The silence from the leafy greens lobby is deafening: A tale of two women with E. coli

Maggie Menditto, the executive administrator of the McDowell Foundation for social justice, writes in the New York Times that before my illness, I was a healthy 22-year-old just out of college. But at some point, my doctors speculated, I must have eaten leafy greens contaminated by E. coli bacteria.

My mother had driven me to my local emergency room in the middle of the night after several days of unbearable abdominal cramps and a startling amount of blood coming out of new and terrifying places. The doctor on call thought it was probably just a bad case of colitis.

As the sun began to rise, I was asked if I’d like to go home and take Imodium or if I’d like to stay in the hospital. Given the severity of my pain, I was surprised that I was even given a choice. I allowed myself to be wheeled upstairs with a needle in my vein administering a steady stream of antibiotics, a common treatment for colitis.

But that weekend, I took a turn for the worse, throwing up every hour until there was nothing left in my system but sticky green bile. An infectious disease doctor was called in, my stool sample tested, and I was finally given a diagnosis of E. coli infection.

Doctors don’t know for sure how I became infected with E. coli — at the time, last October, the outbreak tied to romaine lettuce was still several months in the future — but we do have some clues. I’m a vegetarian, so we know it didn’t come from eating meat. Although none of my family members got sick, my father also tested positive for E. coli. The only food we remembered sharing was a batch of arugula from a local farmers’ market about five days before I became ill, making it the most likely culprit.

The antibiotics were immediately stopped, as they have been linked to an increased likelihood of developing dangerous complications from the bacterial infection. But by then the signs were already beginning to show. My platelet count was dropping at a dangerous rate, my kidney function had begun to falter. I had developed hemolytic uremic syndrome, a life-threatening complication of E. coli infection.

I was treated to the first ambulance ride of my life to transfer to Georgetown University Hospital, where I would remain hospitalized for the next 33 days.

In the critical care unit, I was strapped into several machines that would monitor my vitals. The next morning, a doctor came in and inserted a temporary access catheter into the right side of my neck. I was wheeled down to a lower level of the hospital for the first of my six plasmapheresis treatments, a particularly draining experience in which blood was removed, cleaned and then returned to my body via a large tube in my neck.

A team of hematologists, nephrologists, infectious disease specialists and a general physician visited every morning. They’d ask, “How are you feeling, Frances?”

Everyone knows me as Maggie, but in an annoying quirk of my hospitalization, my medical records and wristband all bear my legal name, Frances. “One name for each grandmother,” my mom reasoned when my parents decided to christen me Frances Margaret. An unintended consequence of their thoughtfulness is that I have spent much of my life correcting people who called me Frances. “It’s Maggie, short for Margaret, my middle name,” I said.

But in the hospital, it helped to have a second persona. Frances put on a brave face during the hours of treatment in sterilized facilities, while Maggie drew inward, refusing books and music or anything else that reminded me of who I was outside the hospital walls. From where I sat, pinned to machines by the needles in my veins, in a body I hardly recognized, and with a label on my wrist displaying a name that wasn’t mine, I couldn’t be sure that it was me this was really happening to. I listened patiently as doctors and nurses and technicians came into my room to offer Frances their well wishes, draw blood, or discuss what medications she should take or what procedures might make her body strong once more.

During my first week of hospitalization, the kidney doctors debated whether to begin the dialysis process, sticking to the typical “wait-and-see” approach. But by the end of the week there was no question. I had gained 30 pounds from all the excess fluid and could hardly stand up and walk on my own. I began my first of many three-hour-long dialysis treatments, where they siphoned off the liquid, doing the work of my kidneys that I had so long taken for granted.

I had mostly avoided social media since getting sick, but one day, I logged onto Facebook to see that across the country, people I knew and people I didn’t — a pair of girls I once babysat for, a football team in Rhode Island — were praying for Maggie, hoping Maggie pulled through. The more people that worried about me, the sicker I must be, I thought.

The dialysis continued for three weeks with tiny but measurable results. My platelet counts began to climb, and I started to pee again. But it wasn’t enough to impress the nephrologists, who decided to surgically place a catheter in my chest, to both drain and administer fluids.

