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SUPPLEMENT ARTICLE
Food and Water Safety for Persons Infected
with Human Immunodeficiency Virus
Celia Hayes, Elisa Elliot, Edwin Krales, and Goulda Downer
Health Resources and Services Administration, HIV/AIDS Bureau, Office of Science and Epidemiology, Service Evaluation and Research Branch,
Rockville, Maryland
Public health and food safety experts estimate that millions of episodes of illnesses annually can be traced to
contaminated food and water. Food and water safety is extremely important to persons infected with the
human immunodeficiency virus (HIV) or with acquired immunodeficiency syndrome (AIDS). A compromised
immune system causes people with HIV or AIDS to be more susceptible to foodborne illness from eating
foods that are unsafely handled and poorly prepared and from using water from unsafe sources. Food- and
waterborne illnesses can cause diarrhea, nausea, and vomiting that can lead to weight loss. These illnesses
can be minimized or prevented if proper precautions are taken.
Because of their weakened immune system, immunocompromised persons are more susceptible to serious
foodborne and waterborne illnesses than are persons
with stronger immune systems. These secondary infections, transmitted through food and water, contribute
significantly to the morbidity and mortality of HIVinfected persons. Food plays an active role in disease
transmission by supporting growth of the etiologic
agent or toxin production, or a passive role where the
food does not support growth but serves as a means
of transmission. Food- and waterborne diseases cause
nausea, vomiting, and/or diarrhea with or without additional symptoms of fever, chills, headache, and fatigue. Chronic diseases that may result from foodborne
diseases include arthropathies, chronic gastroenteritis,
organ compromise, and nutritional and other malabsorptive disorders, and death may occur [1]. The major
pathogens seen in AIDS-related diarrhea are Cryptos-
poridium, Microsporidium, Salmonella, and cytomegalovirus [2–4].
Diarrhea is usually the most significant manifestation
of such an infection and is a possible life-threatening
complication. Diarrhea in immunocompromised patients is a challenge for the treatment and prevention
of wasting. Fifty percent to 90% of persons with AIDS
have serious episodes of diarrhea that can be life threatening [2]. In one New York study of patients with AIDS,
two-thirds had diarrheal disease, and in two-thirds of
these, enteric pathogens could be identified [3]. Many
microorganisms (Giardia lamblia, Entamoeba histolytica, Cryptosporidium, Salmonella, Shigella, Listeria, Yersinia, and Campylobacter sp.) identified as the cause of
enteric infections in HIV-infected patients have also
been recognized as etiologic agents in food- and waterborne diseases. Diarrhea is a common clinical feature
of symptomatic HIV infection.
ETIOLOGY
Reprints or correspondence: Celia Hayes, Health Resources and Services
Administration, HIV/AIDS Bureau, Office of Science and Epidemiology, Service
Evaluation and Research Branch, 5600 Fishers Lane, Rockville, MD 20896
([email protected]).
Clinical Infectious Diseases 2003; 36(Suppl 2):S106–9
This article is in the public domain, and no copyright is claimed.
1058-4838/2003/3607S2-0010
S106 • CID 2003:36 (Suppl 2) • Hayes et al.
Salmonellosis is estimated to be nearly 20 times more
common and 5 times more often bacteremic in AIDS
patients than in patients without AIDS [4]. In persons
with AIDS, nontyphoidal salmonellosis is often lifethreatening and relapsing [5–7]. Similarly, campylo-
bacteriosis can also cause bacteremia and can be difficult to
cure in AIDS patients [8, 9]. Mycobacterium sp., including antimicrobial-resistant M. avium complex and M. tuberculosis,
also cause enteric infections and disseminated infections in patients with AIDS [2]. An epidemiological study of persons with
HIV infection also found an association between consumption
of raw or partially cooked fish and M. avium complex [10, 11].
