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[Surveillance of foodborne diseases in the province of Rio Negro, Argentina, 1993-2001].

A total of 39 outbreaks of foodborne diseases affecting 958 people in the province of Rio Negro, Argentina between 1993 and 2001 are described and evaluated. The main causal agents were identified involving food, sites of occurrence, risk factors and notification system used. Salmonella spp (38%), Trichinella spiralis (15%), Escherichia coli (13%) and Staphylococcus aureus (15%) were the most frequent agents present in outbreaks. Salmonella spp produced the largest number of cases (52%). Food involved were cooked meat (36%), cheese (10%), sandwiches (10%), deserts (10%) and ice cream (8%). Indeed, ice creams were involved in the largest number of cases and of people affected. In relation to the source of food, 41% of outbreaks were caused by homemade meals, 23% by catering or ice cream parlor, 13% in family parties, 8% in county fairs and 8% in hotel restaurants. In 28% of the outbreaks the etiological agent was identified exclusively by epidemiological analysis, in 64% isolation of the agent was carried out, and in 8% of the cases, a final diagnosis could not be obtained. Validity of epidemiological studies in foodborne disease, the necessity of strengthening the notification system of outbreaks, and the importance of good practices in food handling are analyzed.

Argentina↗

Food, hygiene, and the laboratory. A short history of food poisoning in Britain, circa 1850-1950.

Public health concern with food safety and food poisoning emerged in Britain in the 1880s following the first indication that acute gastric illness was caused by a specific organism. Although incidents were for many years only sparsely reported, the central medical department and its scientists were anxious to extend their knowledge of the incidence, specific causal organisms, and epidemiology of the illness. This paper argues for a widespread incidence of food poisoning in Britain in the nineteenth century and traces the social economic, and hygienic contexts within which it occurred. As deadlier infections retreated, food poisoning became an increasing concern of local and national health authorities, who sought both to raise public awareness of the condition as illness, and to regulate and improve food handling practices. Notification of cases was begun in 1939, and this, together with social changes during and after the Second World War, produced an escalating spiral of reported incidents which still continues. This trend, it is argued, is essentially an artefact, whose significance is reduced if considered in its broader historical context.

Food Contamination↗

Where's the beef? The role of cross-contamination in 4 chain restaurant-associated outbreaks of Escherichia coli O157:H7 in the Pacific Northwest.

BACKGROUND: From March through August 1993, outbreaks of Escherichia coli O157:H7 occurred at 4 separate Oregon and Washington steak and salad bar restaurants affiliated with a single national chain. OBJECTIVE: To determine the cause of outbreaks of E coli O157:H7 at 4 chain restaurants. METHODS: Independent case-control studies were performed for each outbreak. Available E coli O157:H7 isolates were subtyped by pulse-field gel electrophoresis and by phage typing. RESULTS: Infection was not associated with beef consumption at any of the restaurants. Implicated foods varied by restaurant but all were items served at the salad bar. Among the salad bar items, no single item was implicated in all outbreaks, and no single item seemed to explain most of the cases at any individual restaurant. Molecular subtyping of bacterial isolates indicated that the first 2 outbreaks, which occurred concurrently, were caused by the same strain, the third outbreak was caused by a unique strain, and the fourth was multiclonal. CONCLUSIONS: Independent events of cross-contamination from beef within the restaurant kitchens, where meats and multiple salad bar items were prepared, were the likely cause of these outbreaks. Meat can be a source of E coli O157:H7 infection even if it is later cooked properly, underscoring the need for meticulous food handling at all stages of preparation.

Adolescent↗

Emergence of pork carnitas as a cause of foodborne disease outbreaks in Chicago.

Carnitas are fried chunks of pork frequently served in Mexican-origin households, food service establishments, and social gatherings. During 1995-2002, carnitas emerged as the most frequently implicated vehicle of transmission in foodborne disease outbreaks in Chicago. Five (6%) of 90 foodborne disease outbreaks investigated and reported in Chicago during this period were linked to carnitas, and they accounted for 108 illnesses and 11 hospitalizations. The etiologic agent in four outbreaks was Salmonella, and these outbreaks accounted for 29% of the 14 Salmonella-associated foodborne disease outbreaks in Chicago during this period. Unsafe food handling practices that occurred after cooking were identified as contributing to multiple carnitas-associated outbreaks. Local health departments that serve significant Mexican-origin populations should be aware of carnitas as a potential source of foodborne disease, particularly salmonellosis.

