My son is getting married in mid-August, and the related preparations are starting to pick up a sense of greater urgency.  I have been instructed not to interfere.  Accordingly, I had a bit of time to follow up on the related morbid question that occurred to me; generally, what is the available CDC published data associating foodborne illness outbreaks with wedding celebrations?

The first relatively recent reference addressed an outbreak in Fayette County, Kentucky. In August 1990, 42 (65 percent) of 65 persons became ill with gastroenteritis following a restaurant brunch for a wedding party on August 11. Twenty-three ill persons sought medical care; four were hospitalized. The median incubation period was 28 hours. Stool cultures from seven patients yielded Salmonella Enteriditis (SE); all five SE isolates tested were phage type 8.  Eating eggs benedict with hollandaise sauce was the only food exposure statistically associated with illness. Review of food handling practices at the restaurant indicated that eggs used in the hollandaise had been pooled, incompletely cooked, and served more than 1 hour after preparation. [2]

From July 21 through September 3, 1990, 90 (36 percent) of 250 persons who attended or ate food taken from a wedding in Des Moines, Iowa, on July 14 developed trichinosis.  Most (approximately 95 percent) of the 250 persons had immigrated to the United States since 1975 from Southeast Asian countries. Of those who became ill, 52 (58 percent) were treated by physicians; one of the 52 was hospitalized. Case histories were obtained from 39 ill and 13 well persons who attended the wedding. Of the 39 ill persons, 34 (87 percent) ate uncooked pork sausage; no other foods were associated with illness. The sausage had been prepared from 120 pounds of commercially purchased pork and was served uncooked, as is customary for that food item in Southeast Asian culture. Interestingly, only four (4 percent) of 107 persons who attended the wedding and were interviewed knew about trichinosis or about the potential hazards of eating undercooked pork. [3]

On June 24, 1995, a total of 76 persons attended a catered wedding reception in Suffolk County, New York.  Following the reception, attendees contacted the local health department to report onset of a gastrointestinal illness. Salmonella group D was isolated from stools of the 13 persons who submitted specimens; 11 of the 13 isolates further typed were identified as Salmonella Enteritidis. An investigation by the Suffolk County Health Department involved the 28 ill attendees and the 12 well attendees that were contacted. Twenty-six (93 percent) of 28 persons who had eaten Caesar salad became ill, compared with two (17 percent) of 12 persons who had not eaten the salad.  The Caesar salad dressing was prepared with 18 raw shell eggs, olive oil, lemon juice, anchovies, Romano cheese, and Worcestershire sauce at 11:30 a.m. on June 24. The mixture was held unrefrigerated at the catering establishment for 2 hours, and was then placed in an unrefrigerated van until delivered and served at the reception at 6 p.m.  [4]

On May 15, 1997, the Westchester County Health Department in New York was notified of two laboratory-confirmed cases of cyclosporiasis and other cases of diarrheal illness among persons who attended a wedding reception on April 20 at a private residence in the county. Of the 140 persons interviewed, 20 (14 percent) had illness that met the case definition; four cases were  laboratory-confirmed.  Eating raspberries was the exposure most strongly associated with risk for illness in univariate analysis and was the only exposure significantly associated with risk for illness in multivariate logistic regression analysis. The raspberries had not been washed.  [5]

On June 10, 2000, a total of 83 persons attended a catered wedding reception in Pennsylvania. Approximately 8 days later, the bride notified the local health department that she, her husband, and many guests at the reception had a gastrointestinal illness. Stool specimens from attendees were positive for oocysts of the coccidian parasite Cyclospora cayetanensis, and an epidemiologic investigation was begun by the Philadelphia Department of Public Health and the Centers for Disease Control and Prevention (CDC).  Fifty-four (68.4 percent) of the 79 interviewed guests and members of the wedding party met the case definition. The wedding cake, which had a cream filling that included raspberries, was the food item most strongly associated with illness (multivariate relative risk, 5.9; 95 percent confidence interval, 3.6 to 10.5). Leftover cake was positive for Cyclospora DNA by polymerase chain reaction analyses. Sequencing of the amplified fragments confirmed that the organism was Cyclospora cayetanensis.  [6]

On July 18, 2001, the New York City Department of Health and Mental Hygiene received a complaint of illness from a person who ate at a wedding celebration on July 14; S. Uganda was isolated from the stool of another wedding attendee. By early August, a distinct strain of S. Uganda had been isolated from 11 New York City residents with illness onsets occurring June 24-August 4.  All 11 case-patients were of Hispanic ethnicity, and 6 of 10 interviewed reported having eaten roast pork from a New York City restaurant in the 3 days before illness onset. Additionally, roast pork from that restaurant had been served at the wedding named in the initial consumer complaint. A sample of leftover roast pork from the wedding was positive for the same strain of S. Uganda as the one isolated from patients.  At the time of a sanitary inspection initiated by the consumer complaint, raw pork was held at inadequate temperatures at the restaurant, and thermometers were inadequately used during cooking and hot-holding. Potential sources of cross-contamination, surfaces and wiping cloths, were not properly sanitized. The same S. Uganda strain found in patients was isolated from a cooked pork sample collected from the restaurant on July 18.  [7]

The CDC has compiled more related recent data, available at its Foodborne Outbreak Online Database.  The Database is designed to allow the public direct access to information on foodborne outbreaks reported to the Centers for Disease Control and Prevention (CDC). Most outbreaks are reported to the National Outbreak Reporting System (NORS) by the state, local, territorial, or tribal health department that conducted the outbreak investigation. Outbreak reporting is voluntary. Multi-state outbreaks are generally reported to NORS by CDC.  Clearly, there are far more outbreaks that simply have not been reported to the CDC, as outbreak reporting is in fact voluntary.

The Database identifies outbreaks from 1999 through 2007 in part by location, including a “wedding” location category.  The wedding reception database indicates the CDC was notified of approximately 65 outbreaks associated with weddings during that time frame, with 2301 persons becoming ill, and 52 being hospitalized. The vast majority of these outbreaks associated with weddings unsurprisingly occurred during the spring and summer months. Thirty-seven outbreaks, over 50 percent, involved confirmed or suspected norovirus cases; eight outbreaks were attributed to a number of Salmonella strains.  The implicated vehicles were quite varied, and included strawberries, chicken dishes, antipasti, roast beef, salads, cakes, and ice water.   [8]

Foodborne illness outbreaks are obviously not associated with weddings only in the United States.  A review of recent related articles identified an outbreak in March, 2010, in Vadodara, India, where as many as 150 persons suffered from food poisoning after eating a wedding feast including dal, rice, laddu and various vegetables.  In May, 2010, wedding food also hospitalized at least one hundred people in Northern India.  Apparently, for ast
rological reasons, a lot of weddings in India take place during May and June, the hottest months.  Food spoils very quickly, and it is common for many wedding guests to become ill.  In July, 2010, approximately four hundred people attending a wedding feast in the Kabylie region of Algeria became violently ill, with sixty wedding guests being hospitalized.  Again, the summer heat increases the number of illnesses due to improperly stored or outdated food.  Additionally, during the summer season and Ramadan, meals are often prepared and served outdoors, increasing the risk of foodborne illnesses.    

Going with professional and experienced caterers may be the wise choice.  Even there, however, there is the risk of a foodborne illness outbreak. A recent story on msnbc.com reported new CDC figures showing that illnesses from reported outbreaks of food poisoning linked to catering outpace those from restaurants or home cooking.  Dana Cole, a CDC researcher quoted in the story, provided data indicating that between 1998 and 2008 there were 833 outbreaks of foodborne illness traced to caterers, causing 29,738 illnesses, 345 hospitalizations, and 4 deaths. Proportionately, the outbreaks from catering are higher than the 22,600 illnesses from 1,546 reported home cooking outbreaks and the 101,907 illnesses from 7,921 outbreaks in restaurants and delis.  In fact, according to Cole, there are 36 illnesses for every outbreak caused by catering compared with 13 illnesses per outbreak from restaurants or home-prepared meals. [9]

A recent paper presented the microbiological and epidemiologic results of a large Clostridium perfringens outbreak in England, in July 2009, occurring simultaneously at two weddings that used the same caterer. The outbreak involved several London locations and required coordination across multiple agencies. A case-control study was carried out to analyze possible associations between the food consumed and becoming ill. Food, environmental, and stool samples were tested for common causative agents, including enterotoxigenic C. perfringens. The clinical presentation and the epidemiologic findings were compatible with C. perfringens food poisoning and C. perfringens enterotoxin was detected in stool samples from two cases. The case-control study found statistically significant associations between becoming ill and eating either a specific chicken or lamb dish prepared by the same food handler of the implicated catering company. [10]

I am pretty confident no one associated with my son’s wedding will read this article before the wedding.  I will inevitably be thinking about it, though, when I grab another canape` from a passing tray.

REFERENCES:

[1]    “Wedding Bell Blues” is a song written and recorded by Laura Nyro in 1966.  It became a number one hit for The 5th Dimension in 1969, spending three weeks as number one on the U.S. pop singles chart in November, 1969, and subsequently becoming a popular phrase in American culture.

[2]    “Epidemiologic Notes and Reports Update: Salmonella enteritidis Infections and Shell Eggs — United States, 1990”, MMWR, December 21, 1990 / 39(50); 909-912.

[3]    “Epidemiologic Notes and Reports Trichinella spiralis Infection — United States, 1990”, MMWR, February 01, 1991 / 40[4]; 57-60.

[4]    “Outbreaks of Salmonella Serotype Enteritidis Infection Associated with Consumption of Raw Shell Eggs — United States, 1994-1995”, MMWR, August 30, 1996 / 45(34); 737-742.

[5]    “Update: Outbreaks of Cyclosporiasis — United States, 1997”, MMWR, May 30, 1997 / 46(21); 461-462.

[6]    Ho AY, Lopez AS, Eberhart MG, Levenson R, Finkel BS, da Silva AJ, et al. “Outbreak of cyclosporiasis associated with imported raspberries, Philadelphia, Pennsylvania, 2000”,  Emerg Infect Dis, Vol. 8, No. 8, August 2002.

[7]    Jones RC, Reddy V, Kornstein L, Fernandez JR, Stavinsky F, Agasan A, et al. “Salmonella enterica serotype Uganda infection in New York City and Chicago”, Emerg Infect Dis, Vol. 10, No. 9, September 2004.

[8]    OutbreakNet Foodborne Outbreak Online Database, Centers for Disease Control and Prevention, at http://wwwn.cdc.gov/foodborneoutbreaks/.

[9]    “Caterers dish up more cases of food poisoning”, JoNel Aleccia, msnbc.com, 7/30/2010.

[10]    Eriksen J, Zenner D, Anderson SR, Grant K, Kumar D. “Clostridium perfringens in London, July 2009: two weddings and an outbreak”. Euro Surveill. 2010;15(25):pii=19598.
Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19598

Parents, nutritionists, and food bloggers, however, immediately voiced concern over the 19 grams of sugar found in each 6-ounce serving, saying products like this contribute to the current obesity epidemic surrounding the nation. When infants are ready to be weaned, sometime after 12 months old, they are ready for nutritious table food, not formula, according to nutritionists, who encourage parents to expose toddlers to a wide range of foods. Critics asserted that infants and toddlers do not need formula–instead, they need to transition from mother’s milk to eating nutritious table foods, drinking milk, and developing healthy eating behaviors.  Toddlers are unpredictable, and what they need are patience, understanding, and plenty of fruits and vegetables, whole grains, protein, and dairy, not an expensive formula supplement drink.  Critics claimed that, with obesity rampant around the world, children should not be introduced at young ages to hyper-sweet and hyper-palatable foods like sugar-sweetened fortified chocolate milk. [2]

Following the outcry, Mead Johnson announced on June 9, 2010, that it would pull its Enfagrow Premium chocolate toddler formula off store shelves.  The chocolate version was discontinued after four months because of “the whole emotional evocative nature of chocolate,” said Mead Johnson spokesman Chris Perille. “It’s more associated with candy and sweets and things potentially not as beneficial. Flavor was more in conflict with a nutritious product.”  In a prepared statement, Mead Johnson said there had been “some misunderstanding and mischaracterization regarding the intended consumer” of the product. “The resulting debate has distracted attention from the overall benefits of the brand.” [1]

The controversy made me curious about the capacity of infants to taste and differentiate between flavors.  How and when do they develop that capacity, and do flavors really have a significant impact on what they are willing to eat?

