Prevention of Listeriosis Outbreaks in a High-Risk Food Service Setting How can an RD help?
description
Transcript of Prevention of Listeriosis Outbreaks in a High-Risk Food Service Setting How can an RD help?
Prevention of Listeriosis Outbreaks in a High-Risk
Food Service Setting
How can an RD help?
Presented by Anne Smith
What is Listeriosis?
A foodborne illness caused by ingesting the bacteria Listeria monocytogenes
Gram-positive bacillus
Found in water and soil, non-pasteurized milk and milk products, and on contaminated vegetation
Can also be found in infected animals who ingested the bacteria
Cold-tolerant; can survive and replicate in temperatures below 40oF
Can colonize on environmental surfaces
Can easily be killed by heat
L. monocytogenes Gram-positive bacillus
Who is at Risk?Pregnant women and the fetus
Highest risk in third trimester Can cause spontaneous abortion
Immunocompromised persons Malignancies Solid organ and bone marrow transplantations Immunosuppressive therapy- HIV infection and AIDS
Neonates
Older adults
Kidney or liver disease
Alcoholism
Diabetic patients
Symptoms
Febrile gastroenteritisMost common in healthy adults
Mild, flu-like symptoms
Fever, intense headaches, nausea, and vomiting
Bacteremia and meningitisMost common in Immunocompromised
Miscarriage, stillbirth, premature delivery, or life-threatening infections in a newborn
9%-30% can be fatal
What foods can be affected?
Cold ready-to-eat foods not heated before consumptionDelicatessen-style meats, hotdogsCold-prepared salads such as tuna salad or egg
saladSoft cheeses- feta, Brie, Camembert, blue-veined
cheeses, or Mexican-style cheeses such as queso blanco, queso fresco and Panela
Contaminated vegetables and animal products
Risk increases for durations of refrigeration
CDC Reported Outbreaks2011- Listeriosis Linked to Whole Cantaloupes
from Jensen Farms, Colorado
2012- Listeriosis Linked to Imported Ricotta Cheese
2013- Listeriosis Linked to Crave Brother Farmstead Cheese
http://www.cdc.gov/listeria/outbreaks/index.html
Global Reported Outbreaks
US- 175 cases reported in 3 yearsAbout 58/yr
Globally in 2006France- 290Germany- 508UK- 208Spain- 78Czech Republic- 78Netherlands- 64
Occurrences of Listeriosis in Healthcare
Fall 2003, UK 5 pregnant women 2 separate facilites Contaminated sandwiches
February 2010, Texas 10 cases in 7 months 5 separate facilities Contaminated diced celery
September 22, 2008, New York 3 listeriosis cases at hospital X 2 other cases identified later Contaminated tuna salad
How is it identified?
Pulsed-field gel electrophoresis (PFGE) patterns
Our study
Serving High-Risk Foods in a High-Risk Setting:
Survey of Hospital Food Service Practices after an Outbreak of Listeriosis in a
Hospital
Carolyn Cokes, MPH, Anne Marie France, PhD, Vasudha Reddy, MPH, Heather Hanson, MPH, Lillian Lee, MS, Laura Kornstein, PhD,
Faina Stavinsky, MS, Sharon Balter, MD
Purpose
“This report summarizes the outbreak investigation for Listeriosis in a NYC hospital as well as the results of a
telephone survey of NYC hospitals that explored risk management practices for foodborne illnesses in hospital settings.”
5 cases of Listeriosis were reported from Hospital X in New York
Subjects
4 male, 1 female
Median age was 62 years (range 52-92 yo)
All had medical conditions that put them at high-risk of ListeriosisComplications from transplanted liverChiari syndromeChronic heart failureMitral valve disorder
Methods
5 Methods of InvestigationEpidemiologic InvestigationEnvironmental InvestigationLaboratory InvestigationHospital SurveyStatistical Methods
Epidemiologic Investigation
Medical record abstractions
Patient interviews Onset dates Clinical illness Food history
Menus from hospital cafeteria
Reports posted to identify other related Listeriosis cases CDC’s Epi-X communication site PulseNet CDC Team electronic bulletin board
Environmental Investigation
9/23/08-Full sanitary inspection- NYC OEI Swabs of food-contact surfaces
9/25/08- HACCP analysis based on prep reviews Tuna salad and turkey sandwiches
9/29/08- Samples collected Environmental surface samples for Listerosis analysis
9/30/08 and 10/3/08- More samples 25 samples from cooking/storage surfaces, kitchen
equipment, vents, drains, and floors 20 food samples- tuna, chicken, and egg salad
Laboratory Investigation
Clinical isolates from NYC cases submitted to PHL for analysis
All samples were analyzed for PFGE patterns
L. monocytogenes DNA was restricted using 2 enzymes Ascl and Apal
Gels were uploaded to PulseNet for identification of related cases
Hospital Survey
Section 1
Director of Infection Control
Prevalence of high-risk patients in comparison to total patients
Units available for high risk patients
Section 2
Food Service Director
Focus on foods served
