Title: Foodborne Illness: Protecting Your Patients, Your Families and Yourself
1Foodborne IllnessProtecting Your Patients,
Your Families and Yourself
- Edward C. Oldfield, III, MD
- VAMDA Annual Conference
- September 13, 2014
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3Serenely full, the epicure would say, Fate
cannot harm me for I have eaten today.
- Sydney Smith (1771-1845)
- Lady Hollands Memoir
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5-
- Foodborne diseases continue to move newspapers
and bowels around the world. - -RV Tauxe
6Foodborne Illness
- 3 facts about foodborne illness lectures
- Always topical always an outbreak to talk about.
- High level of interest (personal and
professional). - Remember I am only the messenger Dont shoot the
messenger.
7Foodborne Illness
- 1.5 billion episodes of diarrhea in the world
each year with 3 million deaths in children less
than 5 years old. - 70 of episodes of diarrhea are felt to be
related to food contamination. - In the U.S., 48 million episodes of foodborne
illness with 128,000 hospitalizations and 3,000
deaths are estimated to occur each year. - 2010 estimate of cost 152 billion.
- David Satcher, Surgeon General JAMA
20002831817 -
8Reality is Worse than Reports
- Only 5 of persons presenting for care with
diarrhea have stool samples taken estimated that
only 1 in 36 cases is reported. - Carpenter L. Clin Infect Dis
20081971709-12. - Center for Science in the Public Interest (CSPI)
maintains an outbreak database but 55-75 of all
outbreaks reported to CDC have no known etiology
or food vehicle and are not included in the
database.
9Foodborne Disease Pyramid
- Reported to Health Department/CDC (reported. 1)
Culture-confirmed case
Lab tests for organism
Specimen obtained
Person seeks care
Person becomes ill
Exposure in the general population (estimated 36)
10Foodborne Outbreaks
- 2009-10 gt1,500 reported outbreaks with 30,000
cases. - Single etiologic agent identified in 64
norovirus (42 of outbreaks, 47 of cases) was
most common, followed by Salmonella. (30). - Beef (13), dairy (12), fish (12), poultry
(11) were the most common foods involved. - MMWR 20136241-7.
11Foodborne Disease, U.S.
- Salmonella was the leading cause of
hospitalizations (35), followed by norovirus
(26). - Salmonella caused the most deaths (28), followed
by Toxoplasma (24), Listeria (19) and norovirus
(11), 58 gt 65 y.o. - Listeria has the highest case fatality ratio
17, with Vibrio second at 6, and Salmonella at
0.5.
12Foodborne Disease and LTCFs
- Up to 50 of all foodborne outbreaks occur in
LTCFs. - LTCF residents are 4-fold more likely to die from
gastroenteritis than community dwelling. - For Salmonella, case fatality is 70-fold higher
in LTCFs than other settings. - 18 of gastroenteritis deaths occur in LTCFs.
- Kirk M. Clin Infect Dis
201050397-404.
13Diagnosis and Management of Foodborne Illness
- A Primer for Physicians
- MMWR 53 (No.RR-4)20041-29.
14Clues to Etiology of Foodborne Disease
- Time to symptom onset (incubation).
- Duration of illness.
- Predominant clinical symptoms.
- Population involved.
- Food type consumed.
15Foodborne Illness Preformed Toxins
- Bacillus cereus
- Abrupt onset 1 - 6 hours
- N/V, 24 hour duration.
- fried rice.
- Staphylococcus aureus
- Abrupt onset 1 - 6 hours
- N/V, 24 - 48 hour duration.
- Potato, egg salad, cream pastries.
16Foodborne Illness Preformed Toxins
- Clostridium perfringens 8-16 hour incubation
- severe cramping abdominal pain, diarrhea, nausea
- 24 - 48 hours duration
- meats, gravy, poor temp control (70-140 F),
food service germ - Clostridium botulinum 12-72 hour incubation
- vomiting, diarrhea, blurred vision, diplopia,
dysphaagia, descending paralysis. - home canned foods/low acid content.
17Foodborne Illness Preformed Toxins
- Ciguatera onset 2-6 hours
- reef fish (grouper, red snapper, amberjack,
barracuda) contaminated by toxin from
dinoflagellates. - GI and Neurologic sx
- Scombroid onset minutes-hours.
