Foodborne Illnesses Nursing CE Course

Gastroenteritis refers to the symptoms of any disease affecting the gastrointestinal (GI) tract. Infectious foodborne diseases are the most common cause of gastroenteritis. Primary symptoms are diarrhea and vomiting. Diarrhea is defined as three or more loose or liquid stools a day. Acute diarrhea lasts less than 2 weeks, while chronic diarrhea lasts longer than 2 weeks. Prolonged or frequent vomiting or diarrhea can deplete intravascular fluid, causing tachycardia and hypotension. The acid–base balance is also affected, with vomiting more likely to result in metabolic alkalosis and diarrhea more likely to result in metabolic acidosis. Both vomiting and diarrhea can cause hypokalemia. The degree and severity of vomiting and diarrhea can vary depending on the etiology of the foodborne disease. Therefore, HCPs should instruct patients on recognizing those symptoms that can be managed at home and those that require medical attention (Gotfried, 2025a; Hinkle et al., 2022; LaRocque & Harris, 2025).

Foodborne diseases are usually acute illnesses that last less than a week. Many people do not seek treatment. A challenge with foodborne diseases is that HCPs often do not see many of those affected. Sometimes, patients do not seek treatment for several days after contracting an infection. The most common symptoms are the sudden onset of diarrhea, nausea, vomiting, abdominal cramping, and fever. Symptoms that indicate a need for medical intervention include bloody stools, a high fever (over 102°F), prolonged vomiting or an inability to keep liquids down, diarrhea for more than 3 days, and severe dehydration with decreased urination or postural hypotension. The most common acute complication is dehydration. Additional risks accompany any foodborne illness that occurs during pregnancy, resulting in miscarriage or stillbirth. Long-term complications can include chronic arthritis, hemolytic-uremic syndrome (HUS), and brain or nerve damage (CDC, 2025h; LaRocque & Harris, 2025; National Institutes of Diabetes and Digestive and Kidney Diseases, 2019).

Risk Factors for Foodborne Disease and Complications

Foodborne diseases can affect anyone; however, children younger than 5, adults over 65, and immunocompromised and pregnant individuals are at increased risk of disease and complications. Those at the most significant risk from GI infections are young children. Dehydration resulting from diarrhea and vomiting is the immediate physiologic complication, but the infection may also damage the gut, leading to nutritional and developmental deficiencies. Young children with Salmonella are three times more likely to be hospitalized. In children under 5 with E. coli 0157 infections, 1 in 7 will develop kidney failure. Worldwide, there are 125,000 deaths annually in children under the age of 5 from foodborne diseases. While much credit is given to improved water sanitation, the use of oral rehydration therapy for infants has also significantly improved outcomes. Rotavirus, the most common viral foodborne infection among children, has had an 80% decrease in incidence in the United States since the implementation of routine immunization in 2006 (CDC, 2025f; Gotfried, 2025a, 2025c; World Health Organization [WHO], 2024).

Adults over 65 are also at higher risk due to decreased immunity. Hospitalization is necessary for approximately half of adults over 65 who have infections caused by Salmonella, Campylobacter, Listeria, or E. coli. Older adults are more likely to have cardiac compromise or renal insufficiency, which increases the risk for fluid and electrolyte imbalance exacerbated by infectious disease. The risk of aspiration from vomiting increases in older adults who have a decreased level of consciousness. Antiemetics with central nervous system (CNS) side effects present additional risks to older adults. Use the lowest effective dose of antiemetics for older adults, as the risk of falls increases due to dehydration, hypotension, and dizziness. HCPs should exercise caution when administering aggressive fluid volume replacement to older adults. For example, using hypotonic fluids in replacement therapy can provoke hyponatremia. The immunocompromised state of patients with diabetes, liver disease, kidney disease, HIV/AIDS, alcoholism, and cancer also increases the risk for and severity of foodborne diseases. For example, people on dialysis are 50 times more likely to get infected with Listeria. Pregnant individuals are also at increased risk of foodborne disease and are 10 times more likely to get a Listeria infection (CDC, 2025f; Gotfried, 2025a, 2025c; Hinkle et al., 2022).

Diagnostic Testing for Foodborne Disease

The classic diagnostic testing for foodborne disease with gastroenteritis is stool cultures. A stool culture is not routinely performed, but it is indicated in cases of diarrhea lasting more than 3 days, in the presence of a high fever, or with severe illness. The stool may also be examined for blood, mucus, white blood cells (WBCs), parasites, or specific toxins. If diarrhea lasts more than 2 weeks, the stool may also be examined for ova and parasites. Subacute, chronic watery diarrhea indicates a need for parasitic testing. Acute diarrhea with gross blood requires a stool culture for E. coli 0157:H7. This test requires a specific order, as it is not part of a standard stool culture. Other indications for stool testing include immunosuppression, exposure to a known outbreak, recent travel, or recent antibiotic use (Gotfried, 2025a, 2025c; Hinkle et al., 2022).

Culture-independent diagnostic tests (CIDTs) are becoming more recently used to detect foodborne illnesses. CIDTs are lab tests that can identify bacteria, viruses, and parasites through nucleic acid amplified tests and antigen-based tests. Polymerase chain reaction (PCR) testing of stool is one example of a CIDT that can detect subtypes of organisms and is especially useful for E. coli subtypes. This rapid diagnostic testing (RDT) of stool identifies numerous common pathogens within one hour of sample preparation. These CIDTs are faster, easier, and less expensive than traditional laboratory cultures, which may reduce the total number of tests a patient must undergo and allow the appropriate medication treatment to begin earlier. Some CIDTs can also detect multiple pathogens in a single sample. The downside of CIDTs is that they do not provide isolates, so the pathogen’s strain or subtype and antimicrobial resistance pattern cannot be determined. Diagnostic stewardship in using RDTs requires a thorough history and review of symptoms by HCPs to ensure that symptoms of infectious diarrhea are present (CDC, 2024k; Gotfried, 2025a, 2025c; Hinkle et al., 2022; Ray et al., 2022).

Laboratory testing is not routinely done for patients with foodborne diseases. In cases of severe vomiting and diarrhea, diagnostic tests for foodborne diseases include serum testing for blood urea nitrogen (BUN), creatinine, electrolytes, and acid–base evaluation. A complete blood count (CBC) is usually nonspecific, but parasitic infections demonstrate eosinophilia. Renal function tests and a CBC should be initiated for patients with foodborne diseases that carry a risk of HUS. With E. coli 0157:H7, where onset begins early, renal testing should begin one week after the onset of symptoms. Another test specific to E. coli 0157:H7 is a rapid enzyme assay for detecting Shiga toxin in the stool. This potent toxin, produced by bacteria, breaks down tissues, particularly in the kidneys. WBCs in the stool are more common with enteric pathogens, including Salmonella, Shigella, Campylobacter, and E. coli, and diarrhea typically does not contain gross blood. A sigmoidoscopy with culture and biopsy is indicated for adults with grossly bloody diarrhea to evaluate for mucosal changes that can differentiate between amebic dysentery, shigellosis, or E. coli 0157:H7 (Gotfried, 2025a, 2025c; Hinkle et al., 2022).

Another tool in investigating foodborne disease outbreaks is strain typing. Traditionally, this involved a pulse-field gel electrophoresis (PFGE) procedure. PFGE was considered the gold standard for the CDC’s PulseNet database until recently due to limitations, including the need for standardized protocols for individual pathogens, extreme sensitivity to the selection of restricted enzymes, and a time-consuming and labor-intensive workflow. Newer techniques, such as whole-genome sequencing (WGS), have gained popularity as this methodology has become more affordable and accessible to clinical and public health laboratories. WGS has a greater ability to identify genetic relationships among organisms of interest; however, barriers to widespread integration include a lack of standardized workflows and inadequate technical training (Simar et al., 2021).

Infectious Foodborne Diseases in the United States

The CDC provides estimates of the average number of seven different pathogens that cause foodborne illnesses, hospitalizations, and deaths, serving as a foundation for public health action. Six of the pathogens cause approximately 9.9 million illnesses, 53,300 hospitalizations, and 931 deaths in the United States annually. Since only some illnesses are reported and diagnosed, periodic assessments of disease burden help set public health goals, allocate resources, and quantify the economic burden of these diseases. The CDC identifies the top five diseases in each category. The CDC identified NoV as the leading cause of foodborne illness and Salmonella as the leading cause of death resulting from foodborne illness (CDC, 2025d).

