DC Medical Malpractice & Patient Safety Blog

Spinach. Cantaloupe. Peanut Butter. All delicious things to eat, and all in the news recently because they were associated with widespread cases of food poisoning. And it’s not just media coverage—according to the Centers for Disease Control and Prevention, food-borne illnesses are increasing in the U.S.

The CDC reports says cases of food poisoning have increased 14% in the last five
years. It looked at trends since 1996, examining nine types of bacteria that transmit infection.

As reported by Bloomberg.com, the number of food-borne cases of illness were about the same as those between 2006-2008, which represents a lack of progress from earlier study periods.

Many cases of food-borne illness are never diagnosed. But in 2012, the CDC report tallied 19,531 food-borne infections and 4,563 hospitalizations.

According to AboutLawsuits.com, nearly 48 million Americans—or 1 in 6 people—get sick from contaminated food each year. About 3,000 will die, and the rest will suffer its miserable effects—diarrhea, abdominal pain, nausea and vomiting.

The most common culprit in food poisoning is salmonella, even though the incidence of salmonella poisoning didn’t increase. Salmonella often is passed from animal droppings (commonly chickens) into water and produce.

The second-most common cause is campylobacter, which also is associated with poultry and with dairy products. The bacteria vibrio also is not your stomach’s friend—it’s found in undercooked shellfish and thrives in warm sea water. Most of the illness it causes is the result of eating raw oysters.

Other increasingly popular “delivery systems” for food infections are poultry and unpasteurized milk and cheese.

Meat-related illness declined. The CDC, says AboutLawsuits, attributed that to more scrutiny by regulatory agencies. Even though the incidence of contaminated meat declined, it still accounted for 29 in 100 deaths from all food-borne illnesses.

Last week, the Center for Science in the Public Interest said that ground beef and chicken are by far the riskiest meat/poultry products for food poisoning—specifically salmonella and E coli. The least risky? Chicken nuggets, ham and sausage. Read the report here.

The people most vulnerable to food infections are children younger than 5 and people older than 65. The percentage of victims who died was highest among the older group infected with vibrio (6 in 100) and salmonella (2 in 100). The percentage of patients who died from all pathogens studied was highest for listeria—11 in 100.

As noted by Bloomberg, the Obama administration has been slow to fully enact the 2011 Food Safety Modernization Act (FSMA), which we wrote about last year. One of two proposals made in January to kick start the FSMA would give companies one year to develop a formal illness prevention plan. The second would force produce farms with a “high risk” of contamination to formulate better hygiene, soil and temperature controls.

Neither proposal has taken effect, nor have any of the other major provisions of the FSMA.

Last week, as reported by FDA Law Blog.com, a U.S. District Court in California granted summary judgment (when the court, or judge, disposes of a case before trial) to the Center for Food Safety and Center for Environmental Health in their lawsuit claiming that the FDA’s delay in issuing regulations to implement the FSMA was unlawful. The court said, according to Law Blog, “the failure to comply with those deadlines constitutes a ‘failure to act’ under the [Administrative Procedure Act].”

“[T]he purpose of ensuring food safety,” the court said, “will not be served by the issuance of regulations that are insufficiently considered, based on a timetable that is unconnected to the magnitude of the task set by Congress.” The court told the parties to confer and set a schedule for implantation. That’s supposed to be submitted by May 20. Stay tuned.

For tips on protecting yourself against food-borne illness, see our blog.

There’s been a lot of news lately about energy drinks, and none of it’s good. We recently wrote about how little is known about their contents, and their link to heart disease and high blood pressure.

Now, as reported in the New York Times, five people died in the last three years after drinking Monster Energy. And the parent of a 14-year-old Maryland girl has sued Monster Beverage, its manufacturer, for failing to warn consumers about its risks after her daughter died of heart arrhythmia.

The FDA released an incident report (which doesn’t prove Monster Energy caused the deaths or any other health issues) about the high-caffeine beverage, which was obtained by Wendy Crossland, the teenager’s mother. The girl had drunk large cans of Monster Energy on two consecutive days. In addition to the five deaths, the FDA has received a report of a nonfatal heart attack possibly associated with the drink.

Other incident reports, according to The Times, included other adverse events including abdominal pain, vomiting, tremors and abnormal heart rate. The reports covered the period from 2004 to June 2012; all the deaths occurred in 2009 or later. According to Bloomberg News, there were 37 adverse reaction reports since 2004 that mentioned Monster drinks.

