CentersforDiseaseControlandPrevention

NationalCenterforEnvironmentalHealth
VesselSanitationProgram

HealthPracticesonCruiseShips:TrainingforEmployees
Transcript

FoodborneIllnesses
TheCentersforDiseaseControlandPrevention's VesselSanitationProgramisproudto
bringyou thefollowingsession:FoodborneIllness.Whilethispresentationisprimarily
intendedforcruisevesselsunderthejurisdiction oftheVesselSanitationProgram,itmay
bealsousedbyanyonewhoisinterestedinthistopic.Thissessionshouldnotbeusedas
areplacementforexistinginteractivetraining,butshouldbeusedasanadjuncttothe
comprehensivetrainingprogram.FoodborneIllness,CausesandPrevention,Vessel
SanitationProgram2007.
Forthissession,thelearningobjectivesincludelistindividualswhoareconsideredhigh
risk,listthewaysinwhich wecancontroloutbreaksofillnessassociatedwithspore
formingbacteria,giveanexampleofbacteriathatproducesaheatlabile,fataltoxin,give
anexampleofabacteriathatproducesaheatstabiletoxin.Additionallearningobjectives
includelistthepathogensassociatedwithfoodborneillnessandthecontrolmeasures
associatedwitheach,listsomeofthesignsandsymptomssupervisorsshouldobserve
foodemployeesfor,listtheisolationtimesforfoodemployeesandnonfoodemployees.
Highriskindividualsincludetheelderly,theveryyoung,immunocompromised
individuals,pregnantwomen,andindividualswithunderlyingillnesses.
Carriers.Itisimportanttounderstandthatthereareindividualswhocanspreadillness
withoutdisplayingsymptomsofthatillness.Itisveryimportanttoaddressasymptomatic
individualswhoarecabinmatesorclosecontactsofindividualsoncruisevessels.There
wasaveryfamousincidentinpublichealth whereawomanbythenameofMary
Mallon,alsoknownas"TyphoidMary,"infectedseveralpeoplewithsalmonellatyphi
throughpoorfoodhandlingpractices.MaryMallonwastestedseveraltimesfortyphoid,
butmanyofhertestresultswerenegative.Nevertheless,Marypassedalongtheinfection
toseveralpeoplesheworkedfor, someofwhomdiedfromtheinfection.Symptomatic
carriersarethoseindividualswhoshowtheclassicsignsandsymptomsofinfection.
Pathogencategories.Pathogensthatcausefoodborneillnessareclassifiedintothree
categories:viruses,bacteria,andparasites.Virusesareverysmallpathogensthatrequire
alivinghosttosurvive.Theyreproducebytakingover theinfectedcell'sreproductive
mechanism,andinsteadofproducinghealthycells, theyproducevirusesthatgoonto
infectothercells.Bacteriaarecompleteorganismsthatcanreproduceontheirown. They
cansurviveoutsideandinsidethebody.Manyarebeneficial,andsomecancauseillness,
includingfoodborneillness.Parasites, likeviruses,requireahost,butonly tocomplete