Norovirus

The most common foodborne disease in the United States and globally is NoV. In the United States, NoV causes approximately 58% of foodborne illnesses, resulting in around 2,500 outbreaks annually. Currently, the CDC estimates 19 to 21 million cases annually, with 109,000 hospitalizations and 900 deaths (mostly in adults 65 and older). The latest global data from the WHO reported 685 million cases and 50,000 deaths in children (mostly in developing countries) attributed to NoV infections. NoV is estimated to cost $60 billion annually due to health care costs and lost productivity. This viral infection spreads predominantly through human feces and vomit. Environmental contamination by virus particles can last from several days to months. NoV is highly infectious, and neither future protection nor cross-protection from other genotypes occurs. Susceptibility to NoV infection and disease is related to histo-blood group antigen (HBGA) expression, as NoV binds to HBGAs. NoV can bind to animal cells, especially oyster guts, and a NoV-like particle that binds to HBGA-like carbohydrates in the cell wall of lettuce has been identified. Infected food handlers, both symptomatic and asymptomatic, have served as sources. The current recommendation is handwashing with soap and water, as alcohol-based hand sanitizers are not as effective in eliminating NoV. An estimated 14% of NoV infections result from ingesting contaminated food. NoV binding to bacteria occurs in the human microbiome and foods, protecting the NoV during food processing treatments. Viruses like NoV typically affect the villi of the small intestine, increasing the amount of fluid and electrolytes in the bowel lumen (transudation), which results in watery diarrhea. The predominant symptom of NoV in adults is diarrhea, while vomiting is more common in children. Fevers can occur, and patients may also report abdominal cramping, headaches, and muscle pain (CDC, 2024o, 2025d; Gotfried, 2025c; O’Ryan, 2025).

Salmonella (Nontyphoidal) 

Salmonella is a bacterium that causes nontyphoidal and typhoid fever. Salmonella (nontyphoidal) causes approximately 1.35 million illnesses, 26,500 hospitalizations, and 420 deaths in the United States each year, making it the second leading cause of foodborne illnesses. Salmonella (nontyphoidal) is contracted by consuming contaminated food or water or touching animals, animal feces, and the animal habitat. The incidence of Salmonella increases in the summer months. Children under 5, nonbreastfed infants, adults over 65, people who are immunocompromised, and those who take certain medications (e.g., those that reduce stomach acid) are more at risk. Salmonella enterica (S. enterica) serotype Typhi (typhoid fever) is a bacterium that causes an estimated 9.2 million illnesses worldwide and 5,700 illnesses in the United States, with 600 cases requiring hospitalization. Most cases of S. enterica serotype Typhi (typhoid fever) occur in regions of the world where water and food are unsafe and sanitation is inadequate, including parts of Asia, Africa, and Latin America. Most cases within the United States occur in patients who have traveled internationally (CDC, 2024d, 2024h; FDA, 2023).

Nontyphoidal salmonellosis has a mortality rate of less than 1% but is highly infectious, with a single bacterium of some strains sufficient to initiate the disease. The onset of symptoms begins 8 to 72 hours after exposure, and acute symptoms usually last 2 to 3 days. Symptoms typically resolve after 4 to 10 days, although the dose and strain may alter the severity and duration. The organism can shed in the stool for several weeks after infection. Typical symptoms include nausea, vomiting, abdominal cramps, diarrhea, fevers, and headaches. Complications often occur in high-risk groups with a significant risk for dehydration and electrolyte balance. Sequelae include reactive arthritis, an autoimmune disorder that develops 3 to 4 weeks after infection, and septicemia or bacteremia, which can affect other internal organs and tissues. Extraintestinal, invasive Salmonella infection can affect the bone (osteomyelitis), joints (septic arthritis), brain, and nervous system (meningitis). Antibiotics are not generally used in treatment but are indicated for severe illnesses or high-risk patients (CDC, 2024d, 2024p; FDA, 2012; Hohmann, 2025).

Typhoid fever, caused by S. enterica serotype Typhi and S. enterica serotype parathyphi, has a mortality rate of 10% if left untreated. With appropriate treatment, the mortality rate is less than 1%. These species of Salmonella are found only in human hosts; thus, foods contaminated with human feces are the primary risk factor. Fewer than 1,000 cells are needed to cause infection. The onset typically occurs within 5 to 21 days, but the incubation period can range from 3 to 60 days. Symptoms include a high fever (103–104°F), lethargy, abdominal pain, diarrhea or constipation, headaches, general aching pain, anorexia, and occasionally, a flat, rose-colored, spotty rash. Complications include septicemia, which can lead to endocarditis, septic arthritis, or chronic gallbladder infection. Chronic infection of the gallbladder can make a person a chronic carrier. Intestinal perforation, neurologic involvement, and death can result from systemic infection. About 10% of patients who are inadequately treated can experience relapse within 1 to 2 weeks after recovery from the initial illness (Andrews et al., 2024; CDC, 2024q; FDA, 2012).

Both types of Salmonella can be foodborne, but they can also spread via fecal particles or contaminated water. Traditionally, Salmonella is associated with meat, especially chicken. Currently, more cases are attributed to fresh produce; even dry foods, such as spices, have led to outbreaks. The list of linked foods is extensive, including eggs, dairy products, yeast, coconut, cake mixes, cream-filled desserts, dried gelatin, peanut butter, cantaloupes, tomatoes, and chocolate. While food testing includes rapid antibody and molecular-based assays, the presence of Salmonella in the culture is currently required to meet regulatory standards for confirmation (Andrews et al., 2024; CDC, 2024m, 2024q; FDA, 2012).

Clostridium perfringens

Nonpathogenic C. perfringens is a gram-positive, anaerobic, spore-forming bacillus associated with acute GI infections. C. perfringens is the third most common cause of foodborne infection in the United States, accounting for approximately 1 million infections annually. It is unlikely to cause large outbreaks, as the symptoms are usually mild, and testing is not routinely indicated. This bacterium replicates quickly and, once it reaches the small intestine, begins to produce an enterotoxin. C. perfringens type A contains the carboxypeptidase E (CPE) gene, which produces the toxin responsible for food poisoning. Less frequently, types B, C, D, and E contain the CPE gene. The CPE gene functions primarily in the small intestine by activating proteins in response to the release of enterotoxins, thereby increasing fluid and electrolyte losses. C. perfringens in food usually results in abdominal cramps and mild self-limiting diarrhea. Symptom onset typically occurs 6 to 24 hours after consuming the contaminated food. Patients rarely have vomiting or fevers. Resolution usually occurs within 24 to 48 hours. Hospitalization is rarely required, and C. perfringens is rarely fatal. In some cases, watery diarrhea can cause significant fluid loss and electrolyte imbalance, with a risk for cardiac dysrhythmias. Another concern is damage to the small bowel with a risk of perforation, which can be fatal (Bush & Vazquez-Pertejo, 2023a; FDA, 2012; LaRocque & Harris, 2025; Yao & Annamaraju, 2023).

A second foodborne disorder caused by C. perfringens, enteritis necroticans (also known as the “Pigbel” form), occurs internationally but is rare in the United States. The Pigbel form occurs in resource-limited settings (especially Papua New Guinea) or in locations where pig intestines are consumed. It is more severe and often fatal. Along with abdominal pain, vomiting, and diarrhea, affected patients may experience abdominal distention, gassy bloating, and bloody diarrhea. Pigbel is caused by type C, which produces a beta toxin that can cause hemorrhagic necrosis of the jejunum. The beta toxin is trypsin-sensitive, and adequate levels of trypsin contribute to the resolution of the disease. Sweet potatoes inhibit trypsin, and a large intake is not recommended (Bush & Vazquez-Pertejo, 2023a; FDA, 2012; LaRocque & Harris, 2025; Yao & Annamaraju, 2023).

Meat is the most common food source for C. perfringens. The bacteria can withstand temperatures of up to 140°F. Prompt refrigeration of leftover cooked meat and reheating to an internal temperature of 170°F is recommended. Fish have various genotypes of C. perfringens, including type A, which are predominantly found on the external surface, indicating environmental contamination and increasing consumer risks. Therefore, commercial food preparation is more commonly the source rather than the person’s home. Small outbreaks usually occur in settings where large groups of people are served and proper food temperature is not maintained, such as nursing homes, large catered events, hospitals, prisons, and school cafeterias. These smaller outbreaks usually occur in November and December. Treatment is supportive as the acute illness is self-limiting, and antibiotics are not given (Bush & Vazquez-Pertejo, 2023a; FDA, 2012; LaRocque & Harris, 2025; Yao & Annamaraju, 2023).