Doctors began discussing a kidney transplant and temporary home-care dialysis training. I was sent home for a weekend to rest up before my first training for an eventual dialysis machine to be brought to my parents’ house, but we didn’t get that far. I went to bed after dinner and woke up in an ambulance racing back to the hospital I had just left. My blood pressure had begun a dangerous rise as my kidneys began to start working again, and I had the first of three seizures that night.

The next few days are mostly lost from memory, but some hazy images survive. Waking up in a tube to discover I was getting an M.R.I. A nurse delicately pulling glue from my hair from where the technicians had inserted sensors. My hospital bed being wheeled out of the operating room after the catheter was removed from inside my chest. The sharp lines of the white hallway walls, every corner offering a shadowy descent into someone else’s hospital story.

Through my half-closed lids, I see a rare pocket of sunlight at the end of the corridor. Briefly I feel the warmth of its gaze as we trek on through the seemingly endless maze of the hospital’s hallways and locked doors. The dryness in my mouth is the first clue that I’m back in my body, that my kidneys have begun to heal themselves at an admirable pace.

My mom finds me soon after, as I’m attempting to drink water from a clear plastic straw. She reaches out and holds it in place. The nurse comes in to tell us that it all went well, that Frances’s vitals look good, that we’ll be ready to transfer her back upstairs soon.

“She goes by Maggie,” my mom says.

“Oh, I’m sorry,” the nurse says, glancing down at her chart before stepping back into the hall, “Maggie.”

I turn to smile at my mom. It doesn’t matter what they call me anymore. She holds my hand as we’re guided back upstairs to my hospital room for the last time.

Sometimes now, in my apartment, on the train, while walking down a crowded street, I like to run my fingers over the fresh scars lining my collarbone. Now that the toxins have left my system, now that my body has built itself back up, I have only the scars to remind me that Frances was tested, that Maggie survived. That it really happened to me.

Altoona, Penn. Area High School student Mia Zlupko was shocked when doctors told her some scary news.

“All the doctors came in, and it was kind of like a big surprise like ‘It’s E. coli,'” Mia said.

The 16-year-old is a dancer who enjoys eating healthy. It’s not uncommon for her to grab a salad from the store, which is exactly what she did earlier this month. However, after eating it she became sick and was throwing up with abdominal pain.

“It was a scary process and I wouldn’t want to go through it again,” she said. “I know everyone else wouldn’t want to go through it.”

After four days in the hospital no one could figure out what exactly was wrong.

Just as Mia was heading home she learned her diagnosis. A relief for her mom Tina.

“Had we not gone back to the doctor and then gone to the emergency room, she could have gotten much sicker very quickly,” Tina Zlupko explained.

Now the teen is hoping to share an important message with others so no one else has to go through what she did.

“I’m definitely more aware and I want other people to be aware about it,” Mia said.

The CDC advisory now includes chopped and bagged romaine lettuce, as well as whole heads and hearts of romaine lettuce.

So far at least 64 people have been infected in 16 states. Pennsylvania is one place that has been hit the hardest with at least 12 people infected.

Officials think the outbreak is coming from Yuma, Arizona. They warn people not to eat any romaine lettuce unless you know where it’s from.

Always use a thermometer: 244 sickened by shiga toxin-producing E. coli at US Marine training base

In Nov. 2017, over 200 U.S. Marines-in-training were sickened by shiga-toxin producing E. coli at Marine Corps Recruit Depot San Diego and Camp Pendleton.

That outbreak was blamed on undercooked beef prepared by a civilian contractor, according to the results of an investigation.

First rule of public health (substitute military or any other organization): make public health look good.

According to Healio, the outbreak occurred in October and November among newly enlisted men at Marine Corps Recruit Depot, San Diego, and Camp Pendleton, a nearby base where recruits conduct weapons and field training, according to Amelia A. Keaton, MD, MS, EIS officer in the CDC’s Outbreak Response and Prevention Branch.

The outbreak involved Shiga toxin-producing E coli (STEC) — a major cause of foodborne illness in the United States each year and the pathogen responsible for the current multistate outbreak of E. coli linked to romaine lettuce. In all, 244 male recruits are suspected of being sickened, including 15 who developed a life-threatening complication of STEC infections called hemolytic uremic syndrome (HUS). Among those who developed HUS, six were deemed critically ill but none died, Keaton told Infectious Disease News during the CDC’s annual EIS conference.

