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Seattle Food Safety Law Firm: 22 Years of E. coli Experience

The E. coli lawyers of Marler Clark have many years of experience working with clients on E. coli outbreak lawsuits.

E. coli are bacteria that can cause serious, sometimes fatal, infections in humans.  The Centers for Disease Control and Prevention (CDC) estimates that E. coli causes 2,000 hospitalizations in the United States each year.

Ten percent of E. coli victims develop hemolytic uremic syndrome (HUS), which can cause kidney failure, damage to the central nervous system, and ultimately death.

The Marler Clark E. coli lawyers have unmatched experience representing victims of E. coli and HUS.  We have represented hundreds of victims of E. coli outbreaks traced to foods such as hamburgers, spinach, raw milk, water, and food served at restaurants.  The Marler Clark E. coli lawyers are the only lawyers in the nation with a practice focused exclusively on plaintiff foodborne illness litigation.

Our E. coli lawyers have represented victims of notable E. coli outbreaks such as the 2006 Dole Spinach E. coli outbreak, the 2007 Cargill beef E. coli outbreak, and the landmark 1993 Jack in the Box E. coli outbreak. Contact us today to learn more about our services.

Aerosolised Vomit Spreads Norovirus

vomit-2-390x285In a recent study, a team of US scientists wanted to study how norovirus, a nasty stomach bug that commonly causes food poisoning, could be spread by vomiting.

So they built a vomit machine.

More than 20 million people in the US catch norovirus every year, according to their Center for Disease Control and Prevention.

Only about 5 million of those get infected from eating contaminated food — the majority of people catch the virus from other sick people, The New York Times reported.

Lee-Ann Jaykis of North Carolina State University and her colleagues built a vomit machine consisting of a fake stomach connected to a pump by a series of tubes, complete with a sad-looking clay face.

They used fake vomit mixed with pudding to get the right consistency, and mixed in a virus called MS2, which is similar to norovirus but can be grown in a lab, and is not as dangerous.

They even watched YouTube videos of people projectile vomiting, to get the process just right. For example, most people cough a few times after upchucking, so they included this in the simulation.

They found that the vomit machine did indeed spread the virus into the air, and it spewed slightly more of the virus when they increased the pump’s pressure, which corresponded with a person’s stomach pressure — the more pressure built up inside your stomach the higher the chance you have of projectile vomiting. Coughing also increased the amount of virus in the air.

Only 0.00007% to 0.03% of the vomit was aerosolised, which equates to between 40 and 10,000 virus particles. But it only takes between 20 and 1,300 norovirus particles to make someone sick, Jaykis told The New York Times.

Norovirus in the News – What You Need to Know

norovirusAn Introduction to Norovirus

The Centers for Disease Control and Prevention (CDC) estimates that noroviruses cause nearly 21 million cases of acute gastroenteritis annually, making noroviruses the leading cause of gastroenteritis in adults in the United States. [5, 9, 13, 31]  According to a relatively recent article in the New England Journal of Medicine,

The Norwalk agent was the first virus that was identified as causing gastroenteritis in humans, but recognition of its importance as a pathogen has been limited because of the lack of available, sensitive, and routine diagnostic methods. Recent advances in understanding the molecular biology of the noroviruses, coupled with applications of novel diagnostic techniques, have radically altered our appreciation of their impact. Noroviruses are now recognized as being the leading cause of epidemics of gastroenteritis and an important cause of sporadic gastroenteritis in both children and adults. [16]

Of the viruses, only the common cold is reported more often than a norovirus infection—also referred to as viral gastroenteritis. [3]

Nature has created an ingenious bug in norovirus. [21] The round blue ball structure of norovirus is actually a protein surrounding the virus’s genetic material. [16, 33] The virus attaches to the outside of cells lining the intestine, and then transfers its genetic material into those cells. [33] Once the genetic material has been transferred, norovirus reproduces, finally killing the human cells and releasing new copies of itself that attach to more cells of the intestine’s lining. [12, 15, 33]

Norovirus (previously called “Norwalk-like virus” or NLV) is a member of the family Caliciviridae. [15, 33] The name derives from the Latin for chalice—calyx—meaning cup-like, and refers to the indentations of the virus surface. [33] The family of Caliciviridae consists of several distinct groups of viruses that were first named after the places where outbreaks occurred. [30] The first of these outbreaks occurred in 1968 among schoolchildren in Norwalk, Ohio. [16] The prototype strain was identified four years later, in 1972, and was the first virus identified that specifically caused gastroenteritis in humans. [16, 33] Other discoveries followed, with each strain name based on the location of its discovery—e.g., Montgomery County, Snow Mountain, Mexico, Hawaii, Parmatta, Taunton, and Toronto viruses. [15, 21] A study published in 1977 found that the Toronto virus was the second most common cause of gastroenteritis in children. [27] Eventually this confusing nomenclature was resolved, first in favor of calling each of the strains a Norwalk-like virus, and then simply, a norovirus – the term used today. [16, 33]