A 2001 study tested the hypothesis that experience with a flavor in amniotic fluid or breast milk modifies the infants’ acceptance and enjoyment of similarly flavored foods at weaning.  Pregnant women who planned on breast-feeding their infants were randomly assigned to 1 of 3 groups, consuming various combinations of carrot juice and water for 3 consecutive weeks during the last trimester of pregnancy and then again during the first 2 months of lactation.  The infants were later videotaped as they were fed cereal prepared with water or carrot juice.   The results demonstrated that the infants who had exposure to the flavor of carrots in either amniotic fluid or breast milk behaved differently in response to that flavor in a food base than did non-exposed control infants. The study concluded that prenatal and early postnatal exposure to a flavor enhanced the infants’ enjoyment of that flavor in solid foods during weaning. These very early flavor experiences could provide the foundation for cultural and ethnic differences in cuisine.  [3]

A study published in 2004 sought to determine why early experience by infants with formulas establishes subsequent preferences.   Infants whose parents had chosen to formula-feed them were randomized into 1 of 4 groups by the second week of life.  One group was fed a milk-based formula, whereas another was fed a particularly unpleasant tasting protein hydrolysate formula. The remaining groups were fed the unpleasant formula for 3 months and the milk-based formula for 4 months.   After 7 months of exposure, infants were videotaped on 3 separate days while feeding on the different formulas. The results indicated that previous exposure to the unpleasant tasting formula significantly enhanced its subsequent acceptance, and that seven months of exposure led to greater acceptance than did 3 months.  The study concluded that such early variation in feeding, including varying exposures to different flavors in amniotic fluid and mothers’ milk, may underlie individual differences in food acceptability throughout the life span.  [4]  

The responses of children to certain tastes differ markedly from adults, including heightened preferences for sweet tasting and greater rejection of bitter tasting foods.  A 2005 study tested the hypothesis that genetic variations in a newly discovered taste gene, as well as cultural differences, are associated with differences in sensitivity to bitter taste and preferences for sucrose and sweet-tasting foods.   The results indicated that variations in the taste receptor gene accounted for a major portion of individual differences in bitterness perception in both children and adults, as well as a portion of individual differences in preferences for sweet flavors in children but not in adults. These findings underscore the genotype effects on behavioral outcomes in children, especially as they relate to taste preferences, and that cultural forces may sometimes override the genotypic effects in adults. New knowledge about the molecular basis of food likes and dislikes in children may suggest strategies to overcome diet-induced diseases. [5]

A 2007 study sought to evaluate the effects of breastfeeding and dietary experiences on acceptance of a fruit and a green vegetable by 4- to 8-month-old infants.  Forty-five infants, 44 percent of whom were breastfed, were assigned randomly to 1 of 2 treatment groups. One group was fed green beans, and the other was fed green beans and then peaches at the same time of day for 8 consecutive days.  Acceptance of both foods, as determined by a variety of measures, was assessed before and after the home-exposure period.  The study results indicated that breastfeeding confers an advantage in initial acceptance of a food, but only if mothers eat the food regularly. Once weaned, infants who receive repeated dietary exposure to a food eat more of it and may learn to like its flavor. However, because infants initially display facial expressions of distaste in response to certain flavors, caregivers may hesitate to continue offering these foods. The study concluded that parents should be encouraged to provide their infants with repeated opportunities to taste fruits and vegetables, and should focus not only on their infants’ facial expressions but also on their willingness to continue feeding.  [6]

These findings regarding the impacts of flavor tasting by infants and children on their eating habits take on greater importance given the acknowledged overweight and obesity epidemic afflicting our children.  The rapid increase in the prevalence of childhood obesity has alarmed public health agencies, health care clinicians, health care researchers, and the general public. On the basis of measured heights and weights from US children assessed approximately every 5 years, obesity prevalence has increased from roughly 5 percent in 1963 to 1970 to 17 percent in 2003 to 2004.   The obesity epidemic has also disproportionately affected some racial/ethnic groups.  In 2003-2004, the prevalence rates were particularly high among African American girls (24 percent) and among Mexican American boys (22 percent). Rates have also increased among Native American and Asian American youths. Generally, greater obesity prevalence among adolescents has also been associated with poverty. [7]

A 2009 study in fact demonstrates the likely association with rapid early weight gain and subsequent obesity. The goal of the study was to
examine the associations of weight-for-length at birth and at 6 months with obesity at 3 years of age.   The study concluded that more rapid increases in weight for length in the first 6 months of life were associated with sharply increased risk of obesity at 3 years of age. Changes in weight status in infancy may thus influence risk of later obesity more than weight status at birth.  [8]

The potential impact of early exposure by infants and toddlers to enhanced sweet flavors could thus significantly affect their life-long food predispositions and related health aspects.  Some more double chocolate fudge ice cream, kids?

References:

1. “Chocolate Toddler ‘Formula’ Pulled After Sugar Uproar”, Susan Donaldson James, ABC NEWS, June 10, 2010.  

2.  http://www.theatlantic.com/food/archive/2010/05/chocolate-formula-baby-doesnt-know-best/56919 .  The Atlantic Monthly Group, May 19, 2010.

3.  Julie A. Mennella, PhD, Coren P. Jagnow, MS, and Gary K. Beauchamp, PhD, “Prenatal and Postnatal Flavor Learning by Human Infants”, Pediatrics, Vol. 107 No. 6, June 2001.  

4.  Julie A. Mennella, PhD, Cara E. Griffin, and Gary K. Beauchamp, PhD, “Flavor Programming During Infancy”, Pediatrics, Vol. 113 No. 4, April 2004.  

5.  Julie A. Mennella, PhD, M. Yanina Pepino, PhD, and Danielle R. Reed, PhD, “Genetic and Environmental Determinants of Bitter Perception and Sweet Preferences”, Pediatrics, Vol. 115 No. 2, February 2005.  

6.  Catherine A. Forestell, PhD, and Julie A. Mennella, PhD, “Early Determinants of Fruit and Vegetable Acceptance”, Pediatrics, Vol. 120, No. 6, February 2007.  

7.  Sarah E. Barlow, MD, MPH, and the Expert Committee, “Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report”, Pediatrics, Vol. 120, Supplement 4, December 2007.  

8.  Elsie M. Taveras, Sheryl L. Rifas-Shiman, Mandy Belfort, Ken Kleinman, Emily Oken and Matthew Gillman, “Weight Status in the First 6 Months of Life and Obesity at 3 Years of Age”, Pediatrics, Vol. 123, Number 4, April 2009.  

The arrival in South Africa of football is credited to British military garrisons located around the Cape Colony and Natal in the mid-1850s.  Football was among the first sports to be banned because of the country’s Apartheid policies.  It was the release of future South African president Nelson Mandela that marked the return of South African sports to the international arena, well before the country’s political structure was changed.  Once Mandela had been released, the process of reintegrating South Africa into the FIFA fold went quickly.  At the FIFA Congress in Zurich in July 1992, South Africa’s membership was restored, and in October 1992 South Africa made its FIFA World Cup debut, losing brutally to Nigeria, 4-0.   The South African team, nicknamed “Bafana Bafana”, became the African champions in 1998, however, and the game has since been the most popular sport in the country.

South Africa is the first African country to host the FIFA World Cup, from 11 June to 11 July 2010, starring teams from 32 countries.  The World Cup will take place in eight of South Africa’s nine provinces, using 10 stadiums in nine host cities; five of the 10 stadiums are new and the rest have been upgraded for the event. [1]

Aware of the world’s attention, South Africans are eagerly promoting the variety of their available foods and cuisines.  South Africa’s people have diverse origins, cultures, languages, and beliefs, and their food is correspondingly diverse.  From “New African Immigrant Food Flair”:

“In the post apartheid era, migrants from all over our continent have introduced a delicious new layer of gastronomic diversity to South Africa. … If you like food markets try Johannesburg’s the Congo Corner Market in Yeoville where you will find everything from aphrodisiac spices to chikwanga cassava breads. The Little Addis building in downtown Jo’burg is a blissful jumble of Ethiopian spice shops, bottle stores and coffee bars.

“If it’s restaurants you’re after try Chef Amsale Debela’s Abyssinia in Kensington, Johannesburg, where sour dough injera breads are piled high on a range of mild curry-like stews, washed down with Tej honey wine. Addis in the Cape on Long Street, Cape Town offers similar fare. Since the Ethiopian Coptic Church has many non-meat fast days within its calendar such restaurants are always ideal for vegetarians, as meat is always in the minority.

“If you fancy your African immigrant food served with Mozambican flair try the Flamingo restaurant in Troyeville, Johannesburg or Port Elizabeth’s Fernando’s Chicken House for super hot piri-piri and so much more.

“No one is ever going to get thin on the opulence of West and Central African food. This African immigrant cooking style is a delicious mélange of peanuts, palm-nuts and plantain bananas. Super-smart Congolese is available at Zemara, Pretoria where the patrons are largely diplomats and big business types. Cheap and cheerful can be had at House Ivorian in Yeoville, Johannesburg, where carp with nya-nya aubergines and attieke couscous is washed down with palm wine and cold beers.”  [2]

The South African government has intensified its focus on food safety and education, with the influx of fans from many nations and the worldwide attention focused on the country.  It explains that, although South Africa is considered a developing country, the food industry of the country is well developed and sophisticated.   The services rendered by health authorities in South Africa are generally referred to as “food safety control”. This is defined as a mandatory regulatory activity of enforcement by the relevant health authority to ensure that all foods during production, handling, storage, processing, and distribution are safe and fit for human consumption and conform to safety requirements as prescribed by law. Legislation exists aimed at ensuring that all foodstuffs and food handling facilities comply with health standards to protect consumers from unsafe food and food prepared under unhygienic conditions.  To ensure compliance, Environmental Health Practitioners (EHPs) are employed by provincial and municipal health authorities to monitor all foodstuffs and facilities through regular inspections and sampling of foodstuffs.   [3]

Government publications do not encourage purchasing food from street vendors.  Food sold by formal outlets such as supermarkets, restaurants, fast food outlets, and such are generally of high quality and considered to be safe.  Visitors are, except for fresh fruits and vegetables, advised to be cautious when obtaining foodstuffs, especially ready to eat prepared meals and other dishes, from informal outlets such as street food vendors. The general rule that the government emphasizes in these instances is: peal it*., cook it*., cool it*., or, leave it!  [3]

In contrast, however, street food in South Africa also enjoys a reputation for being tasty and varied, and is described as an integral component of the culture.  Boerewors is a South African treat sold by many street vendors.  It’s served at nearly every sporting event, farmer’s market or school event in the country. Boerewors is basically coarsely minced beef (sometimes pork and lamb is added) with spices such as coriander, pepper, nutmeg, cloves and allspice. The mixture is then stuffed into a sausage casing and grilled over an open fire.  Once cooked, it is served on a roll with carmelized onions and chutney or mustard.   Another traditional street food in Johannesburg is pap en vleis–corn meal and meat.  Vetkoek (fried cakes) are available on many inner-city street corners.  In Durban, which has the country’s largest Indian population, a “bunny chow” is Durban street food made up of half a loaf of hollowed-out bread filled with hot curry.  [4]

In fact, street food vending in South Africa is probably the largest employer in the informal sector, and one of the major contributors to the South African economy. A 2005 FAO/WHO study summarized prior research focused on improving street food vending and promoting street food safety.  Prior studies concluded that the production of relatively safe street foods, with low bacterial counts, was possible even under improper hygiene conditions and a lack of basic sanitary facilities.  Overall, the microbiological quality of foods from which samples were taken was within acceptable safety limits.  The presence of Escherichia coli, Staphylococcus aureus, Salmonella and yeasts was however also indicative of a degree of ignorance of the food handlers (at the vending sites) towards proper hygiene practices. [5]

A number of local jurisdictions have implemented a variety of efforts to improve the safety of street food.  These include registering all street food vendors, providing them with basic food safety education, and allocating specific sites for them as strictly food-vending sites. At these sites, basic facilities are provided for the vendors such as cleaning services, running water, washbasins, storage facilities, and toilets.  The study concluded that improving the safety of street-vended foods in any developing country is a great challenge, and that experiences in South Africa have shown that more additional research needs to be conducted to determine the safety and socio-economic importance of street foods. [5]

The private sector has also geared up to promote food safety.  The Food Safety Initiative of the Consumer Goods Council of South Africa, in cooperation with the Directorate: Food Control of the Department of Health and the World Health Organization sent a reminder to all businesses in the food productio
n sector to be on their best food safety behavior during the FIFA 2010 Soccer World Cup.  The message stressed the obvious public health and economic implications of a major foodborne disease incident, including damage to the brand name of an implicated product.  It stated that during the World Cup event South Africa will be under an intense media spotlight, which may shape the world’s perceptions of South Africa for years to come. All food businesses, and especially those directly involved in the provision of food for the World Cup, were encouraged to review their food safety practices and procedures to be certain that everything possible has been done to ensure that South Africa will enjoy an incident-free World Cup. [6]

Additionally, Graham Sandford, director of the South African Food Safety Corporation, launched the official South Africa Food Safety Star Rating Scheme at Durban Country Club in Early March, 2010, saying it would put the country on a par with similar standards overseas.  Sandford said that with the World Cup around the corner and the influx of thousands of visitors, “the timing is right”.  The star rating scheme identifies the level of food safety, with the ultimate grading being five stars.  The scheme is based on a technical survey, with inspections covering such issues as how food is prepared, handled, and processed, the level of compliance with food hygiene and safety regulations, how waste food is disposed of and the cleaning operations.  Although it is not compulsory, Sandford believes the industry will support it.  Star ratings would be placed outside restaurants and hotels, and customers would be able to go on to a Website, www.safoodsafetycorporation.co.za, to check on the rating of a business.  [7]   

Ultimately, all vendors and consumers are reminded of the World Health Organization golden rules for safe food preparation:
 
o    Choose foods processed for safety;
o    Cook food thoroughly;
o    Eat cooked foods immediately;
o    Store cooked foods carefully;
o    Reheat cooked foods thoroughly or keep cold;
o    Avoid contact between raw foods and cooked foods;
o    Wash hands repeatedly;
o    Keep all surface and utensils clean;
o    Protect food from insects, rodents and other animals; and
o    Use clean and pure water.    [3]
       

REFERENCES:

1.    South Africa 2010 Fifa World Cup (http://www.sa2010.gov.za), June 10, 2010.

2.    “New African Immigrant Food Flair”, SOUTHAFRICA.info (the official gateway), http://www.southafrica.net, June 10, 2010.

3.    “Food Safety Fact Sheet” Health A-Z, South Africa 2010 FIFA World Cup, http://www.sa2010.gov.za/en/confederations-cup/health-z, June 10, 2010.

4.    “WORLD CUP REPORT: SOUTH AFRICAN STREET FOOD”, New York Street Food, The Best Street Food in New York and Beyond, posted on Thursday, June 3rd, 2010.

