How to Eat Safely After Your Transplant

This handout is designed to provide practical guidance on how to reduce your risk of foodborne illness following a transplant. In addition to this guide, we encourage you to check with your doctor or healthcare provider to identify foods and other products that you should avoid. You have a special need for this important information.

Food safety

Especially important for transplant patients

As a transplant recipient, you may be familiar with the topic of transplant rejection. It is the body's natural reaction or immune system's response to foreign invasion.

• A properly functioning immune system will try to reject or destroy your new solid organ and/or bone marrow transplant - in the same way that your immune system works to clear infection from your body.
• Because of this natural rejection possibility, it is common for transplant recipients to take medications to prevent rejection from happening. These drugs are called immunosuppressive medications because they suppress your immune system to prevent it from attacking or rejecting your transplanted organ. Over the past few decades, substantial progress has been made in the development of these drugs that help prevent you from experiencing a transplant rejection.
• Immunosuppressive medications are important as they can protect your transplanted solid organ. However, a side effect of these immune-suppressants is that they leave you more susceptible to developing infections - like those that can be brought on by disease-causing bacteria and other pathogens that cause foodborne illness.
• Because you are a transplant recipient, you are more likely to have a prolonged illness or may even need to be admitted to hospital should you contract a foodborne illness.
• To avoid contracting a foodborne illness, you must be especially vigilant when handling, preparing and consuming foods. 

Make safe food handling a lifelong commitment to minimize your risk of foodborne illness. Be aware that as you age, your immunity to infection is naturally weakened.

Eating at home

Making wise food choices

Some foods are more risky for you than others. In general, the foods that are most likely to contain harmful bacteria or viruses fall into two categories:

• Uncooked fresh fruits and vegetables.
• Some animal products, such as unpasteurized (raw) milk; soft cheeses made with raw milk; and raw or undercooked eggs, raw meat, raw poultry, raw fish, raw shellfish and their juices; luncheon meats and deli-type salads (without added preservatives) prepared on site in a deli-type establishment.

Interestingly, the risk these foods may actually pose depends on the origin or source of the food and how the food is processed, stored and prepared. Follow these guidelines for safe selection and preparation of your favorite foods.

If you have questions about wise food choices, be sure to consult with your doctor or healthcare provider. He or she can answer any specific questions and help you make the right choices.

• If you are not sure about the safety of a food in your refrigerator, don't take the risk.
• When in doubt, throw it out!
• Wise choices in your food selections are important.

All consumers need to follow the Four Basic Steps to Food Safety:

1. Clean: Wash hands and surfaces often
2. Separate: Don't cross-contaminate
3. Cook: Cook to safe temperatures
4. Chill: Refrigerate promptly

Common foods - select the lower risk options

Type of Food	Higher Risk	Lower Risk
Meat and Poultry	Raw or undercooked meat or poultry	Meat or poultry cooked to a safe minimum internal temperature
Tip: Use a food thermometer to check the internal temperature on the Is It Done Yet? chart for specific safe minimum internal temperature.
Seafood	Any raw or undercooked fish, or shellfish, or food containing raw or undercooked seafood e.g., sashimi, found in some sushi or ceviche. Refrigerated smoked fish Partially cooked seafood, such as shrimp and crab	Previously cooked seafood heated to 75°C Canned fish and seafood S eafood cooked to 65°C
Milk	Unpasteurized (raw) milk	Pasteurized milk
Eggs	Foods that contain raw/undercooked eggs, such as: Homemade Caesar salad dressings*  Homemade raw cookie dough* Homemade eggnog*	At home: Use pasteurized eggs/egg products when preparing recipes that call for raw or undercooked egg  When eating out: Ask if pasteurized eggs were used
*Tip: Most pre-made foods from grocery stores, such as Caesar dressing, pre-made cookie dough, or packaged eggnog are made with pasteurized eggs.
Sprouts	Raw sprouts (alfalfa, bean, or any other sprout)	Cooked sprouts
Vegetables	Unwashed fresh vegetables, including lettuce/ salads	Washed fresh vegetables, including salads and cooked vegetables
Cheese	Soft cheeses made from unpasteurized (raw) milk, such as: Feta  Brie  Camembert  Blue-veined  Queso fresco	Hard cheeses  Processed cheeses  Cream cheese  Mozzarella  Halloumi  Soft cheeses that are clearly labeled made from pasteurized milk"
Hot Dogs and Deli Meats	Hot dogs, deli meats and luncheon meats that have not been reheated (e.g. turkey, mortadella, salami)	Hot dogs, luncheon meats and deli meats reheated to steaming hot or 75°C
Tip: You need to reheat hot dogs, deli meats, and luncheon meats before eating them because the bacteria Listeria monocytogenes grows at refrigerated temperatures (4.4°C or below). This bacteria may cause severe illness, hospitalization, or even death. Reheating these foods until they are steaming hot destroys these dangerous bacteria and makes these foods safe for you to eat.
Pâtés	Unpasteurized, refrigerated pâtés or meat spreads	Canned or shelf-stable pâtés or meat spreads
Miscellaneous	Honey  Tahini (moutabal, hummus, baba ganoush)	Jam  Peanut butter  Pre-packed nuts  Dates  Manakeesh cheese or zaatar (served hot)  Falafel (served hot)

