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Morbidity and Mortality Weekly Report

Recommendations and Reports April 16, 2004 / Vol. 53 / No. RR-4

Diagnosis and Management of Foodborne Illnesses

A Primer for Physicians and Other Health Care Professionals

INSIDE: Continuing Education Examination

department of health and human services Centers for Control and Prevention MMWR

CONTENTS

The MMWR series of publications is published by the Background ...... 1 Program Office, Centers for Disease Control and Prevention (CDC), U.S. Department of Clinical Considerations ...... 2 Health and Human Services, Atlanta, GA 30333. Charts ...... 7 Patient Scenarios ...... 13 SUGGESTED CITATION Congenital ...... 13 Centers for Disease Control and Prevention. Diagnosis and Management of Foodborne Illnesses: A Primer for Acute ...... 15 Physicians and Other Health Care Professionals. ...... 18 MMWR 2004;53(No. RR-4):[inclusive page numbers]. -Resistant ...... 19 Unexplained Illness ...... 22 Centers for Disease Control and Prevention Clinical Vignettes: What’s Your Call? ...... 24 Julie L. Gerberding, M.D., M.P.H. Suggested Resources ...... 27 Director Suggested Reading List ...... 29 Dixie E. Snider, Jr., M.D., M.P.H. (Acting) Deputy Director for Science Tanja Popovic, M.D., Ph.D. (Acting) Associate Director for Science

Epidemiology Program Office Stephen B. Thacker, M.D., M.Sc. Director Office of Scientific and Health Communications John W. Ward, M.D. Director Editor, MMWR Series Suzanne M. Hewitt, M.P.A. Managing Editor, MMWR Series C. Kay Smith-Akin, M.Ed. Lead Technical Writer/Editor Lynne McIntyre, M.A.L.S. Project Editor Beverly J. Holland Lead Visual Information Specialist Lynda G. Cupell Malbea A. LaPete Visual Information Specialists Kim L. Bright, M.B.A. Quang M. Doan, M.B.A. Erica R. Shaver Information Technology Specialists Disclosure of Relationship Elaine F. Brainerd, R.N., M.A., has indicated that she has a financial relationship with CDC because she is the Director of a Safe Schools project that is funded under a cooperative agreement by CDC. The remaining preparers have signed a conflict of interest disclosure form that verifies no conflict of interest. Vol. 53 / RR-4 Recommendations and Reports 1

Diagnosis and Management of Foodborne Illnesses A Primer for Physicians and Other Health Care Professionals

Produced collaboratively by the American Medical Association American Nurses Association–American Nurses Foundation Centers for Disease Control and Prevention Center for and Applied Nutrition, Food and Drug Administration Food Safety and Inspection Service, US Department of Preface Foodborne illness is a serious public health problem. CDC estimates that each year 76 million people get sick, more than 300,000 are hospitalized, and 5,000 die as a result of foodborne illnesses. Primarily the very young, the elderly, and the immunocompromised are affected. Recent changes in human demographics and food preferences, changes in food production and distribution systems, microbial adaptation, and lack of support for public health resources and infrastructure have led to the emergence of novel as well as traditional foodborne . With increasing travel and trade opportunities, it is not surprising that now there is a greater risk of contracting and spreading a foodborne illness locally, regionally, and even globally. Physicians and other health care professionals have a critical role in the prevention and control of food-related disease out- breaks. This primer is intended to provide practical and concise information on the diagnosis, treatment, and reporting of foodborne illnesses. It was developed collaboratively by the American Medical Association, the American Nurses Association- American Nurse Foundation, CDC, the Food and Drug Administration’s Center for Food Safety and Nutrition, and the United States Department of Agriculture’s Food Safety and Inspection Service. Clinicians are encouraged to review the primer and participate in the attached continuing medical education (CME) program.

Background • Obtain stool cultures in appropriate settings, and recog- nize that testing for some specific , eg, E. coli This primer is directed to primary care and emergency phy- O157:H7, spp., must be requested; sicians, who are likely to see the of a potential food- • Report suspect cases to appropriate public health officials; related . It is also a teaching tool to update • Talk with patients about ways to prevent food-related dis- physicians and other health care professionals about foodborne eases; and illness and remind them of their important role in recogniz- • Appreciate that any patient with foodborne illness may ing suspicious symptoms, disease clusters, and etiologic agents, represent the sentinel case of a more widespread outbreak. and reporting cases of foodborne illness to public health Foodborne illness is considered to be any illness that is authorities. related to food ingestion; symptoms are Specifically, this guide urges physicians and other health care the most common clinical manifestations of foodborne ill- professionals to nesses. This document provides detailed summary tables and • Recognize the potential for a foodborne etiology in a charts, references, and resources for health care professionals. patient’s illness; Patient scenarios and clinical vignettes are included for self- • Realize that many but not all cases of foodborne illness evaluation and to reinforce information presented in this have gastrointestinal tract symptoms; primer. Also included is a CME component. This primer is not a clinical guideline or definitive resource An earlier edition of this Primer, covering different foodborne illnesses, for the diagnosis and treatment of foodborne illness. Safe food was published in MMWR in 2001 (MMWR 2001;50[No. RR-2]) and handling practices and technologies (eg, irradiation, food pro- also as a separate publication by the American Medical Association, cessing and storage) also are not addressed. More detailed CDC, the Food and Drug Administration, and the U.S. Department information on these topics is available in the references and of Agriculture. This report updates and supplements the previous edition. It is being reprinted here as a courtesy to the collaborating resources listed in this document, as well as from medical spe- agencies and the MMWR readers. cialists and medical specialty societies, state and local public health authorities, and federal government agencies. 2 MMWR April 16, 2004

For additional copies, please contact appropriate medical specialist or medical specialty society, as Litjen (L.J.) Tan, PhD well as the various resources listed in this primer. Also refer to American Medical Association this section and the accompanying Foodborne Illnesses Tables 515 North State Street when working through the various Patient Scenarios and the Chicago, Illinois 60610 Clinical Vignettes portion of this primer. (312) 464-4147 (312) 464-5841 (fax) Recognizing Foodborne Illness [email protected] (e-mail) Patients with foodborne illnesses typically present with Or visit the following websites: gastrointestional tract symptoms (eg, , , abdominal pain); however, nonspecific symptoms and neuro- The American Medical Association logic symptoms may also occur. Every outbreak begins with http://www.ama-assn.org/go/foodborne an index patient who may not be severely ill. A physician or Centers for Disease Control and Prevention health care professional who encounters this person may be http://www.cdc.gov/foodsafety/cme.htm the only one with the opportunity to make an early and expe- Center for Food Safety and Applied Nutrition, ditious diagnosis. Thus, the physician or health care profes- Food and Drug Administration sional must have a high degree of suspicion and ask appropriate http://www.cfsan.fda.gov questions to recognize that an illness may have a foodborne Food Safety and Inspection Service, US Department etiology. of Agriculture Important clues to determining the etiology of a foodborne http://www.fsis.usda.gov disease are the • ; Clinical Considerations • Duration of the resultant illness; • Predominant clinical symptoms; and Food-related disease threats are numerous and varied, • Population involved in the outbreak. involving biological and nonbiological agents. Foodborne ill- Additional clues may be derived by asking whether the nesses can be caused by and their , patient has consumed raw or poorly cooked (eg, raw or marine organisms and their toxins, fungi and their related undercooked eggs, meats, shellfish, fish), unpasteurized toxins, and chemical contaminants. During the last 20 years, or juices, home-canned goods, fresh produce, or soft cheeses some foods that have been linked to outbreaks include milk made from unpasteurized milk. Inquire as to whether any of (); shellfish (); unpasteurized apple the patient’s family members or close friends have similar symp- cider ( O157:H7), raw and undercooked eggs toms. Inquiries about living on or visiting a farm, pet contact, (); fish (ciguatera ); raspberries (Cyclospora); day care attendance, occupation, foreign travel, travel to coastal strawberries (hepatitis A ); and ready-to-eat meats (). areas, camping excursions to mountains or other areas where While physicians and other health care professionals have a untreated water is consumed, and attendance at group pic- critical role in surveillance for and prevention of potential dis- nics or similar outings also may provide clues for determining ease outbreaks, only a fraction of the people who experience the etiology of the illness. gastrointestinal tract symptoms from foodborne illness seek If a foodborne illness is suspected, submit appropriate speci- medical care. In those who do seek care and submit speci- mens for laboratory testing and contact the state or local health mens, are more likely than other pathogens to be iden- department for advice about epidemiologic investigation. For tified as causative agents. Bacterial agents most often identified the physician or other health care professional, implication of in patients with foodborne illness in the United States are a specific source in disease is difficult from a single Campylobacter, Salmonella, and species, with substan- patient encounter. Attempts to identify the source of the out- tial variation occurring by geographic area and season. Test- break are best left to public health authorities. ing for viral etiologies of diarrheal disease is rarely done in Because infectious diarrhea can be contagious and is easily clinical practice, but are considered the most common spread, rapid and definitive identification of an etiologic agent cause of foodborne illness. may help control a disease outbreak. Early identification of a case This section and the accompanying Foodborne Illnesses of foodborne illness can prevent further exposures. An individual Tables summarize diagnostic features and laboratory testing physician who obtains testing can contribute the clue that ulti- for bacterial, viral, parasitic, and noninfectious causes of mately leads to identification of the source of an outbreak. foodborne illness. For more specific guidance, consult an Vol. 53 / RR-4 Recommendations and Reports 3

Finally, health care professionals should recognize that while Diagnosing Foodborne Illnesses deliberate contamination of food is a rare event, it has been documented in the past. The following events may suggest Differential Diagnosis that intentional contamination has occurred: an unusual agent As shown in Table 1 and the Foodborne Illnesses Tables, a or in a common food, a common agent or patho- variety of infectious and noninfectious agents should be con- gen affecting an unusually large number of people, or a com- sidered in patients suspected of having a foodborne illness. mon agent or pathogen that is uncommonly seen in clinical Establishing a diagnosis can be difficult, however, particularly practice, as might occur with poisoning. in patients with persistent or chronic diarrhea, those with severe abdominal pain, and when there is an underlying dis-

TABLE 1. Etiologic agents to consider for various manifestations of foodborne illness Clinical presentation Potential food-related agents to consider (vomiting as primary Viral gastroenteritis, most commonly in an infant or norovirus and other caliciviruses in an older symptom; fever and/or diarrhea also child or adult; or food poisoning due to preformed toxins (eg, , , may be present) cereus toxin) and heavy metals.

Noninflammatory diarrhea (acute watery Can be caused by virtually all enteric pathogens (bacterial, viral, parasitic) but is a classic symptom of diarrhea without fever/dysentery; some Enterotoxigenic Escherichia coli patients may present with fever)* Enteric viruses (astroviruses, noroviruses and other caliciviruses, enteric adenovirus, rotavirus)

Inflammatory diarrhea (invasive Shigella species gastroenteritis; grossly bloody stool and Campylobacter species fever may be present)† Salmonella species Enteroinvasive E. coli Enterohemorrhagic E. coli E. coli O157:H7

Persistent diarrhea (lasting >14 days) Prolonged illness should prompt examination for parasites, particularly in travelers to mountainous or other areas where untreated water is consumed. Consider Cyclospora cayetanensis, Cryptosporidium, Entamoeba histolytica, and Giardia lamblia.

Neurologic manifestations (eg, ( ) paresthesias, respiratory depression, Organophosphate bronchospasm, cranial nerve palsies) Thallium poisoning Scombroid fish poisoning (histamine, saurine) (ciguatoxin) Tetradon fish poisoning (tetradotoxin) Neurotoxic (brevitoxin) Paralytic shellfish poisoning () Amnesic shellfish poisoning (domoic acid) Guillain-Barré syndrome (associated with infectious diarrhea due to )

