FOOD POISONING

Food poisoning syndrome

results from ingestion of water and wide variety of food contaminated

with pathogenic microorganisms
(bacteria, viruses, protozoa, fungi),
their toxins and chemicals.

Food poisoning must be suspected

when an acute illness with
gastrointestinal or neurological
manifestation affect two or more persons,
who have
shared a meal during the previous 72 hours.

The term as generally used encompasses

both food-related infection and food-related intoxication.
FOOD POISONING

Food poisoning occurs when you swallow

food or water that contains
bacteria, parasites, viruses, or toxins made by these germs
And chgemical.
SYMPTOMS
Abdominal Cramps
Diarrhea(may be bloody)
Fever & Chills
Headache
Nausea & Vomiting
Neurological symptom
Classification Of Food Poisoning:
I.Based on symptoms and duration of onset

a. Nausea and vomiting within six hours

(Staphylococcus aureus, Bacillus cereus)
b. Abdominal cramps and diarrhoea within 8-16 hours
(Clostridium perfringens, Bacillus cereus)
c. Fever, abdominal cramps and diarrhoea within 16-48 hours
(Salmonella, Shigella, Vibrioparahemolyticus,
Enteroinvasive E.coli, Campylobacter jejuni)
d. Abdominal cramps and watery diarrhoea within 16-72 hours
(Enterotoxigenic E.coli, Vibrio cholerae O1, O139,
Vibrio parahemolyticus, NAG vibrios, Norwalk virus)
e. Fever and abdominal cramps within 16-48 hours
(Yersinia enterocolitica)
f. Bloody diarrhoea without fever within 72-120 hours
(Enterohemorrhagic E.coli O157:H7)
g. Nausea, vomiting, diarrhoea and paralysis within 18-36 hours
(Clostridium botulinum)
II. Based on pathogenesis

a. Food intoxications resulting from

the ingestion of preformed bacterial toxins.
(Staphylococcus aureus, Bacillus cereus,
Clostridium botulinum, Clostridium perfringens)

b. Food intoxications caused by noninvasive bacteria

that secrete toxins while adhering to the intestinal wall
(Enterotoxigenic E.coli, Vibrio cholerae, Campylobacter jejuni)

c. Food intoxications that follow an intracellular invasion of

the intestinal epithelial cells.
(Shigella,Salmonella)

d. Diseases caused by bacteria that enter the blood stream

via the intestinal tract.
(Salmonella typhi,Listeria monocytogenes)
Bacterial Etiology Of Food Poisoning:

Food infections by bacteria divided into two types:

1. The food does not ordinarily support the growth
of pathogens but merely carries them. E.g.
Salmonella, Shigella, Vibrio etc.

2. The food can serve as a culture medium

for growth of pathogens to numbers
that can infect the person.
Food borne infections by bacteria
can also be classified
as toxicosis and food-infections.

In toxicosis,
the toxins are released by bacteria
such as
Clostridia, Bacillus and Staphylococcus.

In food-infections,
the bacteria are ingested,which later
initiate the infection.
Staphylococcus aureus:

S.aureus is gram positive cocci

Only those strains that produce
enterotoxin can cause food poisoning.

Food is usually contaminated

from infected food handler.
with an active lesion or carriage
can contaminate food.
Incriminated food:
Custard and cream filled bakery food,
ham, chicken, meat, milk, fish, salads,
puddings, pie etc.

Incubation period: 1-6 hours.

Pathogenesis:
multiply in the food and produce toxin at
room temperature

S.aureus produce six serologically enterotoxins

(A, B, C, C2, D and E) that differ in toxicity.
Most food poisoning iscaused by

enterotoxin

type A. ( phage type III. heat stable)

type B being most heat resistant.

Ingestion of as little as 23 g of enterotoxin

can induce vomiting and diarrhoea.
Staphylococcal enterotoxins act as superantigens,

binding to MHC II molecules

and stimulating T cells to divide
and produce lymphokines such as IL-2 and
TNF-alpha, which induces diarrhea.

The toxin acts on the receptors in the gut and

sensory stimulus is carried to the vomiting
center in the brain
by vagus and sympathetic nerves.
Clinical features:

The onset is sudden and is characterized

by vomiting and diarrhea but no fever.
The illness lasts less than 12 hours.
There are no complications
and treatment is usually not necessary.