Humans are the only host of norovirus, and norovirus has several mechanisms that allow it to spread quickly and easily. [15] Norovirus infects humans in a pathway similar to the influenza virus’ mode of infection. [5, 15, 33] In addition to their similar infective pathways, norovirus and influenza also evolve to avoid the immune system in a similar way. [21] Both viruses are driven by heavy immune selection pressure and antigenic drift, allowing evasion of the immune system, which results in outbreaks. [21, 30] Norovirus is able to survive a wide range of temperatures and in many different environments. [15, 33] Moreover, the viruses can spread quickly, especially in places where people are in close proximity, such as cruise ships and airline flights, even those of short duration. [14, 15] As noted by the CDC in its Final Trip Report,

noroviruses can cause extended outbreaks because of their high infectivity, persistence in the environment, resistance to common disinfectants, and difficulty in controlling their transmission through routine sanitary measures. [10]

Norovirus outbreaks can result from the evolution of one strain due to the pressure of population immunity. [12, 32] Typically, norovirus outbreaks are dominated by one strain, but can also involve more than one strain. [9, 11, 15] For example, some outbreaks associated with shellfish have been found to contain up to seven different norovirus strains. [30, 38] Swedish outbreak studies also reveal a high degree of genetic variability, indicating a need for wide detection methods when studying these outbreaks. [23]

By way of further example, in 2006, there was a large increase in the number of norovirus cases on cruise ships. Norovirus cases were increasing throughout Europe and the Pacific at the same time. [36] One issue with cruise ships is the close contact between people as living quarters are so close, and despite education efforts, there still seems to be a lack of public understanding regarding how the illness is spread. [7, 14] On the other hand, reporting occurs much more quickly in these situations because of the close proximity and concentration of illness, allowing for the quicker detection of outbreaks. [8] Cruise ship outbreaks often occur when new strains of norovirus are appearing, providing a good indicator system for new norovirus strains. [7, 8] In this case, two new variants appeared within the global epidemic genotype, suggesting a strong pressure for evolution against the human immune system. [12] This points to the need for an international system of guidelines in tracing norovirus outbreaks. [36]

How is Norovirus transmitted?

Norovirus causes nearly 60% of all foodborne illness outbreaks. [31] Norovirus is transmitted primarily through the fecal-oral route, with fewer than 100 norovirus particles needed to cause infection. [10, 15, 33] Transmission occurs either person-to-person or through contamination of food or water.  [1, 15, 33] CDC statistics show that food is the most common vehicle of transmission for noroviruses; of 232 outbreaks of norovirus between July 1997 and June 2000, 57% were foodborne, 16% were spread from person-to-person, and 3% were waterborne. [6, 31] When food is the vehicle of transmission, contamination occurs most often through a food handler improperly handling a food directly before it is eaten. [4, 9, 10]

Infected individuals shed the virus in large numbers in their vomit and stool, shedding the highest amount of viral particles while they are ill.  [5, 33] Aerosolized vomit has also been implicated as a mode of norovirus transmission. [24] Previously, it was thought that viral shedding ceased approximately 100 hours after infection; however, some individuals continue to shed norovirus long after they have recovered from it, in some cases up to 28 days after experiencing symptoms. [28, 31, 35] Viral shedding can also precede symptoms, which occurs in approximately 30% of cases. [16] Often, an infected food handler may not even show symptoms. [9] In these cases, people can carry the same viral load as those who do experience symptoms. [5, 9, 33]

A Japanese study examined the ability of asymptomatic food handlers to transfer norovirus. Approximately 12% of asymptomatic food handlers were carriers for one of the norovirus genotypes. [28] This was the first report of norovirus molecular epidemiology relating asymptomatic individuals to outbreaks, suggesting that asymptomatic individuals are an important link in the infectivity pathway. [15, 28] Asymptomatic infection may occur because some people may have acquired immunity, which explains why some show symptoms upon infection and some do not. [16, 28, 33] Such immunity does not last long, though. [16, 21, 28] These discoveries reveal just how complicated the pathway of norovirus infection is, as well as how difficult it is to define the true period of infectivity. [30] Furthermore, it remains unclear why some people do not become sick with norovirus even when they are exposed. [16, 21, 32] Very little is known about the differences in hygiene practices, behaviors, and personal susceptibility between those who become infected and those who do not, which brings up the potential for more research. [17] Discrepancies exist in the published research about infective doses for norovirus, with earlier studies having used a much higher dose to trigger immune responses. [16]

 Symptoms & Risks of Norovirus Infection

Norovirus illness usually develops 24 to 48 hours after ingestion of contaminated food or water. [5, 16, 33] Symptoms typically last a relatively short amount of time, approximately 24 to 48 hours. [5, 25] These symptoms include nausea, vomiting, diarrhea, and abdominal pain.  Headache and low-grade fever may also accompany this illness. [5, 25, 33]  People infected with norovirus usually recover in two to three days without serious or long-term health effects. [5, 25]

Although symptoms usually only last one to two days in healthy individuals, norovirus infection can become quite serious in children, the elderly, and immune-compromised individuals. [10, 18, 33] In some cases, severe dehydration, malnutrition, and even death can result from norovirus infection, especially among children and among older and immune-compromised adults in hospitals and nursing homes. [25, 30] In England and Wales, 20% of those over the age of 65 die due to infectious intestinal illness other than Clostridium difficile. [18] Recently, there have been reports of some long-term effects associated with norovirus, including necrotizing entercolitis, chronic diarrhea, and post-infectious irritable bowel syndrome, but more data is needed to support these claims. [37]

