New South Wales) reported 15,535 cases of Campylobacter infection; a rate of 108 cases per 100,000 population (Table 1). The lowest and highest rates of Campylobacter notification were in Western Australia (84.5 cases per 100,000 population) and in South Australia (124 cases per 100,000 population) respectively. Fifty-four per cent of notified cases were male, which is consistent with previous years. Notification rates were highest among males in nearly all age groups and particularly in males aged less than 5 years and greater than 65 years. The highest age-specific rate of notifications was in 1-year-old infants for both males and females (233 and 180 cases per 100,000 population, respectively) with additional peaks in the 20–29 year age group (Figure 2).
Figure 2: Campylobacteriosis notification rates and sex, Australia, 2008, by age group
OzFoodNet sites reported 65 cases of Listeria monocytogenes infection in 2008 representing a crude rate of 0.3 per 100,000 population; the same as the 5-year historical mean (Table 1).
Similar to previous years, 18% (12/65) of cases were pregnancy-associated infections. In 2008, 47% (25/53) of the non-pregnancy related cases were female. Fifty-one per cent (33/65) of notifications were in people aged 60 years or over. The highest age-specific notification rate was in people aged 85 years or over (1.9 cases per 100,000 population, 7 cases) (Figure 3). Eight per cent (1/12) of pregnancy related cases and 21% (11/53) of non-pregnancy associated cases in 2008 were fatal (Figure 4).
Figure 3: Listeriosis notifications, Australia, 2008, by age group
Figure 4: Notifications and case fatality ratio (CFR %) for fatal and surviving listeriosis cases, Australia, 2003 to 2008, by pregnancy status
Shigella infections
There were 828 notifications of shigellosis in Australia in 2008; a rate of 3.9 notifications per 100,000 population compared with a mean of 568 cases (2.8 notifications per 100,000 population) per year between 2003 and 2008 (Table 1). As in previous years, the Northern Territory reported the highest notification rate with 79.6 cases per 100,000 population compared with a mean of 71.9 cases per 100,000 population between the years 2003 and 2007.
The increased notification rate of shigellosis in 2008 compared with previous years is in part explained by an outbreak of S. sonnei biotype g with matching antibiotic resistance profiles amongst men who have sexual contact with other men (MSM), with cases in New South Wales (n = 12), Queensland (n = 4), Victoria (n = 29) and Western Australia (n = 2). Victoria also reported an outbreak of S. sonnei biotype g with matching antibiotic resistance profiles (different to the MSM cluster) amongst members of the Jewish community in Melbourne, with 12 cases and a further 2 cases from the same geographical area, although no source for the outbreak was identified. South Australia reported clusters of S. flexneri 6 with 3 cases and S. sonnei biotype a with 8 cases.
In 2008, notification rates for shigellosis were highest in males and females aged 0–4 years, with 12.5 and 13.9 notifications per 100,000 population respectively. Secondary peaks were observed in children aged 5–9 years and in males aged 30–44 years (Figure 5). Amongst children aged less than 5 years, the highest notification rates were in children aged 1 year. In 2008, 50% of all shigellosis cases were male. In 2008, 38.4% (318/828) of infections occurred in people of Aboriginal or Torres Strait Island origin and this proportion varied by state or territory.
Figure 5: Age and sex specific notification rates of shigellosis, Australia 2008
The most frequently reported Shigella biotype in 2008 was S. sonnei biotype a, followed by S. sonnei biotype g. Together these biotypes accounted for 50% of all Shigella infections reported in 2008 (Table 7).
Table 7: Number, percentage and ratio of the top 10 Shigella infections, Australia, 2006 to 2008
2008/2006 ratio*
Shigella sonnei biotype a
Shigella sonnei biotype g
Shigella flexneri 2a
Shigella flexneri 4a mannitol neg
Shigella sonnei untyped
Shigella flexneri 4
Shigella flexneri untyped
In Australia during 2008, there were 106 cases of typhoid due to Salmonella serotype Typhi infection. This equated to a rate of 0.5 cases per 100,000 population compared with a mean of 0.3 cases per 100,000 between 2003 and 2007 (Table 1). Cases were reported from all Australian states and territories except for the Australian Capital Territory and Tasmania.
Notification rates for typhoid in 2008 were highest in young adults, with 1.4 cases per 100,000 (21 cases) and 1.1 cases per 100,000 (16 cases) amongst the 20–24 year and 25–29 year age groups, respectively (Figure 6). Overseas travel was the primary risk factor for typhoid in Australia in 2008 with 92.5% (98/106) of cases known to have been acquired overseas. In 2008, 59.4% (63/106) of cases were male.
Figure 6: Age specific notification rates for typhoid, Australia, 2008
India was the most frequently reported country of travel for overseas-acquired cases of typhoid in 2008, with 50% (49/98) of cases, followed by Bangladesh, Indonesia, and Pakistan, each reported as a travel destination by 9% (9/98) of overseas-acquired cases (Table 8). The most common phage type of S. Typhi isolated from cases was E1 (36.8%, 39/106), and the majority of cases infected with E1 (79%, 30/39) reported travel to India (including cases who also reported travel to Bangladesh and Thailand). This was consistent with previous years, with approximately half of overseas-acquired cases in 2007 (51%, 42/83) reporting travel to India and 40% (19/48) being phage type E1.12
Table 8: Salmonella Typhi phage types isolated from cases (n=106), Australia, 2008
Country where travelled
Phage type (n)
Number of cases
India E1(29), 36(2), A (3), D2 (2), degraded (2), E9 (2) J1(5), untypeable (2)
Bangladesh E7 (1), E9 (2), non-typeable(6)
Indonesia D2 (2), degraded(1), E2(1), E2 var(1), M1(1), non-typeable (2), unknown(1)
Pakistan E9 (6), T(1), non-typeable(1), 51(1)
Samoa E1 (4), E7 (1)E9 (1)
Papua New Guinea D2 (2), G3 (1)
Philippines A (1), B1 var 1(1), degraded (1)
Thailand and Burma O var (3)
Cambodia E1 (1)
China and India 36 (1)
India and Bangladesh E1 (1)
India or Thailand D2 (1)
Malaysia E1 (1)
Malaysia and Thailand D1 (1)
Nepal E1 (1)
Sudan Degraded (1)
Thailand and China Untypeable (1)
No travel reported E1 (2), untypeable (1), degraded (1), A (2), 40 (1), C4 (1)
Hepatitis A notifications declined in 2008, with 276 cases reported compared with a mean of 306 cases per year between 2003 and 2007 (Table 1 and Figure 7).13 This decline may have been due to increased uptake of vaccine amongst high risk groups such as travellers, and targeted vaccination programs for Indigenous children.13
Figure 7: Trends in notifications of hepatitis A, Australia, 1991 to 2008, by month of diagnosis and inset, notifications of hepatitis A, 2008, by month and state or territory
In 2008, the median age of notified cases was 24 years old (range 1–97 years) and 57% (158/276) of cases were male. Indigenous status was known for 88.8% of cases in 2008. The proportion of cases of hepatitis A among Indigenous persons declined from a mean of 14% (167/1,193) of cases for the years 2003 to 2006 to 1.2% (3/245) of cases in 2008. This marked decrease in the number and proportion of cases that were Indigenous may have been due to targeted vaccination programs for Indigenous children in Queensland commencing in 199914 as well as free vaccine for Indigenous children in South Australia, Western Australia and the Northern Territory from 2006.
Overseas travel was found to be the most frequently reported risk factor for infection amongst cases of hepatitis A in 2008, with 54.7% (151/276) reporting overseas travel (Table 9). The most commonly reported overseas travel destinations were India (29 cases), Indonesia (11 cases) and Pakistan (8 cases). Household contact with confirmed cases was identified as a risk factor for 4.3% (12/276) of cases, highlighting the importance of post-exposure prophylaxis for contacts. In 2008, 3.6% (10/276) of notified hepatitis A cases were suspected to be associated with foodborne transmission.
Table 9: Risk factors identified for cases of hepatitis A, Australia, 2008
Percentage of cases
Household contact with confirmed cases
Associated with foodborne outbreak
Contact with confirmed cases
Overseas travel and contact with cases
Contact with injecting drug users
Contact with possible cases
Injecting drug use
Overseas travel and male-to-male sexual contact
Recent migrant from endemic area
No known risk factors
Shiga toxin-producing Escherichia coli infections
In 2008, there were 106 notifications of STEC in Australia, equating to a rate of 0.5 cases per 100,000 population. This was an increase over a mean of 0.4 cases per 100,000 population between 2003 and 2007 (Table 1). Cases were reported from South Australia (39), Queensland (37), New South Wales (19) and Victoria (11). There were no cases in the Australian Capital Territory, the Northern Territory, Tasmania or Western Australia in 2008. Rates of STEC infection are strongly influenced by jurisdictional practices regarding the screening of stool specimens.15 In particular, South Australia routinely tests all bloody stools by polymerase chain reaction (PCR) for gene coding for Shiga toxins and other virulence factors, making rates for this State the highest in the country.
In 2008, 51.9% of cases were female. The median age of cases was 24 years (range 0–89 years). Notification rates were highest in people aged 85 years or older, young people aged 10–14 years and children aged 4 years or under (Figure 8).