Systemic illness (eg, fever, weakness, arthritis, ) species Trichinella spiralis Hepatitis A and E viruses Salmonella Typhi and Salmonella Paratyphi Amebic abscess * Noninflammatory diarrhea is characterized by mucosal hypersecretion or decreased absorption without mucosal destruction and generally involves the small intestine. Some affected patients may be dehydrated because of severe watery diarrhea and may appear seriously ill. This is more common in the young and the elderly. Most patients experience minimal dehydration and appear mildly ill with scant physical findings. Illness typically occurs with abrupt onset and brief duration. Fever and systemic symptoms usually are absent (except for symptoms related directly to intestinal fluid loss). † Inflammatory diarrhea is characterized by mucosal invasion with resulting inflammation and is caused by invasive or cytotoxigenic microbial pathogens. The diarrheal illness usually involves the large intestine and may be associated with fever, abdominal pain and tenderness, headache, , vomiting, malaise, and myalgia. Stools may be bloody and may contain many fecal leukocytes. 4 MMWR April 16, 2004 ease process. The extent of diagnostic evaluation depends on The differential diagnosis of patients presenting with neuro- the clinical picture, the differential diagnosis considered, and logic symptoms due to a foodborne illness is also complex. Pos- clinical judgment. sible food-related causes to consider include recent ingestion of The presentation of a patient with a foodborne illness is contaminated , mushroom poisoning, and chemical often only slightly different from that of a patient who pre- poisoning. Because the ingestion of certain toxins (eg, botuli- sents with a viral syndrome. In addition, viral syndromes are num toxin, ) and chemicals (eg, organophosphates) so common that it is reasonable to assume that a percentage can be life-threatening, a differential diagnosis must be made of those diagnosed with a viral syndrome have actually con- quickly with concern for aggressive therapy and life support tracted a foodborne illness. Therefore, the viral syndrome must measures (eg, respiratory support, administration of antitoxin be excluded in order to suspect the foodborne illness and take or atropine), and possible hospital admission. appropriate public health action. Fever, diarrhea, and abdomi- Clinical Testing nal cramps can be present or absent in both cases so they are not very helpful. The absence of myalgias or arthralgias would When submitting specimens for microbiologic testing, it is make a viral syndrome less likely and a foodborne illness (that important to realize that clinical microbiology laboratories does not target the neurologic system) more likely. Foodborne differ in protocols used for the detection of pathogens. To illnesses that do target the neurologic system tend to cause optimize recovery of an etiologic agent, physicians and other paraesthesias, weakness and paralysis that are distinguishable health care professionals should understand routine specimen- from myalgias or arthralgias (see below). The presence of dys- collection and testing procedures as well as circumstances and entery (bloody diarrhea) is also more indicative of a foodborne procedures for making special test requests. Some complex illness, particularly if it is early in the course. tests (eg, toxin testing, serotyping, molecular techniques) may If any of the following occur in patients, only be available from large commercial or public health labo- either alone or in combination, laboratory testing may pro- ratories. Contact your microbiology laboratory for more vide important diagnostic clues (particular attention should information. be given to very young and elderly patients and to immuno- Stool cultures are indicated if the patient is immuno- compromised patients, all of whom are more vulnerable): compromised, febrile, has bloody diarrhea, has severe abdomi- • Bloody diarrhea nal pain, or if the illness is clinically severe or persistent. Stool • Weight loss cultures are also recommended if many fecal leukocytes are • Diarrhea leading to dehydration present. This indicates diffuse colonic inflammation and is •Fever suggestive of invasive bacterial pathogens such as Shigella, • Prolonged diarrhea (3 or more unformed stools per day, Salmonella, and Campylobacter species and invasive E. coli. In persisting several days) most laboratories, routine stool cultures are limited to screen- • Neurologic involvement, such as paresthesias, motor weak- ing for Salmonella and Shigella species and Campylobacter ness, cranial nerve palsies jejuni/coli. Cultures for Vibrio and Yersinia species, E. coli • Sudden onset of nausea, vomiting, diarrhea O157:H7, and Campylobacter species other than jejuni/coli • Severe abdominal pain require additional media or incubation conditions and there- In addition to foodborne causes, a differential diagnosis of fore require advance notification or communication with labo- gastrointestinal tract disease should include underlying medi- ratory and infectious disease personnel. cal conditions such as irritable bowel syndrome; inflamma- Stool examination for parasites generally is indicated for tory bowel diseases such as Crohn’s disease or ulcerative colitis; patients with suggestive travel histories, who are immuno- malignancy; medication use (including antibiotic-related compromised, who suffer chronic or persistent diarrhea, or Clostridium difficile toxin colitis); gastrointestinal tract sur- when the diarrheal illness is unresponsive to appropriate anti- gery or radiation; malabsorption syndromes; immune defi- microbial therapy. Stool examination for parasites is also indi- ciencies; and numerous other structural, functional, and cated for gastrointestinal tract illnesses that appear to have a metabolic etiologies. Consideration also should be given to long incubation period. Requests for ova and parasite exami- exogenous factors such as the association of the illness with nation of a stool specimen will often enable identification of travel, occupation, emotional stress, sexual habits, exposure Giardia lamblia and Entamoeba histolytica, but a special to other ill persons, recent hospitalization, child care center request may be needed for detection of Cryptosporidium and attendance, and nursing home residence. Cyclospora cayetanensis. Each laboratory may vary in its rou- Vol. 53 / RR-4 Recommendations and Reports 5 tine procedures for detecting parasites, so it is important to Surveillance and Reporting contact your laboratory. of Foodborne Illness cultures should be obtained when bacteremia or sys- temic infection is suspected. Reporting of foodborne illnesses in the United States began Direct antigen detection tests and molecular biology tech- more than 50 years ago when state health officers, concerned niques are available for rapid identification of certain bacterial, about the high morbidity and mortality caused by typhoid viral, and parasitic agents in clinical specimens. In some cir- fever and infantile diarrhea, recommended that cases of cumstances, microbiologic and chemical laboratory testing of “enteric fever” be investigated and reported. The intent of vomitus or implicated food items also is warranted. For more investigating and reporting these cases was to obtain informa- information on laboratory procedures for the detection of tion about the role of food, milk, and water in outbreaks of foodborne pathogens, consult an appropriate medical special- gastrointestinal tract illness as the basis for public health ist, clinical microbiologist, or state public health laboratory. actions. These early reporting efforts led to the enactment of important public health measures (eg, the Pasteurized Milk Ordinance) that profoundly decreased the of Treating Foodborne Illness foodborne illnesses. Selection of appropriate treatment depends on identifica- Often health care professionals may suspect foodborne ill- tion of the responsible pathogen (if possible) and determin- ness either because of the organism involved or because of ing if specific therapy is available. Many episodes of acute other available information, such as several ill patients who gastroenteritis are self-limiting and require fluid replacement have eaten the same food. Health care professionals can serve and supportive care. Oral rehydration is indicated for patients as the eyes and ears for the health department by providing who are mildly to moderately dehydrated; intravenous therapy such information to local or state public health authorities. may be required for more severe dehydration. Routine use of Foodborne disease reporting is not only important for disease antidiarrheal agents is not recommended because many of these prevention and control, but more accurate assessments of the agents have potentially serious adverse effects in infants and burden of foodborne illness in the community occur when young children. physicians and other health care professionals report foodborne Choice of therapy should be based on illnesses to the local and state health department. In addition, • Clinical signs and symptoms; reporting of cases of foodborne illness by practicing physi- • Organism detected in clinical specimens; cians to the local health department may help the health • Antimicrobial susceptibility tests; and officer identify a foodborne disease outbreak in the commu- • Appropriateness of treating with an antibiotic (some nity. This may lead to early identification and removal of con- enteric bacterial are best not treated). taminated products from the commercial market. If a Knowledge of the infectious agent and its antimicrobial sus- or other food service establishment is identified as ceptibility pattern allows the physician to initiate, change, or the source of the outbreak, health officers will work to correct discontinue antimicrobial therapy. Such information also can inadequate food preparation practices, if necessary. If the home support public health surveillance of infectious disease and is the likely source of the contamination, health officers can trends in the community. Antimicro- institute public education about proper food handling prac- bial resistance has increased for some enteric pathogens, which tices. Occasionally, reporting may lead to the identification of dictates judicious use of this therapy. a previously unrecognized agent of foodborne illness. Report- Suspected cases of botulism are treated with botulinum ing also may lead to identification and appropriate manage- antitoxin. Equine botulinum antitoxin for types A, B, and E ment of human carriers of known foodborne pathogens, can prevent the progression of neurologic dysfunction if especially those with high-risk occupations for disease trans- administered early in the course of illness. Physicians and other mission such as foodworkers. health care professionals should notify their local and state Table 2 lists current reporting requirements for foodborne health departments regarding suspected cases of botulism. diseases and conditions in the United States. National report- CDC maintains a 24-hour consultation service to assist health ing requirements are determined collaboratively by the Council care professionals with the diagnosis and management of this of State and Territorial Epidemiologists and CDC. Additional rare disease. reporting requirements may also be mandated by state and territorial laws and regulations. Details on specific state reporting requirements are available from state health depart- 6 MMWR April 16, 2004

TABLE 2. Foodborne diseases and conditions designated as tests, so health care professionals should also report potential notifiable at the national level* — United States 2003 foodborne illnesses, such as when 2 or more patients present Notifiable BACTERIAL foodborne diseases and conditions with a similar illness that may have resulted from the inges- Botulism tion of a common food. Local health departments then Brucellosis report the illnesses to the state health departments and deter- Enterohemorrhagic Escherichia coli mine if further investigation is warranted. Hemolytic uremic syndrome, post-diarrheal Each state health department reports foodborne illnesses to Salmonellosis (other than S. Typhi) CDC. CDC compiles these data nationally and disseminates Shigellosis information via the weekly Morbidity and Mortality Weekly (S. Typhi and S. Paratyphi infections) Report and annual summary reports. CDC assists state and Notifiable VIRAL foodborne diseases and conditions Hepatitis A local public health authorities with epidemiologic investigations Notifiable PARASITIC foodborne diseases and conditions and the design of interventions to prevent and control food- related outbreaks. CDC also coordinates a national network of public health laboratories, called , which performs Trichinellosis “molecular fingerprinting” of bacteria (by pulsed-field gel elec- In the United States, additional reporting requirements may be trophoresis) to support epidemiologic investigations. mandated by state and territorial laws and regulations. Details on Thus, in addition to reporting cases of potential foodborne specific state reporting requirements are available from state health departments and from the illnesses, it is important for physicians to report noticeable Council of State and Territorial Epidemiologists (phone increases in unusual illnesses, symptom complexes, or disease number: 770-458-3811). Information available electronically at: patterns (even without definitive diagnosis) to public health www.cste.org/nndss/reportingrequirements.htm. authorities. Prompt reporting of unusual patterns of diarrheal/ Centers for Disease Control and Prevention. Information available electronically at www.cdc.gov/epo/dphsi/phs/ gastrointestinal tract illness, for example, can allow public infdis2003.htm. health officials to initiate an epidemiologic investigation ear- lier than would be possible if the report awaited definitive etiologic diagnosis. ments and from the Council of State and Territorial Epidemi- Finally, new information on food safety is constantly emerg- ologists and CDC. ing. Recommendations and precautions for people at high Typically, the appropriate procedure for health care profes- risk are updated whenever new data about preventing sionals to follow in reporting foodborne illnesses is to contact foodborne illness become available. Physicians and other health the local or state health department whenever they identify a care professionals need to be aware of and follow the most specific notifiable foodborne disease. However, it is often current information on food safety. unclear if a patient has a foodborne illness prior to diagnostic Vol. 53 / RR-4 Recommendations and Reports 7

Foodborne Illnesses (Bacterial) Incubation Duration of Etiology Period Signs and Symptoms Illness Associated Foods Laboratory Testing Treatment 2 days to Nausea, vomiting, malaise, Weeks Insufficiently cooked Blood. Penicillin is first choice for weeks bloody diarrhea, acute contaminated meat. naturally acquired gastrointes- abdominal pain. tinal anthrax. Ciprofloxacin is second option.

Bacillus cereus 1–6 hrs Sudden onset of severe 24 hrs Improperly refrigerated Normally a clinical Supportive care. (preformed nausea and vomiting. cooked or fried , diagnosis. Clinical ) Diarrhea may be present. meats. laboratories do not routinely identify this organism. If indicated, send stool and food specimens to reference laboratory for culture and toxin identification.

Bacillus cereus 10–16 hours Abdominal cramps, watery 24–48 Meats, stews, gravies, Testing not necessary, self- Supportive care. (diarrheal toxin) diarrhea, nausea. hours vanilla sauce. limiting (consider testing food and stool for toxin in outbreaks).

Brucella abortus, 7–21 days Fever, chills, sweating, Weeks Raw milk, goat cheese Blood culture and positive Acute: Rifampin and B. melitensis, and weakness, headache, made from unpasteur- serology. doxycycline daily for >6 weeks. B. suis muscle and joint pain, ized milk, contaminated Infections with complications diarrhea, bloody stools meats. require combination therapy during acute phase. with rifampin, tetracycline, and an aminoglycoside.

Campylobacter 2–5 days Diarrhea, cramps, fever, 2–10 days Raw and undercooked Routine stool culture; Supportive care. For severe jejuni and vomiting; diarrhea , unpasturized Campylobacter requires cases, such as may be bloody. milk, contaminated special media and erythromycin and quinolones water. incubation at 42°C to grow. may be indicated early in the diarrheal disease. Guillain- Barré syndrome can be a sequela.

Clostridium 12–72 hrs Vomiting, diarrhea, blurred Variable Home-canned foods Stool, serum, and food can Supportive care. Botulinum botulinum— vision, diplopia, dysphagia, (from days with a low acid content, be tested for toxin. Stool antitoxin is helpful if given children and adults and descending muscle to months). improperly canned and food can also be early in the course of the (preformed toxin) weakness. Can be commercial foods, cultured for the organism. illness. Contact the state compli- home-canned or These tests can be health department. The 24- cated by fermented fish, herb- performed at some state hour number for state health respiratory infused oils, baked health department departments to call is (770) failure and potatoes in aluminium laboratories and CDC. 488-7100. . foil, cheese sauce, bottled , foods held warm for extended periods of time (eg, in a warm oven).

Clostridium 3–30 days In infants <12 months, Variable Honey, home-canned Stool, serum, and food can Supportive care. Botulism botulinum—infants lethargy, weakness, poor vegetables and , be tested for toxin. Stool immune globulin can be feeding, constipation, corn syrup. and food can also be obtained from the Infant hypotonia, poor head cultured for the organism. Botulism Prevention Program, control, poor gag and These tests can be Health and Human Services, sucking reflex. performed at some state California (510-540-2646). health department Botulinum antitoxin is generally laboratories and CDC. not recommended for infants.

Clostridium 8–16 hrs Watery diarrhea, nausea, 24–48 hrs Meats, poultry, gravy, Stools can be tested for Supportive care. Antibiotics not perfringens toxin abdominal cramps; fever is dried or precooked enterotoxin and cultured for indicated. rare. foods, time- and/or organism. Because temperature-abused can food. normally be found in stool, quantitative cultures must be done.

Enterohemorrhagic 1–8 days Severe diarrhea that is 5–10 days Undercooked beef Stool culture; E. coli Supportive care, monitor renal E. coli (EHEC) often bloody, abdominal especially hamburger, O157:H7 requires special function, hemoglobin, and including pain and vomiting. Usually, unpasteurized milk and media to grow. If E. coli platelets closely. E. coli E. coli O157:H7 little or no fever is present. juice, raw fruits and O157:H7 is suspected, O157:H7 infection is also and other Shiga More common in children vegetables (eg. specific testing must be associated with hemolytic toxin-producing <4 years. sprouts), salami (rarely), requested. uremic syndrome (HUS), which E. coli (STEC) and contaminated testing may be done using can cause lifelong complica- water. commercial kits; positive tions. Studies indicate that isolates should be antibiotics may promote the forwarded to public health development of HUS. laboratories for confirmation and serotyping. 8 MMWR April 16, 2004

Foodborne Illnesses (Bacterial) (Continued) Incubation Duration of Etiology Period Signs and Symptoms Illness Associated Foods Laboratory Testing Treatment Enterotoxigenic 1–3 days Watery diarrhea, 3 to >7 Water or food Stool culture. ETEC Supportive care. Antibiotics E. coli (ETEC) abdominal cramps, some days contaminated with requires special laboratory are rarely needed except in vomiting. . techniques for identifica- severe cases. Recommended tion. If suspected, must antibiotics include TMP-SMX request specific testing. and quinolones.

Listeria 9–48 hrs for Fever, muscle aches, and Fresh soft cheeses, Blood or cerebrospinal fluid Supportive care and monocytogenes gastrointestinal nausea or diarrhea. Variable unpasteurized milk, cultures. Asymptomatic antibiotics; Intravenous symptoms, Pregnant women may inadequately pasteur- fecal carriage occurs; ampicillin, penicillin, or TMP- 2–6 weeks have mild flu-like illness, ized milk, ready-to-eat therefore, stool culture SMX are recommended for for invasive and infection can lead to deli meats, hot dogs. usually not helpful. invasive disease. disease premature delivery or Antibody to listerolysin O stillbirth. Elderly or may be helpful to identify immunocompromised outbreak retrospectively. patients may have bacteremia or meningitis.

At birth and Infants infected from infancy mother at risk for sepsis or meningitis.

Salmonella spp. 1–3 days Diarrhea, fever, abdominal Contaminated eggs, Routine stool cultures. Supportive care. Other than for cramps, vomiting. S. Typhi 4–7 days poultry, unpasteurized S. Typhi and S. Paratyphi, and S. Paratyphi produce milk or juice, cheese, antibiotics are not indicated typhoid with insidious contaminated raw fruits unless there is extra-intestinal onset characterized by and vegetables (alfalfa spread, or the risk of extra- fever, headache, sprouts, melons). S. intestinal spread, of the constipation, malaise, Typhi are infection. Consider ampicillin, chills, and myalgia; often related to fecal gentamicin, TMP-SMX, or diarrhea is uncommon, contamination of water quinolones if indicated. A and vomiting is not usually supplies or street- vaccine exists for S. Typhi. severe. vended foods.

Shigella spp. 24–48 hrs Abdominal cramps, fever, Food or water Routine stool cultures. Supportive care. TMP-SMX and diarrhea. Stools may 4–7 days contaminated with recommended in the US if contain blood and mucus. human fecal material. organism is susceptible; Usually person-to- nalidixic acid or other person spread, fecal– quinolones may be indicated if oral transmission. organism is resistant, Ready-to-eat foods especially in developing touched by infected food countries. workers, eg, raw vegetables, salads, sandwiches.

Staphylococcus 1–6 hrs Sudden onset of severe Unrefrigerated or Normally a clinical Supportive care. aureus (preformed nausea and vomiting. 24–48 hrs improperly refrigerated diagnosis. Stool, vomitus, enterotoxin) Abdominal cramps. meats, potato and egg and food can be tested for Diarrhea and fever may be salads, cream pastries. toxin and cultured if present. indicated.

Vibrio cholerae 24–72 hrs Profuse watery diarrhea Contaminated water, Stool culture; Vibrio Supportive care with (toxin) and vomiting, which can 3–7 days. fish, shellfish, street- cholerae requires special aggressive oral and intra- lead to severe dehydration Causes life- vended food typically media to grow. If V. venous rehydration. In cases of and death within hours. threatening from Latin America or cholerae is suspected, must confirmed cholera, tetracycline dehydra- Asia. request specific testing. or doxycycline is recommended tion. for adults, and TMP-SMX for children (<8 years).

Vibrio para- 2–48 hrs Watery diarrhea, Undercooked or raw Stool cultures. Vibrio Supportive care. Antibiotics haemolyticus abdominal cramps, 2–5 days seafood, such as fish, parahaemolyticus requires are recommended in severe nausea, vomiting. shellfish. special media to grow. If V. cases: tetracycline, doxycy- parahaemolyticus is cline, gentamicin, and suspected, must request cefotaxime. specific testing.

