Food borne Diseases

1. Food borne Diseases

2. Bacterial: Bacillus cereus Brucella Campylobacter* Clostridium botulinum Clostridium perfringens E. coli O157:H7* E. coli, non-O157 STEC* E. coli, other diarrheagenic* Listeria monocytogenes* Salmonella Typhi Salmonella non-typhoidal Shigella Staphylococcus Streptococcus Vibrio cholerae, toxigenic* Bacterial (continued) Vibrio vulnificus* Vibrio, other* Yersinia enterocolitica* Parasitic Cryptosporidium* Cyclospora* Giardia* Taenia Toxoplasma* Trichinella Prions Viral Norwalk-like viruses* Rotavirus* Astrovirus* Hepatitis A Major identified foodborne pathogens, * Recognized as foodborne in last 30 years

3. The varied sources of foodborne pathogens

4. Disease Characteristics • Foodborne Disease and WIC Population • Epidemiology of pathogens • Disease in the WIC Population

5. Foodborne Illness and the WIC Population • Pregnancy places women in a temporary immune-compromised status • Certain pathogens, such as Listeria and Toxoplasmosis, have specific disease outcomes in pregnant women and their fetuses not seen in the healthy general population • Other pathogens, such as Yersenia, Shigella, and E. coli have specific implications in young children and can all be prevented with proper food handling and simple infection control procedures • Recent increases in infections due to contaminated produce items may shift the focus of food safety education to women, the main consumers of fresh produce items • Strict adherence to proper food handling techniques and attention to food safety may reduce the morbidity and mortality due to foodborne infections • Education of pregnant women and new mothers is essential to the reduce the occurrence food related illness in this population

6. Salmonella • Bacterial illness characterized by diarrhea, abdominal cramps, tenderness and fever. Two distinct syndromes, typhoidal (Salmonella Typhi) and non-typhoidal. Most cases of Salmonella in the US are non-typhoidalOver 2000 serotypes • Most Common serotypes and source of infection: • Enteritidis – contaminated egg products • Newport – beef, animal contact • Typhimurium – bovine products, poultry • Asymptomatic infections may occur • Reservoir: domestic and wild animals • Transmission: by ingestion of contaminated food items, contact with infected animals, or by fecal-oral person to person contact • Incubation period, 12-36 hours (range 6 hours to 7 days) • Infectious throughout the course of infection. A temporary carrier state can continue for months, especially in infants. • Prevention measures include improved sanitation, adequate personal hygiene, proper sewage treatment, exclusion of infected individuals as food-handlers and health care providers. In addition, the sale of pet turtles should be prohibited and the sale of other reptiles should be restricted. Eggs and other foods of animal origin should be thoroughly cooked.

7. Salmonella in the WIC Population • No specific risk to pregnant women except for the generic increase in susceptibility to all infections during pregnancy • Children are at an increased risk of infection due to immature immune systems and frequent hand-to-mouth contact • Many, if not all, amphibians and reptiles are colonized with Salmonella species. Contact with animals such as turtles, salamanders, and lizards put children at a increased risk of infection5 • It is estimated that some ~74,000 Salmonella infections annually in the US result from exposure to reptiles and amphibians5 • Wild and domestic animals may be colonized with Salmonella and show no signs of illness or infection. Contact with these animals increases the risk of infection. • Breast feeding may decrease the risk of sporadic Salmonellosis2

8. Shigella • Bacterial illness of variable severity characterized by diarrhea, fever, nausea, abdominal cramps, and tenesmus • Asymptomatic infections may occur. • Transmission: By ingestion of contaminated food or water or by fecal-oral person-to-person contact. Secondary household cases are common • Incubation period varies from 1 to 7 days • Infectious throughout acute infection and until agent is no longer present in feces, usually within 4 weeks after illness. Asymptomatic carriers are rare. Outbreaks are common in in daycare and school settings. • Prevention measures include improved sanitation and adequate personal hygiene. Hand washing should be encouraged and supervised in young children.

9. Shigella in the WIC Population • No specific risk to pregnant women except for the generic increase in susceptibility to all infections during pregnancy • Children are at an increased risk of infection due to immature immune systems and frequent hand-to-mouth contact • Shigella is spread easily from person to person and household contacts are quite common • Children in a daycare or school setting spread Shigella readily. Prompt infection control needs to be practiced to reduce morbidity. • Proper food handling techniques may reduce the incidence of foodborne infection with Shigella. • Hand washing, supervised in young children, will reduce the spread of Shigella.