The reports are not exhaustive—they aren’t clear for example, if the incidents involved other factors, such as alcohol or drugs. The reports are voluntary, so generally the number the FDA receives about any product it regulates represents only a fraction of all incidents.

Monster Energy is only one representative of the energy-blast product niche. Others include Red Bull, Rock Star and 5-hour Energy. Monster Energy has several derivative drinks—Monster Rehab, Monster Assault and Monster Heavy Metal. As their names indicate, the target market is teenagers and young adults. An FDA statement said manufacturers were responsible for investigating reports of death or injuries associated with their products, and that the agency had not established a causal link between the deaths and the beverage.

Still, the report raises concern about how well manufacturers monitor their products for safety and whether the feds exercise oversight of them. Product labels indicate that they’re “not recommended” for children under 12 and people “sensitive” to caffeine. The stimulant can pose risks for people with heart disorders, so there’s a lot of real estate between not being recommended and being deadly.

Manufacturers are not obliged to disclose caffeine content, and it is they who decide whether to call them drinks or dietary supplements. The latter are not subject to FDA oversight for ingredients and labeling.

Anais Fournier, the Marylander teen who died, drank 24-ounce cans of Monster Energy that each contained 240 milligrams of caffeine. An 8-ounce cup of brewed, generic coffee has about 133 mg of caffeine, according to the Center for Science in the Public Interest.

The lawsuit filed on her behalf, The Times reported, quoted autopsy and medical examiner reports that she had died of “cardiac arrhythmia due to caffeine toxicity” that had exacerbated an existing heart problem. Fournier apparently had Ehlers-Danlos syndrome, which can affect blood vessels. She and her family were aware of her underlying heart condition but apparently her doctors had not told her to restrict her physical activities or her caffeine use.

In April, Sen. Richard J. Durbin invoked Fournier’s death in a letter urging the FDA to enforce caffeine levels in energy drinks. In August, agency officials said that there was insufficient evidence to take action on caffeine levels in energy drinks, noting, however, that it had not received medical reports related to Fournier’s death. According to Bloomberg News, emergency room visits involving energy drinks increased tenfold from 2005 through 2009. About half of them, according to Bloomberg, were patients 18 to 25 years old and some involved drugs or alcohol,

If you want Congress to impose stricter ingredient and labeling practices on the energy drink industry, contact your representative. You can find out who and where they are by linking here. To report a problem with a food, drug or dietary supplement, contact the FDA's MedWatch program.

According to the Centers for Disease Control and Prevention (CDC), approximately 3,000 deaths every year are caused by food-borne illnesses and about 48 million people—1 in 6 Americans—gets sick from food contamination.

A couple of nonprofit consumer advocacy organizations don’t believe the federal government is moving fast enough to address the problem, and last month they sued the feds for failing to implement and enforce a new food safety law.

According to Reuters, the Center for Food Safety and the Center for Environmental Health claimed that the feds repeatedly missed mandatory deadlines for issuing final regulations required by the Food Safety Modernization Act, signed in January 2011. They want a federal court to force the FDA and Office of Management and Budget (OMB) to enforce the law.

"The bill,” Andrew Kimbrell, executive director of the Center for Food Safety told Reuters, “is useless unless the agencies actually promulgate regulations that make it work. This is very serious. They are twiddling their bureaucratic thumbs while Americans become sick and die."

Indeed, outbreaks from food-borne illnesses are common. In July, cantaloupes were the culprit in a salmonella outbreak that has reached 22 states, according to FoodSafetyNews.com. The same source says 16 states and Canada have been affected by salmonella-bearing mangoes in recent weeks. E coli and listeria also can sicken people who eat food contaminated with those pathogens.

Diarrhea and abdominal cramps are common symptoms of food poisoning. But different sources determine other aspects of the illness.

People infected with salmonella typically also suffer from fever and vomiting. Generally, the symptoms present 12 to 72 hours after consuming the food carrying the bug. The illness usually lasts 4 to 7 days, and most people recover without treatment. But sometimes the diarrhea can be so severe that the ill person must be hospitalized for dangerous dehydration.

