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Bill Marler: A Week Talking To The Media About Listeria And Ice Cream

Neither agencies nor Blue Bell tested products for Listeria

The Blue Bell recall underscores how Listeria outbreaks can occur without being traced to a specific product, said Bill Marler, a Seattle food-safety lawyer. Blue Bell’s Listeria strains have been matched to 10 illnesses in four states, dating to 2010.

The Centers for Disease Control and Prevention said the Listeria strains found in Blue Bell products were matched to human illnesses using a national computer database, called PulseNet. About 800 listeriosis cases are added to the list annually.

“It shows that the outbreak was going on with no knowledge by Blue Bell, no knowledge by the CDC and no knowledge by health departments,” Marler said. “And the people who had gotten sick had no knowledge that it was the Blue Bell ice cream that made them sick.”

Blue Bell outbreak dates to 2010

“It has evolved with human refrigeration,” said Seattle attorney Bill Marler. “In a sense, we’ve created this monster by our desire to have mass-produced food in cool, wet environments.”

Marler, who built a career on major verdicts for food-borne illness victims, and who may take on clients in this outbreak, said he thinks Blue Bell runs pretty clean plants. But listeria can lurk in crevices of equipment even with aggressive cleaning.

“That doesn’t mean Blue Bell gets a pass legally or morally on this,” he said. “But listeria is a hard thing.”

For Blue Bell, a Drastic Move to Recall Ice Cream as Listeria Findings Rose

Bill Marler, a personal injury lawyer and food safety advocate who is now working with Snoqualmie to make changes at its factory, said that the company had since overhauled its production processes, installing new flooring and sanitizing equipment, and adopting third-party sample testing for all batches of ice cream before they are shipped.Outside experts brought in to track down the source of the listeria infection discovered traces of the bacteria on pallets used by a supplier to deliver milk to the plant, Mr. Marler said. Snoqualmie now keeps pallets out of the production room, and it has also strengthened rules on cleaning uniforms, boots and strip curtains in production zones. Snoqualmie was cleared to start shipping ice cream again after 60 days.Mr. Marler stressed that Snoqualmie had immediately decided to recall all its products even though only a certain line of small-tub ice creams had been linked to the listeria case.“Limiting the recall might seem like a good idea,” he said. “But then if you keep expanding your recall, it’s a death by a thousand cuts. You look like you’re dragging your feet.”

Blue Bell Recalls Entire Line; CEO Vows To ‘Get It Right’

“Once the bacteria gets into a plant, it can grow very rapidly and is really difficult to eradicate,” Bill Marler, a Seattle lawyer who specializes in food-safety cases, tells them.

More listeria illnesses linked to Blue Bell products after recall

More Blue Bell-related listeria cases are likely on the horizon, according to Seattle-based foodborne-illness attorney Bill Marler.

Marler said he has been contacted by “dozens” of people who have been ill with gastrointestinal symptoms and have eaten Blue Bell products — “but there is no way to link them legally. The only sure test is a blood test (or spinal fluid), and you need to be very sick for that usually.” He said he has also heard from several who have listeria infections “but have not yet been linked to Blue Bell genetically,” and that “there are a number of background listeria cases that may or may not be linked.”

“Listeria is an environmental pathogen that loves a cool, wet environment and grows very well at refrigerator temperatures,” Marler said. “That is why it’s such a problem in manufacturing facilities like meat, cheese, cantaloupe and now ice cream. Once it gets into a plant, it is very hard to get rid of.”

“What we know is that the problem has been going on in these [Blue Bell] plants for some time,” he said. “But for South Carolina doing an apparently random test on product in February, no one would have known about this at all.”

CDC expands Blue Bell-related illnesses to 10 people in four states

Food safety attorney Bill Marler said he was “not particularly surprised” by the announcement.

Once tests show Listeria is in a finished product it is likely it is in the manufacturing facility, which is tough to combat, he said.

“Now that it’s expanded, it shows that Listeria is endemic in their plants,” he said.

“What is sad about the Blue Bell situation, had it had more thorough testing of product and more thorough cleaning of its plant and equipment beforehand, an outbreak could have been avoided. The devastation to Blue Bell’s customers and its reputation could have been avoided,” he said.

Marler said other companies have launched broad recalls, including Peter Pan peanut butter, which had years’ worth of products recalled.

“It’s a big hit, but there are a lot of companies that have taken a big hit and come back,” Marler said.

Blue Bell recall shows difficulty of controlling Listeria

“Once the bacteria gets into a plant, it can grow very rapidly and is really difficult to eradicate,” said Bill Marler, a Seattle lawyer who specializes in food-safety cases.

Blue Bell can capitalize on loyalty, industry woes

Frozen desserts have never been a usual suspect for listeria outbreaks, a fact that baffles Seattle attorney Bill Marler, who is helping Snoqualmie through its crisis and who routinely sues food manufacturers. He won a major verdict for one of the Jack in the Box victims.

Listeria thrives in cold, damp places. Ice cream companies and regulators could have been testing for listeria all along, Marler said. He predicts more illnesses and more ice creams linked to listeria before industry catches on – just as costs, tests and safety in ground beef ramped up in the 1990s and early 2000s after E. coli poisonings.

“In six months, instead of having no testing … on ice cream, everybody except tiny companies are going to be testing and swabbing in their facilities looking for listeria,” Marler said. “You won’t see as many recalls, and you won’t see as many illnesses, and that’s exactly what happened with hamburger.”

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Listeria outbreaks. The Listeria lawyers of Marler Clark have represented thousands of victims of Listeria and other foodborne illness outbreaks and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our Listeria lawyers have litigated Listeria cases stemming from outbreaks traced to a variety of foods, such as caramel apples, cantaloupe, cheese, celery and milk.

1 dead, Over 20 Sick After Eating At Church Supper In Ohio

Botulism.jpg-550x0One person is dead, and 19 others are being treated for botulism at Fairfield Medical Center.

Health officials say all of the people who are ill attended a potluck at Cross Pointe Free Will Baptist Church Sunday.

Health officials report 50 to 60 people attended the potluck.

Botulism is a rare paralytic illness caused by a nerve toxin, and can be foodborne. The hospital says a neurologist determined a patient had botulism Tuesday morning, and a short time later, two other cases were identified. All of the patients came in to the Emergency Department at Fairfield Medical Center, but the hospital says several have been transferred to other medical facilities.

All of the people affected had symptoms that included double vision, blurred vision, difficulty swallowing, and blurred vision. Doctors are working on getting an anti-toxin from the Centers for Disease Control to treat the patients.

The Fairfield Medical Center is reminding the community that botulism is not contagious, so there is no threat to the community. But medical officials are encouraging anyone who was at the potluck to come to the emergency department. The medical center has also set up an emergency hotline to answer questions at 740-687-8053.

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Botulism outbreaks. The Botulism lawyers of Marler Clark have represented thousands of victims of Botulism and other foodborne illness outbreaks and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our Botulism lawyers have litigated Botulism cases stemming from outbreaks traced to carrot juice and chili.

CIDRAP: US offers mixed news on drug resistance in foodborne pathogens

A pair of annual federal reports on antimicrobial resistance in pathogens found in poultry and meat brought a mix of good and not-so-good news this week.

The government’s National Antimicrobial Resistance Monitoring System (NARMS) issued its retail meat report for 2012 and an interim report for 2013 that covers only Salmonella.

NARMS is a collaborative program of the Food and Drug Administration (FDA), the Centers for Disease Control and Prevention, and state and local health departments in 11 states. The annual reports focus primarily on Salmonella and Campylobacter.

On the Salmonella front, testing showed that multidrug-resistant strains decreased from 2011 to 2013. In 2012, 33% of retail chicken Salmonella isolates were resistant to three or more classes of antibiotics, which was lower than in 2011. The number dropped to 26% in the 2013 interim report.

There was good news on quinolone resistance: all Salmonella isolates from poultry and meat were susceptible to nalidixic acid and ciprofloxacin in 2012, and in 2013 all were susceptible to ciprofloxacin. (The 2013 report does not mention nalidixic acid.)

The 2012 report shows that third-generation cephalosporin resistance in retail chicken Salmonella isolates increased from 10% to 28% between 2002 and 2012, but the 2013 report shows it dropped to 19.7%.

As for Campylobacter, nearly half of C jejuni and C coli isolates from retail chicken were resistant to tetracycline in 2012, making tetracycline resistance the most common type among Campylobacter.

The report also said that monitoring has revealed no consistent changes in ciprofloxacin resistance among retail chicken C jejuni and C coli isolates since the FDA banned fluoroquinolone use in poultry production in 2005.

