Foodborne Illness: Protecting Your Patients, Your Families and Yourself

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Foodborne IllnessProtecting Your Patients,
Your Families and Yourself

• Edward C. Oldfield, III, MD
• VAMDA Annual Conference
• September 13, 2014

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Serenely 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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• Foodborne diseases continue to move newspapers
  and bowels around the world.
• -RV Tauxe

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Foodborne 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.

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Foodborne 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

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Reality 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.

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Foodborne 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)
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Foodborne 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.

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Foodborne 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.

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Foodborne 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.

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Diagnosis and Management of Foodborne Illness

• A Primer for Physicians
• MMWR 53 (No.RR-4)20041-29.

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Clues to Etiology of Foodborne Disease

• Time to symptom onset (incubation).
• Duration of illness.
• Predominant clinical symptoms.
• Population involved.
• Food type consumed.

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Foodborne 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.

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Foodborne 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.

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Foodborne 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.

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Incubation 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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Salmonella

• 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.

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Salmonella 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.

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Salmonella 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.

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Recent 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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USDA 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).

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USDA 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.

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Chicken

• 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.

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Antibiotics 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.

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Campylobacter

• 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.

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Quinolone 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.

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FDA 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

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Antibiotics 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.

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Good 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).

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Health 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.

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E. 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.

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Alfalfa 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).

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Can 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.

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Sprouts 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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Salmonella 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.

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Salmonella 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.

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Salmonella 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).

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Safe 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.

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Safe 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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Raw 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.

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Raw 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.

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Raw 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.

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Raw 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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E. coli O157H7
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Escherichia 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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E.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.

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E.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.

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E.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.

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E.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.

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HUS 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.

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Detection 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.

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E.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.

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E.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.

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E.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.

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Who 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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Listeria

• 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.

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Listeria

• 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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Listeriosis 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.

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Turkey 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.

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Listeria 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.

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Advice 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

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Problems 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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Pot 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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Safe 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.

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Do 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

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Food 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.

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Safety 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.

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Irradiation 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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Oysters 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.

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Oysters

• 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.

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Oysters 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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Follow 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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Norovirus

• 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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Norovirus 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.

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Norovirus 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.

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Norovirus 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.

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Norovirus Outbreaks

• Nursing homes/hospitals 35
• Restaurants, parties, events 31
• Schools/day care centers 13
• Vacation settings/cruise ships 21
• Other 9

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Kaplans Criteria

• Median incubation 24-48 hours.
• Median duration 12-60 hours.
• gt50 with vomiting.
• No bacterial agent identified.

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Norovirus 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

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Norovirus 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).

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Norovirus 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.

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Norovirus 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.

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Updated Norovirus Outbreak Management and Disease
Prevention Guidelines

• Hall A. MMWR 2011 60(RR03)1-15.

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FDA 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).

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FDA 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.

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Risky 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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Clean, Separate, Cook, Chill

• Clean Wash hands and surfaces often.
• Separate Dont cross contaminate.
• Cook Cook to proper temperature.
• Chill Refrigerate promptly.

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CleanWash 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.

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Kitchen 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.

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Post-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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Making 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.

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Making 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.

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Separate 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.

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Cook 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.

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Chill 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.

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Rules 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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Everything 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.

• George Bernard Shaw

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Food Safety Sources

• USDA Meat and Poultry Hotline [phone]
• 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