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A Review of Foodborne Illness

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Title: A Review of Foodborne Illness


1
A Review of Foodborne Illness an Outbreak
Investigation that Lead to a Product Recall
  • Rashid A. Chotani, MD, MPH
  • Assistant Professor Director
  • Global Infectious Disease Surveillance Alert
    System (GIDSAS)
  • Center for International Emergence, Disaster
    Refugee Studies
  • Johns Hopkins Schools od Medicine Public Health
  • Phone 410-614-8330
  • E-mail rchotani_at_jhsph.edu

2
Significance
  • Foodborne illness is one of the largest
    preventable public health problem in the world
  • In the US it causes an estimated 9,000 deaths/yr
    (CDC)
  • 6.5 to 81 mil cases of diarrheal disease/yr
  • Most of the infections go undiagnosed unreported

3
Sequelae
  • Guillain-Barre Syndrome (C. jejuni)
  • Renal Disease (E. coli O157H7 and other
    Shiga-like toxin producing bacteria)

4
Contributing Factors
  • Poor foodhandler hygiene (inadequate handwashing,
    open wounds, etc.)
  • Inadequate cooking of raw products or holding
    temperatures
  • Cross contamination (equipment/work
    surface/hands)
  • Improper cooking
  • Food obtained from an unsafe source
  • Inadequate washing of fresh produce
  • Others

5
Events and potential contamination sources during
produce processing
Event Contamination
sources Production and harvest Growing,
picking, bundling Irrigation
water, manure,
lack of field sanitation
Initial processing Washing, waxing,
sorting, boxing Wash water, handling

Distribution Trucking Ice,
dirty trucks Final processing Slicing,
squeezing, shredding, peeling Wash water,
handling,
cross-contamination


6
Enteric Host Defense
  • Saliva
  • Gastric Acid
  • Intestinal motility
  • Enteric flora
  • Shedding replication of epithelium
  • Mucus layer
  • Immune system
  • Proteolytic enzymes

7
Changing Patterns of Foodborne Diseases
  • Newly identified pathogens, routes vehicles
    (e.g. increasing frequency of outbreaks
    associated with consumption of raw fruits
    and vegetables)
  • Increasing complexity of of foodborne disease
    outbreaks
  • Old Outbreak Scenario New Outbreak Scenario
  • acute local diffuse multi-state
    inter
  • dose attack rate high dose attack rate
    low
  • detected by groups detected by lab-based
    surveillance

8
Factors in the Emergence of Foodborne Diseases
  • Changes in agricultural practices
  • New methods of food processing, especially mass
    production
  • Globalization of food industry
  • Changes in consumer behavior
  • Changes in consumer susceptibility
  • Epidemiology laboratory

9
FoodNet
10
The Foodborne Disease Activity Surveillance
Network
  • Established in 1995 in 5 states - Minnesota,
    Oregon, Georgia, California, and Connecticut MD
    NY joined the program in 1997
  • Foodborne disease component of Emerging
    Infections Program (EIP)
  • Collaborative project
  • CDC
  • EIP states
  • USDA
  • FDA
  • Active surveillance system

11
FoodNet Goal
  • Determine monitor the burden of foodborne
    diseases
  • Determine the proportion of foodborne diseases
    attributable to specific foods
  • Develop a network to respond to new emerging
    foodborne diseases

12
FoodNet Components
  • Active lab-based surveillance
  • Surveys of clinical labs
  • Survey of physicians
  • Survey of the population
  • Case-Control studies

13
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14
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15
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16
Classification
17
Definition
  • Poisoning results from eating foods containing
    poisons (chemicals or toxins)
  • Infections result from eating food containing
    pathogenic microorganisms
  • Toxin a poison produced by a living organism
  • Intoxication disease caused by consumption of
    food containing toxins

18
Epidemiologic Triad
Agent
Host
Environment
19
Mechanisms of foodborne Agents
  • Preformed toxin in food rapid onset of nausea,
    vomiting, and cramps e.g. S. aureus and Bacillus
    cereus emetic syndrome
  • Direct tissue invasion inflammatory diarrhea
    (often fever /or bloody stool) e.g. Salmonella,
    Shigella, Campylobacter, Vibrio parahaemolyticus,
    Yersinia, and Entamoeba histolytica

20
Mechanisms of foodborne Agents
  • Enterotoxin producing in the gut
    noninflammatory (watery) diarrhea e.g.
    Clostridium perfringens, Bacillus cereus diarrhea
    syndrome, Vibrio cholerae, and Enterotoxigenic E.
    coli
  • Neurotoxin producing e.g. Clostridium
    botulinum mushroom, shellfish, ciguatera fish
    and puffer fish poisioning

21
Etiologic Agents of foodborne Disease
  • 1.Bacteria
  • S. aureus, B. cereus, C. perfringens, C.
    botulinum, E. coli, Salmonella, Shigella,
    Streptococcus, Brucella, Listeria monocytogenes,
    Yersinia sp. Campylobacter sp. Vibrio sp., others
  • 2. Parasites
  • Protozoa
  • Giardia, Cryptosporidium, Entameoba histolytica,
    Toxoplasma gondii, Cylospora, others
  • Helminths
  • Trichinella spiralis, Tapeworms (e.g. taenisis,
    cysticercosis), others.