Diagnosing a Norovirus Infection

Diagnosis of norovirus illness is based on the combination of symptoms, particularly the prominence of vomiting, little fever, and the short duration of illness. [5, 25, 33] If a known norovirus outbreak is in progress, public health officials may obtain specimens from ill individuals for testing in a lab. [5, 9] These lab tests consist of identifying norovirus under an electron microscope. A reverse transcriptase polymerase chain reaction test (RT-PCR assay) also can detect norovirus in food, water, stool samples, and on surfaces. These tests isolate and replicate the suspected virus’ genetic material for analysis. [25, 33] An ELISA can also be performed, which detects antigens. They are easier to perform than RT-PCR, but less sensitive and can also result in many false negatives. [9, 11]

Treating a Norovirus Infection

There is no specific treatment available for norovirus. [16, 33] In most healthy people, the illness is self-limiting and resolves in a few days; however, outbreaks among infants, children, elderly, and immune-compromised populations may result in severe complications among those affected.  [16, 27, 30, 33] Death may result without prompt measures. [5, 16, 25, 33] The replacement of fluids and minerals such as sodium, potassium and calcium – otherwise known as electrolytes – lost due to persistent diarrhea is vital. This can be done either by drinking large amounts of liquids, or intravenously. [16, 25]

Recent research has looked into the potential for developing a norovirus vaccine. [9, 16, 37] Researchers indicate that coming up with a norovirus vaccine would be similar to vaccinating for influenza, by using screening in order to select for the most prevalent strains. This is a quite challenging process. [37] Other challenges include the fact that cell culture and small-animal models are limited, host pre-exposure histories are complicated, and there is always the potential for the evolution of novel immune escape variants, rendering the vaccine useless. [13, 33] Furthermore, scientists would likely face a lack of funding to develop a vaccine because vaccine development is expensive. [12, 21]

Preventing Norovirus Infection

Common settings for norovirus outbreaks include restaurants and events with catered meals (36%), nursing homes (23%), schools (13%), and vacation settings or cruise ships (10%). [6] Proper hand washing is the best way to prevent the spread of norovirus. [9, 17, 25]

The good news about norovirus is that it does not multiply in foods as many bacteria do. [5, 31, 33] In addition, thorough cooking destroys this virus.  [5, 25] To avoid norovirus, make sure the food you eat is cooked completely. [5, 9, 10] While traveling in in areas that have polluted water sources, raw vegetables should be washed thoroughly before being served, and travelers should drink only boiled drinks or carbonated bottled beverages without ice. [9, 16]

Shellfish (oysters, clams, mussels) pose the greatest risk and any particular serving may be contaminated with norovirus; there is no way to detect a contaminated oyster, clam, or mussel from a safe one. [5, 31] Shellfish become contaminated when their waters become contaminated—e.g., when raw sewage is dumped overboard by recreational or commercial boaters).  [19, 33] Shellfish are filter feeders and will concentrate virus particles present in their environment. With shellfish, only complete cooking offers reliable protection; steaming does not kill the virus or prevent its transmission. [19] Some researchers suggest that norovirus monitoring in shellfish areas could be a good preventive strategy as well. [22] Waterborne norovirus outbreaks are ubiquitous, but difficult to recognize. Improved analysis of environmental samples would have the potential to significantly improve the detection for norovirus in shellfish waters. [20]

Finally, and as briefly mentioned earlier, outbreaks of norovirus infections have become synonymous with cruise ships. [7, 8, 36] Healthcare facilities also experience a high incidence of norovirus outbreaks.  [6, 30, 35]The CDC has published information regarding the prevention of norovirus outbreaks on cruise ships and in healthcare facilities on its website. [6, 7] Once a case has occurred, even more stringent hygienic measures than normal are required in order to prevent an outbreak, particularly on an enclosed space such as a cruise ship. [17]

References (more…)

Norovirus and Raw Oysters – Nasty Mix

89949067_oysters_237620cOysters not only transmit human norovirus; they also serve as a major reservoir for these pathogens, according to research published August 28 in Applied and Environmental Microbiology, a journal of the American Society for Microbiology. “More than 80 percent of human norovirus genotypes were detected in oyster samples or oyster-related outbreaks,” said corresponding author Yongjie Wang, PhD.

“The results highlight oysters’ important role in the persistence of norovirus in the environment, and its transmission to humans, and they demonstrate the need for surveillance of human norovirus in oyster samples,” said Wang, who is Professor in the College of Food Science and Technology, Shanghai Ocean University, Shanghai, China.

In the study, the investigators downloaded all oyster-related norovirus sequences deposited during 1983-2014 into the National Center for Biotechnology’s GenBank database, and into the Noronet outbreak database. They conducted genotyping and phylogenic analyses, and mapped the norovirus’s genetic diversity and geographic distribution over time.

In earlier research, the investigators found that 90 percent of human norovirus sequences in China came from coastal regions. The current research showed that the same is true all over the world, except in tropical regions, from which sequences are absent.

