Post-diarrheal hemolytic uremic syndrome (D+HUS) is a severe, life-threatening complication that occurs in about 10 percent of those infected with E. coli O157:H7 or other Shiga toxin- (Stx-) producing E. coli.

The chain of events leading to HUS begins with ingestion of Stx-producing E. coli (e.g., E. coli O157: H7) in contaminated food, beverages, animal to person, or person-to-person transmission.

These E. coli rapidly multiply in the intestine causing colitis (diarrhea), and tightly bind to cells that line the large intestine. This snug attachment facilitates absorption of the toxin into the intestinal capillaries and into the systemic circulation where it becomes attached to weak receptors on white blood cells (WBC) thus allowing the toxin to “ride piggyback” to the kidneys where it is transferred to numerous avid (strong) Gb3 receptors that grasp and hold on to the toxin.

Organ injury is primarily a function of Gb3 receptor location and density. Receptors are probably heterogeneously distributed in the major body organs, and this may explain why some patients develop injury in other organs (e.g., brain, pancreas).

Once Stx attaches to receptors, it moves into the cell’s cytoplasm where it shuts down the cells’ protein machinery resulting in cellular injury and/or death. This cellular injury activates blood platelets and the coagulation cascade, which results in the formation of clots in the very small vessels of the kidney, resulting in acute kidney injury and failure.

The red blood cells undergo hemolytic destruction by Stx and/or damage as they attempt to pass through partially obstructed microvessels. Blood platelets (required for normal blood clotting), are trapped in the tiny blood clots or are damaged and destroyed by the spleen.

Each kidney has between 700,000 and 1,000,000 filtering units, called “nephrons.” The heart of each filter is a microscopic bundle of blood vessels called glomeruli. Blood goes into each glomerulus and waste products pass through a membrane into tubules, which connect together and ultimately collect the urine and pass it out of the kidney.

The glomerulus is the main filter of the nephron and is located within the Bowman's capsule. The glomerulus resembles a twisted mass of tiny tubes through which the blood passes. The glomerulus is semipermeable, allowing water and soluble wastes to pass through and be excreted out of the Bowman's capsule as urine. The filtered blood passes out of the glomerulus into the efferent arteriole to be returned through the medullary plexus to the intralobular vein. Meanwhile, the filtered water and aqueous wastes are passed out of the Bowman's capsule into the proximal convoluted tubule.

In HUS, a certain number of glomeruli are permanently damaged due to loss of blood flow as tiny thrombi occlude those blood vessels. The toxins from E. coli O157:H7 also have a direct effect on the cells lining the blood vessels and tubules and can cause cell death. Once a filter is gone, it is gone forever. When a lot of filters are gone, the remaining ones work harder because there are fewer of them. If enough filters are lost, the remaining filters experience “hyperfiltration,” which leads to enlargement, and over time, scarring, which in turn leads to the loss of more filters.

Serious kidney injury usually manifests through reduced filter function, hypertension, and/or proteinuria. It is easy to get a rough estimate of kidney filter function by looking at the level of waste products, especially creatinine in the blood over time. There are also formulas to estimate filter function once you have a creatinine value. The key is whether filter function changes over time. Since the kidneys primarily regulate blood pressure, the development of hypertension after HUS also signals serious kidney injury and is considered a bad prognostic sign. So too is proteinuria—the passage of protein molecules in the urine—which is a sign that the glomeruli have been damaged, and the remaining filters are hyperfiltrating—i.e. they are being overworked due to the loss of filtering capacity of other dead or damaged filters.

If enough filters are lost either due to injuries suffered during the acute HUS illness, or later in life due to the process of hyperfiltration, a patient will reach end stage renal disease (“ESRD”). ESRD, truly a worst-case scenario for someone who has survived the acute HUS illness, is a very painful process that can take decades to play out. The demands on the kidneys increase through puberty and, for women, especially during pregnancy, adding another variable to issues of future renal health for girls who have suffered severe HUS.

Long-term consequences of hemolytic uremic syndrome (HUS)

Multiple studies have demonstrated that children with HUS who have apparently recovered will develop hypertension, urinary abnormalities and/or renal insufficiency during long-term follow-up. One of the best predictors is the duration of anuria and/or oliguria.

Milford, et al, (J Pediatrics, 1991) studied the importance of proteinuria at one year following the acute episode of HUS in 40 children. They found that a poor prognosis defined as hypertension, decreased renal function or end stage renal disease was strongly associated with proteinuria at the one year follow up.

Perlstein et al, (Arch Dis Child, 1991) reported results of oral protein loading in 17 children with a past history of HUS; they demonstrated that functional renal reserve was reduced in children with a past history of HUS who had normal renal function and normal blood pressure as compared to normal children. This study suggests that functional renal reserve in children with HUS is reduced although renal function and blood pressure are normal. The authors point out that the long-term significance of this finding is unknown and needs to be determined but the study suggests that functional renal reserve may be reduced in spite of normal recovery and that children with HUS need long term follow-up.

In the article by Gagnadouz, et al, (Clinical Nephrology, 1996) 29 children were evaluated 15-25 years after the acute phase of HUS. Only 10 of the 29 children were normal, 12 had hypertension, 3 had chronic renal failure and 4 had end stage renal disease (65.5%). Severe sequelae occurred in children with oligo/anuria for more than or equal to 7 days.

Other studies (Caletti, et al, Pediatric Nephrology, 1996) have demonstrated that histological finding of focal and segmental sclerosis and hyalinosis are observed several years following HUS. In that article, only 25% of the children had normal renal function during long-term follow-up.

Similarly, Moghal, et al. (Journal of Pediatrics, 1998) performed kidney biopsies in children with persistent proteinuria three to seven years following the acute episode of HUS. Global glomerulosclerosis was noted in six of the seven patients and two had segmental sclerosis as well. In addition, tubular atrophy and interstitial fibrosis was seen in all but one. Finally, the glomeruli in the children with HUS were significantly larger than those in normal children. These are finding that are typically found in individual with reduced nephron number and are consistent with changes of hyperperfusion and hyperfiltration is surviving nephrons. Hyperfiltration is a process that frequently leads to progressive renal damage and the development of end stage renal failure.

In 1997 Spizzirri, et al, (Pediatr Nephrol, 1997), reported that 69.2% of children with 11 or more days of anuria and 38.4% of children with 1-10 days of anuria had chronic sequelae. In addition, of patients with proteinuria at the 1-year follow-up, 86% had renal abnormalities at the end of the follow-up. The authors suggested that children with residual proteinuria with or without hypertension would probably develop progressive chronic renal failure.

In 2002, Blahova, et al, reported that long term follow up of 18 children who had HUS 10 or more years previously, only 6 children were normal while the other 12 children had either residual renal symptoms, chronic renal insufficiency or renal failure (66.6%). Many of the children with residual renal symptoms or chronic renal insufficiency/renal failure had appeared to have recovered normally at earlier check ups.

Recently, Lou-Meda, et al, reported that 14 patients with microabluminuria and no overt proteinuria at 6 to 18 months after the acute phase of HUS, on long term follow up three had a decreased glomerular filtration (GFR), one had overt proteinuria, and four had hypertension. Eight of the 14 patients had at least one sequelae for an incidence of 57.1%. Six children had overt proteinuria and at the most recent follow up, two had hypertension, four and a low renal function and two had continued proteinuria; four (66.6%) had at least one renal sequale.

Recently, Oakes, et al, determined the risk of later complications in children who had HUS several years earlier; they found that the incidence of late complications increased markedly in those with more than 5 days of anuria or 10 days of oliguria. Among children with greater than 10 days of oliguria 63.3% had a low glomerular filtration rate, 33.3% had hypertension and 88.7% had at least one long term complication.

In summary, many children who have recovered normal renal function following the acute episode of HUS have a high risk for the development of late complications from their acute episode of HUS. The risk is substantially lower in children who did not require dialysis and in children who were not oliguria or anuric while the risk is the highest in children who had oligo/anuria for more than 7 days. In one study, all children with oligo/anuria for 14 days had residual renal disease (100%).

