It is estimated that there were more than 81 million illnesses caused by food-borne agents in the United States in 2009 (Scharff, 2010). In Connecticut, recent reports indicate that there are an estimated 971,254 illnesses due to food-borne diseases annually, which equates to a ranking of 29 among all states and the District of Columbia and a per capita cost of $541 (Scharff, 2010).
The most common food-borne pathogens in Connecticut are Campylobacter, Salmonella, E.Coli O157, Cryptosporidium, Shigella, Listeria, and Norovirus with produce being the major source of food-borne pathogens and illnesses (Cartter & Starr-Hope, 2001). The rise in food-borne illnesses can be explained by the increase in demand for organic produce and large scale food production in one site among other factors.
The task force created by Governor Harris to combat food-borne illnesses in the state of Connecticut after analyzing the current programs and strategies available in the state, designed an intervention based on a $5 million budget aimed at the prevention of food borne illnesses (through public education and food worker training) and (early) recognition of symptoms to minimize adverse health outcomes. Budgetary requirements for the intervention designed by the task force, is herein described.
Connecticut Food-borne Illness Task Force Feasibility Study and Recommendations
Creating the Task Force-Understanding the Charge, Process and Results
Recognizing the potential negative ramifications that could be caused by a severe outbreak of food-borne disease, Governor Harris and Lt. Governor Lopez assembled a team of experts to assess the feasibility of and determine the most appropriate approaches for protecting the public from food-borne diseases and related illnesses in the state of Connecticut. This interdisciplinary team includes:
• Michelle Dahnke, public policy and behavior change expert
• Pascale Edouard, strategic planning consultant
• Adaugo Ndubuisi, public health program manager and epidemiologist
• Whitney Permuy, meteorologist and environmental health specialist
• Marlinda Saintil, senior demographer
Each expert was honored to have been asked to serve at the pleasure of the Governor and Lt. Governor as the core members of Connecticut's Food-borne Illness Task Force. The Task Force was provided $5 million and four weeks to conduct the feasibility study, and have compiled this summary document and presentation of findings for the Governor, Lt. Governor, and Connecticut General Assembly.
In order to gain a complete understanding of the present situation, the Task Force conducted a thorough assessment of current conditions, which included the following five areas:
1. The Current Situation and Background Information
2. Assessment of Population, including Sociodemographic Distribution
3. Assessment of State Geography and Infrastructure
4. Assessment of Current Resources and Potential Limitations
5. Aligning with the Connecticut Department of Public Health's Mission
Armed with an understanding of the people and conditions of the state of Connecticut, the Task Force created a preliminary intervention and accompanying budget, both of which are also included in this document.
The Current Situation and Background Information
It is estimated that were more than 76 million illnesses caused by food-borne agents in the United States in 1999 (Mead, et al., 1999). These illnesses lead to more than 325,000 hospitalizations and 5,000 deaths (Mead, et al., 1999). Of concern is the increase in number of food-borne illnesses in just a decade. In 2009, it was estimated the number of illnesses was 81.9 million (Scharff, 2010). Specifically in Connecticut, recent reports indicated there are an estimated 971,254 illnesses due to food-borne diseases annually, which equates to a ranking of 29 among all states and the District of Columbia (Scharff, 2010). This translates as more than eight of every 100 persons in Connecticut experiencing illness due to a food-borne pathogen, and there is an extensive cost associated with this level of food-borne illness.
The total cost of food-borne illness in the United States reached more than $152 million and the Connecticut-specific costs were estimated at $1,893 million annually (Scharff, 2010). The sum of physician services, pharmaceutical costs and hospital costs determine the medical costs. The total medical costs are combined with the loss of life expectancy and quality of life losses, which includes lost productivity from missing work and school and lost utility caused by pain and suffering, to arrive at this total cost. When considering total cost per case of food-borne illnesses, Connecticut ranks third in the United States, behind only Hawaii and Florida, spending an estimated $1,949 spent per case. Considering cost per capita of food-borne illness, Hawaii leads the nation at $553 dollars per person in the population, Mississippi ranks second at $543, and Connecticut is a close third at $541 (Scharff, 2010).