Vibrio vulnificus 1–7 days Vomiting, diarrhea, Undercooked or raw Stool, wound, or blood Supportive care and abdominal pain, 2–8 days shellfish, especially cultures. Vibrio vulnificus antibiotics; tetracycline, bacteremia, and wound oysters, other requires special media to doxycycline, and ceftazidime infections. More common contaminated seafood, grow. If V. vulnificus is are recommended. in the immunocompro- and open wounds suspected, must request mised, or in patients with exposed to sea water. specific testing. chronic liver disease (presenting with bullous skin lesions). Can be fatal in patients with liver disease and the immunocompromised. Vol. 53 / RR-4 Recommendations and Reports 9

Foodborne Illnesses (Bacterial) (Continued) Incubation Duration of Etiology Period Signs and Symptoms Illness Associated Foods Laboratory Testing Treatment Yersinia 24–48 hrs Appendicitis-like symptoms Undercooked pork, Stool, vomitus, or blood Supportive care. If septicemia enterocolytica and (diarrhea and vomiting, 1–3 weeks, unpasteurized milk, tofu, culture. Yersinia requires or other invasive disease Y. pseudotuber- fever, and abdominal pain) usually self- contaminated water. special media to grow. If occurs, antibiotic therapy with culosis occur primarily in older limiting Infection has occurred in suspected, must request gentamicin or cefotaxime children and young adults. infants whose specific testing. Serology is (doxycycline and ciprofloxacin May have a scarlitiniform caregivers handled available in research and also effective). rash with Y. pseudotuber- chitterlings. reference laboratories. culosis. Foodborne Illnesses (Viral) Incubation Duration of Etiology Period Signs and Symptoms Illness Associated Foods Laboratory Testing Treatment Hepatitis A 28 days Diarrhea, dark urine, Variable, Shellfish harvested from Increase in ALT, bilirubin. Supportive care. Prevention average jaundice, and flu-like 2 weeks – contaminated waters, Positive IgM and anti- with immunization. (15–50 days) symptoms, i.e., fever, 3 months raw produce, contami- hepatitis A antibodies. headache, nausea, and nated drinking water, abdominal pain. uncooked foods and cooked foods that are not reheated after contact with infected food handler.

Noroviruses (and 12–48 hrs Nausea, vomiting, 12–60 hrs Shellfish, fecally Routine RT-PCR and EM Supportive care such as other caliciviruses) abdominal cramping, contaminated foods, on fresh unpreserved stool rehydration. Good . diarrhea, fever, myalgia, ready-to-eat foods samples. Clinical diagnosis, and some headache. touched by infected food negative bacterial cultures. Diarrhea is more prevalent workers (salads, Stool is negative for WBCs. in adults and vomiting is sandwiches, ice, more prevalent in children. cookies, ).

Rotavirus 1–3 days Vomiting, watery diarrhea, 4–8 days Fecally contaminated Identification of virus in Supportive care. Severe low-grade fever. foods. Ready-to-eat stool via immunoassay. diarrhea may require fluid and Temporary lactose foods touched by electrolyte replacement. intolerance may occur. infected food workers Infants and children, (salads, fruits). elderly, and immunocompromised are especially vulnerable.

Other viral agents 10–70 hrs Nausea, vomiting, 2–9 days Fecally contaminated Identification of the virus in Supportive care, usually mild, (astroviruses, diarrhea, malaise, foods. Ready-to-eat early acute stool samples. self-limiting. Good hygiene. adenoviruses, abdominal pain, headache, foods touched by Serology. Commercial parvoviruses) fever. infected food workers. ELISA kits are now Some shellfish. available for adenoviruses and astroviruses. Foodborne Illnesses (Parasitic) Incubation Duration of Etiology Period Signs and Symptoms Illness Associated Foods Laboratory Testing Treatment Angiostrongylus 1 week to >1 Severe headaches, Several Raw or undercooked Examination of CSF for Supportive care. Repeat cantonensis month nausea, vomiting, neck weeks to intermediate hosts (eg, elevated pressure, protein, lumbar punctures and use of stiffness, paresthesias, several snails or slugs), infected leukocytes, and eosino- corticosteroid therapy may be hyperesthesias, seizures, months paratenic (transport) phils; serologic testing used for more severely ill and other neurologic hosts (eg, crabs, fresh using ELISA to detect patients. abnormalities. water shrimp), fresh antibodies to produce contaminated Angiostrongylus with intermediate or cantonensis. transport hosts.

Cryptosporidium 2–10 days Diarrhea (usually watery), May be Any uncooked food or Request specific Supportive care, self-limited. If cramps, upset remitting and food contaminated by examination of the stool for severe consider paromomycin stomach, slight fever. relapsing an ill food handler after Cryptosporidium. May need for 7 days. For children aged over weeks , drinking water. to examine water or food. 1–11 years, consider to months nitazoxanide for 3 days.

Cyclospora 1–14 days, Diarrhea (usually watery), May be Various types of fresh Request specific TMP-SMX for 7 days. cayetanensis usually at least loss of appetite, remitting and produce (imported examination of the stool for 1 week substantial loss of weight, relapsing berries, ). Cyclospora. May need to stomach cramps, nausea, over weeks examine water or food. vomiting, fatigue. to months 10 MMWR April 16, 2004

Foodborne Illnesses (Parasitic) (Continued) Incubation Duration of Etiology Period Signs and Symptoms Illness Associated Foods Laboratory Testing Treatment Entamoeba 2–3 days to Diarrhea (often bloody), May be Any uncooked food or Examination of stool for Metronidazole and a luminal histolytica 1–4 weeks frequent bowel move- protracted food contaminated by cysts and parasites—may agent (iodoquinol or ments, lower abdominal (several an ill food handler after need at least 3 samples. paromomycin). pain. weeks to cooking, drinking water. Serology for long-term several infections. months)

Giardia lamblia 1–2 weeks Diarrhea, stomach cramps, Days to Any uncooked food or Examination of stool for ova Metronidazole. gas. weeks food contaminated by and parasites — may need an ill food handler after at least 3 samples. cooking, drinking water.

Toxoplasma gondii 5–23 days Generally asymptomatic, Months Accidental ingestion Isolation of parasites from Asymptomatic healthy, but 20% may develop cervical of contaminated substances blood or other body fluids; infected, persons do not lymphadenopathy and/or a (eg, soil contaminated observation of parasites in require treatment. Spiramycin flu-like illness. In with cat feces on fruits patient specimens via or pyrimethamine plus immunocompromised and vegetables), raw or microscopy or histology. sulfadiazine may be used patients: central nervous partly cooked meat Detection of organisms is for pregnant women. system (CNS) disease, (especially pork, lamb, rare; serology (reference Pyrimethamine plus myocarditis, or pneumoni- or venison). laboratory needed) can be sulfadiazine may be used tis is often seen. a useful adjunct in for immunocompromised diagnosing toxoplasmosis. persons, in specific cases. However, IgM antibodies Pyrimethamine plus may persist for 6–18 sulfadiazine (with or without months and thus may not steroids) may be given for necessarily indicate recent ocular disease when indicated. infection. PCR of bodily Folinic acid is given with fluids. For congenital pyrimethamine plus sulfadiaz- infection: isolation of ine to counteract bone marrow T. gondii from placenta, suppression. umbilical cord, or infant blood. PCR of white blood cells, CSF, or amniotic fluid, or IgM and IgA serology, performed by a reference laboratory. Passed from mother Toxoplasma gondii In infants at Treatment of the mother Months (who acquired acute (congenital birth may reduce severity and/ infection during infection) or incidence of congenital pregnancy) to child. infection. Most infected infants have few symptoms at birth. Later, they will generally develop signs of congenital toxoplasmosis (mental retardation, severely impaired eyesight, cerebral palsy, seizures), unless the infection is treated. Raw or undercooked Trichinella spiralis 1–2 days for Acute: nausea, diarrhea, Months contaminated meat, Positive serology or initial vomiting, fatigue, fever, usually pork or wild demonstration of larvae via Supportive care plus symptoms; abdominal discomfort game meat (eg, bear or muscle biopsy. Increase in mebendazole or albendazole. others begin followed by muscle moose). eosinophils. 2–8 weeks soreness, weakness, and after infection occasional cardiac and neurologic complications. Vol. 53 / RR-4 Recommendations and Reports 11

Foodborne Illnesses (Noninfectious) Incubation Duration of Etiology Period Signs and Symptoms Illness Associated Foods Laboratory Testing Treatment Antimony 5 min – 8 hrs. Vomiting, metallic taste. Usually Metallic container. Identification of metal in Supportive care. usually <1 hr self-limited beverage or food.

Arsenic Few hrs Vomiting, colic, diarrhea. Several Contaminated food. Urine. May cause Gastric lavage, BAL days eosinophilia. (dimercaprol).

Cadmium 5 min – 8 hrs. Nausea, vomiting, myalgia, Usually Seafood, oysters, Identification of metal in Supportive care. usually <1 hr increase in salivation, self-limited clams, lobster, grains, food. stomach pain. peanuts.

Ciguatera fish 2–6 hrs GI: abdominal pain, Days to A variety of large reef Radioassay for toxin in fish Supportive care, IV mannitol. poisoning nausea, vomiting, weeks to fish. Grouper, red or a consistent history. Children more vulnerable. (ciguatera toxin) diarrhea. months snapper, amberjack, and barracuda (most 3 hrs Neurologic: paresthesias, common). reversal of hot or cold, pain, weakness.

2–5 days Cardiovascular: bradycardia, hypotension, increase in T wave abnormalities.

Copper 5 min – 8 hrs. Nausea, vomiting, blue or Usually Metallic container. Identification of metal in Supportive care. usually <1 hr green vomitus. self-limited beverage or food.

Mercury 1 week or Numbness, weakness of May be Fish exposed to organic Analysis of blood, hair. Supportive care. longer legs, spastic paralysis, protracted , grains treated impaired vision, blindness, with mercury fungicides. coma. Pregnant women and the developing fetus are especially vulnerable.

Mushroom toxins, <2 hrs Vomiting, diarrhea, Self-limited Wild mushrooms Typical syndrome and Supportive care. short-acting confusion, visual (cooking may not mushroom identified or (museinol, disturbance, salivation, destroy these toxins). demonstration of the toxin. muscarine, diaphoresis, hallucinations, psilocybin, coprius disulfiram-like reaction, artemetaris, confusion, visual ) disturbance.

Mushroom toxin, 4–8 hrs Diarrhea, abdominal Often fatal Mushrooms. Typical syndrome and Supportive care, life- long-acting diarrhea; cramps, leading to hepatic mushroom identified and/or threatening, may need life (amanitin) 24–48 hrs liver and renal failure. demonstration of the toxin. support. failure

Nitrite poisoning 1–2 hrs Nausea, vomiting, Usually Cured meats, any Analysis of the food, blood. Supportive care, methylene cyanosis, headache, self-limited contaminated foods, blue. dizziness, weakness, loss spinach exposed to of consciousness, excessive nitrification. chocolate-brown colored blood.

Pesticides Few min to few Nausea, vomiting, Usually Any contaminated food. Analysis of the food, blood. Atropine; 2-PAM (Pralidoxime) (organophosphates hrs abdominal cramps, self-limited is used when atropine is not or carbamates) diarrhea, headache, able to control symptoms and nervousness, blurred is rarely necessary in vision, twitching, carbamate poisoning. convulsions, salivation and meiosis.

Puffer fish <30 min Parasthesias, vomiting, Death Puffer fish. Detection of tetrodotoxin in Life-threatening, may need (tetrodotoxin) diarrhea, abdominal pain, usually in fish. respiratory support. ascending paralysis, 4–6 hours respiratory failure.

Scombroid 1 min – 3 hrs Flushing, rash, burning 3–6 hrs Fish: bluefin, tuna, Demonstration of histamine Supportive care, antihista- (histamine) sensation of skin, mouth skipjack, mackerel, in food or clinical diagnosis. mines. and throat, dizziness, marlin, escolar, and uriticaria, parasthesias. mahi mahi. 12 MMWR April 16, 2004

Foodborne Illnesses (Noninfectious) (Continued) Incubation Duration of Etiology Period Signs and Symptoms Illness Associated Foods Laboratory Testing Treatment Shellfish toxins Diarrheic Nausea, vomiting, Hrs to 2–3 A variety of shellfish, Detection of the toxin in Supportive care, generally self- (diarrheic, shellfish diarrhea, and abdominal days primarily mussels, shellfish; high-pressure limiting. Elderly are especially neurotoxic, poisoning pain accompanied by oysters, scallops, and liquid chromatography. sensitive to ASP. amnesic) (DSP) — 30 chills, headache, and shellfish from the Florida min to 2 hrs fever. coast and the Gulf of Mexico. Neurotoxic Tingling and numbness of shellfish lips, tongue, and throat, poisoning muscular aches, dizziness, (NSP) — few reversal of the sensations min to hours of hot and cold, diarrhea, and vomiting.

Amnesic Vomiting, diarrhea, shellfish abdominal pain and poisoning neurologic problems such (ASP) — as confusion, memory 24–48 hrs loss, disorientation, seizure, coma.

Shellfish toxins 30 min – 3 hrs Diarrhea, nausea, vomiting Days Scallops, mussels, Detection of toxin in food or Life-threatening, may need (paralytic shellfish leading to parasthesias of clams, cockles. water where fish are respiratory support. poisoning) mouth, lips, weakness, located; high-pressure dysphasia, dysphonia, liquid chromatography. respiratory paralysis.

Sodium fluoride Few min to Salty or soapy taste, Usually Dry foods (eg, dry milk, Testing of vomitus or Supportive care. 2 hrs numbness of mouth, self-limited flour, baking powder, gastric washings. Analysis vomiting, diarrhea, dilated cake mixes) contami- of the food. pupils, spasms, pallor, nated with sodium shock, collapse. fluoride–containing insecticides and rodenticides.

Thallium Few hrs Nausea, vomiting, Several Contaminated food. Urine, hair. Supportive care. diarrhea, painful days parathesias, motor polyneuropathy, hair loss.

Tin 5 min – 8 hrs. Nausea, vomiting, Usually Metallic container. Analysis of the food. Supportive care. usually <1 hr diarrhea. self-limited

Vomitoxin Few min to Nausea, headache, Usually Grains such as , Analysis of the food. Supportive care. 3 hrs abdominal pain, vomiting. self-limited corn, .

Zinc Few hrs Stomach cramps, nausea, Usually Metallic container. Analysis of the food, blood Supportive care. vomiting, diarrhea, self-limited and feces, saliva or urine. myalgias. Vol. 53 / RR-4 Recommendations and Reports 13

Patient Scenarios The CT scan of the child’s head showed periventricular cal- cifications and asymmetric dilation of the lateral ventricles. The learning scenarios in this section can be used to rein- The mother is 35 years old and reiterated that she does not force medical management information pertaining to recall being ill during the pregnancy; however, she also indi- foodborne illnesses, such as that provided from the previous cated that she would not necessarily remember every little sections of this primer. The case studies provide questions that symptom. She also denied having a history of STDs. She had need to be considered when dealing with a potential case of received the mumps-measles-rubella (MMR) vaccine as a child foodborne illness. Answers are provided immediately follow- but no vaccines during pregnancy. The mother recalled eating ing the questions to enhance the learning process. insufficiently cooked meat while traveling in during Similar learning scenarios are also available for other the first trimester of pregnancy. The family does not own a foodborne pathogens. cat, and she does not recall having been exposed to cats dur- ing her pregnancy. Congenital Toxoplasmosis, A Patient Scenario What diagnostic tests are needed? Susan, a 6-month-old infant, is brought to your office for Serologic evaluation of both mother and child focusing evaluation of apparent blindness. Her mother reports that she on potential congenital infection (ie, a ToRCH profile) had been well during the pregnancy and the delivery was based on the history of the mother ingesting raw meat uncomplicated. The baby appeared healthy until age 4 months, while traveling in a foreign country during first trimester when the parents became concerned about her vision. of pregnancy and the clinical findings (blindness, cere- Physical examination was normal except for bilateral macu- bral calcifications, and hydrocephalus). lar scars, microphthalmos, and unresponsiveness to visual stimuli. There were no other neurologic abnormalities, and Results of serologic testing detected both IgG and IgM her growth and development were appropriate for her age. A antibodies to Toxoplasma gondii in both the baby’s and computed tomography (CT) scan of the head was obtained. mother’s serum. The mother’s IgM titer was 1:6400 and IgG titer was 1:6400, while those of the baby were IgM Congenital infection with which of the titer of 1:160 and IgG titer of 1:6400. following should be included in the differential diagnosis? How does this information assist with the • Viruses: diagnosis? — Cytomegalovirus Diagnosis of toxoplasmosis is usually confirmed by — Rubella serologic tests. Occasionally, organisms are identified in — Herpes simplex tissue or body fluids or isolated by culture or animal —Human immunodeficiency virus inoculation. Polymerase chain reaction (PCR)-based • Bacteria: assays are available from some laboratories for diagnosis — Treponema pallidum of fetal infection and infection in compromised hosts. — Listeria monocytogenes For immunocompetent persons, seroconversion or a • Parasites: 4-fold rise of specific IgG antibodies or demonstration of — Toxoplasma gondii specific IgM antibodies indicate recent infection. High titers of IgG antibodies in the absence of IgM antibodies are consistent with chronic latent infection acquired in What additional information would assist the past. The IgM-capture enzyme-linked immunosorbent with the diagnosis? assay (ELISA) is more sensitive than the IgM-indirect fluo- • More history from the mother, including travel to for- rescent-antibody assay (IFA) test. However, IgM tests may eign country be false-positive, and true-positive IgM tests may persist • record, including during pregnancy for a year or more. Therefore, to determine if infection • History of exposure to cats and raw meat occurred during pregnancy, additional tests, such as an • History of multiple sex partners and sexually transmit- anti-Toxoplasma avidity test, may be required at a refer- ted disease (STD) ence laboratory. • History of herpes • Evaluation of CT scan 14 MMWR April 16, 2004