It is important to note that the risks of long-term (more than 20 years) complications are unknown and are likely to be higher than risks at 10 years as many of the above studies describe.

Long-term side effects of hemolytic uremic syndrome (HUS)

Adolescents and young adults with chronic kidney disease face a number of complications from their chronic kidney disease (Andreoli SP, Acute and Chronic Renal Failure in Children, 2009) including alterations in calcium and phosphate balance and renal osteodystrophy (softening of the bones, weak bones and bone pain), anemia (low blood count and lack of energy), hypertension (high blood pressure) as well as other complications.

Renal osteodystrophy (softening of the bones) is an important complication of chronic renal failure. Bone disease is nearly universal in patients with chronic renal failure; in some patients symptoms are minor to absent while others may develop bone pain, skeletal deformities and slipped epiphyses (abnormal shaped bones and abnormal hip bones) and have a propensity for fractures with minor trauma. Treatment of the bone disease associated with chronic renal failure includes control of serum phosphorus and calcium levels with restriction of phosphorus in the diet, supplementation of calcium, the need to take phosphorus binders and the need to take medications for bone disease.

Anemia (low blood cell count that leads to a lack of energy) is a very common complication of chronic renal failure. The kidneys make a hormone that tells the bone marrow to make red blood cells and this hormone is not produced in sufficient amounts in children with chronic renal failure. Thus, children with chronic renal failure gradually become anemic while their chronic renal failure is slowly progressing. The anemia of chronic renal failure is treated with human recombinant erythropoietin (a shot given under the skin one to three times a week or once every few weeks with a longer acting human recombinant erythropoietin).

Renal replacement therapy can be in the form of dialysis (peritoneal dialysis or hemodialysis) or renal transplantation. The average waiting time for a deceased donor kidney for children age 0-17 years is approximately 275-300 days while the average waiting time for patient’s age 18-44 years is approximately 700 days (United States Renal Data Systems, Table 7.8, 2005).

Following transplantation, a patient will need to take immunosuppressive medications for the remainder of his/her life to prevent rejection of the transplanted kidney. Medications used to prevent rejection have considerable side effects. Corticosteroids are commonly used following transplantation. The side effects of corticosteroids are Cushingnoid features (fat deposition around the cheeks and abdomen and back), weight gain, emotional liability, cataracts, decreased growth, osteomalacia and osteonecrosis (softening of the bones and bone pain), hypertension, acne and difficulty in controlling glucose levels.

Cyclosporine and/or tacrolimus are also commonly used as immunosuppressive medications following transplantation. Side effects of these drugs include hirsutism (increased hair growth), gum hypertrophy, interstitial fibrosis in the kidney (damage to the kidney), as well as other complications. Meclophenalate is also commonly used after transplantation (sometimes imuran is used); each of these drugs can cause a low white blood cell count and increased susceptibility to infection. Many other immunosuppressive medications and other medications (anti-hypertensive agents, anti-acids, etc.) are prescribed in the postoperative period.

Lifelong immunosuppression as used in patients with kidney transplants is associated with several complications including an increased susceptibility to infection, accelerated atherosclerosis (hardening of the arteries) and increased incidence of malignancy (cancer) and chronic rejection of the kidney.

A patient may need more than one kidney transplant during his/her life. United States Renal Data Systems (USRDS) report that the half-life (time at which 50% of the kidneys are still functioning and 50% have stopped functioning) is 10.5 years for a deceased transplant in children age 0-17 years and 15.5 years for a living related transplant in children 0-17 years. Similar data for a transplant at age 18 to 44 years is 10.1 years and 16.0 years for a deceased donor and a living related donor, respectively. Thus, depending upon age when the patient receives his/her first transplant he/she may need 1-2 transplants. The life expectancy of a person with a kidney transplant is significantly less than the general population and the life expectancy of person on dialysis a markedly less than the general population.

If and when a child needs a second kidney transplant after loss of his/her first transplant, he/she will need dialysis until a subsequent transplant can be performed. He/She can be on peritoneal dialysis or on hemodialysis. Peritoneal dialysis has been a major modality of therapy for chronic renal failure for several years. Continuous Ambulatory Peritoneal Dialysis (CAPD) and automated peritoneal dialysis also called Continuous Cycling Peritoneal Dialysis (CCPD) are the most common form of dialysis therapy used in children with chronic renal failure. In this form of dialysis, a catheter is placed in the peritoneal cavity (area around the stomach); dialysate (fluid to clean the blood) is placed into the abdomen and changed 4 to 6 times a day. Parents and adolescents are able to perform CAPD/CCPD at home. Peritonitis (infection of the fluid) is major complication of peritoneal dialysis.

E. coli O157:H7 and other shiga-toxin producing E. coli are very dangerous bacteria – especially to children. The acute phase – even for those who do not progress to hemolytic uremic syndrome (HUS) – can be a painful and frightening experience. For those who progress to HUS, the risk of death is real. And, even if the child survives, it may well be left with chronic health problems for the remainder of its life.

In the wake of these outbreaks, the food safety experts and E. coli attorneys at Marler Clark are sharing the answers to frequently asked questions to those who may have been exposed in the outbreak.

Missouri and Oregon Raw Milk E. coli Outbreak: FAQs

Q: I drank raw milk and believe I may have an E. coli infection. How do I know whether it’s E. coli or not? What are the symptoms of E. coli?

A: If you believe you may have an E. coli infection, the E. coli attorneys at Marler Clark recommend that you seek medical attention. E. coli infections are characterized by acute gastroenteritis.E. coli infection symptoms include abdominal pain and severe stomach cramps, followed within 24 hours by diarrhea. The diarrhea caused by E. coli is often bloody. The incubation period, or the time from ingestion of E. coli bacteria until the symptoms start, is generally 2-4 days.

Hemolytic uremic syndrome is a severe and sometimes deadly complication of E. coli infection that can result in acute kidney failure. A small percentage of E. coli outbreak victims – mostly young children and elderly people – suffer this complication. At least two young children have been hospitalized with HUS since this Missouri raw milk E. coli outbreak began.

Q: What should I do if I think I’m part of the raw milk E. coli outbreak?

A: The Marler Clark E. coli attorneys recommend contacting your local health department to report your illness. Again, if you believe you need medical assistance for your E. coli infection, contact your healthcare provide and submit a stool sample for testing. An E. coli diagnosis involves culturing E. coli bacteria from an ill individual’s stool.

Q: How will I know if I’m part of the Missouri or Oregon raw milk E. coli outbreak?

A: E. coli bacteria can be detected in stool. A fecal sample provided to a healthcare provider or health department is placed in nutrient broth or on agar and incubated for 2-3 days. After that time, a trained microbiologist can identify E. coli bacteria and confirm its identity by looking at biochemical reactions.

Treatment with antibiotics before collecting a specimen for testing can affect bacterial growth in culture, and lead to a negative test result even when E. coli causes the infection. If E. coli is isolated from an ill person’s stool, a bacterial isolate can be compared to isolates from other ill individuals – and possibly from raw milk samples. Bacterial isolates that have matching “DNA Fingerprints” indicate a potential common source of E. coli infection. Epidemiologists work to determine whether two people with positive bacterial isolates with indistinguishable DNA fingerprints are part of a common outbreak – in this case, one tied to E. coli-contaminated raw milk.

Q: I drank raw milk and got E. coli. I’m thinking about hiring a law firm to represent me, but am concerned about the cost of legal representation for my E. coli case. What are the costs of hiring a lawyer for an E. coli case? How do I find the most experienced E. coli attorney?

A: The lawyers at Marler Clark have been representing E. coli victims since 1993 and have recovered over $600,000,000 for clients. The Marler Clark E. coli attorneys provide free case evaluations for all potential raw milk E. coli outbreak victims, and victims of other foodborne illness outbreaks. Our E. coli lawyers do not charge an hourly fee. Our firm works on behalf of clients and only collects fee on a contingent basis. That means we collect our fees for E. coli cases as a percentage of the recovery obtained on our clients’ behalf after the case has been resolved. You can contact Marler Clark for a free E. coli case evaluation and further explanation of fees through our free case evaluation form or by calling us toll-free at (866) 770-2032.