Not only are the ramifications of food-borne illness on the minds of economists, politicians, public health and emergency responders, the everyday reality of these statistics are also the concerns of consumers. A 2008 public opinion poll conducted by Hart Research showed that three in four respondents considered food safety a serious problem and were worried about possible contamination of the food they give to their families (Peter D. Hart Research Associates and Public Opinion Strategies, 2008). These results are graphically represented in Exhibit 1. Further, 51 percent of respondents believe the federal government isn't doing enough to ensure food safety and 80 percent would support new requirements in the interest of protecting the public health, even if it would increase the cost of the product (Peter D. Hart Research Associates and Public Opinion Strategies, 2008). These results are represented graphically in Exhibit 2.
As previously mentioned, there was an estimated 971,254 illnesses in Connecticut due to food-borne disease in 2009 (Scharff, 2010). Knowing the number of cases of food-borne illnesses is necessary to determine the prevalence of the disease. Just as knowing the number of illnesses is important, becoming familiar with the sources of food-borne illnesses are also critical. Public health, regulatory, and agricultural professionals are concerned with the etiology of disease outbreaks as well as the vehicle, or type of food through which the etiologic agent is carried or transmitted (Lister & Becker, 2010).
Understanding the routes of transmission of food-borne pathogens is important to shaping intervention strategies and education efforts for food service and food production employees as well as the general public (Centers for Disease Control and Prevention, 2010). Of the 971,254 food-borne diseases in Connecticut, 234,194 of them were linked to produce-related sources (Scharff, 2010). Agriculture was once a primary contributor to the state's economy and while it has declined some in importance, farming is still important to the state (The Official State of Connecticut Website). In addition to agricultural products like greenhouse and nursery products, Connecticut is also known for livestock products, specifically dairy products and chicken eggs, as well as cattle, calves, hogs, aquaculture like hard clams and oysters, and produce like sweet corn (NSTATE, LLC).
The most common food-borne pathogens in Connecticut are Campylobacter, Salmonella, E.Coli O157, Cryptosporidium, Shigella, Listeria, and Norovirus (Cartter & Starr-Hope, 2001). Knowing the source of the culprit pathogen is important to controlling the spread of the infection and reducing the risk of illness, which unfortunately, has been increasing for the last few decades. The four primary factors that contribute to an increase in food-borne illnesses are:
• Increased in eating out. Only 20 percent of reported food-borne illnesses occur from consumption of home cooked foods. The repeat handling and transportation of foods from restaurants or stores allows more opportunities for harmful pathogens to be introduced.
• Increased consumption of fresh fruits and vegetables. Americans are increasingly demanding organic fruits and vegetables, which lack the preservation and processing that inhibits microbial growth (U.S. Food and Drug Administration, 2009).
• Large scale food production in one site. Food production and distribution are no longer regional, rather a large amount of food is processed in one site and distributed nationwide, or even worldwide, thereby allowing for wider distribution of food. Further, if a food-borne pathogen is introduced in the processing, it may multiply or fester via long transportation channels, which can potentially increase the intensity or amount of disease.
• Anti-microbial resistance. New pathogens are being discovered with improvements in laboratory techniques and testing. In addition, pathogens are evolving and becoming resistant to antimicrobial agents (Health Care Encyclopedia, 2006).
Learning which populations have been most affected by food-borne illnesses is also necessary so population characteristics and tendencies can be considered when developing targeted interventions. In general, the populations at the highest risk for serious illnesses due to food-borne illness are infants and young children, the elderly especially nursing home residents, pregnant women, and individuals on certain medication and those with compromised immune systems. Young infants, older adults and persons with illness are at higher risk because of their weakened biological defense systems (Health Care Encyclopedia, 2006).
