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

Wisconsin, Illinois, Pennsylvania, Virginia, New York and Georgia hardest hit.

The CDC just announced that a total of 316 individuals infected with the outbreak strains of Salmonella Bareilly or Salmonella Nchanga have been reported from 26 states and the District of Columbia. The 58 new cases are from Alabama (1), California (2), Colorado (1), Georgia (3), Illinois (4), Indiana (1), Louisiana (1), Maryland (3), Massachusetts (6), New Jersey (1), New York (10), North Carolina (6), Pennsylvania (5), Tennessee (2), Texas (3), Virginia (6), and Wisconsin (3).

Three hundred and four persons infected with the outbreak strain of Salmonella Bareilly have been reported from 26 states and the District of Columbia. The number of ill persons with the outbreak strain of Salmonella Bareilly identified in each state is as follows: Alabama (3), Arkansas (1), California (4), Colorado (1), Connecticut (9), District of Columbia (2), Florida (1), Georgia (13), Illinois (27), Indiana (1), Louisiana (4), Maryland (27), Massachusetts (33), Mississippi (2), Missouri (4), Nebraska (1), New Jersey (26), New York (48), North Carolina (10), Pennsylvania (25), Rhode Island (6), South Carolina (3), Tennessee (4), Texas (7), Virginia (22), Vermont (1), and Wisconsin (19).

Twelve persons infected with the outbreak strain of Salmonella Nchanga have been reported from 5 states. The number of ill persons with the outbreak strain of Salmonella Nchanga identified in each state is as follows: Georgia (2), New Jersey (2), New York (6), Virginia (1), and Wisconsin (1).

Among 316 persons for whom information is available, illness onset dates range from January 28 to May 3, 2012. Ill persons range in age from <1 to 86 years, with a median age of 30. Fifty-nine percent of patients are female. Among 217 persons with available information, 37 (17%) reported being hospitalized. No deaths have been reported.

The FDA Inspection on Moon Marine found that tanks used for storage of process waters have apparent visible debris, filth and microbiological contamination. Sand and activated carbon filter units used in manufacturing of water are not sanitized, and ventilation for tanks is not filtered to protect against contamination. There is no laboratory analysis for water used in ice manufacturing at the REDACTED facility to show the water used to make ice is potable. Ice manufacturing lacks sanitary controls: ice manufacturing equipment at the Moon Fishery facility is located outside and is susceptible to adulteration from pests and the environment. Apparent bird feces were observed on the ice manufacturing equipment at Moon Fishery; insects and filth were observed in and on the equipment. Ice manufacturing equipment at your REDACTED facility is rusty and situated so that the ice cannot be protected against adulteration, as the ice manufacturing process is constructed into the flooring of the ice facility. Tuna processed at your facility, which is consumed raw or cooked, comes in direct contact with water and ice.

Some of the floor and wall tiles in the tuna processing area are broken and cracked, not allowing for proper cleaning.  After cleaning, the ceiling directly above the in-process tuna line was observed to have visible product residue. After cleaning, product residues and rust were observed on knives and utensil storage boxes. These knives are used to cut raw tuna.  Peeling paint was observed directly above the in-process tuna line.  There was no hand drying devices available in the employee rest rooms on the first floor.

As disturbing as the above were the pictures posted on the FDA website that clearly should on the exterior of the boxes that Tuna Scape was supposed to be cooked, not served raw as a “sushi-like” product.

Campylobacter, E. coli and Cryptosporidium.

It has been a bad few months for raw milk hucksters and even worse for their customers.

• January to April – Campylobacter in raw milk from Organic Pastures in California – 10 Ill.

• April – E. coli O157:H7, Campylobacter and Cryptosporidium in raw milk from Foundation Farm in Oregon – 21 Ill including 4 with HUS.

• March to April – E. coli in raw milk from Stroupe Farm in Missouri – 14 Ill including 1 with HUS.

• March – Campylobacter in raw milk from Claravale Farm in California – 9 Ill.

• January to February – Campylobacter in raw milk from Family Cow Dairy in Pennsylvania – 80 Ill.

• January – Campylobacter in raw goat milk from unnamed dairy in Kansas – 18 Ill.

