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Epidemiology of Foodborne

Center for Acute Epidemiology Lucas State Office Building, 321 E. 12th Street Des Moines, Iowa 50319-0075

www.idph.state.ia.us/Cade/Foodborne.aspx Visit our web site at

PATHOGEN INCUBATION PERIOD / ASSOCIATED FOODS/ TREATMENT PUBLIC HEALTH (PH) COMMUNICABILITY TRANSMISSION RESPONSE Bacillus anthracis * 3-7 days, although up to 60 Ingestion of contaminated Nause a, , malaise, bloody Ciprofloxacin is 1st line treatment. Anthrax is a potential (anthrax - days possible. Not undercooked food. , acute followed Alternatives are doxycycline and bioterrorism agent. gastrointestinal) communicable person-to- by fever, septicemia. amoxicillin if susceptible. Begin person. therapy with two intravenous antimicrobials. Cephalosporins and trimethoprim-sulfamethoxazole should not be used. Bacillus cereus 6 - 24 hours. Not Food kept at room Abdominal cramps, watery diarrhea, Rehydration. Illness is self-limiting. Foods should not remain at (diarrheal toxin) communicable person-to- temperature after cooking, . Fever is rare. are of no use. room temperature after person. commonly meats, stews and cooking. Refrigerate leftover gravies. food promptly and reheat thoroughly. Bacillus cereus 0.5 -6 hours. Not Food kept at room Sudden onset of severe nausea and Rehydration. Illness is self-limiting. Proper cooking and storage of (preformed enterotoxin) communicable person-to- temperature after cooking, vomiting, abdominal cramps. Fever is Antibiotics are of no use. foods, particularly rice cooked person. commonly fried rice. rare. Usually last < 24 hours. for later use. Brucella abortus, Highly variable; usually 1-2 Ingestion of raw milk and Acute or insidious onset. Fever, chills, Rifampicin or streptomycin AND Brucella is a potential Brucella melitensis, months with a range of 5-60 dairy products sweating, weakness, headache, muscle doxycycline for at least 6 weeks. bioterrorism agent. PH follow- and Brucella suis * days. Rare person-to- (unpasteurized cheese) from and joint pain, weight loss, diarrhea (may Corticosteroids may be helpful in up to determine source of person transmission. infected animals. Contact of be bloody), sacroiliitis, epididymitis, severely ill patients. infection. Pasteurization of non-intact skin with body orchitis. milk and milk products. fluids of infected animals. Campylobacter * Usually 2-5 days, with a Ingestion of undercooked Diarrhea, abdominal pain, fever, malaise Rehydration and electrolyte Thorough cooking of pork and range of 1-10 days. chicken and pork, and vomiting; diarrhea may be bloody. replacement. Antibiotics are not poultry. Pasteurization of milk Communicable through the contaminated food and Less commonly: typhoid-like syndrome, generally indicated. For severe cases, and milk products. course of infection (usually water, or unpasteurized milk. febrile convulsions, meningeal antibiotics may be indicated early in Chlorination of water. Exclude several days to several syndrome. May mimic acute appendicitis the course of illness. symptomatic people from food weeks), though person-to- or irritable bowel syndrome. handling, childcare, and direct person transmission appears patient care. to be uncommon. Clostridium botulinum Neurological symptoms Ingestion of food in which Early signs are marked fatigue, Intravenous administration as soon as Notify the Center for Acute children and adults ** usually appear within 12-36 toxin has formed, and not weakness, vertigo, , possible of polyvalent botulism Disease Epidemiology (CADE) (preformed toxin) hours. Not communicable destroyed due to inadequate vomiting, and diarrhea, followed by antitoxin. Supportive care, especially immediately at 1-800-362- person-to-person. heating during preservation blurred vision, diplopia, , dry for respiratory failure, which is the 2736 to obtain the botulism and without subsequent mouth and symmetrical descending usual cause of death. antitoxin. Botulism is a adequate cooking, (e.g. muscle weakness with respiratory potential bioterrorism agent. home canned vegetables muscle paralysis. Do not use food containers and fruits, garlic in oil). that bulge. Clostridium botulinum Incubation is unknown. Not Ingestion of botulinum Lethargy, weakness, poor feeding, Supportive care; assisted respiration Contact CADE immediately at intestinal (formerly communicable person-to- spores. Possible sources of constipation, hypotonia, poor head may be required. Botulism IG has 1-800-362-2736. Do not give infant) ** person. spores are multiple, and control, poor gag and suck mechanism, been shown to improve the course of infants honey. include the following foods: “failure to thrive.” Disease can