22
Etiologic Agents of foodborne Disease
  • 3.Virus
  • Hepatitis A, Norwalk virus Norwalk like
    viruses, others
  • 4. Intoxicants Chemical Poisons
  • a) Poisonous plant tissue (jimson weed, rhubarb
    leaves)
  • b) Poisonous animal tissues (puffer fish, blow
    fish, moray eels)
  • c) Mycotoxins and poisonous fungi (ergot
    alkaloids, trichothecenes, zearalenone,
    alfatoxins, poisonous mushrooms)
  • d) Dinoflagellate toxins (ciguatera fish
    poisoning, shell fish poisoning
  • f) Chemicals (pesticides, heavy metals, MSG,
    drugs, nitrates)
  • g) Others

23
Bacteria
  • Single cell organisms
  • Multiply by single division can multiply in
    foods
  • Most common cause of foodborne outbreak
  • Some can produce resistant strains
  • Some may produce toxins in food or gut

24
Parasites
  • Live on another organism (host)
  • Transmitted through food water
  • Do not multiply outside host
  • Some require favourable environment to become
    infectious (e.g. Cyclospora)

25
Viruses
  • Obliterate intracellular organisms
  • Require host cell to multiply
  • Do not produce toxins or multiply in food
  • Reservoirs are humans

26
Foodborne disease Case Investigation
  • I. Sources of case report
  • II. Goals of foodborne illness case investigation
  • III. Information collection
  • Demographics
  • Illness information
  • Exposure information
  • Miscellaneous information
  • IV. Interventions public health actions

27
Source
  • Public
  • Laboratory reports
  • Healthcare providers
  • Health departments
  • Other state departments

28
Goal
  • Prevent transmission
  • Early detection
  • Understanding outbreak disease epidemiology
  • Evaluate food safety programs
  • Identify high risk food processes

29
Information
  • Timing is ESSENCE
  • Designate team leader
  • Assign responsibilities
  • Obtain maximum information on first contact
  • Use standardized form

30
Information
  • Demographic
  • Name, address, phone no., age, occupation, gender
  • Illness
  • Symptoms, onset, duration, have they been to a
    physician
  • Name, Dx, Lab tests, results, Tx
  • Exposure
  • 72 hour food history
  • What was eaten, who else was there, when was the
    meal eaten, where was the meal eaten, was there
    anything unusual

31
Definition
  • The occurrence of more cases of disease than
    expected in a given area or among a specific
    group of people over a particular period of time
  • Single case is considered an outbreak (inclusive)
  • Anthrax, botulism, brucellosis, cholera,
    diptheria, encephalitis, measles, plauge, polio,
    psisticosis, human rabies, rubella, trichinosis,
    typhoid fever, hepatitis A, H. influenza type b,
    or meningococcal disease

32
Interpretation of Outbreak Curves
  • Common source transmission
  • Occur via point, intermittent or a continuous
    source
  • Propagated transmission
  • Person-to-person transmission
  • Cases increase gradually and than decrease
    gradually (uncommon foodborne outbreak)

33
Point Source Outbreak
10
8
6
Catered event
of Cases
4
2
0
4/1/01
4/2/01
4/3/01
4/4/01
4/5/01
4/6/01
4/7/01
4/8/01
Days
34
Intermittent Source Outbreak
10
8
6
of Cases
4
2
0
4/1/01
4/2/01
4/3/01
4/4/01
4/5/01
4/6/01
4/7/01
4/8/01
4/9/01
4/10/01
Days
35
Continuous Source Outbreak
10
8
6
of Cases
4
2
0
4/1/01
4/2/01
4/3/01
4/4/01
4/5/01
4/6/01
4/7/01
4/8/01
4/9/01
4/10/01
Days
36
Propagated Source Outbreak
10
8
6
of Cases
4
2
0
4/1/01
4/2/01
4/3/01
4/4/01
4/5/01
4/6/01
4/7/01
4/8/01
4/9/01
4/10/01
4/11/01
4/12/01
4/13/01
Days
37
Analytical EpidemiologyMeasures of association
Case-Control Study
  • Odds Ratio (OR) odds of exposure in cases
  • odds of exposure in controls
  • ill well
  • Ate suspected YES a b
  • Food item? NO c d
  • OR ad/bc
  • Done when you CANNOT
    interview everyone

38
Analytical EpidemiologyMeasures of association
Cohort Study
  • Relative Risk (RR) attack rate in exposed
  • attack rate in non-exposed
  • ill well
  • Ate suspected YES a b
  • Food item? NO c d
  • RR (a/ab)x100 / (c/cd)x100
  • Done when you CAN interview everyone

39
  • A Foodborne Outbreak of Gastroenteritis in a
    Teaching Hospital

Reference Chotani et al. SHEA Annual Meeting 1998
40
Hospital
  • 940 bed hospital with 4 cafeterias.
  • Cafeteria A, located in the OPD, serves
    approximately 600 visitors and employees daily.

