Common Foodborne Illnesses What Is Salmonella?
The salmonella bacterium is typically found in poultry – especially chicken, raw eggs, unwashed fruit and vegetables and food which has not been prepared properly. It thrives in unclean kitchens and areas where there is poor hygiene and can also be found in water which has been contaminated by bird or reptile faeces.
Normally salmonella bacteria are destroyed during cooking at the correct temperatures. If food is not cooked to the correct temperatures or stored under the correct conditions then contamination will occur.
The elderly, children and people with compromised immune systems e.g. cancer patients are at particular risk from salmonella. It is a highly infectious illness which can be spread by person to person contact. That’s why outbreaks often occur in nursing and residential care homes, hospitals and nurseries.
In order to minimise the risk of salmonella poisoning, controls need to be put in place throughout the food pathway. The responsibility for providing safe food lies with everyone, not just caterers. Farmers, food manufacturers, distributors and those who prepare and serve food have a part to play in maintaining food safety.
Steps have been taken in reducing the risk of salmonella in UK eggs. As a result, the Food Standards Agency has recently changed their guidance. They now “will no longer advise against the consumption of raw and lightly cooked eggs by vulnerable groups, including pregnant women, the young or the elderly, provided that they are produced under the Lion code quality assurance scheme”. This advice however does not include those with severely compromised immune systems.
The STS Food Safety Standard: Protecting the Most Vulnerable is the only UKAS accredited food safety audit standard which targets the controls in place for specific food borne illnesses. We’ll help identify and manage risks and put measures in place to protect your business, customers and reputation.
What Is E-Coli?
E-coli is a misunderstood bacterium as most strains are generally harmless. In fact, it actually helps us with digestion and provides essential vitamins like K and B-complex. But not all strains of e-coli are harmless, particularly e-coli 0157:H7 and 01014.
A common source of e-coli is the intestinal tract of cattle. The Food Safety Agency and other safety agencies around the world are working with farmers and slaughter houses to reduce the risk of contamination by improving hygiene practices.
Spinach, milk, pasteurised fruit juices, salad leaves and blue cheese have caused recent outbreaks. The
deadliest outbreak was in 2011 in Germany where more than 30,000 people were ill and 43 died from a rare strain that was eventually linked to sprouted fenugreek seeds.
The WHO say this “super toxic” strain of the e-coli 0104 hasn’t occurred in people before and is more dangerous. Consequently, it affects everyone, not just the more vulnerable groups as is more common with e-coli 0157.
In order to minimise the risk of an outbreak, controls need to be put in place throughout the food pathway. The responsibility for providing safe food lies with everyone, not just caterers. Farmers, food manufacturers and distributors all have a part to play in maintaining a safe food pathway.
The STS Food Safety Standard: Protecting the Most Vulnerable is the only UKAS accredited food safety audit standard which targets the controls in place for specific food borne illnesses. Our experts will help you identify and manage the risks and put measures in place to protect your business, customers and reputation.
E.coli 0157 – AKA the Burger Bug
The first known E.coli O157 outbreak was reported in the USA in 1982, due to the consumption of undercooked burgers. In the UK the worst outbreaks of this deadly pathogen were in Scotland and Wales, due mainly to cross contamination and failure to comply with food safety laws:
Scotland 1996: 500 cases and 21 deaths after the consumption of contaminated meat products at senior citizens event in Lanarkshire. Wales 2005: 158 cases and tragically the death of 5 year old Mason Jones. The cause was contaminated school meals.
Escherichia Coli 0157 is an extremely tough micro-organism. It can survive for 60 days on a stainless steel surface and the infection dose can be just 10 cells. The onset time is typically 48 hours and the symptoms last around 1-8 days. Illness generally includes abdominal pain, bloody diarrhoea, vomiting and fever. Complications may arise in children and the elderly when toxins from an infection lead to kidney failure (Haemolytic-uraemic syndrome). Luckily with dialysis and blood transfusion most recover.
The intestines of humans and cattle are common sources of E.coli O157. You can also be find it in the natural environment. Contamination can spread via the faecal oral route, food vehicles and water. Beef, especially mince, and other meats are usually the cause of outbreaks. However other foods including spinach, milk and pasteurised fruit juices can cause outbreaks. An outbreak in USA in 2006 lead to 267 illnesses and 3 deaths caused by eating spinach sprayed with irrigation water contaminated with animal faeces.
