Food Poisonings with Food Additives

Food Additives and their Classification

Food additives are non-nutritional chemicals, synthetically added to foodstuffs to enhance their organoleptic properties, to facilitate foodstuff processing and preservation.

For investigating food additives and putting them on the list of permissible ones there is the Joint committee of experts of FАО/WHO on food additives.

Classification of Food Additives Allowed for Application in the Countries of European Union

Е 100 — Е 200 — coloring agents

Е 200 — Е 300 — preservatives

Е 300 — Е 400 — antioxidants, acidity regulators

Е 400 — Е 600 — emulsifying agents, consistence stabilizers, agents preventing conglomeration

Е 600 — Е 900 — agents strengthening taste, flavor

Е 900 — Е 1000 — agents enriching quality of grain and bread.

Such food additives are recommended by EU for application, but each country approves the list of allowed agents itself.

In Ukraine the List of allowed food additives is affirmed by the resolution of Ministry of Ukraine and the addition of new food additives to it is admitted only according to the resolution of Ministry of Public Health Service of Ukraine.

More than 5,000 chemicals are now used as food additives — coloring agents, aromatics, emulsifying agents, preservatives, baking powders, etc. Poisonings occur at application of forbidden additives or at exceeding their permissible amount, e. g. using nitrates as food coloring agents for sausages (see above about their action on person).

Mycotoxicoses

These are food poisonings caused by toxins of microscopic mould fungi on bread and bread products (grain, flour) at their storage in moist conditions. They are characteristic of countryside — bad conditions of flour storage, using spoilt grain during disasters (famine, wars, etc.). Nowadays they are encountered in connection with baking bread by private manufacturers from the untested flour.

Ergotism. Ergot poisoning follows eating grain contaminated by ergot fungus. Foodstuffs can contain such toxins as ergotoxine, ergotamine, ergometrine. They cause a spasm of smooth, then transversal striated muscles.

Three forms of ergotism are distinguished:

· Convulsive, manifested by paresthesias, dizziness, spasms, sometimes — gastroenteritis. The duration is 3-6 weeks.

· Gangrenous ("Saint Anthony fire"), characterized by necrosis of skin with rejection of necrotic sites, severe pains in these sites. In severe cases death occurs in 1-2 days accompanied by secondary infection (sepsis).

· Mixed — a combination of the 1 and 2 forms.

Ergotism is especially dangerous for pregnant women, as it causes a spasm of smooth muscles of uterus leading to abortion, or premature birth.

Fusariosis. This is poisoning with "drunk bread" caused by mould fungus Fusarium graminearum. The symptoms are: gastroenteritis, and damage of CNS like alcohol intoxication. This is an endemic disease in the Far East.

Alimentary-toxic aleukia. As far as 1944 this disease had been called "septic quinsy". It is caused by fungus of a Fusarium type which develops in grain wintered under snow. The disease is characterized by serious disturbance of hematosis, leuko- and thrombocytopenia. The main sign is aleukia (occurs in 1-2 weeks) — a sharp decrease of leukocytes and erythrocytes, increase of lymphocytes. A severe necrotic tonsillitis and sepsis are also marked. The mortality makes up 50-80 %.

Аflatoxicosis. They are caused by fungi of Aspergillis type which are found in peanuts and peanut flour, grain, corn, rice at storage in moist conditions at increased temperature. Recently it has been found in Spanish red wine. The disease causes a severe liver injury and produces a cancerogenic effect on liver — a primary cancer of the liver (earlier it was encountered basically in Africa and Asia). Now it is often found in the Crimea and South Ukraine.

Food Poisonings of Insufficiently Investigated Etiology

River Urova disease (Kashin–Beck disease).Now it is established that it is hyperpolymicroelementosis (strontium rickets). This is an endemic disease for Eastern Siberia (the Urova river is situated there) and for some other territories on Earth. The disease causes deformation of skeleton in the period of growth, severe metabolic disturbances.

Gaffen disease. Gaffen gulf is in Holland. The disease occurs at use of fish from some reservoirs in certain periods of time. The cause of the disease is not established, but it is supposed that in water toxic seaweeds are formed, toxins being accumulated in fish.

