FOODBORNE AND WATERBORNE DISEASES THEIR EPIDEMIOLOGIC CHARACTERISTICS INITIAL REPORT OF ILLNESS Single Two or more case persons ill Not compatible with foodborne outbreak Acute Botulism, Compatible with gastroenteritis trichinosis, foodborne outbreak, chemical, etc. same time andsymptoms, common food consumed List on Interstate Register; consumer No outbreak product; notify OUTBREAK INVESTIGATION investigation regulatory agent {Including notification of appropriate local, state, or federal agencies) Other interstate Beef or poultry products report report to USDA to FDA Environmental Epidemiology Laboratory Hygiene -Food samples : -Describe disease -Human specimens Beveclnts food -Define persons -Environmental een Ss -Incriminate food studies -Determine point of error CONTROL , ya jo ae Ea 7 8 ———— ; ~~ ‘ ey! meee ee ee > if FOODBORNE AND WATERBORNE DISEASES THEIR EPIDEMIOLOGIC CHARACTERISTICS I. Jackson Tartakow, M.D., M.P.H. Former Deputy Commissioner and Epidemiologist Department of Health Nassau County, New York John H. Vorperian, B.S. Principal Sanitarian Former Director Bureau of Food and Beverage Control Department of Health Nassau County, New York avi AVI PUBLISHING COMPANY, ING. Westport, Connecticut ©Copyright 1981 by THE AVI PUBLISHING COMPANY, INC. Westport, Connecticut All rights reserved. No part of this work covered by the copyright hereon may be reproduced or used in any form or by any means—graphic, electronic, or mechanical, including photocopying, recording, taping, or information storage and retrieval systems—without written permission of the publisher. Frontispiece Courtesy of Center for Disease Control, Atlanta Library of Congress Cataloging in Publication Data Tartakow, I Jackson. Foodborne and waterborne diseases. Includes bibliographical references and index. 1. Food poisoning. 2. Waterborne infection. 3. Epidemiology. I. Vorperian, John H., joint author. I. Title) [DNLM: 1. Food poisoning. 2. Water pollution. 3. Disease outbreaks—Prevention and control. WC 268 T193f] RA601.T34 614.4 80-24871 ISBN 0-87055-368-2 Printed in the United States of America by Eastern Graphics Preface The aim of this book is to familiarize the reader with certain char- acteristics of foodborne and waterborne diseases, a knowledge of which is necessary for their prevention and control. The various infective and toxic agents—bacterial, viral, protozoan, parasitic, fungal, and chemical—capable of causing gastrointestinal dis- ease or poisoning when ingested in contaminated food or water are discussed. Their incubation periods, their modes of transmission, and their periods of infectibility are presented. Their clinical signs and symp- toms and laboratory diagnosis are outlined for their identification. Meas- ures for their prevention are recommended. Guidelines for the investigation and control of cases and of outbreaks of foodborne and waterborne diseases are given and examples of such in- vestigations made by the senior author (I.J.T.) are presented as illustra- tions. Illness resulting from the mishandling of foods in food-processing, food-serving establishments and in the home is discussed. A summary of the reports prepared by the United States Public Health Service of the annual incidence of outbreaks of foodborne and waterborne diseases in the United States is also included. A chapter is devoted to the discussion of plants that are poisonous when ingested. Another chapter describes poisons that are naturally contained in certain foods and types of illness they may cause. References from many sources have been included. The reader will note that with the creation of the new Department of Education and its re- moval from the Department of Health, Education and Welfare (HEW) in 1980, the latter agency is now known as the Department of Health and Human Services (HHS). As the use of technical and medical terminology could not be avoided, a glossary of any such terms that appear in the text is included. Not only will the book prove instructive to students of schools of public health, administrative medicine, food sciences, hotel management, and Vv vi FOODBORNE AND WATERBORNE DISEASES those attending agricultural colleges, but also the material in the book should prove of assistance and guidance to health officers and personnel on their staff, such as epidemiologists, sanitary engineers, sanitarians, veterinarians, nurses, nutritionists, health educators, and social workers. Personnel in charge of