.
Laboratory diagnosis:

The large number of S.aureus organisms in a food

may indicate poor handling or sanitation;
however, it is not sufficient evidence
to incriminate a food as the cause of food poisoning.

Staphylococcal food poisoning

can be diagnosed if they are isolated in large numbers
from the food
and their toxins demonstrated in the food or
the isolated S.aureus must be shown to produce
enterotoxins.
Dilutions of food may be plated
on Baird-Parker agar or Mannitol Salt agar.
Enterotoxin may be detected and identified bygel
diffusion
 Bacillus cereus:
B.cereus is a gram positive
aerobic spore bearing bacilli.
It is found abundantly in environment and
vegetation.

Incriminated food:
Commonly associated with rice and vegetables.

Incubation period:
1-6 hours in short-incubation form and
8-16 hours in long incubation form.
Pathogenesis:

During the slow cooling,

spores germinate and
vegetative bacteria multiply

Sporulation is associated with toxin

production.

The toxin is heat-stable,

The short-incubation form
is most often associated with
fried rice that has been cooked
and then held at warm temperatures for several
hours.

The Long-incubation form

is frequently associated
with meat or vegetable-containing foods after
cooking
 The short-incubation
form is caused by a preformed
heat-stable enterotoxin
of molecular weight less than 5,000 daltons.

The longincubation
form of illness is mediated by
a heat-labile enterotoxin
(molecular weight of approximately 50,000 daltons),
which activates intestinal adenylate cyclase
and causes intestinal fluid secretion
Clinical features:
B. cereus causes two types intoxications.
The first type(The emetic-type )
(the short incubation type)

It is characterized by
nausea, vomiting and abdominal cramps

The second type

("long-incubation/ diarrheal form )

primarily by abdominal cramps and diarrhea

a small volume or profuse and watery.

it resembles food poisoning caused by

Clostridium perfringens.
the illness usually lasts less than 24 hours after
onset.
Laboratory diagnosis:

The short-incubation or emetic form

the disease is diagnosed by the isolation of
B.cereus from the incriminated food.

The long-incubation or diarrheal form

is diagnosed by isolation
of the organism from stool and food.

Isolation from stools alone is not sufficient because

14% of healthy adults have been reported to have transient
gastrointestinal colonization with B. cereus.
 Clostridium perfringens
It is a gram positive anaerobic spore bacilli
that is present in
the environment, vegetation,sewage and animal feces.

Incriminated food:
food-borne outbreaks of C.perfringens involve
meat products that are eaten
1- 2 days after preparation.

Fish pastes and cold chicken

.
Pathogenesis:
Spores in food may survive cooking
When these vegetative cells form in the intestine,

The bacterium to produce at least

12 different toxins( enterotoxins)
Food poisoning is mainly caused by
Type A strains,
produces alpha and theta toxins.

The toxins result in excessive fluid accumulation

in the intestinal lumen
Incubation period: 8-24 hours

Clinical features:

Illness is characterized
by acute abdominal pain,
diarrhea, and vomiting.
Illness is selflimiting and
patient recovers in 18-24 hours.
 Laboratory diagnosis:

The bacterium is present normally in the

intestine,
isolation from feces may not be sufficient
to implicate it.

isolation from food

except in large numbers (>105/gram)
may not be significant.

The homogenized food is diluted and plated

on selective medium
(Robertson cooked meat medium and
incubated anaerobically).
The isolated bacteria
must be shown to produce enterotoxin
 Clostridium botulinum

a gram positive anaerobic

spore bearing bacilli

that is widely distributed in

soil, sediments of lakes and
ponds, and decaying vegetation.
Incriminated food:

Most cases of botulism are associated with

home canned or bottled meat, vegetables
and fish.

In general, the low and medium acid canned

foods are often incriminated.

The anaerobic environment

produced by the canning process may further
encourage the outgrowth of spores.
Pathogenesis:
Not all strains of C.botulinum
produce the botulinum toxin.

Seven toxigenic types of the organism exist,

each producing an immunologically distinct
form of botulinum toxin.

The toxins are designated

A, B, C1, D, E, F, and G.

