Header graphic for print

Food Poison Journal

Food Poisoning Outbreaks and Litigation: Surveillance and Analysis

Wisconsin Issues “Cannibal” or “Tiger Meat” Sandwich Warning

Health Agency Warns Against Consuming Raw or Undercooked Meat – Advisory includes traditional raw meat sandwiches

If you are among the Wisconsin residents who consider raw ground beef sandwiches (known as “Cannibal” or “Tiger Meat” sandwiches) a holiday tradition, the Department of Health Services (DHS) wants to remind you that consuming raw or undercooked meat can be dangerous to your health.

Cannibal or Tiger Meat Sandwiches typically consist of raw ground beef topped with salt, pepper and onions, served on rye bread or crackers. Historically in Wisconsin, consumption of these sandwiches has led to outbreaks of E. coli O157:H7 and Salmonella infections, including an outbreak that involved 150 people in 1994. Outbreaks have also been reported in 1986, 1988, 1989, 1990, 1994, 2012 and 2013. Raw beef can also contain other bacteria, including Campylobacter and Listeria. Regardless of where your beef is purchased, eating it raw is always risky.

“We strongly discourage state residents from eating raw or undercooked ground beef. Older adults, pregnant women, children, and people with weakened immune systems are at even greater risk of illness from germs found in raw or undercooked meat”, said State Health Officer Karen McKeown. DHS urges those who are cooking any meat to use a meat thermometer. Color is not a reliable indicator that meat is properly cooked.

Follow these guidelines to avoid illness from the meat you prepare and serve:

  • Wash hands thoroughly with warm water and soap before and after handling raw meat.
  • Cook all meat, poultry and wild game to the proper internal temperature (link is external)
    and use a meat thermometer. Don’t use color as an indicator that meat has reached a safe temperature.

    • Cook ground meat and meat mixtures (e.g., ground beef, pork, veal, lamb) to 160°F.
    • Cook all whole cuts of beef, pork, veal, and lamb to 145°F plus a 3 minute rest.
    • Cook all poultry (e.g., chicken, turkey, duck) and wild game meat to 165°F.
  • Frozen meat should be cooked one and a half times longer than it takes to prepare thawed food. Whole turkey is an exception, as it must be completely thawed before cooking.
  • Eating raw or undercooked wild game meat can also result in illness, including Salmonella, Trichinella, and E. coli infections.
  • Keep raw meat away from other foods that will not be cooked.
  • Wash all work surfaces, cutting boards, and utensils with hot soapy water.
  • Divide leftovers into small portions so they will cool more quickly and put them in the refrigerator as soon as possible. Don’t cool leftovers on the kitchen counter.
  • Cover leftovers to reheat. This helps maintain moisture and ensures the meat is heated all the way through.

Symptoms of foodborne illness can include nausea, vomiting, diarrhea, abdominal cramps, and fever. Contact your healthcare provider if you become ill, especially if you experience diarrhea that lasts more than a few days or is bloody, or if you develop a high fever.

E. coli O26 and O45 Tests Prompt Veal Recall

Gold Medal Packing Inc., a Rome, N.Y. establishment, is recalling approximately 4,607 pounds of boneless veal products that may be contaminated with E. coli O26 and O45, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today.

Screen Shot 2016-12-23 at 4.01.50 PMThe veal trim and top bottom sirloin (TBS) products were produced and packaged on August 16, 2016, and October 25, 2016. The following products are subject to recall:

  • 60-lb. boxes containing “BONELESS VEAL”.
  • 2,387-lb. bin containing “TBS”.

The products subject to recall bear establishment number “EST. 17965” inside the USDA mark of inspection. The “BONELESS VEAL” items were shipped to a warehouse in California and the “TBS” items were shipped to distributor locations in Pennsylvania.

The problem was discovered during routine sample testing. There have been no confirmed reports of illness or adverse reactions due to consumption of these products.