quality control in food manufacturing plants may also benefit from the book. It is hoped that it will provide valuable information to alert persons engaged in the various phases of the food industry whose responsibilities include providing the public with nourishment that is wholesome and free of pollution, contamination, and adulteration. Officials concerned with maintaining the purity of drinking water will find essential facts for the prevention of contamination of the water supply in their charge. Lastly, it is hoped that the reader will enjoy the occasional departure from pedantry, such as the philosophic discussion of sanitation, food, and water (Chapter 1), the occasional description of a historic epidemiologic occurrence such as “The Case of the Broad Street Pump” (Chapter 1), the relating of an interesting anecdote as “Salmonella vs Sanella” (Chap- ter 2), using a quotation from the past as Moses Maimonides on food poisoning (Chapter 5), as well as the descriptions of some of the ex- periences of the senior author in the performance of his duties as ep- idemiologist in a county with a population of approximately 1,750,000 people. I. JACKSON TARTAKOW JOHN H. VORPERIAN October 1, 1980 Dedicated to our esteemed colleague, Dr. George G. Cook, who for many years served as Chairman of the Food Technology Department at SUNY, Farmingdale, N.Y. Contents PREFACE Introduction if Salmonellosis 6 Typhoid Fever 23 Staphylococcal Food Poisoning 34 Botulism 50 Shigellosis 56 Streptococcal Food Infection 62 Cholera 71 Clostridium perfringens Food Poisoning 75 Escherichia coli Diarrhea 78 Brucellosis 88 Tularemia 92 Leptospirosis OF ia CODHFPHhUAT WOO N tHh erW BacteriNal FooFdborne and Waterborne Diseases 105 Infectious Hepatitis 111 Other Viral Foodborne and Waterborne Diseases 3 Protozoan Intestinal Infections 127 arQmOoeHo@ o nP arasitic Foodborne and Waterborne Diseases 136 Fungus Poisoning 164 Chemical Poisoning 172 Poisonous Plants 196 Natural Food Poisons 211: wwoOwNe oo wrr Prevention of Foodborne Diseases 218 Commercial Food Processing 22265 Food Service Establishments 226 bbbtt Wo w e, vii vii FOODBORNE AND WATERBORNE DISEASES 26 Investigation of Foodborne Disease Outbreaks 239 27 Gastrointestinal Illness Aboard Cruise Ships and Aircraft 209 28 Statistical Report of Foodborne and Waterborne Disease Outbreaks 265 GLOSSARY 273 INDEX 281 Introduction A microscopic layer of fecal organisms may be said to cover the whole of humanity, the thickness varying directly with the degree of personal hygiene of each individual and the type of sanitation existing in the environment of the locality he inhabits. This view may be confirmed by the ubiquity of Escherichia coli outside of its natural habitat, the colon. In spite of this condition, these organisms, except for some unusual pathogenic strains, do not produce disease. One person, however, may transmit an intestinal disease to another if he himself has or has had the disease and has become an acute, temporary, convalescent, or chronic carrier with his feces containing the causative microorganism. Such a carrier, if he is engaged in the production, preparation, or service of foods consumed by persons outside his own household, constitutes a danger to the community. He must therefore be prevented from engag- ing in his occupation until he is fully recovered and it is established by laboratory examination that he has been relieved of his carrier state. All food handlers must adhere to strict sanitary techniques so as not to endanger the public health. One of the simplest and most effective measures they must observe before handling any food is the washing of hands, particularly after the use of the toilet. Another is the prompt storage of all raw and prepared foods under proper refrigeration (below 7.2°C or 45°F) so as to arrest the multiplication of any pathogen that may have been introduced into the food. In addition to the spread of foodborne diseases by man, a number of domestic and game animals may also be carriers of organisms capable of causing enteric diseases in humans. This is especially true of animals whose flesh is eaten by man. For example: turkeys and other fowl may transmit salmonellosis to man; pork, beef and fish, if harboring various types of tapeworms, may transmit them if improperly cooked; pork is also capable of causing trichinosis; tularemia may be acquired by the ingestion of inadequately cooked meat of infected wild rabbits; and raw 1