Narciso Tapia, MD, MHPEd, RMT

FOODBORNE DISEASES

Foodborne disease
Caused by consuming contaminated foods or

beverages. Poisonous chemicals, or other harmful substances can cause foodborne diseases if they are present in food. Our focus is on those caused by organisms.

Foodborne disease
More than 250 different foodborne diseases

have been described. Most of these diseases are infections, caused by a variety of bacteria, viruses, and parasites that can be foodborne. Other diseases are poisonings, caused by harmful toxins or chemicals

Campylobacter
causes fever, diarrhea, and abdominal cramps. The most commonly identified bacterial cause of

diarrheal illness in the world. Live in the intestines of healthy birds Most raw poultry meat has Campylobacter on it. Eating undercooked chicken, or other food that has been contaminated with juices dripping from raw chicken is the most frequent source of this infection. Guillain-Barre syndrome can be caused by Campylobacter infection

Salmonella
is widespread in the intestines of birds, reptiles and mammals. can spread to humans via a variety of different foods of animal origin. Salmonellosis, typically includes fever, diarrhea and abdominal cramps. In persons with poor underlying health or weakened immune systems, it can invade the bloodstream and cause life-threatening

infections.

E.Coli O157: H7
has a reservoir in cattle and other similar

animals. Human illness typically follows consumption of food or water that has been contaminated with microscopic amounts of cow feces. The illness it causes is often a severe and bloody diarrhea and painful abdominal cramps, without much fever.

E.Coli O157: H7
In 3% to 5% of cases, a complication called

hemolytic uremic syndrome (HUS) can occur several weeks after the initial symptoms. This severe complication includes temporary anemia, profuse bleeding, and kidney failure.

Calicivirus
is an extremely common cause of foodborne

illness, though it is rarely diagnosed, because the laboratory test is not widely available. It causes an acute gastrointestinal illness, usually with more vomiting than diarrhea, that resolves within two days. Unlike many foodborne pathogens that have animal reservoirs, it is believed that Norwalklike viruses spread primarily from one infected person to another.

Calicivirus
Infected kitchen workers can contaminate a

salad or sandwich as they prepare it, if they have the virus on their hands. Infected fishermen have contaminated oysters as they harvested them.

But facilities available locally for bacteria.

So lets talk more of bacteria that cause

foodborne illness

Foodborne diseases
Foodborne by direct infection Foodborne through toxin

Foodborne through toxin

some foodborne diseases are caused by the

presence of a toxin in the food that was produced by a microbe in the food. For example, the bacterium Staphylococcus aureus
a toxin that causes intense vomiting.

Foodborne through toxin

The rare but deadly disease botulism occurs

when the bacterium Clostridium botulinum grows and produces a powerful paralytic toxin in foods. These toxins can produce illness even if the microbes that produced them are no longer there.

What happens in the body after the microbes that produce illness are swallowed?
After they are swallowed, there is a delay, called

the incubation period, before the symptoms of illness begin. may range from hours to days, depending on the organism, and on how many of them were swallowed. During the incubation period, the microbes pass through the stomach into the intestine, attach to the cells lining the intestinal walls, and begin to multiply there.

What happens in the body after the microbes that produce illness are swallowed?
Some types of microbes stay in the intestine, some produce a toxin that is absorbed into

the bloodstream, and some can directly invade the deeper body tissues.
The symptoms produced depend greatly on

the type of microbe.

What are foodborne disease outbreaks and why do they occur?

Occurs when
a group of people consume the same

contaminated food and two or more of them come down with the same illness.

It may be a group that

ate a meal together somewhere, or who do not know each other at all, but who all

happened to buy and eat the same contaminated item from a grocery store or restaurant.

What are foodborne disease outbreaks and why do they occur?

For it to occur, something must have

happened to contaminate a batch of food Often, a combination of events

A contaminated food may be left out a room

temperature for many hours, allowing the bacteria to multiply to high numbers, and then be insufficiently cooked to kill the bacteria.

How is a foodborne disease outbreak investigated?

Once an outbreak is strongly suspected, an investigation begins. A search is made for more cases among persons who may have been exposed. Determined:

The symptoms and time of onset, and location of possible cases is determined, and a "case definition" is developed that describes these typical cases.

