Fear of fresh: how to avoid foodborne illness from fruits & vegetables.

Kyle Allgood, of Chubbuck, Idaho, would have been three in December. He died on September 20 after E. coli O157:H7 damaged his kidneys. Kyle got the E. coli from the fresh spinach smoothie that his mother made for him.

Jillian Kohl, of Milwaukee, was luckier. The graduate student, who used to run marathons, suffered stomach cramps, muscle aches, fever, and bloody diarrhea after eating spinach. After 2 1/2 weeks in the hospital, Jillian was discharged with less than 10 percent of her normal kidney function.

Since when do we have to worry that even the healthiest foods could harm or kill us?

Q: Is it riskier to eat produce these days?

A: Yes. The outbreaks are bigger and more frequent than they were 20 or 30 or even 15 years ago. Even though we can identify and control outbreaks better than we used to, when contamination occurs with lettuce, spinach, cantaloupe, or tomatoes, we can have a big problem on our hands.

The headlines about E. coli O157:H7 in spinach tell the story. Since some produce is very conveniently packed in a bag and prewashed, there is nothing consumers can do to lower their risk. In many cases, you don't cook it. You don't blanch it. You don't do much except eat it. So it's critically important that it not be contaminated from the beginning.

Q: Why are outbreaks in produce on the rise?

A: One reason is that people are eating more fresh fruits and vegetables than they did 30 years ago. That's a good thing. We want people to eat fresh produce. Before fresh spinach went off the market, something like a third of people we called had eaten fresh spinach in the previous week. That's great news.

Q: Are greens in bags causing more outbreaks?

A: Conceivably. Rather than just one head of lettuce or a bunch of spinach, there could be leaves from many different plants in one bag. Bacteria from one contaminated leaf in a bag, you can just imagine, would be over all the leaves in the bag by the end of the distribution chain.

It's a pooling issue, like ground beef. How many cows are in one patty of ground beef? How many cows contribute to one glass of milk? It means that procedures have to be in place to make sure that none of it is contaminated.

Q: Does the bacteria come from nearby animals?

A: Possibly. We know that feedlots have E. coli O157:H7. How wise is it to grow spinach or lettuce plants, which are very close to the ground, just downwind or downstream or down the hill from a feedlot or cow pasture? Doesn't sound like a good idea to me.

The produce industry has to figure out how to prevent contamination. Maybe we need a half-mile buffer between feedlots and produce farms.

Q: Does it help to wash produce?

A: We recommend washing produce in general, even if you plan to peel it. When you slice a melon, for example, the knife can transfer bacteria from the surface to the inside.

But it's tough to get bacteria off greens. Those germs are very sticky. This triple-washed stuff that comes out of the bag--if it's got contamination on it, there's no way to wash it off, even if you use bleach or detergent.

And you can't wash off germs if they're inside the melon, mango, or apple. For example, bacteria can creep in through the apple core. Germs can go in the hole at the very bottom of the apple where the flower was--it's called the calyx.

Q: Is organic produce less likely to have E. coli?

A: No. I don't see this as an organic versus conventional issue, just like it's not a domestic versus imported issue. There's room for improvement with both kinds of production and on both sides of the border.

Q: Which produce is most likely to have E. coli O157:H7?

A: The recurrent outbreaks have come from leafy greens--especially lettuce--sprouts, and unpasteurized juices and cider. It's not all fruits and vegetables. And apple cider might be a special case because it's sometimes made from apples that have fallen from the tree.

What those fruits and vegetables have in common is that they're grown fairly close to the ground, they're not cooked, and they're not acidic. In general, the bacteria that cause foodborne disease don't like acid. But Americans have a phenomenal sweet tooth, and my understanding is that apples and tomatoes are getting sweeter and less tart and acidic.

Q: Is all foodborne disease rising?

A: No. Over the last ten years, we've witnessed important decreases, 29 to 32 percent, in infections that are related to meat and poultry--like E. coli O157:H7 linked to ground beef; or Listeria infections, which are often linked to processed meats; or Campylobacter, which is linked to poultry. We haven't eliminated them, but we're certainly headed in the right direction.

