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Preventing Foodborne Illness: Talking to Patients About Food Safety

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Salmonella - a quick introduction and overview

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Florida Integrated Food Safety Center of Excellence

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Foodborne Outbreak Investigation: What does an epidemiologist do?

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On August 15, 2016, the Hawaii Department of Health (HDOH) identified raw scallops served at Genki Sushi restaurants on Oahu and Kauai as a likely source of an ongoing hepatitis A outbreak. The product of concern was identified to be Sea Port Bay Scallops (Wild Harvest, Raw Frozen) that originated in the Philippines (states "Product of the Philippines" on the box) and were distributed by Koha Oriental Foods.

As a result, HDOH ordered this product embargoed (not to be sold, purchased, or consumed) throughout the state, and the temporary closure of all Genki Sushi restaurants on Oahu and Kauai.

As of November 30, 2016, HDOH has identified 292 cases of hepatitis A. Seventy-four have required hospitalization. Findings of the investigation suggest that the source of the outbreak is focused on Oahu. Eleven individuals are residents of the islands of Hawaii, Kauai, or Maui, and seven visitors have returned to the mainland or overseas. Onset of illness has ranged between June 12, 2016 and October 9, 2016.

The FDA and CDC are supporting the HDOH in the investigation of hepatitis A virus (HAV) infections linked to scallops supplied by Sea Port Products Corp. On August 17, 2016, the FDA, HDOH, CDC, and state partners informed Sea Port Products Corp. that epidemiological, laboratory, and traceback information indicated that their scallops are the likely source of illnesses. On August 18, 2016, Sea Port Products Corp. initiated a voluntary recall of three lots of frozen Bay Scallops produced on November 23 and 24, 2015. The lot numbers for the recalled scallops are 5885, 5886, and 5887. The products were distributed to California, Hawaii, and Nevada. According to Sea Port Products Corp., the recalled products are not intended for retail sale. The FDA is working with the recalling firm to ensure their recall is effective and that recalled product is removed from the market.

The FDA's traceback investigation involved working with HDOH to trace the path of food eaten by those made ill back to a common source. The traceback investigation determined that Sea Port Products Corp. imported the scallops that were later supplied to certain Genki Sushi locations in Hawaii, where ill people reported eating.

On August 17, 2016, FDA laboratory analysis of two scallop samples, which were collected on August 11, 2016, were confirmed positive for hepatitis A. These samples were imported by Sea Port Products Corp. and were produced on November 23 and 24, 2015.
The Hepatitis A Virus
Throughout history, hepatitis infections have plagued humans. The "earliest accounts of contagious jaundice are found in ancient China." According to the CDC:

The first descriptions of hepatitis (epidemic jaundice) are generally attributed to Hippocrates. Outbreaks of jaundice, probably hepatitis A, were reported in the 17 th and 18 th centuries, particularly in association with military campaigns. Hepatitis A (formerly called infectious hepatitis) was first differentiated epidemiologically from hepatitis B, which has a long incubation period, in the 1940s. Development of serologic tests allowed definitive diagnosis of hepatitis B. In the 1970s, identification of the virus, and development of serologic tests helped differentiate hepatitis A from other types of non-B hepatitis.

Until 2004, HAV was the most frequently reported type of hepatitis in the United States. In the pre-vaccine era, the primary methods used for preventing HAV infections were hygienic measures and passive protection with immune globulin (IG). Hepatitis A vaccines were licensed in 1995 and 1999. These vaccines provide long-term protection against HAV infection.

Fresh produce contaminated during cultivation, harvesting, processing, and distribution has also been a source of hepatitis A. In 1997, frozen strawberries were the source of a hepatitis A outbreak in five states. Six years later, in 2003, fresh green onions were identified as the source of a HAV outbreak traced to consumption of food at a Pennsylvania restaurant. Other fruits and vegetables, such as blueberries and lettuce, have also been associated with HAV outbreaks in the U.S. as well as in other developed countries. HAV is relatively stable and can survive for several hours on fingertips and hands and up to two months on dry surfaces. The virus can be inactivated by heating to 185°F (85°C) or higher for one minute, or disinfecting surfaces with a 1:100 dilution of household bleach in tap water. HAV can still be spread from cooked food if it is contaminated after cooking.

Although ingestion of contaminated food is a common means of spread for HAV, it may also be spread by household contact among families or roommates, sexual contact, or by direct inoculation from persons sharing illicit drugs. Children are often asymptomatic, or have unrecognized infections, and can pass the virus through ordinary play, unknown to their parents, who may later become infected from contact with their children.
What are the Symptoms of Hepatitis A? Fulminant Hepatitis A
Hepatitis A may cause no symptoms at all when it is contracted, especially in children. Asymptomatic individuals will only know they were infected (and have become immune, given that you can only get hepatitis A once) by getting a blood test later in life. Approximately 10 to 12 days after exposure, HAV is present in blood and is excreted via the biliary system into the feces. Although the virus is present in the blood, its concentration is much higher in feces. HAV excretion begins to decline at the onset of clinical illness, and decreases significantly by 7 to 10 days after onset of symptoms. Most infected persons no longer excrete virus in the feces by the third week of illness. Children may excrete HAV longer than adults.
Incidence of Hepatitis A Infection
The fulminant form of hepatitis occurs when this necrotic process kills so many liver cells-upwards of three-quarters of the liver's total cell count-that the liver can no longer perform its job. Aside from the loss of liver function, fulminant hepatic failure can lead to encephalopathy and cerebral edema. Encephalopathy is a brain disorder that causes central nervous system depression and abnormal neuromuscular function. Cerebral edema is a swelling of the brain that can result in dangerous intracranial pressure. Intracranial hypertensions leading to a brain stem death and sepsis with multiple organ failure are the leading causes of death in individuals with fulminant hepatic failure.

