Food Poisoning

1. Food Poisoning Assoc. Prof.Dr. Yesim Gurol

4. Percentage Change in 2012 compared to 2006-2008: Campylobacter-14% increase, E. coli O157-no change, Listeria-no change, Salmonella-no change, Vibrio-43% increase, Yersinia-no change 2012 rate per 100,000 Population: Campylobacter-14.30, E. coli O157-1.12, Listeria-0.25, Salmonella-16.42, Vibrio-0.41, Yersinia-0.33 2020 target rate per 100,000 Population: Campylobacter-8.5, E. coli O157-0.6, Listeria-0.2, Salmonella-11.4, Vibrio-0.2, Yersinia-0.3

5. Campylobacter • Chicken is the most common food implicated as the source of Campylobacter contamination. • Any raw poultry - chicken, turkey, duck, goose meat and its juices may contain Campylobacter, including organic and “free range” products.  • Other foods include unpasteurized (raw) milk, undercooked meats such as beef, pork, lamb, and livestock offal, and occasionally shellfish, fresh produce, and eggs.

6. Most cases of Campylobacter infection occur as isolated, sporadic events, and are not usually part of large outbreaks.  • But, very large outbreaks (>1,000 illnesses) of campylobacteriosis have been documented, most often from consumption of contaminated milk or unchlorinated water supplies.

7. C. jejuni is commonly present in the gastrointestinal tract of healthy cattle, pigs, chickens, turkeys, ducks, and geese.  • Direct exposure to feces from animals carrying Campylobacter can lead to infection.  • People have become ill from contact with infected dogs and cats.  • Pets that may carry Campylobacter include birds, cats, dogs, hamsters, and turtles. • The organism is also occasionally isolated from streams, lakes, ponds, and dairy wastewater (lagoons).

8. The incubation period for Campylobacteriosis (the time between exposure to the bacteria and onset of the first symptom) is typically two to five days, but onset may occur in as few as two days or as long as 10 days after ingestion of the bacteria. • The illness usually lasts no more than one week but severe cases may persist for up to three weeks, and about 25% of individuals experience relapses of symptoms.

9. Diarrhea is the most consistent and prominent manifestation of Campylobacter infection and is often bloody. • Typical symptoms also include fever, nausea, vomiting, abdominal pain, headache, and muscle pain.  • A majority of cases are mild, do not require hospitalization, and are self-limited.  • However, Campylobacter jejuni infection can be severe and life-threatening.  • It may cause appendicitis or infect other organs as well as the blood stream. • It is estimated that about one in 1,000 cases of Campylobacter infection results in death. Death is more common when other diseases (for example, cancer, liver disease, and immune deficiency diseases) are present.

10. Long-term consequences and complications can sometimes result from a Campylobacter infection. • Some people may develop a rare disease that affects the body’s nervous system following infection.  This disease is called Guillain-Barré Syndrome (GBS). • It begins several weeks after the diarrheal illness, may last for weeks to months, and often requires intensive care. Full recovery is common but some affected individuals may be left with mild to severe neurological damage. • Two therapies, intravenous immunoglobulin infusions and plasma exchange, may improve the rate of recovery in patients with GBS.

11. Miller Fisher Syndrome (MFS) is a related neurological syndrome that can occur with a Campylobacter infection. In MFS, the nerves of the head are affected more than the nerves of the body. • Another chronic condition that may be associated with Campylobacter infection is a form of reactive arthritis called Reiter’s Syndrome.  • Reiter’s Syndrome typically affects large weight-bearing joints such as the knees and the lower back. It is a complication that is strongly associated with a particular genetic make-up; persons who have the human lymphocyte antigen B27 (HLA-B27) are most susceptible

12. The single most important and reliable step to preventing Campylobacteriosis is to adequately cook all poultry products. • Make sure that the thickest part of the bird (the center of the breast) reaches 180°F or higher. • It is recommended that the temperature reaches at least 165°F for stuffing and 170°F for ground poultry products, and that thighs and wings be cooked until juices run clear. Do not cook stuffing inside the bird.

