Foodborne Illnesses Wong 2007 July

870 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
870
On SlideShare
0
From Embeds
0
Number of Embeds
6
Actions
Shares
0
Downloads
16
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Specimen i Hektoen Enteric Agar (HE) is a selective and differential medium designed to isolate and differentiate members of the species Salmonella and Shigella from other Enterobacteriaceae .  Bile salts and the dyes bromthymol blue and acid fuchsin inhibit the growth of most Gram positive organisms.  Lactose, sucrose, and salicin provide fermentable carbohydrates to encourage the growth and differentiation of enterics. Sodium thiosulfate provides a source of sulfur. Ferric ammonium citrate provides a source of iron to allow production of hydrogen sulfide from sodium thiosulfate, which provides a source of sulfur. Ferric ammonium citrate also allows the visualization of hydrogen sulfide production by reacting with hydrogen sulfide gas to form a black precipitate.  Enterics that ferment one or more of the carbohydrates will produce yellow to salmon-colored colonies. Non-fermenters will produce blue-green colonies. Organisms that reduce sulfur to hydrogen sulfide will produce black colonies or blue-green colonies with a black center. 
  • In 2/3 of outbreaks with no identified etiology, no stool specimens are submitted for testing
  • Foodborne Illnesses Wong 2007 July

    1. 1. Community Physician’s Role in Foodborne Illness Investigations Chicago Medical Society Chicago Department of Public Health Preparedness and Emerging Infections Training Program 2007
    2. 2. Overview <ul><li>Public health impact of foodborne illnesses and goals for investigations </li></ul><ul><li>Physician role in foodborne illness investigations </li></ul><ul><ul><li>Patient symptoms </li></ul></ul><ul><ul><li>Clusters of illness </li></ul></ul><ul><ul><li>Report to public health </li></ul></ul><ul><ul><li>Appropriate testing </li></ul></ul><ul><ul><li>Educate patients </li></ul></ul><ul><li>Resources for more information </li></ul>Chicago Department of Public Health
    3. 3. Foodborne Illness – United States <ul><li>Each year </li></ul><ul><ul><li>Estimated 76 million illnesses (18% known cause) </li></ul></ul><ul><ul><li>Estimated 5,000 deaths (30% known cause) </li></ul></ul><ul><li>Bacteria, viruses, parasites, toxins </li></ul><ul><li>Primarily affects </li></ul><ul><ul><li>Very young </li></ul></ul><ul><ul><li>Very old </li></ul></ul><ul><ul><li>Immunocompromised </li></ul></ul>Chicago Department of Public Health
    4. 4. Burden of Disease Pyramid Person exposed to pathogen Person becomes ill Person seeks medical care Specimen obtained Lab test(s) done Test confirms case Case Reported
    5. 5. Burden of Disease Pyramid – Foodborne Illnesses Person exposed to foodborne pathogen Person becomes ill Person seeks medical care Specimen obtained Lab test(s) done Test confirms case Case Reported Estimated 76 million annually in U.S.