Animals↗

Linking quantitative exposure assessment and risk management using the food safety objective concept: an example with Listeria monocytogenes in different cross-contamination scenarios.

A practical approach was used to achieve specified food safety objectives (FSOs) by incorporating risk assessment methodology. A series of cross-contamination scenarios at the retail level were evaluated in a spreadsheet and ranked according to their level of risk, and the degree to which they exceeded an FSO for Listeria monocytogenes (100 CFU/g) was determined. Percentiles and analyses of variance were used to identify which scenarios would be most likely not to achieve the FSO. It was also possible to incorporate into the model the effect of additional risk management interventions (e.g., hand washing method) by using "what if" scenarios analysis. The highest risk corresponded to the use of the same gloves to handle contaminated meat and then sliced ham compared with the safer method of using different gloves to handle each product. Nevertheless, in all scenarios bacterial concentrations could be higher than 10(8) CFU/g. A significant lack of knowledge regarding the transfer rates of L. monocytogenes was revealed, which provided the model with an important uncertainty component. The "what if" scenarios analysis based on the scenario representing handling food with bare hands followed by hand washing (scenario 2) revealed that the hand washing procedure had less impact than expected. This study illustrates the use of scenarios to model the most effective food processes and thus provide risk managers with appropriate information on which to base their decisions.

Analysis of Variance↗

An outbreak of campylobacter food poisoning at a university campus.

Twelve cases of Campylobacter jejuni infection were identified on a university campus in the first 12 days of November 1997. Consumption of food from a single outlet, where poor food handling practices were identified, was statistically associated with infection. The epidemiological evidence suggested that what presented as a point source outbreak was a series of small cross contamination incidents associated with multiple strain types. The nature of this outbreak suggests that current surveillance systems are inadequate for the identification of campylobacter outbreaks. Enhanced surveillance should be introduced to identify case clusters of campylobacter infections and public health professionals should remember the risks of cross contamination associated with ubiquitously contaminated foodstuffs, especially raw meats and poultry. The role of strain typing in campylobacter epidemiology is as yet undefined.

Adolescent↗

Crisis in our hospital kitchens: ancillary staffing levels during an outbreak of food poisoning in a long stay hospital.

An investigation into an outbreak of food poisoning caused by Clostridium perfringens showed evidence of poor food handling by catering staff. The reasons behind this were explored by interviewing catering staff, analysing shifts and rotas, and looking at staff vacancies. Morale was low because of staff shortages resulting from a long term recruitment problem. In consequence staff were working double shifts and often for weeks on end without a day off. The reasons for the recruitment problem included the difficulty of recruiting semiskilled labour from a middle class area, low wages, lack of management support, and the poor image of the hospital as a place of work. Similar factors affect the recruitment and retention of ancillary staff nationally. The NHS has a poor record as an employer of ancillary staff, paying lower wages than other organisations for equivalent posts. Competitive tendering has further worsened the position of ancillary staff, with the result that good quality of care and service has often not been achieved. The NHS Review, with its emphasis on quality of care, makes no mention of ancillary staff. Yet high standards of ancillary provision are essential if further outbreaks of food poisoning in hospitals are to be prevented.

Clostridium Infections↗

Response shift bias: a problem in evaluating nutrition training using self-report measures.

The Cooperative Extension Service has been a key partner in the design, implementation, and evaluation of school nutrition training. To evaluate the effectiveness of their training and the effects of response shift bias on outcomes using a self-report measure, 162 foodservice staff from eight rural schools participated in this food-handling behavior study. Nutrition staff were assigned to one of two treatment groups or to the control group. Two different evaluation designs (pretest/ post-test and then/post) were used. The then/post design asks participants to first report their behavior or understanding as a result of the training (post) and then to retrospectively report this behavior before the training. The then/post evaluation design provided more significant change data than did the traditional pretest/post-test design, indicating that a response shift occurred. Such differences in evaluation findings suggest that the educational benefit of such training may be underestimated when using the traditional pre/post evaluation design.

Analysis of Variance↗

Development of a model for evaluation of microbial cross-contamination in the kitchen.

