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Introduction of Hazards: Preparation, Consumption, and the Chain of Transmission Pathogen Reduction Dialogue Panel 1 May 6, 2002 Georgetown University Conference Center. Robert V Tauxe, M.D., M.P.H. Foodborne and Diarrheal Diseases Branch, DBMD, NCID

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Introduction of Hazards:

Preparation, Consumption, and the Chain of Transmission

Pathogen Reduction Dialogue

Panel 1

May 6, 2002

Georgetown University Conference Center

Robert V Tauxe, M.D., M.P.H.

Foodborne and Diarrheal Diseases Branch,

DBMD, NCID

Centers for Disease Control and Prevention,

Atlanta, GA


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Public health burden of foodborne disease

  • Each year an estimated 76 million cases

    • 1 in four Americans gets a foodborne illness each year

    • 1 in 1000 Americans is hospitalized each year

    • $6.5 billion in medical and other costs

  • Prevention depends on efforts from farm to table to reduce contamination of food


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Foodborne diseases

  • Infection with a variety of different pathogens

  • Illness may occur in large focal outbreaks

  • Most illness is “sporadic”: either individual cases or part of unrecognized dispersed outbreaks

  • Reservoir: locus of sustained transmission and persistence

    • Some have a human reservoir: Shigella, hepatitis A, Norwalk virus

    • Some have an animal reservoir: Salmonella, Campylobacter,

      E. coli O157:H7, Listeria, Vibrio, Yersinia, Toxoplasma

  • Often transmitted by several different pathways

    • Specific foods, water, direct contact with animals, direct contact with humans


Major identified foodborne pathogens united states circa 2002 l.jpg

Bacterial:

Bacillus cereus

Brucella

Campylobacter*

Clostridium botulinum

Clostridium perfringens

E. coli O157:H7*

E. coli, non-O157 STEC*

E. coli, other diarrheagenic*

Listeria monocytogenes*

Salmonella Typhi

Salmonella non-typhoidal

Shigella

Staphylococcus

Streptococcus

Vibrio cholerae, toxigenic*

Bacterial, continued:

Vibrio vulnificus*

Vibrio, other*

Yersinia enterocolitica*

Parasitic:

Cryptosporidium*

Cyclospora*

Giardia*

Toxoplasma*

Trichinella

Viral:

Norwalk-like viruses*

Rotavirus*

Astrovirus*

Hepatitis A

Major identified foodborne pathogens, United States – circa 2002

Prions*

* Recognized as foodborne in last 30 years


Major identified foodborne pathogens united states circa 20025 l.jpg

Bacterial:

Bacillus cereus

Brucella

Campylobacter*

Clostridium botulinum

Clostridium perfringens

E. coli O157:H7*

E. coli, non-O157 STEC*

E. coli, other diarrheagenic*

Listeria monocytogenes*

Salmonella Typhi

Salmonella non-typhoidal

Shigella

Staphylococcus

Streptococcus

Vibrio cholerae, toxigenic*

Bacterial, continued:

Vibrio vulnificus*

Vibrio, other*

Yersinia enterocolitica*

Parasitic:

Cryptosporidium*

Cyclospora*

Giardia*

Toxoplasma*

Trichinella

Viral:

Norwalk-like viruses*

Rotavirus*

Astrovirus*

Hepatitis A

Major identified foodborne pathogens, United States – circa 2002

Prions*

* Recognized as foodborne in last 30 years (Zoonotic reservoir)


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The new foodborne zoonoses

  • The infected food animal looks healthy

  • Sustained or repeated infections in animals

  • Contaminated food looks normal

  • Pathogen survives standard processing

    and preparation

  • Missed by current inspection strategies

  • Spreads silently around the globe

  • Requires new control strategies

  • More to be discovered


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The chain of production from farm to table:

A generic scenario

Farm, Feedlot,

Fishing site

Production

Slaughter Plant, Cannery,

Packer, Food Factory

Processing

Final Kitchen: commercial,

institutional or domestic

Final preparation

and cooking


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The chain of production from farm to table:

A generic scenario

Farm, Feedlot,

Fishing site

Production

Slaughter Plant, Cannery,

Packer, Food Factory

Processing

Final Kitchen: commercial,

institutional or domestic

Final preparation

and cooking


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What happens in kitchens?