    6. 6. Serious Consequences of Foodborne Illnesses <ul><li>Chronic diarrhea (certain parasites) </li></ul><ul><li>Miscarriage ( Listeria ) </li></ul><ul><li>Hemolytic uremic syndrome (HUS) (Shiga toxin producing E. coli ) </li></ul><ul><li>Reactive arthritis ( Campylobacter ) </li></ul><ul><li>Guillain-Barr é syndrome ( Campylobacter ) </li></ul>Chicago Department of Public Health
    7. 7. Foodborne Disease Outbreaks: Public Health Priorities <ul><li>Get the facts </li></ul><ul><ul><li>Identify the scope and severity of the outbreak </li></ul></ul><ul><li>Stop disease transmission </li></ul><ul><ul><li>Implement control measures to stop spread </li></ul></ul><ul><li>Prevent future occurrences </li></ul><ul><ul><li>Correct the food safety problem and educate </li></ul></ul>Chicago Department of Public Health
    8. 8. Clinician’s Role <ul><li>Recognize suspicious symptoms in patients </li></ul><ul><li>Recognize suspicious clusters of illness </li></ul><ul><li>Obtain appropriate testing </li></ul><ul><li>Report cases of foodborne illness to public health authorities </li></ul><ul><li>Talk with patients about ways to prevent foodborne illnesses </li></ul>Chicago Department of Public Health
    9. 9. Clinician’s Role <ul><li>Recognize suspicious symptoms in patients </li></ul><ul><li>Recognize suspicious clusters of illness </li></ul><ul><li>Report cases of foodborne illness to public health authorities </li></ul><ul><li>Obtain appropriate testing </li></ul><ul><li>Talk with patients about ways to prevent foodborne illnesses </li></ul>Chicago Department of Public Health
    10. 10. Recognizing Suspicious Symptoms <ul><li>Every outbreak begins with an index patient who may or may not be severely ill </li></ul><ul><li>Important clues to determining the etiology </li></ul><ul><ul><li>Incubation period </li></ul></ul><ul><ul><li>Duration of the resultant illness </li></ul></ul><ul><ul><li>Predominant clinical symptoms </li></ul></ul><ul><ul><li>Types of food consumed </li></ul></ul>Chicago Department of Public Health
    11. 11. Recognizing Suspicious Symptoms <ul><li>Every outbreak begins with an index patient who may or may not be severely ill </li></ul><ul><li>Important clues to determining the etiology </li></ul><ul><ul><li>Incubation period </li></ul></ul><ul><ul><li>Duration of the resultant illness </li></ul></ul><ul><ul><li>Predominant clinical symptoms </li></ul></ul><ul><ul><li>Types of food consumed </li></ul></ul>Chicago Department of Public Health
    12. 12. Usual Incubation Periods for Selected Foodborne Pathogens Hepatitis A Yersinia E. coli O157:H7 Campylobacter Shigella spp. Cyclospora cayetanensis Clostridium botulinum toxin Enterotoxigenic E. coli Norovirus Clostridium perfringens toxin Vibrio parahemolyticus Bacillus cereus toxin Staph aureus toxin Salmonella spp. Invasive disease Listeria GI disease 24h / 1day Hours Days 2 6 10 14 18 22 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46
    13. 13. Recognizing Suspicious Symptoms <ul><li>Every outbreak begins with an index patient who may or may not be severely ill </li></ul><ul><li>Important clues to determining the etiology </li></ul><ul><ul><li>Incubation period </li></ul></ul><ul><ul><li>Duration of the resultant illness </li></ul></ul><ul><ul><li>Predominant clinical symptoms </li></ul></ul><ul><ul><li>Types of food consumed </li></ul></ul>Chicago Department of Public Health
    14. 14. Duration of Illness of Common Foodborne Pathogens Bacterial pre-formed toxins ( Bacillus , C. perfringens , Staph ) 24 – 48 hrs Viruses Norovirus Rotavirus and others 12 hrs – 5 days 2 – 9 days Bacteria Campylobacter E. coli Salmonella / Shigella 2 – 10 days 5 – 10 days 4 – 7 days Parasites Crypto , Giardia , Cyclospora, Entamoeba Weeks to months (may remit and relapse)
    15. 15. Recognizing Suspicious Symptoms <ul><li>Every outbreak begins with an index patient who may or may not be severely ill </li></ul><ul><li>Important clues to determining the etiology </li></ul><ul><ul><li>Incubation period </li></ul></ul><ul><ul><li>Duration of the resultant illness </li></ul></ul><ul><ul><li>Predominant clinical symptoms </li></ul></ul><ul><ul><li>Types of food consumed </li></ul></ul>Chicago Department of Public Health