The official diagnosis is alimentary paroxysmal-toxic myoglobinuria (the excretion of muscular protein myoglobin in blood and urine). The disease causes the attacks of sharp muscular pains and sharp renal insufficiency due to myoglobinaemia. In this case hemodialysis is necessary.

Poisoning with quail meat.Sometimes it causes gastroenteritis of various degree of severity. The causes are not established.

Tactics of the Doctor at Suspicion of Food Poisoning

v The establishment of primary diagnosis on the basis of:

Ø dietary history (what food was eaten by the patient) from the patient or relatives,

Ø characteristic clinical signs and symptoms

v Rendering urgent medical aid by life-saving indication — cardiacs, respiratory analeptics, etc.

v Confirmation of the diagnosis:

Ø gathering and sending to laboratory of Rospotrebnadzor department of nutrition hygiene of remnants of food, gastric lavage waters, vomiting materials, faeces, blood, urine.

Ø writing out the "Accompanying direction to laboratory investigation" with indication of reason of taking food samples and method of laboratory food investigation.

v Disintoxication therapy: gastric lavage, abundant drinking, antibiotics, droppers. In case of botulism — antibotulinic serum, anatoxin.

v To prevent mass food poisoning the "Emergency notification about food poisoning" should be sent to Rospotrebnadzor department of nutrition (especially if poisoning took place in a public catering establishment). On receiving the emergency notification the doctors within 24 hours should carry out the investigation of food poisoning — sanitary inspection of public catering establishment, examination of the personnel, etc.

v If necessary the emergency hospitalization at the infectious department of hospital should be arranged.

 

 

Recommendations for Practical Classes on the Theme

Key Questions

1.Concept of food poisoning. Characteristic features of these poisonings. Classification.

2.Etiology, pathogenesis, symptoms and prevention of food poisonings of microbe nature:

Toxicoinfections

Bacterial toxicoses

3.Etiology, pathogenesis, symptoms and prevention of food poisonings of non-microbe nature:

Food poisonings with poisonous plants and mushrooms;

Food poisonings with foodstuffs sometimes or partially poisonous;

Food poisonings with salts of heavy metals;

Food poisonings with food additives (nitrates);

Food poisonings with agrochemicals (pesticides and fertilizers)

4.Etiology, pathogenesis, symptoms and prevention of mycotoxicoses:

Fusarioses

Ergotism

Aflatoxicoses

5.Food poisonings of the unknown nature, symptoms, diagnostics, causes of occurrence, prevention.

Learning Objectives and Their Concrete Definition

To establish the diagnosis of food poisoning on the basis of suggested clinical tasks or cards of investigation of food poisonings, to determine the product caused it, to draw up the necessary documents (see Problem Solving).

 

Appendix 1

Clinical Symptoms of Some Food Pisonings of a Microbe Etiology

Symptoms	Toxicoinfection	Staphylococcus intoxication	Botulism
Body temperature	elevated or high	normal or elevated	normal or subnormal
Headache	+	+	+
General weakness	+	++	+++
Loss of consciousness	-	-	-
Spasms	-	+	+
Decrease of heart rate	+	++	++
Cyanosis	-	+	-
Cold perspiration	+	+	-
Visual impairment	+	+	+++
Dryness in the mouth	-	-	+++
Nausea, vomiting	+++	++	+++
Pain in epigastrium	+	+++	+
Constipation	-	-	+++
Diarrhea	++	+	-
Blood in faecal masses	-	+	-
Mucus in faecal masses
Duration of disease at adequate treatment	1-3 days	1-3 days	5-20 days

+++ sharply expressed symptoms

++ clearly expressed symptoms

+ infrequently observed symptoms

— symptoms which are not observed

Self Test

1. What is the pathogenesis of botulism?

* A. affection of the medulla

B. involvement of the GIT and CVS

C. involvement of kidneys and liver

D. affection of the brain cortex

E. involvement of the respiratory system

2. What clinical forms are not characteristic of toxicoinfections?

A. gastroenteritis

B. typhoid-like form

C. grippe-like form

D. cholera-like form

E. dysentery-like form

* F. haemolytic form

3. A citizen has picked mushrooms in the wood and has eaten them fried. In 12 hours severe pains in the stomach, vomiting, diarrhea with blood suddenly occurred. At the end of the first day of the disease jaundice, enlargement of the liver, oliguria appeared. Spasms were observed. Death occurred on the third day. What might be the cause of the disease?

