Food Borne Illnesses and more …

Marlene GaitherEH Program Manager

CCPHSD

CDC Statistics say...200 known diseases are transmitted through food. They include viruses, bacteria, parasites, toxins, metals, and prions.

31 million foodborne illnesses annuallyMajority are caused by viruses 3000 deaths annually2014: 4,400 hospitalizationsMain transmission - fecal/oral route

CDC’s 2015 FBI Progress Report

Who is responsible for reporting communicable diseases?Under , a health care provider, an administrator of a health care facility or correctional facility, an administrator of a school, child care establishment, or shelter, or their authorized representatives shall submit a communicable disease report to the local health agency. Violation of reporting rules is a class III misdemeanor and is subject to referral to the facility's licensing agency or provider's state licensing board.

Communicable Disease Code R9-6-203. Reporting Requirements for an Administrator of a School, Child Care Establishment, or Shelter

. An administrator of a school, child care establishment, or shelter shall submit a report by telephone that includes:

1. The name and address of the school, child care establishment, or shelter;

2. The number of individuals with the disease, infestation, or symptoms;

3. The date and time that the disease or infestation was detected or that the symptoms began;

4. The number of rooms, grades, or classes affected and the name of each;

Reporting Requirements5. Individual information:

a. Name;b. Date of birth or age;c. Residential address and telephone number; andd. Whether the individual is a staff member, a student, a child in care, or a

resident;6. The number of individuals attending or residing at the school,

child care establishment, or shelter; and7. The name, address, and telephone number of the individual

making the report.Records to health dept/district does not violate

hippa!

Disease Reporting Requirements

FDA Foodborne Illness Report Major Risk Factors (CDC)

Improper Holding TemperatureInadequate CookingContaminated EquipmentUnsafe Food SourcePoor Personal Hygiene

Foods Associated w/Foodborne Outbreaks

Food Borne Disease

There are more illnesses associated with the consumption of food than all other environmental factors combined.

CDC- Top 5 PathogensPathogen Estimated number of

illnesses90% Credible Interval %

Norovirus 5,461,731 3,227,078–8,309,480

58

Salmonella, nontyphoidal

1,027,561 644,786–1,679,667

11

Clostridium perfringens

965,958 192,316–2,483,309

10

Campylobacter spp. 845,024 337,031–1,611,083

9

Staphylococcus aureus

241,148 72,341–529,417 3

Subtotal     91

SALMONELLA

Salmonella spp.

Disease: Bacterial - about 2,000 known serotypes

Reservoir: Poultry, swine, cattle, rodents, turtles, lizards, cats, dogs, & humans

Food: Raw meats, poultry, eggs, & dairy products

Infective Dose: 15 to 20 cellsIncubation period: 6 to 48 hours

Salmonella

Symptoms: Nausea, vomiting, abdominal cramps, diarrhea, fever, and headache

Duration : 1 to 2 days or longerAssociated foods: Raw meat, poultry, eggs,

dairy, seafood, frogs, yeast, coconut, peanut butter, chocolate, sauces & salad dressings.

Frequency: 2 to 4 million cases annually

Salmonella Cases2014 Georgia High School Sports banquet – 56 probable casesSuspect food smoked chicken

2012 five schools in Illinois – Infected cook at commercial kitchen preparing meals

for schools2005 at two elementary schools – 40 probable cases – 26 confirmedScience clubs dissecting owl pellets did not sanitize

table where snacks were consumed

SHIGELLA

Shigella sp.

Agent - Gram negative bacillus that causes an infection (involving large and distal small intestines)

Reservoir/Occurrence - Humans/WorldwideInfective dose – As few as 10 cellsTransmission - fecal/oral route in food and

waterI.p.- 1-3 days

ShigellaSymptoms - fever, nausea, vomiting, cramps

and tenesmus (spasmodic contractions), diarrhea with mucus and blood (due to ulcers)

Incidence - 300,000 cases annually in USCFR’s depend on host, but is as high as 20%

causes ~ 600,000 deaths/yr worldwide

Shigella Outbreak

2010 West Virginia at 3 elementary schools 105 cases not fatalitiesTransmission occurred at school and at home

Escherichia coli

Escherichia coli 0157:H7

Agent - Gram negative rod shaped bacteria produces a toxin-mediated infection (cytotoxins - Shiga toxins) Elaboration of toxins depends on presence phage. Bacteria attach to intestinal mucosa

