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Food and Water Safety and Other Issues
Celia Hayes, MPH, RD, Elisa Elliot Ph.D., Edwin Krales, MS, CD/N, Goulda Downer,
RD, Ph.D.
Abstract
Public health and food safety experts estimate that millions of illnesses can be
traced to contaminated food and water. Food and water safety is extremely important to
persons with HIV. Their immune systems are compromised and they are very 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.
Introduction
Immunocompromised persons are more susceptible because of their weakened
immune system,to serious food and waterborne illnesses than persons with a stronger
immune system. These secondary infections, transmitted through food and water,
contribute significantly to the morbidity and mortality of HIV-infected 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.
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Chronic diseases which may result from foodborne diseases include arthropathies,
chronic gastroenteritis, organ compromise, nutritional and other malabsorptive disorders
as well as the potential for death [1].
Diarrhea is usually the most significant manifestation of such an infection and a
possible life-threatening complication. Diarrhea in immunocompromised patients is a
challenge for the treatment and prevention of wasting. Fifty to ninety percent of AIDSinfected persons usually have diarrhea that may 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 [10]. Many microorganisms (Giardia lamblia,
Entamoeba histolytica, Cryptosporidium, Salmonella, Shigella, Listeria, Yersinia, and
Campylobacter species, etc.) identified as the cause of enteric infections in HIV-infected
patients, have also been recognized as etiological agents in food and waterborne diseases.
Salmonellosis is estimated to be nearly 20 times more common and 5 times more
often bacteremic in AIDS patients than in patients without AIDS [3]. In AIDS-infected
patients, non-typhoidal salmonellosis is often life-threatening and relapsing [4,5,6].
Similarly, campylobacteriosis can also cause bacteremia and be difficult to cure in AIDS
patients [7]. Mycobacterium species, including antimicrobial-resistant M. avium
complex and M. tuberculosis, also cause enteric infections and disseminated infections in
patients with AIDS [2]. Risk factors for disseminated Mycobacterium avium complex
included decreasing CD4 count (i.e., 35% increase in the odds of developing
disseminated M. avium complex with each 10 x 106/ liter-cell decrease in CD4 count),
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swimming in an indoor pool. (treatments with granulocyte colony-stimulating factor, and
history of bronchoscopy [8]. ) An epidemiologic study of persons with HIV infection also
found an association between consumption of raw fish and M. avium complex [9].
A San Francisco study, Celum et al. 1987 [3] found the average annual incidence of
salmonellosis in men 15 to 60 years old with AIDS was 384 per 100,000 while the
average annual incidence for men the same age, without AIDS, was only 20 per 100,000.
Salmonella bacteremia was more common in AIDS patients (45 percent) than in those
without the disease (9 percent). This report and related reports determine the following
microorganisms could be identified in 55 to 86 percent of cases of patients with AIDS:
cytomegalovirus, and Herpes simplex virus; Salmonella species, Campylobacter species,
Clostridium dificile toxin, Mycobacterium spp., Shigella species, Vibrio
parahaemolyticus; Cryptosporidium, Entameoba histolytica, Giardia lamblia, Isospora
belli, microsporidia, and Strongyloides stercoralis [10,11,12,13,14].
Listeriosis, shigellosis, cholera, and Vibrio vulnificus enteritis are other bacterial
foodborne diseases for which people with HIV/AIDS are at increased risk. Soft cheeses,
contaminated milk, ice cream, lettuce, undercooked poultry, hotdogs not thoroughly reheated, and deli 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 the most
recent report (Mead et al., 1999), the estimated annual incidence of foodborne listeriosis
in the United States is 2518 cases and 499 deaths, an approximate 20 percent case fatality
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rate. This 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 (cirrhosis, diabetes,
immunodeficiency caused by AIDS or other sources) and has a 50 percent 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 [15]. Usually
waterborne, Cryptosporidium also can cause limited diarrhea of short duration in
immunocompetent patients [16,17,2]. Cryptosporidiosis has also been traced to
consumption of raw milk, unpasteurized apple cider, and chicken salad [18,19]. There is
no known effective drug for the treatment of cryptosporidiosis. Immunodeficient
individuals, especially AIDS patients, may have the disease for life, with severe diarrhea
and invasion of the pulmonary system contributing to death [20].