- spoiled fish (bluefish, tuna, mackerel)
- Histamine reaction N/V, skin flushing, throbbing
HA, wheezing.
18Incubation PeriodViruses/Bacteria
- Noroviruses 12 - 48 hour incubation
- N/V/D (diarrhea more common in adults, vomiting
in children). - duration12 - 60 hours.
- shellfish, contamination of salads,
fruits/vegetables by infected workers, cruise
ships. - Salmonella (1 - 3 days)
- Shigella (1 - 2 days)
- Campylobacter (2 - 5 days)
- EHEC (1 - 8 days)
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20Salmonella
- Estimated 1.4 million annual infections, 168,000
physician visits, 85,000 hospitalizations, 550
deaths. - But only 40,000 (3) reported through the passive
National Salmonella Surveillance System. - Many vehicles of transmission produce, eggs,
poultry and other meats, direct animal contact.
21Salmonella Foodborne Illness
- Nontyphoidal Salmonella are the second most
common cause of foodborne illness (11),
surpassed only by Norovirus. - Salmonella was the leading cause of
hospitalizations (35), followed by
norovirus(26). - Salmonella caused the most deaths (28), but had
an overall low case fatality rate of 0.5.
22Salmonella Nomenclature
- All Salmonella belong to 2 species, S. enterica
and S. bongori with 6 subspecies. - S. enterica (99 of human infections).
- gt 2,000 serovars (serological variants) based on
serotyping of somatic (O) and flagellar (H)
antigens about 400 in circulation at any time. - Serovars are named after geographical origin of
first isolate of the new serovar. - PFGE allows DNA fingerprinting to detect strains
within serotypes to reveal epidemiologic
clustering.
23Recent Salmonella Outbreaks
- 2013 430 reported cases of Salmonella Heidelberg
infection from March 2013- Jan. 2014 with 42
hospitalized, 14 bacteremic in 25 states, 73 of
cases from California. - Salmonella were resistant to ampicillin,
chloramphenicol, sulfa and tetracycline. - Traced to 3 lots of Foster Farms brand chicken,
2012 outbreak with 314 cases in 13 states also
traced to Foster Farms.
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25USDA Impotence
- Foster Farms did not issue a recall of the 3
known contaminated lots. - USDA does not have mandatory recall authority.
- USDA can detain adulterated food and have it
seized through the courts, but Salmonella has
never been considered by the FDA as an
adulterant, despite causing gt 1 million foodborne
infections a year. - Costco recalled rotisserie chickens (USDA does
not allow Salmonella on ready-to-eat food).
26USDA Legally Challenged
- In 1974, APHA sued the Secretary of Agriculture
because it did not warn consumers about
Salmonella. - USDA lawyers claimed that bacteria were so wide
spread in the environment that they could not be
considered an adulterant. - To this day, USDA considers Salmonella on raw
poultry a natural organism. - Contamination is allowed as long as the processor
removes it somehow, by washing or antibacterial
treatments. - Denmark and Sweden have a zero-tolerance policy.
27Chicken
- 42 million pounds/day of fresh chicken products
in retail markets. - Most consumed meat in U.S., 83 pounds
consumed/person in 2013. - 11 raw chicken breasts () for Salmonella, 79
resistant to at least one antibiotic, 45 had at
least 3 class resistance, 27 had at least 5
class resistance.
28Antibiotics as Growth Promoters
- 84 of all antibiotics in the U.S are used in
agriculture 70 are given to healthy animals as
growth promoters, as much as 29 million pounds. - All 27 European Union nations have banned
antibiotics as growth promoters. - Between 1992 and 2008, Danish farmers increased
swine production 47 while reducing antibiotics
by 50.
29Campylobacter
- 2 million cases of Campylobacter enteritis each
year in the U.S. - Up to 88 of broiler chicken carcasses are
colonized with Campylobacter. - Infectious dose of Campylobacter is only 500
organisms, an amount easily present in one drop
of raw chicken juice.