range illness. Botulism antitoxin is generally honey, home-canned from mild, with a gradual onset, to not recommended for infants. vegetables and fruits, light sudden infant death. Some studies Antibiotics do not improve the course and dark corn syrup. suggest the cause of an estimated five of disease, and aminoglycosides can percent of sudden infant death. worsen the disease. Rehydration. Clostridium perfringens 6 - 24 hours, usually 10-12 Ingestion of food that has Sudden onset of abdominal cramps Rehydration. Antibiotics are of no use. Do not leave food at room (toxin) hours. Not communicable been contaminated by soil or followed by diarrhea and usually nausea; temperature to cool. Roast, person-to-person. feces and then held under fever and vomiting are usually absent. stews, and gravies should be conditions that permits Mild disease of short duration (1 day or thoroughly cooked and divided multiplication of organism. less). into smaller quantities for Specific foods may include cooling and reheating. meat, poultry, gravy, and dried or precooked foods. Cryptosporidium* Incubation not precisely Person to person and fecal- Diarrhea, which may be profuse and Rehydration. Nitazoxanide for Specific O&P testing must be known; 1-12 days is the oral transmission. watery, cramping abdominal pain. immunocompetent. In requested. Persons with likely range, with an average Contaminated food or water. General malaise, fever, anorexia, immunocompromised persons, diarrhea should not use public of about 7 days. Outbreaks have been nausea, and vomiting occur less often. experimental treatments include recreational water. Hand Communicable from onset of associated with child care Symptoms often wax and wane. paromomycin and orally administered hygiene after handling illness to several weeks after centers, swimming pools and Asymptomatic infections are common. human serum immunoglobulin or animals. symptoms resolve. lakes, and unpasteurized bovine colostrum. Stop or reduce beverages (apple cider) immunosuppressive drugs if possible. contaminated with animal manure. Cyclospora Median incubation 1 week Ingestion of contaminated Profuse watery diarrhea, nausea, Trimethoprim-sulfamethoxazole for 7- Consider this diagnosis in cayetanensis * with a 1-2 week range. No water and foods such as anorexia, abdominal cramping, fatigue, 10 days may shorten the course of persons with prolonged evidence of communicability imported berries, lettuce, and and weight loss; fever is rare. Symptoms illness. Ciprofloxacin if sulfa allergy. diarrheal illness. Specific O&P person-to-person. basil fruits and vegetables. lasts 10-24 days testing must be requested. Hand hygiene after handling animals Entamoeba Variable, from a few days to Ingestion of fecally Varies from acute fulminating dysentery Antiparasitic drugs such as Handwashing, sanitary histolytica several months or years; contaminated foods or water with fever, chills, and bloody or mucoid metronidazole. Asymptomatic carriers disposal of feces, and commonly 2-4 weeks. containing . diarrhea to mild abdominal discomfort may be treated. Corticosteroids and treatment of drinking water. Communicable during the with diarrhea alternating with periods of antimotility drugs can worsen Contact public health if an period the cysts are passed, constipation or remission. Dissemination symptoms. Additional antiparasitic outbreak is suspected. which may continue for via the bloodstream may occur and drugs can be added for refractory or years. produce of the or, less extra-intestinal disease. commonly, the lung or brain. Enterohemorrhagic 2-10 days with a median of Person to person and fecal- Diarrhea that may range from mild and Rehydration. Antimotility drugs may Exclude patients and Escherichia coli (EHEC) 3-4 days. Communicable oral. Ingestion of non-bloody to stools that are virtually all worsen illness. Most experts would symptomatic contacts from * # Includes E. coli from onset of illness to a contaminated foods such as blood, abdominal pain, and vomiting. not treat because no benefit has been high-risk settings (food O157:H7 week later in adults; can be undercooked ground meats, Usually little or no fever present. More proven and harm is possible. handling, direct patient care, up to 3 weeks in one third of unpasteurized milk, fruits or common in children <5 years of age. child care) until 2 negative and other Shiga toxin children. vegetables contaminated Severe clinical manifestations include stools are collected at least 24 producing E. coli (STEC) with feces and contaminated hemolytic uremic syndrome (HUS) and hours apart and at least 48 water. thrombotic thrombocytopenic purpura hours after antibiotics are (TTP). discontinued. If