5.    “IMPROVING STREET FOOD VENDING IN SOUTH AFRICA: ACHIEVEMENTS AND LESSONS LEARNED”, FAO/WHO Regional Conference on Food Safety for Africa, Harare, Zimbabwe, 3-6 October 2005.

6.    Food Safety Initiative (CGCSA), Copyright ©2009 Joburg Market.

7.    “Drive to raise SA’s food safety standards”, Barbara Cole, The Daily News, March 05, 2010.

Obesity and diet-related diseases are increasingly recognized as major public health problems. Research has suggested that some areas and households have easy access to fast food restaurants and convenience stores but limited access to supermarkets.  Limited access to nutritious food and relatively easier access to less nutritious food could be linked to poor diets and, ultimately, to obesity and diet-related diseases. [1]

Accordingly, in 2008 Congress directed the U.S. Department of Agriculture (USDA) to conduct a 1-year study to assess the extent of the problem of limited access to nutritious food, and to identify its characteristics and causes.  The report was completed in June, 2009, and made a number of findings.  Results indicated that some consumers had limited ability to access affordable nutritious food, because they lived far from a supermarket or large grocery store and did not have easy access to transportation.  [1]

Nearly 6 percent of all US households did not always have the food they wanted, or needed, because of access-related problems.  Nationwide, USDA estimates that 23.5 million people, including 6.5 million children, live in low income areas that are more than a mile from a supermarket.  Supermarkets and large grocery stores have lower prices than smaller local convenience stores.  People who live in limited access areas often rely on small local grocery or convenience stores, which may not carry all the foods necessary for a healthy diet, and may offer food at higher prices. [1]

Urban core areas with limited food access are further characterized by higher levels of racial segregation and greater income inequality.  More than half of those households who experienced access to food problems also lacked enough money for food.  The report found that consumers who shopped at local convenience stores in fact also paid prices that on average were higher than at supermarkets.   [1]

An early study examined the distribution of food stores and food service places by neighborhood wealth and racial segregation in Mississippi, North Carolina, Maryland, and Minnesota.  The results of the study, based on 2000 census data, showed that larger numbers of supermarkets and gas stations with convenience stores were located in wealthier neighborhoods, when compared to the poorest neighborhoods.  Regarding neighborhood segregation, there were 4 times more supermarkets located in white neighborhoods compared to black neighborhoods.  In contrast, however, there were 3 times fewer places to consume alcoholic beverages in the wealthiest areas, when compared to the poorest neighborhoods.  [2]

A 2006 report conducted audits in 2003 and 2004 of community supermarkets and fast food restaurants in St. Louis, Mo., to assess the location and availability of food choices that enable individuals to meet the dietary guidelines established by the U.S. Department of Agriculture (e.g., fruit and vegetable consumption, low-fat options). 2000 census data was used to assess the racial distribution and the percentage of individuals living below the federal poverty level in a defined area of St Louis. [3]

The report found that two factors, race and income, seemed to be associated not only with the location of food outlets but also with the selection of food available.  The data suggested that individuals living in mixed or white high-poverty areas and in primarily African American areas (regardless of income) were less likely to have access to food outlets than individuals in primarily white, higher-income communities. Also, the food available in mixed or white high-poverty areas and in primarily African American areas made it more difficult for individuals to make healthy choices than the food available in primarily white, higher-income communities. [3]

Another study’s objective was to evaluate food access, availability, and affordability in 3 separate but similar low-income communities in urban Los Angeles, California, during 2004 through 2006.  Community members mapped the number and type of retail food outlets in a defined area, and then surveyed a sample of stores to determine whether they sold selected healthful foods and how much those foods cost.  Of the 1,273 food establishments mapped in the 3 neighborhoods, the most common types of retail food outlets were fast-food restaurants (30 percent) and convenience/liquor/corner stores (22 percent). Supermarkets made up less than 2 percent of the total. Convenience/liquor/corner stores offered fewer than half of the selected healthful foods and sold healthful foods at higher prices than did supermarkets. The study understandably concluded that access to stores that sold affordable healthful food was a problem in urban Los Angeles communities. [4]

Another study analyzed in December 2007 and January 2008 the availability and affordability of a healthy market basket in Central Falls, a Rhode Island city in which 40.8 percent of children live in poverty.  According to 2000 US census data, 22.8 percent of households in Central Falls had an annual income of less than $10,000, and the median household income was $22,628. Central Falls is also composed of a largely Hispanic community, with 47.8 percent of residents in 2000 identifying as Hispanic or Latino.  21 retail food stores were surveyed, including 9 small grocery stores, 8 convenience stores, 3 bakeries, and 1 meat market.  Results established that healthier foods, such as fresh vegetables and meats, were less readily available than most staple foods.  The aggregate cost of the tested market basket across all Central Falls retailers was also approximately 41 percent higher when compared to the national average cost of the basket items per week.  Again, the report concluded that Central Falls residents had limited access to basic healthy foods, and that those foods, if found, cost more than average. [5]

Finally, research was conducted in Philadelphia to determine if there was a difference in the microbial quality and potential safety of food available to lower income versus higher income populations at the retail level.  Aerobic plate counts, yeast and mold counts, and total coliforms were determined in ready-to-eat greens, precut watermelon, broccoli, strawberries, cucumbers, milk, and orange juice.  Results were then compared among products purchased in stores in low income versus those same products purchased in higher income Philadelphia neighborhoods, between June 2005 and September 2006.  [5]

This research found that perishable produce items available in markets in the low income census tracts had higher microbial indicator counts when compared to those in higher income area markets. The authors speculated that small retail facilities that serve populations in lower income urban areas lacked the resources, time, or knowledge to focus on sanitation and proper refrigeration.   Small urban retailers may also rely on nontraditional transportation methods that are not refrigerated if they are located in small, inner-city streets. Finally, they may also be a captive market for less quality products from suppliers who have strict quality standards to meet for large corporate retailers.  These limitations may contribute to foods being supplied to lower income neighborhoods that have been temperature abused or exposed to unsanitary conditions. [6]

The available data indicates that residents of these low income urban food deserts have less access to high quality produce, lean meat, and low fat dairy products.  They necessarily rely on small markets that primarily sell foods with a long shelf-life, instead of fresh fruits, fresh produce, and low fat foods.  These foods, when available, are also apparently more likely to be more contaminated and more expensive.

Food deserts are such important factors in rates of obesity, diabetes, and other illnesses, that Michelle Obama has made access to healthy, affordably-priced groceries one of the cornerstones of her “Let’s Move!” campaign against childhood hunger and obesity.  On May 11, 2010, The Task Force on Childhood Obesity Taskforce released its action plan to tackle childhood obesity.  Chapter Four of the action plan, “Access to Healthy, Affordable Food”, describes the problem of food deserts, and identifies eleven specific recommendations to reduce the negative impacts on children:

“Healthy options can be hard to find in too many communities. Millions of low-income Americans live in ‘food deserts,’ neighborhoods that lack convenient access to affordable and healthy food. Instead of supermarkets or grocery stores, these communities often have an abundance of fast-food restaurants and convenience stores. In addition, stores in low-income communities may stock fewer and lower quality healthy foods. When available, the cost of fresh foods in low-income areas can be high. Public transportation to supermarkets is often lacking, and long distances separate home and supermarkets in many rural communities and American Indian reservations. It is hard for residents of these areas–even those fully informed and motivated–to follow the necessary and recommended steps to maintain a healthy weight for themselves and their children. Too often, economic incentives strongly favor unhealthy eating, and accessibility, safety concerns, and convenience can also promote unhealthy outcomes.

“Limited access to healthy food choices can lead to poor diets and higher levels of obesity and other diet-related diseases. In addition, limited access to affordable food choices can lead to higher levels of food insecurity, increasing the number of low- and moderate-income families without access to enough food to sustain a healthy, active life. There is a growing, though incomplete, body of research that finds an association between food insecurity and obesity, suggesting that hunger and obesity may be two sides of the same coin.”  [7]

The Action Plan then makes the following recommendations, to be implemented as soon as possible:

Recommendation 4.1: Launch a multi-year, multi-agency Healthy Food Financing Initiative to leverage private funds to increase the availability of affordable, healthy foods in underserved urban and rural communities across the country.

Recommendation 4.2: Local governments should be encouraged to create incentives to attract supermarkets and grocery stores to underserved neighborhoods and improve transportation routes to healthy food retailers.

Recommendation 4.3: Food distributors should be encouraged to explore ways to use their existing distribution chains and systems to bring fresh and healthy foods into underserved communities.

Recommendation 4.4: Encourage communities to promote efforts to provide fruits and vegetables in a variety of settings and encourage the establishment and use of direct-to-consumer marketing outlets such as farmers’ markets and community supported agriculture subscriptions.

Recommendation 4.5: Encourage the establishment of regional, city, or county food policy councils to enhance comprehensive food system policy that improves health.

Recommendation 4.6: Encourage publicly and privately-managed facilities that serve children, such as hospitals, after school programs, recreation centers, and parks (including national parks) to implement policies and practices, consistent with the Dietary Guidelines, to promote healthy foods and beverages and reduce or eliminate the availability of calorie-dense, nutrient-poor foods.

Recommendation 4.7: Provide economic incentives to increase production of healthy foods such as fruits, vegetables, and whole grains, as well as create greater access to local and healthy food for consumers.

Recommendation 4.8: Demonstrate and evaluate the effect of targeted subsidies on purchases of healthy food through nutrition assistance programs.

Recommendation 4.9: Analyze the effect of state and local sales taxes on less healthy, energy-dense foods

Recommendation 4.10: The food, beverage, and restaurant industries should be encouraged to use their creativity and resources to develop or reformulate more healthful foods for children and young people.

Recommendation 4.11: Increase participation rates in USDA nutrition assistance programs through creative outreach and improved customer service, state adoption of improved policy options and technology systems, and effective practices to ensure ready access to nutrition assistance program benefits, especially for children.[7]

REFERENCES:

[1]”Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences”, United States Department of Agriculture, Economic Research Service, June 2009.

[2]Morland K, Wing S, Diez Roux A, Poole C., “Neighborhood characteristics associated with the location of food stores and food service places.”, Am J Prev Med. 2002 Jan;22[1]:23-9.

[3]Baker EA, Schootman M, Barnidge E, Kelly C. “The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines”. Prev Chronic Dis, 2006 Jul.

[4]Azuma AM, Gilliland S, Vallianatos M, Gottlieb R. “Food access, availability, and affordability in 3 Los Angeles communities, Project CAFE, 2004-2006”. Prev Chronic Dis 2010 Mar;7[2]:A27.

[5]Sheldon M, Gans KM, Tai R, George T, Lawson E, Pearlman DN. “Availability, affordability, and accessibility of a healthful diet in a low-income community, Central Falls, Rhode Island, 2007-2008”. Prev Chronic Dis 2010;7[2].

 [6]Marlen E. Koro, MS, Shivanthi Anandan, PhD, Jennifer J. Quinlan, PhD, “Microbial Quality of Food Available to Populations of Differing Socioeconomic Status”, Am J Prev Med, May, 2010.  

[7]”Solving the Problem of Childhood Obesity”, Task Force on Childhood Obesity, Action Plan, May 2010.

Initially, a December 2009 Robert Wood Johnson Foundation-funded report by Health Management Associates, an independent research group, determined that the ability of local health departments to protect and improve health is in jeopardy.  The report focuses mainly on the impact of budget cuts on local health departments. Recently, substantial funding cutbacks from local, state and federal government sources have shrunk response capacity in already-strapped local health departments. [1]

The report’s authors, Jack Meyer and Lori Weiselberg, conducted interviews with small, medium, and large local health departments around the country to collect specific information on the recent budget picture, and the nature and extent of funding cutbacks they have experienced.  The authors found that the combination of federal and state budget woes is dealing a “one-two punch” to local health departments that rely on federal and state grants and programs for a significant portion of their funding (and most do). This, in turn, leads to reductions in vital community-based and clinical prevention services that are in high demand right now, because of unemployment and reduced incomes due to the economic downturn. [1]

Nearly 2,800 local health departments perform a wide range of activities to improve the health of the U.S. population. Yet, less than 5 percent of total health care spending in the U.S. is devoted to public health, and only a fraction of those resources are available to local health departments. The vast majority of our nation’s health resources are devoted to medical services; the U.S. spends more on administrative overhead within the health care system than it does on public health.