All states are required to collect data regarding food-borne diseases and report the results to the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention, 2010). The specific programs that are currently in place to prevent and control the spread of food-borne illnesses in the state of Connecticut will be discussed at length in the section entitled Assessment of Current Resources, Potential Limitations and Competing Priorities.
Assessment of Population, including Sociodemographic Distribution
Understanding the sociodemographic composition of Connecticut is critical prior to developing an intervention. Connecticut has an estimated population of more than 3,500,000 people and with a total area of just 5,543 square miles Connecticut is the second smallest state in the United States, but the fourth most densely populated (U.S. Census Bureau). Areas that are densely populated normally have individuals living in close proximity. Consequently this can pose a public health challenge when there are seasonal pandemics of contagious viruses and bacterial infections. Although, food-borne illnesses are not contagious, there are follow-on illnesses that can develop, like the norovirus, which can be spread among people in close proximity. Norovirus can be found in stool and vomit of infected people and the virus can be spread through contaminated food, touching surfaces contaminated with the virus or through having direct contact with an infected person. (CDC) Educating individuals about proper food handling and sanitation can decrease the number of outbreaks of norovirus as well we food-borne illnesses.
In Connecticut, the median household income is $68,294 and the percentage of residents who live in poverty or below the poverty level is just 9.1 percent which is less than the U.S. average of 13.2 percent. Connecticut's current economic situation is consistent with the state's long-history of prosperity, which dates back to the 17th century when Connecticut's abundance of raw materials were first used in manufacturing-resulting in the launch of a successful manufacturing industry (Gordon, 1983). The state continues to have the highest median household income in the country and is ranked first in the American Human Development Report (U.S. Census Bureau). There is a strong New York City influence apparent in the western and southern regions of the state. This is also the wealthiest area and the area in which most people reside as seen by Exhibit 3 (Social Science Research Council).
The population's race and ethic distribution is 84 percent white, 10.4 percent black, and 5.6 percent of people are American Indian or Alaskan native, Asian, Native Hawaiian or multi-racial. In addition to one of the previous descriptors, 12.3 percent of the population also considers themselves Hispanic or Latino and 10.9 percent of the population is foreign born (U.S. Census Bureau).
Connecticut has an age distribution is older than the national average, with a median age of 37.4 years compared to the United States' median age of 35.3 years (Connecticut Department of Environmental Protection). Adults age 25 years and over make up 67.3 percent of the total state population, while young adults age 18-24 and children under age 17 account for 8 percent and 24.7 percent of the population respectively (Connecticut Department of Environmental Protection).
Connecticut was once known for its incredible farms, but according to the 2000 census, the state only had 12.3 percent rural area. In 2005, 91.3 percent of the population lived in metropolitan areas and 8.7 percent lived in micropolitan areas, which are defined as urban areas that are based around a core city or town with a population of 10,000 to 49,999 (Rural Policy Research Institute). Urbanization is a growing trend in the United States and throughout the world (World Resources Institute). Although the number of rural areas has decreased, the increase in migrant workers has continued to soar (University of Connecticut Center for Public Health and Health Policy). There are roughly 18,000 migrant workers in Connecticut, most of who farm and cultivate seasonal crops (University of Connecticut Center for Public Health and Health Policy). The lack of sanitation and congestion within migrant work areas could increase the risk of contaminating food products as well as the workers.
There is an advantage to having such a mix of urban and rural areas within the same state. Urban areas are rich in resources and the mixture of urban and rural areas allows for the accessibility of those resources to the people who reside in rural areas. In a situation where a food-borne illness is pandemic, the readily available resources in urban areas are beneficial for both the urban residents and those of the surrounding rural area.
The primary language spoken in Connecticut is English, although there are a growing number of immigrants in the state who primarily speak only their native language-Spanish. The school-aged children of migrant workers are often bilingual and translate for their parents and older family members. In Connecticut, 18.3 percent of households speak a language other than English in the home, which is just higher than the U.S. average of 18 percent.
