Viruses, Bacteria, and Parasites in the Digestive Tract

Escherichia coli O157:H7 (or simply E. coli) is just one of the hundreds of strains of the bacterium Escherichia coli. Most strains of E. coli are harmless and live in the intestines of healthy humans and animals. E. coli, however, produces a powerful toxin that can cause a severe infection. (The combination of letters and numbers in the name of the bacterium refers to the specific markers found on its surface and distinguishes it from other types of E. coli.)

An estimated 70,000 cases of E. coli infection occur in the United States each year. The Centers for Disease Control and Prevention (CDC) recognizes E. coli as an emerging food-borne illness. Infection often leads to bloody diarrhea.

Most E. coli illness has been associated with eating undercooked, contaminated ground beef. E. coli bacteria live in the intestines of healthy cattle and, although the number of organisms required to cause disease is not known, it is suspected to be very small. Meat becomes contaminated during slaughter, and organisms can be thoroughly mixed into beef when it is ground. Contaminated beef looks and smells normal. Other ways to transmit E. coli include:

• Person-to-person contact in families and in child-care and other institutional-care centers can also be places where the transmission of the bacteria can occur.
• Bacteria present on a cow's udders, or on equipment, may get into raw milk causing the infection.
• Infection may also occur after swimming in or drinking sewage-contaminated water.
• It has been confirmed that unpasteurized juices, such as apple cider, may also cause the infection.

Bacteria in diarrhea stools of infected persons can be passed from one person to another if hygiene or handwashing habits are inadequate. This is particularly likely among toddlers who are not toilet trained. Family members and playmates of these children are at high risk of becoming infected.

Young children typically shed the organism in their feces for a week or two after their illness resolves.

CDC recommendations for prevention of the infection include:

• Cook all ground beef or hamburger thoroughly. Make sure that the cooked meat is gray or brown throughout (not pink), any juices run clear, and the inside is hot.
• Using a digital instant-read meat thermometer, the temperature of the meat should reach a minimum of 160° F.
• If you are served an undercooked hamburger in a restaurant, send it back.
• Consume only pasteurized milk and milk products. Avoid raw milk.
• Consume only pasteurized juices and ciders.
• Make sure that infected persons, especially children, wash their hands carefully and frequently with soap to reduce the risk of spreading the infection.
• Drink municipal water that has been treated with adequate levels of chlorine, or other effective disinfectants.
• Avoid swallowing lake or pool water while swimming.
• Wash hands thoroughly after using the toilet.
• People with diarrhea should not:
  • swim in public pools or lakes
  • bathe with others
  • prepare food for others

Salmonella is a bacteria that infects the intestines and causes diarrhea, fever, and abdominal cramps 12 to 72 hours after infection. At least 40,000 cases of salmonella infection are reported in the United States each year. The illness usually lasts four to seven days and most persons recover without treatment.

However, in some persons the diarrhea may be so severe that the patient needs to be hospitalized. In those patients, the salmonella infection may spread from the intestines to the blood stream and then to other body sites and can cause death unless the person is treated promptly with antibiotics. Infants and those with impaired immune systems are more likely to have a sever illness.

Salmonella may be spread by:

• eating raw foods contaminated with animal feces.
  Contaminated foods usually look and smell normal. Contaminated foods are often of animal origin, such as beef, poultry, milk, or eggs, but all foods, including vegetables, may become contaminated. Many raw foods of animal origin are frequently contaminated, but fortunately, thorough cooking kills Salmonella.
• handling reptiles. Reptiles (such as iguanas and turtles) are particularly likely to harbor Salmonella and people should always wash their hands immediately after handling a reptile, even if the reptile is healthy. Adults should also be careful that children wash their hands after handling a reptile.

Since foods of animal origin pose the greatest threat of Salmonella contamination, do not eat raw or undercooked eggs, poultry, or meats. Remember that some sauces and desserts use raw eggs in their preparation, so be cautious of these, particularly in foreign countries. Also, follow these recommendations by the Centers for Disease Control and Prevention (CDC):

• Make sure poultry and meat, including hamburgers, are well-cooked, not pink in the middle.
• Do not consume raw or unpasteurized milk or other dairy products.
• Thoroughly wash produce before eating it.
• Avoid cross-contamination of foods. Uncooked meats should be kept separate from produce, cooked foods, and ready-to-eat foods.
• All utensils, including cutting boards, knives, counters, etc., should be thoroughly washed after handling uncooked foods.
• Thoroughly wash hands before handling foods and between handling different food items.
• Thoroughly wash hands after contact with feces.
• Thoroughly wash hands after handling any reptiles, since reptiles are particularly likely to have Salmonella.

Rotavirus is the most common cause of severe diarrhea among children, resulting in the hospitalization of approximately 55,000 children each year in the United States and the death of over 600,000 children annually worldwide.

In the United States, the disease occurs most often in the winter, with annual epidemics occurring from November to April. The highest rates of illness occur among infants and young children, and most children in the United States are infected by two years of age. Adults can also be infected, though disease tends to be mild.

The incubation period for rotavirus disease is approximately two days. The disease is characterized by vomiting and watery diarrhea for three to eight days, and fever and abdominal pain occur frequently. Immunity after infection is incomplete, but repeat infections tend to be less severe than the original infection.