10. Campylobacter • Illness characterized by diarrhea, cramps, malaise, fever, nausea, and vomiting • Reservoir: animals, most commonly cattle and poultry • Transmission: by ingestion of undercooked meat, contaminated food or water, or contact with infected animals • Incubation period: 2 to 5 days (range 1 to 7 days) • Cases are infectious throughout their course of infection (usually 2 to 5 days). Untreated cases may shed Campylobacter in their stool for up to 7 weeks

11. Campylobacter in the WIC Population • No specific risk to pregnant women except for the generic increase in susceptibility to all infections during pregnancy • Children are at an increased risk of infection due to immature immune systems and frequent hand-to-mouth contact • Campylobacter is the most common cause of bacterial gastroenteritis in the United States6 • Campylobacter has a disproportionately high burden in infants less than 1 year of age, with over twice the disease incidence of healthy adults3 • Proper food handling techniques and consumption of potable water may reduce the incidence of foodborne infection with Shigella.

12. Escherichia coli O157:H7 (STEC) • Shiga toxin producing E. coli (STEC) produce an illness characterized by diarrhea (often bloody) and cramps • May be complicated by Hemolytic Uremic Syndrome (HUS), mostly found in young children • Asymptomatic infections may occur • Reservoir: cattle and deer (humans may serve as a reservoir for person-to-person transmission) • Transmission: by ingestion of contaminated food or water, contact with infected animals, or through person-to-person contact with an infected case • Incubation period: 2 to 8 days • Prevention measures include improved sanitation, adequate personal hygiene and avoiding consumption of undercooked ground beef and unpasteurized dairy and fruit juice products

13. Sequence of events in E. coli O157:H7 infection E. coli O157 ingested 3-4 days Non-bloody diarrhea, abdominal cramps 1-2 days bloody diarrhea 94% 5 days 6% resolution HUS

14. Listeria monocytogenes • Illness characterized fever, muscle aches, and sometimes nausea or diarrhea • Infection can lead to many clinical syndromes including stillbirths, listeriosis of a newborn, meningitis, bacterimia, or localized infection • Asymptomatic infections are common • Reservoir: soil, forage, water, mud, and silage are the primary environmental reservoirs. Infected animals, foul, and humans may also serve as reservoirs • Transmission: by ingestion of contaminated food including (but not limited to) unpasteurized dairy products (soft cheeses in particular), ready-to-eat meats, raw vegetables, smoked fish, fermented raw meat sausages • Incubation period: 3 weeks • Listeria can grow and multiply at refrigeration temperatures

15. Listeria in the WIC Population • Pregnant women are at a 20% increased risk of contracting Listeria infection than the general population • Newborns suffer the serious health affects of infection in the mothers • Septic abortion • Stillbirth • Neonatal sepsis/meningitis • Most diagnosis made in third trimester of pregnancy • Speculated reasoning: Because most fetal deaths in the first and some in the second trimester are thought to be due to routing causes of miscarriage and the mothers/fetus are not tested for Listeria infection • Incidence of disease is highest among the Hispanic population, particularly in infants and women of child-bearing age7 • Hispanic infants had a 12-fold higher incidence of listeriosis than their non-Hispanic counterparts • Hispanic women had a 13-fold greater incidence than non-Hispanic women in the same age group • Prevention strategies should be targeted toward protecting infants and women of childbearing age in the Hispanic community

16. Listeria : General Recommendations • Thoroughly cook raw food from animal sources, such as beef, pork, or poultry • Separate raw meat, poultry, and seafood from vegetables and cooked or ready-to-eat foods • Wash hands, knives, and cutting boards after handling raw foods • Wash uncooked vegetables thoroughly before eating • Do not drink unpasteurized (raw) milk • Refrigerate perishable items that are precooked or ready-to-eat at 40° F or below and consume as soon as possible or freeze • “When in doubt, throw it out”. • Pay attention to “sell-by” and “use-by” dates • Store unopened hot dogs, deli meats, and luncheon meats no longer than 2 weeks in the refrigerator, or freeze them • Store opened hot dogs no longer than 1 week and opened deli meats and luncheon meats no longer than 3-5 days in the refrigerator • Use a refrigerator thermometer to make sure the temperature stays at 40° F or below • Clean the refrigerator regularly and right after spills of juices from hot dog packages or raw meat or poultry. Reference: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/listeriosis_g.htm