Oysters’s status as reservoirs and vectors for human norovirus transmission is likely abetted by their presence in coastal waters, which are frequently contaminated by human waste, said Wang. Previous research suggests that noroviruses can persist for weeks in oyster tissues, and commercial depuration fails to expunge them.

Norovirus causes stomach pain, diarrhea, nausea, and vomiting. It is extremely contagious, and infects more than 6 percent of the US population, annually, resulting in around 20 million cases, including 56,000-71,000 hospitalizations and 570-800 deaths, according to the Centers for Disease Control and Prevention. Even touching a contaminated surface can result in infection.

Wang advised that people who eat oysters and other shellfish should eat them fully cooked, and never raw. He also urged development of a reliable method for detecting noroviruses in oysters, and a worldwide oyster-related norovirus outbreak surveillance network.

The American Society for Microbiology is the largest single life science society, composed of over 39,000 scientists and health professionals. ASM’s mission is to advance the microbiological sciences as a vehicle for understanding life processes and to apply and communicate this knowledge for the improvement of health and environmental and economic well-being worldwide.

Where were the Salmonella Hogs Sold in Washington?

Kapowsin Meats, a Graham, Washington establishment, recalling approximately 116,262 pounds of whole hogs that may be contaminated with Salmonella I 4, [5],12:i:-, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced days ago.  Today the FSIS published where those hogs were sold.  Here is the list:

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Canadian Cyclospora Numbers Rise to 87

This update includes 4 additional cases of Cyclospora that have been reported in this investigation.

Why you should take note

The Public Health Agency of Canada is collaborating with provincial public health partners, the Canadian Food Inspection Agency, and Health Canada to investigate 87 Canadian cases of Cyclospora infections in Ontario, British Columbia, Alberta, and Quebec. The source of this outbreak is not yet known, and the Agency and its partners continue to investigate.

The risk to Canadians is low, but people with weakened immune systems, young children and older adults are at increased risk for developing complications if they get sick. In Canada and the US, past foodborne outbreaks of Cyclospora have been linked to various types of imported fresh produce.

Cyclospora is a microscopic single-celled parasite that is passed in people’s feces. If it comes in contact with food or water, it can infect the people who consume it. This causes an intestinal illness called cyclosporiasis.

Cyclospora is most common in certain tropical and subtropical countries and regions. In Canada, non-travel related illnesses due to Cyclospora occur more frequently in the spring and summer months. lllnesses among travellers can happen at any time of year.

Investigation Summary

In Canada, a total of 87 cases have been reported in British Columbia (4), Alberta (1), Ontario (77), and Quebec (5).  Two cases have been hospitalized, and are recovered or recovering. No deaths have been reported. Individuals became sick between May 3 and July 27, 2015. To date, no source has been identified. The investigation is ongoing.

Previous foodborne illness outbreaks of Cyclospora, in Canada and US have been linked to various types of imported fresh produce, such as pre-packaged salad mix, basil, cilantro, berries, mesclun lettuce and snow peas.

To date, no multi-jurisdictional outbreaks have been linked to produce grown in Canada.

Who is most at risk

People living or traveling in tropical or subtropical regions of the world may be at increased risk for infection because the parasite is found in some of these regions.

People with weakened immune systems, young children and older adults are at increased risk for developing complications. Cyclosporiasis infection responds to antibiotic treatment and is not considered to be life-threatening in healthy people.

Most people recover fully, though it may take several weeks to fully recover.

What you should do to protect your health

Although the source of the outbreak has not been identified,  past outbreaks have been associated with imported fresh produce, including pre-packaged salad mix, basil, cilantro, berries, mesclun lettuce and snow peas.

The following general food safety tips are important in reducing the risk of infection from foodborne illnesses:

  • Wash fresh fruits and vegetables before eating them, clean counters and cutting boards and wash your hands regularly.
  • Keep refrigerators clean and at a temperature below 4 °C (40 °F). Install a thermometer in your fridge to be sure.
  • Keep raw food away from other food while shopping, storing, preparing and serving foods.
  • Read labels and follow cooking and storage instructions for all food. When buying food, make sure to check the “best before” date, and if the product has expired, let the store know.
  • Use warm soapy water to clean knives, cutting boards, utensils, your hands and any surfaces that have come in contact with food, especially meat and fish.
  • Refrigerate or freeze perishable food within two hours of cooking.
  • Freeze or consume leftovers within four days of cooking. Always reheat leftovers until steaming hot before eating.


People infected with Cyclospora can experience a wide range of symptoms. Some do not get sick at all, while others feel as though they have a bad case of stomach flu. Few people get seriously ill.

Most people develop the following symptoms within one week after being infected with Cyclospora:

  • Watery diarrhea
  • loss of appetite
  • weight loss
  • stomach cramps
  • abdominal bloating
  • increased gas
  • nausea
  • fatigue

Cyclospora illness can last from a few days to several weeks, if left untreated. Symptoms may seem to go away and then return one or more times.

As with any disease causing diarrhea, people infected with Cyclospora should drink plenty of liquids to replace lost body fluids and prevent dehydration.