Taking care

Handling and preparing food safely

Foodborne pathogens are sneaky. Food that appears completely fine can contain pathogens - disease-causing bacteria, viruses, or parasites - that can make you sick. You should never taste a food to determine whether or not it is safe to eat.

As a transplant recipient, it is especially important that you, or those preparing your food, are always careful with food handling and preparation. The easiest way to do this is to check your steps - clean, separate, cook and chill.

Four basic steps to food safety

STEP 1

Clean: Wash hands and surfaces often

Bacteria can spread throughout the kitchen and get onto cutting boards, utensils, counter tops, and food.

To ensure that your hands and surfaces are clean, be sure to:

• Wash hands in warm soapy water for at least 20 seconds before and after handling food and after using the bathroom, changing diapers, or handling pets.
• Wash cutting boards, dishes, utensils, and counter tops with hot soapy water between the preparation of raw meat, poultry, and seafood products and preparation of any other food that will not be cooked. As an added precaution, sanitize cutting boards and countertops by rinsing them in a solution made of one tablespoon of unscented liquid chlorine bleach per 4L of water, or, as an alternative, you may run the plastic board through the wash cycle in your automatic dishwasher.
• Use paper towels to clean up kitchen surfaces. If using cloth towels, you should wash them often in the hot cycle of the washing machine.
• Wash produce. Rinse fruits and vegetables, and rub firm-skin fruits and vegetables under running tap water, including those with skins and rinds that are not eaten.
• With canned goods: remember to clean lids before opening.

STEP 2

Separate: Don't cross-contaminate

Cross-contamination occurs when bacteria are spread from one food product to another. This is especially common when handling raw meat, poultry, seafood, and eggs. The key is to keep these foods”and their juices”away from ready-to-eat foods.

To prevent cross-contamination, remember to:

• Separate raw meat, poultry, seafood, and eggs from other foods in your grocery shopping cart, grocery bags, and in your refrigerator.
• Never place cooked food on a plate that previously held raw meat, poultry, seafood or eggs without first washing the plate with hot soapy water.
• Don't reuse marinades used on raw foods unless you bring them to a boil first.
• Consider using one cutting board only for raw foods and another only for ready-to-eat foods, such as bread, fresh fruits and vegetables, and cooked meat.

STEP 3

Cook: Cook to safe temperatures

Foods are safely cooked when they are heated to the recommended safe minimum internal temperatures, as shown on the Is It Done Yet? chart.

To ensure that your foods are cooked safely, always:

• Use a food thermometer to measure the internal temperature of cooked foods. Check the internal temperature in several places to make sure that the meat, poultry, seafood or egg product is cooked to safe minimum internal temperatures.
• Cook ground beef to at least 70°C and ground poultry to a safe minimum internal temperature of 75 °C. Color of food is not a reliable indicator of safety or doneness.
• Cook seafood to 65°C. Cook shrimp, lobster, and crab until they turn red and the flesh is pearly opaque. Cook clams, mussels, and oysters until the shells open. If the shells do not open, do not eat the seafood inside.
• Cook eggs until the yolks and whites are firm. Use only recipes in which the eggs are cooked or heated to 70°C.
• Cook all raw beef, lamb, and veal steaks, roasts, and chops to 65°C with a 3-minute rest time after removal from the heat source.

