If you are actually reading our #OutbreakThursday post on Thanksgiving Day, we are thankful that you carved some time out of your busy schedule to check in with us. In lieu of covering an ongoing outbreak this week, we will take stock of various infectious disease and other health-related risks associated with Thanksgiving. For our international friends who may be unfamiliar with Thanksgiving, it is an American holiday—on the fourth Thursday in November—during which we celebrate and give thanks for all that we have. Many Americans travel long distances over the long holiday weekend to spend time with friends and family, watch American football, and eat absurd amounts of turkey.
Hopefully, everything goes well this weekend for you, your families, and your friends, but with the high volume of travel; added stress of the Holiday Season; and large, complex meals prepared by amateur cooks, Thanksgiving poses a variety of risks. A veritable cornucopia, if you will. Below we review some of the most common Thanksgiving-related health threats:
With all the cooking and eating this weekend, particularly involving poultry, foodborne illness is an obvious concern. The CDC, FDA, and other federal agencies post helpful food safety tips, and the US government Foodsafety.gov website has a Thanksgiving-specific page. Because poultry can harbor a wide range of bacteria, the most important tips center around properly washing your hands, keeping uncooked meat away from other food, and cooking the turkey to the proper temperature. The turkey should be at least 165°F in the center of the thickest part of the breast and the innermost part of the thigh and wings. Don’t ask me where you check the Turducken. Wait, the USDA even has a blog post on this unholy monstrosity.
If you will pardon us just for a minute, we will take a look at several historical examples of Thanksgiving-associated foodborne outbreaks and other health risks documented in the peer-reviewed literature and news media.
In 1995, there was a large outbreak of C. perfringens at a juvenile detention center in Sacramento, California. Of the 250 residents and staff, approximately 100 experienced gastroenteritis—with symptoms including diarrhea and vomiting—after eating the Thanksgiving meal. Interestingly, one group of the facility’s residents attended an event outside of the detention facility and ate a different meal. There is no interaction between the groups at this facility, and when none of these individuals became ill, it clearly implicated the holiday meal as the source of the outbreak. Because the affected individuals did not have any options with respect to the food they were served, many of them ate similar items, making it impossible to identify a single source.
A catered Thanksgiving lunch in Pitt County, North Carolina in 2016 also resulted in a sizable outbreak of C. perfringens. Approximately 40 out of 80 attendees reported experiencing gastrointestinal symptoms, including diarrhea and abdominal pain. The epidemiological investigation was able to identify the turkey and/or stuffing as the likely source, ultimately attributing the outbreak to “inadequate [food preparation] facilities, extended time between turkey preparation and consumption, and failure to monitor and control temperature before and during transport” of the food items.
A 1995 outbreak in Las Vegas, Nevada resulted in seven cases gastroenteritis, including two hospitalizations and one death, caused by S. enteritidis. In preparing the turkey, the cook was determined to have started cooking with parts of the turkey still frozen and removed the turkey from the oven when the skin was browned, without checking the temperature using an internal thermometer.
More than 50 million Americans were projected to travel for Thanksgiving this year, which potentially provides an excellent mechanism to facilitate the national spread of influenza. Influenza season typically ramps up through the fall and early winter with peaks typically occurring between late November and March. One study of the intra-regional spread of influenza from 1996 through 2005 found that travel volume in November (much of which centers around Thanksgiving weekend) was predictive of the rate of spread of influenza across the country. Interestingly, during the 2001-02 flu season—when air traffic volume was particularly low after the events of 9/11—the time required for transnational spread of influenza in the United States was 68% longer than in previous years.
In addition to the spread of human cases of influenza, turkeys are also susceptible to avian influenza, also known as bird flu. For example, the spring 2015 avian influenza epidemic in the United States resulted in the culling of more than 45 million birds nationwide, including 7.5 million turkeys (about 3% of the total turkey population). This was done to control the spread of the virus, for which experts could not rule out the possibility of transmission to humans. The epidemic sparked fears that prices of the turkeys leftover from the epidemic would skyrocket or that birds, particularly fresh ones, would not be available for Thanksgiving. Fortunately, nearly all frozen turkeys were already processed prior to the outbreak, and the market for fresh turkeys is relatively small. The wholesale price of turkeys increased by as much as 20% that year, but the price hike had little effect on the cost to consumers. It turns out that grocery stores typically discount the price of turkeys in order to draw in customers, making more profit from the associated fixin’s (eg, potatoes, stuffing, vegetables) they purchase while they are in the store.
While not an infectious disease, physical injuries are also a concern over the holiday weekend. 45.5 million people were projected to travel by automobile for Thanksgiving this year (89% of total expected travel). With this volume of traffic on the road all at once, automobile accidents are a major concern. Publicly available information on traffic accidents for Thanksgiving is limited, but data from the CDC and Department of Transportation show approximately 500 deaths and more than 43,000 emergency department visits over the 2000 Thanksgiving weekend. Additionally, more than 800 people died as a result of alcohol-related automobile collisions over Thanksgiving weekend between 2012 and 2016. We didn’t do much digging into injuries resulting from kitchen knives and ovens, hanging Christmas lights, backyard tackle football, or politically charged discussions that escalate to fisticuffs, but it is probably safe to say be careful with those, too.
Stay safe this weekend, have a great Thanksgiving! Now, go grab another round of leftovers and pumpkin pie—pumpkin; always pumpkin. And remember: Eat ‘til you’re tired, not ‘til you’re full.
Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly in near-real time to allow others to learn from these experiences in order to improve global outbreak response capabilities.
Photo courtesy of CDC/ Richard L. Welch