“These cost data highlight that water-related diseases pose not only a physical burden to the thousands of people sickened by them each year, but also a substantial burden in health care costs, including direct government payments through Medicare and Medicaid,” says Michael Beach of the Centers for Disease Control and Prevention, an author of the study.

Currently, there are no well-documented data on the total health care costs associated with all waterborne diseases. However, using data from a large insurance claims database between 2004 and 2007, Beach and his colleagues estimated the hospitalization cost of three common waterborne diseases in the United States: Legionnaires’ disease, cryptosporidiosis and giardiasis. For each case of disease, they calculated the cost paid by the insurer, the out-of-pocket cost to the patient, and the total amount paid.

Total estimated costs for hospitalization for the three diseases was $154-539 million, including $44-147 million in direct government payments for Medicare and Medicaid. Estimated annual costs for the individual diseases were: giardiasis, $16-63 million; cryptosporidiosis, $37-145 million; and Legionnaires’ disease, $101-321 million.

Inpatient hospitalization costs per case averaged more than $34,000 for Legionnaires’ disease, approximately $9,000 for giardiasis and more than $21,000 for cryptosporidiosis.

“When people think about these diseases, they usually think of a simple case of diarrhea, which is a nuisance but quickly goes away. However, these infections can cause severe illness that often result in hospital stays of more than a week, which can quickly drive up health care costs,” Beach says.

Other symptoms can include rashes, eye and ear infections and respiratory or neurological symptoms and can even be fatal.

Modest investments in preventing these diseases could lead to reduced disease and significant healthcare cost savings, Beach says. Some examples of possible, low-cost interventions include public education campaigns, appropriate maintenance of building water systems, and regular inspection of pools and other recreational water facilities.

Last week, my colleagues and I presented our research on foodborne outbreaks linked to salsa and guacamole. Recently, the number of these reported outbreaks has increased. Between 1998 and 2008, nearly 1 of every 25 outbreaks associated with restaurants or delis may have been caused by contaminated salsa or guacamole.

We received a lot of questions about our research and what it means for people who love salsa and guacamole. (We love them, too!) Here are some answers for consumers.

Should I stop eating salsa and guacamole?

We’re not suggesting that you stop eating these foods or stop eating at restaurants. These are popular foods across the United States and are served in a variety of restaurants and at home. We just want to stress how important it is that these foods are prepared and stored safely.

What kinds of illnesses were associated with these outbreaks?

The most common infection was norovirus, followed by Salmonella, Shigella, E. coli, and other less common germs, which can all cause diarrhea.

Did your research show what contributed to these outbreaks?

Not in all cases, but there were some important clues. In 30 percent of the outbreaks, local investigators reported that the salsa or guacamole wasn’t stored or refrigerated properly. In another 20 percent, the investigators reported that food workers were the likely source of the contamination. In some cases, ingredients may have been contaminated before arriving in a kitchen.

Do you know which specific ingredients were contaminated?

We usually don’t know which ingredients were contaminated. But we do know that salsa and guacamole often contain diced raw produce, such as hot peppers, tomatoes, and cilantro. These ingredients have been implicated in past outbreaks.

Is there anything else about salsa or guacamole that makes it particularly likely to become contaminated?

Germs may grow to levels that can cause sickness if these foods are not prepared or stored safely in restaurants and homes. Also, salsa and guacamole are often made in large batches at restaurants, so even a small amount of contamination can affect many servings.

What about salsa that you buy at the store?

These outbreaks were not caused by commercially prepared (jarred) salsas that you would buy in a grocery store. Jarred salsas are usually heated to kill germs that may be present. Instead, most of the salsas we studied were freshly prepared.

Is homemade salsa or guacamole safe?

That depends on whether you follow these food safety rules:

• Before and after preparing food, wash your hands for 20 seconds with warm water and soap.
• Wash the ingredients thoroughly under running water. That includes ingredients that you plan to peel, such as avocados.
• Make sure that knives, cutting boards, containers, and other kitchen surfaces are clean.
• Keep the salsa or guacamole refrigerated until you serve it. Do not leave it out of the refrigerator for more than 2 hours. If the temperature is above 90 degrees, do not leave it out for more than 1 hour.