Many clinical laboratories do not test for non-O157 Shiga toxin-producing E. coli (STEC), such as STEC O26 or O45, because they are harder to identify than STEC O157. People can become ill from STECs 2–8 days (average of 3–4 days) after consuming the organism. Most people infected with STEC O26 or O45 develop diarrhea (often bloody), and vomiting. Some illnesses last longer and can be more severe. Infection is usually diagnosed by testing of a stool sample. Vigorous rehydration and other supportive care is the usual treatment; antibiotic treatment is generally not recommended.

Most people recover within a week, but, rarely, some develop a more severe infection. Hemolytic uremic syndrome (HUS) is uncommon with STEC O26 or STEC O45 infections. HUS can occur in people of any age but is most common in children under 5 year’s old, older adults and persons with weakened immune systems. It is marked by easy bruising, pallor, and decreased urine output. Persons who experience these symptoms should seek emergency medical care immediately

FSIS and the company are concerned that some product may be frozen and in consumers’ freezers.

Consumers who have purchased these products are urged not to consume them

Salmonella in Powdered Milk Prompts Pork Skin Recall

Screen Shot 2016-12-22 at 5.59.08 PMPork Rinds & Snacks, LLC, a Spartanburg, S.C. establishment, is recalling approximately 7,629 pounds of pork skin products that may be contaminated with Salmonella, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today.

The ready-to-eat pork skin items were produced on various dates between Sept. 27, 2016 and Dec. 13, 2016. The following products are subject to recall:

  • 4022 lbs. of 9/16 oz. plastic packages containing “WALLACE’S OLD FASHIONED FRIED PORK SKINS FLAVORED WITH Salsa & Sour Cream SEASONING CHICHARRONES” with Best By dates ranging from “JAN 05 17” to “MAR 23 17.”
  • 3208-lbs. of 1.5 oz. plastic packages containing “WALLACE’S OLD FASHIONED FRIED PORK SKINS FLAVORED WITH SALSA & SOUR CREAM SEASONING CHICHARRONES” with Best By dates ranging from “JAN 05 17” to “MAR 23 17.”
  • 399-lbs. of 9/16 oz. plastic packages containing “COUNTRY TIME Old Fashioned Fried PORK SKINS CHICHARRONES SALSA & SOUR CREAM FLAVOR” with Best By dates ranging from “JAN 05 17”to “MAR 23 17.”

The products subject to recall bear establishment number “EST. M00888” inside the USDA mark of inspection. These items were shipped to retail locations in Florida, Georgia, North Carolina, South Carolina and Virginia.

The problem was discovered when the company’s seasoning supplier notified the company that the seasoning mix contained milk powder recalled by Valley Milk Products. Valley Milk Products recalled nonfat high heat milk powder and sweet cream buttermilk powder products on December 9, 2016, due to potential Salmonella contamination. For details on that recall please see Valley Milk Products Recalls Milk and Buttermilk Powder Because of Possible Health Risks.

There have been no confirmed reports of illness or adverse reactions due to consumption of these products.  Anyone concerned about an injury or illness should contact a healthcare provider.

Consumption of food contaminated with Salmonella can cause salmonellosis, one of the most common bacterial foodborne illnesses. The most common symptoms of salmonellosis are diarrhea, abdominal cramps, and fever within 12 to 72 hours after eating the contaminated product. The illness usually lasts 4 to 7 days. Most people recover without treatment. In some persons, however, the diarrhea may be so severe that the patient needs to be hospitalized. Older adults, infants, and persons with weakened immune systems are more likely to develop a severe illness. Individuals concerned about an illness should contact their health care provider.

Consumers who have purchased these products are urged not to consume them.

Carbon E. coli Outbreak: 69 confirmed cases and 37 probable cases, 16 of the 40 food handlers tested positive for E. coli, was it Cilantro?

Carbon-thumb-640xauto-954656Introduction. On June 28, 2016, the Chicago Department of Public Health (CDPH) received five reports of Shiga Toxin-producing Escherichia Coli (STEC)1 through routine surveillance. By June 29, routine interviews conducted by the CDPH Communicable Disease (CD) Program revealed that three of the five cases reported consuming food items from Carbon (Restaurant A) within 2-3 days before illness onset. That evening, three separate hospitals reported an increase in the number of patients that presented to the ED with complaints of diarrhea and had preliminary positive STEC diagnostic laboratory tests. By July 1, seven cases reported eating at Restaurant A prior to their illness onset.

