So long, sunny side up: preventing food-borne illness in nursing homes - includes related articles

FDA Consumer, Dec, 1991 by Rebecca D. Williams

Every morning until about three years ago, Janet Tulloch, 67, ate her favorite breakfast of poached eggs at The Washington Home, the longterm care facility in Washington, D.C., where she has lived for 24 years.

But no more. Raw, poached, runny--yolked, or sunny side up eggs are not served in the nursing home because they are a common source of food--borne illness. The alternative--pasteurized eggs-is safer, but not as fresh tasting, Tulloch says.

"They do serve hard-boiled eggs and scrambled eggs made from ready-mixed stuff," says Tulloch, "but they're not as good."

Eggs and many other foods may be contaminated with disease-causing bacteria. If these foods are under-cooked or mishandled, they can cause illness. While most foodborne illnesses are not life-threatening in younger adults, they are not so easily shaken off by the elderly.

According to a recent study, nursing home residents accounted for 2.4 percent of the food-borne illnesses in the United States between 1975 and 1987, but 19.4 percent of the deaths. The elderly were 10 times more likely to die of foodborne illnesses than younger adults.

The study, titled Foodborne Disease Outbreaks in Nursing Homes, 1975 to 1987," was published in the Oct. 16, 1991, issue of the Journal of the American Medical Association (JAMA). It was co-authored by Douglas Archer, Ph.D., deputy director of FDA's Center for Food Safety and Applied Nutrition, and William C. Levine, M.D., Joanne F. Smart, M.D., Nancy H. Bean, Ph.D., and Robert V. Tauxe, M.D., all of the national Centers for Disease Control in Atlanta, Ga.

"Frankly, the results were kind of surprising," says-Archer. "The mortality rates were much higher than we had expected."

Here are some examples of the many cases included in the study:

* In November 1986, five residents of a Windsor, Conn., nursing home died, and 25 others became ill with salmonellosis, a disease caused by bacteria often found in poultry and egg products. Although health officials never pinpointed the source of the outbreak, they suspected that a blender used to puree food had previously been used to mix contaminated foods such as eggs and had not been properly cleaned.

* In September 1984, 34 residents of a Papillion, Neb., nursing home became ill and four of them died after eating undercooked hamburger.

The meat contained a particularly virulent strain of Escherichia coli, a bacterium sometimes found in cattle intestines.

* In the spring of 1986, 88 people at a Minnesota nursing home developed severe diarrhea from Giardia lamblia, an intestinal protozoa spread through food or person-to-person contact.

The infection probably began in a pre-school day-care center located in the nursing home and spread to the elderly residents both by personal contact with the children and through food, since the mother of one of the infected children worked in the nursing home's kitchen.

These are just a few of the 166 outbreaks of food-borne disease that the JAMA study surveyed. The actual number of food-borne illnesses in nursing homes is thought to be much higher, however. Diarrhea is fairly common in nursing homes, so food poisoning may be mistaken for unrelated diseases and therefore go unreported to CDC.

Most of the food-borne illnesses in nursing homes could not be traced to a specific pathogen, according to the JAMA study. Of those that could, Salmonella bacteria, found most often in poultry and eggs, caused 53 percent of the outbreaks and 81 percent of the deaths.

The next most common cause of illness was Staphylococcus, which lives on the skin of healthy people and can be transferred to food during handling.

A third pathogen, found in human and animal feces, Escherichia coli, was not as common, but like Salmonella and Staphylococcus, it caused a higher-than-average rate of hospitalization and deaths.

In 59 of the outbreaks where the origins of the illnesses were known, improper food handling played a key role. Investigators described food handlers who didn't wash their hands before preparing food, didn't store or cook foods at the proper temeratures, or failed to clean and sterilize the equipment. Eggs and poultry were the foods most likely to cause illness.

Why Are Older People More Affected?

Scientists do not know for sure why elderly people die more often from food-borne illnesses than younger adults.

There are several theories: Their immune systems may be weaker, other debilitating diseases may contribute to the problem, or their stomachs may have less acid to kill potentially harmful bacteria. Many older people, particularly in nursing homes, also take antibiotics, which tend to increase the risk of food-borne illnesses because they suppress beneficial bacteria in the intestines.

The predominant symptom of a food-borne illness is diarrhea, which is a contributing factor to death among the elderly far more often than any other age group in the United States. According to another study, this one published in the June 26, 1991, issue of JAMA by Judy F. Lew, M.D., and colleagues from CDC and the Emory University School of Public Health, more than half the people who died of diarrhea between 1979 and 1987 were older than 74. Within this group, 31 percent were living in nursing homes or similar institutions.