Assessment of State Geography and Infrastructure
Connecticut is located in the northeastern United States in what is known as New England. It is bordered by Rhode Island to the east, Massachusetts to the north and New York to the southwest. A majority of the residents reside in what is known as the Tri-State area, which is New York, New Jersey, and Connecticut. Fairfield, New Haven, and Litchfield counties are located in the Tri-State area. According to the Official State of Connecticut Website, the top five most populated cities in 2000 respectively were Bridgeport, New Haven, Hartford, Stamford, and Waterbury (The Official State of Connecticut Website). There are eight counties in the state, which can be seen in Exhibit 4.
The map in Exhibit 4 also the neighboring states and Long Island Sound. Each of the counties is identifiable as are many rivers, lakes, and mountains. The map also provides an indication of the state's terrain, which may need to be considered when planning public health programming. Specifically, the geography, climate, infrastructure and economic conditions all have the potential to compound existing public health challenges or inhibit interventions.
According to the Official State of Connecticut Website, Connecticut is a forested state with compact borders. Despite its small size, the climate changes regionally. Most of the larger cities are located in the coastal plans and central valley areas, which are flat (The Official State of Connecticut Website). However, two-thirds of the state is hilly land that is covered with forests. As previously mentioned the total area of the state is just 5,543 square miles, which should be considered an advantage because it allows for daily intra-state travel. The state is almost divided in half by the Connecticut River, which flows from Canada south where it empties into the Long Island Sound. This is a bay of the Atlantic Ocean located between Southern Connecticut and Long Island, New York. The long shore along the Long Island Sound is the reason Connecticut is known for its coastline; however, it should be noted that the state lacks direct access to the ocean (Connecticut Department of Environmental Protection). Exhibit 5 shows the length of the coastline along the Long Island Sound.
There is a variance in climate from the northern hilly areas to the flat-land areas where the larger cities are located (The Official State of Connecticut Website). The hills can be as much as 10 degrees colder than the valley year-round. Contrary to the rugged climate New England is known for, Connecticut enjoys a temperate, mild climate. In the summer the temperatures rarely rise above 90°F and in the winter there are very few days the temperatures fall below 0°F (The Official State of Connecticut Website). The average winter temperatures ranging from 31°F to 23°F and the average yearly snowfall is can vary between 25 to 100 inches (The Official State of Connecticut Website). The majority of snow falls from December to March, with even heavier snowfall generally in January and February. Summer is hot and humid throughout the state, with average highs ranging from 81°F to 87°F. The state has the potential to be impacted by tropical cyclones during hurricane season and while precipitation is fairly even across the state and throughout the year, thunderstorms, sometimes severe, are frequent during summer afternoons and evenings, occurring on average 20-30 times annually (Connecticut State Climate Center).
There is an abundance of public transportation options for state residents, which include a metro system and a bus system, both of which are provided by the Connecticut Department of Transportation. The southwestern part of the state is serviced by Metro-North Railroad New Haven Line to travel the Tri-State area. The bus system provided by Connecticut Transit provides transportation throughout the state. In summary, population centers, climate and geography and infrastructure systems like transportation should be considered when developing intervention strategies.