A total of 116 persons infected with the outbreak strain of Salmonella Bareilly have been reported from 20 states and the District of Columbia. The number of ill persons identified in each state is as follows: Alabama (2), Arkansas (1), Connecticut (5), District of Columbia (2), Florida (1), Georgia (5), Illinois (10), Louisiana (2), Maryland (11), Massachusetts (8), Mississippi (1), Missouri (2), New Jersey (7), New York (24), North Carolina (2), Pennsylvania (5), Rhode Island (5), South Carolina (3), Texas (3), Virginia (5), and Wisconsin (12).  12 ill persons have been hospitalized, and no deaths have been reported.

Collaborative investigation efforts of state, local, and federal public health agencies indicate that a frozen raw yellowfin tuna product, known as Nakaochi Scrape, from Moon Marine USA Corporation is the likely source of this outbreak of Salmonella Bareilly infections. Nakaochi Scrape is tuna backmeat that is scraped from the bones of tuna and may be used in sushi, sashimi, ceviche, and similar dishes. Moon Marine USA Corporation (also known as MMI) of Cupertino, Calif. is voluntarily recalling 58,828 lbs of a frozen raw yellowfin tuna product, labeled as Nakaochi Scrape AA or AAA. Nakaochi Scrape is tuna backmeat, which is specifically scraped off from the bones, and looks like a ground product.

 What do consumers need to know in a Sushi Salmonella Outbreak?

Q: I ate sushi and think I may have Salmonella. What are the symptoms of Salmonella infection?

A: Salmonella infections can have a broad range of illness, from no symptoms to severe illness. The most common clinical presentation is acute gastroenteritis. Salmonella symptoms include diarrhea, and abdominal cramps, often accompanied by fever of 100°F to 102°F (38°C to 39°C). Other symptoms of Salmonella infection may include bloody diarrhea, vomiting, headache and body aches. The incubation period, or the time from ingestion of the bacteria until the symptoms start, is generally 6 to 72 hours; however, there is evidence that in some situations the incubation can be longer than 10 days.

Q: What should I do if I think I’m part of the sushi Salmonella outbreak?

A: The Marler Clark Salmonella attorneys advise that you contact your local health department to report your illness. Again, if you believe you need medical assistance for your Salmonella infection, contact your healthcare provider. The Centers for Disease Control and Prevention (CDC) estimates that for every reported case of Salmonella, an additional 29.3 infections go undiagnosed and unreported. Undiagnosed Salmonella victims are never counted in official Salmonella outbreak case-counts. There may well be nearly 3,000 sickened.

Q: How will I know if I’m part of the sushi Salmonella outbreak?

A: Salmonella bacteria can be detected in stool. A fecal sample provided to a healthcare provider or health department is placed in nutrient broth or on agar and incubated for 2-3 days. After that time, a trained microbiologist can identify Salmonella bacteria, if present, and confirm its identity by looking at biochemical reactions. Treatment with antibiotics before collecting a specimen for testing can affect bacterial growth in culture, and lead to a negative test result even when Salmonella causes the infection. If Salmonella is isolated from an ill person’s stool, a bacterial isolate can be compared to isolates from other ill individuals – and possibly from food samples. Bacterial isolates that have matching “DNA Fingerprints” indicate a potential common source of Salmonella infection. Epidemiologists work to determine whether two people with positive bacterial isolates with indistinguishable DNA fingerprints are part of a common outbreak – in this case, one tied to Salmonella-contaminated sushi.

Q: I ate sushi and got Salmonella. I’m thinking about hiring a law firm to represent me, but am concerned about the cost of legal representation for my Salmonella case. What are the costs of hiring a lawyer for a Salmonella case? How do I find the most experienced Salmonella attorney?

A: The lawyers at Marler Clark have been representing Salmonella victims since 1998 and have recovered over $600,000,000 for clients. The Marler Clark attorneys provide free case evaluations for all potential sushi Salmonella outbreak victims, and victims of other foodborne illness outbreaks. Our Salmonella lawyers do not charge an hourly fee. Our firm works on behalf of clients and only collects fee on a contingent basis. That means we collect our fees for Salmonella cases as a percentage of the recovery obtained on our clients’ behalf after the case has been resolved. You can contact Marler Clark for a free case evaluation and further explanation of fees through our free case evaluation form or by calling us toll-free at (866) 770-2032.

UC Santa Barbara researchers Michael Mahan and Douglas Heithoff a means to potentially prevent food poisoning outbreaks from these particularly powerful strains. Their findings, in a paper titled "Intraspecies Variation in the Emergence of Hyperinfectious Bacterial Strains in Nature," have been published in the journal PLoS Pathogens.

The article explained what was meant by the term "hypervirulent" Salmonella:

They were found among isolates derived from livestock, and rendered current vaccines obsolete.  Bacteria behave like a Trojan Horse, exposing their weapons only after initiating infection. "These strains exhibit this behavior in the extreme -- essentially having a ‘5th gear' they can switch to during infection," said Heithoff, lead author of the paper.

Researchers hope that advances in identifying these more dangerous strains will increase the ability to combat and remove the strains from livestock and the food supply.

Scientists at Washington State University are studying the maternal antibodies that are passed from hens to their chicks. "These antibodies protect chicks from becoming colonized by Campylobacter in the first week of life," explained Professor Michael Konkel who is leading the research. "Our group has now identified the bacterial molecules that these antibodies attack, which has given us a starting point for a vaccine against Campylobacter," he said. "We have already found that chickens injected with these specific molecules – found on the surface of Campylobacter jejuni – produce antibodies against the bacterium. This response partially protects them from colonization."

A vaccine could be a powerful weapon to help control food-borne illness. "Preventing contamination of poultry at slaughter has not been effective at reducing illness in humans. It has been shown that about 65% of chickens on retail sale in the UK are contaminated with Campylobacter," explained Professor Konkel. "Ideally, the best way to prevent contamination is to stop chickens on the farm from becoming colonized with this microorganism in the first place, which could be achieved by vaccination. Our goal within the next 6 months is to test a vaccine for chickens that will reduce Campylobacter colonization levels. There's still a long way to go, but I'm confident our lab and others are moving in the right direction."

Controlling food-borne illness through vaccination would have a significant impact both in the UK and globally. "A safe food supply is central to human health. If we can decrease the load of human pathogens in food animals, then we can reduce human illness. A 1% reduction in the number of cases of food-borne illness would save the UK around £20 million per year. In developing countries, where people and food animals often share the same environment, diseased animals also pose a direct public health risk; vaccination would help mitigate this risk," said Professor Konkel.

You may have heard of Bill Marler, a prominent and successful foodborne illness attorney based in Seattle, Washington. He has represented thousands of foodborne illness victims and secured more than $600,000,000 in compensation. But did you know that Mr. Marler has also become a leading advocate for food safety and an influential consensus builder on food safety policy?

Over the past several months, I have seen signs of an emerging consensus on important food safety issues. This kind of consensus leads to good policy decisions by regulators because they don’t have to be concerned about fall-out from consumer groups, industry trade associations and food safety activists when they have to make controversial rulings.

We saw an example of the importance of consensus building last week with USDA’s decision to postpone the non-E. coli O157:H7 STEC testing program. Mr. Marler deserves a lot of credit for clearing the way for USDA. After attending the 2007 FSIS/FDA/CDC meeting on STEC’s, he personally funded a $500,000 baseline study, which led to a much better understanding of the issue. In response to the USDA announcement on testing, he was able to build a coalition of consumer activists, academicians and industry leaders who all recognized that the STEC policy simply wasn’t ready for implementation. I have no doubt that most if not all of the individuals who made up Mr. Marler’s consensus support the STEC testing policy, but recognized that a delay was in the interest of all parties. The result was a good decision by USDA.