Local health departments are found in very diverse settings. A few serve populations that approach 10 million people (e.g. New York, Los Angeles, and Chicago) while some serve very rural areas with less than 1,000 residents.  About two-thirds (64 percent) of the nation’s local health departments serve populations of less than 50,000.  Yet, nearly half of the US population (about 46 percent) lives in jurisdictions of the 5 percent of local health departments serving populations greater than half a million people. [1]

Most city and county health departments employ a small number of professional staff to carry out their essential functions, including investigating and responding to health threats, preparing for emergencies, and ensuring that our food is safe.  Roughly 155,000 people work for local health departments across the United States. But more than 60 percent of local health departments have fewer than 25 full-time employees, and only 12 percent have more than 100 full-time employees. Occupations include nurses, public health professionals, physicians, environmental health coordinators, nutritionists, health educators, epidemiologists, and emergency preparedness coordinators. [1]           

Local health departments, on average, receive 25 percent of their funding from local sources–including city/township revenue and county revenue. Another 20 percent of local health department funding comes from direct state funds. Federal funds that “pass through” states en route to localities account for another 17 percent of the typical local health department revenues. [1]            
           
Sixty percent of local health departments are established as units of local government, and over 12 percent are units of a state health agency.  Twenty-seven percent are mixed local and state. Both state and local governments are suffering from the severe economic downturn, and unlike the federal government, they must balance their budgets year after year. This requirement forces painful choices among vital public services and the revenue base needed to support such services. [1]

Specifically, the Meyer and Weiselberg report finds that health department funding cutbacks will translate into an overall deterioration of people’s health due to: higher rates of infectious diseases in communities; fewer community-based interventions to help prevent and control chronic diseases such as diabetes and asthma; and a lower level of preparedness. [1]

A March 1, 2010 report from the Trust for America’s Health and the Robert Wood Johnson Foundation found that federal spending for public health has been flat for nearly five years, and that states around the country cut nearly $392 million for public health programs in the past year. These cuts leave communities around the country struggling to deliver basic disease prevention and emergency health preparedness services. [2]  

“Chronic under funding for public health means that millions of Americans are needlessly suffering from preventable diseases, health care costs have skyrocketed, and our workforce is not as healthy as it needs to be to compete with the rest of the world,” said Jeffrey Levi, PhD, Executive Director of Trust for America’s Health.  “If we are going to improve the health of Americans, we need to fundamentally rethink our approach to funding and managing public health and disease prevention in the United States.” [3]

Federal funding to states from the U.S. Centers for Disease Control and Prevention (CDC) averaged out to only $19.23 per person in FY2009. The amount spent to prevent disease and improve health in communities ranged significantly from state to state, with a per capita low of $13.33 in Virginia to a high of $58.65 in Alaska. [2]

States in the Midwest received the least federal funding support for disease prevention at public health, at only $16.50 per person in fiscal year (FY) 2009, according to the analysis.  This is $3.30 less per person than the Northeastern states, which receive the highest amount, at $19.80 per person. Western states receive $19.22 per person, while Southern states receive $19.75 per person. [2]

State funding for public health ranged dramatically across the country, from a low of $3.55 per person in Nevada to a high of $169.92 per person in Hawaii.  The national median is $28.92 per person.  The funding structure of state and local health departments varies from state to state, with some states relying more on local funds.  [2]

“Public health departments are responsible for finding ways to address the systemic reasons why some communities are healthier than others and for developing policies and programs to remove obstacles that get in the way of making health choices possible,” Levi said.  “But right now, public health departments do not have the resources they need to improve health in communities.  Our ability to address the geographic and racial/ethnic disparities in health is limited by our failure to invest adequately in creating a modernized public health system.” [2]

Finally, new data in another report also released on March 1, 2010 illustrates the uphill battle that local public health departments are fighting in the face of budget cuts. The latest job loss survey by the National Association of County and City Health Officials (NACCHO) found that local health departments lost 8,000 jobs in the second half of 2009–compounding the loss of another 8,000 positions in the first half of the year. [4]

NACCHO surveyed a sample of local health departments nationwide in the months of J
anuary and February 2010. This was the third in a series of nationally representative surveys designed to measure the impact of the economic recession on local health departments’ jobs, budgets, and programs. [4]

More than a third of local health departments report a lower budget this year when compared to the previous year. When one-time funding from the American Recovery and Reinvestment Act and/or H1N1 supplemental funding is excluded, an additional 15 percent of local health departments report a lower budget, for a cumulative 53 percent of local health departments experiencing cuts to core funding. [4]

In 2008, NACCHO had found that local health departments had lost 7,000 jobs through budget-related cuts, layoffs, position eliminations, and attrition. In the last six months of 2009, nearly half of local health departments (46%) lost additional skilled people needed to protect the health of their communities as 8,000 local health department jobs were lost. When combined with the previous NACCHO findings, this results in a cumulative 23,000 jobs lost from 2008-2009, approximately 15 percent of the entire local health department workforce in the country.  In 2009, an additional 25,000 local health department employees were affected by cuts in working hours or mandatory furloughs resulting from budget cuts.  In 14 states, more than 75 percent of Local health departments lost jobs due to layoffs or attrition. [4]

“While local health departments will do the best job they can with the resources available to them to protect Americans from public health threats, these data sound a warning,” said NACCHO Executive Director Robert M. Pestronk. “The cumulative effects of budget cuts and job losses have taken a major toll on the ability of health officials to respond not only to large-scale emergencies and disease outbreaks like H1N1 influenza, but to the everyday situations for which the health department is the first line of defense.” [5]

The Meyer and Weiselberg report calls for several new approaches to funding, to sustain the broad range of local public health activities that are vital to keeping Americans safe and healthy. The report recommends that: (a) The federal government should assign high priority to full funding for state and local health departments, through grants from the Department of Health and Human Services and the Department of Agriculture and from agencies such as the Centers for Disease Control and Prevention, Health Resources and Services Administration, the Office of the Surgeon General, the Food and Drug Administration, and the Environmental Protection Agency.  (b)  The federal government should also provide a dedicated and sustainable source of federal funding to secure the vital activities of state and local public health departments through a new prevention and public health investment fund. (c)  Finally, state, city and county governments should make every effort to preserve adequate funding for local and state health departments, even in a difficult economic climate. [1]

The need for these new funding strategies appears to be self-evident. However, the critical role of local and state health departments in promoting and preserving public health must first be recognized and acknowledged.  Our public health system needs substantive and consistent funding, and deserves to be a higher priority in all relevant budget decisions.

REFERENCES:

[1] Jack Meyer and Lori Weiselberg. “County and City Health Departments: The Need for Sustainable Funding and the Potential Effect of Health Reform on Their Operations.” A Report Prepared by Health Management Associates for the Robert Wood Johnson Foundation and the National Association of County & City Health Officials. December 2009.

[2] “Shortchanging America’s Health”, March 1, 2010, Trust for America’s Health and the Robert Wood Johnson Foundation, available at www.healthyamericans.org and www.rwjf.org.

[3] “Flat Federal Funding and Cuts in States Put America’s Health at Risk”, Trust for America’s Health press release, March 1, 2010

[4] “Local Health Department Job Losses and Program Cuts: Overview of Survey Findings from January/February 2010 Survey”, The National Association of County and City Health Officials, March 1, 2010, available at www.naccho.org.

[5] “New NACCHO Survey Shows Local Health Departments Lost 16,000 Jobs in 2009”, NACCHO press release, March 1, 2010.

Much has been written about food safety issues related to the increasing sales of imported food in this country.  What about the individual traveler, however, who is coming back to the United States, and wants to share a rare French cheese, or a homemade Italian salami, with family and friends?  What restrictions, if any, apply when that traveler hits the US border?

U.S. Customs and Border Protection (CBP) currently collects import duties, carries out immigration inspection and clearance of passengers, and carries out inspection and clearance of agricultural items (in commercial and passenger areas) at U.S. ports of entry. On March 1, 2003, approximately seven years ago, CBP combined the inspectional work forces and border authorities of the U.S. Customs Service, Immigration and Naturalization Service, and the Animal and Plant Health Inspection Service (APHIS) of the U.S. Department of Agriculture (USDA). Accordingly, it is CBP personnel who are charged with inspecting everyone who arrives at a U.S. port of entry.

On a typical day, CBP welcomes more than 1.1 million international travelers into the United States at land, air, and sea ports.  They can ask if you are bringing anything back to the U.S., and they have the legal authority to also search your baggage, just in case.[2]

CBP has the authority to take any agricultural items from your baggage. Agricultural items cannot be brought into the United States because they may carry animal and plant pests and diseases. Some of these organisms are highly contagious animal diseases that could cause severe economic damage and losses in production, which would mean increased costs for meat and dairy products. Restricted items generally include meats, fruits, vegetables, plants, soil, and products made from animal or plant materials.

All travelers entering the United States are required to declare any meats, fruits, vegetables, plants, seeds, animals, and plant and animal products (including soup or soup products) they may be carrying. The declaration must cover all items carried in checked baggage, carry-on luggage, or in a vehicle.[2]

Upon examination of plants, animal products, and associated items, CBP agriculture specialists at the ports of entry will determine if these items meet the entry requirements of the United States.

Prohibited items that are not declared by passengers are confiscated and disposed of by CBP agriculture specialists. Civil penalties may be assessed for violations and may range up to $1,000 for a first-time offense. Depending on whether the confiscated, undeclared items are intentionally concealed, or determined to be for commercial use, civil penalties may be assessed as high as $50,000 for individuals.[2]

Many people complain that they see similar products on the shelves in their grocery stores in the U.S. so they don’t know why they can’t bring them back in their luggage. The reason is that commercial imports (what ends up on the grocery shelves) go through very extensive permitting and inspection procedures that are not available to the traveler who is buying something for their own use.[3]

Also, many duty-free shops in foreign counties offer animal food products for sale. Just because they are offered for sale in a duty-free shop does not mean the goods are admissible into the U.S.

General List of Approved Products:

Aloe Vera (above ground parts) 

Bat nut or devil pod (Trapa bicornis) 

Breads, cakes, cookies, and other bakery goods 
Candies 
Cannonball fruit 

Chinese water chestnut 

Coffee (roasted beans only) 

Fish 

*Flower bulbs 

Fruits, canned 

Garlic cloves (peeled) 

Lily bulbs (Lilium spp.) for planting

Maguey leaf 

Matsutake 

Mushrooms 

Nuts (roasted only) 

Palm hearts (peeled) 

Sauces, canned or processed 

Seaweed 

*Seeds for planting or consumption

Shamrocks leaves without roots or soil 

St. John’s Bread 

Singhara nut (Trapa bispinosa) 

Tamarind bean pod 

Truffles 

Vegetables, canned or processed 

Water chestnut (Trapa natans)

*Check with the consulate or agricultural office in the country of origin to confirm that your item is allowed. A phytosanitary certificate is required for propagative material. Pre-departure inspection is required for passengers traveling from Hawaii to the mainland, Puerto Rico to the mainland, and from the U.S. Virgin Islands to the mainland.

Many products grown in Canada or Mexico are allowed to enter the United States. This includes most vegetables and many fruits; however, seed potatoes from Canada currently require a permit. Additionally, stone fruit, apples, mangoes, oranges, guavas, sopote, cherimoya and sweet limes from Mexico require a permit.  [2]     

Alcohol:

Each U.S. citizen over the age of 21 is allowed to bring into the country up to one liter (33.8 fluid ounces) of alcoholic beverages, for personal use or for a gift, without having to pay duty and tax.  The importation of absinthe is subject to interesting special U.S. Food and Drug Administration regulations: the absinthe content must be “thujone-free” (that is, it must contain less than 100 parts per million of thujone); the term “absinthe” cannot be the brand name; the term “absinthe” cannot stand alone on the label; and the artwork and/or graphics cannot project images of hallucinogenic, psychotropic or mind-altering effects. Absinthe imported in violation of these regulations is subject to seizure.

Fruits, Vegetables, and Plants:

Every single plant or plant product, including handicraft items made with straw, must be declared to the CBP officer and must be presented for CBP inspection, no matter how free of pests it appears to be.

Depending on the country of origin, some fruits, vegetables, and plants may be brought into the United States without advance permission, provided they are declared, inspected, and found free of pests.

Many fruits and vegetables, however, are prohibited from entering the United States or require either an import permit (for commercial importers) or a phytosanitary certificate from the country of origin (a phytosanitary certificate is a document often required by many states and foreign countries for the import of nonprocessed plant products).  An example of problems imported fruits and vegetables can cause is the Mediterranean fruit fly outbreak during the 1980s.  The outbreak cost the state of California and the federal government approximately $100 million to get rid of the pest.  The likely cause of the outbreak was one traveler who brought home one contaminated piece of fruit.[5]           

Some plants, cuttings, and seeds that are capable of propagation, unprocessed plant products, and certain endangered species are allowed into the U.S. but require import permits and other documents; some are prohibited entirely. Threatened or endangered species that are permitted must have export permits from the country of origin. Plant and plant product permits include plants for planting, such as nursery stock, and small lots of seed; plant products such as fruits and vegetables, timber, cotton and cut flowers; protected plants and plant products such as orchids, and threatened and endangered plant species; transit permits to ship regulated articles into, through, and out of the U.S.; and departmental permits to import prohibited plant materials for research.[6]

Meat and Animal Products and Byproducts:

Fresh, dried, or canned meats and meat byproducts are prohibited entry into the United States from most foreign countries because of the continuing threat of foot-and-mouth disease (FMD), bovine s
pongiform encephalopathy (BSE, or mad cow disease), and other animal diseases.  If meat from restricted countries is used in preparing a product (e.g., beef broth), the product is usually prohibited. Animal hunting trophies, game animal carcasses, and hides are severely restricted.[2]

Because regulations concerning meat and meat byproducts change frequently, travelers should contact the consulate or local agricultural office in the country of origin for up-to-date information on the disease status of that country.  All decisions about the admissibility of animal products are dependent on disease conditions in their country of origin or the country where the products were processed and/or packaged. Because disease conditions can change at a moment’s notice, travelers who purchase such goods must be prepared for the fact that the goods may be confiscated during customs clearance. APHIS, which regulates meats and meat products as well as fruits and vegetables, can be contacted for more information on importing meats.[2]

Other reasons that such products might be confiscated is if the traveler fails to declare them–in which case they are automatically seized–or the inability of the CBP officer to determine the country of origin or the nature of the product being presented for inspection. Labels on goods purchased overseas are rarely in English, and if the officer can’t tell what the ingredients are through pictures or similar names (i.e. porc, poullet, etc.) then they won’t be allowed entry.  For this same reason, food items without any labels are also inadmissible.[3]

The complex nature of these regulations applicable to the popular meat products below is apparent:
 
•    Cured Bacon–Unless it is from Canada, or from two specifically approved producers allowed to sell certified pork products in duty free shops in Dublin and Shannon Airports–not allowed
•    Sausage–not allowed
•    Salami and other cured deli products–not allowed
•    Prosciutto–not allowed
•    Pate–If cooked and in a hermetically sealed container, maybe–otherwise, not allowed
•    Fois Gras–If cooked and in a hermetically sealed container, maybe–otherwise, not allowed
•    Parma, Iberian or Serrano hams–Only certain plants are certified exporters, and the hams must be accompanied by certificates and seals–otherwise, not allowed
•    Bouillon Cubes and Dry Soup Mixes–Beef or other ruminant-based (goat, sheep, etc.) bouillon products are not admissible if from a BSE (Mad Cow) country–(Basically, none from Europe or European territories such as Martinique or British Virgin Islands). No poultry-based bouillon from Asia, which has Highly Pathogenic Avian influenza. [3]

Foods from Canada:

Fruits and vegetables grown in Canada are generally admissible, if they have labels identifying them as products of Canada. Fruits and vegetables purchased in Canada, but grown elsewhere, are not necessarily admissible, ie. citrus or tropical fruits such as mangoes, which clearly were not grown in Canada because it does not have a climate that supports those crops.