13. Irradiation within approved dosages has been shown to destroy at least 99.9% of common foodborne pathogens including Campylobacter, which are associated with meat, poultry, and secondary contamination of fresh produce.  • Transport meat and poultry home from the market in the coolest part of the vehicle (generally the trunk in winter and cab in summer). • Defrost meat and poultry in the refrigerator. Place the item on a low shelf, on a wide pan, lined with paper towel; ensure that drippings do not land on foods below. If there is not enough time to defrost in the refrigerator, use the microwave.

14. Make sure that other foods, such as fruits or vegetables, do not come into contact with cutting boards or knives that have been used with raw meat or poultry.  • To avoid cross-contamination, carefully clean all cutting boards, countertops, and utensils with soap and hot water after preparing raw meat or poultry.

15. Rapidly cool leftovers. Never leave food out at room temperature (either during preparation or after cooking) for more than 2 hours. • Avoid consuming raw milk and other unpasteurized dairy products and untreated (not chlorinated or boiled) surface water. • Wash fruits and vegetables carefully, particularly if they are eaten raw. If possible, vegetables and fruits should be peeled. • Wash hands thoroughly using soap and water, concentrate on fingertips and nail creases, and dry completely with a disposable paper towel after contact with pets, especially puppies or farm animals; before and after preparing food, especially poultry; and after changing diapers or having contact with an individual with an intestinal infection. Children should always wash their hands on arrival home from school or daycare. 

17. Botulism • Botulism is a rare but serious paralytic illness caused by a nerve toxin that is produced by the bacterium Clostridium botulinum.  • Clostridium botulinum is the name of a group of bacteria commonly found in soil.  • The bacteria are anaerobic, Gram-positive, spore-forming rods that produce a potent neurotoxin

18. Sausages, meat products, canned vegetables, and seafood products have been the most frequent vehicles for foodborne botulism.

19. Classic symptoms of botulism include double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness.  • Infants with botulism appear lethargic, feed poorly, are constipated, and have a weak cry and poor muscle tone.  • These are all symptoms of the muscle paralysis caused by the bacterial toxin.  • If untreated, these symptoms may progress to cause paralysis of the arms, legs, trunk, and respiratory muscles.  • In foodborne botulism, symptoms generally begin 18 to 36 hours after consuming contaminated food, but they can occur as early as 6 hours or as late as 10 days after consumption.

20. Botulinum toxin causes flaccid paralysis by blocking motor nerve terminals at the myoneural junction.  • The flaccid paralysis progresses symmetrically downward, usually starting with the eyes and face, then moving to the throat, chest, and extremities.  • When the diaphragm and chest muscles become fully involved, respiration is inhibited and unless the patient receives treatment in time, death from asphyxia results.

21. the most sensitive and widely used method for detecting toxin is the mouse neutralization test, which involves injecting serum or stool into mice and looking for signs of botulism.  This test typically takes 48 hours. • Culturing of specimens takes 5-7 days.

22. If diagnosed early, foodborne botulism can be treated with an antitoxin that blocks the action of toxin circulating in the blood.  This can prevent patients from worsening, but recovery still takes many weeks. 

23. While botulism has been known to cause death due to respiratory failure • The respiratory failure and paralysis that occur with severe botulism may require a patient to be on a ventilator for weeks, plus intensive medical and nursing care.  • After several weeks, the paralysis slowly improves.

24. Infant botulism • Infant botulism is more common in the spring and the summer and is rare in the winter. Infants younger than one year of age, particularly between the ages of two to four months, are at highest risk. Symptoms include muscle weakness, a weak cry, a poor suck (difficulty in feeding), feeble crying, constipation, head lag, increased heart rate and a decreased gag reflex. • A baby with infant botulism is described as a "floppy baby," as the baby will have weak muscles, especially in the arms, legs and neck. Infant botulism has been associated with the ingestion of honey. • The United States Center for Disease Control suggests that honey should not be given to infants under the age of 6 months. The Honey Industry Council extends that limit to one year of age to be extra safe. Honey is not an essential food for infants and should not be given.

