We know that food safety is a"farm to fork" endeavor. Safety starts on the farm, works its way through food processing & distribution… and then finds its way to our foodservice operations and consumers' homes. About 7 of every 10 of foodborne illnesses are linked to food we eat away from home. At the same time, there are many complex factors at play from farm to fork. Many steps along the way can either introduce new hazards, or eliminate hazards. (For example, cooking food to recommended endpoint cooking time and temperature standards can reduce or eliminate a hazard.) Wherever the final step in the flow of food occurs, food safety risks take their final form. At the plate, we can always say: The fork stops here!
We won't be able to solve the problem of foodborne illness together in this CE program. But we WILL be able to take a look at what we know about foodborne illness… and how it's changing. We'll look at some headlines, and then step back to get a deeper understanding of what's behind them. We'll become informed dietetic professionals. Knowledge is power!
You can barely watch or read the news without hearing of a recall or illness connected with food.
The list goes on… but look at the recalls for Salmonella alone:
In 2010, we experienced a massive shell egg recall. Over 500 million eggs were recalled, and more than 1500 people were reported sick due to Salmonella enteritidis.
According to the CDC, foodborne illness is a serious public threat that causes some alarming statistics. Every year in the US, foodborne illness causes:
The CDC estimates that 1 in 6 Americans gets sick from foodborne illness every year.
Results of foodborne illness can be devastating:
Morbidity and mortality. Distrust and anxiety among consumers. Long-term consequences of illness, like Gullian Barre syndrome or Reiter's syndrome. Suffering that we want to prevent.
While foodborne illness causes much human suffering—and damages reputations of food and foodservice organizations—there's more. Economic damage can reach anywhere from $6.5 to $35 billion annually.
Why is foodborne illness under-reported?
According to FoodNet, which is responsible for surveillance of selected foodborne illness outbreaks in 10 states, complete reporting requires a chain of events, as illustrated below. We know, for example, that people do not always report illness. When they do, it may not follow all subsequent steps leading to identification and confirmation of the pathogen and food source.
The Burden of Illness Pyramid tells a story.
Outbreaks are generated from investigative information. How this information is gathered is reflected in the previous diagram. When an illness occurs, a seven-stage process begins.
The process of an illness being reported involves the exposure of individuals to the illness, affected individuals then reporting their illness, investigation of the illness, and finally synthesis of gathered information to create a full epidemiological profile for foodborne outbreaks.
Given that reporting is sporadic and that there is not a follow-up system for foodborne illness, the long-term health implications are difficult to pinpoint.
Evidence and information have primarily been obtained through small case studies and individual cases. So, essentially, there is a gap in information. This lack of information presents a gap in our understanding of health outcomes and long-term consequences. With the attention given to the peanut butter recall, egg recall, and the many other food products implicated in an outbreak, renewed interest is being given to preventive measures for foodborne illness. To gain a clear picture as to what is occurring with foodborne illness, many factors need to be reviewed.
A big picture approach must be acknowledged to understand the overall implications of foodborne illness. We will be looking at trends and the health implications involved with disease attributed to foodborne pathogens, environmental changes, and consumer behavioral changes.
Let's begin with some significant figures reported by FoodNet.
FoodNet is the Active Surveillance Network of the Centers for Disease Control and Prevention.
infantFoodNet provides reporting figures and conducts surveillance on foodborne illness for selected foodborne bacteria and parasites. Viruses are not included in the scope of their work.
According to FoodNet, the scope of their work "provides a network for responding to new and emerging foodborne disease of national importance, monitoring the burden of foodborne diseases, and identifying the sources of specific foodborne diseases."
As of the 2017 FoodNet report, non-viral foodborne illness was caused by the following pathogens, in order from most cases to least:
Occurrence of illness attributed to Salmonella did not change significantly.
FoodNet data shows that the overall incidence of foodborne illness increased 96% in 2017, as compared with 2014-2016.
Let's take a closer look at the top five bacterial foodborne pathogens that can cause significant economic and health damage:
Campylobacter is a source of foodborne illness that can cause paralysis. Transmission occurs through farm animals or pets, or through raw or undercooked poultry products.
It causes diarrhea, cramping, abdominal pain, and fever within 2-5 days of eating contaminated food.
The key points to focus on are the complications—and who is most at risk:
Prevention includes cooking poultry to 165°F, observing handwashing protocols, and preventing cross contamination.
