Eating Dangerously Read online

  A case of the real influenza can certainly upset your stomach. And a bout with food poisoning can certainly leave parts of your body aching as if you’d been laid up with the flu. But a basket of disparate symptoms does not add up to an illness called the stomach flu.

  What people call the stomach flu, for lack of a better term, is more than likely a foodborne pathogen from the list of common food-related illnesses compiled annually by the CDC. Norovirus can cause severe vomiting and diarrhea a few hours after ingestion or inhalation. Salmonella can cause fever and diarrhea a couple of days after eating undercooked, contaminated chicken. The parasite Giardia can cause an acute and then lingering gut attack a week after drinking tainted ice cubes at a foreign cafe, or drinking untreated water from a mountain stream.

  There are clear medical clues, though, and some new developments in health care and food science, that can distinguish your illness from that morass of “stomach flu” suffered by millions of unknowing Americans every year. Counting backward to the camping trip where you drank untreated water can help pinpoint Giardia and find you the right drug to prevent weeks of ignorant suffering. Helping a doctor diagnose E. coli O157 can prevent lifelong kidney damage in a loved one and steer authorities toward compiling information for a widespread food recall. Making the connection between your child’s vomiting and a bigger outbreak at the daycare center can contribute to the momentum building for a norovirus vaccine, one of the coming advances in pathogen control.

  If a pathogen has ridden along on food and disrupted your family’s life, use the following guide to narrow down the possibilities and help speed recovery. Obviously no layman’s summary can substitute for sound medical advice, and only a family doctor should prescribe treatment when an illness becomes severe. But at the very least, you can be prepared, and learn how to ask the right questions.1

  Norovirus

  The malady most commonly misidentified as “stomach flu” actually stems from norovirus, and it has a more accurate nickname. Imagine it stitched in red across a blue supervillain costume: PP, for “perfect pathogen.”

  Norovirus is omnipresent, hardy, opportunistic, adaptable, and self-preserving. Not to mention the most ominous trait—“aerosolized,” which should bring to mind a cloud of millions of threatening droplets settling on surfaces passed by oblivious citizens every day. The symptoms accompanying “noro” are often characterized as “explosive,” which along with “aerosolized” may fill in more of the picture than you really wanted to know.

  Norovirus is by far the most common foodborne illness in the United States, though it also spreads by other viral contact methods: your airplane seat mate sneezing on your drink and your book, or a hundred people touching the same cruise ship doorknob originally grabbed by an ill partier. Its many nicknames include the “nursing home” virus, or the “cruise ship” virus, because it causes so many of the large and fast-spreading outbreaks where masses of people congregate in a small space, served by people who come into contact with a high percentage of guests.

  One of the world’s leading experts on norovirus wrote a paper that included a chilling tale of one outbreak investigation, which helped researchers reinforce their knowledge of the pathogen’s “aerosolized” traits. A group of girls was on a road trip on a sports bus, headed to another city to play a big game. One of the athletes came down with norovirus somewhere along the way and retreated to a bathroom at a tour stop. All of us who have ever had that kind of sudden-onset stomach bug can imagine the private horror show of that bathroom: the back-wrenching nausea, the mad dashes back to the toilet stall, the gasping pauses at the sink for a splash of cold water on the back of the neck. Someone on the team had brought into that bathroom a plastic shopping bag filled with food for the team lunch, and that unfortunate cloud of illness settled all over the bathroom, including onto the bag. The sick girl left the athletic tour, but that food bag stayed with the team. The sick girl never touched it. But when the other team members ate their lunch, they were touching the bag that had sat in the middle of the pathogen cloud, then opening food, then putting hand to mouth and passing germs around the team.

  Seven of the eleven girls who handled the shopping bag or its food contents also got sick with norovirus. When a norovirus sufferer walks through a public area, they leave an invisible stain across a mind-boggling number of surfaces, much like Peanuts’ Pigpen. In researching other outbreaks, scientists have found norovirus lurking in light fixtures, among other “that’s not possible!” locations. In another notorious outbreak, 2,700 people got sick from one strain—traceback researchers found all of them were connected to forty-six different weddings. The forty-six weddings all used the same bakery for the cake, and a baker’s illness there was where it all began.

  Elsewhere, illness tracers found 115 norovirus victims who had all eaten sandwiches made by one sub shop employee.

  Norovirus causes twenty-one million U.S. cases of gastroenteritis a year, with more than five million of those delivered on or in food. The food cases alone in the United States cause about fifteen thousand hospitalizations, and 150 deaths. Worldwide, the virus may cause about two hundred thousand child deaths a year, especially in nations without the medical facilities to treat the debilitating, acute diarrhea and dehydration that can define an unattended case. (Some literature still occasionally refers to it as “Norwalk,” after an Ohio city with a major outbreak of the illness in the 1960s.)