The outbreak is systematically described by time, place, and person.

How is a foodborne disease outbreak investigated?

A graph is drawn of the number of people

who fell ill A map of where the ill people live, work, or eat. Calculating the distribution of cases by age and sex shows who is affected. If the causative microbe is not known, samples of stool or blood are collected from ill people and sent to the public health laboratory to make the diagnosis.

To identify the food or other source of the outbreak

The investigators first interview a few

persons with the most typical cases about exposures

In this way, certain potential exposures may be

excluded while others that are mentioned repeatedly emerge as possibilities.

Combined with other information, such as

the likely sources for the specific microbe involved, these hypotheses are then tested in a formal epidemiologic investigation.

To identify the food or other source of the outbreak

The investigators conduct systematic

interviews about a list of possible exposures with the ill persons, and with a comparable group people who are not ill. By comparing how often an exposure is reported by ill people and by well people, investigators can measure the association of the exposure with illness. Using probability statistics, the probability of no association is directly calculated.

To identify the food or other source of the outbreak

Once a food item is statistically implicated in

this manner, further investigation

into its ingredients and
preparation, and microbiologic culture of leftover ingredients or the

food itself (if available) may provide additional information about the nature of contamination.

To identify the food or other source of the outbreak

Some might think
that the best investigation method would be just

to culture all the leftover foods in the kitchen, and conclude that the one that is positive is the one that caused the outbreak.

can be misleading, because it happens after the fact.

Remember
Laboratory testing without epidemiologic

investigation can lead to the wrong conclusion.

Even without isolating microbes from food, a wellconducted epidemiologic investigation can guide immediate efforts to control the outbreak.

How does food become contaminated?

Many foodborne microbes are present in healthy animals (usually in their intestines) raised for

food. Meat and poultry carcasses can become contaminated

during slaughter by contact with small amounts of

intestinal contents.

Similarly, fresh fruits and vegetables can be contaminated

if they are washed or irrigated with water that is

contaminated with animal manure or human sewage.

How does food become contaminated?

Some types of Salmonella can infect a hen's ovary so that the internal contents of a normal

looking egg can be contaminated with Salmonella even before the shell in formed. Oysters and other filter feeding shellfish can concentrate
Vibrio bacteria that are naturally present in sea water, or other microbes that are present in human sewage

dumped into the sea.

How does food become contaminated?

Later in food processing, other foodborne

microbes can be introduced

from infected humans who handle the food, or
by cross contamination from some other raw

agricultural product.
For example, Shigella bacteria, hepatitis A virus and Norwalk virus can be introduced by the unwashed hands of food handlers who are themselves infected.

How does food become contaminated?

In the kitchen, microbes can be transferred

from one food to another food by

using the same knife, cutting board or other

utensil to prepare both without washing the surface or utensil in between.

A food that is fully cooked can become recontaminated if it touches other raw foods or drippings from raw foods that contain

pathogens.

How does food become contaminated?

The way that food is handled after it is

contaminated can also make a difference in whether or not an outbreak occurs. Many bacterial microbes need to multiply to a larger number before enough are present in food to cause disease.

How does food become contaminated?

Given warm moist conditions and an ample

supply of nutrients, one bacterium that reproduces by dividing itself every half hour can produce 17 million progeny in 12 hours.
As a result, lightly contaminated food left out

overnight can be highly infectious by the next day.

Refrigeration or freezing
In general, refrigeration or freezing prevents

virtually all bacteria from growing but generally preserves them in a state of suspended animation. This general rule has a few surprising exceptions.
Two foodborne bacteria, Listeria monocytogenes

and Yersinia enterocolitica can actually grow at refrigerator temperatures.

High salt, high sugar or high acid

High salt, high sugar or high acid levels keep

bacteria from growing,

which is why salted meats, jam, and pickled

vegetables are traditional preserved foods.

Heat
Microbes are killed by heat. If food is heated to an internal temperature

above 160oF, or 78oC, for even a few seconds

sufficient to kill parasites, viruses or bacteria, except

for the Clostridium bacteria, which produce a heatresistant form called a spore.

Clostridium spores are killed only at temperatures above boiling.

This is why canned foods must be cooked to a high

temperature under pressure as part of the canning process.

