I know you already knew this, but it’s National Healthcare Foodservice Workers Week.
All sarcasm aside, the importance of safe food handling practices for healthcare workers is likely underrated. While safe food is important to all of us, healthcare food service workers serve a particularly vulnerable population. The elderly, in particular, are foremost among that vulnerable population.
The Increased Risks Posed by Foodborne Pathogens to the Elderly
One group of persons served by healthcare foodservice workers is the elderly. Morbidity and mortality in the elderly from infectious disease is far greater than in other populations. For instance, death rates for infectious diarrheal disease alone are five times higher in people over 74 years of age than in the next highest group, children under four years of age, and fifteen times higher than the rates seen in younger adults. Published studies attribute the elderly’s heightened risks, both of infection and mortality due to enteric infectious disease, to several factors: (1) the aging of the gastrointestinal tract (reduced gastric acidity/reduced gastric mobility); (2) a higher prevalence of underlying medical disorders (co-morbidity factors); and (3) malnutrition and a decline in the immune response that leaves the host less able to defend itself against infectious agents.
1. Aging of the Gastrointestinal Tract–An Invitation to Infection
Inflammation and shrinkage of the gastric mucosa increase with age. These changes lead to low gastric acidity. Because stomach acids play an important role in limiting the number of bacteria that enter the small intestine, low gastric acidity increases the likelihood of infection if a pathogen is ingested with food or water.
Gastrointestinal mobility also decreases with age, meaning that life-threatening pathogens are removed from the body more slowly. This delay contributes substantially to the increased prevalence and severity of infection in the elderly. When the pathogen is E. coli O157:H7, decreased gastrointestinal mobility allows the bacteria to multiply and produce more of the toxin that is absorbed in the gastrointestinal tract and leads to a higher likelihood of complications.
2. A Higher Prevalence of Underlying Medical Conditions– Co-Morbidity Factors
Underlying medical conditions or disease (co-morbid factors) also contribute to the morbidity and mortality of infection in the elderly. Among hospitalized patients, those older than 65 develop pneumonia twice as often as younger patients. Pneumonia is the leading infectious cause of death in the elderly.
When an infectious microorganism, regardless of source, gains access to the bloodstream, the patient may develop systemic sepsis, also known as bacteremia. Bacteremia is most common in people who are already affected by, or are being treated for, some other medical problem (co-morbid disease); conversely, people in good health with strong immune systems rarely develop bacteremia. The main sources of bacteremia in elderly patients are the urinary tract, gastrointestinal tract, respiratory tract, and the skin. Other potential sources include surgical wounds, invasive tubes and catheters, intravenous lines–virtually any site where an invasive medical procedure has occurred. Bacterial organisms most likely to cause bacteremia include members of the Staphylococcus, Streptococcus, and Escherichia coli genera.
3. A Weakened Immune System–An Inability to Fight Off Infection
With advancing age come progressive weakness, decline, and dysfunction of the immune system. Many of the body’s natural physiologic responses to infection are therefore blunted in the elderly; and the intensity of many clinical signs and symptoms in an elderly patient with an infectious process are muted when compared to those in a younger person. This age-related decline contributes significantly to the increased risk of severe illness and mortality in elderly persons with infectious disease. The effect of a weakened immune response on the health of an elderly person often manifests most apparently during periods of intense stress (e.g., surgery, sepsis, multiple organ failure, malnutrition, dehydration).
Prior Foodborne Illness Outbreaks in Healthcare Settings
2005 E. coli O157:H7 Outbreak, King County, Washington
In late September 2005, Pubic Health Seattle and King County (PHSKC) and the State of Washington Department of Health (WDOH) began investigating a cluster of E. coli O157:H7 illnesses in King County. The agencies eventually concluded that an outbreak consisting of 14 cases of E. coli O157:H7 (4 laboratory confirmed cases, and 10 probable cases) was tied to consumption of food served at a senior living facility in Bellevue, Washington. One of the members of the outbreak, an 83-year-old woman, who was culture confirmed with E. coli O157:H7, died as the result of her infection. PHSKC determined that the source of illness was traced to ready-to-eat foods prepared at the facility–likely a garnish. PHSKC investigators conducted an on-site inspection of the kitchen, and found food-handling errors, that supported the conclusion that the ready-to-eat foods had been cross-contaminated through contact with raw meat products.
2003 E. coli O157:H7 Outbreak, San Mateo County, California
In 2003, the San Mateo County Health Services Agency investigated an outbreak of E. coli O157:H7 and determined that sixteen confirmed and probable E. coli O157:H7 cases were linked to spinach served by Sodexho at an upscale retirement facility in Portola Valley. The spinach, which was pre-packaged before it reached the facility, was never washed by Sodexho staff in the kitchen prior to serving. As with the 2005 outbreak in Washington state, one of the residents of the facility died as the result of her infection.
As the tragic examples above demonstrate, healthcare foodservice workers have a lot at stake when preparing food for their patients and clients. Those with compromised immune systems, including the elderly, are at great risk for severe complications of foodborne illness.
National Healthcare Foodservice Workers Week is being promoted by the American Society for Healthcare Food Service Administrators.