Campylobacter Campylobacter EnteritisEnteritis

Summer, 2010Summer, 2010SW Montana County Health DepartmentsSW Montana County Health Departments

Allison McIntosh, PhD StudentAllison McIntosh, PhD StudentWalden University PubH 8165-1Walden University PubH 8165-1Instructor: Dr. Howard RubinInstructor: Dr. Howard Rubin

Purpose of PresentationPurpose of PresentationTo exchange knowledge of the To exchange knowledge of the

transmission, recognition, reporting transmission, recognition, reporting of, treatment, and prevention of of, treatment, and prevention of Campylobacter Campylobacter enteritis in enteritis in Southwest Montana. Southwest Montana.

AgendaAgenda1.1. Discuss terminologyDiscuss terminology2.2. Prevalence Prevalence 3.3. Routes of exposureRoutes of exposure4.4. Reporting procedureReporting procedure5.5. TreatmentTreatment6.6. PreventionPrevention

Learning Objectives: By Learning Objectives: By the end of the session the end of the session

participants will: participants will: Define campylobacter and enteritisDefine campylobacter and enteritis List three routes of exposure to campylobacterList three routes of exposure to campylobacter Identify an example of a food borne Identify an example of a food borne

transmission and a water borne transmissiontransmission and a water borne transmission List the main two symptoms of campylobacterList the main two symptoms of campylobacter Explain the reporting procedure in MontanaExplain the reporting procedure in Montana List one treatment option for campylobacterList one treatment option for campylobacter List two complications of Campylobacter List two complications of Campylobacter

enteritisenteritis Expand on ways to avoid cross contamination Expand on ways to avoid cross contamination

and list two ways to prevent campylobacterand list two ways to prevent campylobacter

Picture of Campylobacter Picture of Campylobacter jejunijejuni

Public Health Image Library (2010). Campylobacter. Image 5781. Public Health Image Library (2010). Campylobacter. Image 5781. Retrieved July 15, 2010 from Retrieved July 15, 2010 from

http://phil.cdc.gov/phil/quicksearch.asp

So what is enteritis?So what is enteritis? Inflammation of the small intestine.Inflammation of the small intestine.Causes:Causes: Eating or drinking substances that are Eating or drinking substances that are

contaminated with bacteria (in this case contaminated with bacteria (in this case Campylobacter jejuni). Campylobacter jejuni).

RESULTS IN: inflammation and RESULTS IN: inflammation and swelling, which may lead to swelling, which may lead to painpain, , cramping, dicramping, diarrheaarrhea, , feverfever, and , and dehydrationdehydration..

MedLine Plus (2010). Enteritis. Retrieved July 10, 2010 from MedLine Plus (2010). Enteritis. Retrieved July 10, 2010 from http://www.nlm.nih.gov/medlineplus/ency/article/001149.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001149.htm

PrevalencePrevalence 2008 in Montana: 14.9 cases per 2008 in Montana: 14.9 cases per

100,000 population per year100,000 population per year May to August are the most common May to August are the most common

months when 49% of all infections months when 49% of all infections occurred occurred

Communicable Disease Stats and Facts (2008). Annual report. Retrieved July 18, 2010 from Communicable Disease Stats and Facts (2008). Annual report. Retrieved July 18, 2010 from http://www.dphhs.mt.gov/PHSD/epidemiology/documents/AnnualReport2008FINAL_03_31_2010.pdf

Nationwide there are an estimated 2.5 Nationwide there are an estimated 2.5 million cases million cases (Alterkruse, Stern, Fields, & Swerdlow, 1999)(Alterkruse, Stern, Fields, & Swerdlow, 1999)

Routes of ExposureRoutes of Exposure Food-borne: eating meat or drinking milk Food-borne: eating meat or drinking milk

of infected animalsof infected animals Cross-contamination: from cooking Cross-contamination: from cooking

utensils such as a raw chicken placed on a utensils such as a raw chicken placed on a cutting board and then using the board to cutting board and then using the board to prepare other foodprepare other food

Water-borne: Drinking un-chlorinated Water-borne: Drinking un-chlorinated waterswaters

