Whether you tried your hand at baking bread, followed a new recipe on Tik Tok, or even thought up some creative dishes “Iron Chef” style, the past 18 months have turned many more of us into home cooks. For Food Safety Education Month (FSEM) in September, we’re sharing advice on another important part of a tasty meal: How to prevent food poisoning when you cook at home.

Meet Food Safety Chef, who will share ways you can handle and keep food safe in your home kitchen. During September, follow along on social media to see these tips and share them with others: @Foodsafetygov Twitter, FoodSafety.gov Facebook, @CDCgov Twitter, @CDC_NCEZID Twitter, CDC Facebook, and CDCgov Instagram. Look for the hashtags #FSEM2021 and #CDCFoodSafety.

Safety is an ingredient for everyone
Being a chef in your own home can be fun. During Food Safety Education Month, make room for food safety in your kitchen and help educate others about preventing food poisoning. Here are some resources from the Centers for Disease Control and Prevention you can use:

• CDC’s Food Safety Education Month Page
• Social Media Messages
• Social Media Graphics
• Videos
• Charts With Food Safety Guidelines

• CDC Feature: Key Facts About Food Poisoning [English] [Español]

Spotlight on Salmonella
The CDC estimates that Salmonella causes more foodborne illnesses in the United States than any other bacteria. Chicken is a major source of these illnesses, although Salmonella can contaminate a variety of foods. Large Salmonella outbreaks linked to ground beef have also occurred in recent years. Federal agencies and their partners are working along the food chain to prevent Salmonella illnesses associated with chicken and ground beef.

You can help prevent Salmonella and other foodborne infections by following food safety advice while preparing your favorite chicken and ground beef dishes. Try a recipe for spice-crusted chicken that includes food safety steps.

Add these steps to all your recipes to make your meals delicious and safe.

Get cooking: Food Safety Chef’s 4-step recipe for food safety

• Clean: Wash your hands often. Clean your counters with hot soapy water, but don’t wash your chicken or meat! Washing raw meat, chicken, turkey, fish or eggs can spread germs to your sink, countertops, and other surfaces in your kitchen.
• Separate: Keep raw meat, chicken, turkey, seafood, and eggs separate from other foods. Use different cutting boards for uncooked meats and vegetables to avoid germs from raw meat contaminating food that won’t be cooked before you eat it.
• Cook: Cook foods to a safe internal temperature to kill germs that could make you sick. Measure with a food thermometer because you can’t tell if food is fully cooked just by looking at the color.
• Chill: Refrigerate your leftovers and other perishable food within 2 hours of cooking. If it’s warmer than 90 degrees F outside, refrigerate leftovers after only an hour. Keep your refrigerator at 40 degrees F or below.

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Remember to pack your picnic basket with food safety in mind, as foodborne bacteria that cause food poisoning multiply faster in warm weather.

Follow these tips to keep your food safe when eating outdoors:

Before your picnic

• Defrost meat, poultry, and seafood in the refrigerator or by submerging sealed packages in cold water. You can also microwave-defrost, but only if the food will be grilled immediately afterward.
• Marinate foods in the fridge not the countertop. Never reuse marinade that touched raw foods unless you boil it first or set some of the marinade aside before marinating food to use for sauce later.
• Wash all produce before eating, even if you plan to peel it. The knife you use to peel it can carry bacteria into the part you eat. Fruits and vegetables that are pre-cut or peeled should be refrigerated or kept on ice to maintain quality and safety.
• If your picnic site doesn’t offer clean water access, bring water or pack moist towels for cleaning surfaces and hands. Don’t forget to pack a food thermometer!

Packing coolers

• Place food from the refrigerator directly into an insulated cooler immediately before leaving home.
• Use ice or ice packs to keep your cooler at 40 degrees F or below.
• Pack raw meat, poultry, and seafood in a separate cooler, or wrap it securely and store at the bottom of the cooler where the juices can’t drip onto other foods. Place beverages in a separate cooler; this will offer easy drink access while keeping perishable food coolers closed.
• Avoid loading coolers in the trunk of the car, as it can collect heat. Once at the picnic site, keep food in coolers until serving time (out of direct sun) and avoid opening the lids often.

Grilling

• Have clean utensils and platters available. Cook meat, poultry, and seafood to the right temperatures ─ use a food thermometer to be sure (see Safe Minimum Cooking Temperatures Chart). Keep cooked meats hot at 140 °F or warmer until serving time — set them to the side of the grill rack to keep them hot.
• When removing foods from the grill, place them on a clean platter.
• Never use the same platter and utensils for cooked food that you used for raw meat, poultry, or seafood.

Time and temperature

Don’t let hot or cold food sit in the “Danger Zone” (between 40 °F and 140 °F) for more than 2 hours – or 1 hour if the outdoor temperature is above 90 °F. If they do, throw them away.

Learn more:

https://www.fda.gov/food/buy-store-serve-safe-food/handling-food-safely-while-eating-outdoors

https://www.fda.gov/consumers/consumer-updates/barbecue-basics-tips-prevent-foodborne-illness

To Do List from the CDC:

— Visit parks that are close to your home

Traveling long distances to visit a park may contribute to the spread of COVID-19, as:

• Travel may require you to stop along the way or be in close contact with others with whom you may not otherwise have contact.
• Travel may also expose you to surfaces contaminated with SARS-CoV-2, the virus that causes COVID-19.

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— Check with the park or recreation area in advance to prepare safely.

The federal or state and local authorities will decide whether parks and other recreational facilities will open. Check with the park in advance to be sure you know which areas or services are open, such as visitors’ centers, bathroom facilities, and concessions, and bring what you need with you, such as hand sanitizer or other supplies to maintain proper hygiene.

— Beaches or other swimming areas: State and local authorities will decide whether swim areas at oceans, lakes, and other natural bodies of water will be open. Please check with individual beaches for specific details, including whether the water is open for swimming.

— Stay at least 6 feet away from people you don’t live with (social distancing), and take other steps to prevent COVID-19 spread.

— When visiting parks, beaches, or recreational facilities open for public use, try to protect against exposure to SARS-CoV-2, the virus that causes COVID-19, by practicing social distancing and everyday steps such as washing hands often and covering coughs and sneezes.

— Follow these actions when visiting a park, beach, or recreational facility:

• Do not go into a crowded area.
• Avoid gathering with people you don’t live with.
• Wear a cloth face covering as feasible. Face coverings are most essential in times when social distancing is difficult. Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, can’t move, or otherwise unable to remove the mask without assistance.
• Wash hands often with soap and water for at least 20 seconds, especially after going to the bathroom, before eating, and after blowing your nose, coughing, or sneezing.
• Adults and older children who can safely use hand sanitizer: Use hand sanitizer that contains at least 60% alcohol and rub hands together until dry, if soap and water are not readily available.

— Carefully consider use of playgrounds, and help children follow guidelines.

In communities where there is ongoing spread of COVID-19, playgrounds can be hard to keep safe because:

• They are often crowded and could make social distancing difficult;
• It can be difficult to keep surfaces clean and disinfected;
• SARS-CoV-2, the virus that causes COVID-19, can spread when young children touch contaminated objects, and then touch their eyes, nose, or mouth.

If you choose to visit a playground:

• Maintain a distance of at least 6 feet away from people you don’t live with.
• Wash hands with soap and water for at least 20 seconds.
  • Adults and older children who can safely use hand sanitizer: Use hand sanitizer that contains at least 60% alcohol and rub hands together until dry, if soap and water are not readily available.

— Play it safe around and in swimming pools, hot tubs, and water playgrounds, and keep space between yourself and others. Evidence suggests that COVID-19 cannot be spread to humans through most recreational water. Additionally, proper operation of these aquatic venues and disinfection of the water (with chlorine or bromine) should inactivate SARS-CoV-2, the virus that causes COVID-19.

Swimming and other water-related activities are excellent ways to get the physical activity needed for a healthy life. Taking steps to reduce the spread of COVID-19 is one way you can play it safe in and around swimming pools, hot tubs, and water playgrounds. Don’t visit a swimming pool if you are sick with, tested positive for, or were recently exposed to COVID-19. Practice social distancing by staying at least 6 feet (two meters) from people you don’t live with. Swimming does carry some health and safety risks. Visit CDC’s Healthy Swimming website for information to help you prevent illness and drowning, so you can safely enjoy the fun and health benefits of swimming.

The Don’t List from the CDC

Don’t: Visit parks if you are sick with, tested positive for COVID-19, or were recently (within 14 days) exposed to COVID-19.

• If you are sick with or tested positive for COVID-19, were recently exposed (within 14 days) to someone with COVID-19, or just don’t feel well, do not visit public areas including parks or recreational facilities.
• Follow recommended steps to take if you are sick.

Don’t: Visit crowded parks

• Do not visit parks where you cannot stay at least 6 feet away from people you don’t live with.

Editor’s note: With summer unofficially beginning with this holiday weekend, the number of festive events and trips to farmers markets begin to balloon. Most offer foods and drinks that can easily pose food safety threats, especially for young children. Food Safety News encourages everyone to be mindful of frequent vectors for foodborne illnesses.

The cases corresponding to the three isolates were identified in Illinois, Iowa, and Michigan. Isolation dates ranged from Oct. 15, 2017, to Oct. 29, 2017. Patients ranged in age from 55 to 71 years (median = 69 years), and all three patients were male. All patients were hospitalized for listeriosis; no deaths were reported. PulseNet was queried routinely for new isolate matches during the investigation, and no additional cases were identified.

Interviews were conducted with all three patients or their surrogates using the standard Listeria Initiative questionnaire, which asks about a variety of foods consumed in the month preceding illness onset. Grocery store receipts were collected for the patient in Michigan. Review of reported exposures indicated that all three patients had consumed prepackaged caramel apples purchased from retail establishments in the month preceding illness onset. A case-case analysis was performed comparing exposure frequencies for all food items included in the Listeria Initiative questionnaire for the three outbreak-associated cases with exposure frequencies for 186 sporadic cases of listeriosis from the same states reported to CDC since 2006. Caramel apple consumption was significantly higher among patients included in the outbreak, compared with that among patients with sporadic illnesses (odds ratio = 21.7; 95% confidence interval = 2.3–infinity). None of the interviewed patients had leftover caramel apples in their home for testing.

State and local officials collected records at two of the three retail locations where caramel apples had been purchased. All three retailers sold the same brand of caramel apples (brand A). The product was packaged in a plastic clamshell containing three caramel apples, each on a stick. Caramel apples were seasonal products that were only available for a short period in the fall at two of the retail locations. However, the retail location where the Illinois patient purchased caramel apples had the product in stock at the time of the investigation. Eight packages of caramel apples were collected for testing by the Illinois Department of Public Health, but L. monocytogenes was not detected in any samples. It was not known whether the tested caramel apples were from the same lots as those consumed by the ill persons in this outbreak.