Q: What about Salmonella?

A: In the same ten-year period, it's down 9 percent, which is not a brilliant success. Salmonella is complicated, because it can come from a number of foods and even non-food sources like pet turtles or lizards. And antibiotic-resistant Salmonella--much of it from ground beef--has become more of a problem over the last decade.

WHEN TO CALL THE DOCTOR

Q: Which symptoms should alert people to call the doctor?

A: The red flag is diarrheal illness that's not resolved in three days or that's accompanied by a fever over 101.5[degrees]F or by blood in the stools.

If a very young child seems lethargic or doesn't seem to be making much urine or tears, that could be a sign of dehydration and is another reason to seek medical attention. Any young child with diarrhea should start drinking pediatric electrolyte solution--it's in all the drugstores--to prevent dehydration.

Q: How soon do the symptoms of E. coli O157:H7 show up?

A: They usually appear within 3 to 4 days, but it could be anywhere from I to 10 days. Most people have bloody diarrhea and severe abdominal cramps, but sometimes the infection causes nonbloody diarrhea or no symptoms at all. Usually the person gets little or no fever, and the illness resolves in 5 to 10 days.

Q: How many people end up with life-threatening complications?

A: About 3 to 8 percent get hemolytic uremic syndrome, or HUS. Some don't have complete kidney failure, but most do.

There are two parts to HUS. One is the kidney failure--that's uremia, the 'U.' The other is hemolysis, the 'H.' That's when red blood cells look like they've been through a blender.

The E. coli toxin damages blood vessels by creating small strands across the insides, so when the red blood cells go through them, it's like they're going through a cheese cutter. It just slices up the red cells.

So people may need transfusions and dialysis before the blood vessels get better. They're destroying their own red blood cells. Even with intensive care, 3 to 5 percent of these patients die.

Q: Should doctors send a stool sample to the local health department?

A: That's absolutely vital to our tracing the outbreaks. But the doctor may wait to see if the diarrhea goes away in a few days rather than sock the patient with a bill for the lab. We recommend a stool specimen if it's a severe illness, bloody diarrhea, high fever, or if the illness is lasting.

A stool sample can also tell the doctor whether the infection will respond to an antibiotic and to which antibiotic. With so much resistant bacteria around, that could be especially important. But often the patient will get better with no antibiotics.

Q: Can antibiotics make E. coli O157:H7 infections worse?

A: There's a real paradox. The E. coli harms people by producing a toxin that destroys blood vessels in the gut, kidney, and brain. An antibiotic drug kills the E. coli, but it also can provoke them to make a lot more toxin. So it may make the patient worse. Antidiarrheal agents like Imodium should also be avoided.

WHAT'S NEXT?

Q: What new foodborne illnesses are emerging?

A: Some new and highly resistant strains of Salmonella have appeared in recent years. In Japan, they've seen cases of hepatitis E from pork sushi.

And in Finland, they're seeing outbreaks of Yersinia pseudotuberculosis. It's a second cousin to the bug that causes the plague. Finland recently realized that the outbreaks of what looks like appendicitis were due to this bug, which was traced to eating local lettuce.

Q: So people there may have unnecessary surgery for appendicitis?

A: Yes. Doctors perform surgery and find no problem with the appendix, but they see big swollen nodes all over the intestines. That's what the gastrointestinal tuberculosis looks like.

The working assumption is that Yersinia causes disease in deer and rabbits, which are getting into the lettuce and carrot fields and contaminating them. It's not a problem in this country, but there are other problems elsewhere in the world, and I expect that we'll be finding more of them in our food supply.

Q: What about in the United States?

A: Some investigators have raised the possibility that the E. coli that causes urinary tract infections comes from the animals we eat, but the link is by no means proven.

Q: Have antibiotics made some Salmonella resistant?

