FOOD BORNE EPIDEMICS KILL 5,000 AMERICANS EACH YEAR.

The latest Swine flu scare is concentrating the minds of us all to illnesses initiated from animals in our food chain. We remained glued to CNN reporting on deaths from Swine flu. At this writing, only one death has occurred even though more are tragically expected. However, what we must also realize is that the US has regular epidemics of food borne illnesses, which annually kill hundreds of Americans.

Mead PS et al. [Food-related illness and death in the United States. Emerg Infect Dis. 1999 Nov-Dec; 5(6):840-2.] estimates that food borne diseases cause approximately 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths in the United States each year. Known pathogens account for an estimated 14 million illnesses, 60, 000 hospitalizations, and 1,800 deaths. Three pathogens, Salmonella, Listeria, and Toxoplasma, are responsible for 1,500 deaths each year, more than 75% of those caused by known pathogens, while unknown agents account for the remaining 62 million illnesses, 265,000 hospitalizations, and 3,200 deaths.

Recent reported food-borne illnesses include Cyclosporiasis associated with imported raspberries, hepatitis A associated with green onions, Salmonella serotype Saint Paul infections associated with multiple raw produce items, Shiga toxin-producing Escherichia coli in beef cattle and their products and Salmonella infections associated with peanut butter and peanut butter-containing products.

L. R. Schiller [Food-borne infections in 2009 echoes this. Gastroenterology and Hepatology 6, 197-198 (April 2009) |doi:10.1038/nrgastro.2009.40]

Schiller tells us that the recent outbreak of Salmonella typhimurium, associated with peanut butter and products containing it in the US and Canada, highlights our ongoing susceptibility to food-borne infections despite advanced food production systems. As the globalization of food resources continues, it is increasingly difficult to control outbreaks and minimize their effect on health.

We live in a germy world, says Schiller. We have more bacterial cells in and on our bodies than we do human cells, and every day we are exposed to countless microorganisms: in the air that we breathe, on the surfaces we touch, in the water we drink, and in the food, we eat. Most of the time human mechanisms and barriers against germs work well, but sometimes they are weak or, in some cases, microorganisms evolve counterstrategies, and we become ill.

Despite 21st century improved sanitation, fecal–oral transmission of disease is still prevalent, even in the Western world, and as many as 9,000 Americans die each year from food-borne illnesses. Why? Globalization of food sources has made cases of imported disease more likely. Outbreaks of Cyclospora from imported raspberries, hepatitis A from green onions, salmonellosis from peppers, and Escherichia coli from meat and fruit juice have all been reported in the US.

A global network, which facilitates the spread of food-borne diseases. The centralization of food production has increased the potential for cross-contamination during processing, and broadened the distribution of contaminated products to millions of people.

The outbreak of Salmonella typhimurium associated with peanut butter and products containing it that took place in the US and Canada between September 2008 and January 2009 is a good example of this problem. A reported 529 people from 43 American states and 1 person from Canada were infected, and the contamination may have contributed to eight deaths. Prompt recognition of the outbreak by the Centers for Disease Control's PulseNet surveillance staff and local public-health partners led to identification of the source of the outbreak—a peanut processing plant in Georgia. What can be learned from this experience? About 40,000 laboratory-confirmed. However, only an estimated 3% of salmonella infections are laboratory-confirmed; therefore, about 1.2 million cases probably occur each year. During the 2003–2007 periods, an average of 18 S. typhimurium outbreaks was reported to the US Center for Disease Control each year. Industrialized food production thus can place millions at risk.

What might have been only a local problem with the recent peanut butter infections was magnified as its plant produced peanut butter and other peanut products that were distributed to over 2,000 food companies in the US and 23 other countries. This necessitated over 400 peanut-containing products were recalled because of potential contamination.

Food processing says Schiller must include sufficient safeguards to ensure that contaminants are not introduced during manufacture and that the integrity of systems is checked at critical junctures. If not then we can expect pandemics of food-borne illnesses to worsen. Clean transport and maintenance of a cold chain (when necessary) are essential and proper handling, cooling and preparation of food at stores and restaurants should be mandatory. In the home --clean preparation, avoidance of cross-contamination, thorough cooking, and chilling can all reduce the chance of pathogenic, food-borne bacteria being ingested. A simple step such as using a disposable paper towel on top of a cutting board will decrease the chances of the next food item on that cutting board from being infected too.