Carbon Final Outbreak Summary – City of Chicago Dept. of Public Health

Restaurant. Restaurant A has two Chicago locations, one on the south side and another on the west side of the city. The restaurant is open 7 days a week and serves Mexican-style foods. Both locations serve the same menu and use the same food suppliers. The majority of food preparation is performed out of the south side location; most food for the west side location is transported after preparation at the south side kitchen. Catering is also available. Overall, approximately 40% of food orders are placed by phone or through online ordering websites (i.e. GrubHub, Eat24, etc.) for delivery or pickup. Catering and other delivery orders are prepared in the same kitchen and by the same staff as dine-in orders at both locations. Staff members at each location reported regularly consuming restaurant food.

Epidemiological investigation. Case finding was conducted through public messaging and disease surveillance. On June 30, 2016, CDPH issued a health alert to all Chicago hospitals to notify them of the outbreak, to request prompt reporting of STEC cases, and to discourage use of antibiotics and encourage aggressive hydration if suspecting a diagnosis of STEC. Concurrently, the Illinois Department of Public Health (IDPH) issued an alert via the Food borne Outbreak Network to state health departments to notify them of any STEC cases with travel to Chicago and mention of Restaurant A.

A standard questionnaire was created to collect information about signs and symptoms of illness, food consumption and other potential exposures occurring in the seven days prior to the case’s onset of illness, and meal companions. A case-control study was conducted to determine risk factors for infection with STEC. Case definitions were in accordance with the Centers for Disease Control and Prevention (CDC) and Council of State and Territorial Epidemiologists standards2. A confirmed case was defined as isolation of E. coli O157:H7 (STEC) from a clinical specimen in a person with illness onset between June 3-July 23, 2016, with either reported exposure to Restaurant A or a pulsed-field gel electrophoresis (PFGE) pattern indistinguishable from one of 14 patterns associated with the outbreak. Confirmed cases with reported Restaurant A exposure and onset dates that preceded others within their household were considered confirmed primary cases. A probable case was defined as a person with clinically compatible illness (bloody diarrhea or ~3 days of diarrhea with ~3 stools in a 24-hour period) in the absence of laboratory confirmation, and exposure to Restaurant A or shared household with a primary case. Secondary cases were defined as household contacts of primary confirmed or probable cases, with onset of diarrhea one to eight days after the primary case’s symptom onset date. Case-control analysis was limited to primary confirmed cases and well controls. To identify controls, CD Program staff asked confirmed cases about their meal companions and obtained a list of individuals who placed orders through the online delivery service GrubHub. Controls were frequency matched 4:1 to cases by meal date (June 17th-June 30th) and restaurant location.

Contingency tables were arranged to evaluate the bivariate relationships between case status and individual food items, and odds ratios (OR) with 95% confidence intervals {95% Cl) were estimated for each. Chi-Square tests were performed to identify statistically significant associations, except when expected cell counts were less than or equal to 5, in which case Fisher’s Exact test was used. P-values <0.05 were considered statistically significant. The independent effects of variables found to be significantly associated with disease in the bivariate analyses were further evaluated using multivariable logistic regression, adjusted for age and gender. All statistical analyses were carried out with SAS version 9.3 (SAS Institute, Cary, NC).

Environmental investigation. On July 1, 2016, the Food Protection Division (FPD) conducted an environmental inspection of Restaurant A and collected the following: food samples, initial information about restaurant employees and food preparation, and copies of invoices for food items. Food items collected included steak, chicken, cilantro, elote (corn), elote mix, cheese, sour cream, grilled corn & pineapple salsa, salsa fresca, tequila lime sauce, red and green salsas. CD Program staff performed in depth interviews of the owners of the restaurant and employees. Because employees at both locations often functioned in multiple roles, all on-site restaurant employees were considered food handlers for the purposes of this outbreak investigation. Food handlers were asked to submit stool specimens to screen for STEC.