[1] Feinstone, Stephen and Gust, Ian, "Hepatitis A Virus," in Mandell, Douglas, & Bennett's PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES, Fifth Edition, Chap. 161, pp. 1920-40 (2000); Mayo Clinic Staff, "Hepatitis A," (last updated Sept 1, 2011). Articles available online at http://www.mayoclinic.com/health/hepatitis-a/DS00397.

[2] Feinstone, Stephen and Gust, Ian, "Hepatitis A Virus," supra note 1.

[3] Mayo Clinic Staff, "Hepatitis A," supra note 1.

[4] Feinstone, Stephen and Gust, Ian, "Hepatitis A Virus," supra note 1.

[5] CDC, "Hepatitis A," in EPIDEMIOLOGY AND PREVENTION OF VACCINE-PREVENTABLE DISEASES (also known as "The Pink Book"), Atkinson W, Wolfe S, Hambrosky J, McIntyre L, editors, 12th edition. Chapter available online at http://www.cdc.gov/vaccines/pubs/pinkbook/hepa.html.

[7] Id.; See also Fiore, Anthony, Division of Viral Hepatitis, CDC, "Hepatitis A Transmitted by Food," Clinical Infectious Diseases, Vol. 38, 705-715 (March 1, 2004). Full text online at http://www.cdc.gov/hepatitis/PDFs/fiore_ha_transmitted_by_food.pdf.

[8] Feinstone, Stephen and Gust, Ian, "Hepatitis A Virus," supra note 1.

[11] Feinstone, Stephen and Gust, Ian, "Hepatitis A Virus," supra note 1.

[12] Id.; See also Jaykus Lee Ann, "Epidemiology and Detection as Options for Control of Viral and Parasitic Foodborne Disease," Emerging Infectious Diseases, Vol. 3, No. 4, pp. 529-39 (October-December 1997). Full text of the article is available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640072/pdf/9366607.pdf

[13] Fiore, Anthony, supra note 7; CDC, "Hepatitis A," supra note 5; See also CDC, "Surveillance for Acute Viral Hepatitis - United States, 2007, Morbidity and Mortality Weekly Report, Surveillance Summaries, Vol. 58, No. SS03 (May 22, 2009) at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5803a1.htm.

[14] Fiore, Anthony, Division of Viral Hepatitis, CDC, "Hepatitis A Transmitted by Food," supra note 7.

[15] Id.; See also, Wheeler, C, et al., "An Outbreak of Hepatitis A Associated with Green Onions," New England Journal of Medicine, Vol. 353, 890-97 (2005). Full text of article available at http://www.nejm.org/doi/full/10.1056/NEJMoa050855.

[16] Hutin YJF, et al., "A Multistate, Foodborne Outbreak of Hepatitis A," New England Journal of Medicine, Vol. 340, pp. 595-602 (1999). Full text of article is online at http://nejm.org/doi/full/10.1056/NEJM199902253400802.

[18] Butot S, et al., "Effects of Sanitation, Freezing and Frozen Storage on Enteric Viruses in Berries and Herbs," Intentional Journal of Food Microbiology, Vol. 126, No. 4, pp. 233-246 (2003). Full text of article is available at http://www.prograd.uff.br/virologia/sites/default/files/bulot_et_al_2008_inactivation.pdf.; Calder, L, et al., An Outbreak of Hepatitis A Associated with Consumption of Raw Blueberries," Epidemiology and Infection, Vol. 131, No. 1 745-51 (2003) at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870016/pdf/12948375.pdf.

[20] CDC, "Updated recommendations from Advisory Committee on Immunization Practices (ACIP) for use of hepatitis A vaccine in close contacts of newly arriving international adoptees," Morbidity and Mortality Weekly Report, Vol. 58, No. 36, (Sept. 18, 2006), http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5836a4.htm; Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations, Morbidity & Mortality Weekly Review, Vol. 55, Report 407, (May 29, 2006) at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm; Todd, Ewan C.D., et al., "Outbreaks Where Food Workers Have Been Implicated in the Spread of Foodborne Disease. Part 6. Transmission and Survival of Pathogens in the Food Processing and Preparation-environment," Journal of Food Protection, Vol. 72, 202-19 (2009). Full text of the article is available online at http://courses.washington.edu/eh451/articles/Todd_2009_food%20processing.pdf.

[21] Fiore, Anthony, Division of Viral Hepatitis, CDC, "Hepatitis A Transmitted by Food," supra note 7.

[23] Feinstone, Stephen and Gust, Ian, "Hepatitis A Virus," supra note 1; Piazza, M, et al., "Safety and Immunogenicity of Hepatitis A Vaccine in Infants: A Candidate for Inclusion in Childhood Vaccination Program," Vol. 17, pp. 585-588 (1999). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/10075165; Schiff, E.R., "Atypical Manifestations of hepatitis-A," Vaccine, Vol. 10, Suppl. 1, pp. 18-20 (1992). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/1475999.

[24] Fiore, Anthony, Division of Viral Hepatitis, CDC, "Hepatitis A Transmitted by Food," supra note 7

[25] Mayo Clinic Staff, "Hepatitis A," supra note 1.

[27] Feinstone, Stephen and Gust, Ian, "Hepatitis A Virus," supra note 1

[29] Id.; See also Sagliocca, Luciano, et al., "Efficacy of Hepatitis A Vaccine in Prevention of Secondary Hepatitis A Infection: A Randomized Trial," Lancet, Vol. 353, 1136-39 (1999). Abstract at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)08139-2/abstract.

[30] CDC, "Hepatitis A," supra note 5.

[34] Mayo Clinic Staff, "Hepatitis A," supra note 1.