30Quinolone Resistant Campylobacter
- Quinolone resistant Campylobacter infections
increased from 1.3 in 1992 to 10.2 in 1993. - Ciprofloxacin resistant Campylobacter was found
in 14 of chicken products in retail markets. - Molecular subtyping showed a link between
resistant Campylobacter in human infections and
domestic chicken products. - Smith KE. NEJM
19993501525-32. -
31FDA and Antibiotic Growth Promoters
- FDA made first steps to limit antibiotics as
growth promoters in 1977. - In a 2012 article in the Atlantic, the author
noted that the FDA has mastered the art of
making inaction look like action. - Francis Beinecke. The Failure of the
FDA -
32Antibiotics in Animal Feed
- 12/2013 FDA announced it will ask pharmaceutical
companies to voluntarily stop labeling
antibiotics important for human infection as
acceptable for growth promotion in animals. - Antibiotics would require an Rx for animal
illness - If it was mandatory, would require a regulatory
process that would take years. - Two largest companies, Zoetis and Elanco, have
given signals that they will comply.
33Good News from Perdue
- Perdue hatchery in Salisbury, Md. receives 1
million eggs a week, each egg was robotically
vaccinated against a common chicken virus and
gentamicin to prevent infection, even for
organic. - By improving sanitary practices, they announced
the gentamicin has been eliminated from all 15
hatcheries. - Feed antibiotics have been shifted to ionophores,
only sick chickens receive antibiotics in their
water (lt5).
34 35Health Food Outbreaks
- According to Center for Science in the Public
Interest (CSPI), sprouts are the 9th riskiest
food with 31 outbreaks and 2,000 reported cases
from 1990-2009. - In California in the 1990s, more than 50 of
Salmonella and E. coli 0157H7 outbreaks where a
food vehicle was confirmed were due to sprouts. - Banned from California schools in 2001.
- Salmonella species can survive for months under
dry seed storage conditions and increases 3-5
orders of magnitude during sprouting. -
36E. coli 0104H4
- 2011 outbreak from raw sprouts traced to an
organic farm in northern Germany. - Single lot of fenugreek seeds from Egypt was the
likely source . - 3,910 reported cases with 782 cases of HUS and 54
deaths 88 adults (median 42 yo), 68 women. - Frank C. NEJM 20113651771-80.
37Alfalfa Sprouts and Salmonella
- Alfalfa spout outbreaks have a preponderance of
adult cases (esp. women, 65-95). - Longer incubation period.
- Low recall of ingestion (cross contamination on
salad bars?). - UTIs (5-50 of isolates from urine).
-
38Can You Rinse Off E.coli 0157H7?
- Sprouts grown in contaminated water had an
increase in bacterial counts of 100,000 times
early in plant growth. - Mercury chloride disinfectant eliminated E.coli
from the outer surface within 10 minutes. - Half of the surface disinfected sprouts grew
E.coli 0157H7 when sliced. - The inner surface of the sprouts were colonized.
39Sprouts The Un Health Food
- As currently produced, raw sprouts are an
inherently dangerous food. - Mohle-Boetani J. Ann Int Med
2001135239-47.
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41Salmonella Serotype Enteritidis (SE) and Eggs
- Average US egg consumption 258 eggs/person or
- 65 billion/year.
- According to the CSPI, eggs are the 2nd riskiest
food with 352 outbreaks with 11,000 reported
cases from 1990-2009. - Estimated that only 1 in 38 infections are
reported - true estimate is 400,000 annual SE
infections. - 82 of the outbreaks were associated with raw or
undercooked shell eggs. -
42Salmonella and Eggs
- Hens have ovarian infections which contaminate
the egg interior, esp the yolk, difficult to
eliminate because of the contaminated
environments in chicken production facilities. - Current estimate is that 1 in 20,000 eggs are
infected in the U.S. or 2.2 million infected eggs
consumed each year - Most notorious outbreak resulted in estimated
225,000 cases from shipping ice cream in tanker
trailer trucks previously used to transport raw,
unpasteurized eggs. - Hennessey T. NEJM 19963341281-6.
43Salmonella and Eggs, 2010
- Outbreak with 1,519 cases of Salmonella
Enteritidis with the same PFGE pattern
(JEGX01.0004) was identified in July 2010. - Traced to Hillandale and Wright County Egg in
Iowa, over 550 million eggs were recalled. - Egg Safety Rules now require routine testing for
SE for all producers with 50,000 hens and egg
refrigeration within 3 days of laying (previously
only when packaged for the consumer).