She said the outbreak presented several challenges for investigators and highlighted some unique risk factors among military trainees living in close quarters.

“Nobody on our team had a military background, so we first wanted to understand what their training environment is like,” Keaton said. “Do they have any unique exposures that people in the general public don’t have? We wanted to get a sense of what day-to-day life was like for these guys and what risk factors for infection they were exposed to.”

Keaton and colleagues interviewed 43 case patients and 135 healthy controls, plus Marine officers, food workers and staff. They observed food preparation practices and studied recruit sleeping quarters, bathroom facilities and cafeterias where meals were served to around 2,000 to 3,000 recruits at a time, Keaton said.

Although they were unable to directly test any meat, through interviews investigators found that ill recruits were 2.4 times likelier to report consuming undercooked beef than healthy controls. Moreover, Keaton said investigators directly observed beef being undercooked.

According to Keaton, most dining facilities on military bases are run by civilian contractors, including the facilities involved in this outbreak, which offered the same menu prepared by the same company. The Navy is in charge of inspecting such facilities once a month, she said.

“A lot of people reported eating meals that were visibly undercooked,” Keaton said. “When we observed food preparation, we saw that food workers were cooking a large number of hamburger patties and a large number of meals. Because such a large number of meals are being prepared, they’re only able to check foods intermittently with a meat thermometer. In some instances, we saw there were temperature abuses where they weren’t necessarily cooking to temperatures recommended by California state law.”

The role of meat in foodborne disease

Meat has featured prominently as a source of foodborne disease and a public health concern. For about the past 20 years the risk management paradigm has dominated international thinking about food safety. Control through the supply chain is supported by risk management concepts, as the public health risk at the point of consumption becomes the accepted outcome-based measure.

Foodborne pathogens can be detected at several points in the supply chain and determining the source of where these pathogens arise and how they behave throughout meat production and processing are important parts of risk-based approaches. Recent improvements in molecular and genetic based technologies and data analysis for investigating source attribution and pathogen behaviour have enabled greater insights into how foodborne outbreaks occur and where controls can be implemented. These new approaches will improve our understanding of the role of meat in foodborne disease and are expected to have a significant impact on our understanding in the next few years.

The role of meat in foodborne disease: Is there a coming revolution in risk assessment and management?

Meat Science

Narelle Fega, Ian Jenson

https://doi.org/10.1016/j.meatsci.2018.04.018

https://www.sciencedirect.com/science/article/pii/S0309174018300731

Risk is not low if cause is not known: 5, then 19, now 34 sick and 1 dead sick in E. coli outbreak linked to Edmonton restaurant

If the E. coli-romaine lettuce made it to an Alaskan prison, maybe it made it to an Edmonton restaurant.

Just asking.

According to the Toronto Star, one person has died and more than 30 people have fallen ill following an E. coli outbreak that Alberta Health Services has called “extremely complex” to investigate.

In a statement, AHS says it has expanded its investigation into the source of an outbreak of E. coli, beyond cases directly linked to an Edmonton restaurant late last month.

While 21 of these lab-confirmed cases are linked to Mama Nita’s Binalot restaurant in Edmonton, AHS no longer has public health concerns related to the restaurant.

The number of lab-confirmed cases of E. coli has increased to 34, including 11 patients who have needed hospital care, and one patient who has died likely due to E. coli infection.

“This outbreak is extremely complex, however AHS, in partnership with other provincial and federal agencies, is doing all we can to protect the health of Albertans,” said Dr. Chris Sikora, a medical officer of health in the Edmonton zone, in a statement. “The risk of illness remains very low.”

AHS has not yet identified the source of these cases, but believes they are linked to the initial outbreak.

The risk is not low if the cause is not known.

AHS has worked closely with the owners of Mama Nita’s Binalot since it was identified that a cluster of people with lab-confirmed E. coli ate at the restaurant. AHS says the owners have taken significant steps to manage this issue, including voluntarily closing until AHS was confident the restaurant could reopen without presenting a risk to the public.

Flour power: Raw is risky

When I was a kid, I had this multi-colored swim towel that stated Flower Power (right, not exactly as shown).

I should have known that if a 1960s slogan had been co-opted by towel manufacturers in the early 1970s, it was a sign of corporate greed rather than earth-tone sentiment.

For the past decade, raw flour has increasingly come under the food safety microscope.