Reservoir/Occurrence - Cattle/N.America,Europe,Australia, Japan, S.Africa and a portion of S.America

E. coliInfective Dose ~10 to 15 cellsTransmission - Cross-contamination of

infected meat, consumption of undercooked meat, fecal/oral, waterborne

I.p. - 3-4 daysSymptoms - abdominal cramps, low grade

fever, profusely bloody diarrhea, may develop into HUS

E. Coli CasesJuly 2015 in Wisconsin elementary school

– 19 students illNo source has been determined

Summer 2014 in Milwaukee Sizzler sickened 60 people with one fatality – 3 year old girl

E. coli found in raw ground meat that was transferred to watermelon and other salad bar items

Campylobacter jejuni

Campylobacter jejuniDisease: Campylobacterosis - curved, and motile

rod-shaped bacteriaReservoir: Cattle, chickens, birds, and fliesInfective dose: 400 to 500 cellsIncubation period: 2 to 5 daysSymptoms: Watery, stick or bloody diarrhea;

fever; abdominal pain; nausea; headache, & muscle pain

Campylobacter

I.p. - 2-5 daysSymptoms - diarrhea, abdominal pain,

malaise, fever, nausea & vomitingCFR - 1 in 1,000 will die – 4 to 6 million

cases/yr in US

Hepatitis A

Hepatitis VaccinationTWINRIX Vaccine

Age

Dose (ELISA units)2

Volume (mL)

No. of doses

Schedule

≥ 18 yrs

720 1.0 3 0, 1, 6 mos

≥ 18 yrs

720 1.0 4 0, 7, 21–30 days + 12 mos3

CDC 2015

What is Norovirus?The genus contains

multiple strainsSingle-stranded RNA,

non-enveloped, cannot be cultured

Genus Norovirus, family Caliciviridae (used to be known as Norwalk-like virus)

(CDC, 2006; Gerba, 2001)

What do we know about Norovirus?

Causes acute gastrointestinal illness in humans

Noroviruses are highly contagious (both diarrhea and vomit contain the virus)

Infective dose may be as few as 10 viral particles

CDC, 2006

Occurrence of NorovirusCDC Norovirus leading cause of AGI

in U.S.21 Million per year800 deaths 50% more illnesses when a new strains introduced CDC, 2013

Testing for Norovirus

Reverse-transcriptase polymerase chain reaction (RT-PCR)

Sequencing to determine strain

CDC, 2006

Symptoms of NorovirusOnset: Often begins suddenly within 1 to 2 days

after exposure, but can occur w/in 12 hours and lasts 1 to 2 days

Symptoms: Abdominal cramps, nausea, vomiting (projectile) and diarrhea – some may experience low-grade fever, chills, headache & muscle aches

Death is rare – common complication is dehydration

CDC, 2006

Is there Immunity to Norovirus?There is evidence that suggests that

immunity may be strain specific and lasts for only a few months

Individuals are likely to be repeatedly infected throughout their lifetimes

Recent evidence also suggests that susceptibility may be genetically determined with people of “0” blood type experiencing more severe infections

CDC, 2006

Carriers of Norovirus

Studies with volunteers given stool filtrates have shown that asymptomatic infection may occur in as many 30%

“The walking ill”

CDC, 2006

Treatment

To date, there are no antiviral treatments or vaccine for norovirus

Treatment: Replacement of fluids and electrolytes (prevent hyponatremia)

CDC, 2006

How does Norovirus spread?Transmission: Fecal/oral route involving food, water,

person-to-person Evidence exists for transmission to occur through

aerosolization of vomitus that results in droplets contaminating surfaces or entering the oral mucosa and being swallowed

A person will begin shedding the virus with the start of symptoms and continue to shed the virus for two weeks after recovery

CDC, 2006

Modes of Transmission Include “Fomites”

Inanimate objects involved in the spread of disease

What are Fomites?