On the other hand, Campylobacter rarely shows resistance to multiple drugs, as only 26 of 620 poultry isolates were resistant to three or more antibiotic classes in 2012.

NARMS 2012 Retail Meat Report

NARMS 2013 interim report on Salmonella

With the DeCosters Heading to Jail, The Park Doctrine Remembered

business-man-in-handcuffs-300x205This week two former egg industry executives received three month long jail sentences for their roles in a major 2010 Salmonella outbreak. Austin “Jack” DeCoster and his son, Peter DeCoster’s Quality Egg company will pay a $6.8 million fine as part of a plea agreement, and the DeCosters individually paid $100,000.

The U.S. Centers for Disease Control and Prevention linked 1,939 illnesses to the outbreak, but officials estimate that up to 56,000 people may have been sickened. The three-month sentences handed down by U.S. District Judge Mark Bennett are noteworthy because only a handful of cases of corporate misconduct end with executives behind bars. The extent of harm caused by the outbreak and the pattern of problems led to the decision for jail time.

In the past 18 months, two Colorado cantaloupe farmers were convicted and received probation in a deadly 2011 listeria outbreak, and the former owner of Peanut Corporation of America was convicted in a 2008 salmonella outbreak. The peanut executive, Stewart Parnell, also could face jail time when sentenced.

United States v. Park 421 U.S. 658 (U.S. Sup. Ct. 1975) was decided just a few months after I graduated from High School, and long before I decided (as one food pundit coined), to become the “the Assassin in Armani” – at least to the food industry.

Park is an interesting (and seldom used) case where the Court ruled that Mr. Park, the CEO of Acme International (Acme Markets, Inc., was a national retail food chain with approximately 36,000 employees, 874 retail outlets, 12 general warehouses, and four special warehouses), had failed to comply with the Federal Food, Drugs, and Cosmetics Act (FDCA), to keep conditions within his warehouses sanitary. Rats and rat feces were found in two of the company’s warehouses (on more that one occasion) and the FDA had warned Acme to clean it up. There appears to have been no reported illnesses. At trial Acme pled guilty, but Park claimed he was not personally responsible for the violations. The jury disagreed and he was ultimately fined $50 per violation. The case eventually made its way to the Supreme Court.

In part, the focus of the Court’s opinion was whether “the manager of a corporation, as well as the corporation itself, may be prosecuted under the FDCA for the introduction of misbranded and adulterated articles into interstate commerce.” The Court concluded the answer to be yes. In fact, the Court found that “[t]he Act imposes upon persons exercising authority and supervisory responsibility reposed in them by a business organization not only a positive duty to seek out and remedy violations but also, and primarily, a duty to implement measures that will insure that violations will not occur, … [I]n order to make food distributors the strictest censors of their merchandise, … the Act punishes “neglect where the law requires care, or inaction where it imposes a duty.”

The Court further looked to the purposes of the Act and noted that they “touch phases of the lives and health of people which, in the circumstances of modern industrialism, are largely beyond self-protection.” It observed that the Act is of “a now familiar type, “which” dispenses with the conventional requirement for criminal conduct – awareness of some wrongdoing. In the interest of the larger good it puts the burden of acting at hazard upon a person otherwise innocent but standing in responsible relation to a public danger.”

Thus, the Court reaffirmed the proposition that “the public interest in the purity of its food is so great as to warrant the imposition of the highest standard of care on distributors.”

Today a misdemeanor conviction under the FDCA still, unlike a felony conviction, does not require proof of fraudulent intent, or even of knowing or willful conduct. Rather, a person may be convicted if he or she held a position of responsibility or authority in a firm such that the person could have prevented the violation. Convictions under the misdemeanor provisions are punishable by not more than one year or fined not more than $250,000, or both.

My strong suspicion is that those that produce and sell food are now paying a bit more attention.

Baby Food With Glass Recalled

Screen Shot 2015-04-15 at 10.14.33 PMBeech-Nut Nutrition, an Amsterdam, N.Y. establishment, is recalling approximately 1,920 pounds of baby food products that may be contaminated with small pieces of glass, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today.

The baby food product was produced on December 12, 2014. The following product is subject to recall:
4-oz. glass jars containing “Stage 2 Beech-Nut CLASSICS sweet potato & chicken”

The product subject to recall bears the establishment number “P-68A” inside the USDA mark of inspection. The affected product expires in “DEC 2016” and includes product numbers “12395750815” through “12395750821”. These items were shipped to retail locations nationwide.

The problem was discovered after the firm received a complaint from a consumer who found a small piece of glass in the product.

The company has received a report of an oral injury associated with consumption of these products. FSIS has received no additional reports of injury or illness from consumption of these products. Anyone concerned about an injury or illness should contact a healthcare provider.

Subway – Think Hepatitis

subwayindexThe Arkansas Department of Health (ADH) is warning of a possible Hepatitis A Virus (Hep A) exposure after a Subway employee in Morrilton tested positive for the virus. The Subway is located at 1812 State Highway 9 Business, just off of Exit 108 on Interstate 40 in Morrilton.

Any individual, who has eaten food from the Morrilton Subway between March 25 and April 5 and is experiencing symptoms should contact their primary care provider immediately. Typical symptoms of Hep A include, but are not limited to: fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain or jaundice (yellowing of the skin or eyes).

Hep A is a contagious liver disease that results from infection with the Hepatitis A virus. It can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months. A person can transmit the virus to others up to 2 weeks before and one week after symptoms appear.

There are no specific treatments once a person gets Hep A. However, it can be prevented through vaccination or through receipt of a medicine called immune globulin. This medicine contains antibodies from other people who are immune to Hep A.

People without symptoms who have eaten at this Subway between March 25 and April 5 and are:

  • under 1 year of age, are too young to be vaccinated and may wish to seek out immune globulin from a health care provider.
  • between 1 year to 40 years of age, and if never vaccinated for Hep A, may wish to seek out vaccination from a health care provider.
  • 41 years old and older, and never vaccinated for Hep A, may wish to seek out immune globulin. Vaccine is not known to be effective in this group post-exposure.

As a matter of policy, employees at Subway use disposable gloves between customers and while preparing food. These behaviors have likely reduced the risk of illness to the public. Nevertheless, individuals who have eaten at this Subway between March 25 and April 5, who are pregnant or have severe chronic illness, in particular, liver-related disease, are encouraged to consult with their doctor and consider the above treatment.

The Conway County Health Unit, located at 100 Hospital Drive in Morrilton, will have immune globulin and Hep A vaccine, which can be administered upon request with an appointment on or after Wednesday, April 15. If you wish to get one of these medicines from the health department, call (501) 354-4652 to make an appointment.

At this time, no other Hep A illnesses have been reported to ADH; however, the virus can cause illness anytime from 2-7 weeks after exposure. If infected, most people will develop symptoms 3-4 weeks after exposure.

Hep A is usually spread when a person ingests fecal matter – even in microscopic amounts – from contact with objects, food or drinks contaminated by the feces, or stool, of an infected person.

Many people, especially children, may have no symptoms. The older a person is when they get Hep A, typically the more severe symptoms they have.

Almost all people who get Hep A recover completely and do not have any lasting liver damage, although they may feel sick for months.

Hepatitis A is preventable through vaccination. Hepatitis A vaccine has been recommended for school children for many years and one dose of Hep A vaccine is required for entry into kindergarten and first grade as of 2014. Most adults are likely not vaccinated, but may have been if they received vaccinations prior to traveling internationally.

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Hepatitis A outbreaks. The Hepatitis A lawyers of Marler Clark have represented thousands of victims of Hepatitis A and other foodborne illness outbreaks and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our Hepatitis A lawyers have litigated Hepatitis A cases stemming from outbreaks traced to a variety of sources, such as green onions, lettuce and restaurant food. The law firm has brought Hepatitis A lawsuits against such companies as Subway, McDonald’s, Chipotle, Quiznos and Carl’s Jr.

All You Need To Know About E. coli

ecoli-1184pxWhat is E. coli?

Escherichia coli (or E. coli) is the most prevalent infecting organism in the family of gram-negative bacteria known as enterobacteriaceae. E. coli bacteria were discovered in the human colon in 1885 by German bacteriologist Theodor Escherich. Dr. Escherich also showed that certain strains of the bacterium were responsible for infant diarrhea and gastroenteritis, an important public health discovery. Although E. coli bacteria were initially called Bacterium coli, the name was later changed to Escherichia coli to honor its discoverer.