With an E. coli infection, diarrhea typically turns bloody within 24 after symptoms begin. Its incubation period (time from exposure to the onset of symptoms) usually is 3 to 4 days, but can be as short as 1 day or as long as 10. In rare cases, it can cause the bowel tissue to die and perforate. It’s more common in children, and E. coli infection is the most common cause of acute kidney failure in infants and young children. Most people get better in about a week, but the risk of dehydration remains.

Listeria symptoms also include fever and muscle aches, but diarrhea is less common. Incubation generally is between 3 and 70 days, and 21 days is typical. If the infection spreads to the central nervous system, symptoms can include headache, stiff neck, confusion, loss of balance and even convulsions. Healthy people seldom become seriously ill from Listeria.

The Food Safety Modernization Act was the first time in more than 70 years that food safety laws had been overhauled. The act establishes standards for possible sources of contamination of fresh fruits and vegetables, and makes importers responsible for the safety of food they import. It also compels food companies to identify possible causes of contamination and develop ways to prevent them.

But if the act isn’t being implemented, it’s more a waste of ink than a protection of the food supply.

The lawsuit charges that the FDA has failed to meet hundreds of deadlines established by the legislation. "These are the basics on standards, procedures, traceability ... upon which the entire system is based," said Kimbrell. "They haven't done what is required to actually begin the process of getting this new food safety law in place."

The Center for Justice & Democracy at New York Law School bolsters the argument. In a white paper called “Our Fatal Food Attraction—Regulatory Failures and the Civil Justice System,” it notes that “food safety regulation and information, which, depending on the situation, involves the … FDA, the United States Department of Agriculture Food and Safety Inspection Service (USDA) and/or the … CDC, are failing to keep Americans safe, or even properly informed of foodborne illness dangers.

“In fact, when it comes to the FDA, some of its most critical functions have been privatized,
assigned to corporations subject to corrupting influences that can ultimately result in foodborne illness outbreaks. What’s more, even when the CDC is aware that a restaurant caused a large-scale foodborne illness outbreak, it has the discretion to conceal this information from not only the public, but also the actual victims of the outbreak.”

That’s grim, but even in the absence of regulatory monitoring and enforcement, you can help prevent food-borne illness:

• Wash your hands with soap and water before preparing food.


• Cook meat, poultry and eggs thoroughly.


• Don't cross-contaminate one food with another (don’t use a common surface for cutting raw meat and vegetables unless it’s washed thoroughly between uses).


• Refrigerate leftovers promptly.


• Clean produce properly by rinsing fresh fruits and vegetables to remove visible dirt and grime and removing the outermost leaves of a head of lettuce or cabbage.


• Don’t prepare food for others if you have a diarrheal illness.

In addition, always report suspected food-borne illnesses to your local health department—it might be a public safety issue. Locate your local agency here.

A couple of recent news reports support the notion that the more we know medicine, the less we know about health. The latest yes/no/maybe answer to a health question concerns grapefruit, a fruit long known to affect how our bodies process drugs.

As reported by U.S. News & World Report, patients with incurable cancer who drank 8 ounces of grapefruit juice a day enhanced the effect of a drug they were taking. The study was reported in Clinical Cancer Research.

The drug, sirolimus (Rapamune), suppressed the immune system and is not approved for treating cancer. It’s generally prescribed to prevent rejection after a kidney transplant, and to treat psoriasis. It was included in this study because its derivatives have been used to treat kidney and breast cancer.

Some study patients responded positively to the drug/juice combo—their condition stabilized for a while. With the exception of one patient, tumors did not disappear. But the primary result of the admittedly small study (about 150 patients with incurable cancer and no effective treatment) was that grapefruit juice enabled the drug to be used in smaller doses, which would reduce side effects and possibly cost.

Sirolimus has poor “bioavailabilty”—that means the body can’t use it efficiently. Only about 14 percent of it is metabolized. Because grapefruit is known for boosting the effects of other drugs, researchers wanted to see if it could improve this one’s bioavailability. And it did.

Sirolimus costs about $1,000 a month. Combine it with drinking grapefruit juice, researchers suggest, and the cost could drop to around $300 a month. The cost of other expensive cancer drugs ($3,000-$10,000 a month) also could be slashed by equivalent amounts when taken with grapefruit juice.

Lowering the dose, of course, also could reduce side effects, which include nausea and diarrhea.

But because the effects of grapefruit vary among different drugs and dosages, broad generalizations can’t be drawn, and consumers are advised not to experiment on their own.