high-risk setting is involved, immediately contact CADE at 1-800-362- 2736. Hand hygiene after handling animals. Enterotoxigenic Usually 24-72 hours, may be Ingestion of water or food Watery diarrhea, abdominal cramps, Rehydration. Most cases do not When traveling internationally, Escherichia coli (ETEC) as short as 10 -12 hours. contaminated with human some vomiting. May have low grade require additional treatment. drink carbonated beverages or (Travelers’ diarrhea) Communicable for duration feces. Primarily an infection fever. Range from mild watery diarrhea Ciprofloxacin or norfloxacin for severe sealed bottled water and avoid of excretion of pathogenic of developing countries. to profuse cholera-like. Symptoms last cases. ice, salads, and fruits that are ETEC, which may be > 5 days. not peeled. Eat foods hot. prolonged. Giardia lamblia * Usually 3-25 days or longer; Person-to-person and fecal- 1) Acute diarrhea or 2) chronic diarrhea, Antiparasitic drugs, such as median 7-10 days. oral transmission, especially , , fatigue, pale greasy metronidazole, are available for Communicable for entire in child care centers. May stools, malabsorption, weight loss. treatment. Treatment of asymptomatic period of infection, often also be transmitted through Reactive arthritis may occur. carriers is not necessary. months. contaminated water. A * 15-50 days, average 28-30 Person to person and fecal Diarrhea, dark urine, , and Supportive care. Can be prevented by Immediate patient interview days. Communicable oral transmission. Sources generalized symptoms such as fever, administration of or IG after and assessment by PH. approximately 2 weeks include raw produce, headache, nausea, and abdominal pain. exposure. Contact investigation and post- before and 1 week after undercooked foods and Many cases, especially infants and exposure prophylaxis - vaccine onset of jaundice. cooked foods that are not children, will be asymptomatic. Can last or IG - if warranted. reheated after contact with weeks to months. Counseling. If case is in high- infected food handler, and risk situation (food-handling, shellfish harvested from direct patient care or child contaminated waters. care, contact CADE at 1-800- 362-2736 immediately. Can be prevented with vaccine. Listeria Variable; 3-70 days. Median Ingestion of fresh soft Fever, muscle aches, and nausea or Penicillin or ampicillin alone or If pregnant or monocytogenes * # incubation is estimated to be cheeses, unpasteurized milk, diarrhea. Infection in pregnant women together with aminoglycosides. For immunocompromised, avoid 3 weeks. Communicable for ready-to-eat deli meats, hot can lead to premature delivery or penicillin-allergic patients, high-risk foods. Contact PH if duration of excretion of dogs, undercooked poultry, stillbirth. Elderly, immunocompromised, trimethoprim-sulfamethoxazole or an outbreak is suspected. organism, this may be unwashed raw vegetables. and neonates are at risk for septicemia erythromycin is preferred. several months. or meningitis. Transmission is unlikely after diarrhea has stopped. Norovirus Usually 24-48 hours with a Person to person and fecal Nausea, vomiting, and large-volume of Rehydration and electrolyte The State Hygienic Laboratory (Norwalk virus) range of 10-50 hours. oral transmission. Ingestion watery diarrhea, malaise, headache, replacement. Children < 5 year of at the University of Iowa is the Communicable during acute of ready-to-eat foods, such myalgia, and low grade fever. GI age, give 20 mg elemental zinc daily only lab in the state that can stage of disease and up to as salads, sandwiches, ice, symptoms usually last 1-2 days. for 10-14 days. Illness is self-limiting. identify noroviruses, a 48 hours after diarrhea cookies, and fruit that are Antibiotics are of no use. common cause of foodborne stops. handled by infected persons; outbreaks. Exclude ill food poorly cooked shellfish. handlers, healthcare providers and child care staff and attendees from work and child care for 48 hours after diarrhea and vomiting stops; everyone else, 24 hours. Rotavirus Approximately 1-3 days. Person to person and fecal Vomiting, watery diarrhea, low-grade Rehydration. Children < 5 years of Vaccine is available. Communicable during acute oral. Ingestion of fecally fever. Infants and children, elderly, and age, give 20 mg elemental zinc daily stage of disease and later contaminated foods. immunocompromised are especially for 10-14 days. Antibiotics and while viral shedding vulnerable. antimotility drugs should not be given. continues (around 8 days). Salmonella spp. * # 6-72 hours, average 12-36 Contaminated eggs, poultry, Diarrhea, fever, abdominal cramps, Rehydration and electrolyte Cook eggs until