Heat
The toxins produced by bacteria vary in their

sensitivity to heat.
The staphylococcal toxin which causes vomiting is

not inactivated even if it is boiled. Fortunately, the potent toxin that causes botulism is completely inactivated by boiling.

What foods are most associated with foodborne illness?

Raw foods of animal origin are the most likely to be contaminated;
raw meat and poultry,
raw eggs, unpasteurized milk, and

raw shellfish.

Because filter-feeding shellfish strain microbes from the sea over many months, they are particularly likely to be contaminated if there are any pathogens in the seawater.

What foods are most associated with foodborne illness?

Foods that mingle the products of many

individual animals, are particularly hazardous because a pathogen present in any one of the animals may contaminate the whole batch.
such as bulk raw milk,

pooled raw eggs, or

ground beef,.

A single hamburger may contain meat from

hundreds of animals.

What foods are most associated with foodborne illness?

A single restaurant omelet may contain eggs

from hundreds of chickens. A glass of raw milk may contain milk from hundreds of cows. A broiler chicken carcass can be exposed to the drippings and juices of many thousands of other birds that went through the same cold water tank after slaughter.

What foods are most associated with foodborne illness?

Fruits and vegetables consumed raw are a

particular concern.
Washing can decrease but not eliminate

contamination. The quality of the water used for washing and chilling the produce after it is harvested is critical. Using water that is not clean can contaminate many boxes of produce.

What foods are most associated with foodborne illness?

Fresh manure used to fertilize vegetables can

also contaminate them. Unpasteurized fruit juice can also be contaminated if there are pathogens in or on the fruit that is used to make it.

What can consumers do to protect themselves from foodborne illness?

COOK
For example, ground beef should be cooked to an

internal temperature of 160o F

SEPARATE CHILL CLEAN REPORT

Bacteria causing foodborne infections

Bacillus cereus Brucella sp. Campylobacter spp. Clostridium botulinum Clostridium perfringens Escherichia coli
STEC, ETEC, EPEC, EIEC

Bacteria causing foodborne infections

Listeria monocytogenes Salmonella typhi Nontyphoidal salmonella Shigella sp. Staphylococcus aureus Streptococcus group A Vibrio cholerae, O1 or O139 Vibrio cholerae other serotypes Vibrio parahemolyticus Vibrio vulnificus Yersinia enterocolitica

Emerging diseases: diseases whose incidence has increased

within the past 2 decades or threatens to increase in the near future Global travel Irrigation, deforestation

globalization of food

supply and centralized processing of foods population growth and increased urbanization and crowding population movement due to civil wars, famines and other manmade or natural disasters

and reforestation projects that alter habits of disease-carrying insects Increased use of antimicrobial agents and pesticides, hastening the development of resistance Human habits and behavior

E. Coli O157:H7
Currently, there are four recognized classes of

enterovirulent E. coli (collectively referred to as the EEC group) that cause gastroenteritis in humans. Among these is the enterohemorrhagic (EHEC) strain designated E. coli O157:H7.

E. Coli O157:H7
E. coli serotype O157:H7 is a rare variety of

E. coli that produces large quantities of one or more related, potent toxins that cause severe damage to the lining of the intestine. These toxins [verotoxin (VT), shiga-like toxin] are closely related or identical to the toxin produced by Shigella dysenteriae.

Nature of disease
characterized by severe cramping (abdominal

pain) and diarrhea which is initially watery but becomes grossly bloody. Occasionally vomiting occurs. Fever is either low-grade or absent. The illness is usually self-limited and lasts for an average of 8 days. Some individuals exhibit watery diarrhea only.

Nature of disease
Infective dose -- Unknown, but from a compilation of outbreak data,
the dose may be similar to that of Shigella spp. (as

few as 10 organisms).

Course of disease and Complications

Some victims, particularly the very young,

have developed the hemolytic uremic syndrome (HUS),

characterized by renal failure and hemolytic

anemia.

The disease can lead to permanent loss of kidney function.

Course of disease and Complications

In the elderly, thrombotic thrombocytopenic purpura (TTP).
HUS, plus two other symptoms, fever and neurologic

symptoms, constitutes This illness can have a mortality rate in the elderly as high as 50%.