Fecal-oral: Feces of infected animals are Fecal-oral: Feces of infected animals are introduced to the oral cavity from poor introduced to the oral cavity from poor hand hygiene hand hygiene

Food-borne Gastroenteritis Food-borne Gastroenteritis from confirmed from confirmed campylobactercampylobacter

Australian study: Population risk factorsAustralian study: Population risk factors Eating cooked and/or undercooked chicken (29.3%)Eating cooked and/or undercooked chicken (29.3%) Barbequed meats placed on plate used for raw Barbequed meats placed on plate used for raw

meatmeat Around domestic chickens less than 6 month oldAround domestic chickens less than 6 month old Around dogs less than 6 months old Around dogs less than 6 months old Having a gastrointestinal condition, liver disease, Having a gastrointestinal condition, liver disease,

or being immuno-compromised from drugsor being immuno-compromised from drugsStafford, R..J., Schluster, P.J., Wilson, A.J., Kirk, M.D., Hall, G., Unicomb, L. (2008). Population-Stafford, R..J., Schluster, P.J., Wilson, A.J., Kirk, M.D., Hall, G., Unicomb, L. (2008). Population-

attributable risk estimates for risk factors associated with attributable risk estimates for risk factors associated with campylobacter infection, campylobacter infection, Australia. Australia. Emerging Infectious Disease (4)Emerging Infectious Disease (4)6, 895-901. Retrieved July 18, 2010 from 6, 895-901. Retrieved July 18, 2010 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600281/pdf/07-1008_finalR.pdfhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600281/pdf/07-1008_finalR.pdf

Waterborne OutbreaksWaterborne Outbreaks Summer 1981, Colorado, drinking Summer 1981, Colorado, drinking

water for campers water for campers (Hopkins, Olmstead, & Istre (1984).(Hopkins, Olmstead, & Istre (1984).

Summertime camping trip, Grand Teton Summertime camping trip, Grand Teton Park, WY, untreated surface water Park, WY, untreated surface water (Taylor, (Taylor, Brown, & McDermott, 1982).Brown, & McDermott, 1982).

Outdoor infantry drill in Utti, Finland, Outdoor infantry drill in Utti, Finland, untreated surface water untreated surface water (Aho, Kurki, Rautlin, & (Aho, Kurki, Rautlin, &

Kosunen, (1989).Kosunen, (1989). Sweden, communal tap water Sweden, communal tap water (Martin, (Martin,

Penttinen, Hedin, Ljungstrom, Allestam, Andersson, & Giesecke (2006)Penttinen, Hedin, Ljungstrom, Allestam, Andersson, & Giesecke (2006)

Characteristics of the Characteristics of the illnessillness

Incubation 24 to 72 hours but may be a week Incubation 24 to 72 hours but may be a week if small amounts of bacteria are ingestedif small amounts of bacteria are ingested

Prodromal syptoms: nonspecific-headache, Prodromal syptoms: nonspecific-headache, muscle pain, chills, fever)muscle pain, chills, fever)

Hallmark symptom: DIARRHEA, watery Hallmark symptom: DIARRHEA, watery stools, 8 or more in a day, may turn bloodystools, 8 or more in a day, may turn bloody

Abdominal pain may be like appendicitisAbdominal pain may be like appendicitis The peak of the illness lasts 24 to 48 hours The peak of the illness lasts 24 to 48 hours

and usually resolves in a weekand usually resolves in a weekBlaser, M.J. (1997). Epidemiologic and clinical features of Blaser, M.J. (1997). Epidemiologic and clinical features of

Campylobacter jejuni Campylobacter jejuni infection. Journal of Infectious Disease, 176 infection. Journal of Infectious Disease, 176 (SuppS), S103-S105. Available at (SuppS), S103-S105. Available at http://www.cdc.gov/ncidod/eid/vol5no1/altekruse.htmhttp://www.cdc.gov/ncidod/eid/vol5no1/altekruse.htm

Serious but Rare Serious but Rare Guillain-Barré syndrome (GBS)Guillain-Barré syndrome (GBS) Reiter syndromeReiter syndrome Both GBS and Reiter syndrome Both GBS and Reiter syndrome

are thought to be autoimmune are thought to be autoimmune responses stimulated by infection. responses stimulated by infection.

