GI DISEASE FOCUS: FOODBORNE ILLNESS 3

I) MACRO QUESTION
→ Given what you have learned so far, why do you think that the following food handling protocols are recommended by food safety boards?
– 1. Clean – wash hands and surfaces regularly
– 2. Separate – keep raw meats separate from other foods
– 3. Cook – cook food to the temperatures recommended by the FDA
– 4. Chill –
* Promptly refrigerate foods after cooking or purchasing
* Don’t thaw foods at room temperature
* Always marinate in the refrigerator
* Separate large amounts of food into smaller containers for refrigeration
II) HEPATITIS
→ Overview
– “Hepat” refers to the liver
– Hepat-itis is inflammation of the liver
– Caused by several viruses (A, B, C, D and E)
– These viruses vary in their viral family, clinical presentation, infectivity, epidemiology, etc. What unites them is that they cause hepatitis.
– Note: non-infectious reasons for inflammation of the liver include alcohol and drug use as well as some autoimmune conditions
→ Mechanism of Disease
– Viruses that cause hepatitis all result in a similar set of symptoms, though the severity of the symptoms varies.
– Mechanism (general)
* Hepatitis virus multiplies within intestinal cells
* Virions enter the bloodstream (viremia)
* Infect hepatocytes (liver cells)
* Inflammation develops and liver function is impaired
» Bilirubin removal is limited
» Causes yellowing of the skin and sclera
→ Types of Hepatitis
– Hepatitis A
* Etiological agent
» Hepatitis A virus (HAV, Picornaviridae family)
» Nonenveloped, single-stranded RNA virus
* Transmission
» Fecal–oral route
» Viral particles are most concentrated in the feces two weeks before symptoms develop
» Remains infectious for months outside the body
» HAV is inactivated by high temperature
* Signs & Symptoms
» Most children under age 6 are asymptomatic
» Low-grade fever • Nausea, vomiting, abdominal pain
» Fatigue
» Clay-colored feces and jaundice
» Infection in those with a preexisting liver condition, infection can be severe and even life threatening
* Treatment
» Infections are usually self-limiting and resolve within a few weeks without drug therapies •
* Prevention
» Vaccine
– Hepatitis B
* Overview
 » Hepatitis B (HBV, Hepadnaviridae family)
» Double-stranded enveloped DNA virus
» Since 1991, HBV vaccinations have reduced infections by ~82% worldwide
» Chronic HBV affects up to 2.2 million people in the U.S.
* Transmission
» Direct contact with bodily fluids or open sores from an infected individual (e.g., sexual contact, HBV-contaminated needles, razors, toothbrushes)
» Accidental percutaneous exposures
» Vertical transmission during childbirth
» No evidence of transmission through breastmilk
* Acute & Chronic Infections
» Signs and symptoms
› Incubation takes ~120 days and ~50% of cases are asymptomatic (hard to track!)
› HBV can cause an acute infection (clears up in a few weeks)
› Can establish a chronic infection with intermittent inflammation, particularly in children under 6 and in the elderly
› Can lead to Cirrhosis and liver failure
› Viruses can also cause hepatocellular carcinoma
» Prevention
› HBV vaccine and HBIG (hepatitis B immune globulin) are given to infants born to HBV+ mothers
– Hepatitis C
* Hepatitis C viruses (Flaviviridae family)
* Etiological agent
» Hepatitis C virus (HCV)
» Single-stranded, enveloped RNA genome
» Continually mutates •
* Characteristics
» ~3.2 million people are infected with HCV in the U.S. (hard to estimate because most people aren’t diagnosed until later stages)
* Transmission
» Direct contact with HCV-infected blood and bodily fluids (e.g., shared HCV-infected needles)
» Vertical transmission from mother to child
* The Silent Killer (3 of 4)
» Signs and symptoms
› Early infection is usually asymptomatic
› Chronic infections are not diagnosed until liver problems begin (75–85% of patients develop a chronic infection)
› Complications like HBV: Liver cancer and cirrhosis
» Treatment
› Up to 20% of patients spontaneously clear the virus without treatment
› Drug treatment (protease, polymerase, and other viral protein inhibitor medications)
» Prevention
› No vaccine
– Hepatitis D & E
* There are two other forms of Hepatitis, called “D” and “E”
* Not really a concern in most countries, but of some concern in developing countries.
* One interesting note: Hepatitis D requires coinfection with Hepatitis B to be transmitted, though the mechanism isn’t well understood.
III) EUKARYOTES THAT CAUSE GI DISEASE
→ Common Protozoan Infections Include Giardiasis & Amoebiasis
– Protozoans are single-celled eukaryotes
– The top three intestinal protozoans in developed countries are:
* Giardia lamblia
* Entamoeba histolytica
* Cryptosporidium species (not covered in this class, very common though)
→ Giardia Lamblia
– Sometimes called “hiker’s disease”, “travelers' diarrhea” or “beaver fever”
– Most common intestinal parasite in the US
– Discovered by Antony van Leeuwenhoek (remember him?) in a sample of his own stool:
* “Animalcules a-moving very prettily. . . all of one and the same make…Their bodies were somewhat longer than broad, and their
belly, which was flatlike, furnisht with sundry little paws. . . and albeit they made a quick motion with their paws, yet for all that
they made but slow progress”
– Often contracted from contaminated water sources
– Life cycle consists of two stages: Cyst and trophozoite
→ Life cycle
–