Immunodeficient persons usually do not have measur- Human infection with the intracellular protozoan parasite able IgM antibodies, even in the presence of active dis- Toxoplasma gondii occurs globally. Infection is usually sub- ease. The diagnosis of central nervous system (CNS) clinical or produces a mild illness, except in immunodeficient toxoplasmosis in such persons is therefore based on clini- persons and fetuses infected in utero. Most infants with con- cal picture, typical CT scan or magnetic resonance imag- genital toxoplasmosis appear healthy at birth but have a high ing (MRI) showing multiple ring-enhancing hypodense incidence of developing serious ophthalmologic and neuro- nodules, and a positive IgG test. Brain biopsy is reserved logic sequelae during the next 20 years of life. Severe congeni- for cases that fail to respond to an empiric trial of anti- tal toxoplasmosis may be apparent at birth or become apparent Toxoplasma drugs. during the first 6 months of life. Chorioretinitis, intracerebral calcifications, and hydrocephalus, as in the present case, are The baby was diagnosed with congenital toxoplasmosis. typical features The child was treated with pyrimethamine, sulfadiazine, and How is toxoplasmosis best treated? folinic acid for 6 months. She remains blind, and has devel- oped moderate psychomotor retardation. Toxoplasmosis in immunocompetent persons rarely requires treatment, whereas infection in immunodeficient How could Toxoplasma infection have persons or in infants with congenital infections usually been prevented in this child? requires treatment. The combination of pyrimethamine and sulfadiazine is the treatment of choice. Folinic acid Toxoplasma gondii may be transmitted transplacentally (leucovorin) is given to prevent bone marrow suppres- to the fetus if the mother acquired toxoplasmosis during sion. Treatment must be continued for the duration of pregnancy. There is almost no risk of transplacental trans- immunosuppression and for life in AIDS patients whose mission if the mother was infected prior to conception; immunity is not reconstituted by highly aggressive accordingly, women with positive IgG antibody tests for antiretroviral therapy (HAART). toxoplasmosis at the onset of pregnancy are not at risk for For persons unable to tolerate the pyrimethamine and developing acute toxoplasmosis. Women with negative sulfadiazine combination, high doses of pyrimethamine IgG antibody tests during pregnancy should avoid eating (and leucovorin) and clindamycin are effective. insufficiently cooked or uncooked meat and should avoid The management of toxoplasmosis acquired during preg- ingestion of soil and water or food that may be contami- nancy is controversial. Testing of newly pregnant women nated with cat feces. for T. gondii infection is not routinely done, and routine Transmission occurs by a) ingestion of tissue cysts in testing is not recommended by CDC or by the American raw or insufficiently cooked meat, especially lamb, pork, College of Obstetricians and Gynecologists. To prevent and wild game; b) accidental ingestion of food, water, or fetal infection, one approach is to administer spiramycin (a soil contaminated with cat feces that contain infective macrolide antibiotic, which is concentrated in the placenta oocysts; c) transplacental passage of infective tachyzoites; and is not harmful to the fetus). At the same time, amni- d) transfusion of infected white blood cells or transplan- otic fluid is submitted for PCR-based testing to determine tation of an infected organ; and e) laboratory accidents. whether fetal infection has occurred. If so, options may Prevention of toxoplasmosis is particularly important include pyrimethamine and sulfadiazine given after the 16th for uninfected (ie, seronegative) pregnant mothers, HIV- week of pregnancy (since pyrimethamine is potentially ter- infected persons, and other immunocompromised atogenic) or consideration of terminating the pregnancy. If patients: the fetus is shown to be uninfected, spiramycin is contin- • Avoid ingestion of raw or insufficiently cooked meat ued throughout pregnancy. and poultry; cook meat to 160°F (71°C) or freeze to -4°F Different protocols exist for treatment of infants born (-20°C). For more details on preventing toxoplasmo- with congenital infection. The most commonly recom- sis, please see the Suggested Resources and Suggested mended treatment is pyrimethamine and sulfadiazine plus Reading List. leucovorin during the first year of life. In the present case, • Avoid ingestion of environmental oocysts by avoiding the child was treated for 6 months with pyrimethamine contact with cat litter, soil, water, and vegetables and sulfadiazine plus leucovorin. potentially contaminated with cat feces. Vol. 53 / RR-4 Recommendations and Reports 15

Infection acquired by healthy persons is usually asymptom- What should be included in the differential atic or may lead to painless lymphadenopathy or a mononucleo- diagnosis of acute hepatitis? sis syndrome. Maternal infection is usually unrecognized. Disease in persons with depressed cellular immunity (eg, • Viral infections: persons with AIDS, transplant recipients, persons receiving — hepatitis A, B, C, D, and E immunosuppressants) usually is due to reactivation of latent — varicella infection but can result from acute infection. Toxoplasmosis — cytomegalovirus in these persons leads to lethal meningoencephalitis, focal — herpes virus lesions of the CNS, and less commonly, myocarditis or pneu- — Epstein-Barr virus monitis. The clinical picture may include headache, seizures, • Bacterial infections: mental status changes, focal neurologic signs, and aseptic — typhoid fever meningitis. Thirty to forty percent of AIDS patients with IgG — antibodies to T. gondii (indicating chronic latent infection) — Rocky Mountain spotted fever develop active toxoplasmosis unless they take preventive medi- — leptospirosis cation. — secondary syphilis Congenital infection occurs when a previously uninfected — sepsis mother develops infection during pregnancy. Infection prior • Parasitic infections: to conception, demonstrated by specific IgG antibodies, in — toxocariasis nearly all cases guarantees against infection of the fetus. How- — liver flukes ever, transplacental transmission occurs from mothers whose • Drugs: prior infections reactivate when they receive immunosuppres- — acetaminophen sant medications or develop AIDS. Congenital toxoplasmosis — isoniazid may result in abortion, stillbirth, mental retardation, and reti- — rifampin nal damage. Recurrent toxoplasmic chorioretinitis in children — oral contraceptives and young adults is frequently the result of congenital infec- — anti-seizure medications tion that was asymptomatic at birth. — sulfonamides • Toxins: Acute Hepatitis A: A Patient Scenario — , carbon tetrachloride • Autoimmune disease: While working in an emergency room, you are asked to see — autoimmune hepatitis a 31-year-old Asian-American woman who has had fever, — systemic lupus erythematosus nausea, and fatigue for the past 24 hours. She also reports dark urine and has had 3 light colored stools since yesterday. She has previously been healthy and has no previous history What additional information would assist of jaundice. Her physical examination shows a low-grade with the diagnosis? fever of 100.6°F/38.1°C, faint scleral icterus, and hepatome- galy. Her blood pressure and neurologic exam are normal and • Has she traveled outside the United States recently? there is no rash. Initial laboratory studies show an alanine ami- • Does she use illicit drugs? notransferase (ALT) result of 877 IU/L, aspartate amino trans- • Is anyone else in the household ill? ferase (AST) enzyme levels of 650 IU/L, an alkaline phosphatase • How many sex partners has she had in the past 6 months? of 58 IU/L and a total bilirubin of 3.4 mg/dL. White blood • Does she have regular contact with animals? count is 4.6, with a normal differential; electrolytes are normal; • What medications is she taking? the blood urea nitrogen level is 18 mg/dL; and serum creati- • Has she ever had a transfusion? nine level is 0.6 mg/dL. Pregnancy test is negative. • Does she drink alcohol? • Does she take care of children? • Has she ever received hepatitis B vaccination? • Has she ever received hepatitis A vaccination? • Did she receive immune globulin within the past 3 months? • What is her occupation? 16 MMWR April 16, 2004

She has no children, and her boyfriend is not ill. She has You obtain the following results from the serologic testing: been in a monogamous relationship with her boyfriend for 2 • Total anti-HAV: positive years. She was born in the United States; her parents immi- • IgM anti-HAV: positive grated to the United States from Taiwan in the 1950s. She • Total anti-HBc: positive works as a food preparer for a catering business. She returned • IgM anti-hepatitis B core antigen: negative 4 weeks ago from a 1-week vacation in Mexico (Mexico City • HBsAg: negative and nearby areas), where she stayed with her boyfriend in sev- • anti-HBs: positive eral hotels. She drank only bottled water but ate both cooked • anti-HCV: negative and uncooked food at numerous while in Mexico, and she visited a family friend and her 3 young children in a What is the diagnosis? Mexico City suburb. The diagnosis is hepatitis A. The hepatitis B serologic She did not receive hepatitis A vaccine or immune globulin tests indicate past, resolved infection with no chronic before going on vacation. She is not sure if she has received infection. Acute hepatitis C is also possible; the appear- hepatitis B vaccine. She has not gone camping or hiking and ance of anti-HCV may be delayed for as long as 9 months had no recent tick exposures. She has never used illicit drugs, after exposure. However, with a confirmed diagnosis of drinks alcohol rarely, and has never received a transfusion. hepatitis A, further testing for HCV RNA is not indi- She is taking oral contraceptives but no other prescription ® cated at this point. Finally, note that is rarely medication, and took 500 milligrams of Tylenol once after reported in travelers, and results of serologic tests for hepa- onset of her current symptoms. She has a pet cat but no other titis E virus (HEV) are difficult to interpret. Tests for HEV animal exposures. She had chickenpox and mononucleosis should only be performed if other more common causes during childhood. of hepatitis have been excluded.

How does this information assist with the The incubation period for hepatitis A is 15–50 days, with diagnosis? an average of 28 days. The most common signs and symp- Lack of animal or tick exposures makes leptospirosis toms associated with acute hepatitis A include jaundice, fever, and Rocky Mountain spotted fever unlikely, and Q fever malaise, anorexia, and abdominal discomfort. The illness can less likely. Yellow fever and typhoid fever are very unlikely be severe and approximately 10% to 20% of reported cases with no history of travel to rural areas, and require hospitalization. The likelihood of having symptoms assuming exposure occurred in Mexico, inconsistent with with HAV infection is related to the person’s age. In children the long incubation period. Hepatitis A virus (HAV), <6 years of age, most (70%) infection is asymptomatic; if ill- hepatitis B virus (HBV), hepatitis C virus (HCV), and ness does occur it is not usually accompanied by jaundice. hepatitis E virus (HEV) infection are all possible diag- Older children and adults are more likely to have symptom- noses. A drug reaction to the oral contraceptive is a pos- atic disease, although jaundice may be absent in as many as sible cause of hepatitis. The history of travel to an endemic one third of adults with HAV infection. In many developing area makes hepatitis A the most likely diagnosis. countries in Asia, Africa, and Central and South America, infection is nearly universal during early childhood and is often asymptomatic. What diagnostic tests are needed? Specific diagnostic serologic studies are necessary to What treatment is indicated? distinguish one form of from another. There is no specific treatment for hepatitis A. Bed rest Testing for total (IgG+ IgM) anti-HAV does not distin- does not hasten recovery. Hepatitis A is never a chronic guish between a past history of hepatitis A virus infec- infection, although 10% to 15% of symptomatic persons tion and current infection and is not useful in diagnosing have prolonged or relapsing disease lasting up to 6 months. acute hepatitis A. Hepatitis A can be easily confirmed While rarely fatal in younger persons, the case-fatality rate with an anti-IgM anti-HAV test. This test is widely avail- is nearly 2% among reported patients who are more than able and results are usually available within 24 hours. A 50 years old. Following is a depiction of a typical course, hepatitis panel is ordered, and results from such a panel including times of peak fecal excretion of HAV, liver func- are shown here. tion test abnormalities, and clinical symptoms. Vol. 53 / RR-4 Recommendations and Reports 17

® Clinical illness & Co.), and Twinrix (combined hepatitis A and hepati- tis B vaccine, Glaxo SmithKline). Vaccination is admin- ® ALT istered in a 2-dose schedule (0, 6 months) for Havrix Infection ® IgG and VAQTA , and a 3-dose schedule (0, 1, 6 months) ® IgM for Twinrix . The second (or third) dose is provided to

Viremia ensure protection in those who did not respond to the

Response first dose of vaccine. Ninety-nine percent of vaccinees will

HAV in stool be protected after 2 doses of vaccine. For persons who present for hepatitis A immuno- prophylaxis <30 days before departure to an endemic