44Safe Egg Practices
- No one should eat food containing raw eggs such
as shakes with raw eggs, Caesar salad,
Hollandaise sauce, homemade mayonnaise, ice cream
or egg nog. - Take special care with lightly cooked eggs in
omelets, French toast, lasagna and meringue pies.
45Safe Egg Practices
- Eggs should be cooked until the whites and yolks
are firm. - Salmonella can consistently be isolated from
experimentally contaminated eggs from fried sunny
side up, over easy, soft scrambled or boiled less
than 8 minutes. - Eggs should not be held at room temp and hard
boiled eggs should be refrigerated within 2
hours.
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47Raw Milk and Disease
- In the 1930s, raw milk was associated with 25 of
all food related outbreaks, fell to 1 with
universal pasteurization. - Unpasteurized products account for 30 of all
dairy product outbreaks 70 of milk related
outbreaks 148 from 1998-2011 with 248
hospitalizations. - Common source of Salmonella Dublin infections,
- E coli 0157H7, Yersinia, Listeria,
Tuberculosis, Brucella, Cryptosporidia, Q fever. - LeJeune J. Clin Infect Dis
20094893-100.
48Raw Milk Returns
- Raw milk movement involves 100,000s of people who
consume raw milk as health food, 1-3 in U.S. - FDA banned interstate sales in 1987 illegal in
15 states, but can be bought in 29 states and
sold in retail markets in 13 states. - 20-fold more cases reported in states that allow
raw milk. - 2013 AAP policy statement endorsed a ban on the
sale of raw or unpasteurized milk products,
including cheeses.
49Raw Milk Returns
- 2013 Campylobacter outbreak traced to the same
Pennsylvania dairy that had an outbreak with 148
reported cases in 2012 (est. 4,500 cases). - From 2005-13, 17 Salmonella and Campylobacter
outbreaks traced to raw milk in Pennsylvania
alone. - MMWR 201362702.
- Estimated 150-fold increased risk of foodborne
illness compared with pasteurized milk.
50Raw Milk Returns
- In Virginia, you can buy shares in a cow with raw
milk as your return on your investment. - Wisconsin outlawed cow sharing in 2001 after 75
people developed Campylobacter infections. - Sold by clandestine milk clubs and legally
shipped interstate as pet food. - Nutrition advocacy groups (Westin A. Price
Foundation) list sources at realmilk.com. - 40 bills to allow raw milk sales have been
introduced in 23 states.
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52E. coli O157H7
53Escherichia coli 0157H7
- First detected in 1982 from cases of hemorrhagic
colitis associated with hamburger consumption at
fast food restaurants. - Developed their pathogenic potential 30 years ago
with acquisition of a bacteriophage that carried
two shiga like toxins (SLTs). - Name derived from agglutination with antisera to
the somatic or O antigen 157 and the flagellar or
H antigen 7.
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55E.coli 0157H7 Epidemiology
- 20,000 annual cases of hemorrhagic colitis and
250 deaths. In many series, is more common than
Shigella. - 6-10 of children will develop Hemolytic Uremic
Syndrome (HUS), 50 will require dialysis, now
the leading cause of acute renal failure in
children. - Also responsible for many cases of Thrombotic
Thrombocytopenic Purpura (TTP) in adults.
56E.coli 0157H7 Epidemiology
- Low inoculum will cause infection, similar to
Shigella, with an infective dose of about 100
organisms. - Leads to person-to-person transmission,
especially in day care facilities. - Allows contamination of recreational water.
- Susceptibility to chlorine is normal.
57E.coli 0157H7 Clinical
- More than 90 of cases have bloody diarrhea.
- In some series, 20-30 of all person with bloody
diarrhea have E.coli 0157H7 infections. - Average case begins with non-bloody diarrhea for
one to two days, then a marked increase in
abdominal pain with the onset of bloody diarrhea
which usually prompts the provider visit. - Abdominal pain is prominent and can cause
confusion with ischemic colitis.
58E.coli 0157H7 Clinical
- Patients usually afebrile or have only a low
grade temperature and are only moderately
dehydrated. - Duration of illness is usually 4-6 days.
- If HUS is going to occur, it usually begins about
one week after the onset of diarrhea with pallor,
oliguria or anuria and edema.