Laboratory investigation. Clinical culture or polymerase chain reaction tests were performed by hospital and commercial laboratories and results were reported to the CD program. Specimens from cases, food handlers, and food were sent to the Illinois Department of Public Health Division of Laboratories for culture, and for serotyping and PFGE analysis of STEC isolates. PFGE patterns were uploaded to the national Pulse Net database and compared by the Centers of Disease Control (CDC). Sixteen isolates selected to represent all outbreak-associated PFGE patterns and a variety of source patients (primary and secondary cases as well as food handlers), restaurant locations, and meal dates were sent to CDC for characterization by multiple locus variable number of tandem repeats analysis (MLVA).

Epidemiologic findings. Sixty-nine confirmed and 37 probable cases were identified as part of this outbreak. Among the confirmed, 55 met the primary case definition, four were secondary cases, and ten of the confirmed cases matched the outbreak PFGE pattern but their association with the restaurant was not identified (five denied eating at the restaurant and five were unable to locate). One additional case, identified after the restaurant closure and reopening, was unable to be classified due to multiple

Restaurant A meal dates and a PFGE pattern that was similar but not identical to other outbreak patterns. Illness onset dates of the 55 confirmed primary cases ranged from June 19-July 3.

Median age was 29 years (range, 3 to 69 years); 29 (53%) of the cases were female. Median incubation period was 3 days (range 12 hours-5 days). Twenty-one primary and one secondary case were hospitalized. No cases developed hemolytic uremic syndrome, and none died. Among the 55 confirmed primary cases, 50 (91%) ate at the south side location (meal date range 6/17 to 6/30) and 5 (9%) ate at the west side location (meal date range 6/19 to 6/26).

Multiple food items were associated with illness on bivariate analysis (Table 1) including consumption of cilantro (odds ratio [OR] 3.5, 95% Cl: 1.5-8.1), salsa fresca (OR 3.1, 95% Cl: 1.6-6.1), chicken taco (OR 3.1, 95% Cl: 1.6-6.0), and lettuce (OR 2.01, 95% Cl: 1.1-3.8). Multivariable analysis using logistic regression (Table 2) revealed that consumption of cilantro (adjusted OR [aOR] 4.64, 95% Cl: 1.87-12.011.6), salsa fresca (aOR 2.85, 95% Cl: 1.31-6.05.4), and lettuce (aOR 2.57, 95% Cl: 1.23-5.26) remained independently associated with illness after adjusting for age and gender. The observed epidemiologic association with chicken tacos may reflect collinearity between chicken tacos and cilantro, meaning that an association was identified because the chicken tacos are prepared and served with raw cilantro. All cases who reported eating a chicken taco also reported eating cilantro. Other chicken-containing items (e.g., chicken burritos, chicken salad bowls) were not associated with illness. Because salsa fresca was known to contain raw cilantro, an additional multivariable logistic regression analysis was performed including a combined variable indicating consumption of either cilantro or salsa fresca. In this model, consumption of cilantro or salsa fresca was associated with an adjusted odds ratio of 6.9 [Cl: 2.0-24.0]

Lettuce was associated with illness in both multivariable models but was consumed by only 44% of cases. In comparison, cilantro was consumed by 87% of cases, and either cilantro or salsa fresca were consumed by 95% of cases.

Environmental findings and food handler interviews. Meats, salsas, and marinades were fully or partially prepared at the south side location and transported daily to the west side location. Most fresh produce items, including cilantro and lettuce, were received by each location in separate deliveries and chopped and prepared on-site. Several critical violations were identified during the sanitarians’ inspection of Restaurant A on July 1, including improper temperatures for several food items (i.e. red & green salsas, tequila lime sauce, raw fish, guacamole, and cheese), and improper hand hygiene practices among food handlers. Because of concern for a potential ongoing public health threat associated with food served by Restaurant A, CDPH recommended that the restaurant voluntarily cease operations and withdraw from a large outdoor food festival until more information about the source of the contamination was known. The owner agreed, and Restaurant A voluntarily closed both locations. CD staff subsequently interviewed and tested forty food handlers from both locations. According to the restaurant owner, there was no cross-over of food handlers at the two locations. Among the forty food handlers interviewed none reported any history of gastrointestinal illness in the two weeks preceding or during the outbreak period, though absenteeism was reported for one. Nearly all food handlers had stool tests performed within one week after the restaurant closure.