The Department of Agriculture has recently relaxed rules for travelers arriving from Canada with food products involving some meat products. Beef and game products are now allowed entry. This includes frozen, cooked, canned, or otherwise processed beef, veal, venison, elk, bison, etc. Hunter-harvested game, including deer, moose, wild sheep, goats and bison is admissible from Canada for the traveler’s personal use if accompanied with a hunting license, tag or equivalent permit.  Meat products from domestic lamb, sheep and goats are otherwise still prohibited entry from Canada.  [7]

Additional resources:

If you have any questions about CBP procedures, requirements, or policies regarding travelers, please contact:

Customer Service Center 
Office of Public Affairs 
U.S. Customs and Border Protection
1300 Pennsylvania Avenue, NW
Washington, DC 20229 
(877) 227-5511

For further information:

The CBP Web site, www.cbp.gov, contains a wealth of information on both import and export regulations and requirements for many items and commodities. From the site’s home page, click on “Questions” and search the database for answers on a specific topic, or click on the “Imports”, “Exports” or “Travel” section for detailed information.

APHIS-PPQ Permit Unit, U.S. Department of Agriculture, can provide information about import requirements and permits for plants, plant parts, fruits, vegetables, and other agricultural items. Call the unit at (301) 734-8645, or visit the Web at Animal and Plant Health Inspection Service.[2]

REFERENCES:

1.  Kemel, W., “Health dilemma at the borders: a call for global action”.  Proceedings of the 34th Session of the WHO Advisory Committee on Health Research; Geneva, Switzerland, October 1996.

2.  “Bringing Agricultural Products into the United States”, Travel Advisories, US Customs and Border Protection, at www.cbp.gov, last revised 7/02/2008.

3.  “Can I bring any meat, poultry or pork products into the US?”  Answers, U.S. Customs and Border Protection, at www.cbp.gov, last updated 1/12/ 2010.

4.  “Absinthe (Alcohol)”, Prohibited and Restricted Items, U.S. Customs and Border Protection, at www.cbp.gov.

5.  “Fruits and Vegetables”, Prohibited and Restricted Items, U.S. Customs and Border Protection, at www.cbp.gov.

6.  “Plants and Seeds”, Prohibited and Restricted Items, U.S. Customs and Border Protection, at www.cbp.gov.

7.  “What food can I bring into the US?” Answers, U.S. Customs and Border Protection, at www.cbp.gov, last updated 1/28/ 2010.

Opponents, however, argue that this legislation favors an industrial agricultural system, and that local food systems provide significant food safety benefits.  In fact, in Wyoming and in Florida, state legislatures were considering bills to lessen the regulation of local “cottage” foods, with their proponents arguing at least in part that this approach would increase food safety.  

An increasing number of Americans is justifiably becoming concerned about outbreaks of illness linked to contaminated food, and about the capacity of our existing food safety system.  A September 2009 survey among likely voters across the nation found that about 9 in 10 support the federal government adopting additional food safety measures.  Overall, 58 percent of voters were worried about bacterial contamination of the food supply–with about a third saying they worry “a great deal.”  The survey showed that American voters overwhelmingly believed the federal government should be responsible for protecting the food supply, and that the voters supported new measures to ensure it has the authority and capacity to do so.[1]

The public’s increasing concern about food safety was recently validated by the results of a study on the cost of acute foodborne illnesses in the Unites States.  The study by a former U.S. Food and Drug Administration (FDA) economist estimates the total economic impact of foodborne illness across the nation to be a combined $152 billion annually. The Centers for Disease Control and Prevention (CDC) estimates that approximately 76 million new cases of food-related illness–resulting in 5,000 deaths and 325,000 hospitalizations–occur in the United States each year. This recent study used an FDA cost-estimate approach: health-related costs were the sum of medical costs (physician services, pharmaceuticals, and hospital costs) and losses to quality of life (lost life expectancy, pain and suffering, and functional disability). The study ranked states according to their total costs related to foodborne illness, and determined the annual cost per case for an individual, which was approximately $1,850 on average per illness nationwide.[2]

Many have been pressing for changes in the food safety system to enhance the regulatory and enforcement authority of local, state, and federal agencies to inspect, investigate, and recall food products as needed.  A report released in April 2009 called for leadership by Congress and the U.S. Department of Health and Human Services (HHS) to build an integrated national food safety system to make effective use of the best science and all available public resources to prevent foodborne illness.  The report noted progress in how federal, state, and local agencies collaborate to detect foodborne outbreaks, but also found that state and local agencies are hampered in their response to and prevention of outbreaks by lack of focused federal leadership, chronic underfunding, wide disparities in capacity in all areas of food safety, and barriers to information sharing and collaboration. The report then made 19 specific recommendations for strengthening state and local roles, and for building an integrated national food safety system that works effectively to prevent foodborne illness.[3]

In October 2009, the American Public Health Association (APHA) recommended legislative changes to establish new authority to strengthen the food safety system. The APHA found that FDA lacks the authority to require tracking, maintenance, and access to records on foods, including fresh fruits and vegetables. The FDA does not have the authority to mandate a recall when a food is identified as contaminated or is a source of an outbreak. Also, limited funding at all levels restricts the ability of state and local health agencies to conduct robust prevention and surveillance activities.  The APHA accordingly recommended legislation that would in part: improve coordination among local, state, and federal agencies to enhance surveillance, investigations, and response; implement national food safety plans, including testing, record maintenance, and reporting of positive contamination results; and authorize FDA mandatory recalls and tracebacks.  The APHA finally supported food safety enhancement and modernization legislation then already pending in Congress.[4]

Most recently, “The Hill”, a Capitol Hill newspaper, published several Op-Eds highlighting the bipartisan support for the pending FDA Food Safety Modernization Act, S. 510, and urging the Senate to act.  Caroline Smith DeWaal, director of food safety at the Center for Science in the Public Interest, emphasized the broad, bipartisan support for S. 510, a bill that would increase the FDA’s authority and capacity to regulate 80 percent of the food supply.  Sen. Herb Kohl (D-WI), chairman of the Senate agriculture appropriations subcommittee, called for urgent action in his Op-Ed, stating that “The Senate must act this year to restore consumer confidence and ensure a safe and abundant food supply.”  Rep. Rosa DeLauro (D-CT), chairwoman of the House appropriations subcommittee, which oversees the USDA and FDA budgets, called for simplifying the food safety system by centralizing food safety activities into one agency.[5]

In sharp contrast, however, recent headlines have also highlighted a quite different approach to the issue.  This other approach in fact favors reducing food safety inspections, certifications, and similar regulations, advocating instead for the increased freedom of local producers to produce and market their products.  State legislators in Wyoming and Florida have recently been working to enact similarly inspired “Food Freedom Acts”.  

House Bill 54, the Wyoming Food Freedom Act, passed out of a Wyoming House committee on February 18, 2010.  The bill proposed to exempt all “cottage foods”, or foods prepared in home kitchens, including potentially hazardous foods such as dairy products, canned foods, and sauces, from regulation.  The stated purpose of the bill was “…to allow for traditional community social events involving the sale and consumption of homemade foods and to encourage the expansion and accessibility of farmers’ markets, roadside stands, ranch, farm, and home based sales and producer to end consumer agricultural sales …”.  

Those in favor of the Wyoming Food Freedom Act claimed it would allow small farmers and food producers to sell direct to consumers without their need to spend the significant funds required to get proper certifications–a financial burden that can put small farmers and food producers out of business.  As regards food safety, proponents argued that industrialized and inspected foods are no guarantee of safety, and that the highest quality, and most nutrient-dense food is the closest to the source.  Also, those in favor of the bill claimed that community fosters responsibility, and that local producers who sold low quality and unsafe food would have to answer to their neighbors and would not be in business long.[6]

Critics, however, fear the increased risk for foodborne illness outbreaks if House Bill 54 passed into law.  Those in opposition to the bill supported the inspection and licensing process in place because it allows inspectors to help cottage businesses minimize the risk of distributing foods contaminated with foodborne pathogens.  Ultimately, they prevailed, and despite passing through the House Committee, the b
ill failed to pass through the Senate Agriculture Committee on February 26, 2010, effectively shelving the legislation, at least for this session.

In the meantime, in Florida, legislators are debating the merits of the proposed Florida Food Freedom Act. The articulated purpose of the Act is to initiate lighter inspection from USDA for small farmers. The Florida Food Freedom Act would define a single link food distribution chain that starts with the food producer, or the producer’s agent, and ends with the consumer.  The Act would then exempt that single link food distribution chain from the regulatory oversight that a longer, multi-layered food distribution chain would be required to have.   Its proponents argue that the Act would allow family farms to remain profitable and viable, creating new local businesses and jobs, as well as feeding the growing demand for locally grown food.[7]

Advocates for the Act also claim that it would enhance food safety.  They argue in part that the closer relationship between the producer and the consumer, including the producer’s integrity and the consumer’s interest in and knowledge of how the food is raised, harvested, and prepared, would provide sufficient oversight.  The biggest threats to food safety are claimed to be centralized production, centralized processing, and long distance transportation.  Small farms and local food processors would instead be part of the solution to food safety, as local food systems are inherently safer and more traceable.  Additionally, the Florida Food Freedom Act would require all people selling directly to the end consumer to become certified food protection managers.[8]

It is likely that the substantial differences in these approaches for legislation to increase food safety are primarily a function of different political philosophies and economic agendas, as well as concern with the safety of food products.  It is somewhat comforting, however, that the importance of improving food safety as a necessary goal is increasingly acknowledged and recognized, regardless of the diversity of means proposed to attain that goal.

REFERENCES:

1.    Pew Charitable Trusts, Commissioned Survey: “Americans’ Attitudes on Food Safety”, September 2009.  Available at www.makeourfoodsafe.org.  

2.    “Health-Related Costs from Foodborne Illness in the United States”, Robert L. Scharff, March 2010, Produce Safety Project.  Available at www.producesafetyproject.org.

3.    ” Stronger Partnerships for Safer Food: An Agenda for Strengthening State and Local Roles in the Nation’s Food Safety System”, Department of Health Policy at the George Washington University School of Public Health and Health Services, with the Association of Food and Drug Officials (AFDO), the Association of State and Territorial Health Officials (ASTHO), and the National Association of County and City Health Officials (NACCHO), April 17, 2009.

4.    “Creating a Safe Food System for America”, American Public Health Association, Issue Brief, October 2009.

5.    “More Calls for Senate to Act on Food Safety“, Helena Bottemiller, Food Safety News, Feb 26, 2010.

6.    “Committee hears testimony on food freedom”, Bill McCarthy, Wyoming Tribune Eagle, February, 17, 2010.

7.     “Florida Farmers Anxiously Await Florida Food Freedom Act”, Suzanne Richmond, Orlando Gardening Examiner, February 22, 2010.

8.     “Support Florida Food Freedom Act”, Farm-To-Consumer Legal Defense Fund, at the ftcldf.org website, last edited 2/26/2010.

First, the good news.  Oysters have been prized from the early days of civilization for their silky texture and taste of the sea. The cultivation of oysters began more than 2,000 years ago when Romans collected oyster seed stock near the mouth of the Adriatic Sea and transported them to another part of Italy for grow-out. The Romans had such a passion for oysters that they imported them from all over the Mediterranean and European coasts.  Also, raw oysters nutritionally consist of 23 percent carbohydrates, 33 percent fat and 44 percent protein. This makes them a balanced food and a good source of protein and Omega-3 fatty acids. Oysters are a good source of zinc, selenium, vitamin D, iron, magnesium and phosphorus. [1]

Perhaps of equal importance, raw oysters have always been linked with love. Aphrodite, the Greek goddess of love, sprang forth from the sea on an oyster shell, promptly gave birth to Eros, and the word “aphrodisiac” was born.  Casanova, the renowned 18th century lover, famously used to breakfast on 50 oysters.  This may not be simply myth.  A team of American and Italian researchers in 2005 analyzed bivalve mollusks – a group of shellfish that includes oysters – and found they were rich in rare amino acids that trigger increased levels of sex hormones.  The scientists stressed that the oysters have to be eaten raw to be most effective!

In contrast, raw oysters may contain a number of different harmful bacteria, and have been linked to serious illness and death.  As such, food safety experts and public health agencies have consistently warned of the serious potential risk created by these mollusks, when consumed uncooked.