    16. 16. Diagnosis of Foodborne Illness by Clinical Presentation Prominent Clinical Presentation Additional Signs or Symptoms Potential Food-Related Agent Vomiting Acute onset (within minutes to hours) <ul><li>Chemical agent (heavy metals, ammonia) </li></ul><ul><li>Bacterial toxins ( S. aureus , B. cereus, C. perfringens ) </li></ul>Fever and/or diarrhea <ul><li>Norovirus </li></ul><ul><li>Rotavirus </li></ul><ul><li>Bacterial toxins ( S. aureus , B. cereus, C. perfringens ) </li></ul>
    17. 17. Diagnosis by clinical presentation, continued Prominent Clinical Presentation Additional Signs or Symptoms Potential Food-Related Agent Diarrhea Acute, watery, non-bloody (noninflammatory) <ul><li>Nearly all enterics, but especially: </li></ul><ul><li>Enteric viruses (norovirus, rotavirus, astrovirus) </li></ul>Prolonged, non-bloody <ul><li>Enterotoxigenic E. coli (ETEC) </li></ul><ul><li>Parasites: Cryptosporidium, Cyclospora, Giardia </li></ul>Bloody (inflammatory) Fever also more likely to be present with inflammatory process <ul><li>Shigella </li></ul><ul><li>Salmonella (nontyphoidal) </li></ul><ul><li>Campylobacter </li></ul><ul><li>E. coli (enteroinvasive, enterohemorrhagic) </li></ul><ul><li>Shiga toxin producing E. coli (STEC), including E. coli 0157:H7 </li></ul><ul><li>Yersinia </li></ul><ul><li>Entamoeba </li></ul>
    18. 18. Diagnosis by clinical presentation, continued Prominent Clinical Presentation Signs or Symptoms Potential Food-Related Agent Neurological Descending paralysis, blurred vision, constipation <ul><li>Clostridium botulinum (preformed toxin) </li></ul>Numbness and tingling of lips and mouth, weakness, vomiting and diarrhea <ul><li>Ciguatera toxin </li></ul><ul><li>Shellfish toxins </li></ul>Flushing, rash, hives, burning sensation of skin and mouth, dizziness <ul><li>Scombroid (histamine) </li></ul>
    19. 19. Diagnosis by clinical presentation, continued Prominent Clinical Presentation Additional Signs or Symptoms Potential Food-Related Agent <ul><li>Systemic </li></ul><ul><li>Malaise </li></ul><ul><li>Fever </li></ul><ul><li>Chills </li></ul><ul><li>Muscle aches </li></ul>Nausea, diarrhea <ul><li>Listeria monocytogenes </li></ul>Diarrhea, dark urine, jaundice <ul><li>Hepatitis A </li></ul>Abdominal pain, constipation may be an early feature, diarrhea later, minimal vomiting <ul><li>Salmonella Typhi </li></ul><ul><li>(typhoid fever) </li></ul>
    20. 20. Recognizing Suspicious Symptoms <ul><li>Every outbreak begins with an index patient who may or may not be severely ill </li></ul><ul><li>Important clues to determining the etiology </li></ul><ul><ul><li>Incubation period </li></ul></ul><ul><ul><li>Duration of the resultant illness </li></ul></ul><ul><ul><li>Predominant clinical symptoms </li></ul></ul><ul><ul><li>Types of food consumed </li></ul></ul>Chicago Department of Public Health
    21. 21. **Disclaimer** <ul><li>Because new vehicles are constantly being identified for various pathogens, it is important not to exclude the possibility of an organism contaminating almost any food. </li></ul>Chicago Department of Public Health
    22. 22. Some Food-Pathogen Associations Chicago Department of Public Health Unpasteurized Milk and Cheese Listeria monocytogenes Brucella spp. Fresh Produce Berries, Melon, Juice, Sprouts, Lettuce, Spinach, Tomatoes Cyclospora, E. coli, Salmonella Ground Beef E. coli (especially O157:H7)
    23. 23. Chicago Department of Public Health Pork Trichinella spiralis, Yersinia spp. Chicken Campylobacter, Salmonella Fried Rice Bacillus cereus Tuna Marlin Scombroid (histamine) Mahi Mahi Oysters Vibrio parahaemolyticus Eggs Salmonella spp.
    24. 24. Chicago Department of Public Health Deli Meats Listeria monocytogenes Hot Dogs Home-canned fruits and vegetables Botulinum toxin Ice Cream Salmonella spp.