25. Unlike adults, infants younger than 12 months are vulnerable to Clostridium botulinum bacteria colonizing (growing inside) the large intestine. • The disease starts when an infant swallows spores at a moment in time when the baby's large intestine is vulnerable to spore germination and toxin production. • It is thought that most infants are exposed by swallowing spore-containing dust which is naturally present in the environment. • The spores are found in honey and honey has been clearly linked to infant botulism. Other foodstuffs (such as corn syrup) have been suggested as sources but links to other foods are uncertain or disproven. For most cases of infant botulism, no specific source of C. botulinum spores is ever identified. • After being swallowed, spores can germinate in the intestine and, as the bacteria grow, they produce botulinum toxin that is then absorbed into the infant's body. • Although exposure to the spores is very common if not universal in various parts of the world, only rarely do the bacteria manage to get inside an infant at a vulnerable age, germinate, and create the toxin.

26. Any food that is conducive to outgrowth and toxin production, that when processed allows spore survival, and is not subsequently heated before consumption, can be associated with botulism.  • Almost any type of food that is not very acidic (pH above 4.6) can support growth and toxin production by C. botulinum.  • Botulinal toxin has been demonstrated in a considerable variety of foods, such as canned corn, peppers, green beans, soups, beets, asparagus, mushrooms, ripe olives, spinach, tuna fish, chicken and chicken livers and liver pate, and luncheon meats, ham, sausage, stuffed eggplant, lobster, and smoked and salted fish.

27. Botulinum toxin is heat-labile, or unstable if heated to a certain temperature, and can be destroyed if heated and held at 80 degrees Centigrade (176 degrees Fahrenheit) for ten minutes or longer. 

28. Salmonella • Salmonella is one of the most common enteric (intestinal) infections • Salmonellosis – the disease caused by Salmonella – is the second most common bacterial foodborne illness after Campylobacter infection

29. Salmonella infection occurs when bacteria are ingested, typically from food derived from infected animals, but infection can also occur by ingesting the feces of an infected animal or person. • Food sources include raw or undercooked eggs/egg products, raw milk or raw milk products, contaminated water, meat and meat products, and poultry. • Raw fruits and vegetables contaminated during slicing have been implicated in several foodborne outbreaks, as have foods contaminated by food handlers who did not adhere to proper hygienic standards and practice proper handwashing techniques.

30. The acute symptoms of Salmonella gastroenteritis include the sudden onset of nausea, abdominal cramping, and bloody diarrhea with mucous. • Fever is almost always a symptom. Vomiting is less common than diarrhea. • Headaches, myalgias (muscle pain), and arthralgias (joint pain) are often reported as well. • The onset of symptoms usually occurs within 6 to 72 hours after the ingestion of Salmonella bacteria. The infectious dose is small, probably from 15 to 20 cells.

31. Reiter’s Syndrome, which includes and is sometimes referred to as “reactive arthritis,” is an uncommon, but debilitating, result of Salmonella infection. • The symptoms of Reiter’s Syndrome usually occur between one and three weeks after infection, and include at least two of three seemingly unrelated symptoms: reactive arthritis, conjunctivitis (eye irritation), and urinary tract infection. • The arthritis associated with Reiter’s Syndrome typically affects the knees, ankles, and feet, causing pain and swelling.