If you were eating out, what would you do to make sure these foods are safe?

If I were worried about the food safety practices in a restaurant, I would ask to see health department inspection results. I might also ask whether the restaurant has a manager who is certified in food safety. Some counties or states require this.

“Fresh salsa and guacamole, especially those served in retail food establishments, may be important vehicles of foodborne infection,” says Magdalena Kendall, an Oak Ridge Institute for Science and Education (ORISE) researcher who collaborated on the CDC study. “Salsa and guacamole often contain diced raw produce including hot peppers, tomatoes and cilantro, each of which has been implicated in past outbreaks.”

To better assess the role of these popular foods in outbreaks, Kendall and her colleagues searched all foodborne outbreaks reported to the CDC for those with salsa, guacamole or pico de gallo as a confirmed or suspected food vehicle and analyzed trends in the proportion of all outbreaks with identified food sources.

CDC began conducting surveillance for foodborne disease outbreaks began in 1973, yet no salsa- or guacamole-associated (SGA) outbreaks were reported before 1984. Restaurants and delis were the settings for 84 percent of the 136 SGA outbreaks. SGA outbreaks accounted for 1.5 percent of all food establishment outbreaks from 1984 to 1997. This figure more than doubled to 3.9 percent during the ten-year period from 1998 to 2008.

Inappropriate storage times or temperatures were reported in 30 percent of the SGA outbreaks in restaurants or delis and may have contributed to the outbreaks. Food workers were reported as the source of contamination in 20 percent of the restaurant outbreaks.

“Possible reasons salsa and guacamole can pose a risk for foodborne illness is that they may not be refrigerated appropriately and are often made in large batches so even a small amount of contamination can affect many customers,” Kendall says. “Awareness that salsa and guacamole can transmit foodborne illness, particularly in restaurants, is key to preventing future outbreaks.”

Risk can be lowered by following guidelines for safe preparation and storage of fresh salsa and guacamole to reduce contamination or pathogen growth.

“We want restaurants and anyone preparing fresh salsa and guacamole at home to be aware that these foods containing raw ingredients should be carefully prepared and refrigerated to help prevent illness,” says Kendall.

The FDA’s announcement comes amid rising concern that the over-use of antibiotics in food animals may pose a risk to public health by contributing to antibiotic-resistant strains of bacteria.

“The development of resistance to this important class of drugs, and the resulting loss of their effectiveness as antimicrobial therapies, poses a serious public health threat,” wrote the FDA in Monday’s statement.

The FDA is also urging meat producers to consult with veterinarians about the best type of drugs to use and when to properly administer them.

Throughout recent years, drug-resistant bacteria have posed a serious risk to public health.  As the name suggests, these infections cannot be treated with traditional antibiotics, making them very difficult to contain or cure.  According to a 2005 report from the CDC, nearly half of Campylobacter infections are now drug resistant, as are 1 in 5 Salmonella infections.

Representatives of the meat industry launched their responses to the FDA’s announcement, saying there is no direct evidence that antibiotic usage in animals has any affect on drug-resistant bacteria and that restricting antibiotic usage would lead to unbearably high costs.  On the other side of the spectrum, food safety advocates claim many studies define the link and are urging the FDA to take more serious action restricting the usage of antimicrobials.

The products subject to recall include:

• 24, 8-ounce burgers in 12-pound boxes of “W.B. STOCKYARD, KEEP REFRIGERATED, BURGER FRESH, WB HOME STYLE 8 OZ.”
• 32, 6-ounce burgers in 12-pound boxes of “W.B. STOCKYARD, KEEP REFRIGERATED, BURGER FRESH 6 OZ.”
• 48, 4-ounce burgers in 12-pound boxes of “W.B. STOCKYARD, KEEP REFRIGERATED, BURGER FRESH, 4 OZ.”
• 10-pound boxes of “W.B. STOCKYARD, KEEP REFRIGERATED, BEEF GROUND/EXTRA LEAN.”
• 10- and 20-pound boxes of “W.B. STOCKYARD, KEEP REFRIGERATED, BEEF GROUND 80/20.”