Campylobacter

Campylobacter is a bacterial species found in both domestic animals and fowl. Sources of infection include contact with infected animals (most commonly, puppies) or the ingestion of contaminated food. The route of infection is either fecal–oral or sexual contact. The incidence in the United States is about 1.5 million cases annually, with a mortality rate of approximately 76 patients annually. The two most common species are Campylobacter jejuni (C. jejuni) and Campylobacter coli (C. coli). People with certain comorbidities are 14 times more likely to have a hospital admission based on stool cultures. Campylobacter fetus (C. fetus) poses a specific risk to fetuses and neonates and has a mortality rate of up to 70%. This disorder is associated with contaminated food and beverages and animal contact. The peak incidence of Campylobacter infections occurs between the ages of 1 and 5 years. Adults, especially those over age 65, are more likely to be affected if they have conditions like diabetes, cirrhosis, or immunodeficiency. Meningitis can develop in infants with C. jejuni. Campylobacter affects more males than females (Bush & Vazquez-Pertejo, 2024b; CDC, 2024l, 2025c; Fischer et al., 2024).

Undercooked poultry is the most common source of Campylobacter, and chicken livers pose a significant risk from inadequate cooking. Other food sources include unpasteurized dairy products, vegetables, seafood, and contaminated water. Therefore, avoiding cross-contamination is critical, especially when working with raw poultry products (Bush & Vazquez-Pertejo, 2024b; CDC, 2025c; FDA, 2012; Fischer et al., 2024).

Campylobacter infections most frequently result in mild, acute enteritis that is self-limiting (usually 5–7 days) but can become severe or progress to colitis. Watery diarrhea is the most common symptom, but bloody diarrhea can occur. Systemic Campylobacter infection can provoke a fever of 100.4°F to 104°F, which follows a relapsing or intermittent course. The fever can be accompanied by abdominal pain in the right lower quadrant, headaches, and myalgias. People in industrialized countries experience more severe symptoms than people in developing countries, likely due to acquired immunity in the latter group (Facciola et al., 2017). Some people can exhibit subacute bacterial endocarditis, reactive arthritis, meningitis, or fevers of unknown origin rather than enteric symptoms. Stool samples contain WBCs, and rapid molecular stool tests are used for diagnosis. Antibiotics are not prescribed routinely, as the infection typically resolves on its own. Azithromycin (Zithromax) can be given when spontaneous resolution does not occur. Patients with extraintestinal infections may be prescribed gentamicin (Genoptic), ampicillin (Omnipen), erythromycin (Erythrocin), or a third-generation cephalosporin, such as ceftazidime (Fortaz), to prevent relapses (Bush & Vazquez-Pertejo, 2024b; CDC, 2025c; Fischer et al., 2024).

Sequelae consist of reactive arthritis, Guillain–Barre syndrome (GBS), Miller-Fisher Syndrome (MFS; a rare variant of GBS), HUS, inflammatory bowel disease (IBD), and functional GI disorders. Reactive arthritis typically begins 2 to 4 weeks after the infection and most commonly affects the knees; complete resolution usually occurs within 6 months. GBS is rare, with estimates of occurrence ranging from 1:1000 to 1:5000, but it is the most significant health consequence of Campylobacter infections. Previous Campylobacter infection has been found in approximately 20% to 50% of GBS cases worldwide. Progression is rapid, with the most significant weakness experienced in the first 2 weeks after the onset of neurologic symptoms. Approximately one-third of patients report experiencing muscle weakness for more than 3 years, and 3% experience relapses of weakness for many years. C. jejuni is most closely related to the onset of GBS due to its ability to mimic peripheral nerve proteins. Early diagnosis and treatment of neurologic symptoms are key to positive outcomes. Care for these patients includes plasmapheresis, high-dose immunoglobulin therapy, and supportive care with possible mechanical ventilation. MFS is a nonparalytic variation of GBS with ataxia, areflexia, and ophthalmoplegia. HUS following a Campylobacter infection can lead to a pulmonary-renal syndrome that causes life-threatening pulmonary hemorrhage on rare occasions. The incidence of irritable bowel syndrome (IBS) increases 3-fold following a Campylobacter infection. Other GI disorders, such as functional dyspepsia and constipation, have been reported following an infection (Bush & Vazquez-Pertejo, 2024b; CDC, 2024l, 2025c; Fischer et al., 2024; LaRocque & Harris, 2025).

Staphylococcus aureus

S. aureus is a gram-positive organism that is everywhere and virtually impossible to eliminate from the environment, as they are among the most resistant non-spore-forming human pathogens. S. aureus survives in a wide range of temperatures (44°F–118°F, with an optimum of 95°F) and pH ranges (4.5–9.3, with an optimum of 7.0–7.5). It grows in environments with low water activity and is highly tolerant of salt and sugar. Due to these characteristics, approximately 25% of people carry Staphylococcus on their skin. Under specific conditions, like those found in food products, the organism produces a toxin that causes food poisoning. The onset of symptoms after ingestion is typically rapid, occurring within 30 minutes to 8 hours. The toxins produced are heat-stable and act as pyrogenic toxin superantigens, causing immunosuppression and nonspecific T-cell proliferation. The single-chain protein of this enterotoxin resists trypsin and pepsin, which usually destroy protein molecules. Each known staphylococcal enterotoxin exerts emetic activity (Bush & Vazquez-Pertejo, 2024h; CDC, 2024e; FDA, 2012; Gotfried, 2025b; LaRocque & Harris, 2025).

Severe vomiting typically begins early in the infection, accompanied by nausea and abdominal cramps. Diarrhea can also occur. Significant systemic symptoms from fluid loss can occur, including transient changes in blood pressure and pulse, dehydration, headaches, and muscle cramps. Symptoms are intense but usually resolve in a few hours to a day. Death is rare but can occur in infants, older adults, and those who are severely ill. Toxin identification in food and a patient’s emesis or stool is a diagnostic tool. Enzyme-linked immunosorbent assay (ELISA)–based methods are commonly used to identify enterotoxins (Bush & Vazquez-Pertejo, 2024h; FDA, 2012; Gotfried, 2025b; LaRocque & Harris, 2025).

The first outbreak investigation of staphylococcal foodborne disease happened in 1884 in Michigan, involving contaminated cheese. Since that time, other infections caused by various foods have been identified, along with corresponding preventive measures. The most common foods associated with S. aureus outbreaks are meat and poultry dishes (55% of outbreaks), followed by dairy products and eggs. Handling food increases the risk of transmission, and more cases occur in restaurants and delis compared to homes. Risk is decreased by ensuring adequate cooking time and temperature, limiting holding times, and consolidating food preparation steps instead of taking multiple actions. Individuals can also avoid cross-contamination by adequately cleaning all processing equipment. Handwashing is key to prevention; while gloves are helpful, frequently changing gloves and handwashing are the most important measures. Treatment can include oral or intravenous (IV) fluids and antiemetics (Bush & Vazquez-Pertejo, 2024h; Gotfried, 2025b; LaRocque & Harris, 2025).

Toxoplasma gondii

Toxoplasmosis is typically asymptomatic in healthy individuals, often presenting with mild lymphadenopathy and flu-like symptoms. Pregnant and immunocompromised people, especially those with HIV/AIDS, are at the highest risk for more severe symptoms. Infection with T. gondii during pregnancy can be asymptomatic or provoke general symptoms. However, transplacental transfer to a fetus can result in increased placental thickness, fetal splenomegaly, fetal hepatomegaly, hydrocephalus, fetal ventricular dilation, fetal intracranial calcification, or fetal chorioretinitis. An ultrasound can be used to detect many of these changes. Spontaneous abortion, stillbirth, or congenital disabilities may occur. Neonates with toxoplasmosis have jaundice, a rash, hepatosplenomegaly, and a characteristic tetrad of abnormalities (i.e., bilateral retinochoroiditis, cerebral calcifications, hydrocephalus or microcephaly, and psychomotor impairment). Children born with only a few symptoms can still experience intellectual disability, seizure, or retinochoroiditis within months or years (Heavey, 2018; Madireddy & Mangat, 2024; Marie & Petri, 2025a; Petersen, 2025).