Food service practices and policies
Policies restricting service of items that present high risk
61 acute care hospitals in NYC were asked to participate in a telephone survey, 54 responded
January-April 2009
Statistical Methods
SAS software, version 9.1 SAS Institute
P values 2-sidedCalculated by Fisher exact test, x2 analysis or t test
Epidemiologic Results
Food historiesPts 1-3 obtained by direct interviewPt 4- no history, patient diedPt 5- partial history from next of kin
Common foods- Tuna salad and sliced turkeyPts 1-3- reported having bothPt 5- most likely consumed both
Hospital did not keep copies of food orders
None of the 5 patients have been in rooms on the same floor at the same time
Laboratory Results
Contaminated samples 4 samples of tuna salad1 can-opener sample 1 floor drain sample
All 5 human isolates contained L. monocytogenes
No similar PFGE patterns were in PulseNet
PFGE
Environmental Results
Inspections showed no violations of NYC health codes
HACCP investigation showed tuna was held at 41oF for 4 days before being served
2 environmental samples contained L. monocytogenesCan opener base- opened the cansFloor drain- located near 100 qt mixer
October 2009- all negative samples
9 were public hospitals, 45 were private hospitals
23 reported maintaining patient food orders
8 kept records with patient charts
29 reported outside food vendor contracts
Survey Results
Food Safety Practices"Despite the potential for severe outcomes of Listeria infection among hospitalized patients,
the majority of NYC hospitals that participated in the food practice survey had no food
preparation policies or practices to minimize risk for L. monocytogenes contamination."
Foodborne Illness Risk Management Guidelines
Reported Raw fruits and vegetable use
•62% of Large hospitals reported not using raw F&V
•Facilities with transplant pts less likely to report use of raw F&V
• 75% with bone marrow transplant units
• 100% with organ transplant units
Helpful PoliciesFrom the study:
Steam deli meats before servingDo not serve soft cheesesUse only cooked (irradiated) F&V components
Other Suggestions:Severely limit storage time of high-risk foodsKeep better food records for healthcare providersRoutine and thorough cleaning of food surfacesKeep records of patient food orders and diet
historyTest strips? Contract out food service?
Role of the RD
Menu planning
Food purchasing planning, budgeting, and source approval
Education of food service workers on food safety
Daily/weekly dietary assessments of high-risk patients
Eurosurveillance- improve procedures
Computer system to track orders
Global Food Safety
Global Food Safety InitiativeManufacturers
ServSafe certificationsCostly?
Australia’s Food Safety GuidelinesSafer food alternatives
Food Standards Agency –UKVideo learning
Comments
Stacy- “Do you think it is the role of the RD or DTR to monitor patient charts to prevent them from receiving potentially dangerous foods? Listeria outbreaks are preventable with proper food safety practices, so do you believe better training of kitchen staff is more important than monitoring food ordered?”
Liz- “A computer based diet record and food ordering system should have flags that prevent at-risk persons of ordering risky items off the menu. I know its possible to flag for such things as a "heart healthy diet" or "diabetic diet", why not create another category for "at-risk".
Other Comments?
References Cokes, Carolyn, MPH, Anne Marie France, PhD, Vasudha Reddy, MPH, Heather Hanson, MPH, Lillian
Lee, MS, Laura Kornstein, PhD, Faina Stavinsky, MS, Sharon Balter, MD. “Serving High-Risk Foods in a High-Risk Setting: Survey of Hospital Food Service Practices after an Outbreak of Listeriosis in a Hospital.” Infection Control and Hospital Epidemiology. April 2011. Vol 32 No 4
Denny, Justin, Jim McLauchlin. “Human Listeria monocytogenes infections in Europe - an opportunity for improved European surveillance.” EUROSURVEILLANCE Vol. 13 · Issues 1–3 · Jan–Mar 2008.
http://www.health.ny.gov/diseases/communicable/listeriosis/fact_sheet.htm. Accessed online September 5, 2013.
http://www.cdc.gov/listeria/index.html. Accessed online September 5, 2013.
Dawson, SJ, MR Evans, D Willby, J Bardwell, N Chamberlain, DA Lewis. “Listeria outbreak associated with sandwich consumption from a hospital retail shop, United Kingdom.” Eurosurveillance, Volume 11, Issue 6, 01 June 2006.
Gaul, Linda Knudson, Noha Farag, Trudi Shim, Monica Kingsley, Benjamin Silk, Eija Hyytia-Trees. “Hospital-Acquired Listeriosis Outbreak Caused by Contaminated Diced Celery—Texas, 2010”. Clin Infect Dis. (2013) 56 (1): 20-26
http://www.food.gov.uk/. Accessed online September 9, 2013.
http://www.health.sa.gov.au/pehs/food-index.htm. Accessed online September 9, 2013.