Salmonella is a leading cause of foodborne illness and is typically associated with raw eggs and chicken, but has also been linked to fresh produce, peanut butter, and other food sources.
There are many strains of Salmonella. Which strain causes the most illnesses varies by year; there is an ongoing evolution of strains.
Shigella causes symptoms of diarrhea, fever, and stomach cramps 1-2 days after exposure. The CDC estimates it causes about half a million cases of foodborne illness in the US every year.
It is very contagious and is spread through fecal matter. Lack of attention to hygiene can make foodservice workers a serious source of transmission. This makes handwashing and hygiene practices extremely important in the control of Shigella. In addition, it is important not to let infected foodservice workers come to work.
Antibiotic-resistant strains of Shigella are on the rise.
While many strains of E. coli live in the intestinal tracts of people and animals, some strains can cause illness. A variety that is often associated with foodborne illness outbreaks is called Shiga toxin-producing E. coli (STEC). E. coli O157 is a type of STEC. It was first identified in 1982. It literally produces a toxin, which contributes to the illness.
Symptoms, appearing in 1-10 days, typically include severe stomach cramps, diarrhea (sometimes bloody), and vomiting. E. coli (STEC) can cause very serious illness, sometimes leading to hemolytic anemia, kidney failure, and death.
The CDC says less is known about the non-STEC strains, but says that overall, they are less likely to cause as severe an infection as E. coli (STEC).Children are at the greatest risk for illness and complications.
Sources of contamination can include ground beef, unpasteurized juices, unpasteurized soft cheeses, and raw fruits and vegetables, such as leafy greens. Prevention tips include:
Cryptosporidium is a microscopic parasite that can appear in food, water, or soil. Because it is soil-borne, it can be a contaminant on produce. It causes watery diarrhea 2-10 days after exposure, and symptoms typically last 1-2 weeks.
The illness, cryptosporidiosis, takes hold when a person consumes oocytes, the infective stage of the parasite. A healthy person’s body typically fights off the illness in 3-4 days. People with compromised immune systems are particularly susceptible, and for them, the illness can become fatal.
Handwashing and personal hygiene are critical controls. Other prevention tips include:
Food safety is a complex combination of many factors.
There is a three-part equation for foodborne illness to occur:
According to the Institute of Food Technologists, foodborne illness occurs ONLY when all three of these factors converge. For example, pathogens that don't contact people do not cause foodborne illness. Or, let's say a pathogen exists in food, like E. coli in ground beef. When we cook to endpoint cooking standards, the pathogen is eliminated. Once again, we do not have all three factors for foodborne illness.
The Institute of Food Technologists suggests that to tackle foodborne illness, we need to work on multiple levels. We can decrease pathogen counts in foods — and also decrease exposure through standard operating procedures … through our HACCP systems (in food service)… and through food-safe practices in the home. Because the problem is complex and the stakes are high, we need a multi-pronged approach to food safety. For example, in food service, standard operating procedures cover everything from purchasing habits to safe receiving to safe storage to employee handwashing to proper thawing to endpoint cooking to safe holding! Through these, we are tackling the pathogens, the people who carry and transmit pathogens, and the opportunities for exposure.
Scientists also offer insight into how the world of food safety is changing… why we see new headlines. According to experts in the field, "microbiological food safety is a complex, fundamental issue of continuing concern. Contributing to this complexity and the emergence of food safety issues are ongoing changes in demographics, geographic origin of food, food production and processing, food consumption patterns, and microorganisms themselves. These host, environmental and pathogen changes challenge our food safety policies and our ability to manage food safety throughout the food system."
- IFT Expert Report
Two ongoing trends make foodborne illness a moving target:
Listeria monocytogenes became a concern only in the 1980s. The Cyclospora parasite as a vehicle of foodborne illness was discovered in 1996, when it made people ill after being found in Guatemalan raspberries.
Behravesh and team provide some interesting lists in their analysis of emerging pathogens. They list many pathogens identified as being foodborne identified since 1970, including forms of E. coli, Listeria moncytogenes, Campylobacter jejuni, Cryptosporidium, Rotavirus, a prion that causes Creutzfeldt Jacob Disease, and many others. Some of these you may recognize from ongoing news headlines today. About 70% of these are sustained in animal populations, say Behravesh and colleagues.