Assessment of Current Resources and Potential Limitations
In 2009, the Government Accountability Office identified 15 federal agencies that shared responsibilities for overseeing food safety laws in the U.S. (U.S. Government Accountability Office, 2009). Many of these agencies work through state departments of health, agriculture, and regulation among others. States also play a vital role in carrying out many food safety activities including inspecting food service facilities and investigating outbreaks. Specifically in Connecticut, there are several systems in place that administer federal laws related to food safety and there are some state programs that capture food-borne disease information and provide education to those who work in food processing, handling, service or distribution as well as the general public. Some of these key programs are:
• Food-borne Pathogen Active Surveillance Network (FOODNET): The Food-borne Pathogen Active Surveillance Network is the main component of the Epidemiology and Emergency Infections Program managed by the Centers for Disease Control and Prevention (CDC). This collaborative project between the CDC, the U.S. Department of Agriculture (USDA) and the Food and Drug Administration (FDA) works with 10 states throughout the U.S to track the incidence of individual laboratory-confirmed infections caused by several bacteria and parasites. Two counties in Connecticut, New Haven and Hartford, have been under active surveillance since the inception of the program in 1996; Fairfield County was added in 1997; and surveillance expanded to cover the entire state in 1998 (Cartter & Starr-Hope, 2001). Currently, the surveillance system monitors all of Connecticut's leading food-borne pathogens: Campylobacter, Salmonella, E.Coli O157, Cryptosporidium, Shigella, and Listeria, including Cyclospora, Vibrio and Yersinia enterococolitica (Centers for Disease Control and Prevention). Incidence reports for all ten states under monitoring are published on the CDC's website and is available for public viewing.
• Epidemiology and Emerging Infections Program: The Epidemiology and Emerging Infections Program is an effort by the State of Connecticut to prevent illness, disability and death due to infectious diseases. Through this program the state, in collaboration with local and federal public health professionals and medical practitioners, carryout surveillance on food-borne infections and conduct training and public health education (Connecticut Department of Health). The state has specific diseases it collects information on and set processes for reporting that are defined in Sections 19a-36-A3 and 19a-36-A4 of the Public Health Code and Sections 19a-2a and 19a-215 of the Connecticut General Statutes (Connecticut Department of Public Health).
• Food Protection Program and Food Worker and Education Campaign: Infection through food workers and food services establishments is responsible for a significant number of food-borne illnesses. The aims of the Food Protection Program of the Connecticut Department of Public Health are to minimize the risk of contaminated food, improve sanitary conditions of food establishments and to decrease pathogen transmission by unhealthy workers (Connecticut Department of Public Health). The program educates workers about health policies and encourages them not to report to work when they are ill (Connecticut Department of Public Health). One specific education effort includes posters that are printed in English, Spanish and Chinese and distributed to Class III & IV food service establishments throughout the state (Connecticut Department of Public Health). This program also manages food recalls and food service inspections for all food establishments in the State of Connecticut (Connecticut Department of Public Health).
• Food Safety Program: According to Altekruse, Cohen, & Swerdlow (2005) emerging food-borne diseases, industry consolidation and mass food distribution have been linked to outbreaks of food-borne disease. For this reason the Food Safety Program, operated by the Connecticut Department of Consumer Protection, specializes in the inspection of food manufacturers who operate, transport or store food in Connecticut (Connecticut Department of Consumer Protection).
• State Shellfish Sanitation Program: Shell fishing has become a vital part of a thriving seafood industry in Connecticut, with oysters harvested off their shores being transported to supermarkets nationwide (Connecticut Department of Agriculture). The State Shellfish Sanitation Program monitors shellfish harvested from state waters in the interest of protecting the public's health. The program carries out shoreline surveys as well as bacterial and viral testing to monitor water contamination. In addition, the program is responsible for carrying-out inspections of processing and handling operations (Connecticut Department of Agriculture).
• Local Health Departments (LHDs): Connecticut has 77 health departments-52 are full-time and 25 are part-time. The full-time LHDs serve approximately 94 percent of the state's population and include 32 individual municipal health departments and 20 health district departments that each serve between two and 19 towns. Exhibit 6 delineates the LHDs and the populations they serve.
The LHDs are government entities and while separate from the Department of Public Health (DPH), they are critical providers of health services locally and are linked to DPH by statue. One specific mandate of each DPH is to, "carry out critical public health functions in the areas of infectious disease control in the community" (Connecticut Department of Public Health). In addition, codes, while created by the DPH, are enforced by LHDs.
