Is the Big Apple Clean Enough for Eating?
Abstract & Commentary
With Comment by Philip R. Fischer MD, DTM&H, Professor of Pediatrics, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN, and Associate Editor, Travel Medicine Advisor.
Synopsis: As demonstrated by a series of patients with Mycobacterium bovis infection in New York City, careful attention to sources and preparation of food can be as important while in the United States as during foreign travel.
Source: Munsiff S, Winters A. 2005 Health Alert #8: Mycobacterium bovis in US-born children. Department of Health and Mental Hygiene. The City of New York. March 15, 2005.
Thirty-five cases of Mycobacterium bovis were detected in New York City from 2001 through 2005. Seven of the cases occurred in children less than 6 years of age who had been born in the United States, but to parents who had been born in Mexico. Each of these children had extra-pulmonary disease, 5 with adenitis and 2 with peritoneal disease. One of the children with M. bovis peritonitis died.
The usual sources of human disease due to M. bovis are unpasteurized dairy products. Since pasteurized products are widely available in New York, and cattle in New York State are not infected with M. bovis, the finding of 7 M. bovis-infected US-born children stimulated great interest in a source investigation.
All adult cases with M. bovis had been born outside the United States, whereas 11 of 13 pediatric cases (and all the cases occurring prior to 6 years of age) had been born in the United States to Mexican-born parents. Twenty-one percent of M. bovis patients (all adults) were HIV-positive, and 60% had extra-pulmonary disease (compared to just 21% of New York’s non-M. bovis tuberculosis being extra-pulmonary).
Courier services provide delivery of food between New York City and Mexico. Most families affected by M. bovis in New York reported using either food delivered by courier or by family members from Mexico, food from Mexican grocery stores in New York where unlabeled cheeses are sold, or from door-to-door by vendors who sell unlabeled dairy products.
The health department in New York is continuing an investigation into the sources of unlabeled dairy products sold in the city. At the same time, the health department warns that “infants, children, pregnant women, the elderly, and those with weakened immune systems are at especially high risk for food borne illness” and that they “should avoid eating foods that contain raw, unpasteurized milk such as Mexican-style soft cheese.”
Comment
Tuberculosis was a major concern in New York in the late 1980s and early 1990s as the yearly incidence rose and peaked in 1992 at 3811 cases. Drug-resistant TB was noted even in nosocomial outbreaks. With the use of broadened initial treatment regimens, directly observed therapy, and improved prevention guidelines, the epidemic slowed. By 2002, the incidence had reached a historic low of 1084 cases.1 Nonetheless, health workers in New York remain actively vigilant in combating tuberculosis of all sorts. This report of M. bovis is a helpful result of those careful public health efforts.
Medical personnel routinely advise travelers to less-developed regions of the world to be careful about ingesting food and beverage items that were not boiled, bottled, purified, or recently well cooked. The New York report offers a timely reminder that, even in the home part of our global village, we should apply the same careful attention to food and beverage sources.
The findings of this New York investigation should not surprise us. Two years ago, the Centers for Disease Control and Prevention reported on the epidemiology of M. bovis disease in southern California, and compared 129 M. bovis cases with 1802 M. tuberculosis cases.2 In 90% of M. bovis cases, the individual was Hispanic, while 23% were children and 53% had extra-pulmonary disease. Hispanic identity, young age, and extra-pulmonary disease were all more common with M. bovis infections than with M. tuberculosis. Cheese and other dairy products from Mexico were not infrequently consumed in the area of this investigation. Interestingly, recreational deer hunters are also potentially at risk of M. bovis disease due to improper handling and cooking of potentially infected deer.3
Mycobacterial disease is not the only infectious disease problem transmitted by incompletely prepared foods in the United States. Illicitly produced Mexican-style cheese was linked to an outbreak of listeriosis in North Carolina in 2000.4 In that situation, 11 patients were pregnant. As a result, there were 5 stillbirths, 3 premature deliveries, and 3 infected newborns. The Listeria organisms had seemingly identical genotypes, even though the sources seemed to vary from cheese sold door-to-door, cheese sold by public vendors, and raw milk sold illicitly from a licensed vendor. This is reminiscent of an outbreak of listeriosis that occurred among 142 individuals in Los Angeles, CA, in 1985, which was associated with Mexican-style soft cheese that was commercially prepared, yet contaminated by unpasteurized milk.5 Similarly, serious consequences of pregnancy outcomes were noted in that report.
So, pre-travel advice about avoiding unpasteurized dairy products should apply to residents of the United States, just as it applies to foreign travelers. Sometimes, it is also important to avoid raw fruits and vegetables, even in Philadelphia. In 2000, 54 wedding guests in Pennsylvania developed diarrheal disease associated with cyclosporiasis. Imported raspberries had been used in the preparation of the wedding cake. Sadly, this represented the fifth of 6 consecutive years during which there was a springtime outbreak of cyclosporiasis in North America related to Guatemalan raspberries.6 In recent years, green onions from Mexico, served in a Pennsylvania restaurant, were associated with an outbreak of hepatitis A that involved over 500 people.7
The spring and summer seasons are upon us. Both we, our patients and clients, will have many opportunities to enjoy a variety of foods and drinks in a variety of settings. Stricter attention to sources of our dairy products and our uncooked foods will be important—certainly for travelers, but also for us here at home, as the world and its microbial flora come to visit us.
References
1. Paolo WF, et al. Tuberculosis in New York City: Recent Lessons and a Look Ahead. Lancet Infect Dis. 2004; 4:287-293.
2. LoBue PA, et al. Epidemiology of Mycobacterium bovis in San Diego County, 1994-2000. Int J Tuberc Lung Dis. 2003;7:180-185.
3. Wilkins MJ, et al. Mycobacterium bovis (bovine TB) Exposure as a Recreational Risk for Hunters: Results of a Michigan Hunter Survey, 2001. Int J Tuberc Lung Dis. 2003;7:1001-1009.
4. MacDonald PD, et al. Outbreak of Listeriosis Among Mexican Immigrants as a Result of Consumption of Illicitly Produced Mexican-Style Cheese. Clin Infect Dis. 2005; 40:677-682.
5. Linnan MJ, et al. Epidemic Listeriosis Associated with Mexican-Style Cheese. N Engl J Med. 1988;319: 823-828.
6. Ho AY, et al. Outbreak of Cyclosporiasis Associated with Imported Raspberries, Philadelphia, Pennsylvania, 2000. Emerg Infect Dis. 2002;8:783-788.
7. Hepatitis A Outbreak Associated with Green Onions at a Restaurant—Monaca, Pennsylvania, 2003. MMWR. 2003;52:1155-1157.
As demonstrated by a series of patients with Mycobacterium bovis infection in New York City, careful attention to sources and preparation of food can be as important while in the United States as during foreign travel.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.