Food Borne Illnesses and more

1
Food Borne Illnesses and more
Marlene Gaither EH Program Manager CCPHSD
2
CDC Statistics say...

• 200 known diseases are transmitted through food.
  They include viruses, bacteria, parasites,
  toxins, metals, and prions.
• 31 million foodborne illnesses annually
• Majority are caused by viruses
• 3000 deaths annually
• 2014 4,400 hospitalizations
• Main transmission - fecal/oral route

3
CDCs 2015 FBI Progress Report
4
Who is responsible for reporting communicable
diseases? Under , a health care provider, an
administrator of a health care facility or
correctional facility, an administrator of a
school, child care establishment, or shelter, or
their authorized representatives shall submit a
communicable disease report to the local health
agency. Violation of reporting rules is a class
III misdemeanor and is subject to referral to the
facility's licensing agency or provider's state
licensing board.
5
Communicable Disease Code R9-6-203. Reporting
Requirements for an Administrator of a School,
Child Care Establishment, or Shelter

• . An administrator of a school, child care
  establishment, or shelter shall submit a report
  by telephone that includes
• 1. The name and address of the school, child care
  establishment, or shelter
• 2. The number of individuals with the disease,
  infestation, or symptoms
• 3. The date and time that the disease or
  infestation was detected or that the symptoms
  began
• 4. The number of rooms, grades, or classes
  affected and the name of each

6
Reporting Requirements

• 5. Individual information
• a. Name
• b. Date of birth or age
• c. Residential address and telephone number and
• d. Whether the individual is a staff member, a
  student, a child in care, or a resident
• 6. The number of individuals attending or
  residing at the school, child care establishment,
  or shelter and
• 7. The name, address, and telephone number of the
  individual making the report.
• Records to health dept/district does not violate
  hippa!

7
Disease Reporting Requirements

8
FDA Foodborne Illness Report Major Risk Factors
(CDC)

• Improper Holding Temperature
• Inadequate Cooking
• Contaminated Equipment
• Unsafe Food Source
• Poor Personal Hygiene

9
Foods Associated w/Foodborne Outbreaks
10
Food Borne Disease

• There are more illnesses associated with the
  consumption of food than all other environmental
  factors combined.

11
CDC- Top 5 Pathogens
Pathogen Estimated number of illnesses 90 Credible Interval
Norovirus 5,461,731 3,227,0788,309,480 58
Salmonella, nontyphoidal 1,027,561 644,7861,679,667 11
Clostridium perfringens 965,958 192,3162,483,309 10
Campylobacter spp. 845,024 337,0311,611,083 9
Staphylococcus aureus 241,148 72,341529,417 3
Subtotal     91
12
SALMONELLA
13
Salmonella spp.

• Disease Bacterial - about 2,000 known serotypes
• Reservoir Poultry, swine, cattle, rodents,
  turtles, lizards, cats, dogs, humans
• Food Raw meats, poultry, eggs, dairy products
• Infective Dose 15 to 20 cells
• Incubation period 6 to 48 hours

14
Salmonella

• Symptoms Nausea, vomiting, abdominal cramps,
  diarrhea, fever, and headache
• Duration 1 to 2 days or longer
• Associated foods Raw meat, poultry, eggs, dairy,
  seafood, frogs, yeast, coconut, peanut butter,
  chocolate, sauces salad dressings.
• Frequency 2 to 4 million cases annually

15
Salmonella Cases

• 2014 Georgia High School Sports banquet
• 56 probable cases
• Suspect food smoked chicken
• 2012 five schools in Illinois
• Infected cook at commercial kitchen preparing
  meals for schools
• 2005 at two elementary schools
• 40 probable cases 26 confirmed
• Science clubs dissecting owl pellets did not
  sanitize table where snacks were consumed

16
SHIGELLA
17
Shigella sp.

• Agent - Gram negative bacillus that causes an
  infection (involving large and distal small
  intestines)
• Reservoir/Occurrence - Humans/Worldwide
• Infective dose As few as 10 cells
• Transmission - fecal/oral route in food and water
• I.p.- 1-3 days

18
Shigella

• Symptoms - fever, nausea, vomiting, cramps and
  tenesmus (spasmodic contractions), diarrhea with
  mucus and blood (due to ulcers)
• Incidence - 300,000 cases annually in US
• CFRs depend on host, but is as high as 20
  causes 600,000 deaths/yr worldwide

19
Shigella Outbreak

• 2010 West Virginia at 3 elementary schools
• 105 cases not fatalities
• Transmission occurred at school and at home