firm. hours. Communicability is beef, unpasteurized milk or vomiting. Can cause extra intestinal replacement. Antibiotics may not Thoroughly cook poultry and usually several days to juice, cheese, contaminated infections in 2% of cases (septic arthritis, eliminate the carrier state and may do not cross-contaminate raw several weeks, throughout raw fruits and vegetables , pericarditis, etc. lead to resistant strains or more poultry with other ready-to-eat the course of infection. (alfalfa sprouts, melons, severe infections. However, in some foods. Note: therapy may etc.). Contact with infected high-risk groups antibiotics therapy prolong excretion. animals. should be used. Consult CADE. Salmonella Typhi * # Depends on size of dose Person to person and fecal Insidious onset of sustained fever, Oral fluoroquinolone is the drug of Exclude patients and () ingested; from 3 days to over oral transmission. Fecal marked headache, constipation, malaise, choice for adults but resistance is symptomatic contacts from 60 days, usual range of 8-14 contamination of water chills, bradycardia, splenomegaly, and emerging. Oral chloramphenicol, high-risk settings (food days. Communicable as supplies or street-vended myalgia; diarrhea is uncommon, and amoxicillin or trimethoprim- handling, direct patient care, long as bacilli appear in foods with feces or urine of vomiting is usually not severe. sulfamethoxazole (particularly in child care) until 3 negative excreta, usually from the first infected patients or carriers. children) have comparable high stools are collected at least 1 week throughout Rare in developed countries. efficacy for acute infections. month apart and at least 48 convalescence. 2-5% Vaccinate those traveling to high risk hours after antibiotics are become carriers. areas. discontinued. If asymptomatic contacts work in a high risk setting, evaluation is required. Contact CADE at 1-800-362- 2736 immediately. Shigella spp. * # 12-96 hours, average 1-3 Usually person to person Abdominal cramps, fever, and diarrhea. Rehydration and electrolyte Exclude patients and days. Up to one week with spread, fecal-oral Stools may contain blood and mucus. replacement. If illness is severe, or if symptomatic contacts from Shigella dysenteriae. transmission. Food or water Children may get convulsions. epidemiologically indicated, antibiotics high-risk settings (food Communicable during acute contaminated with fecal (based on antibiogram) may be given handling, direct patient care, infection and up to 4 weeks material. Ready-to-eat foods to shorten the duration and severity of child care) until 2 negative after onset of illness. touched by infected food illness and the duration of the stools are collected at least 24 workers. pathogen excretion. Antimotility hours apart and at least 48 agents are contraindicated as these hours after antibiotics are drugs may prolong the illness. discontinued. If high-risk setting is involved, immediately contact CADE at 1-800-362- 2736. Staphylococcus aureus 30 minutes to 8 hours, Foods that come in contact Abrupt and sometime violent onset of Rehydration. Antibiotics are of no use. Hold cooked food for no more (preformed enterotoxin) average 2-4 hours. Not with hands of infected food severe nausea, abdominal cramps, than 4 hours at room communicable person-to- handlers, either without vomiting, and prostration, often temperature. Cooked foods person. subsequent cooking or with accompanied by diarrhea. Sometimes should be refrigerated at inadequate heating or with subnormal temperature and low temperatures less than 41° F refrigeration, such as blood pressure. in containers no greater than 4 pastries, custards, salad inches deep. People with dressing, sandwiches, boils, abscesses, and other poultry, sliced meat, and lesions of the hands, face, or meat products. nose should be excluded from handling food until they are non-infectious. Toxoplasma gondii Approximately 7 days, with a Ingestion of raw or Usually asymptomatic. Twenty percent Asymptomatic healthy, but infected Wash hands thoroughly after range of 4-23 days. Not undercooked infected meat may develop cervical people do not require treatment. In handling raw meat, after directly transmitted person- (pork or mutton, more rarely and or an -like specific cases spiramycin or contact with soil that may be to-person except in utero. beef) containing tissue cysts illness. Central nervous system disease, pyrimethamine plus sulfadiazine and contaminated with cat feces, or by ingestion of infected myocarditis, skeletal involvement or folic acid may be used for and after cleaning litter boxes. oocysts in food or water pneumonia is often seen in the immunocompromised persons, contaminated