[36] Mayo Clinic Staff, "Hepatitis A," supra note 1.

[37] Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations," supra note 20; Gilkson Miryam, et al., "Relapsing Hepatitis A. Review of 14 cases and literature survey," Medicine, Vol. 71, No. 1, 14-23 (Jan. 1992). Abstract of article online at http://www.ncbi.nlm.nih.gov/pubmed/1312659.

[38] Feinstone, Stephen and Gust, Ian, "Hepatitis A Virus," supra note 1.

[43] Mayo Clinic Staff, "Hepatitis A," supra note 1.

[44] CDC Summary, "Disease Burden from Viral Hepatitis A, B and C in the United States, 2004-2009, at http://www.cdc.gov/hepatitis/pdfs/disease_burden.pdf; CDC, "Hepatitis A," supra note 5.

[45] Detry, Oliver, et al., "Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure: Pathophysiology and Management," World Journal of Gastroenterology, Vol. 12, No. 46 pp. 7405-7412 (Dec. 14, 2006). Full article is available online at http://www.wjgnet.com/1007-9327/12/7405.pdf.

[46] Taylor, Ryan, et al., "Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes," Hepatology, Vol. 44, 1589-1597. Full text http://deepblue.lib.umich.edu/bitstream/2027.42/55879/1/21349_ftp.pdf.

[59] CDC, "Update: Prevention of Hepatitis A after Exposure to Hepatitis A Virus and in International Travelers, Updated ACIP Recommendations," Morbidity and Mortality Weekly Report, Vol. 56, No. 41, pp. 1080-84 (Oct. 19, 2007), online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a3.htm.

[65] CDC, "Surveillance for Acute Viral Hepatitis - United States 2007," supra note 13.

[68] Roos, B. (1956). Hepatitis epidemic transmitted by oysters. Sven Lakartidn, 53: 989-1003.

[69] Pintó, R. M., Costafreda, M. I., Bosch, A. (2009). Risk assessment in shellfish-borne outbreaks of hepatitis A. Appl Environ Micro, 75(23): 7350-7355.

[70] Portnoy, B. L., Mackowiak, P. A., Caraway, C. T., Walker, J. A., McKinley, T. W., Klein, C. A. (1975). Oyster-associated hepatitis: failure of shellfish certification programs to prevent outbreaks. JAMA, 233: 1065-1068.

[71] Mason, J. O., & McLean, W. R. (1962). Infectious hepatitis traced to the consumption of raw oysters. Am J Hyg, 75: 90-111.

[72] Dougherty, W. J., and Altman, R. (1962). Viral hepatitis in New Jersey 1960-1961. Am J Med, 32: 704-716.

[73] Ruddy, S. J., Johnson, R. F., Mosley, J. W., Atwater, J. B., Rossetti, M. A., Hart, J. C. (1969). An epidemic of clam-associated hepatitis. JAMA, 208: 649-655.

[74] Mackowiak, P. A., Caraway, C. T., Portnoy, B.L. (1976). Oyster-associated hepatitis: lessons from the Louisiana experience. Am J Epidemiol, 103: 181-191.

[75] Portnoy, supra note 70.

[76] Lee, H. C., Ang, L. W., Chiew, P. K., James, L., & Goh, K. T. (2011). Changing epidemiological patterns of hepatitis A infection in Singapore. Ann Acad Med Singapore, 40(10): 439.

[77] Goh, K. T. (1981). Epidemiological studies of hepatitis A in Singapore. Ann Acad Med Singapore, 10: 25-33.

[78] O'Mahoney, M. C., Gooch, C. D., Smyth, D. A., Thrussell, A. J., Bartlett, C.L.R., Noah, N. D. (1983). Epidemic hepatitis A from cockles. Lancet, 1: 518-20.

[79] Fujiyama, S., Akahoshi, M., Sagara, K., Sato, T., Tsurusaki, R. (1985). An epidemic of hepatitis A related to ingestion of raw oysters. Gastroenterol Jpn, 20: 6-13.

[80] Mele, A., Rastelli, M. G., Gill, O. N., di Bisceglie, D., Rosmini, F., Pardelli, G., Valtriani, C. & Patriarchi, P. (1989). Recurrent epidemic hepatitis A associated with consumption of raw shellfish, probably controlled through public health measures. Am J Epidemiol, 130: 540-546.

[81] Desenclos, J. C., Klontz, K. C., Wilder, M. H., Nainan, O. V., Margolis, H. S., Gunn, R. A. (1991). A multistate outbreak of hepatitis A caused by the consumption of raw oysters. Am J Public Health, 81: 1268-1272.

[82] Halliday, M. L., Kang, L.-Y., Zhou, T.-K., Hu, M.-D., Pan, Q.-C., Fu, T.-Y., et al. (1991). An epidemic of hepatitis A attributable to the ingestion of raw clams in Shanghai, China. J Infect Dis, 164: 852-859.

[83] Apaire-Marchais, V., Robertson, B. H., Aubineau-Ferre, V., Le Roux, M. G., Leveque, F., Schwartzbrod, L., & Billaudel, S. (1995). Direct sequencing of hepatitis A virus strains isolated during an epidemic in France. Applied and environmental microbiology, 61(11): 3977-3980.

[84] Chironna, M., Germinario, C., De Medici, D., et al. (2002). Detection of hepatitis A virus in mussels from different sources marketed in Puglia region (South Italy). Int J Food Microbiol, 75: 11-18.

[85] Conaty, S., Bird, P., Bell, G., Kraa, E., Grohmann, G., McAnulty, J. M., et al. (2000). Hepatitis A in New South Wales, Australia from consumption of oysters: the first reported outbreak. Epidemiol Infect, 124: 121-130.