At the same time, a list of 15 new foods implicated in foodborne illness emerged from just 2006 to 2012:
Contamination can begin early in the farm-to-fork chain, say the authors, and our food systems have become very complex. The global nature of food production also complicates surveillance and control. Say the authors, “Improving the safety of the food supply thus depends on stronger public health capacity around the world, better understanding of new challenges wherever they are identified, and translating that understanding into effective prevention from farm to table.”
Many of today's toughest germs are antibiotic-resistant.
According to the World Health Organization (WHO), "Since their discovery during the 20th century, antimicrobial agents (antibiotics and related medicinal drugs) have substantially reduced the threat posed by infectious diseases. The use of these 'wonder drugs', combined with improvements in sanitation, housing, and nutrition, and the advent of wide-spread immunization programs, has led to dramatic drop in deaths from diseases that were previously widespread, untreatable, and frequently fatal."
But there has been some debate and evidence concerning the use of antibiotics and the consequences of overuse.
Many pathogens have genetically evolved to become antibiotic-resistant. Overuse of antibiotics in the food supply and overuse of human medicine are contributing factors to this pathogenic virulence.
The American Medical Association warns about the overuse of antibiotics and suggests the need to educate providers and patients.
The CDC (2018) calls antibiotic resistance "one of the most urgent threats to the public's health" because antibiotic-resistant bacteria can make illnesses untreatable.
As the debate over antibiotic use continues between regulatory groups and public interest groups, the impact becomes apparent. The CDC (2013) says that:
How does this occur and what is the impact? First and foremost the problem is global. Antibiotic-resistant organisms or "super bugs" are emerging worldwide, with the overall impact becoming a tremendous liability on public health.
The CDC says, “Every year, more than two million people in the United States get infections that are resistant to antibiotics and at least 23,000 people die as a result.” They note that antibiotic resistance is rising for many different pathogens. They attribute this to use of antibiotics, saying half of antibiotics used for people are prescribed inappropriately. Antibiotics are also used for food-producing animals.
Steve Solomon, M.D., director of CDC’s Office of Antimicrobial Resistance, explained in a CDC report, “Every time antibiotics are used in any setting, bacteria evolve by developing resistance. This process can happen with alarming speed. These drugs are a precious, limited resource—the more we use antibiotics today, the less likely we are to have effective antibiotics tomorrow.”
The CDC estimates the economic cost of antibiotic resistance as “20 billion in excess direct health care costs, with additional costs to society for lost productivity as high as $35 billion a year.”
Not all antibiotic-resistant bacteria are associated with foodborne illness, but some are, including strains of Salmonella, Streptococcus, STEC, and others. Of particular concern now is a pathogen called Clostridium difficile, which causes about 250,000 hospitalizations and at least 14,000 deaths every year in the U.S., according to the CDC. There is current discussion about whether or not this is a foodborne pathogen. Spores have been found in meat, but researchers are not sure whether food can be a vehicle.
Not only have pathogens become resistant from overuse of antibiotics, there is concern about the use in agriculture. According to the World Health Organization, nearly 50% of the world production of antibiotics is for use with animals.
The USDA believes "…it is likely that the use of antibiotics in animal agriculture does lead to some cases of antibacterial resistance among humans and in animals themselves…" (Bottemiler. 2010)
The Infectious Disease Society of America says, "A large and compelling body of scientific evidence demonstrates that antibiotic use in agriculture contributes to the emergence of resistant bacteria and their spread to humans."
Here is an example of how the use of agricultural antibiotics contributed to pathogenic resistance for Campylobacter in Minnesota:
While we see the implications of antibiotic overuse and the impact of antibiotics in agriculture, what must also be taken into account is that this type of environment allows an opportunity for bacteria to adapt. Bacteria adapt by exchanging small bits of genetic information that convey resistant factors. Through this process, new and tougher strains emerge. Methicillin-resistant Staphylococcus aureus (MRSA) is an example.
The World Health Organization says, “Antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi.” They also note, “Patients with infections caused by drug-resistant bacteria are generally at increased risk of worse clinical outcomes and death, and consume more health-care resources than patients infected with the same bacteria that are not resistant.”
What are the overall consequences of these tougher germs?
Although no one is recommending we change our habits of cleanliness and sanitation, many observers note that these habits carry consequences.
A book called Chasing Dirt, by Suellen Hoy (Oxford University Press, 1995) points out that as a culture, we've gone from "filthy" a century ago to being obsessed with cleanliness. This may affect our resistance to microbes. We have less exposure over a lifetime, less immunity, and become more vulnerable.