012345678910111213 region and for children <2 years old, immune globulin Week (IG) is an effective means of preventing hepatitis A. IG is the appropriate immunoprophylaxis for children <2 years old. IG is a sterile preparation of concentrated antibodies (immunoglobulins) made from pooled human plasma. How is hepatitis A virus transmitted, and IG provides protection against hepatitis A for 3–5 months, who is at risk for this disease? depending on dosage, through passive transfer of anti- HAV is an RNA virus that only infects primates. HAV body. Vaccine and IG may be given simultaneously. has a fecal-oral route of transmission and is easily trans- mitted person to person. HAV is also transmitted through Hepatitis A is the most common vaccine-preventable dis- contaminated food or water. Because HAV is present in ease among travelers. The risk varies according to region vis- the blood during acute infection, bloodborne transmis- ited and the length of stay, and is increased even among sion is also possible, but rare. The highest levels of HAV travelers who report observing measures to protect themselves are found in the stool, and peak levels occur in the 2 weeks against enteric infection or stay only in urban areas. In the before onset of illness. United States, children account for approximately one third Groups at increased risk for hepatitis A include travel- of reported travel-related cases. ers to developing countries, men who have sex with men, and injecting and noninjecting drug users. In the United What else needs to be done? States, 4% to 6% of reported cases occur among interna- tional travelers, many of whom presumably acquired HAV Cases of hepatitis A should be reported to the local infection from contaminated food or water. Approximately health department immediately. The patient’s boyfriend 50% of persons with hepatitis A do not report any known and any other household or sexual contacts whose last risk factors, and some of these infections may be from exposure to the patient was <14 days ago should be given unrecognized transmission via HAV-contaminated food. IG. Screening for immunity before administering IG is not recommended in this situation because it is more costly than IG and would delay its administration. IG is not indicated for family members or friends not living in the How might this illness have been household. prevented? Persons planning to travel to an endemic region should Prompt reporting of hepatitis A cases allows time to decide receive hepatitis A vaccine or immune globulin before on a course of action and provide timely immunoprophylaxis departure. Hepatitis A vaccination can be given to any- when appropriate. Because this patient works as a food one 2 years of age and older, and has the advantage of preparer, the health department will need to visit the estab- providing long-term protection (at least 20 years). Hepa- lishment to assess the likelihood that her duties and hygiene titis A vaccine is an inactivated HAV preparation; the first practices pose a significant risk of food contamination. IG is dose of vaccine provides protective anti-HAV levels within often recommended for co-workers of commercial food han- 30 days for >90% of vaccine recipients. Licensed hepati- dlers with hepatitis A. In addition, if she worked at any time tis A vaccines available in the United States are consid- during the 2 weeks before onset of jaundice to 1 week after ® ered to be equivalent in effectiveness, and include Havrix onset, persons who ate food prepared or handled by this ® (manufactured by Glaxo SmithKline), VAQTA (Merck patient may be candidates for IG prophylaxis. Determina- 18 MMWR April 16, 2004 tions of the need for IG prophylaxis are made on a case-by- has no history of a sexually transmitted disease and that she case basis by experienced health department personnel. Again, and her boyfriend have a monogamous sexual relationship. immediate reporting of hepatitis A cases allows time to decide on a course of action and provide timely treatment and inter- How does this information assist with the vention when appropriate. diagnosis? Based on the rapid onset of symptoms, Nancy’s reported Norovirus Infection: A Patient Scenario past history of good health, and the fact that her boy- Nancy is a 25-year-old previously well graduate student who friend has an almost identical history, inflammatory bowel presents to the emergency department with a 12-hour history disease, appendicitis, and pelvic inflammatory disease are of nausea, diarrhea, abdominal cramping, and vomiting (about the least likely diagnoses. 6 episodes), malaise, and a low-grade fever. She describes her Food intoxication is also not very likely. Assuming that onset of symptoms as sudden. the wedding reception was the source of the toxin, and Physical examination shows that Nancy is afebrile with a this was their most recent common meal, the time from supine blood pressure of 123/74 mm Hg. She has a diffusely exposure to onset of symptoms is too long. Toxins usually tender abdomen and is dehydrated. Stool examination is nega- cause illness within minutes to hours after ingestion. tive for occult blood. The most likely diagnosis is infectious gastroenteritis. There is a possibility that Nancy’s and her boyfriend’s ill- What is the possible differential diagnosis ness may be associated with an outbreak of gastroenteritis. for her chief complaint? • Infectious gastroenteritis What additional information would assist • Food intoxication (noninfectious gastroenteritis) with the identification of the etiologic • Inflammatory bowel disease agent? • Appendicitis • Pelvic inflammatory disease • What sorts of foods were served at the wedding recep- tion? • When did the couple last share a meal prior to the wed- What additional information would assist ding reception? with the diagnosis? • Has an outbreak of gastroenteritis associated with this reception has been reported to the local health depart- • Did anyone in her household experience similar illness ment?. The health department may be able to aid in within the week prior to onset of symptoms? determining what the etiologic agent was if it is cur- • Has she been in contact with anyone outside her house- rently investigating the outbreak. hold with similar symptoms within the previous week? • Has she had such symptoms before? At the wedding, the couple had a choice of meal. Nancy • Does she know if anyone else became ill? had lobster tail and filet mignon. Her boyfriend had chicken. • Has she traveled outside the United States within the They both consumed stuffed mushrooms, salad, and hors last month? d’oeuvres preceding the main meal. For dessert they both had • Has she previously had a sexually transmitted diseases wedding cake and fresh fruit. Both drank wine or beer during or does she have multiple sex partners? the reception. The couple attended a barbecue the previous week. This Nancy reports that she rarely has diarrhea or vomiting. She outing was a function sponsored by Nancy’s employer. Nancy also reports no contact with anyone who was ill in the past tells you that none of her co-workers have been ill with vom- week, nor has she been out of the country in the past month. iting and diarrhea. Her boyfriend, who does not live with her, has similar symp- You place an inquiry with the local health department about toms with an almost identical onset time. Both attended a the possible outbreak. The health department notifies you that wedding 2 days ago. The meal at the wedding reception, which an investigation is currently under way. Illness has also been was held at a local reception hall, was the only meal they shared reported among 75% of attendees at a wedding the day in the past several days. Nancy does not know if anyone else before the one Nancy attended, at the same reception hall. who attended the wedding became ill. Nancy reports that she The only common food between the 2 weddings is the salad, Vol. 53 / RR-4 Recommendations and Reports 19 and the health department currently suspects a food handler who worked during both weddings who was experiencing How could this norovirus infection have been prevented? diarrhea. Most patients have reported nausea, vomiting (about 90%), and diarrhea (70%), with some fever, malaise, head- The food handler with diarrhea should not have ache, chills, and abdominal pain. The mean incubation returned to work for at least 24–48 hours after symptoms period for those who have reported illness is 28.6 hours, with subsided. a mean duration of 31.8 hours. The health department suspects viral gastroenteritis caused Proper hand washing procedures can prevent the spread of by a norovirus. A norovirus is suspected because of the rapid the virus between persons. Hands should be washed under onset of symptoms, the short 36-hour incubation period and warm water with soap for approximately 15 seconds to pre- relatively short duration of illness, the absence of bloody diar- vent fecal-oral transmission. rhea, and the high percentage of vomiting. Bacterial cultures are negative for enteric pathogens on stool samples collected Antibiotic-Resistant Salmonellosis: thus far. A Patient Scenario Andrea brings her 3-year-old son, Marcus, to your office What are the complications of norovirus with a 2-day history of low-grade fever, nausea, and 6–8 infection? watery stools per day. Marcus has also been complaining of Noroviruses are common causes of self-limiting acute abdominal pain and feeling tired. He has been eating and gastroenteritis, with illness frequently lasting no longer drinking less than usual. His medical history is remarkable than 60 hours. They commonly cause outbreaks in such for recurrent otitis media, for which he was prescribed oral settings as restaurants, catered events, cruise ships, schools, antibiotics 10 days prior to this visit. and nursing homes. The viruses can be spread person to Physical examination reveals a well-developed boy who person through the fecal-oral route, through contaminated appears fatigued. Vital signs are remarkable for low-grade food or water, or by raw or undercooked shellfish. fever (99.5°F/37.5°C). He does not have signs of dehydra- tion. His otitis appears resolved and he has a normal cardiop- ulmonary exam. The abdominal exam reveals hyperactive How should norovirus infections be bowel sounds, mild diffuse tenderness, and stool negative for managed? occult blood. There is no antiviral agent that can be used to treat norovirus infections. Supportive care such as oral or What is the differential diagnosis intravenous fluids for rehydration should be provided. for Marcus’ chief complaint? To reduce the spread of illness, patients should be edu- • Infectious gastroenteritis cated to use good hand washing practices, particularly • Appendicitis after using the bathroom and before preparing and han- • Celiac disease dling food. • Inflammatory bowel disease • Antibiotic-associated colitis The health department requests that a stool sample be col- lected. The sample should be collected in a sterile container without transport media, and kept at 4°C (40°F) until shipped. What additional information would assist The sample should be shipped on ice packs to the local health with the diagnosis? department laboratory for testing. The health department also • Has he had similar symptoms before? asks you to encourage Nancy’s boyfriend to submit a stool sample. • Does he attend child care? If yes, have other children attending the same care facility been ill with similar symptoms? • Has the child recently consumed a meal outside his home; eg, at a birthday party or restaurant? • Do other members of the household or close acquain- tances have diarrhea or bloody diarrhea? 20 MMWR April 16, 2004

• Has he traveled in the month prior to the onset of ill- • Have there been other cases of diarrhea recognized in ness? If yes, where? the cruise ship travelers, in their community, or at • Has he had contact with pet reptiles or farm animals or Marcus’ school? visited petting zoos in the week prior to his symptom onset? An open-ended food history reveals multiple common meals eaten by Andrea and Marcus. Andrea denies the consump- Marcus has not had similar episodes of diarrhea in the past. tion of unpasteurized milk, raw shellfish, and undercooked He attends preschool and is cared for by his grandmother meats. She does report that, unlike the rest of the family, she after school in her home. He last visited a petting farm 3 and Marcus used to wake up early enough to enjoy the break- months prior to this illness. Their family returned the previ- fasts served on board the cruise. Breakfast served on the cruise ous day from a 5-day Caribbean cruise. Marcus was diagnosed consisted of a choice of French toast or pancakes with fruit with otitis media 4 days prior to their departure and was pre- compote, scrambled eggs or omelets made to order, potatoes, scribed a 1-week course of oral antibiotics. Andrea has had and fresh fruit along with a choice of beverages, including nausea and 3–4 loose stools per day for the previous 2 days. milk, coffee, and tea. Andrea complained that the eggs were She has not had any fever, abdominal pain, or vomiting. occasionally runny. Several fellow passengers told Andrea at Marcus’ father and two sisters also traveled on the cruise and breakfast that they were experiencing vomiting and diarrhea. are asymptomatic. None of the family members took prophy- Andrea and Marcus ate the remainder of their meals with the lactic antibiotics for travelers’ diarrhea during the cruise. entire family. They did not drink any untreated water or eat items purchased from street vendors at ports of call. In How does this information assist with the response to your other questions, Marcus does not have a rep- diagnosis? tile at home. Andrea has not been prescribed antibiotics for The additional history suggests that Marcus’ and more than 1 year. The family lives in a city and has access to Andrea’s illness may be an infectious gastroenteritis municipal water. related to their recent travel. Antibiotic-associated colitis Based on the additional historical details, it appears that caused by Clostridium difficile infection must be consid- many people on board the cruise were experiencing symp- ered since the child was prescribed antibiotics for otitis 8 toms of vomiting and diarrhea. This suggests an outbreak of days prior to this illness. Given the recent onset, travel infectious gastroenteritis that may be related to a common history, and his mother’s symptoms, it is unlikely that food or water source on the ship. The etiologic agent may be appendicitis, celiac disease, or inflammatory bowel dis- bacterial, viral, or parasitic. The most likely bacterial organ- ease are the etiologies of Marcus’ illness. isms causing this diarrheal illness are Campylobacter jejuni, Escherichia coli, Shigella species, and Salmonella. C. jejuni is The most likely diagnosis is infectious gastroenteritis. the most common bacterial cause of diarrheal illness in the United States. Outbreaks of C. jejuni have been linked to raw milk, poultry, eggs, and water. Enterotoxigenic E. coli (ETEC) What additional historical information will is recognized as the most common cause of “travelers’ diar- assist in the identification of the etiologic rhea” and can be transmitted via food or water. Salmonella is organism? an important bacterial cause of foodborne illness, ranking just • What foods did Marcus and Andrea consume in the pre- behind C. jejuni in its frequency. Vehicles most commonly vious week? In particular, which foods/ beverages did they implicated in foodborne outbreaks of salmonellosis include consume that the other family members did not? beef, poultry, produce, eggs, pork, and dairy products. Large • Did either Marcus or Andrea consume undercooked waterborne outbreaks of salmonellosis have occurred rarely. meats, runny eggs, unpasteurized milk, raw shellfish, or untreated water? Why is identification of the cause of the • Is there a reptile in the home? diarrhea important? • Marcus was prescribed antibiotics for otitis media 1 week prior to the onset of his gastrointestinal symptoms. Has Identification of the cause of diarrhea in these two cases Andrea been prescribed antibiotics during the month is important because of the impact on treatment, identi- prior to the onset of her diarrheal illness? fication of related cases, and detection of an outbreak and identification of the responsible vehicle. Stool cultures Vol. 53 / RR-4 Recommendations and Reports 21

Three days after the initial visit, Andrea feels better with should be performed to detect common bacterial patho- fewer stools per day, but Marcus has had worsening vomiting gens such as Campylobacter, Salmonella, Shigella, or E. coli and diarrhea. He has had several episodes of high fever and O157:H7. Antimicrobial susceptibility results can guide has not been drinking ORS adequately. In the office, Marcus antibiotic therapy if a resistant organism is detected. is febrile (102°F/38.8°C) and appears dehydrated with dry Additional testing may be conducted to detect nonbacte- mucous membranes and decreased skin turgor. No signifi- rial organisms. Stool examination for ova and parasites cant change is noted in the abdominal examination. You (O&P) will reveal parasitic causes of foodborne and water- admit Marcus for intravenous hydration and encouragement borne illness such as Cyclospora cayetanensis. Rotavirus of oral rehydration and consider a change in antibiotic therapy. infection, one of the most common etiologies of pediat- Because of the progressive systemic nature of his illness, you ric diarrhea, may be diagnosed with enzyme immunoas- also obtain blood cultures at this time. say (EIA). The presence of fecal leukocytes suggests bacterial infection but may be found in other infectious What information will guide your therapy or inflammatory states. Testing for the presence of Shiga at this time? toxin to detect infection with enterohemorrhagic E. coli (EHEC) would be appropriate if Marcus or Andrea had The use of intravenous fluids to improve volume status bloody diarrhea. is reasonable given Marcus’ inability to maintain hydra- tion with ORS. However, during hospitalization, he should be encouraged to resume drinking ORS as early as What approaches would you take to possible. The decision to change from oral to intravenous treating Marcus’ and Andrea’s illness? antibiotics may be based on Marcus’ increased vomiting Are antibiotics indicated for both Marcus and on his clinical decline. The choice of antibiotics should and Andrea? What other therapeutic reflect the results of stool culture and antimicrobial sensi- measures are useful for the management tivities. of diarrheal illness? The laboratory reports the growth of Salmonella Because Andrea’s symptoms are mild, she does not wish Typhimurium from Marcus’ stool cultures. Susceptibility test- to receive antibiotics. For Marcus, you prescribe ing reveals an organism resistant to multiple antibiotics, trimethoprim-sulfamethoxazole at appropriate doses. You including ampicillin and sulfamethoxazole. Multidrug- encourage Andrea to monitor for worsening fever, diar- resistant S. Typhimurium has been on the rise in the United rhea, vomiting, and dehydration. You obtain stool speci- States since the early 1990s and now accounts for at least 25% mens for culture and O&P from both Marcus and Andrea of these isolates. Definitive type 104 (DT 104), the most com- to confirm the etiologic agent. mon phage type of multidrug-resistant S. Typhimurium, may The primary goal of therapy for Marcus and Andrea is be responsible for more invasive disease than other phage types. the maintenance of adequate hydration and electrolyte In an outbreak, resistant organisms appear to cause more cases balance. A commercial oral rehydration solution (ORS) than do sensitive strains. Marcus’ recent exposure to antibiot- may be used, particularly for Marcus, to provide glucose ics for otitis media likely increased his susceptibility to Salmo- and . You encourage Andrea to give Marcus ORS to nella infection, perhaps by decreasing the usual protection prevent dehydration. Bismuth subsalicylate or loperamide offered by normal bowel flora, and thus decreasing the infec- may be used to decrease the number of unformed stools tious dose necessary to cause illness. In addition, he was placed and shorten the duration of diarrhea, although neither is at increased risk for infection with a resistant strain of available over the counter for children of Marcus’ age. S. Typhimurium if he was exposed while still taking the anti- Loperamide should not be used in those patients who biotic. develop fever or dysentery. Treatment of Salmonella gastroenteritis with antibiotic Finally, empiric antibiotic therapy can be used to treat therapy is controversial because of the resulting increase in “travelers’ diarrhea,” which is most commonly caused by asymptomatic carriage, particularly among children less than ETEC, after obtaining the stool samples but prior to 5 years of age. However, given the systemic nature of his ill- obtaining results of stool cultures. ness, you choose to treat Marcus with several days of an intra- venous third-generation cephalosporin. This is a reasonable choice in light of the antimicrobial resistance and the reluc- tance to use fluoroquinolones in the pediatric population. 22 MMWR April 16, 2004