Rotavirus may be spread:

• through accidentally swallowing the virus picked up from surfaces contaminated with stool from an infected person, such as toys, bathroom fixtures, changing tables, and diaper pails.
• through ingestion of contaminated food, or contaminated water, such as the type of water found in a public swimming pool.

A rotavirus vaccine that was approved by the US Food and Drug Administration (FDA) in 1998 was pulled from the market in 1999 because of an association between the vaccine and an increased risk for intussusception in infants aged one year or younger. However, no direct link was established to the vaccine as a cause of intussusception.

A new rotavirus vaccine was approved by the FDA in 2006. The risk for intussusception with the new vaccine was evaluated in a large clinical trial of over 70,000 children, and no increased risk was found. The manufacturer of the vaccine will continue to closely monitor the vaccine’s safety in additional clinical studies.

Handwashing is a very important means of preventing the spread of rotavirus. Careful and frequent handwashing can prevent the spread of infection to other people.

The Centers for Disease Control and Prevention (CDC) recommends:

• Adults should wash their hands after using the toilet, after helping a child use the toilet, after diapering a child, and before preparing, serving, or eating food.
• Children should wash their hands after using the toilet, after having their diapers changed (an adult should wash infant's or small child's hands), and before eating snacks or meals.
• Toys, bathrooms, and food preparation surfaces are disinfected frequently, especially if a sick child has been in the home.
• Use diapers with waterproof outer covers that can contain liquid stool or urine, or use plastic pants.
• Make sure that children wear clothes over diapers.

During the past 15 years, Giardia lamblia has become recognized as one of the most common waterborne diseases in humans in the United States. Giardia is a tiny parasite that lives in the intestines of people and animals. The parasite is passed in the bowel movement of an infected person or animal. It is found in every region of the United States and throughout the world.

Diaper-aged children who attend day care centers, international travelers, hikers, campers, and others who drink untreated water from contaminated sources, are most at risk for developing infection with Giardia. Several community-wide outbreaks of infection have been linked to drinking municipal water contaminated with Giardia.

People become infected after accidentally swallowing the parasite. Giardia may be found in soil, food, water, or on surfaces.

Some of the ways people can become infected with Giardia include:

• eating uncooked food contaminated with Giardia.
• swallowing water from swimming pools, lakes, rivers, springs, ponds, or streams contaminated with sewage or feces from humans or animals.
• accidentally swallowing the parasite picked up from surfaces contaminated with stool from an infected person, such as toys, bathroom fixtures, changing tables, diaper pails.

The Centers for Disease Control and Prevention (CDC) recommends:

• washing hands with soap and water after using the toilet, changing diapers, and before handling food.
• washing and peeling all raw vegetables and fruits before eating.
• avoiding drinking water from lakes, rivers, springs, ponds, or streams unless it has been filtered and chemically treated.
• boiling drinking water for one minute to kill the Giardia parasite. This will ensure safe drinking water during community-wide outbreaks caused by contaminated drinking water.
• when camping or traveling in countries where the water supply may be unsafe, avoid drinking unboiled tap water and avoid uncooked foods washed with unboiled tap water. Bottled or canned carbonated beverages, seltzers, pasteurized fruit drinks, and steaming hot coffee and tea, are safe to drink.

If your child has Giardia, avoid swimming in pools for two weeks after the diarrhea or loose stools have cleared. Giardia is fairly chlorine resistant and is passed in the stools of infected people for several weeks after they no longer have symptoms.

Cryptosporidium, often referred to as "crypto," is a tiny parasite that can live in the intestines of humans and animals. The parasite is protected by an outer shell that allows it to survive outside the body for long periods of time and makes it very resistant to chlorine disinfection.

Cryptosporidium may be spread by:

• accidentally swallowing anything that has come in contact with the stool of a person or animal
• swallowing contaminated water from swimming pools, hot tubs, lakes, rivers, springs, ponds, or streams contaminated with sewage or feces from humans or animals.
• eating uncooked contaminated food.
• picking cryptosporidium up from surfaces contaminated with stool from an infected person (such as toys, bathroom fixtures, changing tables, and diaper pails).

• The Centers for Disease Control and Prevention (CDC) recommends:
• your child should wash their hands with soap and water after using the toilet, changing diapers, and before eating or helping prepare food.
• avoid water or food that may be contaminated.
• washing and/or peeling all raw vegetables and fruits before giving them to your child to eat.
• avoiding drinking water from lakes, rivers, springs, ponds, or streams unless it has been filtered and chemically treated.
• boiling drinking water for one minute to kill the Giardia parasite. This will ensure safe drinking water during community-wide outbreaks caused by contaminated drinking water.
• when camping or traveling in countries where the water supply may be unsafe, avoid drinking unboiled tap water and avoid uncooked foods washed with unboiled tap water.
• avoiding swimming in pools if your child has had cryptosporidium and for at least two weeks after diarrhea stops. Crypto can be passed in the stool and contaminate water for several weeks after your child no longer has symptoms. This has resulted in several outbreaks of cryptosporidium among pool users. Crypto can survive in chlorinated pools for several days.