A common source of E.coli is the intestinal tract of cattle. The FSA and other food safety agencies around the world are working with farmers and slaughter houses to reduce the risk of contamination by improving current hygiene practice. One study, following E.coli O157 outbreak in Norway, showed cleaning meat carcasses with hot water above 82C reduced contamination by 99%.
E.coli O157 can cause kidney failure in children and can be found in low levels on raw foods. As few as 10 E.coli O157 bacteria transferred from raw to ready to eat food can be fatal.
The FSA has issued the following guidance following the recent E.coli O157 outbreak in Wales where a school boy died needlessly from eating a school dinner of cooked meat supplied by a butcher whose unacceptable practices led to cross contamination.
The guidance identifies procedures that food businesses are expected to have in place to avoid cross contamination from raw foods (includes raw meats, raw poultry, non ready to eat leaf and root vegetables) to ready to eat foods.
You may well already have many practices in place which meet the guidance, however STS advise you take a fresh look at controls within your organisation and tighten up your food safety management system where necessary. Of course, your team will need training and supervision in the practices you decide on for your operation.
Whereas the guidance focuses on avoiding cross contamination (and will help control other pathogens such as Campylobacter), remember that another important control for E.coli O157 is thorough cooking of minced meat products and rolled meat joints.
Separate facilities, including staff, should be provided for raw food and ready to eat food, This includes facilities such as: Work areas Storage facilities Sinks Equipment Utensils Complex equipment such as slicers, mincers and vacuum packing machines must NEVER be used for raw and ready to eat foods; separate machines must be provided. Consider other, less obvious items which could be vehicles for cross contamination for example: Cash registers Packaging Clothing Aprons Pens Mobile phones Cleaning materials & equipment Cleaning & disinfection Where separate facilities cannot be provided for raw food, cleaning and disinfection after use for raw food must be thorough: Heat The guidance promotes the use of dishwashers to disinfect equipment such as boards and utensils. To disinfect, the final rinse cycle needs to reach 82ºC or above. Several of STS’ clients check and log dishwasher temperatures daily. Reusable cloths should be hot washed at this temperature. Chemicals Where sanitisers and disinfectants are used, be sure your chemicals are up to scratch and also that your team are using them properly. STS find a common problem with use of sanitizers is use at the incorrect dilution or that staff are unaware of the correct contact time. Disinfectants and sanitisers must meet the official standards of BS EN1276:1997 and BS EN 13697:2001 – check with your supplier. Hand washing The guidance advises that movement of staff handling raw then ready to eat food must be minimised. It stresses hand washing after handling raw food, using the toilet (we can be carriers of E.coli), and before handling ready to eat food. The guidance refers to using a “recognised technique” and also cites that gels should not be used instead of hand washing. The use of non-hand operable taps is recommended but if unavailable they should be turned off using a paper towel so that hands are not recontaminated. The guidance stresses that contact with food should be minimised; tongs and gloves (if used properly) can be used in preference to hands. Further information The guidance is available in full at the Food Standards Agency website. What Is Campylobacter?
Campylobacter is the most common cause of food poisoning in the UK. The
Food Standards Agency estimates that campylobacter causes more than 280,000 cases of food poisoning each year, with around 100 deaths and an estimated cost to the UK economy of around £900 million. It can affect anyone but there are certain groups who are particularly vulnerable to this illness, including children, the elderly and anyone who has a weakened immune system.
Campylobacter is a naturally occurring bug that lives in poultry. It’s harmless to chickens but roughly 4 in 5 cases of campylobacter poisoning have been
traced to contaminated poultry. Campylobacter is also found in red meat, unpasteurised milk, unwashed fruit and vegetables and untreated water.
Campylobacter does not normally grow in food but it does spread easily. Even a very small amount of bacteria can cause illness. Bacteria is present in undercooked or raw chicken and can transfer from these to other ready to eat foods. By washing raw chicken, you run the risk of it spreading onto kitchen work surfaces, which increases the risk of contaminating other foods. You can also spread it by not washing your hands after contact with infected birds and animals.