Greenson et al. [12] studied 22 patients with advanced HIV
infection by analysis of endoscopic samples taken during biopsy. Eleven of 22 patients with chronic diarrhea showed occult
enteric pathogens, specifically Mycobacterium avium-intracellulare and microsporidia. Patients with diarrhea and occult
enteric infections experienced more weight loss and died sooner
than those with diarrhea but no identified pathogens.
In a San Francisco study, Celum et al. [4] found the average
annual incidence of salmonellosis in men 15–60 years old with
AIDS was 384 per 100,000, whereas the average annual incidence for men the same age without AIDS was only 20 per
100,000. Salmonella bacteremia was more common in persons
with AIDS (45%) than in those without the disease (9%). This
report and related reports identified the following microorganisms in 55%–86% of cases of patients with AIDS: cytomegalovirus and herpes simplex virus; Salmonella sp., Campylobacter sp., Clostridium difficile toxin, Mycobacterium spp.,
Shigella sp., Vibrio parahaemolyticus, Cryptosporidium, Entamoeba histolytica, Giardia lamblia, Isospora belli, microsporidia,
and Strongyloides stercoralis [4, 13–16].
Listeriosis, shigellosis, cholera, and Vibrio vulnificus enteritis
are other bacterial foodborne diseases for which people with
HIV/AIDS are at increased risk [17]. Soft cheeses, contaminated
milk, ice cream, lettuce, undercooked poultry, hot dogs not
thoroughly reheated, and delicatessen food are associated with
sporadic listeriosis outbreaks in the United States. The organism
that causes listeriosis, Listeria monocytogenes, is an unusual
pathogen that grows and multiplies at refrigeration temperatures. According to a report in Emerging Infectious Diseases [17],
the estimated annual incidence of foodborne listeriosis in the
United States is 2518 cases and 499 deaths, a case fatality rate
of ∼20%. These data confirmed that although foodborne listeriosis is rare, the associated mortality rate is high among those
who are most at risk, including individuals with HIV/AIDS.
Vibrio vulnificus is usually associated with consumption of
raw shellfish, especially oysters. It can also be transmitted directly to wounds from seawater. The organism causes a rapidly
developing septicemia in those at risk (persons with cirrhosis,
diabetes, or immunodeficiency caused by AIDS or other
sources) and has a 50% mortality rate. The disease is so severe,
with extensive lesions, that it may require surgical debridement
or amputation of affected limbs.
Cryptosporidium parvum, a protozoal parasite, was hardly
recognized as a human pathogen until it appeared in AIDS
patients, with life-threatening diarrhea [18]. Usually waterborne, Cryptosporidium also can cause limited diarrhea of short
duration in immunocompetent patients [19, 20]. Cryptosporidiosis has also been traced to consumption of raw milk, unpasteurized apple cider, and chicken salad [21–23]. There is no
known effective drug for the treatment of cryptosporidiosis.
Immunodeficient individuals, especially persons with AIDS,
may have the disease for life, with severe diarrhea and invasion
of the pulmonary system contributing to death [17].
Beginning in 1985, and similar to the emergence of Cryptosporidium, 4 microsporidian protozoan parasites have been
found almost exclusively in AIDS patients. Two microsporidians implicated in chronic diarrhea are Enterocytozoon bieneusi
and Encephalitozoon intestinalis [24]. However, the sources and
modes of transmission are uncertain. Environmental waterborne transmission is possible, as are ingestion of the spores,
inhalation of aerosolized spores, and sexual transmission [25].
Effective therapies for Enterocytozoon bieneusi have not been
established [26, 27]. Another protozoan parasite causing diarrhea and malabsorption, Isospora belli, may require repeated
antimicrobial therapy in patients with AIDS [28–30].
FOOD AND WATER SAFETY PRECAUTIONS
The following precautions for preventing or minimizing foodor waterborne diseases are recommended in the fifth edition
of Nutrition and Your Health: Dietary Guidelines for Americans
[31]:
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•
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•
Do not eat raw or undercooked meat, poultry, fish, or
shellfish (clams, oysters, scallops, and mussels). Whole
poultry should be cooked to 180F, poultry breast and
well-done meats to 170F, and medium-rare beefsteaks,
roasts, veal, and lamb to 140F.
