Header graphic for print

Food Poison Journal

Food Poisoning Outbreaks and Litigation: Surveillance and Analysis

RAW Meal Organic Shake & Meal Salmonella Outbreak is Over

big-map-4-21-16A total of 33 people infected with the outbreak strain of Salmonella Virchow were reported from 23 states. Among people for whom information was available, illnesses started on dates ranging from December 5, 2015 to March 18, 2016. Ill people ranged in age from less than 1 year to 84, with a median age of 35. Fifty-three percent of ill people were female. Among 27 ill people with available information, 6 (22%) were hospitalized, and no deaths were reported.

Epidemiologic and laboratory evidence indicated that RAW Meal Organic Shake & Meal products made by Garden of Life, LLC were the likely source of this outbreak.

State and local public health officials interviewed ill people to obtain information about foods they might have eaten and other exposures in the week before they became ill. Of the 30 ill people who were interviewed, 28 (93%) reported consuming powdered supplements or meal replacement powders in the week before illness onset; 27 of these 28 (96%) ill people specifically reported consuming RAW Meal products made by Garden of Life, LLC.

On January 29, 2016, Garden of Life, LLC voluntarily recalled a limited quantity of its RAW Meal Organic Shake & Meal products available in chocolate, original, vanilla, and vanilla chai because they had the potential to be contaminated with Salmonella Virchow. The recalled products were available for purchase nationwide in many retail stores and online.

The Utah Public Health Laboratory and Oklahoma Public Health Laboratory isolated the outbreak strain of Salmonella Virchow from open containers of Garden of Life RAW Meal collected from ill people’s homes in Utah and Oklahoma.  Both products that were tested were from lots covered under the recalls announced by Garden of Life, LLC.

FDA sampling confirmed the presence of the outbreak strain of Salmonella Virchow in Organic Moringa Leaf powder used in RAW Meal Organic Shake & Meal Replacement products. On February 12, 2016, Garden of Life, LLC issued an expanded recall of its RAW Meal Organic Shake & Meal products available in chocolate, original, vanilla, and vanilla chai to include additional lots that contained the contaminated Organic Moringa Leaf powder.

This outbreak investigation is over. However, the recalled products have a long shelf life and may still be in people’s homes. Consumers unaware of the recalls could continue to eat the products and get sick.

Soup Recalled Over Botulism Fears

recalled-Marys-vegetable-soupVegetable soup distributed to retailers and farmers markets in three states is under recall because laboratory tests showed it could be contaminated with Clostridium botulinum, which causes botulism poisoning.

Mary’s Home Canning of Lancaster, PA, produced the vegetable soup, which is sold in glass jars with plain black and white labels that do not include any traceability  or expiration codes, according to the recall notice on the Food and Drug Administration’s website.

“Consumers are warned not to use the product even if it does not look or smell spoiled,” according to the recall notice.

“Botulism, a potentially fatal form of food poisoning, can cause the following symptoms: general weakness, dizziness, double-vision and trouble with speaking or swallowing. Difficulty in breathing, weakness of other muscles, abdominal distention and constipation may also be common symptoms. People experiencing these problems should seek immediate medical attention.”

Retailers and farmers markets in Pennsylvania, Maryland and Delaware received the Mary’s Homemade Vegetable Soup. The labels read, in part: “Mary’s Home Made Vegetable Soup … Heat and Serve … 829-A Strasburg Road, Paradise, PA 17562.”

Inspectors with the FDA discovered the potential for Clostridium botulinum contamination when lab tests on a sample of the soup showed high pH levels, indicating inadequate time and temperature during its production.

What you need to know about hepatitis A

What is hepatitis A?

Hepatitis A is one of five human hepatitis viruses (hepatitis A, B, C, D, and E) that primarily infect the liver and cause illness. An estimated 80,000 cases occur each year in the U.S., although much higher estimates have been proposed based on mathematical modeling of the past incidence of infection. Each year, an estimated 100 persons die as a result of acute liver failure in the U.S. due to hepatitis A, but the rate of infection has dramatically decreased since the hepatitis A vaccine was licensed and became available in the U.S. in 1995.