Flour was suspect in a 2008 outbreak of Salmonella in New Zealand. In June, 2009, an outbreak of shiga-toxin producing E. coli (primarily O157:H7) in Nestle Toll House cookie dough sickened at least 77 people in 30 American states. Thirty-five people were hospitalized – from flour in the cookie dough.

Hemp seed flour sickened 15 Germans in 2010.

There was the U.S. General Mills outbreak of 2016 which sickened at least 56 people with the outbreak strain of E. coli O121 and O26, followed by a separate outbreak of E. coli O121 in Robin Hood flour in Canada in late 2016 going into 2017, that sickened at least 29.

It’s this latter outbreak that has journalist Jim Romahn’s attention.

Romahn writes the release of 759 pages of mostly e-mails indicates there was a massive effort involved in a recall of flour milled in Saskatoon that was contaminated with E. coli O121.

Twenty-two Canadians were identified as sickened by the flour, including one key case where the person consumed raw dough.

With hindsight, health officials were able to determine the first person sickened was Nov. 13, 2016. The others sickened and linked to the flour were between then and Feb. 26, 2017.

Robin Hood flour was identified as the source in March and on March 26 the Canadian Food Inspection Agency began a recall that eventually grew to scores of brand-name products across Canada and even an export shipment to Guyana.

The recall involved a number of major companies, such as Smucker Foods of Toronto and the Sobeys supermarket chain.

There were some unusual difficulties, including the challenge of contacting Mennonites who have no telephones.

The investigation and lab results eventually traced the source to flour milled at Ardent’s Saskatoon plant on Oct. 15, 16 and 17.

A high percentage of packages of flour milled on those dates turned up with E. coli O121.

But even then it’s not clear where the wheat originated.

Ardent Mills said it was probably spring wheat, but it could have also contained soft wheat, and that it probably was from the 2016 harvest, but might have had some wheat from the 2015 harvest.

That’s reflective of the amount of blending that happens both with the wheat used in milling and the flours that are blended into products for sale.

The documents were released under Access to Information at the request of a woman who spent time in a hospital in Medicine Hat, Alta.

 An Outbreak of Shiga Toxin–Producing Escherichia coli O121 Infections Associated with Flour – Canada, 2016–2017

MMWR Morb Mortal Wkly Rep 2017; 66: 705–706

Morton V, Cheng JM, Sharma D, Kearney A.

Canadian E. coli cases believed to have been caused by deer meat

Cured deer meat is believed to be behind a series of E. coli cases in Tavistock, Oxford County, in Ontario, Canada.

Public Health says they can’t confirm it yet, but they believe the illnesses were caused by the meat which was sourced and processed from two private hunt camps in December 2017.

The first case was reported by a Tavistock resident in mid-February with the second coming a month later in March and a third in the first week of April.

They say laboratory results, expected later this week, will confirm if E.coli is present in the deer meat.

Restaurant liable in 2011 E. coli outbreak with 5 dead: Food safety disasters nothing new in Japan

In June 1996, initial reports of an outbreak of E. coli O157:H7 in Japan surfaced in national media.

By July 1996, focus had centered on specific school cafeterias and two vendors of box lunches, as the number of illnesses approached 4,000. Lunches of sea eel sushi and soup distributed on July 5 from Sakai’s central school lunch depot were identified by health authorities as a possible source of one outbreak. The next day, the number of illnesses had increased to 7,400 even as reports of Japanese fastidiousness intensified. By July 23, 1996, 8,500 were listed as ill.

Even though radish sprouts were ultimately implicated — and then publicly cleared in a fall-on-sword ceremony, but not by the U.S. — the Health and Welfare Ministry announced that Japan’s 333 slaughterhouses must adopt a quality control program modeled on U.S. safety procedures, requiring companies to keep records so the source of any tainted food could be quickly identified. Kunio Morita, chief of the ministry’s veterinary sanitation division was quoted as saying “It’s high time for Japan to follow the international trend in sanitation management standards.”

Japanese health authorities were terribly slow to respond to the outbreak of E. coli O157:H7, a standard facilitated by a journalistic culture of aversion rather than adversarial. In all, over 9,500 Japanese, largely schoolchildren, were stricken with E. coli O157:H7 and 12 were killed over the summer of 1996, raising questions of political accountability.