Bill Marler has been working on food safety cases since the Jack-in-the-Box outbreak in 1993. Clearly, he is one of the most successful foodborne illness lawyers in the U.S. It’s impossible to work in the area of food safety without developing a personal interest in the people who are affected by foodborne illness tragedies. I believe that his work with foodborne illness victims transformed Bill Marler into a dedicated food safety activist and an important contributor to food safety policy. In addition to building consensus on the STEC testing issue, he was instrumental in raising the interest of the US Congress on food safety issues and helped establish a coalition of consumer groups and victims’ organizations to support the passage of the Food Safety Modernization Act.

He also supports college scholarships, makes donations to organizations involved with food safety issues and frequently speaks on food safety at meetings across the country and around the world, always paying his own expenses.

Since food safety emerged as a major issue in the early 1990’s, there has been too little consensus. Too much time and effort has been wasted on disagreements founded on mistrust. It may seem over simplistic, but food safety really is an objective that is shared by consumers and food companies alike. Bill Marler has taken on the important roles of food safety advocate and consensus builder. He has challenged the food industry to “Put me out of business – please”. I believe he means it and is trying hard to make it happen.

Do not think that this isn't a problem.  It's a problem everywhere, in states where there is no attempt to simply allow food producers to opt out of food safety regulation entirely, and it will be a problem in a state that is on the precipice of allowing exactly that.  Raw milk producers are the primary offenders--i.e. producing a product with known risks and not doing right by customers by having insurance in place to address medical costs, past and future, for severely injured people--and it is no enticement toward insuring a business to completely de-regulate it. 

These bills will:

• eliminate license requirements for so-called homestead food and allowing on-farm sales of raw milk products
• exempt home-based operations with annual sales of $10,000 or less and exclude potentially hazardous food from license requirements (potentially hazardous foods, including acidified and low-acid canned foods, are those requiring temperate controls because they are "capable of supporting the rapid growth of pathogenic or toxigenic microorganisms" such as Clostridium botulinum (botulism)).
• Permit home and roadside sales and transactions at farmers' markets.
• Allow raw milk dairies that produce 20 gallons or less a day to operate without being licensed; these dairies could also sell other raw milk-based products.  

These bills will also result in more foodborne illness.  At the very least, Legislators should put some thought in to what comes out the other end of this process.  It's not just going to be rich butter, cream, and bucolic goodness.  This is the real world.

In his opinion, Stengel discounted an arrangement by which a private group, Right to Choose Healthy Food's Rawesome Club, was leasing Allgyer's cows and distributing milk to Grassfed on The Hill members.

Buyers each paid a $25 fee to join the Rawesome Club, according to court papers.

But, Stengel wrote, such "cow sharing" transactions amounted to a "subterfuge" in which raw milk was taken out of state and left at a "drop point."

This issue, and this case specifically, has been percolating for some time, and it is good to see a judge put pen to paper on the issue of whether cow-shares are a valid legal arrangement for selling raw milk in states that don't allow it, or across state lines.  His reasoning sounds familiar--i.e. that the FDA does have the power to regulate the interstate distribution of raw milk under the commerce clause, and that so-called cow-shares are a sham.  It validates my opinion a couple of years ago in an article on Food Safety News titled "Cow Share Agreements: Fooling Nobody," followed by "Raw Milk, An Issue of Safety or Freedom?"

Seems like there is a bit of a disconnect between raw milk proponents and valid legal analysis.  Honestly, their case is more effectively fought in the halls of state legislatures and city halls nationally, not in courthouses. 

Health officials said the exposure may have occurred between Dec. 13 and Jan. 22.

The employee who was confirmed to have Hepatitis A wasn't involved in food preparation, and the risk to the public is "extremely low" -- but there was some possibility of exposure to diners, the health department said. The employee is said to have used good hand hygiene.

Hepatitis A is a liver disease caused by the hepatitis A virus. It is usually spread by eating or drinking food items that have been contaminated with hepatitis A from someone who hasn’t properly washed their hands after using the bathroom, but it is also spread easily when a person doesn't wash his or her hands after changing a baby's diaper.

Symptoms of the disease include: fever, loss of appetite, abdominal discomfort, jaundice, tiredness, nausea and dark urine. Anyone who ate at the Cheesecake Factory between Dec. 13. and Jan. 22 and has these symptoms is advised to see their doctor. Symptoms vary from mild to severe, lasting anywhere from a couple weeks to several months.

Health officials said the Cheesecake Factory, which is at 330 N. Milwaukee Ave., fully cooperated with the investigation.

Lab results results released today though, indicate that, for at least one of the cases, there is no indication of "mad cow" disease: 

Laboratory tests have confirmed that at least one of the two cases of Creutzfeldt-Jakob disease diagnosed recently in Marin is not the variety linked to mad cow disease.  "That is definitive," Dr. Craig Lindquist, Marin County's interim public health officer, said Thursday morning.  California Department of Public Health officials notified Lindquist on Friday that two Marin residents had recently been diagnosed with Creutzfeldt-Jakob disease and one of them had died due to the exceedingly rare, fatal illness.  "This is the case of the individual who is deceased," Lindquist said. He declined to identify the victim or where in Marin the person lived.

BSE is a chronic degenerative nervous system disease affecting cattle. The disease was first diagnosed in 1986 in Great Britain. BSE is so named because of the spongy appearance of the brain tissue of infected cattle when sections are examined under a microscope.

The incubation period (the time from when an animal becomes infected until it first shows signs of disease) is from 2 to 8 years. Following the onset of clinical signs, the animal's condition deteriorates until it dies. Currently, there is no test to detect the disease in a live animal; veterinary pathologists confirm BSE by postmortem microscopic examination of brain tissue or by the detection of the abnormal form of the prion protein.

Since November 1986, over 178,000 head of cattle have been diagnosed with BSE in Great Britain. The epidemic peaked in January 1993 at approximately 1,000 new cases reported per week.

In a victory for raw-milk farmers, Maine's Portland City Council has given a unanimous thumbs-up to allow raw-milk sales at the city's farmers' markets.

The City Council also handed the dairy farmers another victory by voting 5 to 4 against an amendment that would have required them to post a placard informing consumers of the potential health risks linked to drinking raw milk.

Raw milk is milk that hasn't been pasteurized to kill potentially harmful bacteria such as E. coli, Salmonella and E. coli that can cause severe illness.

The proposed placard, as drawn up by the city's Department of Health and Human Services, warned that children, pregnant women, the elderly and those living with conditions that weaken the immune system are at the greatest risk of becoming ill from drinking raw milk. It also warned that raw milk outbreaks are responsible for nearly three times more hospitalizations than outbreaks involving any other food.

The issue came before the City Council after the city's newly hired food-service inspector visited the Portland farmers' markets last fall and told the raw-milk vendors that sales of unpasteurized milk were not allowed there. That came as a surprise to the vendors, because they had been selling raw milk at the markets for several years, with no previous indications from the city that they weren't supposed to.

It turned out that although state law permits raw milk from state-licensed dairies to be sold at retail stores throughout the state, and even though raw milk is sold at other farmers' markets in the state, the city of Portland had its own list of items that can't be sold at its farmers' markets. Raw milk was on that list, even though it can be sold in stores in the city.

During the City Council meeting, Mayor Michael Brennan, who cast one of the four votes in favor of requiring the placard, made no comments about why he had voted that way. But in an email to Food Safety News after the meeting, he said he voted in favor of the placard because he believes it's important to provide "the most information" possible to consumers about "any number of food products."

He also said his vote supported the recommendation of the council committee that had originally proposed the placard, as well as the recommendation of the city's Department of Health and Human Services, "because both had reviewed the issue more fully."

During the council meeting, Heather Donahue, co-owner of Balfour Farm and a raw-milk vendor at the city's Wednesday farmers' market, told council members that raw-milk farmers are required to inform customers that the milk hasn't been pasteurized by putting the words "not pasteurized" on the containers' labels.