The harmful bacterium most commonly associated with the consumption of raw oysters is Vibrio vulnificus.  It is a bacterium in the same family as those that cause cholera. It normally lives in warm seawater and is part of a group of Vibrios that are called “halophilic” because they require salt. V. vulnificus can cause disease in those who eat contaminated seafood or have an open wound that is exposed to seawater. It is found in all of the coastal waters of the United States. Environmental factors responsible for controlling members of V. vulnificus in seafood and in the environment include temperature, pH, salinity, and increased dissolved organics. [2]

V. vulnificus causes wound infections, gastroenteritis, or a syndrome known as “primary septicemia.”  Wound infections result either from contaminating an open wound with sea water harboring the organism, or by lacerating part of the body on coral, fish, etc., followed by contamination with the organism. The ingestion of V. vulnificus by healthy individuals can result in gastroenteritis.

Ingestion of the organism by individuals with some type of chronic underlying disease [such as diabetes, cirrhosis, leukemia, lung carcinoma, acquired immune deficiency syndrome (AIDS), AIDS- related complex (ARC), or asthma requiring the use of steroids] may cause the “primary septicemia” form of illness.  A recent study showed that people with these pre-existing medical conditions were 80 times more likely to develop V. vulnificus bloodstream infections than were healthy people.  In these individuals, the microorganism enters the blood stream, resulting in septic shock, rapidly followed by death in many cases; the mortality rate for individuals with this form of the disease is over 50%. [2]

Although oysters can be harvested legally only from waters free from fecal contamination, even legally harvested oysters can be contaminated with V. vulnificus because the bacterium is naturally present in marine environments. V. vulnificus does not alter the appearance, taste, or odor of oysters.

V. vulnificus is a rare cause of disease, and is likely underreported. Between 1988 and 2006, CDC received reports of more than 900 V. vulnificus infections from the Gulf Coast states, where most cases occur.  Before 2007, there was no national surveillance system for V. vulnificus, but CDC collaborated with the states of Alabama, Florida, Louisiana, Texas, and Mississippi to monitor the number of cases of V. vulnificus infection in the Gulf Coast region.  In 2007, infections caused by V. vulnificus and other Vibrio species became nationally notifiable. [3]

Another Vibrio pathogen often associated with raw oysters is Vibrio parahaemolyticus.   V. parahaemolyticus is a marine bacterium that occurs naturally in filter-feeding molluscan shellfish, like oysters. V. parahaemolyticus is also a bacterium in the same family as those that cause cholera. It lives in brackish saltwater and causes gastrointestinal illness in humans.   V. parahaemolyticus was first implicated in an outbreak of food poisoning in Japan, in 1950, and has been associated with sporadic cases and outbreaks (multiple cases) of illness in the United States since 1969.  An estimated 4500 cases of V. parahaemolyticus infection occur each year in the United States.

Most people become infected with V. parahaemolyticus bacteria by eating raw or undercooked shellfish, particularly oysters. Less commonly, this organism can cause an infection in the skin when an open wound is exposed to warm seawater. When ingested, V. parahaemolyticus causes watery diarrhea often with abdominal cramping, nausea, vomiting, fever, and chills. Usually these symptoms occur within 24 hours of ingestion. Illness is usually self-limited and lasts 3 days. Severe disease is rare and occurs more commonly in persons with weakened immune systems. [4]

Public health agencies have been consistently warning of these potential risks associated with the consumption of raw oysters. The U.S. Food and Drug Administration (FDA) has advised people with certain medical conditions not to eat raw oysters, and to only eat oysters that have been thoroughly cooked. In people with medical conditions such as cancer, diabetes, or liver disease death can occur within two days.  The FDA list of such medical conditions includes: liver disease (from hepatitis, cirrhosis, alcoholism, or cancer); iron overload disease (hemochromatosis); diabetes; cancer (including lymphomas, leukemia, Hodgkin’s disease); stomach disorders; or any illness or medical treatment that weakens the body’s immune system, including HIV infection.  [5]

People who drink alcoholic beverages (including beer and wine) regularly may be at risk for liver disease, and, as a result, may also be at risk for serious illness or death from consuming raw oysters. Even drinking two to three drinks daily can contribute to the development of liver disease, which may occur without symptoms. Alcoholism and infections from Hepatitis can injure the liver and impair its function years before an individual begins to experience symptoms. Liver disease puts people at risk for V. vulnificus infection from raw oysters. The risk of death is almost 200 times greater in those with liver disease than those without liver disease. [5]

In June of 2005, the FDA issued its “Letter to Health Professionals Regarding the Risk of Vibrio vulnificus Septicemia Associated with the Consumption of Raw Oysters”. The letter asked for the help of health professionals in alerting their patients in the at risk group about the threat of Vibrio vulnificus septicemia associated with the consumption of raw oysters. The FDA therefore advised that those persons at-risk for V. vulnificus septicemia should only eat oysters that have been fully cooked. [6]

In addition to the Vibrios, raw oysters may also contain
other harmful organisms.&nb
sp; In March 2007, the FDA issued an alert regarding an outbreak of norovirus-associated illness linked to eating raw oysters harvested from San Antonio Bay, TX.  Illnesses had been reported by 25 individuals who ate raw oysters at an event in Maryland. The Maryland Department of Health & Mental Hygiene’s test results from ill patients were positive for norovirus.  Symptoms of illness associated with norovirus include nausea, vomiting, diarrhea and stomach cramping. Affected individuals often experience low-grade fever, chills, headache, muscle aches and a general sense of tiredness within 48 hours of exposure to the virus.  The implicated oyster beds in San Antonio Bay were closed for some time, and the oyster distributors issued voluntary recalls of the product.  [7]

The FDA has consistently sought to dispel a number of common but wrong assumptions about the risks involved with the consumption of raw oysters.  These myths include: eating raw oysters is safe if you drown them in hot sauce, which kills everything; avoid oysters from polluted waters and you’ll be fine; an experienced oyster lover can tell a good oyster from a bad one; alcohol kills harmful bacteria; just a few oysters can’t hurt you; and avoid raw oysters in months without the letter “R” and you’ll be safe.  [5]

The 2005 FDA Food Code currently recognizes that food establishments may serve undercooked animal foods to a consumer upon his or her specific request, if the consumer is properly advised of the hazards associated with eating undercooked animal foods.  Many consumers and food establishments exercise this “consumer advisory” option with oysters. For oysters, the term “fully cooked” means that the product is allowed to reach an internal temperature of at least 145°F for 15 or more seconds.  The FDA Food Code contains additional recommendations for safe food handling practices in retail and foodservice operations.

The risk posed by raw oysters has also been addressed by various legislatures, which have typically mandated related warnings to potential consumers. For example, California  mandates a warning that contains the language ” THIS FACILITY OFFERS RAW OYSTERS FROM THE GULF OF MEXICO. EATING THESE OYSTERS MAY CAUSE SEVERE ILLNESS AND EVEN DEATH IN PERSONS WHO HAVE LIVER DISEASE (FOR EXAMPLE ALCOHOLIC CIRRHOSIS), CANCER OR OTHER CHRONIC ILLNESSES THAT WEAKEN THE IMMUNE SYSTEM.” See, 17 CCR 13675.  Florida requires a warning stating “Consumer Information: There is risk associated with consuming raw oysters. If you have chronic illness of the liver, stomach or blood or have immune disorders, you are at greater risk of serious illness from raw oysters, and should eat oysters fully cooked. If unsure of your risk, consult a physician.” See, 64D-3.040, F.A.C.    

Finally, the courts have also addressed the nature of risk posed by raw oysters, primarily in the context of personal injury claims, with somewhat inconsistent results. Louisiana’s highest court, for example, has held that the Vibrio vulnificus bacteria, which occurs naturally in the Gulf of Mexico, and is harmless to most people, does not render raw oysters containing the bacteria unreasonably dangerous. Thus, neither the distributor of oysters nor a restauranteur was liable where the plaintiff died after consuming raw oysters containing these bacteria. See, Simeon v. Doe, 618 So. 2d 848, 851 (La. 1993). A Kentucky court found that the presence of Vibrio bacteria in raw oysters did not constitute a manufacturing or design defect, because there are no reasonably available alternatives to bacteria-laced oysters, screening is not feasible, and bacterium poses little threat to healthy persons.  See, Edwards v. Hop Sin, Inc., 2003 Ky. App. LEXIS 213, at *4 (Aug. 29, 2003).  

In contrast, a Texas court found that there is no question Vibrio vulnificus bacteria are highly dangerous to people who suffer an immunosuppressed condition.  Therefore, the issue of whether raw oysters constitute a product that is “dangerous to an extent beyond that which would be contemplated by the ordinary consumer who purchases it, with the ordinary knowledge common to the community as to its characteristics”, could not be resolved as a matter of law, and needed to be determined by the trier of facts.  See, Ayala v. Bartolome, 940 S.W.2d 727 (1997). In Cain v. Sheraton Perimeter Park South Hotel, 592 So. 2d 218 (Ala.1991), a patron sued a hotel and its restaurant alleging that he contracted hepatitis from consuming raw oysters served by the restaurant.  The Supreme Court of Alabama held that a fact question was presented as to whether a patron should have reasonably expected that raw oysters may have been contaminated.

Most recently, during the fall of 2009, the issue of raw oyster safety was again raised, and publicly and heatedly debated. On October, 17, 2009, the FDA announced, at a meeting of shellfish regulators, the agency’s intention to reformulate its policy on processing raw oysters to reduce Vibrio vulnificus.  The FDA announced that it would change HACCP rules to require post-harvest processing to reduce the risk posed by the bacterium.  The new rule was intended to take effect by the beginning of risk season in 2011.  

“There’s just a very clear public health case,” said Michael Taylor, the top food safety official at the FDA. “Vibrio is one of the most horrific infections we know about. Fifteen people a year die from this. It’s excruciating. And the people who don’t die suffer life-changing injuries. But we can prevent this.” Federal officials, who are emphasizing food safety improvements, point to California as an example. Between 1991 and 2001, 40 people in California died of Vibrio infection.  In 2003, the state banned raw untreated oysters from the Gulf during warm months and fatalities dropped to zero, Taylor said.

Oystermen, state officials, and their representatives on Capitol Hill, however, quickly complained that the federal government was overreaching, and was likely to destroy a gastronomical delight and its related industry, setting off a flurry of political action.  Opponents of the proposed new rule argued that antibacterial processing, which is similar to pasteurization, would ruin the taste of raw oysters, triple their cost, and place excessive burdens on a business with over 3500 workers, and with deep cultural and culinary roots, that was already at risk.

The FDA reacted by temporarily shelving the proposed new rule.  On November 13, 2009, in a media release, the FDA announced “Since making its initial announcement, the FDA has heard from Gulf Coast oyster harvesters, state officials, and elected representatives from across the region about the feasibility of implementing post-harvest processing or other equivalent controls by the summer of 2011.  These are legitimate concerns.”  Accordingly, the FDA delayed the implementation of the rule, deciding instead that, prior to its proceeding, it would “conduct an independent study to assess how post-harvest processing or other equivalent controls can be feasibly implemented in the Gulf Coast in the fastest, safest and most economical way.”  [8]

So, pending possible future action by the FDA, consumers who choose to eat raw oysters should continue to be aware of the potential health hazards posed by these controversial mollusks. The Florida Department of Agriculture and Consumer Services provides the following tips on how to handle oysters safely:

BUYING, STORAGE AND HANDLING

Live Oysters:


• Remember to purchase seafood last and keep it cold during the trip home.

• Live oysters should close tightly when tapped. 

• Discard any oysters that don’t close; this is an indication that the shellfish are dead.

• They should have a mild odor, similar to the ocean.

• Live oysters should be free of cracks

  .


• They will remain alive for up to seven days in the refrigerator when stored at a constant 41 degrees F in a container with the lid slightly open. 

• Drain excess liquid daily.



Shucked Oysters: 


• Remember to purchase seafood last and keep it cold during the trip home.

• Oysters have a fresh odor when freshly shucked.

• A clear, slightly milky or gray liquid should surround freshly shucked oysters.

• Freshly shucked scallops should have very little liquid in the package

• Refrigerate shellfish in a sealed container on ice or in the coldest part of the refrigerator.

• Store shucked oysters up to five days.

PREPARATION

• Keep raw and cooked seafood separate to prevent bacterial cross-contamination.


• After handling raw seafood thoroughly wash knives, cutting surfaces, sponges and your hands with hot soapy water.


• Always marinate seafood in the refrigerator.


• Discard marinade; it contains raw juices which may harbor bacteria.


• When marinade is needed for basting reserve a portion before adding raw seafood.


COOKING

• Wash live oysters thoroughly under cold running water prior to cooking.


• Steamed or grilled: cook until shell opens.


• Shucked oysters: bread and fry in oil for 3 to 4 minutes at 375 degrees F.


• Shucked oysters: bake for 10 minutes at 450 degrees F.    [1]

REFERENCES:

[1]    “Oysters”, Foodreference.com;
[2]    Vibrio vulnificus, Bad Bug Book: Foodborne Pathogenic Microorganisms and Natural Toxins Handbook, Centers for Disease Control and Prevention;
[3]    Vibrio vulnificus, General Information, Centers for Disease Control and Prevention;
[4]    Vibrio parahaemolyticus, General Information, Centers for Disease Control and Prevention;
[5]    Vibrio vulnificus Health Education Kit, U.S. Food and Drug Administration;
[6]    “Letter to Health Professionals Regarding the Risk of Vibrio vulnificus Septicemia Associated with the Consumption of Raw Oysters”, U.S. Food and Drug Administration, June, 2005;
[7]    “FDA Investigating Norovirus Outbreak Linked to Oysters”, FDA News Release, March 2, 2007;
[8]    “FDA Statement on Vibrio Vulnificus in Raw Oysters”, FDA News Release, Nov. 13, 2009.

