Food-borne disease

The vast majority of reported cases of food-borne illness of known etiology are of bacterial origin. Among the bacterial pathogens are Campylobacter jejuni, Salmonella, Staphylococcus aureus, Escherichia coli O157:H7, Shigella, Bacillus cereus, Clostridium perfringens, Listeria monocytogenes, Yersinia enterocolitica, and Clostridium botulinum. These pathogens account annually for more than 5 million cases (estimated) of food-borne illness in the United States. Illness can result from a bacterial infection or intoxication. Food-borne infection occurs when a pathogen grows in the human body. Food-borne intoxication results when a pathogen grows in food and releases toxins that cause illness when ingested in sufficient amounts. Infectious pathogens include C. jejuni, Salmonella, E. coli O157:H7, Shigella, and Y. enterocolitica. Toxin-producing pathogens are C. botulinum and Sta. aureus.

Campylobacter jejuni

Campylobacter jejuni is the leading cause of acute bacterial diarrheal illness in the United States, responsible for more than 2 million cases (estimated) of gastroenteritis annually. The disease is inexplicably most prevalent in California, where the incidence is up to four times greater than in other states. Poultry is the primary vehicle of infection, being associated with 5075% of cases of Campylobacter enteritis. Approximately 5080% of retail poultry is contaminated by C. jejuni, often at levels of 104106 cells per gram. Campylobacter jejuni also has been associated with Guillain-Barr syndrome, the leading cause of acute neuromuscular paralysis in the United States. Guillain-Barr syndrome is an autoimmune disease that is triggered by several factors, including an acute infectious illness of the gastrointestinal tract. It is estimated that 2550% of cases of the syndrome are precipitated by C. jejuni infections. Hence, C. jejuni accounts for up to 2100 cases annually.

Salmonella species

Another leading cause of food-borne illness is Salmonella, which is responsible for 2 million cases (estimated) of gastroenteritis per year. Salmonella enteritidis and Sal. typhimurium are the two leading serotypes causing human food-borne illness. Each serotype is responsible for about 2025% of salmonellosis cases. Salmonella enteritidis is largely transmitted by eggs. This pathogen colonizes the ovarian tissue of laying hens and is present within the egg contents. Present estimates suggest that 1 in 20,000 eggs in the United States is internally contaminated with Sal. enteritidis. Properly refrigerating and thoroughly cooking eggs are the best preventive measures to avoid egg-borne salmonellosis. An increasing public health concern is the development of strains of Salmonella that are multiresistant to antibiotics used for human therapy. Salmonella typhimurium phage type DT 104, which is resistant to five commonly used antibiotics, including chloramphenicol, has emerged as a major cause of salmonellosis in humans. In 19791980, 0.6% of cases of Sal. typhimurium infection in the United States were attributed to phage type DT 104. In 1996, DT 104 was responsible for 34% of such cases. Interestingly, the total number of annual cases of salmonellosis caused by Sal. typhimurium has not changed substantially in

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recent years, but DT 104 is rapidly becoming the dominant phage type among the strains of Sal. typhimurium responsible for gastroenteritis. Only one effective antibiotic, fluoroquinolone, remains available for use in the treatment of Sal. typhimurium DT 104 in human infections. Reports from the United Kingdom indicate that some strains of DT 104 have also acquired resistance to fluoroquinolone. Strains having this antibiotic-resistance profile may not be treatable in life-threatening cases of salmonellosis.

Escherichia coli O157:H7

Enterohemorrhagic E. coli O157:H7 (EC O157) is an unusually virulent bacterium that has led food microbiologists to rewrite the rule book on food safety. This pathogen has a very low infectious dose (it is