Hepatitis A is a communicable (or contagious) disease that spreads from person-to-person. It is spread almost exclusively through fecal-oral contact, generally from person-to-person, or via contaminated food or water. Food contaminated with the virus is the most common vehicle transmitting hepatitis A. The food preparer or cook is the individual most often contaminating the food, although he or she is generally not ill at the time of food preparation. The peak time of infectivity, when the most virus is present in the stool of an infectious individual, is during the two weeks before illness begins. Although only a small percentage of hepatitis A infections are associated with foodborne transmission, foodborne outbreaks have been increasingly implicated as a significant source of hepatitis A infection.

Hepatitis A may also be spread by household contact among families or roommates, sexual contact, ingestion of contaminated water, ingestion of raw or undercooked fruits and vegetables or shellfish (like oysters), and from persons sharing illicit drugs. Children often have asymptomatic or unrecognized infections and can pass the virus through ordinary play to family members and other children and adults.

Symptoms of hepatitis A Infection

Hepatitis A infection may cause no symptoms at all when it is contracted, especially in children. Such individuals will only know they were infected (and have become immune ñ you can only get hepatitis A once) by getting a blood test later in life. The incubation period (from exposure to onset of symptoms) is 15-50 days, with an average of 30 days. Many children and most adults will experience the sudden onset of flu-like symptoms. After a day or two of muscle aches, headache, anorexia (loss of appetite), abdominal discomfort, fever and malaise, jaundice (also termed icterus) sets in. Jaundice is a yellowing of the skin, eyes and mucous membranes that occurs because bile flows poorly through the liver and backs up into the blood. The urine will turn dark with bile and the stool will be light or clay-colored from lack of bile. When jaundice sets in, the initial symptoms begin to subside.

In general, the period of acute illness lasts from 10 days to three weeks, at which time affected individuals tend to recapture some sense of wellness. It is not unusual for blood tests to remain abnormal for six months (or more), prolonging recovery for up to a year. Most affected individuals show complete recovery within three to six months of the onset of illness. Relapse is possible, and although more common in children, it does occur with some regularity in adults.

Diagnosis and treatment of hepatitis A

There are blood tests widely available to accurately diagnose hepatitis A; blood samples are tested for hepatitis antibodies, which are present when the immune system responds to the hepatitis virus. Antibodies of the immune globulin (Ig) M variety, which indicate acute disease, and IgG antibodies, which stay positive for life, should both be measured.

Hepatitis A infection is an acute self-limiting disease. There is no specific treatment; treatment and management is merely supportive. The liver function tests generally improve as the affected individual begins to feel better. It is therefore well accepted that the need for rest is best determined by the person’s own perception of the severity of fatigue or malaise.

Preventing hepatitis A Infection

Hepatitis A infection is totally preventable. Ill food-handlers should be excluded from work. Commercial food workers and other individuals who prepare food for others must always wash their hands with soap and water after using the bathroom, changing a diaper, and before preparing food. Cooking food to a temperature of 185∞F or higher will inactivate hepatitis A.

After a known exposure to hepatitis A, administration of a shot of immune globulin should be considered. If administered within two weeks of the exposure, it will usually be effective in preventing or at least ameliorating the disease.

Hepatitis A vaccine is the best protection from hepatitis A infection. The vaccine is recommended for persons traveling to areas with increased rates of hepatitis A, men who have sex with men, injecting and non-injecting drug users, persons with blood clotting factor disorders (such as hemophilia), persons with chronic liver disease, and children living in regions of the U.S. with increased rates of hepatitis A. The vaccine may also help protect household contacts of those with hepatitis A infection. Vaccination of food handlers would likely substantially diminish the incidence of hepatitis A outbreaks. The vaccine is licensed for individuals aged two and older, but there is good evidence that the vaccine is safe and effective at one year of age.

References

Advisory Committee on Immunization Practices (ACIP), Fiore AE, Wasley A, Bell BP. (2006). Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.55(RR-7):1-23.

Bialek SR, Thoroughman DA, Hu D, Simard EP, Chattin J, Cheek J, Bell BP. (2004). Hepatitis A Incidence and Hepatitis A Vaccination Among American Indians and Alaska Natives, 1990–2001. Am J Public Health. 94(6):996-1001.