The problem was discovered through FSIS microbiological sampling which confirmed a positive result for E. coli O157:H7. FSIS and the company have received no reports of illnesses associated with consumption of these products.

E. coli O157:H7 is a potentially deadly bacterium that can cause bloody diarrhea, dehydration, and in the most severe cases, hemolytic uremic syndrome (HUS), a potentially deadly blood disease that commonly causes kidney failure. The very young, seniors and persons with weak immune systems are the most susceptible to foodborne illness.

40 people were sickened and 3 others died as a result of the foodborne illness outbreak, which was linked to the Central State Hospital cafeteria.  Louisiana’s Department and Health and Hospitals and the CDC investigated the illnesses, and determined that Clostridium perfringens was likely spread through chicken salad that was prepared and served by the center’s cafeteria. 

The victim ate the chicken salad in question and became violently ill, requiring hospitalization and a long recovery process.

Clostridium perfringens, is a rare, but serious illness that is caused by ingesting foods contaminated with the spore-forming bacteria.  This foodborne pathogen is often associated with foods that are not kept at proper temperatures, which allows the bacteria to quickly multiple.

As of now, no illnesses have been linked to the Campbell’s recalled Spaghetti O’s. Campbell’s initiated their recall after a warehouse inspection. It appears that a faulty cooker may not have allowed the meat to reach the proper internal cooking temperature. According to CampbellSoup.com:

There is no information indicating that any under-processed product has reached consumers. In an abundance of caution, the three varieties of “SpaghettiOs” with Meatballs products that may have been under-processed are being retrieved from the marketplace.

The products subject to the recall were produced in Paris, Texas, and shipped to retail customers nationwide. The recall is limited to the U.S. The problem was discovered through a routine warehouse inspection and subsequent investigation.

The “SpaghettiOs” recall highlights why proactive protocols need to be in place to monitor the quality of a product through the entire processing, from the initial arrival of the ingredients to the final place in the consumers cupboard. Campbell Soup did not wait until foodborne illnesses began to spring up throughout the country. They did not spend weeks waiting for someone to connect their product to a cluster of E. coli O157:H7 illnesses to attempt to recall tons of retail distributed product. Steps were in place to get back a potential problem product without trying to deal with tens of thousands of customers and dozens of severe illnesses. No recall is a good recall, but a recall initiated before anyone gets ill is a positive recall.

Marie Callender meals are being investigated as a source of a recent outbreak of Salmonella serotype Chester.  So far, 30 people have been sickened with salmonellosis in 15 states. The Marie Callender recall was initiated when the Centers for Disease Control (CDC) informed ConAgra of an investigation involving a possible connection between the frozen meals and the recent salmonellosis outbreak. The Salmonella outbreak has spread across 15 states.

The ConAgra recall is a perfect example of reactive food safety monitoring. The connection to the Marie Callender’s frozen meals was made after the product had been on store shelves for weeks and illnesses around the country were in a large enough number to make a connection. Essentially, the CDC needed people to get sick enough to seek treatment so they could investigate the recent diets of the Salmonella victims.

Recalls implemented quickly and efficiently can prevent foodborne illnesses. If contaminated food products are never allowed to reach store shelves, cases of food poisoning including those related to Salmonella, Escherichia coli, Camplyobacter, Clostridium botulinum, Listeria and other foodborne illnesses can be prevented.

Food poisoning from bacteria including Salmonella, E. coli, Campylobacter, and Listeria can cause nausea and diarrhea. In addition, in certain cases, food poisoning from these and other related bacteria can cause additional health complications and can be potentially fatal. E. coli O157:H7, a Shiga toxin producing strain of E. coli, has been linked to Hemolytic Uremic Syndrome (HUS), a potentially fatal kidney disorder which often affects young children. Campylobacter, on the other hand, has, in rare instances, led to cases of Guillain-Barre Syndrome (GBS), a disorder affecting the nervous system causing paralysis.

United efforts between the Centers for Disease Control and Prevention, the Food Safety Inspection Service, and the Food and Drug Administration have helped implement recall systems that attempt to keep dangerous foods off store shelves and out of America’s kitchens. These recalls are intended to try to prevent the spread of E. coli, Salmonella, and other food poisoning agents. Unfortunately, the current systems often rely on the pattern of foodborne illnesses caused by these dangerous foods before a recall is suggested. The safety system shouldn’t need the system to fail to make it work.