Figure 8: Age specific notification rates of Shiga toxin-producing Escherichia coli, Australia, 2008
*	Low case numbers make rates unstable and only age specific rates (not age and sex) have been calculated for Shiga toxin-producing Escherichia coli, with counts of less than 20 in all groups.
The number of STEC notifications has increased over the past 5 years, from an average of 5 cases per month between 2003 and 2006 to 9 cases per month between 2007 and 2008 (Figure 9). Seven cases of STEC in 2008 were associated with an outbreak due to waterborne transmission at a camp in Queensland. STEC notifications have a seasonal association, tending to increase during the warmer months (November to April).
Figure 9: Shiga toxin-producing Escherichia coli notifications, Australia, 2003 to 2008, by month and year of diagnosis
The most commonly identified serogroups of STEC cases in 2008 were O157, with 27 cases (25.5%), followed by O111 (8 cases, 7.5%) and O26 (7 cases, 6.6%). No organism was isolated or the serogroup was reported for 33.0% (35/106) of cases.
Haemolytic uraemic syndrome
In 2008, OzFoodNet sites reported 31 cases of HUS; a rate of 0.15 cases per 100,000 population (Table 1), compared with a mean of 0.08 cases per 100,000 population for the years 2003 to 2007. New South Wales reported the largest number of cases (17 cases), followed by Queensland (7 cases) and Victoria (4 cases). Similar to previous years, the highest notification rate in 2008 was in children aged 0–4 years (Figure 10), with 35.5% (11/31) of cases notified in this age group.
Figure 10: Age specific notifications of haemolytic uraemic syndrome, Australia, 2008
HUS may be due to causes other than Shiga toxin-producing E. coli, including other non-foodborne pathogens and genetic predisposition. In 2008, an antecedent STEC infection was reported for 52% (16/31) of cases, with serogroup information reported for 56% (9/16) of these cases. E. coli O111 was reported in 5 instances, while serogroup O157 and O166 were reported for 1 case each. In 2008, 1 case of HUS was known to be due to a non-bacterial cause, 2 cases resulted from Streptococcus pneumoniae infection, and in the remaining 11 cases no aetiology was reported.
In Australia, HUS cases are more common during late spring and early summer,12 with 37.4% (58/155) of cases occurring in the months of November, December or January for the years 2003 to 2008 (Figure 11). This was significantly more than expected (P = 0.01).
Figure 11: Notifications of haemolytic uraemic syndrome by month and year of diagnosis, Australia, 2003 to 2008
During 2008, OzFoodNet sites reported 1,545 outbreaks of gastroenteritis, including foodborne disease, which affected 25,555 people and hospitalised 691 (Table 10). There were 99 deaths during these outbreaks. This compares with 1,882 and 1,544 outbreaks reported across Australia in 2007 and 2006, respectively.
Table 10: Outbreaks of gastroenteritis including foodborne disease reported to state and territory health departments, Australia, 2008
Mode of transmission
Number of outbreaks
Number affected
Hospitalised
Foodborne
Unknown mode (Salmonella cluster)
Unknown mode (other pathogen)
Unknown mode (unknown aetiology)
*	Two outbreaks are included that commenced in December 2007, but were notified and investigated in 2008, one of them foodborne transmission and the other person-to-person.
Outbreaks due to person-to-person spread
In 2008, 83% (1,276/1,545) of all gastroenteritis outbreaks were due to person-to-person spread. There were 22,508 people affected in these outbreaks and 81 deaths. These outbreaks were most common in aged care homes, with 61% (784/1,276) of outbreaks occurring in this setting, followed by 17% (211/1,276) and 15% (189/1,276) in hospitals and child care centres respectively. Approximately 40% (513/1,276) of outbreaks spread from person-to-person were caused by norovirus, followed by only 3% of outbreaks caused by rotavirus. Forty-two per cent (531/1,276) of outbreaks due to person-to-person spread were of unknown aetiology. Late winter and early spring were the peak seasons for person-to-person outbreaks, with 38% (487/1,276) of outbreaks reported in the months of August to October 2008.
Waterborne outbreaks
There was 1 outbreak due to waterborne transmission; an outbreak of E. coli (multiple serotypes) associated with the consumption of tank water, affecting 7 people at a camp.
Outbreaks with unknown mode of transmission
There were 162 outbreaks where the mode of transmission was not determined, affecting a total of 1,551 people. There were 22 investigations of Salmonella and 22 investigations of other pathogens that were clustered in time, place or person where investigators were unable to develop an adequate hypothesis for the source of illness. There were 118 outbreaks where investigators were unable to determine the mode of transmission or the aetiology.
In 2008, there were 104 outbreaks of foodborne disease affecting 1,454 people, compared with 149 and 115 foodborne outbreaks in 2007 and 2006, respectively (Appendix). There were 96 people hospitalised and 11 deaths reported during these outbreaks.
The overall rate of reported foodborne disease outbreaks for Australia was 4.9 outbreaks per million population in 2008 (Table 11). The highest rates of foodborne outbreak reporting were from the Northern Territory with 22.7 per million population and New South Wales with 7.6 per million population. Outbreaks were more common in warmer months (Figure 12).
Table 11: Outbreaks of foodborne disease, Australia, 2008, by OzFoodNet site
People affected
Mean size (persons)
Outbreaks per million population
Figure 12: Outbreaks of foodborne Salmonella infections and other aetiological agents (n=687) reported to state and territory health departments, Australia, 2003–2008, by month and year of outbreak
Aetiological agents
The mostly commonly implicated aetiological agent in outbreaks of foodborne illness was Salmonella, which caused 34% (35/104) of outbreaks; 89% (31/35) of these being due to S. Typhimurium (Table 12).
Table 12: Aetiological agents responsible for foodborne disease outbreaks, number of outbreaks and persons affected, Australia, 2008
Agent category
Mean size (people)
Salmonella Typhimurium
Foodborne intoxication
Ciguatera/histamine poisoning
Other Salmonella serotypes
Toxin-mediated outbreaks comprised 18% (19/104) of all foodborne outbreaks, with 32% (6/19) of these due to fish toxins (5 outbreaks of ciguatera fish poisoning, and 1 outbreak of histamine poisoning) and 68% (13/19) due to foodborne intoxications with Bacillus cereus, Clostridium perfringens or Staphylococcus aureus.
There were also 4 foodborne outbreaks of Campylobacter, and 8 outbreaks were caused by viral agents. In 2008, 37% (38/104) of foodborne outbreaks were of unknown aetiology compared with 38% in the previous year.
Food vehicles
A wide variety of food vehicles were implicated in outbreaks of foodborne disease in 2008. Investigators were unable to identify a food vehicle in 28% (29/104) of outbreaks (Table 13).
Table 13: Categories of food vehicles implicated in foodborne disease outbreaks, Australia, 2008
Egg-containing desserts
Chicken and chicken-containing dishes
Meat and meat-containing dishes
Salads and/or sandwiches
Egg-based sauces and dressings
Pasta dish
Vitamised foods
Egg-containing dish
Rice based dish
Suspected chicken and/or eggs
There were 20 outbreaks associated with eggs; these comprised 19% of all foodborne outbreaks and included all outbreaks that investigators considered to be egg-associated (Table 14). Nine of these outbreaks involved desserts that commonly contain raw egg (such as chocolate mousse and tiramisu), five were due to egg-based sauces or dressings (such as aioli or hollandaise sauce), three were due to eggs as a whole food and 1 outbreak each was due to mixed dishes, a dish containing eggs and suspected chicken and/or eggs. These outbreaks affected a total of 289 people and hospitalised 36 people.
Table 14: Outbreaks of foodborne illness associated with egg-based dishes (n=20), Australia, 2008
Setting prepared
Agent responsible
Responsible vehicles
ACT Restaurant S. Typhimurium 44
Hollandaise sauce and poached eggs
NSW Private residence S. Typhimurium
Private residence S. Typhimurium 170
Eggs used to make cake filling
Restaurant S. Typhimurium 126
Chicken salad made with raw egg dressing
Aged care facility S. Typhimurium 144
Chocolate mousse with raw eggs
Bakery S. Typhimurium
Restaurant S. Typhimurium 170 var
Raw eggs in Caesar salad dressing
National franchised fast food S. Typhimurium 44
Bacon and egg sandwich
Restaurant Unknown
Aioli made with raw eggs
NT Restaurant S. Typhimurium 9
Suspected raw egg mayonnaise/Caesar salad dressing
SA Bakery S. Typhimurium 9
Sweet bakery products
Tas Restaurant S. Typhimurium 135a
Private residence S. Typhimurium 135a
Cake mix containing raw egg
Vic Private residence S. Typhimurium 135a
Ice cream cake made with raw eggs
Private residence S. Typhimurium 44
Lemon dessert made with raw eggs
Desserts suspected
Restaurant S. Typhimurium 44
D	Descriptive evidence implicating the vehicle
A	Analytical epidemiological association between illness and vehicle
M	Microbiological confirmation of aetiology in vehicle and cases.
