Gastrointestinal Conditions

Published in Infectious Diseases in Children May 2009

Vigilance at all levels necessary to ensure food safety

Pediatricians can deliver a few basic messages about food safety that can help reduce morbidity and mortality.

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When President Obama announced the creation of a Food Safety Working Group earlier this year, he said he was inspired by his daughter Sasha. She eats peanut butter sandwiches regularly, and he thought of her when he first heard the news of the Peanut Corporation of America salmonella outbreak.

“Food safety is on a lot of parents’ minds. With so many big outbreaks, parents are very receptive to the message [of keeping food safe]. They are looking to their pediatricians for guidance,” said Barbara Mahon, MD, MPH, Foodborne Diseases Active Surveillance Network (FoodNet) team lead and a pediatrician.

Nationwide, foodborne illness rates had been declining since the mid-1990s, mainly due to improvements in the food industry. But several high-profile outbreaks — such as the ones last year that involved imported hot peppers and the more recent salmonella outbreak in peanut products — have kept rates stable for the past four years, according to FoodNet data published last month by the CDC.

The outbreaks have caused many to reexamine their food safety practices. In addition to the creation of the Food Safety Working Group, the FDA has hired more food inspectors. Food businesses are taking a closer look at their manufacturing practices. Many consumers are asking what they can do to keep their food safe.

James Nataro, MD, vice-chairman of pediatrics and associate director for the Center for Vaccine Development at the University of Maryland School of Medicine, said he was not surprised to hear that the foodborne illness rate had reached a plateau. He said that physicians could do a better job addressing this issue with their patients during well-child visits.

“Anybody whose immune system is not at its peak is more susceptible to any of the foodborne illnesses, especially those children who are immunocompromised or those at extremes of age,” Nataro said. “As health care providers, we need to educate the consumer.”

Sunil K. Sood, MD, professor of clinical pediatrics at Albert Einstein College of Medicine and chief of pediatric infectious diseases at Schneider Children’s at North Shore in New York, said that pediatricians should be incorporating into the well-child visit the message about the need to wash hands, to exercise care when handling food, and to avoid exotic pets like reptiles, which have been shown to carry foodborne illnesses.

“There are a few basic messages pediatricians can deliver about food safety that can help reduce mortality,” he said.

CDC findings

The CDC findings were from 2008 data reported by FoodNet, a collaborative project involving 10 state sites. In the report, the researchers noted that infection rates with Campylobacter, Cryptosporidium, Listeria, Shiga toxin-producing Escherichia coli (STEC) O157, Salmonella, Shigella, Vibrio and Yersinia did not change significantly when compared with rates from the previous three years.

The incidence of Salmonella infections has been 14 to 16 cases per 100,000 people since the first years of surveillance. Campylobacter and shigella were the second and third most common types of illnesses, occurring at rates of about 13 and seven per 100,000, respectively.

“The idea that the reported rates of illness actually represent the tip of the iceberg is a little bit sobering,” Nataro said.

Insufficient regulatory laws

In an address that announced tougher food safety measures, President Obama faulted outdated regulatory laws that “were written in the time of Teddy Roosevelt” as contributing to the foodborne illness rates. He said that food inspection systems are dispersed among different agencies, making it “difficult for different parts of our government to share information, work together and solve problems.”

These agencies have been underfunded, Obama said. In recent years, the FDA was inspecting an average of 7,000 of the 150,000 food processing plants and warehouses, leaving the remainder uninspected. These periodic inspections left critical cracks that likely contributed to the high-profile spinach, pepper and peanut-related foodborne illnesses.

Food production, according to Nataro, is a business, and “the purpose of business is to make money … this is not to criticize the industry, but to be profitable and efficient, they have to pursue the same kinds of enterprises that other businesses undertake.

“They employ outsourcing and very complicated and rapid transportation systems. These business processes are moving targets, so ensuring safety of the product they provide also becomes a moving target,” Nataro said.

But food safety does not stop at the business level. Nataro said that consumers do not always assume responsibility for reducing the potential for foodborne illness. Many illnesses associated with the ConAgra chicken and turkey pot pie outbreak occurred because consumers did not read the preparation instructions on the package, he said. It is common for cooking times for pot pies to be based on microwave wattage.

“Most people don’t know the wattage of their microwaves. I don’t know mine and I research this for a living,” Nataro said.

Efforts to control illness

New efforts to control foodborne illness rates have been initiated. The foodborne division at CDC is increasing the capacity of several health departments so that outbreaks can be better detected and investigated, Robert Tauxe, MD, MPH, deputy director of CDC’s Division of Foodborne, Bacterial and Mycotic Diseases, said in a press conference announcing the FoodNet findings.

The USDA’s Salmonella Initiative Program, which began in 2006, has significantly reduced the presence of Salmonella in raw meat and poultry products, David Goldman, MD, MPH, assistant administrator of USDA’s Food Safety Inspection Service, said during the conference. “We have worked hard to reduce contamination in FSIS-regulated products and have seen marked success in Salmonella and Listeria monocytogenes.”

FDA officials said they are using new tools to help predict potential threats to foods and the best options for prevention.

But these detection tools are only as good as the cultures physicians obtain in their offices, Mahon said. “If doctors don’t order cultures, it is hard for us to know what’s going on.”

Additional research measures are needed, she said.

Herbert L. DuPont, MD, of St. Luke’s Episcopal Hospital in Houston, said that physicians “unfortunately are left with uncertainty about how to reduce the risk of disease. We need to develop better methods of food production, processing, distribution and storage to reduce the overall risk of foodborne disease.”

More research should be devoted to the microbiology of foodborne illnesses. “Improved methods of monitoring foods for their safety will require new research,” he said.

Treatment options, prevention

Treatment for foodborne diseases usually includes oral rehydration and preparations of bismuth subsalicylate if diarrhea and cramps occur without bloody stools or fever. However, taking these medications if there is high fever or blood in the stools can actually exacerbate symptoms.

Because treatment offerings are limited, researchers are working toward vaccine development. Last month, a Michigan State University researcher reported that he has developed a working vaccine for an E. coli strain. Other vaccines for use in cattle are under investigation.

But ultimately, protective efforts come back to the consumer, Sood said. “We’ve become complacent. Most people heed the advice to avoid drinking the water when they visit the developing world, but in the United States, we almost take the opposite for granted and assume there is no contamination of our food.

“The public is aware of E. coli from meat and salmonella contamination. But I don’t think they realize that any raw food should be treated with care. If it comes from a farm, it is likely to contain some type of contamination so it needs to be thoroughly washed and cooked,” Sood said.

Consumers can reduce their risk for foodborne illness by following safe food-handling and preparation recommendations and by avoiding consumption of unpasteurized milk, raw or undercooked oysters, or other raw or undercooked foods of animal origin such as eggs, ground beef and poultry.

Risk of illness also can be decreased by choosing pasteurized eggs, high pressure-treated oysters and irradiated produce.

Women of child-bearing age should be reminded about the dangers of Listeria. Also, Sood said, breastfeeding has been shown to have a protective effect against Salmonella.

Everyone should wash hands before and after contact with raw meat, raw foods derived from animal products, and animals and their environments. More detailed information on food safety practices is available at www.foodsafety.gov and www.fightbac.org. – by Colleen Zacharyczuk

For more information:

• CDC. Preliminary FoodNet Data on the Incidence of Infection with Pathogens Transmitted Commonly Through Food — 10 States, 2008. MMWR. 2009;58(13);333-337