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

theirlifecycle.Theycancausefoodborneillness,buttoalesserextentthanvirusesand
bacteria.
Transmissionofpathogens.Inordertopreventmanyofthesepathogensfromspreading,
itisimportanttounderstandthevariousroutesoftransmission.Foodscanalsobe
contaminatedatthesource. Forexample,poultryiscontaminatedwithsalmonellaand
campylobactorduringprocessing.Shellstockcanbecomecontaminatedinshellstock
bedsbecauseofsewagecontaminatedwater.Foodsthatgrowinthegroundare
contaminatedwithbothbacteriaandbacterialspores.Foodsthatareharvestedfromthe
oceanandfreshwatercanbecontaminatedwithbacteria,viruses,andparasites.Both
foodandwatercanbesubjecttocrosscontamination.
Majorcausesoffoodborneillness.GenerallyintheUnitedStates,mostfoodborne
illnessesareattributedtopathogenicbacteria.Whilethishaschangedwenowfind
norovirustobethenumberonecauseoffoodborneillnessintheUnitedStates thereare
stillpracticesthatwhendoneimproperly canleadtofoodborneillness.Someofthese
specificallyrelatetobacteria,whileotherscanrelatetoanyofthepathogencategories.
Theyincludeimproperholdingtemperatures,eitherhotorcoldholding,improper
cooling,leavingfoodinthetemperaturedangerzonetoolong,impropercookingor
reheating,eithertherequiredminimumtemperatureortherequiredholdingtimes,
infectedemployees,poorpersonalhygieneanexamplebeingpoorhandwashing
crosscontaminationanexamplemightbecuttingfreshvegetablesonacuttingboard
previouslyusedtocutrawchicken withoutproperwash,rinse,andsanitizingbetween
use.
Norovirus,previouslyknownasNorwalkvirus.Noroviruscanresultfromfecal
contaminationoffoodandwater. Foodcontaminationcanoccuratthesource, suchas
seafoodharvestedfromfecallycontaminatedwaters, orbyaninfectedfoodhandler
throughpoorpersonalhygiene.Oncruisevessels,themajorcauseofnorovirusoutbreaks
hasbeenattributedtopersontopersonspread.Herewewillrelatenorovirusas
foodborneorwaterborneillnessonly.
HepatitisAvirus.Hepatitisoccurswhenfoodorwaterarecontaminatedbyfeces.This
contaminationcanoccuratthesource, asintheexampleofsewagecontaminationof
shellfishbeds.Thecontaminationcouldalsocomefromafoodhandler.Thisfood
handlercaneitherbesymptomaticorasymptomatic,aswasdiscussedearlier.The
reservoirforhepatitisAishumans.
Bacterialillnesscharacterization.Aninfectioniscausedbyconsumingbacteriathathave
multipliedinthefood.Anintoxicationiscausedbyconsumingfoodswherebacteriahave
producedatoxin.Toxicalinfectionhasreplacedthetermtoxinmediatedinfection andis
causedbyconsumingfoodswithabacteriathatproducesatoxininsideyourbody.Itis
importanttounderstandthesetermswhendiagnosinganinvestigationoffoodborne

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

illnessoutbreaks.Forexample,anintoxicationislikely toproducesymptoms more

quickly,with vomitingshowingupasthepredominantsymptom.E.Coli0157H7isa
toxinmediatedinfection whenatitsmostseverecancausedeathinchildren duetothe
toxinproducedinsidethebodyofthechild.
Clostridium Botulinum.This bacteriaproducesafatal toxin.Thistoxincanalsobe
destroyedbyheatat80degreesCentigrade.Thisbacteriaproducesasporewhichmakes
propercoolingandreheatingveryimportant. Outbreakshavebeenimplicatedinlowacid
cannedfoods, garlicandoilpreparations.Inaddition,outbreakshavebeencausedby foil
wrappedbakedpotatoesimproperlycooledandthenusedtomakepotatosalads.And
lastly,outbreakshavealsoresultedfromtheuseofhomecannedfoods.
Staphylococcusaureus.Whilethisbacteriaproducesatoxin thatisheatstable,itisnota
fataltoxin.50%ofindividualsarecarriersofthisbacteriaintheirmucousmembranesor
ontheirskinorhair.Thispathogenhasalsobeenassociatedwithotherillnessesofthe
skin thatcanbeasmildaspimplesandinfectedcuts tosepsisleadingtodeath.Outbreaks
havebeenassociatedwithcoldproteinsalads,meats,andcreampastries.Thecontrol
measurestopreventStaphylococcusintoxication arepropertimeandtemperaturecontrol
andgoodpersonalhygiene.
Campylobacterjejuni.Poultryisveryheavilycontaminatedwithbothsalmonellaand
campylobacterbecauseofthewayinwhichitisprocessed.Itisbecauseofthisbacterial
loadthatwemustcookpoultryto165degreesFahrenheit.Outbreakshavebeen
associatedwithunpasteurizedmilkaswellaspoultryproducts. Themostimportant
controlmeasuresareavoidingcrosscontamination,propercookingtemperatures,and
properhandwashing.
E.Coli0157H7.E.Coli0157H7isatoxicoinfection thathascausedseveraldeathsinthe
UnitedStatesasaresultofbothfoodborneandwaterborneillness.Inveryyoung
children,thispathogencanleadtoashutdowninkidneyfunction.Ithasbeenassociated
withundercookedgroundbeef,inparticularhamburgers,unpasteurizedmilk,andfecally
contaminateddrinkingwater. Thecontrolmeasurestopreventillnessincludecookingto
propertemperatures,avoidingcrosscontamination,andgoodpersonalhygiene.
Clostridiumperfringens.Clostridiumperfringensisatoxicoinfection causedbyanother
sporeformingbacteria.Itismostcommonlyassociatedwithmeats,gravies,andstews,
andmanyoutbreakshaveresultedfromthereheatingofleftovers,givingitthenickname
"LeftoversDisease."Thereareapproximately10,000casesreportedintheUnitedStates
eachyear.Thecontrolmeasurestoprevent illness includepropertimeandtemperature
controls,particularlywhenreheatingfoods.
Salmonellaspecies.Salmonellosiscan beverysevere,even fatal,especially in
individuals fromthehighriskgroupswediscussedearlier.Thereservoirforthis