• Migrant Farm Worker Clinics coordinated by the University of Connecticut's Center for Public Health and Health Policy: The University of Connecticut, the Connecticut Area Health Education Centers (CT AHEC) Program and other local organizations have formed a coalition to help address the medical needs of Connecticut's migrant and seasonal farm workers. This coalition provides farm workers access to care by offering free medical and dental screenings on-site at farm worker barracks annually from June to October (University of Connecticut Center for Public Health and Health Policy). These clinics are a trusted source for migrant workers and could be used to relay information to these people who are among the most economically disadvantaged and most medically vulnerable. Language barriers and limited or no available transportation are just two of many reasons they lack access to care through established channels.
Despite the aforementioned measures already in place to conduct surveillance, many challenges remain in the collection of data and efforts to combat food-borne-related illnesses in Connecticut. One such limitation is the ever-evolving methods for and locations of food production and distribution. New locations for processing are constantly coming on-line as new systems are developed and old systems are updated or replaced. This constant transition necessitates inspections of both established and new facilities. Foods have the potential to be distributed farther from their original farm or location as transportation infrastructure and distribution methods continue to advance. This results in wide dispersion of contaminated products, which has the potential to make tracking the original source of contamination more difficult (Connecticut Department of Public Health). Further, the complexity of the food distribution system is also increasing as the globalization of food supply continues to expand (U.S. Food and Drug Administration, 2009).
In April 2010, the Congressional Research Services prepared a resource report for members and committees of Congress as they have expressed interest in updating the food safety laws and programs administered by the Food and Drug Administration (Lister & Becker, 2010). Specifically, the aim of enacting new legislation is to, "reduce the burden of food-borne illness, which is a considerable and persistent public health problem in the United States" (Lister & Becker, 2010).
The way in which food-borne disease data are collected is cited as one of several shortcomings of the systems currently in place. The most critical assessment of the current system was that it doesn't capture all data. There are two factors that contribute to the incomplete collection of this data. First, food-borne illnesses tend to be underreported and second, the current tracking systems only monitor a limited number of known food safety threats. Together these factors prevent officials from grasping the true burden of illness caused by food-borne disease. Exhibit 7 depicts the "burden of illness" pyramid used by the Centers for Disease Control and Prevention that demonstrates how the number of cases captured by FOODNET represents just the tip of the iceberg (Lister & Becker, 2010).
This happens because the FoodNet only tracks the incidence of individual laboratory-confirmed infections, meaning unless someone seeks medical care and is tested, their illness isn't captured. A second shortfall of the current system related to what is collected. Most often the contaminant that leads to the food-borne illness is tracked, rather than the type of food that is actually contaminated. This is inconsistent in that the food is what is regulated by government, not the illness (Lister & Becker, 2010).
Finally, local health departments as well as state departments' of public health are constantly faced with the challenge of addressing competing priorities. Unfortunately, because of competing priorities, not all recognized illnesses are documented correctly, fully investigated or reported to the CDC (Centers for Disease Control and Prevention, 2010). The impacts of not investigating or not reporting food-borne illnesses and outbreaks can be recognized as a long-term hindrance to the health of the public because the epidemiologic information obtained through this process is often the foundation for shaping future food safety policies.
Aligning with the Connecticut Department of Public Health's Mission
The creation of the Department of Public Health, as well as the powers and duties of the Commissioner of Public Health, is defined by Chapter 368a of Connecticut General Statues. In addition to administering Public Health Code, the Commissioner of Public Health is charged with overseeing the prevention and suppression of disease in the state (State of Connecticut). The mission of the Connecticut Department of Public Health (DPH) provides slightly more definition and specifies DPH's charge "to protect and improve the health and safety of the people of Connecticut by assuring the conditions in which people can be healthy; promoting physical and mental health, and preventing disease, injury, and disability" (Connecticut Department of Public Health). Therefore, any effort that aims to protect the residents of Connecticut from contracting a food-borne disease or related illness can be considered within the constitutional duties of the Department of Public Health (DPH).