[86] Sanchez, G., Pintó, R. M., Vanaclocha, H., Bosch, A. (2002). Molecular characterization of hepatitis A virus isolates from a transcontinental shellfish-borne outbreak. J Clin Microbiol, 40: 4148-4155.

[87] Bosch, A., Sánchez, G., Le Guyader, F., Vanaclocha, H., Haugarreau, L., Pintó, R. M. (2001). Human enteric viruses in Coquina clams associated with a large hepatitis A outbreak. Water Science and Technology, 43(12): 61-65.

[88] Costa-Mattioli, M., Monpoeho, S., Schvoerer, C., Besse, B., Aleman, M. H., Billaudel, S., et al. (2001). Genetic analysis of hepatitis A virus outbreak in France confirms the co-circulation of subgenotypes Ia, Ib and reveals a new genetic lineage. J Med Virol, 65(2): 233-40.

[89] Pontrelli, G., Boccia, D., Di Renzi, M., Massari, M., Giugliano, F., Celentano, L. P., ... & Rapicetta, M. (2008). Epidemiological and virological characterization of a large community-wide outbreak of hepatitis A in southern Italy. Epidemiology and infection, 136(08): 1027-1034.

[90] Bialek, S. R., George, P.A., Xia, G. L., Glatzer, M. B., Motes, M. L., et al. (2007) Use of molecular epidemiology to confirm a multistate outbreak of hepatitis A caused by consumption of oysters. Clin Infect Dis, 44: 838-840.

[91] Shieh, Y. C., Khudyakov, Y. E., Xia, G., Ganova-Raeva, L. M., Khambaty, F. M., et al. (2007) Molecular confirmation of oysters as the vector for hepatitis A in a 2005 multistate outbreak. J Food Prot, 70: 145-150.

[92] Guillois-Bécel, Y., Couturier, E., Le Saux, J. C., Roque-Afonso, A. M., Le Guyader, F. S., Le Goas, A., et al. (2009). An oyster-associated hepatitis A outbreak in France in 2007. Eurosurveillance, 14(10): 1-6.

[93] Pintó, s upra note 69.

[94] Polo, D., Vilariño, M. L., Manso, C.F., Romalde, J. L. (2010). Imported Mollusks and Dissemination of Human Enteric Viruses. Letters to the Editor. Emerg Infect Dis, 16(6): 1036-1037. Accessed online at http://wwwnc.cdc.gov/eid/article/16/6/09-1748_article

[95] Lung, R.-Y. & Kay, L. (2013). CDC cautions against raw food as hepatitis A cases hit 4-year high. News Article. Published October 15, 2013. Focus Taiwan News Channel, The Central News Agency. Accessed online at http://focustaiwan.tw/news/asoc/201310150033.aspx

[96] Taiwan Centers for Disease Control. (2014). As Taiwan CDC confirms cluster of hepatitis A cases due to consumption of raw bivalves using genetic sequencing for the first time, public urged to pay attention to food safety. Press Release. Published December 8, 2014. Available at http://www.cdc.gov.tw/english/info.aspx?treeid=bc2d4e89b154059b&nowtreeid=ee0a2987cfba3222&tid=BA36E519A4A2F338 Also available on ProMED Mail at http://www.promedmail.org/post/3021721

[97] Centers for Disease Control and Prevention (CDC). (2016). Outbreak of hepatitis A in Hawaii linked to raw scallops. Press Release. Published August 19, 2016. Available at http://www.cdc.gov/hepatitis/outbreaks/2016/hav-hawaii.htm

[98] Hawaii Department of Health (HI DOH). (2016). Hepatitis A Outbreak 2016. Available at http://health.hawaii.gov/docd/hepatitis-a-outbreak-2016/

[99] CDC, Summary, "Disease Burden from Viral Hepatitis A, B, and C in the United States," supra note 44.

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Genki Sushi Scallops Hepatitis A Outbreak in Hawaii

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On August 15, 2016, the Hawaii Department of Health (HDOH) identified raw scallops served at Genki Sushi restaurants on Oahu and Kauai as a likely source of an ongoing hepatitis A outbreak. The product of concern was identified to be Sea Port Bay Scallops (Wild Harvest, Raw Frozen) that originated in the Philippines (states "Product of the Philippines" on the box) and were distributed by Koha Oriental Foods.

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FDA Begins Testing Cake mixes in search of E. Coli outbreak

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FDA Begins Testing Cake mixes in search of E. Coli outbreak

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They have not yet named any specific brands or flavors of cake mix related to an outbreak of E. coli infections, but federal officials have begun product testing in relation to the illnesses.

Sixteen people across 12 states have been confirmed as being infected, with seven requiring hospitalization, according to the Centers for Disease Control and Prevention. Illnesses began Feb. 26 with the most recent one beginning June 21.

More patients will likely be identified, according to federal officials because of the long shelf life of cake mixes and the time lag between when a person becomes ill and when the illness is confirmed and reported to the CDC.

The Food and Drug Administration has been working with the CDC on the outbreak investigation and reported on Aug. 4 that the agency has begun product testing. The FDA has also initiated traceback efforts and onsite inspections. However no producer or specific products have been named by the FDA or CDC.

Sick people in the outbreak range in age from 2 to 73 years old, with a median of 13. Seventy-five percent are children under the age of 18. Children are more likely to have a severe E. coli infection.

One person has developed a type of kidney failure called hemolytic uremic syndrome (HUS) but no deaths have been reported.

Of the eight patients interviewed, six reported tasting or eating raw batter made with a cake mix. People said they bought different varieties and brands.

Illinois, Iowa, Nebraska, and Ohio have two patients while Indiana, Massachusetts, Michigan, Oregon, South Carolina, Utah, Virginia, and Washington all have one.