E. coli is often referred to as the best or most-studied free-living organism. More than 700 serotypes of E. coli have been identified. The “O” and “H” antigens on the bacteria and their flagella distinguish the different serotypes. It is important to remember that most kinds of E. coli bacteria do not cause disease in humans. Indeed, some E. coli are beneficial, while some cause infections other than gastrointestinal infections, such as urinary tract infections.

The E. coli that are responsible for the numerous reports of contaminated foods and beverages are those that produce Shiga toxin, so called because the toxin is virtually identical to that produced by Shigella dysenteria type 1. The best-known and also most notorious E. coli bacteria that produce Shiga toxin is E. coli O157:H7. The Centers for Disease Control and Prevention (CDC) has estimated that every year at least 2,000 Americans are hospitalized, and about 60 die as a result of E. coli infection and its complications. A study published in 2005 estimated the annual cost of E. coli O157:H7 illnesses to be $405 million (in 2003 dollars), which included $370 million for premature deaths, $30 million for medical care, and $5 million for lost productivity.

E. coli O157:H7—a foodborne pathogen

E. coli O157:H7 is one of thousands of serotypes of Escherichia coli. The testing done to distinguish E. coli O157:H7 from its other E. coli counterparts is called serotyping.

Pulsed-field gel electrophoresis (PFGE), sometimes also referred to as genetic fingerprinting, is used to compare E. coli O157:H7 isolates to determine if the strains are distinguishable. A technique called multilocus variable number of tandem repeats analysis (MLVA) is used to determine precise classification when it is difficult to differentiate between isolates with indistinguishable or very similar PFGE patterns. 

E. coli O157:H7 was first recognized as a pathogen in 1982 during an investigation into an outbreak of hemorrhagic colitis associated with consumption of hamburgers from a fast food chain restaurant. Retrospective examination of more than three thousand E. coli cultures obtained between 1973 and 1982 found only one isolate with serotype O157:H7, and that was a case in 1975. In the ten years that followed, there were approximately thirty outbreaks recorded in the United States. This number is likely misleading, however, because E. coli O157:H7 infections did not become a reportable disease in any state until 1987, when Washington became the first state to mandate its reporting to public health authorities. Consequently, an outbreak would not be detected if it was not large enough to prompt investigation.

E. coli O157:H7’s ability to induce injury in humans is a result of its ability to produce numerous virulence factors, most notably Shiga toxin (Stx), which is one of the most potent toxins known to man.  Shiga toxin has multiple variants (e.g., Stx1, Stx2, Stx2c), and acts like the plant toxin ricin by inhibiting protein synthesis in endothelial and other cells.  Endothelial cells line the interior surface of blood vessels, and are known to be extremely sensitive to E. coli O157:H7, which is cytotoxigenic to these cells.

In addition to Shiga toxin, E. coli O157:H7 produces numerous other putative virulence factors, including proteins which aid in the attachment and colonization of the bacteria in the intestinal wall and which can lyse red blood cells and liberate iron to help support E. coli metabolism.

E. coli O157:H7 evolved from enteropathogenic E. coli serotype O55:H7, a cause of non-bloody diarrhea, through the sequential acquisition of phage-encoded Stx2, a large virulence plasmid, and additional chromosomal mutations. The rate of genetic mutation indicates that the common ancestor of current E. coli O157:H7 clades likely existed some 20,000 years ago. E. coli O157:H7 is a relentlessly evolving organism, constantly mutating and acquiring new characteristics, including virulence factors that make the emergence of more dangerous variants a constant threat. The prospect of emerging pathogens as a significant public health threat has been emphasized by the CDC for some time. As Robert Tauxe of the CDC notes:

After 15 years of research, we know a great deal about infections with E. coli O157:H7, but we still do not know how best to treat the infection, nor how the cattle (the principal source of infection for humans) themselves become infected.

Although foods of a bovine origin are the most common cause of both outbreaks and sporadic cases of E. coli O157:H7 infections, outbreaks of illnesses have been linked to a wide variety of food items. For example, produce has been the source of substantial numbers of outbreak-related E. coli O157:H7 infections since at least 1991.   Outbreaks have been linked to alfalfa, clover and radish sprouts, lettuce, and spinach. Other vehicles for outbreaks include unpasteurized juices, yogurt, dried salami, mayonnaise, raw milk, game meats, hazelnuts, and raw cookie dough.

Non-O157 Shiga Toxin-Producing E. coli

E. coli are classified by their O and H antigens (e.g., E. coli O157:H7, E. coli O26:H11) and broadly categorized as Shiga toxin-producing E. coli (STEC) O157 or non-O157 STEC.  For many years, most recognized STEC outbreaks were associated with STEC O157. Despite the dominance of STEC O157, at least 150 non-O157 strains of E. coli are known to cause human illness and have been associated with outbreaks.

In the US, documented outbreaks of non-O157 E. coli include 10 involving O111; 6 involving O26; 3 involving O45; 2 involving O145, O104, and O6; and, one each involving O51; O103; O27; and, O84. Non-O157 STEC outbreaks are rare, but tend to primarily be due to contaminated food and person-to-person transmission.

Non-O157 STEC infections are under-recognized and under-reported due to inadequate epidemiological and laboratory surveillance. In the United States, E. coli O157:H7 became nationally notifiable in 1994, whereas non-O157 STEC infections were not reportable until 2000. Screening for non-O157 STEC remains rare. This is no surprise since by 2007 only 66% of clinical labs screened all stool samples for E. coli O157:H7 and fewer than 10% of labs ever conducted on-site testing for non-O157 STEC. As with E. coli O157:H7, non-O157 STEC cases tend to occur during the summer months.

Non-O157 STEC can be difficult to identify in laboratory screening for E. coli O157 because they do not ferment sorbitol. Most stool cultures suspected to contain STEC are first screened for Shiga toxin; a positive test could be either E. coli O157:H7 or non-O157 STEC. Unfortunately, some labs will discard Shiga toxin-positive cultures after reporting to the referring doctor without identifying the strain. State laboratories can send STEC cultures to the CDC to determine the serotype. Some states, such as Minnesota and Connecticut have begun studies of their own to identify non-O157 STEC.

In recent years, improved diagnostic assays for non-O157 STEC have contributed to an increased appreciation of the severity of disease caused by these strains, including hemolytic uremic syndrome (HUS). Notably, the number of non-O157 STEC cases reported to CDC’s FoodNet has risen steadily each year; from 2000-2006, there was an overall 4-fold increase in incidence (0.12 cases per 100,000 to 0.42 cases per 100,000 population) at FoodNet sites. The most common serogroups reported to cause foodborne illness in the United States are O26, O111, O103, O121, O45, and O145. [56] These six serotypes account for 75% of human infections.

Worldwide, non-O157 STEC outbreaks emerged in the 1980s, and the first reported outbreaks in the United States occurred in the 1990s. The number of reported outbreaks due to non-O157 STECs remains relatively low in the United States, but experts agree that documented outbreaks probably represent the “tip of the iceberg.” From 1983-2002, seven non-O157 STEC outbreaks were reported in the United States. [55] During the following five-year period from 2003-2007, CDC documented an additional five non-O157 STEC outbreaks (CDC Outbreak Surveillance Data, http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm).

An extraordinary non-O157 outbreak occurred in Germany beginning in May 2011. The STEC involved was extremely rare: E. coli O104:H4. It was also extremely virulent. Ultimately, the outbreak sickened nearly 4,000 people and killed more than 50. This strain was not only resistant to many antibiotics, it possessed a novel mechanism for sticking to intestinal cells. Other unusual aspects of this outbreak were that it affected a disproportionately large percentage of women. Further, nearly a quarter of those infected developed HUS and of those the vast majority was women. It appears that this non-O157 STEC acquired its particular virulence factors and antibiotic resistance through horizontal gene acquisition rather than point mutations or descent from prior generations of bacteria. The outbreak was ultimately traced to contaminated seeds of fenugreek from Egypt, sold as sprouts by an organic farm in Germany.

A study of non-O157 STEC concluded that these strains may account for up to 20 to 50% of all STEC infections in the United States. The prevalence of non-O157 STEC infections is placing an increasing burden on society and the health care system in the United States.

Prevalence

E. coli O157:H7 bacteria and other pathogenic E. coli mostly live in the intestines of cattle, but E. coli bacteria have also been found in the intestines of chickens, deer, sheep, and pigs.  A 2003 study on the prevalence of E. coli O157:H7 in livestock at 29 county and three large state agricultural fairs in the United States found that E. coli O157:H7 could be isolated from 13.8% of beef cattle, 5.9% of dairy cattle, 3.6% of pigs, 5.2% of sheep, and 2.8% of goats. [36] Over 7% of pest fly pools also tested positive for E. coli O157:H7. Shiga toxin-producing E. coli does not make the animals that carry it ill. The animals are merely the reservoir for the bacteria.