    25. 25. Patient’s Hypothesis <ul><li>“ I’m sick… It must have been the _________.” </li></ul><ul><li>(Fill in the blank with the last food eaten before becoming ill) </li></ul>Chicago Department of Public Health
    26. 26. Clinician’s Role <ul><li>Recognize suspicious symptoms in patients </li></ul><ul><li>Recognize suspicious clusters of illness </li></ul><ul><li>Report cases of foodborne illness to public health authorities </li></ul><ul><li>Obtain appropriate testing </li></ul><ul><li>Talk with patients about ways to prevent foodborne illnesses </li></ul>Chicago Department of Public Health
    27. 27. Foodborne Disease Outbreak <ul><li>Definition: </li></ul><ul><ul><li>An incident in which two or more individuals from separate households experience a similar illness resulting from the ingestion of a common food or visiting a common food establishment </li></ul></ul>Chicago Department of Public Health
    28. 28. Could This Be an Outbreak? <ul><li>Yes, No, Maybe? </li></ul><ul><ul><li>“ The only thing that these ill people had in common was the meal/food named in the complaint.” </li></ul></ul><ul><ul><li>If yes, definitely investigate further. </li></ul></ul><ul><ul><li>If no, still may need to investigate. Examine all aspects of situation before deciding. </li></ul></ul><ul><ul><li>If maybe, need to ask complainant more questions. </li></ul></ul>Chicago Department of Public Health
    29. 29. Could This Be an Outbreak? <ul><li>Possibility of other shared exposures </li></ul><ul><ul><li>Office workers ate lunch at a restaurant to celebrate completion of a project that they worked on together for the past two weeks; half now have GI symptoms </li></ul></ul><ul><li>Long interval between dates of onset </li></ul><ul><ul><li>Child and mother eat at fast-food restaurant, child ill with diarrhea next day, mother ill 3 days later </li></ul></ul><ul><li>Dissimilar symptoms </li></ul><ul><ul><li>Two days after a birthday party one child ill with vomiting/diarrhea and two others ill with cough, runny nose, no appetite </li></ul></ul>Chicago Department of Public Health
    30. 30. <ul><li>When in doubt, call your local health department </li></ul>Chicago Department of Public Health
    31. 31. Reported Foodborne Outbreaks <ul><li>Illinois </li></ul><ul><ul><li>60-92 foodborne outbreaks reported annually </li></ul></ul><ul><ul><li>Outbreak etiologies (1999-2005) </li></ul></ul><ul><ul><ul><li>29% Confirmed </li></ul></ul></ul><ul><ul><ul><li>71% Suspect or Unknown </li></ul></ul></ul><ul><li>Chicago </li></ul><ul><ul><li>9–18 foodborne outbreaks reported annually </li></ul></ul><ul><ul><li>14 in 2006 </li></ul></ul>Chicago Department of Public Health
    32. 32. Chicago Foodborne Outbreaks: Hospitalizations, Illnesses, & Evaluations 1997-2006 (N=116 outbreaks)
    33. 33. Chicago Foodborne Outbreaks: Etiologic Agents 1997-2006 (N=116) (60%) (17%) (15%) S. aureus , A. cantonensis , B. cereus , Ciguatoxin, E. coli O157, raphides
    34. 34. Chicago Foodborne Outbreaks: Detection Methods 1997-2006 (N=116) *FSE = Food Service Establishment, CD = Communicable Disease
    35. 35. Could This Be Intentional? <ul><li>Unusual agent or pathogen in a common food </li></ul><ul><ul><li>Example: Arsenic-laced curry served at a festival in Japan, 1998; 4 of 67 patients died </li></ul></ul><ul><li>Common agent or pathogen affecting an usually large number of people </li></ul><ul><ul><li>Example: Religious commune contaminated salad bars with Salmonella at multiple restaurants in an Oregon town, 1984; 751 persons ill </li></ul></ul><ul><li>Common agent or pathogen that is uncommonly seen in clinical practice </li></ul><ul><ul><li>Example: pesticide poisoning </li></ul></ul>Chicago Department of Public Health