A. death-cup poisoning

B. supercooling

* C. toadstool poisoning

D. poisoning with false honey fungus

E. nitrate poisoning

Problem Solving

1. A case of food microbe poisoning took place on 20 July in the family of a clerk after eating fried veal cutlets (the calf had been ill for a week and that is why was slaughtered without knowledge of veterinary inspectors). The main symptoms of the disease: a 12-16-hour incubational period, high temperature, severe pains in the abdomen, vomiting, diarrhea, general weakness, headache. Which is the most probable causative agent of the given poisoning?

2. In the reception ward of the local hospital two children of the same family aged 4 and 6 were admitted in May with complaints of nausea, vomiting, frequent liquid stool. The disease began soon after eating boiled unpeeled potatoes. On examining the potatoes used in food by the family, many sprout and green samples were revealed. Which is the most probable causative agent of the given poisoning?

3. On examination of patient С., aged 26, in order to render him first aid, the following has been established: he works on the collective farm, takes meals at home. On July 20 pains in the abdomen, nausea occurred at 11.00. At 13.00 he had vomiting. He feels bad. A daily diet for the last 3 days consists of the following: July 18 — breakfast: rice, cottage cheese, tea, bread; dinner: meat soup, bread; supper: sausage, coffee, bread. July 19 — breakfast: pasties, milk; dinner: soup with fresh fish, meat with macaroni, tea, bread; supper: meat with macaroni (left from dinner), tea, bread. July 20 — breakfast: coffee, bread.

Objectively: body temperature is 37.8°C, pulse is full, 86 per minute, the abdomen is tense and tender on palpation; there is diarrhea with mucus discharge. Make the diagnosis of food poisoning, identify the product which has caused it.

Standard Answers

1. Salmonella

2. Solanine

3. Food poisoning of a microbe etiology, toxicoinfection caused by pasties

 

Methods of Investigation of Food Poisoning Cases

Key Questions

Tactics of the doctor on revealing food poisoning.

1.Rules of taking samples for the laboratory analysis.

2.Rules of drawing up documentation in case of revealing food poisoning (name of documents, the order and terms of paper work).

3.Measures of prevention of food poisonings.

4.Scheme of investigation of food poisoning.

Self Test

1. Put the following points of the common plan of food poisoning investigation in a correct sequence:

A. Inspection of conditions and ways of manufacture, storage and processing of the suspected foodstuff

B. Drawing up the act of investigation based on block of data of laboratory analyses

* C. Revealing clinical symptoms characteristic of the given case

D. Revealing the suspected foodstuff and its exclusion from the use

E. Sending samples of patients’ biosubstances, samples of suspected foodstuffs, lavages for laboratory research

 

2. What documents does the doctor send to Rospotrebnadzor department of nutrition on revealing food poisoning?

A. case history

* B. urgent notification on food poisoning

C. a sick-leave certificate (medical certificate)

D. a statistical coupon

E. an accompanying appointment card for laboratory analysis

 

3. How long should the investigation of food poisoning be carried out?

A. 7 days

* B. 24 hours

C. 12 hours

D. 10 days

E. 72 hours

Problem Solving

1. Last year on August 30 from 9.00 p.m. the inhabitants of a village with the population of 91 persons addressed the medical station with complaints of high temperature (38ºC and higher), headache, pain in the epigastrium, nausea, vomiting, diarrhea. All the patients had been on the wedding party which began at 11.00 a.m. The meal was prepared overnight. As there were only two refrigerators, meat, gammon, cutlets and sausages were kept in a kitchen cellar. It was very hot that day, the air temperature during the day was 25-29ºС. In the food remnants, vomiting and faecal masses the culture Salmonella enteritidis was found out. Identify and substantiate the probable reason of food poisoning, reveal the foods, which could have caused this food poisoning. Enumerate the preventive measures necessary in this case.

2. During investigation of food poisoning, caused by a river fish (it was caught, salted within 5 days, then dried and used in meal), botulinum toxin Е was revealed. What measures should the doctor take in this case?