The research is in its infancy. Grapefruit juices vary in how well they inhibit the enzymes in the liver and intestine that break down drugs, leaving more of the drug available to be metabolized, and individual biochemistry also affects absorption.

But yang to that study’s yin was noted recently by consumer organization Public Citizen’s recent Best Pills, Worst Pills newsletter. It warned that drinking grapefruit juice while taking certain medications can be really bad medicine, a cautionary tale described by AboutLawsuits.com.

Public Citizen listed 82 medications whose effects can be altered by drinking grapefruit juice. The combination might result in some delivering too much of the drug, and others too little, the organization said. Earlier this year, the FDA reported that grapefruit juice might reduce the effectiveness of some drugs.

Among the common drugs Public Citizen identified as problematic in terms of grapefruit interaction are:

• Lipitor;


• Tegretol;


• Propulsid;


• Celexa;


• Valium;


• Benadryl;


• Multaq;


• Prozac;


• Haldol;


• Serzone;


• Viracept;


• Prilosec;


• Paxil;


• Seroquel;


• Zoloft;


• Viagra;


• Zocor; and


• Coumadin.

In addition to its subscription resource, Public Citizen says the National Library of Medicine’s DailyMed website offers a useful guide for drug interactions and information. And the FDA has these tips for patients who take over-the-counter or prescription drugs:

• Ask your pharmacist or doctor if grapefruit or grapefruit juice affects absorption of the medicine. If so, ask other juices are a safer option.


• Read the medication guide or patient information sheet that comes with your prescription medicine. Some advise not to take the drug with grapefruit juice.


• Read the drug facts label on nonprescription medicine; it often mentions grapefruit or other fruit juices that might pose a problem.


• If you must avoid grapefruit juice with your medicine, check the label on other fruit juice or drinks flavored with fruit juice to make sure they don’t contain grapefruit juice.


• Seville oranges (often used to make orange marmalade) and tangelos (a cross between tangerines and grapefruit) affect the same enzyme as grapefruit juice, so avoid them if your medicine interacts with grapefruit juice.

A few weeks ago we wrote about the unknowable contents of energy drinks, particularly caffeine, and their potential to cause problems.

Now, the feds are homing in on Aeroshot Breathable Energy, a dietary supplement that promotes its “unique blend of caffeine and B vitamins in a fine powder that dissolves quickly in your mouth.” The FDA is investigating Aeroshot amid concerns that it’s as much a party drug as a legitimate—and safe—energy booster. Using Aeroshot and alcohol simultaneously, the thinking goes, enables people to drink larger amounts of alcohol than normal because its effects are masked until consumers are extremely inebriated.

Inhaled via dispenser, Aeroshot imparts a large coffee cup’s worth of caffeine with every spray; each container yields 4 to 6 puffs.

In 2010, the FDA and the Federal Trade Commission (FTC) warned people that caffeinated malt beverages might not be “generally recognized as safe” (GRAS), the standard used to analyze food with added ingredients that haven’t been subject to approval. As a result, caffeinated malt beverages such as Four Loko effectively were banned.

But because Aeroshot is marketed as a dietary supplement, not as food, it isn’t subject to the regulatory muscle the FDA can flex for food products. “[I]t bears watching,” said the FDA Law Blog, “whether FDA takes account of the manufacturer’s marketing practices, and of whether the product is associated with ‘adverse behavioral effects’–factors that the agency cited in support of its conclusion that the use of caffeine in caffeinated malt beverages such as Four Loko is not GRAS.”

The investigation, then, will focus on whether Aeroshot is safe and legally marketable as a dietary supplement. If such products make no claims about curing medical problems, they may be sold without FDA approval. But they may not contain active pharmaceutical ingredients that are regulated by the agency. Supplements often have been found in violation of this rule, but the FDA generally does nothing until adverse effects become known.

Although Aeroshot is promoted as a “breathable” product, it actually dissolves in the mouth, and is swallowed, which complicates its categorization for regulatory oversight. The almost incomprehensible category of “breathable” food is not unfamiliar to some food scientists, but it’s a concept few other people can wrap their minds around. Really, who wants to inhale, in the literal sense, their Thanksgiving dinner?

So what’s a consumer to do about Aeroshot? Certainly, if you’ve used the product to ill effect, make a report to the FDA by linking here. If you’re only considering using Aeroshot and questioning its value, think about this: If you can’t even define the category under which something you’re contemplating eating, drinking or inhaling falls, if the full nature of its contents are unknown and have the potential to cause or exacerbate a problem, do you really want it in your body?

