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Preventing Foodborne Infection in Pregnant Women and Infants
CNE Preventing Foodborne Infection in Pregnant Women and Infants Michael C. Bazaco, MS Susan A. Albrecht, PhD, RN, FAAN Angela M. Malek, MPH
INTRODUCTION
Objectives Upon completion of this activity, the learner will be able to:
1. Identify microorganisms most commonly associated with foodborne illness in pregnant women and infants. 2. Describe food handling practices that may increase risk of foodborne illness. 3. Summarize strategies for preventing foodborne illness.
Continuing Nursing Education (CNE) Credit A total of 2 contact hours may be earned as CNE credit for reading “Preventing Foodborne Infection in Pregnant Women and Infants” and for completing an online posttest and evaluation. To take the test and complete the evaluation, please visit http://JournalsCNE. awhonn.org. Certificates of completion will be issued on receipt of the completed evaluation form, application and processing fees. Note: AWHONN contact hour credit does not imply approval or endorsement of any product or program. AWHONN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AWHONN also holds California and Alabama BRN numbers: California CNE provider #CEP580 and Alabama #ABNP0058.
Foodborne illness occurs as a result of the consumption of microorganisms (bacteria, parasites, viruses) or chemical contaminants found in some foods or drinking water. Symptoms vary, but may include stomach cramps, vomiting, diarrhea, fever, headache or body aches. In some cases of foodborne infection, a pregnant woman may not feel sick but may still pass on the illness to the fetus. Pregnant women are at increased risk for some foodborne illnesses due to hormonal changes that can increase the susceptibility of their immune systems (Dean & Kendall, 2006). This weakened state of the immune system makes it more difficult for the woman’s body to fight off harmful foodborne microorganisms. In addition, the fetus’s immune system is not developed enough to fight off unsafe foodborne bacteria that may cross the placenta. Without early detection and treatment of foodborne illness, complications can occur, resulting in serious health problems for the fetus, pregnant mother or newborn including miscarriage and stillbirth. For both mother and baby, severe foodborne illness can cause death. Despite efforts to reduce transmission of infectious agents in both the mother and fetus, pregnancy is still a time of especially high concern. The pregnant woman and her fetus or newborn are susceptible to many foodborne illnesses such as hepatitis E (Hep E), toxoplasmosis, listeriosis, infant botulism as well as infections from enterohaemorrhagic E. coli due in part to the suppression of the mother’s and child’s immune system (WHO, 2007c). Prevention and early treatment of foodborne infections in the mother, fetus or neonate can help to reduce the development of further complications.
resents e illness p n r o b d o o pregnant •F isk to the e r t n a c ifi sign nd th er fetus a woman, h neonate. the ashing is w d n a h r e • Prop ention. ne of prev cornersto hclude teac in ld u o h s nt • Nurses all pregna to e s e th ing about women.
Michael C. Bazaco, MS, is a doctoral student in public health; Susan A. Albrecht, PhD, RN, FAAN, is associate professor and associate dean of the School of Nursing; Angela M. Malek, MPH, is a doctoral student in public health; all authors are at the University of Pittsburgh, Pittsburgh, PA. The authors report no conflicts of interest or financial relationships relevant to this article. Address correspondence to: [email protected]. DOI: 10.1111/j.1751-486X.2007.00275.x
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BOX 1 SYMPTOMS OF HEPATITIS E INFECTION
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Each year in the United States approximately 1.5 million people are infected with toxoplasmosis (Dean & Kendall, 2006); there is a 50 percent chance that a fetus will contract toxoplasmosis from an infected mother (March of Dimes, 2006). In addition, it’s estimated that 1 out of 1,000 to 10,000 neonates is born with this infection in the United States (Schwarz, 2006). This percentage accounts for 400 to 4,000 fetuses affected annually (FDA, 2007). In addition, some estimates suggest that toxoplasma kills as many as 80 infants each year in the Unites States (FDA, 2007). A severe infection occurs in 1 out of 10 US babies and can result in pneumonia, an enlarged spleen and liver, or jaundice (Schwarz, 2006). Testing is especially important because many cases of toxoplasmosis are asymptomatic among all age groups. In fact, 90 percent of babies infected appear normal and healthy
In some cases of foodborne infection, a pregnant woman may not feel sick but may still pass on the illness to the fetus. at birth, although most will develop problems such as mental retardation, hearing and vision loss, seizures, eye problems and other complications following birth (Schwarz, 2006; March of Dimes, 2006). Toxoplasmosis is a disease caused by the parasite Toxoplasma gondii that is spread through the consumption of undercooked meat or contaminated unwashed fruits and vegetables; contact with cat feces or fur; and contact with contaminated water (Schwarz, 2006; Dean & Kendall, 2006). Toxoplasmosis is one of
BOX 2 WAYS TO PREVENT HEPATITIS E INFECTION • Wash hands well with soap and warm water after changing diapers, using the bathroom, and handling raw food. • When traveling to areas where the water quality is questionable, don’t consume raw foods (such as salads, unpeeled fruits, and uncooked shellfish), tap water or ice. Use bottled water or boiled water for drinking, preparing infant formula, face washing and tooth brushing.
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Hep E is a viral infection spread through the feces of infected animals or humans. It is contracted through the consumpFatigue tion of contaminated food or drinking Jaundice water (CDC, 2005). Hep E occurs most Loss of appetite commonly in developing countries, Abdominal pain where it is mainly transmitted through unclean drinking water (CDC, 2005). Nausea Hep E can also be spread through inapVomiting propriate food handling. However, Hep Tea-colored urine E is rarely spread by person-to-person contact (CDC, 2005). The highest attack rate of Hep E occurs in those 15 to 40 years of age (CDC, 2005). People at increased risk for Hep E include travelers to developing countries or areas where epidemics have occurred, especially North and West Africa, Central and Southeast Asia, and Mexico (CDC, 2005; WHO, 2007a; WHO, 2007b). In the United States, however, rare cases have been reported among people with no travel history to countries where the virus is endemic (CDC, 2005). The presence of Hep E can be detected by a blood test (although not widely available) or through an epidemiologic investigation in some cases (WHO, 2007b). Symptoms of Hep E include fatigue, jaundice, loss of appetite, abdominal pain, nausea, vomiting and dark (tea-colored) urine (CDC, 2005) (see Box 1). Pregnant women experience Hep E more severely than others, especially during the third trimester, during which a case fatality rate of 10 percent to 42 percent exists (CDC, 2005; WHO, 2007c). A severe and sudden form of Hep E can affect pregnant women more often than any other group; however, this is rare (WHO, 2007b). Hospitalization may be necessary in some cases of Hep E infection during pregnancy (WHO, 2007b). Aside from infections occurring during pregnancy, risk of death from infection is usually low (WHO, 2007a). Most hepatitis infections are self-limited and will be successfully cleared by the body without complications. No hyperimmune E globulin therapy exists for pre- or post-exposure prophylaxis, or for altering the course of acute infection (WHO, 2007b). Those with abrupt occurring Hep E infections should be hospitalized (WHO, 2007b). At the time of this writing, a vaccine against Hep E is being developed but has not yet been approved. Because Hep E is a virus and is, therefore, not resolvable with antibiotic therapy, prevention is optimal (WHO, 2007b) (see Box 2). Hep E transmission can be prevented through proper hand-washing techniques, including using soap and warm water after changing diapers, using the bathroom or handling raw food. Travelers should avoid consuming raw foods (such as uncooked shellfish, salads and unpeeled fruits), ice and tap water if the water source quality is unknown. In such areas, bottled water or boiled tap water should be used for drinking, cooking, preparing infant formula, face washing and tooth brushing.
