# Presentation: 463200

## Introduction of Hazards:
Preparation, Consumption, and the Chain of Transmission

Pathogen Reduction Dialogue
Panel 1
May 6, 2002
Georgetown University Conference Center

- <date/time>

**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**

## 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

- <date/time>

**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**

**Public health burden of foodborne disease**

## 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

- <date/time>

**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**

**Foodborne diseases **

## Major identified foodborne pathogens, United States – circa 2002

- <date/time>

**Major identified foodborne pathogens, United States – circa 2002**

**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**

*** Recognized as foodborne in last 30 years**

**Prions***

## Major identified foodborne pathogens, United States – circa 2002

- <date/time>

**Major identified foodborne pathogens, United States – circa 2002**

**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**

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

**Prions***

- <date/time>

**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**

## The chain of production from farm to table:
 A generic scenario

- <date/time>

**The chain of production from farm to table:**
** ****A generic scenario**

- Production

- Processing

- Final preparation
- and cooking

- Farm, Feedlot,
- Fishing site

- Slaughter Plant, Cannery,
- Packer, Food Factory

- Final Kitchen: commercial,
- institutional or domestic

## The chain of production from farm to table:
 A generic scenario

- <date/time>

**The chain of production from farm to table:**
** ****A generic scenario**

- Production

- Processing

- Final preparation
- and cooking

- Farm, Feedlot,
- Fishing site

- Slaughter Plant, Cannery,
- Packer, Food Factory

- Final Kitchen: commercial,
- institutional or domestic

- <date/time>

**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 **

- <date/time>

**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**

- <date/time>

**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**

- <date/time>

**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**

- <date/time>

**When an ill food handler arrives in the 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***

- <date/time>

**Food may be contaminated by other environmental sources**

**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**

- <date/time>

**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**

- <date/time>

**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**

- <date/time>

**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**

- <date/time>

**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**

## The chain of production from farm to table:
 Where contamination can occur 

- <date/time>

**The chain of production from farm to table:**
** ****Where contamination can occur **

- Production

- Processing

**Final preparation**
**and cooking**

- Feed, water, manure, wildlife, new stock

- Lairage, water baths,
- Manure, sanitation, cross contamination

**Time, temperature,**
**Cross-contamination,**
**Worker health, hygiene**

## Pathogens:

Campylobacter
E. coli O157:H7
Salmonella
Yersinia

Listeria monocytogenes

Norwalk-like viruses
Hepatitis A 

- <date/time>

**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**

**Principle sources of pathogens **

## The chain of production from farm to table:
 Where contamination can occur

- <date/time>

**The chain of production from farm to table:**
** ****Where contamination can occur**

- Production

- Processing

**Final preparation**
**and cooking**

**Land**
**Animals**

**Plants**

**Fish and **
**shellfish**

**Meat, poultry,**
**dairy, eggs**

**Fruits, nuts,**
**vegetables**

**Seafoods**

## The chain of production from farm to table:
 Where contamination can occur with
Vibrio parahaemolyticus

- <date/time>

**The chain of production from farm to table:**
** ****Where contamination can occur with**
***Vibrio parahaemolyticus***

- Production

- Processing

**Final preparation**
**and cooking**

**Land**
**Animals**

**Plants**

**Fish and **
**shellfish**

**Meat, poultry,**
**dairy, eggs**

**Fruits, nuts,**
**vegetables**

**Seafoods**

**Shellfish in their beds**

## The chain of production from farm to table:
 Where contamination can occur with
 Norwalk like viruses

- <date/time>

**The chain of production from farm to table:**
** ****Where contamination can occur with**
** ****Norwalk like viruses**

- Production

- Processing

**Final preparation**
**and cooking**

**Land**
**Animals**

**Plants**

**Fish and **
**shellfish**

**Meat, poultry,**
**dairy, eggs**

**Fruits, nuts,**
**vegetables**

**Seafoods**

**Ill humans**

## The chain of production from farm to table:
 Where contamination can occur with
 zoonotic Salmonella

- <date/time>

**The chain of production from farm to table:**
** ****Where contamination can occur with**
** ****zoonotic *****Salmonella***

- Production

- Processing

**Final preparation**
**and cooking**

**Land**
**Animals**

**Plants**

**Fish and **
**shellfish**

**Meat, poultry,**
**dairy, eggs**

**Fruits, nuts,**
**vegetables**

**Seafoods**

**Carrier food animals **

## The chain of production from farm to table:
 Prevention possible at many points

- <date/time>

**The chain of production from farm to table:**
** ****Prevention possible at many points**

- Production

- Processing

- Final preparation
-  and cooking

- {Pathogen Killing Step}

- On-farm sanitation, safety of
- animals' food and water
- biosecurity, and other
- "Good Agricultural Practices"

- Factory sanitation, quality control
- HACCP, microbial verification, inspection and other "Good Manufacturing Processes"

- Food handler training, handwashing, sick leave,
- Restaurant inspection, Consumer education

- Pasteurization, retort canning, irradiation

## Schematic map of food industry 

- <date/time>

- Schematic map of food industry

|  |  |  |
| --- | --- | --- |
|  |  |    |
|  |  |    |

- Production

- Processing

- Preparation

- Land animals

- Plants

- Seafood

- Fish &
-  shellfish

- Meat, poultry,
-  dairy,eggs

- Fruit, nuts
- & vegetables

-  Distribution

- Transport/
-   lairage

**Consumption (and foodborne illness)**

**HACCP**

**HACCP**

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

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

**Baseline**

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

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

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

- 15%
- 25%
- 31%49%

- Decrease of

## Some future prevention points for foodborne disease (with microbial validation) 

- <date/time>

- Some future prevention points for foodborne disease (with microbial validation)

|  |  |  |
| --- | --- | --- |
|  |  |    |
| E,HW,SL |  |    |

- Production

- Processing

- Preparation

- Land animals

- Plants

- Seafood

- Fish &
-  shellfish

- Meat, poultry,
-  dairy,eggs

- Fruit, nuts
- & vegetables

-  Distribution

- Transport/
-   lairage

**Consumption (and foodborne illness)**

**HACCP**

**HACCP**

**QAP**

## Some future prevention points for foodborne disease (with microbial validation) 

- <date/time>

- Some future prevention points for foodborne disease (with microbial validation)

|  |  |  |
| --- | --- | --- |
|  |  |    |
| E,HW,SL |  |    |

- Production

- Processing

- Preparation

- Land animals

- Plants

- Seafood

- Fish &
-  shellfish

- Meat, poultry,
-  dairy,eggs

- Fruit, nuts
- & vegetables

-  Distribution

- Transport/
-   lairage

**Consumption (and foodborne illness)**

**HACCP**

**HACCP**

**HACCP**

**QAP**

## 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

- <date/time>

**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**

**Summary**