Is it done yet?

Use a food thermometer to be most accurate. You can't always tell by looking.

• Bring sauces, soups, and gravy to a boil when reheating. Heat other leftovers to 75°C.
• Reheat hot dogs, luncheon meats, bologna, and other deli meats until steaming hot or 75°C.
• When cooking in a microwave oven, cover food, stir, and rotate for even cooking. If there is no turntable, rotate the dish by hand once or twice during cooking. Always allow standing time, which completes the cooking, before checking the internal temperature with a food thermometer. Food is done when it reaches recommended safe minimum internal temperature.

STEP 4

Chill: Refrigerate promptly

Cold temperatures slow the growth of harmful bacteria. Keeping a constant refrigerator temperature of 4°C or below is one of the most effective ways to reduce risk of foodborne illness. Use an appliance thermometer to be sure the refrigerator temperature is consistently 4°C or below and the freezer temperature is 0°C or below.

To chill foods properly:

• Refrigerate or freeze meat, poultry, eggs, seafood and other perishables within two hours of cooking or purchasing. Refrigerate within 1 hour if the temperature outside is above 32°C.
• Never thaw food at room temperature, such as on the countertop. It is safe to thaw food in the refrigerator, in cold water, or in the microwave. If you thaw food in cold water or in the microwave, you should cook it immediately.
• Divide large amounts of food into shallow containers for quicker cooling in the refrigerator.
• Follow the recommendations in the USDA-FDA Cold Storage Chart below.

USDA-FDA Cold Storage Chart

These time limit guidelines will help keep refrigerated food safe to eat.

Because freezing keeps food safe indefinitely, recommended storage times for frozen foods are for quality only.

Product	Refrigerator (4.4°C)	Freezer (0°C)
Eggs: Fresh, in shell Hard-cooked	3 5 weeks 1 week	Don't freeze Don't freeze well
Liquid Pasteurized Eggs, Egg Substitutes: Opened Unopened	3 days 10 days	Don't freeze well 1 year
Deli and Vacuum-Packed Products: Egg, chicken, tuna and macaroni salads	3 5 days	Don't freeze well
Hot Dogs:  Opened package Unopened package	1 week  2 weeks	1 2 months 1 2 months
Luncheon Meat: Opened package Unopened package	3 5 days 2 weeks	1 2 months 1 2 months
Hamburger and Other Ground Meats: Hamburger, ground beef, turkey, veal, pork, lamb and mixtures of them.	1 2 days	3 4 months
Fresh Beef, Veal or Lamb: Steaks Chops Roasts	3 5 days 3 5 days 3 5 days	6 12 months 4 6 months 4 12 months
Fresh Poultry: Chicken or turkey (whole) Chicken or turkey (pieces)	1 2 days 1 2 days	1 year 9 months
Seafood: Lean fish (flounder, hammour, sea bass, etc.) Fatty fish (salmon, tuna, etc.)	1 2 days 1 2 days	6 8 months 2 3 months
Leftovers: Cooked meat or poultry  Chicken nuggets, patties  Pizza	3 4 days 3 4 days 3 4 days	2 6 months 1 3 months 1 2 months

Check your steps

• Check Sell By date or Best Before or Use By date.
• Put raw meat, poultry, or seafood in plastic bags.
• Buy only pasteurized milk, soft cheeses made with pasteurized milk, and pasteurized or juices that have been otherwise treated to control harmful bacteria.
• When buying eggs: Purchase refrigerated shell eggs. If your recipe calls for raw eggs, purchase pasteurized, refrigerated liquid eggs.
• Don't buy food displayed in unsafe or unclean conditions 

Ordering smart when eating out

Higher risk

• Cheese made from unpasteurized (raw) milk.
• Raw or undercooked seafood.
• Cold hot dogs.
• Sandwiches with cold deli or luncheon meat.
• Raw or undercooked fish, such as sashimi or some kind of sushi.
• Soft-boiled or over-easy eggs, as the yolks are not fully cooked.