That’s why controls are put in place throughout the food pathway, all the way from the farm to the table. The responsibility for providing safe food lies with everyone, not just caterers. Farmers, food manufacturers and distributors all have a part to play in maintaining a safe food pathway.
One of the predominant reasons it is the main cause of gastroenteritis in the UK is because only a very small number are required to cause illness. Usually about 500 organisms can cause illness but reports have shown that as few as 100, if consumed with milk or other foods which lower the pH of the stomach acid, can cause illness as well.
The incubation period (the time between consumption and first signs of illness) for Campylobacter is usually 2 to 5 days. However this can vary from as quick as 1 day to as long as 10 days. This incubation period depends upon the health of the person, the number of
Campylobacter organisms consumed and various other factors.
Its main symptoms are stomach pains and diarrhoea. Often mucus is excreted in the stool as well (apologises if you are eating whilst reading this!). An additional complication to the already horrible symptoms is reactive arthritis (also known as Reiter’s syndrome).
Campylobacter is a natural part of the gut flora of many animals including birds and reptiles.
A UK-wide survey was undertaken by the Food Standards Agency in 2007/2008 and found that the prevalence of Campylobacter in chicken on retail sale in the UK was 65.2%.
It is most commonly associated with eating undercooked poultry or by eating ready to eat food which has been cross contaminated by Campylobacter from raw poultry/meat.
Another method of contamination is actually from the beaks of birds, typically Magpies, where they have peaked at the bottle tops of milk left on doorsteps. I am sure we have all experienced this at some point if we have our milk delivered. This is one of the reasons it is vital that milk which has been damaged in this way must not be used.
The Food Standards Agency in partnership with DEFRA (Department for Environment, Food and Rural Affairs) and a number of other organisations have developed a risk management program which aims to reduce the levels of Campylobacter in chickens by 2015. This has identified 3 separate categories of severity:
Less than 100 cfu/g* 100 / 1000 cfu/g More than 1000 cfu/g
*cfu/g standing for colony-forming units per gram
Each category has an individual target to achieve. Currently, 27% of birds are in the highest category. By 2015 this should be down to 10%. This target alone will result in a reduction of about 90,000
Campylobacter food poisoning cases a year.
You should assume most raw chicken is naturally contaminated by Campylobacter and handle it accordingly.
Here are some simple ways you can avoid Campylobacter:
Avoid cross contamination Keep raw and cooked foods separate at all times Clean and disinfect food contact surfaces, equipment and utensils after use for raw food. Use separate surfaces, equipment and utensils for raw food where possible. Cook all food, especially poultry, thoroughly. Wash hands frequently and thoroughly, especially after handling raw foods
The STS Food Safety Standard: Protecting the Most Vulnerable is the only UKAS accredited food safety audit standard which targets the controls in place for specific food borne illnesses. Our experts will help you identify and manage the risks and put measures in place to protect your business.
What Is Clostridium Botulinum?
If you are not familiar with
Clostridium botulinum, don’t worry, it’s probably because it very rarely occurs in the UK. The organism produces a toxin which interrupts the transmission of nerve impulses to muscles i.e. it paralyses. The mortality rate can vary from 15%-90% depending on type of toxin, dosage, age of patient, speed of diagnosis etc. Therefore, once identified it requires fast and efficient action. When it comes to botulinum poisoning, every second counts. The sooner an outbreak is identified, the sooner those who have consumed the contaminated items can be offered lifesaving treatment.
As mentioned earlier it is very rare in the UK. In fact since 1922 only 52 cases have been reported. 27 cases were from a single outbreak which was caused by contaminated Hazelnut yogurt in 1989. There is a long history for Clostridium Botulinum. In fact we are able to trace it right back to 1793 when it was first researched by a German doctor (and poet) by the name of Justinus Kerner. He had been alerted to an outbreak in Wildbad, Germany where 13 people had become ill, 6 of whom died, after eating a local produce known as “blood sausage”. After further research Kerner discovered 230 similar cases where people had become ill after eating sausages. Of course micro-organisms had yet to be discovered and so after briefly being known as “Kerner disease” it soon was given the name “botulism” after the Latin word “botulus” meaning sausage.