During an inspection at the caramel apple production facility, FDA reviewed records and practices and collected environmental samples for testing. No significant food safety concerns were observed. None of the environmental swabs yielded L. monocytogenes. Environmental swabs collected at a single whole apple supplier yielded L. monocytogenes, but it was not the outbreak strain. Traceback activities did not implicate a specific lot or supplier of whole apples used in brand A caramel apple production during the period of interest.

No additional outbreak-associated illnesses were identified during the investigation. In light of the limited shelf life of the product (reported by the production facility to be 15 days), it was unlikely that caramel apples consumed by ill persons in this outbreak would have still been available for purchase or in persons’ homes at the time of the investigation. Because there was no evidence to suggest an ongoing risk to the public, no public warning was issued by federal or state agencies.

Although the outbreak strain of L. monocytogenes was not isolated from caramel apples or their production environment, the epidemiologic evidence indicated that caramel apples were the suspected vehicle in this outbreak. All outbreak-associated ill persons consumed a specific brand of a relatively uncommon food product in the month before their illness onset, and all were infected with indistinguishable L. monocytogenes strains. Caramel apples were previously implicated in a large multistate outbreak of listeriosis during 2014–2015, caused by contamination of whole apples. Ready-to-eat food processors, including those that make caramel apples, could consider the introduction and persistence of L. monocytogenes in food production environments as a potential hazard and mitigate that risk through appropriate environmental monitoring and preventive controls. Further research into the control of L. monocytogenes in fresh produce, including fresh apples, might help identify prevention strategies to reduce or eliminate the pathogen in some ready-to-eat foods.

Note on the authors: This report was originally in the Morbidity and Mortality Weekly Report published by the Centers for Disease Control ad Prevention. Authors, as listed in the MMWR, are Jessica R. Marus, MPH; Sally Bidol, MPH; Shana M. Altman; Oluwakemi Oni, MPH; Nicole Parker-Strobe, MPH; Mark Otto, MSPH; Evelyn Pereira, MPH; Annemarie Buchholz, PhD; Jasmine Huffman; Amanda R. Conrad, MPH;  and Matthew E. Wise, PhD. All of the authors completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed, according to the research report.

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Editor’s note: This is the first in a series of articles and opinion columns we are publishing in recognition of Food Safety Education Month.

September is National Food Safety Education Month. It provides an opportunity to raise awareness about steps consumers, educators and others can take to prevent food poisoning.

Every year, an estimated 1 in 6 Americans — or 48 million people — get sick, 128,000 are hospitalized, and 3,000 die from eating contaminated food.

Some people are more likely to get a foodborne illness, also called food poisoning, or to get seriously ill.

Join us in sharing information about which groups of people are more likely to get food poisoning, symptoms of food poisoning, and what steps they or their caregivers can take to help prevent it.

Also, learn when to see a doctor and how to report food poisoning.

Everyone is at risk of food poisoning, but some groups are at higher risk. Children under the age of 5, adults age 65 and older, pregnant women, and people with weakened immune systems are more likely to get a foodborne illness, and to get seriously ill.

The CDC advises people to see a doctor if they experience severe symptoms such as fever over 101.5 degrees F, bloody diarrhea, frequent vomiting, diarrhea lasting more than three days, or signs of dehydration.

Help increase food safety awareness in your community by sharing key messages through social media, on your website, and in your newsletters.

You can also:

• Watch and share videos of groups at higher risk for food poisoning and severe symptoms that should lead to a doctor’s visit.
• Join the food safety Twitter chat on Sept. 24 from 2 p.m. to 3 p.m. EDT, co-hosted by Media Planet, the National Restaurant Association, and CDC. Use #FoodSafetyChat to join the conversation.
• Promote food safety resources for restaurant managers and environmental health professionals.
• Share information for health departments as it relates to their role in outbreak investigations.

Resources

• Most of the CDC’s food safety materials are available in Spanish and some are also available in other languages.
• CDC Feature: Prevent Food Poisoning (English) (Español)
• Graphics for Food Safety Education Month
• Social Media Messages for Food Safety Education Month
• Video on Safety Tips for Handling and Preparing Common Food
• Environmental Health Resources for Restaurants
• Free Course: Legal Aspects of Public Health Food Safety

Additional information and prevention tips

• CDC Food Safety
• Food Safety Web Features
• Food Safety Infographics
• Be Food Safe: Protect Yourself from Food Poisoning
• Food Safety for Food Workers
• Preventing Norovirus Infection
• Foodsafety.gov
• Fight BAC! Partnership for Food Safety Education
• FDA: Food Safety: It’s Especially Important for At-Risk Groups
• FDA: Safe Food Handling: What You Need to Know
• FDA: Refrigerator Thermometers: Cold Facts About Food Safety
• USDA: At-Risk Populations
• USDA: Foodkeeper App: Your Tool for Smart Food Storage

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But, before the tests are ordered, it is crucial to ask patients the right questions. Their health could depend on it. Those who don’t receive treatment for brucellosis can develop serious disease that can affect their lives and persist for years.

Although brucellosis is mainly a bacterial disease of animals, several species of Brucella bacteria are known to cause disease in humans. Because the diagnostic test and treatment vary, it is important to identify not only whether a patient is infected with Brucella, but also what kind of Brucella is causing disease.

Each species of Brucella has distinct risk factors. When brucellosis is suspected, getting a thorough medical history is an important first step because symptoms can develop anywhere from five days to six months after exposure.

Diagnosing brucellosis cannot be done by symptom presentation alone because initial symptoms are nonspecific and resemble those of other febrile illnesses. A person who is infected with Brucella typically presents with a history of fever; sweats; malaise; anorexia; headache; fatigue; and muscle, joint, or back pain.

About 70 to 75 percent of U.S. brucellosis cases reported annually to CDC are due to the bacterial species Brucella melitensis and Brucella abortus. Many of these cases are associated with consumption of unpasteurized dairy products — such as raw milk and cheese made with raw milk — during international travel to places where brucellosis is endemic in animals. Although acquired outside the United States, these cases are not diagnosed until after the patient has returned home, due to brucellosis’ long incubation period.

In the United States, 25 to 30 percent of brucellosis cases are due to Brucella suis and almost all are diagnosed in people who hunt and slaughter feral swine. People usually become infected through contact with blood and fluids from infected swine while dressing the carcass. However, keep in mind that dogs can contract brucellosis from feral swine and they can then spread the infection to people.

Although less common in humans, Brucella canis is found in dogs all over the world, including the United States, and generally causes mild illness in people.

Finally, people can become infected with Brucella RB51, a strain of Brucella abortus that is used to vaccinate cattle in the United States and other parts of the world. Although RB51 was developed to be less pathogenic, it can cause disease in humans. Human cases of RB51 are often associated with needle-stick exposures while vaccinating cattle, and cases are usually veterinarians or veterinary technicians.

Human cases in 2017 linked to raw milk
Although very rare, the CDC has received notification of two confirmed human infections with RB51 brucellosis associated with consumption of raw milk in the United States this year, emphasizing the need for healthcare professionals to ask patients whether they have consumed raw milk or other unpasteurized dairy products.

Most clinical diagnostic laboratories are able to run serologic tests, which detect an antibody response to most of the Brucella species. However, Brucella canis and Brucella RB51 won’t show up on serology, so cultures are needed to confirm the infection. State health departments can provide assistance in finding laboratories with culture capabilities. They can also guide physicians and assist in determining the appropriate route of sample submission for a proper diagnosis.

Always remember to inform the lab that brucellosis is suspected when submitting a sample. This will ensure that the lab staff will take appropriate precautions when performing tests and prevent additional exposures to the bacteria.

Treatment for brucellosis is typically a combination of doxycycline and rifampin for at least six weeks. However, Brucella RB51 is resistant to rifampin and it should not be used if this strain is suspected.

If not treated appropriately, brucellosis can lead to long-term disease associated with arthritis, endocarditis, chronic fatigue, depression, or swelling of the liver or spleen.

Visit the CDC’s brucellosis website or consult the CDC’s brucellosis reference guide for more information on the different types of diagnostic tests available, treatment, and prevention of brucellosis.

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When you prepare homemade cookie dough, cake mixes, or even bread, you may be tempted to taste a bite before it is fully cooked. But steer clear of this temptation—eating or tasting unbaked products that are intended to be cooked, such as dough or batter, can make you sick. Children can get sick from handling or eating raw dough used for crafts or play clay, too.

Raw dough can contain bacteria that cause disease
Flour is typically a raw agricultural product. This means it hasn’t been treated to kill germs like E coli. Harmful germs can contaminate grain while it’s still in the field or at other steps as flour is produced. The bacteria are killed when food made with flour is cooked. This is why you should never taste or eat raw dough or batter — whether made from recalled flour or any other flour.

In 2016, an outbreak of E. coli infections linked to raw flour made 63 people sick. Flour products have long shelf lives and could be in people’s homes for a long time. If you have any recalled flour products in your home, throw them away.

In addition, raw eggs that are used to make dough or batter can contain a germ called Salmonella that can make you sick if the eggs are eaten raw or lightly cooked. Eggs are safe to eat when cooked and handled properly.

Don’t taste or eat raw dough
Follow safe food handling practices when you are baking and cooking with flour and other raw ingredients:

• Do not taste or eat any raw dough or batter, whether for cookies, tortillas, pizza, biscuits, pancakes, or crafts made with raw flour, such as homemade play dough or holiday ornaments.
• Do not let children play with or eat raw dough, including dough for crafts.
• Bake or cook raw dough and batter, such as cookie dough and cake mix, before eating.
• Follow the recipe or package directions for cooking or baking at the proper temperature and for the specified time.
• Do not make milkshakes with products that contain raw flour, such as cake mix.
• Do not use raw, homemade cookie dough in ice cream.
  • Cookie dough ice cream sold in stores contains dough that has been treated to kill harmful bacteria.
• Keep raw foods such as flour or eggs separate from ready-to eat-foods. Because flour is a powder, it can spread easily.
• Follow label directions to refrigerate products containing raw dough or eggs until they are cooked.
• Clean up thoroughly after handling flour, eggs, or raw dough:
  • Wash your hands with running water and soap after handling flour, raw eggs, or any surfaces that they have touched.
  • Wash bowls, utensils, countertops, and other surfaces with warm, soapy water.

Pay Close Attention to Any Symptoms
Food poisoning symptoms may range from mild to severe and may differ depending on the germ you swallowed. The symptoms of E. coli infections vary for each person but often include severe stomach cramps, diarrhea (often bloody), and vomiting.

People usually get sick 3 to 4 days after swallowing the germ. Most people recover within a week. However, some people develop a serious type of kidney failure called hemolytic uremic syndrome (HUS).

The symptoms of Salmonella infections typically appear 6 to 48 hours after eating a contaminated food, though this period is sometimes longer. Symptoms typically include diarrhea, fever, and abdominal cramps. In most cases, illness lasts 4 to 7 days and people recover without antibiotics. Illness from Salmonella bacteria can be serious and is more dangerous for older adults, infants, and people with weakened immune systems.

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For many people, the holiday season is the perfect time to spend time together in the kitchen and share delicious baked foods and desserts. Follow these safety tips to help you and your loved ones stay healthy when handling raw dough.