According to a study published in 2011, an estimated 93,094 illnesses are due to domestically acquired E. coli O157:H7 each year in the United States. Estimates of foodborne-acquired O157:H7 cases result in 2,138 hospitalizations and 20 deaths annually.

What makes E. coli O157:H7 remarkably dangerous is its very low infectious dose, and how relatively difficult it is to kill these bacteria.  “E. coli O157:H7 in ground beef that is only slightly undercooked can result in infection.” As few as 20 organisms may be sufficient to infect a person and, as a result, possibly kill them. And unlike generic E. coli, the O157:H7 serotype multiplies at temperatures up to 44° Fahrenheit, survives freezing and thawing, is heat-resistant, grows at temperatures up to 111 F, resists drying, and can survive exposure to acidic environments.   And, finally, to make it even more of a threat, E. coli O157:H7 bacteria are easily transmitted by person-to-person contact.

The colitis caused by E. coli O157:H7 is characterized by severe abdominal cramps, diarrhea that typically turns bloody within 24 hours, and sometimes fever. The incubation period—that is, the time from exposure to the onset of symptoms—in outbreaks is usually reported as 3 to 4 days, but may be as short as 1 day or as long as 10 days.  Infection can occur in people of all ages but is most common in children.

Unlike other E. coli pathogens, which remain on intestinal surfaces, Shiga toxin-producing bacteria, like O157:H7, are invasive. After ingestion, E. coli bacteria rapidly multiply in the large intestine and then bind tightly to cells in the intestinal lining.  This snug attachment facilitates absorption of the toxins into the small capillaries within the bowel wall.   Once in the systemic circulation, Shiga toxin becomes attached to weak receptors on white blood cells, 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.

Inflammation caused by the toxins is believed to be the cause of hemorrhagic colitis, the first symptom of E. coli infection, which is characterized by the sudden onset of abdominal pain and severe cramps. Such symptoms are typically followed within 24 hours by diarrhea, sometimes fever.

As the infection progresses, diarrhea becomes watery and then may become grossly bloody; that is, bloody to the naked eye. E. coli symptoms also may include vomiting and fever, although fever is an uncommon symptom.

On rare occasions, E. coli infection can cause bowel necrosis (tissue death) and perforation without progressing to hemolytic uremic syndrome (HUS)—a complication of E. coli infection that is now recognized as the most common cause of acute kidney failure in infants and young children. In about 10 percent of E. coli cases, the Shiga toxin attachment to Gb3 receptors results in HUS.

The duration of an uncomplicated illness can range from one to twelve days.  In reported outbreaks, the rate of death is 0-2%, with rates running as high as 16-35% in outbreaks involving the elderly, like those that have occurred at nursing homes.

Shiga toxin–producing E. coli (STEC) cause approximately 100,000 illnesses, 3,000 hospitalizations, and 90 deaths annually in the United States.   As noted, most reported STEC infections in the United States are caused by E. coli O157:H7, with an estimated 73,000 cases occurring each year. According to the CDC:

Non-O157 STEC bacteria also are important causes of diarrheal illness in the United States; at least 150 STEC serotypes have been associated with outbreaks and sporadic illness. In the United States, six non-O157 serogroups (O26, O45, O103, O111, O121, and O145) account for the majority of reported non-O157 STEC infections.

Persons with non-O157 STEC tend to have less severe illness, but some non-O157 STEC members can cause very severe infections, including those that result in HUS and death. Non-O157 STEC that cause HUS overwhelmingly produce Shiga toxin 2 with or without Shiga toxin 1. As with E. coli O157:H7, more severe disease results from Shiga toxin 2 production by non-O157 STEC.

How is an E. coli Infection Diagnosed?

Infection with E. coli O157:H7 or other Shiga toxin-producing E. coli is usually confirmed by the detection of the bacteria in a stool specimen from an infected individual. Most hospitals labs and physicians know to test for these particular bacteria, especially if the potentially infected person has bloody diarrhea.  Still, it remains a good idea to specifically request that a stool specimen be tested for the presence of Shiga toxin-producing E. coli.

Treatment for an E. coli Infection

In most infected individuals, symptoms of a Shiga toxin-producing E. coli infection last about a week and resolve without any long-term problems. Antibiotics do not improve the illness, and some medical researchers believe that these medications can increase the risk of developing HUS. Therefore, apart from supportive care, such as close attention to hydration and nutrition, there is no specific therapy to halt E. coli symptoms.   The recent finding that E. coli O157:H7 initially speeds up blood coagulation may lead to future medical therapies that could forestall the most serious consequences.  Most individuals who do not develop HUS recover within two weeks.

A Life-Threatening Complication—Hemolytic Uremic Syndrome

E. coli O157:H7 infections can lead to a severe, life-threatening complication called the hemolytic uremic syndrome (HUS). HUS accounts for the majority of the acute deaths and chronic injuries caused by the bacteria. HUS occurs in 2-7% of victims, primarily children, with onset five to ten days after diarrhea begins. “E. coli serotype O157:H7 infection has been recognized as the most common cause of HUS in the United States, with 6% of patients developing HUS within 2 to 14 days of onset of diarrhea.” And it is the most common cause of renal failure in children.

Approximately half of the children who suffer HUS require dialysis, and at least 5% of those who survive have long term renal impairment. The same number suffers severe brain damage.  While somewhat rare, serious injury to the pancreas, resulting in death or the development of diabetes, also occurs. There is no cure or effective treatment for HUS. And, tragically, children with HUS too often die, with a mortality rate of five to ten percent.

Once Shiga toxins attach to receptors on the inside surface of blood vessel cells (endothelial cells), a chemical cascade begins that results in the formation of tiny thrombi (blood clots) within these vessels.  Some organs seem more susceptible, perhaps due to the presence of increased numbers of receptors, and include the kidney, pancreas, and brain. Consequently, organ injury is primarily a function of receptor location and density.

Once they move into the interior of the cell (cytoplasm), Shiga toxins shut down protein machinery, causing cellular injury or death. This cellular injury activates blood platelets too, and the resulting “coagulation cascade” causes the formation of clots in the very small vessels of the kidney, leading to acute kidney failure.

The red blood cells are either directly destroyed by Shiga toxin (hemolytic destruction), or are damaged as cells attempt to pass through partially obstructed micro-vessels. Blood platelets become trapped in the tiny blood clots, or they are damaged and destroyed by the spleen.

By definition, when fully expressed, HUS presents with the triad of hemolytic anemia (destruction of red blood cells), thrombocytopenia (low platelet count), and renal failure (loss of kidney function). Although recognized in the medical community since at least the mid-1950s, HUS first captured the public’s widespread attention in 1993 following a large E. coli outbreak in Washington State that was linked to the consumption of contaminated hamburgers served at a fast-food chain.  Over 500 cases of E. coli were reported; 151 were hospitalized (31%), 45 persons (mostly children) developed HUS (9%), and three died.

Of those who survive HUS, at least five percent will suffer end stage renal disease (ESRD) with the resultant need for dialysis or transplantation.  But, “[b]ecause renal failure can progress slowly over decades, the eventual incidence of ESRD cannot yet be determined.”  Other long-term problems include the risk for hypertension, proteinuria (abnormal amounts of protein in the urine that can portend a decline in renal function), and reduced kidney filtration rate. Since the longest available follow-up studies of HUS victims are 25 years, an accurate lifetime prognosis is not really available and remains controversial.

Other Complications from Infection

IBS is a chronic disorder characterized by alternating bouts of constipation and diarrhea, both of which are generally accompanied by abdominal cramping and pain. Suffering an E. coli O157:H7 infection has been linked to the development of post-infectious irritable bowel syndrome (IBS). This link was demonstrated by the Walkerton Health Study (WHS), which followed one of the largest O157:H7 outbreaks in the history of North America. In this outbreak, contaminated drinking water caused over 2,300 people to be infected, resulting in 27 recognized cases of HUS, and 7 deaths. The WHS followed 2,069 eligible study participants. Among its findings, WHS noted 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.”

Not surprisingly, E. coli O157:H7 infection is associated with long-term emotional disruption as well, not just for the victim, but for entire families.   A recent study reported that “parents experienced long-term emotional distress and substantive disruption to family and daily life” following an E. coli O157:H7 infection in the family.

