Hilary Whitham, PhD, MPH, on Foodborne Outbreaks in Correctional Facilities


In this podcast, Hilary Whitham, PhD, MPH, talks about her team's research on foodborne outbreaks in correctional facilities, why these outbreaks happen, and what can be done (and by whom) to ameliorate future risks.

Additional Resource:


Hilary K. Whitham, PhD, MPH, is a senior epidemiologist and advisor in the Prevention Office in the Division of Foodborne, Waterborne, and Environmental Diseases at the Centers for Disease Control and Prevention in Atlanta, Georgia.



Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

Incarcerated individuals experience a disproportionate burden of outbreak-associated food borne illnesses, which has become a public health burden. Using CDC data, analysts have been able to identify issues and help create solutions. This was the topic of discussion during a session at the Food & Nutrition Conference & Expo 2020.

My guest today is the speaker of the session and lead author of the upcoming publication, Dr Hilary Whitham, who is a senior epidemiologist and advisor in the Prevention Office in the Division of Foodborne, Waterborne, and Environmental Diseases at the Centers for Disease Control and Prevention.

Thank you for joining me today, Dr Whitham. Before we jump into your study, can you tell us a little bit about foodborne illnesses and why implementing prevention strategies is so important?

Hilary Whitham: Foodborne illnesses can be very mild and naturally resolve in time. But they can cause some very serious long-term consequences, which include Guillain-Barre syndrome; hemolytic–uremic syndrome, which can involve the kidneys; irritable bowel syndrome, which can be chronic.

That really emphasizes, I think, how key prevention is so that these long-term sequalae never develop and never affect people for the really, really long term.

The best way to do that is prevention and making sure everyone has access to safe and nutritious food. I think that keeping an eye on that bigger picture can be really helpful in terms of galvanizing support, especially for those on the ground who can be part of this kind of grassroots movement to increase adherence and acceptance of some of these food code provisions.

Amanda Balbi: Can you talk about the burden of foodborne illness in correctional settings?

Hilary Whitham: We examined foodborne outbreaks that have been reported to the CDC since 1990. We compared outbreaks and correctional settings to outbreaks in other settings. And a couple of key findings emerged. The first is that when accounting for population size, there's a disproportionate burden of foodborne illnesses in correctional settings.

Specifically, the number of illnesses per 100,000 is roughly 9 times greater for correctional settings than that in other settings. To put this in context, there are 48 million cases of foodborne illnesses each year in the United States. The magnitude of this effect is really striking.

A second key finding was that there were differences in the median size of outbreaks. Specifically, the number of illnesses per outbreak was roughly 7 times greater in correctional settings than in other settings.

A last key finding was notable differences in pathogens. For instance, Clostridium perfringens was the underlying etiology for about 21% of correctional outbreaks and only 4% of noncorrectional outbreaks. That provides some clues about what went wrong and how to prevent future outbreaks. Specifically, this finding likely speaks to errors that were made when cooling or heating large trays of food, which we refer to as hot-cold holding practices.

The EpiData really speaks to some key FDA provisions that are basic but can be pretty powerful. One thing that we did as part of this analysis was look at elements that were considered really key to the FDA food code. We compared them in state correctional facilities as opposed to state regulations for, say, restaurant or retail settings.

We looked at 7 key prevent provisions, and we found that for these provisions, most states had these provisions for restaurant or retail settings. But when we looked at correctional settings, they didn't have all—or some didn't even have any—on the books as requirements in correctional facilities.

I think that that kind of provides a starting place in terms of what actions we might take. I think also correctional settings are challenging. This is a really large population of several million. They have diverse health needs, diverse religious needs, all of which need to be considered in terms of providing safe and nutritious food.

I think that those factors coupled together leave some areas for improvement. 

Amanda Balbi: What preventive actions can be taken, and what people or organizations need to be involved?