    36. 36. Clinician’s Role <ul><li>Recognize suspicious symptoms in patients </li></ul><ul><li>Recognize suspicious clusters of illness </li></ul><ul><li>Report cases of foodborne illness to public health authorities </li></ul><ul><li>Obtain appropriate testing </li></ul><ul><li>Talk with patients about ways to prevent foodborne illnesses </li></ul>Chicago Department of Public Health
    37. 37. <ul><li>Medical providers and laboratories are required by law to report certain infectious diseases and syndromes </li></ul>Foodborne Surveillance Chicago Department of Public Health Hospital Doctor’s office Citizens Private Laboratory Public Health Laboratory Local Health Department Media CDC
    38. 38. Reportable Foodborne Illnesses in Illinois <ul><li>Amebiasis </li></ul><ul><li>Botulism </li></ul><ul><li>Campylobacteriosis </li></ul><ul><li>Cholera </li></ul><ul><li>Cryptosporidiosis </li></ul><ul><li>Cyclosporiasis </li></ul><ul><li>Enteric E. coli infections </li></ul><ul><li>Giardiasis </li></ul><ul><li>HUS </li></ul><ul><li>Hepatitis A </li></ul><ul><li>Listeriosis </li></ul><ul><li>Salmonellosis </li></ul><ul><li>Shigellosis </li></ul><ul><li>Trichinosis </li></ul><ul><li>Typhoid fever </li></ul><ul><li>Yersiniosis </li></ul><ul><li>Foodborne or waterborne illness </li></ul><ul><li>Any unusual case/cluster that may indicate a public health hazard </li></ul>Chicago Department of Public Health
    39. 39. What Happens When I Call the Health Department? (It’s not at all like the TV shows…) <ul><li>You will speak with an epidemiologist or physician </li></ul><ul><li>You will be asked questions about the situation: who, how many, when, what, etc. </li></ul><ul><li>Note </li></ul><ul><li>HIPAA is not an issue </li></ul><ul><li>Patient information can be disclosed to public health authorities for public health investigations, surveillance, and interventions </li></ul><ul><li>Don’t worry about duplicate reporting </li></ul><ul><li>Health department staff check for duplicate reports before launching an investigation </li></ul>Chicago Department of Public Health
    40. 40. Prompt Case Report Revealed an Outbreak January 2007 <ul><li>67 y.o. female presents to ED with 2 day h/o vomiting, bloody diarrhea, abdominal pain. She attended a baby shower 3 days ago. </li></ul><ul><li>Patient found to have renal failure, ischemic colitis, thrombocytopenia, mild anemia </li></ul><ul><li>ID physician consulted in ED. She notified the hospital infection control practitioner (ICP), who called the health department to report case of possible HUS. </li></ul><ul><li>Subsequent investigation revealed 23 of 40 attendees of baby shower ill with GI symptoms. C. perfringens found in the leftover chili that was served at the baby shower. </li></ul>Chicago Department of Public Health
    41. 41. The Foodborne Disease Outbreak Investigation Team <ul><li>Communicable disease: Epidemiologists </li></ul><ul><li>and Physicians </li></ul><ul><ul><li>Design questionnaires and conduct interviews </li></ul></ul><ul><ul><li>Manage data and perform statistical analysis </li></ul></ul><ul><ul><li>Follow patient’s clinical course and obtain lab results </li></ul></ul><ul><ul><li>Guide overall response, talk with media, write reports </li></ul></ul><ul><li>Food protection: Sanitarians </li></ul><ul><ul><li>Perform inspections </li></ul></ul><ul><ul><li>Collect left over foods </li></ul></ul><ul><li>Public health laboratory: IDPH Laboratorians </li></ul><ul><ul><li>Test patient specimens and food </li></ul></ul><ul><ul><li>Perform molecular analysis </li></ul></ul>Chicago Department of Public Health
    42. 42. http://www.elpasocitycountyhealth.com/environment/FoodInspection/FoodInspection.asp Sanitarians at work…