A: Yes. Anytime an antibiotic is used in a hospital, in a child with an earache, or in animals on a farm, there are winners and losers in the local bacterial population. You hope that the losers are the bacteria that were making the patient, child, or animal sick. But if there's a bacterium there that's resistant, it's a winner.

The bacteria in food that make us ill--like Salmonella or Campylobacter--have their natural home in animals, not people. So antibiotic use in those animals can make those bacteria resistant.

Q: Are bacteria that live in people also becoming resistant?

A: Yes. The antibiotics we use in people cause resistance in the bacteria that cause pneumonia and tuberculosis. We have a program here at the CDC called Get Smart, which tries to reduce unnecessary antibiotic use for people who have colds. Antibiotics aren't going to make them better. Likewise, we have a program called Get Smart on the Farm to promote prudent antibiotic use in animals.

Q: And the farm is where contamination starts?

A: Right. Most of the progress we've made with E. coli, Listeria, and Campylobacter has been at the slaughterhouse. The process is cleaner than it was before. But many of the animals coming in off ranches and farms are still contaminated.

And I'm concerned that back on the farm, bugs are transferring from animals to plants or cycling back and forth from animals to plants. You can't slaughter a spinach plant in a way that guarantees that it comes out clean. So the effort has to be focused on the farm, and that includes the animal farm.

Q: Should people stop eating leafy greens?

A: No. We want to encourage people to eat fresh fruit and vegetables. But obviously, the spinach problem--and previous problems with lettuce, tomatoes, and other fresh produce--show us that contamination is not under control.

SAFE AT HOME

How you handle food matters. With enough warmth, moisture, and nutrients, one bacterium that divides every half hour can produce 17 million progeny in 12 hours.

Putting food in the fridge or freezer stops most bacteria from growing. Exceptions: Listeria (typically found in soft cheese, lunch meats, and hot dogs) and Yersinia enterocolitica (typically found in undercooked pork and unpasteurized milk) grow at refrigerator temperatures.

Rules for Leftovers 2 Hours--2 Inches--4 Days

2 Hours from oven to refrigerator

Refrigerate or freeze leftovers within 2 hours of cooking. Otherwise throw them away.

2 inches thick to cool it quick

Store food at a shallow depth--about 2 inches--to speed chilling.

4 Days in the refrigerator--otherwise freeze it

Use leftovers from the refrigerator within 4 days. Exception: use stuffing and gravy within 2 days. Reheat solid leftovers to 165[degrees]F and liquid leftovers to a rolling boil. Toss what you don't finish.

* Buy fresh-cut produce like half a watermelon or bagged salad greens only if it's refrigerated or surrounded by ice.

* Store perishable fresh fruits and vegetables (like strawberries, lettuce, herbs, and mushrooms) or pre-cut or peeled produce in a clean refrigerator at a temperature of 40[degrees]F or below.

* Wash your hands for 20 seconds with warm water and soap before and after preparing any food.

* Wash fruits and vegetables under running water just before eating, cutting, or cooking, even if you plan to peel them. Don't use soap (it leaves a residue). Produce washes are okay. (Exception: triple-washed bagged lettuce or other produce needs no further washing.)

* Scrub firm produce, like melons and

cucumbers, with a clean produce brush. Let them air dry before cutting.

* Remove the outer leaves of heads of leafy vegetables like cabbage and lettuce.

* Don't eat raw sprouts (alfalfa, bean, clover, or radish).

* Cooking a food at 160[degrees]F will kill any E. coli O157:H7.

* Neither processed spinach (frozen or canned) nor other fresh or processed leafy greens (like lettuce or kale) were implicated in the recent E. coli outbreak.

* Drink only pasteurized milk, juice, or cider.

* For more information on handling produce safely: www.cfsan.fda.gov/~dms/prodsafe.html.

* For information on E. coli O157:H7: www.cdc.gov/ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm

Sources: Centers for Disease Control and Prevention, U.S. Department of Agriculture, Food and Drug Administration, Center for Science in the Public Interest.