The leadership of the State of Connecticut and Department of Public Health recognize the importance of protecting the public from food-borne illnesses. As such, many programs like those previously discussed in this report are already in place. Additionally, DPH programs work daily toward meeting the objectives defined in Health People 2010, several of which relate to reducing food-borne illnesses. While some of the specific Healthy People 2010 targets related to reduction of food-borne illness have been achieved on the national level, it has been suggested that new approaches to prevention will need to be implemented to fully achieve the goals. The Food-borne Illness Task Force is pleased to recommend a combination of interventions and an accompanying budget to Governor Harris and Lt. Governor Lopez that is based on the findings of this feasibility study and aligns with the mission of the Connecticut Department of Public Health.
Intervention Framework, Proposed Budget and Justification
Intervention efforts are often structured in phases; as such the Task Force has created three: (1) planning, (2) creation of concepts, messages, and materials, and (3) implementation and evaluation. The planning phase is largely defined by activities that were carried out during the feasibility study like research about the population, the impacts of the current problem, the resources available and any potential limitations that may exist. During the planning phase, it is also common to create actionable goals that can define what success will look like for each intervention component. Based on the the information gained during the initial planning phase, effective concepts, messages, materials and strategies can be developed, which is phase two. This may require additional consumer research or market analysis of target populations. The Task Force has considered this need and has allocated funds for this additional research and market testing within the line item called "creation and licensure" of each intervention component.
The third phase of the intervention will be the implementation and evaluation phase during which the specific strategies of each component will be carried out and assessment of the impact will be measured. The evaluation of each intervention component is independently reliant on initial data collection to establish a baseline so change can be monitored and the overall rate of success can be calculated. It would be ideal to allow the intervention strategies to become multi-year efforts so evaluation can be conducted and results can be gauged in both the short- and long-term.
When considering intervention strategies, the Task Force considered what behaviors and processes were necessary to change in order to better protect the public from illnesses caused by food-borne pathogens. In many cases, preventing food-borne disease is possible and something that can be reduced through increased awareness, education and behavior change. The Task Force recognized the need for an integrated, theory-based approach that aims to change individual behavior and public policies. As such, for each intervention component there is at least one targeted behavior change as demonstrated in Exhibit 8.
In addition to the intervention components targeting individual behavior change, the Task Force is also recommending efforts to influence public policy that can reduce food-borne diseases. Specifically, the Task Force is recommending a multi-faceted intervention approach with five components. The Task Force is recommending the state hire a public health professional who will serve as the overall manager of all intervention activities. This person will be responsible for overseeing each of the five components and the personnel who will be charged with carrying them out. The Intervention Manager will ultimately be responsible for the evaluation of all components of the intervention and managing all cross-component elements. In addition, the Intervention Manager will have an administrative support person to track the budget, personnel and administrative issues as well as perform general office functions.
Under the Intervention Manager there will be a Policy and Coalition Coordinator who will oversee all efforts pertaining to the development and day-to-day management of a new coalition of interested parties who are able to support the important efforts of the intervention. In addition, the Policy and Coalition Coordinator will manage efforts related to enacting policy changes supported by and necessary to achieve maximum intervention outcomes for each component.
The target audience of component 1 is middle and high school students. It has become commonplace to target preventative public health efforts toward younger audiences with the intent of preventing adverse behaviors before they begin. It is easier to influence behavior before an unhealthy pattern has been established or risky behavior has become commonplace. For this reason, the Task Force is recommending the creation of two curriculum guides, one each for middle and high school grades that will be provided to all middle and high school science and health teachers. The Curriculum Program Coordinator will work through each of the local school districts to promote the incorporation of the food-borne disease prevention curriculum into the traditional science and health courses.
Intervention component 2, like component 5, has a broad audience. The component involves providing point-of-purchase education to consumers at grocery stores and markets. In-store displays with palm cards will be set-up near produce and meat sections. Signage will encourage patrons to take the palm cards, each of which will contain one of four messages about safe food handling and storage-either clean, separate, cook or chill.