TOXOPLASMOSIS
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HEPATITIS E
the most common infections worldwide, LISTERIOSIS BOX 3 SYMPTOMS OF although it’s mainly seen in places where Listeria monocytogenes is a bacterial CLINICAL TOXOPLASMOSIS raw or undercooked meat is commonly pathogen that can cause serious infecINFECTION eaten, or in places with low hygiene tion in the pregnant woman and her levels (Schwarz). The majority of cases Swollen glands fetus. Pregnant women account for 27 are undiagnosed because the infection percent of all listeriosis cases and exFever is often subclinical or shows symptoms perience listeriosis at a rate 14 times Headache similar to that of the flu; however, this higher than the average person (Dean Muscle pain infection poses significant risk to the & Kendall, 2006). Human infection pregnant woman and fetus (Schwarz). Stiff neck from Listeria monocytogenes is linked Symptoms of clinical infection include to the consumption of contaminated swollen glands, fever, headache, muscle food such as deli meats and soft cheeses pain or a stiff neck (see Box 3). Those who’ve had toxoplasmosis (Moos, 2006). Listeria monocytogenes is a very ubiquitous orin the past are immune to the infection and immune status can ganism; it’s prevalent throughout all natural environments be ascertained through serological testing. and can come in contact with food products during any raw Prompt treatment of toxoplasmosis is required to prevent processing procedures (FDA, 2006b). It’s a psychotropic ordeath, chronic health problems and other serious conditions. ganism and grows well at refrigeration temperatures. Because Pregnant women testing positive for toxoplasmosis may agree of this adaptive feature, it has a competitive advantage against to amniocentesis to determine the fetus’ status (Schwarz, 2006). other microorganisms in food processing and storage areas that Antibiotics can then be administered to decrease symptoms in usually operate under cool temperatures.
Listeriosis is especially important with regard to pregnant women because it’s commonly associated with spontaneous abortion. the newborn (March of Dimes, 2006). If the pregnant woman alone is infected, spiramycin can be administered to decrease the chances of the fetus contracting the infection (Schwartz). Sulfadiazine and pyrimethamine are prescribed for fetal infection (Schwartz). Previously uninfected babies born to mothers who have had the illness are tested at birth for toxoplasmosis. Strategies to prevent toxoplasmosis include avoiding the consumption of raw or undercooked meat, and cooking meat until it is no longer red or to an internal temperature of at least 160 degrees (see Box 4). Because the parasite can enter the body through contact with one’s mouth, eyes or nose, thorough hand washing after the handling of raw meat is important (Schwarz, 2006). Produce should be washed or peeled before eating, and cutting boards, utensils and areas used when dealing with raw meat should be washed with hot, soapy water (Schwarz). Housecats should not be fed raw or undercooked meat, and pregnant women should not clean or handle the litter box (Schwarz). To prevent infection through contact with contaminated soil or animal fur, hands should be thoroughly washed after a person has been working in the garden or handling animals (Dean & Kendall, 2006).
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Listeriosis is caused by Listeria monocytogenes. It’s a systemic infection that can manifest as meningitis, bacteremia and sepsis (Cliver, 1990). Listeriosis is especially important with regard to pregnant women because it’s commonly associated with spontaneous abortion. It accounts for nearly 1,600 illnesses and 415 deaths annually (FDA, 2006b); although it accounts for less than 0.2 percent of total foodborne illnesses, it’s responsible for more than 40 percent of foodborne illness–related deaths (FDA, 2006b). This high mortality rate of infected individuals
BOX 4 WAYS TO PREVENT TOXOPLASMOSIS • Do not eat raw or undercooked meat. • Cook meat to an internal temperature of at least 160 degrees (use a food thermometer to determine temperature). • Wash hands well after handling raw meat. • Do not use the same utensils or cutting board that were used to handle raw meat for raw produce. • Wash utensils and cutting boards well with hot, soapy water. • Do not feed housecats raw or undercooked meat. • If pregnant, do not handle the litter box. • Wash hands well after working in the garden or handling animals.
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Pregnant women or those who could become pregnant in the near future should avoid the following foods: • Hot dogs, prepared mayonnaise-based salads and luncheon meats unless they are cooked until “steaming hot” • Unpasteurized raw milk and foods that contain it
• Refrigerated pates and meat spreads (shelfstable canned pates are fine) • Fish found in the refrigerator section or sold at deli counters in grocery stores including “nova style lox,” “kippered,” “smoked,” or “jerky” salmon, trout, whitefish, cod, tuna or mackerel
(more than 25 percent) is of major concern regarding public health as well as maternal child safety. Pregnant women must be aware of Listeria and foods commonly associated with it. Foods to be avoided include but are not limited to deli meats, hot dogs, soft cheeses and unpasteurized milk (IFT, 2004). Studies show that Hispanic pregnant women may have a higher incidence of listeriosis than pregnant non-Hispanic women. This is most likely because they prepare and eat soft cheese called queso fresco, which is made with unpasteurized milk. Outbreaks associated with this food have been linked to listeriosis and subsequent miscarriage, premature delivery and neonatal mortality (FDA, 2007). During pregnancy, it’s best to avoid these foods and to thoroughly cook food before consuming. All women who are pregnant or may become pregnant in the near future should avoid eating hot dogs, prepared mayonnaise-based salads and luncheon meats unless they are cooked until “steaming hot” (see Box 5). They should not eat soft cheeses unless they are made with pasteurized milk. Pregnant women should also avoid pates and meat spreads. Fish found in the refrigerator section or sold at deli counters in grocery stores including “nova style lox,” “kippered,” “smoked,” or “jerky” salmon, trout, whitefish, cod, tuna or mackerel should not be consumed (FDA, 2007). Complications may be associated with the disease but, in general, infection with listeria is usually asymptomatic. Flulike complications, fever, nausea, vomiting and diarrhea may occur alone or prior to a worsening infection (FDA, 2006b). Gastrointestinal symptoms can take place 12 hours after ingestion of listeria-contaminated food, while a severe form of the
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INFANT BOTULISM Botulism is a serious disease caused by a toxin produced by the bacterium Clostridium botulinum (Cox & Hinkle, 2002). Although this disease is rare, a form that affects infants known as infant botulism is still a major health concern. Infant botulism occurs when babies consume spores of the bacteria; it’s the most prevalent form of botulism in the United States and has been gaining more recognition and concern worldwide (Cox & Hinkle). In adults, consumption of spores or live bacteria will not cause illness, as the natural flora of the adult gut can destroy C. botulinum. But in infants this natural flora is not yet developed, and the bacteria are able to produce toxin, causing serious disease. Along with the discovery of this form of infection, two other strains of Clostridia (Clostridium baratii, Clostridium butyricum) have been shown to produce potent neurotoxins that can lead to infant botulism–like symptoms (Scarlatos et al., 2005). Infant botulism has only been definitively linked to consumption of honey at this point, although it has many possible environmental sources, such as dust and soil. In addition, corn syrup is a likely source of C. botulinum spores (Cox & Hinkle, 2002; FDA, 2006a). Mothers should not use honey or corn syrup to sweeten formula or medicine for their babies (Cox & Hinkle). These foods produce an ideal environment for C. botulinum spores and can be a vector for infection in newborns and young children. Infection can occur between six weeks and 9 months of age; two to three months of age is the most common time of occurrence (Cox & Hinkle, 2002). Symptoms include hypotonia, hyporeflexia, constipation, weakness, cranial nerve abnormalities, and respiratory problems in severe cases, (Cox & Hinkle) (see Box 6). Infant weakness can include loss of head control, a weak cry and gag reflex, decreased sucking, and irritability (Cox & Hinkle). Infection can be confirmed through culture of a stool and blood sample. If botulism toxin is present, the infant will be hospitalized in the intensive care unit (ICU) to receive necessary treatment. Physical and occupational therapy, airway management and nasogastric tube feedings are needed (Cox & Hinkle, 2002). Equine-derived antitoxin was administered in the past, but due to side effects this medication is not currently used; instead, a human-derived antitoxin—botulinum immune globulin—is now used. In spite of treatment advancements, the average hospital stay for infants with botulism is 44 days (Cox & Hinkle).