“We needn’t have been so surprised by the swine flu, and we must make sure that we are not caught off guard by the epidemics that will certainly follow it,” said
Nathan Wolfe, the director of the Global Viral Forecasting Initiative in an April 30, 2009 NYT OP-ED PIECE “How to Prevent a Pandemic”
He continued-
“Many federal agencies — including the Centers for Disease Control and Prevention, the United States Agency for International Development and the Department of Defense — as well as the World Health Organization are looking for ways to stop pandemics early. Nevertheless, much more work is needed. To establish a worldwide safety net, we would need to devote more resources to expanding disease surveillance in people and in wild and domestic animal populations throughout the world. Our current global public health strategies are reminiscent of cardiology in the 1950s — when doctors focused solely on responding to heart attacks and ignored the whole idea of prevention.”

According to reports “State and federal officials intensifying their response to the swine flu outbreak with President Obama asking Congress for $1.5 billion in supplemental funding.

”Since Obama’s staff director has been quoted as saying something to the effect that “a crisis should be taken advantage of, perhaps this is the time to spend some of this money answering the question of where in the community are various infectious agents being harbored, and also how to curtail the transmission of infectious agents.

How to Confirm Suspected Swine Flu

Swine Flu information resources that are frequently updated:

Google maps has a nice tool for tracking swine flu.
http://maps.google.com/maps/ms?ie=UTF8&hl=en&t=p&msa=0&msid=106484775090296685271.0004681a37b713f6b5950&z=2

There's also HealthMap which tracks all kinds of outbreaks:
http://www.healthmap.org/en

For those of you who follow events on social media sites, CDC has a Twitter feed that contains updates on the Swine Flu:
http://twitter.com/cdcemergency

If you are interested in the view from overseas - European Centre for Disease Prevention and Control
http://ecdc.europa.eu/

Swine Flu Virus-What I Tell My Patients

Many of my patients are calling for more information about about the new Swine Flu. This is what I tell them.

Pigs, birds, and humans are each susceptible to lots of influenza viruses. Typically, these viruses infect only one species. However, sometimes the viruses swap genes, creating new viruses that have the capacity to infect more than one species. That’s why having taken the human flu vaccine last season may theoretically help you in with this flu-but only a bit because this new strain of influenza virus has been identified as containing a combination of two parts swine, one part avian, and one part human influenza virus genes.

How is this New Virus Transmitted?
The World Health Organization and the CDC have confirmed that the new swine flu virus is transmitted between humans. It is not clear yet how transmissible it is, nor how it is transmitted. Almost surely, like other flu viruses, it can be transmitted by aerosol and by skin-to-skin contact with an infected person. There is no vaccine yet for the new virus.

The 20 confirmed cases in the U.S. young students are all recovering (with only 1 case requiring hospitalization) in contrast to many of the deaths in Mexico which seem to have occurred in healthy young adults, a pattern seen in past pandemics — not young children and the frail elderly, as is most often seen with the flu.

Precautions
The usual precautions for patients apply:
• Sneeze and cough into tissues and throw the tissues in the trash.
• Wash your hands or use alcohol-based hand cleaners frequently.
• On greeting people, don’t shake hands or exchange kisses.

Contagious period
People should be considered contagious until at least 7 days after the start of symptoms; with children, it may be 10–14 days. If a global pandemic ensues, governments may well close schools and public places, require as many people as possible to work from home, warn any people who develop symptoms to isolate themselves at home.More updated information from the CDC is available at http://www.cdc.gov/swineflu/.

Symptoms
The initial symptoms with this swine flu virus are like those with the annual flu viruses: fever, sore muscles, running nose, and sore throat. Nausea, vomiting, and diarrhea may be more common with this flu than with regular flu. Also dizziness has been a prominent symptom. A symptom indicating a more severe disease is breathlessness. If this occurs seek medical attention immediately.

Treatment
The new virus is resistant to amantadine and rimantadine, but sensitive to oseltamivir (Tamiflu) and zanamivir (Relenza). Based on experience with other flu viruses, treatment would be most effective if given within two days of the onset of symptoms.

• Swine Flu Update: What to Expect from Doctors & Public Health Professionals

• Swine Flu Update: What to Expect from Doctors & Public Health Professionals from the Centers for Disease Control and Prevention; 1600; Clifton Rd; Atlanta, GA 30333; 800-CDC-INFO; (800-232-4636); TTY: (888) 232-6348

• cdcinfo@cdc.gov

Doctors
Clinicians should consider the possibility of swine influenza virus infections in patients presenting with febrile respiratory illness.If swine flu is suspected, clinicians should obtain a respiratory swab for swine influenza testing and place it in a refrigerator (not a freezer). Once collected, the clinician should contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory.