59HUS Risk Factors Adults
- OR
- Fever 2.7
- Age gt 65 3.6
- Antibiotics 4.7
- WBC gt 20K 8.3
- Dundas S. Clin Infect Dis
200133923-31.
60Detection of Shiga Toxins
- An EIA has been developed to detect Shiga
toxin-producing E.coli (Premier EHEC assay
Meridian Diagnostics). - The EIA test had a 100 sensitivity and a 97
specificity compared to 60 and 100,
respectively, for the Sorbitol-MacConkey culture
method. - The EIA detected an additional 20 Shiga
toxin-producing E.coli that were non 0157H7. - Kehl KS. Jour Clin
Micro 1997352051-4. - Recent estimate is that 20-50 of all STEC
infections are due to non-O157. Johnson K. CID
2006431587-95. -
61E.coli 0157H7 and Antibiotics
- Prospective cohort study of 71 children under 10
y.o. with E.coli 0157H7 diarrhea. - 5 of the 10 children who developed Hemolytic
Uremic Syndrome received antibiotics. - In a mutlivariate analysis, use of antibiotics
had a relative risk of 17.3 fold for development
of HUS. - Wong CS. NEJM 20003421930-6
. - In one study, 62 of patients took an antibiotic
and 32 an antimotility agent 29 after
laboratory confirmation. - Nolson J. CID 2011521130-2.
62E.coli 0157H7 1993 Outbreak
- Severity of the 1993 outbreak led the USDA Food
Safety Inspection Service (FSIS) to declare
E.coli 0157H7 an adulterant in ground beef. - Meat and grocers groups sued the USDA.
- Federal judge in Texas sided with the USDA saying
E.coli 0157H7 was so harmful that the USDA was
correct. - In 2012, the USDA adopted a zero-tolerance policy
for 6 other serotypes.
63E.coli 0157H7 Prevention
- Thorough cooking is the most effective preventive
measure. - Currently, 25 of Americans cook hamburgers rare
or medium rare. - Core temperature of meat should reach 160 degrees
F to ensure eradication of the organism, meat
should be gray or brown and the juices clear (not
as reliable as 160 F). - Reliance on meat inspection is not currently
possible.
64Who Eats Pink Hamburger?
- Decreases with age
- (22 lt 30, 13 gt 60 y.o.)
- Increases with education
- (less than grade 12 12, college education 24)
- Increases with income
- (lt15,000 12, gt50,000 29)
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66Listeria
- Listeria has the highest case fatality ratio of
foodborne infections 17. - 2,000 annual cases with 450 deaths, mostly
sporadic cases. - Particularly dangerous for pregnant women,
neonates, - gt 60 y.o. and immunocompromised.
- Develop invasive infections with bacteremia and
meningitis.
67Listeria
- L. monocytogenes was grown from at least one food
specimen from 64 of the refrigerators and 11 of
all food samples of patients with invasive
disease. - Significant match between strains from food and
from patients, especially from ready-to-eat foods
(those intended to be eaten without further
cooking, such as cole slaw or pates). - More likely to have eaten undercooked hotdogs (12
times) or chicken (20 times). - Pinner R. JAMA 19922672046-50.
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69Listeriosis and Hot Dogs
- From August 1998 thru January 1999, at least 100
cases of Listeriosis and 20 deaths due to a rare
serotype (4b) were reported from 22 states. - Cases were traced to hot dogs (Ball Park franks
and deli meats from Bil Mar Foods, a subsidiary
of Sara Lee Corporation), which recalled 35
million pounds of meat. - MMWR 1999 471117-18.
-
70Turkey Deli Meat
- 54 cases of Listeriosis with 8 deaths, 3 pregnant
women had fetal deaths in multistate outbreak in
2002 traced to turkey deli meat. Gottlieb S.
Clin Infect Dis 20064229-36. - Led to recall of 30 million pound of products
resulted in new FDA testing program for
ready-to-eat meat. - Listeria grows at refrigerator temperatures in
these very long shelf life foods, 50 reported
outbreaks related to hot dogs and luncheon meats. - Irradiation not yet FDA approved for use with
ready-to-eat meat. -
71Listeria and Canteloupes
- 2011 outbreak traced to canteloupes from
Colorado-based Jensen Farms. - 147 reported infections with 33 deaths, 1
miscarriage from 28 states. - 86 were gt 60 y.o.