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• Soft cheeses, such as feta, Brie, Camembert, blue-veined cheeses, and Mexican-style cheeses
infection may take three days to three weeks to appear (FDA, 2006b). Treatment of listeria includes antibiotics such as penicillin or ampicillin for the mother and possibly a baby if infection is confirmed with a blood test, culture from cerebrospinal fluid or rarely a stool sample (FDA, 2006b). Trimethoprim-sulfamethoxazole can be prescribed in place of these medications if a patient is allergic to penicillin (FDA, 2006b).
CNE
BOX 5 PREGNANT WOMEN AND LISTERIOSIS
E. COLI O157:H7
H7. Of particular concern is ground beef and other types of ground meat Many strains of the bacterium E. coli because of the way they are processed, live naturally in the intestines of huwhich spreads contamination beyond a mans and animals. However, some Hypotonia single animal or portion of the animal pathogenic strains of E. coli can cause (CDC, 2006c). Unpasteurized milk may moderate to severe gastrointestinal disHyporeflexia also contain E. coli since the bacteria can ease in humans. A report by the CentConstipation live on cows’ udders (CDC, 2006c), and ers for Disease Control and Prevention Weakness unpasteurized juice and cider can also (CDC) found that 140 outbreaks of E. Cranial nerve abnormalities contain E. Coli. coli occurred between 1998 and 2002, Effective hand washing after using leading to close to 5,000 illnesses and Respiratory problems the bathroom, changing diapers or playfour deaths (Lynch, Painter, Woodruff, Loss of head control ing with small children is an important & Braden, 2006). Because E. coli infecWeak cry and gag refl ex method of preventing the spread of E. tion is often underreported, this is likely Decreased sucking coli to others (CDC, 2006c). Ground a vast underestimate of the true burden beef should be cooked to 160 degrees of disease. In a 1999 assessment, it was Irritability as measured by a food thermometer inmore accurately estimated to affect serted in the thickest part of the meat. 73,000 people in the United States anRaw meat should be kept away from other food. Utensils or nually, leading to close to 60 deaths (CDC, 2006c). food cooking and preparation areas should be washed with One strain in particular, E. coli O157:H7, is especially danhot, soapy water after cutting raw vegetables or meats (CDC, gerous and can lead to extremely serious disease if ingested by 2006c). Lake or swimming pool water should not be swallowed, way of contaminated food or water (CDC, 2006a). This parand drinking water should come from treated water facilities ticular strain of E. coli has come to national attention recently or bottled water (CDC, 2006c). Consumption of unpasteurized with two large, multistate outbreaks occurring in produce in cider, juice or milk should be avoided (CDC, 2006c). the United States. The larger of the two occurred in September Symptoms of infection with E. coli O157:H7 usually include 2006 and resulted in contamination across 26 US states, leadstomach pain and bloody diarrhea, and less often, a slight fever ing to nearly 200 illnesses. Of the ill, 26 were confirmed to be (CDC, 2006c). Stomach ache and diarrhea usually subside after hospitalized for hemolytic uremic syndrome. In addition, there 5 to 10 days with no additional complications (CDC, 2006c). was one confirmed death due to the outbreak, and two other Most adults and older children carrying the strain are symptodeaths likely associated (CDC, 2006b). matic, making it easier to identify and treat (CDC, 2006c). On Infection with E. coli can cause a pregnant woman to bethe other hand, the bacteria can be spread through contact with come critically ill, and E. coli can occasionally be passed by a an infected child’s stool for two weeks after he/she has recovpregnant woman to her fetus (March of Dimes, 2006). In this ered (CDC, 2006c). case, the fetus can experience fever and diarrhea. A rare comInfection with E. coli O157:H7 can be confirmed with a plication of meningitis infection may even develop after birth stool sample (CDC, 2006a). Self-treatment is not recommend(March of Dimes, 2006). Hemolytic uremic syndrome is a seried and diarrhea medication or antibiotics should not be taken ous complication resulting in kidney failure and the destrucunless prescribed by a physician or nurse practitioner due to tion of red blood cells; this occurs in 2 to 7 percent of E. coli the immobilization of the bacteria in the gut and prolongation infections (CDC, 2006c; CDC, 1993). Hospitalization may be of the illness (CDC, 2006c). It’s believed that kidney complicanecessary in the case of hemolytic uremic syndrome (CDC, tions could result from the use of some antibiotics, and they 2006c; CDC, 1993). About one-third of affected individuals are have not been found to be helpful in treating this particular at risk of having kidney problems in the future. In rare occurinfection (CDC, 2006a). Treatment of E. coli O157:H7 involves rences, blindness, paralysis or high blood pressure may result supportive care. from illness with E. coli O157:H7 (CDC, 2006c). E. coli can be spread through improper hand washing. It ROLE OF HEALTH PROFESSIONALS also can be spread by improper handling of raw vegetables, Nurses and other health professionals on the front line of pasprouts and fruits by workers, or through contaminated watient care have an important role to play in the identification ter used to wash or grow vegetables (CDC, 2006c). In addition, of foodborne illnesses (see “Case Examples” box), as well as in other sources of water can serve as a source of transmission of the prevention of foodborne infections. It’s important to make the organism, including swimming pools without proper chlopatients aware of the risks and how foodborne illnesses can be rination, lakes and drinking water (CDC, 2006c). Undercooked prevented. First and foremost is the avoidance of contaminated and uncooked meat may be contaminated with E. coli O157:
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BOX 6 SIGNS AND SYMPTOMS OF INFANT BOTULISM
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September 2006. Morbidity and Mortality Weekly Report, 55, 1–2. Centers for Disease Control and Prevention. (2006c). Questions and answers: Sickness caused by E. coli. Retrieved January 25, 2007, from http://www.cdc.gov/ecoli/qa_ecoli_sickness.htm Cliver, D. O. (1990). Foodborne diseases. San Diego, CA: Academic Press.
160°F
Ground beef, game meat, pork, and eggbased dishes
Cox, N., & Hinkle, R. (2002). Infant botulism. American Family Physician, 65, 1388–1392.
