APPENDIX C
Foodborne Illnesses in Institutions

Data from around the world indicate that food-service establishments, including catering companies, are the most frequently listed venues associated with outbreaks of foodborne illness. Deaths and severe illnesses are more likely to occur in care homes for the aged and hospitals and less frequently in child-care centers. Susceptible persons may become ill from smaller doses of organisms and may be more likely than other persons to die of foodborne disease. For example, children under the age of 1 year have the highest rate of Campylobacter infections. Other populations at high risk for foodborne illness are residents of nursing homes and chronic-care facilities; hospitalized, cancer, and organ-transplantation patients; persons with acquired immune deficiency syndrome (AIDS); persons with cirrhosis; persons on antimicrobial treatments; and persons with reduced stomach acid, for example, because of antacid medication. Pregnant women, fetuses, and newborns are at higher risk of listeriosis and toxoplasmosis than other groups.

A short review of outbreaks involving food served in institutions around the world, both with highly susceptible populations and with the usual spectrum of susceptibility to infections, showed that although outbreaks occurred, outbreaks associated with meat, poultry, or egg products were rare. An analysis of outbreak data in England and Wales from 1992 to 2002 by Gillespie et al. (2005) revealed that outbreaks of Salmonella Enteritidis PT4 infection were associated with schools, private residences, and residential institutions and mainly with egg dishes but not with meat or poultry. A review of outbreaks in Australia from 1995 to 2000 (Dalton et al., 2004) showed the following percentages of the total number (214): aged-care homes, 4% with four deaths; other undefined institutions, 2%; hospitals, 1% with three deaths; fairs, festivals, and mobile food-service facilities, 1% with one death; schools and camps, 2% each; and military bases, less than <1%. In one outbreak in an aged-care home, braised steak and gravy had a high concentration of Clostridium perfringens (CDI, 2005). Severe Escherichia coli O157:H7 infections have occurred in some institutional settings but primarily through person-to-person contact (Spika et al., 1986; Carter et al., 1987). A summary of outbreak data for the United States from 1998 to 2002 showed that schools had the most outbreaks recorded (4.3%); they were caused mainly by norovirus, followed by Salmonella, C. perfringens, and Staphylococcus aureus (CDC, 2006). The following were much less frequently involved: churches (1.7%), nursing homes (1.0%), camps (1.0%), prisons (0.9%), hospitals (0.8%), fairs and festivals (0.7%), and day-care centers (0.4%). Some of those are marginally businesses; camps may include military camps, but most will be centers of outdoor activities. Several pathogens were responsible for the outbreaks even though the number of outbreaks was small. The primary agents were Salmonella, norovirus, S. aureus, E. coli O157:H7, and Shigella; C. perfringens and Salmonella were equally responsible for outbreaks in prisons.

Cretikos et al. (2008) indicated that although outbreaks of gastroenteritis occur in institutions—such as schools, child-care centers, and residential-care facilities—they are usually caused by highly infectious viruses, such as norovirus and rotavirus, and are spread predominantly through person-to-person contact. An analysis (Todd et al., 2007) of 816