20
Escherichia coli
21
Escherichia coli 0157H7

• Agent - Gram negative rod shaped bacteria
  produces a toxin-mediated infection (cytotoxins -
  Shiga toxins) Elaboration of toxins depends on
  presence phage. Bacteria attach to intestinal
  mucosa
• Reservoir/Occurrence - Cattle/N.America,Europe,Aus
  tralia, Japan, S.Africa and a portion of
  S.America

22
E. coli

• Infective Dose 10 to 15 cells
• Transmission - Cross-contamination of infected
  meat, consumption of undercooked meat,
  fecal/oral, waterborne
• I.p. - 3-4 days
• Symptoms - abdominal cramps, low grade fever,
  profusely bloody diarrhea, may develop into HUS

23
E. Coli Cases

• July 2015 in Wisconsin elementary school
• 19 students ill
• No source has been determined
• Summer 2014 in Milwaukee Sizzler sickened 60
  people with one fatality 3 year old girl
• E. coli found in raw ground meat that was
  transferred to watermelon and other salad bar
  items

24
Campylobacter jejuni
25
Campylobacter jejuni

• Disease Campylobacterosis - curved, and motile
  rod-shaped bacteria
• Reservoir Cattle, chickens, birds, and flies
• Infective dose 400 to 500 cells
• Incubation period 2 to 5 days
• Symptoms Watery, stick or bloody diarrhea
  fever abdominal pain nausea headache, muscle
  pain

26
Campylobacter

• I.p. - 2-5 days
• Symptoms - diarrhea, abdominal pain, malaise,
  fever, nausea vomiting
• CFR - 1 in 1,000 will die 4 to 6 million
  cases/yr in US

27
Hepatitis A
28
Hepatitis Vaccination TWINRIX Vaccine
Age Dose (ELISA units)2 Volume (mL) No. of doses Schedule
18 yrs 720 1.0 3 0, 1, 6 mos
18 yrs 720 1.0 4 0, 7, 2130 days 12 mos3 CDC 2015
29
What is Norovirus?

• The genus contains multiple strains
• Single-stranded RNA, non-enveloped, cannot be
  cultured
• Genus Norovirus, family Caliciviridae (used to be
  known as Norwalk-like virus)
• (CDC, 2006 Gerba, 2001)

30
What do we know about Norovirus?

• Causes acute gastrointestinal illness in humans
• Noroviruses are highly contagious (both diarrhea
  and vomit contain the virus)
• Infective dose may be as few as 10 viral
  particles
• CDC, 2006

31
Occurrence of Norovirus

• CDC Norovirus leading cause of AGI in U.S.
• 21 Million per year
• 800 deaths
• 50 more illnesses when a new strains introduced
  
• CDC, 2013

32
Testing for Norovirus

• Reverse-transcriptase polymerase chain reaction
  (RT-PCR)
• Sequencing to determine strain
• CDC, 2006

33
Symptoms of Norovirus

• Onset Often begins suddenly within 1 to 2 days
  after exposure, but can occur w/in 12 hours and
  lasts 1 to 2 days
• Symptoms Abdominal cramps, nausea, vomiting
  (projectile) and diarrhea some may experience
  low-grade fever, chills, headache muscle aches
• Death is rare common complication is
  dehydration
• CDC, 2006

34
Is there Immunity to Norovirus?

• There is evidence that suggests that immunity may
  be strain specific and lasts for only a few
  months
• Individuals are likely to be repeatedly infected
  throughout their lifetimes
• Recent evidence also suggests that susceptibility
  may be genetically determined with people of 0
  blood type experiencing more severe infections
• CDC, 2006

35
Carriers of Norovirus

• Studies with volunteers given stool filtrates
  have shown that asymptomatic infection may occur
  in as many 30
• The walking ill
• CDC, 2006

36
Treatment

• To date, there are no antiviral treatments or
  vaccine for norovirus
• Treatment Replacement of fluids and
  electrolytes (prevent hyponatremia)
• CDC, 2006

37
How does Norovirus spread?

• Transmission Fecal/oral route involving food,
  water, person-to-person
• Evidence exists for transmission to occur through
  aerosolization of vomitus that results in
  droplets contaminating surfaces or entering the
  oral mucosa and being swallowed
• A person will begin shedding the virus with the
  start of symptoms and continue to shed the virus
  for two weeks after recovery
• CDC, 2006

38
Modes of Transmission Include Fomites
39
What are Fomites?

• Inanimate objects involved in the spread of
  disease

40
Enteric Bacteria (Coliforms) in the Home by
Location
Bath Sink
Cutting Board
Kitchen Sink
Sponge
Bath Floor
Kitchen Floor
Bath Counter
Toilet Seat
Charles P. Gerba Departments of Soil, Water and
Environmental Science and Epidemiology and
Environmental Health Univeristy of Arizona
Tucson, AZ
Charles P. Gerba Departments of Soil, Water and
Environmental Science and Epidemiology and
Environmental Health Univeristy of Arizona
Tucson, AZ
41
Teaching The Germiest Profession?