When you prepare homemade cookie dough, cake mixes, or even bread, you may be tempted to taste a bite before it is fully cooked. But steer clear of this temptation — eating or tasting unbaked products that are intended to be cooked, such as dough or batter, can make you sick.Children can get sick from handling or eating raw dough used for crafts or play clay, too.

Raw dough can contain bacteria that cause disease.

Flour is typically a raw agricultural product. This means it hasn’t been treated to kill germs like E. coli. Harmful germs can contaminate grain while it’s still in the field or at other steps as flour is produced. The bacteria are killed when food made with flour is cooked. This is why you should never taste or eat raw dough or batter — whether made from recalled flour or any other flour.

This year an outbreak of E. coli infections linked to raw flour made 63 people sick. Flour products have long shelf lives and recalled products could be in people’s homes for a long time. If you have any recalled flour products in your home, throw them away.

In addition, raw eggs that are used to make raw dough or batter can contain a germ called Salmonella that can make you sick if the eggs are not fully cooked. Eggs are safe to eat when cooked and handled properly.

Follow safe food handling practices when you are baking and cooking with flour and other raw ingredients:

• Do not taste or eat any raw dough or batter, whether for cookies, tortillas, pizza, biscuits, pancakes, or crafts made with raw flour, such as homemade play dough or holiday ornaments.
• Do not let children play with or eat raw dough, including dough for crafts.
• Bake or cook raw dough and batter, such as cookie dough and cake mix, before eating.
• Do not make milkshakes with products that contain raw flour, such as cake mix.
• Do not use raw, homemade cookie dough in ice cream.
• Follow the recipe or package directions for cooking or baking at the proper temperature and for the specified time.
• Keep raw foods such as flour or eggs separate from ready-to eat-foods. Because flour is a powder, it can spread easily.
• Follow label directions to refrigerate products containing raw dough or eggs until they are cooked.
• Clean up thoroughly after handling flour, eggs or raw dough by washing your hands with running water and soap after handling flour, raw eggs or any surfaces that they have touched. Also wash bowls, utensils, countertops and other surfaces with hot water and soap.

Is recalled flour in your kitchen?
Earlier this year, a large outbreak of E. coli ­ infections made people sick in 24 states. Disease detectives linked the illnesses to flour sold under several brand names, including Gold Medal, Gold Medal Wondra and Signature Kitchens.

This flour, and baking mixes and other foods containing this flour, were recalled. Check your pantry and throw away any recalled products.

If you stored flour in a container and no longer have the package, throw out the flour to be safe. Make sure that you clean your container with soap and hot water before using it again.

Pay close attention to any symptoms
The symptoms of E. coli infections vary for each person but often include severe stomach cramps, diarrhea that is often bloody, and vomiting.

People usually get sick three to four days after swallowing the germ. Most people recover within a week. However, some people develop a serious type of kidney failure called hemolytic uremic syndrome (HUS).

The symptoms of Salmonella infections typically appear six to 48 hours after eating a contaminated food, though this period is sometimes longer.

Symptoms typically include diarrhea, fever, and abdominal cramps. In most cases, illness lasts 4 to 7 days and people recover without antibiotics. Illness from Salmonella bacteria can be serious and is more dangerous for older adults, infants, and people with weakened immune systems.

More information on related topics can be found at the following links:

• CDC Food Safety Website
• Shiga Toxin-Producing E. coli and Food Safety
• Salmonella and Eggs
• Multistate Outbreak of Shiga toxin-producing Escherichia coli Infections Linked to Flour
• Flour Recall and Advice to Consumers and Retailers
• FDA Consumer Update: Raw Dough’s a Raw Deal and Could Make You Sick

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Handwashing is like a “do-it-yourself” vaccine to reduce the spread of diarrheal and respiratory illness so you and those around you can stay healthy.

Proper hand washing at the proper times could reduce diarrhea illnesses by a third and respiratory illnesses by almost a fifth according to multiple research reports.

While many of those illnesses are among residents of underdeveloped countries, many cases of norovirus and other foodborne illnesses, as well as colds and flu, in the U.S. could be avoided every day if more people practiced better hand hygiene.

Global Handwashing Day is a way to support a global and local culture of handwashing with soap, shine a spotlight on the state of handwashing in each country, and raise awareness about the benefits of handwashing with soap.

Since 2008, Global Handwashing Day has been celebrated annually on Oct. 15 worldwide. The Global Public-Private Partnership for Handwashing with Soap founded Global Handwashing Day and encourages school children, teachers and families to get involved.

Although people around the world clean their hands with water, many do not use soap because it can be less accessible in developing countries. Even when soap is available, it might be reserved primarily for laundry and bathing instead of for handwashing.

In most parts of the United States, the availability of soap and running water is not a problem, yet effective hand washing is not an automatic behavior.

For parents, child care providers and educators, the challenge of instilling this life-saving behavior can be complicated by the dreaded “Why” question when they are describing the five steps to effective handwashing. The CDC has the answers you’ve been seeking.

The what and why of the 5 steps
Step 1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.

Why? Because hands could become recontaminated if placed in a basin of standing water that has been contaminated through previous use, clean running water should be used. However, washing with non-potable water when necessary may still improve health.

The temperature of the water does not appear to affect microbe removal; however, warmer water may cause more skin irritation and is more environmentally costly.

Turning off the faucet after wetting hands saves water, and there are few data to prove whether significant numbers of germs are transferred between hands and the faucet.

Using soap to wash hands is more effective than using water alone because the surfactants in soap lift soil and microbes from skin, and people tend to scrub hands more thoroughly when using soap, which further removes germs.

Step 2. Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails.

Why? Lathering and scrubbing hands creates friction, which helps lift dirt, grease, and microbes from skin.  Microbes are present on all surfaces of the hand, often in particularly high concentration under the nails, so the entire hand should be scrubbed.

Step 3. Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice.

Why? Determining the optimal length of time for handwashing is difficult because few studies about the health impacts of altering handwashing times have been done. Of those that exist, nearly all have measured reductions in overall numbers of microbes, only a small proportion of which can cause illness, and have not measured impacts on health. Solely reducing numbers of microbes on hands is not necessarily linked to better health.

The optimal length of time for handwashing is also likely to depend on many factors, including the type and amount of soil on the hands and the setting of the person washing hands.

For example, surgeons are likely to come into contact with disease-causing germs and risk spreading serious infections to vulnerable patients, so they may need to wash hands longer than a woman before she prepares her own lunch at home. Nonetheless, evidence suggests that washing hands for about 15-30 seconds removes more germs from hands than washing for shorter periods.

Step 4. Rinse your hands well under clean, running water.

Why? Soap and friction help lift dirt, grease, and microbes — including disease-causing germs — from skin so they can then be rinsed off of hands. Rinsing the soap away also minimizes skin irritation.

Because hands could become recontaminated if rinsed in a basin of standing water that has been contaminated through previous use, clean running water should be used. While some recommendations include using a paper towel to turn off the faucet after hands have been rinsed, this practice leads to increased use of water and paper towels, and there are no studies to show that it improves health.

Step 5. Dry your hands using a clean towel or air dry them.

Why? Germs can be transferred more easily to and from wet hands; therefore, hands should be dried after washing. However, the best way to dry hands remains unclear because few studies about hand drying exist, and the results of these studies conflict.

Additionally, most of these studies compare overall concentrations of microbes, not just disease-causing germs, on hands following different hand-drying methods. Nonetheless, studies suggest that using a clean towel or air drying hands are best.

When there’s no water and soap
Washing hands with soap and water is the best way to reduce the number of germs on them in most situations.

If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol.

Alcohol-based hand sanitizers can quickly reduce the number of germs on hands in some situations, but sanitizers do not eliminate all types of germs and might not remove harmful chemicals.

Some experts suggest using hand sanitizer, followed by vigorous drying with a paper towel, followed by a second application of hand sanitizer that is allowed to air dry.

(To sign up for a free subscription to Food Safety News, click here.)

The Outbreak

1. Communicating with the company responsible for the tainted chicken, which helped provide critical information needed to confirm the source.
2. Developing simple messages that explained the outbreak and how individuals could prevent Salmonella were developed. These messages followed the Crisis & Emergency Risk Communication  framework, which encourages the use of transparent messaging that provides the public with meaningful actions to protect themselves from harm.
3. Growing a strong partnership between our epidemiologists, leadership, and risk communication officer over the course of the investigation provided a basis for mutual trust and respect. This rapport led to faster message development.
4. Finally, by following Incident Command System principles, we were able to better coordinate communication activities across the several agencies involved.

Although we were successful in getting the message out, there were several factors that we felt slowed this outbreak response down:

1. Despite having several state and federal agencies collecting clues, we weren’t doing it together, which meant more time was spent on the backend to get everyone on the same page.
2. Not all staff had been trained on the laws and policies related to release of information, which was needed for rapid decision-making during the outbreak.
3. Oregon Public Health (as we suspect is the case with many state health departments) has no risk communication policy, which meant not everyone was on the same page about how and when we would share information and release information to our partners and the public.
4. Political happenings unrelated to the outbreak ended up blocking the release of important health messages by two days — another all-too-common experience for many risk communicators.

How Can We Improve? Given these pros and cons, we still think much can be done to improve decision-making and risk communication during an outbreak. The federal Food Safety and Modernization Act of 2011 was an important step toward improving the safety of our nation’s food supply. However, our experience responding to Salmonella Heidelberg outbreak in Oregon also suggests that additional state and federal policies are needed not only to prevent outbreaks, but also to help public health authorities implement best practices in risk communications and public health responses when outbreaks do occur. No state health department funded with federal dollars — CDC or otherwise — should be without a well-developed risk communications plan that can be operationalized at a moment’s notice. Similarly, states should be held accountable to ensure information about emerging outbreaks is shared between epidemiologists, other partners, and response staff, and to identify the triggers for public warning and messaging about health risks. Depending on the risk, even a one day delay in response could mean more sick people, and in turn more health care and social costs.

Dr. Kathleen Vidoloff is the Emergency Risk Communication Officer for Oregon Public Health Division where she oversees the development, implementation and evaluation of risk communication activities.  She is also an Adjunct Professor of risk communication at the University of Oregon. Dr. Vidoloff previously worked as a contractor at the U.S. Centers for Disease Control and Prevention evaluating emergency risk communication strategy for international and domestic emergency responses. Dr. Jean O’Connor was Oregon’s Deputy Public Health Director and the Principal Investigator for Oregon’s public health preparedness and infrastructure improvement funding awards from 2011 to 2013.  She has more than 15 years of experience with CDC, state public health agencies, and non-profit organizations,  including work on numerous responses to domestic and international public health events.  She is also an Adjunct Associate Professor at Emory University’s Rollins School of Public Health where she teaches law and policy. Disclaimer: This blog post does not represent the official views of the Oregon Public Health Division or the Oregon Health Authority Editor’s Note: This article originally appeared on CDC’s Public Health Matters Blog May 1, 2013.