- Deadliest foodborne outbreak in 90 years.
- McCollum J. NEJM 2013369944-53.
72Advice for the Immunocompromised, Pregnant Women
and Older Adults
- Avoid all soft cheeses, including feta,
camembert, brie and blue veined cheeses like
Roquefort. - Cook hot dogs until internal temperatures reach
165. Cooking in the microwave is not
recommended. - Hot dogs can be kept unopened 2 weeks, opened one
week in refrigerator. - Avoid deli meats like salami, bologna, corned
beef, and liverwurst, unless cooked as in a hot
corned beef sandwich. - FDA Consumer Advisory
73Problems with Pot Pies
- ConAgra sells 100 million pot pies each year
(Banquet). - 10/07 Outbreak of Salmonellosis related to
Banquet Pot Pies with 181 cases reported from 33
states, estimated 15,000 became ill. - Pot pies are not ready-to-eat.
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75Pot Pies and Microwaves
- Microwave oven cook only one product at a time.
- Microwave on high. 1100 watt oven or more 4 to 6
minutes. Do not cook in microwave ovens below
1100 watts as potpie may not cook thoroughly.
Conventional oven preparation is recommended. - Let stand 3 minutes in microwave to complete
cooking. - Check that pot pie is cooked thoroughly. Internal
temperature needs to reach 165F as measured by a
food thermometer in several spots.
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77Safe Microwave Cooking
- Salmonella outbreaks from frozen not-ready-to-eat
chicken dinners E. coli out break from frozen
pizzas. - Microwaves produce short radio waves that
penetrate food about 1 inch, which excite water,
fat and sugar molecules to produce heat. - Heats food unevenly, should not be used to cook
raw foods, esp. frozen foods. - Use an instant read food thermometer should
reach 165 F, check in multiple places.
78Do You Know Your Wattage?
- Cooking instructions are based upon the power or
wattage of the microwave oven only 29 know the
wattage of their home and 13 outside the home
microwave. MMWR 2008571277-80. - Actual output may differ from manufacturers
rating and can deteriorate over time. - Testing Heat one cup of ice water on high.
- Boils in lt 2 minutes at least 1,000 watts, 2 ½
minutes is 800 watts and 3 or more 700 watts or
less. - www.microwaveovenfacts.com
79Food Irradiation
- Uses gamma rays from cobalt 60 with very short
wavelengths similar to ultraviolet light and
microwaves. - Gamma radiation does not elicit neutrons (the
sub-atomic particles which make substances
radioactive) - No radioactivity
produced. - Similar to microwaves most of the energy passes
through the food, the small amount that doesnt
is retained as heat.
80Safety of Irradiated Food
- More than 40 years of multi-species,
multi-generational animal studies have shown no
toxic effects from eating irradiated foods. - Irradiation produces so little chemical change in
foods that it is difficult to design a test to
determine if a food has been irradiated. Free
radicals and other compounds produced during
irradiation are identical to those formed during
cooking. - Endorsed by CDC, WHO, AMA.
81Irradiation of Meat
- Only FDA and USDA approved method known to
eliminate E.coli 0157H7, and reduce Listeria,
Salmonella, and Campylobacter. - National Center for Policy Analysis estimated
that if half of the highest risk food was
irradiated, foodborne illness would decline by
900,000 cases and 352 deaths would be averted.
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83Oysters and Vibrios
- Consumption of raw oysters has been consistently
associated with non-cholera Vibrio infections,
including V. parahemolyticus and V. vulnificus. - Rates of invasive Vibrio disease are 80 times
higher and mortality 200 times higher for those
with liver disease. - FDA proposed a ban on gulf oysters from warmer
months unless treated, put on hold due to
political pressure. - Compared to 2010-12, there was a 32 increase in
2013, highest rates since tracking began in 1996.
- MMWR
201463328-32.
84Oysters
- Oysters filter 2 gallons of water/hour,
Chesapeake Bay levels are at 1 of historic
levels. - Most Vibrio infections are associated with
oysters harvested in water with temperatures gt 71
F between March and November, primarily from Gulf
of Mexico. - Increasing outbreaks of V. parahemolyticus
gastroenteritis have been associated with change
from a cold-season oyster harvest to a year-round
harvest, Chesapeake Bay has seen an increase in
oyster farming and summer harvests.