• The most bacteria per square inch was found on
  surfaces commonly used by school teachers

Measures taken of the phone, desk and computer
mouse.
Charles P. Gerba Department of Soil, Water and
Environmental Science and Epidemiology and
Environmental Health Univeristy of
Arizona Tucson, AZ
42
Sites with the Highest Percent of Coliforms in
all Schools its not the Restroom!!
Site Percent of sites positive for Coliforms
Desk 59
Computer Mouse 57
Cafeteria Table 55
Library Table 53
Bathroom Sink Faucets 36
Water Fountain 33
Keyboard 33
Bathroom Paper Towel Handle 29
Charles P. Gerba Department of Soil, Water and
Environmental Science and Epidemiology and
Environmental Health Univeristy of
Arizona Tucson, AZ
43
Impact of Disinfectant Wipes on Absenteeism
-Seattle

• Study
• Two school semesters
• 3rd and 4th graders
• Intervention
• Childrens desk wiped with a disinfectant wipe at
  the end of each school day
• Results
• 50 reduction in absenteeism
• Bright et al, 2010 J. School Nursing

44
How long can Norovirus survive in the Environment?

• Studies indicated that Norovirus may survive
• Up to 4 weeks in cold surface water can
  survive freezing temps
• Temps up to 1400F
• Up to 10 ppm free chlorine
• 4 weeks or more as long as 56 days (Gerba, 2005)
  on surfaces including slot machine handles (Calif
  Resort 04) , door knobs, lavatory faucets, toilet
  lids, refrigerator door handles (Gerba, 2005)
• CDC, 2006

45
Sanitizing Surfaces

• Recent studies indicate that
• Contaminated fingers can contaminate up to 7
  surfaces
• Combined chlorine detergent using 5,000 ppm
  chlorine (1 part bleach per 8 parts water for
  2,500 ppm w/5-7 available CL) reduced
  contamination of surfaces to 28
• Best Method Wash with detergent followed by
  chlorine/detergent combination
• NAU Wrestling Outbreak samples
• (J. Barker, I. Vipond, S. Bloomfield, 2004)

46
Interactive Exercise

• Hot Springs Elementary School K-8 with 350
  students and teachers
• On Monday morning a student vomits in a 5 grade
  classroom
• What are your first steps?
• Who should be contacted?
• What other information is needed?

47
Tuesday

• The next day a student vomits in the school
  cafeteria and 4 students and two teachers are
  home with AGI
• What needs to be done?
• Who should be contacted?
• What other information is needed?
• What are some of your resources?

48
Wednesday

• 20 students in grades 4th 5th are ill and four
  more teachers from 4th 5th grade classrooms
  called in sick with AGI, and a Lunch Monitor was
  experiencing AGI
• A teacher with AGI went to a clinic and they
  stated it was the 24 hour flu
• More students are falling ill at school and the
  high school across the street has 10 with AGI
• What control measures may be taken to control the
  spread?
• What do you think the causative agent might be?

49
Thursday

• ¼ of the students are ill
• ½ of the cafeteria servers are ill
• It has spread to other grades
• What do you do?
• Who do you contact?
• Who will make lunch?

50
Actual Case

• 2005 several high school wrestling teams from
  California attended a wrestling camp at NAU
  staying in the dorms
• July 18th One student became ill with AGI late
  one evening
• July 20th ED reported to Health District 3
  students were ill with vomiting, diarrhea
  dehydration (two severely dehydrated)

51
NAU Case

• July 21st HD visited wrestling camp and
  interviewed students and 40 more students were
  ill
• Samples were collected swabbed surfaces door
  knobs, toilet and lavatory handles and stool
  samples were collected

52
Outbreak Spreads

• Wrestling students are vomiting at lunch buffet
  and at Sky Dome on wrestling pads
• Students from other camps are becoming ill and
  NAU cafeteria staff are ill
• 115 individuals were ill (53) from the wrestling
  camp no fatalities
• Outbreak peaked on July 20th

53
Response

• An emergency operation center was set-up at NAU
• Sample results were positive for norovirus
  toilet seats, bathroom sinks, door knobs and
  stool specimens
• Surfaces were disinfected using 5,000ppm chlorine
• Spread through fomite surfaces and airborne from
  vomiting