17. Toxoplasmosis • Illness caused by parasite Toxoplasma gondii • Infections generally mild and symptoms may include malaise, fever, fatigue and lymphadenopathy • Many infections are asymptomatic • Reservior: Cats and other felines. Intermediate hosts include swine, cattel, sheep, goats, rodents, and birds. • Transmission: Three primary ways humans are infected • Ingestion of undercooked infected meat • Ingestion of oocysts passed in feline feces through contact with litter or soil • Verticle transmission during pregnancy or delivery • Incubation period: Average 7 days, range 4 to 23 days • Infections in immunocomprimised are severe

18. Hepatitis A • Acute viral infection with fever, fatigue, malaise, loss of appetite, nausea, abdominal pain, dark urine, and jaundice • Severity of disease varies, asymptomatic infections are possible. • Reservoir: Humans • Transmission: Primarily foodborne. Sexual transmission can occur and rarely bloodborne transmission occurs. • Incubation period is usually 28 to 30 days • Highly infectious, requiring only a few virus particles to cause infection

19. Hepatitis A and the WIC Population • No specific risk to pregnant women except for the generic increase in susceptibility to all infections during pregnancy • Children are at an increased risk of infection due to immature immune systems and frequent hand-to-mouth contact • Severity of infection generally increases with age • Children rarely are symptomatic, they are however infectious and can easily infect household members • Disease is most common among school age children and young adults • Hepatitis A, even during the acute infectious period, is generally not a contraindication to breastfeeding • Special attention should be paid to infection control procedures in the home • Perinatal transmission of hepatitis A is rare, and there is no evidence for transmission through breast milk • In the US, sporadic transmission of Hepatitis A is frequent in daycare centers with diapered children • A vaccine is available and licensed for adults and children over the age of 2 years

20. How do we prevent foodborne disease? • There are no vaccines for most foodborne pathogens • Educating consumers, foodhandlers and producers is important, but not sufficient to reduce illness • Contamination of food products can occur from farm to table, at any step along the production chain • Use outbreaks and other investigations to learn how to prevent disease, through targeted prevention strategies • Educational campaigns to certain populations, i.e. the WIC population

21. On-farm sanitation, safety of animals' food and water biosecurity, and other "Good Agricultural Practices“ Production The chain of production from farm to table: A generic prevention scenario Processing Factory sanitation, quality control HACCP, inspection and other "Good Manufacturing Processes" {Pathogen Killing Step} Pasteurization, retort canning Foodhandler certification Consumer education, Restaurant inspection Final preparation and cooking This is where we target!

22. Core concepts in the surveillance of foodborne disease • Many different diseases can be caused by contaminated foods (More than 250 were listed in a 1981 manual) • For many of these diseases, the source of an individual case might be food, or it might be water, animal contact, or contact with other ill persons • For an individual case of illness, it is often impossible to know the source of the infection • Outbreaks are our best opportunity to learn the specific source of infection • We track individual cases of some diseases, regardless of whether or not they may be from food or other sources (pathogen or condition-specific surveillance) • We also track outbreaks of foodborne diseases, regardless of which microbe caused them (source-specific surveillance)

23. Food Safety • Food Safety is complex and requires a multifaceted approach to ensure success • Safe food handling can be broken down into four easy and user friendly steps • Clean • Separate • Cook • Chill • Fightbac – Great resource for educational materials regarding food safety and foodborne illness prevention http://www.fightbac.org

24. Food Safety: Clean • Clean: Wash hands and surfaces often • Wash hands in hot soapy water before preparing food and after using the bathroom, changing diapers and handling pets. For best results, consumers should use warm water to moisten their hands and then apply soap and rub their hands together for 20 seconds before rinsing thoroughly. • Wash cutting boards, knives, utensils and counter tops in hot soapy water after preparing each food item and before going on to the next one. • Use plastic or other non-porous cutting boards. Cutting boards should be run through the dishwasher - or washed in hot soapy water - after use. • Consider using paper towels to clean up kitchen surfaces. Or, if using cloth towels, consumers should wash them often in the hot cycle of the washing machine. Source: http://www.Fightbac.org