Hilary Whitham: The key aspects of the FDA food code that we focused on were those that had the most scientific evidence in terms of reducing illness and those that were also feasible for implementation in really diverse settings, things that didn't require infrastructural changes.

Those included washing hands and key guidance around barehanded contact with foods, hot-cold holding practices, training for food workers, excluding sick food workers, and then inspections. So that's what we focused on. I think that the FDA food code is hundreds of pages, there's a lot there.

But these are really basic powerful provisions and evaluating whether or not folks can implement them, increasing adherence to them, I think is a is a great starting place. This would require involvement from state governments, correctional facilities, correctional accreditation programs, which could maybe have a national standard, and then also the FDA. So, there's a lot of players here that could all have a distinct role and voice in creating better practices and standardizing these key provisions.

Amanda Balbi: What would you say are the clinical takeaways for people who are practicing in correctional facilities? How can they implement these findings or these preventive measures?

Hilary Whitham: I think that's a great question, and as opposed to kind of this formal legal or regulatory approach that I just outlined, I think that dietitians and other public health professionals in correctional facilities can be part of more of a grassroots approach.

In fact, I think there's a role for everyone in public health. Some facilities might not legally require a practice, but folks can serve as a local champion in terms of providing education on this topic, encouraging training on food safety, working to recognize best practices. I think efforts to change everyday practices can be really profound

The law isn't enough also. We might be able to have all states put these regulations on the books, but some places might have those laws in place, but not really be following them to a tee, and actual implementation matters.

Those on the ground can have a really meaningful impact to socialize these best practices. So, I think that for folks who are listening and working in the field, thinking about “What do our kitchens look like,” “What kind of illnesses have we seen,” “Am I observing these simple but best practices,” and “How can we work to improve their adoption and adherence to them?”

Amanda Balbi: What is the next step in your research? How do you plan to use this data in the future?

Hilary Whitham: We think that there's a couple of areas that we're going to, and the first in terms of next steps for research is actually to look at practice as opposed to law. And so, I think that that's going to be really revealing in terms of having more field data on what's going wrong and how to best also support facilities.

What are the key challenges and obstacles? How can CDC and other public health partners step in to address those and provide support? There are nurses and medical facilities nested within correctional facilities, and those staff have a lot on their plate.

Looking to them to say, “Okay, what's a gap that you're seeing? How can we help amplify your voice or help you address this element of inmate health?” So that's our first step that we're doing on our end in terms of research, but we're also modifying certain practices here at the CDC based on our research.

One of them was actually changing our surveillance form to include a section that's entirely about foodborne illnesses that are specific to correctional settings to get more nuances. What type of facility was this? Were inmates involved in food prep? What kind of training was afforded to everyone who was involved in food prep?

I think those details will also be fairly revealing in terms of how we prioritize outreach and education on this topic.

A couple of other things that we're doing is we do offer training to correctional staff for conducting foodborne outbreak investigations. They can be really challenging, because sometimes symptoms don't actually present until a week or maybe even a few weeks after exposure. So that can be really difficult when you're going back to historically try to figure out what went wrong so that it doesn't happen again.

We do provide that educational opportunity, and we also have a new outreach campaign for state and local health departments to increase understanding of jurisdictional issues to help build local relationships between correctional leaders and public health officials.

I think we all do better when we have streamlined practices, existing relationships, and we know what our lane is and how we work together in an outbreak setting. This can be helpful in terms of tackling this challenge in real time together. So those are a few things that are on the horizon are either under implementation.

Amanda Balbi: Thank you so much for joining me today and answering my questions.

Hilary Whitham: And thank you for giving us the opportunity to talk about this topic. We appreciate that and we hope that this brings about some interest in the topic.

I do really want to provide a “thanks” for Mitchel Holliday, who is in the Federal Bureau of Prisons, and Abby Ferrell, who is in the CDC’s Public Health Law Program. They provided a lot of invaluable insight for this analysis. They might not be in this interview, but they were very much involved in this research and are involved in the publication that will be coming soon.