Of course raw cookie dough isn’t as sweet as Mom–but it might be a close second! As you bake up a batch of Mother’s Day cookies, or help Mom with her famous family recipe, keep this information in mind to keep yourself and your mom safe.

Cracking the Cookie Dough Case

May 2009, we learned about a number of people who became sick from E. coli O157, a germ that can cause stomach cramps, diarrhea, vomiting, and can even be life-threatening.

CDC and state and local health departments began to investigate. We originally suspected ground beef was making people sick. It is one of the “usual suspects” for E. coli O157, along with leafy greens and sprouts. But as we learned about more and more people who were infected with the same specific strain of E. coli O157, we noticed that they were generally young and female, which isn’t what we normally see in outbreaks linked to ground beef.

Our disease detectives asked the people who were affected by this outbreak many questions and had them talk about everything that they had eaten and done the week before they became sick, looking for things in common among them. The mother of a sick child mentioned that he had eaten raw, prepackaged cookie dough during the days before he became sick. Another person who had been ill told us she ate ice cream with cookie dough and brownie mix-ins at an ice cream shop (and, later, that she had also eaten raw, prepackaged cookie dough at home). Then another person mentioned eating raw cookie dough, and another.

When cookie dough was mentioned on a conference call between investigators from CDC and health departments in affected states, investigators in several states mentioned that an ill person in their state also reported eating raw cookie dough. It was a “Eureka” moment! Further investigation strengthened the link between eating raw prepackaged, cookie dough and becoming ill. As a result of the investigation, the company recalled the product.

Resist Temptation: Don’t Lick that Spoon!

As gooey and delicious as it might look, eating raw cookie dough could make you very sick. When handling raw cookie dough, keep these safety tips in mind:

– Do not eat any raw cookie dough or any other raw dough product that’s supposed to be cooked or baked.

– Follow package directions for cooking at proper temperatures and for specified times.

– Wash hands, work surfaces, and utensils thoroughly after contact with raw dough products.

– Keep raw foods separate from other foods while preparing them to prevent any contamination that might be present from spreading.

– Follow label directions to chill products promptly after purchase and after using them.

For more information, check out these resources:

E. coli

Consumer Advisory: FDA Continues to Warn Against Eating Raw Dough for Cookies or Other Raw Dough Products before Cooking

E. coli Outbreak and Raw Cookie Dough [PODCAST]

Animal Planet: Killer Outbreaks: E. coli O157 [VIDEO]

More about the outbreak [BLOG]:

– Linking Raw Cookie Dough to an E. coli Outbreak

– The First Step in Identifying a Foodborne Outbreak…PulseNet

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This article first appeared May 8, 2012 on FoodSafety.gov

– Cookie Dough – Gooey, Sweet, and Seasoned with…Bacteria?!

Dining Out

People in the U.S. do a lot of eating out, on Valentine’s Day and the other 364 days of the year. According to the National Restaurant Association, 49 cents of every dollar spent on food was predicted to be spent at restaurants in 2011. Most diners do have a safe meal. However,  more than half–59%–of the 13,405 outbreaks of foodborne illness reported in the U.S. between 1998 and 2008 involved food prepared in a restaurant or deli setting, according to CDC.

So whether you’re reserving a corner table at the local hotspot or grabbing takeout on your way home this February 14, make sure to keep you and your valentine safe.

Table for Two

All restaurants are required to follow food safety guidelines set by state and local health departments–but you can also follow these simple steps to keep your food safe.

– When you get to a restaurant, look at how clean things are before you even sit down. Are the glasses, silverware, napkins, and tablecloths clean? Is the floor free of bits of food and debris? If not, consider eating elsewhere. If available, check the results of the restaurant’s latest health inspection.

– Always order your food cooked thoroughly. Remember that foods like meat, poultry, fish, and eggs need to be cooked thoroughly to kill harmful bacteria that may be present. When you’re served a hot meal, make sure it’s served to you piping hot and thoroughly cooked. If it’s not, send it back.

– Don’t eat undercooked or raw foods, such as raw or undercooked eggs. Undercooked or raw eggs can be a hidden hazard in some foods like Caesar salad, custards, and some sauces. If these foods are made with commercially pasteurized eggs they are safe, but if you are unsure about the ingredients in a particular dish, ask before ordering it.

– Not going to finish that? Get that doggie bag in the fridge–fast. If you will not be arriving home within 2 hours of being served (1 hour if temperatures are above 90°F), it is safer to leave the leftovers at the restaurant. Also, remember that the inside of a car can get very warm so any food left inside may be affected. Bacteria grow rapidly in temperatures above 40°F, so it is always safer to go directly home after a meal and put your leftovers in the refrigerator.

A Quiet Night In

Whether you’re picking up food to eat at home or having food delivered, do the following to keep your food safe.

– Keep HOT Food HOT! Once food is cooked it should be held hot at an internal temperature of 140°F or above. Just keeping food warm (between 40°F and 140°F) is not safe. Use a food thermometer to monitor the internal temperature of the food. A preheated oven, chafing dishes, preheated warming trays, or slow cookers may be used.

– Keep COLD Food COLD! Cold foods must be kept at 40°F or below.

– Follow the Two-hour rule. Throw away all perishable foods such as meat, poultry, eggs, and casseroles that have been left at room temperature longer than 2 hours (1 hour in temperatures above 90°F).

– Save it for later–safely. If you plan to eat at a later time, take-out or delivered food should be divided into smaller portions or pieces, placed in shallow containers, and refrigerated.

The Celebration Continues…with Leftovers!

If your romantic dinner is just too big to finish, go ahead and put it in the fridge–but eat it soon, within three to four days. Consult this chart for storage times for the refrigerator and freezer.

For more information, check out these resources:

– Eating Out, Bringing In 

– Safe Handling of Take-Out Foods

– How to Report a Foodborne Illness

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By Kate Levinson, MPH, MA, Division of Foodborne, Waterborne, and Environmental Diseases, CDC. Reposted from FoodSafety.gov

What do you think of when you hear the word “outbreak”?  Maybe you envision a population decimated by a terrible, novel, and incurable disease like in the aformentioned movie Contagion or you think of Dustin Hoffman roaming around California in a blue biocontainment suit with Rene Russo trying to protect folks from a tiny monkey and narrowly preventing an airstrike by the US military?

Hollywood has done their best to capture what an outbreak is…but here are the facts. An outbreak, or epidemic, occurs when there are more cases of disease than would normally be expected in a specific time and place.  The disease may be something doctors have already seen before just in a new form or abnormally high numbers, such as foodborne or healthcare-associated infections, or it may be an emerging disease that we don’t know much about like SARS.  Either way, we need to investigate to determine why it is happening and how to prevent other people from getting sick or dying.

Outbreaks are usually noticed by an astute clinician, such as those who first noticed AIDS in New York City and San Francisco, but there are also many high tech disease detection systems available to help us spot any increase in illness. PulseNet is a laboratory network that uses PFGE (pulsed-field gel electrophoresis) to help identify foodborne outbreaks by monitoring the genetic make-up of the bacteria causing what may otherwise look like unrelated illnesses. In the recent events of the Salmonella outbreak in ground turkey, PulseNet and the National Antimicrobial Resistance Monitoring System helped identify the cause of the outbreak as well as determine how widely it had spread. Programs such as Biosense and First Watch monitor the chief complaint or reason that someone called 9-1-1 or went to the hospital (aka syndromic surveillance).  We also monitor news media for reports of outbreaks and websites such as Google Flu trends,  which tracks circulating viruses and illnesses. With new technology ordinary citizens can also increasingly report outbreaks in their communities too.

The Magic Formula

So how do you figure out the who, what, when, and where of a disease outbreak? We usually teach our disease detectives a 10-step process for investigating outbreaks, which I’ve condensed into 5 steps below. When we investigate outbreaks they are often in urgent situations with patients and their families wanting immediate answers and the news media asking why we are not working hard and fast enough.  This can be a lot of pressure when you are trying to make sure you gather all the clues and piece them together properly. If you’re wrong, not only do more people die, but you may implicate the wrong product, microbe, or disease transmission (such as the false accusation of Spanish cucumbers as the cause of the recent European E. coli outbreak). For that reason it’s important you follow each step.

Step 1: Determine an outbreak is occurring (seems obvious, I know)

Too often an initial suspicious outbreak is just lots of different illnesses that are being confused for the same thing or an error from the lab or other monitoring system. So the first step involves lots of listening and then asking some basic questions:

— What are the signs and/or symptoms?

— Is this an increased number for this area, time of year, or age group?  Are the cases linked to a common source or agent?  Keep in mind that a change in disease monitoring, laboratory diagnostics, reporting requirements or even increased publicity might affect the number of cases reported without accurately reflecting a true disease outbreak.

— How many cases are there?

— The 5 “W’s” of any investigation apply here as well. Who? What? Where? When? Why?

The most critical piece here is often the “what is the problem” also referred to as verifying the diagnosis. This is where the Sherlock Holmes part of being a disease detective gets turbocharged with leading edge laboratories that should best be called CSI-CDC. The CDC labs were the first labs to identify the agents responsible for a long list of diseases such as Legionella, Hantavirus Pulmonary Syndrome, Ebola, West Nile virus in the US, SARS, and most recently the novel H1N1 influenza virus.

Step 2: Now that we have confirmed an outbreak, we need a case definition (not very sexy but critical)

All of the information we gathered in Step 1 allows us to piece together the person, place, and time aspects of the outbreak to develop a case definition for who we think is likely to be part of the outbreak. This is much easier if we have a lab test, but for a new disease – like AIDS or SARS – we often have to use clinical data instead (data aquired from patient observation and treatment). With a case definition we can ask if there are commonalities among all the cases. For example, are people of a certain age, race, ethnicity, location, occupation, underlying medical condition, or travel itinerary affected by this?

The case definition will create a standardized method for identifying past, present and future cases.  It should include clinical information, characteristics of those with the disease, and geographic and timing information about the cluster of cases.  A good case definition starts out very inclusive so as not to miss any potential cases that do not have the typically identified symptoms.  As the investigation continues for an unknown disease, this definition may become more restricted to ensure we focus on persons who truly have the illness of concern.  When the SARS outbreak occurred in 2003, the case definition continually changed as we learned more about the disease, its manifestations, and transmission patterns.  It started very general as a type of pneumonia, and then the definition became more specific when the transmission method and symptoms were further identified and finally a lab test was developed by CDC.

Step 3: Get a clue (often better known as throwing darts)

This is the same step we learned in grade-school for coming up with a scientific hypothesis.  You must develop a question or educated guess of how something works in order to test whether you’re correct.  That is essentially what we do in an investigation. We use information about those who are ill, in addition to knowledge
about existing diseases, and some intuition to determine a plausible hypothesis.

This is when listening and close observation comes in handy to identify the public health misadventure that led to the outbreak: lots of dead crows surrounding the West Nile Virus outbreak in NYC, rodents associated with people with Hantavirus Pulmonary syndrome, or Hepatitis C cases that went to a specific clinic that was reusing needles.