People who experience symptoms or suspect they have been infected with cyclospora, should contact their health care providers or local public health.

What you need to know about Salmonella before, during and after an outbreak


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 one in charge, Dr. Salmon got all the credit. In any case, today the number of known strains of the bacteria totals over two thousand. In recent years, concerns have been raised, as particular strains of the bacteria have become resistant to traditional antibiotics, in both animals and humans.

The term Salmonella refers to a group or family of bacteria that variously cause illness in humans. The taxonomy and nomenclature of Salmonella have changed over the years and are still evolving. Currently, the Centers for Disease Control and Prevention (CDC) recognizes two species which are divided into seven subspecies. These subspecies are divided into over 50 serogroups based on somatic (O) antigens present. The most common Salmonella serogroups are A, B, C, D, E, F, and G. Serogroups are further divided into over 2,500 serotypes. Salmonella serotypes are typically identified through a series of tests of antigenic formulas listed in a document called the Kauffmann-White Scheme published by the World Health Organization Collaborating Centre for Reference and Research on Salmonella.[1]

Three serotypes – Enteriditis, Typhimurium, and Newport – have persisted as the serotypes most often isolated in patients and reported to the CDC over the last decade. In 2009, these three serotypes accounted for 42% of all reported cases of Salmonella.[2] Salmonella Schwarzengrund is relatively rare. In 2009 S. Montevideo accounted for less than 1% of all salmonellosis reported, causing 348 infections.

Where Does Salmonella Come From?

Salmonella is an enteric bacterium, which means that it lives in the intestinal tracts of humans and other animals, including birds. Salmonella bacteria are usually transmitted to humans by eating foods contaminated with animal feces or foods that have been handled by infected food service workers who have practiced poor personal hygiene. Contaminated foods usually look and smell normal. Contaminated foods are often of animal origin, such as beef, poultry, milk, or eggs, but all foods, including vegetables, may become contaminated. Many raw foods of animal origin are frequently contaminated, but thorough cooking kills Salmonella. The food handler who neglects to thoroughly wash his or her hands with soap and warm water after using the bathroom may contaminate foods that have otherwise been properly prepared.

What are the Symptoms of Salmonellosis?

Once in the lumen of the small intestine, the bacteria penetrate the epithelium, multiply, and enter the blood within 24 to 72 hours. Variables such as the health and age of the host and virulence differences among the serotypes affect the nature of the diagnosis. Infants, the elderly, individuals hospitalized, and the immune-suppressed are the populations that are the most susceptible to disease and suffer the most severe symptoms.

“The majority of persons infected with Salmonella have diarrhea, fever, and abdominal cramps 12-72 hours after exposure. The illness usually lasts 4-7 days, and the majority of persons recover without treatment.” MMWR Weekly, supra at 684. However, much longer incubation periods of 120 hours to 31 days have been documented in previous Salmonella outbreaks.[3]

The acute symptoms of Salmonella gastroenteritis include the sudden onset of nausea, abdominal cramping, and bloody diarrhea with mucous. As already noted, there is no real cure for a Salmonella infection; treatment, therefore, tends to be palliative – although prescription of antibiotics is common, even if usually contraindicated.

Medical treatment is acutely important if the patient becomes severely dehydrated or if the infection spreads from the intestines. Persons with severe diarrhea often require re-hydration, usually with intravenous fluids. Antibiotics are not necessary or indicated unless the infection spreads from the intestines, and then it can be treated with ampicillin, gentamicin, trimethoprim/sulfamethoxazole, or ciprofloxacin. Unfortunately, some Salmonella bacteria have become resistant to antibiotics, largely as a result of the use of antibiotics to promote the growth of feed animals.


Reactive 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. Several bacteria, including Salmonella, induce septic arthritis.[4] The resulting joint pain and inflammation can resolve completely over time or permanent joint damage can occur.[5]

The reactive arthritis associated with Reiter’s may develop after a person eats food that has been tainted with bacteria. In a small number of persons, the joint inflammation is accompanied by conjunctivitis (inflammation of the eyes), and uveitis (painful urination). Id. This triad of symptoms is called Reiter’s Syndrome.[6] Reiter’s syndrome, a form of reactive arthritis, is an uncommon but debilitating syndrome caused by gastrointestinal or genitourinary infections. The most common gastrointestinal bacteria involved are Salmonella, Campylobacter, Yersinia, and Shigella. Reiter’s syndrome is characterized by a triad of arthritis, conjunctivitis, and urethritis, although not all three symptoms occur in all affected individuals.[7]

Although the initial infection may not be recognized, reactive arthritis can still occur. Reactive arthritis typically involves inflammation of one joint (monoarthritis) or four or fewer joints (oligoarthritis), preferentially affecting those of the lower extremities; the pattern of joint involvement is usually asymmetric. Inflammation is common at enthuses—i.e., the places where ligaments and tendons attach to bone, especially the knee and the ankle.