The Maryland Community Health Administration defines catering services as “The preparation or provision and the serving of food or drink by a food service facility for service at the provider’s premises or elsewhere in connection with a specific event or a business or social function or affair”. [1]  In other words, a licensed caterer provides food and/or drink for a specific function at a location generally determined by that specific function.  
Image by Flickr.com, courtesy of Aaron Matthews

Caterers must be licensed, and licensing requirements and certifications vary from state to state. Typically, the state Department of Health is responsible for establishing the guidelines for training and certification of all food handlers. Caterers generally must take food-hygiene courses to learn to prepare and serve food items, and to avoid potential hazards that surround the issue of food safety.

Professional caterers are also required to comply with the food safety regulations otherwise applicable to other food service establishments. Officials from the health department will conduct routine inspections to make sure catering businesses have sanitary environments. A caterer must also be up to date with current FDA guidelines for storing and preparing food safely.  Catering is specifically included in the definition of a “food establishment” provided by the Food Code 2009: “‘Food establishment’ means an operation that: (a) stores, prepares, packages, serves, vends food directly to the consumer, or otherwise provides food for human consumption such as a restaurant; satellite or catered feeding location; catering operation if the operation provides food directly to a consumer or to a conveyance used to transport people; market; vending location; conveyance used to transport people; institution; or food bank; and…”.

Today, the distinction between grocery and catering businesses is eroding as more and more grocery retailers extend their businesses into offering hot take-away food and delicatessen items. Similarly, some caterers now supply a more traditional grocery line on their premises, usually focusing on the ingredients used in the preparation of their food. Catering businesses, however, must be especially diligent about staff personal hygiene, the hygiene of the equipment and premises as well as staff training. The transient nature of workers in the catering business can put a particularly heavy burden on the ability of the business to train its staff. Unless staff are trained appropriately in food hygiene the risks of food poisoning increase, and many outbreaks of foodborne illness can be attributed to lack of adequate hygiene knowledge and consequential poor practices in catering establishments. [2]

The epidemiology of general outbreaks of infectious intestinal disease associated with domestic catering for large numbers was  described and compared with other foodborne outbreaks in a 1996 British study.  From 1 January 1992 to 31 December 1994, 101 foodborne general outbreaks of infectious intestinal disease were identified as being associated with domestic catering in England and Wales (16% of all foodborne outbreaks). Outbreaks occurred most commonly in summer. The commonest vehicles implicated were poultry/eggs in 44 outbreaks, desserts in 13, and meat/meat products in nine.  Salad/vegetables, sauces, and fish/shellfish were each implicated in eight outbreaks. Raw shell eggs were implicated in a fifth of outbreaks. Inappropriate storage was the commonest fault, reported in association with 50 outbreaks (ambient temperature for long periods before serving in 29), inadequate heat treatment was reported in 35, cross contamination in 28, an infected food handler in 11, and other faults in 14. Outbreaks associated with catering on domestic premises were independently more likely than outbreaks in other settings to be associated with Salmonella, inappropriate storage of food, and consumption of poultry, eggs, or sauces. [3]

Data on the number of foodborne illness outbreaks tied to catering can be deceptive. In 1996, approximately 73% of foodborne illness complaints in Massachusetts involved restaurants, while 1% were associated with caterers.  When foodborne illness cases are analyzed by establishment type, however, 38% of cases involved catered food.  This information illustrates that while outbreaks at catered events are less common, larger numbers of people are affected. Caterers may prepare large amounts of food for large groups, under conditions that are not always ideal. [4]

Marler Clark has represented clients involved in a number of foodborne illness outbreaks associated with catered food. An unusual one was identified in September, 2004, when health agencies from many U.S. states, as well as international health agencies, began reporting persons ill with Shigella sonnei infections.  Tests conducted on many U.S. residents who had cultured positive for the bacteria revealed a matching genetic pattern amongst the samples provided.  Epidemiological investigation revealed that a cluster of persons ill with the genetically identical strain of Shigella sonnei had traveled by air from Honolulu, Hawaii during August 22 through 24, 2004.  Further investigation established that food from the airline’s catered food service in Honolulu, Hawaii, was the common link between the airlines and the cluster of persons ill with the genetically identical strain of Shigella sonnei.  In February, 2005, the Food and Drug Administration (FDA) inspected the caterer’s facility, which provided food and beverage service to various airlines at Honolulu Airport.  The FDA identified a litany of violations, including: perishable food holding temperature violations; pest and vermin violations; equipment maintenance and cleanliness violations; and bare-handed contact with ready-to-serve items.

A more representative outbreak occurred in Alexandria, Virginia, in July, 2002. A barbecue was catered at a private home, with approximately 20 coworkers and spouses attending the barbecue.  Approximately one week later, the Alexandria Health Department received a report of a confirmed case of campylobacteriosis apparently linked to the barbecue.  The environmental investigation by the health department revealed that all foods prepared for the barbecue were prepared the morning of the event, and that several food items were also sold in the catering establishment’s grocery store. The investigation identified several problems with the food handling and preparation procedures for buffalo chicken skewers. The head chef and food worker involved with the chicken preparation for the barbecue provided differing versions of the food preparation procedures.  The recipe did not require a cooking time or temperature, and thus there was no way for the person preparing the chicken to know if they had cooked enough to a safe internal temperature. Finally, there was also some indication that the same pan was used to transport both the raw and the cooked chicken.  This latter possibility gave rise to the theory that cross-contamination occurred between the previously raw chicken to the cooked chicken.

The Houston Department of Health and Human Services has put together the following questions to ask a potential caterer before an event, to reduce the odds of having the event spoiled by a foodborne illness:

Q: Does
the catering company have a
permit or license? 

A.    Catering companies are considered food service establishments and must be licensed as a food establishment. You can check to see if they are certified food handlers, who have taken the food safety course offered by many local health departments.

Q: Where is the food cooked?

A.    If the food preparation is to take place at the caterer’s establishment, visit the facility. The facility must be clean, provided with enough refrigeration space for large quantities of food, cooking and holding facility for large batches of cooking so that cooking will not need to be done too far in advance. There should be separate areas in the kitchen for handling raw and cooked products as when raw and cooked products mix, cross contamination can cause an illness outbreak. Check to see if the employees in the kitchen follow good hygienic practices by washing hands frequently.

Q: How will they transport the food?

A.    The transportation of food, and all raw products is critical. All perishable foods must be held cold (41°F or below) or hot (140°F or above) during transit. The caterers can use refrigerated trucks, insulated coolers, warming units, etc. If they do not, insist on it.

Q: How will the food be kept hot or cold during the party/serving?

A.    No cooked food should sit at room temperature for more than two to three hours. Cold foods must be kept at 41°F or below by using coolers, insulated containers, or on a bed of crushed ice. They can serve hot foods from chafing dishes or warming units that maintain the foods at 140°F or above.

Q: How is the caterer planning to replenish foods on buffet tables?

A.    The caterer should prepare many dishes of each food to be served. The back up dishes should be kept cold or hot before serving. When the plates are empty, they should be removed and replaced with full trays. It is unsafe to add new food to a serving dish that has been out of refrigeration or hot holding.

Q: What will be done with leftovers?

A.    If the food is prepared under safe food handling practices, and held at safe temperatures throughout the party, enjoying the leftovers should be safe. Divide the leftovers into smaller portions for quick chilling or freezing. Use anything you plan to refrigerate within 1-2 days. Make sure that you reheat the leftovers thoroughly before serving. When in doubt, throw it out!
HAPPY PARTYING   [5]
REFERENCES:

1.  “Guidelines for the Prevention of Foodborne and Waterborne Outbreaks for Nonprofit Organizations Who Operate as “Excluded Organizations”, Maryland Community Health Administration, Maryland Department of Health & Mental Hygiene, 2002.

2.  Reilly, A., “Defining the responsibilities and tasks of different stakeholders within the    framework of a national strategy for food control”, Second FAO/WHO global forum of food safety regulators, Bangkok, Thailand, 12-14 October 2004.

3.  Ryan MJ, Wall PG, Gilbert RJ, Griffin M, Rowe B, “Risk factors for outbreaks of infectious intestinal disease linked to domestic catering”, Commun Dis Rep CDR Rev. 1996 Dec 6;6(13):R179-83.

4. Foodborne Illness Investigations and Control Reference Manual, Massachusetts Department of Public Health, 1997.

5. “Catering Tips”, Houston Department of health and Human Services, at
www.houstontx.gov › … › Food Safety Tips

At Marler Clark, we take pride in working hard to identify the likely sources of the foodborne pathogens inflicting illness on victims who contact us in the hopes of recovering compensation for lost time at work, medical bills, and other losses associated with their illnesses.  We use the experience and knowledge of our staff epidemiologist, and the resources provided by our many epidemiology and microbiology experts.  Inevitably, however, we face the same challenges as those faced by public health agencies and in many cases it is simply not possible to trace back a likely source.  In those unfortunate cases, the illness victims have no way to identify a potentially responsible party, and to recover at least some of their related losses.

A comprehensive national study in 1999 summed up those illnesses attributable to foodborne gastroenteritis caused by both known and unknown pathogens, and yielded an estimate of 76 million illnesses, 318,574 hospitalizations, and 4,316 deaths per year.  Adding to these figures the nongastrointestinal foodborne illness caused by Listeria, Toxoplasma, and hepatitis A virus, the study arrived at a final national estimate of 76 million illnesses, 323,914 hospitalizations, and 5,194 deaths each year.  The analysis further suggested that unknown agents account for approximately 81 percent of those foodborne illnesses and hospitalizations, and for approximately 64 percent of deaths. [1]        

The available existing data on foodborne illnesses does not fully depict the extent of the problem. Public health experts believe that the majority of cases of foodborne illness are not reported, because the initial symptoms of most foodborne illnesses are not severe enough to warrant medical attention, because the medical facility a person is treated at or the state health department does not report such cases, or the illness is not recognized as foodborne. [2]

It is often assumed that the sources of foodborne illness outbreaks are typically identified, given the extensive coverage of national outbreaks such as the recent contaminated spinach and peanut butter outbreaks.   In fact, however, according to the Centers for Disease Control and Prevention (CDC), in nearly 60 percent of outbreaks, a source of the pathogen involved is never found.  [1]

Tracking the source of the far more numerous cases of sporadic and single illness is even more difficult, and is far less successful. Investigated outbreaks account for only a small and nonrepresentative share of all foodborne illnesses.  Although sporadic illnesses involving a single person are far more common, public health agencies are more likely to learn of, and to investigate, outbreaks affecting many people. [3]


While the overall annual economic cost of foodborne illnesses is unknown, it is estimated to be in the billions of dollars. The range of estimates is wide, primarily because of the uncertainty about the number of cases of foodborne illness and related deaths.  The range of estimates may also depend on the differences in the analytical approach used to prepare the estimate. Some economists attempt to estimate the costs related to medical treatment and lost wages (the cost-of-illness method); others attempt to estimate the value of reducing the incidence of illness or loss of life (the willingness-to-pay method).  

Two estimates demonstrate these differences in analytical approach. In the first, USDA’s Economic Research Service (ERS) used the cost-of-illness approach to estimate that the 1993 medical costs and losses in productivity resulting from seven major foodborne pathogens ranged between $5.6 billion and $9.4 billion.  In the second analysis, ERS used the willingness-to-pay method to estimate the value of preventing deaths for five of the seven major pathogens (included in the first analysis) at $6.6 billion to $22 billion in 1992. [2]

More recently, CDC has studied and estimated the cost of a specific pathogen, the Shiga toxin-producing Escherichia coli O157 (O157 STEC) bacteria.   Escherichia coli O157 infections cause 73,000 illnesses annually in the United States, resulting in more than 2,000 hospitalizations and 60 deaths. In the CDC study, the economic cost of illness due to O157 STEC infections transmitted by food or other means was estimated based on the CDC estimate of annual cases and newly available data from the Foodborne Diseases Active Surveillance Network (FoodNet) of the CDC Emerging Infections Program. The annual cost of illness due to O157 STEC was $405 million (in 2003 dollars), including $370 million for premature deaths, $30 million for medical care, and $5 million in lost productivity. The average cost per case varied greatly by severity of illness, ranging from $26 for an individual who did not obtain medical care to $6.2 million for a patient who died from hemolytic uremic syndrome.  [4]

The effect can be catastrophic on everyday life for those who lack the resources to cover these costs. 62.1 percent of all bankruptcies in 2007 were medical; 92 percent of these medical debtors had medical debts over $5000, or 10 percent of pretax family income. The rest met criteria for medical bankruptcy because they had lost significant income due to illness or mortgaged a home to pay medical bills. Most medical debtors were well educated, owned homes, and had middle-class occupations. Three quarters had health insurance. Using identical definitions in 2001 and 2007, the share of bankruptcies attributable to medical problems rose by 49.6 percent.  The odds that a bankruptcy had a medical cause were 2.38-fold higher in 2007 than in 2001. [5]

Even more importantly, the long term health impacts of foodborne illness can be substantial and severe.  The severity of acute foodborne disease varies greatly, depending on the pathogen and the vulnerability of the person infected.  Diarrhea and vomiting are common symptoms and, in most cases, last for only a few days.  While foodborne illnesses are often temporary, they can also result in more serious illnesses requiring hospitalization, long-term disability, and death.  