All people are believed to be susceptible to hemorrhagic colitis, but young children and the elderly appear to progress to more serious symptoms more frequently.

Associated food
Undercooked or raw hamburger (ground

beef) Others implicated

alfalfa sprouts, unpasteurized fruit juices, dry-cured salami, lettuce, game meat, and cheese curds.

Raw milk was the vehicle in a school outbreak

in Canada.

Diagnosis
Hemorrhagic colitis is diagnosed by isolation

of E. coli of serotype O157:H7 or other verotoxin-producing E. coli from diarrheal stools. Alternatively, the stools can be tested directly for the presence of verotoxin. Confirmation can be obtained by isolation of E. coli of the same serotype from the incriminated food.

Food analysis
Unlike typical E. coli,
isolates of O157:H7 do not ferment sorbitol and are negative with the MUG assay; therefore, these criteria are commonly used for

selective isolation.

Sorbitol-MacConkey agar has been used extensively to isolate this organism from clinical specimens. Hemorrhagic colitis agar, a selective and

differential medium, is used in a direct plating method to isolate O157:H7 from foods.

Food analysis
A third procedure uses Sorbitol-MacConkey

medium containing potassium tellurite and Cefixime. It includes an enrichment step Rapid methods using a variety of technologies, including recombinant DNA methods, are being developed.

Yersinia enterocolitica
a small rod-shaped, Gram-negative bacterium, is often isolated from clinical specimens such as

wounds, feces, sputum and mesenteric lymph nodes. However, it is not part of the normal human flora. Yersiniosis is frequently characterized by such symptoms as
gastroenteritis with diarrhea and/or vomiting; however, fever and abdominal pain are the hallmark

symptoms.

Yersinia enterocolitica
Yersinia infections mimic appendicitis and

mesenteric lymphadenitis. Illness onset is usually between 24 and 48 hours after ingestion

Associated food
Strains of Y. enterocolitica can be found in
meats (pork, beef, lamb, etc.), oysters, fish, and raw milk.

The exact cause of the food contamination is unknown.

Associated food
However, the prevalence of this organism in

the soil and water and in animals such as beavers, pigs, and squirrels, offers ample opportunities for it to enter our food supply. Poor sanitation and improper sterilization techniques by food handlers, including improper storage, cannot be overlooked.

Diagnosis
Stool culture is the best way to confirm a

diagnosis of Yersinia enterocolitica. The culture result is usually positive within 2 weeks of onset of disease. Instruct the laboratory to plate enteric specimens onto enteric media, with incubation at 25C for 48 hours.

Diagnosis
If Y enterocolitica is suspected,
cold enhancement techniques or cefsulodin-irgasan-novobiocin (CIN) agar should be

used.
Colonies deep red center with clear colorless zone, 1-2 mm in diameter

Confirmation occurs with

the isolation, as well as biochemical and serological identification, of Y. enterocolitica from both

the human host and the ingested foodstuff.

Diagnosis
Presumptive biochemical ID
LIA: alkaline/acid (no gas, H2S -negative) Urease -positive

Other biochemical tests:

Motility test medium (semisolid) Y. ent. are motile at 25C (2 left tubes) and nonmotile at 35C ( 2 right tubes)

Diagnosis
Other biochemical tests:
Lipase test. When grown on agar media containing egg yolk such as Anaerobic egg yolk agar, colonies may exhibit lipase activity. A positive reaction is indicated by oily, iridescent, pearl-like colony surrounded by precipitation ring and outer clearing zone.

Diagnosis
Identification
use of API 20 E system
Determination of pathogenicity is more

complex.

presumptive pathogenic Y. enterocolitica: esculin and salicin negative

YERSINIA ENTEROCOLITICA
Pathogenicity testing
Pyrazinamidase test(PYZ)*
Congo Red Magnesium Oxalate (CR-MOX)*

Crystal Violet binding Test

Autoagglutination test# Freezing Cultures# DNA colony hybridization

Listeria monocytogenes
a Gram-positive bacterium, motile by means of flagella. Some studies suggest that 1-10% of humans may be intestinal carriers of L. monocytogenes. It has been found in at least
37 mammalian species, both domestic and feral, 17 species of birds and possibly some species of fish and shellfish.