Salmonella has been the most frequently studied bacteria associated with reactive arthritis. Overall, studies have found rates of Salmonella-associated reactive arthritis to vary between 6 and 30%.[8] The frequency of postinfectious Reiter’s syndrome, however, has not been well described. In a Washington State study, while 29% developed arthritis, only 3% developed the triad of symptoms associated with Reiter’s syndrome.[9] In addition, individuals of Caucasian descent may be more likely those of Asian descent to develop reactive arthritis,[10] and children may be less susceptible than adults to reactive arthritis following infection with Salmonella.[11]

A clear association has been made between reactive arthritis and a genetic factor called the human leukocyte antigen (HLA) B27 genotype. HLA is the major histocompatibility complex in humans; these are proteins present on the surface of all body cells that contain a nucleus, and are in especially high concentrations in white blood cells (leukocytes). It is thought that HLA-B27 may affect the elimination of the infecting bacteria or an individual’s immune response.[12] HLA-B27 has been shown to be a predisposing factor in one-half to over two-thirds of individuals with reactive arthritis.[13] While HLA-B27 does not appear to predispose to the initial infection itself, it increases the risk of developing arthritis that is more likely to be severe and prolonged. This risk may be slightly greater for Salmonella and Yersinia-associated arthritis than with Campylobacter, but more research is required to clarify this.[14]

Irritable Bowel Syndrome

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.[15] 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.[16]

In terms of its own data, the “study confirm[ed] a strong and significant relationship between acute enteric infection and subsequent IBS symptoms.”[17] 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.[18]

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.[19] 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.[20] IBS sufferers typically experienced symptoms for an average of 8.1 days per month.[21]

As would be expected from a chronic disorder with symptoms of such persistence, 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.[22] And even when able to work, a significant majority (67%), felt less productive at work because of their symptoms.[23] 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.[24] Finally, although 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 fact cause IBS or its symptoms.[25]


The occurrence of bacterial infection is a function of several major variables: (1) the virulence of the bacterial pathogen, that is, its ability to cause severe disease; (2) how the pathogen is transmitted to the “host”—for example, whether it is airborne, foodborne, blood borne, etc.; and (3) host susceptibility—i.e. how well the host can defend itself against the bacterial pathogen. Increased susceptibility, in turn, may result from two different processes: a bigger infectious dose in a given case of disease may cause a more severe infection, and physical characteristics particular to an individual host may render him or her less able to limit the spread of infectious microorganisms from the intestinal tract to the bloodstream.[26]

Morbidity and mortality in the elderly from infectious disease is far greater than in other populations. For instance, death rates for infectious diarrheal disease alone are five times higher in people over 74 years of age than in the next highest group, children under four years of age, and fifteen times higher than the rates seen in younger adults.[27] Published studies attribute the elderly’s heightened risks, both of infection and mortality due to enteric infectious disease, to several factors: (1) aging of the gastrointestinal tract (reduced gastric acidity/reduced gastric mobility); (2) higher prevalence of underlying medical disorders (co-morbidity factors); and (3) malnutrition and a decline in the immune response that leaves the host less able to defend itself against infectious agents.[28]

Aging of the Gastrointestinal Tract – An Invitation to Infection

Inflammation and shrinkage of the gastric mucosa increase with age, leading to low gastric acidity. In patients with gastric ulcer disease, the drugs used to treat the condition further block gastric acid production. Because stomach acids play an important role in limiting the number of bacteria that enter the small intestine, low gastric acidity increases the likelihood of infection upon ingesting contaminated food or water.[29]

Peristalsis, which is the mechanism that propels the stomach contents through the intestinal tract, decreases with age. Peristalsis is also the mechanical means for removing ingested, life-threatening pathogens. Because the risk of infection by potentially invasive pathogens corresponds with the duration of contact between the pathogen and the intestinal mucosa, a decrease in peristalsis delays the clearance of the pathogen from the intestinal tract and contributes substantially to the increased prevalence and severity of infection in the elderly.[30] If the pathogen is Salmonella, decreased peristalsis allows more of the bacteria to be absorbed in the gastrointestinal tract, thus increasing the risk of suffering one of the complications described above.

A Higher Prevalence of Underlying Medical Conditions – Co-Morbidity Factors

Underlying medical conditions or disease (co-morbid factors) also contribute to the morbidity and mortality of infection in the elderly. Among hospitalized patients, those older than 65 develop pneumonia twice as often as younger patients due to poor nutrition, neuromuscular disease (poor cough reflex and aspiration), pharyngeal colonization, depressed level of alertness, endotracheal intubation, intensive care unit admission, nasogastric tube use, and antacid use.[31] Pneumonia is the leading infectious cause of death in the elderly.[32]

Atherosclerosis, another common co-morbid disease, compromises circulation and blood flow to the peripheral tissues and the skin, particularly in elderly individuals who are hospitalized and bedridden with an infectious illness. Unfortunately, it is the skin and the previously discussed mucous membranes that serve as the body’s first line of defense against invasion by infectious microorganisms. Loss of the integrity of the skin may result in the development of pressure ulcers, which are warm, moist mediums for infectious microorganisms to rapidly multiply and are associated with a number of infectious complications.