Beginning in 1985 and similar to the emergence of Cryptosporidium, four
microsporidian protozoan parasites have been found, almost exclusively in AIDS
patients. Two microsporidians implicated in chronic diarrhea are Enterocytozoon
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bieneusi, and Septata intestinalis, [21] however, the sources and modes of transmission
are uncertain. Environmental waterborne transmission (contact) is possible, as are
ingestion of the spores, inhalation of aerosolized spores, and sexual transmission [22].
Effective therapies for Enterocytozoon bieneusi, have not been established [23,24].
Another protozoan parasite causing diarrhea and malabsorption, Isospora belli, may
require repeated antimicrobial therapy in patients with AIDS [25,26,27,28].
The following precautions for preventing or minimizing food/waterborne diseases are
recommended by the USPHS/IDSA Prevention of OIs Working Group:
1. Do not consume raw or undercooked eggs, including foods that might contain raw
eggs (e.g., some preparations of cookie dough ice-creams, hollandaise sauce, Caesar
and other salad dressings/mayonnaise); raw or undercooked poultry, meat, seafood;
and unpasteurized dairy products that might contain enteric pathogens. Poultry/meat
should be cooked until no longer pink in the middle (internal temperature, >165 F
[73.8 C ]. Produce should be washed thoroughly before being eaten.
2. Avoid cross-contamination of foods. Uncooked meats should not come in contact
with other foods. Hands, cutting boards, counters, and knives, and other cooking
utensils should be washed thoroughly after contact with uncooked foods.
3. 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
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listeriosis. Listeriosis can be prevented by reheating these foods until they are
steaming before eating them.
4. 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 avoid swallowing water
during swimming.
5. Boiling water for 1 minute will eliminate the risk for acquiring cryptosporidiosis.
Using submicron, personal-use water filters and/or drinking bottled water might also
reduce the risk for acquiring cryptosporidiosis. Current data is inadequate to support
a recommendation that all HIV-infected persons boil or otherwise avoid drinking tap
water in non out-break 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 non-carbonated 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 risk- free from
Cryptosporidium. Other pasteurized beverages and beers are considered safe to drink.
No data is available concerning survival of Cryptosporidium oocysts in wine.
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Knowledge of safe food/water-handling techniques is essential for HIV-infected
patients, 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 for HIVinfected patients. To decrease the risk of infection from enteric pathogens, emphasis
should be placed on the proper storage of perishable foods, adequate cooking of animal
foods, avoiding cross-contamination of raw and cooked foods, appropriate sanitation in
the kitchen, proper personal hygiene, and using water from safe sources.
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18. Centers for Disease Control and Prevention. 1996. An outbreak of cryptosporidiosis
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and R.V. Tauxe. 1999. Food-related illness and death in the United States.
Emerging Infectious Diseases 5(5):607-625.
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Estimates of Foodborne Transmission (Source: Mead, P.S., L. Slutsker, V. Dietz, L.F.
McCaig, J.S. Bresee, C. Shapiro, P.M. Griffin, and R.V. Tauxe. 1999. Food-related
illness and death in the United States. Emerging Infectious Diseases 5(5):607-625.)
Agent
% Foodborne transmission (estimates)
Campylobacter spp.
80
Escherichia coli O157:H7
85
E. coli, enterotoxigenic
70
E. coli, other diarrheogenic
30
Listeria monocytogenes
99
Salomonella, spp., nontyphoidal
95
Shigella spp.
20
Staphylococcus food poisoning
100
Vibrio cholerae, toxigenic
90
Vibrio vulnificus
50 (the rest are wound infections)
Vibrio, other
65
Yersinia enterocolitica
90
Cryptosporidium parvum
10 (presumably most are waterborne)
Cyclospora cayetanensis
90
Giardia lamblia
10
Toxoplasma gondii
50
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