Serologic testing, PCR-based blood assays, cerebrospinal fluid, tissue or amniotic fluid, and histopathologic evaluation of biopsies are diagnostic. With neurologic toxoplasmosis, a head computed tomography (CT) or magnetic resonance imaging (MRI) with contrast is performed in addition to a lumbar puncture (for patients with no signs of increased intracranial pressure). Treatment of neonates and immunocompromised patients includes pyrimethamine (Daraprim), sulfadiazine (Lantrisul), and leucovorin (Wellcovorin). Due to toxic fetal effects, these drugs are not recommended during pregnancy. Spiramycin (Provamicina) is not available directly in the United States, but the FDA can assist in its acquisition. Primary prevention involves avoiding contact with cat feces, especially before and during pregnancy. Since soil can pose a risk for contamination, gloves should be worn for gardening. Food is commonly contaminated; strict handwashing by all food handlers and ensuring all meats reach an internal temperature of 170^°F can prevent transmission. Further research is needed, but recent studies have linked the presence of T. gondii antibodies to neurologic changes, including schizophrenia, suicidal ideation, dementia, addiction, and autism (Heavey, 2018; Madireddy & Mangat, 2024; Marie & Petri, 2025a; Petersen, 2025).

Escherichia coli

E. coli is among the most prevalent organisms of the normal flora within the large intestine. While the most common infection caused by E. coli affects the urinary system, some strains can lead to diarrhea and are frequently foodborne. The five strains that often cause diarrhea are enterohemorrhagic (EHEC), enterotoxigenic (ETEC), enteroinvasive, enteropathogenic (EPEC), and enteroaggregative (EAEC). ETEC is most commonly associated with traveler’s diarrhea. Both food and water can be sources (e.g., if food is washed in local water or mishandled, initiating the infection). Symptoms are usually mild and brief, but some patients experience extremely watery stools. Antibiotics are not commonly used but can effectively reduce the duration and severity. ETEC and EPEC pose high risks for children, and EPEC frequently affects bottle-fed infants. In the past, EPEC had a high mortality rate (25%–50%), but improvements in sanitation and medical treatment of fluid loss have decreased its prevalence in developed countries. The onset of symptoms typically occurs within 4 hours and is characterized by profuse, watery diarrhea, vomiting, and a low-grade fever. Occasionally, diarrhea lasts 21 to 120 days (Bush & Vazquez-Pertejo, 2024d; FDA, 2012; Gotfried, 2025c; LaRocque & Harris, 2025; Nataro, 2024).

EHEC strains are associated with the most severe disease consequences, including STEC. These strains can produce cytotoxins, neurotoxins, and enterotoxins. While there are over 100 serotypes of STEC, the most common in North America is 0157:H7. These toxins harm the mucosal and vascular endothelial cells of the large intestine. Diarrhea may begin as watery but becomes grossly bloody within 24 hours. The patient often has severe abdominal pain, usually lasting from 1 to 8 days. Fever is typically low-grade, if present, but can occasionally reach a temperature of 102°F. HUS and thrombotic thrombocytopenic purpura develop in approximately 15% to 20% of cases. A sudden decrease in hematocrit and platelets, an increase in serum creatinine, hypertension, signs of fluid overload, signs of increased bleeding events, and neurologic changes are indications of HUS. Diagnostic testing of stool cultures requires special media and a specific request for organism serotype identification. Rapid stool assay for Shiga toxin or genetic testing provides more specificity and can be essential for outbreak management (Bush & Vazquez-Pertejo, 2024e; FDA, 2012; Holtz & Tarr, 2024a).

Treatment for EHEC is supportive. Antibiotics are not beneficial, and fluoroquinolones such as ciprofloxacin (Cipro) and levofloxacin (Levaquin) increase the risk of HUS. One possible explanation is that antibiotics break down the bacteria, releasing more of the Shiga toxin into the bloodstream. Cattle are the primary reservoir for STEC, and changes in animal processing have reduced the contamination of meat. Correct disposal of stool from infected individuals, good hygiene, and careful handwashing with soap and water can limit the spread of infection. Initiating contact precautions for hospitalized patients with STEC can also help reduce the transmission of the infection. Daycare and schools can also require a negative stool culture before a child returns to those settings. Notification of public health authorities regarding outbreaks of bloody diarrhea promotes more effective outbreak management and prevention. Foods that have significant risks are undercooked beef (especially ground beef), unpasteurized milk, and vegetable crops contaminated by cow manure (Bush & Vazquez-Pertejo, 2024e; FDA, 2012; Holtz & Tarr, 2024b).

Listeria monocytogenes

Listeriosis is a foodborne disease that affects a relatively small number of people compared to other foodborne diseases; however, it is a leading cause of death from foodborne illnesses. While most healthy people experience only mild gastroenteritis, the more severe invasive form results in an overall fatality rate of 15% to 30%. Among people with septicemia, the fatality rate is 50%; when meningitis occurs, the fatality rate is approximately 70%. Perinatal/neonatal infections have a fatality rate of 80%. Onset is rapid for the GI form, occurring a few hours to 3 days after food ingestion. The invasive form, which results in septicemia and meningitis, has a variable incubation from 3 days to 3 months. The health status of most patients at the onset of the disease is a predictor of disease severity. Healthy individuals are most likely to experience the gastroenteric form, which typically has a shorter duration. At the same time, people with chronic health problems, immunocompromise, or advanced age are prone to the invasive type (Bush & Vazquez-Pertejo, 2023b; de St. Maurice, 2025; FDA, 2012; Rogalla & Bomar, 2023).

The most common food sources are unpasteurized dairy products, soft cheeses, blue-veined cheese, deli meats, hot dogs, meat salads, unwashed raw vegetables, and refrigerated smoked seafood. Treatment consists of IV ampicillin (Omnipen) for at least 14 days. For those allergic to ampicillin (Omnipen), trimethoprim-sulfamethoxazole (Bactrim) is generally accepted. Listeria is salt-tolerant and can grow in temperatures below 34°F. It inhabits moist environments, including soil and decaying vegetation, throughout the natural world. Listeria is highly tenacious. For example, in a single meat processing plant, the same strain was first identified in 1989 and then again 11 years later. Efforts to limit disease have led to declines over the last 20 years. Since Listeria contamination can occur through food workers, incoming air, raw materials, and food processing environments, all food production employees require sufficient education on effective control and prevention measures. In processing areas, the most significant risk involves cross-contamination after food is processed (Bush & Vazquez-Pertejo, 2023b; de St. Maurice, 2025; FDA, 2012; Rogalla & Bomar, 2023).

Listeriosis presents a specific risk during pregnancy. Approximately 14% of cases affect pregnant individuals, who have a 10-fold risk compared to the general public. Immunologic changes during pregnancy increase susceptibility, with the highest risk occurring during the third trimester. The bacteria target placental cell receptors. Transmission during pregnancy can happen directly from a pregnant patient or can be introduced to neonates as a nosocomial infection due to inadequate staff handwashing and surface hygiene. While its occurrence is rare, the consequences are extreme. Pregnant individuals may not readily report symptoms, attributing them to flu-like illness, including headaches, gastritis, diarrhea, and backache; some experience severe abdominal pain and fevers. Sometimes, 2 months or more pass after infection before symptoms appear. As a precaution, any fever at or above 100.6°F in a pregnant patient with signs and symptoms of Listeria indicates the need for blood cultures. Even if the patient experiences mild to moderate symptoms, their fetus is greatly affected (e.g., via miscarriage, intrauterine fetal demise, neonatal meningitis, and death). Early onset symptoms in neonates include respiratory distress, poor muscle tone, pallor, meconium staining, and a diffuse, grainy rash that can develop into abscesses (granulomatous infantiseptica). Late-onset symptoms, with an average onset time of 14 days after birth, generally involve the CNS and include irritability, lethargy, stiff neck, fever, and seizures (Bush & Vazquez-Pertejo, 2023b; de St. Maurice, 2025; FDA, 2012; Rogalla & Bomar, 2023).

Additional Reportable Foodborne Diseases

Shigella

There are four genera of Shigella that cause inflammatory dysentery: A (Shigella dysenteriae [S. dysenteriae]), B (Shigella flexneri [S. flexneri]), C (Shigella boydii [S. boydii]), and D (Shigella sonnei [S. sonnei]). S. sonnei is most common in the United States. Shigellosis (bacillary dysentery) is a common name for this acute enteric illness, and it is transmitted only to humans. Shigellosis is one of the more common domestically acquired foodborne illnesses in the United States. Contamination of food or water with human feces is the primary source. Raw foods, dairy products, poultry, and salads (e.g., tuna, potato, and macaroni) can transmit the disease. Food or fomites can spread bacteria indirectly, and flies can serve as vectors. The organism is sensitive and will break down quickly; therefore, samples must be tested as soon as possible to ensure accuracy. Diarrhea can consist of watery stool or, in severe cases, contain blood and mucus. Young children, older adults, and immunocompromised people are more severely affected. In unsanitary conditions, the disease spreads rapidly (Agha & Goldberg, 2025; Aslam et al., 2024; Bush & Vazquez-Pertejo, 2024g; FDA, 2012).