Robert Tauxe is Acting Deputy Director of the Division of Foodborne, Bacterial and Mycotic Diseases at the Centers for Disease Control and Prevention, He spoke to Nutrition Action's Bonnie Liebman by phone from his office in Atlanta.

Bugs are Breaking Out All Over

The Centers for Disease Control and Prevention (CDC) estimates that 76 million Americans become sick, more than 325,000 are hospitalized, and 5,000 die from foodborne illness each year. Experts estimate that foodborne illness costs the nation $10 billion to $83 billion each year in pain and suffering, reduced productivity, and medical expenses.

Here are some of the foods that are most likely to cause foodborne illness. The list is drawn from a database of some 5,000 outbreaks that sickened more than 150,000 people from 1990 through 2004. The database is maintained by the Center for Science in the Public Interest (publisher of Nutrition Action). A few caveats from CSPI director of food safety Caroline Smith DeWaal:

* Most foodborne illnesses are isolated cases, so outbreaks (two or more people sickened by the same food) are the exception.

* Many outbreaks and illnesses are never investigated or reported to the CDC.

* The outbreak data cover 15 years, so they don't necessarily reflect current trends. For example, eggs caused a much higher percentage of outbreaks in the early 1990s than they do today.

* Foods with multiple ingredients (like tacos, lasagna, cheeseburgers, chili, egg salad, stuffing, and some sandwiches) are in the database but most aren't listed here.

All Bugs (includes E. coli O157: H7)

Food                 Outbreaks      Cases *

Greens-based salad         199      7,555
Turkey                     109      5,832
Chicken                    215      3,979
Ground beef                171      3,425
Shellfish                  155      3,399
Berries                     20      3,330
Tomatoes                    19      2,852
Lettuce                     56      2,380
Eggs                        74      2,117
Ham                         46      2,107
Sprouts                     30      2,018
Ice cream                   44      1,807
Cheese                      50      1,791
Melon                       29      1,683
Juice & cider               22      1,514
Unpasteurized milk          56      1,457
Scallions                    9      1,221
Potatoes                    40      1,099
Luncheon meat               50      1,014
Bread                       32        980
Fresh tuna                 193        824
Fruit salad                 17        538
Mahi-mahi                   71        422
Fresh salmon                14        195

E. coli O157: H7

Food                 Outbreaks      Cases *

Ground beef                107      2,028
Lettuce                     12        336
Unpasteurized milk           4        222
Greens-based salad           9        216
Coleslaw                     3        194
Apple cider/juice            6        142
Alfalfa sprouts              3        120
Potato salad                 2         49
Melon                        2         36

* Number of people sickened. (For the latest report from
the CSPI outbreak database, see www.cspinet.org/foodsafety/
outbreak_report.html)

Source: Outbreak Alert/2005, Center for Science in the Public Interest.

THE DIRTY DOZEN

Bug                  Major Symptoms

Campylobacter        diarrhea (can be bloody),
(bacteria)           cramps, fever, vomiting

Ciguatera            within 2 to 6 hours: abdominal
(toxin)              pain, diarrhea, general pain and
                     weakness, nausea, temperature
                     reversal (hot things feel cold
                     and cold things feel hot),
                     tingling, vomiting within 2 to
                     5 days: slow heartbeat, low
                     blood pressure

Clostridium          vomiting, diarrhea, blurred
botulinum            vision, double vision,
(bacteria)           difficulty swallowing, muscle
                     weakness that spreads from
                     the upper to the lower body

Cyclospora           diarrhea (usually watery),
(parasite)           loss of appetite, substantial
                     weight loss, stomach cramps,
                     nausea, vomiting

E. coli 0157:H7      severe diarrhea that is often
(bacteria)           bloody, abdominal pain,
                     vomiting (usually accompanied
                     by little or no fever)

Hepatitis A          diarrhea, dark urine, jaundice
(virus)              (yellow "whites" of the
                     eyes), flu-like symptoms

Listeria             fever, muscle aches, nausea,
(bacteria)           diarrhea (pregnant women
                     may have mild flu-like symptoms;
                     can lead to premature
                     delivery or stillbirth)

