Groundhog Day, Alaska Campylobacter-in-raw-milk version

Folks in Alaska must be undergoing their own kind of public health Groundhog Day – where the same day is relived with slight variations.

But unlike the Bill Murray movie, no matter how much the health types cajole, persuade, and act nice, things won’t change.

Ask Hugh Pennington.

Just days after a report implicated raw milk as the cause of 31 cases of campylobacteriosis, including four cases of reactive arthritis, in early 2013, bill.murray.groundhog.day_.storyAlaskan health profesionals had a paper published in the Journal of Food Protection documenting a 2011 outbreak of Campylobacter linked to … raw milk.

Snappy title, though: Sharing milk but not messages: Campylobacteriosis associated with consumption of raw milk from a cow-share program in Alaska, 2011.

Abstract below.

Alaska public and environmental health authorities investigated a cluster of campylobacteriosis cases among people who had consumed raw, unpasteurized milk obtained from a cow-share program in Alaska. Although raw milk is not permitted by law to be offered commercially, consumers can enter into cow-share agreements whereby they contribute funds for the upkeep of cows and in turn receive a share of the milk for their personal use. Laboratory testing of stool specimens collected from ill persons and from cows on the farm revealed an indistinguishable strain of Campylobacter. In this outbreak, numerous confirmed and suspected cases were not among cow shareholders; therefore, these individuals had not been advised of the potential health hazards associated with consumption of raw milk nor were they informed of the outbreak developments.

Journal of Food Protection®, Number 5, May 2013, pp. 744-918 , pp. 744-747(4)

Castrodale, L.J.; Gerlach, R.F.; Xavier, C.M.; Smith, B.J.; Cooper, M.P.; McLaughlin, J.B.

31 sick, 4 develop reactive arthritis; Campylobacter from raw milk, Alaska, Jan–Feb 2013

As noted in that World Health Organization report, the major sequelae of Campylobacteriosis are Guillain-Barré syndrome (GBS), reactive arthritis (ReA) and irritable bowel syndrome (IBS).

GBS is a severe disease, requiring intensive care in some 20% of cases; case-fatality rates in high-income countries are between 3 and 10%. Globally, santa.barf.sprout.raw.milkapproximately one-third of GBS cases have been attributed to Campylobacter infection.

While it is difficult to determine the true extent of ReA, because of a lack of clear diagnostic and classification criteria, studies suggest that it occurs in 1–5% of those infected with Campylobacter. It has been estimated that 25% of ReA cases may go on to chronic spondyloarthropathy.

That’s exactly what happened in the Campylobacter-from-raw-milk outbreak in Alaska earlier this year.

On February 13, 2013, Alaska State Public Health Laboratory (ASPHL) notified the Alaska Section of Epidemiology (SOE) of a cluster of four C. coli isolates with an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern that was new to Alaska. All four isolates were grown from stool specimens collected in late January from ill Kenai Peninsula residents.

Patient interviews and other investigative work indicated that all four of the ill persons with PFGE-matching C. coli strains reported consuming raw (unpasteurized) milk within a few days of their illness onset. These initial interviews also led to additional case finding, primarily by way of ill persons reporting others they knew who were also ill with similar symptoms. While some of the persons napoleon milkwho were initially identified during this investigation were reluctant to say where their raw milk came from, four individuals reported that it came from Farm A, a cow-share farm on the Kenai Peninsula.

A confirmed case was defined as a laboratory-confirmed, PFGE-matched, C. coli infection diagnosed from January 1, 2013 onward. A clinical case was defined as an acute GI illness with self-reported diarrhea lasting ≥2 days in a person with exposure to Farm A raw milk within 10 days of illness onset. A secondary case was defined as an acute GI illness lasting ≥2 days in a person with close contact to a confirmed or clinical case within 10 days of illness onset.

On February 14, SOE notified the Office of the State Veterinarian (OSV) of the outbreak, and a joint press release and health advisory were issued on February 15.2 OSV immediately notified Farm A of the outbreak and requested a list of all active shareholders. Despite notification of the outbreak, Farm A continued to distribute raw milk to shareholders living in the Kenai Peninsula and in Anchorage.

During the week of February 18, two additional confirmed cases were reported—one of which was in a school-aged child who was hospitalized for 4 days with fevers, abdominal pain, rash, and acute reactive arthritis involving the wrists, ankles, knees, and hips. On February 22, an updated health advisory describing new developments in the outbreak was issued.3 On February 22, Farm A provided SOE with an incomplete shareholder list, which lacked contact information for the majority of shareholders. Calls were made to notify persons on the list about the outbreak and to identify additional cases.

In total, 31 cases were identified during the investigation. Ill persons ranged in age from 7 months to 72 years (median: 10 years). Three children and one adult developed reactive arthritis lasting a minimum of 6 weeks. Two persons were colbert.raw.milkhospitalized. All ill persons were Kenai Peninsula residents who either personally consumed Farm A raw milk within 10 days of illness onset (n=29) or met the secondary case definition (n=2).

Environmental Investigation

On February 22, OSV and SOE toured Farm A and collected cow feces, milk, and other environmental samples. Steps where the milk could be contaminated (from collection to bottling) were reviewed with the farmer, and the inherent risk of bacterial contamination of unpasteurized milk was discussed. The outbreak strain of C. coli was not isolated from the samples collected at the farm that day; however, three different strains of C. jejuni were isolated from cow manure, and Listeria monocytogenes grew from a raw milk sample.