Enteric Bacteria (Coliforms) in the Home by Location

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Charles P. GerbaDepartments of Soil, Water and Environmental Science and Epidemiology and Environmental HealthUniveristy of Arizona Tucson, AZ

Charles P. GerbaDepartments of Soil, Water and Environmental Science and Epidemiology and Environmental HealthUniveristy of Arizona Tucson, AZ

Teaching: The “Germiest” Profession? Germs per square inch by occupation

5002500450065008500

105001250014500165001850020500

Average All Sites

The most bacteria per square inch was found on surfaces commonly used by school teachers

Measures taken of the phone, desk and computer mouse.

Charles P. GerbaDepartment of Soil, Water and Environmental Science andEpidemiology and Environmental HealthUniveristy of ArizonaTucson, AZ

Site Percent of sites positive for Coliforms

Desk 59

Computer Mouse 57

Cafeteria Table 55

Library Table 53

Bathroom Sink Faucets 36

Water Fountain 33

Keyboard 33

Bathroom Paper Towel Handle

29

Sites with the Highest Percent of Coliforms in all Schools – it’s not the Restroom!!

Charles P. GerbaDepartment of Soil, Water and Environmental Science andEpidemiology and Environmental HealthUniveristy of ArizonaTucson, AZ

StudyTwo school semesters3rd and 4th graders

InterventionChildren’s desk wiped with a disinfectant wipe at the

end of each school day Results50% reduction in absenteeism

Bright et al, 2010; J. School Nursing

Impact of Disinfectant Wipes on Absenteeism -Seattle

How long can Norovirus survive in the Environment?

Studies indicated that Norovirus may survive:Up to 4 weeks in “cold” surface water – can survive

freezing tempsTemps up to 1400FUp to 10 ppm free chlorine4 weeks or more as long as 56 days (Gerba, 2005)

on surfaces including slot machine handles (Calif Resort 04) , door knobs, lavatory faucets, toilet lids, refrigerator door handles (Gerba, 2005)

CDC, 2006

Sanitizing SurfacesRecent studies indicate that:Contaminated fingers can contaminate up to 7

surfacesCombined chlorine & detergent using 5,000 ppm

chlorine (~1 part bleach per 8 parts water for ~2,500 ppm w/5%-7% available CL) reduced contamination of surfaces to 28%

Best Method: Wash with detergent followed by chlorine/detergent combination

NAU Wrestling Outbreak samples(J. Barker, I. Vipond, S. Bloomfield, 2004)

Interactive Exercise

Hot Springs Elementary School K-8 with 350 students and teachers

On Monday morning a student vomits in a 5 grade classroomWhat are your first steps?Who should be contacted?What other information is needed?

Tuesday

The next day a student vomits in the school cafeteria and 4 students and two teachers are home with AGIWhat needs to be done?Who should be contacted?What other information is needed?What are some of your resources?

Wednesday20 students in grades 4th & 5th are ill and four

more teachers from 4th & 5th grade classrooms called in sick with AGI, and a Lunch Monitor was experiencing AGI

A teacher with AGI went to a clinic and they stated it was the 24 hour flu

More students are falling ill at school and the high school across the street has 10 with AGIWhat control measures may be taken to control the

spread?What do you think the causative agent might be?

Thursday

¼ of the students are ill½ of the cafeteria servers are illIt has spread to other gradesWhat do you do?Who do you contact?Who will make lunch?

Actual Case

2005 several high school wrestling teams from California attended a wrestling camp at NAU staying in the dorms;

July 18th: One student became ill with AGI late one evening

July 20th: ED reported to Health District 3 students were ill with vomiting, diarrhea & dehydration (two severely dehydrated);

NAU Case

July 21st: HD visited wrestling camp and interviewed students and 40 more students were ill;

Samples were collected: swabbed surfaces – door knobs, toilet and lavatory handles and stool samples were collected;

Outbreak Spreads

Wrestling students are vomiting at lunch buffet and at Sky Dome on wrestling pads

Students from other camps are becoming ill and NAU cafeteria staff are ill

115 individuals were ill (53%) from the wrestling camp – no fatalities

Outbreak peaked on July 20th

ResponseAn emergency operation center was set-up

at NAUSample results were positive for norovirus:

toilet seats, bathroom sinks, door knobs and stool specimens

Surfaces were disinfected using 5,000ppm chlorine

Spread through fomite surfaces and airborne from vomiting