Step 4: The leap of faith (testing the hypothesis)

While the earlier steps are often about the art of epidemiology, this step is all about the science.  Once we establish who is ill we need to find the factor that is causing them to become infected or poisoned.

A common way of conducting epidemiological studies (studying the patterns and causes of disease) is through a case-control study, where identical surveys or lab data are collected from those who are ill and those who are not.  We then see if there are factors that are significantly (not due to chance) different in cases vs. controls.  For example, in a multi-state outbreak of a rare but serious parasitic eye infection, Ancathamoeba Keratitis, an interview was conducted with both cases and controls regarding a myriad of factors that scientists thought might be implicated in the occurrence of the disease mainly among contact lens wearers.  After the questionnaires were completed, an analysis was run and sure enough, certain variables were strongly associated with an increased number of cases.  One brand of contact lens solution was recalled from the market because a significantly higher number of cases used this solution.

Step 5: Take Action!

Accurately identifying the risk factor allows us to put in place the appropriate prevention method. This public health protection step is as old as John Snow (the so-called “father” of Epidemiology) taking the handle off the Broad Street pump in 1854 after recognizing it as the source of the cholera outbreak (and long before we had identified the cholera bacterium).  In some cases it may be an “easy” fix such as recalling a product or altering manufacturing practices, but it may require a long-term outreach and education measure to promote behavior change such as the consistent use of condoms to prevent sexually transmitted diseases or smoking cessation to prevent lung cancer.

While this five-step process may appear fairly clear and logical, many investigations will throw us curve balls in the process. For example, on many international outbreaks the logistical and security challenges can present significant hurdles. I’ve been on a monkeypox outbreak in Zaire that suddenly ended when a civil war spilled over into the area where we were working, giving us sufficient time to leave with only our specimens and data sheets.  Even on domestic outbreaks, it can take a while to get everybody working together. However, no matter what the circumstances, public health officers will persevere “until we get our man.”

For more information about CDC’s current investigations or to learn more about real-life disease detectives, please visit http://www.cdc.gov/eis/index.html.

What Do You Think?

Are you planning on seeing the movie Contagion? Or maybe you’ve seen one of the many other movies about a deadly disease outbreak. What did you think? Could it happen to you and if you were the epidemiologist in charge of solving the mystery would you be able to figure it out in time?

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From the CDC’s Public Health Matters Blog, originally published Sept. 7, 2011 as “Outbreak Investigation: A Cheat Sheet.”

(During the past century, public health was challenged with promoting sanitation and childhood immunization programs to eradicate smallpox and polio and reduce other diseases such as typhoid fever, tuberculosis, and whooping cough. However, in the 21st Century, the challenges of public health continue to surface as we battle infectious disease and foodborne outbreaks such as H1N1 flu and Salmonella Typhimurium.  Public health has become a new face in the preparedness arena and has been instrumental in responses such as the September 11th attacks, the 2005 Hurricanes Katrina and Rita, and the 2010 Deepwater Horizon Oil Spill.

In this blog, we share our public health passions about the evolution of public health and the continual strides that are being made to protect and save lives through education, awareness, research, and promoting healthy lifestyles.  We look forward to listening to our communities for greater transparency and accountability. I will be joined by our scientists and other subject matter experts who spend their days working with some of the most critical infectious diseases, as well as preparing for and responding to public health emergencies that threaten us in the United States and around the world.  From high-tech labs in Atlanta to the field worldwide, please join us as we share our perspective and personal experiences working on the front lines of emerging infectious diseases and public health emergencies.

– RADM Ali S. Khan

Salmonella are bacteria that cause over one million illnesses each year. This “bug” causes more hospitalizations and deaths than any other type of germ found in food and $365 million in direct medical costs each year. At CDC, we’re concerned that Salmonella infections have not declined in 15 years. So, how does Salmonella sneak into foods, what foods do they get into, and what can be done?

How does Salmonella get into foods?

Simply put–it gets into food through the poop of animals, such as cows, birds, and mice. Because the natural home for Salmonella bacteria is in the gut of these animals, their poop becomes a carrier of the germ if it gets into food or water. For example, if water used to irrigate a field has animal poop in it, the water can contaminate the food growing in the field. 

Contamination can also occur where food is being made. For instance, a tainted ingredient can get on equipment, floors, storage bins, or someone’s hands and then spread to other food. In fact, a cutting board or knife that has germs on it can contaminate other foods and lead to food poisoning.

What foods does Salmonella get into?

One reason why it’s tough to reduce Salmonella infections is because the germ makes its way into so many different types of foods. Salmonella can contaminate meats, poultry, eggs, fruits, vegetables, and even processed foods such as peanut butter.

What can be done?

You can’t smell or see Salmonella in or on food. That’s why it’s important to do everything that you can to be food safe at home:

Follow the tried-and-true behaviors of CLEAN, SEPARATE, COOK, and CHILL. When it comes to Salmonella, this means:

— Wash your hands, utensils, cutting boards, and other surfaces before and after handling meat and poultry.

— Thoroughly wash fresh fruits and vegetables.

— Assume that raw chicken and other meat have Salmonella and don’t allow them to contaminate surfaces and other foods, such as produce.

— Don’t wash meat, poultry, and eggs! This can actually spread Salmonella to other foods.

— Cook meat, poultry, and eggs thoroughly to safe temperatures.

— Avoid unpasteurized dairy products (including soft cheeses) and juices.

— Make sure shellfish are cooked or treated for safe eating.

— Report suspected food poisoning to your local health department.

— Never prepare food for others if you have diarrhea or vomiting.

— Pay attention to food recall notices. Never serve or eat food that has been recalled.

You can also support policies that encourage good food safety practices among farmers, grocery stores, and places that make, sell, or serve food.

For more information, check out these resources:

— Food Poisoning: Salmonella

— CDC Vital Signs report: Making Food Safer to Eat

— Salmonella Is a Sneaky Germ: Seven Tips for Safer Eating

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By Capt. Christopher R. Braden, MD, Director of the Division of Foodborne, Waterborne, and Environmental Diseases, CDC. Republished from foodsafety.gov.

Hello, I’m Dr. Robert Tauxe, internal medicine physician and infectious disease epidemiologist at the Centers for Disease Control and Prevention (CDC). I’m pleased to speak with you today as part of the CDC Expert Video Commentary Series on Medscape about the dangers — as well as some persistent myths and misperceptions — surrounding raw milk or products made from raw milk.

Milk is an important and nutritious natural food, but the recurrent outbreaks related to unpasteurized milk and milk products require that we work together to put out accurate and consistent messages about the serious illnesses that can be caused by consuming raw milk.

First, let’s dispel some common myths about raw milk.

Myth #1. Raw milk is healthier and more nutritious than pasteurized milk.

Not so! All of the nutritional benefits of drinking milk are available from pasteurized milk without the risk for disease that comes with drinking raw milk.

Myth #2. Drinking raw milk can prevent or cure diseases such as asthma, allergies, heart disease, or cancer.

No. There are no health benefits from drinking raw milk that cannot be obtained from drinking pasteurized milk that is free of disease-causing bacteria.

Myth #3. Milk is safe as long as it is labeled “organic.”

Again, this is not true. Even raw organic milk is not safe. Only organic milk that has been pasteurized is safe to drink.

Myth #4. Milk and raw milk products like soft cheeses and yogurts are safe if they come from healthy animals.

No, even the healthiest of animals can carry pathogens, such as Escherichia coli O157, Campylobacter, and Salmonella that can contaminate milk.

Myth #5. If animals are raised in sanitary conditions on humane farms, this ensures that their milk is safe.

It may surprise many to know that the dairy farm environment, even when every precaution is taken, is a reservoir for illness-causing germs. Even if the farm’s raw milk tests come back negative, it is no guarantee that the milk, or the products made from the milk, are always free of those pathogens.

Myth #6. Drinking raw milk may not be safe, but no harm will come from eating products (cheeses, yogurts) made from raw milk.

Unfortunately, this too is quite false. In fact, both people who died in outbreaks related to unpasteurized milk between 1999 and 2008 died of infections caused by fresh Mexican-style cheese made from raw milk. These unfortunate cases show how raw milk made into fresh cheese can cause dangerous infections.

Now that we’ve put to rest the myths about raw milk, let’s discuss the recent facts about the illnesses caused by consuming raw milk and raw milk products. In the 10 years from 1999 to 2008, 86 outbreaks related to unpasteurized milk were reported to CDC, leading to 1676 illnesses, 191 hospitalizations, and 2 deaths.

That is about 8 outbreaks per year. Most of them were due to either E. coli O157, Campylobacter, or Salmonella. Especially concerning was that, of the 86 outbreaks reported to CDC, 79% involved at least 1 person under the age of 20. Some of the most severe illnesses can occur in young children, like kidney failure due to E. coli O157. And remember, E. coli O157 can spread from one young child to another in a day care or nursery school.

Some states permit sale of raw milk and, not surprisingly, about 80% of these outbreaks occurred in states that permit the sale of raw milk. Finally, because not all foodborne outbreaks are investigated or reported to CDC, the actual number of outbreaks that occur is likely to be greater than the number reported.

Our recommendations are simple and straightforward.

* Pasteurization of milk is a fundamentally important food safety measure;

* CDC strongly supports measures to promote pasteurization and restrict the sale of raw milk; and

* Specifically for clinicians, we urge you to educate your patients about the dangers of consuming raw milk or raw milk products.

Thank you!

Robert V. Tauxe, MD, MPH , is Deputy Director, Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention. Dr. Tauxe is Deputy Director of the division that is charged with prevention and control of foodborne, waterborne, and fungal infections at the Centers for Disease Control and Prevention. The Division monitors the frequency of these infections in the United States, investigates outbreaks, and develops strategies to reduce the disease, disability, and deaths that they cause.

Dr. Tauxe graduated cum laude from Yale University, in New Haven, Connecticut, in 1975, and received his medical degree from Vanderbilt Medical School in Nashville, Tennessee. In addition, he holds a Masters in Public Health degree from Yale University. Dr. Tauxe’s interests include bacterial enteric diseases, epidemiology and pathogenesis of infectious diseases, epidemiologic and clinical consequences of bacterial genetic exchange, antimicrobial use and resistance to antimicrobial agents, and teaching epidemiologic methods. Dr. Tauxe has supervised many domestic and overseas epidemiologic investigations. Dr. Tauxe has authored/co-authored 254 scientific journal articles, letters, and book chapters.

Why focus on raw milk? What about other foods that have made people sick?

We get a lot of questions from people who are trying to decide whether or not to drink raw milk, and we want to provide them with science-based information on the risks of drinking raw milk. 

I work with the group at the Centers for Disease Control and Prevention (CDC) that investigates outbreaks of foodborne illnesses caused by germs like Salmonella and E. coli O157:H7 (a dangerous form of E. coli). Over the years, we have collected extensive data based on experience investigating these outbreaks. Many different foods have been associated with recent outbreaks, such as unpasteurized juice and cider, eggs, and sprouts.