    43. 43. “ No, I’m not trying to sell you anything, sir. I’m investigating an outbreak and all I ask is two or three hours of your time to answer a few thousand questions.” Epidemiologists at work…
    44. 44. Notify Public Health <ul><li>For cases that reside in Chicago, call </li></ul><ul><ul><li>311 (if dialing from a city area code) or </li></ul></ul><ul><ul><li>312-744-5000 (if dialing from a non-city area code) </li></ul></ul><ul><ul><li>Ask for the ‘Communicable Disease physician on-call’ </li></ul></ul><ul><ul><li>(available 24/7) </li></ul></ul><ul><li>If case resides outside of Chicago, notify the appropriate local health department </li></ul><ul><ul><li>Cook County Department of Public Health: 708-492-2000 </li></ul></ul><ul><li>If unable to reach your local health department, call Illinois Department of Public Health duty officer </li></ul><ul><ul><li>217-782-7860 or 800-782-7860 </li></ul></ul>Chicago Department of Public Health
    45. 45. Clinician’s Role <ul><li>Recognize suspicious symptoms in patients </li></ul><ul><li>Recognize suspicious clusters of illness </li></ul><ul><li>Report cases of foodborne illness to public health authorities </li></ul><ul><li>Obtain appropriate testing </li></ul><ul><li>Talk with patients about ways to prevent foodborne illnesses </li></ul>Chicago Department of Public Health
    46. 46. When to Consider Testing <ul><li>Bloody diarrhea </li></ul><ul><li>Weight loss </li></ul><ul><li>Fever </li></ul><ul><li>Diarrhea leading to dehydration </li></ul><ul><li>Prolonged diarrhea (>3 days) </li></ul><ul><li>Neurological involvement </li></ul><ul><li>Severe abdominal pain </li></ul>Chicago Department of Public Health
    47. 47. Collection of Stool Specimen <ul><li>Stool sample or rectal swab placed in stool culture transport vial </li></ul><ul><ul><li>Cary-Blair or C&S </li></ul></ul><ul><li>Whole stool: Clean, dry, leak-proof container </li></ul><ul><li>Rectal swab: Pass swab beyond the anal sphincter, carefully rotate, and withdraw </li></ul><ul><li>Regular bacterial transport is not acceptable, but the swab may be used for stool collection (e.g., from a diaper) and then placed in a stool culture transport vial </li></ul>Chicago Department of Public Health
    48. 48. Reasons for Specimen Rejection <ul><li>Frozen specimen </li></ul><ul><li>Incorrect transport device </li></ul><ul><li>Expired transport medium </li></ul><ul><li>No visible stool on swab </li></ul><ul><li>Overfilled vial </li></ul><ul><li>Diapers </li></ul><ul><li>Dry specimen </li></ul><ul><li>Specimen >72 hours old </li></ul>Chicago Department of Public Health
    49. 49. What does ordering a “routine” stool culture get? <ul><li>LabCorp and ARUP : Campylobacter , Shigella , Salmonella , and detection of Shiga toxin by EIA </li></ul><ul><li>Quest : Campylobacter , Shigella , Salmonella </li></ul><ul><li>Hospital labs : varies; contact the microbiology section </li></ul><ul><li>Therefore, </li></ul><ul><ul><li>** Best to order the individual tests you want ** </li></ul></ul>Chicago Department of Public Health
    50. 50. Bacterial Special Requests <ul><li>Require special media </li></ul><ul><ul><li>E. coli O157:H7 </li></ul></ul><ul><ul><li>Yersinia spp. </li></ul></ul><ul><ul><li>Vibrio spp. </li></ul></ul><ul><li>Require quantitative culture </li></ul><ul><ul><li>C. perfringens </li></ul></ul><ul><li>Bacterial toxins </li></ul><ul><ul><li>Only consider testing food and stool in outbreak situations </li></ul></ul>Chicago Department of Public Health
    51. 51. Norovirus Diagnostic Methods <ul><li>Many different genome types, some of which can be distinguished by PCR </li></ul><ul><li>Must obtain whole stool for analysis </li></ul><ul><li>IDPH State Lab can perform PCR but only for outbreak related cases </li></ul><ul><li>Private labs may perform testing – need to call </li></ul>Chicago Department of Public Health
