Food Poisoning

Its spring, by the calendar it is, not by your weatherman and it is BBQ time. Farmers markets are open, fruits and vegetables everywhere, something we all have been waiting for all winter. We have heard over and over again to wash fruits and vegetables, and may even purchase the “vegetable wash”. However, if you do use a fruit and vegetable wash no one knows how long you keep it on for. Do you just spray and rinse, soak, or scrub? How do you now it’s clean of all bacteria? After all, hundreds of consumer’s hands have touched that mango and cucumber looking for the one they will eventually buy, only after it has been felt, squeezed, and maybe even a fingernail puncture in the skin. Thus, introducing bacteria into your food. The New England Journal reports an increase in numbers of E. coli O157:H7 outbreaks as the result of fresh U.S.-grown fruit and vegetables fecally contaminated by cattle. 2006. Maki DG.

Contaminated produce is especially worrisome. Studies have shown that E. coli O157:H7 and Salmonella found in soil enriched with contaminated manure can be internalized in growing vegetables that are later often eaten raw. Visser and Van Diepeningen reported in the 2007 Journal of Food Microbiology that internalized pathogens are impossible to remove from vegetables such as radishes, lettuce, parsley, and spinach by washing. What about the vegetable wash sold in supermarkets today? I used that and scrubbed everything and now I read this. OMG and I started juicing with celery, spinach, cucumbers, kale and apples.

Who doesn’t love family reunions and picnics, the taste of Chicago, places where food is out for you to taste. Nothing but fun. Think again. What do peanut butter, ground beef, chicken, bacon, hot dogs, salami, cheese, spinach, green onions, lettuce, tomatoes, alfalfa sprouts, orange juice, apple juice, cantaloupes, raspberries, ice cream, and strawberries have in common? Contamination with foodborne pathogens. Yes, even the platter of burgers and chicken that has been cooked and stacked up on a platter for everyone to select their choice may have been left out for 30 minutes or longer. What happens to the piece on the bottom as everyone takes from the top? Someone eats it.

During the past two decades, the incidence of salmonellosis has doubled in the United States, where it’s either the first or second most common bacterial foodborne disease and the leading cause of food-related deaths. http://www.fda.gov/bbs/topics/NEWS/2006/NEW01504.html. Salmonellosis is usually contracted through eating contaminated food of animal origin (e.g., meat, poultry, eggs and milk) or other foods (e.g., green vegetables) contaminated with animal feces during growth, transport or processing. I no longer just rinse, I personally soak my spinach and kale in cold water and cannot believe what’s left in the bowl. Each year, Salmonella caused an estimated 1.4 million infections resulting in 168,000 physician visits, 15,000 hospitalizations and 400 deaths. The total cost for Salmonella infections in the United States is estimated at $3 billion annually. 2005. Mandell G, Bennett JE, Dolin R.

Chicken
Although, Campylobacter species were not recognized as a cause of foodborne disease until the mid-1970s, they are now one of the most frequently identified causes of bacterial foodborne disease in the United States, with an estimated 2 million cases each year. Most cases of campylobacteriosis are sporadic or involve small family groups. The bacteria are common commensals in the GI tracts of chicken, cattle, sheep, pigs, domestic dogs and cats, rodents and other animals. (Commensals live in host organisms without hurting or benefiting the host.) When we traveled to Bali and throughout Indonesia, there were places, I just drank a coke from a can and ate nothing. Yes, I am a nurse, and very paranoid. It is also important to note that chickens are the single most important source of human infection, and more than 80% of chickens purchased in U.S. supermarkets are contaminated with the bacteria. As I am writing this, I just made curried chicken salad with kale, grapes, celery and apples, hope I make it to the end. I had no idea that this was so prevalent. People usually acquire Campylobacter infection by eating raw or undercooked chicken or eating other foods cross-contaminated by raw chicken during preparation in a kitchen, particularly restaurant kitchens. So do I just eat at 5 star restaurants? No, it can happens in all. Infected restaurant employees were identified as a contributing factor in more than 65% of U.S. foodborne illness outbreaks in restaurants in a 2002–03 study. The pathogens that cause foodborne illness can be transmitted directly from an infected food employee through food to the consumer. That’s why hand washing is so important for everyone. If I see a food worker handling food without gloves and playing cashier, I wont eat there.