165°F
Ground turkey and chicken, leftovers, stuffing, casseroles, hot dogs and lunch meats
Dean, J., & Kendall, P. (2006). Food safety during pregnancy. Retrieved January 5, 2007, from http://www.ext.colostate.edu/ pubs/FOODNUT/09372.html
170°F
Chicken and turkey breasts
180°F
Whole chickens and turkeys; chicken or turkey legs, thighs and wings
Food and Drug Administration. (2006a). Foodborne pathogenic microorganisms and natural toxins handbook: Clostridium botulinum. Retrieved January 5, 2007, from http://www.cfsan.fda. gov/~mow/chap2.html
Source: Dean & Kendall, 2006
food or water. Meat, poultry, fish and eggs should be cooked thoroughly and the temperature checked with a food thermometer (Dean & Kendall, 2006) (see Box 7). Cross-contamination between utensils, dishes and food preparation areas must also be avoided, and foods must be stored properly at temperatures of 40 degrees or below (Dean & Kendall). Ready-to-eat or prepared foods should be eaten within four days (Dean & Kendall). If this is not possible, the food should be frozen or discarded. Respect for various cultural and religious beliefs and practices must be taken into consideration when health professionals are discussing dietary choices, food handling and food safety strategies with clients. In addition, health care professionals must educate women about food safety precautions before they become pregnant as well as during the ante, intra and postpartum periods. Once pregnancy has occurred, prevention remains the key, although the goal is to prevent further transmission of foodborne illness for both the mother and fetus. More research is needed to determine the most effective methods to reduce foodborne infections during pregnancy. Lastly, the public must gain greater awareness about the dangers of foodborne illnesses. NWH
Food and Drug Administration. (2006b). Foodborne pathogenic microorganisms and natural toxins handbook: Listeria monocytogenes. Retrieved January 2, 2007, from http://vm.cfsan.fda. gov/~mow/chap6.html
Get the Facts CDC
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/ foodborneinfections_g.htm#mostcommon FDA
http://www.cfsan.fda.gov/pregnancy.html http://vm.cfsan.fda.gov/~mow/chap6.html http://www.cfsan.fda.gov/~mow/chap2.html Foodsafety.gov
http://www.foodsafety.gov HomeFoodSafety.org
http://www.homefoodsafety.org March of Dimes
http://www.marchofdimes.com/aboutus/681_ 1152.asp
REFERENCES Centers for Disease Control and Prevention. (1993). Preventing foodborne illness: Escherichia coli O157: H7. Retrieved May 11, 2007, from http://wonder.cdc.gov/wonder/prevguid/p0000417/ p0000417.asp#head005000000000000 Centers for Disease Control and Prevention. (2005). Hepatitis e virus. Retrieved January 4, 2007, from http:www.cdc.gov/hepatitis Centers for Disease Control and Prevention. (2006a). Escherichia coli O157:H7. Retrieved July 2, 2007, from http://www.cdc.gov/ ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm Centers for Disease Control and Prevention. (2006b). Ongoing multistate outbreak of Escherichia coli O157:H7 infections associated with consumption of fresh spinach—United States,
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Lamb, beef (not ground beef), veal, fish and eggs (hint: the fish should flake with a fork and the yolk and white of the egg should be firm)
145°F
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BOX 7 SAFE COOKING TEMPERATURES
FOODBORNE ILLNESS CASE EXAMPLES CASE #1
A 5-month-old infant presents with blindness. No problems occurred during the pregnancy and the fetus was healthy. The mother first became worried about the baby’s vision when he was around 4 months old. Upon examination, the baby appears to be at the appropriate level of growth and development for his age, but he is unresponsive to visual stimuli. Microphthalmos and bilateral macular scars are also present. Everything else appears normal. A CT scan of the baby’s head displays asymmetric dilation of the lateral ventricles and periventricular calcifications. The mother reports a trip to France during her pregnancy in which she ate meat that wasn’t completely cooked. She does not own a cat nor was she exposed to a cat during pregnancy. Serologic testing for IgG and IgM antibodies in the baby’s and mother’s blood serum confirm toxoplasmosis. CASE #2
A pregnant woman enters the OB/GYN office with chills, fever, headache, sore throat and myalgias. She is at 28 weeks’ gestation and up to this point has had a healthy pregnancy. She recently returned from a trip to South Africa and reports experiencing diarrhea and vomiting one day during her trip. This is believed to be due to changes in diet, namely drinking more milk and eating more fruits. Clinical examination reveals a temp of 101 degrees, pulse of 100 bpm, and blood pressure of 100/60. Tests for A Streptococcus, infectious mononucleosis, bacteria, and malaria are all negative. She is given acetaminophen and sent home. Five months later she delivers in the hospital at 33 weeks’ gestation. The infant is tachypneic with intercostal retractions around age 21 hours. The infant dies soon after in spite of efforts to resuscitate. Right before death, the infant experiences delayed capillary refill and was bradycardiac. Cultures discover gram-positive short rods/cocci indicating Listeria monocytogenes. CASE #3
A 4-year-old girl has been experiencing diarrhea and severe abdominal cramps for the past two days. Blood was seen in her stools once and no vomiting or fever occurred. She was healthy prior to the illness and has since been drinking only fluids and not eating anything. Upon examination she is found to have normal blood pressure and no fever. Her abdomen is tender with hyperactive bowel sounds and blood in the rectal vault. No family history exists for bowel or bleeding disorders. No other friends or family members have had bloody diarrhea, although two members report mild abdominal cramping. The child eats a variety of vegetables in her diet, or at least tries many vegetable dishes, as her parents are vegetarians. She may be at risk for a few different infections, but a stool culture should be obtained for verification purposes. Outbreaks of E. coli have been associated with contaminated produce as well as uncooked meat. She tests positive for E. coli. She is monitored for the development of hemolytic uremic syndrome throughout the first week after the occurrence of diarrhea.
Food and Drug Administration. (2007). Food safety for moms-to-be (educator’s resource guide). Retrieved November 10, 2007, from http://www.cfsan.fda.gov/pregnancy.html Institute of Food Technologists. (2004). Bacteria associated with foodborne diseases: Scientific status summary. Food Technology, 58, 69–78. Lynch, M., Painter, J., Woodruff, R., & Braden, C. (2006). Surveillance for foodborne-disease outbreak—United States, 19982002. Morbidity and Mortality Weekly Report, 55, 1–34. March of Dimes. (2006). Foodborne risks in pregnancy. Retrieved November 10, 2007, from http://www.marchofdimes.com/ aboutus/681_1152.asp Moos, M. K. (2006). Listeriosis: How nurses can prevent the preventable. AWHONN Lifelines, 10, 498–501.
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Scarlatos, A., Welt, B. A., Cooper, B. Y., Archer, D., DeMarse, T., & Chau, K. V. (2005). Methods of detecting botulinum toxin with applicability to screening foods against biological terrorist attacks. Journal of Food Science, 70, 121–130. Schwarz, R. H. (2006). Pregnancy infections. Retrieved January 4, 2007, from http://health.discovery.com/centers/pregnancy/ americanbaby/infections.html World Health Organization. (2007a). Executive summary. Retrieved May, 11, 2007, from http://www.who.int/water_ sanitation_health/bathing/recreadisexecsum.pdf World Health Organization. (2007b). Hepatitis E. Retrieved January 4, 2007, from http://www.who.int/mediacentre/factsheets/ fs280/en/print.html World Health Organization. (2007c). Zoonotic infections. Retrieved May 11, 2007, from http://www.who.int/vaccine_research/ diseases/zoonotic/en/index2.html
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CNE
Post-Test Questions Instructions: To receive contact hours for this learning activity, please complete the online post-test and evaluation at http://JournalsCNE.awhonn.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted. 1.
2.
Which of the following is not cause of foodborne illness? a. E. coli b. Listeria c. Streptococcus B
3.
Pregnant women are more susceptible to foodborne illness because they: a. Experience increased water retention b. Have increased blood volume in pregnancy c. Undergo hormonal changes that can weaken their immunity
4.
5.
The virus hepatitis E is spread through? a. Airborne transmission b. Feces of infected animals or humans c. Saliva of infected animals or humans Which of the following is not a symptom of hepatitis E infection? a. Fatigue b. Light-colored urine c. Loss of appetite
6.
Which is the best way to prevent hepatitis E infection? a. Proper hand-washing b. Prophylactic antibiotic therapy c. Traveling abroad only in the winter
7.
What is the chance that a fetus will contract toxoplasmosis from an infected mother? a. 25 percent b. 50 percent c. 75 percent
8.
Treatment of toxoplasmosis in an infected pregnant woman may include: a. Amnioinfusion b. Antibiotics c. Antiviral agents
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9.
Listeriosis in pregnant women is most commonly associated with: a. Preeclampsia b. Postdates pregnancy c. Spontaneous abortion
10. What is unique about listeria compared with some other foodborne pathogens? a. It grows well at boiling temperatures b. It grows well at freezing temperatures c. It grows well at refrigeration temperatures 11. To prevent listeriosis, what should pregnant women do to deli meats? a. Eat them cold the same day they purchase them. b. Eat them only during their first trimester. c. Re-heat them to steaming before eating them. 12. Which of the following foods is linked to infant botulism? a. Barley cereal b. Honey c. Pureed carrots 13. Which of the following is a potential source of E. Coli infection? a. Fresh (unpasteurized) cider b. Fried oysters c. Pasteurized milk 14. To lower the risk of foodborne illness, which temperature should fish be cooked to? a. 130°F b. 145°F c. 150°F 15. What is the best way to determine if a hamburger is cooked to the safe temperature? a. Cutting it open and observing the color of the meat b. Inserting a food thermometer into the thickest part of the hamburger c. Pre-heating the grill before cooking the hamburger
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A pregnant woman with foodborne illness will: a. Always have symptoms but never pass the infection on to the fetus b. Never have symptoms but always pass the infection on to the fetus c. Sometimes have no symptoms but may pass the infection on to the fetus
INTRODUCTION
Objectives Upon completion of this activity, the learner will be able to:
1. Identify microorganisms most commonly associated with foodborne illness in pregnant women and infants. 2. Describe food handling practices that may increase risk of foodborne illness. 3. Summarize strategies for preventing foodborne illness.