Altekruse, S.F., Stern, N.J., Fields, P.I., Swerdlow, D.L. (1999). Altekruse, S.F., Stern, N.J., Fields, P.I., Swerdlow, D.L. (1999). Campylobacter jejuni- Campylobacter jejuni- An emerging foodborne pathogen. Emerging An emerging foodborne pathogen. Emerging Infectious Disease, 5(1), Retrieved july 18, 2010 from Infectious Disease, 5(1), Retrieved july 18, 2010 from http://www.cdc.gov/ncidod/eid/vol5no1/altekruse.htmhttp://www.cdc.gov/ncidod/eid/vol5no1/altekruse.htm

Costs Associated with Costs Associated with Guillain-Barré syndromeGuillain-Barré syndrome

Of an estimated 2,628 to 9,575 new Of an estimated 2,628 to 9,575 new U.S. cases with GBS annually, 526 to U.S. cases with GBS annually, 526 to 3,830 are triggered by infection with 3,830 are triggered by infection with Campylobacter.Campylobacter.Reducing

Campylobacter in food could prevent up to $5.6 billion in costs annually. Buzby, J.C., Roberts, T., Allos, B.M.(1997). Estimated annual costs of Campylobacter associated Guillain-Barre Syndrom. Agricultural Economic Report No. (AER 756). USDA, Economic Research Service. Retrived July 3, 2010 from http://www.ers.usda.gov/Publications/AER756/

Reporting procedureReporting procedure). ). Clinical descriptionClinical description An infection that may result in diarrheal illness of variable An infection that may result in diarrheal illness of variable

severityseverityLaboratory criteria for diagnosisLaboratory criteria for diagnosis Isolation of Isolation of Campylobacter Campylobacter from any clinical specimen (stool from any clinical specimen (stool

culture)culture)Case classificationCase classification ProbableProbable: a clinically compatible case that is : a clinically compatible case that is

epidemiologically linked to a confirmed caseepidemiologically linked to a confirmed case ConfirmedConfirmed: a case that is laboratory confirmed: a case that is laboratory confirmedOnly confirmed cases are reported to the laboratory-based Only confirmed cases are reported to the laboratory-based

surveillance system managed by the Foodborne and Diarrheal surveillance system managed by the Foodborne and Diarrheal Diseases Branch, Division of Bacterial and Mycotic Diseases, Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.National Center for Infectious Diseases, CDC.

Case Definitions for Infectious Conditions Under Public Health SurveillanceCase Definitions for Infectious Conditions Under Public Health Surveillance [MMWR [MMWR 1997;46(RR10)] (available at 1997;46(RR10)] (available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00047449.htm

TreatmentTreatment Usually cases resolve on their own. Usually cases resolve on their own. Potential for dehydration: May need Potential for dehydration: May need

replacement intraveneously or by oral replacement intraveneously or by oral routeroute

If symptoms progress treat with If symptoms progress treat with Erythromycin or ciprofloxacin Erythromycin or ciprofloxacin (Blaser, 1997)(Blaser, 1997)

Resistant strains are increasing with both Resistant strains are increasing with both animals as hosts and also humans animals as hosts and also humans (Judicious (Judicious Use, 2001).Use, 2001).

Seek medical care for bloody diarrhea and Seek medical care for bloody diarrhea and fever over 101 degrees fever over 101 degrees (Javid & Ahmed, 2009)(Javid & Ahmed, 2009)

Control of Campylobacter spread Control of Campylobacter spread through the Food Safety and through the Food Safety and

Inspection Service of the USDAInspection Service of the USDAOn the farm:On the farm: The USDA recommends good sanitary practices to help The USDA recommends good sanitary practices to help

control the spread among farm animals and birds control the spread among farm animals and birds Pasteurization of milk and dairy productsPasteurization of milk and dairy products Treatment/testing of municipal water supplies Treatment/testing of municipal water supplies In the plant:In the plant: At Plants:At Plants: Recommendations on how to handle raw (non-sterile) Recommendations on how to handle raw (non-sterile)

foods where up to 50 to 80% of poultry carry foods where up to 50 to 80% of poultry carry campylobactercampylobacter