She also pointed out that while in the past raw milk was a "significant" carrier of diseases, many improvements have been made since then. She said that to be certified as a raw-milk dairy in Maine, the dairy herd has to be tested at regular intervals and strict sanitation practices must be followed.

In an interview after the meeting, she told Food Safety News that she was relieved that raw-milk dairies won't have to display the placard about the potential health risks of raw milk.

"In general, the people who shop at farmers' markets know about raw milk and seek it out," she said. "They can get more information from us than they can from a store clerk."

She described the proposal to require the placard as "a wrinkle that needed to be ironed out."

Lauren Pignatello, co-owner of Swallowtail Farm and Creamery and also the manager of Portland's winter farmers' market, said that if consumers are being informed about the health risks of raw milk, they should also be informed about what he sees as the benefits of drinking raw milk.

The Centers for Disease Control and Prevention says there are no health benefits from drinking raw milk that cannot be obtained from drinking pasteurized milk that is free of disease-causing bacteria.

Raw-milk producer Lee Straw told council members that state-licensed raw-milk dairies are held to the same standards as conventional dairies.

"Even though the feds will say otherwise, by holding us to the same ordinances as pasteurized milk, the state seems to feel we can put out a safe product," he said.

But Portland resident Charles Bragdon took the opposite tack, telling the council members that raw milk is "very dangerous to some members of our population" and that providing people with information about the health risks is "important, if not critical."

Council member Cheryl Leeman, who voted in favor of requiring the placard, held up a newspaper featuring an article about a recent outbreak of food poisoning cases linked to a raw-milk dairy in Pennsylvania.

On Feb. 7, Pennsylvania health officials said there were 43 confirmed cases of Campylobacter infections among people who drank raw milk sold by the Your Family Cow farm. Maryland public health officials confirmed that the outbreak strain of bacteria was detected in two unopened containers of unpasteurized milk from the Pennsylvania dairy.

"There is a health risk with raw milk," Leeman said, emphasizing the word "is."

At the same time, she acknowledged that there is "clearly a public demand for raw milk."

Looking at the issue from the perspective of a City Council member, Leeman said that because the issue is raw-milk sales on city property, the city should go along with its Health Department's recommendation requiring the placard.

"It's not an unreasonable request for those folks who want to sell raw milk on our property," she said, pointing out that with the placards, the city will have done its job of making sure the public is informed.

"Then, it will be up to the consumers to weigh the pros and cons," she said. "The final decision is really up to the consumers."

Council member Ed Suslovic had his own concerns, saying that if he were in a rush and grabbed a container of raw milk, it would be easy for him to miss the label saying that the milk hadn't been pasteurized.

"I'd like to see the placard," he said.

He even went so far as to say that he'd like to offer an amendment that would require informational placards at any point of sale for raw milk in the city, which would include retail stores as well as farmers' markets.

The amendment was not acted on.

When a council member asked why the the requirement for a placard was proposed in the first place, Douglas Gardner, director of the city's Health and Human Services Department, explained that it seemed appropriate to tie it in with the proposal that the city allow raw milk sales at its farmers' markets. That way consumers could have information about the basic risks associated with raw milk.

Through all of this, some council members struggled with the issue of fairness. If, for example, placards were to be required at the farmers markets but not at retail stores in the city, then the farmers' market vendors would be at a disadvantage.

Even council member John Anton, who made the motion to remove the requirement for a placard, said he wasn't basing his motion on public health arguments but rather concerns about how it would affect those who sell at farmers' markets, compared with those whose milk is sold in stores.

"It feels unfair and arbitrary," he said.

But he also said that if the city wanted a citywide requirement for an informational placard, he might support it.

In an interview after the meeting, Health Department director Gardner told Food Safety News that during the meeting, he heard several council members express an interest in looking at a citywide requirement for informational placards that would apply to all points of sale -- in stores as well as at farmers' markets.

"There was an interest at looking at a broader approach," he said.

Warnings or Not?

Food-safety attorney Bill Marler, publisher of Food Safety News, said that a warning sign, such as the one on the placard proposed by Portland, MEs health department, should be on a bottle of raw milk as well as at the place of sale of raw milk.

He provided this example of such a sign: "WARNING: This product has not been pasteurized and may contain harmful bacteria (not limited to E. coli O157:H7, Campylobacter, Listeria and Salmonella). Pregnant women, infants, children, the elderly and persons with lowered resistance to disease (immune compromised) have the highest risk of harm, which includes diarrhea, vomiting, fever, dehydration, Hemolytic Uremic Syndrome, Guillain-Barre Syndrome, reactive arthritis, irritable bowel syndrome, miscarriage, or death, from use of this product."

"Consumption of raw milk, especially for the young, the elderly and those with compromised immune systems, should be warned against," Marler said. "Just saying that the milk is not pasteurized is not enough."

Raw Milk in Maine

Amy Robbins, epidemiologist with Maine's Center for Disease Control of Prevention, said in an email to Food Safety News that in the past 5 years, no outbreaks related to raw (unpasteurized) milk products have been identified in Maine, although outbreaks related to raw (unpasteurized) milk products have occurred in other states.

The state does not allow raw milk or raw milk products to be sold in restaurants, schools, hospitals or nursing homes.

 Maine, which has 32 dairy operations that are allowed to sell raw milk, and 65 licensed to sell cheese, is one of 11 states that allows the sale of raw milk at retail stores separate from the farm. Along with 7 other states, it has high standards for cleanliness of the milk, with a coliform standard of no more than 10 coliform bacteria per milliliter, which is equivalent to the national and some international standards for pasteurized milk.

The sandwiches being recalled have expirations dates of January 19 and January 22 and UPC 0543200194.  The sandwich is packaged in white butcher wrap. The Best Buy date is located on the white press on circular label. The UPC Code is located on the bottom of the product beneath the Ingredient and Nutrition Facts label.

No illnesses have been reported to date.

The recall was the result of a routine sampling program by the Florida Department of Agriculture and Consumer Services which revealed that the finished products contained Listeria.

The product has already been removed from store shelves; however, consumers who may have purchased the sandwich for later consumption are urged to return it to the place of purchase for a full refund. Consumers with questions may contact the company at 1-800-394-6258 Monday through Friday 8:00 AM to 5 PM EST.

The outbreak involved a commercially available Salmonella Typhimurium strain used in laboratories, and health officials believe students or lab employees may have carried the bacteria home on contaminated lab coats, pens, cell phones, or other items. Some of the patients were children who live in households with a person who studies or works in a microbiology lab.

The number of patients sickened in the outbreak grew by 36 since the CDC's initial announcement about it on Apr 28, 2011, with three more states reporting cases. The death toll in the outbreak remained at one, and the last illness onset date was Jun 14, 2011, according to yesterday's report, which the CDC said is its final update on the event.

Over the past several months the number of new cases has decreased substantially, returning to the background level of 0 to 4 cases that the CDC said it expects to see each week.

An earlier epidemiologic study had suggested the cases were linked to exposure to clinical or teaching microbiology labs, and the CDC said it would survey labs to identify areas where biosafety improvements are needed.

In yesterday's update, the CDC said a survey of staff members in labs that had outbreak illnesses and in labs that had none found that lab practices and settings were similar, but several differences were found in biosafety training.

Safety training in labs that didn't have illnesses was more likely to cover the signs and symptoms of Salmonella infections, the agency said. Though labs in both groups had similar safety policies in place, some policies appeared to be tougher to enforce and monitor, such as not allowing handheld devices such as cell phones and music players in the lab work space.

The CDC said the survey suggests that lab instructors should improve the training of staff and students on proper biosafety measures.

The CDC advised lab students and workers to observe biosafety practices when working with agents such as Salmonella and to avoid bringing home pens, notebooks, and other items used inside the lab. The agency also warned against bringing food, drinks, and personal items such as car keys and cell phones into the labs, where they can become contaminated.

The statement also listed a number of safety reminders for lab directors, managers, and faculty, including recommendations such as not allowing lab coats to leave the lab and making sure students have dedicated items at work stations, such as writing utensils and other supplies that don't leave the area.

