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Foodborne Illnesses Pose a Serious but Preventable Hazard to Public Health Part I: Identifying the Most Common Threats

May 1, 2009 Foodborne Illnesses Pose a Serious but Preventable Hazard to Public Health – Part I: Identifying the Most Common Threats

The Centers for Disease Control (CDC) estimates there are about 76 million cases of foodborne illness reported in the U.S. each year. Thus, about one in four Americans can expect to contract a foodborne illness in the next twelve months from something they eat at a restaurant or buy at a store.

The CDC’s Morbidity and Mortality Weekly Report states in 2006, the latest year for which information is available, there were 1,270 foodborne disease outbreaks (FBDO) reported from 48 states. These outbreaks accounted for approximately 27,634 cases of illness and 11 deaths. Most cases were attributed to single food vehicles and according to the report: poultry was blamed for 21% of outbreaks, leafy vegetables for 17%, and fruits and nuts for 16%.

According to the CDC, most foodborne illnesses are preventable. Although FBDOs are usually sporadic, prompt reporting and analysis helps health officials identify effective measures of control. The CDC receives voluntary reports from state and local health departments via an electronic Foodborne Outbreak Reporting System (eFORS) which classifies a FBDO as, “Two or more cases of similar illness resulting from the ingestion of a common food.”

While most cases of foodborne illness resolve without medical intervention, approximately 350,000 people are hospitalized and 5,000 die each year. Recently, there have been massive food recalls, and consumer advocates have made people increasingly aware of the risks to America’s food supply. Still, too many Americans are not fully aware of the impact a foodborne illness could have on themselves or their families (especially children). Thus, while these diseases and infections are generally treatable if diagnosed promptly, when left untreated many of these illnesses may have serious, or even deadly, consequences.

E. coli

The E. coli bacteria, short for Escherichia coli, can grow in air (aerobically) or by fermentative metabolism (anaerobically). While the majority of E. coli strains are harmless, some can become extremely dangerous and spread quickly. The numerous different types of E. coli are classified into groups. E. coli O157: H7, was identified by the CDC as the most harmful form of the bacteria.

E. coli O157: H7 usually takes about 3-9 days to incubate. It travels through the stomach and small intestine, and then attaches itself to the inside surface of the large intestine, causing inflammation of the intestinal wall. This inflammatory reaction is caused by toxins secreted by the bacteria, which then causes hemorrhagic colitis. Hemorrhagic colitis is characterized by the onset of abdominal pain and severe cramps, followed within 24 hours by diarrhea as well as vomiting in some cases. As the disease progresses, the diarrhea becomes watery and then bloody.

While most people fully recover within two weeks, a small percentage of infected individuals, primarily children, go on to develop a severe, life-threatening complication known as hemolytic uremic syndrome (HUS). E. coli O157: H7 is responsible for over 90% of the cases of HUS in North America and is the most common cause of kidney failure in children.

HUS is believed to develop when E. coli enters into circulation through the inflamed bowel wall. Some organs that are more susceptible to HUS are the kidney, pancreas, and brain. There is currently nothing to stop the progression of HUS. The active stage of the disease usually lasts one to two weeks and about 5% of those affected with HUS die. Other consequences kidney failure, pancreatitis, seizures, and diabetes mellitus.

Another severe condition that can be caused by E. coli bacteria is thrombotic thrombocytopenic purpura (TTP), otherwise described as “adult HUS.” TTP affects most of the major body organs, including the heart, brain, kidneys, pancreas and adrenals. Other organs are involved to a lesser degree. Symptoms and warning signs of TTP include vomiting, diarrhea, malaise, weakness, hypertension, headache, confusion, stupor, coma, and seizures.

Since eating undercooked ground beef remains the number one risk factor for acquiring the E. coli virus, always make sure that ground beef and hamburgers are cooked thoroughly especially since they can turn brown and appear ready to eat long before disease causing bacteria are actually killed. Never eat ground beef patties that are still pink in the middle.