The onset of symptoms occurs 8 to 50 hours after ingesting contaminated food. Adults often experience abdominal pain, the urgency to defecate (tenesmus), and the passage of formed feces that temporarily relieves the pain. The severity of diarrhea progresses, and the stools become liquid, with mucus, pus, and sometimes blood. Severe tenesmus may result in rectal prolapse or consequent fecal incontinence. The disease is self-limiting, with mild cases resolving in 4 to 8 days; however, more severe cases can take 3 to 6 weeks to resolve. Rarely, some patients have a sudden onset of stool that is white liquid without fecal material, often described as rice-water stool, with vomiting and rapid dehydration. In these severe cases, illness may rapidly progress to delirium, seizures, and coma, and death may occur in 12 to 24 hours. Children have more severe symptoms and can die in the first 12 days if untreated. Initially, an infected child will have a fever, irritability, drowsiness, anorexia, nausea, vomiting, diarrhea, abdominal pain and distention, and tenesmus. Progression in 3 days can result in stool containing blood, pus, and mucus, with more than 20 stools per day, leading to weight loss and severe dehydration (Agha & Goldberg, 2025; Aslam et al., 2024; Bush & Vazquez-Pertejo, 2024g; FDA, 2012).

Diagnosis of Shigella can be facilitated by a high index of suspicion and the presence of fecal leukocytes on a smear stained with methylene blue, particularly during outbreaks or in endemic areas. Diagnostic testing typically includes stool cultures, an elevated WBC count (usually around 13,000), hemoconcentration, and indications of metabolic acidosis. Supportive care, including fluid replacement, is essential. For severely ill patients, antibiotics can be used. These may include a fluoroquinolone (e.g., ciprofloxacin [Cipro]), azithromycin [Zithromax]), or a third-generation cephalosporin (e.g., ceftriaxone [Rocephin]). Never give antidiarrheal drugs such as loperamide (Imodium), as these may prolong the illness. Meticulous handwashing by patients and caregivers is crucial. Clothes and bed linen require detergent and hot water for cleaning. Vaccines are being developed, and trials in endemic areas have shown promise (Aslam et al., 2024; Bush & Vazquez-Pertejo, 2024g).

Vibrio

Vibrio is a bacterium found in saltwater and brackish waters (those containing a mixture of salt and freshwater). Raw or undercooked seafood, especially oysters, are the primary food source. The United States has about 80,000 cases per year, with 500 hospitalizations and 100 deaths. Transmission typically occurs from May through October. Factors that increase the risk of Vibrio include immunosuppression, liver disease, cancer, diabetes, HIV, thalassemia, bariatric surgery (or any partial gastrectomy), and using medications to lower stomach acid. Vibrio organisms are susceptible to acidity, freezing, and cooking and are killed by common disinfectants, including bleach and alcohol (Bell & Bott, 2021; FDA, 2012; Rodriguez et al., 2024).

Cholera—the most severe foodborne disease caused by these bacteria—is caused by Vibrio cholerae (V. cholerae). Contaminated water and seafood can cause acute infections in the small intestine. The bacteria produce an enterotoxin that causes the small bowel mucosa to hypersecrete an isotonic electrolyte solution. Patients often experience an abrupt onset of painless, rice-water diarrhea that can sometimes exceed one liter per hour. Vomiting is typical, but nausea is not. Hypovolemia, hypokalemia, and hemoconcentration occur, but serum sodium remains normal. Symptoms include extreme thirst, scant urine, muscle cramps, weakness, sunken eyes, and skin wrinkling on the fingers. Renal tubular necrosis, circulatory collapse with cyanosis, and stupor can occur without fluid replacement. Incubation is 1 to 3 days. While cases are rare, some people become chronic biliary tract carriers. Culture and serotyping of the stool are used for diagnosis. Rapid dipstick testing for cholera is available for public health purposes if laboratory testing is limited (Bush & Vazquez-Pertejo, 2024c; FDA, 2012; Rodriguez et al., 2024).

Milder cases can be managed with standard rehydration, but severe cases require IV administration of isotonic fluids and potassium replacement to resolve hypokalemia, which is critical in pediatric patients. Once a patient is rehydrated, the fluid administration rate is based on the volume of stool. Oral rehydration solution (ORS) packets are available in areas where cholera is endemic. The packets contain 13.6 g of glucose, 2.6 g of sodium chloride, 2.9 g of trisodium citrate dihydrate (or 2.5 g of potassium bicarbonate), and 1.5 g of potassium chloride, added to one liter of clean water. When packets are unavailable, six small spoons of sugar and one-half spoonful of salt can be substituted. The cessation of vomiting and return of appetite are indications that solid food can be resumed (Bush & Vazquez-Pertejo, 2024c; Rodriguez et al., 2024).

Vibrio vulnificus (V. vulnificus) is much less common, with approximately 96 cases per year acquired in the United States; it has a mortality rate of 35% in septicemia cases. The onset of V. vulnificus infection ranges from 12 hours to 21 days, with a mean time to septicemia of approximately 4 days. The mean duration of septic illness is 1.6 days, reflecting, to some extent, the high mortality rate that occurs once septicemia develops. For healthy people, acute enteritis is usually mild and self-limiting, but some people are at increased risk for septicemia. Factors that increase risk are chronic liver disease (including transplantation or liver cancer), medications and diseases causing immunosuppression, insufficient gastric acid, diabetes, renal disease, or intestinal disease. While other seafood and cross-contamination are risk factors, 90% of cases in the United States are from eating raw Gulf Coast oysters. HCPs must educate individuals at risk of consuming cooked seafood and implement measures to minimize cross-contamination (Bush & Vazquez-Pertejo, 2024f; FDA, 2012).

The Vibrio species that cause less severe foodborne diseases include Vibrio parahaemolyticus (V. parahaemolyticus), Vibrio mimicus (V. mimicus), and Vibrio hollisae (V. hollisae), which are typically associated with inadequately cooked seafood, especially shellfish. V. parahaemolyticus is rarely transmitted by the fecal–oral route because the organism is damaged by freshwater. Symptoms typically include watery, large-volume diarrhea, abdominal pain, weakness, and tenesmus. Less frequently, patients may exhibit nausea, vomiting, low-grade fevers, and bloody stools (which can contain granular leukocytes). The culture medium specifically used for Vibrio is the thiosulfate–citrate–bile salts–sucrose (TCBS) medium, which can be used to culture both stool samples and suspected food sources. Treatment involves replacing a large amount of fluid and electrolytes that have been lost. Antibiotics are not typically used; however, for severe cases, ciprofloxacin (Cipro) or doxycycline (Vibramycin) can be administered as a single dose. Oral cholera vaccines, such as Vaxchora, are available and recommended for individuals planning to travel to endemic areas (Bush & Vazquez-Pertejo, 2024f; FDA, 2012; Rodriguez et al., 2024).

Clostridium botulinum

Botulism is a rare but life-threatening neuroparalytic syndrome caused by Clostridium botulinum (C. botulinum). Even with treatment, mortality is between 5% and 10%. The bacteria are anaerobic and produce a potent neurotoxin. The neurotoxin blocks motor nerve terminals at the neuromuscular junction, resulting in flaccid paralysis. Improperly home-canned foods are the most common source; this is particularly common in low-acid foods, such as corn, peppers, green beans, beets, asparagus, and mushrooms. Other at-risk foods are tuna fish, chicken and chicken livers, liver pate, luncheon meats, lobster, and smoked or salted fish. The onset of the disease varies from 4 hours to 8 days but is typically between 18 and 36 hours. Neurologic symptoms typically begin early, characterized by diplopia, drooping eyelids, slurred speech, difficulty swallowing, a dry mouth, and muscle weakness. Neurologic progression is symmetric and downward, starting at the head with eventual paralysis of the arms, trunk, legs, and respiratory muscles. Death from asphyxia can occur without immediate intervention when the diaphragm and chest muscles become involved. Early administration of botulinum antitoxin, available from the CDC, can improve outcomes. Mechanical ventilation may be necessary for weeks to months. While the symptoms are highly diagnostic, differentiating them from other disorders may be challenging. Stool and serum samples can be tested for the toxin; however, the most specific test is mouse neutralization (which involves injecting a sample suspected of containing botulism toxin into mice and observing for signs of botulism), which requires 48 hours (Bush & Vazquez-Pertejo, 2025a; FDA, 2012; Jeffrey et al., 2024; Pegram & Stone, 2025).

