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Food Poison Journal

Food Poisoning Outbreaks and Litigation: Surveillance and Analysis

At Least 18 E. coli O111 Cases in 4 States Likely Linked to Cabbage

Minnesota State health officials have identified green whole head cabbage as the likely source of an E. coli O111 outbreak that sickened 15 people in Minnesota in July.

The cabbage was likely contaminated at some point prior to distribution to restaurants.

Routine monitoring by the Minnesota Department of Health (MDH) identified the 15 cases of illness associated with Shiga toxin-producing E. coli O111. Bacterial isolates from all of the cases had the same DNA fingerprint. This genetic strain of E. coli O111 had not been seen in the United States previously.

MDH investigators were able to interview 14 of the cases: 13 of them ate at 9 different Applebee’s restaurants in Minnesota, and one ate at Yard House.

Many cases had reported eating the Oriental Chicken Salad at Applebee’s, leading Applebee’s to voluntarily and out of an abundance of caution pull the menu item and specific ingredients from the salad from their menu for a time. It was returned to the menu after Applebee’s obtained different sources for the ingredients.

The common food item across all foods consumed by cases was green whole head cabbage.

Minnesota officials traced the cabbage to a common supplier outside of Minnesota and continue to work with the United States Food and Drug Administration (FDA) to investigate its source. The FDA examination of the potentially involved farms is still ongoing.

Single cases of illness that match the outbreak strain have occurred in three other states.

The illnesses occurred between June 25 and July 3. Four of the people who became ill were hospitalized and all have recovered. No new cases connected with this outbreak have been identified in Minnesota since July 10.

Symptoms of illness caused by E. coli O111 typically include stomach cramps and diarrhea, often with bloody stools, but only a low-grade or no fever. People usually become ill two to five days after exposure, but this time period can range from one to at least eight days. Most people recover in five to 10 days. Complications from infection are more common among those with weaker immune systems, including young children and the elderly. As with E. coli O157:H7, infection with E. coli O111 should not be treated with antibiotics, as this practice might promote further complications.

Cilantro is cause of Texas Cyclospora Outbreak

The Cyclospora illness outbreak being investigated by DSHS and local health departments in Texas along with the federal Centers for Disease Control and Prevention and Food and Drug Administration appears to have ended. The number of new illnesses being reported has returned to background levels, and the investigation has linked the cases in four restaurant clusters to cilantro imported from Puebla, Mexico.

Cyclosporiasis is an intestinal illness caused by consuming food or water contaminated with the Cyclospora parasite. The major symptom is watery diarrhea lasting a few days to a few months. Additional symptoms may include loss of appetite, fatigue, weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting and a low fever. Symptoms may come and go multiple times over a period of weeks.

126 cases are considered part of the outbreak with an onset of illness after May 1 and no history of international travel within the two weeks before onset. Most cases occurred in June and July. However, it is unknown whether all illnesses are linked to cilantro. 166 total cyclosporiasis cases have been reported in Texas in 2014. Most of the cases are in residents of North Texas.

DSHS, in conjunction with local health departments, investigated four restaurant clusters in North Texas that included a total of 21 people who got ill. All 21 reported eating a food item from the restaurant containing cilantro within two weeks before becoming ill. A preliminary traceback investigation conducted by FDA and DSHS has identified Puebla, Mexico as the source of the cilantro that was served in all four restaurants. While the investigation has not found samples of cilantro contaminated with cyclospora, there is enough evidence to establish a strong epidemiological link between the illnesses and the cilantro. The state of Puebla was also identified as the source of fresh cilantro linked to a cyclosporiasis outbreak in 2013.

Listeria Recall: Mom’s Chicken Extra Thin Cutlets

TNUVA USA, a Fairfield, N.J., establishment is recalling approximately 8,316 pounds of Mom’s Chicken Extra Thin Cutlets product due to possible contamination with Listeria monocytogenes (Lm), the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today.

The product was produced on August 18, 2013, and shipped to the company’s distributor in New Jersey. FSIS will post complete store locations as the list becomes available on its website at www.fsis.usda.gov. The following product is subject to recall:

28.8-oz. (1.8 lb.) bags containing “MOM’S CHICKEN EXTRA THIN CUTLETS, THIN-CUT BREADED CUTLET SHAPED CHICKEN BREAST PATTIES.”

Bags bear the Israeli establishment number “209” within the Israeli mark of inspection. The product’s expiration date is February 18, 2015, and bears the following UPC number on the packaging: 843426005866.

The problem was discovered when FSIS personnel conducted a routine sampling of product which tested positive for Lm. FSIS held the product and it did not enter commerce. Further investigation by FSIS determined that other products were produced on the same line without clean up between products. FSIS and the company are concerned that some product may be frozen and in consumers’ freezers. FSIS and the company have received no reports of illnesses associated with consumption of these products.

Consumption of food contaminated with Lm can cause listeriosis, a serious infection that primarily affects older adults, persons with weakened immune systems, and pregnant women and their newborns. Less commonly, persons outside these risk groups are affected.

Listeriosis can cause fever, muscle aches, headache, stiff neck, confusion, loss of balance and convulsions sometimes preceded by diarrhea or other gastrointestinal symptoms. An invasive infection spreads beyond the gastrointestinal tract. In pregnant women, the infection can cause miscarriages, stillbirths, premature delivery or life-threatening infection of the newborn. In addition, serious and sometimes fatal infections in older adults and persons with weakened immune systems. Listeriosis is treated with antibiotics. Persons in the higher-risk categories who experience flu-like symptoms within two months after eating contaminated food should seek medical care and tell the health care provider about eating the contaminated food.

Whole Genome Sequencing Prompts Nut Butter Salmonella Recall

The CDC reports as of August 20, 2014, a total of four persons infected with the outbreak strain of Salmonella Braenderup have been reported from four states since January 1, 2014.

The number of ill persons identified in each state is as follows: Connecticut (1), Iowa (1), Tennessee (1), and Texas (1).  One ill person has been hospitalized. No deaths have been reported.

Collaborative investigation efforts of state, local, and federal public health and regulatory agencies indicate that almond and peanut butter manufactured by nSpired Natural Foods, Inc. is the likely source of this outbreak.

The U.S. Food and Drug Administration (FDA) isolated the same strain of Salmonella Braenderup from environmental samples collected from an nSpired Natural Foods facility during routine inspections in January and July 2014.

Public health investigators are using the PulseNet system to identify cases of illness that may be part of this outbreak. PulseNet, the national subtyping network of public health and food regulatory agency laboratories coordinated by CDC, receives DNA “fingerprints” of Salmonella bacteria obtained through diagnostic testing using pulsed-field gel electrophoresis, or PFGE. Whole genome sequencing, a highly discriminatory subtyping method, was also used to define the outbreak strain. Whole genome sequencing helped clarify which illnesses were related to the outbreak.

On August 19, 2014, nSpired Natural Foods, Inc. voluntarily recalled certain lots of almond and peanut butters because of potential contamination with Salmonella.  The recalled brands include Arrowhead Mills, MaraNatha, Trader Joe’s, Whole Foods, Safeway, and Kroger.  A complete listing of all of the recalled products is available on the FDA website.