Fifteen per cent (16/104) of outbreaks were due to mixed dishes, including buffets where a variety of dishes were served, and investigators were unable to implicate a particular ingredient (1 outbreak was suspected to be egg-associated). Nine per cent (9/104) of outbreaks were due to chicken or dishes containing chicken and 7% (7/104) were due to meat or dishes containing meat, 6% (6/104) due to fish and 6% (6/104) due to salads and/or sandwiches and 4% (4/104) due to molluscs. The remaining outbreaks were due to pasta dishes (3), vitamised foods (2), a rice-based dish (1) and a non-egg-based sauce or gravy (1).
Settings where food was prepared
In 2008, foods implicated in outbreaks were most commonly prepared in restaurants (43%, 45/104), by commercial caterers (12%, 12/104) or in private residences (12%, 12/104). Outbreaks were less frequently reported as being associated with foods prepared in aged care facilities (7%, 7/104), takeaway premises (6%, 6/104) or primary produce (5%, 5/104) (Table 15). In 2008 the only implicated foods that were contaminated in primary produce environments were fish involved in ciguatera fish poisoning outbreaks. The species of fish involved in these outbreaks included yellowtail kingfish, black kingfish, red throat emperor/reef snapper, yellow king/Samson fish and cod.
Table 15: Food preparation settings implicated in disease outbreaks, Australia, 2008
Proportion of all outbreaks (%)*
Number affected (persons)
Commercial caterer
Primary produce
Grocery store/delicatessen
Institution – other
National franchised fast food
*	Percentages do not add up to 100% due to rounding.
Investigative methods and levels of evidence
To investigate these foodborne outbreaks, state and territory investigators conducted 28 retrospective cohort studies and 4 case control studies. Descriptive case series were obtained for 62 outbreaks. No individual data were collected on patients in 10 outbreaks. An analytical association between illness and the implicated food as well as microbiological evidence of the aetiological agent in the implicated food was obtained for 3 outbreaks. Analytical evidence alone was obtained for 14 outbreaks and microbiological evidence alone for 9 outbreaks. These confirmed outbreaks comprised 25% (26/104) of all outbreaks compared with 46% in 2007 and 41% in 2006. Investigators relied on descriptive evidence implicating the food vehicle in 54 outbreaks, and there were no data available on the evidence obtained for 24 outbreaks (many of these were not attributed to a specific food vehicle).
Significant outbreaks
In 2008 there were 8 outbreaks of foodborne illness affecting 40 or more people: 2 outbreaks of C. perfringens; 1 mixed outbreak of C. perfringens and B. cereus; 3 outbreaks of norovirus; one of S. Typhimurium 135a; and one of unknown aetiology. In total, these outbreaks affected 481 people, with a range of 41 to 78 people affected per outbreak. Nine people were hospitalised, all of them associated with a Salmonella outbreak.
Tasmania reported the largest of these outbreaks; an outbreak of S. Typhimurium 135a affecting 78 people who dined at the same restaurant over a 4-day period. A cohort study of 212 restaurant patrons showed a very strong association between the consumption of aioli and illness (odds ratio [OR] = 511, 95% CI 90–4,709), P < 0.000). S. Typhimurium 135a was isolated from 4 food items collected from the food premises; the aioli, 2 foods containing the aioli, and a guacamole, which was considered by the investigators likely to have been cross-contaminated. Eggs supplied to the food business were from the same producer who was implicated in outbreaks of this Salmonella strain in 2005 and 2007.16,17
New South Wales reported 3 outbreaks of foodborne intoxication affecting more than 40 people:
an outbreak of gastrointestinal illness affecting all 75 guests of a birthday party where food had been supplied by an unregistered catering business. Several foods contained C. perfringens and B. cereus enterotoxins, and the proprietor was advised to cease preparing any foods for sale until the premises used for food preparation was brought up to a satisfactory standard.
an outbreak of gastroenteritis affecting 45 of 100 people at an army training facility. A cohort study found an association between a curry meal and illness. Seven stool specimens were positive for C. perfringens enterotoxin type A. Temperature abuse of foods and inadequate equipment were considered by investigators to have been contributing factors in this outbreak.
an outbreak of gastrointestinal illness affected 69 of 131 residents of an aged care facility over a 1 month period beginning in June. The outbreak may have involved two or more smaller peaks of illness accounting for the long time period of the outbreak. Seven out of 10 stool specimens were positive for C. perfringens enterotoxin type A. Consumption of vitamised or pureed diets and living in the high dependency unit were found to increase the risk of illness, although these 2 factors were not independent. Food handling and hygiene practices were found to be satisfactory.
A large outbreak of norovirus affected 56 of 138 attendees on a 5-day training course at a Brisbane academy in March. A retrospective cohort study identified an association between a cold meat and salad dish, provided by an outside caterer, and illness (RR = 2.0, 95% CI 1.5–2.7, P = 0.004). Eight stool specimens were positive for norovirus.18
An outbreak of norovirus gastroenteritis affected 75 of 366 people eating a buffet meal at a Western Australian restaurant. A Thai fish curry was the only food significantly associated with illness (RR=1.30, P < 0.05), however this food was consumed by only 28% of cases. Six faecal specimens obtained were positive for norovirus. An inspection of the premises did not identify any major deficiencies and there were no reports of staff illness.19
An outbreak of norovirus at an aged care facility in Western Australia affected 42 people including residents and staff. The index case was a chef who had prepared food while he was ill with gastroenteritis. Other staff and residents subsequently became ill over a 24 hour period. No single food was identified as the vehicle in this outbreak, and some person-to-person spread may have been possible.
Victoria reported an outbreak of unknown aetiology affecting 41 people from 3 different groups who ate at a large buffet restaurant in October. While C. perfringens enterotoxin was suspected as the cause of this outbreak, it was detected in only one out of 13 stool specimens collected. Univariate analysis showed that illness was associated with consumption of lamb tenderloin (RR 4.0; 95% CI 2.3–7.0), chicken cacciatore (RR 2.0; 95% CI 1.4–2.8) and roast pork (RR 2.4; 95% CI 1.4–4.0).20
This report documents changes in the incidence of gastrointestinal diseases commonly transmitted by food in Australia. There was a decrease in the number of notifications of Salmonella and Campylobacter compared with previous years. Despite these declines, these 2 infections continue to be reported at higher rates than in other developed countries.2,21 This is the first time hepatitis A has been included in the annual report. While the proportion of hepatitis A infections that may be foodborne is thought to be less than 10%, it is important to keep this infection under surveillance as it can cause large outbreaks of foodborne disease.22,23
Similar to 2007, higher rates of campylobacteriosis were observed in males than in females, particularly those over the age of 45 years.12 The reasons for this were unclear, but may relate to higher susceptibility of males in this age group due to the use of acid suppressive medications.24 In Australia, the primary source of Campylobacter infection is thought to be chicken consumption, causing an estimated 29.3% of all infections.25 This is consistent with findings from other countries, although recent work in New Zealand highlights that the fraction of campylobacteriosis due to chicken meat consumption may be considerably higher.26 The New Zealand Food Safety Authority recently announced that the poultry industry had successfully reduced the prevalence of Campylobacter on chicken meat, which had lead to a marked decline in human cases.27
In 2008, the proportion of Salmonella isolates that contained appropriate information on serotype and/or phage type decreased by 3% compared with 2007. Typing is vital for outbreak detection and monitoring trends. Western Australia ceased phage typing isolates in 2007 in favour of pulsed field gel electrophoresis, which is a discriminatory technique for typing Salmonella but not routinely used by other Australian laboratories.28 Other jurisdictions used multi-locus variable number of tandem repeats analysis to compare strains during outbreaks, which proved rapid and very useful. The use of these different typing schemes caused some complexity during multi-jurisdictional investigations. Despite this there is increasing harmonisation in typing schemes used by Australian laboratories.
Despite travel warnings and vaccine recommendations, travellers continue to acquire infections abroad, the risk being higher for long-term travellers and people who visit friends or relatives.29 In this report, we summarised data on 3 infections that are commonly acquired overseas; typhoid (96% of cases), hepatitis A (54.7% of cases) and S. Enteritidis (83% of cases). A large proportion of hepatitis A infections are likely to be acquired while visiting friends or relatives, with a recent study in New South Wales showing travellers who were born in endemic areas were at higher risk of infection.30 Travellers visiting friends or relatives may be less likely than other travellers to seek advice from a website such as the Department of Foreign Affairs' Smartraveller (http://www.smartraveller.gov.au), or from a travel clinic or general practitioner prior to travel, due to a perception of lower risk and lack of access to culturally and linguistically appropriate advice. It is important that prevention information is targeted at these groups. We compared the reported country and region of acquisition for S. Enteritidis infections with the proportion of all returning travellers who had nominated that place as their primary destination and observed that cases were more likely to have travelled to the South East Asian region.
In 2008, OzFoodNet sites reported 1,545 outbreaks of gastrointestinal disease, which was less than that reported in 2007.12 Similar to previous years, the majority of outbreaks in 2008 were transmitted from person to person (83%), with 61% of these reported from aged care facilities, reflecting the frequency with which outbreaks of gastrointestinal illness occur, the ease of transmission in this setting and the improved reporting practices of these facilities. Outbreaks transmitted person-to-person were most frequently of unknown aetiology (42%) followed by norovirus (40%). Norovirus outbreaks peaked in late winter and early spring in 2008.
