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Foodborne Infectious Disease

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Brian Guhl

on 25 February 2014

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Transcript of Foodborne Infectious Disease

2003 - Chi Chi's Restaurant; Hepatitis A
- Over 650 confirmed cases occurred in October 2003 associated with contaminated green onions

- 4 people died
2006 - Dole Spinach; E.coli O157:H7
- Resulted in a nationwide recall of all fresh bagged spinach

- 205 cases spanning 26 states

- 31 cases of HUS

- 4 deaths
2006 - Taco Bell/Taco Johns; E.coli O157:H7
- 158 cases attributed to contaminated lettuce between the two restaraunts

- No Deaths

- Resulted in stricter food handling laws in California
2009 - Salmonella
- 714 cases spanning 46 states

- Resulted in the largest food recall in national history

- Largest foodborne outbreak since a Milk-borne Salmonella outbreak in 1985 involving 16,000 cases
1985 - Jalisco Cheese; Listeria
- Jalisco Cheese company uses unpasteurized milk to make cheese product

- 142 confirmed cases of Listeriosis in an 8 month span

- The Listeria outbreak caused the death of 10 adults, 18 infants, and 20 still-births.
1993 - Jack in the Box: E.coli O157:H7
- Between November 1992 to February 1993,

- 4 states (Washington, Idaho, Nevada, and California) reported 708 cases of bloody diarrhea caused by E.coli O157:H7

- 41 cases of HUS

- 4 children died
Worst Foodborne Outbreaks in Recent US History
Foodborne Infectious Disease
Review U.S. historical outbreaks
Review common causal organisms
Briefly review current methods of prevention
Understand surveillance organizations role in food safety
Listeria Microbiology
• Gram-positive rod; often mistaken for diphtheroids, streptococci or enterococci
Listeria Clinical Features
• Bloodstream and meningoencephalitis most common invasive infections
• Neonatal infection occurs as both early- and late-onset similar disease, similar to group B streptococcus
• Can cause acute febrile gastroenteritis; consider especially in foodborne outbreak with negative routine stool cultures
Listeria Treatment
• Ampicillin plus gentamicin is recommended for CNS infection
• Cephalosporins are not adequate therapy
• Trimethoprim-sulfamethoxazole is recommended for penicillin allergic patients
Listeria Epidemiology
• Mother-to-fetus/neonate transmission possible in utero or at delivery
• Typically foodborne illness; highest risk with deli-style ready-to-eat meats and unpasteurized cheeses
• Primarily affects neonates, pregnant, immunocompromised, and elderly
1600 Cases annually with 20% mortality
Campylobacter Epidemiology
Causes 1.5 million cases of gastroenteritis annually in the U.S. (2nd most common)
Transmitted through undercooked poultry, meat, and unpasteurized milk
Campylobacter Clinical Features
Generally causes a mild, self-limited diarrheal illness
Estimated to cause 30-40% of cases of Guillan-Barre through molecular mimicry
Campylobacter treatment
Generally supportive cares are sufficient
Abx treatment is generally NOT indicated
Use Abx to shorten treatment course in those who are immunocompromised, have bloody diarrhea, or severe disease
High rates of resistance to PCN, cephalosporins, and fluoroquinolones.
Azithromycin or erythromycin are treatment of choice
Salmonella Epidemiology
1.5-2 million cases with 600 deaths annually
1/3 cases occur in children <4y/o with the highest incidence in the first months of life
Widely dispersed through beef, pork, chicken, eggs, and vegetables
Rapid multiplication and long term viability contribute to tendency toward outbreaks

Salmonella typhi
causes an estimated 20 million annual illnesses and 600,000 deaths worldwide
Salmonella Clinical Manifestations
Nontyphoid sp. generally cause self-limited gastroenteritis lasting <1 week
~3-5% of cases have transient bacteremia
Metastatic infection may occur in nearly every organ
After clinical disease, fecal excretion occurs for weeks and may lead to a chronic carrier state
Salmonella Treatment
Regimen depends on type and site of infection
Uncomplicated gastroenteritis usually requires supportive care only
Bacteremia is treated with 10-14 days of abx therapy initially starting with a third gen cephalosporin
Vibrio epidemiology
Primarily a contaminated water-borne illness though Non-cholerae species cause foodborne illness through contaminated shellfish
Vibrio vulnificus
Unlikely to cause gastroenteritis!
Primarily causes blood stream infections with a 35% mortality
Vibrio parahaemolyticus
4500 cases/year with low mortality, likely undereported due to special growth media
Causes gastroenteritis
E. coli
Diarrheagenic E.coli
Overall incidence is unknown though there are thought to be 80,000 cases of ETEC in the U.S. annually
Antibiotics (fluoroquinolones) are helpful in shortening the course of illness
Antidiarrheals may be helpful with ETEC but are contraindicated with the others
Almost invariably O157:H7 in the U.S. though O104:H4 is a potential epidemic
Antibiotics are relatively contraindicated
Associated with HUS
E.coli is primarily associated with undercooked beef
but milk, apple cider, yogurt, and vegetables have been implicated (usually contaminated by bovine manure)
Yersinia enterocolitica
Roughly 100,000 cases annually
Transmitted primarily through undercooked pork products
Replicates at refrigerator temperatures
Yersinia clinical manifestations
Primarily presents with mesenteric adenitis
Entericolitis with abd pain, fever, vomiting, with mucoid and
sometimes bloody diarrhea
Blood stream infections in neonates
The Iceberg
In 1992 the WHO estimated that 2.2 million people (1.9 million children) die each year globally from foodborne illness.
The CDC estimates that 1 in 6 Americans falls ill from a foodborne disease each year resulting in 128,000 hospitalizations and 3,000 deaths