Continuing Nursing Education (CNE) Credit A total of 2 contact hours may be earned as CNE credit for reading “Preventing Foodborne Infection in Pregnant Women and Infants” and for completing an online posttest and evaluation. To take the test and complete the evaluation, please visit http://JournalsCNE. awhonn.org. Certificates of completion will be issued on receipt of the completed evaluation form, application and processing fees. Note: AWHONN contact hour credit does not imply approval or endorsement of any product or program. AWHONN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AWHONN also holds California and Alabama BRN numbers: California CNE provider #CEP580 and Alabama #ABNP0058.
Foodborne illness occurs as a result of the consumption of microorganisms (bacteria, parasites, viruses) or chemical contaminants found in some foods or drinking water. Symptoms vary, but may include stomach cramps, vomiting, diarrhea, fever, headache or body aches. In some cases of foodborne infection, a pregnant woman may not feel sick but may still pass on the illness to the fetus. Pregnant women are at increased risk for some foodborne illnesses due to hormonal changes that can increase the susceptibility of their immune systems (Dean & Kendall, 2006). This weakened state of the immune system makes it more difficult for the woman’s body to fight off harmful foodborne microorganisms. In addition, the fetus’s immune system is not developed enough to fight off unsafe foodborne bacteria that may cross the placenta. Without early detection and treatment of foodborne illness, complications can occur, resulting in serious health problems for the fetus, pregnant mother or newborn including miscarriage and stillbirth. For both mother and baby, severe foodborne illness can cause death. Despite efforts to reduce transmission of infectious agents in both the mother and fetus, pregnancy is still a time of especially high concern. The pregnant woman and her fetus or newborn are susceptible to many foodborne illnesses such as hepatitis E (Hep E), toxoplasmosis, listeriosis, infant botulism as well as infections from enterohaemorrhagic E. coli due in part to the suppression of the mother’s and child’s immune system (WHO, 2007c). Prevention and early treatment of foodborne infections in the mother, fetus or neonate can help to reduce the development of further complications.
resents e illness p n r o b d o o pregnant •F isk to the e r t n a c ifi sign nd th er fetus a woman, h neonate. the ashing is w d n a h r e • Prop ention. ne of prev cornersto hclude teac in ld u o h s nt • Nurses all pregna to e s e th ing about women.
Michael C. Bazaco, MS, is a doctoral student in public health; Susan A. Albrecht, PhD, RN, FAAN, is associate professor and associate dean of the School of Nursing; Angela M. Malek, MPH, is a doctoral student in public health; all authors are at the University of Pittsburgh, Pittsburgh, PA. The authors report no conflicts of interest or financial relationships relevant to this article. Address correspondence to: [email protected]. DOI: 10.1111/j.1751-486X.2007.00275.x
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BOX 1 SYMPTOMS OF HEPATITIS E INFECTION
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Each year in the United States approximately 1.5 million people are infected with toxoplasmosis (Dean & Kendall, 2006); there is a 50 percent chance that a fetus will contract toxoplasmosis from an infected mother (March of Dimes, 2006). In addition, it’s estimated that 1 out of 1,000 to 10,000 neonates is born with this infection in the United States (Schwarz, 2006). This percentage accounts for 400 to 4,000 fetuses affected annually (FDA, 2007). In addition, some estimates suggest that toxoplasma kills as many as 80 infants each year in the Unites States (FDA, 2007). A severe infection occurs in 1 out of 10 US babies and can result in pneumonia, an enlarged spleen and liver, or jaundice (Schwarz, 2006). Testing is especially important because many cases of toxoplasmosis are asymptomatic among all age groups. In fact, 90 percent of babies infected appear normal and healthy
In some cases of foodborne infection, a pregnant woman may not feel sick but may still pass on the illness to the fetus. at birth, although most will develop problems such as mental retardation, hearing and vision loss, seizures, eye problems and other complications following birth (Schwarz, 2006; March of Dimes, 2006). Toxoplasmosis is a disease caused by the parasite Toxoplasma gondii that is spread through the consumption of undercooked meat or contaminated unwashed fruits and vegetables; contact with cat feces or fur; and contact with contaminated water (Schwarz, 2006; Dean & Kendall, 2006). Toxoplasmosis is one of
BOX 2 WAYS TO PREVENT HEPATITIS E INFECTION • Wash hands well with soap and warm water after changing diapers, using the bathroom, and handling raw food. • When traveling to areas where the water quality is questionable, don’t consume raw foods (such as salads, unpeeled fruits, and uncooked shellfish), tap water or ice. Use bottled water or boiled water for drinking, preparing infant formula, face washing and tooth brushing.
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Hep E is a viral infection spread through the feces of infected animals or humans. It is contracted through the consumpFatigue tion of contaminated food or drinking Jaundice water (CDC, 2005). Hep E occurs most Loss of appetite commonly in developing countries, Abdominal pain where it is mainly transmitted through unclean drinking water (CDC, 2005). Nausea Hep E can also be spread through inapVomiting propriate food handling. However, Hep Tea-colored urine E is rarely spread by person-to-person contact (CDC, 2005). The highest attack rate of Hep E occurs in those 15 to 40 years of age (CDC, 2005). People at increased risk for Hep E include travelers to developing countries or areas where epidemics have occurred, especially North and West Africa, Central and Southeast Asia, and Mexico (CDC, 2005; WHO, 2007a; WHO, 2007b). In the United States, however, rare cases have been reported among people with no travel history to countries where the virus is endemic (CDC, 2005). The presence of Hep E can be detected by a blood test (although not widely available) or through an epidemiologic investigation in some cases (WHO, 2007b). Symptoms of Hep E include fatigue, jaundice, loss of appetite, abdominal pain, nausea, vomiting and dark (tea-colored) urine (CDC, 2005) (see Box 1). Pregnant women experience Hep E more severely than others, especially during the third trimester, during which a case fatality rate of 10 percent to 42 percent exists (CDC, 2005; WHO, 2007c). A severe and sudden form of Hep E can affect pregnant women more often than any other group; however, this is rare (WHO, 2007b). Hospitalization may be necessary in some cases of Hep E infection during pregnancy (WHO, 2007b). Aside from infections occurring during pregnancy, risk of death from infection is usually low (WHO, 2007a). Most hepatitis infections are self-limited and will be successfully cleared by the body without complications. No hyperimmune E globulin therapy exists for pre- or post-exposure prophylaxis, or for altering the course of acute infection (WHO, 2007b). Those with abrupt occurring Hep E infections should be hospitalized (WHO, 2007b). At the time of this writing, a vaccine against Hep E is being developed but has not yet been approved. Because Hep E is a virus and is, therefore, not resolvable with antibiotic therapy, prevention is optimal (WHO, 2007b) (see Box 2). Hep E transmission can be prevented through proper hand-washing techniques, including using soap and warm water after changing diapers, using the bathroom or handling raw food. Travelers should avoid consuming raw foods (such as uncooked shellfish, salads and unpeeled fruits), ice and tap water if the water source quality is unknown. In such areas, bottled water or boiled tap water should be used for drinking, cooking, preparing infant formula, face washing and tooth brushing.