At retail:At retail: Voluntary food recalls by distributorsVoluntary food recalls by distributorsUSDA (2006). Foodborne Illness and Disease. Retrieved July USDA (2006). Foodborne Illness and Disease. Retrieved July

18, 2010 from 18, 2010 from http://www.fsis.usda.gov/factsheets/Campylobacter_Questiohttp://www.fsis.usda.gov/factsheets/Campylobacter_Questions_and_Answers/index.aspns_and_Answers/index.asp

Prevention of Prevention of Campylobacter exposure for Campylobacter exposure for

consumersconsumers Freezing poultry in home freezers generally Freezing poultry in home freezers generally

not cold enough to kill natural bacteria in not cold enough to kill natural bacteria in poultrypoultry

CLEAN: Wash Hands and Surfaces OftenCLEAN: Wash Hands and Surfaces Often Wash your hands with warm soapy water Wash your hands with warm soapy water Wash utensils, cutting boards, dishes, and Wash utensils, cutting boards, dishes, and

countertops countertops Paper towels may be more safePaper towels may be more safeUSDA (2006). Foodborne Illness and Disease. Retrieved July 18, 2010 USDA (2006). Foodborne Illness and Disease. Retrieved July 18, 2010

from from http://www.fsis.usda.gov/factsheets/Campylobacter_Questions_and_Anshttp://www.fsis.usda.gov/factsheets/Campylobacter_Questions_and_Answers/index.aspwers/index.asp

Separate food itemsSeparate food items Keep raw chicken and meat separate Keep raw chicken and meat separate

in the shopping cart and refrigeratorin the shopping cart and refrigerator It is recommended that it may be a It is recommended that it may be a

good investment to use one cutting good investment to use one cutting board for raw meats and one for board for raw meats and one for fresh vegetablesfresh vegetables

USDA (2006). Foodborne Illness and Disease. Retrieved July USDA (2006). Foodborne Illness and Disease. Retrieved July 18, 2010 from 18, 2010 from http://www.fsis.usda.gov/factsheets/Campylobacter_Questihttp://www.fsis.usda.gov/factsheets/Campylobacter_Questions_and_Answers/index.aspons_and_Answers/index.asp

Food SafetyFood Safety Cook all meats and poultry and leftovers Cook all meats and poultry and leftovers

to 160 to 165 degreesto 160 to 165 degrees Refrigerate leftovers promptlyRefrigerate leftovers promptly Cool quickly, place in shallow bowl so Cool quickly, place in shallow bowl so

that food cools before placing in that food cools before placing in refrigeratorrefrigerator

USDA (2006). Foodborne Illness and Disease. Retrieved July 18, USDA (2006). Foodborne Illness and Disease. Retrieved July 18, 2010 from 2010 from http://www.fsis.usda.gov/factsheets/Campylobacter_Questions_ahttp://www.fsis.usda.gov/factsheets/Campylobacter_Questions_and_Answers/index.aspnd_Answers/index.asp

Learning Objectives: By Learning Objectives: By the end of the session the end of the session

participants will: participants will: Define campylobacter and enteritisDefine campylobacter and enteritis List three routes of exposure to campylobacterList three routes of exposure to campylobacter Identify an example of a food borne Identify an example of a food borne

transmission and a water borne transmissiontransmission and a water borne transmission List the main two symptoms of campylobacterList the main two symptoms of campylobacter Explain the reporting procedure in MontanaExplain the reporting procedure in Montana List one treatment option for campylobacterList one treatment option for campylobacter List two complications of Campylobacter List two complications of Campylobacter

enteritisenteritis Expand on ways to avoid cross contamination Expand on ways to avoid cross contamination

and list two ways to prevent campylobacterand list two ways to prevent campylobacter

TO Sum UpTO Sum Up Campylobacter enteritis may be even more common than Campylobacter enteritis may be even more common than

we knowwe know There are potential serious conditions which may result There are potential serious conditions which may result

with campylobacter infectionswith campylobacter infections Immuno-suppressed patients are expected to increase Immuno-suppressed patients are expected to increase

with our aging population and so rates of serious with our aging population and so rates of serious infections may go upmaking them more susceptibleinfections may go upmaking them more susceptible

There are concerns about antibiotic resistant strains of There are concerns about antibiotic resistant strains of Campylobacter and Salmonella which could result in a Campylobacter and Salmonella which could result in a crisiscrisis

Montana has possibly more of a potential for water-Montana has possibly more of a potential for water-borne campylobacter exposure because of the popularity borne campylobacter exposure because of the popularity of recreation in the back-country with untreated water.of recreation in the back-country with untreated water.