Raw Dairy Outbreaks and Recalls from 1998 to the present:

119 total outbreaks

86 fluid milk: 18 cow, 4 goat, 64 unspecified milk type

27 cheese: 2 aged, 3 homemade, 17 Mexican-style queso fresco, 1 goat chevre, 1 curds, 3 unspecified

6 multiple raw dairy products (fluid milk, cheese, and/or colostrum)

2,147 total illnesses, 2 deaths

1,514 fluid milk-related illnesses, no deaths: 249 cow, 63 goat, 1,202 unspecified

576 cheese-related illnesses: 46 aged, 80 homemade, 324 Mexican-style queso fresco (2 deaths), 5 goat chevre, 63 curds, 58 unspecified cheese type

57 multiple raw dairy products-related illnesses (fluid milk, cheese, and/or colostrum)

A risky elixir! For the facts about raw milk, see Real Raw Milk Facts.

Notice to Health Care Providers: 
Shiga Toxin-producing E. coli cases in Spartanburg County

The South Carolina Department of Health and Environmental Control (DHEC) is requesting heightened surveillance for persons presenting with symptoms consistent with Shiga toxin producing E. coli (i.e., enterohemorrhagic E. coli), including diarrhea that is often bloody, hemolytic uremic syndrome (HUS) in children or thrombocytopenia purpura in adults.

Summary

DHEC is investigating an outbreak of Shiga toxin-producing Escherichia coli (STEC) related to dining at a Spartanburg-area Mexican restaurant during the last week of April, 2012. Preliminary lab results indicate the E. coli serotype being O157:H7. Of the 3 cases interviewed thus far, two reported the infection has progressed to hemolytic uremic syndrome (HUS), a severe condition associated with STEC infection that can lead to kidney failure. Interviews with an additional 8 cases are in progress.

Guidance for Clinicians

Symptoms

DHEC recommends a high index of suspicion for STEC infection for patients presenting with STEC symptoms and a history of dining at a Spartanburg- area Mexican restaurant near the end of April, 2012.

Clinical syndromes associated with a Shiga toxin producing E. coli infection include

Gastroenteritis with diarrhea and abdominal cramps (fever and bloody stools may or may not be 
present), and/or Hemolytic uremic syndrome (HUS) with or without gastroenteritis, which typically develops a week after the onset of diarrhea. 
Hemolytic uremic syndrome (HUS) is characterized by the triad of acute onset of microangiopathic hemolytic anemia, renal injury, and low platelet count. Most cases of HUS occur after an acute gastrointestinal illness (usually diarrheal). 
Management 
Management of STEC is typically supportive, as most patients recover within 5-7 days. Antibiotics for gastroenteritis are generally not recommended, as there have been reports of increased incidence of post-diarrheal HUS when antibiotics are used to manage STEC infections. 
The CDC does not recommend the use of antibiotics for patients with suspected STEC infections until complete diagnostic testing can be performed and STEC infection is ruled out. However, clinical decision making must be tailored to each individual patient. There may be indications for antibiotics in patients with severe intestinal inflammation if perforation is of concern.

Testing

•  All stools submitted for testing from patients with acute community-acquired diarrhea should be cultured for STEC O157:H7. These stools should be simultaneously assayed for non-O157 STEC with a test that detects the Shiga toxins or the genes encoding these toxins.

•  Clinical laboratories should report and send E. coli O157:H7 isolates and Shiga toxin- positive samples to the SC DHEC Bureau of Laboratories (BOL) as soon as possible for additional characterization.

•  Specimens or enrichment broths in which Shiga toxin or STEC are detected, but from which O157:H7 STEC isolates are not recovered should be forwarded as soon as possible to the SC DHEC BOL so that non-O157:H7 STEC can be isolated.