TOXOPLASMOSIS
CNE
HEPATITIS E
the most common infections worldwide, LISTERIOSIS BOX 3 SYMPTOMS OF although it’s mainly seen in places where Listeria monocytogenes is a bacterial CLINICAL TOXOPLASMOSIS raw or undercooked meat is commonly pathogen that can cause serious infecINFECTION eaten, or in places with low hygiene tion in the pregnant woman and her levels (Schwarz). The majority of cases Swollen glands fetus. Pregnant women account for 27 are undiagnosed because the infection percent of all listeriosis cases and exFever is often subclinical or shows symptoms perience listeriosis at a rate 14 times Headache similar to that of the flu; however, this higher than the average person (Dean Muscle pain infection poses significant risk to the & Kendall, 2006). Human infection pregnant woman and fetus (Schwarz). Stiff neck from Listeria monocytogenes is linked Symptoms of clinical infection include to the consumption of contaminated swollen glands, fever, headache, muscle food such as deli meats and soft cheeses pain or a stiff neck (see Box 3). Those who’ve had toxoplasmosis (Moos, 2006). Listeria monocytogenes is a very ubiquitous orin the past are immune to the infection and immune status can ganism; it’s prevalent throughout all natural environments be ascertained through serological testing. and can come in contact with food products during any raw Prompt treatment of toxoplasmosis is required to prevent processing procedures (FDA, 2006b). It’s a psychotropic ordeath, chronic health problems and other serious conditions. ganism and grows well at refrigeration temperatures. Because Pregnant women testing positive for toxoplasmosis may agree of this adaptive feature, it has a competitive advantage against to amniocentesis to determine the fetus’ status (Schwarz, 2006). other microorganisms in food processing and storage areas that Antibiotics can then be administered to decrease symptoms in usually operate under cool temperatures.
Listeriosis is especially important with regard to pregnant women because it’s commonly associated with spontaneous abortion. the newborn (March of Dimes, 2006). If the pregnant woman alone is infected, spiramycin can be administered to decrease the chances of the fetus contracting the infection (Schwartz). Sulfadiazine and pyrimethamine are prescribed for fetal infection (Schwartz). Previously uninfected babies born to mothers who have had the illness are tested at birth for toxoplasmosis. Strategies to prevent toxoplasmosis include avoiding the consumption of raw or undercooked meat, and cooking meat until it is no longer red or to an internal temperature of at least 160 degrees (see Box 4). Because the parasite can enter the body through contact with one’s mouth, eyes or nose, thorough hand washing after the handling of raw meat is important (Schwarz, 2006). Produce should be washed or peeled before eating, and cutting boards, utensils and areas used when dealing with raw meat should be washed with hot, soapy water (Schwarz). Housecats should not be fed raw or undercooked meat, and pregnant women should not clean or handle the litter box (Schwarz). To prevent infection through contact with contaminated soil or animal fur, hands should be thoroughly washed after a person has been working in the garden or handling animals (Dean & Kendall, 2006).
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Listeriosis is caused by Listeria monocytogenes. It’s a systemic infection that can manifest as meningitis, bacteremia and sepsis (Cliver, 1990). Listeriosis is especially important with regard to pregnant women because it’s commonly associated with spontaneous abortion. It accounts for nearly 1,600 illnesses and 415 deaths annually (FDA, 2006b); although it accounts for less than 0.2 percent of total foodborne illnesses, it’s responsible for more than 40 percent of foodborne illness–related deaths (FDA, 2006b). This high mortality rate of infected individuals
BOX 4 WAYS TO PREVENT TOXOPLASMOSIS • Do not eat raw or undercooked meat. • Cook meat to an internal temperature of at least 160 degrees (use a food thermometer to determine temperature). • Wash hands well after handling raw meat. • Do not use the same utensils or cutting board that were used to handle raw meat for raw produce. • Wash utensils and cutting boards well with hot, soapy water. • Do not feed housecats raw or undercooked meat. • If pregnant, do not handle the litter box. • Wash hands well after working in the garden or handling animals.
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Pregnant women or those who could become pregnant in the near future should avoid the following foods: • Hot dogs, prepared mayonnaise-based salads and luncheon meats unless they are cooked until “steaming hot” • Unpasteurized raw milk and foods that contain it
• Refrigerated pates and meat spreads (shelfstable canned pates are fine) • Fish found in the refrigerator section or sold at deli counters in grocery stores including “nova style lox,” “kippered,” “smoked,” or “jerky” salmon, trout, whitefish, cod, tuna or mackerel
(more than 25 percent) is of major concern regarding public health as well as maternal child safety. Pregnant women must be aware of Listeria and foods commonly associated with it. Foods to be avoided include but are not limited to deli meats, hot dogs, soft cheeses and unpasteurized milk (IFT, 2004). Studies show that Hispanic pregnant women may have a higher incidence of listeriosis than pregnant non-Hispanic women. This is most likely because they prepare and eat soft cheese called queso fresco, which is made with unpasteurized milk. Outbreaks associated with this food have been linked to listeriosis and subsequent miscarriage, premature delivery and neonatal mortality (FDA, 2007). During pregnancy, it’s best to avoid these foods and to thoroughly cook food before consuming. All women who are pregnant or may become pregnant in the near future should avoid eating hot dogs, prepared mayonnaise-based salads and luncheon meats unless they are cooked until “steaming hot” (see Box 5). They should not eat soft cheeses unless they are made with pasteurized milk. Pregnant women should also avoid pates and meat spreads. Fish found in the refrigerator section or sold at deli counters in grocery stores including “nova style lox,” “kippered,” “smoked,” or “jerky” salmon, trout, whitefish, cod, tuna or mackerel should not be consumed (FDA, 2007). Complications may be associated with the disease but, in general, infection with listeria is usually asymptomatic. Flulike complications, fever, nausea, vomiting and diarrhea may occur alone or prior to a worsening infection (FDA, 2006b). Gastrointestinal symptoms can take place 12 hours after ingestion of listeria-contaminated food, while a severe form of the
February
March 2008
INFANT BOTULISM Botulism is a serious disease caused by a toxin produced by the bacterium Clostridium botulinum (Cox & Hinkle, 2002). Although this disease is rare, a form that affects infants known as infant botulism is still a major health concern. Infant botulism occurs when babies consume spores of the bacteria; it’s the most prevalent form of botulism in the United States and has been gaining more recognition and concern worldwide (Cox & Hinkle). In adults, consumption of spores or live bacteria will not cause illness, as the natural flora of the adult gut can destroy C. botulinum. But in infants this natural flora is not yet developed, and the bacteria are able to produce toxin, causing serious disease. Along with the discovery of this form of infection, two other strains of Clostridia (Clostridium baratii, Clostridium butyricum) have been shown to produce potent neurotoxins that can lead to infant botulism–like symptoms (Scarlatos et al., 2005). Infant botulism has only been definitively linked to consumption of honey at this point, although it has many possible environmental sources, such as dust and soil. In addition, corn syrup is a likely source of C. botulinum spores (Cox & Hinkle, 2002; FDA, 2006a). Mothers should not use honey or corn syrup to sweeten formula or medicine for their babies (Cox & Hinkle). These foods produce an ideal environment for C. botulinum spores and can be a vector for infection in newborns and young children. Infection can occur between six weeks and 9 months of age; two to three months of age is the most common time of occurrence (Cox & Hinkle, 2002). Symptoms include hypotonia, hyporeflexia, constipation, weakness, cranial nerve abnormalities, and respiratory problems in severe cases, (Cox & Hinkle) (see Box 6). Infant weakness can include loss of head control, a weak cry and gag reflex, decreased sucking, and irritability (Cox & Hinkle). Infection can be confirmed through culture of a stool and blood sample. If botulism toxin is present, the infant will be hospitalized in the intensive care unit (ICU) to receive necessary treatment. Physical and occupational therapy, airway management and nasogastric tube feedings are needed (Cox & Hinkle, 2002). Equine-derived antitoxin was administered in the past, but due to side effects this medication is not currently used; instead, a human-derived antitoxin—botulinum immune globulin—is now used. In spite of treatment advancements, the average hospital stay for infants with botulism is 44 days (Cox & Hinkle).
