Prevention of Listeriosis Outbreaks in a High-Risk Food Service Setting How can an RD help?

1. Prevention of Listeriosis Outbreaks in a High-Risk Food Service SettingHow can an RD help? Presented by Anne Smith

2. What is Listeriosis? • A foodborne illness caused by ingesting the bacteria Listeria monocytogenes • Gram-positive bacillus • Found in water and soil, non-pasteurized milk and milk products, and on contaminated vegetation • Can also be found in infected animals who ingested the bacteria • Cold-tolerant; can survive and replicate in temperatures below 40oF • Can colonize on environmental surfaces • Can easily be killed by heat

3. L. monocytogenes Gram-positive bacillus

4. Who is at Risk? • Pregnant women and the fetus • Highest risk in third trimester • Can cause spontaneous abortion • Immunocompromised persons • Malignancies • Solid organ and bone marrow transplantations • Immunosuppressive therapy- HIV infection and AIDS • Neonates • Older adults • Kidney or liver disease • Alcoholism • Diabetic patients

5. Symptoms • Febrile gastroenteritis • Most common in healthy adults • Mild, flu-like symptoms • Fever, intense headaches, nausea, and vomiting • Bacteremia and meningitis • Most common in Immunocompromised • Miscarriage, stillbirth, premature delivery, or life-threatening infections in a newborn • 9%-30% can be fatal

6. What foods can be affected? • Cold ready-to-eat foods not heated before consumption • Delicatessen-style meats, hotdogs • Cold-prepared salads such as tuna salad or egg salad • Soft cheeses- feta, Brie, Camembert, blue-veined cheeses, or Mexican-style cheeses such as quesoblanco, queso fresco and Panela • Contaminated vegetables and animal products • Risk increases for durations of refrigeration

7. CDC Reported Outbreaks • 2011- Listeriosis Linked to Whole Cantaloupes from Jensen Farms, Colorado • 2012- Listeriosis Linked to Imported Ricotta Cheese • 2013- Listeriosis Linked to Crave Brother Farmstead Cheese • http://www.cdc.gov/listeria/outbreaks/index.html

8. Global Reported Outbreaks • US- 175 cases reported in 3 years • About 58/yr • Globally in 2006 • France- 290 • Germany- 508 • UK- 208 • Spain- 78 • Czech Republic- 78 • Netherlands- 64

10. Occurrences of Listeriosis in Healthcare • Fall 2003, UK • 5 pregnant women • 2 separate facilites • Contaminated sandwiches • February 2010, Texas • 10 cases in 7 months • 5 separate facilities • Contaminated diced celery • September 22, 2008, New York • 3 listeriosis cases at hospital X • 2 other cases identified later • Contaminated tuna salad

11. How is it identified? • Pulsed-field gel electrophoresis (PFGE) patterns

12. Our study Serving High-Risk Foods in a High-Risk Setting:Survey of Hospital Food Service Practices after an Outbreak of Listeriosis in a Hospital Carolyn Cokes, MPH, Anne Marie France, PhD, Vasudha Reddy, MPH, Heather Hanson, MPH, Lillian Lee, MS, Laura Kornstein, PhD, FainaStavinsky, MS, Sharon Balter, MD

13. Purpose “This report summarizes the outbreak investigation for Listeriosis in a NYC hospital as well as the results of a telephone survey of NYC hospitals that explored risk management practices for foodborne illnesses in hospital settings.” 5 cases of Listeriosis were reported from Hospital X in New York

14. Subjects • 4 male, 1 female • Median age was 62 years (range 52-92 yo) • All had medical conditions that put them at high-risk of Listeriosis • Complications from transplanted liver • Chiari syndrome • Chronic heart failure • Mitral valve disorder

15. Methods • 5 Methods of Investigation • Epidemiologic Investigation • Environmental Investigation • Laboratory Investigation • Hospital Survey • Statistical Methods

16. Epidemiologic Investigation • Medical record abstractions • Patient interviews • Onset dates • Clinical illness • Food history • Menus from hospital cafeteria • Reports posted to identify other related Listeriosis cases • CDC’s Epi-X communication site • PulseNet CDC Team electronic bulletin board

17. Environmental Investigation • 9/23/08-Full sanitary inspection- NYC OEI • Swabs of food-contact surfaces • 9/25/08- HACCP analysis based on prep reviews • Tuna salad and turkey sandwiches • 9/29/08- Samples collected • Environmental surface samples for Listerosisanalysis • 9/30/08 and 10/3/08- More samples • 25 samples from cooking/storage surfaces, kitchen equipment, vents, drains, and floors • 20 food samples- tuna, chicken, and egg salad

18. Laboratory Investigation • Clinical isolates from NYC cases submitted to PHL for analysis • All samples were analyzed for PFGE patterns • L. monocytogenes DNA was restricted using 2 enzymes • Ascl and Apal • Gels were uploaded to PulseNet for identification of related cases