3. Among the pupils of a children's house the case of a mass food poisoning is revealed. The reason was eating cakes with cream stored in the nutrition unit with abnormal conditions of temperature. Name the most effective method of prevention of staphylococcus toxicosis?

Standard Answers

1. The reason: non-observance of storage conditions of meat products, in which further Salmonella enteritidis has developed and caused food poisoning. It is necessary to render medical aid to the patients, to interrogate them with the purpose of revealing persons who have taken the same food, to forbid the use of meat products stored in a cellar, to observe the patients during the incubation period.

2. It is necessary to inject antibotulinic serum intravenously in a dose of 15,000 IU to all patients having symptoms of this disease. All the other persons who have eaten this fish should be injected the serum in a dose of 1,000-2,000 IU. The intake of the given product, if remained, should be forbidden.

3. Prevention of opportunity of staphylococcus multiplication in foodstuffs and producing toxin; with this purpose to supervise the conditions and terms of food storage.

Additional Material for Self-Preparation

All cases of food poisonings should be obligatory taken into account and thoroughly investigated with the purpose of establishing the reasons of their occurrence and carrying out preventive measures of eliminating their consequences. For this purpose it is necessary to know the rules and order of filling in documentation on revealing cases of food poisonings.

 

Appendix 1

Accompanying Appointment Card for Laboratory Investigations

“___” ________ 200  № ______                                                                       Simferopol

(Name of Rospotrebnadzor department of nutrition, where the analysis is made) ______________________________________________________________________________________________________________________________________________________

(Name of laboratory, its address)

______________________________________________________________________________________________________________________________________________________

(Name of establishment, sending sample, its address, phone number)

 

№	Name of stuff	Weight of sample	Characteristics of container (sterility, glass, polythene, cardboard, etc.)	Date and time of sending sample to laboratory
1
2
3

 

Urgency of investigation, what product is suspected as the cause of food poisoning ___________________________________________________________________________________________________________________________________________________________________

(Full name, position of a person who sends a sample for investigation

 

At reception of samples the laboratory should give the receipt with indication of samples and time of their reception.

 

Appendix 2

Objects Liable to Investigation and Order of their Sending to Laboratory

Name of stuff		Amount of stuff	Time of taking a food sample
Foodstuffs			1-st day
A.	Remnants of suspected food	200-300 g	- //-
B.	Samples of liquid or half-liquid dishes or foodstuffs	200-300 ml after careful stirring	- //-
C.	Second dishes	1-2 portions	- //-
D.	Meat of various parts of carcass	500 g	- //-
E.	Brine from barrels with pickles	100-200 ml	- //-
F.	Poultry	1-2 samples	- //-
G.	Fish: if large — samples from 2-3 places, if small — several pieces		- //-
H.	Tinned goods: open tins, not open tins	5-10
Examination of personnel			1-st day
A.	Bacterial samples from hands and, if necessary, smears from the oral and nasal cavity of personnel engaged in cooking food		- //-
B	Referral of personnel to revealing intestinal infections		- //-
Objects of investigation from ill persons			during the first hours or day after the disease onset
A.	vomiting masses	50-100 g
B.	first lavage waters	100-200 ml
C.	faecal masses	50-100 g
D.	urine	200 ml
E.	blood culture	8-10 ml from vein
F.	blood for serological test	2-3 ml from a finger is possible	7-10 days after the disease onset
Section material
A.	content of the stomach	50-60 g	reaction of agglutination on the 28-30th day for revealing the decrease of antibody titer
B.	a segment of small or large intestine
C.	liver, spleen		during the first hours after section
D.	heart blood

 

Appendix 3

Urgent Notification about Food Poisoning

1.Diagnosis____________________________________________________________

2. Full name of patient__________________________________________________

3. Sex _______________________________

4. Age______________________________________________________________

5. Address: city/village _________________________ district ___________________

street_______________________house_______________apartment ______________

6. Place and address of work (study)________________________________________

7. Dates of:

disease onset________________________________________________________

primary address to the doctor (revealing) ___________________________________

establishment of the diagnosis ___________________________________________

last visit to school, higher school, work _____________________________________

hospitalization________________________________________________________

8. Place of hospitalization_______________________________________________

9. Indicate the place of food poisoning, the cause of poisoning

___________________________________________________________________

10. Primary antiepidemic measures and additional data

__________________________________________________________________

11. Date and time of primary notification of SES about disease _________________________________________________________________________

Full name of a person who notified SES_____________________________________

Full name, position of a person who received urgent notification ___________________________________________________________________________

12. Date and time of sending urgent notification _____________________________

        Signature of the person having sent notification to SES

13. Date and time of reception of notification by SES_________________________

Registration No_________ in register No ______ SES __________________

Signature of person who sent urgent notification _________________________

Note: It is sent to SES not later than 12 hours from the moment of establishing the diagnosis.