Lysogenic phages encode

toxin C and D serotypes.
 Food-borne botulism
is not an infection but an intoxication

the ingestion of foods that contain the preformed

clostridial toxin.

Incubation period: 12-36 hours

Spoilage of food or swelling of cans or

presence of bubbles
inside the can indicate clostridial growth.
insufficiently sterilized / canned improperly,
contaminated food
The toxin is released only after the death
and lysis of cells.

The toxin resists digestion

the upper part of the GI tract the blood.
the peripheral neuromuscular synapses
binds to the presynaptic stimulatory
terminals
blocksthe release of the neurotransmitter
acetylcholine.
flaccid paralysis.

Even 1-2 g toxin can be lethal to humans.

 Clinical features:
Common features include vomiting, thirst,
dryness of mouth,
constipation, ocular paresis(blurred-vision),
difficulty in speaking,
breathing and swallowing.
Coma or delirium may occur in some cases.
Death may occur
due to respiratory paralysis within 7 days.
 Laboratory diagnosis:
Food is homogenized in broth and inoculated in
Robertson cooked meat medium and blood agar or
egg-yolk agar,

incubated anareobically for 3-5 days at 37oC.

The toxin demonstrate :

injecting intraperitoneally the extract of food or

culture into mice or guinea pig
 Enterotoxigenic E.coli (ETEC):
Incubation period: 16-72 hours
E.coli are gram negative enteric bacilli
normally in the intestine of humans and animals.
Some specific serotypes
harbor plasmids that code for toxin production.
The enterotoxin O serotypes:
O6, O8, O15, O25, O63, O78, O148 and O159.

Incriminated food:
Infection by ingestion of food or water
Contamination of water with human sewage
Infected food handlers may also contaminate
foods. The infective dose is 106-1010 bacilli.
Pathogenesis:
The bacteria colonize the GI tract
of the proximal small intestine.

Enterotoxins produced include

the LT (heat-labile) toxin and or
the ST(heat-stable) toxin.
LTs are similar to cholera toxin .
holotoxin consisting of A subunit and B subunit.

The B subunit binds to specific ganglioside receptors

(GM1) on the epithelial cells of small intestine
and facilitates the entry of A sub unit

A subunit activates adenylate cyclase.

adenylate cyclase causes an increased cAMP,
which hypersecretion of water and electrolytes
and inhibition of sodium reasborption.
 Clinical features:

Sudden onset of watery diarrhea

associated with nausea, vomiting,
abdominal cramping and bloating
is commonly observed.

This bacterium is responsible

for majority of travelers diarrhea.
The disease is self-limiting
and resolves in few days.
Laboratory diagnosis:
The sample of feces is cultured on McConkey's agar.

The ETEC stains are

indistinguishable from E.coli by biochemical tests.

These strains are from

nontoxigenic E.coli differentiated present in the bowel
by in vitro immunochemical, tissue culture, or
DNA hybridization tests designed to detect either the toxins
or genes that encode for these toxins.

With a gene probe method, foods can be analyzed directly

for the presence of enterotoxigenic E.coli in about 3 days.

LTs can be detected by Ligated rabbit ileal loop test,

ELISA, immunodiffusion, coaglutination etc.

 Enterohemorrhagic E.coli (EHEC):

EHEC strains
associated with many serogroups:

O4, O26, O45, O91, O111, O145 and O157.

The most serotype is O157:H7.

Incubation period: 72-120 hours

Incriminated food:
Cattle appear to be the main source of infection;
most cases being associated with the
consumption of undercooked beefburgers and
similar foods.

This disease is often associated with ingestion of

inadequately cooked hamburger meat, raw milk,
cream and cheeses made from raw milk.
 Pathogenesis:

EHEC strains may produce

one or more types of cytotoxins,
referred as Shiga-like toxins (SLT)
antigenically and functionally similar to Shiga toxin
produced by Shigella dysenteriae.

The toxins provoke cell secretion

and kill colonic epithelial cells.
 Clinical features:
Initial symptoms may be diarrhea with abdominal cramps,
which may turn into grossly bloody diarrhoea in a few days.
There is however, no fever.
Laboratory diagnosis:

culturing the faeces

on McConkey's agar or on
sorbitol McConkey's agar,
where they don't ferment sorbitol.
Strains identified by using specific antisera.