Thankfully, research has developed much further. We now know Clostridium botulinum is a spore producing organism which can be found extensively in soil and mud. It therefore can also be found in animals, especially those that forage around water, and fish. The toxin is thermolabile, which means that it is destroyed by good cooking. However, the spores that the organism creates require much higher temperatures in order to be destroyed. A process such as boiling will not reach the temperatures required.
Due to the high temperature required to kill the organism, canned goods go through heat treatment; to preserve and protect. During heat treatment, canned goods are heated to a temperature of 121°C for a period of time so as to destroy all spores. The reason we focus on canned and also vacuum packed goods is because Clostridium botulinum is an anaerobic organism – it prefers an environment without oxygen. What better place to set up home than in a container filled with food that has had virtually all the air removed? It’s almost like we invited it into our food supply.
Clostridium botulinum is not without its uses however. I’m sure you will have at some point meet someone or have a friend of a friend who has had Botox, maybe you have even had the treatment yourself? Well, Botox is botulinum toxin type A. I did say earlier it caused paralysis! And that is exactly what the desired effect is. It is paralysing the facial muscles so as to reduce wrinkles. Another common beneficial use for botulinum toxin type A (BTX-A) is its use to help treat hyperhidrosis (excessive sweating) and the beneficial effects of BTX-A are also being researched for conditions such as asthma. It has already been approved in the USA by the FDA (Food and Drug Administration) for the treatment of chronic migraines.
So though deadly, this micro-organism is proving to be very beneficial with the correct application!
What Is Listeriosis?
Although cases and outbreaks of listeriosis are relatively rare, the concern with listeriosis is that the fatality rate is high – approx. 30% in vulnerable groups. As a consequence, listeriosis kills more people in the UK than any other food-borne disease. Listeriosis outbreaks have occurred in hospitals, giving rise to the need for listeriosis guidelines for healthcare establishments in order to reduce the risks.
The research into previous listeriosis outbreaks in hospitals found that almost all were linked to consumption of pre-packed sandwiches. Almost all listeriosis outbreaks were thought to have been caused by low level contamination of the ingredients with
Listeria monocytogenes during manufacture in the factory, followed by a breakdown in the control of the cold chain in the hospitals, leading to multiplication of Listeria monocytogenes to infective levels.
This is not to say that pre-packed sandwiches are the only product which can be affected – listeriosis has been linked to many different products, usually those which support bacterial growth and are ready to eat. Neither does this mean listeriosis is only caused by contamination of food brought in – contamination could occur in the healthcare organisation, and if time and temperature are not adequately controlled, risks could be high.
Listeriosis is caused by the bacteria
Listeria monocytogenes. One of the features that make the listeriosis bacteria different from other harmful, pathogenic micro-organisms is that it can grow at low temperatures, including in a refrigerator. If high risk foods are contaminated and given enough time they can grow and multiply to harmful levels in the food, putting patients at risk.
One surprising and very significant fact that came form the research was that the rate at which the
Listeria monocytogenes bacteria multiply doubles at 8°C compared to 5°C. For this reason the listeriosis guidelines encourage the cold chain to be maintained at 5°C or less. This could well give rise to CapEx considerations for health care organisations with ineffective kit.
During research into current practices and previous outbreaks, STS found that hospitals who had experienced listeriosis outbreaks were the most exemplary in their standards – showing that tight practices are possible. We found catering managers who had experienced listeriosis outbreaks had become very knowledgeable and put excellent procedures in place to prevent recurrence.
Lessons learned from the hospitals and environmental health professionals who had dealt with previous listeriosis outbreaks were invaluable, especially those in Northern Ireland who have undertaken extensive work into prevention. The extent of the precautions in place even extend to patient locker checks by nursing staff as some cases of listeriosis have been linked to patients squirrelling sandwiches away in lockers, leading to rapid multiplication of
Listeria monocytogenes at room temperature.
In 2014 STS carried out a research project on behalf of the FSA in order to draft new listeriosis guidelines.
As one of the leading food safety specialists in healthcare we were well positioned to undertake the listeriosis guidelines research project. As well as having assessed the NHS supply chain for food safety for over 20 years, we work with NHS Trusts, private hospitals, care homes and contract caterers in care settings nationwide.
