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Foodborne Illness: Protecting Your Patients, Your Families and Yourself


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Title: Foodborne Illness: Protecting Your Patients, Your Families and Yourself

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

Foodborne Illness
  • 3 facts about foodborne illness lectures
  • Always topical always an outbreak to talk about.
  • High level of interest (personal and
  • Remember I am only the messenger Dont shoot the

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

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
  • 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

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)
Foodborne Outbreaks
  • 2009-10 gt1,500 reported outbreaks with 30,000
  • 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.

Foodborne Disease, U.S.
  • Salmonella was the leading cause of
    hospitalizations (35), followed by norovirus
  • 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

Foodborne Disease and LTCFs
  • Up to 50 of all foodborne outbreaks occur in
  • 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

Diagnosis and Management of Foodborne Illness
  • A Primer for Physicians
  • MMWR 53 (No.RR-4)20041-29.

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

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.

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.

Foodborne Illness Preformed Toxins
  • Ciguatera onset 2-6 hours
  • reef fish (grouper, red snapper, amberjack,
    barracuda) contaminated by toxin from
  • GI and Neurologic sx
  • Scombroid onset minutes-hours.
  • spoiled fish (bluefish, tuna, mackerel)
  • Histamine reaction N/V, skin flushing, throbbing
    HA, wheezing.

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
  • Salmonella (1 - 3 days)
  • Shigella (1 - 2 days)
  • Campylobacter (2 - 5 days)
  • EHEC (1 - 8 days)

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  • Estimated 1.4 million annual infections, 168,000
    physician visits, 85,000 hospitalizations, 550
  • 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.

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
  • Salmonella caused the most deaths (28), but had
    an overall low case fatality rate of 0.5.

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

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).

USDA Legally Challenged
  • In 1974, APHA sued the Secretary of Agriculture
    because it did not warn consumers about
  • 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
  • Denmark and Sweden have a zero-tolerance policy.

  • 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.

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.

  • 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.

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

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

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
  • 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.

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
  • By improving sanitary practices, they announced
    the gentamicin has been eliminated from all 15
  • Feed antibiotics have been shifted to ionophores,
    only sick chickens receive antibiotics in their
    water (lt5).


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.

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.

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).

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.

Sprouts The Un Health Food
  • As currently produced, raw sprouts are an
    inherently dangerous food.
  • Mohle-Boetani J. Ann Int Med

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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
  • true estimate is 400,000 annual SE
  • 82 of the outbreaks were associated with raw or
    undercooked shell eggs.

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.

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).

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.

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

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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
  • Common source of Salmonella Dublin infections,
  • E coli 0157H7, Yersinia, Listeria,
    Tuberculosis, Brucella, Cryptosporidia, Q fever.
  • LeJeune J. Clin Infect Dis

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.

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
  • MMWR 201362702.
  • Estimated 150-fold increased risk of foodborne
    illness compared with pasteurized milk.

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
  • 40 bills to allow raw milk sales have been
    introduced in 23 states.

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E. coli O157H7
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
  • 6-10 of children will develop Hemolytic Uremic
    Syndrome (HUS), 50 will require dialysis, now
    the leading cause of acute renal failure in
  • Also responsible for many cases of Thrombotic
    Thrombocytopenic Purpura (TTP) in adults.

E.coli 0157H7 Epidemiology
  • Low inoculum will cause infection, similar to
    Shigella, with an infective dose of about 100
  • Leads to person-to-person transmission,
    especially in day care facilities.
  • Allows contamination of recreational water.
  • Susceptibility to chlorine is normal.

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.

E.coli 0157H7 Clinical
  • Patients usually afebrile or have only a low
    grade temperature and are only moderately
  • 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.

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

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
  • 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

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.

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
  • In 2012, the USDA adopted a zero-tolerance policy
    for 6 other serotypes.

E.coli 0157H7 Prevention
  • Thorough cooking is the most effective preventive
  • 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

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 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,
  • gt 60 y.o. and immunocompromised.
  • Develop invasive infections with bacteremia and

  • 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
  • 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.

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.

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.

Advice for the Immunocompromised, Pregnant Women
and Older Adults
  • Avoid all soft cheeses, including feta,
    camembert, brie and blue veined cheeses like
  • Cook hot dogs until internal temperatures reach
    165. Cooking in the microwave is not
  • 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

Problems with Pot Pies
  • ConAgra sells 100 million pot pies each year
  • 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
  • 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
  • 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.

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

Food Irradiation
  • Uses gamma rays from cobalt 60 with very short
    wavelengths similar to ultraviolet light and
  • Gamma radiation does not elicit neutrons (the
    sub-atomic particles which make substances
  • No radioactivity
  • Similar to microwaves most of the energy passes
    through the food, the small amount that doesnt
    is retained as heat.

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
  • Endorsed by CDC, WHO, AMA.

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

  • Oysters filter 2 gallons of water/hour,
    Chesapeake Bay levels are at 1 of historic
  • 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.

Oysters and Vibrios
  • Nationally, there are an estimated 35,000 cases
  • 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

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  • 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
  • Chan M. Emerg Infect Dis

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

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.

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

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

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

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).

Norovirus Prevention
  • Avoiding bare-hand contact with ready-to-eat
  • HCWs and food handlers exclude from work until
    48-72 hours after sx have resolved.
  • Paid sick-leave programs.

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
  • Carpenter L. J Food Protect
  • Training and certification of kitchen managers in
    appropriate food safety practices was assoc. with
    decreased Norovirus outbreaks.
  • Hedberg C. J Food Protect

Updated Norovirus Outbreak Management and Disease
Prevention Guidelines
  • Hall A. MMWR 2011 60(RR03)1-15.

  • 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).

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.

Risky Behavior in the Kitchen
  • CDC survey of 20,000 persons
  • 50 eat undercooked eggs.
  • 20 eat pink hamburgers.
  • 20 do not wash hands after handling raw meat or
  • 20 do not wash a cutting board with soap or
    bleach after using it to cut raw meat or chicken.
  • MMWR 199847

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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.

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
  • Use plastic or non-porous cutting boards.
  • Consider paper towels for cleaning surfaces.

Kitchen Sanitation
  • 90 of kitchen cloths and 46 of kitchen sinks
  • 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.

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

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
  • Reports of sponges catching fire while being
    microwaved sponges should be treated while damp

Separate Dont cross contaminate.
  • Especially important with raw meat, poultry and
  • Never place cooked food on a plate that
    previously held raw meat, poultry or seafood.

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.

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

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

Food Safety Sources
  • USDA Meat and Poultry Hotline 1-800-535-4555
  • FDA Food Information Line 1-888-Safe Food
  • FDA Food Safety Website
  • Fight Bac! Web site
  • Egg Nutrition Center
  • Interstate Shellfish Sanitation Conference
  • 1-803-788-7559