Anything that touches E. coli bacteria can become a hazard as well. To avoid spreading dangerous bacteria, always keep raw meat separate from ready-to-eat foods. Wash hands, counters, and utensils with hot soapy water after they touch raw meat and never place cooked hamburgers or ground beef back on the plate that held raw patties unless it has been thoroughly washed.

Milk, juice, or cider that is not pasteurized may also contain harmful pathogens. Fruits and vegetables bought at the store or the market should always be washed thoroughly, especially those that will not be cooked.

Even when not life threatening, E. coli can be quite unpleasant with the infection lasting about 5-10 days. The use of Antibiotics is not recommended.

Norwalk Virus (Norovirus)

The Norwalk Virus, commonly known as the Norovirus, is extremely common in the United States, making up 54% of outbreaks with a single cause. In fact, the common cold is the only virus reported more frequently than Norwalk Virus, otherwise referred to as viral gastroenteritis.

Norovirus is contained in a round blue protein ball that attaches to the outside lining your intestine and transfers its genetic material into intestinal cells where it reproduces and,   eventually, kills the human cell. It then releases new copies of itself that attach to more cells. Norwalk causes more outbreaks of food borne illness than bacteria and parasites - approximately 181,000 cases occur annually, with no known associated deaths.

The Norovirus is generally transmitted via contaminated food either from the source or an infected food preparer. The virus is transmitted though the vomit and stool of infected individuals and may also be spread from person to person with the potential to reach hundreds to thousands.

Common symptoms of Norwalk include nausea, vomiting, diarrhea, abdominal pain, headache, and sometimes low-grade fever. It will usually develop 24 to 48 hours after consuming contaminated food or water and can last up to 60 hours. People usually recover in 2 to 3 days without any serious or long-term health effects.

Outbreaks of Norwalk Virus have been linked to raw shellfish, especially oysters and clams. Even steaming does not kill the virus or prevent its transmission. Contaminated water, ice, eggs, salad ingredients, and ready-to-eat foods have also been known to cause outbreaks of Norwalk Virus. In 2002 alone, there were 9 major Norwalk outbreaks in the United States.

Although extremely common, Norovirus is easy to avoid. It does not multiply in foods as other bacteria do and thorough cooking can destroy the virus completely. Always wash your hands with soap and warm water after using the bathroom, before preparing or eating food, and after taking care of someone infected by the virus.

Raw vegetables should be washed thoroughly before eating or preparing salads. If you are traveling in an area with polluted water, try to drink only boiled drinks or carbonated bottled beverages without ice.


Salmonella is a bacteria that causes typhoid fever and many other intestinal infections. Over 2300 different strains of these bacteria exist. More common strains have recently become resistant to several of the antibiotics traditionally used to treat it.

According to the CDC, there were 28 FBDOs in 2006 attributed to Salmonella Enteritidis. Salmonellosis can be detected by examining stool or blood samples; however, in most cases, it is the stool and not the blood stream that is infected. In addition, many persons submit cultures after they have started antibiotics, therefore the diagnosis of salmonellosis may be problematic and many mild cases are never detected at all.

Contaminated meat, poultry, and uncooked eggs may cross-contaminate other ready-to-eat foods or anything else with which they come into contact. Washing hands, cutting boards, counters, knives, and other utensils after handling uncooked foods is essential for the prevention of cross-contamination.

Poultry, ground beef, and eggs need to be cooked thoroughly and properly at all times. Eggs are one of the major sources of Salmonella poisoning. In order to ensure that eggs do not contain viable Salmonella they must be cooked at least until the yoke is solid. Eating or drinking raw eggs can dangerous. Raw, unpasteurized milk can also be dangerous.

The symptoms of Salmonella are diarrhea, abdominal cramps, fever, nausea, and/or vomiting which are common among other bacteria pathogens. If symptoms persist after initial medical care, you should contact your physician for further treatment.