The first sign of infant botulism is constipation, present in 90% of cases. Subsequently, an affected infant exhibits a flat facial expression, poor feeding with weak sucking, a weak cry, decreased movement, difficulty swallowing, excessive drooling, progressive muscle weakness, and breathing problems. Stool tests should be performed for diagnosis, but treatment should not be delayed when there is a high index of suspicion. An antitoxin specific to infant botulism (BIG-IV) is available and should be administered early. Supportive treatment is given with the implementation of mechanical ventilation and intensive care for weeks to months. While many items may pose risks, honey is one food specifically linked to an increased risk of adverse effects. HCPs should educate parents and caregivers about the risks associated with giving honey to children under 12 months of age. An adult form of botulism similar to infant botulism can affect patients with a surgical alteration of the GI system or on antibiotic therapy (Bush & Vazquez-Pertejo, 2025b; FDA, 2012; Van Horn & Shah, 2025).

Brucella

As a foodborne disease, brucellosis in the United States is rare; however, when cases occur, they are most frequently contracted by consuming imported raw milk or soft cheese products made from raw goat or cow milk. Humans are more likely to contract the species Brucella melitensis (B. melitensis), which is found in goats. The disease burden is the greatest in endemic countries where goats are raised and there is no pasteurization. A zoonotic transfer (infectious disease spread from an animal species to a human) occurs, with raw milk being the most common source. However, another source is human contact with the reproductive parts of infected animals. Human-to-human transfer is rare but has occurred through reproduction and breastfeeding. Among animals, spontaneous abortion is a common symptom; for humans, this is rare. Pasteurization of milk (mandated by law since 1947), along with surveillance and control measures, has minimized the risk of this disease from food products in the United States. The onset of symptoms typically occurs within 3 weeks but can be delayed longer (Bush & Vazquez-Pertejo, 2024a; FDA, 2012; Hayoun et al., 2023).

Brucellosis was once known as undulant fever due to its intermittent fevers and sweating. After the initial febrile phase, weight loss, anorexia, abdominal pain, joint pain, headache, weakness, irritability, depression, insomnia, and emotional instability can occur. Patients can also develop splenomegaly, hepatomegaly, and enlarged lymph nodes. Without treatment, the disease can become chronic with the recurrence of febrile illness. The development of brucellar spondylitis, a focalization of brucellosis in the bones (especially in the lumbar vertebrae), can also occur. Diagnostic tests include isolating the organism from blood or bone marrow, testing for anti-Brucella antibodies, and radiologic examination for vertebral changes and bone spurs. An aggressive combination antibiotic treatment, administered for up to 6 weeks, can prevent relapses in approximately 90% of patients. The most common combinations are doxycycline (Vibramycin) plus rifampin (Rifadin) or doxycycline (Vibramycin) plus streptomycin (Strepomycon). Pasteurization of milk helps to prevent brucellosis. People who handle animals or carcasses that could be infected should wear goggles and rubber gloves (Bush & Vazquez-Pertejo, 2024a; FDA, 2012; Hayoun et al., 2023).

Francisella tularensis

Two types of Fancisella tularensis (F. tularensis), types A and B, cause tularemia. Type A is found primarily in rabbits and rodents, is more virulent, and occurs mainly in the United States and Canada. Food can be contaminated; however, other routes of contamination include bites from arthropod vectors (e.g., deer flies, ticks, and fleas), inhalation, and direct contact with infected tissues or materials. Animal meat, especially undercooked meat from rabbits and hares, and milk can be food sources. The other risk involves rodent droppings contaminating the food. It is among the most infectious microorganisms because inhaling as few as 10 bacteria cells can lead to infection with a high mortality rate; in foodborne cases, over 1 million are required. The onset of symptoms can be from 1 day to a week but is typically 3 to 6 days. Some organisms are more virulent, and this factor significantly influences outcomes. Infected food can cause either an oropharyngeal infection, which leads to pharyngitis and necrotic cervical adenopathy, or a GI infection, resulting in a range of symptoms from mild diarrhea to severe bowel damage. Diagnosis includes confirmation made by culture on enriched media; however, real-time PCR, direct fluorescent antibody (DFA), and ELISA-based techniques are also used for preliminary diagnosis. Leukocytosis, or an elevation in the proportion of neutrophils, eosinophils, and basophils in the CBC, provides evidence of infection. Streptomycin (Streptomycin) injectable is used to treat severe cases of tularemia. Foodborne tularemia is rare in the United States. Any form can spread to the lungs or meninges, causing severe disease and increased mortality (Bush & Vazquez-Pertejo, 2024i; FDA, 2012; Snowden & Simonsen, 2023).

Hepatitis A

In 2023, there were 1,648 cases of Hepatitis A (HepA) and 85 deaths. With the implementation of the hepatitis vaccine, there was a 95% decrease in incidence from 1995 to 2011. However, from 2015 to 2019, the incidence increased by 1,325%; the increase in 2019 was due to unprecedented person-to-person outbreaks reported in 31 states among people who use IV drugs and those experiencing homelessness. In addition, the CDC identified other people at risk for HepA: travelers to countries with high or endemic HepA, men who have sex with men, people with clotting factor disorders, people who work with primates, and people with adopted children from countries with high or intermediate endemic HepA. HepA is a hardy virus that can survive freezing; food must be cooked to above 185°F for at least 1 minute. The virus can live for months in environments with poor sanitation and improper sewage disposal. After annual increases from 2015 to 2019, the rate of HepA decreased by 91% from 2019 to 2023 (CDC, 2025a; Girish et al., 2024; Kumar, 2024).

People with HepA may be asymptomatic (especially children under 6), or it can be a severely disabling disease. Incubation is typically 28 days but can range from 15 to 50 days. In adults, the onset is usually abrupt, with abdominal pain, fever, malaise, anorexia, nausea with or without vomiting, and diarrhea. The progression of the disease is characterized by liver symptoms that include jaundice, dark urine, clay-colored stool, and hepatomegaly. Diagnosis consists of a blood test for serum immunoglobulin M (IgM) anti-HepA antibodies that are detectable 5 to 10 days after exposure. Reverse transcriptase-polymerase chain reaction (RT-PCR) may also be used to detect HepA ribonucleic acid (RNA). Fulminate hepatitis can occur with liver failure, particularly in patients with chronic liver disease. Mortality in these cases is 70% to 80%. Throughout the disease course, a patient’s liver status can be established by tests for serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and bilirubin. Physical care during the disease includes adequate rest, a diet consisting of small meals high in calories and protein (based on liver status), and modification of medications metabolized by the liver as directed by the HCP. Environmental care includes routine handwashing with soap and water for 15 to 20 seconds, refraining from sharing eating utensils or toothbrushes with family members, wearing gloves, and disinfecting bed linens, bathroom surfaces, and laundry used by the patient. After recovery, serum immunoglobulin G (IgG) antibodies persist, providing lifelong immunity (CDC, 2025a; FDA, 2012; Girish et al., 2024; Kumar, 2024).

Vaccination has made HepA a preventable disease. Children aged 12 to 23 months should receive two doses of Havrix or Vaqta, the second dose administered 6 months after the initial dose. These vaccines can also be administered to adults who are not fully vaccinated or who request vaccination. For general prevention among adults, the CDC recommends completing the 2-dose HepA series with Havrix (administered 6 to 12 months apart) or Vaqta (administered 6–18 months apart). Adults 18 years of age and older can also receive three doses of the Twinrix vaccine, which includes both HepA and hepatitis B (HepB). The second dose is given one month after the initial dose, and the third dose is administered five months after the second dose. If a person has travel plans with a risk of exposure, an accelerated administration of Twinrix is acceptable, consisting of three doses given 21 days apart (initial, day 7, and days 21–30), followed by the fourth dose 12 months after the initial dose. HepA vaccine can be given during pregnancy. Neither health care workers nor food service workers need routine vaccination against HepA. Immune globulin can be administered to individuals exposed to HepA, but it must be administered within 2 weeks of exposure (CDC, 2025e; Girish et al., 2024; Kumar, 2024).

Cryptosporidium

Based on serologic surveys, an estimated 80% of the US population has had cryptosporidiosis at some point in their lives, often without being aware of it. The organism, an oocyte, is half the size of a red blood cell and requires as few as 10 to cause an infection. Ingested food and water are likely sources. Still, pool water is a major vehicle, as the organism is extremely tolerant of chlorine and can exist for long periods in the presence of bleach. Infection from person to person by the fecal–oral route is common. Fresh produce is the most common food source, but juices and milk may also be infected. Once in the body, Cryptosporidium differentiates into two forms: thick-walled organisms are shed in the stool, and thin-walled organisms break down in the intestinal wall, causing symptoms (FDA, 2012; Janssen & Snowden, 2023; Marie & Petri, 2024a).