85Oysters and Vibrios
- Nationally, there are an estimated 35,000 cases
annually. - California banned the sale of raw gulf oysters
(2/3 of all U.S. oysters) from April 1 October
31 in 2003 as too dangerous. - From 2003-2010, there were only 4 V. vulnificus
cases and no deaths in California.
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88Follow Your Mothers Advice
- Only Eat Oysters in a Month with an R
- Actually William Butler (1535-1618) said
- It is unreasonable and unwholesome in all months
that have not an r in their name to eat an
oyster.
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90Norovirus
- Noroviruses, a genus in the family Caliciviridae.
- Study has been limited because they can not be
grown in culture or in animal model. - Noroviruses are the most common viral cause of
food and waterborne outbreaks of acute
gastroenteritis, responsible for 30-50 of all
outbreaks 93 of all nonbacterial outbreaks. - Estimated 21 million cases annually in the US.
- Large outbreaks in nursing homes, hospitals and
cruise ships, strong winter seasonality
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92Norovirus Outbreaks
- 4 genogroups, gt20 genotypes, undergoes genetic
drift and shift similar to influenza virus. - Recent widespread increase in outbreaks with the
emergence of 2 new strains of GII norovirus. - MMWR 200756842-6.
- Median viral load in fecal specimens is gt
100-fold higher with GII as compared to GI
strains. - Chan M. Emerg Infect Dis
2006121278-80.
93Norovirus Infectivity
- Shed primarily in stool and vomitus for an
average of 4 weeks, with peak shedding 2-5 days
after infection with 100 billion virions in a
gram of stool. - Extremely contagious infectious dose 18 virions
(5 billion infectious doses/gram of stool, world
population 7 billion). - 30 of infections may be asymptomatic with viral
shedding.
94Norovirus Transmission
- Infected food handlers during preparation (70 of
outbreaks), esp. foods eaten raw (leafy
vegetables, fruits, shellfish) responsible for
75 of outbreaks. - Fecal contamination oysters from fishermen,
raspberries from fieldhands.
95Norovirus Outbreaks
- Nursing homes/hospitals 35
- Restaurants, parties, events 31
- Schools/day care centers 13
- Vacation settings/cruise ships 21
- Other 9
96Kaplans Criteria
- Median incubation 24-48 hours.
- Median duration 12-60 hours.
- gt50 with vomiting.
- No bacterial agent identified.
97Norovirus Diagnosis
- Diagnostic tests generally not available to
practicing clinician. - PCR of stool or vomitus is the preferred
technique Electron microscopy can also be used. - EIA of acute/convalescent serum specimens, not
recommended for clinical dx in sporadic cases. - CDC Viral Gastroenteritis Section 404 639 3577
calicinet_at_cdc.gov
98Norovirus Prevention
- Cruise ship voluntary isolation in cabin until
24-48 hours after sx have resolved. - Handwashing with soap and water, efficacy of
alcohol/hand sanitizers minimal to no activity. - Surface decontamination 5.25 sodium
hypochlorite (bleach).
99Norovirus Prevention
- Avoiding bare-hand contact with ready-to-eat
foods. - HCWs and food handlers exclude from work until
48-72 hours after sx have resolved. - Paid sick-leave programs.
100Norovirus Prevention
- Observational study of food workers in
restaurants found proper handwashing in only 27
of activities 16 when gloves were used. Green
L. J Food Prot 2006692417-23. - 20 admitted to having worked at least one shift
in the last year while ill with vomiting or
diarrhea. - Carpenter L. J Food Protect
2013762146-54. - Training and certification of kitchen managers in
appropriate food safety practices was assoc. with
decreased Norovirus outbreaks. - Hedberg C. J Food Protect
2006692697-702.
101Updated Norovirus Outbreak Management and Disease
Prevention Guidelines
- Hall A. MMWR 2011 60(RR03)1-15.
102FDA FSMA
- FDA Food Safety Modernization Act was passed in
January 2011. - Mandates adoption of control plans and increased
inspections with frequency determined by risk
based standards. - Development of food tracing systems.