Shigella epidemiology
164 million cases annually worldwide
1.1 million deaths
15,000-20,000 annual reported cases in the U.S.
Due to underreporting, likely >20x higher (CDC estimate)
Shigella species
S. dysenteriae
Accounts for most cases of blood stream infection, HUS, and severe dehydration
Produces shiga-toxin
S. flexneri
Most cases in developing countries
S. boydii
S. sonnei
80% of cases in developed countries
Shigella clinical manifestations

S. flexneri
S. sonnei
, and
S. boydii
cause mild dehydration whereas
S. dysenteriae
may causes severe dehydration and fluid losses
Seizures, lethargy, and confusion may precede GI symptoms.
May results in Reye-like syndrome with hyperpyrexia, posturing, and lethargy
Shigella treatment
Fluid and electrolyte replacement
Early initiation of feeding (<12hrs from onset)
Antibiotics decrease duration of fever, symptoms, complications, and fecal excretion
3rd Generation cephalosporins or TMP/SMX are first line therapy

Intestinal Protozoa
Primary transmission is through fecal-oral route via contaminated water, foodborne illness is rare but possible
Giardia Intestinalis
~5,000 cases annually
Entamoeba Histolytica
50 million symptomatic cases annually worldwide
Clinical manifestations
- Amebic colitis
- Acute fulminant colitis
- Amebomas
- Liver abscess
750,000 cases annually (U.S.)
- eg. In 1993 a waterborne outbreak caused 400,000 cases of diarrhea in Milwaukee.
- Greater affect on HIV/AIDS and other immunocompromised hosts
- May cause biliary tract disease in immunocompromised hosts (15% of cases)
I have no disclosures
I take no personal credit for any of the images provided
- Currently there are 3 primary methods for prevention of foodborne illness
Hazard Analysis and Critical Control Points
Raw milk production accounts for <1% of U.S. dairy production but is responsible for 60% of dairy related illness outbreaks
Approval Purpose
1963 Wheat flour Control of mold
1964 White potatoes Inhibit sprouting
1986 Pork Kill Trichina parasites
1986 Fruit and vegetables Insect control
1986 Herbs and spices Sterilization
1992 - USDA Poultry Bacterial reduction
1999 - USDA Meat Bacterial reduction

Currently 10% of herbs and spices and 0.002% of meat is irradiated in the U.S.
Outbreak Surveillance
Foodborne Disease
Surveillance Network
National Notifiable Disease Surveillance System
Collaborative effort between the CDC, FDA, USDA FSIS, and 10 State Health Departments
- Reportable foodborne agents/diseases
o Cyclospora
o Botulism
o Vibrio Cholera
o Cryptosporidiosis
o Giardiasis
o HepA
o Listeria
o Salmonella
o Shigella

September 2 - 10, 2011
9/2/12 - 7 Cases
of Listeria noted by CDPHE
9/2/12 - 7 Cases
of Listeria noted by CDPHE
9/2/12 - 7 Cases
of Listeria noted by CDPHE
Surveys from the ill reveal they all had recently eaten Rocky Ford cantaloupe
PulseNet identifies outbreak strains of Listeria in CO, NE, and TX
Jensen Farms stops distribution of cantaloupe and issues a recall
High outbreak potential
Inoculum of as few as 10 organisms
Live up to a month on food products and 6 months in room temp water
Intestinal Trematodes
Clonorchis and Opisthorcis
Estimated 35-50 million infected worldwide with ~7500 deaths annually
Primary reservoir is cats and dogs (fish eating mammals)
Source of infection: undercooked fish
Trichinella epidemiology: a public health success story
- With a cost: 50 cents per pig

Nematodes with 7 species that cause human disease
Primary reservoir is the pig
Two phases of infection
Early GI (<1 week): abdominal pain, nausea
Late Muscle (1-5 weeks): Muscle pain, subjective weakness, joint pain
Hepatitis A
CDC: http://www.cdc.gov/hepatitis/HAV/HAVfaq.htm#general
Hepatitis A as a foodborne illness
- Typically contracted from raw vegetables or shellfish
- 70% of cases in patients <6y/o are asymptomatic
CDC: http://www.cdc.gov/norovirus/
Norovirus epidemiology
20 million cases annually
1 million pediatric medical visits
$2 billion healthcare and lost productivity cost
Norovirus spread
Most commonly spread person to person
May be spread by contaminated food products
Particularly common in healthcare facilities and schools
CaliciNet is a CDC organization that tracks Norovirus outbreaks
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