In 2008, OzFoodNet sites reported 104 foodborne or suspected foodborne outbreaks, a rate of 4.9 outbreaks per million people, with a mean outbreak size of 14 people affected per outbreak. This compares with 7.1 outbreaks per million in Australia in 2007, and an estimated 4.2 outbreaks per million in the United States in 2006.31 Salmonella continues to be the leading cause of reported outbreaks of foodborne illness in Australia, with 34% of outbreaks due to this pathogen, the majority of them due to S. Typhimurium. In 2008, there were 8 large outbreaks of foodborne illness (affecting 40 or more people). The largest of these was due to S. Typhimurium 135a, which affected 78 people who dined at the same restaurant over a 4-day period. Eggs used at the restaurant were supplied by a producer who had been implicated in previous foodborne outbreaks.
Eggs were suspected as the cause of 27% (20/75) of foodborne outbreaks where investigators were able to identify a food vehicle. Eggs are a commonly consumed food, and as an ingredient of many dishes, and may be served raw or lightly cooked in dishes such as aioli, sauces and desserts. It is important that egg safety continues to be improved in Australia. During 2009, FSANZ continued developing a primary production and processing standard for eggs and egg products that is considering safety of the whole production chain from farm through to retail.32
Since the commencement of OzFoodNet in 2000, the network has successfully enhanced surveillance and conducted applied research into foodborne diseases in Australia. In 2008, OzFoodNet and the New South Wales Food Authority conducted the National Gastroenteritis Survey II (NGSII), which repeated the original survey in 2001–2002.33 The NGSII survey was completed in early 2009 and is currently being analysed. OzFoodNet continues to be engaged in regional capacity building activities through the World Health Organization's Global Foodborne infections network, and has sent epidemiologists as trainers to 2 training workshops (held in Papua New Guinea and Thailand) in 2008.
It is important to recognise some of the limitations of the data used in this report. Where there are small numbers of notifications, caution must be used in comparisons between jurisdictions and over time. Some of the most common enteric pathogens are not notifiable, particularly norovirus and C. perfringens, which is why surveillance of outbreaks is so important. A limitation of the outbreak data provided by OzFoodNet sites for this report is the potential for variation in categorising features of outbreaks depending on investigator interpretation and circumstances. States and territories are working towards harmonising surveillance and outbreak data to address some of these issues.
Foodborne disease surveillance provides information to assist in not only immediate public health action and the prevention of these diseases, but also to the assessment of food safety policies and campaigns. A national program of surveillance for foodborne diseases and outbreak investigation has many benefits including identifying foods that cause human illness by identifying outbreaks that occur across state and territory borders. Continuing efforts to strengthen the quality of these data will ensure their use by agencies to develop food safety policy and thereby help prevent foodborne illness.
We thank the many epidemiologists, project officers, interviewers and research assistants at each of the OzFoodNet sites who contributed to this report. We acknowledge the work of various public health professionals and laboratory staff around Australia who interviewed patients, tested specimens, typed isolates and investigated outbreaks. We would particularly like to thank jurisdictional laboratories, the Microbiological Diagnostic Unit Public Health Laboratory, the Australian Salmonella Reference Centre at the Institute of Medical and Veterinary Science, and the National Enteric Pathogen Surveillance Scheme for their help with foodborne disease surveillance in 2008. The quality of their work was the foundation of this report. OzFoodNet is an initiative of the Australian Government.
In 2008, the OzFoodNet Working Group and additional contributors were (in alphabetical order): Robert Bell (Qld), Therese Carroll (NSW), Barry Combs (WA), Craig Dalton (HNE Health), Gerard Fitzsimmons (DoHA), Lindy Fritsche (NSW), Kathleen Fullerton (DoHA), Robyn Gibbs (WA), Joy Gregory (Vic), Jenine Gunn (NT) Gillian Hall (NCEPH), Michelle Harlock (NT), Geoff Hogg (MDU), Rebecca Hundy (ACT), Cameron Moffatt (ACT), Katina Kardamanidas (NSW), Martyn Kirk (DoHA), Katrina Knope (DoHA), Karin Lalor (Vic), Mark Salter (FSANZ), Lisa McCallum (SA), Charlotte McKercher (Tas), Michelle McPherson (SA), Tony Merritt (HNE Health), Sally Munnoch (HNE Health), Jennie Musto (NSW), Lillian Mwanri (SA), Nevada Pingault (WA), Jane Raupach (SA), Michelle Robertson (FSANZ), April Roberts-Witeveen (HNE Health), Mark Salter (FSANZ), Cameron Sault (Tas), Craig Shadbolt (NSWFA), Russell Stafford (Qld), Nicola Stephens (Tas), Dayna Swiatek (DoHA), Barbara Telfer (NSW), Hassan Vally (NCEPH, WA), Tory Worgan (HNE Health).
Correspondence: Ms Katrina Knope, A/Coordinating Epidemiologist, OzFoodNet, Office of Health Protection, Australian Government Department of Health and Ageing, GPO Box 9848, MDP 14, CANBERRA ACT 2601. Telephone: +61 2 6289 2751. Facsimile: +61 2 6289 2500. Email: ozfoodnet@health.gov.au
1.	Hall G, Kirk MD, Becker N, Gregory JE, Unicomb L, Millard G, et al. Estimating foodborne gastroenteritis, Australia. Emerg Infect Dis 2005;11(8):1257–1264.
2.	Centers for Disease Control and P. Preliminary FoodNet Data on the incidence of infection with pathogens transmitted commonly through food—10 States, 2008. MMWR Morb Mortal Wkly Rep 2009;58(13):333–337.
3.	Allos BM, Moore MR, Griffin PM, Tauxe RV. Surveillance for sporadic foodborne disease in the 21st century: the FoodNet perspective. Clin Infect Dis 2004;38 Suppl 3:S115–S120.
4.	Hocking AD, ed. Foodborne microorganisms of public health significance. 6th edn: Australian Institute of Food Science and Technology Incorporated; 2003.
5.	Majowicz SE, Edge VL, Fazil A, McNab WB, Doré KA, Sockett PN, et al. Estimating the under-reporting rate for infectious gastrointestinal illness in Ontario. Can J Public Health 2005;96(3):178–181.
6.	Hall G, Raupach J, Yohannes K, Halliday L, Unicomb L, Kirk M. An estimate of under-reporting of foodborne notifiable diseases: Salmonella, Campylobacter, Shiga toxin-like Escherichia coli (STEC). National Centre for Epidemiology and Population Health Working Paper No. 52, 2006.
7.	Kirk MD, McKay I, Hall GV, Dalton CB, Stafford R, Unicomb L, et al. Food safety: foodborne disease in Australia: The OzFoodNet experience. Clin Infect Dis 2008;47(3):392–400.
8.	Lindenmayer P. Networking for health protection: the Communicable Diseases Network Australia. Commun Dis Intell 2001;25(4):266–269.
9.	Australian Bureau of Statistics. Population by age and sex, Australian states and territories, June 2008. ABS Cat. no. 3101.0. Canberra; 2008.
10.	Australian Government Department of Customs. Check-in ports 2007.
11.	Ashbolt R, Kirk MD. Salmonella Mississippi infections in Tasmania: the role of native Australian animals and untreated drinking water. Epidemiol Infect 2006;134(6):1257–1265.
12.	OzFoodNet Working Group. Monitoring the incidence and causes of diseases potentially transmitted by food in Australia: annual report of the OzFoodNet Network, 2007. Commun Dis Intell 2008;32(4):400–424.
13.	National Health and Medical Research Council. The Australian Immunisation Handbook. 7th edn. Canberra: Australian Government Publishing Service; 2000.
14.	Hanna JN, Hills SL, Humphreys JL. Impact of hepatitis A vaccination of Indigenous children on notifications of hepatitis A in north Queensland. Med J Aust 2004;181(9):482–485.
15.	Combs BG, Raupach JC, Kirk MD. Surveillance of Shiga toxigenic Escherichia coli in Australia. Commun Dis Intell 2005;29(4):366–369.
16.	Stephens N, Sault C, Firestone SM, Lightfoot D, Bell C. Large outbreaks of Salmonella Typhimurium phage type 135 infections associated with the consumption of products containing raw egg in Tasmania. Commun Dis Intell 2007;31(1):118–124.
17.	Stephens N, Coleman D, Shaw K. Recurring outbreaks of Salmonella Typhimurium phage type 135 associated with the consumption of products containing raw egg in Tasmania. Commun Dis Intell 2008;32(4):466–468.
18.	OzFoodNet Working Group. OzFoodNet quarterly report, 1 January to 31 March 2008. Commun Dis Intell 2008;32:267–271.
19.	OzFoodNet Working Group. OzFoodNet quarterly report, 1 April to 30 June 2008. Commun Dis Intell 2008;32(3):335–340.
20.	OzFoodNet Working Group. OzFoodNet quarterly report, 1 October to 31 December 2008. Commun Dis Intell 2009;33(1):53–58.