Manufacturers and processors must use the most current technologies and hold themselves to higher standards to ensure the safety and quality of their products. The only way to guarantee foodborne pathogens don’t make it to the homes of innocent people is to never sell contaminated foods in the first place. Proactive approaches to safety and recalls are important links in the food safety net.  

The premise is simple, the quicker consumers are notified, the more effectively illnesses can be prevented. As of now, the Salmonella Chester outbreak has sickened thirty individuals in fifteen states, for these innocent victims the recall is a little late. Estimates of the numbers of sickened individuals could actually be in the hundreds. Hopefully, the actions taken by the CDC’s investigative teams will prevent further illnesses and help to control this current outbreak. Only time will tell.

As of 9:00 AM EDT on June 18, 2010, a total of 30 individuals infected with a matching strain of Salmonella Chester have been reported from 15 states since April 11, 2010. The number of ill people identified in each state with this strain is as follows: CA (4), CO (2), GA (6), IL (1), KY (1), MA (2), MN (2), MO (1), NC (1), OK (1), OR (2), SC (2), TN (1), UT (1), and VA (3). Among those for whom information is available about when symptoms started, illnesses began between April 5, 2010 and May 29, 2010. Case-patients range in age from <1 to 88 years old, and the median age is 37 years. Fifty-four percent of patients are female. Among the 15 patients with available hospitalization information, 6 (40%) were hospitalized. No deaths have been reported.

The outbreak can be visually described with a chart showing the number of people who became ill each day. This chart is called an epidemic curve or epi curve. Illnesses that occurred after May 22, 2010, might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2 to 3 weeks.

Investigation of the Outbreak

A widely distributed contaminated food product might cause illnesses across the United States. The identity of the contaminated product often is not readily apparent.  In outbreaks like this one, identification of the contaminated product requires conducting detailed standardized interviews with persons who were ill.  It may also require conducting interviews with non-ill members of the public (”controls”) to get information about foods recently eaten and other exposures to compare with information from the ill persons. The investigation is often supplemented by laboratory testing of suspected products.

Beginning on June 14, 2010, CDC and public health officials in multiple states began conducting an epidemiologic study by comparing foods eaten by ill and well persons. As of June 18, information had been collected on 14 ill and 21 well persons. Preliminary analysis of this study suggests eating a Marie Callender’s frozen meal as a possible source of illness. Ill persons (86 percent) were significantly more likely than well persons (10 percent) to report eating a frozen meal. All ill persons (100 percent) who ate frozen meals reported eating a Marie Callender’s frozen meal. None (0 percent) of the well persons who ate a frozen meal reported eating a Marie Callender’s frozen meal. At this time there are insufficient data to implicate a specific frozen meal type. However, many of the ill persons have reported eating a Marie Callender’s cheesy chicken and rice frozen entrée in the week before becoming ill.

Today, the Minnesota Department of Agriculture Laboratory reported to CDC that it has isolated Salmonella Chester from an unopened package of Marie Callender’s Cheesy Chicken & Rice single-serve frozen entrée collected from a case patient.  Subtyping of the Salmonella strain is under way.

This investigation is ongoing. CDC and state and local public health partners are continuing surveillance to identify new cases and identify the contaminated product or products that are causing illness. The CDC will update the public on the progress of this investigation as information becomes available.

Clinical Features/Signs and Symptoms

Most persons infected with Salmonella develop diarrhea, fever, and abdominal cramps 12-72 hours after infection. Infection is usually diagnosed by culture of a stool sample. The illness usually lasts from 4 to 7 days. Although most people recover without treatment, severe infections may occur. Infants, elderly persons, and those with weakened immune systems are more likely than others to develop severe illness. When severe infection occurs, Salmonella may spread from the intestines to the bloodstream and then to other body sites and can cause death unless the person is treated promptly with antibiotics.