Red Bull. Rockstar. Monster.

They could be the names of ultimate fighters or black diamond ski runs, but as any American not living off the grid knows, they are the names of energy drinks, a food category that exploded into consumer consciousness in the late 1990s.

Basically, whether marketed as food or dietary supplements, they all sell caffeine. And while caffeine in moderation isn’t harmful for most people, there’s little guidance about the quantity of caffeine—which some sources define as a drug, others as a food additive and others as a stimulant chemical found in plants—in these drinks. There’s also a paucity of information about other ingredients in these drinks.

As noted in a recent story on NPR, there’s no consensus on exactly what an “energy drink” is. Today, you find canned coffee, tea and even fruit juice spiked with extra caffeine. There’s little research about their effects.

One researcher for the Center on Young Adult Health and Development at the University of Maryland School of Public Health called for better labeling of these products in an article published in the Journal of the American Medical Association (JAMA) titled “The ‘High’ Risk of Energy Drinks.”

The American Beverage Association drafted guidelines for energy drinks, but it’s up to manufacturers to include them on product labels. The guidelines call for caffeine quantity, warnings about mixing drinks with alcohol and noting that they are not intended to be consumed by children, pregnant or nursing women or people who are sensitive to caffeine. A few years ago, we wrote about energy drinks being linked to heart problems.

Still, what is an energy drink? According to Susan Carlson of the FDA’s Office of Food Additive Safety, “They range all over the place, from products that have probably no caffeine to products that do have caffeine and products that have ingredients that may contain caffeine. But there is no regulatory definition for energy drinks, per se.”

Regardless of whether an energy drink calls itself a food or a dietary supplement, the FDA has no regulatory limits for caffeine content. Those apply only to cola drinks. Red Bull has about twice as much caffeine per can than Coke.

By law, the FDA has the right to question a manufacturer's use of an ingredient and its safe use of an ingredient. The agency is concerned about conventional foods being marketed as dietary supplements, and, Carlson told NPR, it has taken public comment to draft industry guidelines.

If you’re sensitive to caffeine, or simply like to be informed about the contents of manufactured food products before you consume them, make your feelings about energy drinks known to the FDA.

In addition, visit product websites, where more information might be forthcoming. If not, let manufacturers know that you’re not likely to purchase their product unless you know what’s in it.

Now that even Minute Maid has introduced juice “enhanced” with caffeine, the energy drink craze really deserves scrutiny.

Given our propensity to pop an antibiotic at the first sign of a sniffle—and much of the medical establishment’s willingness to gratify this often unwise habit—it’s hard to believe that the use of antibiotics to fight infection has been common practice for only a couple of generations.

Like all medications, they come with risks of side effects, but in the right circumstances, antibiotics are truly wonder drugs. They’re so wonderful, however, that we overuse them. The problem then becomes not just one of risky and/or unpleasant side effects, but of reduced efficacy.

The more frequently antibiotics are used, the better bacteria become at resisting them. It’s simple evolution—survival of the fittest bacteria. The fitter (stronger) the bacteria, the more compromised the antibiotics. In order to keep up with the demand of increasingly resistant bacteria, new compounds must constantly be developed. The old ones simply don’t work anymore.

Antibiotic resistance occurs when humans ingest the drugs more frequently and for disorders they are not meant to address. But one contributor to this diminishing-effects scenario is not the direct result of human behavior—it results from the routine use of antibiotics in agriculture. They’re given to livestock to prevent disease and promote growth. That practice has been called into question often in recent years.

As explained in the Los Angeles Times, last year, the American Medical Association (AMA), the World Health Organization (WHO) and other medical groups warned that “the misuse of antibiotics in food animal production may be creating a serious problem for human health by fostering development of drug-resistant bacteria."

Further, some studies showed that taking antibiotics out of animal feed "made antibiotic-resistant bacteria less prevalent in both animals and people with no ill effects for animals or ranchers."

Earlier this month, the FDA put its foot down on some unapproved uses of antibiotics for livestock. The agency prohibited use in certain animals of one class of antibiotics called cephalosporins, and prohibited using the drugs for purposes other than their original intent (called “off-label” or “extra-label” use) except for animals that are rarely consumed by humans.