32. Salmonella infections usually resolve in five to seven days, and many times require no treatment, unless the affected person becomes severely dehydrated or the infection spreads from the intestines

34. To prevent salmonellosis, cook poultry, ground beef, and eggs thoroughly before eating. In order to ensure that eggs do not contain viable Salmonella they must be cooked at least until the yoke is solid.  Meat and poultry must reach 160ºF or higher throughout. Be particularly careful with foods prepared for infants, the elderly, and those with a compromised immune system, including diabetics, pregnant women, HIV/AIDS patients, cancer patients, and transplant recipients. • Do not eat or drink foods containing raw eggs, such as homemade eggnog and hollandaise sauce. Avoid drinking raw (unpasteurized) milk or products made from raw milk. • Wash hands, kitchen work surfaces, and utensils with soap and water immediately after they have been in contact with foods of animal origin. Also, wash hands with soap after handling reptiles, amphibians, or birds, or after contact with pet feces. Infants and immune-compromised persons should have no direct or indirect contact with such pets. 

35. Shigella • Shigella is a bacterium that can cause sudden and severe diarrhea (gastroenteritis) in humans. • Shigellosis is the name of the disease that Shigella causes. The illness is also known as “bacillary dysentery.”

36. Shigella bacteria are found in the excrement (feces) of infected individuals, and cause illness when ingested.  • Infectious material can be spread to new cases by person-to-person contact or via contaminated food or water • Infected food workers can contaminate food, or food can become contaminated during processing.

37. Most people who are infected with Shigella develop diarrhea, fever, and abdominal cramps. The severity of illness ranges from mild to very severe diarrhea. Diarrhea is bloody 25-50 percent of the time and most often contains mucus. Rectal spasms are common. • The illness, shigellosis, starts 12 hours to six days, usually one to two days, after exposure to the bacterium. Dehydration is also a common symptom.

38. Frequent and careful hand washing with soap and water should be done by both the ill individual and anyone who is in contact with that person. • Supervised hand washing of all children should be followed in day care centers and as soon as children return home. • Children’s handwashing should be supervised in daycare centers, and children should wash hands after returning home.  Young children with a Shigella infection, or with diarrhea of any cause, should not be in contact with uninfected children.

39. Staphylococcus aureus • Foods that are frequently a problem with staphylococcal food poisoning include meat and meat products; poultry and egg products; salads such as egg, tuna, chicken, potato, and macaroni; bakery products such as cream-filled pastries, cream pies, and chocolate eclairs; sandwich fillings; and milk and dairy products. • Foods that require considerable handling during preparation and that are kept at slightly elevated temperatures after preparation are frequently involved in staphylococcal food poisoning.

40. Staph may also be present in raw milk and raw milk products. Staph can cause mastitis in dairy cows, and other infections in meat animals. In this way, such meat sources may cause staph outbreaks in people.

41. Some S. aureus strains are able to produce staphylococcal enterotoxins (SEs) and are the causative agents of staphylococcal food poisonings. Unlike C. perfringens, C. botulinum, and B. cereus, S. aureus does not form spores. • Thus, S. aureus contamination can be readily avoided by heat treatment of food. Nevertheless, it remains a major cause of FBD because it can contaminate food products during preparation and processing.

42. Staphylococcal toxins are fast acting, sometimes causing illness in as little as 30 minutes. Symptoms usually develop within one to six hours after eating contaminated food. Patients typically experience several of the following: nausea, vomiting, stomach cramps, and diarrhea. The illness is usually mild and most patients recover after one to three days. In a small minority of patients the illness may be more severe.

43. Vibrio parahaemolyticus • In Asia, V. parahaemolyticus is a common cause of foodborne disease • Most people become infected by eating raw or undercooked shellfish, particularly oysters. Less commonly, this organism can cause an infection in the skin when an open wound is exposed to warm seawater. • When ingested, V. parahaemolyticus causes watery diarrhea often with abdominal cramping, nausea, vomiting fever and chills. Usually these symptoms occur within 24 hours of ingestion. Illness is usually self-limited and lasts 3 days. Severe disease is rare and occurs more commonly in persons with weakened immune systems.