21.	Vally H, Hall G, Scallan E, Kirk MD, Angulo FJ. Higher rate of culture-confirmed Campylobacter infections in Australia than in the USA: is this due to differences in healthcare-seeking behaviour or stool culture frequency? Epidemiol Infect 2009;137(12):1751–1758.
22.	Conaty S, Bird P, Bell G, Kraa E, Grohmann G, McAnulty JM. Hepatitis A in New South Wales, Australia from consumption of oysters: the first reported outbreak. Epidemiol Infect 2000;124(1):121–130.
23.	Hall G, Kirk M, Department of Health and Ageing. Foodborne illness in Australia : annual incidence circa 2000. Canberra: Department of Health and Ageing; 2005.
24.	Tam CC, Higgins CD, Neal KR, Rodrigues LC, Millership SE, O'Brien SJ. Chicken consumption and use of acid-suppressing medications as risk factors for Campylobacter enteritis, England. Emerg Infect Dis 2009;15(9):1402–1408.
25.	Stafford RJ, Schluter PJ, Wilson AJ, Kirk MD, Hall G, Unicomb L, et al. Population-attributable risk estimates for risk factors associated with Campylobacter infection, Australia. Emerg Infect Dis 2008;14(6):895–901.
26.	Mullner P, Jones G, Noble A, Spencer SE, Hathaway S, French NP. Source attribution of food-borne zoonoses in New Zealand: a modified Hald model. Risk Anal 2009;29(7):970–984.
27.	New Zealand Food and Safety Authority. Media release. New Zealand leads world on controlling dangerous bacteria. Available from: http://www.nzfsa.govt.nz/publications/media-releases/2009/2009-10-15-campy-codex-work.htm Accessed on 27 November 2008.
28.	Swaminathan B, Gerner-Smidt P, Ng LK, Lukinmaa S, Kam KM, Rolando S, et al. Building PulseNet International: an interconnected system of laboratory networks to facilitate timely public health recognition and response to foodborne disease outbreaks and emerging foodborne diseases. Foodborne Pathog Dis 2006;3(1):36–50.
29.	Chen LH, Wilson ME, Davis X, Loutan L, Schwartz E, Keystone J, et al. Illness in long-term travelers visiting GeoSentinel clinics. Emerg Infect Dis 2009;15(11):1773–1782.
30.	Ward K, McAnulty J. Hepatitis A: who in NSW is most at risk of infection? N S W Public Health Bull 2008;19(1–2):32–35.
31.	Lynch MF, Tauxe RV, Hedberg CW. The growing burden of foodborne outbreaks due to contaminated fresh produce: risks and opportunities. Epidemiol Infect 2009;137(3):307–315.
32.	Food Standards Australia New Zealand. Media release. Primary production and processing standard for eggs. Available from: http://www.foodstandards.gov.au/thecode/primaryproductionprocessingstandards/eggstandard/index.cfm Accessed on 27 November 2009.
33.	Hall GV, Kirk MD, Ashbolt R, Stafford R, Lalor K. Frequency of infectious gastrointestinal illness in Australia, 2002: regional, seasonal and demographic variation. Epidemiol Infect 2006;134(1):111–118.
Appendix: Foodborne outbreak summary for OzFoodNet sites, Australia, 2008
Month of outbreak
Epidemiological study
Food vehicle category
November Restaurant Salmonella Typhimurium 44
Hollandaise sauce and poached eggs Egg-based sauces and dressings
December Aged care facility Salmonella Typhimurium
February Commercial caterer Bacillus cereus and Clostridium perfringens
Curry pumpkin, curry chicken, rice with lamb Mixed dishes
June Institution Unknown
Lasagne Pasta dish
January Institution Unknown
January Private residence Unknown
Mussels - fresh Bivalves and molluscs
March Private residence Salmonella Typhimurium 170
Eggs used to make cake filling Egg-containing desserts
January Private residence Salmonella Typhimurium
Eggs Eggs
July Restaurant Unknown
Oysters Bivalves and molluscs
September Restaurant Staphylococcus aureus
Chicken Chicken & chicken-containing dishes
May Restaurant Salmonella Anatum
Chicken meal Chicken & chicken-containing dishes
December Restaurant Unknown
Aioli made with raw eggs Egg-based sauces and dressings
March Restaurant Salmonella Typhimurium 126
Chicken salad with raw egg dressing Egg-containing dish
January Restaurant Unknown
Suspected ham Meat and meat-containing dishes
April Restaurant Salmonella Typhimurium U290
Most likely chilli beef Meat and meat-containing dishes
Variety of Chinese foods Mixed dishes
Unknown - suspected Indian takeaway food Mixed dishes
Rice, naan, butter chicken and lamb sabjwala Mixed dishes
May Restaurant Unknown
Stir fry beef with dried hot chilli and peanut Mixed dishes
April Restaurant Unknown
Rice or salt and pepper prawn Mixed dishes
March Restaurant Unknown
Spring roll, suspected Mixed dishes
September Restaurant Unknown
Barramundi, lamb, salad Mixed dishes
Fried rice Rice based dish
November Restaurant Unknown
Unknown, possibly pizza Unknown
February Restaurant Unknown
October Restaurant Unknown
September Takeaway Unknown
Lamb kebab suspected Meat and meat-containing dishes
November Takeaway Unknown
Pasta with tomato sauce (suspected) Pasta dish
December Takeaway Unknown
January Takeaway Unknown
May Unknown Unknown
Unknown but likely chicken and or eggs Suspected chicken and/or eggs
January Bakery Scombroid
Tuna from can used to prepare tuna salad roll in hot bread shop Fish
November Camp Campylobacter
November Grocery store/ delicatessen Salmonella Typhimurium
Cabanossi and pepperoni sausages Meat and meat-containing dishes
December National franchised fast food Salmonella Typhimurium 44
Bacon and egg sandwich - likely eggs Eggs
November Restaurant Salmonella Typhimurium 170 var
Raw eggs in Caesar salad dressing Egg-based sauces and dressings
August Aged care facility Salmonella Typhimurium 144
Chocolate mousse with raw eggs Egg-containing desserts
June Aged care facility Clostridium perfringens
Unknown possibly pureed food Unknown
November Bakery Salmonella Typhimurium
Chocolate mousse cake Egg-containing desserts
August Commercial caterer Viral
Mixed sandwiches Salads and/or sandwiches
April Commercial caterer Clostridium perfringens
Gravy Sauces and gravies
August Institution Clostridium perfringens
Macaroni bolognaise Pasta dish
March Military Clostridium perfringens
Curry Meat and meat-containing dishes
Fattouch salad Salads and/or sandwiches
November Restaurant Salmonella Typhimurium 9
Suspect raw egg mayonnaise/ Caesar salad dressing Egg-based sauces and dressings
June Takeaway Salmonella Weltevreden
January unknown Salmonella Typhimurium 182
Steak and/ or fried rice Mixed dishes
March Commercial caterer Unknown
October Camp Staphylococcus aureus
Roast chicken Chicken & chicken-containing dishes
December Primary produce Ciguatera fish Poisoning
July Primary produce Ciguatera fish Poisoning
'Yellow king' - Samson fish Fish
Red throat emperor/ reef snapper Fish
March Primary produce Ciguatera fish Poisoning
Black kingfish Fish
Yellowtail kingfish Fish
October Private residence Salmonella Virchow 8
Chicken curry Chicken & chicken-containing dishes
February Restaurant Campylobacter
Chicken liver pate Chicken & chicken-containing dishes
April Restaurant Clostridium perfringens
Refried Mexican beans Mixed dishes
November Restaurant Staphylococcus aureus
November Commercial caterer Staphylococcus aureus
Multiple foods Mixed dishes
March Institution Norovirus
Deli meat & salad dish Mixed dishes
December Bakery Salmonella Typhimurium 9
Sweet bakery products Mixed dishes
January Private residence Salmonella Typhimurium 9
June Aged care facility Salmonella Typhimurium 135
Unspecified vitamised food Vitamised foods
September Commercial caterer Norovirus
No specific food identified Unknown
March Private residence Salmonella Typhimurium 135a
Raw egg Eggs
January Restaurant Salmonella Typhimurium 135a
Aioli Egg-based sauces and dressings
February Aged care facility Clostridium perfringens
September Aged care facility Salmonella Typhimurium 44
Vitamised food Vitamised foods
March Commercial caterer Salmonella Typhimurium 44
August Institution – other Clostridium perfringens
Savoury mince Meat and meat-containing dishes
January Private residence Salmonella Typhimurium 135a
Ice cream cake made with raw eggs Egg-containing desserts
June Private residence Salmonella Typhimurium 135a
Suspect egg/custard dessert Egg-containing desserts
April Restaurant Salmonella Typhimurium 44
Desserts suspected Egg-containing desserts
October Restaurant Salmonella Typhimurium 170
Tiramisu Egg-containing desserts
May Restaurant Salmonella Johannesburg
Roast pork Meat and meat-containing dishes
May Restaurant Norovirus
Breakfast meals Mixed dishes
June Restaurant Unknown
Ready to eat uncooked foods such as salads Salads and/or sandwiches
May Restaurant Hepatitis A
Ready to eat foods such as salads and sandwiches Salads and/or sandwiches
December Restaurant Norovirus
May Commercial caterer Unknown
February Commercial caterer Unknown
Continental custard cake Mixed foods
February Commercial caterer Salmonella Typhimurium 170
Chicken and pasta salad and ham Salads and/or sandwiches
February Commercial caterer Campylobacter
Chicken and pasta salad Salads and/or sandwiches
January Private residence Salmonella Typhimurium 44
Lemon dessert made with raw eggs Egg-containing desserts
Several foods had statistically significant associations with illness. Mixed dishes
Lamb tenderloin and gravy or roast pork or chicken cacciatore Mixed dishes
May School Salmonella Typhimurium 44
July Commercial caterer Clostridium perfringens
BBQ Asian chicken Chicken & chicken-containing dishes
April Aged care facility Norovirus
April Restaurant Norovirus
C	Cohort study
D	Descriptive case series
CCS	Case-control study
N	Individual patient data not collected
OzFoodNet annual reports
Communicable Diseases Intelligence Volume 33 No 3 - September 2009
This issue - Vol 33 No 4, December 2009


I'm a fan of heist movies, and I'm always happy to see interaction fiction works that avoid the most heavily-trodden genres and settings of the field. "Let's Rob a Bank" offers the player the chance to do exactly what the title describes, primarily through choosing the diversion, the driver, and the muscle on your team. After briefly playing through the encounter at the bank, the player gets to see the results of the attempted heist and try again with a different team. It's a quick, fun diversion that can be played in a few minutes.