When an infectious microorganism, regardless of source, gains access to the bloodstream, the patient may develop systemic sepsis, also known as bacteremia.[33] Bacteremia is most common in people who are already affected by, or are being treated for, some other medical problem (co-morbid disease); conversely, people in good health with strong immune systems rarely develop bacteremia. The main sources of bacteremia in elderly patients are the urinary tract, gastrointestinal tract, respiratory tract, and the skin. Other potential sources include surgical wounds, invasive tubes and catheters, intravenous lines—virtually any site where an invasive medical procedure has occurred. Bacterial organisms most likely to cause bacteremia include members of the Staphylococcus, Streptococcus, Salmonella and Escherichia coli genera. Because bacteremia is far more prevalent in those with co-morbid conditions, which group is substantially populated by the elderly, the presence of co-morbid conditions is clearly a determinant of the mortality associated with infectious disease.


[1]           Grimont, PAD, Weill, F. Antigenic formulae of the Salmonella serovars, 2007, 9th Edition. WHO Collaborating Centre for Reference and Research on Salmonella. Paris: Pasteur Institute. http://www.pasteur.fr/ip/portal/action/WebdriveActionEvent/oid/01S-000036-089.

[2]           http://www.cdc.gov/ncezid/dfwed/PDFs/SalmonellaAnnualSummaryTables2009.pdf, Table 1.

[3]           O’ Mahony, et al. An outbreak of Salmonella Heidelberg infection associated with a long incubation period. J. Public Health (1990) 12 (1): 19-21; Abe, et al. Prolonged Incubation Period of Salmonellosis Associated with Low Bacterial Doses. J. Food Protection (2004) Vol. 67, No. 12; 2735-2740.

[4]           See J. Lindsey. “Chronic Sequellae of Foodborne Disease,” Emerging Infectious Diseases, Vol. 3, No. 4, Oct-Dec, 1997.

[5]           Id.

[6]           Id. See also, Dworkin, et al. “Reactive Arthritis and Reiter’s Syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis,” Clin. Infect. Dis., 2001 Oct. 1;33(7): 1010-4; Barth, W. and Segal, K. “Reactive Arthritis (Reiter’s Syndrome),” American Family Physician, Aug. 1999, online at www.aafp.org/afp/990800ap/499.html.

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

[8]           Id.

[9]           Dworkin MS, Shoemaker PC, Goldoft MJ, Kobayashi JM. “Reactive arthritis and Reiter’s syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis.” Clin. Infect. Dis. 33(7):1010-1014.

[10]          McColl GJ, Diviney MB, Holdsworth RF, McNair PD, Carnie J, Hart W, McCluskey J. “HLA-B27 expression and reactive arthritis susceptibility in two patient cohorts infected with Salmonella Typhimurium,” Australian and New Zealand Journal of Medicine. 30(1):28-32 (2001).

[11]          Rudwaleit M, Richter S, Braun J, Sieper J. “Low incidence of reactive arthritis in children following a Salmonella outbreak,” Annals of the Rheumatic Diseases, 60(11):1055-1057 (2001).

[12]          Hill Gaston and Lillicrap, supra Note 7.

[13]          Id.; Barth WF, Segal K., “Reactive arthritis (Reiter’s syndrome).” American Family Physician, 60(2):499-503, 507 (1999).

[14]          Hill Gaston and Lillicrap, supra Note 7.

[15]          J. Marshall, et al. Incidence and Epidemiology of Irritable Bowel Syndrome After a Large Waterborne Outbreak of Bacterial Dysentery, Gastro., 2006; 131;445-50 (hereinafter “Walkerton Health Study” or “WHS”). The WHS followed one of the largest E. coli O157:H7 outbreaks in the history of North America. Contaminated drinking water caused over 2,300 people to be infected with E. coli O157:H7, resulting in 27 recognized cases of HUS, and 7 deaths. Id. at 445. The WHS followed 2,069 eligible study participants. Id. For Salmonella specific references, see Smith, J.L., Bayles, D.O., Post-Infectious Irritable Bowel Syndrome: A Long Term Consequence of Bacterial Gastroenteritis. Journal of Food Protection, 2007:70(7);1762-1769.

[16]          Id. at 445 (citing multiple sources).

[17]          WHS, supra note 34, at 449.

[18]          Id. at 447.

[19]          A.P.S. Hungin, et al. Irritable Bowel Syndrome in the United States: Prevalence, Symptom Patterns and Impact, Aliment Pharmacol. Ther., 2005:21 (11); 1365-75.

[20]          Id. at 1367.

[21]          Id.

[22]          Id. at 1368.

[23]          Id.

[24]          Id.

[25]          Amy Foxx-Orenstein, DO, FACG, FACP. IBS—Review and What’s New. General Medicine, 2006:8(3) (Medscape 2006) (collecting and citing studies). Indeed, PI-IBS has been found to be characterized by more diarrhea but less psychiatric illness with regard to its pathogenesis. See Nicholas J. Talley, MD, PhD. Irritable Bowel Syndrome: From Epidemiology to Treatment, from American College of Gastroenterology 68th Annual Scientific Meeting and Postgraduate Course (Medscape 2003).

[26]          Morris, JG, Morris P. Emergence of New Pathogens as a Function of Changes in Host Susceptibility. Emerging Infectious Diseases 1997;3(4):435-440.