estimated that ingestion of less than 10 cells can cause illness), and produces severe illness that affects all age groups. It has unusual tolerance to acid, and an inexplicable association with ruminants. The symptoms of E. coli O157:H7 infection are often severe and can be life-threatening. They include hemorrhagic colitis (overtly bloody diarrhea), hemolytic uremic syndrome (acute kidney failure), and thrombotic thrombocytopenic purpura (diminished platelet count, prolonged bleeding time). The last resembles hemolytic uremic syndrome but causes less renal failure and has neurological involvement that includes seizures and strokes. Escherichia coli O157:H7 can survive for several days to weeks in acidic foods such as apple juice, fermented sausage, and yogurt that contain sufficient amounts of acid to kill most food-borne pathogens. Cattle are the primary reservoir of E. coli O157:H7. The bacteria persist in the animal's forestomachs and lower gastrointestinal tract. From 1 to 3% of cattle carry E. coli O157:H7 with no apparent symptoms of sickness. Eating undercooked ground beef and handling animals (especially cattle) on farms are leading risk factors associated with E. coli O157:H7 infection. An estimated 10,000 20,000 cases of such infection occur annually in the United States.

Trends
Many changes have occurred during the past generation that likely contribute to increases in foodborne illness. These trends include changes in diet, increasing use of commercial food services, new methods of producing and distributing foods, new and reemerging food-borne microbial pathogens, and an increased number of immunocompromised people who are at risk of severe food-borne illness. During the past two decades, consumption patterns of many foods have changed substantially. Efforts to promote a heart-healthy diet have led to increased consumption of fruits and vegetables, which has led to an increase in importation of produce. Fresh produce has been increasingly associated with food-borne disease, accounting for one-third of all outbreaks reported in Minnesota from 1990 to 1996. During the last 20 years, imported produce has been associated with many outbreaks of food-borne illness in the United States. In addition, beef consumption has decreased in part because of public concern about E. coli O157:H7 contamination, whereas poultry consumption has almost doubled in 20 years, greatly increasing the risk of acquiring Campylobacter infection. Cultural changes have also affected where people eat and how their food is prepared. The timepressured life-styles of Americans lead to reduced time available for shopping and preparing meals. These pressures can affect food selection and safety, with more reliance on leftovers, increased purchase of prepared or convenience foods, and frequent eating away from home. There has been a dramatic change in consumption of foods away from home. About one-third of food dollars was spent eating away from home in 1970, whereas in 1996, 46% of food dollars went to meals and snacks prepared outside the home. These changes have led to a substantial increase in the number of

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people handling food. Recent studies in Minnesota have revealed an increased risk of transmission of Sal. typhimurium associated with food handlers. Major changes have occurred in the processing and distribution of foods. Today, large volumes of foods

are processed in very large manufacturing plants. A few decades ago there were many smaller plants. Mass preparation and packaging of food in large processing facilities increases the potential of very widespread outbreaks if contamination occurs. Low-level contamination of a ready-to-eat product can result in thousands of cases of illness because of the large quantity of product consumed. The largest reported outbreak of salmonellosis in the United States was associated with ice cream that was sporadically contaminated with low levels of Salmonella and then widely distributed. Emerging and reemerging food-borne pathogens, which include new, recurring, or drug-resistant pathogens, have caused an increase in the incidence of food-borne illness in the last two decades. Examples include E. coli O157:H7, Cyclospora (a coccidia), Sal. enteritidis in eggs, and Sal. typhimurium DT 104. Many of these cause more severe symptoms than the typical mild gastrointestinal ailments frequently associated with food-borne illness. Overt bloody diarrhea, kidney failure, arthritis, and paralysis are some of the pronounced symptoms attributed to the emerging food-borne pathogens. Host susceptibility is an important factor associated with the risk of acquiring food-borne illness. The competence of an individual's immune system to resist infection is critical to reducing the risk of foodborne infection. Elderly persons with weakened immune systems and people with cancer and chronic diseases that result in an immunosuppressed state are highly susceptible to food-borne microbial pathogens. The number of elderly in the United States is increasing rapidly, with an estimated onefifth of the population being over age 65 by 2030. There is also an increasing number of people with immunosuppressive diseases such as human immunodeficiency virus. Food-borne disease of microbial origin is a major issue in the United States. With the emergence of previously unrecognized food-borne pathogens and new influences that facilitate the dissemination of pathogens or the acquisition of food-borne illness, even greater concerns regarding food-borne pathogens are likely. See also: Bacteria; Escherichia; Food microbiology; Food poisoning; Food science; Gastrointestinal tract disorders; Kidney disorders