Whole-genome sequencing showed that bacteria from sick people's samples are closely related genetically. This means patients in this outbreak likely got sick from the same food.

The CDC is advising people not to taste or eat raw cake batter, whether made from a mix or homemade. Eating raw cake batter can make you sick as it can contain harmful bacteria. Bacteria are killed only when the raw batter is baked or cooked.

The agency also told the public not to make milkshakes with products that contain raw foods such as cake mix, flour, or eggs, to keep raw foods such as cake mix, flour, or eggs separate from ready-to-eat foods, and to follow the recipe or package directions for cooking or baking.

About E. coli infections
Anyone who has developed symptoms of E. coli infection should seek medical attention and tell their doctor about their possible exposure to the bacteria. Specific tests are required to diagnose the infections, which can mimic other illnesses.

The symptoms of E. coli infections vary for each person but often include severe stomach cramps and diarrhea, which is often bloody. Some patients may also have a fever. Most patients recover within five to seven days. Others can develop severe or life-threatening symptoms and complications, according to the Centers for Disease Control and Prevention (CDC).

About 5 to 10 percent of those diagnosed with E. coli infections develop a potentially life-threatening kidney failure complication, known as a hemolytic uremic syndrome (HUS). Symptoms of HUS include fever, abdominal pain, feeling very tired, decreased frequency of urination, small unexplained bruises or bleeding, and pallor.

Many people with HUS recover within a few weeks, but some suffer permanent injuries or death. This condition can occur among people of any age but is most common in children younger than five years old because of their immature immune systems, older adults because of deteriorating immune systems, and people with compromised immune systems such as cancer patients.

People who experience HUS symptoms should immediately seek emergency medical care. People with HUS will likely be hospitalized because the condition can cause other serious and ongoing problems such as hypertension, chronic kidney disease, brain damage, and neurologic problems.

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FDA begins testing cake mixes in search of specific product in E. coli outbreak

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They have not yet named any specific brands or flavors of cake mix related to an outbreak of E. coli infections, but federal officials have begun product testing in relation to the illnesses. Sixteen people across 12 states have been confirmed as being infected, with seven requiring hospitalization, according to the Centers for Disease Control and Prevention.

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Chilling stored foods to proper temperatures is one of the best ways to slow the growth of dangerous bacteria.

A Refrigerator Thermometer Can Make a Big Difference

When it comes to protecting yourself and your family from foodborne illness, one of your most effective tools is the kitchen refrigerator. In fact, at room temperature, the numbers of bacteria that cause foodborne sickness can double every 20 minutes! Chilling foods to proper temperatures is one of the best ways to slow the growth of these bacteria.

To ensure that your refrigerator is doing its job, it's important to keep its temperature at 40 °F or below; the freezer should be at 0 °F. Since few refrigerator controls show actual temperatures, using an inexpensive freestanding appliance thermometer will allow you to monitor the temperature and adjust the setting of the refrigerator and/or freezer if necessary. Buy one for the fridge, one for the freezer, and check them often.

Items on this page:

Refrigerator Strategies: Keeping Food Safe

In addition to keeping the temperature in your fridge at 40 °F, you can take additional steps to make sure your refrigerated foods stay as safe as possible.

Avoid "Overpacking." Cold air must circulate around refrigerated foods to keep them properly chilled.

Wipe Up Spills Immediately. In addition to helping reduce the growth of the Listeria bacteria (which can grow at refrigerated temperatures), getting rid of spills - especially drips from thawing meats - will help prevent "cross-contamination," where bacteria from one food spread to another.

Keep It Covered: Store refrigerated foods in covered containers or sealed storage bags, and check leftovers daily for spoilage.

Check Expiration Dates On Foods. If food is past its "use by" date, discard it. If you're not sure or if the food looks questionable, the simple rule is: "When in doubt, throw it out."

Clean The Fridge Out Frequently. Make this task part of your kitchen cleaning routine!

Quick Chill

Whether you're dealing with leftovers or just-purchased foods, it's important to get foods that need refrigeration into your fridge quickly. Leaving perishable foods out for 2 hours or more allows bacteria to multiply rapidly - and can put you at serious risk of contracting foodborne illness.

Groceries: When you get home from the grocery store, put your refrigerated items away as quickly as possible. Never allow raw meat, poultry, seafood, eggs, or produce that requires refrigeration to sit at room temperature for more than 2 hours; the limit is one hour if the air temperature is above 90 °F. (If you're not sure whether certain produce requires refrigeration, ask your grocer.) Also, keep in mind that your car is probably even hotter than typical room temperature, so it's important not to leave groceries in your car longer than absolutely necessary - and never more than 2 hours (or 1 hour on a hot day).

Leftovers: These need to be refrigerated or frozen within 2 hours, as well. Despite what some people believe, putting hot food in the refrigerator doesn't harm the appliance. To help hot food cool faster, divide leftovers into smaller containers before putting them in the refrigerator.

Doggie Bags and Take-out Foods: Again, the "2-hour rule" applies to carry-home foods. Leftovers from take-out or restaurant meals need to go into the refrigerator within 2 hours at most. If you can't get home within 2 hours after eating out, don't request a doggie bag.

Marinated Foods: Always keep food in the refrigerator while it's marinating. Bacteria can multiply rapidly in foods left to marinate at room temperature. Also, remember this tip for marinating safely: never reuse marinating liquid as a sauce unless you bring it to a rapid boil first.

Thaw with Care

Because bacteria can multiply so rapidly in unrefrigerated food, it's simply unsafe to let food thaw at room temperature. If left unrefrigerated, some organisms can create toxins that will survive the cooking process even if the food is cooked to temperatures that kill the bacteria themselves.