Here are a few more examples of food companies behaving badly:

• FDA Warning Letter to Greencore OARS LLC for the presence of Listeria in the processing facility, and for other serious food safety violations.
• FDA Warning Letter to Jang Soo Farm Inc. d/b/a "Rainier Sprouts":  During the inspection, FDA collected two samples -- consisting of various mung beans, rodent excreta pellets, rodent hair, old nesting material, and rodent-gnawed packaging material -- from your facility that confirmed the presence and activity of rodents and insects. Our investigators documented insanitary conditions and practices that contribute directly or indirectly to possible contamination of your sprouts with filth and pathogens. Accordingly, sprouts grown in your facility are adulterated within the meaning of Section 402(a)(4) of the Federal Food, Drug, and Cosmetic Act (the Act) [21 U.S.C. § 342(a)(4)] because they have been prepared, packed, or held under insanitary conditions whereby they may have been contaminated with filth or rendered injurious to health."
• FDA Warning Letter to Homeneeds Samamish, Inc.: FDA’s laboratory tests of samples collected from your warehouse and various lots of food product confirmed the findings of rodent excreta pellets (REPs), rodent hair, and rodent urine stained and gnawed packaging throughout your facility.
• FDA Warning Letter to Gulfish LP: Failure to have a HACCP plan, which is incumbent upon seafood processors.
• FDA Warning Letter to Li Da Seafood Trading Inc.:  Failure to have a seafood processing HACCP plan, as well as failure to monitor temperature and sanitation, failures in recordkeeping, and a failure to do just about everything necessary to protect consumers from dangerous bacteria and viruses. 

Reviews:

"A fast-paced narrative and a cautionary tale about how public health policy, corporate practices and public relations, and lawyers' chutzpah and frenzy for fees can converge in a place we all know well." --Associated Press

"A new, thriller-style account of the horrors of that E. coli outbreak and the subsequent events, including the groundbreaking rulings making O157:H7 an "adulterant". --Mark Bittman, The New York Times

"Spartan prose delivers a chilling, page-turning lesson in food safety." --Kirkus Reviews

"Movie-like ...Benedict does a dramatic public service by showing us what happened behind the scenes." --Christian Science Monitor

"Part thriller, part investigative expose, and all human, "Poisoned" lays out in rich, untold detail the tragic yet ultimately inspiring story behind the largest deadly E. coli outbreak in history." --Armen Keteyian, CBS News

Happy Holidays - whatever you celebrate, or not.  I wish all well - especially my opponents.  May your Holiday meals be safe, and I wish for all of us less work for you in the New Year. 

Say, you all still have time to vote for Marler Blog as one of the top ABA Law Journal Blawg 100 for 2001.  Look for Marler Blog under Torts.

Ill customers had dined at the El Gran Burrito restaurant between July 6 and July 11. On Monday, July 11 CDPH staff informed Dr. Corland Lohff, state epidemiologist at the Illinois Department of Public Health (IDPH), of the ill patients and the suspected source, El Gran Burrito. CDPH staff began to interview ill persons about symptoms and possible exposures to a foodborne pathogen using a standardized questionnaire. Patient answers clearly implicated food prepared and sold at the El Gran Burrito restaurant located on South Pulaski Road. 

Illness complaints among El Gran Burrito customers prompted CDPH restaurant inspectors to make an on-site visit to the restaurant on Monday, July 11. The restaurant “passed” inspection although food and non-food contact surfaces were in obvious need of cleaning. By July 12 more patient data were gathered and evidence connecting illnesses to the El Gran Burrito mounted. Leftover foods and environmental swabs were collected for laboratory analysis. CDPH staff met with employees to discuss food safety procedures, proper temperature controls, and good hygienic practices. El Gran Burrito voluntarily closed on July 12 for thorough cleaning and sanitizing.

Ultimately, at least 30 people tested positive for Salmonella Newport that they had contracted from food prepared by the Pulaski Road El Gran Burrito.  One of the restaurant's employees tested positive for the same strain of Salmonella during the health department investigation.  The outbreak prompted a lawsuit by Gloria Molden, who was hospitalized as a result of her severe illness.

Here is a list of several other raw milk, or raw milk product-related, E. coli outbreaks and recalls over the last few years. 

• Dungeness Valley Raw Whole Milk E. coli Outbreak 2009:  An outbreak was linked to the consumption of raw, unpasteurized, whole milk produced by the Dungeness Valley Creamery. There were a total of three cases. There were two E. coli strains implicated. One strain was confirmed and was E. coli O121. The other strain was suspected and was E. coli O157:H7. Raw milk was legal to sell and buy in Washington, provided the dairy underwent a series of inspections and was licensed. This dairy had been licensed since 2006.
• Dee Creek Farms Raw Milk E. coli Outbreak 2005:  In November 2005, at least 18 people were sickened in an outbreak linked to the consumption of raw milk from Dee Creek Farm, located near Woodland, Washington. The farm was not licensed to sell raw milk, and during its investigation into the outbreak, the Washington State Department of Agriculture (WSDA) noted several milk processing violations that would have been addressed during the licensing process had Dee Creek applied for the license. In addition, sample testing confirmed the presence of E. coli O157:H7 in two milk samples provided by Dee Creek Farm and in five environmental samples taken from Dee Creek Farm milk-barn areas by investigators. In the Dee Creek outbreak, five Clark County, Washington, children were hospitalized, with two developing Hemolytic Uremic Syndrome and requiring critical care and life support for kidney failure as a result of their E. coli infections.
• Grace Harbor Farms Raw Milk E. coli Outbreak 2006:  In September 2006, two young children were infected by E. coli O157:H7 as a result of consuming raw goat’s milk produced and sold by Grace Harbor Farm. Multiple environmental specimens collected at the farm during the course of the outbreak investigation tested positive for the same strain of E. coli O157:H7 that infected the two young children.
• Pride and Joy Creamery Raw Milk E. coli Recall 2011:  The Pride & Joy Creamery of Granger, Washington recalled raw milk sold at numerous retail outlets due to potential contamination with E. coli in September 2011. According to a news report, Washington State Department of Agriculture investigators discovered the E. coli bacteria during a routine sampling at Pride & Joy.
• Sally Jackson Raw Milk Cheese E. coli Outbreak 2010:  In December 2010, at least 8 people were sickened in a multi-state E. coli O157:H7 outbreak linked to raw milk-based cheeses made by Sally Jackson, an artisan cheesemaker in Washington State
• Estrella Family Creamery Raw Milk Cheese Listeria Recall 2010:  In fall 2010, this small cheesemaker in Washington State found itself doing battle, and pitting wills, with the FDA due to repeated positive tests for Listeria found at the cheese-producing premises.  The situation sparked quite a controversy; for full reading, see Is there reason hidden in the debate over Estrella cheeses?
• Queseria Bendita Mexican Soft Cheese Listeria Recall 2010:  In February 2010, Queseria Bendita of Yakima, Washington recalled three types of cheese, Queso Fresco, Panela, and Requeson, due to contamination by Listeria monocytogenes.
• Reports of Baby Deaths Linked to Listeria-contaminated Soft Cheeses (2009):  According to the Spokane Newspaper, in March 2009 Washington State health investigators tried to solve several cases of food-borne infections that caused several pregnant women to lose their babies in the first months of the year. They suspected the women in Yakima, Klickitat and King counties ate unpasteurized cheese that was contaminated with listeria bacteria. Listeria is often found in soft cheeses such as Mexican-style queso fresco and queso Blanco, along with feta, brie, camembert, Roquefort and bleu. 

Kosher Broiled Chicken Livers Salmonella Heidelberg - According to the CDC, between April 1 to November 16, 2011, a total of 179 illnesses due to Salmonella Heidelberg with this PFGE pattern were reported in states where the “kosher broiled chicken livers” were distributed. The number of ill persons identified in each state the product is distributed to is as follows: New York (99), New Jersey (61), Pennsylvania (10), Maryland (6), Ohio (2), and Minnesota (1). Rhode Island and Florida have not identified any cases linked to this outbreak during this period. Among persons for whom information is available in in these states, ill persons range in age from <1 to 97 years with a median age of 13 years. Forty-nine percent are female. Among the 126 ill persons with available information, 25 (20%) have been hospitalized.