Lower risk

• Hard or processed cheeses. Soft cheeses only if made from pasteurized milk.
• Fully cooked smoked fish or seafood.
• Hot dogs reheated to steaming hot. If the hot dogs are served cold or lukewarm, ask to have the hot dogs reheated until steaming, or else choose something else.
• Grilled sandwiches in which the meat or poultry is heated until steaming.
• Fully cooked fish that is firm and flaky; vegetarian sushi.
• Fully cooked eggs with firm yolk and whites.

In the know

Becoming a better shopper

Follow these safe food-handling practices while you shop:

• Carefully read food labels while in the store to make sure food is not past it's Sell By date.
• Put raw packaged meat, poultry, or seafood into a plastic bag before placing it in the shopping cart, so that its juices will not drip on”and contaminate”other foods. If the meat counter does not offer plastic bags, pick some up from the produce section before you select your meat, poultry and seafood.
• Buy only pasteurized milk, cheese, and other dairy products from the refrigerated section. When buying fruit juice from the refrigerated section of the store, be sure that the juice label says it is pasteurized.
• Purchase eggs in the shell from the refrigerated section of the store. (Note: store the eggs in their original carton in the main part of your refrigerator once you are home.) For recipes that call for eggs that are raw or undercooked when the dish is served”homemade Caesar salad dressing and ice cream are two examples”use either shell eggs that have been treated to destroy Salmonella by pasteurization or pasteurized egg products. When consuming raw eggs, using pasteurized eggs is the safe choice.
• Never buy food that is displayed in unsafe or unclean conditions.
• When purchasing canned goods, make sure that they are free of dents, cracks, or bulging lids. (Once you are home, remember to clean each lid before opening the can.)
• Purchase produce that is not bruised or damaged.

When shopping for food, it is important to read the label carefully.

Food product dating

Read the Safe Handling Label for food safety information on raw foods.

Open dates

• Open dating is found primarily on perishable foods such as meat, poultry, eggs and dairy products. A Sell-By date tells the store how long to display the product for sale. You should buy the product before the date expires.
• A Best If Used By (or Before) date is recommended for best flavour or quality. It is not a purchase or safety date.
• A Use-By date is the last date recommended for the use of the product while at peak quality. The date has been determined by the manufacturer of the product.

Closed or coded dates are packing numbers for use by the manufacturer.

• Closed or coded dating might appear on shelf-stable products such as cans and boxes of food.

Transporting your groceries

Follow these tips for safe transporting of your groceries:

• Pick up perishable foods last, and plan to go directly home from the grocery store.
• Always refrigerate perishable foods within 2 hours of cooking or purchasing.
• Refrigerate within 1 hour if the temperature outside is above 32°C.
• In hot weather, take a cooler with ice or another cold source to transport foods safely.

Being smart when eating out

Eating out can be lots of fun, so make it an enjoyable experience by following some simple guidelines to avoid food-borne illness. Remember to observe your food when it is served, and do not ever hesitate to ask questions before you order. Waiters and waitresses can be quite helpful if you ask how a food is prepared. Also, let them know you do not want any food item containing raw meat, poultry, seafood, sprouts or eggs.

Here are some basic rules when ordering food:

• Ask whether the food contains uncooked ingredients such as eggs, sprouts, meat, poultry or seafood. If so, choose something else.
• Ask how these foods have been cooked. If the server does not know the answer, ask to speak to the chef to be sure your food has been cooked to a safe minimum internal temperature.
• If you plan to take away left or save leftovers to eat at a later time, refrigerate perishable foods as soon as possible”and always within 2 hours after purchase or delivery. If the leftover food is in air temperatures above 32°C, refrigerate it within 1 hour.

If in doubt, make another selection!

Foodborne illness

Know the symptoms

Despite your best efforts, you may find yourself in a situation where you suspect you have a foodborne illness. Foodborne illness often presents itself with flu-like symptoms.

These symptoms include:

• Nausea
• Vomiting
• Diarrhoea
• Fever

If you suspect that you could have a foodborne illness contact your doctor or healthcare provider right away.

When in doubt”contact your doctor or healthcare provider!