There are three ways to thaw safely: in the refrigerator, in cold water, and in the microwave. If you thaw food in cold water, change the water every half hour to make sure it stays cold. Foods thawed in the microwave must be cooked immediately after thawing.

In Case of Disaster...

If your home loses power, how do you know what foods you can safely keep and eat?

If you have adequate warning that you may lose power, freeze water in quart size sealable plastic food storage bags and place them in your freezer and fridge to help food stay cold when the power goes out.

If you do lose power, keep the doors to your fridge and freezer closed as much as possible to keep foods cold.

Before using any foods, check your refrigerator and freezer thermometers. If the fridge is still at or below 40 °F, or the food has been above 40 °F for only 2 hours or less, it should be safe to eat.

Frozen food that still has ice crystals or is at 40 °F or below (to be sure, check the appliance thermometer or use a food thermometer to check each individual food package) can be safely refrozen or cooked.

If you're unsure how long the temperature has been at or above 40 °F, don't take a chance. Throw the food out.

How Long Is Too Long?

Even when your refrigerator and freezer are chilling foods at the right temperatures, and you've followed all the other rules for safe storage, there are limits to how long you can safely store foods in the refrigerator. (Foods will stay safe indefinitely in the freezer, but quality/taste of the food may be affected.)

More Than an "Upset Stomach"
Foodborne Illness Is Serious Business
Foodborne diseases are far more serious than many people realize. The Federal government estimates that there are about 48 million cases of foodborne illness annually - the equivalent of sickening 1 in 6 Americans each year. And each year these illnesses result in an estimated 128,000 hospitalizations and 3,000 deaths.

Salmonella, for example, causes millions of cases of foodborne illness annually and is the leading cause of foodborne deaths.

E. coli O157:H7 is a bacterium that can produce a deadly toxin. Infections from E. coli O157:H7 are estimated to be between 20,000 and 40,000 cases per year.

The Clostridium botulinum bacterium produces a deadly toxin that causes botulism, a disease characterized by muscle paralysis.

Illnesses caused by Campylobacter, noroviruses, Shigella, and other organisms can create severe health problems, particularly for children, the elderly, and people with chronic illness or suppressed immune systems.

You may be surprised to learn that food can make you very sick even when it doesn't look, smell, or taste spoiled. That's because foodborne illnesses are caused by pathogenic bacteria, which are different from the spoilage bacteria that make foods "go bad."

Many pathogenic organisms are present in raw or undercooked meat, poultry, seafood, milk, and eggs; unclean water; and even on fruits and vegetables. Keeping these foods properly chilled will slow the growth of bacteria; following the other recommended food handling practices (clean your hands, surfaces and produce, separate raw foods from ready-to-eat foods, and cook to safe temperatures) will further reduce your risk of getting sick.

Safe Food Handling: Four Simple Steps

CLEAN
Wash hands and surfaces often

Wash your hands with warm water and soap for at least 20 seconds before and after handling food and after using the bathroom, changing diapers, and handling pets.

Wash your cutting boards, dishes, utensils, and counter tops with hot soapy water after preparing each food item.

Consider using paper towels to clean up kitchen surfaces. If you use cloth towels, launder them often in the hot cycle.

Rinse fresh fruits and vegetables under running tap water, including those with skins and rinds that are not eaten. Scrub firm produce with a clean produce brush.

With canned goods, remember to clean lids before opening.

SEPARATE
Separate raw meats from other foods

Separate raw meat, poultry, seafood, and eggs from other foods in your grocery shopping cart, grocery bags, and refrigerator.

Use one cutting board for fresh produce and a separate one for raw meat, poultry, and seafood.

Never place cooked food on a plate that previously held raw meat, poultry, seafood, or eggs unless the plate has been washed in hot, soapy water.

Don't reuse marinades used on raw foods unless you bring them to a boil first.

COOK
Cook to the right temperature

Color and texture are unreliable indicators of safety. Using a food thermometer is the only way to ensure the safety of meat, poultry, seafood, and egg products for all cooking methods. These foods must be cooked to a safe minimum internal temperature to destroy any harmful bacteria.

Cook eggs until the yolk and white are firm. Only use recipes in which eggs are cooked or heated thoroughly.

When cooking in a microwave oven, cover food, stir, and rotate for even cooking. If there is no turntable, rotate the dish by hand once or twice during cooking. Always allow standing time, which completes the cooking, before checking the internal temperature with a food thermometer.

Bring sauces, soups and gravy to a boil when reheating.

CHILL
Refrigerate foods promptly

Use an appliance thermometer to be sure the temperature is consistently 40° F or below and the freezer temperature is 0° F or below.

Refrigerate or freeze meat, poultry, eggs, seafood, and other perishables within 2 hours of cooking or purchasing. Refrigerate within 1 hour if the temperature outside is above 90° F.

Never thaw food at room temperature, such as on the counter top. There are three safe ways to defrost food: in the refrigerator, in cold water, and in the microwave. Food thawed in cold water or in the microwave should be cooked immediately.

Always marinate food in the refrigerator.

Divide large amounts of leftovers into shallow containers for quicker cooling in the refrigerator.

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Refrigerator Thermometers - Cold Facts about Food Safety

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Print & Share (PDF 566KB) Chilling stored foods to proper temperatures is one of the best ways to slow the growth of dangerous bacteria. A Refrigerator Thermometer Can Make a Big Difference When it comes to protecting yourself and your family from foodborne illness, one of your most effective tools is the kitchen refrigerator.

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Pregnant Hispanic women are even more likely than non-Hispanic pregnant women to get a Listeria infection. This is probably caused by eating traditional soft cheese, such as "queso fresco," and other traditional foods made with milk that is unpasteurized. Brands of these traditional foods made with pasteurized milk are available in stores and online.