When determining if one food is riskier than another, it is important to understand how many people consume that food. For example, did you know that an estimated 4 percent of dairy products consumed in the United States are unpasteurized, based on a 2006-2007 FoodNet Population Survey, yet more than half of dairy-associated outbreaks are linked to raw milk products?

I know people who have been drinking raw milk for years, and it’s never made them sick. Why is that?

Several things can affect whether or not a person becomes sick after consuming a contaminated food or drink. These include the number and type of germs contaminating the food or drink, as well as the immune defenses of the person who consumes the food or drink.

The presence of germs in raw milk is unpredictable. The number of disease-causing germs in the raw milk may be too low to make a person sick at first, but the germs may later multiply so that there are enough to make the same person seriously ill. As seen in these videos, for some people, drinking contaminated raw milk just once could make them really sick; for others, illness comes after years of drinking raw milk.

I’ve heard that raw milk has enzymes that kill dangerous bacteria. Is that true?

No, the enzymes in raw milk are not strong enough to kill dangerous bacteria. In the United States, pasteurization is the only method routinely used to eliminate disease-causing organisms in milk.

My farmer has set up humane and sanitary conditions for raising his animals and producing raw milk. His animals are really healthy. Doesn’t this ensure that his milk is safe?

Even animals that appear healthy and clean may carry germs that can contaminate milk. Adhering to good hygienic practices during milking can reduce the risk of contaminating the milk, but it doesn’t eliminate it. If the milk is raw, small numbers of bacteria might multiply and grow in the milk before someone drinks it. No matter what precautions the farmer takes, it’s impossible to guarantee that raw milk is free of harmful germs.

What about raw milk that’s been laboratory tested for bacteria?

Negative tests do not guarantee that raw milk is safe to drink. People have become very sick from drinking raw milk that came from farms that regularly tested their milk for bacteria, and whose owners were sure that their milk was safe.

What are the statistics on outbreaks of illness related to raw milk?

Among outbreaks of illness transmitted by dairy products reported to CDC between 1973 and 2008 in which the investigators reported whether the dairy product was pasteurized or raw, 82 percent were due to raw milk or cheese. From 1998 through 2008, 86 outbreaks due to consumption of raw milk or raw milk products were reported to CDC. These outbreaks resulted in 1,676 illnesses, 191 hospitalizations, and 2 deaths.

The data that concerns me the most is about the impact on children: among these 86 raw dairy product outbreaks, 79 percent involved at least one person under the age of 20. These illnesses, which are entirely preventable, can be severe or even life-threatening.

Keep in mind that reported outbreaks represent the tip of the iceberg. For every outbreak and every illness reported, many others occur, and most illnesses are not part of recognized outbreaks.

Can outbreaks be caused by pasteurized milk products?

Pasteurized milk and cheese products can cause outbreaks, but these are usually due to contamination that occurs after the pasteurization process. Also, the most common germ that affects pasteurized milk products is norovirus, which is typically spread from one person to another, not from animals to people. This is different from the germs that can most often contaminate raw milk like Salmonella and E. coli O157 H7, which are spread from animals to people. Also illness from norovirus typically lasts for only 2 days, whereas illness from Salmonella and E. coli is usually more serious.

For more statistics and other information, see Raw Milk Questions and Answers.

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This article was initially posted Feb. 28, 2011 at www.foodsafety.gov by LCDR Casey Barton Behravesh, DVM, DrPH, U.S. Public Health Service.

As a public health epidemiologist and veterinarian, I know firsthand how animals and their germs can contaminate all kinds of food, including milk. Also, in my job in the Outbreak Response and Prevention Branch at CDC, I help investigate outbreaks caused by contaminated food and contact with infected animals.

If you’re thinking about adding raw milk to your diet (or your family’s diet), it’s important for you to understand the risks of drinking raw milk.

Why raw milk is dangerous

Raw milk can carry harmful bacteria and other germs that can make you very sick or kill you. Yes, it’s true that it’s possible to get “food poisoning” or foodborne illnesses from many foods, but raw milk is one of the riskiest of all. Raw milk and products made from raw milk (such as cheeses and yogurts) can cause serious infections, such as Salmonella, Listeria, and E. coli.

What happens if you get sick from raw milk

Getting sick from raw milk can mean many days of diarrhea, stomach cramping, and vomiting. Less commonly, it can mean kidney failure, paralysis, chronic disorders, and even death. The seriousness of the illness is determined by many factors, such as the type of germ, the amount of contamination, and the person’s immune defenses.

Speaking of immune defenses… it’s important to remember that some people are at higher risk of getting sick from drinking raw milk. The risk is greater for certain age groups, such as infants, young children, and older adults. It’s also particularly risky for pregnant women (and their unborn babies) and those with weakened immune systems, such as people with cancer, an organ transplant, or HIV/AIDS.

Though some people are at higher risk of getting sick from raw milk, even healthy adults and older children can get seriously ill. Those who recover often suffer from life-long medical consequences. To see how devastating these illnesses can be, check out these real-life stories about the dangers of raw milk.

Even healthy animals may carry germs that contaminate raw milk

Outbreaks of illness related to raw milk have been traced back to both grass-fed and grain-fed animals. Raw milk supplied by “certified,” “organic,” or “local dairies has no guarantee of being safe.

How to stay safe

To keep your family safe, follow these simple tips:

— Always drink pasteurized milk. Check the label or package to be sure.

— If you prefer organic milk, make sure that it’s pasteurized. Raw, organic milk is not safe.

— If you or a member of your family consumes raw milk and then becomes ill, call your health care provider immediately. If it’s an emergency, call 911.

For more information, including questions and answers about raw milk, see Food Safety and Raw Milk (CDC).

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LCDR Casey Barton Behravesh, DVM, DrPH, U.S. Public Health Service works in the Outbreak Response and Prevention Branch at the Centers for Disease Control and Prevention. This article was originally posted Feb. 15, 2011 at www.foodsafety.gov.

What is raw milk?

Raw milk is milk from cows, goats, sheep, or other animals that has not been pasteurized. Although precise data are not available, it is thought that less than 1% of milk sold to consumers in the United States has not been pasteurized.

What are the risks associated with drinking raw milk?

Raw milk can carry harmful bacteria and other germs that can make you very sick or kill you. While it is possible to get foodborne illnesses from many different foods, raw milk is one of the riskiest of all.

Getting sick from raw milk can mean many days of diarrhea, stomach cramping, and vomiting. Less commonly, it can mean kidney failure, paralysis, chronic disorders, and even death.

Many people who chose raw milk thinking they would improve their health instead found themselves (or their loved ones) sick in a hospital for several weeks fighting for their lives from infections caused by germs in raw milk. For example, a person can develop severe or even life-threatening diseases, such as Guillain-Barré syndrome, which can cause paralysis, and hemolytic uremic syndrome, which can result in kidney failure and stroke.

Illness can occur from the same brand and source of raw milk that people had been drinking for a long time without becoming ill.

A wide variety of germs that are sometimes found in raw milk, can make people sick, including bacteria (e.g.,  Brucella, Campylobacter, Listeria, Mycobacterium bovis (a cause of tuberculosis), Salmonella, Shiga toxin-producing Escherichia coli [e.g., E. coli O157], Shigella, Yersinia), parasites (e.g., Giardia), and viruses (e.g., norovirus).

Each ill person’s symptoms can differ, depending on the type of germ, the amount of contamination, and the person’s immune defenses.

Who is at greatest risk of getting sick from drinking raw milk?

The risk of getting sick from drinking raw milk is greater for infants and young children, the elderly, pregnant women, and people with weakened immune systems, such as people with cancer, an organ transplant, or HIV/AIDS, than it is for healthy school-aged children and adults. But, it is important to remember that healthy people of any age can get very sick or even die if they drink raw milk contaminated with harmful germs.

Can drinking raw milk hurt me or my family?

Yes. Raw milk can cause serious infections. Raw milk and raw milk products (such as cheeses and yogurts made with raw milk) can be contaminated with bacteria that can cause serious illness, hospitalization, or death. These harmful bacteria include Brucella, Campylobacter, Listeria, Mycobacterium bovis, Salmonella, Shiga toxin-producing E. coli, Shigella, Streptococcus pyogenes, and Yersinia enterocolitica. From 1998 through 2008, 86 outbreaks due to consumption of raw milk or raw milk products were reported to CDC. These resulted in 1,676 illnesses, 191 hospitalizations, and 2 deaths. Because not all cases of foodborne illness are recognized and reported, the actual number of illnesses associated with raw milk likely is greater.

How does milk get contaminated?

Milk contamination may occur from:

Cow feces coming into direct contact with the milk

Infection of the cow’s udder (mastitis)

Cow diseases (e.g., bovine tuberculosis)

Bacteria that live on the skin of cows

Environment (e.g., feces, dirt, processing equipment)

Insects, rodents, and other animal vectors

Humans, for example, by cross-contamination from soiled clothing and boots

Pasteurization is the only way to kill many of the bacteria in milk that can make people very sick.

What is pasteurization, and how does it work in milk?

Pasteurization is the process of heating milk to a high enough temperature for a long enough time to kill illness-causing bacteria contained in the milk. As most commonly applied, pasteurization heats milk to a high temperature for a short time, which kills the bacteria that cause illness. It was invented in a time when millions of people became sick and died of diseases like tuberculosis, scarlet fever, typhoid fever, and other infections that were transmitted through raw milk. Pasteurization has prevented millions of people from becoming ill.

Raw milk contains bacteria, and some of them can be harmful. So, if you’re thinking about consuming raw milk because you believe that it is a good source of beneficial bacteria, you need to know that it isn’t and you may instead get sick from the harmful bacteria. If you think that certain types of bacteria may be beneficial to your health consider getting them from foods that don’t involve such a high risk. For example, so-called probiotic bacteria are sometimes added to pasteurized fermented foods, such as yogurt and kefir.

Pasteurized milk products have occasionally caused illnesses and outbreaks. Usually, this has happened because of germs introduced in the dairy after the pasteurization process. Pasteurized milk that is correctly handled in the dairy, bottled, sealed, and refrigerated after pasteurization, and that is properly handled by the consumer, is very unlikely to contain illness-causing bacteria. Considering the amount of pasteurized milk consumed in the United States, illness from it is exceedingly rare.

What is the history of the recommendation for pasteurization in the United States? 

Routine pasteurization of milk began in the United States in the 1920s and became widespread by 1950 as a means to reduce contamination and reduce human illnesses. It led to dramatic reductions in the number of people getting sick from diseases that had previously been transmitted commonly by milk. Most public health professionals and health care providers consider pasteurization to be one of public health’s most effective food safety interventions ever!

Many medical and scientific organizations recommend pasteurization for all milk consumed by humans; these include CDC, the Food and Drug Administration, the American Academy of Pediatrics, the American Veterinary Medical Association, the National Association of State Public Health Veterinarians, and others.

Does pasteurization change milk’s nutritional benefits?

No. Many studies have shown that pasteurization does not significantly change the nutritional value of milk and dairy products. All of the nutritional benefits of drinking milk are available from pasteurized milk without the risk of disease that comes with drinking raw milk.