Salmonella Heidelberg Turkey Burgers - According to the CDC a total of 136 persons infected with the outbreak strain of Salmonella Heidelberg were reported from 34 states with illness onset dates between February 27 and September 13, 2011. The number of ill persons identified in each state was as follows: Alabama (1), Arkansas (1), Arizona (3), California (7), Colorado (4), Connecticut (1), Georgia (2), Illinois (16), Indiana (2), Iowa (2), Kansas (3), Kentucky (2), Louisiana (1), Massachusetts (4), Maryland (1), Michigan (12), Minnesota (2), Mississippi (2), Missouri (7), Nebraska (2), Nevada (1), New Jersey (1), New York (3), North Carolina (4), Ohio (12), Oklahoma (2), Oregon (1), Pennsylvania (8), South Dakota (3), Tennessee (2), Texas (18), Utah (1), Vermont (1), and Wisconsin (4).

Turkish Pine Nuts Salmonella Enteritidis - A total of 42 individuals infected with the outbreak strain of Salmonella Enteritidis have been reported from 6 states. The number of ill persons identified in each state with the outbreak strain is as follows: Arizona (1), Maryland (1), New Jersey (2), New York (26), Pennsylvania (8), and Virginia (4). Turkish pine nuts sold in bulk bins at Wegmans grocery stores, and some Turkish pine nuts consumed as an ingredient in prepared foods, such as Caprese salad or asparagus with pine nuts, sold at Wegmans stores, have been linked to an outbreak of Salmonella Enteritidis. According to the CDC, among 30 ill persons for whom information is available, 19 (63%) reported consuming Turkish pine nuts or products containing these pine nuts in the week before their illness began.

What is Salmonella?

Salmonella is one of the most common enteric (intestinal) infections in the United States. Salmonellosis (the disease caused by Salmonella) is the second most common foodborne illness after Campylobacter infection. It is estimated that 1.4 million cases of salmonellosis occur each year in the U.S.; 95% of those cases are foodborne-related. Approximately 220 of each 1000 cases result in hospitalization and eight of every 1000 cases result in death. About 500 to 1,000 or 31% of all food-related deaths are caused by Salmonella infections each year. Salmonellosis is more common in the warmer months of the year.

Salmonella infection occurs when the bacteria are ingested, typically from food derived from infected food-animals, but it can also occur by ingesting the feces of an infected animal or person. Food sources include raw or undercooked eggs/egg products, raw milk or raw milk products, contaminated water, meat and meat products, and poultry. Raw fruits and vegetables contaminated during slicing have been implicated in several foodborne outbreaks.

Symptoms of Salmonella infection

The acute symptoms of Salmonella gastroenteritis include the sudden onset of nausea, abdominal cramping, and bloody diarrhea with mucous. Fever is almost always present. Vomiting is less common than diarrhea. Headaches, myalgias (muscle pain), and arthralgias (joint pain) are often reported as well. The onset of symptoms usually occurs within 6 to 72 hours after the ingestion of the bacteria. The infectious dose is small, probably from 15 to 20 cells.

Reiter’s Syndrome, which includes and is sometimes referred to, as reactive arthritis is an uncommon, but debilitating, result of a Salmonella infection. The symptoms of Reiter’s Syndrome usually occur between one and three weeks after the infection. Reiter’s Syndrome is a disorder that causes at least two of three seemingly unrelated symptoms: reactive arthritis, conjunctivitis (eye irritation), and urinary tract infection. The arthritis associated with Reiter’s Syndrome typically affects the knees, ankles, and feet, causing pain and swelling. Wrists, fingers and other joints can be affected, though with less frequency. With Reiter’s Syndrome, the affected person commonly develops inflammation where the tendon attaches to the bone, a condition called enthesopathy. Some people also develop heel spurs, bony growths in the heel that cause chronic or long-lasting foot pain. Arthritis from Reiter’s Syndrome can also affect the joints of the back and cause spondylitis, inflammation of the vertebrae in the spinal column. The duration of reactive arthritis symptoms can vary greatly. Most of the literature suggests that the majority of affected persons recover within a year. The condition, can, however, be permanent.

Detection and treatment of Salmonella Infection

Salmonella bacteria are discovered in stool cultures. Although blood cultures are rarely positive, bacteremia (bacteria in the blood stream) does occur in 5% of adults with Salmonella gastroenteritis and can result in spread to the heart (endocarditis), spleen, bone (osteomyelitis), and joints (Reiter’s Syndrome or reactive arthritis). However, blood cultures are often not performed and in most cases the blood stream is not infected. In the stool, the laboratory is challenged to pick out Salmonella from many other similar bacteria that are normally present. In addition, many persons submit cultures after they have started antibiotics, which may make it even more difficult for a microbiology lab to grow Salmonella. So, the diagnosis of salmonellosis may be problematic and many mild cases are culture negative. 

Salmonella infections usually resolve in five to seven days, and many times require no treatment, unless the affected person becomes severely dehydrated or the infection spreads from the intestines. Persons with severe diarrhea may require rehydration, often with intravenous fluids. Treatment with antibiotics is not usually necessary, unless the infection spreads from the intestines, or otherwise persists, in which case the infection can be treated with ampicillin, gentamicin, trimethoprim/sulfamethoxazole, or ciprofloxacin. Some Salmonella bacteria have become resistant to antibiotics, possibly as a result of the use of antibiotics to promote the growth of feed animals.

For those persons who develop Reiter’s Syndrome, symptomatic treatment with high doses of a nonsteroidal anti-inflammatory drug and steroid injections into affected joints can be helpful in reactive arthritis. For people with severe joint inflammation, injections of corticosteroids directly into the affected joint may reduce inflammation. A small percentage of patients with reactive arthritis have severe symptoms that cannot be controlled with these treatments, in which case medicine that suppresses the immune system, such as sulfasalazine or methotrexate, may be effective. Exercise, when introduced gradually, may help improve joint function. Topical corticosteroids can be applied directly on the skin lesions associated with reactive arthritis.

Preventing Salmonella Infection

To prevent salmonellosis, cook poultry, ground beef, and eggs thoroughly before eating. In order to insure that eggs do not contain viable Salmonella they must be cooked at least until the yoke is solid, and meat and poultry must reach 160∫F or greater throughout. Be particularly careful with foods prepared for infants, the elderly, and those with a compromised immune system.

Do not eat or drink foods containing raw eggs, such as homemade eggnog and hollandaise sauce. Avoid drinking raw (unpasteurized) milk or products made from raw milk.

Wash hands, kitchen work surfaces, and utensils with soap and water immediately after they have been in contact with foods of animal origin. Also, wash hands with soap after handling reptiles, amphibians or birds, or after contact with pet feces. Infants and immunocompromised persons should have no direct or indirect contact with such pets.

Salmonella Infection Complications

The following infections result in very few people, but the few who are diagnosed will suffer for the rest of their lives.

Irritable Bowel Syndrome (IBS)

A recently published study surveyed the extant scientific literature and noted that post-infectious irritable bowel syndrome (PI-IBS) is a common clinical phenomenon first described over five decades ago. The Walkerton Health Study further notes that:

Between 5% and 30% of patients who suffer an acute episode of infectious gastroenteritis develop chronic gastrointestinal symptoms despite clearance of the inciting pathogens.

In terms of its own data, the “study confirm[ed] a strong and significant relationship between acute enteric infection and subsequent IBS symptoms.” The WHS also identified risk factors for subsequent IBS, including: younger age; female sex; and four features of the acute enteric illness—diarrhea for > 7days, presence of blood in stools, abdominal cramps, and weight loss of at least ten pounds.

