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

On January 25, 2012, it was announced that Anytime Deli Turkey & Ham Footlong Sandwiches are being recalled due to potential Listeria monocytogenes contamination.  The sub sandwiches were distributed on January 2nd and 3rd to convenience stores in Florida and South Georgia.

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.

Pick up today's edition of just about any major daily and you'll find more than you wanted to read about food producers, and the auditors who are supposed to hold them in check, behaving poorly.  Try Stephanie Armour's article, or this from the AP, just for starters.  The upshot is that the companies that participated in the food safety audit of Jensen Farms, the company that produced cantaloupes that have killed 31 people since August, failed miserably.  See Third Party Auditing Industry Indicted for more. 

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. 

On Sunday, July 10, 2011 the Mount Sinai Hospital Emergency Department notified the City of Chicago Department of Public Health (CDPH) of a possible foodborne illness outbreak. Over the weekend at least 15 people had been seen at the hospital for gastrointestinal symptoms. Five patients were admitted. Laboratory analysis of stool specimens collected from two patients were positive for Salmonella. At least four ill persons reported eating at El Gran Burrito located at 1207 South Pulaski Road in Chicago in the 72 hours before symptom onset. 

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.

Salmonella in the News

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

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Front Row Produce of St. Louis MO is recalling its 10oz pint and 10lb bulk grape tomatoes supplied by Rio Queen Citrus, Mission TX, because they have the potential to be contaminated with Salmonella, an organism which can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems. The recalled 10oz pint and 10lb bulk grape tomatoes were distributed throughout Missouri and Illinois to foodservice distributors and retail stores.

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.