with cat feces. immunocompromised. pregnant women, or those with organ system involvement. Trichinella spiralis * GI symptoms within a few Ingestion of raw or Clinical illness ranges from unapparent Albendazole and mebendazole. Cook all pork and wild game (trichinosis) days. Systemic symptoms insufficiently cooked infection to a fulminating, fatal disease, Corticosteroids delay elimination of the meat thoroughly. within a range of 5-45 days, contaminated meat, usually depending on the number of larvae adult worms from the intestine, but usually 8-15 days. Not pork or wild game meat (e.g. ingested. Sudden appearance of muscle may be needed to alleviate communicable person-to- bear or moose). soreness and pain together with edema inflammatory reactions in the CNS or person. of the upper eyelids fever and ocular heart. hemorrhage are early characteristic signs. Other symptoms are thirst, chills, diarrhea, and weakness. Vibrio cholerae ** From a few hours to 5 days, Ingestion of contaminated Painless profuse diarrhea without Aggressive oral and IV rehydration Contact CADE immediately at (cholera) usually 2-3 days. water or food (particularly abdominal cramps or fever. Stools are and electrolyte replacement. In case 1-800-362-2736. Lab testing Communicable as long as raw or undercooked colorless, with small flecks of mucus of confirmed cholera, tetracycline, or for Vibrio must be specifically stools are positive; usually shellfish), moist grains held (“rice-water”). Nausea and profuse doxycycline for adults. Alternate asked for. Cook all shellfish only a few days after at room temperature, and vomiting occur early. antibiotics include furazolidone, thoroughly. recovery. raw or partially dried fish. erythromycin, ciprofloxacin for children <8 years of age. Vibrio Usually 12-24 hours but can Ingestion of undercooked or Watery diarrhea, abdominal cramps, Rehydration. Antibiotics are Lab testing for Vibrio must be parahaemolyticus range from 4-96 hours. Not raw seafood, such as fish nausea, vomiting, fever, and headache. recommended for septicemia - specifically asked for. Cook all normally communicable and shellfish or food Symptoms usually last 1-7 days. tetracycline, aminoglycosides, 3rd seafood thoroughly. Wash person-to-person except prepared with contaminated generation cephalosporins, hands, surfaces, and cooking fecal-oral transmission. water. fluoroquinolones. utensils after handling raw seafood. Vibrio vulnificus Usually 12-72 hours after Ingestion of undercooked or Vomiting, diarrhea, abdominal pain, Rehydration. Tetracycline, Lab testing for Vibrio must be eating raw or undercooked raw seafood, especially bacteremia, and wound infections. doxycycline, and ceftazidime are specifically asked for. Cook all seafood. Not communicable oysters. Open wounds Bullous skin lesions often present, recommended antibiotics. seafood thoroughly. Do not person-to-person. exposed to seawater can disseminated intravascular coagulation eat raw oysters, especially if at also be infected. (DIC), . More common high-risk. Any open wound in patients with chronic or in should be rinsed with clean the immunocompromised. One third of fresh water. patients are in shock when they present. Yersinia enterocolitica Probably 3-7 days, generally Ingestion of contaminated Appendicitis-like symptoms (diarrhea and Rehydration. Illness is usually self- Thoroughly cook pork and Yersinia pseudo- less than 10 days. food or water. Pathogenic vomiting, fever, and abdominal pain) limiting. If septicemia or other invasive products. Communicability is probably strains are most commonly occur primarily in older children and disease occurs, antibiotic treatment for the duration of excretion isolated from raw pork and young adults. In young children, acute with aminoglycosides and TMP/SMX. of the organism, which pork products. In the US, febrile diarrhea (sometimes with blood Quinolones, such as ciprofloxacin, are averages 2-3 weeks after chitterlings (pig intestines) and mucus) with abdominal pain. also highly effective. diagnosis. However, are a common source of Systemic infections can occur. secondary transmission infection. appears to be rare.

* Disease is reportable to Center for Acute Disease Epidemiology (CADE) ** Disease is IMMEDIATELY reportable to CADE: 1-800-362-2736 Revised March 2013 # Disease for which isolates are required to be sent to the State Hygienic Laboratory at the University of Iowa: 319- 335-4500 Contact public health of any suspected outbreak Immediately report any disease when there is reasonable suspicion that it may be the result of a deliberate such as terrorism

REMEMBER: HANDWASHING IS THE MOST IMPORTANT ACT A PERSON CAN DO TO PREVENT TRANSMISSION OF DISEASE!!!!