Foodborne Illness: Protecting Your Patients, Your Families and Yourself

1. Foodborne Illness:Protecting Your Patients, Your Families and Yourself Edward C. Oldfield, III, MD VAMDA Annual Conference September 13, 2014

3. “Serenely full, the epicure would say, Fate cannot harm me for I have eaten today.” Sydney Smith (1771-1845) Lady Holland’s Memoir

5. “Foodborne diseases continue to move newspapers and bowels around the world.” -RV Tauxe

6. 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; Don’t shoot the messenger.

7. 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 2000;283:1817

8. 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 2008;197:1709-12. • 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.

9. Foodborne Disease Pyramid Reportedto Health Department/CDC (reported. 1) Culture-confirmed case Lab tests for organism Specimen obtained Person seeks care Person becomes ill Exposurein the general population (estimated 36)

10. Foodborne Outbreaks • 2009-10: >1,500 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 2013;62:41-7.

11. 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% > 65 y.o. • Listeria has the highest case fatality ratio: 17%, with Vibrio second at 6%, and Salmonella at 0.5%.

12. 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 2010;50:397-404.

13. Diagnosis and Management of Foodborne Illness A Primer for Physicians MMWR 53 (No.RR-4):2004;1-29.

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

15. 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.

16. Foodborne Illness: Preformed Toxins Clostridium perfringens8-16 hour incubation • severe cramping abdominal pain, diarrhea, nausea • 24 - 48 hours duration • meats, gravy, poor temp control (70-140 F), “food service germ” Clostridium botulinum12-72 hour incubation • vomiting, diarrhea, blurred vision, diplopia, dysphaagia, descending paralysis. • home canned foods/low acid content.

17. 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.

18. Incubation Period:Viruses/Bacteria Noroviruses12 - 48 hour incubation • N/V/D (diarrhea more common in adults, vomiting in children). • duration:12 - 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)

20. Salmonella • Estimated 1.4 million annual infections, 168,000 physician visits, 85,000 hospitalizations, 550 deaths. • But only 40,000 (3%) reported through the passiveNational Salmonella Surveillance System. • Many vehicles of transmission: produce, eggs, poultry and other meats, direct animal contact.

21. 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%.

22. Salmonella Nomenclature • All Salmonella belong to 2 species, S. enterica and S. bongori with6 subspecies. • S. enterica (99% of human infections). • > 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.

23. 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.

25. 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 > 1 million foodborne infections a year. • Costco recalled rotisserie chickens (USDA does not allow Salmonella on ready-to-eat food).

26. 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.

27. 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.

28. 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%.

29. 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.

30. 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 1999;350:1525-32.

31. 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”

32. 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.

33. 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 (<5%).

35. “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 0157:H7 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.

36. E. coli 0104:H4 • 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 2011;365;1771-80.

37. 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).

38. Can You Rinse Off E.coli 0157:H7? • 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 0157:H7 when sliced. • The inner surface of the sprouts were colonized.

39. Sprouts: The “Un” Health Food “As currently produced, raw sprouts are an inherently dangerous food.” Mohle-Boetani J. Ann Int Med 2001;135:239-47.

41. 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.

42. 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 1996;334:1281-6.

43. 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).

44. 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.

45. 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.

47. 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 0157:H7, Yersinia, Listeria, Tuberculosis, Brucella, Cryptosporidia, Q fever. LeJeune J. Clin Infect Dis 2009;48:93-100.

48. 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.

49. 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 2013;62:702. • Estimated 150-fold increased risk of foodborne illness compared with pasteurized milk.

50. 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.