9,000 will die every year, often due to complications. A scientist specializing in intestinal diseases at the CDC states that the 6.5 million annual cases noted in the report represents a sound estimate, but that the affliction rate of two leading causes of foodborne illness (Salmonella and Campylobacter) alone may be as high as eight million (Tauxe, Personal Communication, 1986). Other microbiologists have estimated that the total annual number of cases of foodborne illness could be over 28 million (Archer, et al., 1985). The CDC estimates are derived from national surveillance data which is collected from public health authorities in each state and published in annual summaries. The number of reported outbreaks an incident in which two or more persons experience a similar illness after the ingestion of a common food, and epidemiological analysis implicates the food as the source of the represents only a fraction of the actual number of cases. The CDC uses the number of reported cases to extrapolate the full extent of the problem. illness Thousands of individual cases and minor outbreaks are never reported to the CDC or public health authorities because the illness may last only a few days, or because many of those afflicted are unaware that their suspected virus is really food poisoning. The 1974 Proceedings on Food Protection, which explored issues involving food hazards, notes this serious flaw in surveillance activity. "The quality of data collected is variable and at times may be unreliable" (DHHS, 1984). Whether illnesses are reported to public health authorities as food poisoning or at all depends upon the magnitude of the incident. As the CDC's 1982 Annual Summary of Foodborne Illness notes, "The likelihood of an outbreak coming to the attention of health authorities varies considerably depending on consumer and physician awareness, interest, and motivation to report the incident; for example, large outbreaks, interstate outbreaks, restaurant-associated outbreaks, and outbreaks involving serious illness, hospitalizations, or deaths are more likely to come to the attention of health authorities than cases of mild illness following a family cookout" (DHHS, 1985). The lax surveillance activity is illustrated by a survey published in the American Journal of Public Health which analyzed reporting activity in Washington State (population 3,000,000) for the year 1969. The survey revealed 69 foodborne outbreaks resulting in 1,135 individual cases. In contrast, only 371 food and waterborne outbreaks and 28,563 individual cases were reported by the CDC for the entire country (population 200,000,000). If the incidence of disease and the surveillance activity in Washington State were similar to those of other states in 1969, about 4,600 outbreaks and 76,000 cases should have been reported to the CDC. "Even at these higher estimates, the figures must be multiplied by factors of unknown magnitude to account for the still undetected foodborne outbreaks and cases, including those gastrointestinal illnesses that could not be conclusively linked to food (Hauschild et al., 1980). Little-known bacteria which cause foodborne illness can also contribute to inaccurate reporting. For example, the most recent surveillance data available indicates that only .2% of foodborne illness is attributable to Campylobacter, but this is because local health departments often do not report this bacteria. "There is an enormous number of foodborne cases from Campylobacter that goes unreported. We estimate two to four million. It is thought to be more of a problem than Salmonella but we just don't know enough about it," observes one scientist at the CDC. "We encourage localities to report cases, but each state has it's own area of emphasis. The New York City Health Department took the lead early on, but unfortunately even in New York there is an enormous number of cases of foodborne illness that goes unreported" (Tauxe, Personal Communication, 1986). A higher proportion of food poisoning cases is reported in New York State compared to the rest of the country. The most recent CDC statistics available indicate that out of 656 outbreaks, New York State reported 323; 160 of those outbreaks were reported by New York City. The CDC report notes, "While it is possible that New York has an increased rate of foodborne disease, it is more likely that such a high proportion may represent differences in surveillance activity" (DHHS, 1985). New York City has reported 25% of foodborne illness cases from 1972 to 1982. No annual summary of national surveillance data since 1982 has been available. Economic Costs Epidemiologists and food microbiologists estimate the extent of foodborne illness in a given city, county or state. These estimates are then used to determine the public cost of such illness and to justify expenditures for control programs. In light of the shortcomings in surveillance activity, microbiologists cannot always arrive at precise numbers. In the 1984 Proceedings on Food Protection, published by the U.S. Department of Health and Human Services and the Food and Drug Administration, it was estimated that the economic impact of foodborne illness in the United States is between one and ten billion dollars a year. "If it is assumed that there are five million cases each year, the average cost per case would range from $200 to $2,000" (DHHS, 1984). Although no detailed analysis of the estimated annual costs of foodborne disease is available, several studies have examined the costs of specific foodborne disease outbreaks. A 1978 study in the New England Journal of Medicine provides a cost breakdown of a Salmonella outbreak involving 134 people: "Medical costs ranged from $125 to $1,750 [per person]. Lost income