Listeria monocytogenes is a disease-causing bacterium that causes Listeriosis. Annually, there are approximately 2,500 cases of Listeriosis in the United States leading to about 500 deaths. Major outbreaks of Listeria have occurred in numerous states over the past several years.

Since Listeria survives in temperatures from below freezing (20°F) to body temperature, it may even be transmitted in ready-to-eat foods that have been properly refrigerated.  

Pregnant women and their fetuses are at higher risk for Listeriosis. Some of the serious outcomes of Listeriosis in pregnant women are spontaneous abortion, stillbirths, or sepsis in infants. Listeriosis can be transmitted to an unborn fetus through the placenta or during  birth.

Listeria bacteria enter the body through the gastrointestinal tract, travel through the blood stream and may be found inside cells. Listeria can manipulate the host cell genes, produce a toxin that damages cells, and move directly from cell-to-cell thereby avoiding the body’s natural defense mechanisms.

Listeria is found in soil and vegetation and easily contracted and transmitted by herd animals. It can live in the intestines of humans, animals, and birds for long periods of time without causing infection. It can be passed to humans from eating infected cattle and fowl, as well as dairy products, fruits, and vegetables.

After eating contaminated food, the incubation period ranges from 1 to 8 weeks, averaging about 31 days. Symptoms of listeriosis include fever, muscle aches, and gastrointestinal symptoms such as nausea or diarrhea. If the nervous system is affected, other symptoms can include headache, stiff neck, loss of balance, confusion, or convulsions. In such cases, listeriosis may mimic a stroke.

Although Listeria is generally treatable, it remains a serious public health threat, especially to pregnant women, people with AIDS, or those who are immuno-compromised. Although major outbreaks of Listeria have been infrequent, the illness is one of the more serious foodborne illnesses and can be fatal.


Shigella bacteria live in the human intestine and can be spread through food and by person to person contact. About 25,000 cases of shigellosis are reported each year in the United States; however, it is estimated that another 425,000 cases either go undiagnosed or unreported. Individuals who are at increased risk are small children and persons infected with HIV.

Symptoms of Shigellosis include diarrhea, fever, abdominal cramps, and rectal spasms. The diarrhea can sometimes contain blood or mucus. The illness can begin from 12 hours to 6 days after initial exposure and usually lasts for 5 to 7 days. Bowel problems can persist for several months. Hospitalization may be necessary for young children, the elderly, and immune-compromised persons. Complications associated with shigellosis include severe dehydration, seizures in small children, rectal bleeding, and invasion of the blood stream by the bacterium.

Shigellosis is more severe than other forms of gastroenteritis, because Shigella bacteria in the human digestive system invade cells causing serious tissue damage. Approximately 700 shigellosis-related deaths occur annually in the U.S., while more than one million deaths occur worldwide, most of which involve children in underdeveloped nations.

A small percentage of persons who are infected with Shigella may later develop a syndrome called reactive arthritis, or Reiter’s Syndrome, that includes joint pain and swelling, irritation of the eyes, and sometimes painful urination as well. Reiter's syndrome can last for months or years and may be difficult to treat.

The primary source of Shigella bacteria is the excrement of an infected individual. That infectious material then spreads by person-to-person contact such as caring for a sick child, sexual contact, and even ordinary household contact. Contaminated food or water can also spread the disease. Food can be contaminated by handlers or preparers or even during processing. Contaminated drinking water is particularly problematic in under-developed countries.

Thorough cooking kills Shigella bacteria and its spread can be stopped by frequent and thorough hand washing with soap and water. Basic food safety precautions help to prevent shigellosis. Anyone caring for a baby with shigellosis should dispose of diapers properly. People with shigellosis or diarrhea should not prepare food for others until they are bacteria free. Antibiotics are used to treat Shigellosis and, in the most serious cases, may even be life saving.