SLTs can be detected by ELISA

Genes coding detected by DNA hybridization
techniques.
 Vibrio parahemolyticus:
They are straight or curved gram negative
halophilic bacilli.

In morphology and staining it resembles

V.cholerae
and is actively motile in liquid cultures.

It is commonly found in coastal seas,

isolated from
marine fauna such as crabs, shrimps, fishes
and molluscs.
Incriminated food:
Infections are associated with consumption
of uncooked or undercooked crabs,

prawns,shrimps and other seafood

Pathogenesis:
No enterotoxin

The infection is thought to

result from invasion of intestinal epithelium
Incubation period: 7-48 hours

Clinical features:
characterized by a sudden onset of
acute gastroenteritis.
diarrhoea, abdominal pain, vomiting and fever.
Laboratory diagnosis:
Homogenized food may be inoculated into
TCBS agar
or into double strength alkaline peptone water and
incubated overnight at 37oC.

positive for
Kanagawa phenomenon
Where isolates from human feces
show hemolysis on blood agar.
 Salmonella enteritidis:

gram negative rod shaped bacteria

family enterobacteriaceae.

This species
does not occur normally in humans
but several animals act as reservoirs.
Incriminated food:

Most important sources

are chicken and poultry.
Chicken, duck, turkey and goose
may be infected with Salmonella,

which then find its way into

its feces, eggs or flesh of dressed fowl.
Milk and milk products
including ice creams have been
incriminated.
Pathogenesis:
Organism penetrates and passes
through the epithelial cells
lining the terminal portion of the small intesti
Multiplication in the lamina propria produces
inflammatory mediators,
recruits neutrophils and
triggers inflammation.

Release of LPS causes fever.

Inflammation causes release of
prostaglandins from epithelial cells.
Cause electrolytes water flows into lumen
in response
to osmotic imbalance resulting in diarrhea.
Incubation period: 12-36 hours

Clinical features:
Sudden onset of abdominal pain,
nausea, vomiting and diarrhea,
which may be watery,greenish and foul
smelling.
This may be preceded by headache and
chills.
Other findings include prostration,
muscular weakness and moderate fever.
In most cases the symptoms resolve in 2-3
days without any
complications.
 Yersinia enterocolitica:
a gram negative
psychrophilic rod shaped bacterium
motile only at temperature below 30oC.

Yersinia enterocolitica isolated

from soil, water and animals.

The major animal reservoir

Y.enterocolitica strains that
cause human illness is
pigs, also rodents, rabbits, sheep, cattle,
horses, dogs, and cats.
Serogroups that predominate in
human illness are O:3, O:8, O:9, and O:5.
Incriminated food:
eating contaminated food, raw or
undercooked pork products
contaminated unpasteurized milk or untreated
water

Pathogenesis:
This organism survive and grow during refrigerated
storage.
Strains human yersiniosis carry a plasmid
associated with a number of virulence traits.
Ingested bacteria adhere and invade M cells or
epithelial cells.
They exhibit resistance to complement and
phagocytosis.
They produce ST only at temperatures below 30C.
The role of ST in the disease process remains
uncertain
Incubation period: 4-7 days

Clinical features:

Y.enterocolitica is a typical gastroenteritis

characterized by
fever,abdominal pain, and diarrhea,
which is often bloody.
Illness generally lasts from 1 to 2 weeks
chronic cases may persist for up to a year.
it may also cause pseudoappendicitis,
Mesenteric lymphadenitis, and terminal
ileitis.
Laboratory diagnosis:

Suspected food is homogenized in

phosphate-buffered saline
and inoculated into selenite F broth
held at 4oC for six weeks.
The broth is sub-cultured at weekly
intervals on DCA or Yersinia selective
agar plates.
 Campylobacter jejuni:
These are small, curved-spiral gram
negative bacilli with polar flagella.

Campylobacter jejuni appear in comma,

S-shaped or gull-wings/sea-gull form.

Campylobacter are harbored in

reproductive and alimentary tracts of some
animals.
Incriminated food:

Transmission via a fecal-oral route,

originating from farm animals, birds,dogs,
and processed poultry,
with chicken preparation comprising
50-70% of all campylobacter infections.

transmitted to man in milk, meat products

and contaminated water.
Undercooked poultry and
unpasteurized dairy are most often
implicated as a source of C.jejuni.
Pathogenesis:

As few as 500 organisms can cause

enteritis.
The organism is invasive but generally
less so than Shigella.