Irritable bowel syndrome (IBS) is a chronic disorder characterized by alternating bouts of constipation and diarrhea, both of which are generally accompanied by abdominal cramping and pain. In one recent study, over one-third of IBS sufferers had had IBS for more than ten years, with their symptoms remaining fairly constant over time. IBS sufferers typically experienced symptoms for an average of 8.1 days per month.

As would be expected from a chronic disorder, IBS sufferers required more time off work, spent more days in bed, and more often cut down on usual activities, when compared with non-IBS sufferers. And even when able to work, a significant majority (67%), felt less productive at work because of their symptoms. IBS symptoms also have a significantly deleterious impact on social well-being and daily social activities, such as undertaking a long drive, going to a restaurant, or taking a vacation. Finally, while a patient’s psychological state may influence the way in which he or she copes with illness, and responds to treatment, there is no evidence that supports the theory that psychological disturbances in facts cause IBS or its symptoms.

Reiter’s Syndrome

Several bacteria, including Salmonella, induce septic arthritis. The resulting joint pain and inflammation can resolve completely over time or permanent joint damage can occur. In a small number of persons, the joint inflammation is accompanied by conjunctivitis and uveitis, (inflammation of the eyes), and cystitis (painful urination). This triad of symptoms is called Reiter's Syndrome. Reiter’s Syndrome is a special form of reactive arthritis, autoimmune disorder triggered by the Salmonella infection. It occurs in persons with a genetic predisposition and can last for a year or more. Antibiotic treatment does not make a difference in whether or not the person later develops arthritis.

The term reactive arthritis refers to an inflammation of one or more joints, following an infection localized at another site distant from the affected joints. The predominant site of the infection is the gastrointestinal tract. During outbreaks of Salmonella infections, reactive arthritis incidences from 1% to 15% have been reported.

References

Angulo FJ, Baker NL, Olsen SJ, Anderson A, Barrett TJ. (2004). Antimicrobal Use in Agriculture: Controlling the Transfer of Antimicrobal Resistance to Humans. Seminars in Pediatric Infectious Diseases. 15(2): 78-85.

Angulo FJ, Nargund VN, and Chiller TC. (2004). Evidence of an Association Between Use of Anti-microbial Agents in Food Animals and Anti-microbial Resistance Among Bacteria Isolated from Humans and the Human Health Consequences of Such Resistance J. Vet. Med. B Infect. Dis. Vet. Public Health. 51(8-9):374-9.

CDC. (2005, October 13). Salmonella: Technical Fact Sheet. Retrieved August 29, 2007 from Centers for Disease Control and prevention Web site, http://www.cdc.gov/ncidod/dbmd/diseaseinfo/salmonellosis_t.htm.

CDC. 2007. Salmonella Surveillance: Annual Summary, 2005. Atlanta, Georgia: US Department of Health and Human Services.

Glynn MK, Bopp C, Dewitt W, Dabney P, Mokhtar M, Angulo FJ. (1998). Emergence of multidrug-resistant Salmonella enterica serotype typhimurium DT104 infections in the United States. N Engl J Med 338:1333–1338.

Hill Gaston JS, Lillicrap MS. (2003). Arthritis associated with enteric infection. Best Practices & Research Clinical Rheumatology 17(2):219-239.

Inman RD, Johnston MEA, Hodge M, Falk J, and Helewa A. (1988). Postdysenteric Reactive Arthritis, A Clinical and Immunogenic Study following an Outbreak of Salmonellosis. Arthritis and Rheumatism 31:1377-1383.

Mayo Clinic. (2007, April 12). Salmonella. Retrieved August 29, 2007 from Mayo Clinic Web site, http://www.mayoclinic.com/health/salmonella/DS00926.

Mead PM, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, Griffin PM, and Tauxe RV. (1999). Food-related Illness and Death in the United States. Emerg. Infect. Dis. 5:607-625.

MMWR Recomm Rep. (2001). Diagnosis and management of foodborne illnesses: a primer for physicians. January 26, 2001 / 50 (RR-2):1-69. Atlanta, GA: Centers for Disease Control and Prevention.

MMWR Surveillance Summaries, Appendix B. (1996). Guidelines for confirmation of foodborne-disease outbreaks. October 25, 1996 / 45:(SS-5) 59-66. Atlanta, GA: Centers for Disease Control and Prevention.

MMWR Weekly. (1996). Guidelines for confirmation of foodborne-disease outbreaks. October 25, 1996 / 45(S-5): 58-66. Atlanta, GA: Centers for Disease Control and Prevention.

MMWR Weekly. (2001). Summary of Notifiable Diseases, United States, 1999. April 06, 2001 / 48(53):1-104. Atlanta, GA: Centers for Disease Control and Prevention.

MMWR Weekly. (2006). Preliminary FoodNet Data on the Incidence of Infection with Pathogens Transmitted Commonly Through Food – 10 States, United States, 2005. April 14, 2006 / 55(14);392-395. Atlanta, GA: Centers for Disease Control and Prevention.

Stevenson JE, White DG, Torpey III DJ, Craig AS, Smith KE, Park MM, Pascucilla MA, Anderson AD, and the NARMS Working Group. (2002). Enhanced Surveillance for Antimicrobial Resistance Among Enteric Bacteria: NARMS Retail Food Study. International Conference on Emerging Infectious Diseases. Atlanta, GA, March 2002.

Wallinga, D. (2002, October). Antimicrobial Use in Animal Feed: an Ecological and Public Health Problem. Minnesota Medicine. 85. Retrieved January 16, 2008, from http://www.mmaonline.net/publications/MNMed2002/October/Wallinga.html.

ABA Top 100 Law Blawgs:

On its 5th birthday, you'll see some familiar faces at the party: bloggers who've been on our list in years past.

But 2011 also brought along a lot of newcomers, and we're delighted that so many RSVP'd our invitation to nominate their favorites. We received more than 1,300 Blawg Amici this year, and that made for a hard time narrowing the field to 100 law blogs.

Click here to peruse the law blogs in alphabetical order. To vote for your favorites online before the polls close Dec. 30, scroll down and click a category title to see the list of blogs in that category. There are 12 categories, and registration gets you 12 votes. But you can vote more than once in the same category.  Go to Torts to vote.

Lexis Nexis Top 25 Blogs:

The results are in, and the LexisNexis Litigation Resource Community is pleased to announce the LexisNexis Top 25 Tort Law Blogs of 2011. Congratulations to all the honorees and to all those who were nominated!

The honored blogs contain a wealth of information for Tort Law practitioners, with timely news items, practical information, expert analysis, tips, frequent postings, and helpful links to other sites.

The voting isn't over, though. You can have your voice heard as to the selection of the Top Tort Law Blog of the Year!  You will need to be registered in order to vote.  If you haven't previously registered, follow this link  to create a new registration or use your sign in credentials from your favorite social media site.  Registration is free and does not result in sales contacts. Once you are logged in, you can then VOTE by checking the box next to your favorite Tort Law blog then submitting the results.

Voting ends on Friday Dec. 10, 2011, at midnight ET, so VOTE now!!!

The product for retail sale is packaged in a 10-ounce, clear plastic package marked with a Front Row Produce “Grape Tomatoes” label on the top of the package. Currently, the lot number does not appear on the clear plastic package but it does appear on the case label. The lot numbers on the cases containing the 10-oz. packages are 2310802, 2310405, or 2510401. The 10lb bulk grape tomatoes are packaged for wholesale in a plain brown cardboard box labeled only with lot # 2310801.

As of 12/1/2011, all shipments of Front Row Produce Grape Tomatoes packaged in clear 10-oz. plastic packages sold in retail stores will now have a green lot number sticker placed on the bottom side of each package. The lot number will consist of a 7-digit number used to aid in identifying specific shipments of product. Any packages that do not contain this green sticker should be considered suspect and under recall.

No illnesses have been reported to date in connection with this problem.

The contamination was noted after random testing by Rio Queen Citrus, Mission TX, revealed the presence of Salmonella in some 20lb bulk containers.

Production of the product has been suspended while FDA and the company continue their investigation as to the source of the problem.