Bownds L, Lindekugel R, Stepak P. (2003). Economic impact of a hepatitis A epidemic in a mid-sized urban community: the case of Spokane, Washington. J Community Health. 28(4):233-246.

Butot S, Putallaz T, Sánchez G. (2008). Effects of sanitation, freezing and frozen storage on enteric viruses in berries and herbs. Int J Food Microbiol. 126(1-2):30-35.

Calder L, Simmons G, Thornley C, Taylor P, Pritchard K, Greening G, Bishop J. (2003). An outbreak of hepatitis A associated with consumption of raw blueberries. Epidemiol Infect. 131(1):745-751.

Centers for Disease Control and Prevention (2009a). Disease Burden from Viral Hepatitis A, B, and C in the United States. Available at http://www.cdc.gov/hepatitis/PDFs/disease_burden.pdf).

Centers for Disease Control and Prevention (2009b). Surveillance for Acute Viral Hepatitis—- United States, 2007. Surveillance Summaries. 58 (SS03):1-27.

Centers for Disease Control and Prevention (2009c). Hepatitis A. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, McIntyre L, eds. 11th ed. Washington DC: Public Health Foundation, pp. 85-97.

Centers for Disease Control and Prevention (2009d). Updated recommendations from the Advisory Committee on Immunization Practices (ACIP) for use of hepatitis A vaccine in close contacts of newly arriving international adoptees. Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 58(36):1006-7.

CDC (2007). Update: Prevention of Hepatitis A after Exposure to Hepatitis A Virus and in International Travelers. Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 56(41);1080-1084.

Detry O, De Roover A, Honore P, Meurisse M. (2006). Brain edema and intracranial hypertension in fulminant hepatic failure: pathophysiology and management. World J Gastroenterol. 12: 7405-7412.

Feldman, M, Friedman, LS, Sleisenger, MH. (2002). Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. [2-volume set]. St. Louis, MO: Saunders. 80: 1571.

Fiore, AE. ( 2004). “Hepatitis A Transmitted by Food.” Clinical Infectious Diseases. 38:705-715.

Gilkson M, Galun E, Oren R, Tur-Kaspa R, Shouval D. (1992). Relapsing hepatitis A. Review of 14 cases and literature survey. Medicine. 71:14-23.

Hutin YJF, Pool V, Cramer EH, et al. (1999). A multistate, foodborne outbreak of hepatitis A. N Engl J Med. 340:595–602.

Jaykus L. (1997). Epidemiology and Detection as Options for Control of Viral and Parasitic Foodborne Disease. Emerg Infect Dis. 3(4):529-539.

Mayo Clinic. (2009). Hepatitis A. Available at http://www.mayoclinic.com/health/hepatitis-a/DS00397.

Piazza M, Safary A, et al. (1999). Safety and immunogenicity of hepatitis A vaccine in infants: a candidate for inclusion in the childhood vaccination program. Vaccine. 17:585-588.

Rawls RA and Vega KJ (2005). Viral Hepatitis in Minority America. J Clin Gastroenterol. 39:144–151.

Sagliocca L, Amoroso P, et al. (1999). Efficacy of hepatitis A vaccine in prevention of secondary hepatitis A infection: A randomized trial. Lancet. 353:1136-39.

Scharff RL, McDowell J, Medeiros L. (2009). Economic Cost of Foodborne Illness in Ohio. J Food Prot. 72(1):128-136.

Schiff ER. (1992). Atypical Manifestations of hepatitis-A. Vaccine. 10(Suppl. Vol. 1): 18-20.

Taylor R, Davern T, Munoz S, Han S-H, McGuire B, Larson AM, et al. (2006). Fulminant hepatitis A virus infection in the United States: incidence, prognosis, and outcomes. Hepatology. 44:1589-1597.

Todd EC, Greig JD, Bartleson CA, Michaels BS. (2009). Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 6. Transmission and survival of pathogens in the food processing and preparation environment. J Food Prot. 72(1):202-219.

Wheeler C, Vogt TM, Armstrong GL, et al. (2005). An Outbreak of Hepatitis A Associated with Green Onions. N Engl J Med. 353: 890-897.