Advice to Consumers

• Salmonella is sometimes present in raw foods (e.g., chicken, produce, and spices) which can be used as ingredients in not-ready-to-eat frozen dinners.
• Consumers should follow the instructions on the package label of the frozen dinner. Conventional ovens are better at cooking foods thoroughly. Microwave ovens vary in strength and tend to cook foods unevenly.
• If you choose to cook the frozen dinner using a microwave, be sure to:
  • Cook the food for the time specified for your microwave’s wattage.
  • Let the food “stand” for the stated time, so cooking can continue.
  • Use a food thermometer to make sure that it is fully cooked to an internal temperature of 165 degrees Fahrenheit.
• Individuals who think they might have become ill from eating a Marie Callender’s frozen dinner should consult their health care providers.
• Consumers who have Marie Callender’s Cheesy Chicken & Rice single-serve frozen entrées in their freezer should discard or return the entrées to their retailer for a refund.  
• Consumers are urged to read and follow the preparation instructions on the label of all frozen entrees.  If the package says “Do Not Microwave,” consumers should follow that instruction and use a conventional oven.  Consumers should use a food thermometer to make sure the entrees reach at least 165 degrees Fahrenheit.

The company is recalling all Marie Callender’s brand Cheesy Chicken and Rice frozen meals in commerce, regardless of production date. These products are being recalled after the company was informed by the U.S. Centers for Disease Control and Prevention (CDC) of an investigation involving 29 people in 14 states who have been diagnosed with salmonellosis linked to Salmonella serotype Chester. Eight of the case-patients specifically reported eating this product in April and May, 2010, prior to illness onset; the last reported illness was reported on May 22.

FSIS became aware of the problem during the course of an ongoing investigation of a multi-state outbreak of Salmonella serotype Chester illnesses. CDC, the Food and Drug Administration (FDA), FSIS, and state health and agriculture departments are cooperating in this ongoing investigation. The investigation is ongoing, and has not yet definitively identified a food vehicle(s). Further information will be released to the public as it becomes available.

The products subject to recall include:

• 13-ounce packages of “Marie Callender’s Cheesy Chicken & Rice White Meat Chicken and Broccoli over Rice Topped with Rich Cheddar Sauce.”

Each package bears a label with establishment number “P-45″ inside the USDA mark of inspection. The establishment is recalling all the products listed above which are currently in commerce. These products were distributed to retail establishments nationwide. When available, the retail distribution list(s) will be posted on FSIS’ Web site at http://www.fsis.usda.gov/FSIS_Recalls/Open_Federal_Cases/index.asp.

FSIS routinely conducts recall effectiveness checks to verify recalling firms notify their customers of the recall and that steps are taken to make certain that the product is no longer available to consumers.

While the recalled products should be safely discarded and not consumed, FSIS would also remind consumers how to safely prepare other, non-recalled frozen entrees. FSIS strongly urges consumers to always follow all cooking and preparation instructions on the label. Special attention to proper heating is important to ensure the entrees are fully cooked and all ingredients reach a safe minimum internal temperature of 165°F. Consumers should use a food thermometer to make sure the entrees reach at least 165°F.

Consumption of food contaminated with Salmonella can cause salmonellosis, one of the most common bacterial foodborne illnesses. Salmonella infections can be life-threatening, especially to those with weak immune systems, such as infants, the elderly, and persons with HIV infection or undergoing chemotherapy. The most common manifestations of salmonellosis are diarrhea, abdominal cramps, and fever within eight to 72 hours. Additional symptoms may be chills, headache, nausea and vomiting that can last up to seven days.

As of May 11, 2010, a total of 23 confirmed and 7 probable cases related to this outbreak have been reported from 4 states since March 1, 2010. The number of ill persons identified in each state with this strain is: MI (10 confirmed and 3 probable), NY (4 confirmed and 3 probable), OH (8 confirmed and 1 probable), and TN (1 confirmed).
Among the confirmed and probable cases with reported dates available, illnesses began between April 10, 2010 and April 26, 2010. Infected individuals range in age from 13 years old to 31 years old and the median age is 19 years. Sixty-six percent of patients are male.

Among the 30 patients with available information, 12 (40%) were hospitalized. Three patients have developed a type of kidney failure known as hemolytic-uremic syndrome, or HUS. No deaths have been reported.