Some pathogens have the ability to cause very serious acute illnesses, with parasites, bacteria or bacterial toxins invading the bloodstream. When this occurs, various organs may become compromised or fail, leading to serious health complications or premature death (Mead et al. 1999). For a subset of patients, other serious long-term health outcomes, such as kidney failure, paralysis, seizures, and neurological/cognitive impacts, can develop (Reeseet al. 2004; Lindsay 1997).  Serious complications can result when diarrhetic infections resulting from foodborne pathogens act as a triggering mechanism in susceptible individuals, causing an illness such as reactive arthritis to flare up.  In other cases, no immediate symptoms may appear, but serious consequences may eventually develop. [6]

Children, the elderly, pregnant women, and other individuals with compromised immune systems are at high risk for developing serious cases of foodborne illness. Children are of special concern.  About half of the reported cases of foodborne illnesses occur
in children under 15 years o
f age (CDC, FoodNet data, 2008), and children have more years of life ahead of them in which to be affected by long-term health outcomes. [6]

The likelihood of serious complications is unknown, but some experts estimate that 2 to 3 percent of all cases of foodborne illness lead to serious consequences. For example: E. coli O157:H7 can cause kidney failure in young children and infants; Salmonella can lead to reactive arthritis, serious infections, and deaths; Listeria can cause meningitis and stillbirths and is fatal in 20 to 40 percent of cases; and Campylobacter may be the most common precipitating factor for Guillain-Barre syndrome, which is one of the leading causes of paralysis from disease in the United States. [2]

These numbers are significant, of course, but somewhat dry.  The statistics necessarily fail to account for the subjective and highly personal emotional impacts on those who become ill, and on their families.  These illnesses too often cause permanent anxiety, stress, and fear of the future, in addition to pain, physical limitations, and economic uncertainty.  

It is frustrating when a likely source of a client’s illness cannot be identified, especially when the illness has been severe, and its impacts will be many, life-changing, and permanent.  That person has no available remedy or recourse to help reduce at least the economic burdens imposed by the illness.
 

REFERENCES:
[1] Mead, Slutsker, Dietz, McCaig, Bresee, Shapiro, Griffin, and Tauxe, “Food-Related Illness and Death in the United States”, Emerging Infectious Diseases, Vol. 5, No. 5, 1999.
[2] “Food Safety, Reducing the Threat of Foodborne Illnesses”, US General Accounting Office, GAO/T-RCED-96-185 (1996).
[3] Buzby, Frenzen, and Rasco, “Product Liability and Microbial Foodborne Illness”Agricultural Economic Report No. (AER799) 45 pp, April 2001.
[4] Frenzen PD, Drake A, Angulo FJ; “Economic cost of illness due to Escherichia coli O157 infections in the United States”. J Food Prot. 2005 Dec: 68 (12):2623-30.
[5] Himmelstein, Thorne, and Woolhandler, “Medical Bankruptcy in the United States, 2007: Results of a National Study”, The American Journal of Medicine, Vol. 122, No. 8, August 2009.
[6] Roberts, Kowalcyk, and Buck, “The Long-Term Health Outcomes of Selected Foodborne Pathogens”, Center for Foodborne Illness Research & Prevention.

Enterobacter sakazakii, a gram-negative bacillus, is a rare cause of bloodstream and central nervous system infections.  In 2007, following extensive study, it was proposed that the original taxonomy of Enterobacter sakazakii be revised, to consist of five new species moved to a new genus, identified as “Cronobacter”. (1)  A review of the what, the how, and the why the change was first proposed, and why it was eventually approved, provides an insight into the related scientific process of taxonomy at work, involving this notorious neonatal pathogen.

Initially, taxonomy is the science of classifying organisms, identifying and naming species, and organizing them into systems of classification.  At least 1.7 million species of living organisms have been discovered, and the list grows longer every year.   Ideally, classification should be based on homology, i.e., the shared characteristics that have been inherited from a common ancestor.  Until recent decades, the study of homologies was limited to anatomical structures and pattern of embryonic development.  However, since the birth of molecular biology, homologies can now also be studied at the level of proteins and DNA. (2)

More specifically, E. sakazakii is a rare, but life-threatening cause of neonatal meningitis, sepsis, and necrotizing enterocolitis. In general, E. sakazaii kills 40-80 % of infected newborns diagnosed with this type of severe infection. (5) E. sakazakii meningitis may lead to cerebral abscess or infarction with cyst formation and severe neurologic impairment. E. sakazakii can cause a variety of infections, though central nervous system infection has been most commonly described. (6)  For infants, infection typically manifests through signs of sepsis in the first week of life: irritability or lethargy, temperature instability, and feeding intolerance.  Meningitis often produces overwhelming infection that rapidly moves through cerebral hemorrhage, infarct, necrosis, liquefaction, and eventually, cyst formation. (7)

E. sakazakii invasive infections occur more frequently in infants than in older children. (9) The neonate’s immature immune system may increase the risk of acquiring an E. sakazakii infection. (10) In a study of E. sakazakii cases over a 47 year period, investigators found that the median age at infection onset was two days and 94% of cases were less than 28 days old. (11)  

While the reservoir for E. sakazakii is unknown in many cases, a growing number of reports have established powdered infant formula as the source and vehicle of infection.  In several investigations of outbreaks of E. sakazakii infection that occurred among neonates in neonatal intensive care units, investigators were able to show both statistical and microbiological association between infection and powdered infant formula consumption.  These investigations included cohort studies which implicated infant formula consumed by the infected infants. In addition, there was no evidence of infant-to-infant or environmental transmission; all cases had consumed the implicated formula.  The stomach of newborns, especially of premature babies, is less acidic than that of adults: a possible important factor contributing to the survival of an infection with E. sakazakii in infants.  (13)

The first cases attributed to this organism occurred in 1958 in England (Urmenyi and Franklin, 1961). Since then, up to July 2008, around 120 documented cases of E. sakazakii infection, and at least 27 deaths, have been identified from all parts of the world in the published literature and in reports submitted by public health organizations and laboratories. (12)

E. sakazakii used to be previously known as a “yellow pigmented Enterobacter cloacae”, until 1980.  E. sakazakii was first defined as a novel species in 1980, when it was introduced as a new species based on differences in DNA-DNA hybridization, biochemical reactions, and antibiotic susceptibility. The bacteria was named sakazakii in honour of the Japanese microbiologist, Riichi Sakazaki, when the species was first designated in 1980. (15)  Enterobacter sakazakii (E. sakazakii) then became identified as one of sixteen distinct species in the genus Enterobacter, within the Enterobacteriaceae family. (14)  

From the beginning, however, many different biogroups were defined as E. sakazakii, with the existence of these divergent geno- and biogroups suggesting that E. sakazakii could in fact represent multiple species. (14)  Accordingly, in 2007, a research group clarified the taxonomic relationship among the various E. sakazakii strains, by using sophisticated new means of viewing and analyzing the bacteria.  Iverson et al were thus able to distinguish numerous separate species.  Their work resulted in the proposal of an alternative classification of E. sakazakii into a new genus, Cronobacter. (16)

The new techniques used by the research group provide clear proof of the substantial advances made in molecular biology, and included f-AFLP, automated ribotyping, full-length 16S rRNA gene sequencing and DNA-DNA hybridization. (14)  F-AFLP (fluorescent amplified fragment length polymorphism) is a means to genotype bacteria, by selecting pre-adapted fragments of DNA and amplifying them to easily detectable and accurately sizeable concentrations.  Automated ribotyping is a genotyping method that can be used to generate genetic fingerprints of bacterial isolates.  Full-length 16S rRNA gene sequencing provides a means to compare a stable part of the genetic code (the 16S rRNA gene) amongst different bacteria.  The technique of DNA-DNA hybridization provides genetic comparisons amongst the total genome of two species. 

E. sakazakii has thus now been reclassified as 6 separate species in the new genus, Cronobacter,  gen. nov., within the Enterobacteriaceae family. The new species are presently Cronobacter sakazakii; C. turicensis; C. malonaticus; C. muytjensii and C. dublinensis; the sixth species is identified simply as genomospecies I, as currently it includes only two representative strains. (19)

The name Cronobacter was appropriately derived from Greek mythology.  E. sakazakii constitutes a microbiological hazard in the infant food chain, with historic high mortality in neonates.  Accordingly, it was named after the Greek mythological god, Cronos. (17). Cronos was the son of Uranus (Heaven) and Gaea (Earth), being the youngest of the 12 Titans. He eventually became the king of the Titans, and took for his consort his sister Rhea.  Rhea bore him a number of children, including Hestia, Demeter, Hera, Hades, and Poseidon.  Cronos, however, had been previously warned by his parents that he would be overthrown by his own child.  Accordingly, he swallowed all those children.  When Zeus was born, however, Rhea hid him in Crete, and tricked Cronus into swallowing a stone instead. Zeus grew up, forced Cronus to disgorge his brothers and sisters, waged war on Cronus, and was victorious. (18)
   
It was proposed that these species be moved to the new genus, “Cronobacter”, in order to facilitate their identification for the diagnosis of infection and the microbiological monitoring of food products.  (20)  All these species have been linked retrospectively to clinical cases of infection in either infants or adults, and therefore all these species should be considered pathogenic. (21)  The correct and more detailed identification of these organisms will improve the understanding of the broader epidemiology of the members of the new genus. 

It is also important, however, that this reclassification of species not be detrimental to health protection measures a

lready in place, and that al
l these risk organisms continue to be recognized. (22)  As the genus Cronobacter is synonymous with Enterobacter sakazakii, current identification schemes developed for E. sakazakii remain applicable for the Cronobacter genus.  The reclassification of E. sakazakii to the new genus Cronobacter will not require the modification of dedicated culture-based laboratory isolation and detection protocols. All currently valid laboratory methods will continue to facilitate the recognition of all of the organisms defined within the new taxonomy.  (23)  Furthermore, the reclassification does not require any change to the regulatory framework currently in place. (24)

REFERENCES:

(1)    Iversen, C., Lehner, A., Mullane, N., Marugg, J., Fanning, S., Stephan, R., and Joosten, H., “Identification of ‘Cronobacter’ spp. (Enterobacter sakazakii)”, Journal of Clinical Microbiology, Nov. 2007, Vol. 45, No. 11, p. 3814-3816.

(2)    Kimball’s Biology Pages, http://www.ultranet.com/~jkimball/BiologyPages/ (9/25/2009)

(3)    Dauga, C and Breeuwer, P Taxonomy and Physiology of Enterobacter sakazakii, in ENTEROBACTER SAKAZAKII. Washington D.C.: ASM Press; 2008:1 (Farber, JM and Forsythe, SJ editors).

(4)    Bowen AB, Braden CR. Invasive Enterobacter sakazakii disease in infants. Emerg Infect Dis [serial on the Internet]. 2006 Aug publication. Available from http://www.cdc.gov/ncidod/EID/vol12no08/05-1509.htm. 

(5)    Bowen, AB and Braden, CR Enterobacter sakazakii Disease and Epidemiology. Farber, JM and Forsythe, SJ ed. ENTEROBACTER SAKAZAKII. Washington D.C.: ASM Press; 2008:104.

(6)    Id.

(7)    Id.

(8)    Id.

(9)    “Enterobacter sakazakii and other microorganisms in powdered infant formula” Microbiological Risk Assessment Series 6, World Health Organization (2004).

(10)    “Enterobacter sakazakii (Cronobacter spp.) in follow-up formula”, Microbiological Risk Assessment Series 15- FAO/WHO (2008).

(11)    Iversen, C., A. Lehner, N. Mullane, E. Bidlas, I. Cleenwerck, J. Marugg, S. Fanning, R. Stephan, and H. Joosten. 2007. “The taxonomy of Enterobacter sakazakii: proposal of a new genus Cronobacter”, 1. BMC Evol. Biol. 7:64

(12)    “Enterobacter sakazakii (Cronobacter spp.) in follow-up formula”, Microbiological Risk Assessment Series 15- FAO/WHO (2008).

(13)    Id.

(14)    Iversen, C., A. Lehner, N. Mullane, E. Bidlas, I. Cleenwerck, J. Marugg, S. Fanning, R. Stephan, and H. Joosten. 2007. “The taxonomy of Enterobacter sakazakii: proposal of a new genus Cronobacter”, 1. BMC Evol. Biol. 7:64.

(15)    “Enterobacter sakazakii (Cronobacter spp.) in follow-up formula”, Microbiological Risk Assessment Series 15- FAO/WHO (2008).

(16)    Id.

(17) Iversen, C., A. Lehner, N. Mullane, E. Bidlas, I. Cleenwerck, J. Marugg, S. Fanning, R. Stephan, and H. Joosten. 2007. “The taxonomy of Enterobacter sakazakii: proposal of a new genus Cronobacter”, 1. BMC Evol. Biol. 7:64.

(18)    “Cronus.” Encyclopædia Britannica. 2009. Encyclopædia Britannica Online. 21 Sep. 2009.

(19)    Iversen, C., Lehner, A., Mullane, N., Marugg, J., Fanning, S., Stephan, R., and Joosten, H., “Identification of ‘Cronobacter’ spp. (Enterobacter sakazakii)”, Journal of Clinical Microbiology, Nov. 2007, Vol. 45, No. 11, p. 3814-3816.

 (20)    “Enterobacter sakazakii (Cronobacter spp.) in follow-up formula”, Microbiological Risk Assessment Series 15- FAO/WHO (2008).

(21)    Iversen, C., Lehner, A., Mullane, N., Marugg, J., Fanning, S., Stephan, R., and Joosten, H., “Identification of ‘Cronobacter’ spp. (Enterobacter sakazakii)”, Journal of Clinical Microbiology, Nov. 2007, Vol. 45, No. 11, p. 3814-3816.

(22)    “Enterobacter sakazakii (Cronobacter spp.) in follow-up formula”, Microbiological Risk Assessment Series 15- FAO/WHO (2008).

(23)    Id.