It all comes down to what the food safety experts have identified. The five foodborne pathogens, the "Big 5," that are easily transmitted through food and can cause severe illness: Norovirus, Salmonella Shigella, Enterohemorrhagic or Shiga-toxin producing E. coli and Hepatitis A virus. When I marinate my chicken I toss the marinade. I do not place the cooked chicken in the same dish that I used for the marinade. I use a fresh clean one.

A study of risk factors for campylobacteriosis found that 24% of the population-attributable risk for Campylobacter in the U.S. population is related to eating chicken prepared in a restaurant. 2011. Allos BM. http://www.uptodate.com/contents/microbiology-pathogenesis-and-epidemiology-of-campylobacter-infection

Is it ok because it was grown in our own State? No, not all of the problems are from imported food. Safety tests on U.S.-produced food have dropped 75% since 2003. This decrease in FDA testing did not occur because U.S.-produced food is becoming safer. Risks of tainted food rise as inspections drop. http://www.msnbc.msn.com/id/17349427 2007.
In April 2007, preliminary data from the CDC’s Food Net surveillance system, which has collected information on foodborne illnesses from 10 states since 1996, indicated that the number of illnesses associated with E. coli O157:H7, Salmonella and Listeria, increased from 2005 to 2006 while the number of illnesses caused by Campylobacter remained about the same. Reuter’s http://www.reuters.com/article/idUSTRE61C1K620100213.

As an illustration of unsafe U.S.-produced food, a study in the January 2007 Consumer Reports magazine revealed that 83% of chickens (fresh whole broilers) purchased at supermarkets nationwide were contaminated with Campylobacter, Salmonella or both — a 34% increase in contamination since a previous study in 2003. http://www.upc-online.org/health/120706consumerreports.html

(That’s great, I made chicken noodle soup this week). That is alarming. Up to 70% of sporadic Campylobacter infections (about 1 million) in the United States can be attributed to contaminated chickens. In addition to Campylobacter, 110,000 Americans become infected with (a mouth full) entero-hemorrhagic shiga toxin-producing E. coli each year, with as many as 80 dying of the disease. Maki et al. As I was in the midst of writing this article, I took a drive to Chicago from MI. I never saw this in my life, but a truck carrying live chickens all stacked up on each other, feathers flying, feet and wings hanging out the crates visible to every motorist. I felt ill. There were hundreds, and they were dirty looking and alive. I started questioning why I even eat chicken after seeing this.

Red Meat
The most important reservoir for E. coli O157:H7 is the GI tract of cattle, and the majority of infections are the result of undercooked ground beef. In fact, I can tell you that it’s shocking to see the number of patients presenting to the emergency department with a foodborne illness. It’s avoidable and preventable. Some get admitted, while others may be able go home. Maybe to return later, but sicker.

Foodborne illnesses are common, but the majority are transient and resolve within a few days. On occasion, however, eating contaminated food can be a costly experience that results in long-term medical complications or death. For all of us, and especially for people who are immunocompromised, knowing how to prevent foodborne diseases is a priority.
We as Nurses can provide information to patients and families. Education is particularly important when food is being prepared for people who are elderly or very young, pregnant or immunocompromised by diseases or medications. Because foodborne infections can be life-threatening for many people, nurses should encourage patients to take the following precautions when preparing food: practice good personal hygiene, wash your hands after handling raw poultry and meat; cook foods through, check to be certain your turkey burger is well done, no pink; avoid cross-contamination, don’t touch raw meat and poultry and then feed your baby or your elderly Mother; wash wash wash your hands. Keep food at safe temperatures, refrigerate, refrigerate refrigerate; and avoid foods that are likely to be contaminated with pathogens, i.e., those salad bars.. The spoon that rests in the fruit bowl and lettuce has everyone’s finger prints. (That’s everyone’s DNA), It is sitting in your meal. How do you know they haven’t washed their hands? I believe there should be a regulation like healthcare providers have to do before each patient, wash your hands before entering into any salad bar or buffet. Eater Beware!

Patients who are especially vulnerable to infection should be advised to avoid the following foods:
• Raw or undercooked meat, poultry, and fish
• Unpasteurized milk and milk products
• Raw or undercooked eggs or foods containing raw eggs
• Soft cheeses, such as Mexican-style cheeses, feta and Brie
• Raw sprouts of all types
• Unpasteurized fruit juices
• Contaminated water

The treatment of food poisoning depends on the cause and on its severity.

For most people, food poisoning resolves quickly without treatment. For people with mild diarrhea lasting less than 24 hours, treatment should consist of drinking clear fluids such as oral replacement solutions. These solutions contain the right balance of water, salts, and sugar needed to prevent or treat mild dehydration. Mixing 1 teaspoonful of salt and 4 heaping teaspoonfuls of sugar with 1 liter of water can make a solution.