Is it true that raw milk has more enzymes and nutrients than pasteurized milk?

While it’s true that the heating process of pasteurization does inactivate some enzymes in milk, the enzymes in raw animal milk are not thought to be important in human health. Some nutrients are somewhat reduced in raw milk, but the United States diet generally has plenty of other sources of these nutrients. For example, vitamin C is reduced by pasteurization, but raw milk is not a major source of vitamin C.

Aren’t raw or natural foods better than processed foods?

Many people believe that foods with no or minimal processing are better for their health. Many people also believe that small, local farms are better sources of healthy food. However, some types of processing are needed to protect health. For example, consumers process raw meat, poultry, and fi
sh for safety by cooking.
Similarly, when milk is pasteurized, it is heated just long enough to kill disease-causing germs. Most nutrients remain after milk is pasteurized. There are many local, small farms that offer pasteurized organic milk and cheese products.

Does milk have a “built-in” safety mechanism that prevents bacterial contamination?

No. Disease-causing organisms can only be eliminated in milk through pasteurization or by adding chemicals to the milk. Pasteurization is the best method of eliminating disease-causing organisms in milk and the only method routinely used in the United States.

Is it legal to buy or sell raw milk?

Yes, in some states. Because of the potential for serious illness, federal law prohibits dairies from distributing raw milk across state lines in final package form (packaged so that it can be consumed). This means that raw milk can only be distributed across state lines if it is going to be pasteurized or used to make aged (over 60 days) cheese before being sold to consumers. Each state makes its own laws about selling raw milk within the borders of the state. In about half of states, sale of raw milk directly to consumers is illegal. In the remaining states, raw milk may be sold to directly to consumers.

Does drinking raw milk prevent or cure any diseases, such as asthma, allergies, heart disease, or cancer?

No. There are no health benefits from drinking raw milk that cannot be obtained from drinking pasteurized milk that is free of disease-causing bacteria. The process of pasteurization of milk has never been found to be the cause of chronic diseases, allergies, or developmental or behavioral problems.

I know people who have been drinking raw milk for years, and they never got sick. Why is that?

The presence of germs in raw milk is unpredictable. The number of disease-causing germs in the raw milk may be too low to make a person sick for a long time, and later high enough to make the same person seriously ill. For some people, drinking contaminated raw milk just once could make them really sick. Even if you trust the farmer and your store, raw milk is never a guaranteed safe product. Drinking raw milk means taking a real risk of getting very sick.

My farmer performs laboratory tests for bacteria in raw milk, so isn’t it safe?

Even negative tests do not guarantee that raw milk is safe to drink. People have become very sick from drinking raw milk that came from farms that regularly tested their milk for bacteria and whose owners were sure that their milk was safe.

My farmer uses grass-fed cows and goats to produce raw milk, so isn’t it safe?

Outbreaks of illness related to raw milk have been traced back to both grass-fed and grain-fed animals.

My farmer’s raw milk is organic, so isn’t it safe?

Raw organic milk is not safe. Pasteurized organic milk is available in many places, including supermarkets, farmers’ markets, and dairies.

I’ve heard that many organic and raw milk producers are creating sanitary and humane conditions for raising animals and producing “safe” raw milk and raw milk products (like cheeses and yogurts). Does this help reduce milk contamination?

Adherence to good hygienic practices during milking can reduce, but not eliminate, the risk of milk contamination. The dairy farm environment is a reservoir for illness-causing germs. No matter what precautions farmers take, and even if their raw milk tests come back negative, they cannot guarantee that their milk, or the products made from their milk, are free of harmful germs.

Germs such as Escherichia coli O157, Campylobacter, and Salmonella can contaminate milk during the process of milking dairy animals, including cows and goats. Animals that carry these germs are usually healthy.

Can I still get a disease from raw milk and raw milk products if the cows or goats are healthy, clean, and grass-fed or if the dairy is especially careful and clean when collecting the milk?

Yes. Even healthy animals may carry germs that can contaminate milk. Milk may be contaminated with bacteria during the milk collection process. Small numbers of bacteria might multiply and grow in the milk before someone drinks it if it is raw. Dairying methods have improved over the years but are still no substitute for pasteurization in assuring that milk is safe to drink. Raw milk supplied by “certified,” “organic,” or “local” dairies has no guarantee of being safe.

Information about raw milk-related outbreaks

States that allow the legal sale of raw milk for human consumption have more raw milk-related outbreaks of illness than states that do not allow raw milk to be sold legally.

CDC collects data on foodborne disease outbreaks voluntarily reported by the state, local, territorial, or tribal health departments. The health departments conduct most outbreak investigations reported to CDC. The data reported may change frequently as reporting agencies enter new records and modify or delete old ones.

Among dairy product-associated outbreaks reported to CDC between 1973 and 2008 in which the investigators reported whether the product was pasteurized or raw, 82 percent were due to raw milk or cheese. From 1998 through 2008, 86 outbreaks due to consumption of raw milk or raw milk products were reported to CDC. These resulted in 1,676 illnesses, 191 hospitalizations, and 2 deaths. Most of these illnesses were caused by Escherichia coli O157, Campylobacter, or Salmonella. It is important to note that a substantial proportion of the raw milk-associated disease burden falls on children; among the 86 raw dairy product outbreaks from 1998 to 2008, 79 percent involved at least one person less than 20 years old.

Reported outbreaks represent the tip of the iceberg. For every outbreak and every illness reported, many others occur, and most illnesses are not part of recognized outbreaks.

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For more information on raw milk see Marler Clark’s www.realrawmilkfacts.com

However, milk and products made from milk (like cheese, ice cream, and yogurt) are foods that, when consumed raw, pose severe health risks. Milk and products made from milk need minimal processing, called pasteurization, which can be done by heating the milk briefly (for example heating it to  161°F for about 20 seconds), to kill disease-causing germs (e.g., Salmonella, Escherichia coli O157, Campylobacter) that can be found in raw milk. 

Before the invention and acceptance of pasteurization, raw milk was a common source of the bacteria that cause tuberculosis, diphtheria, severe streptococcal infections, typhoid fever, and other foodborne illnesses.  These illnesses killed many people each year, especially young children.  In the 1900s many mothers recognized this risk and would boil milk (bringing it to a temperature of 212°F) before giving it to their infants and young children. 

Many studies have shown that pasteurization does not significantly change the nutritional value of milk – pasteurized milk is rich in proteins, carbohydrates, and other nutrients. Heat slightly affects a few of the vitamins found in milk–  thiamine, vitamin B12, and vitamin C– but milk is only a minor source of these vitamins.    

This website provides information for people who want to know about:

— Important things to consider if you are trying to decide whether you and your family want to try raw milk and milk products

— Diseases caused by raw milk and milk products

— Outbreaks of foodborne illnesses involving raw milk and raw milk products

Trying to Decide About Raw Milk?

Developing a healthy lifestyle is a process with many decisions and steps.  One step you might be thinking about is adding raw milk to your diet.  Raw milk is milk that has not been pasteurized to kill harmful germs.  Germs include bacteria, viruses, and parasites. It’s important to understand the risks of drinking raw milk, especially because you may be hearing claims about the supposed “benefits” of raw milk.

Maybe you want to eat less processed food, or maybe you’ve heard that raw milk contains more of certain nutrients than pasteurized milk. Perhaps you’ve heard that raw milk can even prevent or solve various health problems.  For some people, buying raw milk is one way they try to support local farmers and sustainable agriculture.

It is important to know that milk can be a very efficient home for bacteria and other germs. When milk is pasteurized, some bacteria remain in it, but the disease-causing ones are killed. Pasteurization is the process of heating milk to a high enough temperature for a long enough time to kill disease-causing germs. Harmful germs usually don’t change the look, taste, or smell of milk, so only when milk has been pasteurized can you be confident that these germs are not present.  To ensure that milk is safe, processors rapidly cool it after pasteurization, practice sanitary handling, and store milk in clean, closed containers at 45 degrees F or below.

You can’t look at, smell, or taste a bottle of raw milk and tell if it’s safe to drink. Make the best decision for the health of your family. If you want to keep milk in your family’s diet, protect them by not giving them raw milk.  Even healthy adults can get sick from drinking raw milk.  If you’re thinking about drinking raw milk because you believe it has health benefits, consider other options.

Meet three women whose choice of raw milk for themselves or their loved ones had life-long consequences. Each of the women or their loved ones were part of an outbreak caused by raw milk.

More information about raw milk can be found on the Raw Milk Questions and Answers page.

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Centers for Disease Control and Prevention photos.

It takes only 20 seconds (if you do it the right way).

It requires only 3 ingredients.

Anyone can do it, even very young children.

The answer is Wash Your Hands. Over and over again, studies have shown that handwashing is one of the most effective ways to prevent the spread of many types of infection and illness–including foodborne illness.

Wash Your Hands the Right Way

When you wash your hands the right way, it takes only 20 seconds and requires only three ingredients: running water, soap, and something to dry your hands (a clean towel or air).

Here’s how to do it:

Wet your hands with clean running water (warm or cold) and apply soap.

Rub your hands together to make a lather and scrub them well; be sure to scrub the backs of your hands, between your fingers, and under your nails.

Continue rubbing your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice.

Rinse your hands well under running water.

Dry your hands using a clean towel or air dry.

And here’s when to do it:

Before, during, and after preparing food

Before eating food

After using the toilet

After changing diapers or cleaning up a child who has used the toilet

Before and after caring for someone who is sick

After blowing your nose, coughing, or sneezing

After touching an animal or animal waste

After touching garbage

Before and after treating a cut or wound

What About Hand Sanitizers?

Washing hands with soap and water is the best way to reduce the number of germs on them. But, if soap and water are not available, use a hand sanitizer.

Important: Hand sanitizers are not effective if your hands are visibly dirty.

Alcohol-based hand sanitizers can quickly reduce the number of germs on hands in some situations, but sanitizers do not eliminate all types of germs.

Always use an alcohol-based hand sanitizer that contains at least 60% alcohol. Here’s how to use hand sanitizer properly:

Apply the product to the palm of one hand.

Rub your hands together.

Rub the product over all surfaces of your hands and fingers until your hands are dry.

For more information on handwashing, check out these resources:

Handwashing: Clean Hands Save Lives

CDC Kidtastics Podcast: All You Have to Do Is Wash Your Hands

Video: Put Your Hands Together

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This post, by Michael J. Beach, PhD, Associate Director for Healthy Water and Chief, Waterborne Disease Prevention Branch, National Center for Emerging and Zoonotic Infectious Diseases, CDC, first appeared on FoodSafety.gov on Jan. 11, 2011

By J. Glenn Morris, Jr. 