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

pathogenishumansandawiderangeofotheranimals, includingpoultry,reptiles,
rodents,dogs,cats,andothers.Outbreaks in humans havebeenassociatedwithdriedpig
earsfedtodogs. ApproximatelytwotofourmillioncasesoccurintheUnitedStateseach
year.In institutionalsettingssuchashospitals,persontopersonspreadhasalsobeen
implicated.Thecontrol measures includepropercooking,crosscontamination
prevention,andgoodpersonal hygiene.
Listeriamonocytogenes.Listeriamonocytogenescangrowwellunderrefrigeration
temperatures,although veryslowly.This isthebasisforthesevendaydatemarking
requirementsforrefrigeratedpotentially hazardousfoods. This illnesscanbevery severe
forpregnantwomen.Thereareseveraloutbreakseach yearassociatedwith freshcheeses
made fromunpasteurizedmilk.Quesofrescoisacheesethatis verypopularinthe
Hispaniccommunity.Outbreakseach yearoccurinstatesaroundtheMexicanborder. It
is importantforpregnantwomentoavoidthesetypesofcheesesbecauselisteriosiscan
leadtospontaneousabortionsorfetaldeathevenifthemotherisasymptomatic.The
deathrateamongnewbornchildrencanbeashighas50%. Thecontrolmeasuresfor
controllingillnessincludepreventionofcrosscontamination andusingpasteurizedmilk.
Toxinsfishtoxins,shellfishtoxins,aflatoxins.Wewilldiscussthesetoxins briefly
duringthefollowingslides.
Seafoodtoxins.Theseseafoodtoxinsarenotdestroyedby heat. Ciguaterafishpoisoning
iscausedwhenweconsumefishthathavefedontoxicalgae.Thesymptomsarea
combinationofgastrointestinal, neurological,andcardiovascular.This illness isusually
selflimiting.Scombroidpoisoningiscausedwhenweconsumefishcontaminatedwith
histamines.Thesehistaminesareproducedby bacteriaonthefish.Itis importanttopoint
outthatthistypeofpoisoningcanalsooccurwith otherfoods thathavetheappropriate
aminoacidsandbacteria.Thesymptomsofthis illnessgenerally beginwithtinglingor
burningsensations inthemouth.Symptomscanbesevereenoughtorequire
hospitalization,especially intheelderly.Shellfish poisoningiscausedbyconsuming
shellfish thathavefedontoxicalgae.Thesetoxinsaccumulateintheshellfish duetothe
feedingaction.Thisgroupoftoxinscancauseparalyticshellfishpoisoning,diarrheic
shellfishpoisoning,amnesicshellfishpoisoning,orneurotoxicshellfishpoisoning.
Planttoxins.Planttoxinsarenotdestroyedby heat.Examples includecertainspeciesof
mushrooms,aflatoxinsproducedby fungicontaminatedgrains,andhemlockand
jimsonweedortoxicplants.
Parasites.Parasitesaredestroyedby heatandfreezing,andthefishparasites formthe
basis fortheVSPrequirementsforcertificatesofparasitedestruction.Anisakissimplex
andrelatedwormsarefoundin herring,cod,haddock,Pacificsalmon,andflounder.
Trichinosisusedtobeamajorconcern intheU.S. andwastypically associatedwithpork.
Achangeinthefeedingpracticeshas ledtoareduction inthis illnessaswellasa