[27]          Lew, JF, et al. Diarrheal deaths in the United States, 1979 through 1987. A special problem for the elderly. JAMA 1991;265:3280-3284.

[28]          Smith, JL. Foodborne Illness in the Elderly. J Food Prot. 1998;61(9):1229-1239.

[29]          Berkow, R. (Ed.) 1992. The Merck manual of diagnosis and therapy, 16th ed. Merck & Co., Inc.

[30]          Sprinz, H. Pathogenesis of intestinal infections. Arch. Pathol. 1969; 87:556-562.

[31]          Hanson, LC, et al. Risk factors for nosocomial pneumonia in the elderly. Am. J. Med. 1992;92:161-166.

[32]          Pinner, RW, Teutsch, SM, Simonsen, L, et al. Trends in infectious diseases mortality in the United States. JAMA 1996;275:189-193.

[33]          Bryan, CS, Dew, CE, Reynolds, KL. Bacteremia associated with decubitus ulcers. Arch. Intern. Med. 1987;82:602-606.

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.

If you or a family member became ill with a Salmonella infection, including Reactive Arthritis or Irritable bowel syndrome (IBS), after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark Salmonella attorneys for a free case evaluation.

Several E. coli Illnesses and a Death Likely Linked to Indiana Daycare

Health officials said out of the 5 cases, 2 are confirmed in Wabash and Fulton counties.  Original source of infection unknown.

8554935_GAccording to press reports, the family of 9-year-old Destiny Smith said their daughter died last week from hemolytic uremic syndrome (HUS) caused by an E. coli bacterial infection.

Kendra and Kyle Creighbaum, a Rochester family who said their two sons were suffering from an E. coli infection in May. Tucker and Hunter Creighbaum are twins, and they have both recovered from their infections.

The Fulton County Health Department, Wabash County Health Department and Indiana State Department of Health announced that they are investigating cases of E. coli O157 among children who attend a local daycare. Currently, all confirmed cases being investigated with this outbreak are associated with this daycare.

E. coli O157 is a contagious diarrheal illness that causes symptoms such as abdominal cramping, diarrhea, vomiting, and sometimes bloody stool. Symptoms usually begin three to four days after exposure but can appear from one to eight days after exposure. Symptoms typically last five to 10 days. While most people resolve infection on their own, about 3 percent to 7 percent of people will develop severe complications that require hospitalization. Some people may have no symptoms but can still spread the infection to others. For this reason, careful and frequent hand washing is important.

Ill children who attend school or daycare should be excluded until they are symptom-free and have two negative stool tests to prevent other children from getting sick. Parents and caretakers of ill individuals also are at risk of contracting E. coli O157 and should limit contact with others as much as possible and see a health care provider if symptoms develop. Adults infected with E. coli O157 who work in food service or health care settings should not attend work while ill.

E. coli O157 is normally found in animals, such as cattle, but not found in humans. People become infected by having contact with contaminated food or water or through contact with animals or infected people. Once infected, people shed the bacteria in their stool.

Hand washing is the single best defense against E. coli O157. Hands should be washed after using the restroom, before eating or preparing food, and after contact with animals. Adults should supervise children to make sure they are washing their hands properly for at least 20 seconds while using soap and warm water. Children under 5 years of age should avoid direct contact with farm animals (such as from petting zoos or county fairs).

E. coli: 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.

If you or a family member became ill with an E. coli infection or HUS after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark E. coli attorneys for a free case evaluation.

Texas Tallies Cyclospora Illnesses

A recent surge in reports of illnesses due to the parasite Cyclospora has prompted DSHS to investigate the infections in hopes of determining a common source. DSHS has received reports of 224 Cyclosporiasis cases from around Texas this year. Past outbreaks have been associated with cilantro from the Puebla area of Mexico. While the investigation into the current outbreak is ongoing, DSHS has identified imported cilantro as a possible source of some infections.

Cyclosporiasis is an intestinal illness caused by consuming food or water contaminated with the Cyclospora parasite. The major symptom is watery diarrhea lasting a few days to a few months. Additional symptoms may include loss of appetite, fatigue, weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting and a low fever. People who think they may have a Cyclospora infection should contact their health care provider.

DSHS recommends thoroughly washing fresh produce, but that may not entirely eliminate the risk because Cyclospora can be difficult to wash off. Cooking will kill the parasite.

Last year, Texas had 200 cases, some of which were associated with cilantro from the Puebla region in Mexico.

County    # Cases
Anderson    1
Andrews    1
Archer    1
Bexar    7
Caldwell    1
Collin    11
Comal    2
Coryell    1
Dallas    18
Denton    9
El Paso    2
Ellis    3
Fort Bend    2
Galveston    2
Grayson    1
Guadalupe    1
Harris    7
Hays    5
Henderson    1
Hidalgo    1
Hood    1
Hunt    1
Johnson    1
Kaufman    1
Kendall    2
Kleberg    3
Llano    1
Lubbock    1
McCulloch    1
Medina    1
Nacogdoches    1
Parker    2
Potter    1
Rockwall    1
Tarrant    9
Taylor    2
Tom Green    2
Travis    79
Washington    1
Webb    1
Wichita    1
Williamson    10