State Public Health Laboratories
Laboratories should send all unsubtypable influenza A specimens as soon as possible to the Viral Surveillance and Diagnostic Branch of the CDC’s Influenza Division for further diagnostic testing.

Public Health /Animal Health Officials
Officials should conduct thorough case and contact investigations to determine the source of the swine influenza virus, extent of community illness and the need for timely control measures.

Guidance Documents
• Interim Guidance for Swine influenza A (H1N1): Taking Care of a Sick Person in Your Home Apr 25, 2009

• Interim Guidance on Antiviral Recommendations for Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection and Close Contacts Apr 25, 2009

• Interim CDC Guidance for Nonpharmaceutical Community Mitigation in Response to Human Infections with Swine Influenza (H1N1) Virus Apr 26, 2009, 11:45 PM ET

• Interim Recommendations for Facemask and Respirator Use in Certain Community Settings Where Swine Influenza A (H1N1) Virus Transmission Has Been Detected Apr 26, 2009

Swine Flu Public Health Emergency –What To Look For; What To Do.

A public health emergency was declared today in the U.S. as 20 cases of the disease were confirmed in this country. The Centers for Disease Control, in a news conference in Washington stated, “We expect to see more cases of swine flu. Homeland Security Secretary Janet Napolitano, speaking at the same news conference called the emergency declaration a “declaration of emergency preparedness.” However, experts at the WHO will wait until Tuesday before meeting to decide if it should increase its rating of the seriousness of the pandemic potential from the current level three to level four - which would indicate a "significant increase in risk of a pandemic.” Officials said they had confirmed eight cases in New York, seven in California, two in Kansas, two in Texas and one in Ohio, and that the cases looked to be similar to the deadly strain of swine flu that has killed more than 80 people in Mexico and infected 1,300 more. This was amid further reports of potential new cases from New Zealand to Hong Kong to Spain, raising concerns about the potential for a global pandemic. Canada also confirmed six cases of the flu. Swine flu was also likely in 10 New Zealand students.

WHAT TO LOOK FOR:
The symptoms of swine flu are nearly identical to the symptoms of other influenza, including high fever, aches, coughing, and congestion. It appears to spread through human-to-human contact and human contact with live pigs but not by eating pork products.

WHAT TO DO if pandemic is declared by WHO
-Interim Guidance for Swine influenza A (H1N1)
• Wash hands frequently

• stay home

• don't board airplanes, if you feel sick

• Keep sick children out of school.

• Use Facemasks

• Avoid close contact (less than about 6 feet away) with the sick person as much as possible.

• If you must have close contact with the sick person (for example, hold a sick infant), spend the least amount of time possible in close contact and try to wear a facemask (for example, surgical mask)

• An N95 respirator that fits snugly on your face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through an N95 mask for long periods.

• Wear an N95 respirator if you help a sick person with respiratory treatments using a nebulizer or inhaler, as directed by their doctor.

• Respiratory treatments should be performed in a separate room away from common areas of the house when at all possible.

• Used facemasks and N95 respirators should be taken off and placed immediately in the regular trash so they do not touch anything else.

• Avoid re-using disposable facemasks and N95 respirators if possible.

• If a reusable fabric facemask is used, it should be laundered with normal laundry detergent and tumble-dried in a hot dryer.

• After you take off a facemask or N95 respirator, clean your hands with soap and water or an alcohol-based hand sanitizer.

• Ask your doctor whether you are a candidate for Tamiflu or Relenza.

• Do not take any drugs or medications prophylactic ally without your doctor’s permission.

FACTS ABOUT THE NEW SWINE FLU EPIDEMIC

Is Mexico city ground zero for a global epidemic of a new kind of flu — a strange mix of human, pig and bird viruses?

The illnesses breaking out in Mexico currently have epidemiologists at the U.S. Centers for Disease Control and Prevention deeply concerned. The World Health Organization [W.H.O.] says there have been 800 cases in Mexico in recent weeks, 60 of them fatal, of a flulike illness that appeared to be more serious than the regular seasonal flu. Doctors have warned for years about the potential for a pandemic from viruses that mix genetic material from humans and animals. The most notorious flu pandemic, thought to have killed at least 40 million people worldwide in 1918-19, also first struck otherwise healthy young adults. Scientists have long been concerned that a new killer flu could evolve when different viruses infect a pig, a person or a bird, mingling their genetic material. The resulting hybrid could spread quickly because people would have no natural defenses against it.