• Clean - Wash hands, utensils, and cutting boards before and after contact with raw meat, poultry, seafood, and eggs to avoid spreading bacteria when preparing food.
• Separate - Use different cutting boards for meat, poultry, seafood, and vegetables and keep raw meat, poultry, seafood, and eggs apart from foods that won't be cooked.
• Cook - Use a food thermometer - you can't tell if a food item is done by how it looks.
• Chill - Keep your refrigerator at 40 degrees or below to keep bacteria from growing and chill leftovers and takeout foods within 2 hours.
The target audience for intervention component 3 is anyone who works in food preparation or food service, inclusive of personnel who work in restaurants, bakeries, meat markets, schools, day care centers, nursing homes and assisted living facilities, hospitals and clinics, and prisons and detention centers. This intervention component will begin as a voluntary effort and will require an accompanying policy change to fully implement. The goal is to have all food services personnel complete a training annually to learn about safe food handling and storage practices and personal hygiene methods that should be followed to reduce risk of spreading disease-causing pathogens. The training curriculum will be created and tested for cultural sensitivity in English, Spanish and Chinese and will be delivered by Curriculum Training Specialists who will travel throughout their assigned region to the establishments.
Intervention component 4 is designed to educate patients to recognize the most common signs and symptoms of food-borne diseases, and the importance of contacting your primary care physician or other trusted medical profession when experiencing any of the signs or symptoms. This will require the creation of educational and promotions materials that will be brought to doctor's offices, hospitals, health centers, veteran's affairs clinics and migrant clinics throughout the state by Education Representatives. The representatives will speak with physicians and health care providers, specifically those who work with elderly persons and pregnant women, about conveying messages and providing intervention materials directly to their patients during office visits. There are several objectives for this component-to educate at-risk populations about the signs and symptoms, to have them engage in preventative behaviors to reduce their risk, and to contact a health care professional when they are experiencing any of the signs or symptoms of food-borne disease. Not only will accomplishing these objectives help keep the public more safe, it should increase reporting of food-borne illness, which in turn can be useful to researchers and epidemiologists who are investigating food-borne illness.
Finally, intervention component 5 is different from the previous four components in that it incorporates using social marketing approaches. Social marketing relies on applying the four P's of marketing (price, product, placement and promotion) strategically to influence behavior change. The marketing and media component will use many distribution channels including mass media advertising, public service announcements, newsletters, the Internet and could potentially also include press conferences, targeted outreach activities or special events. In addition, component 5 includes allocations for general marketing and media elements, like an overall intervention website and the creation of public service announcements for radio and television.
The Task Force is looking forward to reviewing the measurable outcomes of the suggested intervention components, both individually and as a combined effort. Exhibit 9 is a detailed breakdown of the total proposed intervention budget.
Appendix
Exhibit 1: Respondents views regarding the seriousness of produce contamination
Source: Adapted from Peter D. Hart Research Associates and Public Opinion Strategies, 2008
Exhibit 2: Respondents opinions regarding the creation of new federal requirements
Source: Adapted from Peter D. Hart Research Associates and Public Opinion Strategies, 2008
Exhibit 3: Population per sq. mile
Source: U.S. Census Bureau Census 2000, http://commons.wikimedia.org/wiki/File:Connecticut_population_map.png
Exhibit 4: Map of Connecticut
Source: http://qb.mindhenge.org/
Exhibit 5: Coastline along the Long Island Sound
Source: http://www.lisrc.uconn.edu/coastalaccess/sitemap.asp?siteid=0
Exhibit 6: Local Health Departments and the population they serve
Source: Adapted from https://www.han.ct.gov/local_health/
Exhibit 7: The "burden of illness" pyramid used by the CDC
Source: http://www.cdc.gov/foodnet/surveillance_pages/burden_pyramid.htm
Exhibit 8: Targeted behavior changes for each component of the recommended intervention
Exhibit 9: Budget Detail for Proposed Intervention
Exhibit 9: Budget Detail for Proposed Intervention (continued)