- Provides mandatory recall authority (previously
voluntary for food producer).
103FDA FSMA Problems
- Does not regulate meat, poultry and egg products
(USDA control). - Cost 1.4 billion over next 5 years, but no
additional funds or fees were approved. - Concern about lack of funding and enforcement
House of Representatives cut 87 million from
2012 FDA food safety budget. - Small producers are exempt.
104Risky Behavior in the Kitchen
- CDC survey of 20,000 persons
revealed - 50 eat undercooked eggs.
- 20 eat pink hamburgers.
- 20 do not wash hands after handling raw meat or
chicken. - 20 do not wash a cutting board with soap or
bleach after using it to cut raw meat or chicken. - MMWR 199847
(No.55-4)33-42.
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106Clean, Separate, Cook, Chill
- Clean Wash hands and surfaces often.
- Separate Dont cross contaminate.
- Cook Cook to proper temperature.
- Chill Refrigerate promptly.
107CleanWash hands/surfaces often.
- Wash your hands at least 20 seconds.
- Wash your cutting boards, dishes, utensils and
counter tops with hot soapy water after preparing
each food item and before you go on to the next
food. - Use plastic or non-porous cutting boards.
- Consider paper towels for cleaning surfaces.
108Kitchen Sanitation
- 90 of kitchen cloths and 46 of kitchen sinks
had - gt 100,000 bacteria per cm2
- 15 of sponges and dishcloths grew Salmonella
with high rates of transfer to fingers. - Neat housekeepers had the highest bacterial
counts, using contaminated sponges all over. -
109Post-flush toilet bowl is cleaner than the
kitchen sink. Thats why your dog drinks from it.
He probably looks at you drinking from the
kitchen sink and thinks Humans. Thats just so
gross. Chuck Gerba Professor U. of Arizona.
- You could eat your dinner in a U.S. toilet.
- John Oxford Prof of Virology
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111Making Sponges Dishcloths Safe
- Soaking sponges or dishcloths in bleach for 5-10
minutes, rinsing and air drying three times/week
decreased bacterial counts by gt 99. - Spraying cutting boards and counter tops with
Clorox Clean-up (1.84) and wiping clean after 30
seconds had similar effects. - Rusin P. J Applied Microbiol
199885819-28.
112Making Sponges Dishcloths Safe
- Sponges soaked in raw wastewater and then
microwaved for 30 seconds at 100 power had
complete inactivation of E. coli. - Park D. J Environ Health
20066917-24. - Reports of sponges catching fire while being
microwaved sponges should be treated while damp
only.
113Separate Dont cross contaminate.
- Especially important with raw meat, poultry and
seafood. - Never place cooked food on a plate that
previously held raw meat, poultry or seafood.
114Cook Cook to proper temperature.
- Use a clean thermometer that measures the
internal temperatures of cooked foods to make
sure that meat, poultry and casseroles are cooked
all the way through. - Cook roasts and steaks to at least 145 degrees F
whole poultry to 160 degrees F. - Cook ground beef to at least 160 degrees F.
- Dont use recipes in which eggs remain raw or
partially cooked.
115Chill Refrigerate promptly.
- Refrigerate or freeze perishables, prepared foods
and leftovers within two hours or sooner. - The Thaw Law Never defrost food at room
temperatures. Thaw food in the refrigerator,
under cold running water or in the microwave.
Marinate foods in the refrigerator. - Divide large amounts of leftovers into small,
shallow containers for quick cooling in the
refrigerator.
116Rules for Leftovers
- 2 hours 2 inches 4 days
- 2 hours from oven to refrigerator.
- 2 inches thick to cool it quick.
- 4 days in the refrigerator otherwise freeze it.
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118Everything I eat has been proven by some doctor
or other to be a deadly poison and everything I
dont eat has proved to be indispensable for
life. But I go marching on.
119Food Safety Sources
- USDA Meat and Poultry Hotline 1-800-535-4555
- FDA Food Information Line 1-888-Safe Food
- FDA Food Safety Website www.cfsan.fda.gov
- Fight Bac! Web site www.fightbac.org
- Egg Nutrition Center www.enc-online.org
- Interstate Shellfish Sanitation Conference
- 142_at_ibm.net 1-803-788-7559