At the same time, the prevalence of antimicrobial products means that we are practicing a form of "super sanitation" that could potentially backfire. As an example, the product Microban® is added to consumer goods of all types, from kitchen utensils to textiles to clothing to flooring to pens and pencils, and more. Microban® is embedded in manufacturing materials and lasts the lifetime of the product. It is highly effective in inhibiting the growth of bacteria. But does the prevalence of these products encourage the mutation and adaptation of tougher pathogens? Some scientists express this concern.
The CDC says: "Antibacterial-containing products have not been proven to prevent the spread of infection better than products that do not contain antibacterial chemicals. Although a link between antibacterial chemicals used in personal cleaning products and bacterial resistance has been shown in vitro studies (in a controlled environment), no human health consequence has been demonstrated. More studies examining resistance issues related to these products are needed."
The CDC also says antibacterial soaps do not offer any extra benefits over regular soaps. (It's handwashing and drying hands that counts.)
Many companies utilize Microban® to inhibit the growth of bacteria. This type of bacterial prevention is highly effective and provides a lifetime warranty. Many common household products utilize this type of preventative practice. Some products that utilize Microban® include: cutting boards, utensils, potholders, carpeting…even socks. Not everyone agrees on the impact of these products, and answers are not all in… but the battle of the germ continues.
What about our global society?
We live in a transient world that allows for international travel and international exposure. Dangerous pathogens can spread faster and further through food and people.
While people traveling and carrying pathogens on their bodies is a contributing factor to globetrotting germs, keep in mind that the food supply has evolved from domestic to international as well. The food supply is inundated with international food products as well as internationally sourced ingredients.
Even ingredients for US-processed foods are sourced globally. For example, The New York Times ("A Multinational Loaf" June 16, 2007) reported that a loaf of bread could contain guar gum from India, calcium proprionate from the Netherlands, flour enrichments from China, beta carotene from Switzerland, wheat gluten from France… You get the idea!
Global sourcing means that safety is a complex issue, involving multiple regulatory agencies. It also means pathogens, toxins, or any problems in food safety can have massive reach.
Globalization of the food supply means globalization of the pathogen pool as well. Here is what happens when a global food carries a pathogen that can contribute and cause foodborne illness:
In February of 2010, Daniele Inc., recalled sausage that was linked to many illnesses. The pathogen in question was Salmonella Montevideo.
Investigative research traced the pathogen back to pepper that was imported from Vietnam. The black pepper was used as an ingredient and coating for pepper-coated salami products.
There were over 203 cases reported, with the illness being spread out over 43 states in the US.
Gould and colleagues (2017) say that 19% of the U.S. food supply is imported. They point out that "only a small proportion" of FDA-regulated foods are inspected upon entry. From 1996 through 2014, imported foods were implicated in 195 foodborne illness outbreaks, resulting in:
Another factor receiving intense scrutiny is the traceability in the food supply.
In the course of investigating suspect foodborne illnesses, one of the first steps for health officials is to match symptoms with a common food. Then they can begin tests and genetic fingerprints.
But what happens when they determine there is a common food…like tomatoes? How do investigators locate the rest of the potentially contaminated foods and get them out of circulation? The sooner these products are recalled and removed, the fewer people will get sick.
As we have seen with the peanut butter recall and many other outbreaks, this is not always an easy task.
Traceability has taken a high priority. Recent efforts by scientists are focused on reducing foodborne illness and focusing on traceability. One innovative technique focuses on using infrared spectroscopy. This technique for ground beef can differentiate between strains of E. coli within an hour, as opposed to conventional plating, which requires a minimum of 48 hours.
Marc Allard and colleagues describe the GenomeTrakr network, a whole-genome sequencing network of state, federal, international, and commercial partners developed by the FDA. It is intended to assist with tracebacks of pathogens when outbreaks occur, speed up outbreak investigations, and assist with recalls to better manage public health.
There are many factors that are in play with foodborne illness and food safety. In this CE program, we've examined:
The ever-present risk of foodborne pathogens challenges dietetics professionals to take the lead in food safety education. Says the ADA in its position paper on food safety:
As the food and nutrition experts, food and nutrition professionals must assume a major role in food and water safety education and research.
If you are looking for powerful food safety education tools, try starting at the massive online portal, www.FoodSafety.gov.
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Michael Foods, Inc.