or productivity accounted for 26% of the total cost of the outbreak; 87% of the employed patients lost an average of 12 days from work and 39 family members missed an average of three workdays caring for a patient." The study also showed that salmonellosis and other foodborne illnesses are more than expensive inconveniences. "The outbreak examined in the study was responsible for complications, operations, and hospitalizations of five to six days for previously well persons in all age groups, not just infants and the elderly. It also demonstrated that salmonellosis is expensive not only for those who are ill, but also for society, as such outbreaks adversely affect the economy. Since this is a preventable disease, the cost of public health programs to detect, control, and prevent salmonellosis must be measured against the unnecessary medical expenses and loss-of-productivity cost" (Cohen et al., 1978). In addition to direct expenses, consumers also bear indirect costs. "Education of administrators and politicians, and costs relating to food spoilage, foodborne disease and recalls are eventually borne by the public, whether they are the victims of illness, or are shareholders trying to recover from a recall or are taxpayers responsible for funding of government health control agencies and loans to help bail out industries that have poor quality control" (DHHS, 1984). Special Victims Infants, the aged, the malnourished, and those suffering from an immune system deficiency are particularly susceptible to foodborne illness. Immune-compromised patients do not have adequate defenses to fight off infection. Those suffering from AIDS or receiving chemotherapy treatment, for example, should avoid all raw or undercooked meat or poultry. Thus, quack "treatments" which recommend that cancer victims eat raw liver can be extremely hazardous, even deadly. The USDA is aware of the particular seriousness of the problem for highly susceptible persons. In a speech at the 1984 International Symposium on Salmonella, the Director of the USDA's Food Safety Inspection Service (FSIS) explained: "These individuals may be the recipients of organ transplants or they may have undergone other types of surgery; they may have received chemotherapy for treatment of cancer: they may be suffering from diseases that affect the immune mechanism. In any event, immune-suppressed persons are exceptionally vulnerable to environmental contaminants and invasive bacteria, especially in the food supply. A recent Salmonella dublin outbreak in California affected 24 persons, all of whom were immune-compromised in some way." He continued, "Individuals may have been successfully treated for heart, liver or kidney problems and yet they may succumb to infection by bacteria that would be of lesser concern to most people. Of course, what I have said about the potential effect of Salmonella on immune-suppressed individuals can be said about other organisms. Because of the growing number of immune-suppressed persons, there has been increased concern about the potential lethality of Campylobacter...Although statistics on the scope of the problem are lacking, recent incidents of infections of immune-compromised individuals by these organisms have drawn our attention to the problem" (AAAP, 1984). Chapter Two PATHOGENS THAT CAUSE FOOD POISONING Summary Both the federal government and industry claim that although bacteria which causes food poisoning exist on meat and poultry they will be killed when the product is heated. Contrary to this position and what many consumers believe, cooking does not necessarily kill all bacteria. Foodborne illness-causing pathogens are often spread through cross-contamination and time-temperature abuse. Uncontaminated foods, such as lettuce, can be contaminated through contact with the same surface as the raw meat or poultry, or by a butcher touching one piece of meat, then another, with contaminated hands. Some bacteria actually grow when heated unless a temperature of 140 degrees or above is maintained. The larger the number of bacteria per gram, the greater the chance of the bacteria to grow or spread. Salmonella Salmonella is the general name applied to a group of approximately 2,000 closely-related bacterial strains. This group of bacteria ranks among the three leading causes of foodborne disease in the United States. Since Salmonella can survive under many environmental conditions, it is a difficult bacteria to control (AAAP, 1984). Poultry is considered to be the most important host of Salmonella; the USDA, in fact, recognizes its presence on 37% of the chickens sold today (Green et al., 1981). Conditions leading to outbreaks of salmonellosis and other forms of bacterial food poisoning may result from inadequate cooking of contaminated foods, especially large pieces of meat such as a roast beef or turkey. If a food product contaminated with a pathogen has not been thoroughly cooked, the organism may not be killed. Also, a slow cooling process allows bacteria to multiply. Foods may become recontaminated in a kitchen by unhygienic practices, such inadequate washing of hands, or the re-use of unwashed utensils, tabletop surfaces, and cutting boards. The number of reported cases of salmonellosis in humans has steadily increased in the past 20 years (See Appendix D). Any member of the genus Salmonella presents some degree of hazard to human health. Some, notably Salmonella typhi, pose a severe hazard. Salmonellosis, like many other forms of food poisoning, is a gastrointestinal disease. The incubation period is approximately six to forty-eight hours. The symptoms include diarrhea, nausea, vomiting, abdominal cramps, and sometimes fever. The illness usually lasts from two to four days, but children |