Willner IR, Uhl MD, Howard SC, Williams EQ, Riely CA, Waters B. (1998). Serious hepatitis A: an analysis of patients hospitalized during an urban epidemic in the United States. Ann Intern Med. 128:111-114.

CDC: We Need Bacterial Cultures to Catch Foodborne Outbreaks

p0414-foodborne-illness-test-400pxChanges in the tests that diagnose foodborne illness are helping identify infections faster but could soon pose challenges to finding outbreaks and monitoring progress toward preventing foodborne disease, according to a report published today in CDC’s Morbidity and Mortality Week Report.

Culture-independent diagnostic tests (CIDTs) help doctors diagnose infections quickly because they provide results in hours instead of the days needed for traditional culture methods, which require growing bacteria to determine the cause of illness. But without a bacterial culture, public health officials cannot get the detailed information about the bacteria needed to help find outbreaks, check for antibiotic resistance, and track foodborne disease trends.

In 2015, the percentage of foodborne infections diagnosed only by CIDT was about double compared with the percentage in 2012-2014.

“Foodborne infections continue to be an important public health problem in the United States,” said Robert Tauxe, M.D., M.P.H, director of CDC’s Division of Foodborne, Waterborne and Environmental Diseases. “We are working with partners to make sure we still get important information about harmful bacteria despite the increasing use of diagnostic tests that don’t require a culture.”

The increased use of CIDT could affect public health officials’ ability to monitor trends and detect outbreaks. In the short term, clinical laboratories should work with their public health laboratories to make sure a culture is done whenever a CIDT indicates that someone with diarrheal illness has a bacterial infection. For a long-term solution, CDC is working with partners to develop advanced testing methods that, without culture, will give health care providers information to diagnose illness and also give the detailed information that public health officials need to detect and investigate outbreaks.

Limited progress in reducing foodborne illness

The report included the most recent data from CDC’s Foodborne Diseases Active Surveillance Network, or FoodNet. It summarizes preliminary 2015 data on nine germs spread commonly through food. Overall, progress in reducing rates of foodborne illnesses has been limited since 2012, according to the report. The most frequent causes of infection in 2015 were Salmonella and Campylobacter, which is consistent with previous years.

Other key findings from the FoodNet report include:

  • The incidence of Salmonella Typhimurium infection, often linked to poultry and beef, decreased 15 percent from 2012-2014 levels.
    • This decline may be due in part to tighter regulatory standards and vaccination of chicken flocks against Salmonella.
  • The incidence of some infections increased:
    • Reported Cryptosporidium infections increased 57 percent since 2012-2014, likely due to increased testing for this pathogen.
    • Reported non-O157 Shiga toxin-producing Escherichia coli (STEC) infections increased 40 percent since 2012-2014. Quicker and easier testing likely accounted for some or all of this increase.

FoodNet has been monitoring illness trends since 1996. FoodNet provides a foundation for food safety policy and prevention efforts because surveillance data can tell us where prevention efforts are needed to reduce foodborne illnesses.

CDC is working with federal, state, and local partners, and the food industry to improve food safety. New regulations and continuing industry efforts are focusing on challenging areas. USDA has made improvements in its poultry inspection and testing models and has tightened standards for both Salmonellaand Campylobacter in poultry.

“In 2013, we launched a series of targeted efforts to address Salmonella in meat and poultry products, known as the Salmonella Action Plan, and recent data show that since then the incidence of Salmonella Typhimurium infection has dropped by 15 percent,” said USDA Deputy Undersecretary for Food Safety, Al Almanza. “However our work is not done. The newly published performance standards for poultry parts will lead to further Salmonellareductions and fewer foodborne illnesses.”

In 2015, FDA published new rules to improve the safety of the food supply including produce, processed foods, and imported foods.

Dr. Kathleen Gensheimer, MD, MPH, director of the FDA’s Coordinated Outbreak Response and Evaluation team and Chief Medical Officer, Foods and Veterinary Medicine Program, said, “We want to respond quickly to foodborne illness, but our true goal is to move forward with preventive measures that will be implemented from farm to table. In addition to collaboration with other government agencies at the local, state and federal level, the rules we are implementing under the FDA Food Safety Modernization Act will help the food industry minimize the risk of contamination to our food supply.”