 

Appendix 4

Plan of Preventive Measures
(for the Given Case of Food Poisoning)

Carrying out sanitary-educational work (to specify the forms).

· The necessity of sanitary inspection of a nutrition unit.

· The necessity of examination of personnel of a nutrition unit.

· The necessity of withdrawal of foods or closing a nutrition unit.

· Measures on prevention of similar poisonings in home conditions.

· Other measures.

Signature of student ___________________________

 

Appendix 5

Scheme of Analysis of Disease Symptoms (Food Poisoning)

1. Full name of patient__________________________________________________

2. Date, time of disease onset, date of hospitalization ____________________

3. Main symptoms: nausea (+ -), vomiting, diarrhea, constipation, pains in the stomach, body temperature (°С), fever, headache, general weakness, dizziness, diplopia, blepharoptosis, mydriasis of pupils, dryness in the mouth, deglutitive problem, change of voice, spasms, cyanosis, muscle pains, joint pains, influenzal phenomena, blood in feces, pulse, arterial pressure, changes of CNS.       The revealed symptoms are marked by signs "+" or "-", temperature — in degrees by Celsius, the severity of disease is indicated as mild, moderate or severe.

It is necessary to specify:

4. Name and address of manufacture or establishment, where samples are taken.

5. The main findings of sanitary-epidemic inspection:

· date of food poisoning

· time of occurrence of disease symptoms after taking suspicious meal

· description of clinical signs and symptoms in patient

· number of victims

· number of hospitalized persons

· presence of cases with lethal outcome

· primary diagnosis

6. At presence of samples of several products it is necessary to specify, which of them is suspected as the cause of food poisoning.

7. Purpose of investigation:

· establishment of diagnosis

· last visit to children's establishment, school; hospitalization

8. Place of hospitalization.

9. If it is poisoning, it is necessary to specify, where poisoning occurred, what caused poisoning.

10. Primary antiepidemic measures.

11. Date and time of the primary signal about disease to SES (over telephone, telegraph). The surname of the person, who has sent the message and who has accepted the message.

12. Date and time of sending notification. Signature of the person, who has sent notification.

13. Date and time of reception of notification by SES, registration number in a register. Signature of the person, who has received notification.

 

Appendix 6

Scheme of Drawing up the Act of Investigation of Food Poisoning

Name of doctor, date of drawing up the act of investigation.

1.Description of disease onset.

2.Clinical state of the patient.

3.Establishment of the primary diagnosis.

4.To specify the number of persons having used a suspicious product.

5.To specify the number of fallen ill persons.

6.To list the stuff sent for the laboratory analysis.

7.To specify the place of food intake.

8.To identify the time passed after intake of suspicious food.

9.To identify, what particularly product could have caused food poisoning.

10.To interview the victims in order to reveal the disturbance of оrganoleptic properties of food. 11. To specify the place, where a suspected product is delivered from, or place and date of its manufacture.

12.To make a brief description of a sanitary state of a manufacturer or public catering unit.

13.To specify the name of withdrawn or utilized product.

14.To specify the results of laboratory investigation of the product.

15.To draw a valid conclusion in case of food poisoning.

 

Theme No 8.

Medical and Prophylactic Nutrition.

Prophylactic Nutrition

Prophylactic nutrition or therapeutic-prophylactic nutrition as a measure of prevention of occupational diseases is of great importance.

The basis of prophylactic nutrition is a balanced diet composed in view of metabolic changes of organism occurred under the influence of harmful physical and chemical industrial factors, using separate components of the food rendering protective effect at influence of toxic chemical compounds and adverse physical factors of manufacture.