•  It is often difficult to isolate STEC in stool by the time a patient presents with HUS. Immunomagnetic separation (IMS) has been shown to increase recovery of STEC from HUS patients. For any patient with HUS without a culture-confirmed STEC infection, stool can be sent to the SC DHEC BOL for IMS or to the CDC (through the BOL). In addition, serum can be sent to CDC (through the BOL) for serologic testing of common STEC serogroups. 
The benefits of adhering to the recommended testing strategy include early diagnosis, improved patient outcome, and detection of all STEC serotypes. 
Reporting of Cases 
Cases of bloody diarrhea or a clinical presentation consistent with STEC, coupled with the epidemiologic criteria described above, should be reported to your local health department via the phone numbers listed below. DHEC will arrange for collection of stool samples for testing, as appropriate. 
Any laboratory confirmed acute case associated with Shiga toxin producing E. coli or E. coli identified as serogroup O157:H7 should be reported within 24 hours to DHEC, as per the current DHEC List of Reportable Conditions.

Resources for Additional Information

•  www.about-ecoli.com

•  CDC E. coli Investigation updates (www.cdc.gov/ecoli/2011/ecoliO104/index.html)

•  CDC E. coli Resources for Clinicians (www.cdc.gov/ecoli/clinicians.htm)

•  CDC E. coli General Information (http://www.cdc.gov/nczved/divisions/dfbmd/diseases/ecoli_157h7/)

•  MMWR – “Recommendations for Diagnosis of Shiga Toxin–Producing Escherichia coli Infections by Clinical Laboratories” (www.cdc.gov/mmwr/PDF/rr/rr5812.pdf)

•  WHO E. coli Investigation updates (www.who.int/csr/don/en/index.html)

•  FoodSafety.gov (www.foodsafety.gov/) 
DHEC contact information for reportable diseases and reporting requirements 
Reporting of confirmed and suspected Shiga Toxin-producing E. coli cases is consistent with South Carolina Law requiring the reporting of diseases and conditions to your state or local public health department. (State Law # 44-29-10 and Regulation # 61-20) as per the DHEC 2011 List of Reportable Conditions available at: http://www.scdhec.gov/administration/library/CR-009025.pdf Federal HIPAA legislation allows disclosure of protected health information, without consent of the individual, to public health authorities to collect and receive such information for the purpose of preventing or controlling disease. (HIPAA 45 CFR §164.512).

CDC reports a total of 124 persons infected with outbreak strains of Salmonella Sandiego, Salmonella Pomona, and Salmonella Poona have been reported from 27 states.

The number of ill persons identified in each state is as follows: Alaska (2), Alabama (1), Arizona (3), California (21), Colorado (5), Delaware (3), Georgia (3), Illinois (1), Indiana (1), Kentucky (1), Massachusetts (3), Maryland (6), Michigan (2), Minnesota (1), Nevada (4), New Jersey (7), New Mexico (3), New York (24), North Carolina (1), Ohio (2), Oregon (1), Pennsylvania (9), South Carolina (3), Texas (12), Virginia (3), Vermont (1), and West Virginia (1).

19 ill persons have been hospitalized, and no deaths have been reported.

67% of ill persons are children 10 years of age or younger.

Two new multistate outbreaks linked to small turtles have been identified since the prior update on April 5, 2012. Overall, 5 multistate outbreaks of human Salmonella infection are linked with exposure to small turtles.

Results of the epidemiologic and environmental investigations indicate exposure to turtles or their environments (e.g., water from a turtle habitat) is the cause of these outbreaks.

75% of ill persons reported exposure to turtles prior to their illness.

Small turtles (shell length less than 4 inches) were reported by 93% of cases with turtle exposure. Forty-three percent of ill persons with small turtles reported purchasing the turtles from street vendors.

Small turtles are a well-known source of human Salmonella infections, especially among young children. Because of this risk, the Food and Drug Administration has banned the sale and distribution of these turtles as pets since 1975. Turtles with a shell length of less than 4 inches in size should not be purchased as pets or given as gifts.

On Thursday, May 10, Buncombe County Department of Health received final test results from the NC Department of Public Health laboratory confirming that the unopened bag of culture that was added to the tempeh tested positive for the matching strain of Salmonella Paratyphi B linked to the current disease outbreak.

The US Food and Drug Administration is already involved in tracing the origin of the ingredient to identify source of contamination as well as the potential for other Salmonella outbreaks in the US.

As of May 10 at 2 PM, Buncombe County Department of Health reports 58 cases associated with salmonella outbreak. Please keep in mind that this number does not include cases being reported in other counties or states.

NC Department of Public Health reports 63 cases, which includes cases in NC and other states; however there is a slight delay in reporting.