  What makes norovirus so perfect in such an awful way? CDC researcher Aron Hall, a veterinarian who is one of the world leaders on the virus, listed the reasons. It’s highly contagious, and in an epidemiologist’s phrase, “well-shed.” Imagine that cloud coming off Pigpen: one gram of feces, for example—the weight of a paper clip or dollar bill—can contain five million doses of norovirus. It can survive two weeks on a surface by being resistant to both heat and cold, and in a stable, refrigerated environment, it can survive for months. Norovirus is also clever enough to make many people sick without making many of them too sick; in other words, it does not kill its host. Those people recover, and because norovirus is constantly evolving, they do not build up full immunity to the next slightly different strain of the same virus. They are ready to play host again, and norovirus is happy to be a return guest.

  Though most people who get norovirus are only symptomatically sick for one to three days, they are shedding the virus for weeks in their stool, mostly without knowing it. They may think their family is in the clear a week after their illness, but if the recovered family member serves food and doesn’t practice careful hygiene, that norovirus cloud is ready and waiting.

  The high survivability and voluminous “shedding” inherent to norovirus are two of the factors that landed it the dubious status of the Cruise Ship Virus. Even more accurate would be the Nursing Home Virus—by far the largest number of identified outbreaks of norovirus take place in nursing homes, where residents may have a hard time maintaining hygiene and where aides circulate from room to room many times a day, touching beds, hand rails, bathroom fixtures, doorknobs, and TV remote controls.

  The virus can be a nightmare in the restaurant business as well, since it can be added into food at any stage of preparation and service while surviving almost every step of the way.

  Detecting the outbreaks of norovirus is a greater challenge because the retail medical community isn’t yet set up to look for the superbug. The average doctor’s office or lab does not have a norovirus test kit, allowing clusters of cases to develop and multiply long before a public health agency can make all the connections.

  Many foodborne illnesses share symptoms, but there are a few ways to zero in on what you or a family member might have. The incubation period for norovirus illnesses averages about twenty-four hours after contact, which is longer than a food illness caused by a toxin and shorter than the waiting period for Salmonella or E. coli to manifest.

  Norovirus causes diarrhea, as in other g
astrointestinal illnesses, and it is often quick onset—severely, if temporarily, debilitating. (How do we define debilitating? Curled up on a bed or a bathroom floor while calling for your mommy, and not being able to venture more than a few feet from a bathroom while the intestines are churning.) But one key to norovirus is the addition of vomiting, which can be frequent and severe, to accompany the diarrhea. The virus inflames both the stomach and the intestines. The terrible feeling for a few hours at both ends, soon followed by what can be wrenching body cramps and soreness from all the upheaval, are signs of norovirus whipping through to make your part of the universe miserable. You may also have a low-grade fever.

  Generally healthy people, in the wide range between childhood and late senior years, need not worry too much about norovirus. It’s awful while it’s happening, yes, and will make many people beg for relief in the middle of the night, but the symptoms are usually dangerous only to the ego. Issues to look out for include severe headaches, light-headedness, and crippling fatigue that could signal dangerous dehydration. Children, the elderly, and pregnant women need to be watched more closely, since the fever and dehydration could exacerbate other medical issues.

  The treatment for norovirus is time. Rest, sleep, distract yourself with favorites in your movie queue, and let the microbial invaders flush out of your body. Start sucking on ice chips when you think you might be able to hold something down, and progress to small sips of water if that goes well. Don’t worry about eating any time soon; the best trick is to replace lost fluids as soon as you can tolerate them.

  For those suffering an acute case that feels more dangerous, a visit to the doctor or emergency room might result in a prescription for an antinausea drug or an IV drip to more quickly replace fluid when the stomach still can’t hold any. When the prospect of swallowing something other than water finally feels tolerable, some acetaminophen will help with a lingering headache or other body throbs left behind by heaving episodes.

  Because norovirus sheds in such enormous quantities even after most symptoms are gone, public health officials ask parents to keep their children home from school for three days after the diarrhea has resolved in order to protect other children in close-contact settings. Scrub down the bathrooms, doorknobs, counters, and other high-contact areas with bleach-based disinfectant to stop noro from taking down anyone else in the family.

  Salmonella

  A case of salmonellosis caused by the Salmonella bacteria may be hard to distinguish at first from norovirus or other pathogens. But there are a few telling clues, and Salmonella also comes with some added dangers that make sorting out those clues a worthy venture.

  Salmonella bacteria is almost always delivered to humans by the foods they eat. A significant number of cases, though, are caused by contact with pets and other animals, particularly turtles and reptiles. Moms who yell at their kids to put the turtle down and wash their hands are far from crazy—thousands of cases a year result from kids handling pets and then going straight to snack time.

  The foods that turn up most often in tracebacks are undercooked poultry, raw or undercooked egg products, ground beef, and salad greens like spinach and mixed lettuce. If a meal or a snack with any of those suspect items comes to mind during the first stages of a family bout with stomach illness, note it down.

  The CDC estimates about 1.4 million U.S. cases of salmonellosis a year. The average case of salmonellosis takes slightly longer to incubate than most norovirus cases. Symptoms are likely to appear eighteen to seventy-two hours after ingesting the bacteria, while many norovirus cases have shown up within twenty-four hours after contact.