Gameplay: Aside from a few nontrivial choices that arise during the heist itself, the main means by which the player interacts with the game is in choosing among three candidates for each of the three positions on the team. They aren't heavily described, but that's perfectly fine for a work of this length, and they feel different during the heist itself. 5/10.
Mechanics: The game is a simple, choice-based one without anything to slow down the process of playing it. It's short enough to allow the player to retry with several different team compositions, and it's an entertaining puzzle to try to find the optimal one. 5/10.
Presentation: The text is well-suited to a light game about robbing a bank. The Lucy Honeysuckle scenario is odd, but the game doesn't take itself seriously. 5/10.
You might be interested in this game if: You like heist movies and have secretly always wanted to be a criminal mastermind.
Next Article Abbess Otilia's Life and Death, by A.B.


text:
InvestmentsMortgage
Ginnie Mae takes steps to squash VA loan churning
Will move forward with proposal to exclude high LTV loans from securities
August 1, 2019, 3:07 pm By Jessica Guerin
The churning of loans backed by the Department of Veterans Affairs has long been a thorn in Ginnie Mae's side, as the agency has worked for three years to curb abuses by VA lenders.
Now, Ginnie is taking yet another step to squash abuses, announcing Thursday that it is moving forward with a proposal to remove VA-backed cash-out refinances with high loan-to-value ratios from its flagship securities.
First announced in May, the proposal revises the pooling eligibility requirements for VA refinances, creating new criteria for cash-out refis with loan-to-value ratios that exceed 90%.
After a three-month period to collect industry feedback on the proposed rule, the agency has announced that 90% LTV cash-outs will officially be ineligible for Ginnie Mae I Single Issuer Pools and Ginnie Mae II Multiple Issuer Pools starting November 1, 2019. Instead, these high LTV loans can be placed into a custom Ginnie Mae pool.
Permanent construction financing loans will be the only exception, Ginnie noted.
According to a release issued by the agency, the revised pooling requirement "provides global investors with increased certainty in the performance of the Ginnie Mae security, which ultimately lowers mortgage rates for all borrowers served by the program."
Ginnie's move coincides with steps taken by the Federal Housing Administration to limit cash-out refinances on FHA-backed loans.
In a release announcing both changes, the FHA said the prevalence of VA cash-outs was an increasing concern for investors.
"Cash-out refinance programs are particularly susceptible to accelerated prepayment speeds, which is why Ginnie Mae is restricting the inclusion of such loans to custom MBS securities," the statement read. "This allows for greater market transparency for investors pricing Ginnie Mae securities."
Ginnie Mae Acting President Maren Kasper also weighed in.
"Today's announcement underscores Ginnie Mae's commitment to ensuring the agency's policies enable homeowners to borrow prudently, utilizing the government-guaranteed mortgage market," Kasper said. "Additionally, this policy provides global investors with increased certainty in the performance of the Ginnie Mae security, which ultimately lowers mortgage rates for all borrowers served by our program."

redpajama_set_name: RedPajamaCommonCrawl


Completing the fourth delivery of 10 navigation payloads for Lockheed Martin's GPS III satellites, Harris Corporation delivered the advanced navigation payload for the fourth GPS III Space Vehicle (SV04) to Lockheed Martin on October 29 – establishing a proven and reliable production cadence. Harris delivered two payloads in 2017 and is committed to delivering four more in 2018.
Harris is under contract with Lockheed Martin for the 10 GPS III navigation payloads. The first payload is fully integrated on the U.S. Air Force's first GPS III satellite, GPS III SV01, which was declared Available for Launch in September, with an expected launch in 2018. The payload moved flawlessly through space vehicle integration and test – exceeding specification requirements.


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How to Practice Mindful Meditation and Tools That Can Guide You
How meditation can make you happier and more successful than ever.
by Cat Perry CatPerry_
Previous story 4 Life Benefits of Meditation Next story Spring's Hottest Gear
Stress will come and go, from overstuffed schedules to ambitious hopes for your future. Yet how you handle the challenges can mean the difference between emotional chaos and clarity. But relax: Recent research suggests that calming yourself, redirecting frustration, and viewing life from the brighter side are habits you can practice. In other words, we can all learn to live happier lives every day.
Trending relaxation techniques are more than just hype. Far from its roots in the Indus Valley in 5,000 B.C., meditation has become "mental housekeeping" for everyone from yogis to busy parents and executives alike. The research is there: Studies show deep breathing and clearing the mind can reduce stress, obsessive thinking, and anxiety and improve memory and slow aging of the brain. Plus, it promises to increase your efficiency and ability to multitask, as well as brighten your day on the spot. Find your favorite form of this stress-melting practice to get more out of life.
The gist of meditation is the practice of sitting in a cross-legged or seated position, breathing deeply, and allowing your body and mind to relax. However, it comes in countless forms the world over—from well-known ones like Zen and Transcendental Meditation (made famous by the Beatles) to others like Mindfulness Meditation, or even yoga, which is often viewed as a moving meditation.
SEE ALSO: 5 Heath Benefits of Yoga
According to the Institute of Noetic Sciences, there are four om-filled umbrellas: concentrative meditation (returning your focus as it drifts to a single object, sound, image, or breath), open awareness (being present and aware of whatever happens in and around you), mindfulness (a combo of concentration and open awareness that can even extend to everyday tasks like eating, driving, or housework), and guided meditation (any form of meditation that can be guided by a teacher or audio recording that elicits certain imagery). "Meditation is personal, and it's important for people to find a practice that is comfortable for them. Luckily, there are so many types," says Krystal L. Culler, M.A., a certified brain-health gerontologist and the Nathan and Lenore Oscar Endowed Director of the Center 4 Brain Health, in Beachwood, OH.
Taking time out of your day for deep breathing, concentrating, and visualizing "impacts our frontal lobes, which are responsible for higher-order thinking processes, such as problem solving, memory, language, judgment, and impulse control. Many of the positive effects of meditation practice can be attributed to function in the limbic system, or emotional, area of our brains," says Culler. It also affects the brain's neurotransmitters, including serotonin (happiness), cortisol (stress), GABA (calm), endorphins (feel good), and melatonin (sleep).
See the next page for ways you can make meditation easier.
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Queen Elizabeth Caught on Hot Mic Criticizing World Leaders' Inaction on Climate
A government minister, Transport Secretary Grant Shapps, said the queen's comments had not been intended for broadcast
Published October 16, 2021 • Updated on October 16, 2021 at 10:12 am
(Photo by Ben Stansall - WPA Pool/Getty Images)
Queen Elizabeth II has appeared to criticize the global lack of action on climate change in comments caught on microphone.
The 95-year-old British monarch was filmed on a phone as she visited Cardiff to open the Welsh parliament on Thursday.
At one point, speaking to her daughter-in-law Camilla, Duchess of Cornwall, and parliament presiding officer Elin Jones, she said "I've been hearing all about COP … I still don't know who's coming."
On the recording, parts of which are inaudible, the queen also appears to say it is "irritating" when "they talk, but they don't do."
The queen is due to welcome leaders from around the world to COP26, a United Nations climate conference in Glasgow, Scotland, at the end of the month. Several heads of state or government, including China's Xi Jinping, have not said whether they will attend.
Queen Elizabeth II Oct 2, 2021
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UK's Princess Beatrice Names First Child Sienna Elizabeth
A government minister, Transport Secretary Grant Shapps, said the queen's comments had not been intended for broadcast.
"I think comments made in private should stay private, but we all share the desire to see progress made and we know there will be hundreds of leaders coming to Glasgow for COP," he told Sky News.
In Britain's constitutional monarchy the queen is meant to be above politics, and she rarely expresses opinions in public.
Her son and heir, Prince Charles, though, has long been outspoken on environmental issues. And Charles' son Prince William has also taken up the cause, backing the Earthshot Prize for environmental innovation that will be awarded on Sunday.