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

reductioninthecookingtemperaturesforpork. Thispathogenisstillamajorconcernin
certainwildgamepopulations.Wildgameservedonacruisevesselmustbefroma
commercialsource. Thissourcemustbefroman inspectedfacility.
Toxicchemicalsandmetals.Toxicchemicalsandmetalshaveresultedinfoodborne
illness.Zincfromusinggalvanizedcontainershasresultedinzincpoisoning.Coppermay
leachfromcopperplumbingandcausepeopletobecomeillfromcopperpoisoning.
Antimonypoisoningmayresultfromtheuseofenamelware.Leadpoisoningmayresult
inillnessfromleadleachingfromplumbingorsolder. TheVSPrequiresthatall
chemicalsusedinthegalleysarestoredproperly.Pesticidesarerequiredtobestoredin
lockedcabinetsoutsideofthefoodareasofthevessel.
Physicalcontaminants.Physical hazardscanrangefromanuisancetosevereinjury.
Examplesofphysicalcontaminants includeglass,metalshavings,hair,nailpolish,
bandages,andcigarettebuttsandfood.
Foodemployeehealth.Thereareseveralinfectionsinwhichfoodemployeesmustbe
excludedfromfoodserviceoperations.TheFDAhasincludedthefollowingintheirlist:
Salmonellatyphi,Shigellaspecies,E.Coli0157H7,HepatitisA,andnownorovirus.
Noroviruswasaddedtothe2005FDAfoodcode. ItisnotlistedintheVSPoperations
manual,butdoesfallunderthe"others"category.
Observefoodemployeesforsignsandsymptoms.Staphylococcusaureuscanbe
associatedwithcuts,sores,andopenwounds.Noroviruscanbeassociatedwithdiarrhea
orvomiting.HepatitisAcanbeassociatedwithjaundice.Andwhilecoughing,sneezing,
andnasaldischargearenotassociatedwithgastrointestinalillness,theycanbe
transmittedtofoodbycontaminationofhands.Foodhandlersshouldbeobservedfor
symptomsonadailybasis.Whenindoubt,sendindividualstothemedical facility for
assessment.
Foodemployeerestriction.Foodemployeesthatarediagnosed,suspectedof,
symptomaticof,orexposedtoanyofthepathogens listedinthemanual aretobe
restrictedfrom foodservicework. Inaddition, inordertoreturntowork, theremustbea
followuprequiredbythemedicaldepartment, they mustbefree fromsymptomsfor48
hours,andtheycannotreturntoworkunless itis inwriting.
Isolationhowlong?Foodemployees infectedwithoneofthepathogensdiscussed
earlieraretobeisolatedforaminimumof48hoursafterthelastsymptom.Themanual
requires isolationofnonfoodemployees foraminimumof24hoursafterthelast
symptom.Pleasenotethatfoodworkersmay includeanengineerwhoisresponsiblefor
cleaningice machinesoraroomstewardthathandlescleanglassware.Theytooare
consideredtobefoodworkersandmustbeisolatedforaminimumof48hours.

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

Asymptomaticcabinmatesandimmediatecontacts.TheVSPoperations manual2005
requiresmonitoringofasymptomaticcabin matesandimmediatecontactsof infected
persons.They mustberestrictedfromexposure,averbalinterviewbyeitherthe
supervisorsorthemedicalauthorityisrequired.Theymustbeadvisedonpersonal
hygieneproceduresandmustbemonitoredfor48hoursaftertheonsetofillnessofthe
casetowhichtheywereexposed,anddocumentationoftheirrestrictionsmustbe
maintained.
Passengerillness.Forpassengerswhoareillwithacutegastroenteritis,thevesselstaff
mustencourageisolationforaminimumof24hours.Youcanencourageisolationby
deliveringfoodtothecabinsandprovidingactivitiesfortheillpassengersandtheircabin
mates.Also,wemustprovideawritteninformationsheetonpersonalhygieneandhand
washingtips.Pleasenotethatitisrequiredtobeinwriting.
Thisconcludesthefoodborneillnesspresentation.Referencesandresources.For
additionalinformation,visitthefollowingWebsites.ForCDC,www.cdc.gov.Forthe
VesselSanitationWebsite,visitwww.cdc.gov/nceh/vsp.Foradditionalinformationfrom
theFDAWebsite,visitwww.fda.gov,aswellaswww.cfsan.fda.govfortheBadBug
Book. Andlastly,fortheUSDAWeb site,visitwww.usda.gov andwww.fsis.usda.gov.