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of E. coli outbreaks and hemolytic uremic syndrome (HUS). The E. coli lawyers of Marler Clark have represented thousands of victims of E. coli and other foodborne illness infections and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our E. coli lawyers have litigated E. coli and HUS cases stemming from outbreaks traced to ground beef, raw milk, lettuce, spinach, sprouts, and other food products. The law firm has brought E. coli lawsuits against such companies as Jack in the Box, Dole, ConAgra, Cargill, and Jimmy John’s. We have proudly represented such victims as Brianne Kiner, Stephanie Smith and Linda Rivera.

All You Need To Know About Salmonella

salmonella (1)An Introduction to Salmonella

Salmonella is a bacterium that causes one of the most common enteric (intestinal) infections in the United States – salmonellosis.  It has long been said that, in 1885, pioneering American veterinary scientist, Daniel E. Salmon, discovered the first strain of Salmonella. Actually, Theobald Smith, research-assistant to Dr. Salmon, discovered the first strain of SalmonellaSalmonella cholerae suis. But, being the person in charge, Dr. Salmon received credit for the discovery. In any case, today the number of known strains of the bacteria totals over two thousand.

The term Salmonella refers to a group or family of bacteria that variously cause illness in humans. Salmonella serotype typhimurium and Salmonella serotype enteritidis are the most common in the United States. Salmonella javiana is the fifth most common serotype in the United States and accounted for 3.4% of Salmonella isolates reported to the CDC during 2002. According to one study:

During the 1980s, S. Enteritidis emerged as an important cause of human illness in the United States. In 1976, the incidence of S. Enteritidis was 0.55 per 100,000 population and represented only 5% of all Salmonella isolates. By 1985, this proportion reached 10%, and the rate increased to 2.4 per 100,000 population. During the same time, total Salmonella infection rates rose from 10.7 per 100,000 in 1976 to 24.3 in 1985. The highest rates of S. Enteritidis were seen in the Northeast, although rates in the western region also increased during this time.

The number of outbreaks of S. Enteritidis infection also increased during the 1980s, particularly in the northeastern United States. Laboratory subtyping of S. Enteritidis isolates from outbreaks indicated that phage types (PT) 8 and 13a were the most common phage types in the United States. Although PT4 was common in Europe, where it coincided with a large increase in S. Enteritidis infections, it was seen in the United States only among persons with a history of foreign travel.

Of the Salmonella outbreaks that occurred from 1985 through 1999, “[f]ive hundred twenty-two (62%) outbreaks of S. Enteritidis infection were associated with food prepared at commercial food establishments (restaurants, caterers, delicatessens, bakeries, cafeteria, or market).”

Symptoms of a Salmonella Infection

Salmonella infections can have a broad range of illness, from no symptoms to severe illness. The most common clinical presentation is acute gastroenteritis. Symptoms include diarrhea, and abdominal cramps, often accompanied by fever of 100°F to 102°F (38°C to 39°C). Other symptoms 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. People with salmonellosis usually recover without treatment within 3 to 7 days. Nonetheless, the bacteria will continue to be present in the intestinal tract and stool for weeks after recovery of symptoms—on average, 1 month in adults and longer in children.

Typhi and Paratyphi generally cause a bacteremic illness—Salmonella found in the blood—of long duration. This illness is called enteric, typhoid, or paratyphoid fever. Symptoms start gradually, and include fever, headache, malaise, lethargy, and abdominal pain. In children, it can present as a non-specific fever. The incubation period for S. Typhi is usually 8 to 14 days, but it can range from 3 to 60 days. For S. Paratyphi infections, the incubation period is similar to that of non-typhoidal Salmonella, 1 to 10 days.

Complications of a Salmonella Infection

In approximately 5% of non-typhoidal infections, patients develop bacteremia. In a small proportion of those cases, the bacteria can cause a focal infection, where it becomes localized in a tissue and causes an abscess, arthritis, endocarditis, or other severe illness. Infants, the elderly, and immune-compromised persons are at greater risk for bacteremia or invasive disease. Additionally, infection caused by antimicrobial-resistant non-typhoidal Salmonella serotypes appears to be more likely to cause bloodstream infections.

Overall, approximately 20% of cases each year require hospitalization, 5% of cases have an invasive infection, and one-half of 1% die. Infections in infants and in people 65 years of age or older are much more likely to require hospitalization or result in death. There is some evidence that Salmonella infections increase the risk of developing digestive disorders, including irritable bowel syndrome.

Although most persons that become ill with diarrhea caused by Salmonella recover without any further problems, a small number of persons develop a complication often referred to as reactive arthritis. The terminology used to describe this type of complication has changed over time. The term “Reiter’s Syndrome” was used for many years, but has now fallen into disfavor. The precise proportion of persons that develop reactive arthritis following a Salmonella infection is unknown, with estimates ranging from 2 to 15%. Symptoms of reactive arthritis include inflammation (swelling, redness, heat, and pain) of the joints, the genitourinary tract (reproductive and urinary organs), or the eyes.

More specifically, symptoms of reactive arthritis include pain and swelling in the knees, ankles, feet and heels. It may also affect wrists, fingers, other joints, or the lower back. Tendonitis (inflammation of the tendons) or enthesitis (inflammation where tendons attach to the bone) can occur. Other symptoms may include prostatitis, cervicitis, urethritis (inflammation of the prostate gland, cervix or urethra), conjunctivitis (inflammation of the membrane lining the eyelid) or uveitis (inflammation of the inner eye). Ulcers and skin rashes are less common. Symptoms can range from mild to severe.

One study showed that on average, symptoms developed 18 days after infection. A small proportion of those persons (15%) had sought medical care for their symptoms, and two thirds of persons with reactive arthritis were still experiencing symptoms 6 months later. Although most cases recover within a few months, some continue to experience complications for years. Treatment focuses on relieving the symptoms.

There are a lot of gaps in our knowledge surrounding this complication. Since there is no specific test for reactive arthritis, doctors rely on signs and symptoms of the patient in order to make the diagnosis. However, there are no clearly defined criteria or set of symptoms used to diagnose this condition. The role of genetics is also unclear. It is thought that the presence of a gene called human leukocyte antigen (HLA)-B27 predisposes a person to develop reactive arthritis, along with other autoimmune diseases; however, several studies have shown that many persons that develop reactive arthritis lack this genetic factor.

Diagnosis of Salmonella Infections

Salmonella bacteria can be detected in stool. In cases of bacteremia or invasive illness, the bacteria can also be detected in the blood, urine, or on rare occasions in tissues. The test consists of growing the bacteria in culture. A fecal, blood or other sample is placed in nutrient broth or on agar and incubated for 2-3 days. After that time, a trained microbiologist can identify the 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.

Treatment for Salmonella Infections

Salmonella infections usually resolve in 3 to 7 days, and many times require no treatment. Persons with severe diarrhea may require rehydration, often with intravenous fluids. Antimicrobial therapy (or treatment with antibiotics) is not recommended for uncomplicated gastroenteritis. In contrast, antibiotics are recommended for persons at increased risk of invasive disease, including infants younger than 3 months of age.

In situations in which antibiotics are needed, trimethoprim/sulfamethoxazole, ampicillin, or amoxicillin, are the best choices. Ceftriaxone, cefotaxime, or flouroquinolones are effective options for antimicrobial-resistant strains, although fluoroquinolones are not approved for persons less than 18 years of age. For persons with an infection in a specific organ or tissue (invasive disease), treatment with an expanded-spectrum cephalosporin is recommended, until it is known if the bacteria is susceptible to one of the more commonly used antibiotics listed above. For these rare situations, treatment with antibiotics for 4 weeks is generally recommended. For enteric fever, including S. Typhi infections, treatment for 14 days is recommended. The specific antibiotic chosen depends on the susceptibility of the bacteria and the response to treatment.

The Incidence of Salmonella Infections

In 2009, over 40,000 cases of Salmonella (13.6 cases per 100,000 persons) were reported to the Centers for Disease Control and Prevention (CDC) by public health laboratories across the nation, representing a decrease of approximately 15% from the previous year, but a 4.2% increase since 1996. Overall, the incidence of Salmonella in the United States has not significantly changed since 1996.

Only a small proportion of all Salmonella infections are diagnosed and reported to health departments. It is estimated that for every reported case, there are approximately 38.6 undiagnosed infections. The CDC estimates that 1.4 million cases, 15,000 hospitalizations, and 400 deaths are caused by Salmonella infections in the U.S. every year.