It may be best to stay away from solid food during diarrhea and vomiting. Once you are able to take fluids, gradually start eating plain foods as tolerated. Avoid alcohol and caffeine while you are sick. People with severe symptoms or severe dehydration may need to be admitted to the hospital so they can receive rehydration solutions intravenously (into a vein).

Most bacterial food poisonings do not need antibiotics, but some types of infections may need antibiotic treatment.
You can't always prevent food poisoning, but there are some things that you can do to minimize your risk. The following are some tips:

• Wash your hands thoroughly with soap and warm water for at least 20 seconds before and after handling food, and after using the bathroom, changing diapers, or touching animals.
• If you have a skin infection like impetigo (Staphylococcus bacteria), don't prepare food for others while spots or sores are visible.
• Try to keep different foods and food types separate during preparation and storage.
• Use a separate cutting board and knife for raw foods and cooked foods.
• When reheating food, cook it thoroughly enough that the core reaches at least 170°F (or 75°C). This won't remove all poisons or kill all bacteria, but it helps against some common kinds.
• Be aware that some foods are more prone to causing food poisoning than others, which means you have to handle them more carefully. Green vegetables and carrots, for example, are less likely to be toxic than fish, meat, poultry, eggs, and dairy.
• Thoroughly cook meat and poultry, ensuring that recommended internal temperatures are reached.
• If you're keeping leftovers, refrigerate them as soon as possible. Do not let them sit out for longer than one hour or cool to room temperature.
• Do not thaw foods at room temperature - put them in the refrigerator for thawing.
• Throw out foods that could be contaminated. 2 days is usually the maximum that prepared foods should be stored in the refrigerator. Otherwise, they should be frozen. ( Now everyone should go and clean your Mothers refrigerator)

Admission to the hospital will be contingent on meeting intensity of service and severity of illness criteria using InterQual®. Thousands of people in hospitals, health plans and government agencies use InterQual evidence-based clinical decision support criteria daily to help answer critical questions about the appropriateness of levels of care and resource use. If a hospital is found to have a high frequency of short inpatient hospital stays Medicare will investigate and if inappropriate admissions are found the sanctions can be severe. As a result, hospital health information management (HIM) and utilization management (UM) staff closely monitor the medical necessity of inpatient hospital admissions and short inpatient hospital stays. Their efforts put pressure on emergency department physicians to make sure that each hospital admission is medically necessary and will pass the fiscal intermediary or Medicare Area Contractor (MAC) scrutiny. Not all food borne illness patients go to ICU. There are parameters that help us define appropriate bed placement. However, as nurses, we must be able to identify significant changes in a patients condition that warrant a transfer to a higher level of care from a general medical unit. That can make all the difference in a patient’s outcome.

References

1. Maki DG. Don't eat the spinach: controlling foodborne infectious disease. N Engl J Med. 2006;355:1952-1955

2. Franz E, Visser A, Van Diepeningen A, et al. Quantification of contamination of lettuce by GFP-expressing Escherichia coli O157:H7 and salmonella enterica serovar typhimurium. Food Microbiology. 2007;24:106-112

3. FDA notifies consumers that tomatoes in restaurants linked to Salmonella typhimurium outbreak. FDA Web site. http://www.fda.gov/bbs/topics/NEWS/2006/NEW01504.html. Accessed 5/11/2011.

4. Mandell G, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 6th ed. Oxford, England: Churchill Livingstone; 2005.

5. Allos BM. Microbiology, pathogenesis, and epidemiology of Campylobacter infection.http://www.uptodate.com/contents/microbiology-pathogenesis-and-epidemiology-of-campylobacter-infection

6. Risks of tainted food rise as inspections drop. MSNBC Web site. http://www.msnbc.msn.com/id/17349427 Updated February 26, 2007. Accessed 5/11/2011.

7. Unsafe conditions prompt 4.9 million pound meat recall. Reuters Web site. http://www.reuters.com/article/idUSTRE61C1K620100213

8. Interqual decision support http://www.mckesson.com/en_us/McKesson.com/For%2BPayors/Private%2BSector/InterQual%2BDecision%2BSupport/InterQual%2BDecision%2BSupport.html

9. Utilization Review Issues. FAQ. http://www.acep.org/content.aspx?id=36598 accessed 5/19/2011.



Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.