The national Mainichi newspaper demanded in an editorial on July 31, 1996, “Why can’t the government learn from past experience? Why were they slow to react to the outbreak? Why can’t they take broader measures?” The answer, it said, was a “chronic ailment” — the absence of anyone in the government to take charge in a crisis and ensure a coordinated response. An editorial cartoon in the daily Asahi Evening News showed a health worker wearing the label “government emergency response” riding to the rescue on a snail. Some of the victims have filed lawsuits against Japanese authorities, a move previously unheard of in the Japanese culture of deference.

Fifteen years later, with at least four dead and 100 sick from E. coli O111 served in raw beef at the Yakiniku-zakaya Ebisu barbecue restaurant chain, Japanese corporate, political and media leaders are still struggling.

Anrakutei Co., a Saitama-based yakiniku barbecue chain, stopped serving yukke at its 250 outlets, mainly in the Kanto region, on Tuesday.

“We’ve been providing the dish to customers based on strict quality control, but customers’ concerns make it difficult to continue to serve it,” a public relations official of the company said.

Anrakutei said the company conducts bacteria tests on the Australian beef it uses for yukke three times–first before it is purchased, again before it is sent to the company’s meat processing plant and finally before it is shipped to outlets. At the plant, the meat is processed separately from other food materials to prevent it from coming into contact with bacteria, the company explained.

There is no discussion of what is being tested, and how valid those tests are at picking up a non-O157 shiga-toxin producing E. coli like O111 There is no verification that anyone is testing anything.

In the absence of meat goggles that can magically detect dangerous bacteria, eating raw hamburger remains a risk.

Today, the Tokyo District Court ordered restaurant chain operator Foods Forus Co. to pay ¥169 million ($1.58 million) to the families of three victims who died from food poisoning after eating raw meat at one of its barbecue restaurants in 2011.

While the court awarded damages to the plaintiffs, it ruled that the former president of Foods Forus, which is filing for special liquidation, was not guilty of gross negligence. The plaintiffs had sought around ¥209 million in damages and medical treatment expenses from the company and the former president.

Around 180 customers developed symptoms of food poisoning after dining at six Yakiniku-zakaya Ebisu restaurants in four prefectures — Kanagawa, Toyama, Ishikawa, and Fukui — in April 2011. A strain of E. coli, O-111, was found in many of the victims.

Five died due to illness. Nine plaintiffs, including the families of three who died after eating at the outlet in Tonami, Toyama Prefecture, sued the company and the former president in October 2014.

In February 2016, police investigated the former president on suspicion of professional negligence resulting in death or injury and sent the case to prosecutors. But the prosecutors decided not to indict him.

The families of the victims are considering filing a petition with a prosecution inquest panel in a bid to overturn the decision.

California sisters fighting to recover from E. coli

The Public Health Agency of Canada may think Shiga-toxin producing E. coli is no biggie, but tell that to the Niles sisters of southern California, who were both hospitalized with hemolytic uremic syndrome (HUS).

ABC 30 reports that Mariska and Willow were active and healthy kids with no medical history. Their parents thought it was a terrible case of the flu. Originally their pediatrician thought it was norovirus. But after days of worsening symptoms, they were admitted to Valley Children’s Hospital with E. coli.

13-year-old Mariska Niles is finally starting to improve after 16 days in the hospital. She’s had more blood transfusions than she can count along with excruciating stomach pain and she was hallucinating.

The sisters were diagnosed with E. coli HUS or typical hemolytic uremic syndrome but the girls had unique cases.

Dr. Molly Dorfman said, “There’s was pretty atypical. Particularly the severity of Willow’s case was very very severe.”

This form of bacteria usually originates from contaminated food or water products. Pinpointing the exact source has been difficult. They haven’t traveled anywhere recently. The family hadn’t eaten out lately. It’s likely other family members also ate what the girls did but did not become violently ill. Even more puzzling, Mariska and Willow rarely eat the same things.

9-year-old Willow’s kidney’s still are not working. She has been debilitated by toxins from the infection, and at one point couldn’t wake up. Both sisters have had blood transfusion and dialysis.

Hucksterism fail: Ells out as CEO at Chipotle

Joe Rubino of The Denver Post writes the man who turned a tiny burrito shop near the University of Denver into an international brand will soon be out as Chipotle Mexican Grill’s CEO.