  The early symptoms match the usual list in any stomach-centered malady. Vomiting, headaches, fever, aches, diarrhea. One thing to watch for is diarrhea becoming bloody, which is a marker for Salmonella. The symptoms also can last much longer than typical norovirus, with the body feeling wracked for four to seven days in many patients.

  If you need a doctor’s attention and they suspect Salmonella, they will seek lab testing. But those results can take days, so your medical group will be treating the symptoms or even the bacteria itself before that. Dehydration is the main thing to watch for early in the illness, again especially with younger patients, the elderly, or those with previously compromised immune systems from another condition.

  There are a number of different strains of this bacteria, though Salmonella enteridis is by far the most common.

  Those patients still feeling terrible a few days into the illness will likely hear about a possible bacterial cause and ask for antibiotics to fight the salmonellosis. But they may get a fight from their doctor if they are exhibiting “normal” symptoms, however debilitating, with no complications. Overuse of antibiotics is part of what has gotten the world into more trouble with Salmonella in the first place. Fast-feeding livestock operations have put so much antibiotic in animal feed because preventing illness preserves profits that Salmonella over time developed resistant strains. As with overtreatment of childhood ear infections, the medical community wants to avoid creating superstrains and knocking more medicines from the shrinking list of effective antibiotics. And perhaps the more relevant problem: for people with those basic symptoms, antibiotics have not been shown to speed up recovery. In some research, those who were put on antibiotics had more relapses than untreated patients.

  Where Salmonella gets worse is when it survives the stomach and intestines and moves into the bloodstream, creating a more dangerous blood infection. It can also move into other organs. This is when it becomes enteric, or typhoid, and since most Americans are not routinely immunized for typhoid, the medical problems become very serious. About 30 percent of these cases develop a telltale chest and torso rash that can help doctors identify the course of the illness.

  Typhoid Salmonella cases present other special problems, including the possibility of long-term carriers. People can shed the bacteria and endanger those around them for years, sometimes without any idea they are putting people at risk. “Typhoid Mary” carried this version, and she infected dozens of members of various families from her position as an itinerant household cook in the early 1900s. Signs of Salmonella reaching the typhoid stage include fever spikes to 104 degrees or more, slow heartbeat, and inflammation in the stomach and intestines.

  E. coli

  The beginnings of an E. coli episode may seem like a repeat of other foodborne illness descriptions, but the special dangers of certain bacteria strains make it all the more important to distinguish if you and your medical provider suspect it as a cause.

  E. coli has been around, and inside, all of us for as long as we’ve been eating and living in an imperfectly clean world. Various strains of the bacteria are part of the human and animal intestinal system. But a few strains attacking humans from outside sources can cause bloody diarrhea, kidney failure, and in extreme cases, death. The one we’ve been hearing the most about in recent years is Escherichia coli O157:H7, which has been responsible for many of the hamburger- and spinach-related outbreaks that brought food safety awareness in the United States to new levels.

  E. coli symptoms can arrive quickly, but their incubation window stretches wider than some of the other pathogens, up to eight days in some cases, compared to a day for many norovirus cases or one to three days for Salmonella. Once it appears, though, it is much more associated with severe diarrhea, and eventually bloody diarrhea, than with the double-whammy of vomiting from other pathogens. Severe abdominal cramps are a common accompaniment to the frequent diarrhea.

  Doctors will likely ask about foods eaten, but the long incubation period for E. coli can make that discussion a challenge. Undercooked hamburger is highly suspect, since ground-up cattle parts bring all the potential pathogens clinging to the surface of meat deep into the heart of the food, where cooking temperatures take longer to penetrate. Other outbreaks have eventually been traced back to improperly washed spinach and other salad gre
ens, or alfalfa sprouts that food safety officials constantly find problematic.

  Dehydration from the loss of body fluids, as we’ve said with the other illnesses, is a prime danger from E. coli, particularly with children, who have less margin for fluctuation. So keep a careful eye on that; doctors will recommend replacement fluids and even resort to an IV if there’s no other way to deliver the vital replenishment.

  Not all labs test automatically for E. coli, but the doctor should seek that form of test, especially if bloody diarrhea is present. In the meantime, the other signs to be watchful for are markedly white pallor that could indicate the beginnings of anemia, and failure to produce urine. A halt to urine could be a sign that E. coli has begun breaking down kidney tissues, which are a prime target for the bacteria. That can lead to hemolytic uremic syndrome, or HUS, which develops in about 10 percent of children under age ten who have an E. coli infection. The syndrome usually shows up, if it does at all, about a week after severe diarrhea has begun. For some patients, dialysis can prevent organ failure; more severe cases can lead to permanent kidney loss and the need for lifetime dialysis or transplant.

  Antibiotics are not usually recommended to fight E. coli’s foodborne illness symptoms, and treatment focuses on helping the body get over the symptoms, whether by adding fluids or through more drastic measures such as the blood cleansing provided by dialysis.

  All E. coli O157 cases should be reported to local health authorities to help them isolate and recall contaminated foods that could still be on the market. Shared reporting can also alert local medical offices to catch other undiagnosed patients early enough in their illness to make a difference.