Hepatitis A

Hepatitis viruses A through E primarily infect the human liver. Although Hepatitis A is usually not a serious problem in developed countries with adequate sanitation systems and is now completely preventable, there are still approximately 30,000 to 50,000 cases and 100 deaths (from acute liver failure) annually in the U.S.

There are often no immediate symptoms; however, Hepatitis A is usually associated with the onset of flu-like symptoms (starting about 30 days after the virus is contracted) followed by muscle aches, headache, loss of appetite, abdominal discomfort, fever and malaise, and jaundice.

The recovery time is about 2 months but some people can experience relapses lasting up to 6 months. Most people who contract Hepatitis A fully recover and do not experience chronic Hepatitis. Unfortunately, about .2% (2/1000) of those with symptomatic acute Hepatitis A may die. Those most at risk for fatal consequences are people with chronic liver disease, Hepatitis B, Hepatitis C, and cirrhosis of the liver.

Hepatitis A is contagious and may be spread from person to person; however, the virus is usually ingested with contaminated food. The illness is most communicable during the 2 weeks before the onset of symptoms. In that time period, an infected food handler may spread the illness while not exhibiting any signs of infection.

Hepatitis A may also be contracted from close contact with family members and roommates, sexual activity, contaminated drinking water, eating raw or undercooked shellfish, or persons sharing illicit intravenous drugs. Children often do not display the pronounced symptoms found in adults and frequently transmit the virus to playmates and their own parents.

Immediately after diagnosis, Immune Globulin should be administered within 2 weeks of exposure to the virus. It will often prevent the disease or at least reduce its effect. Any individual age 3 or older can be vaccinated. Prompt medical attention is the best way to treat Hepatitis A.


Over 10,000 cases of Campylobacteriosis, with some 500 fatalities, are reported to the CDC each year in isolated or sporadic events with outbreaks occurring more frequently in the summer. There are about 46,000 unreported cases yearly.

Food becomes contaminated from the intestinal material of animals during processing. Contaminated chicken is associated with about 70% of the annual cases of the illness. A study by Consumer Reports identified Campylobacter in 63% of more than 1000 chickens obtained in grocery stores. Other foods that may carry the bacteria include unpasteurized milk, undercooked meats, mushrooms, hamburger, cheese, pork, shellfish, and eggs.

Campylobacter can survive on properly refrigerated foods and will grow if the contaminated food is left out at room temperature. Pasteurization of milk, adequate cooking of meat and poultry, and chlorination of water will adequately destroy these bacteria.

Larger outbreaks of Campylobacteriosis have occurred due to contaminated water, chicken, fruit, or milk and milk products. The bacteria can also be spread by contact with an animal carrier such as cattle, pigs, chickens, turkeys, ducks, and geese, birds, cats, dogs, hamsters, and turtles. The bacterial organism is also occasionally isolated from streams, lakes and ponds.

Children under the age of five and young adults aged 15-29 are the age groups most frequently affected. The incubation period is typically two to five days but may be as long as 10 days after initial exposure. Campylobacteriosis usually lasts no more than one week but symptoms may continue for up to three weeks.

Symptoms include diarrhea, blood in the stool, fever, nausea, vomiting, abdominal pain, headache, and muscle pain. Although the majority of cases are mild and do not require hospitalization, the bacterial infection can be severe and in some cases even fatal. Death is more likely to occur where other diseases, such as cancer, liver disease, and immuno-deficiency diseases are present.

Long-term consequences, although rare, may occur as a result of Campylobacter infection. A small percentage of victims people develop Guillain-Barré syndrome, which affects the nervous system and may cause acute generalized paralysis. Guillain-Barré syndrome begins in the feet and spreads up the body and is detectable by prickling sensations that give way to weakness that may lead to paralysis. Most people fully recover but some people sustain severe neurological damage. It is estimated that approximately .1% (1/1000) of the reported Campylobacteriosis cases lead to Guillain-Barré syndrome.