The Purpose of Prophylactic Nutrition

v Increase of general resistibility of organism;

v Compensation of power and plastic stocks of organism under influence harmful chemical and physical factors on manufacture.

v Increase of specific resistibility of organism to industrial poisons and harmful industrial physical factors by means of:

Ø decreasing the entry of harmful substances into organism;

Ø acceleration of removing toxicants from an organism;

Ø acceleration of metabolism of toxic substances in order to form less toxic compounds;

Ø protection of separate organism systems against harmful effect of industrial physical and chemical factors.

Structure of Prophylactic Nutrition

· High-grade proteins, performing plastic function, stimulating general resistibility of organism, participating in detoxication of some poisons.

Thus, amino acids cystine, cysteine, methionine, containing SH groups, are capable of binding heavy metals, phenol, arsenic. Methionine, producing lipophilic effect, prevents fatty infiltration of the liver, improves its antitoxic function.

· Carbohydrates restore the energy losses of organism caused by poisons, participate in neutralization of some poisons. For example, fructose and saccharose transform cyanides and phosphorus compounds into low-toxic substances, pectin substances bind and excrete lead and other heavy metals, stop absorption of strontium and radium.

· Mineral substances, first of all calcium, increase general resistibility of organism. Calcium has an antagonistic effect on strontium, weakens the effect of chlorine, nitrogen oxides which cause pathological increase of vascular permeability and development of lung hypostasis.

Salts of copper accelerate molybdenum excretion. Phytin reduces or prevents clinical signs of poisoning with lead.

· Vitamins increase the general resistibility of organism to adverse physical and chemical factors. They are of great importance in destruction and removing many toxic substances from organism.

Thus, vitamin C transforms arsenic poisons into less toxic compounds and promotes their removing from organism. Vitamin B1 increases resistance of organism to lead, benzene, fluorine, styrene.

The Basic Therapeutic-Prophylactic Diets

Milk. All mentioned above substances in the optimal ratio are contained in milk. Therefore milk is applied to prevent many industrial poisonings. However a protective effect of milk is produced on rather small number of poisons, e.g. arsenic, heavy metals, phosphorus, phenol, aromatic compounds.

In other cases, milk as high-grade foodstuff, only improves a general condition of organism increasing its nonspecific resistibility.

Depending on mechanism of effect of physical and chemical industrial factors, some types of therapeutic-prophylactic nutrition diets are distinguished:

Diet No. 1 is used in conditions of lowered atmospheric pressure when hypoxia develops and non-oxidized products accumulate in organism, the functions of the nervous, cardiovascular, digestive and other systems are disturbed. In these conditions the decrease of fat amount and increase of easily digestible carbohydrates, reduction of protein quantity are necessary.

Diet No. 2is used under conditions of noise; it is prescribed in case of disturbances of oxidation-reduction processes caused by noise, lack of vitamins C, Р, B1, B2, B6, decrease of capillary and cellular membrane resistibility. The increase of protein amount in diet is conditioned by reduction of fats and carbohydrates.

Diet No. 3is used under conditions of radiation effect. This type of diet includes three groups of substances:

Amino acids: cystine, cysteine, methionine acids having ability of shielding (SH-group in molecules);

Substances capable of binding and removing from organism free radicals: pectin substances, cystine, cysteine, methionine, glycine, bilious and nuclein acids, vitamins and mineral substances, primarily, calcium;

Lipotropic substances improving exchange of fats and increasing antitoxic function of the liver: cystine, methionine, phosphatides, polyunsaturated fatty acids, vitamins.

Diet No. 4 is desensibilization nutrition administered to workers contacting the chemical substances producing an allergenic effect. The diet is limited in carbohydrates, especially sugar. A slight increase of fats, basically of vegetative origin is recommended. The acid strengthening removal from an organism of calcium, chloride sodium, biogenic amines (histamine, serotonin), spicy and extractive dishes should be limited. The products containing active biological allergens, pesticides, food additives are limited as well.

Diet No. 5provides special energy supply at contact with various groups of industrial poisons. It is composed in view of mechanism of effect of poisons and properties of various components of food to produce detoxical effect on the given chemical compounds by delaying their entry into organism, acceleration of removing from an organism or transfer into less toxic compounds.