Most of Mexico’s dead are young, healthy adults, and none were over 60 or under 3 years old, the World Health Organization said. That alarms health officials because seasonal flus cause most of their deaths among infants and bedridden elderly people, but pandemic flus — like the 1918 Spanish flu, and the 1957 and 1968 pandemics — often strike young, healthy people the hardest. The leading theory on why so many young, healthy people die in pandemics is the “cytokine storm,” in which vigorous immune systems pour out antibodies to attack the new virus. That can inflame lung cells until they leak fluid, which can overwhelm the lungs. But older people who have had the flu repeatedly in their lives may have some antibodies that provide cross-protection to the new strain, she said. And immune responses among the aged are not as vigorous.

FACTS:
• Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza that regularly cause outbreaks of influenza among pigs.

• Swine flu viruses do not normally infect humans, however, human infections with swine flu do occur, and cases of human-to-human spread of swine flu viruses has been documented.

• From December 2005 through February 2009, a total of 12 human infections with swine influenza were reported from 10 states in the United States.

• Since March 2009, a number of confirmed human cases of a new strain of swine influenza A (H1N1) virus infection in California, Texas, and Mexico have been identified. An investigation into these cases is ongoing.

• The C.D.C. said that eight nonfatal cases had been confirmed in the United States, and that it had sent teams to California and Texas to investigate.

• Still, only a small number have been confirmed as cases of the new H1N1 swine flu, according to , a W.H.O. spokesman.

• Tests show 20 people in Mexico have died of the new swine flu strain, and that 48 other deaths were probably due to the same strain.

• The caseload of those sickened has grown to 1,004 in Mexico.

• The same virus also sickened at least eight people in Texas and California, though there have been no deaths yet in the U.S.

• If the confirmed deaths are the first signs of a pandemic, then cases are probably incubating around the world by now, says a pandemic flu expert.

• The new strain contains gene sequences from North American and Eurasian swine flus, North American bird flu and North American human flu, said the Centers for Disease Control and Prevention.

• This similar virus has been found in the American Southwest, where officials have reported eight nonfatal cases.

This swine flu and regular flu can have similar symptoms — mostly fever, cough and sore throat, though some of the U.S. victims who recovered also experienced vomiting and diarrhea.

UP-TO-DATE ACTIONS ON SWINE FLU
The World Health Organization has convened an emergency expert panel to consider whether to declare the outbreak an international public health emergency — a step that could lead to travel advisories, trade restrictions and border closures.

• The CDC and Canadian health officials were studying samples sent from Mexico, and some governments around Latin America said they would monitor passengers arriving on flights from Mexico.

• No vaccine specifically protects against swine flu, and it is unclear how much protection current human flu vaccines might offer.

• Actually producing the vaccines could take months.

• The relatively good news is--CDC says two flu drugs, Tamiflu and Relenza, seem effective against the new strain. Roche, the maker of Tamiflu, said the company is prepared to immediately deploy a stockpile of the drug if requested. Both drugs must be taken early, within a few days of the onset of symptoms, to be most effective.

• anyone with a fever, a cough, a sore throat, shortness of breath or muscle and joint pain should seek medical attention.

• When a new virus emerges, it can sweep through the population.

• The Spanish flu is believed to have infected at least 25 percent of the United States population, but killed less than 3 percent of those infected.

• Among the swine flu cases in the United States, none had had any contact with pigs; cases involving a father and daughter and two 16-year-old schoolmates convinced the authorities that the virus was being transmitted from person to person.

LINKS TO MORE FACTS
General Information about Swine Flu

Questions and answers and guidance for treatment and infection control
Human Swine Flu Investigation Apr 24, 2009
Information about the investigation of human swine flu in California

Swine Influenza: General Information

Swine Flu and You Apr 24, 2009
What is swine flu? Are there human infections with swine flu in the U.S.?

Swine Flu Video Podcast Apr 25, 2009
Dr. Joe Bresee, with the CDC Influenza Division, describes swine flu - its signs and symptoms, how it's transmitted, medicines to treat it, steps people can take to protect themselves from it, and what people should do if they become ill.

Key Facts about Swine Influenza (Swine Flu) Apr 24, 2009, 5:45 PM ET
How does swine flu spread? Can people catch swine flu from eating pork?