Campylobacter enteritis is a reportable disease in Campylobacter enteritis is a reportable disease in Montana Montana

ReferencesReferencesAho, M., Kurkis, M., Tautelin, H., Kosunen, T.U. (1989). Waterborne outbreak of Aho, M., Kurkis, M., Tautelin, H., Kosunen, T.U. (1989). Waterborne outbreak of

Campylobacter Campylobacter enteritis after outdoors infantry drill in Utti, Finland. enteritis after outdoors infantry drill in Utti, Finland. Epidemiology of Infections, 103, Epidemiology of Infections, 103, 133-141. Retrieved July 1, 2010 from 133-141. Retrieved July 1, 2010 from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2249494/pdf/epidinfect00016-0137.pdf

Altekruse, S.F., Stern, N.J., Fields, P.I., Swerdlow, D.L. (1999). Altekruse, S.F., Stern, N.J., Fields, P.I., Swerdlow, D.L. (1999). Campylobacter Campylobacter jejuni- jejuni- An emerging foodborne pathogen. Emerging Infectious Disease, 5(1), An emerging foodborne pathogen. Emerging Infectious Disease, 5(1), Retrieved july 18, 2010 from Retrieved july 18, 2010 from http://www.cdc.gov/ncidod/eid/vol5no1/altekruse.htmhttp://www.cdc.gov/ncidod/eid/vol5no1/altekruse.htm

Bad Bug Book (2009). Foodborne pathogenic microorganisms and natural toxins Bad Bug Book (2009). Foodborne pathogenic microorganisms and natural toxins handbook: handbook: Campylobacter jejuni. Campylobacter jejuni. U.S. Food and Drug Administration. Retrieved U.S. Food and Drug Administration. Retrieved July 1, 2010 from Public Health Image Library (2010). Campylobacter. Image July 1, 2010 from Public Health Image Library (2010). Campylobacter. Image 5781. Retrieved July 15, 2010 from 5781. Retrieved July 15, 2010 from http://phil.cdc.gov/phil/quicksearch.asp

Blaser, M.J. (1997). Epidemiologic and clinical features of Blaser, M.J. (1997). Epidemiologic and clinical features of Campylobacter jejuni Campylobacter jejuni infection. Journal of Infectious Disease, 176 (SuppS), S103-S105. Available at infection. Journal of Infectious Disease, 176 (SuppS), S103-S105. Available at http://www.cdc.gov/ncidod/eid/vol5no1/altekruse.htmhttp://www.cdc.gov/ncidod/eid/vol5no1/altekruse.htm

. .

ReferencesReferencesBuzby, J.C., Roberts, T., Allos, B.M.(1997). Estimated annual costs of

Campylobacter associated Guillain-Barre Syndrom. Agricultural Economic Report No. (AER 756). USDA, Economic Research Service. Retrived July 3, 2010 from http://www.ers.usda.gov/Publications/AER756

Case Definitions for Infectious Conditions Under Public Health Case Definitions for Infectious Conditions Under Public Health SurveillanceSurveillance [MMWR 1997;46(RR10)] (available at [MMWR 1997;46(RR10)] (available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00047449.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00047449.htm

Communicable Disease Summary ( 2008). Montana Department of Communicable Disease Summary ( 2008). Montana Department of Public Health and Human Services. Retrieved June 28, 2008 from Public Health and Human Services. Retrieved June 28, 2008 from http://www.dphhs.mt.gov/PHSD/Communicable-disease/documentshttp://www.dphhs.mt.gov/PHSD/Communicable-disease/documents/2008stats.pdf /2008stats.pdf