How safe is our food?  Put another way, how much illness in the United States is caused by foodborne pathogens?  It sounds like a simple question.  Getting a reasonable answer, however, is far from simple.  The basic problem lies in the fact that only a small fraction of foodborne disease cases get reported through official (or unofficial) reporting systems.  Calculating the “real” rate of foodborne illness requires development of models that use reported cases as a starting point to estimate underlying disease rates.  Given the plethora of pathogens that can be transmitted through foodborne routes, this is a complex, and somewhat daunting, process.  It is, however, necessary for assessing the safety of foods and developing strategies for disease prevention.  The articles by Scallan et al. (1,2) in this issue represent the latest efforts to develop such estimates of the magnitude of foodborne illness in the United States.

In 1999, Mead et al. (3) published initial estimates of foodborne disease in the United States.  This landmark undertaking was the first to provide a comprehensive compilation of data from a variety of sources, including the Centers for Disease Control and Prevention (CDC) and the medical literature.  It resulted in the often-cited estimates that foodborne pathogens cause 76 million episodes of illness, 325,000 hospitalizations, and 5,000 deaths each year in the United States.  (Hereafter, episodes of illness are referred to as illnesses.)  During the past decade, these numbers have strongly driven ongoing efforts to implement or reform regulatory systems to protect the public from foodborne illness.  However, some aspects of the methods have been criticized, particularly the high degree of uncertainty of particular parameters and thus of the results themselves (4-6).  These concerns have led to requests for CDC to repeat and update the work of Mead et al., using better methods and parameter estimates that more closely reflect current realities.

Now, ≈11 years later, Scallan et al. have produced “Sons of Mead,” which include substantial improvements to the methods used by Mead et al. and to the quality and timeliness of data (1,2).  Scallan et al. should be commended, especially for 2 specific improvements: their advanced treatment of statistical uncertainty and variability and their transparent inclusion of voluminous appendixes of data, models, and assumptions.  These authors followed the same basic approach as Mead et al. but chose to report their estimates in 2 articles.   In the first article, they based their estimates of illnesses caused by 24 major pathogens (e.g., Salmonella spp., Escherichia coli O157:H7) primarily on data from the Foodborne Diseases Active Surveillance Network (FoodNet) and other pathogen-specific surveillance systems.  In the second article, they estimated illnesses caused by unknown (or unspecified) pathogens by subtracting illnesses caused by known pathogens from the annual estimated number of cases of acute gastroenteritis in the US population and adjusting the result by the percentage assumed to be acquired domestically through food.  If these 2 estimates are combined, as they were by Mead et al., the new totals are 47.8 million foodborne illnesses, 127,839 hospitalizations, and 3,037 deaths per year in the United States.

When one compares the 1999 and 2010 estimates (76 million vs. 47.8 million illnesses), the immediate response is to ask: Does this mean that food in this country is safer than it was 11 years ago?  Unfortunately, the Scallan et al. articles do not enable us to answer this question. The methods, underlying assumptions, and parameter estimates used to generate these new numbers differ sufficiently from those used ≈11 years ago to preclude comparisons.  In fact, if one looks simply at rates of overall gastrointestinal illness in the United States, based on FoodNet Population Surveys (2), one might infer that overall rates of acute gastrointestinal illness have increased during this period, from 0.49 episodes per person per year in 2000-2001, to 0.54 in 2002-2003, and to 0.73 in 2006-2007 (see [7] for a discussion of some methodologic issues with regard to the 2006-2007 survey).  For the Scallan et al. articles, these 3 numbers were averaged to arrive at a rate of 0.6 episodes of acute gastroenteritis per person per year over the past decade.  In contrast, Mead et al. used an estimate of 0.79 episodes of gastroenteritis per person per year, based on FoodNet data but also on older community surveys; they also used a somewhat different definition of acute gastrointestinal illness.  This difference in estimated annual rates of acute gastroenteritis, when combined with a lower assumed proportion of gastroenteritis that is foodborne, explains much of the dramatic drop in total annual episodes of foodborne disease.  Had Scallan et al. elected to use the 2006-2007 FoodNet estimate of 0.73 cases per person per year rather than use the average of 0.6 cases, their numbers would have been substantially higher and closer to the Mead et al. estimates.

Thus, if we can’t use the Scallan estimates for comparison, is there any way to say whether food in the United States is safer now than it was 11 years ago?  The best answer to this question comes from the FoodNet system (8), an active laboratory-based sentinel surveillance system that was established to monitor the public health impact of the 1995 U.S. Department of Agriculture (USDA) Pathogen Reduction: Hazard Analysis and Critical Control Point (HAACP) System regulations (the first major revision of USDA food safety regulations since 1906). FoodNet provides annual data from designated sentinel surveillance sites on numbers of laboratory-diagnosed cases of 10 predominantly foodborne bacterial and parasitic pathogens; it reports actual case totals, not estimates.  Despite year-to-year variability (including significant decreases in incidence of Shigella spp. and E. coli O157:H7 for 2009) (8), the overall trends show an initial drop in incidence of infection with the major bacterial foodborne pathogens after implementation of the 1995 USDA regulations, followed by a leveling off of incidence in subsequent years.  One exception is infections caused by Vibrio spp., which are increasing, partly because climate change is affecting coastal environments (9). Bottom line: with the exception of Vibrio spp., things don’t seem to be getting worse; however, after the initial decline since the USDA regulatory changes in 1995, one does not see evidence of sustained improvement.

How do numbers from the United States compare with those from Europe and the rest of the world?  Again, differences in methods used by Scallan et al. make it difficult, if not impossible, to directly compare these numbers with those being published by other countries, including Canada, Australia, and members of the European Union (10-12).  Although these new estimates cannot be compared directly with previous estimates or with estimates from other countries, these articles nonetheless constitute a necessary starting point for generation of more robust and regularly updated numbers.  Looking across time, use of a consistent method, with regular updating of data (ideally annually), would provide a basis for assessing the effect of changes in regulation and other interventions at a national level.  Similarly, if the methods are further modified in keeping with current international d
iscussions on standardization of foodborne disease estimates (13), direct comparison of U.S. numbers with those from other countries may become possible.

Estimates of the relative burden of disease caused by specific pathogens are crucial for improving our understanding of foodborne illness risks, but they are insufficient on their own.  To target interventions (which are almost always food specific), illnesses must be quantified in terms of food-pathogen combinations.  Doing so, in turn, requires development of what have been termed food attribution data (14,15).  That is, how much salmonellosis is caused by eating contaminated chicken versus eggs, beef, or pork?  How often is beef, compared with produce, the source of infection with E. coli O157:H7?  Likewise, summary statistics such as number of cases, hospitalizations, and deaths ignore at-risk subpopulations and chronic sequelae such as end-stage renal disease, congenital toxoplasmosis, and irritable bowel syndrome.  As such, the World Health Organization and many industrialized countries are increasingly reporting integrated measures of disease, such as disability-adjusted life years, which more fully capture disease symptoms and severities (13).  Furthermore, to reduce specific foodborne hazards, we need information about the many factors along the complex farm-to-table pathway that can lead to the introduction or amplification of pathogens that contaminate food.  This information would also help determine feasibility and efficacy of potential interventions.

As outlined in a recent Institute of Medicine report (16), implementation of a modern, risk-based food safety system in the United States will ultimately require much better data and a strong analytic capacity at the federal level that cuts across current agency lines.  Although we still have a long way to go to bring our food safety system into the current century, the articles by Scallan et al. are critical steps in the right direction.

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Dr. Morris is director of the Emerging Pathogens Institute and professor of medicine at the College of Medicine, University of Florida; a member of the Institute of Medicine Food and Nutrition Board; and an associate editor for CDC’s Emerging Infectious Diseases journal. He has worked extensively with foodborne pathogens and served on 5 National Academy of Sciences/Institute of Medicine expert committees dealing with food safety.

References:

1. Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson M-A, Roy SL, et al. Foodborne illness acquired in the United States–major pathogens. Emerg Infect Dis. 2011 Jan; [Epub ahead of print]

2. Scallan E, Griffin PM, Angulo FJ, Tauxe RV, Hoekstra RM. Foodborne illness acquired in the United States–unspecified agents. Emerg Infect Dis. 2011 Jan; [Epub ahead of print]

3. Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, et al. Food-related illness and death in the United States. Emerg Infect Dis. 1999;5:607-24. PubMed DOI: 10.3201/eid0505.990502

4. Powell M, Ebel E, Schlosser W. Considering uncertainty in comparing the burden of illness due to foodborne microbial pathogens. Int J Food Microbiol. 2001;69:209-15. PubMed DOI: 10.1016/S0168-1605(01)00495-0

5. Phillips CV, LaPole LM. 2003. Quantifying errors without random sampling. BMC Medical Research Methodology 2003;3:9 [cited 2010 Nov 15]. http://www.biomedcentral.com/1471-2288/3/9

6. Frenzen PD. Deaths due to unknown foodborne agents. Emerg Infect Dis. 2004;10:1536-43. PubMed

7. Cantwell LB, Henao OL, Hoekstra RM, Scallan E. The effect of different recall periods on estimates of acute gastroenteritis in the United States, FoodNet Population Survey 2006-2007. Foodborne Pathog Dis. 2010;7:1225-8. PubMed DOI: 10.1089/fpd.2010.0567

8. Centers for Disease Control and Prevention. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food–10 states, 2009. MMWR Morb Mortal Wkly Rep. 2010;59:418-22. PubMed

9. Lipp EK, Huq A, Colwell RR. Effects of global climate on infectious disease: the cholera model. Clin Microbiol Rev. 2002;15:757-70. PubMed DOI: 10.1128/CMR.15.4.757-770.2002

10. Adak GK, Long SM, O’Brien SJ. Trends in indigenous foodborne disease and deaths, England and Wales: 1992-2000. Gut. 2002;51:832-41. PubMed DOI: 10.1136/gut.51.6.832

11. OzFoodNet Net Working Group. Monitoring the incidence and causes of diseases potentially transmitted by food in Australia: annual report of the OzFoodNet Network, 2008. Commun Dis Intell. 2009;33:389-413. PubMed

12. Flint JA, Van Duynhoven YT, Angulo FJ, DeLong SM, Braun P, Kirk M, et al. Estimating the burden of acute gastroenteritis, foodborne disease, and pathogens commonly transmitted by food: an international review. Clin Infect Dis. 2005;41:698-704. PubMed DOI: 10.1086/432064

13. Kuchenmuller T, Hird S, Stein C, Kramarz P, Nanda A, Havelaar AH. Estimating the global burden of foodborne diseases–a collaborative effort. Euro Surveill. 2009;14:pii:19195. PubMed

14. Batz MB, Doyle MP, Morris JG, Painter J, Singh R, Tauxe RV, et al.; Food Attribution Working Group. Linking illness to food: summary of a workshop on food attribution. Emerg Infect Dis. 2005;11:993-9. PubMed

15. Pires SM, Evers EE, van Pelt W, Ayers T, Scallan E, Angulo FJ, et al.; Med-Vet-Net Workpackage 28 Working Group. Attributing the human disease burden of foodborne infections to specific sources. Foodborne Pathog Dis. 2009;6:417-24. PubMed DOI: 10.1089/fpd.2008.0208

16. Institute of Medicine. Enhancing food safety: the role of the Food and Drug Administration. Washington: National Academy Press; 2010. p. 1-576.