    52. 52. PulseNet Pulsed-Field Gel Electrophoresis (PFGE) <ul><li>Participants: labs from state and local health departments and federal agencies (CDC, USDA, FDA) </li></ul><ul><li>Labs perform PFGE on Escherichia coli O157:H7, Salmonella , Shigella , Listeria , and Campylobacter isolates </li></ul><ul><li>PFGE patterns uploaded electronically to CDC </li></ul><ul><li>Facilitates detection of foodborne illness clusters </li></ul>Lanes 2, 3, 4, and 6, 7, 8 are S. berta Salmonella berta outbreak
    53. 53. Barriers to Testing in Foodborne Disease Outbreaks <ul><li>Delays in collecting specimens from ill people </li></ul><ul><li>Lack of easy-to-use collection materials and instructions </li></ul><ul><li>Inconvenience of storing and transporting specimens to the laboratory </li></ul><ul><li>About 65% of foodborne outbreaks reported to CDC lack a confirmed etiology </li></ul><ul><ul><li>In 2/3 of these outbreaks no stool specimen submitted for testing </li></ul></ul>Chicago Department of Public Health
    54. 54. Facilitating Specimen Collection <ul><li>Use of Stool Collection Kits Delivered to Patients Can Improve Confirmation of Etiology in Foodborne Disease Outbreaks Jones TF, et al. Clin Infect Dis 2004;39:1454-9 </li></ul><ul><li>Stool collection kits delivered to and from patients by courier or mail during 2-year period </li></ul><ul><li>Etiologic agent confirmed in 71% (37/52) of outbreaks in which ≥ 1 kit was received at lab </li></ul><ul><ul><li>28 (76%) attributable to norovirus </li></ul></ul><ul><ul><li>9 (24%) attributable to bacterial pathogens </li></ul></ul>Chicago Department of Public Health
    55. 55. Clinician’s Role <ul><li>Recognize suspicious symptoms in patients </li></ul><ul><li>Recognize suspicious clusters of illness </li></ul><ul><li>Report cases of foodborne illness to public health authorities </li></ul><ul><li>Obtain appropriate testing </li></ul><ul><li>Talk with patients about ways to prevent foodborne illnesses </li></ul>Chicago Department of Public Health
    56. 56. Physicians as Food-Safety Educators: A Practices and Perceptions Survey Wong S, et al. Clin Infect Dis 2004:38 (Suppl 3) pp. S212-S218. <ul><li>Survey of 1110 physicians in U.S. (OB/gyn, neph, onc, ID) </li></ul><ul><li>70% agreed that ‘many of my patients are at risk for foodborne diseases’ </li></ul><ul><li>Only 30% worked in practices that provide food-safety information to patients </li></ul><ul><li>Of the 769 physicians who worked in practices that did not provide food-safety information, 524 (68%) reported that they would like to provide such information to their patients </li></ul>Chicago Department of Public Health
    57. 57. Risk Awareness vs. Risk Perception <ul><li>Persons can be aware of risks but choose to continue such behaviors if they believe they or others can control the risk </li></ul><ul><ul><li>“ The government inspects raw meat and poultry, don’t they?” </li></ul></ul><ul><ul><li>“ The food will smell bad if it’s contaminated, right?” </li></ul></ul><ul><li>Persons may believe that negative events are relatively unlikely to harm them personally </li></ul><ul><ul><li>“ Food contamination is more likely to occur at manufacturing plants or at restaurants—not in my own kitchen.” </li></ul></ul>Chicago Department of Public Health
    58. 58. Advice for Patients for the Prevention of Foodborne Illness <ul><li>COOK meat, poultry, and eggs thoroughly. Use a thermometer to measure the internal temperature of large cuts of meat. </li></ul><ul><li>SEPARATE : Don’t cross-contaminate cooked or ready-to-eat foods with raw meat, poultry, or eggs. </li></ul><ul><li>CHILL : Refrigerate leftovers promptly. Divide large volumes of food into several containers for quicker cooling. </li></ul><ul><li>CLEAN : Wash hands with soap and water before preparing food and after touching raw meat, poultry, or eggs. Wash produce with running water. </li></ul>Chicago Department of Public Health