With adequate hydration and your chosen antimicrobial Should these cases be reported to the therapy, Marcus will likely recover fully from this diarrheal local health department? What are the illness without residual complications. public health implications of these two cases of salmonellosis? Unexplained Illness: A Patient Scenario Salmonellosis is a nationally notifiable disease, and most states require clinicians to report cases to local or state pub- You have been a primary care practitioner in Manhattan, lic health agencies. The health department and its public New York, for several years. Jack, a 29-year-old otherwise health partners can conduct studies to determine whether healthy male, has been your patient for the past year. At 8:00 these cases indicated an outbreak of salmonellosis aboard a.m. he calls your triage nurse complaining of a very sudden the cruise ship. If an outbreak is confirmed, additional onset of nausea, cramps, coughing, and sweating. The nurse investigation is necessary to identify the contaminated food is concerned about the suddenness of onset and wants to know or the ill food worker infected with Salmonella, and whether what you would like to do. there were correctable food-handling errors. If a food vehicle is identified, traceback and recall may be necessary Should you have him call again later if he to remove it from the market and prevent the occurrence does not improve? Should you have him of other cases. Given the increasing of drug- make an acute-visit appointment, or resistant strains of S. Typhimurium, public health labora- should you send him to the emergency tories may perform bacteriophage typing or pulsed-field room? gel electrophoresis (PFGE) to further characterize the drug- You are concerned about the suddenness of the onset of resistance patterns of these organisms. Reporting of these symptoms but not the severity, so you decide to have him cases will contribute to essential nationwide surveillance of come to the office immediately. salmonellosis, foodborne outbreaks, and antimicrobial resistance. Jack presents in your office 30 minutes later. In addition to nausea, cramps, coughing, and sweating, his eyes have begun to tear uncontrollably and he complains of having had diffi- What prevention measures will you culty breathing while en route to the office. Upon arrival, he recommend to Marcus and Andrea? Are immediately asks to use the bathroom. repeat stool cultures necessary? Jack reports that he started his morning routine as usual To prevent Salmonella infections, all meat and egg dishes with a run. Upon returning home, he finished drinking the should be fully cooked. Andrea can purchase eggs that bottle of water he had purchased earlier from the local deli are pasteurized in the shell, and irradiated ground beef and began to get ready for work. By the time he had finished and poultry to reduce the risk of contamination. Basic showering and dressing, he began to feel sick to his stomach. food safety practices in the kitchen can also help prevent He then developed cramping but no diarrhea. Shortly there- such infections, such as refrigerating leftovers promptly, after, he began to have bouts of coughing uncontrollably. He washing hands and utensils after contact with raw meat does not know when the sweating started. He states that he and poultry, and keeping raw meat and poultry separate had difficulty breathing while en route to the office, and that from ready-to-eat foods. Marcus and Andrea should be the tearing just started. He denies vomiting, hemoptysis, reminded to wash their hands with warm running water hematuria, bright red blood per rectum (BRBPR), chills, fever, and soap after using the bathroom and before and after headache, myalgia, arthralgia, or diarrhea. Jack also denies the meals to avoid transmitting the infection to others. Marcus use of any medication, other drugs or alcohol. “That stuff is likely to have prolonged carriage of Salmonella in the rots your gut.” intestines. While he may return to preschool as soon as Jack reports that he finished his run at about 7:00 a.m. It is he is feeling well enough to do so because direct spread now 9:00 a.m.. from one child to another is rare, clinicians should defer Despite having just urinated, he states that he must go again to their local health departments regarding their clear- and immediately. However, Jack experiences incontinence on ance policies for convalescing children attending pre- his way to the bathroom. Upon his return to the exam room, school. you notice a slight tremor in his left arm. He states that this has only just begun. Vol. 53 / RR-4 Recommendations and Reports 23

What preliminary diagnosis can you make Jack’s presentation appears to involve at this point? which of the following systems? • An anxiety attack • Autonomic nervous system • A viral syndrome • Lymphatic system • A potential foodborne illness • Central nervous system • Anticholinergic poisoning The signs and symptoms in Jack’s presentation predomi- You are not ready to reach a conclusion at this point, so you nantly involve increased autonomic responses, and are per- move to a physical exam and observe the following: haps progressing to include the central nervous system as well. Objective: You decide that immediate treatment is called for and order Respiration rate: 20 oxygen, atropine, and pralidoxime (2-PAM). Given that Jack BP: 92/60 mm Hg. does not appear to have been exposed dermally, the most likely Heart rate: 50 route appears to have been oral. Therefore, you also appropri- Temperature: 98.6°F (37°C) ately begin an IV with normal saline You note that Jack is anxious but oriented to time, place, and person. His head, ears, eyes, nose, throat (HEENT) examina- What is the initial diagnosis? tion shows bilateral miosis and decreased reactivity. There are This presentation is not consistent with bacterial, viral, no signs of trauma or bleeding. His heart has regular rate and or parasitic food poisoning. While the signs and symp- rhythm, no murmur, and good perfusion. Radial and dorsal toms indicate acute organophosphate poisoning, the his- pulses are 2+. His lung examination reveals scattered wheez- tory provides no indication, and indeed seemingly ing. His abdomen is soft, nontender, not distended, with contradicts this theory because of the lack of exposure. increased bowel sounds, and no mass. Extremities appear There has been no exposure to places where organophos- within normal limits. The neurologic exam reveals the slight phates are typically used, such as on lawns, house , tremor in his left arm, slightly slurred speech, excessive saliva- and parks. Nevertheless, Jack has presented with a fairly tion, and transient fasciculations in both upper extremities. classic case of organophosphate poisoning. Therefore, You note negative Babinski and his cranial nerves (CN) 2-11 ingestion must be considered. Since you have no sugges- appear intact, while CN 12 appears slightly abnormal. tion of deliberate ingestion on Jack’s part, it must be assumed that he has consumed it unintentionally. What other information would assist with the diagnosis? Organophosphate poisoning has an onset of 30 minutes to More history from Jack, including most recent activity 2 hours. Jack has actually made it easy to identify the most and diet. likely source: the only thing he has consumed in 10 hours is water. The broccoli could have had pesticides on it that may You now seek additional history. Jack lives alone and does not have been removed when Jack washed it, but then he would not believe that he has been in contact with anyone who is ill. have developed his symptoms during the night. Taking into He works in an office as a lawyer. His run takes him up 5th account the temporal relationship between his ingestion of Avenue and then over to 3rd Avenue, then back home. He the bottled water and the onset of his symptoms, the bottled does not run through Central Park. He does not have plants water seems the most likely candidate. and does not garden as a hobby. His most recent meal was the night before, about 10 hours prior to the onset of his symp- Given this information, what are key toms. It consisted of boiled pasta, steamed broccoli, and olive questions you should consider? oil. He prepared the meal himself. He states that he carefully • Is the water truly contaminated? washed the broccoli, the oil was from a bottle he opened last • If it is, how did it become contaminated? week, and the pasta was from a box he had already used 2 • Who else may have ingested it? days before. All he had to drink was tap water with dinner last • Who else is at risk? evening and the bottled water from this morning. • What action should be taken? 24 MMWR April 16, 2004

parts of the public health system, including law enforcement, You realize that if your diagnosis and conclusions are CDC, and the state health department. They may even issue correct then a public health hazard may exist. Two things a public notice. need to be done. First, the health department must be There is another possible cause for the case you have just contacted, and second, tests need to be done that will seen: sarin gas can cause a similar presentation. If sarin gas confirm your diagnosis. While the usual work-up for had been sprayed into the air, it is possible that Jack could organophosphate poisoning is clinical diagnosis, there are have respiratory exposure to the nerve gas. assays available to measure cholinesterase activity in plasma and red blood cells. It is also possible to detect some pes- If this were true, how would it change ticides in urine. You decide to order both tests as this will what you did? provide the greatest insight into what the possible expo- sure is for other people in Jack’s building, neighborhood, Persons exposed to sarin, and possibly other nerve or even his city. agents, will have a clinical presenation similar to those with organophosphate poisoning. Hence, medical man- agement will likely be similar. When communicating with the local public health department, whom should you ask Finally, you are gratified to have helped detect a possible act to speak to concerning this situation? of contamination that could potentially harm or even kill a great many people. Afterward, while making rounds in the • The medical epidemiologist? hospital that day you are told by a colleague that a number of • The medical director? runners from a 5K race in Central Park this morning and • The infectious disease officer? tourists visiting the Empire State Building were brought to You ask to speak with the medical director. You present the emergency room complaining of sudden onset of nausea, Jack’s case, making careful note of the time course, and cramps, and coughing. It was reported that all had been drink- also inform the medical director of your suspicions of the ing bottled water. source. The medical director takes this information and agrees with your concerns. She then asks you to speak with the chief epidemiologist so that an investigation can Clinical Vignettes: What’s Your Call? begin. In many large cities, there is a city health department; The following clinical vignettes are provided for your self- in smaller cities or towns, it will usually be necessary to evaluation. All are possible situations that may present at your contact the local or state health department. Try to match practice. The “Diagnostic Considerations” section and the the level with the greatest number of people who may tables of etiologic agents that are also part of this primer will become affected. Other persons who may be of immedi- provide the information necessary for you to adequately ate help if you cannot reach the medical officer are the address these clinical situations. Note that these vignettes epidemiologist or even an officer. include both infectious and noninfectious forms of foodborne These people will most likely know what to do with the illness. information you have. For the following clinical vignettes, choose the best answer Most health departments across the country have been from the choices listed at the end of the vignettes: working to increase their knowledge or at least their aware- A — likely diagnosis; choose the best possible answer listed ness of the possibility of intentional contamination. Many on “answer selections” page under A selections. have also created positions solely devoted to this task. B — most appropriate choice to confirm the diagnosis (there Therefore, it is possible that you will be directed to such may be more than one correct answer — list all of them). an individual. Choose from the possible answers listed on “answer selections” page under the B section. The health department initiates an investigation that Finally, decide whether the situation warrants reporting to includes testing the water; looking for other cases of organo- the local or state health department. phosphate poisoning; interviewing the patient; notifying other Vol. 53 / RR-4 Recommendations and Reports 25

Clinical Vignettes VI. A patient calls and states that most family members have developed severe vomiting, about 1 hour after I. You receive a long-distance call from a patient who is eating at a picnic. They ate barbecued beef, chips, an outdoorsman. He is with a group that collected potato salad, and homemade root beer. Some are com- and ate some wild mushrooms less than 2 hours ago. plaining of a metallic taste. Several members of the group have since developed vomiting, diarrhea, and some mental confusion. A — likely diagnosis: B — most appropriate test to confirm etiology/follow-up A — likely diagnosis: action: B — most appropriate test to confirm etiology/follow-up Report to the health department? ___Yes ___No action: Report to the health department? ___Yes ___No VII. A patient has had chronic intermittent diarrhea for about 3 weeks. There is no fever or vomiting and no II. A newborn child has symptoms of sepsis. Cerebrospi- blood in the stool. The patient travels to Latin America nal fluid studies are consistent with meningitis. The and Eastern Europe frequently, most recently 2 weeks mother had a flu-like syndrome prior to delivery. ago. A — likely diagnosis: A — likely diagnosis: B — most appropriate test to confirm etiology/follow-up B — most appropriate test to confirm etiology/follow-up action: action: Report to the health department? ___Yes ___No Report to the health department? ___Yes ___No

III. This patient has just returned today from Latin VIII. The parents of a 6-month-old infant are concerned America following a 2-day business trip. He reports because she is listless and weak. The infant is feeding having eaten several meals of fish that he bought from poorly, has poor head control, and is constipated. street vendors around his hotel. He feels very ill with There is no fever or vomiting. profuse, watery diarrhea, and vomiting. A — likely diagnosis: A — likely diagnosis: B — most appropriate test to confirm etiology/follow-up B — most appropriate test to confirm etiology/follow-up action: action: Report to the health department? ___Yes ___No Report to the health department? ___Yes ___No IX. A businessman who travels frequently is ill with IV. An 18-month-old child is brought to your office with fatigue, jaundice, abdominal pain, and diarrhea. About fever, bloody diarrhea, and some vomiting. She has 1 month ago, he returned from an international trip been drinking unpasteurized milk in the last 48 hours. during which he consumed raw oysters. No other family members are ill. A — likely diagnosis: A — likely diagnosis: B — most appropriate test to confirm etiology/follow-up B — most appropriate test to confirm etiology/follow-up action: action: Report to the health department? ___Yes ___No Report to the health department? ___Yes ___No X. Several members of a single family are ill with abdomi- V. A patient calls and states that he and several family nal cramps and watery diarrhea. They just returned members are ill with severe vomiting. They ate at a from visiting friends on the East Coast of the United church picnic 4 hours earlier. States, where they consumed raw oysters 48 hours ago. A — likely diagnosis: A — likely diagnosis: B — most appropriate test to confirm etiology/follow-up B — most appropriate test to confirm etiology/follow-up action: action: Report to the health department? ___Yes ___No Report to the health department? ___Yes ___No 26 MMWR April 16, 2004

XI. A minister at a local church calls to report that many XVI. Sally arrives at your office with acute gastrointestinal members began experiencing watery diarrhea on the illness characterized by diarrhea, abdominal cramps, morning after the annual turkey dinner fundraiser. chills, fever, and body aches. She also informs you Some people also reported nausea and abdominal that about 3 days before she started getting sick, she cramps, but no one has fever or bloody stools. had consumed raw ground beef that was seasoned with A — likely diagnosis: and an herb mix. B — most appropriate test to confirm etiology/follow-up A — likely diagnosis: action: B — most appropriate test to confirm etiology/follow-up Report to the health department? ___Yes ___No action: Report to the health department? ___Yes ___No XII. You receive a long-distance call from a patient on a fishing vacation off the coast of Belize. Her family has XVII. James presents to the emergency room with a low- been eating a variety of local fish and shellfish that grade fever and complaining of fatigue and nausea for they caught. She reports that several family members the past 24 hours. He also describes his urine as being developed abdominal pain, severe diarrhea, and weak- dark and states that he has had 4 bowel movements in ness the morning after they consumed the seafood for the past 24 hours, all of which were light colored. dinner. One family member began having difficulty Upon further questioning, James says that he has no speaking later on that same night. history of jaundice and that he returned from a busi- A — likely diagnosis: ness trip to the Philippines a month ago. B — most appropriate test to confirm etiology/follow-up A — likely diagnosis: action: B — most appropriate test to confirm etiology/follow-up Report to the health department? ___Yes ___No action: Report to the health department? ___Yes ___No XIII. A family in a rural community is worried that their father may be having a stroke. He is complaining of XVIII. You are halfway through your shift in the ER. There double vision and is having trouble swallowing. They are four patients, two adults and two children, with a have a large garden and eat home-canned vegetables. history of nausea, vomiting, abdominal pain, and pro- A — likely diagnosis: fuse (especially in the children) watery diarrhea in the B — most appropriate test to confirm etiology/follow-up absence of fever. They each report that these symp- action: toms began 5 days ago and resolved after 1 day. They Report to the health department? ___Yes ___No had all been symptom free for 3 days, but now the symptoms have returned. There is also a new onset of XIV. A 2-year-old child who attends day care presents with jaundice and bloody diarrhea. Lab results indicate el- abdominal cramps and severe bloody diarrhea, which evated LFTs. The patients do not know each other, has been present for 2 days. He has no fever. but all report eating hamburgers several hours before A — likely diagnosis: the initial onset of symptoms. B — most appropriate test to confirm etiology/follow-up A — likely diagnosis: action: B — most appropriate test to confirm etiology/follow-up Report to the health department? ___Yes ___No action: Report to the health department? ___Yes ___No XV. Susan tells you that she has had diarrhea, nausea, and abdominal cramping for almost 12 hours now. She XIX. A mother has brought in a 5-month-old child with ap- also presents with malaise and a low-grade fever and parent blindness. She reports that the child had been informs you that as far as she can tell, the symptoms healthy until the past month when the vision problems developed very suddenly. Stool examination is nega- appeared. The mother states that she had been well dur- tive for occult blood. Susan informs you that her good ing the pregnancy, but further questioning reveals that friend is also sick and they both attended a company the mother had two young cats at home for which she picnic less than 2 days ago. was the sole care provider. The cats were given away A — likely diagnosis: just before the birth of the child because of concerns B — most appropriate test to confirm etiology/follow-up about the child being smothered by the cats. action: A — likely diagnosis: Report to the health department? ___Yes ___No B — most appropriate test to confirm etiology/follow-up action: Report to the health department? ___Yes ___No Vol. 53 / RR-4 Recommendations and Reports 27