  • 1993-1997: Among 2,751 foodborne outbreaks reported to CDC, 43% in restaurants/delis/etc

  • Contributing kitchen factors noted

    73% - poor holding temperatures

    38% - poor personal hygiene

    21% - inadequate cooking

  • 1980-1995: New York State: 1806 outbreaks:

    • 32% - contaminated ingredients

    • 24% - consumption of raw/lightly heated

    • 23% - food from unapproved source

    • 23% - ill food handler


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Outbreaks are multi-factorial events

  • Problems in food handling are often reported in foodborne outbreak investigations

  • Probably frequent in kitchens where an outbreak has not occurred

  • Training focused on better food handling important, so is handwashing

  • Reducing the arrival of the pathogens into kitchen is also important


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Introduction of pathogens into food during final preparation: what are the sources?

  • Foods arrive contaminated

    (particularly raw foods of animal origin)

  • Food handler infected with the pathogen

  • Other environmental sources


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When contaminated raw foods of animal origin arrive in the kitchen,

  • Handling may further amplify risk

  • Easily cross-contaminate other foods

    via hands, utensils, surfaces

  • A direct risk if undercooked (FoodNet 2000 survey)

    • Raw oysters - 2.5% in preceding month

    • Pink ground beef - 26%

    • Runny egg dish - 27%

  • 3% use a thermometer for burgers


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When an ill food handler arrives in the kitchen, kitchen,

  • They work, because they have no paid sick leave

  • They may be shedding the organism in feces or vomit

  • Lapses in personal hygiene can contaminate food

  • Particularly for pathogens with human reservoir:

    • Norwalk-like viruses, Shigella, hepatitis A

  • Occasionally for pathogens with animal reservoirs:

    • Salmonella, E. coli O157, Campylobacter


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Food may be contaminated by other environmental sources kitchen,

  • Food prepared or consumed around animals

    • Petting zoos, county fairs, “barn dances”

    • Large E. coli O157 outbreak, U Wisconsin, 2001

      34 cases after a breakfast in the stock pavilion

  • Food prepared with contaminated water

  • Rodents, insects, and other vermin may

    cross-contaminate food


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Prevention strategies for the general public to reduce contamination in the kitchen

  • Basic food safety education

  • Avoid risky food practices

  • Separate handling raw meat and infant care

  • Purchase foods processed for safety:

    • Pasteurized milk, juice

    • Pasteurized shell eggs

    • Irradiated ground beef

  • Ask restaurants about their sick leave policies


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Prevention strategies for food establishments to reduce contamination in the kitchen

  • Basic food safety training and certification

  • Paid sick leave policies

  • Make handwashing easy and frequent

  • Reduce contact with ready to eat food

  • Include pathogen reduction standards in purchase contracts


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For institutional kitchens serving high risk populations, foods processed for safety are available now

  • Pasteurized shell eggs and liquid eggs to avoid Salmonella Enteritidis infections

  • Irradiated ground beef to avoid E. coli O157:H7 and Salmonella infections

  • Frozen chicken and turkey, to reduce risk of Campylobacter infections


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Food safety education is important but not sufficient to protect public health

  • Raw foods of animal origin are often contaminated

  • Serious infections, grave complications

  • Traditional recipes call for limited cooking

    • Raw oysters, rare ground beef, soft boiled eggs, hollandaise sauce

  • Hard to tell when food is thoroughly cooked

    • Boiled eggs, baked lasagna, “browned” burgers

  • Raw meat, poultry, eggs in the kitchen is handled by someone also handling other foods

  • Fresh produce, rinsed and eaten without cooking


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The chain of production from farm to table: protect public health

Where contamination can occur

Feed, water, manure, wildlife, new stock

Production

Lairage, water baths,

Manure, sanitation, cross contamination

Processing

Time, temperature,

Cross-contamination,

Worker health, hygiene

Final preparation

and cooking


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Principle sources of pathogens protect public health

  • Pathogens:

  • Campylobacter

  • E. coli O157:H7

  • Salmonella

  • Yersinia

  • Listeria monocytogenes

  • Norwalk-like viruses

  • Hepatitis A

  • Sources:

  • Poultry, production level

  • Cattle, production level,

  • Poultry, cattle, pig, produce, production level

  • Pigs, production level

  • Ready to eat meats, processing level

  • Humans, production and preparation level

  • Humans, production and preparation level


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The chain of production from farm to table: protect public health

Where contamination can occur

Fish and

shellfish

Land

Animals

Plants

Production

Processing

Final preparation

and cooking

Fruits, nuts,

vegetables

Seafoods

Meat, poultry,

dairy, eggs


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Shellfish in their beds protect public health

The chain of production from farm to table:

Where contamination can occur with

Vibrio parahaemolyticus

Fish and

shellfish

Land

Animals

Plants

Production

Processing

Final preparation

and cooking

Fruits, nuts,

vegetables

Seafoods

Meat, poultry,

dairy, eggs


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The chain of production from farm to table: protect public health

Where contamination can occur with

Norwalk like viruses

Fish and

shellfish

Land

Animals

Plants

Production

Ill humans

Processing

Final preparation

and cooking

Fruits, nuts,

vegetables

Seafoods

Meat, poultry,

dairy, eggs


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The chain of production from farm to table: protect public health

Where contamination can occur with

zoonotic Salmonella

Carrier food animals

Fish and

shellfish

Land

Animals

Plants

Production

Processing

Final preparation

and cooking

Fruits, nuts,

vegetables

Seafoods

Meat, poultry,

dairy, eggs


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The chain of production from farm to table: protect public health

Prevention possible at many points

On-farm sanitation, safety of

animals' food and water

biosecurity, and other

"Good Agricultural Practices"

Production

Factory sanitation, quality control

HACCP, microbial verification, inspection and other "Good Manufacturing Processes"

Processing

{Pathogen Killing Step}

Pasteurization, retort canning, irradiation

Final preparation

and cooking

Food handler training, handwashing, sick leave,

Restaurant inspection, Consumer education


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Schematic map of food industry protect public health

Fish &

shellfish

Land animals

Plants

Production

Transport/

lairage

HACCP

Processing

HACCP

Distribution

Preparation

Meat, poultry,

dairy,eggs

Fruit, nuts

& vegetables

Seafood

Consumption (and foodborne illness)


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HACCP monitoring samples (FSIS data). Percent of ground beef samples yielding Salmonella, by size of processing plant, and year

Baseline


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HACCP monitoring samples. Percent of broiler, ground turkey and hog samples yielding Salmonella, by year, large processing plants (FSIS data)


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Human illness data (CDC-FoodNet). Change in incidence of foodborne infections relative to 1996

Decrease of

15%

25%

31%49%


Some future prevention points for foodborne disease with microbial validation l.jpg
Some future prevention points for foodborne disease (with microbial validation)

Fish &

shellfish

Land animals

Plants

Production

QAP

Transport/

lairage

HACCP

Processing

HACCP

Distribution

Preparation

Meat, poultry,

dairy,eggs

Fruit, nuts

& vegetables

Seafood

Consumption (and foodborne illness)


Some future prevention points for foodborne disease with microbial validation31 l.jpg
Some future prevention points for foodborne disease (with microbial validation)

Fish &

shellfish

Land animals

Plants

Production

QAP

Transport/

lairage

HACCP

Processing

HACCP

HACCP

Distribution

Preparation

Meat, poultry,

dairy,eggs

Fruit, nuts

& vegetables

Seafood

Consumption (and foodborne illness)


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Summary microbial validation)

  • Foodborne pathogens enter food chain at multiple points

  • Pathogen reduction approaches can reduce risk at each step

  • Microbial monitoring can verify control measures

  • In the kitchen:

    • Educating the food preparers is important, so is

    • Handwashing

    • Keeping ill workers out of the kitchen, and

    • Decreasing contamination of food coming into the kitchen

  • Microbial standards in purchase contracts may help

  • For high risk populations, using safer food products