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• Soft cheeses, such as feta, Brie, Camembert, blue-veined cheeses, and Mexican-style cheeses
infection may take three days to three weeks to appear (FDA, 2006b). Treatment of listeria includes antibiotics such as penicillin or ampicillin for the mother and possibly a baby if infection is confirmed with a blood test, culture from cerebrospinal fluid or rarely a stool sample (FDA, 2006b). Trimethoprim-sulfamethoxazole can be prescribed in place of these medications if a patient is allergic to penicillin (FDA, 2006b).
CNE
BOX 5 PREGNANT WOMEN AND LISTERIOSIS
E. COLI O157:H7
H7. Of particular concern is ground beef and other types of ground meat Many strains of the bacterium E. coli because of the way they are processed, live naturally in the intestines of huwhich spreads contamination beyond a mans and animals. However, some Hypotonia single animal or portion of the animal pathogenic strains of E. coli can cause (CDC, 2006c). Unpasteurized milk may moderate to severe gastrointestinal disHyporeflexia also contain E. coli since the bacteria can ease in humans. A report by the CentConstipation live on cows’ udders (CDC, 2006c), and ers for Disease Control and Prevention Weakness unpasteurized juice and cider can also (CDC) found that 140 outbreaks of E. Cranial nerve abnormalities contain E. Coli. coli occurred between 1998 and 2002, Effective hand washing after using leading to close to 5,000 illnesses and Respiratory problems the bathroom, changing diapers or playfour deaths (Lynch, Painter, Woodruff, Loss of head control ing with small children is an important & Braden, 2006). Because E. coli infecWeak cry and gag refl ex method of preventing the spread of E. tion is often underreported, this is likely Decreased sucking coli to others (CDC, 2006c). Ground a vast underestimate of the true burden beef should be cooked to 160 degrees of disease. In a 1999 assessment, it was Irritability as measured by a food thermometer inmore accurately estimated to affect serted in the thickest part of the meat. 73,000 people in the United States anRaw meat should be kept away from other food. Utensils or nually, leading to close to 60 deaths (CDC, 2006c). food cooking and preparation areas should be washed with One strain in particular, E. coli O157:H7, is especially danhot, soapy water after cutting raw vegetables or meats (CDC, gerous and can lead to extremely serious disease if ingested by 2006c). Lake or swimming pool water should not be swallowed, way of contaminated food or water (CDC, 2006a). This parand drinking water should come from treated water facilities ticular strain of E. coli has come to national attention recently or bottled water (CDC, 2006c). Consumption of unpasteurized with two large, multistate outbreaks occurring in produce in cider, juice or milk should be avoided (CDC, 2006c). the United States. The larger of the two occurred in September Symptoms of infection with E. coli O157:H7 usually include 2006 and resulted in contamination across 26 US states, leadstomach pain and bloody diarrhea, and less often, a slight fever ing to nearly 200 illnesses. Of the ill, 26 were confirmed to be (CDC, 2006c). Stomach ache and diarrhea usually subside after hospitalized for hemolytic uremic syndrome. In addition, there 5 to 10 days with no additional complications (CDC, 2006c). was one confirmed death due to the outbreak, and two other Most adults and older children carrying the strain are symptodeaths likely associated (CDC, 2006b). matic, making it easier to identify and treat (CDC, 2006c). On Infection with E. coli can cause a pregnant woman to bethe other hand, the bacteria can be spread through contact with come critically ill, and E. coli can occasionally be passed by a an infected child’s stool for two weeks after he/she has recovpregnant woman to her fetus (March of Dimes, 2006). In this ered (CDC, 2006c). case, the fetus can experience fever and diarrhea. A rare comInfection with E. coli O157:H7 can be confirmed with a plication of meningitis infection may even develop after birth stool sample (CDC, 2006a). Self-treatment is not recommend(March of Dimes, 2006). Hemolytic uremic syndrome is a seried and diarrhea medication or antibiotics should not be taken ous complication resulting in kidney failure and the destrucunless prescribed by a physician or nurse practitioner due to tion of red blood cells; this occurs in 2 to 7 percent of E. coli the immobilization of the bacteria in the gut and prolongation infections (CDC, 2006c; CDC, 1993). Hospitalization may be of the illness (CDC, 2006c). It’s believed that kidney complicanecessary in the case of hemolytic uremic syndrome (CDC, tions could result from the use of some antibiotics, and they 2006c; CDC, 1993). About one-third of affected individuals are have not been found to be helpful in treating this particular at risk of having kidney problems in the future. In rare occurinfection (CDC, 2006a). Treatment of E. coli O157:H7 involves rences, blindness, paralysis or high blood pressure may result supportive care. from illness with E. coli O157:H7 (CDC, 2006c). E. coli can be spread through improper hand washing. It ROLE OF HEALTH PROFESSIONALS also can be spread by improper handling of raw vegetables, Nurses and other health professionals on the front line of pasprouts and fruits by workers, or through contaminated watient care have an important role to play in the identification ter used to wash or grow vegetables (CDC, 2006c). In addition, of foodborne illnesses (see “Case Examples” box), as well as in other sources of water can serve as a source of transmission of the prevention of foodborne infections. It’s important to make the organism, including swimming pools without proper chlopatients aware of the risks and how foodborne illnesses can be rination, lakes and drinking water (CDC, 2006c). Undercooked prevented. First and foremost is the avoidance of contaminated and uncooked meat may be contaminated with E. coli O157:
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BOX 6 SIGNS AND SYMPTOMS OF INFANT BOTULISM
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September 2006. Morbidity and Mortality Weekly Report, 55, 1–2. Centers for Disease Control and Prevention. (2006c). Questions and answers: Sickness caused by E. coli. Retrieved January 25, 2007, from http://www.cdc.gov/ecoli/qa_ecoli_sickness.htm Cliver, D. O. (1990). Foodborne diseases. San Diego, CA: Academic Press.
160°F
Ground beef, game meat, pork, and eggbased dishes
Cox, N., & Hinkle, R. (2002). Infant botulism. American Family Physician, 65, 1388–1392.