Salmonella can be grouped into more than 2,400 serotypes. The two most common serotypes in the U.S. are S. Typhimurium and S. Enteritidis. S. Typhi, the serotype that causes typhoid fever, is uncommon in the U.S. But, globally, typhoid fever continues to be a significant problem, with an estimated 12-33 million cases occurring annually. Moreover, outbreaks in developing countries have a high death-rate, especially when caused by strains of the bacterium that are resistant to antibiotic treatment.

Salmonella are found in the intestinal tract of wild and domesticated animals and humans. Some serotypes of Salmonella, such as S. Typhi and S. Paratyphi are only found in humans. For ease of discussion, it is generally useful to group Salmonellae into two broad categories: typhoidal, which includes S. Typhi and S. Paratyphi, and non-typhoidal, which includes all other serotypes.

The Prevalence of Salmonella in Food and Elsewhere

Eating contaminated food, especially food from animal origins, causes most Salmonella infections. One study found that 87% of all confirmed cases of Salmonella were foodborne, with 10 percent from person-to-person infection and 3% caused by pets. As explained in a comprehensive report issued by the USDA’s Economic Research Service:

Salmonella contamination occurs in a wide range of animal and plant products. Poultry products and eggs are frequently contaminated with S. enteritidis, while beef products are commonly contaminated with S. typhimurium. Other food sources of Salmonella may include raw milk or other dairy products and pork. Salmonella outbreaks also have been traced to contaminated vegetables, fruits, and marijuana.

Another study went into even greater detail in explaining the prevalence of Salmonella and the sources of human infection, stating as follows:

A food item was implicated in 389 (46%) outbreaks of S. Enteritidis infection from 1985 through1999; in 86 (22%) of these, more than one food item was implicated. Of the 371 outbreaks for which information was available, 298 (80%) were egg associated. This proportion ranged from 10 (71%) of 14 in 1985 to 19 (95%) of 20 in 1997. Of outbreaks caused by a single vehicle for which information was known, 243 (83%) of 294 were egg-associated, as were 55 (71%) of 77 outbreaks in which more than one food item was implicated.

Among single foods implicated in egg-associated outbreaks, 67 (28%) of 243 were foods that contained raw eggs (e.g., homemade ice cream, Caesar salad dressing, tiramisu, egg nog). Sixty-five (27%) of the outbreaks implicated traditional egg dishes such as omelets, French toast, pancakes, and foods that use egg batter, such as crab cakes, chile rellenos, egg rolls, and Monte Cristo sandwiches. Sixty-three (26%) outbreaks implicated dishes known to contain eggs, such as lasagna, ziti, and stuffing, which would have been expected to have been fully cooked but probably did not reach temperatures sufficient to kill S. Enteritidis. Thirty-six (15%) outbreaks implicated egg dishes that were “lightly cooked” (e.g., hollandaise sauce, meringue, cream pies). The food vehicles in 12 (5%) outbreaks were reported to contain eggs but could not be classified because information on how the dishes were prepared was not provided.

Seventy-three (20%) of the 371 confirmed outbreaks for which information was provided involved vehicles that did not contain eggs. Twenty (27%) of these outbreaks were associated with poultry (chicken or turkey), 8 (11%) with beef, and 6 (8%) with foods containing shrimp (3 outbreaks), bologna (1), pork (1), and pepper loaf (1). Other implicated foods included potatoes (3), beans (3), desserts (3), salad (3), macaroni and cheese (1), cheese sauce (1), goat cheese (1), chili (1), and a pureed diet (1). In 22 (30%) of the non–egg-associated outbreaks, more than one food was implicated. In four of these outbreaks, cross-contamination with raw eggs was suspected.

In sum, food remains the most common vehicle for the spread of Salmonella, and eggs are the most common food implicated. As one authority points out, “Studies showed that the internal contents of eggs can be contaminated with [Salmonella], and this contamination has been identified as a major risk factor in the emergence of human illness.” Part of this risk stems from the variety of ways that Salmonella can contaminate an egg. For example, the FDA has documented the following:

Bacteria can be on the outside of a shell egg. That’s because the egg exits the hen’s body through the same passageway as feces is excreted. That’s why eggs are required to be washed at the processing plant. All USDA graded eggs and most large volume processors follow the washing step with a sanitizing rinse at the processing plant. It is also possible for eggs to become infected by Salmonella Enteritidis fecal contamination through the pores of the shells after they’re laid. SE also can be inside an uncracked, whole egg. Contamination of eggs may be due to bacteria within the hen’s reproductive tract before the shell forms around the yolk and white. SE doesn’t make the hen sick.

Chicken is also a major cause of Salmonella. Beginning in 1998, the publisher of Consumer Reports magazine has conducted surveys and tested chicken at retail for Salmonella and Campylobacter. Its 2009 study found 14% of broiler chickens at grocery stores to contain Salmonella. A USDA Baseline Data Collection Program report done in 1994 documented Salmonella contamination on 20.0% of broiler-chicken carcasses. However, in 2009 the same USDA data collection survey showed the prevalence of Salmonella in broiler chickens at 7.5%. Additionally, turkey carries a lower risk with a prevalence of 1.66%.

While Salmonella comes from animal feces, fruits and vegetables can become contaminated. A common source is raw sprouts, which have been the subject of at least 30 reported outbreaks of foodborne illnesses since 1996. The U.S. Department of Health and Human Services cautions against consuming raw sprouts under any circumstances: “Unlike other fresh produce, seeds and beans need warm and humid conditions to sprout and grow. These conditions are also ideal for the growth of bacteria, including Salmonella, Listeria, and E. coli.”

Prevention

In general, safe cooking and preparation of food can kill existing Salmonella bacteria and prevent it from spreading. Additionally, safe choices at the grocery store can greatly reduce the risk of Salmonella.

  • Always wash your hands before you start preparing food.
  • Cook poultry until it reaches an internal temperature of 165 ºF.
  • Cook beef and pork until they reach 160ºF. High quality steaks (not needle or blade tenderized) can be safely cooked to 145ºF.
  • Cook eggs until they reach 160ºF or until the yoke is solid. Pasteurized eggs are available in some grocery stores.
  • Do not eat or drink foods containing raw eggs. Examples include homemade eggnog, hollandaise sauce, and undercooked French toast.
  • Never drink raw (unpasteurized) milk.
  • Avoid using the microwave for cooking raw foods of animal origin. Microwave-cooked foods do not reach a uniform internal temperature, resulting in undercooked areas and survival of Salmonella.
  • If you are served undercooked meat, poultry, or eggs in a restaurant don’t hesitate to send your food back to the kitchen for further cooking.
  • Avoid cross-contamination. That means that you should never allow foods that will not be cooked (like salads) to come into contact with raw foods of animal origin (e.g., on dirty countertops, kitchen sinks, or cutting boards). Wash hands, kitchen work surfaces, and utensils with soap and water immediately after they have been in contact with raw foods of animal origin.
  • Wash hands with soap after handling reptiles, amphibians or birds, or after contact with pet feces. Infants and persons with compromised immune systems should have no direct or indirect contact with such pets.
  • Reptiles, amphibians or birds, or any elements of their housing (such as water bowls) should never be allowed in the kitchen.
  • Avoid eating in animal barns, and wash your hands with soap and water after visiting petting zoos or farm settings.
  • Always wash your hands after going to the bathroom. The hands of an infected person who did not wash his or her hands adequately after using the bathroom may also contaminate food.

Steps for proper hand washing:

  • Wet your hands with clean warm running water;
  • Apply soap;
  • Rub your hands making lather for 20 seconds. Make sure that you scrub your hands entirely (not just the fingertips);
  • Rinse your hands under warm running water;
  • If possible, turn the faucet off using a paper towel;
  • Dry your hands using paper towels or an air dryer;
  • Do not use an alcohol-based (waterless) sanitizer instead of washing your hands when cooking or when hands are visibly soiled. Hand sanitizers are only effective when there is no visible organic matter (like dirt, food, or other matter) on the hands.

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Salmonella outbreaks. The Salmonella lawyers of Marler Clark have represented thousands of victims of Salmonella and other foodborne illness outbreaks and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our Salmonella lawyers have litigated Salmonella cases stemming from outbreaks traced to a variety of foods, such as cantaloupe, tomatoes, ground turkey, salami, sprouts, cereal, peanut butter, and food served in restaurants. The law firm has brought Salmonella lawsuits against such companies as Cargill, ConAgra, Peanut Corporation of America, Sheetz, Taco Bell, Subway and Wal-Mart.

All You Need to Know About Listeria

listeria1What is Listeria?