25. Food Safety: Separate • Separate: Don't cross-contaminate • Cross-contamination is how bacteria spreads from one food product to another. This is especially true for raw meat, poultry and seafood. Experts caution to keep these foods and their juices away from ready-to-eat foods. • Separate raw meat, poultry and seafood from other food in the grocery shopping cart. • Store raw meat, poultry and seafood on the bottom shelf of the refrigerator so juices don’t drip onto other foods. • If possible, use one cutting board for raw meat products and another for salads and other foods which are ready to be eaten. • Always wash cutting boards, knives and other utensils with hot soapy water after they come in contact with raw meat, poultry and seafood. • Never place cooked food on a plate which previously held raw meat, poultry or seafood. Source: http://www.Fightbac.org

26. Food Safety: Cooking • Food safety experts agree that foods are properly cooked when they are heated for a long enough time and at a high enough temperature to kill the harmful bacteria that cause foodborne illness. • Use a meat thermometer, which measures the internal temperature of cooked meat and poultry, to make sure that the meat is cooked all the way through. • Cook roasts and steaks to at least 145°F. Whole poultry should be cooked to 180°F for doneness. • Cook ground meat, where bacteria can spread during grinding, to at least 160°F. Information from the Centers for Disease Control and Prevention (CDC) links eating undercooked, pink ground beef with a higher risk of illness. If a thermometer is not available, do not eat ground beef that is still pink inside. Source: http://www.Fightbac.org

27. Food Safety: Cooking (continued) • Cook eggs until the yolk and white are firm, not runny. Don't use recipes in which eggs remain raw or only partially cooked. • Cook fish until it is opaque and flakes easily with a fork. • Make sure there are no cold spots in food (where bacteria can survive) when cooking in a microwave oven. For best results, cover food, stir and rotate for even cooking. If there is no turntable, rotate the dish by hand once or twice during cooking.Bring sauces, soups and gravy to a boil when reheating. Heat other leftovers thoroughly to 165°F. Source: http://www.Fightbac.org

28. Food Safety: Chill • Chill: Refrigerate properly and promptly • Refrigeration at 40°F or below is one of the most effective ways to reduce risk of foodborne illness • Microorganisms grow more rapidly at warmer temperatures, and research shows that keeping a constant refrigerator temperature of 40°F or below helps slow growth of these harmful microbes. • Use a refrigerator thermometer to be sure the temperature is consistently 40°F or below • The best way to make sure your refrigerator is maintaining the recommended temperature of 40°F or below is to check it with a refrigerator thermometer. This type of thermometer is usually a separate tool that stays in the refrigerator and displays the actual temperature. It is not a numbered dial that helps you adjust temperature. Refrigerator thermometers are available at grocery, discount and hardware stores and are recommended for all home refrigerators. Source: http://www.Fightbac.org

29. Food Safety: Chill (continued) • The Chill Factor. Refrigerate or freeze perishables, prepared foods and leftovers within two hours of purchase or use. Always marinate foods in the refrigerator. • The Thaw Law. Never defrost food at room temperature. Thaw food in the refrigerator. For a quick thaw, submerge in cold water in an airtight package or thaw in the microwave if you will be cooking it immediately. • Divide and Conquer. Separate large amounts of leftovers into small, shallow containers for quicker cooling in the refrigerator. • Avoid the Pack Attack. Do not over-stuff the refrigerator. Cold air must circulate to keep food safe. • Rotate Before It’s Too Late. Use or discard chilled foods as recommended in the USDA Cold Storage Chart found at http://www.foodsafety.gov/~fsg/f01chart.html. • Don’t Go Too Low. As you approach 32°F ice crystals can begin to form and lower the quality of some foods such as raw fruits, vegetables and eggs. A refrigerator thermometer will help you determine whether you are too close to this zone. Source: http://www.Fightbac.org

30. How to prevent the spread of illness Hand washing is the single most important way to prevent the spread of germs!!!!

31. How do I properly wash my hands? • Use soap and running water • Use lots of friction- for at least 10 seconds • Wash all surfaces, especially under nails and thumbs • Dry with a disposable paper towel • Turn off the faucet with paper towel • Discard paper towel

32. When should I wash my hands? • Before • Preparing or eating food • Treating a cut or wound • Tending to someone who is sick • After • Using the bathroom • Changing a diaper or helping a child in the bathroom • Handling raw meats, poultry or eggs • Touching pets • Sneezing or blowing your nose • Tending to someone who is sick or injured