In an interview with the BBC broadcast Thursday, William criticized space tourism, saying the world's greatest minds should focus on fixing the Earth instead.
His comments were aired a day after the 90-year-old "Star Trek" actor William Shatner became the oldest person to fly to space, in a rocket funded by Amazon founder Jeff Bezos.
British Royal Familyclimate changeclimateQueen Elizabeth


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Magic dominant at times, beat Bucks in home finale, 107-98
By TERRANCE HARRIS, Associated Press | Posted - April 11, 2016 at 10:30 p.m.
ORLANDO, Fla. (AP) — Mario Hezonja has certainly had challenges during his rookie season with the Orlando Magic.
There have been flashes but there have been nights when little seemed to go right. Through it all, the Magic's first-round (fifth overall) pick in the 2015 has never lacked for confidence.
Hezonja's belief in himself proved crucial Monday night as he knocked down the biggest shot of the game to secure the Magic's 107-98 win over Milwaukee in the home finale.
With the Bucks closing in the waning minutes of the fourth quarter, Hezonja stepped up and buried a 3-pointer to push the Magic's lead to 103-96 with 2:25. Milwaukee had rallied within four points after trailing by as many as 20.
"I just wanted to get it to the advantage we had before, we had maybe 10 or 15," Hezonja said. "I took it because of that."
The 3-pointer capped an impressive night for Hezonja, who finished with 19 points and career highs in assists with seven and steals (five) in a game in which he started in place of injured Victor Oladipo, who was out with a concussion.
"We didn't think he would hesitate, but we had a couple good ball-movement sequences," said Magic coach Scott Skiles. "Evan (Fournier) made the extra pass, (Hezonja) knocked down the one that we really needed."
There was never any doubt in Hezonja's mind that he would take the shot if given the opportunity to stop the Bucks' momentum.
His clutch basket allowed the Magic to close out the home season on a positive note. They won five of their final six games at home and finished the year 23-18 at the Amway Center, which is the first time in four years they have won more than 20 games at home. The Magic (35-46) won 10 more games at home than they did last season and with one game remaining at Charlotte, have already improved their overall win total by 10 games over a year ago.
"We really wanted to win this one, even if we were on a back-to-back," said Fournier, referencing the loss at Miami on Sunday. "(The fans) were here all season long. The crowd was really good again tonight. It's just a good feeling. We feel good about ourselves."
In a night where the Magic were missing three starters in the lineup, the subs came up big. Ersan IIyasova, who started in place of Aaron Gordon (concussion), led the team with 22 points on 10-of-13 shooting, including 2 for 2 from 3-point range. Center Dewayne Dedmon added 17 points and eight rebounds while filling in for Nikola Vucevic, who sat out with a groin and leg injury.
The Bucks were healthier but their front-line players were simply outplayed by Orlando as they fell behind 58-44 at halftime and by 20 points late in the third quarter as a combination of Jason Smith, Fournier and Dedmon dominated Bucks center Greg Monroe and power forward Giannis Antetokounmpo early.
Milwaukee did bounce back and manage to make a game of it down the stretch with Jabari Parker and Khris Middleton both hitting big shots on the perimeter and driving the ball. Monroe led the Bucks with 23 points, while Parker and Middleton had 17 points apiece.
"When you're down in this league, you have to be perfect," said Bucks coach Jason Kidd, whose team moved to 33-48 heading into its season finale on Wednesday. "Whether it's two minutes or three minutes, your defense has to be perfect. And offensively you have maybe a small margin of error because of the 3-point shot."
Bucks: Monroe scored 15 of his 21 points in the first quarter on 6-of-11 shooting in 9:38. He didn't score in the second quarter. ...The Bucks were outscored in the paint 42-24 in the first half.
Magic: Orlando was without three starters. Victor Oladipo and Aaron Gordon missed their second straight game with concussion symptoms. Vucevic sat out with a groin and right leg injury.
Bucks: Host Indiana on Wednesday.
Magic: Play at Charlotte on Wednesday.
NBANational Sports


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About | Press Room | Press Releases | SharecareNow Identifies the Most Influential Online Voices in Heart Disease, the Number 1 Killer in the United States
SharecareNow Identifies the Most Influential Online Voices in Heart Disease, the Number 1 Killer in the United States
Atlanta, GA – February 21, 2012 – SharecareNow, powered by WCG, today announced the "SharecareNow 10 – Heart Disease" list, ranking the top influencers of heart disease conversation online. These experts and organizations provide relevant resources for individuals seeking reliable information online related to heart disease, the leading cause of death in the United States that claims almost a half-million lives each year.1
Introduced during American Heart Month, a nationally recognized month dedicated to raising heart health awareness, the "SharecareNow 10 – Heart Disease" is the most up-to-date online influencer list designed to connect Americans with an array of credible heart disease experts and resources to recognize, prevent and manage one of the most deadly health conditions in the U.S. The list aims to help improve awareness and education around heart disease and reduce the one in every three deaths in the U.S. that results from heart disease and stroke, equating to 2,200 deaths per day.1 Dr. Mehmet Oz, two-time Emmy® Award-winning host of the nationally syndicated and Emmy® Award-winning show, "The Dr. Oz Show", expressed enthusiasm about the creation of the "SharecareNow 10 – Heart Disease" list.
"Even though heart disease is the number-one killer in our country, millions of Americans are unaware of their risk factors, warning signs, or that simple heart-smart habits can drastically improve one's overall health and save their life," said Dr. Mehmet Oz, M.D. "That's why I'm proud there is now a great list of influencers working to make a difference in a field that's near and dear to me. It's imperative Americans across the country are aware of who they can rely on to provide real-time, credible information online in order to combat the on-set of heart disease and commit to a heart-healthy lifestyle before it's too late."
Heart disease refers to a variety of conditions that occur within the heart, but the most common type is coronary artery disease (CAD), a buildup of fatty plaque in the coronary arteries that reduces blood flow to the heart and worsens overtime. According to the American Heart Association, an American will experience some type of a coronary event approximately every 25 seconds, and every minute someone will die of one.2
By identifying the common risk factors – which include high blood pressure, high cholesterol, a family history of the disease, diabetes, stress, history of smoking, obesity and physical inactivity3 – individuals can decrease their chances of developing heart disease and minimize the severity of the disease before it becomes life-threatening.
"Oftentimes, the first sign of heart disease is a devastating and fatal heart attack, which is why the 'SharecareNow 10 – Heart Disease' aims to improve the overall lack of education and awareness around the severity of this disease for at-risk patients and their loved ones who are looking for information online," said Jeff Arnold, chairman and CEO of Sharecare. "Based on the vast number of Americans with diagnosed and undiagnosed heart disease, the list represents one of the most powerful resources available to empower people with the knowledge to develop a personalized heart healthy plan and live healthier lives."
In order to be included in the "SharecareNow 10 – Heart Disease" list, influencers must have demonstrated a consistent impact on heart disease-specific conversations online over the past year. The individuals' influence is measured and quantified through a proprietary algorithm based on more than 40 individual metrics, including heart disease relevance, syndication, presence and reach. The influence of these individuals and organizations is then ranked based on a unique scoring structure.
The following top influencers make up the "SharecareNow 10 – Heart Disease" list:
American Heart Association – http://my.americanheart.org
Shelley Wood – http://www.theheart.org
Larry Husten – http://cardiobrief.org
Richard N. Fogoros – http://heartdisease.about.com/
Chris Kaiser – http://www.medpagetoday.com
Carolyn Thomas – http://myheartsisters.org
Stephen Sinatra – http://blog.drsinatra.com
Tara Parker-Pope – http://well.blogs.nytimes.com
Deepak Chopra – http://www.huffingtonpost.com
Michael O'Riordan – http://www.theheart.org
Additional information, including bios and the methodology behind the influencer list, is available at https://now.sharecare.com.
About SharecareNow, powered by WCG
SharecareNow, powered by WCG was developed in partnership with Sharecare, an interactive social Q&A platform, and WCG, a market-leading digital communications agency. Sharecare Now, powered by WCG is an online platform developed to access real-time analytics on various health topics, conversations and influencers, and to use these insights to meaningfully impact the conversation through strategic engagement. The platform allows health and wellness professionals, organizations and brands to leverage the most accurate data, solutions and best practices to participate in the social service of expert health and wellness content and communities.
About WCG
Founded and led by chairman and CEO Jim Weiss, WCGC, the newly formed parent company of WCG, an award-winning independent global communications agency, is focused on integrated business solutions in the areas of product supremacy, innovation, change and growth for the world's leading companies. WCGC serves clients through a network of offices in San Francisco, New York, Chicago, Washington, D.C., Austin, Los Angeles and London. The company is celebrating its 11th year in business in 2012.
WCGC's seasoned professionals specialize in branding, design, digital and traditional marketing, corporate and product PR, media, investor and advocacy relations, clinical trial recruitment and grassroots direct-to-patient communications campaigns. For more information, please visit www.wcgworld.com.
Follow us on Twitter @WCGWORLD
Read our CommonSense Blog


You've heard it before, I'm sure. Once you're pregnant you have to "eat right." At the very least, you have to eat better than you have been.