Miller Fisher Syndrome is another neurological syndrome that can be precipitated by Campylobacteriosis. It affects the nerves of the head more than those of the body. Reiter's syndrome, or reactive arthritis, is another illness associated with Campylobacter. The bacterial infection may also cause appendicitis or infect the abdominal cavity, the heart, the central nervous system, the gallbladder, the urinary tract, and the blood stream.

There are several treatments available for Campylobacteriosis. Affected individuals can take anti-diarrheal medications, such as loperamide, to alleviate symptoms and drink plenty of fluids in order to maintain hydration. In more severe cases of gastroenteritis, antibiotics may shorten the course of the illness.

To prevent Campylobacter infection the following precautions should be taken:

•    Cook all poultry completely and avoid eating poultry at a restaurant if it appears to be undercooked or pink inside.
•    Transport meats home quickly and in the coolest part of your vehicle, especially in warm weather.
•    Meat and poultry should be defrosted in the refrigerator (taking precautions to prevent the drippings from reaching other foods) or a microwave. Do not leave meat and poultry out in order to defrost it.
•    Never leave food out at room temperature, either during preparation or after cooking, for more than 2 hours.
•    Do not place cooked meats and chicken back onto a platter or pan that contained the raw food unless it has been thoroughly washed. The same applies to cutting boards (especially porous or wooden boards), trays or plates.
•    Wash utensils and hands thoroughly after cutting raw meat or poultry and before cutting other food. (Also after coming in contact with pets, changing diapers, or interacting with someone with an intestinal infection)
•    Avoid unpasteurized or raw milk products.
•    Avoid food sold by street vendors. It is often undercooked, improperly stored, cross-contaminated, or improperly prepared.
•    Wash fruits and vegetables carefully, especially if they are to be eaten raw.

Botulism Poisoning

Botulism weakens the muscles by invading nerve cells and disrupting regular chemical activity. This can lead to paralysis, blurry vision, falling eyelids and slurred speech. Some damage done to the nerves can be permanent. About eight percent of these cases can be fatal. Other scenarios might require those infected to be hospitalized if breathing muscles become paralyzed.

The disease usually resides in canned goods and can exist even without contact to air. Their ability to live with a lack of oxygen classifies them as anaerobic bacteria.


Cryptosporidium is a disease caused by microscopic parasites that reside in the intestines of an animal or person and exits the body by means of excretion. The parasite, also known as crypto, creates an outer shell which allows it to survive for long periods of time outside the body.

The disease is foodborne as well as waterborne and exists usually in soil, food, vegetables, water and anything else that has come in contact with fecal matter.
Anyone who works around small children (especially those with diapers) is also at risk of coming into contact with crypto.

Fruits and vegetables play a large role in the spread of crypto since the soil in which they grow may be infected. The best way to combat the illness at this stage is by thorough washing of all produce in your home.

Symptoms of Cryptosporidium include diarrhea, cramps and stomach pains, nausea and vomiting, a fever, dehydration and even weight loss. The symptoms do not show until a few days after contact with the infection. The entire cycle of the sickness can last for about 1 to 2 weeks.  


Cyclospora is a parasitic infection that stays in the intestines of animals and humans and comes from food as well as water. Although not a U.S. born disease, Cyclospora has been linked to imported fruits such as raspberries and basil.

The symptoms of Cyclospora come in the form of abdominal cramping, fatigue, mild fever, weight loss, diarrhea, nausea and vomiting. The condition is treatable and can be cured by trimethoprim-sulfamethoxazole, but if not treated, the infection can last for over one month.

Like other parasite-based infections, produce is suspect of being a home to pathogens. Washing fruits and vegetables is an easy and effective way of ridding your food of harmful organisms.

If you or a loved one has suffered a preventable foodborne illness as the result of negligent food handling or processing by a restaurant, food store, or food processor, please contact Parker Waichman LLP at for a free case evaluation.  

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