44. Bacillus cereus • One type is characterized by nausea and vomiting and abdominal cramps and has an incubation period of 1 to 6 hours. It resembles Staphylococcus aureus food poisoning in its symptoms and incubation period. This is the "short-incubation" or emetic form of the disease. • The second type is manifested primarily by abdominal cramps and diarrhea with an incubation period of 8 to 16 hours. Diarrhea may be a small volume or profuse and watery. This type is referred to as the "long-incubation" or diarrheal form of the disease, and it resembles more food poisoning caused by Clostridium perfringens. In either type, the illness usually lasts less than 24 hours after onset. In a few patients symptoms may last longer. • Starchy foods such as rice, macaroni and potato dishes are most often involved. The spores may be present on raw foods, and their ability to survive high cooking temperatures requires that cooked foods be served hot or cooled rapidly to prevent the growth of this bacteria.

45. Clostridium perfringens • C. perfringens is found in soil, dust and the gastrointestinal tracts of animals and man. When food containing a large number of C. perfringens is consumed, the bacteria produce a toxin in the intestinal tract that causes illness. • C. perfringens can exist as a heat-resistant spore, so it may survive cooking and grow to large numbers if the cooked food is held between 40 degrees F and 140 degrees F for an extensive time period. • Meat and poultry dishes, sauces and gravies are the foods most frequently involved. Hot foods should be served immediately or held above 140 degrees F. • When refrigerating large volumes of gravies, meat dishes, etc., divide them into small portions so they will cool rapidly. The food should be reheated to 165o F. prior to serving.

46. Yersinia enterocolitica • Y. enterocolitica is commonly present in foods but with the exception of pork, most isolates do not cause disease. Like Listeria this organism is also one that can grow at refrigeration temperatures. It is sensitive to heat (5%) and acidity (pH 4.6), and will normally be inactivated by environmental conditions that will kill Salmonellae

47. E.Coli O157:H7 • E. coli O157:H7 is the source of an estimated 73,000 illnesses, 2,000 hospitalizations, and 60 deaths in the United States every year • E. coli O157:H7 was firmly associated with hemorrhagic colitis.  The majority of infections are thought to be food-related, although E. coli O157:H7 accounts for less than one percent of all food poisoning cases.

48. E. coli O157:H7 bacteria are believed to mostly live in the intestines of cattle but have also been found in the intestines of chickens, deer, sheep, goats, and pigs. E. coli O157:H7 does not make the animals that carry it ill; the animals are merely the reservoir for the bacterium. • While a large number of foodborne illness outbreaks associated with E. coli O157:H7 have involved ground beef, such outbreaks have been increasingly associated with fresh produce, such as lettuce and spinach, but outbreaks have also been traced to unpasteurized apple and orange juices, raw milk, alfalfa sprouts, and water.  • Person-to-person transmission of the bacterium has been documented in homes, hospitals, daycare centers, nursing homes and many other locations.

49. characterized by the sudden onset of abdominal pain and severe cramps, followed within 24 hours by diarrhea. • As the disease progresses, the diarrhea becomes watery and then may become grossly bloody. • Vomiting, and rarely fever, can also be symptoms. The incubation period for the illness (the period from ingestion of the bacterium to the start of symptoms) is typically three to nine days, although slightly shorter and longer periods are not that unusual. • An incubation period of less than 24 hours would be unusual, however. In most infected individuals, the intestinal illness lasts about a week and resolves without any long-term problems.

50. about five to ten percent of infected individuals develop hemolytic uremic syndrome (HUS), a severe, life-threatening complication of E. coli O157:H7 bacterial infection.  HUS develops when E. coli’s toxins enter the circulation by binding to special receptors.  • During HUS, red blood cells are destroyed and cellular debris accumulates within the blood vessels while the body’s clot-breaking mechanisms are disrupted, causing blockage of the terminal arterioles and capillaries (microcirculation) of most of the major body organs, commonly the heart, brain, kidneys, pancreas and adrenals.