Foods can become contaminated with pathogenic microorganisms from hands, the cutting board, and knives during preparation in the kitchen. A laboratory model was developed to determine occurrence of cross-contamination and efficacy of decontamination procedures in kitchen food-handling practices. Enterobacter aerogenes B199A, an indicator bacterium with attachment characteristics similar to that of Salmonella spp., was used. Chicken meat with skin inoculated with 10(6) CFU of E. aerogenes B199A/g was cut into small pieces on a sterile cutting board. The extent of cross-contamination occurring from meat to the cutting board and from the cutting board to vegetables (lettuce and cucumbers) subsequently cut on the board was determined. Swab samples from the cutting board, hand washings, and lettuce and cucumber samples revealed that approximately 10(5) CFU of E. aerogenes/cm2 were transferred to the board and hands and approximately 10(3) to 10(4) CFU of E. aerogenes/g to the lettuce and cucumbers. The surfaces of the cutting board and hands were treated with antibacterial agents after cutting the meat, and counts of E. aerogenes on the cutting board and vegetables (lettuce and cucumbers) were determined. Results revealed that use of the disinfectant reduced the population of E. aerogenes to almost nondetectable levels on the cutting boards. The average counts after treatment were < 20 CFU/g of vegetable and ranged from < 20 to 200 CFU per cm2 or g on the cutting board and subsequently on the vegetables. These results indicate that bacteria with attachment characteristics similar to Salmonella spp. can be readily transferred to cutting boards during food preparation and then cross-contaminate fresh vegetables if the boards are not cleaned. Application of a kitchen disinfectant can greatly reduce bacterial contamination on cutting boards.

Bacterial Adhesion↗

Dietary behaviour of pregnant versus non-pregnant women.

This study investigates dietary behaviour and the perceived role of food for health of pregnant versus non-pregnant women. Data were collected between 15 January 2003 and 15 March 2003 in Belgium. One hundred and forty-eight pregnant and 130 non-pregnant women aged between 20 and 40 years completed a self-administered questionnaire about their dietary behaviour and nutritional attitudes. Both sub-samples match with respect to individual factors such as relevant socio-demographics and general food perceptions. Pregnant women report higher consumption of fruits, which results in a better score for fibre intake. They also report higher consumption of beef and dairy products, as well as a higher fat intake. No difference in fish consumption between pregnant and non-pregnant women is observed. In line with recommendations, pregnant women report reduced consumption of food products with heightened safety-related risks, lower use of alcohol and tobacco, and safer food handling practices. Reduced intake of raw vegetables for food safety reasons is not compensated by higher intake of cooked vegetables. Pregnant women also report a lower frequency of moderate physical activity. Most differences in food choice by pregnant versus non-pregnant women pertain to the avoidance of specific, potentially harmful food groups. A substantial share of pregnant women does not follow upon recommendations with respect to alcohol use and exposure to tobacco. Personal medical sources for pregnant women and personal social sources for non-pregnant women are reported as the most attended sources of diet-related information. The perceived role of food for health is not different between pregnant and non-pregnant women, and there were no significant interaction effects between pregnancy and presence of children, which indicates that the observed differences in dietary behaviour can be attributed to the state of being pregnant.

Adult↗

Design and development of food safety knowledge and attitude scales for consumer food safety education.

OBJECTIVE: The objective of this study was to design and develop food safety knowledge and attitude scales based on food-handling guidelines developed by a national panel of food safety experts. DESIGN: Knowledge (n=43) and attitude (n=49) questions were developed and pilot-tested with a variety of consumer groups. Final questions were selected based on item analysis and on validity and reliability statistical tests. SUBJECTS/SETTING: Knowledge questions were tested in Washington State with participants in low-income nutrition education programs (pretest/posttest n=58, test/retest n=19) and college students (pretest/posttest n=34). Attitude questions were tested in Ohio with nutrition education program participants (n=30) and college students (non-nutrition majors n=138, nutrition majors n=57). STATISTICAL ANALYSES PERFORMED: Item analysis, paired sample t tests, Pearson's correlation coefficients, and Cronbach's alpha were used. RESULTS: Reliability and validity tests of individual items and the question sets were used to reduce the scales to 18 knowledge questions and 10 attitude questions. The knowledge and attitude scales covered topics ranked as important by a national panel of experts and met most validity and reliability standards. The 18-item knowledge questionnaire had instructional sensitivity (mean score increase of more than three points after instruction), internal reliability (Cronbach's alpha >.75), and produced similar results in test-retest without intervention (coefficient of stability=.81). Knowledge of correct procedures for hand washing and avoiding cross-contamination was widespread before instruction. Knowledge was limited regarding avoiding food preparation while ill, cooking hamburgers, high-risk foods, and whether cooked rice and potatoes could be stored at room temperature. The 10-item attitude scale had an appropriate range of responses (item difficulty) and produced similar results in test-retest ( P </=.01). Internal consistency ranged from alpha=.63 to .89. Students anticipating a career where food safety is valued had higher attitude scale scores than participants of extension education programs. CONCLUSIONS: Uses for the knowledge questionnaire include assessment of subject matter knowledge before instruction and knowledge gain after instruction. The attitude scale assesses an outcome variable that may predict food safety behavior.