    59. 59. Additional Precautions for Patients at Higher Risk <ul><li>Should avoid: </li></ul><ul><ul><li>Soft cheeses, pâté </li></ul></ul><ul><ul><li>Uncooked hot dogs and deli meats </li></ul></ul><ul><ul><li>Raw (unpasteurized) milk or cheeses </li></ul></ul><ul><ul><li>Raw or partially cooked eggs </li></ul></ul><ul><ul><li>Foods containing raw eggs </li></ul></ul><ul><ul><li>Raw or undercooked meat and poultry </li></ul></ul><ul><ul><li>Unpasteurized juices </li></ul></ul><ul><ul><li>Raw sprouts </li></ul></ul><ul><ul><li>Raw or undercooked fish or shellfish </li></ul></ul>Chicago Department of Public Health Pregnant women / Elderly / Immunocompromised
    60. 60. Additional Precautions for Patients at Higher Risk <ul><ul><li>Any leftover formula, milk, or juice in bottles should be discarded after infant has finished feeding and not kept longer than 1-2 hours after bottle prepared </li></ul></ul><ul><ul><li>Honey should not be fed to infants < 1 year old (risk of botulism) </li></ul></ul>Chicago Department of Public Health Infants
    61. 61. Eating Out? <ul><li>Choose which restaurants to patronize </li></ul><ul><ul><li>Chicago restaurant inspections: </li></ul></ul><ul><ul><li>http://webapps.cityofchicago.org/health/inspection.jsp </li></ul></ul><ul><li>Ask for meats to be prepared well done—especially ground meats </li></ul><ul><ul><li>Don’t hesitate to send back if still pink in middle </li></ul></ul><ul><li>Ask if sauces or dressings contain raw eggs </li></ul><ul><li>Refrigerate leftovers promptly </li></ul>Chicago Department of Public Health
    62. 62. Making Food Safer <ul><li>Food irradiation </li></ul><ul><ul><li>Already approved in the U.S. for most perishable foods </li></ul></ul><ul><ul><li>Doesn’t impair nutritional value or make food unsafe </li></ul></ul><ul><ul><li>Endorsed by WHO, CDC, FDA, USDA, AMA </li></ul></ul><ul><li>Reduce antibiotics in animal feed </li></ul><ul><ul><li>Antibiotics fed to animals for growth promotion increase pressure for bacteria to become resistant </li></ul></ul><ul><ul><li>World Health Organization (WHO) has recommended that antibiotics not be used for this purpose </li></ul></ul><ul><li>Eat locally </li></ul><ul><ul><li>Smaller scale food production, less transport  lower risk of contamination? </li></ul></ul>Chicago Department of Public Health
    63. 63. When Seeing Patients With Acute Diarrhea <ul><li>Ask about the patient’s occupation </li></ul><ul><ul><li>Food handler </li></ul></ul><ul><ul><li>Health care worker </li></ul></ul><ul><ul><li>Child care worker </li></ul></ul><ul><li>Consider a lower threshold for sending cultures on patients in sensitive occupations </li></ul>Chicago Department of Public Health
    64. 64. Food Safety Web Sites <ul><li>CDC </li></ul><ul><ul><li>http://www.cdc.gov/foodsafety </li></ul></ul><ul><li>FDA Center for Food Safety and Applied Nutrition (CFSAN) </li></ul><ul><ul><li>http://www.cfsan.fda.gov/ </li></ul></ul><ul><ul><li>“ Bad Bug Book” </li></ul></ul><ul><li>USDA Food Safety and Inspection Service (FSIS): for meat, poultry, eggs </li></ul><ul><ul><li>http://www.fsis.usda.gov/ </li></ul></ul><ul><li>National Food Safety Initiative </li></ul><ul><ul><li>http://www.foodsafety.gov </li></ul></ul>Chicago Department of Public Health
    65. 65. Diagnosis and management of foodborne illnesses: A primer for physicians and other health care professionals (2 nd Ed. 2004) <ul><li>Available at: </li></ul><ul><li>http://www.ama-assn.org/ama/pub/category/3629.html </li></ul><ul><li>Print copies gone, but can get PDF version online </li></ul>Chicago Department of Public Health

    ×