Listeria monocytogenes
It can be isolated from soil, silage, and other environmental sources. is quite hardy and resists the deleterious

effects of freezing, drying, and heat remarkably well for a bacterium that does not form spores.

Listeria monocytogenes
some reports suggest that normal, healthy

people are at risk,

although antacids or cimetidine may predispose.

Its ability to grow at temperatures as low as

3C permits multiplication in refrigerated foods.

Listeria monocytogenes
has been associated with such foods as
raw milk, supposedly pasteurized fluid milk, cheeses

(particularly soft-ripened varieties), ice cream, raw vegetables, fermented raw-meat sausages, raw and cooked poultry, raw meats (all types), and raw and smoked fish.

Listeria monocytogenes
The manifestations of listeriosis include
septicemia, meningitis (or meningoencephalitis), encephalitis, and intrauterine or cervical infections in pregnant

women,
which may result in spontaneous abortion (2nd/3rd trimester) or stillbirth.

Listeria monocytogenes
The infective dose of L. monocytogenes is

unknown but is believed to vary with the strain and susceptibility of the victim. From cases contracted through raw or supposedly pasteurized milk, it is safe to assume that in susceptible persons, fewer than 1,000 total organisms may cause disease.

Listeria monocytogenes
Food analysis complex and time consuming Identification based on: Gram stain, gray colonies with halo on PALCAM Hemolysis on BAP, narrow zone of beta hemolysis, Motilitytumbling motility, end to end with characteristic inverted test tube brush on semi solid agar Catalase positive Absence of hydrogen sulfide Hemolysis by CAMP test using test organisms Blue colonies by Henrys illumination API Listeria Serotyping: 1/2a, 1/2b and 4b commonly reported in outbreaks

Go to video of tumbling motility

PALCAM agar

Campylobacter jejuni
a Gram-negative slender, curved, and motile rod. It is a microaerophilic organism,
it has a requirement for reduced levels of oxygen.

It is relatively fragile, and sensitive to environmental stresses (e.g., 21% oxygen, drying, heating, disinfectants, acidic conditions). Because of its microaerophilic characteristics the organism requires
3 to 5% oxygen and 2 to 10% carbon dioxide for optimal growth

conditions.

Campylobacter jejuni
leading cause of bacterial diarrheal illness in

the United States.

It causes more disease than Shigella spp. and

Salmonella spp. combined.

causes diarrhea, which may be watery or

sticky and can contain blood (usually occult) and fecal leukocytes (white cells).

Campylobacter jejuni
Other symptoms often present are fever,

abdominal pain, nausea, headache and muscle pain. The illness usually occurs 2-5 days after ingestion of the contaminated food or water.

Campylobacter jejuni
The infective dose of C. jejuni is considered to

be small.
about 400-500 bacteria
in others, greater numbers are required.

The pathogenic mechanisms still not

completely understood, but it does produce a heat-labile toxin that may cause diarrhea. may also be an invasive organism.

Associated foods
frequently contaminates raw chicken.
20 to 100% of retail chickens are contaminated. This is not overly surprising since many healthy

chickens carry these bacteria in their intestinal tracts.

Raw milk is also a source of infections. The bacteria are often carried by healthy cattle

and by flies on farms. Non-chlorinated water may also be a source of infections. However, properly cooking chicken, pasteurizing milk, and chlorinating drinking water will kill the bacteria.

Recovery from food

Isolation from food is difficult
because the bacteria are usually present in very

low numbers (unlike the case of diarrheal stools).

The methods require

an enrichment broth containing antibiotics,

special antibiotic-containing plates and a

microaerophilic atmosphere

with 5% oxygen and an elevated concentration of carbon dioxide (10%).

Campylobacter jejuni

Campylobacter jejuni

Other procedures for cheese products available in Bacteriological Analytical Manual (FDA)

Isolation procedures
is usually present in high numbers in the diarrheal stools of individuals,

Cultured on Skirrows medium with vancomycin, trimethoprim, cephalothin, polymixin and amphoteracin B Failure to grow at 25C, oxidase positive and sensitivity to nalidixic acid
The optimal temperature for growth is 42C for

C jejuni, and 37C for many of the other enteric Campylobacters.