Answer Choices 15. Isolation of T. gondii from infant blood. PCR of white blood cells or CSF, or IgM and IgA serology, per- A: Choose from any of these possible etiologies: formed by a reference laboratory. 1. Intoxication from preformed toxins of Staphylococcus 16. Rapid and aggressive antitoxin therapy. There is no aureus or Bacillus cereus single effective antidote at this time, but silibinin (with 2. Intoxication from toxins produced in vivo by Clostridium penicillin G) and N acetyl cysteine are showing prom- perfringens ise. Plan for hepatic and renal failure. 3. Salmonella or Campylobacter are possible. 4. E. coli O157:H7 Answers 5. Noroviruses, Vibrio parahaemolyticus, and other Vibrio infections Question Choice(s) Choice(s) Report to 6. Vibrio cholerae infection number for A for B Health Dept.? 7. Botulism must be ruled out I 12 11 Yes 8. Listeria monocytogenes sepsis II 8 12 Yes 9. Cryptosporidium parvum III 6 5,6 Yes IV 3,4 2 Yes 10. Cyclospora cayetanensis V 1 1,3 Yes 11. A form of metal poisoning VI 11 9 Yes 12. A form of mushroom poisoning VII 14 8 Yes VIII 7 5 Yes 13. Likely fish/shellfish toxin IX 16 13,7,14 Yes 14. Giardia lamblia X 5 5,6,7 Yes 15. Trichinella spiralis XI 2 1,5 Yes XII 13 10 Yes 16. Hepatitis A virus XIII 7 3,5 Yes 17. Congenital toxoplasmosis XIV 4 5,6 Yes 18. Intentional amanitin poisoning XV 3,5 5,6,7 Yes XVI 3,4 2 Yes XVII 16 13,7,4 Yes B: Choose from any of these following tests/actions XVIII 18 16, Yes (intentional 1. Clinical diagnosis; laboratory tests may not always contamination?) be indicated. XIX 17 15,13 Yes 2. Generally detected on routine stool cultures. 3. Generally, a reference laboratory is needed to iden- tify the toxin from food, stool, or vomitus. Suggested Resources 4. Important to identify causative organism for public health reasons. General Information 5. Send stool samples to health department (Vibrio CDC Food Safety Information cholerae, other , E. coli O157:H7, special toxin http://www.cdc.gov/foodsafety tests, Clostridium perfringens, ). Continuing Medical Education (CDC) 6. Not detected by routine stool cultures (E. coli http://www2.cdc.gov/mmwr/cme/conted.html O157:H7, Vibrio cholerae, other vibrios). US Government Food Safety Information Gateway 7. Should test for viral agents. http://www.foodsafety.gov 8. For cysts, ova, and parasite detection, at least 3 stool Fight BAC!™ Education Campaign samples must be collected. Sometimes the organism http://www.fightbac.org may still be missed. Foodborne Illness Education Information Center 9. Test for appropriate metal. http://www.nal.usda.gov/fnic/foodborne/foodborn.htm 10. Special test needed to identify a fish toxin. Public Health Partners — Networks and Resources 11. Consult a mycologist to identify the mushroom. http://www.cdc.gov/other.htm 12. Blood culture is the best source for diagnosis. Bad Bug Book (FDA) 13. Blood test helpful to identify the agent. http://www.cfsan.fda.gov/~mow/intro.html 14. May need acute and convalescent serum or viral Travelers’ Health Information (CDC) cultures. http://www.cdc.gov/travel 28 MMWR April 16, 2004

Listing of foodborne diseases, pathogens and toxins (CDC) US Department of Health and Human Services (DHHS): http://www.cdc.gov/foodsafety/disease.htm Centers for Disease Control and Prevention Searchable database: U.S. Foodborne Disease Outbreaks, http://www.cdc.gov 1990–1995 US Food and Drug Administration www2.cdc.gov/ncidod/foodborne/fbsearch.asp http://www.fda.gov Terrorism and Public Health (CDC) Center for Food Safety and Applied Nutrition (CFSAN) http://www.bt.cdc.gov/ Information for Health Professionals http://www.cfsan.fda.gov/~dms/hpro-toc.html Professional Organizations State and local government agencies http://www.foodsafety.gov/~fsg/fsggov.html American Academy of Family Physicians Role of Government Agencies in Food Safety http://www.aafp.org http://vm.cfsan.fda.gov/~lrd/foodteam.html American Medical Association (AMA) Gateway to government food safety information http://www.ama assn.org http://www.foodsafety.gov Infectious Diseases Society of America http://www.idsociety.org American Academy of Pediatrics Reports and Journals http://www.aap.org CDC, Morbidity and Mortality Weekly Report American Nurses Association (ANA) http://www.cdc.gov/mmwr http://www.nursingworld.org CDC, Emerging Infectious Diseases Journal American Association for Health Education http://www.cdc.gov/eid http://www.aahperd.org American Dietetic Association Food Safety Education Resources http://www.eatright.org An Ounce of Prevention Keeps the Germs Away http://www.cdc.gov/ncidod/op State and Local Organizations Attention Pregnant Women: What you can do to keep germs Association of Food and Drug Officials from harming you and your baby http://www.afdo.org http://www.cdc.gov/foodsafety/edu.htm Association of State and Territorial Directors of Health Pro- Consumer Advice from CFSAN motion and Public Health Education http://www.cfsan.fda.gov/~lrd/advice.html http://www.astdhpphe.org Cooking for Groups: A Volunteer’s Guide to Food Safety Association of Public Health Laboratories (APHL) www.fsis.usda.gov/OA/pubs/cfg/cfg.htm http://www.aphl.org Fight BAC: Keep Food Safe From Bacteria Association of State and Territorial Health Officials http://www.fightbac.org (ASTHO) Food Safety Resources for Kids, Teens and Educators http://www.astho.org http://www.foodsafety.gov/~fsg/fsgkids.html Council of State and Territorial Epidemiologists (CSTE) For Kids, Teens, and Educators http://www.cste.org http://www.cfsan.fda.gov/~dms/educate.html National Public Health Information Coalition (NPHIC) Hand Hygiene in Healthcare Settings http://www.nphic.org http://www.cdc.gov/handhygiene National Association of County and City Health Officials Healthy Pets, Healthy People (NACCHO) http://www.cdc.gov/healthypets http://www.naccho.org Healthy Schools, Healthy People — It’s a SNAP http://www.ItsASnap.org Government Listeriosis and Pregnancy: What is Your Risk? http://www.fsis.usda.gov/OA/pubs/lm_tearsheet.htm US Department of Agriculture (USDA) Food Safety and National Food Safety Education Month Inspection Service http://www.nraef.org/nfsem http://www.fsis.usda.gov Thermy™ Campaign http://www.fsis.usda.gov/thermy Vol. 53 / RR-4 Recommendations and Reports 29

Thinking Globally, Working Locally: A Conference on Food Suggested Reading List Safety Education http://www.fsis.usda.gov/Orlando2002 General Reading To Your Health: Food Safety for Seniors Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the http://www.foodsafety.gov/%7Efsg/sr2.html management of infectious diarrhea. Clin Infect Dis. 2001:32:331–351. Toxoplasmosis: An important message for pregnant women Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the http://www.cdc.gov/ncidod/dpd/parasites/toxoplasmosis/ United States. Emerg Infect Dis [serial online]; 1999;5 (5):607–625. Available from: URL: http://www.cdc.gov/ncidod/eid/vol5no5/ ToxoWomen.pdf mead.htm. CDC. Surveillance for foodborne-disease outbreaks—United States, 1993– Food Safety Education Partnerships 1997. MMWR. 2000;49 (No. SS-01):1–66. Swerdlow DL, Altekruse SF. Foodborne diseases in the global village: what’s Clean Hands Coalition on the plate for the 21st century. In: Scheld WM, Craig WA, Hughes Email to: [email protected] JM, eds. Emerging Infections 2. Washington, DC: ASM Press; Food Safety Training and Education Alliance 1998:273–293. http://www.FSTEA.org Tauxe RV, Swerdlow DL, Hughes JM. Foodborne disease. In: Mandell National Coalition for Food Safe Schools GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Dis- eases, Fifth Edition. New York: Churchill Livingstone; 2000:1150–1165. http://www.FoodSafeSchools.org Tauxe RV. Emerging foodborne diseases: an evolving public health chal- Partnership for Food Safety Education lenge. Emerg Infect Dis. [serial online] 1997;3:425–434. Available from http://www.fightbac.org URL http://www.cdc.gov/ncidod/eid/vol3no4/tauxe.htm Canadian Partnership for Consumer Food Safety Education http://www.canfightbac.org Anthrax -related anthrax. Emerg Infect Dis [serial online]. 2002;8 Toll-free Information Phone Numbers (10)(entire issue). Available from: URL: http://www.cdc.gov/ncidod/ eid/vol8no10/pdf/Vol8No10.pdf USDA Meat and Poultry Hotline: Turnbull PCB. Guidelines for the surveillance and control of anthrax in 1-800-535-4555 humans and animals. Geneva: World Health Organization, 1998. Pub- FDA Safe Food Hotline: lication #WHO/EMC/ZDf/98.6. 1-888-SAFE FOOD (723-3366) Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax as a biological CDC Voice Information System: weapon: medical and public health management. Working Group on 1-888-CDC-FAXX (232-3299) Civilian Biodefense. JAMA. 1999;281:1735–1745.

Bioterrorism/Food Bioterrorism Botulism Informational Web Sites Arnon SS, Schechter R, Inglesby TV, et al. Botulinum toxin as a biological weapon: medical and public health management. JAMA. 2001; AMA Resources on Disaster Preparedness and Emergency 285:1059–1070. Response Shapiro RL, Hatheway C, Becher J, Swerdlow DL. Botulism surveillance http://www.ama-assn.org/go/disasterpreparedness and emergency response: a public health strategy for a global challenge. JAMA. 1997;278:433–435. ANA Bioterrorism and Disaster Response Angulo FJ, Getz J, Taylor JP, et al. A large outbreak of botulism: the http://www.ana.org/news/disaster hazardous baked potato. J Infect Dis. 1998;178:172–177. DHHS/CDC Bioterrorism Resources Angulo FJ, St. Louis ME. Botulism. In: Evans AS, Brachman PS, eds. http://www.bt.cdc.gov Bacterial Infections of Humans. New York: Plenum; 1998:131–53. DHHS/FDA Counterterrorism Resources http://www.fda.gov/oc/opacom/hottopics/bioterrorism.html Brainerd Diarrhea DHHS/FDA/CFSAN Food Safety and Terrorism Resources Mintz ED, Weber JT, Tauxe RV, et al. An outbreak of Brainerd diarrhea http://www.cfsan.fda.gov/~dms/fsterr.html among travelers to the Galapagos Islands. J Infect Dis. 1998; 177:1041– USDA-FSIS Biosecurity Resources 1045. http://www.fsis.usda.gov/oa/topics/biosecurity.htm Osterholm MT, MacDonald KL, White KE, et al. An outbreak of newly recognized chronic diarrhea syndrome associated with raw milk con- sumption. JAMA. 1986;256:484–490. 30 MMWR April 16, 2004

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Askew GL, Finelli L, Genese CA, Sorhage FE, Sosin DM, Spitalny KC. Ries AA, Wells JG, Olivola D, et al. Shigella dysenteriae type 1 in Boilerbasse: an outbreak of methemoglobinemia in New Jersey in 1992. Burundi: panresistance and implications for prevention. J Infect Dis. Pediatrics. 1994;94:381. 1994;169:1035–1041. Bhat RV, Beedu SR, Ramakrishna Y, Munshi KL. Outbreak of Lee LA, Shapiro CN, Hargrett- N, Tauxe RV. Hyperedemic shigello- mycotoxicosis associated with consumption of mould-damaged wheat sis in the United States: a review of surveillance data for 1967–1988. products in Kashmir Valley, India. Lancet. 1989;1:35. J Infect Dis. 1991;164:894–900. Cartwright CP. Utility of multiple-stool-specimen ova and parasite examina- tions in a high-prevalence setting. J Clin Microbiol. 1999; 37:2408–2411. Toxoplasmosis CDC. Appendix B. Guidelines for confirmation of foodborne-disease out- breaks. MMWR. 1996;45(No. SS-5):58. Jones J, Lopez A, Wilson M. Congenital toxoplasmosis. Am Fam Physi- CDC. Prevention of hepatitis A through active and passive immunization: cian. 2003;67:2131–2138. Recommendations of the Advisory Committee on Immunization Prac- Masur H, Kaplan JE, Holmes KK, U.S. Public Health Service; Infectious tices (ACIP). MMWR 1999;48(No. RR-12). Diseases Society of America. Guidelines for preventing opportunistic CDC. “Norwalk-like viruses:” public health consequences and outbreak infections among HIV-infected persons—2002. Recommendations of management. MMWR 2001;50(No. RR-9). the U.S. Public Health Service and the Infectious Diseases Society of Chien L, Robertson H, Gerrard JW. Infantile gastroenteritis due to water America. Ann Intern Med. 2002;137:435–478. with high sulfate content. Can Med Assoc J. 1968;99:102. CDC. Preventing congenital toxoplasmosis. In: CDC recommendations Corbel, MJ. Brucellosis: an overview. Emerg Infect Dis [serial online]. regarding selected conditions affecting women’s health. MMWR 1997;3:213. Available at URL http://www.cdc.gov/ncidod/eid/vol3no2/ 2000;49(No. RR-2): 57–75. corbel.htm CDC. 1999 USPHS/IDSA guidelines for the prevention of opportunistic DuPont HL. The Practice Parameters Committee of the American Col- infections in persons infected with human immunodeficiency virus: US lege of Gastroenterology. Guidelines on acute infectious diarrhea in Public Health Service (USPHS) and Infectious Diseases Society of adults. Am J Gastroenterol. 1997;92:1962. America (IDSA). MMWR 1999;48(No. RR-10): 7–9. Eliason BC, Lewan RB. Gastroenteritis in children: principles of diagno- sis and treatment. Am Fam Physician. 1998;58:1769. Trichinellosis Fleming CA, Caron D, Gunn JE, Barry MA. A food borne outbreak of Cyclospora cayetanensis at a wedding: clinical features and risk factors for Schellenberg RS, Tan BJ, Irvine JD, et al. An outbreak of trichinellosis due illness. Arch Intern Med. 1998;158:1121. to consumption of bear meat infected with Trichinella nativa, in 2 north- Morgan MRA, Fenwick GR. Foodborne illness: natural foodborne toxi- ern Saskatchewan communities. J Infect Dis. 2003;188:835–843. cants. Lancet. 1990;336:1492. Bruschi F, Murrell KD. New aspects of human trichinellosis: the impact of Neill MA, Osterholm MT, Swerdlow DL. New threats from food borne new Trichinella species. Postgrad Med J. 2002;78:15–22. infections. Patient Care. July 15, 1994;47–71. Capo V, Dickson DD. Clinical aspects of infections with Trichinella spp. Rodrigue DC, Etzel RA, de Porras E, et al. Lethal paralytic shellfish poi- Clin Microbiol. 1996;9:47–54. soning in Guatemala. Am J Trop Med Hyg. 1990;42:267. Laurichesse H, Cambon M, Perre D, et al. Outbreak of trichinellosis in France Schlech WF, III. Listeria gastroenteritis: old syndrome, new pathogen. associated with eating horse meat. Com Dis Rep. 1997;7(5):R69-73. N Engl J Med. 1997; 336:130–132. MacLean JD, Viallet J, Law C, Staudt M: in the Canadian Seamens CM, Schwartz G. Food-borne illnesses: differential diagnosis and Arctic: report of five outbreaks and a new clinical syndrome. J Infect targeted management. Emerg Med Ref. 1998;19:120. Dis. 1989;160:513. Talal AH, Murray JA. Acute and chronic diarrhea. Postgrad Med. 1994;96:30. Typhoid Fever Tangermann RH, Etzel RA, Mortimer L, Renner GD, Paschal DC. An outbreak of a food-related illness resembling boric acid poisoning. Arch Olsen SJ, Bleasdale SC, Magnano AR, et al. Outbreaks of typhoid fever in Environ Contam Toxicol. 1992;90:228. the United States, 1960–99. Epidemiol Infect. 2003;130:13–21. Tauxe RV, Hughes JM. Foodborne disease. In: Mandel GF, Bennett JE, Stephens I, Levine MM. Management of typhoid fever in children. Pediatr Dohr R, eds. Principles and Practices of Infectious Diseases 5th ed. Infect Dis J. 2002;21:157–58. Churchill Livingstone: New York; 2000;1150. Mermin JH, Townes JM, Gerber M, et al. Typhoid fever in the United Wong CS, Jelacic S, Habeed RL, Watkins SL, Tarr PI. The risk of the States, 1985–1994: changing risks of international travel and increas- hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli ing antimicrobial resistance. Arch Intern Med. 1998;158:633–638. O157:H7 infections. N Engl J Med. 2000; 342:1930–1936. Vol. 53 / RR-4 Recommendations and Reports 33