Steve Ells, the founder of the Denver-based fast-casual chain, will leave his post as chairman and CEO to become executive chairman after a replacement has been found, the company announced Wednesday.

A committee that includes Ells and directors Ali Namvar and Robin Hickenlooper, wife of Colorado Gov. John Hickenlooper, has been formed to find a leader with demonstrated turnaround expertise, the company said.

Whoever takes the job will be tasked with helping the chain climb out of protracted market malaise caused, in part, by outbreaks of foodborne illness linked to some of its restaurants, first in 2015, then again earlier this year

Co-CEO Monty Moran stepped down in December, leaving Ells with control of the company as it faced pressures from activist investor Bill Ackman, whose Pershing Square Capital hedge fund took a nearly 10 percent stake in September 2016. Ackman said then that he wanted improvement in Chipotle’s “operations, cost structure, management and strategy.”

E. coli: Flour fights not such a good idea

In June, 2009, an outbreak of shiga-toxin producing E. coli (primarily O157:H7) in Nestle Toll House cookie dough sickened at least 77 people in 30 American states. Thirty-five people were hospitalized – from cookie dough.

The researchers could not conclusively implicate flour as the E. coli source, but it remains the prime suspect. They pointed out that a single purchase of contaminated flour might have been used to manufacture multiple lots and varieties of dough over a period of time as suggested by the use-by dates on the contaminated product.

The study authors concluded that “foods containing raw flour should be considered as possible vehicles of infection of future outbreaks of STEC.”

So it wasn’t much of a surprise when 56 people fell sick from with the outbreak strain of E. coli O121 from Dec. 2015 to Sept. 2016 were linked to raw General Mills flour.

The peer-reviewed summary of the outbreak investigation was published last week in The New England Journal of Medicine.

Abstract below:

In 2016, a multijurisdictional team investigated an outbreak of Shiga toxin–producing Escherichia coli (STEC) serogroup O121 and O26 infections linked to contaminated flour from a large domestic producer.

Methods

A case was defined as infection with an outbreak strain in which illness onset was between December 21, 2015, and September 5, 2016. To identify exposures associated with the outbreak, outbreak cases were compared with non-STEC enteric illness cases, matched according to age group, sex, and state of residence. Products suspected to be related to the outbreak were collected for STEC testing, and a common point of contamination was sought. Whole-genome sequencing was performed on isolates from clinical and food samples.

Results

A total of 56 cases were identified in 24 states. Univariable exact conditional logistic-regression models of 22 matched sets showed that infection was significantly associated with the use of one brand of flour (odds ratio, 21.04; 95% confidence interval [CI], 4.69 to 94.37) and with tasting unbaked homemade dough or batter (odds ratio, 36.02; 95% CI, 4.63 to 280.17). Laboratory testing isolated the outbreak strains from flour samples, and whole-genome sequencing revealed that the isolates from clinical and food samples were closely related to one another genetically. Trace-back investigation identified a common flour-production facility.

Conclusions

This investigation implicated raw flour as the source of an outbreak of STEC infections. Although it is a low-moisture food, raw flour can be a vehicle for foodborne pathogens.

Shiga toxin–producing E. coli infections associated with flour

N Engl J Med 2017; 377:2036-2043, November 23, 2017, DOI: 10.1056/NEJMoa1615910

Samuel J. Crowe, Ph.D., M.P.H., Lyndsay Bottichio, M.P.H., Lauren N. Shade, B.S., Brooke M. Whitney, Ph.D., Nereida Corral, M.P.H., Beth Melius, M.N., M.P.H., Katherine D. Arends, M.P.H., Danielle Donovan, M.S., Jolianne Stone, M.P.H., Krisandra Allen, M.P.H., Jessica Rosner, M.P.H., Jennifer Beal, M.P.H., Laura Whitlock, M.P.H., Anna Blackstock, Ph.D., June Wetherington, M.S., Lisa A. Newberry, Ph.D., Morgan N. Schroeder, M.P.H., Darlene Wagner, Ph.D., Eija Trees, D.V.M., Ph.D., Stelios Viazis, Ph.D., Matthew E. Wise, M.P.H., Ph.D., and Karen P. Neil, M.D., M.S.P.H.

http://www.nejm.org/doi/full/10.1056/NEJMoa1615910