The outbreak can be visually described with a chart showing the number of persons who became ill each day. This chart is called an epidemic curve or epi curve. Of note, it takes an average of 2 to 3 weeks from the time a person becomes ill to the time when the illness is confirmed by laboratory testing and reported.

The bacteria responsible for this outbreak are referred to as Shiga toxin-producing E. coli, or STEC. STECs have been associated with human illness, including bloody diarrhea and HUS. STEC bacteria are grouped by serogroups (e.g., O157 or O145). The STEC serogroup found most commonly in U.S. patients is E. coli O157. Other E. coli serogroups in the STEC group, including O145, are sometimes called “non-O157 STECs.” Currently, there are limited public health surveillance data on the occurrence of non-O157 STECs, including E. coli O145; therefore, E. coli O145 may go unreported. Because it is more difficult to identify than E. coli O157, many clinical laboratories do not test for non-O157 STEC infection.

Investigators are using pulsed-field gel electrophoresis (PFGE), a type of DNA fingerprint analysis of E. coli bacteria obtained through diagnostic testing to identify cases of illness that might be part of this outbreak. This testing is done in public health laboratories as part of the PulseNet network. Investigators have established a common definition of confirmed and probable cases related to this outbreak.

Confirmed cases are persons with:

(1) E. coli O145 infection, or E. coli infection with O Group pending, AND
(2) an illness onset on or after March 1, 2010, AND
(3) a DNA fingerprint matching the outbreak strain; AND
(4) an epidemiologic link to the outbreak.

Probable cases are persons with an epidemiologic link to the outbreak and

(1) E. coli O145 infection with an illness onset on or after March 1, 2010 regardless of DNA fingerprint pattern, AND/OR
(2) hemolytic-uremic syndrome (HUS); AND/OR
(3) a laboratory isolate positive for Shiga toxin 2 [stx2] or isolate positive for Shiga toxin, but toxin type is unknown or pending.

Current Status of the Investigation

Multiple lines of evidence have implicated shredded romaine lettuce from one processing facility as a source of infection in this outbreak. This evidence includes the identification of the outbreak strain of E. coli O145 from an unopened package of shredded romaine lettuce obtained at an institution that received product from the processing facility linked to the outbreak. A case-control study in Michigan found a significant association between illness and consumption of romaine lettuce processed at the same facility that processed lettuce consumed by ill persons in New York, Ohio and Tennessee.

The lettuce processing company has issued a recall of lettuce produced at their facility as a result of the evidence obtained to date.  An additional recall was issued by a separate company that received lettuce from the same farm as the processing company linked to the outbreak.

This investigation is ongoing. At this time, local, state, and federal health officials are involved in many different types of investigative activities, including:

• Conducting surveillance for additional illnesses that could be related to the outbreak.
• Conducting epidemiologic studies that includes gathering detailed information from persons who were ill persons (cases) and from healthy persons (controls) about foods recently eaten and other exposures.
• Gathering and testing food products that are suspected as possible sources of infection to see if they are contaminated with bacteria.
• Following any epidemiologic leads gathered from interviews with patients, food purchase information, or from patterns of processing, production and/or distribution of suspected products.
• FDA is working closely with its state partners in the investigations at the food processor and at the farm level to determine where in the distribution chain the point of contamination likely occurred.

Public health and agriculture officials in Michigan, New York, Ohio, and Tennessee, along with CDC and FDA, are actively engaged in this investigation. Updates on the progress of this investigation will be shared as information becomes available.

Clinical Features/Signs and Symptoms

Most people infected with E. coli develop diarrhea (often bloody) and abdominal cramps 2-8 days (average of 3-4 days) after swallowing the organism, but some illnesses last longer and can be more severe. Infection is usually diagnosed by culture of a stool sample. Many clinical laboratories do not test for non-O157 STEC, such as E. coli O145, because identifying it is more difficult than for E. coli O157. Most people recover within a week, but some develop a severe infection. Hemolytic uremic syndrome (HUS) can begin as the diarrhea is improving and can occur in people of any age but is most common in children under 5 years old and the elderly.