Laboratory findings. Specimens from 69 cases and 16/40 (40%) food handlers yielded STEC isolates. From primary case isolates, 10 PFGE patterns were identified. An additional four similar patterns were identified among food handler isolates. The 16 isolates analyzed by MLVA displayed four unique MLVA patterns. One predominant MLVA pattern was shared by 10 isolates. Food handler and case isolates displayed a variety of MLVA patterns, with some food handlers sharing MVLA patterns indistinguishable from restaurant patrons despite differing PFGE patterns. There were no distinct pattern groupings according to restaurant location. None of the 12 food items cultured were positive for STEC.

Food product traceback. In collaboration with CDPH, FPO and IDPH department of Food, Drugs and Dairy, invoices collected from the restaurant for the outbreak period meal dates were reviewed. Cilantro was purchased from a distributor serving multiple other restaurants throughout Illinois. The distributor repackaged cilantro from multiple sources, including suppliers in Mexico and Illinois. Of the five laboratory-confirmed cases who denied Restaurant A exposure, none reported cilantro consumption, although cooperation with re-interview was limited. In the absence of confirmed cases reporting consumption of implicated food items from another restaurant, it was not possible to perform further traceback to assess for a common source of contamination. No other restaurants serviced by the distributor were linked to the outbreak.

Re-inspection and reopening. FPO performed re-inspections at both locations, during which instruction and guidance were provided on hand hygiene and it was ensured that food preparation and storage areas were adequately sanitized. Only food workers who had two consecutive negative tests for STEC were permitted to work at the reopened locations, which delayed reopening of the south side location. After passing FPO re-inspections, the south and west side restaurants re-opened on July 9 and 29, respectively.

An additional case of STEC was subsequently identified with a meal date of July 11, 2016 at the reopened west side location, prompting imposed restriction of all food handlers who had been involved with preparation of the case’s meal. All of these food handlers and the case’s meal companions were tested for STEC, with negative results. The case had also eaten food from the restaurant on June 21 with a household member, prior to the restaurant’s closing; neither reported symptoms of illness at that time. PFGE analysis revealed an additional pattern not previously identified in this outbreak, but which appeared related to other outbreak patterns. Because of the multiple meal dates, negative test results of all meal companions and involved food handlers, and absence of additional reported restaurant-associated cases after the re-opening, we could not definitively determine if the case was primary, secondary or unrelated. Food handlers were permitted to return to work after repeated negative test results. No additional complaints were received in association with the restaurant in the two months following this case’s illness onset

Conclusion. This was a large restaurant-associated outbreak of Shiga toxin-producing E. coli O157:H7 infections. Closure of the restaurant during the early stage of the investigation prevented additional cases of illness from occurring. Cilantro was the most likely food-vehicle causing this outbreak, based on the strong statistical association of raw cilantro consumption with illness, and the high percentage of cases explained by cilantro consumption. The large number of PFGE patterns associated with the outbreak was suggestive of a heavily contaminated food item rather than introduction from a point source such as an ill food worker at the restaurant. However, STEC was not isolated from cilantro or cilantro-containing food items collected from the restaurant or the restaurant’s distributor. Inability to isolate STEC from food samples may have been hindered by imperfect sensitivity of testing, imperfect representativeness of food samples, or turnover of produce items through the distribution chain leading to items no longer being contaminated at the time of collection. Additionally, cross-contamination during food preparation and transmission by food handlers who were found to have STEC infection likely contributed to the outbreak.

_________________

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.