→ Transmission
– Person-to-person, fecal-oral route is most important (hand to mouth transfer of cysts)
* Infected food/food handlers
* Ingestion of fecal-contaminated water • From contaminated soil or surfaces
* Anal sex also known to facilitate transmission •
– Zoonotic
* Genotypes A-F, only A+B affect both animals and humans
* Very little evidence for zoonosis from companion animals, but some for agricultural
– Infectious dose:
* Less than 10 cysts when given orally, may even be as low as 1 cyst
→ Giardiasis
– Signs and symptoms
* Diarrhea • Excessive flatulence
* Vomiting
– Treatment
* Symptoms usually subside without treatment in 2–6 weeks
* Metronidazole was the standard, but resistance is emerging. 75% to 100% effective, but side effects often lead to patient non-
compliance.
* Tinidazole in one 2g dose is the FDA-approved drug for treatment of Giardiasis and is highly effective (>95%); single dose eliminates non-compliance despite some
increased side effects.
* Even after treatment: intestinal scarring
→ Prevention
– Prevention:
* Normal chlorine, iodine, or ozone treatments are not adequate to kill the cysts.
* Best prevention is filtering (<1𝜇m pore) or boiling, either is recommended for drinking water in wilderness conditions.
* Solar or UV disinfection is also effective against both the cysts and trophozoites and may be more convenient for hikers/campers.
IV) HELMINTH INFECTIONS
→ Numerous Helminths can Infect the Digestive Tract & May Migrate to Other Tissues
– Helminths (or worms)
* Multicellular animals
* In their adult form they can often be seen with the naked eye
* Usually transmitted as microscopic eggs or larvae in either soil or water
* Either round worms or flatworms (tapeworms and flukes)
→ Infection
– Wide variety of worms that infect the GI tract
– Many of the symptoms resemble other GI tract infections
– Blood work usually reveals eosinophilia (an increase in eosinophils in the blood). Eosinophils
help fight multicellular infections.
→ Tapeworms in General
– Tapeworms
* Flattened, segmented bodies
* Scolex (head) at one end
» Possesses hook and/or sucker structures for attachment
* Mature and release eggs and proglottids in the definitive host
* Eggs and proglottids released in feces
– Most tapeworm infections in humans are caused by:
* Hymenolepis nana (human tapeworm, no other host)
* Taenia species (pork and beef tapeworm, today’s focus)
* Diphyllobothrium latum (fish tapeworm)
→ Taenia Species
– 32 recognized Taenia species
– Only 3 cause human infections
– Taenia species
* Immediate host = cow or pig (depending on species)
* Definitive host = human
→ Life cycle
–

→ Tapeworms
– Transmission
* Ingestion of cysticerci in raw or undercooked meat
– Epidemiology
* 50–100 million people infected worldwide
* ~1,000 cases per year in the U.S. •
» Most occur in newly immigrated people from Latin America
– Treatment
* Anthelminthic drugs (e.g., praziquantel)
* Anti-inflammatory agents
* Surgery to remove cysticerci (if present)
– Prevention:
* Wash hands, thoroughly cook veg and meat in places where tapeworms are common, reduce exposure to feces for both animals and humans
– Mechanism of disease
* Worm attaches to the intestinal wall
* Tapeworm reaches maturity after 5–12 weeks
* Begins to release eggs
– Signs and symptoms
* Most infections are asymptomatic
* Can result in nausea, abdominal pain, diarrhea
* Eggs can be detected in fecal samples
* Tapeworms can become very long
» Causes intestinal irritation and bowel obstruction
– Cysticercosis
* Occurs when humans ingest the eggs instead of cysticerci
» Eggs hatch in the intestines
» Larvae burrow through the intestines
» Migrate to tissues (e.g., brain, eyes)
» Form cysticerci
» Impair tissue function
» Potentially deadly symptom