Why? Because it's good for the baby, obviously.
But what does that mean, exactly? How do your prenatal food choices affect the little one growing inside you?
Your placenta is an amazing organ! Every minute of your pregnancy, your placenta exchanges an entire pint of blood to transfer nutrition from your blood stream directly to Baby's blood stream. Your placenta also breathes for your baby, delivering oxygen straight to her blood stream, and provides some immunity and infection protection. Whew! That's a lot of work!
What happens if you're not regularly nourishing your placenta by eating nutritious foods during pregnancy?
Poor nutrition can result in your membranes rupturing before Baby's ready to be born. Ruptured membranes mean you may need to go to the hospital for labor induction or augmentation if you don't go into active labor within 24 hours (depending on your provider's protocol). Once in the hospital, you're stuck in bed, monitored, probably given drugs you may or may not want, all affecting the progression of your birth and probably throwing your ideal birth plan out the window.
More importantly, preterm babies lose the benefits that come along with remaining in the womb full term.
Read our list of foods to eat during pregnancy for brain development.
There's a wide range of vital nourishment your baby needs in utero, from macronutrients like healthy fats and high quality proteins to essential vitamins and minerals like folate and calcium. Depriving Baby of optimal nutrition increases her chances of developmental delays, physical disabilities, and/or neurological disabilities. It also increases the risk of low birthweight.
The list goes on. Suffice it to say, good nutrition is one of the simplest yet most important gifts you can give yourself and your child during pregnancy. Changing your diet may be hard in the beginning, but it's more than worth it! A healthy, vibrant, thriving child is all the thanks you'll need.


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Liverpool's Mohamed Salah broke a 23-year-old record that Ronaldo and Suarez couldn't
Anfield might as well name a stand after the Egyptian wonder
Liverpool forward Mohamed Salah is the living embodiment of the famous Latin phrase 'Veni, Vidi, Vici,' for he came to Anfield, played in the English Premier League and calmly conquered it. Termed as a Chelsea reject in the beginning, Liverpool manager Jurgen Klopp must have seen something special as the German signed Salah for EUR42 million (INR338 crores) in the beginning of the 2017/18 season. But neither Klopp nor anyone else in the league cloud have even remotely fathomed what this Egyptian maestro was capable of accomplishing. Once the season started, Mohamed Salah's transfer fee began looking like a steal, as he went from match to match, scoring like nobody's business.
But many wondered, still doubting the forward's potential -- was this just a purple patch or was he actually that good? The only way we'd know was to see him perform, and perform he did. Guiding Liverpool to the Champions League final and finishing fourth in the league, Salah has had an impact at Anfield like no one else in the club's recent history.
So as the curtains came down on the domestic season, Salah had scored 31 goals with one game left to play. In the Premier League's 25 year history, three players have reached that tally but were unable to better the other. Alan Shearer reached it first in the historic 1995 season when he scored 31 goals to take Blackburn to their only title. Cristiano Ronaldo emulated it in the 2008 season when Manchester United won the domestic as well as the European league. And Luis Suarez scored the exact same number in the season where he almost led Liverpool to league glory in 2014.
Mohamed Salah reached the tally two weeks ago, with him needing a single goal in three matches to become Premier League's all-time top scorer in a single season. After two goalless matches, Salah had to score in their final game, home to Brighton Hove Albion. It took him only 25 minutes as we saw what he had been doing all season with his left foot, slotting the ball into the net for the 32nd time and thus etching his name as the league's top goalscorer in a single season.
Mohamed Salah has now won the EPL golden boot award, scoring the most number of goals in the league this season while Tottenham Hotspur's Harry Kane came second with a tally of 30 goals this season. Manchester City forward Sergio Aguero finished third with 21 goals.
With the UEFA Champions League against Real Madrid left to play, Liverpool will look to the Egyptian wonder for one last time this season to inspire them to their sixth European title. Meanwhile, with a season which has often won players the coveted Ballon D'Or trophy in the past, a lot of clubs are ready to break the bank to acquire the most in-form player on the planet while Salah has expressed his intent to stay at Anfield.
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> More on Sports
KeywordsCristiano RonaldoLiverpoolMADRIDManchester CityManchester United
Cristiano Ronaldo and Lionel Messi finally join forces – in the name of fashion
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To Be a Sports Editor
Nate Levinson, Sports Editor
This editorial is the last in my run as one of the sports editors of this paper, and I can't help but feel a little nostalgic. By my unofficial count, I've written 67 articles in my two-plus years with the paper, including 21 "In the Locker Room" interviews and 25 editorials, including this one.
I'd be lying if I said I envisioned this long tenure with the paper when I got to Oberlin. I didn't join until second semester my sophomore year, and I only wrote five articles before interviewing for the job. Thankfully I got it, and if I do say so myself, it has been a match made in heaven.
My time at the Review has given me the chance to write about the national sports topics I love in addition to offering me the opportunity to connect with Oberlin athletics in a way most non-athletes can't or don't. Most students at Oberlin are aware when their friends' teams are doing well or in season, but don't care much beyond that. As a sports editor, I've gotten to delve deeper than that. It probably goes without saying that I'm far more interested in covering national sports topics, but the chance to cover athletes I go to school with is still pretty cool. There's definitely been a shift in the talent level and culture of the athletics teams in the four years I've been here, and that's been fun to watch and write about.
Talking about sports has always been a way for me to connect with people I know only superficially, but that option hasn't been so readily available at Oberlin. I definitely get to talk sports with some people on campus, but it's not like being back home, where my friends, for the most part, are up to date on all the sports-related news I obsess over every day.
Looking at it negatively, it's pretty disappointing that I can't talk about something I love with more than a handful of friends, but I don't always see it that way. Writing and talking about sports here is a challenge — a challenge to see if I can get a mostly unenthused student body to care just a little bit more.
I've definitely tried to keep an open mind about being a sports fan at Oberlin, but my patience has certainly worn thin at times. For some reason I won't take the time to get into, sports, and competition more generally, carry a pretty large stigma at Oberlin. I can't begin to count the number of times I've heard people say something sarcastic along the lines of "Sports, yeah!" when I get excited about some specific sporting event. As far as I'm concerned, it's akin to saying "Art, yeah!" at the Met, as if all forms of art there are the same. I get that not everyone is as passionate about sports as I am, but what I don't understand is the passionate dislike people seem to have for athletic competition.
At the Review, I'm most definitely the office's biggest sports fan — sorry, present and past co-editors — so my biggest challenge has been conveying my passionate views about the games to a campus that is apathetic, at most, about nearly every topic I've written about. I've tried to bridge the gap by writing about social issues in sports, but I can't help but feel like people gloss over the Sports section most weeks. That makes sense — I'm not exactly an avid reader of the Arts section of the Review — but I hope I've at least encouraged a few non-sports people to take an interest in either Oberlin athletics or the national topics I cover in my editorials.
At the very least, I hope I've taught a few of the uninitiated a thing or two, and maybe I've even given some other campus sports fans something to read about every week. Or maybe my mom is still the only one who reads my work. Either way, I've enjoyed writing every word.
final editorial
Nate Levinson


Severe lightning strikes in St. Petersburg Florida during a powerful June 2013 storm - Nikon D300 Tamron 17-50mm @ f/8 ISO 200 bulb mode lens covered until strike tripod mounted with cable releaseWhile out teaching a 1-on-1 DSLR Photography Lesson in downtown St. Petersburg on June 25, 2013 my photography student and I were treated (?) to a spectacular view of a powerful storm that produced a waterspout, funnel clouds and ground shaking lightning. While keeping a safe distance, I was able to quickly setup to try and capture some lightning shots. This means setting the shutter speed to bulb mode and covering the front of the lens until lightning is visible and keeping the lens exposed just long enough so the overall shot looks good. I only had three chances and was lucky enough to get the above lightning photograph on that third try.
Waterspout over Vinoy Park in St. Petersburg Florida June 2013 - Nikon D300 Tamron 17-50mm @ f/11 ISO 200 1.6 sec tripod mounted with cable releaseThis waterspout attracted a lot of onlookers. In grew in size greatly and I could not get my camera around the tree in the foreground to show its full length. It was eerily translucent and silent dipping up and down from the clouds above.
Oncoming ominous storm clouds approach St. Petersburg Florida waterfront - Nikon D300 Tamron 17-50mm @ f/11 ISO 200 5-exposure HDR tripod mounted with cable releaseThis is the approach to the storm before we saw any lightning, waterspouts or funnel clouds. I had never seen such a long, thin band of angry looking clouds stretch all the was from Tampa Bay to south St. Petersburg. The sun was going down adding a bit of pretty color to the underside of what really was a menacing stormy sky.
Funnel clouds came from this cloud band along the downtown St. Petersburg Florida waterfront - Nikon D300 Tamron 17-50mm @ f/11 ISO 200 5-exposure HDR tripod mounted with cable releaseTurning and looking to my right from the same spot as the previous photo shows just how long that band of clouds stretched too. Right above the sailboats two funnel clouds would eventually form right in front of us! They never touched the ground and all we ended up was a little wet once the rain came, but the storm added a lot of excitement to our photography lesson!