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APPENDIX C Foodborne Illnesses in Institutions Data from around the world indicate that food-service establishments, including catering companies, are the most frequently listed venues associated with outbreaks of foodborne illness. Deaths and severe illnesses are more likely to occur in care homes for the aged and hospitals and less frequently in child-care centers. Susceptible persons may become ill from smaller doses of organisms and may be more likely than other persons to die of foodborne disease. For example, children under the age of 1 year have the highest rate of Campylobacter infections. Other populations at high risk for foodborne illness are residents of nursing homes and chronic-care facilities; hospitalized, cancer, and organ-transplantation patients; persons with acquired immune deficiency syndrome (AIDS); persons with cirrhosis; persons on antimicrobial treatments; and persons with reduced stomach acid, for example, because of antacid medication. Pregnant women, fetuses, and newborns are at higher risk of listeriosis and toxoplasmosis than other groups. A short review of outbreaks involving food served in institutions around the world, both with highly susceptible populations and with the usual spectrum of susceptibility to infections, showed that although outbreaks occurred, outbreaks associated with meat, poultry, or egg products were rare. An analysis of outbreak data in England and Wales from 1992 to 2002 by Gillespie et al. (2005) revealed that outbreaks of Salmonella Enteritidis PT4 infection were associated with schools, private residences, and residential institutions and mainly with egg dishes but not with meat or poultry. A review of outbreaks in Australia from 1995 to 2000 (Dalton et al., 2004) showed the following percentages of the total number (214): aged-care homes, 4% with four deaths; other undefined institutions, 2%; hospitals, 1% with three deaths; fairs, festivals, and mobile food-service facilities, 1% with one death; schools and camps, 2% each; and military bases, less than <1%. In one outbreak in an aged-care home, braised steak and gravy had a high concentration of Clostridium perfringens (CDI, 2005). Severe Escherichia coli O157:H7 infections have occurred in some institutional settings but primarily through person-to- person contact (Spika et al., 1986; Carter et al., 1987). A summary of outbreak data for the United States from 1998 to 2002 showed that schools had the most outbreaks recorded (4.3%); they were caused mainly by norovirus, followed by Salmonella, C. perfringens, and Staphylococcus aureus (CDC, 2006). The following were much less frequently involved: churches (1.7%), nursing homes (1.0%), camps (1.0%), prisons (0.9%), hospitals (0.8%), fairs and festivals (0.7%), and day-care centers (0.4%). Some of those are marginally businesses; camps may include military camps, but most will be centers of outdoor activities. Several pathogens were responsible for the outbreaks even though the number of outbreaks was small. The primary agents were Salmonella, norovirus, S. aureus, E. coli O157:H7, and Shigella; C. perfringens and Salmonella were equally responsible for outbreaks in prisons. Cretikos et al. (2008) indicated that although outbreaks of gastroenteritis occur in institutions—such as schools, child-care centers, and residential-care facilities—they are usually caused by highly infectious viruses, such as norovirus and rotavirus, and are spread predominantly through person-to-person contact. An analysis (Todd et al., 2007) of 816 24

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LETTER REPORT 25 outbreaks involving food workers around the world showed that most of the outbreaks came from food-service facilities (46.1%), followed by catered events (15.4%), homes (10.2%), schools and day-care centers (6.0%), and health-care institutions (5.3%). The analysis described the typical outbreaks in each type of institution in detail; very few involved foods typically regulated by FSIS. The foods involved in outbreaks in hospitals, nursing homes, long-term-care facilities, schools, colleges, universities, and child-care centers were mainly ready-to-eat (RTE) foods, such as sandwiches, salads, and fruit. One different type of outbreak in a school involved chocolate milk contaminated with Yersinia enterocolitica. Two outbreaks each occurred in jails and prisons where turkey was handled by an infected worker. Contaminated RTE foods caused all nine outbreaks recorded on military bases. REFERENCES Carter, A. O., A. A. Borczyk, J. A. K. Carlson, B. Harvey, J. C. Hockin, M. A. Karmali, C. Krishnan, D. A. Korn, and H. Lior. 1987. A severe outbreak of Escherichia coli O157:H7 associated hemorrhagic colitis in a nursing home. N. Engl. J. Med. 317:1496–1500. CDC (Centers for Disease Control). 2006. Surveillance for foodborne-disease outbreaks - United States, 1998 - 2002. Morbidity and Mortality Weekly Report (MMWR) 55(SS10):1–34. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5510a1.htm. Accessed January 26, 2009. CDI (Communicable Diseases Intelligence). 2005. OzFoodNet: Enhancing foodborne disease surveillance across Australia: Quarterly Report, January to March 2005. 29:197–200. Cretikos, M., B. Telfer, and J. McAnulty. 2008. Enteric disease outbreak reporting, New South Wales, Australia, 2000 to 2005. NSW Public Health Bull. 19:3–7. http://www.publish.csiro.au/?act=view_file&file_id=NB07078.pdf. Accessed November 10, 2008. Dalton, C. B., J. Gregory, M. D. Kirk, R. J. Stafford, R. Givney, E. Kraa, and D. Gould. 2004. Foodborne disease outbreaks in Australia, 1995 to 2000. Commun. Dis. Intell. 28:211– 224. Gillespie, I. A., S. J. O’Brien, G. K. Adak, L. R. Ward, and H. R. Smith. 2005. Foodborne general outbreaks of Salmonella Enteritidis phage type 4 infection, England and Wales, 1992–2002: where are the risks? Epidemiol. Infect. 133:795–801. Spika J. S., J. E. Parsons, D. Nordenberg, J. G. Wells, R. A. Gunn, and P. A. Blake. 1986. Hemolytic uremic syndrome and diarrhea associated with Escherichia coli O157:H7 in a day care center. J. Pediatr.109:287–291. Todd, E. C. D., J. D. Greig, C. A. Bartleson, and B. S. Michaels. 2007. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 2. Description of outbreaks by size, severity, and settings. J. Food Prot. 70:1975–1993.