Writers, Reviewers, Contributors Writing/Working Group — Original Primer American Medical Association: Litjen (L.J.) Tan, Ph.D. (Working Group Chair); Jim Lyznicki, M.S., M.P.H. CDC: Penny M. Adcock, M.D.; Eileen Dunne, M.D., M.P.H.; Julia Smith, M.P.H. Center for Food Safety and Nutrition, Food and Drug Administration: Eileen Parish, M.D. Arthur Miller, Ph D.; Howard Seltzer. Food Safety and Inspection Service, U.S. Department of Agriculture: Ruth Etzel, M.D., Ph.D. Writing/Working Group — Primer Update, 2004 American Medical Association: Litjen (L.J.) Tan, Ph.D. (Working Group Chair) American Nurses Association–American Nurses Foundation Elaine Brainerd, R.N., M.A. CDC: Julia Smith, M.P.H., CHES (Coordinator of CDC participants); Christopher Braden, M.D.; Joseph S. Bresee, M.D.; Lenee Brown, M.P.H.; Sandra N. Bulens, M.P.H.; Tom Chiller, M.D.; Anthony Fiore, M.D., M.P.H.; Jeff Jones, M.D., M.P.H.; Pavani Kalluri, M.D.; Adriana S. Lopez, M.H.S.; James Maguire, M.D., M.P.H.; Stephan S. Monroe, Ph.D.; Umesh Parashar, M.B.B.S., M.P.H.; Vincent Radke, Sanitarian; Marc-Alain Widdowson, Vet M.B., M.Sc. Center for Food Safety and Nutrition, Food and Drug Administration: Eileen Parish, M.D.; Howard Seltzer. Food Safety and Inspection Service, U.S. Department of Agriculture: Bessie Barrie, M.S.; Olga Catter, M.D.; David Goldman, M.D., M.P.H.; Jonathon S. Rose, M.D., M.P.H., D.A.B.P.M. Reviewers/Contributors The following organizations and individuals reviewed drafts of this document and provided valuable comments: Organizations: American Academy of Family Physicians, American Academy of Pediatrics, American Association of Public Health Physicians, American College of Emergency Physicians, American College of Physicians, American College of Preventive , American Nurses Association, Association of State and Territorial Health Officials, Council of State and Territorial Epidemiologists, Infectious Diseases Society of America, Johns Hopkins General Preventive Medicine Residency Program. Individuals: Mona R. Bomgaars, M.D., M.P.H., Hawaii Department of Health, Honolulu, Hawaii; Peter Chien, Jr., American Medical Association Student Section, Ad-Hoc Committee on Scientific Issues; Michael Crutcher, M.D., M.P.H., Oklahoma State Department of Health, Oklahoma City, Oklahoma; Jeffrey Davis, M.D., M.P.H., Wisconsin Department of Health and Family Services, Madison, Wisconsin; Roy Dehart, M.D., Center for Occupational and , Nashville, Tennessee; B. Clair Eliason, M.D., University of Illinois School of Medicine at Rockford, Illinios; Richard Guerrant, M.D., Health Sciences Center, University of Virginia, Charlottesville, Virginia; Bennett Lorber, M.D., Temple University School of Medicine, Philadelphia, Pennsylvania; Janet Mohle-Boetani, M.D., M.P.H., California Department of Health Services, Berkeley, California; Dale Morse, M.D., New York State Department of Health, Albany, New York; Michael Moser, M.D., M.P.H., Kansas Department of Health and Environment, Topeka, Kansas; Margaret Neill, M.D., Memorial Hospital of Rhode Island, Pawtucket, Rhode Island; Michael Osterholm, Ph.D., M.P.H., Center for Infectious Disease Research and Policy, School of Public Health, University of Minnesota, Minneapolis Minnesota; Louis Pickering, M.D., National Immunization Program, CDC, Atlanta, Georgia; Christopher Shearer, M.D., Phoenix Baptist Hospital Family Medicine Center, Phoenix, Arizona; Vincenza Snow, M.D., FACP, American College of Physicians, Philadelphia, Pennsylvania; Melvyn Sterling, M.D., FACP, Orange, California; Made Sutjita, M.D., Ph.D., Morehouse School of Medicine, Atlanta, Georgia; Philip Tarr, M.D., Washington University in Saint Louis School of Medicine, St. Louis, Missosuri; James Walker, D.V.M., Oklahoma State Department of Health, Oklahoma City, Oklahoma; William Weil, M.D., Michigan State University, East Lansing, Michigan. Morbidity and Mortality Weekly Report

Recommendations and Reports April 16, 2004 / Vol. 53 / No. RR-4

Continuing Education Activity Sponsored by CDC Diagnosis and Management of Foodborne Illnesses EXPIRATION — April 16, 2007 You must complete and return the response form electronically or by mail by hours Continuing Nursing Education (CNE) credit. If you return the form April 16, 2007, to receive continuing education credit. If you answer all of electronically, you will receive educational credit immediately. If you mail the the questions, you will receive an award letter for 2.75 hours Continuing form, you will receive educational credit in approximately 30 days. No fees are Medical Education (CME) credit; 0.25 Continuing Education Units (CEUs); charged for participating in this continuing education activity. 3.0 hours Certified Health Education Specialist (CHES) credit; or 3.3 contact INSTRUCTIONS By Internet By Mail or Fax 1. Read this MMWR (Vol. 53, RR-4), which contains the correct answers to 1. Read this MMWR (Vol. 53, RR-4), which contains the correct answers to the questions beginning on the next page. the questions beginning on the next page. 2. Go to the MMWR Continuing Education Internet site at . name, mailing address, phone number, and e-mail address, if available. 3. Select which exam you want to take and select whether you want to register 3. Indicate whether you are registering for CME, CEU, CNE, or CHES credit. for CME, CEU, CNE, or CHES credit. 4. Select your answers to the questions, and mark the corresponding letters on 4. Fill out and submit the registration form. the response form. To receive continuing education credit, you must 5. Select exam questions. To receive continuing education credit, you must answer all of the questions. Questions with more than one correct answer answer all of the questions. Questions with more than one correct answer will instruct you to “Indicate all that apply.” will instruct you to “Indicate all that apply.” 5. Sign and date the response form or a photocopy of the form and send no 6. Submit your answers no later than April 16, 2007. later than April 16, 2007, to 7. Immediately print your Certificate of Completion for your records. Fax: 404-639-4198 Mail: MMWR CE Credit Office of Scientific and Health Communications Epidemiology Program Office, MS C-08 Centers for Disease Control and Prevention 1600 Clifton Rd, N.E. Atlanta, GA 30333 6. Your Certificate of Completion will be mailed to you within 30 days. ACCREDITATION Continuing Medical Education (CME). This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through joint sponsorship of CDC; the Food Safety and Inspection Service, U.S. Department of Agriculture; and the Center for Food Safety and Applied Nutrition, Food and Drug Administration. CDC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CDC designates this educational activity for a maximum of 2.75 hours in category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. Continuing Education Unit (CEU). CDC has been approved as an authorized provider of continuing education and training programs by the International Association for Continuing Education and Training and awards 0.25 Continuing Education Units (CEUs). Continuing Nursing Education (CNE). This activity for 3.3 contact hours is provided by CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation. Certified Health Education Specialist (CHES). CDC is a designated provider of continuing education contact hours in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for CHES to receive 3.0 hours in category 1 credit in health education, CDC provider number GA0082. Centers for Disease Control and Prevention SAFER • HEALTHIER • PEOPLETM CE-2 MMWR April 16, 2004

Goal and Objectives This MMWR provides recommendations for physicians and other health-care professionals who have a critical role in diagnosing, treating, and reporting food-related disease outbreaks. These recommendations were developed by the American Medical Association, the American Nurses Association-American Nurse Foundation, the Centers for Disease Control and Prevention, the Food and Drug Administration’s Center for Food Safety and Nutrition, and the United States Department of Agriculture’s Food Safety and Inspection Service. The goal of this report is to provide health-care providers with guidance and patient-education materials regarding foodborne illness. After completing this continuing education activity, the reader should be able to 1) differentiate between the six etiologic agents that should be considered regarding manifestations of foodborne illness; 2) describe four criteria to consider when treating a diagnosed foodborne illness; 3) summarize the reporting requirements for foodborne illness; and 4) identify three groups of persons who are at higher risk for foodborne illnesses. To receive continuing education credit, please answer all of the following questions:

1. Which of the following provide important clues to the possible 8. Intentional contamination of food is uncommon, but which of the etiology of a food-associated illness? following would make you suspect that such an act had occurred (i.e., A. Incubation period. the unusual nature of the situation would induce suspicion of B. Duration of illness. intentional contamination)? C. Predominant clinical signs and symptoms (e.g., vomiting, diarrhea, A. An unusual agent or pathogen in a common food. and abdominal pain). B. A common agent or pathogen affecting an unusually large number of D. Travel history. persons. E. All of the above. C. A common agent or pathogen that is uncommonly seen in clinical practice. 2. Which group is at higher risk for complications from foodborne D. All of the above. illness? A. Persons with weakened immune systems. 9. Multidrug-resistant Salmonella typhimurium cases . . . B. Persons with liver disease. A. have been on the rise in the United States since the 1990s. C. Pregnant women. B. might be responsible for more invasive disease than other types. D. Older adults. C. often are resistant to ampicillin and sulfamethoxazole. E. All of the above. D. cause more cases in an outbreak than do sensitive strains. E. all of the above. 3. Which of the following is not a safe food-handling behavior? A. Using the same cutting board for raw foods and cooked foods. 10. Norovirus infection, which often results in nausea, vomiting, and B. Using a food to check the internal temperature of food watery/large-volume diarrhea within 24–48 hours, can be caused by . . . before eating it. A. inadequately cooked shellfish. C. Rinsing raw produce with water. B. inadequately cooked hamburger. D. Washing hands before and after handling food. C. ready-to-eat foods (e.g. salads). D. iced drinks. 4. What is the appropriate method to use in determining if a hamburger E. A, C, and D are correct. is cooked to a proper temperature? A. Cooking it until it is brown inside. 11. Indicate your work setting. B. Using a food thermometer to ensure that the internal temperature A. State/local health department. reaches 160ºF. B. Other public health setting. C. Determining if a hamburger is cooked to a proper temperature is not C. Hospital clinic/private practice. necessary because it is too small. D. Managed care organization. D. Taking a bite of the hamburger to ensure that it tastes cooked. E. Academic institution. F. Other. 5. When a foodborne outbreak is suspected, who would be a helpful contact at the health department? 12. Which best describes your professional activities? A. Medical officer. A. Physician. B. Epidemiology officer. B. Nurse. C. Environmental health officer. C. Health educator. D. Any of the above would be helpful. D. Office staff. E. Other. 6. Which of the following is not consistent with inflammatory diarrhea? A. Presence of fecal leukocytes. 13. I plan to use these recommendations as the basis for . . . (Indicate all B. Grossly bloody stool. that apply.) C. Infection with invasive or cytotoxigenic bacterial and protozoan A. health education materials. species. B. insurance reimbursement policies. D. Involvement of the small intestine. C. local practice guidelines. D. public policy. 7. If a foodborne illness is suspected, which of the following should be E. other. considered? A. Submission of appropriate specimens for laboratory testing. B. Contacting the state or local health department. C. Initiating oral rehydration therapy. D. All of the above. Vol. 53 / No. RR-4 Recommendations and Reports CE-3

14. Each month, approximately how many patients with a foodborne 18. After reading this report, I am confident I can summarize the illness do you treat? reporting requirements for foodborne illness. A. None. A. Strongly agree. B. 1–5. B. Agree. C. 6–20. C. Neither agree nor disagree. D. 21–50. D. Disagree. E. 51–100. E. Strongly disagree. F. >100. 19. After reading this report, I am confident I can identify three groups of 15. How much time did you spend reading this report and completing the persons who are at higher risk for foodborne illnesses. exam? A. Strongly agree. A. <2.0 hours. B. Agree. B. >2.0 hours but <3.0 hours. C. Neither agree nor disagree. C. >3.0 hours but <4.0. D. Disagree. D. >4.0 hours. E. Strongly disagree. 16. After reading this report, I am confident I can differentiate between 20. The objectives are relevant to the goal of this report. the six etiologic agents that should be considered regarding A. Strongly agree. manifestations of foodborne illness. B. Agree. A. Strongly agree. C. Neither agree nor disagree. B. Agree. D. Disagree. C. Neither agree nor disagree. E. Strongly disagree. D. Disagree. E. Strongly disagree. 21. The teaching strategies used in this report (text, figures, and tables) were useful. 17. After reading this report, I am confident I can describe four criteria to A. Strongly agree. consider when treating a diagnosed foodborne illness. B. Agree. A. Strongly agree. C. Neither agree nor disagree. B. Agree. D. Disagree. C. Neither agree nor disagree. E. Strongly disagree. D. Disagree. E. Strongly disagree. (Continued on pg CE-4) Detach or photocopy.

CME Credit CEU Credit CNE Credit CHES Credit

Check One

all of the test questions; April 16, 2004/Vol. 53/No. RR-4 April 16, 2004/Vol.

To receive continuing education credit, you must 1. provide your contact information; 2. indicate your choice of CME, CEU, CNE, or CHES credit; 3. answer 4. sign and date this form or a photocopy; 5. submit your answer form by April 16, 2007. Failure to complete these items can result in a delay or rejection of your application for continuing education credit. Response Form for Continuing Education Credit Response Diagnosis and Management of Foodborne Illnesses MMWR 1. [ ] A2. ] B [ [ ] A [ ] C3. ] B [ [ ] D [ ] A [ ] C ] E [ 4. ] B [ [ ] D [ ] A [ ] C ] E [ 5. ] B [ [ ] D [ ] A [ ] C6. ] B [ [ ] D [ ] A [ ] C7. ] B [ [ ] D [ ] A [ ] C8. ] B [ [ ] D [ ] A [ ] C9. ] B [ 14. [ ] D [ ] A [ ] A [ ] C ] B [ 15. ] B [ [ ] D [ ] A [ ] C [ ] C [ ] D ] B [ [ ] D ] E [ [ ] C ] E [ [ ] D [ ] F 16. [ ] A 17. ] B [ [ ] A [ ] C 18. ] B [ [ ] D [ ] A [ ] C ] E [ 19. ] B [ [ ] D [ ] A [ ] C ] E [ 20. ] B [ [ ] D 22. [ ] A [ ] C [ ] A ] E [ 21. ] B [ [ ] D ] B [ [ ] A [ ] C ] E [ [ ] C ] B [ [ ] D [ ] D [ ] C ] E [ ] E [ [ ] D ] E [

Last NameStreet Address or P.O. Box Apartment or Suite CityPhone NumberE-Mail Address First Name Fill in the appropriate blocks to indicate your answers. Remember, you must answer all of the questions to receive continuing education credit! Fax Number State ZIP Code 10. [ ] A11. ] B [ [ ] A [ ] C12. ] B [ [ ] D [ ] A [ ] C ] E [ 13. ] B [ [ ] D [ ] A [ ] C ] E [ ] B [ [ ] D [ ] F [ ] C ] E [ [ ] D ] E [ Signature 24. [ ] A 23. [ ] A ] B [ ] B [ [ ] C [ ] D [ ] C 25. [ ] D ] E [ [ ] A ] E [ 26. ] B [ [ ] A [ ] C ] B [ [ ] D [ ] C ] E [ [ ] D ] E [ [ ] F Date I Completed Exam CE-4 MMWR April 16, 2004

22. Overall, the presentation of the report enhanced my ability to 25. The availability of continuing education credit influenced my understand the material. decision to read this report. A. Strongly agree. A. Strongly agree. B. Agree. B. Agree. C. Neither agree nor disagree. C. Neither agree nor disagree. D. Disagree. D. Disagree. E. Strongly disagree. E. Strongly disagree. 23. These recommendations will affect my practice. 26. How did you learn about this continuing education activity? A. Strongly agree. A. Internet. B. Agree. B. Advertisement (e.g., fact sheet, MMWR cover, newsletter, or journal). C. Neither agree nor disagree. C. Coworker/supervisor. D. Disagree. D. Conference presentation. E. Strongly disagree. E. MMWR subscription. F. Other. 24. The content of this activity was appropriate for my educational needs. A. Strongly agree.

B. Agree.

C. Neither agree nor disagree. E. 10. E; 9. D; 8. D; 7. D; 6. D; 5. B; 4. A; 3. E; 2. E; 1. D. Disagree. 1–10. questions for answers Correct E. Strongly disagree. MMWR

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