41
Events
  • On 12/9/97 individuals who ate at Cafeteria A
    reported nausea and projectile vomiting after
    eating a noon meal.

42
Method case definition
  • Any person who ate lunch prepared at cafeteria A
    on December 9, 1997 and developed sudden onset of
  • vomiting or
  • diarrhea or
  • abdominal cramps
  • and
  • Any of the following symptoms including nausea,
    fever, body aches, headache, chills or fatigue.

43
Method case finding
  • We identified all cases who identified
  • individuals who ate with them.
  • All non-Ill persons were used as
  • controls.
  • Additional cases were found when we contacted
  • Nurse managers
  • Hospital managers
  • Directors of nursing, functional unit directors,
    JHH vice-presidents
  • Several employee groups were notified via e-mail
    and asked to identify cases.

44
Methods questionnaires
  • Standard questionnaires were
  • used to obtain medical and food
  • history from
  • Food service workers
  • Ill and non-ill employees
  • Menu reviewed at Cafeteria A.

45
Control Measures and Interventions Cafeteria A
  • Cafeteria
  • Kitchen was inspected
  • Leftover foods recovered and cultured
  • Food preparation, kitchen cleaning procedures
    reviewed
  • Certain food items quarantined
  • Employees were interviewed, inspected for sores,
    boils, cuts, IV tract marks and sent to
    occupational health services
  • We obtained nares swabs
  • 3 cafeteria staff members submitted stool samples
    or rectal swabs
  • All staff (n17) were questioned daily for
    symptoms

46
Laboratory
  • Food was processed in standard fashion
  • Blood agar plate R/O Bacillus
  • CAN plate R/O Staphylococcus
  • Plates for enteric pathogens
  • R/O
  • Salmonella, Shigella, Aeromonas, Campylobacter,
    Yersinia
  • Samples sent to city, state, FDA, and commercial
    laboratory
  • Sequencing preformed
  • Heavy metal testing

47
Results
  • N 75 (ill 40 non-ill 35)
  • Mean age 39 years (range 25-56)
  • Sex 85 female

48
Incubation period JHH employees (n40)
49
Symptoms
50
Results outcomes
  • Duration of illness mean--24 hr.
    (range lt24 - 72 hr.)
  • Bedridden 62.5
  • Sought medical care 27.5
  • Hospitalized 2.5

51
Results univariate analysis
  • Food item OR CI 95 p-value
  • Green beans 36.4 6.93,341.60 lt0.0001
  • Tortellini 5.50 1.03, 54.50 0.02
  • Corn soup 0.23 0.04, 1.10 0.03
  • Veg soup 0.23 0.04, 1.10 0.03
  • Not associated bread, breadsticks, chicken
    salad, broccoli salad, cheese salad, caesar
    salad, havarti cheese, swiss cheese, beef stew,
    Thai beef, couscous, honey turkey, chicken
    fingers, cheese pizza, sausage pizza, chow mein
    noodles, marinated tomatoes, onions, mixed
    greens, cucumbers, dressing tomato-bacon/peppercor
    n, creamy, sunflower seeds, crackers, chips,
    cookies, yogurt, and fresh fruits

52
Results multivariate analysis
  • Variable OR CI 95 p-value
  • Green beans 1.84 1.49,2.27 lt0.005
  • Tortellini 1.25 0.98,1.59 NS
  • Corn soup 0.89 0.69,1.16 NS
  • Veg soup 0.93 0.71,1.21 NS

53
Results laboratory
  • Bacillus sp. recovered from garlic mix
    (opened/unopened jars), Moroccan beef stew and
    vegetable soup.
  • Bacillus subtilis was identified based on the
    library profiles.
  • Heavy metals negative.
  • Patient/employees culture negative.

54
Food preparation
  • Frozen green beans steamed for 10 minutes.
  • Seasoned with salt, pepper, olive oil and garlic
    mix.
  • Baked in oven for 15 minutes at 375 OF.
  • Stored in warmer at 180 degrees.
  • Placed in pan and sent to serving line (140
    degrees) maximum time 4 hours.

55
Summary
  • 40 persons became ill after eating green beans.
  • We under-estimated magnitude of problem because
    case ascertainment difficult.
  • The symptoms pointed to a toxin mediated illness.
  • The process of preparing green beans with garlic
    (in soy oil base) most likely led to the illness.
  • Bacillus was isolated from opened/unopened jars.

56
Conclusions
  • FDA
  • Inspected the manufacturing facility
  • Inspected food supplier
  • Ordered recall of all garlic jars produced by
    company A
  • Mandated new control protocols
  • Aggressive control measures should be taken to
    prevent the spread of any outbreak particularly
    in a hospitals in order to protect not just the
    patients but the staff.
  • Rarely bacillus subtilis has been associated in
    food poisoning.

57
  • Thank you
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