Campylobacter produces adenylate cyclase-

activating toxins

same as of E.coli LT and cholera.

Incubation period:
Ranges from 2 to11 days.

Clinical features:

Abdominal pain and cramps, diarrhea,

malaise, headache, and fever.
Typically the diarrhoea is watery,
in severe cases bloody diarrhea may occur.
Diarrhea may last 2-7days
the organism may be shed in
the patients stool for up to 2 months.
Bacteremia is observed in
a small minority of cases.
The disease is usually self-limiting.
Laboratory diagnosis:

The feces may be inoculated in

enrichment medium or
on selective media such as
Campy BAP or Skirrow's medium.

The plates are incubated in

microaerophilic conditions
at 42oC for 2-5 days.
 JENIS MAKANAN YANG SERING
MENIMBULKAN FOOD POISONING

FAST FOOD POISINING

FOOD POISINING

FOOD POISINING
ROAD TO FOOD POSONING
BACTERIAL FOOD POISONING
 TREATMENT FOOD POISONING

Drink any fluid

(except milk or caffeinated beverages)
to replace fluids lost by diarrhea and vomiting.

toxins from mushrooms or shellfish,

need medical attention right away.

The emergency room doctor will take steps

to empty out stomach and remove the toxin.

Don't eat solid foods until

the diarrhea has passed, and avoid dairy products,
which can worsen diarrhea
 A 2x2 table
For the purpose of this study,
the occurrence of illness
in the exposed and unexposed groups is
known.

A 2x2 table can be used illustrate

for each food item to the relative risk
associated with eating certain foods.

The following table clearly shows that there

is a very high risk associated with the
consumption of lobster.(SEE NEXT PAGE)
Attack Rate Table:

A Table used to compile food history data

so that
the probability of illness can be compared
against the consumption of specific foods.
To calculate use the following equation:

Attack rate= a/(a+b)

Illness NoIllness

Atelobster a b

Nolobster c d
 Relative Risk:

The ratio of the risk of disease or death

among the exposed
to the risk among the unexposed.
The relative risk is calculated as:

RR = (a /(a+b)) / (c/ (c+d)).

Illness NoIllness

Atelobster a b

Nolobster c d
Odds Ratio:

The ratio of the odds in favour of exposure among

the cases to the odds in favour of exposure among
non-cases.
This is an approximation of the Relative Risk
if there is unbiased subject selection and a rare
disease.

OR= ad/bc
No
Illness
Illness
Ate
a b
lobster
No
c d
lobster
 FOOD SPESIFIC ATTACK RATE
Number
Food/ Number of Difference Relativ Odds
of NOT
Beverage ATE in Percent e Risk Ratio
ATE

Attack Attack
ill well total ill well total
rate rate

LobsterTails 55 15 70 0.786 2 10 12 0.2 0.586 3.93 18.33

Steak 52 21 73 0.712 3 5 8 0.375 0.337 1.89 4.127

Sauteed
27 20 47 0.574 23 22 45 0.511 0.063 1.12 1.291
Mushrooms

Cornonthecob 26 22 48 0.542 19 13 32 0.594 -0.052 0.912 0.809

ThreeBean
18 17 35 0.514 17 15 32 0.531 -0.017 0.968 0.934
Salad

Coleslaw 18 6 24 0.75 32 22 54 0.593 0.157 1.26 2.063

PotatoSalad 38 14 52 0.73 16 12 28 0.571 0.159 1.27 2.036

Pickles 23 9 32 0.719 32 17 49 0.653 0.066 1.1 1.358

Bread 32 13 45 0.711 23 13 36 0.639 0.072 1.11 1.391

ChocolateCake 30 41 71 0.422 4 9 13 0.301 0.121 1.4 1.646

Tea/Coffee/Soft
28 15 43 0.651 27 11 38 0.711 -0.06 0.916 0.265
drinks
Without going into detail
beyond the scope of this module,

Some analysis programs will provide

estimates of
the confidence limits and the p-value.
These tests provide numbers which increase
the investigator's assurance of the
calculations' accuracy.