Listeria (pronounced liss-STEER-ē-uh) is a gram-positive rod-shaped bacterium that can grow under either anaerobic (without oxygen) or aerobic (with oxygen) conditions. Of the six species of Listeria, only L. monocytogenes (pronounced maw-NO-site-aw-JUH-neez) causes disease in humans. These bacteria multiply best at 86-98.6 degrees F (30-37 degrees C), but also multiply better than all other bacteria at refrigerator temperatures, something that allows temperature to be used as a means of differentiating Listeria from other contaminating bacteria.

Called an “opportunistic pathogen,” Listeria is noted to cause an estimated 2,600 cases per year of severe invasive illness. Perhaps not surprisingly then, “foodborne illness caused by Listeria monocytogenes has raised significant public health concern in the United States, Europe, and other areas of the world.” As one noted expert observed, summarizing the history of these bacteria and their significance for public health:

Although L. monocytogenes was recognized as an animal pathogen over 80 years ago, the first outbreak confirming an indirect transmission from animals to humans was reported only in 1983, in Canada’s Maritime provinces. In that outbreak, cabbages, stored in the cold over the winter, were contaminated with Listeria through exposure to infected sheep manure. A subsequent outbreak in California in 1985 confirmed the role of food in disseminating listeriosis. Since then Listeria has been implicated in many outbreaks of food-borne illness, most commonly from exposure to contaminated dairy products and prepared meat products, including turkey and deli meats, pâté, hot dogs and seafood and fish.

Given its widespread presence in the environment and food supply, the ingestion of Listeria has been described as an “exceedingly common occurrence.”

Transmission and Infection

Except for the transmission of mother to fetus, human-to-human transmission of Listeria is not known to occur. Infection is caused almost exclusively by the ingestion of the bacteria, most often through the consumption of contaminated food. The most widely-accepted estimate of foodborne transmission is 85-95% of all Listeria cases

The infective dose—that is, the amount of bacteria that must be ingested to cause illness—is not known. In an otherwise healthy person, an extremely large number of Listeria bacteria must be ingested to cause illness—estimated to be somewhere between 10–100 million viable bacteria (or colony forming units “CFU”) in healthy individuals, and only 0.1–10 million CFU in people at high risk of infection. Even with such a dose, a healthy individual will suffer only a fever, diarrhea, and related gastrointestinal symptoms.

The amount of time from infection to the onset of symptoms—typically referred to as the incubation period—can vary to a significant degree. Symptoms of Listeria infection can develop at any time from 2 to 70 days after eating contaminated food. According to one authoritative text:

The incubation period for invasive illness is not well established, but evidence from a few cases related to specific ingestions points to 11 to 70 days, with a mean of 31 days. In one report, two pregnant women whose only common exposure was attendance at a party developed Listeria bacteremia with the same uncommon enzyme type; incubation periods for illness were 19 and 23 days.

Adults can get listeriosis by eating food contaminated with Listeria, but babies can be born with listeriosis if their mothers eat contaminated food during pregnancy. The mode of transmission of Listeria to the fetus is either transplacental via the maternal blood stream or ascending from a colonized genital tract. Infections during pregnancy can cause premature delivery, miscarriage, stillbirth, or serious health problems for the newborn.

Incidence of Listeria infection in HIV-positive individuals is higher than in the general population. One study found that:

The estimated incidence of listeriosis among HIV-infected patients in metropolitan Atlanta was 52 cases per 100,000 patients per year, and among patients with AIDS it was 115 cases per 100,000 patients per year, rates 65–145 times higher than those among the general population. HIV-associated cases occurred in adults who were 29–62 years of age and in postnatal infants who were 2 and 6 months of age.

Pregnant women make up around 30% of all infection cases, while accounting for 60% of cases involving the 10- to 40-year age group.

Symptoms of Listeria infection

When a person is infected and develops symptoms of Listeria infection, the resulting illness is called listeriosis. Only a small percentage of persons who ingest Listeria fall ill or develop symptoms. For those who do develop symptoms as a result of their infection, the resulting illness is either mild or quite severe—sometimes referred to as a “bimodal distribution of severity.”

On the mild end of the spectrum, listeriosis usually consists of the sudden onset of fever, chills, severe headache, vomiting, and other influenza-type symptoms. Along these same lines, the CDC notes that infected individuals may develop fever, muscle aches, and sometimes gastrointestinal symptoms such as nausea or diarrhea. When present, the diarrhea usually lasts 1-4 days (with 42 hours being average), with 12 bowel movements per day at its worst.

Most healthy adults and children who consume contaminated food experience only mild to moderate symptoms. The infection is usually self-limited, since, in healthy hosts, exposure to Listeria stimulates the production of tumour necrosis factor and other cytokines, which activate monocytes and macrophages to eradicate the organism. Few people with normal immune function go on to have more severe, life-threatening forms of listeriosis, characterized by septic shock, meningitis and encephalitis.

As already noted, when pregnant, women have a mildly impaired immune system that makes them susceptible to Listeria infection. If infected, the illness appears as an acute fever, muscle pain, backache, and headache. Illness usually occurs in the third trimester, which is when immunity is at its lowest. Infection during pregnancy can lead to premature labor, miscarriage, infection of the newborn, or even stillbirth. Twenty-two percent of such infections result in stillbirth or neonatal death.

Newborns may present clinically with early-onset (less than 7 days) or late-onset forms of infection (7 or more days). Those with the early-onset form are often diagnosed in the first 24 hours of life with sepsis (infection in the blood). Early-onset listeriosis is most often acquired through trans-placental transmission. Late-onset neonatal listeriosis is less common than the early-onset form. Clinical symptoms may be subtle and include irritability, fever and poor feeding. The mode of acquisition of late-onset listeriosis is poorly understood.

Diagnosis and Treatment of Listeria Infections

Because there are few symptoms that are unique to listeriosis, doctors must consider a variety of potential causes for infection, including viral infections (like flu), and other bacterial infections that may cause sepsis or meningitis.

Early diagnosis and treatment of listeriosis in high-risk patients is critical, since the outcome of untreated infection can be devastating. This is especially true for pregnant women because of the increased risk of spontaneous abortion and preterm delivery. Depending on the risk group, rates of death from listeriosis range from 10% to 50%, with the highest rate among newborns in the first week of life.

Methods typically used to identify diarrhea-causing bacteria in stool cultures interfere or limit the growth of Listeria, making it less likely to be identified and isolated for further testing. On the other hand, routine methods are effective for isolating Listeria from spinal fluid, blood, and joint fluid. Magnetic-resonance imaging (MRI) is used to confirm or rule out brain or brain stem involvement.

Listeriosis is usually a self-limited illness—which means that a majority of infected individuals will improve without the need for medical care. But for those patients with a high fever, a stool culture and antibiotic-treatment may be justified for otherwise healthy individuals. Although there have been no studies done to determine what drugs or treatment duration is best, ampicillin is generally considered the “preferred agent.” There is no consensus on the best approach for patients who are allergic to penicillins.

Invasive infections with Listeria can be treated with antibiotics. When infection occurs during pregnancy, antibiotics given promptly to the pregnant woman can often prevent infection of the fetus or newborn. Babies with listeriosis receive the same antibiotics as adults, although a combination of antibiotics is often used until physicians are certain of the diagnosis.

Those Most Susceptible to Infection

Several segments of the population are at increased risk and need to be informed so that proper precautions can be taken. The body’s defense against Listeria is called “cell-mediated immunity” because the success of defending against infection depends on our cells (as opposed to our antibodies), especially lymphocytes called “T-cells.” Therefore, individuals whose cell-mediated immunity is suppressed are more susceptible to the devastating effects of listeriosis, including especially HIV-infected individuals, who have been found to have a Listeria-related mortality of 29%.

Pregnant women naturally have a depressed cell-mediated immune system. In addition, the immune systems of fetuses and newborns are very immature and are extremely susceptible to these types of infections. Other adults, especially transplant recipients and lymphoma patients, are given necessary therapies with the specific intent of depressing T-cells, and these individuals become especially susceptible to Listeria as well.