It wasn’t the first time the FDA attempted to curb the use of antibiotics in animals. In 2008, the FDA made a move to limit off-label antibiotic use in livestock, but wussed out in the face of opposition by agricultural interests.

Congressional Rep. Louise Slaughter (D-N.Y.) is a microbiologist who has written legislation addressing antibiotic overuse. In a statement about the latest action, she said, "We need to start acting with the swiftness and decisiveness this problem deserves. With over 1 million Salmonella cases in the U.S. each year, at least 30,000 Americans will contract cephalosporin-resistant bacteria every year. I'm glad the FDA is finally acting but how many Americans have needlessly been sickened in the meantime?"

The new rules take effect April 5, but as in 2008, there’s a comment period in the interim. Comments received last time helped sway the FDA against enforcing the restrictions. So if you care about antibiotic resistance, you might want to weigh in about the latest proposal. Link here to read a Q&A about general antibiotic use in animals and specifically this action. To submit comments, link here and include the docket number FDA-2008-N-0326.

According to a report by the Department of Health and Human Services, every year 128,000 Americans are hospitalized and 3,000 die from food poisoning. The FDA is responsible for safeguarding the food supply and for inspecting food facilities. A recent study addressed concerns about the rigor of these inspections.

As reported on the FDA Law Blog, the report enumerated several “significant weaknesses” in oversight of food facilities inspected by state agencies under contract to the FDA.

They include:

• failure to ensure that the number of required inspections was completed;


• payment for incomplete inspections;


• failure to ensure that all state inspections were properly classified and that all violations were remedied;


• failure to complete the required number of audits for one-third of the states and inconsistent follow-up on systemic problems.

The findings are important because in recent years state contractors have conducted most food facility inspections. Questions about the reliability of inspections and audits conducted by an agency other than the FDA have come from many quarters. Third-party auditors have taken the heat for several recent outbreaks of food-borne illness, such as the 2009 salmonella outbreak in a peanut processing facility.

Some such outbreaks have resulted in wrongful death lawsuits, including the listeriosis found in cantaloupes last year from which 30 people died.

As dire as the HHS report seems, the long-term effect on food safety is rosier once the FDA implements an accreditation system for third-party auditors authorized by the Food Safety Modernization Act (FSMA) enacted last year. That system focuses on imported food, but the FDA is interested in recognizing third-party certification programs generally.

As the report suggests, ultimate success is a matter of the FDA stepping up to answer the question “Who guards the guards?”

At the end of last week, the Centers for Disease Control and Prevention reported that 15 people had died and 84 were ill from eating listeria-contaminated cantaloupes.

It’s the deadliest food-borne outbreak in 13 years.

Listeria is a bacteria that causes listeriosis, a kind of food poisoning. Every year, according to WebMd, approximately 2,500 people become seriously ill with listeriosis. Most people recover on their own, but the outbreak is particulary dangerous for pregnant women, newborns, the elderly and people with compromised immune systems. Once diagnosed, they are given antibiotics.

Listeria can infect a variety of foods, and it’s more insidious than some other food-borne microbes because it thrives under refrigeration and can incubate for weeks before a person exhibits symptoms. The latter makes it difficult to identify the origin, and therefore stop the supply line of germs.

Here’s a primer on listeriosis.

Symptoms include one or more of:

• fever


• muscle aches


• nausea


• diarrhea


• headache


• stiff neck

Prevention involves practicing safe food handling:

• While shopping, bag raw meat, poulty and fish separately from other food items.


• Store food as soon as possible after shopping.


• Wash your hands before and after handling food.


• Wash fresh produce by rinsing well under running water.


• Use two cutting boards, one for fresh produce and one for raw meat, poultry and seafood.


• Wash knives and cutting boards in the dishwasher to disinfect them.


• Cook, refrigerate or freeze meat, poultry, eggs, fish and prepared foods within two hours of preparation.


• Refrigerators should be 40 degrees or colder. But because listeria grows in the cold, clean refrigerator spills promptly.


• Reheat leftovers to at least 165 degrees; don’t eat undercooked hamburger and beware the risk of eating raw fish.


• If in doubt, throw it out.

If you’re pregnant, do not eat:

• hot dogs, lunch or deli meats unless steaming hot;


• soft cheese unless the label says they’re made from pasteurized milk;


• refrigerated pate or meat spreads;


• raw milk;


• store-prepared salads, such as ham, chicken, egg, tuna or seafood.