Communicable Disease Stats and Facts (2008). Annual report. Communicable Disease Stats and Facts (2008). Annual report. Retrieved July 18, 2010 from Retrieved July 18, 2010 from http://www.dphhs.mt.gov/PHSD/epidemiology/documents/AnnualRhttp://www.dphhs.mt.gov/PHSD/epidemiology/documents/AnnualReport2008FINAL_03_31_2010.pdfeport2008FINAL_03_31_2010.pdf

ReferencesReferencesHopkins, R.S., Olmstead, R., & Istre, G.R. (1984). Endemic Hopkins, R.S., Olmstead, R., & Istre, G.R. (1984). Endemic

Campulobacter jejuni Campulobacter jejuni infection in Colorad: identified risk factors. infection in Colorad: identified risk factors. American Journal of Public Health , 74, American Journal of Public Health , 74, 249-250.249-250.

Javid, M.H. & Ahmed, S.H. (2009). Javid, M.H. & Ahmed, S.H. (2009). Campylobacter Campylobacter Infections: Infections: Treatment and Mediction. eMedicine. Retrieved July 5, 2010 from Treatment and Mediction. eMedicine. Retrieved July 5, 2010 from http://emedicine.medscape.com/article/213720-treatmenthttp://emedicine.medscape.com/article/213720-treatment

Judicious Use of Antimicrobials for Poultry Veterinarians (2009). The Judicious Use of Antimicrobials for Poultry Veterinarians (2009). The Food and Drug Administration, Center for Veterinary Medicine., 1-13.Food and Drug Administration, Center for Veterinary Medicine., 1-13.

Martin, S., Penttinin, P., Hedin, G., Ljungstrom M., Allesam, G. Martin, S., Penttinin, P., Hedin, G., Ljungstrom M., Allesam, G. Anderson, Y., Giesecke, J. (2006). A case-control study to investigate Anderson, Y., Giesecke, J. (2006). A case-control study to investigate concomitant waterborne outbreaks of concomitant waterborne outbreaks of CampylobacterCampylobacter and and gastroenteritis in Sweden, 2002-2003. Retrieved June 19, 2010 from gastroenteritis in Sweden, 2002-2003. Retrieved June 19, 2010 from http://www.iwaponline.com/jwh/004/0417/0040417.pdfhttp://www.iwaponline.com/jwh/004/0417/0040417.pdf

MedLine Plus (2010). Enteritis. Retrieved July 10, 2010 from MedLine Plus (2010). Enteritis. Retrieved July 10, 2010 from http://www.nlm.nih.gov/medlineplus/ency/article/001149.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001149.htm

ReferencesReferences

Public Health Image Library (2010). Campylobacter. Image 5781. Retrieved Public Health Image Library (2010). Campylobacter. Image 5781. Retrieved July 15, 2010 from http://phil.cdc.gov/phil/quicksearch.aspJuly 15, 2010 from http://phil.cdc.gov/phil/quicksearch.asp

Stafford, R..J., Schluster, P.J., Wilson, A.J., Kirk, M.D., Hall, G., Unicomb, L. Stafford, R..J., Schluster, P.J., Wilson, A.J., Kirk, M.D., Hall, G., Unicomb, L. (2008). Population-attributable risk estimates for risk factors associated (2008). Population-attributable risk estimates for risk factors associated with with campylobacter infection, campylobacter infection, Australia. Australia. Emerging Infectious Disease Emerging Infectious Disease (4)(4)6, 895-901. Retrieved July 18, 2010 from 6, 895-901. Retrieved July 18, 2010 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600281/pdf/07-http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600281/pdf/07-1008_finalR.pdf1008_finalR.pdf

Taylor, D.N., Brown, M., McDermott, K.T. (1982). Waterborne transmission Taylor, D.N., Brown, M., McDermott, K.T. (1982). Waterborne transmission of of CampylobacterCampylobacter enteritis. enteritis. Microbial Ecology, 8, Microbial Ecology, 8, 347-354. 347-354.

USDA (2006). Foodborne Illness and Disease. Retrieved July 18, 2010 from USDA (2006). Foodborne Illness and Disease. Retrieved July 18, 2010 from http://www.fsis.usda.gov/factsheets/Campylobacter_Questions_and_Answehttp://www.fsis.usda.gov/factsheets/Campylobacter_Questions_and_Answers/index.asprs/index.asp