The Risk

Certain foods - including ready-to-eat refrigerated foods, unpasteurized (raw) milk, and foods made with unpasteurized milk - often may be contaminated with Listeria monocytogenes (LM), the third leading cause of death from food poisoning. These foodborne bacteria can grow at refrigerator temperatures and can cause an illness that in most healthy people is unpleasant but not serious. But in people who are at high risk, LM can cause an illness called listeriosis which can be severe and even lead to death. The people at high risk include pregnant women and their unborn babies, newborns, older adults, and other persons with weakened immune systems, such as those with HIV/AIDS, cancer, diabetes or kidney disease, and transplant patients.

While a pregnant woman may have only a mild, flu-like illness, or may not feel sick at all, listeriosis can lead to miscarriage, death of the unborn baby, a low-birth weight infant, health problems for the newborn, or even infant death. That's why reducing risks from Listeria is so important.

How to Reduce Your Risk from Listeria: 3 Easy Steps

There are three very simple things you can do to help prevent illness from Listeria:
1. Chill at the Right Temperature
The right temperatures slow the growth of Listeria. Put a refrigerator thermometer in the refrigerator and adjust the refrigerator temperature control, if necessary. Put a second thermometer in the freezer.

Your refrigerator should register at 40°F (4°C) or below and your freezer at 0°F (-18°C).
2. Use Ready-to-Eat Foods Quickly!
Use ready-to-eat, refrigerated foods by the Use By date on the package. The longer they're stored in the refrigerator, the more chance Listeria has to grow.
3. Keep the Refrigerator Clean
Clean your refrigerator regularly.

Wipe up spills immediately. This is particularly important, so Listeria doesn't have a place to grow and then spread to other foods.

Clean the inside walls and shelves with hot water and a mild liquid dishwashing detergent, rinse, then dry with a clean cloth or paper towel.

Temperature Check!

Use an appliance thermometer for your refrigerator and, if possible, one in your freezer:

Put the thermometer in the middle of the refrigerator. After 5 to 8 hours, if the temperature is above 38° to 40°F (3° to 4°C), adjust the refrigerator temperature control to a lower setting. Check again after 5 to 8 hours.

Put the thermometer between frozen food packages in the freezer. After 5 to 8 hours, if the temperature is above 0° to 2°F (-18° to -17°C), adjust the freezer temperature control to a lower setting. Check again after 5 to 8 hours.

To Eat or Not to Eat?

Choosing the right foods and preparing them safely helps reduce the risk illness from Listeria for at-risk people.

Hot dogs and luncheonmeats - unlessthey're thoroughlyreheated

Hot dogs and luncheonmeats that are heated to an internal temperature of 165°F measured witha food thermometer.

Soft cheeses, such as Feta, Brie,Camembert, "blue-veinedcheeses," or "queso blanco,""queso fresco," or Panela- that are made with unpasteurized milk.

Soft cheeses labeled"Made with pasteurized milk"

Refrigeratedpâtés or meat spreads

Canned or shelf-stable* pâtés or meat spreads

Refrigeratedsmoked seafood - unlessit's ina cooked dish,such as a casserole.(Refrigerated smoked seafood, such as salmon,trout, whitefish,cod, tuna, or mackerel is most often labeledas "nova- style,""lox," "kippered,""smoked," or "jerky." These types of fish are found ingrocery store refrigerator sections or delicounters or soldat delicatessens.)

Canned or shelf-stable* smoked seafood.

Unpasteurized milk or foods that contain unpasteurized milk

Pasteurized milk and foods made with pasteurized milk

*Foods that can be safely stored at room temperature, or "on the shelf," are called shelf stable.

Follow These Steps For Food Safety

Clean: Wash your hands before, during and after handling food. Wash utensils, cutting boards, and any surfaces that food touches after each use. Wash fruits and veggies-but not meat, poultry, or eggs.

Separate: Use separate cutting boards, plates, and utensils for raw (uncooked) produce and for raw (uncooked) meat, poultry, seafood, and eggs. Keep meat, poultry, seafood, and eggs separate from all other foods while shopping and in the refrigerator.

Cook: Only a food thermometer can make sure meat, poultry, fish, and casseroles are cooked to a safe internal temperature. For example, internal temperatures should be 145°F for whole meats (allow the meat to rest after cooking for 3 minutes) and fish, 160°F for ground meats, and 165°F for all poultry. Eggs should be cooked until the yolk is firm.

Chill: Use appliance thermometers to be sure your refrigerator is at or below 40ºF and your freezer is 0ºF or below. Between 40ºF and 140ºF is the Danger Zone, when bacteria can multiply rapidly. Generally, the more bacteria, the more likely someone will get sick. Most refrigerators have just a colder/ warmer adjustment, so the only way to know is to put a thermometer inside.

About Foodborne Illness: Know the Symptoms

Consuming dangerous foodborne bacteria will usually cause illness within 1 to 3 days of eating the contaminated food. However, sickness can also occur within 20 minutes or up to 6 weeks later. Although most people will recover from a foodborne illness within a short period of time, some can develop chronic, severe, or even life-threatening health problems. Foodborne illness can sometimes be confused with other illnesses that have similar symptoms. The symptoms of foodborne illness can include:

Vomiting, diarrhea, and abdominal pain

Flu-like symptoms, such as fever, headache, and body ache

Take Action

If you think that you or a family member has a foodborne illness, contact your healthcare provider immediately. Also, report the suspected foodborne illness to FDA in either of these ways:

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What You Need to Know ABou Preventing Listeria Infections

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Pregnant Hispanic women are even more likely than non-Hispanic pregnant women to get a Listeria infection. This is probably caused by eating traditional soft cheese, such as "queso fresco," and other traditional foods made with milk that is unpasteurized. Brands of these traditional foods made with pasteurized milk are available in stores and online.