Consumer Product Safety↗

Lead consumption of 18- to 36-month-old children as determined from duplicate diet collections: nutrient intakes, blood lead levels, and effects on growth.

OBJECTIVE: To determine the amount of lead ingested in food by means of duplicate diet collections, nutrient intakes, and anthropometric measurements of young children. DESIGN: Once a month for a year, data were collected from 24-hour duplicate diets, hand wipes, a dust index, and anthropometric measurements. Quarterly, venous blood samples were obtained. Thermal ionization spectrometry by means of a lead-205 tracer was used to determine lead present in food, blood, and the hand wipes. A dust index was determined on the basis of observation of dust on surfaces in the home. Anthropometric measurements obtained were height, weight, head circumference, and mid-upper arm circumference. SUBJECTS/SETTING: Subjects were 21 children, aged 18 to 36 months, who resided in homes located in an urban area with potentially high lead levels. MAIN OUTCOMES MEASURED: Lead contamination in food and on hands, and blood lead values, were determined. STATISTICAL ANALYSIS PERFORMED: Pearson correlation coefficients were used to determine relationships between lead content in food, blood, and hand wipes and growth. Multiple regression analyses examined the effect of food types and dust lead on lead levels in food, and the effect of these variables on head circumference. RESULTS: Mean blood levels were 0.3089 +/- 0.1496 micromol/L; 12 samples contained more than 0.4826 micromol/L. Total intake of lead from food was 4.95 microg/day and ranged from 1.10 to -22.10 microg/day. More than a fourth of the diets collected exceeded 6.00 microg/day. Foods considered home prepared were moderately related to blood lead level, and the dust index and hand wipe lead levels were related to total food lead. Home-handled foods, canned foods, and hand-wipe lead were significant predictors of the lead content in food. A negative relationship was found between head circumference and blood lead level. APPLICATIONS: Level of lead in food was directly related to hand-wipe lead. This finding underscores the need for dietitians and other health professionals to stress the importance of cleanliness in environments that are potentially lead contaminated. Appropriate hand washing and surface cleaning should be emphasized when preparing and consuming food. The inverse relationship between head circumference and blood lead levels points to the need for additional studies to validate this finding while controlling for other extraneous variables.

Anthropometry↗

Waterborne outbreak among Spanish tourists in a holiday resort in the Dominican Republic, August 2002.

On 3 September 2002, the Spanish national centre of epidemiology (Centro Nacional de Epidemiologia--CNE) was alerted to a high number of gastroenteritis cases in Spanish tourists who had travelled to a hotel in Punta Cana on different days during august 2002. Entamoeba hystolitica cysts have been visualised by microscopy in the stools of several patients that sought medical attention in the Dominican Republic. The CNE informed the health authorities in the Dominican Republic and conducted in conjunction an epidemiological investigation. A descriptive study of the 76 initial cases estimated a mean illness duration of 5.1+2.9 days and a exposure period of 3.6+2.2 days. Following a retrospective cohort study, the attack rate was found to be 32.4%. Consequently, 216 (95% CI=114.75-317.25) spanish tourists had probably developed the illness. Stool samples were collected in Spain from untreated patients who still felt unwell. None of the samples were positive for E.hystolitica. On 10 September, a hygiene inspection was undertaken at the hotel. Samples of the ice and meals served at the buffet that day, yielded coliform bacteria. Consumption of water from the resort water system was the only risk factor associated with the symptoms (RR= 3.55; 95% CI =1.13-10.99). To avoid similar outbreaks occurring again at the hotel, it is essential to regularly monitor the water quality and to improve food handling hygiene standards. Basic food hygiene training for food handlers should be mandatory. An international guideline for the management foodborne and waterborne outbreaks among tourists in holiday resorts should be drawn up, involving all competent authorities of both destination and tourist origin countries.

Adult↗