The onset of symptoms typically occurs within 1 week, and 80% of those infected experience symptoms. The onset is usually sudden for immunocompetent people, with profuse, watery diarrhea and abdominal cramping. Occasionally, the person may have nausea, anorexia, a fever, and malaise. Symptoms typically resolve within 1 or 2 weeks but may persist for up to a month. Caution should be advised because the organism is shed in stools for several weeks after symptoms have resolved. Symptom onset for immunocompromised patients is much more gradual, but the diarrhea is more severe, with fluid losses of more than 5 to 10 liters per day for patients with AIDS. Diarrhea can become intractable and may persist for life for these patients. A CD4 count of fewer than 180 cells/mm³ is the trigger point for the greatest risk for severe and protracted disease in patients with AIDS. Diagnostic testing includes microscopic stool examination of multiple samples using phase-contrast microscopy, staining with modified Ziehl-Neelsen or Kinyoun techniques, as well as immunofluorescence microscopy with fluorescein-labeled monoclonal antibodies. Specific enzyme immunoassay for fecal Cryptosporidium provides greater sensitivity than microscopic examination alone. Intestinal biopsies can reveal Cryptosporidium in digestive epithelial cells. For immunocompromised patients, treatment with nitazoxanide (Alinia) can be used to reduce symptoms (FDA, 2012; Janssen & Snowden, 2023; Marie & Petri, 2024a).

Cyclospora cayetanensis

Cyclospora cayetanensis (C. cayetanensis) is a protozoan parasite shed in vertebrates’ feces. It requires 1 to 2 weeks outside the body (i.e., in the environment) to mature and become infective. The disease is more prevalent in tropical and subtropical climates, particularly during the rainy season. Outbreaks in the United States have been linked to contaminated fresh vegetables, including prewashed salad mixes, basil, snow peas, and cilantro. Symptom onset happens 7 to 10 days after ingestion. The diarrhea is watery, can be explosive, and is accompanied by abdominal pain and bloating. While some patients are asymptomatic, others have severe, flu-like symptoms with headaches, vomiting, fevers, and general aching. Patients with AIDS are at risk for developing severe, intractable, voluminous diarrhea, as well as extraintestinal disease that includes cholecystitis and disseminated infection. Diagnosis involves identifying the organism in stool using the Ziehl-Neelsen or Kinyoun acid-fast staining technique, as a unique characteristic of the organism is autofluorescence. More than three stool specimens may be necessary because cyst secretion is intermittent. A biopsy of intestinal tissue can reveal the stages of intracellular parasites. Treatment is with trimethoprim/sulfamethoxazole (Bactrim), and patients with AIDS require higher doses and a longer duration of treatment. Ciprofloxacin (Cipro) is the alternative to trimethoprim/sulfamethoxazole (Bactrim). Death is extremely rare, but symptoms can last for months without treatment, and relapses are possible (FDA, 2012; Marie & Petri, 2024b; Weller & Leder, 2025).

Trichinella

Trichinosis is a parasitic infection in which at least one male and one female parasite are ingested via infected meat. These parasites spend 1 to 2 days in the epithelium of the small intestine. Within 3 days, the newborn larvae they produced are shed into the intestine. From there, the larvae migrate to the liver, lungs, eyes, heart, and brain, but can only survive long-term in skeletal muscle. Once in skeletal muscle, the larvae live until the animal dies or is eaten. Any animal that eats meat can be at risk, but the most common food source for humans has been pork. In the United States, changes in pork production have contributed to a decrease in the incidence of trichinosis, including the requirement to cook all meat products fed to pigs, the prevention of rodent contamination in pig enclosures, and the requirement for surveillance for Trichinella. Even with these measures, raw pork should always be cooked thoroughly (to an internal temperature greater than 160°F). Commercial freezing to a lower temperature can also destroy the larvae, but home freezing is insufficient and should never be considered effective for eliminating Trichinella from wild animal meat. Cases in the United States have included walrus, bear, cougar, and other wildlife meat (FDA, 2012; Furhad & Bokhari, 2023; Marie & Petri, 2025b).

Symptoms of nausea, abdominal cramping, and diarrhea begin when newborn larvae increase in number in the digestive system. As the larvae migrate, systemic symptoms occur, including periorbital edema, myalgia, a persistent fever (greater than 102°F), headaches, petechiae, and subconjunctival hemorrhages. Eye pain and photophobia frequently occur before chronic myalgia. Eosinophil count begins to increase when the larvae invade tissues, peaks 2 to 4 weeks after infections, and decreases once the larvae become encysted in the muscle cells. The larvae that do not reach muscle tissue eventually die, but large numbers present and dying in tissue can result in cardiac, neurologic, or pulmonary complications with possible death. Enzyme immunoassay is the fastest test to confirm the diagnosis. Laboratory measurement of increased creatine kinase and lactic dehydrogenase is found in 50% of patients. A muscle biopsy is usually not necessary but can be performed for species identification purposes. Early treatment with an anthelmintic, such as albendazole (Albenza) or mebendazole (Vermox), can eliminate adult worms. Once the larvae reach muscle tissue, the medication may be ineffective in killing them, and higher doses can have adverse effects. Analgesics can be used to relieve muscle pain. Some patients experience an allergic response to the larvae; when the myocardium or the CNS is involved, prednisone (Deltasone) may be given (Furhad & Bokhari, 2023; Marie & Petri, 2025b).

Common Foodborne Diseases That Do Not Require Reporting

Yersinia

Yersinioses are zoonotic infections of domestic and wild animals. The two most common species of Yersinia that cause gastroenteritis are Yersinia enterocolitica (Y. enterocolitica) and Yersinia pseudotuberculosis (Y. pseudotuberculosis). It is transmitted by the fecal–oral route, and the organism is found in animals (pigs, birds, beavers, cats, and dogs) and insects (fleas, flies, and frogs). Refrigeration does not kill the organism. Foods that primarily carry Yersinia are meats (especially pork), seafood, and unpasteurized milk. The spread of the organism can occur when handling meat products, during storage, or with poor sanitation and improper sterilization. In the home, practicing handwashing and using a separate cutting board exclusively for meat, with a separate board for other products, can help decrease the risk. Foods like chitlins, which are often prepared at home and include pork intestines, are a known risk. Persons preparing these foods should avoid all physical contact with young children. For adult patients, the disease consists of self-limiting diarrhea. Children under 5 years old exhibit fevers, abdominal pain, diarrhea, and vomiting. Some children develop headaches and a sore throat at the onset of the disease, and some may experience bloody stools. Abdominal pain frequently affects the right lower quadrant, and differentiation from appendicitis can be challenging, but yersiniosis has a much higher rate of diarrhea. Unnecessary appendectomies have been performed without adequate diagnostic consideration of yersiniosis (Aziz & Yelamanchili, 2023; FDA, 2012; Tauxe, 2025).

Specimens of feces, blood, or vomit can be tested for Yersinia in patients with symptoms suggestive of a possible infection. Serology and PCR methods can be used to confirm. Treatment for gastroenteritis is supportive. Complications tend to affect people with the human immunologic leukocyte antigen, HLA-B27. These include reactive arthritis, glomerulonephritis, endocarditis, erythema nodosum, uveitis, and thyroid disorders. Reactive arthritis can occur in asymptomatic patients. Bacteremia is a rare complication. Antibiotics such as gentamicin (Garamycin) or cefotaxime (Claforan) may be given for septicemia or other complications (Aziz & Yelamanchili, 2023; FDA, 2012; Tauxe, 2025).

Bacillus cereus

Foodborne Bacillus cereus (B. cereus) affects approximately 63,400 people annually in the United States. It is of two types based on the predominant symptom: diarrheal and emetic. The diarrheal form has an incubation of 6 to 15 hours, followed by watery diarrhea, abdominal cramps, and occasionally, nausea. The emetic form has an incubation of 30 minutes to 6 hours, followed by nausea and vomiting. Both forms are usually self-limited and resolve within 24 hours. A cytotoxin was identified in a strain of B. cereus, which caused a severe outbreak, resulting in three deaths. Local and systemic infections of B. cereus can provoke pyogenic infections, gangrene, sepsis, meningitis, cellulitis, panophthalmitis, lung abscesses, infant death, and endocarditis. Outbreaks have been attributed to various foods, including rice, beef, turkey, beans, and vegetables; food mixtures such as sauces, casseroles, and soups have also been implicated. Diagnosis is based on the isolation of the organism from food, patient feces, or vomit. The emetic enterotoxin of B. cereus has been linked to the development of liver failure in otherwise healthy individuals (Cairo et al., 2021; FDA, 2012; Foodsafety.gov, 2024; McDowell et al., 2023).