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Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Juneteenth, also known as Freedom Day or Emancipation Day, commemorates the end of slavery in the United States. This historic day is celebrated through community gatherings, parades, music, storytelling, dance and barbecues. Food is central to many cultural celebrations and it is essential to ensure that the food we share is not only flavorful and delicious, but also safe to eat.

Learn Food Safe Barbecue Tips

Reducing Salmonella in Poultry

Through Science-Based Action

USDA is mobilizing a stronger and more comprehensive effort to reduce Salmonella illnesses related to poultry products.

Learn About This Collaborative Effort

Evidence-Based Policies in Action

Food Safety Facts

establishments that FSIS monitors

food safety and food defense procedures

Humane Handling & Good Commercial Practices Enforcement Activities

Did you know that the 1905 book The Jungle was a driver of the Federal Meat Inspection Act that governs FSIS' activities today?

Upton Sinclair's novel took aim at the poor working conditions in a Chicago meatpacking house. The ensuing public furor moved Congress to pass the Federal Meat Inspection Act (FMIA), which President Theodore Roosevelt signed into law in 1906 and requires federal inspectors in meat-packing houses.

total public health alerts in 2023

Top 2023 Recall Reasons

USDA Coronavirus Disease (COVID-19) Information

Get Answers and Find Resources

President Biden's National Strategy for the COVID-19 Response and Pandemic Preparedness calls on all parts of the federal government to contribute resources, facilities, personnel, and expertise to contain the pandemic. USDA is responding to that call.

Visit USDA's COVID-19 Info Center

Free & Open Access to Information

In keeping with our society's interest in an open government, the Freedom of Information Act (FOIA) allows any person access to almost all Federal agency records unless they are protected by one of nine exemptions.

Learn About FOIA

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FSIS actively promotes and encourages collaboration to improve food safety outcomes and protect public health. Sharing information, promoting discussion and seeking input on science-based, data-driven policy decisions helps stakeholders become part of the food safety solution.

Learn About Our Rulemaking

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The Food Safety and Inspection Service is responsible for ensuring that meat, poultry, Siluriformes, and eggs are safe and are properly labeled and packaged. Learn more about our inspection services and process.

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Health and Safety - Basic Introduction to Food Hygiene

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National Institute of Environmental Health Sciences

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Health Impacts of Climate Change

Nutritious food is a basic necessity of life, and failure to obtain sufficient calories, macronutrients (fats, proteins, carbohydrates), and micronutrients (vitamins, minerals) can result in illness and death. While malnutrition and hunger are typically problems in the developing world, the United States and other developed countries still have significant populations affected by insufficient food resources and under-nutrition. Food can also be a source of foodborne illnesses, resulting from eating spoiled food or food contaminated with microbes, chemical residues or toxic substances. The potential effects of climate change on foodborne illness, nutrition, and security are mostly indirect, but on a global scale, can result in large numbers of populations affected.

Health Impacts

Extreme weather events and changes in temperature and precipitation can damage or destroy crops and interrupt the transportation and delivery of food

Changes in agricultural ranges, practices and changing environmental conditions can reduce the availability and nutritional content of food supplies. For example, an increase in the use of pesticides leads to a decrease in nutritional content of food

Increased drought in some areas encourages crop pests such as aphids, locusts, and whiteflies, as well as the spread of the mold that produces aflatoxin, which may contribute to the development of liver disease in people who eat contaminated corn or nuts

Spread of agricultural pests and weeds may lead to an increased use of pesticides, herbicides, and fungicides

Extreme weather events, such as flooding, drought, and wildfires can contaminate crops and fisheries with metals, chemicals, and toxicants released into the environment

Increased temperatures and impacts on other environmental parameters (e.g., ocean acidification) can affect potential contaminant-induced immune suppression and can lead to more virulent strains of existing pathogens and changes in their distribution or emergence of new pathogens. For instance, rising sea surface temperatures can result in an increase in many Vibrio bacteria species, which can cause seafood-borne diseases, such as cholera.

Mitigation and Adaptation

Diversification of stable crops for biofuel feedstock

Increase in the need for agricultural chemicals due to increases in pests and pest habitats

Planning for maintenance of food supply infrastructure and transportation during extreme weather events

Research Needs

Projecting impacts of climate change including increases in CO2, temperature, drought, floods, and other extreme weather events and changes in growing seasons on food production, availability, contamination, and nutritional value.

Understanding and predicting potential ecosystem changes from climate change that may establish new foodborne pathogens, chemical contaminants, or biotoxins, as well as new pathways for human exposure.

Understanding of changes in nutritional status associated with climate change that may increase individual susceptibility to the adverse health impacts of other environmental exposures such as chemicals and heavy metals.

Understanding the effect of ocean acidification from climate change-related increases in air pollution on seafood quality and availability.

Developing and implementing models linking climate change and other environmental data to crops and seafood to improve prediction and risk assessment.

For more information, please visit the chapter on Foodborne Diseases and Nutrition in A Human Health Perspective on Climate Change (Full Report) (4MB) .

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Foodborne Diseases and Nutrition - Climate and Human Health

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Nutritious food is a basic necessity of life, and failure to obtain sufficient calories, macronutrients (fats, proteins, carbohydrates), and micronutrients (vitamins, minerals) can result in illness and death. While malnutrition and hunger are typically problems in the developing world, the United States and other developed countries still have significant populations affected by insufficient food resources and under-nutrition.

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National Institute of Diabetes and Digestive and Kidney Diseases

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View or Print All Sections

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.

The NIDDK would like to thank: Cynthia L. Sears, M.D., Johns Hopkins University School of Medicine

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View or Print All Sections This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public.

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Second Harvest Food Bank Santa Cruz County