19. Hospital Survey 61 acute care hospitals in NYC were asked to participate in a telephone survey, 54 responded January-April 2009 Section 1 Director of Infection Control • Prevalence of high-risk patients in comparison to total patients • Units available for high risk patients Section 2 Food Service Director • Focus on foods served • Food service practices and policies • Policies restricting service of items that present high risk

20. Statistical Methods • SAS software, version 9.1 • SAS Institute • P values • 2-sided • Calculated by Fisher exact test, x2 analysis or t test

21. Epidemiologic Results • Food histories • Pts 1-3 obtained by direct interview • Pt 4- no history, patient died • Pt 5- partial history from next of kin • Common foods- Tuna salad and sliced turkey • Pts 1-3- reported having both • Pt 5- most likely consumed both • Hospital did not keep copies of food orders • None of the 5 patients have been in rooms on the same floor at the same time

23. Laboratory Results • Contaminated samples • 4 samples of tuna salad • 1 can-opener sample • 1 floor drain sample • All 5 human isolates contained L. monocytogenes • No similar PFGE patterns were in PulseNet

24. PFGE

25. Environmental Results • Inspections showed no violations of NYC health codes • HACCP investigation showed tuna was held at 41oF for 4 days before being served • 2 environmental samples contained L. monocytogenes • Can opener base- opened the cans • Floor drain- located near 100 qt mixer • October 2009- all negative samples

26. Survey Results • 9 were public hospitals, 45 were private hospitals • 23 reported maintaining patient food orders • 8 kept records with patient charts • 29 reported outside food vendor contracts

27. Food Safety Practices "Despite the potential for severe outcomes of Listeria infection among hospitalized patients, the majority of NYC hospitals that participated in the food practice survey had no food preparation policies or practices to minimize risk for L. monocytogenes contamination." 

28. Foodborne Illness Risk Management Guidelines • Reported Raw fruits and vegetable use • 62% of Large hospitals reported not using raw F&V • Facilities with transplant pts less likely to report use of raw F&V • 75% with bone marrow transplant units • 100% with organ transplant units

29. Helpful Policies From the study: • Steam deli meats before serving • Do not serve soft cheeses • Use only cooked (irradiated) F&V components Other Suggestions: • Severely limit storage time of high-risk foods • Keep better food records for healthcare providers • Routine and thorough cleaning of food surfaces • Keep records of patient food orders and diet history • Test strips? • Contract out food service?

30. Role of the RD • Menu planning • Food purchasing planning, budgeting, and source approval • Education of food service workers on food safety • Daily/weekly dietary assessments of high-risk patients • Eurosurveillance- improve procedures • Computer system to track orders

31. Global Food Safety • Global Food Safety Initiative • Manufacturers • ServSafecertifications • Costly? • Australia’s Food Safety Guidelines • Safer food alternatives • Food Standards Agency –UK • Video learning

32. Comments • Stacy- “Do you think it is the role of the RD or DTR to monitor patient charts to prevent them from receiving potentially dangerous foods?  Listeria outbreaks are preventable with proper food safety practices, so do you believe better training of kitchen staff is more important than monitoring food ordered?”

33. Liz- “A computer based diet record and food ordering system should have flags that prevent at-risk persons of ordering risky items off the menu.  I know its possible to flag for such things as a "heart healthy diet" or "diabetic diet", why not create another category for "at-risk".   Other Comments?

34. References • Cokes, Carolyn, MPH, Anne Marie France, PhD, Vasudha Reddy, MPH, Heather Hanson, MPH, Lillian Lee, MS, Laura Kornstein, PhD, FainaStavinsky, MS, Sharon Balter, MD. “Serving High-Risk Foods in a High-Risk Setting: Survey of Hospital Food Service Practices after an Outbreak of Listeriosis in a Hospital.” Infection Control and Hospital Epidemiology. April 2011. Vol 32 No 4 • Denny, Justin, Jim McLauchlin. “Human Listeriamonocytogenes infections in Europe - an opportunity for improved European surveillance.” EUROSURVEILLANCE Vol. 13 · Issues 1–3 · Jan–Mar 2008. • http://www.health.ny.gov/diseases/communicable/listeriosis/fact_sheet.htm. Accessed online September 5, 2013. • http://www.cdc.gov/listeria/index.html. Accessed online September 5, 2013. • Dawson, SJ, MR Evans, D Willby, J Bardwell, N Chamberlain, DA Lewis. “Listeria outbreak associated with sandwich consumption from a hospital retail shop, United Kingdom.” Eurosurveillance, Volume 11, Issue 6, 01 June 2006. • Gaul, Linda Knudson, NohaFarag, Trudi Shim, Monica Kingsley, Benjamin Silk, EijaHyytia-Trees. “Hospital-Acquired Listeriosis Outbreak Caused by Contaminated Diced Celery—Texas, 2010”. Clin Infect Dis. (2013) 56 (1): 20-26 • http://www.food.gov.uk/. Accessed online September 9, 2013. • http://www.health.sa.gov.au/pehs/food-index.htm. Accessed online September 9, 2013.