Viral Conditions

Astrovirus, rotavirus, sapovirus (SaV), and Hepatitis E (HepE) are viral GI illnesses that do not require reporting to the CDC or state agencies. They are all transmitted through the fecal–oral route, and most are spread from person to person, with food handlers being at the greatest risk of spreading. Fecal contamination of water where food is obtained is also a source. Foodborne transmission of the HepE virus is on the rise, with processed pork, wildlife meat, and shellfish identified as the primary sources. SaV is similar to NoV; it is found in shellfish but rarely transmitted through food. SaV does not bind to HGBAs, and no susceptibility pattern occurs with NoV. Rotavirus and astrovirus are also rarely transmitted through food but typically from person to person. Emerging viruses with the potential for foodborne transmission include SARS coronavirus, H1N1 influenza, and Zika virus. While food consumption is a risk, people who handle food also risk cutaneous transmission. Although fecal matter is the primary source, nurses must understand that viruses can also be spread through urine, saliva, and breast milk (Chiejina & Samant, 2023; Girish et al., 2025).

Before vaccination, rotavirus was the most common viral foodborne infection in young children. In 95 countries, a 49% to 89% decrease in hospital admissions for rotavirus and an overall 17% to 55% decrease in all hospital admissions for gastroenteritis in children under the age of 5 occurred within 2 years of the immunization being initiated. Without immunization, children are at greatest risk from ages 4 to 23 months. Food contaminated with feces from an infected person is the transmitting agent. Diarrhea and vomiting are typical; without rehydration, this can progress to hypovolemic shock, coma, and death. Unlike NoV, rotavirus immunity progresses with each subsequent infection. The rotavirus vaccine decreases incidence by limiting both infections and the shedding of the organism. Diagnosis of even subclinical cases is possible with the detection of viral nucleic acid (Banyai et al., 2018; LeClair & McConnell, 2023; Savoy, 2025).

In developed countries, rotavirus is more common during the winter months, but in undeveloped countries, there is no discernible seasonal pattern. A lack of adequate rehydration therapies results in severe illness, and 90% of the 200,000 deaths worldwide happen in developing countries. Treatment with antimotility drugs is not recommended. Probiotics containing Lactobacillus rhamnosus strain GG, Lactobacillus reuteri, and Saccharomyces boulardii can help decrease the duration of diarrhea. Continuation of breastfeeding or resumption of feeding after rehydration is recommended for children under 6 months of age. Zinc supplementation is an added recommendation in developing countries. Both rotavirus vaccines for use in infants are administered as oral drops. RotaTeq (RV5) is administered in three doses at 2, 4, and 6 months. Rotarix (RV1) is given in two doses at 2 months and 4 months. The vaccine should not be given after 8 months, even if dosing is incomplete. Contraindications include an allergic response to the vaccine, immunodeficiency, or a history of intussusception. A vaccine dose should be postponed if a child has moderate or severe illness, including diarrhea or vomiting. Side effects of the vaccine include irritability, mild diarrhea, or vomiting. Adverse effects include a risk of intussusception, which typically occurs within one week after the first or second dose (LeClair & McConnell, 2023; Sadiq & Khan, 2024; Savoy, 2025; Steyer et al., 2022).

Noninfectious Foodborne Diseases

Food is a daily requirement of all humans. The following examples serve as a reminder that risks can be present beyond infectious diseases.

Mercury Poisoning

Most HCPs know the risk of mercury poisoning from fish during pregnancy. While mercury exposure should be minimized for everyone, it is most critical during pregnancy because it is linked to changes in fetal brain development. Microorganisms in water process inorganic and elemental mercury and deposit an organic compound—methylmercury—in the tissue of fish. Fish that eat other fish and have a longer lifespan accumulate more mercury and are at the greatest risk. Fish in this category include orange roughy, king mackerel, marlin, shark, swordfish, tilefish, and bigeye tuna. These should be avoided, especially during pregnancy. During fetal development, exposure to methylmercury is known to result in abnormalities and cerebral palsy. Chronic exposure at other ages results in neurologic damage. Current recommendations for nutrition during pregnancy include a maximum of 8 to 12 ounces of low-mercury fish per week, such as catfish, cod, flounder, salmon, sardines, shrimp, light tuna, tilapia, and trout (CDC, 2024n; FDA, 2024c).

Arsenic Poisoning

Rice is a major food source worldwide. Inorganic arsenic occurs in rice, even in countries like the United States, where water has a low arsenic content. Inorganic arsenic is carcinogenic to the bladder, lungs, skin, and prostate. Signes-Pastor and colleagues (2019) found an elevated risk of arsenic poisoning with the intake of brown rice, which is associated with a risk of bladder cancer. Arsenic also increases the risk of developing heart disease. Immediate arsenic poisoning symptoms include muscle cramping, GI problems, and hands and feet lesions. Current experimentation to decrease this risk focuses on identifying and growing rice varieties that absorb less arsenic from the soil and water. The recommended safe intake for adults is no more than two or three servings of rice each week. Traditionally, rice has been cooked with equal parts of water and rice; cooking rice with three times as much water as rice and rinsing the rice before and after cooking can decrease the arsenic content by 30% (Kuivenhoven & Mason, 2023; Signes-Pastor et al., 2019).

Scombroid Syndrome

Scombroid syndrome occurs when histamines are present in contaminated fish. Approximately 5% of food poisoning cases in the United States are from scombroid syndrome. Bacteria in fish gills and GI tracts impart histamine. Scombridae and Scomberesocidae families of fish are the usual sources; this group includes tuna, mackerel, albacore, sardines, anchovies, and mahi-mahi. Neither food processing nor cooking eliminates histamine from fish. The onset of symptoms typically occurs 10 to 30 minutes after ingestion and usually resolves within 24 hours. Infection is typically self-limiting but can persist for several days. Flushing, sometimes accompanied by hives and edema, can be confused with a fish allergy. Scombroid syndrome symptoms include abdominal pain, diarrhea, nausea, vomiting, headaches, dizziness, and palpitations. Some people experience a metallic, peppery, or bitter taste sensation; rarely, wheezing and hypotension occur. Diagnosis includes taking a patient’s history and testing for histamine in the patient’s plasma and in the fish. Patients on isoniazid and monoamine oxidase inhibitors are at increased risk of scombroid syndrome. Administration of rapid-acting antihistamines targets the cause, and symptomatic treatment (i.e., IV fluids and H1 or H2 antihistamines for GI irritation and nausea) can be used (FDA, 2017; Traylor & Matthew, 2023).

Foodborne Disease Control Measures in the Home

The home serves both as a setting for food preparation and as a shared environment for individuals with diverse risks and exposures. While this is evident globally, food safety and handling in the United States have undergone changes that have led to an increased risk. Current public health education emphasizes the importance of changing habits to enhance food safety, including avoiding foods containing raw flour, such as dough, which may be contaminated with organisms and have not been treated to prevent disease. The CDC and FDA provide information on food safety for home use. Figures 2 and 3 are examples of teaching tools that target the risk of foodborne illness by encouraging safer food-handling practices (CDC, n.d.; FDA, 2024a).

Figure 2

Food Safe Shopping and Storage

(FDA, 2018b)

Figure 3

Food Safe Meal Prep

(FDA, 2018a)

Evans and Redmond (2018) evaluated the knowledge and food-handling practices of oncology patients in their homes. Patients with cancer are more at risk for severe consequences of foodborne organisms, with 15% to 25% of serious Salmonella infections occurring in this population. Recommendations that are good practice with the general population but essential for oncology patients include strict adherence to use-by dates on ready-to-eat food, eating ready-to-eat food within 2 days of opening, ensuring temperatures of refrigerators are at or below 41°F (using a thermometer for accuracy), and avoiding raw or undercooked foods, especially seafood, eggs, meat, soft cheeses, and unpasteurized dairy products. A thermometer is also necessary to ensure meat and other foods reach an internal temperature of 145°F to 165°F. Reviews of handwashing should include the use of hot water and soap, rubbing all hand surfaces, including the palms, back of the hands, and fingers, and drying hands only on paper towels. Household cleaning practices and areas of highest risk should be reviewed and updated as needed. Family members and patients should be taught food safety practices to implement before and during chemotherapy treatment (Evans & Redmond, 2018).

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