Food Poison Journal - Food poisoning outbreaks and litigation: surveillance and analysis

The size and breadth of the Salmonella outbreak linked to Daniele Salami - 202 people in 42 states since last July - is a big part of the reason the source of the illnesses has been pinpointed.  The CDC has estimated that there are 75 million cases of food-poisoning in the U.S. each year.  Only a fraction of these illnesses are ever tied to a specific food item.

The epidemiological work of local and state health officials that respond to reports of illness is the first step to a connection.   State laws require that positive lab results for Salmonella  (among other pathogens) be reported to health officials.   Once alerted, health officials then contact the ill individual and attempt to determine his or her potential exposures.   In an isolated case, making determinations can be tricky.   When multiple people share the same bacteria strain however, looking for a common exposure factor can be more fruitful.   

A spokesman for the Washington State Department of Health explained some of its involvement in the national investigation in response to a report of a Jefferson County man who was one of 15 Washington residents reported as part of the outbreak:

Donn Moyer, state Department of Health spokesman, said the outbreak was unique in that a national study actually pinpointed the source of the salmonella montevideo contamination. "Often you don't find the source," he said. "In this case you've got a number of people exposed to the same source. That's why this was an outbreak."

Moyer stated that  a review of shopping receipts verified that 13 cases showed purchases of the same salami variety pack before getting sick.

The investigation also relied upon laboratory evidence, both from private and public labs, in Washington and elsewhere.  These tests not only confirmed the presence of Salmonella in the Daniele product, but also suggested the product was contaminated with multiple strains:

A private Washington state lab tested a different salami product, also produced by Daniele, and found it contained another type of salmonella.  A bacterial culture from the private lab, but not the salami product, was provided to the Washington State Department of Health for additional testing.Results from the state lab tests of that bacterial culture on Monday identified two types of the bacteria. One type matched the findings of the private lab, and the other matched the outbreak strain of salmonella montevideo.

An antiquated system exposes Americans to unnecessary risks.

By JEFF ALMER and LOUIS TOUSIGNANT

Shirley Almer was a cancer survivor and a fighter who had twice defied her doctor's prediction by beating both lung and brain cancer.

Clifford Tousignant was a fighter, too. A decorated veteran of the Korean War, he earned three purple hearts in battle, faithfully serving his country for over 22 years.

The two Minnesotans never met but will forever be linked because they are among the nine people who died last year as a result of contaminated peanut products.

Shirley and Clifford were our parents. Had a strong food-safety law been in place, they would likely still be with us.

It wasn't until well after their first trips to the hospital that we found out they were part of a group of 700 Americans from 46 states to be sickened by peanut products in which the dangerous pathogen salmonella had been found.

Over time, we learned that the outbreak was not just a random occurrence, but part of a pattern of outbreaks impacting tens of millions of Americans every year.

Like many Americans who have watched a loved one suffer from a preventable foodborne illness, we were both shocked and appalled to find out that the nation's food-safety system is based, in large part, on century-old laws. Furthermore, the agency charged with overseeing about 80 percent of the U.S. food supply -- the Food and Drug Administration (FDA) -- inspects domestic food-processing facilities on average only once every 10.5 years.

In the area of inspections, as well as other components of our food-safety system, the laws and regulations are severely lacking and simply unsatisfactory in successfully managing what has evolved into a complex global food supply.

The CDC reports that a total of 202 individuals infected with a matching strain of Salmonella Montevideo have been reported from 42 states and District of Columbia since July 1, 2009. The number of ill persons identified in each state with this strain is as follows: AK (1), AL (2), AZ (5), CA (30), CO (4), CT (4), DC (1), DE (2), FL (3), GA (3), IA (1), ID (2), IL (11), IN (3), KS (3), LA (1), MA (12), MD (1), ME (1), MI (3), MN (4), MO (1), NC (9), ND (1), NE (1), NH (1), NJ (7), NM (2), NY (16), OH (9), OK (1), OR (9), PA (5), RI (2), SC (1), SD (3), TN (4), TX (7), UT (7), VA (1), WA (15), WV (1), and WY (2). Because this is a commonly occurring strain, public health investigators may determine that some of the illnesses are not part of this outbreak.