Noroviruses          nausea, vomiting (more common
(virus)              in children), abdominal
                     cramping, diarrhea (more
                     common in adults), fever

Salmonella           diarrhea, fever, abdominal
(bacteria)           cramps, vomiting

Scombrotoxin         flushing; rash; burning sensation
(toxin)              in skin, mouth, and throat;
                     dizziness; hives; tingling

Vibrio               watery diarrhea, abdominal
parahaemolyticus     cramps, nausea, vomiting
(bacteria)

Vibrio vulnificus    vomiting, diarrhea, abdominal
(bacteria)           pain, bacteria in the blood,
                     wounds that become infected

Bug                  Some Foods that have
                     Caused Outbreaks

Campylobacter        undercooked poultry,
(bacteria)           unpasteurized (raw) milk,
                     contaminated water

Ciguatera            large reef fish like barracuda,
(toxin)              grouper, red snapper,
                     and amberjack

Clostridium          home-canned foods, improperly
botulinum            canned commercial foods,
(bacteria)           herb-infused oils, potatoes
                     baked in aluminum foil;
                     bottled garlic

Cyclospora           imported berries, lettuce
(parasite)

E. coli 0157:H7      undercooked beef, unpasteurized
(bacteria)           (raw) milk or juice, raw produce,
                     salami, contaminated water

Hepatitis A          shellfish, raw produce, foods
(virus)              that are not reheated after
                     coming into contact with an
                     infected food handler

Listeria             fresh soft cheeses, unpasteurized
(bacteria)           (raw) or inadequately
                     pasteurized milk, ready-to-eat
                     deli meats and hot dogs

Noroviruses          poorly cooked shellfish,
(virus)              ready-to-eat foods
                     touched by infected food
                     handlers, salads, sandwiches

Salmonella           eggs, poultry, unpasteurized
(bacteria)           (raw) milk or juice,
                     cheese, raw produce

Scombrotoxin         fresh tuna, bluefish, mackerel,
(toxin)              marlin, mahi-mahi

Vibrio               undercooked or raw seafood
parahaemolyticus
(bacteria)

Vibrio vulnificus    undercooked or raw shellfish
(bacteria)           (especially oysters), other
                     contaminated seafood

                    How Soon it         How Soon it
                     Typically           Typically
Bug                   Strikes              Ends

Campylobacter       2 to 5 days         2 to 10 days
(bacteria)

Ciguatera           2 hours to          days to months
(toxin)             5 days

Clostridium         12 to 72            days to
botulinum           hours               months (get
(bacteria)                              treatment
                                        immediately)

Cyclospora          1 to 14 days        weeks to
(parasite)          (usually at         months
                    least 1 week)

E. coli 0157:H7     1 to 8 days         5 to 10 days
(bacteria)                              (get treatment
                                        immediately,
                                        especially for
                                        a child or
                                        elderly person)

Hepatitis A         15 to 50            2 weeks to
(virus)             days                3 months

Listeria            9 to 48             days to
                    hours for           months (get
(bacteria)          gastro-intestinal   treatment
                    symptoms, 2 to      immediately)
                    6 weeks for
                    infections in
                    the blood, brain,
                    or uterus

Noroviruses         12 to 48 hours      12 to 60
(virus)                                 hours

Salmonella          1 to 3 days         4 to 7 days
(bacteria)

Scombrotoxin        1 minute to         3 to 6 hours
(toxin)             3 hours

Vibrio              2 to 48 hours       2 to 5 days
parahaemolyticus
(bacteria)

Vibrio              1 to 7 days         2 to 8
vulnificus                              days (get
(bacteria)                              treatment
                                        immediately)

Source: Adapted from Diagnosis and Management of Foodborne Illnesses:
A Primer for Physicians and Other Health Care Professionals
(www.cdc.gov/mmwr/preview/mmwrhtmi/rr5304al.htm), by the American
Medical Association, American Nurses Association, Centers for
Disease Control and Prevention, Food and Drug Administration,
and U.S. Department of Agriculture.