The listeriosis project involved undertaking considerable research, upon which the new listeriosis guidelines are based. Main threads of research included:
Literature review in conjunction with the University of Surrey Research into previous listeriosis outbreaks including visits and interviews with hospitals and/or EHO’s departments that investigated the listeriosis outbreaks Research into current practices, which included: Site visits to healthcare organisations nationwide A survey to ascertain current practices – with almost 400 respondents
We adopted a collaborative approach to the listeriosis guidelines project, involving the following partners in the project team:
Healthcare organisations e.g. HCA, NACC, NHS Trusts from England, Northern Ireland, Scotland , Wales, private hospitals, care groups Enforcement officers/bodies from England, Northern Ireland, Scotland and Wales, and the CIEH
We believed involvement and partnership was important in order to ensure the listeriosis guidelines were well rounded and practical.
The FSA then further consulted wider on the listeriosis guidelines draft with other stakeholders.
The listeriosis guidelines are pitched to apply both to a small care home or a large complex hospital. They not only benefit healthcare organisations by helping them to protect patients/residents from listeriosis, but also provide sensible food safety advice in general.
We observed that food safety is commonly seen as the responsibility of the catering department alone, however, this is most certainly not the case.
Many of the listeriosis outbreaks in hospitals have not arisen from patient catering from the main kitchen but from other sources. The listeriosis guidelines rightly bring out that Trusts/healthcare organisations needs to look at all food pathways – routes by which food can reach patients – and do what they reasonably can to make sure each pathway is safe. In the light of this guidance STS urges Trusts and other healthcare organisations to examine the food pathways which exist within their operation and ensure they are addressed in their organisational-wide food safety policy, taking into consideration the listeriosis guidelines.
One example of a food pathway is sandwiches purchased in retail outlets, including those run by voluntary organisations. Onsite contractors and retailers may not have the same standards in terms of procurement, temperature control etc as the main catering operations.
Other food pathways include food which is brought in for patients by relatives or volunteers. The listeriosis guidelines provide sensible advise which can be taking into consideration when developing such policies.
Over the years, STS has found that food safety within a hospital catering department is often at a high standard, and it can be at ward level where food safety can come unravelled, especially where food service is dependent on staff outside the catering team e.g. housekeepers, domestics or nursing staff. Of course there are wards where food service is exemplary, but STS has observed that too often responsibilities are blurred, or bad practices are observed.
As recently as the last few weeks, Fiona Sinclair from STS recalls observing sandwiches left at room temperature in ward kitchens, sandwiches which are past their use by date, and sandwiches placed in pantry fridges holding above 8°C. Such practices are unacceptable when providing food for vulnerable groups, and should be a thing of the past.
Why does this happen? Food service at ward level is often the responsibility of departments and staff for whom food is not a primary role and, sometimes, there is less awareness of the fundamental acceptable/unacceptable practices which are the norm for a member of the catering team. Furthermore at ward level, responsibilities for disposal of out of date food, checking fridge temperatures etc can sometimes be blurred amongst departments which leads to them falling between the gaps.
STS’s Fiona Sinclair says: “Catering managers regularly express frustration and concern about what happens when the food leaves the control of the catering department. We very much hope that these guidelines will be the catalyst to consistently raising food safety standards across the UK at ward level and that it will become more and more common to see the food safety culture extending into food service.”
The fact that Listeria monocytogenes double in number twice as fast at 8°C than 5°C is significant as, in our experience, hospitals and care homes often have domestic fridges in ward/pantry/kitchenettes.
Fiona Sinclair says: “It is not uncommon to find fridges struggling to hold temperatures even at 8°C or below – the legal maximum. Just because a small satellite kitchen used for food service is termed a pantry or kitchenette, it does not mean that domestic standards are acceptable – it is unacceptable to store high risk foods such as sandwiches and salads in fridges which do not maintain temperature.”
Some Trusts and homes will need to invest in maintaining the cold chain to address such issues.
The thought that a loved one should lose their life from eating a sandwich in hospital is ridiculous. The new guidelines which have been released are a helpful step towards raising awareness of the problem and taking sensible preventative measures to reduce the risk of listeriosis. It’s trusted that healthcare organisations will find the guidance helpful in understanding the risks, and incorporating safe measures into their management systems.