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
 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
 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
• Bacterial: • Bacterial, continued:
 Bacillus cereus  Vibrio vulnificus*
 Brucella  Vibrio, other*
 Campylobacter*  Yersinia enterocolitica*
 Clostridium botulinum
 Clostridium perfringens • Parasitic:
 E. coli O157:H7*  Cryptosporidium*
 E. coli, non-O157 STEC*  Cyclospora*
 E. coli, other diarrheagenic*  Giardia*
 Listeria monocytogenes*  Toxoplasma*
 Salmonella Typhi  Trichinella
 Salmonella non-typhoidal Prions*
 Shigella • Viral:
 Staphylococcus  Norwalk-like viruses*
 Streptococcus  Rotavirus*
 Vibrio cholerae, toxigenic*  Astrovirus*
 Hepatitis A

* Recognized as foodborne in last 30 years

 Major identified foodborne pathogens,
United States – circa 2002
• Bacterial: • Bacterial, continued:
 Bacillus cereus  Vibrio vulnificus*
 Brucella  Vibrio, other*
 Campylobacter*  Yersinia enterocolitica*
 Clostridium botulinum
 Clostridium perfringens • Parasitic:
 E. coli O157:H7*  Cryptosporidium*
 E. coli, non-O157 STEC*  Cyclospora*
 E. coli, other diarrheagenic*  Giardia*
 Listeria monocytogenes*  Toxoplasma*
 Salmonella Typhi  Trichinella
 Salmonella non-typhoidal Prions*
 Shigella • Viral:
 Staphylococcus  Norwalk-like viruses*
 Streptococcus  Rotavirus*
 Vibrio cholerae, toxigenic*  Astrovirus*
 Hepatitis A

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

 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

Farm, Feedlot,
Productio Fishing site
n
Processing Slaughter Plant,
Cannery,
Packer, Food Factory

Final Final Kitchen:

preparation commercial,
and cooking institutional or
domestic
 The chain of production from farm to table:
A generic scenario

Farm, Feedlot,
Productio Fishing site
n
Processing Slaughter Plant,
Cannery,
Packer, Food Factory

Final Final Kitchen:

preparation commercial,
and cooking institutional or
domestic
 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
 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
 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

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

 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
 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
 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

 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
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
 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

Feed, water,
Productio manure, wildlife,
n new stock
Processing Lairage, water baths,
Manure, sanitation, cross
contamination

Final Time, temperature,

preparation Cross-contamination,
and cooking Worker health,
hygiene
 Principle sources of pathogens
• Sources:
• Pathogens:

• Campylobacter • Poultry, production level

• E. coli O157:H7 • Cattle, production level,
• Salmonella • Poultry, cattle, pig, produce, production level
• Yersinia • Pigs, production level
• Listeria monocytogenes • Ready to eat meats, processing level

• Humans, production and preparation level

• Norwalk-like viruses
• Hepatitis A • Humans, production and preparation level
 The chain of production from farm to table:
Where contamination can occur
Land Plants Fish and
Animals shellfish
Productio
n
Processing

Final
preparation Meat, poultry, Fruits, nuts, Seafoods
and cooking dairy, eggs vegetables
 The chain of production from farm to table:
Where contamination can occur with
Vibrio parahaemolyticus
Shellfish
Fish and
Land Plants in shellfish
their
Productio Animals beds
n
Processing

Final
preparation Meat, poultry, Fruits, nuts, Seafoods
and cooking dairy, eggs vegetables
 The chain of production from farm to table:
Where contamination can occur with
Norwalk like viruses
Land Plants Fish and
Animals shellfish
Productio
n
Processing
Ill humans

Final
preparation Meat, poultry, Fruits, nuts, Seafoods
and cooking dairy, eggs vegetables
 The chain of production from farm to table:
Where contamination can occur with
zoonotic Salmonella
Land food Plants Fish and
Carrier
Animals shellfish
Productio animals
n
Processing

Final
preparation Meat, poultry, Fruits, nuts, Seafoods
and cooking dairy, eggs vegetables
 The chain of production from farm to table:
Prevention possible at many points
On-farm sanitation, safety of
animals' food and water
Productio biosecurity, and other
"Good Agricultural Practices"
n
Factory sanitation, quality
Processing control
HACCP, microbial verification,
inspection and other "Good
Manufacturing Processes"
{Pathogen Killing Pasteurization, retort
Step} canning, irradiation

Final Food handler training,

handwashing, sick
preparation leave,
and cooking Restaurant inspection,
 Schematic map of food industry

Land animals Plants Fish &

Production shellfish
Transport/
lairage
Processing HACCP HACCP
Distribution

Preparation Meat, poultry, Fruit, nuts

dairy,eggs Seafood
& vegetables

Consumption (and foodborne illness)

HACCP monitoring samples (FSIS data). Percent of
ground beef samples yielding Salmonella, by size of
8
processing plant, and year
Baseline
7
6
Percent positive

5
4
3
2
1
0
1998 1999 2000 2001

Large Small Very small

 HACCP monitoring samples. Percent of broiler,
ground turkey and hog samples yielding Salmonella,
by
40
year, large processing plants (FSIS data)

30
Percent positive

20

10

0
1998 1999 2000 2001

Broilers Ground turkey Hogs

 Human illness data (CDC-FoodNet). Change in
1.4 incidence of foodborne infections relative to 1996
1.2

1 Decrease of
Relative Rate

15%
0.8
25%
0.6 3
1%4
0.4
9%
0.2

0
1996 1997 1998 1999 2000 2001

Salmonella Campylobacter Listeria Yersinia

 Some future prevention points for
foodborne disease (with microbial
validation)
Land animals Plants Fish &
Production shellfish
QAP
Transport/
lairage
Processing HACCP HACCP
Distribution
E,HW,S
Preparation L
Meat, poultry, Fruit, nuts
dairy,eggs Seafood
& vegetables

Consumption (and foodborne illness)

 Some future prevention points for
foodborne disease (with microbial
validation)
Land animals Plants Fish &
Production shellfish
QAP
Transport/
lairage
Processing HACCP HACCP HACCP
Distribution
E,HW,S
Preparation L
Meat, poultry, Fruit, nuts
dairy,eggs Seafood
& vegetables

Consumption (and foodborne illness)

 Summary
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