165°F
Ground turkey and chicken, leftovers, stuffing, casseroles, hot dogs and lunch meats
Dean, J., & Kendall, P. (2006). Food safety during pregnancy. Retrieved January 5, 2007, from http://www.ext.colostate.edu/ pubs/FOODNUT/09372.html
170°F
Chicken and turkey breasts
180°F
Whole chickens and turkeys; chicken or turkey legs, thighs and wings
Food and Drug Administration. (2006a). Foodborne pathogenic microorganisms and natural toxins handbook: Clostridium botulinum. Retrieved January 5, 2007, from http://www.cfsan.fda. gov/~mow/chap2.html
Source: Dean & Kendall, 2006
food or water. Meat, poultry, fish and eggs should be cooked thoroughly and the temperature checked with a food thermometer (Dean & Kendall, 2006) (see Box 7). Cross-contamination between utensils, dishes and food preparation areas must also be avoided, and foods must be stored properly at temperatures of 40 degrees or below (Dean & Kendall). Ready-to-eat or prepared foods should be eaten within four days (Dean & Kendall). If this is not possible, the food should be frozen or discarded. Respect for various cultural and religious beliefs and practices must be taken into consideration when health professionals are discussing dietary choices, food handling and food safety strategies with clients. In addition, health care professionals must educate women about food safety precautions before they become pregnant as well as during the ante, intra and postpartum periods. Once pregnancy has occurred, prevention remains the key, although the goal is to prevent further transmission of foodborne illness for both the mother and fetus. More research is needed to determine the most effective methods to reduce foodborne infections during pregnancy. Lastly, the public must gain greater awareness about the dangers of foodborne illnesses. NWH
Food and Drug Administration. (2006b). Foodborne pathogenic microorganisms and natural toxins handbook: Listeria monocytogenes. Retrieved January 2, 2007, from http://vm.cfsan.fda. gov/~mow/chap6.html
Get the Facts CDC
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/ foodborneinfections_g.htm#mostcommon FDA
http://www.cfsan.fda.gov/pregnancy.html http://vm.cfsan.fda.gov/~mow/chap6.html http://www.cfsan.fda.gov/~mow/chap2.html Foodsafety.gov
http://www.foodsafety.gov HomeFoodSafety.org
http://www.homefoodsafety.org March of Dimes
http://www.marchofdimes.com/aboutus/681_ 1152.asp
REFERENCES Centers for Disease Control and Prevention. (1993). Preventing foodborne illness: Escherichia coli O157: H7. Retrieved May 11, 2007, from http://wonder.cdc.gov/wonder/prevguid/p0000417/ p0000417.asp#head005000000000000 Centers for Disease Control and Prevention. (2005). Hepatitis e virus. Retrieved January 4, 2007, from http:www.cdc.gov/hepatitis Centers for Disease Control and Prevention. (2006a). Escherichia coli O157:H7. Retrieved July 2, 2007, from http://www.cdc.gov/ ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm Centers for Disease Control and Prevention. (2006b). Ongoing multistate outbreak of Escherichia coli O157:H7 infections associated with consumption of fresh spinach—United States,
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Lamb, beef (not ground beef), veal, fish and eggs (hint: the fish should flake with a fork and the yolk and white of the egg should be firm)
145°F
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BOX 7 SAFE COOKING TEMPERATURES
FOODBORNE ILLNESS CASE EXAMPLES CASE #1
A 5-month-old infant presents with blindness. No problems occurred during the pregnancy and the fetus was healthy. The mother first became worried about the baby’s vision when he was around 4 months old. Upon examination, the baby appears to be at the appropriate level of growth and development for his age, but he is unresponsive to visual stimuli. Microphthalmos and bilateral macular scars are also present. Everything else appears normal. A CT scan of the baby’s head displays asymmetric dilation of the lateral ventricles and periventricular calcifications. The mother reports a trip to France during her pregnancy in which she ate meat that wasn’t completely cooked. She does not own a cat nor was she exposed to a cat during pregnancy. Serologic testing for IgG and IgM antibodies in the baby’s and mother’s blood serum confirm toxoplasmosis. CASE #2
A pregnant woman enters the OB/GYN office with chills, fever, headache, sore throat and myalgias. She is at 28 weeks’ gestation and up to this point has had a healthy pregnancy. She recently returned from a trip to South Africa and reports experiencing diarrhea and vomiting one day during her trip. This is believed to be due to changes in diet, namely drinking more milk and eating more fruits. Clinical examination reveals a temp of 101 degrees, pulse of 100 bpm, and blood pressure of 100/60. Tests for A Streptococcus, infectious mononucleosis, bacteria, and malaria are all negative. She is given acetaminophen and sent home. Five months later she delivers in the hospital at 33 weeks’ gestation. The infant is tachypneic with intercostal retractions around age 21 hours. The infant dies soon after in spite of efforts to resuscitate. Right before death, the infant experiences delayed capillary refill and was bradycardiac. Cultures discover gram-positive short rods/cocci indicating Listeria monocytogenes. CASE #3
A 4-year-old girl has been experiencing diarrhea and severe abdominal cramps for the past two days. Blood was seen in her stools once and no vomiting or fever occurred. She was healthy prior to the illness and has since been drinking only fluids and not eating anything. Upon examination she is found to have normal blood pressure and no fever. Her abdomen is tender with hyperactive bowel sounds and blood in the rectal vault. No family history exists for bowel or bleeding disorders. No other friends or family members have had bloody diarrhea, although two members report mild abdominal cramping. The child eats a variety of vegetables in her diet, or at least tries many vegetable dishes, as her parents are vegetarians. She may be at risk for a few different infections, but a stool culture should be obtained for verification purposes. Outbreaks of E. coli have been associated with contaminated produce as well as uncooked meat. She tests positive for E. coli. She is monitored for the development of hemolytic uremic syndrome throughout the first week after the occurrence of diarrhea.
Food and Drug Administration. (2007). Food safety for moms-to-be (educator’s resource guide). Retrieved November 10, 2007, from http://www.cfsan.fda.gov/pregnancy.html Institute of Food Technologists. (2004). Bacteria associated with foodborne diseases: Scientific status summary. Food Technology, 58, 69–78. Lynch, M., Painter, J., Woodruff, R., & Braden, C. (2006). Surveillance for foodborne-disease outbreak—United States, 19982002. Morbidity and Mortality Weekly Report, 55, 1–34. March of Dimes. (2006). Foodborne risks in pregnancy. Retrieved November 10, 2007, from http://www.marchofdimes.com/ aboutus/681_1152.asp Moos, M. K. (2006). Listeriosis: How nurses can prevent the preventable. AWHONN Lifelines, 10, 498–501.
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Scarlatos, A., Welt, B. A., Cooper, B. Y., Archer, D., DeMarse, T., & Chau, K. V. (2005). Methods of detecting botulinum toxin with applicability to screening foods against biological terrorist attacks. Journal of Food Science, 70, 121–130. Schwarz, R. H. (2006). Pregnancy infections. Retrieved January 4, 2007, from http://health.discovery.com/centers/pregnancy/ americanbaby/infections.html World Health Organization. (2007a). Executive summary. Retrieved May, 11, 2007, from http://www.who.int/water_ sanitation_health/bathing/recreadisexecsum.pdf World Health Organization. (2007b). Hepatitis E. Retrieved January 4, 2007, from http://www.who.int/mediacentre/factsheets/ fs280/en/print.html World Health Organization. (2007c). Zoonotic infections. Retrieved May 11, 2007, from http://www.who.int/vaccine_research/ diseases/zoonotic/en/index2.html
Volume 12
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CNE
Post-Test Questions Instructions: To receive contact hours for this learning activity, please complete the online post-test and evaluation at http://JournalsCNE.awhonn.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted. 1.
2.
Which of the following is not cause of foodborne illness? a. E. coli b. Listeria c. Streptococcus B
3.
Pregnant women are more susceptible to foodborne illness because they: a. Experience increased water retention b. Have increased blood volume in pregnancy c. Undergo hormonal changes that can weaken their immunity
4.
5.
The virus hepatitis E is spread through? a. Airborne transmission b. Feces of infected animals or humans c. Saliva of infected animals or humans Which of the following is not a symptom of hepatitis E infection? a. Fatigue b. Light-colored urine c. Loss of appetite
6.
Which is the best way to prevent hepatitis E infection? a. Proper hand-washing b. Prophylactic antibiotic therapy c. Traveling abroad only in the winter
7.
What is the chance that a fetus will contract toxoplasmosis from an infected mother? a. 25 percent b. 50 percent c. 75 percent
8.
Treatment of toxoplasmosis in an infected pregnant woman may include: a. Amnioinfusion b. Antibiotics c. Antiviral agents
February
March 2008
9.
Listeriosis in pregnant women is most commonly associated with: a. Preeclampsia b. Postdates pregnancy c. Spontaneous abortion
10. What is unique about listeria compared with some other foodborne pathogens? a. It grows well at boiling temperatures b. It grows well at freezing temperatures c. It grows well at refrigeration temperatures 11. To prevent listeriosis, what should pregnant women do to deli meats? a. Eat them cold the same day they purchase them. b. Eat them only during their first trimester. c. Re-heat them to steaming before eating them. 12. Which of the following foods is linked to infant botulism? a. Barley cereal b. Honey c. Pureed carrots 13. Which of the following is a potential source of E. Coli infection? a. Fresh (unpasteurized) cider b. Fried oysters c. Pasteurized milk 14. To lower the risk of foodborne illness, which temperature should fish be cooked to? a. 130°F b. 145°F c. 150°F 15. What is the best way to determine if a hamburger is cooked to the safe temperature? a. Cutting it open and observing the color of the meat b. Inserting a food thermometer into the thickest part of the hamburger c. Pre-heating the grill before cooking the hamburger
Nursing for Women’s Health
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A pregnant woman with foodborne illness will: a. Always have symptoms but never pass the infection on to the fetus b. Never have symptoms but always pass the infection on to the fetus c. Sometimes have no symptoms but may pass the infection on to the fetus