Among the persons with reported dates available, illnesses began between July 4, 2009 and January 11, 2010. Infected individuals range in age from < 1 year old to 93 years old and the median age is 37 years. Fifty-three percent of patients are male. Among the 148 patients with available information, 38 (26%) were hospitalized. No deaths have been reported.

In 2000, the drinking water in the Ontario town of Walkerton was contaminated with E. coli O157:H7 and campylobacter.  7 people died, and roughly 2,300 suffered illness as a result.   The large number of people involved in the outbreak has provided doctors and scientists an opportunity to look at the long term impacts of foodborne illness. 

According to this report, studies on Walkerton survivors are now revealing genetic risk factors associated with the likelihood of developing post-infectious irritable bowel syndrome:

Of the 2,300 people who were sickened, 36 per cent developed post-infectious irritable bowel syndrome or PI-IBS.

Patients suffer from chronic abdominal pain and discomfort, bloating, and defecation problems that develop suddenly after an episode of acute gastroenteritis or inflammation of the stomach and intestines. Doctors diagnose PI-IBS after ruling out structural and biochemical abnormalities and other known disorders like Crohn's disease or ulcerative colitis.

The study, which linked three particular genes to an increased risk of post-infectious irritable bowel syndrome, will be published in the March edition journal Gastroenterology.

The Tremeloes got it wrong.  Silence is far from golden when it comes to matters of public health.  We now know that the salami Salmonella outbreak linked to Daniele Inc.'s pepper-coated salami occurred because of contaminated pepper, and that the pepper came from a company called (oh the irony) Wholesome Spice, a New York distributor.  But there remain too many questions with regard to this outbreak, not to mention other significant public health matters (see "the silence of the steaks and the perjury of the peppers"), to say that consumer health is being adequately monitored and protected. 

Wholesome Spice is merely a distributor, meaning that the company did not grow, harvest, or package the contaminated pepper.  We do not yet know where the contamination occurred, but odds are that it happened prior to receipt of the product by Wholesome Spice.  The implications are clear.  Wholesome Spice may have only received a portion of the contaminated product.  This is certainly something that the CDC and FDA have considered and are likely looking into.  The significance of this fact to public health?  Contaminated pepper may be in the homes of American consumers in other forms, and on other products.

It is possible, also, that there is no further threat to consumer health in America.  Wholesome Spice may be the only American company to receive the contaminated pepper, and Daniele Inc may be the only company to have purchased and sold the contaminated pepper to consumers.  But that doesn't sound very logical.  Is Wholesome Spice the exclusive seller of pepper to Daniele Inc., or vice versa?  Isn't it more logical to assume that the contaminated pepper has reached American consumers in other forms? 

The flow of information to the public in this particular outbreak and recall has not exactly been unimpeded, timely, or free.  Recall the CDC's statement to the public late on the friday evening that the outbreak and recall was announced:  "A widely distributed contaminated food product might cause illnesses across the United States."  In fact, the CDC commented in the same statement on the outbreak that other products may be implicated.

So we know the distributor of the pepper, but we don't know what country it came from or the identity of the company who grew, harvested, or packaged it.  We don't know whether other American food companies received the contaminated pepper, not to mention other companies worldwide, whose residents are just as susceptiblle to illness and death from Salmonella as we are.  We don't know whether other products are contaminated, and there has been no further word from the CDC on the issue, despite the obvious wide-spread contamination and the early suspicion about whether other products were implicated.  Nor do we even have any official statement on what other strains of Salmonella the CDC, or other State health departments, have found in the contaminated Daniele salami products.  Recall the CDC's statement on this issue:

This recall followed isolation of Salmonella in a private laboratory from a retail sample of a salami product produced by Daniele International. FSIS reviewed and affirmed these private laboratory results.  This Salmonella strain is different from the strains causing the outbreak. In addition, this product was different than the sliced salami variety pack purchased at different grocery store locations by the 11 ill persons.

We have the right to know these things.