Reheat sauces, soups, marinades, and gravies to a boil.
Reheat leftovers thoroughly to at least 165F. Use a food
thermometer to determine temperature. If a microwave
oven is used, cover the container and turn or stir the
food to make sure it is heated evenly throughout.
Do not eat raw or partially cooked eggs, or foods containing raw eggs, raw (unpasteurized) milk, or cheeses
made with raw milk. Cook eggs until whites and yolks
are firm.
The risk of contamination is high from undercooked
hamburger and from raw fish (including sushi), clams,
and oysters. Cook fish and shellfish until it is opaque;
fish should flake easily with a fork. When eating out,
order foods that have been thoroughly cooked and make
sure they are served piping hot.
When cooking, keep hot foods hot (140F or above) and
cold foods cold (40F or below.) Harmful bacteria can
Food and Water Safety • CID 2003:36 (Suppl 2) • S107
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grow rapidly in the danger zone between these temperatures. Whether raw or cooked, never leave meat, poultry,
eggs, fish, or shellfish out at room temperature for 12 h
(1 h in weather 90F or above). Chill leftovers as soon
as possible. Use refrigerated leftovers within 3–4 days.
Freeze fresh meat, poultry, fish, and shellfish that cannot
be used in a few days. Thaw frozen meat, poultry, fish,
and shellfish in the refrigerator, microwave, or cold water
changed every 30 min. Cook foods immediately after
thawing.
Avoid cross-contamination of foods. Uncooked meats
should not come in contact with other foods. Hands,
cutting boards, counters, knives, and other cooking utensils should be washed thoroughly after contact with uncooked foods.
Listeriosis is a serious disease that occurs frequently
among HIV-infected persons who are severely immunosuppressed. Some soft cheeses and some ready-to-eat
foods (e.g., hot dogs and cold cuts from delicatessen
counters) have been known to cause listeriosis. Reheating
these foods until they are steaming before eating them
can prevent listeriosis.
HIV-infected persons should not drink water directly
from lakes or rivers because of the risk for cryptosporidiosis and giardiasis. They should avoid swimming in
water that may be contaminated with human or animal
waste, and they should avoid swallowing water during
swimming.
Boiling water for 1 min will eliminate the risk of acquiring
cryptosporidiosis infection. The use of submicron, personal-use water filters or the drinking of bottled water
might also reduce the risk for acquiring cryptosporidiosis.
Current data are inadequate to support a recommendation that all HIV-infected persons boil or otherwise avoid
drinking tap water in nonoutbreak settings. Persons
choosing to use a personal-use filter or bottled water
should be aware of the complexities involved in selecting
the appropriate products, the lack of enforceable standards for destruction or removal of oocysts, the cost of
the products, and the difficulty of using these products
consistently.
Nationally distributed brands of bottled or canned carbonated soft drinks are safe to drink. Commercially packaged noncarbonated soft drinks and fruit juices that do
not require refrigeration until after they are opened are
also safe. Nationally distributed brands of frozen fruit
juice concentrate are safe if they are reconstituted with
water from a safe source. Only juices labeled as pasteurized should be considered free of Cryptosporidium risk.
Other pasteurized beverages and beers are considered safe
S108 • CID 2003:36 (Suppl 2) • Hayes et al.
to drink. No data are available concerning survival of
Cryptosporidium oocysts in wine.
CONCLUSION
Knowledge of safe food- and water-handling techniques is essential for persons living with HIV and AIDS, their caretakers,
and for health care providers to prevent the potentially lifethreatening nature of such infections. The prevention of foodborne and waterborne illnesses as a component of an overall
strategy for defensive living is critical. To decrease the risk of
infection from enteric pathogens, emphasis should be placed
on proper storage of perishable foods, adequate cooking of
animal foods, avoiding cross-contamination of raw and cooked
foods, ensuring appropriate sanitation in the kitchen, ensuring
proper personal hygiene, and using water from safe sources.
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