According to the CDC and other public health organizations, individuals at increased risk for being infected and becoming seriously ill with Listeria include the following groups:

  • Pregnant women: They are about 20 times more likely than other healthy adults to get listeriosis. About one-third of listeriosis cases happen during pregnancy.
  • Newborns: Newborns rather than the pregnant women themselves suffer the serious effects of infection in pregnancy.
  • Persons with weakened immune systems
  • Persons with cancer, diabetes, or kidney disease
  • Persons with AIDS: They are almost 300 times more likely to get listeriosis than people with normal immune systems.
  • Persons who take glucocorticosteroid medications (such as cortisone)
  • The elderly

Complications of Listeria infection

For those persons who suffer a Listeria infection that does not resolve on its own, the complications (or sequelae) can be many. The most common is septicemia (bacterial pathogens in the blood, also known as bacteremia), with meningitis being the second most common. Other complications can include inflammation of the brain or brain stem (encephalitis), brain abscess, inflammation of the heart-membrane (endocarditis), and localized infection, either internally or of the skin.

Death is the most severe consequence of listeriosis, and it is tragically common. For example, based on 2009 FoodNet surveillance data, 89.2% of Listeria patients ended up in the hospital, the highest hospitalization rate for pathogenic bacterial infection. In persons 50 years of age and older, there was a 17.5% fatality rate—also the highest relative to other pathogens.

The Incidence of Listeria Infections

Listeria bacteria are found widely in the environment in soil, including in decaying vegetation and water, and may be part of the fecal flora of a large number of mammals, including healthy human adults. According to the FDA, “studies suggest that 1-10% of humans may be intestinal carriers of Listeria.” Another authority notes that the “organism has been isolated from the stool of approximately 5% of healthy adults.” Overall, seasonal trends show a notable peak in total Listeria cases and related-deaths from July through October.

Ingested by mouth, Listeria is among the most virulent foodborne pathogens, with up to 20% of clinical infections resulting in death. These bacteria primarily cause severe illness and death in persons with immature or compromised immune systems. Consequently, most healthy adults can be exposed to Listeria with little to any risk of infection and illness.

A study published in 1995 projected Listeria infection-rates to the U.S. population, suggesting that an estimated 1,965 cases and 481 deaths occurred in 1989 compared with an estimated 1,092 cases and 248 deaths in 1993, a 44% and 48% reduction in illness and death, respectively. In comparison, a USDA study published in 1996 estimated that there had been 1,795-1860 Listeria-related cases in 1993, and 445-510 deaths, with 85-95% of these attributable to the consumption of contaminated food. Listeriosis-related mortality rates decreased annually by 10.7% from 1990 through 1996, and by 4.3% from 1996 through 2005.

Among adults 50 years of age and older, infection rates were estimated to have declined from 16.2 per 1 million in 1989 to 10.2 per 1 million in 1993. Perinatal disease decreased from 17.4 cases per 100,000 births in 1989 to 8.6 cases per 100,000 births in 1993. Neonatal infections are often severe, with a mortality rate of 25-50%.

According to the CDC’s National Center for Zoonotic, Vector-Borne, and Enteric Diseases:

Listeriosis was added to the list of nationally notifiable diseases in 2001. To improve surveillance, the Council of State and Territorial Epidemiologists has recommended that all L. monocytogenes isolates be forwarded to state public health laboratories for subtyping through the National Molecular Subtyping Network for Foodborne Disease Surveillance (PulseNet). All states have regulations requiring health care providers to report cases of listeriosis and public health officials try to interview all persons with listeriosis promptly using a standard questionnaire about high risk foods. In addition, FoodNet conducts active laboratory- and population-based surveillance.

In 2006, public health officials from 48 states reported 1,270 foodborne disease outbreaks, with a confirmed or suspect source in 884 of the outbreaks (70%). Only one of the outbreaks with a confirmed source was attributed to Listeria, with this outbreak involving eleven hospitalizations and one death. The next year, of 17,883 lab-confirmed infections, the CDC attributed 122 to Listeria. In 2009, there were 158 confirmed Listeria infections, representing an incidence-rate of .34 cases for every 100,000 persons in the United States. Such data revealed an incidence-rate of 0.27 cases per 100,000 persons, a decrease of 42% compared with 1996—1998. But, according to CDC’s Technical Information website, it is estimated that there are 1,600 cases of Listeria infection annually in the United States, based on data through 2008.

The 2009 numbers represented a reported 30% decrease in the number of infections compared to the 1996—1998 rates of infection. Although the nature and degree of underreporting is subject to dispute, all agree that the confirmed cases represent just the tip of the iceberg. Indeed, one study estimates the annual incidence rate for Listeria to be around 1,795-1,860 cases per 100,000 persons, with 445-510 of the cases ending in death.

Finally, in a study of FoodNet laboratory-confirmed invasive cases—where infection is detected in blood, cerebrospinal fluid, amniotic fluid, placenta or products of conception—the number of listeriosis cases decreased by 24% from 1996 through 2003. During this same period, pregnancy-associated disease decreased by 37%, while cases among those fifty years old and older decreased by 23%.

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Listeria outbreaks. The Listeria lawyers of Marler Clark have represented thousands of victims of Listeria and other foodborne illness outbreaks and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our Listeria lawyers have litigated Listeria cases stemming from outbreaks traced to a variety of foods, such as caramel apples, cantaloupe, cheese, celery and milk.

World Health Day 2015: From farm to plate, make food safe

New data on the harm caused by foodborne illnesses underscore the global threats posed by unsafe foods, and the need for coordinated, cross-border action across the entire food supply chain, according to WHO, which next week is dedicating its annual World Health Day to the issue of food safety.

World Health Day will be celebrated on 7 April, with WHO highlighting the challenges and opportunities associated with food safety under the slogan “From farm to plate, make food safe.”

“Food production has been industrialized and its trade and distribution have been globalized,” says WHO Director-General Dr Margaret Chan. “These changes introduce multiple new opportunities for food to become contaminated with harmful bacteria, viruses, parasites, or chemicals.”

Dr Chan adds: “A local food safety problem can rapidly become an international emergency. Investigation of an outbreak of foodborne disease is vastly more complicated when a single plate or package of food contains ingredients from multiple countries.”

Unsafe food can contain harmful bacteria, viruses, parasites or chemical substances, and cause more than 200 diseases – ranging from diarrhoea to cancers. Examples of unsafe food include undercooked foods of animal origin, fruits and vegetables contaminated with faeces, and shellfish containing marine biotoxins.

Today, WHO is issuing the first findings from what is a broader ongoing analysis of the global burden of foodborne diseases. The full results of this research, being undertaken by WHO’s Foodborne Disease Burden Epidemiology Reference Group (FERG), are expected to be released in October 2015.

Some important results are related to enteric infections caused by viruses, bacteria and protozoa that enter the body by ingestion of contaminated food. The initial FERG figures, from 2010, show that:

there were an estimated 582 million cases of 22 different foodborne enteric diseases and 351 000 associated deaths;
the enteric disease agents responsible for most deaths were Salmonella Typhi (52 000 deaths), enteropathogenic E. coli (37 000) and norovirus (35 000);
the African region recorded the highest disease burden for enteric foodborne disease, followed by South-East Asia;
over 40% people suffering from enteric diseases caused by contaminated food were children aged under 5 years.
Unsafe food also poses major economic risks, especially in a globalized world. Germany’s 2011 E.coli outbreak reportedly caused US$ 1.3 billion in losses for farmers and industries and US$ 236 million in emergency aid payments to 22 European Union Member States.

Efforts to prevent such emergencies can be strengthened, however, through development of robust food safety systems that drive collective government and public action to safeguard against chemical or microbial contamination of food. Global and national level measures can be taken, including using international platforms, like the joint WHO-FAO International Food Safety Authorities Network (INFOSAN), to ensure effective and rapid communication during food safety emergencies.

At the consumer end of the food supply chain, the public plays important roles in promoting food safety, from practising safe food hygiene and learning how to take care when cooking specific foods that may be hazardous (like raw chicken), to reading the labels when buying and preparing food. The WHO Five Keys to Safer Food explain the basic principles that each individual should know all over the world to prevent foodborne diseases.

“It often takes a crisis for the collective consciousness on food safety to be stirred and any serious response to be taken,” says Dr Kazuaki Miyagishima, Director of WHO’s Department of Food Safety and Zoonoses. “The impacts on public health and economies can be great. A sustainable response, therefore, is needed that ensures standards, checks and networks are in place to protect against food safety risks.”

WHO is working to ensure access to adequate, safe, nutritious food for everyone. The Organization supports countries to prevent, detect and respond to foodborne disease outbreaks—in line with the Codex Alimentarius, a collection of international food standards, guidelines and codes of practice covering all the main foods.

Food safety is a cross-cutting issue and shared responsibility that requires participation of non-public health sectors (i.e. agriculture, trade and commerce, environment, tourism) and support of major international and regional agencies and organizations active in the fields of food, emergency aid, and education.