This large outbreak of C. coli infection on the Kenai Peninsula was caused by consumption of Farm A raw milk. While this outbreak appears to be over, additional campylobacteriosis cases could still be identified at any time as Campylobacter species were identified from Farm A manure during the environmental investigation. Furthermore, this is the second outbreak of campylobacteriosis associated with consumption of raw milk distributed by an Alaskan cow-share operation in the past 2 years. These outbreaks are an unfortunate reminder of the inherent risks associated with raw milk consumption, and underscore the importance of pasteurization.

It is not surprising that the C. coli outbreak strain was not isolated from the environmental samples, as Campylobacter bacteria are difficult to isolate from the environment, they are shed intermittently in cow manure, and the farm visit occurred weeks after the outbreak peaked. Incidentally, L. monocytogenes—a bacteria that can cause life-threatening meningitis—was isolated from Farm A milk; no listeriosis cases were reported during the outbreak.

Finally, four (13%) ill persons developed reactive arthritis, a painful form of inflammatory arthritis that sometimes occurs in reaction to a bacterial infection and can persist for up to 12 months. These cases underscore the fact that Campylobacter infection can lead to prolonged adverse health consequences.

Stories, not just statistics, matter in food safety

Back in grad school Doug told me how to give a successful talk: Present in a series of stories; get those stories right; be passionate; and, end early (because everyone goes over time).

Storytelling in food safety matters. Folks aren’t compelled by the fancy facts and figures that all of us nerds have access to. What connects are the weird stories about symptoms, contamination and tragedy of outbreaks. And there’s some stuff in the literature to back this up. Morgan and colleagues (2002) evaluated various safety messages targeted at farmers regarding the use of personal protective structures for vehicles by presenting combinations of different message delivery methods. Participants reported that messages based on stories, and those that were meant to elicit fear about individual practices, had more impact on their desire to use safe practices than presenting consequence-based statistics alone. Slater and Rouner (1996) found that folks rate messages with narratives as higher quality and perceived them to be the most persuasive when looking at alcohol risks. pickled+eggs6

A couple of my colleagues who are designing a course on acidified foods processing for regulatory folks asked me for some help in identifying stories to supplement the technical information they were teaching about. I went back through barfblog and FSNet files and pulled up some nice ones. Like the restaurant-linked botulism cases linked to a chopped-garlic-in-soybean-oil that was held at room temp for several months before being used on a sandwich. Or the home pickled eggs that lead to a 68-year-old man acquiring bot intoxication. The eggs were boiled, peeled and punctured with toothpicks and placed into a jar with beets, hot peppers and vinegar – and then held at room temperature for a week. While the pickling liquid had a pH of 3.5, bot toxin was detected in both the liquid and the yolks. Although the yolks had 1000x greater concentration. Best guess is that C. botulinum spores were driven into the yolk during the puncturing and the liquid never made it in to acidify.

Add stories on fermented seal flipper and native Alaskan meat preservation to the list. According to Discover Magazine’s Rebecca Kreston, many of the botulism intoxication cases seen in the U.S. annually are linked to changing processes for fermenting meat. She relates a story told to her in an bacterial pathogenesis class and goes on to investigate the anecdote.

[O]ur professor noted that several cases of botulism in Alaskan Natives occurred as a result of changing methods of fermenting meat. Professor, you had me at “fermenting meat”.

Investigating the veracity of this anecdote I found that tried and true Alaskan Native methods of burying meat underground to ferment had been modified by the introduction of Western conveniences. Tupperware containers and sealable plastic bags were now being used to create a meaty, anaerobic environment that C. botulinum was happy to vacation in. Oh plastics, you synthetic polymers, what have you wrought!

I also discovered the staggering statistic that Alaska ranks among the highest incidence of foodborne botulism in the world. Indeed, nearly half of all cases of foodborne botulism cases in the United States occur in that icy Northern state; the incidence of botulism in Alaska is 8.46 cases per 100,000 compared to Washington’s paltry 0.43 per 100,000 (see here, and here).

This is truly a public health dilemma! Botulism has been repeatedly referred to as an endemic “hazard of the North” but typically occurs in western Eskimo coastal villages and Native Americans regions in the southwestern region of Alaska due to their proximity to aquatic foodstuffs

The term “fermented” might be putting it kindly – many ethnographers have described these prepared foods as intentionally putrefied. And, in fact, the fermentation process cannot occur without a carbohydrate substance and these meats aren’t technically “fermented”. The researcher Nelson reported the preparation process quite evocatively in 1971:

“Meat is frequently kept for a considerable length of time and sometimes until it becomes semiputrid. This meat was kept in small underground pits, which the frozen subsoil rendered cold, but not cold enough to prevent the bluish fungus growth which completely covered the carcasses of the animals and the walls of the storerooms”.

The customary preparation process has since been modified from fermenting food in a buried clay pit, enclosed in a woven basket or sewn seal skin (known as a “poke”) for weeks or months at a time. Food is now stored in airtight, Western consumer goods such as plastic or glass jars, sealable plastic bags or even plastic buckets, and eaten shortly after in a week or month. Additionally, the food many be stored indoors, above ground or in the sun at milder, less optimal temperatures. This move towards storing meat in warmer, anaerobic settings for shorter lengths of time may expedite the fermentation process and, subsequently, enhance the risk of botulinum toxin production.

21 now sick; Campylobacter outbreak traced to Alaskan raw milk

The state health department has traced the source of the campylobacter outbreak that has infected now more than 21 people back to Peninsula Dairy, a dairy farm in Kasilof on the Kenai Peninsula; two people have been hospitalized.

The farm operates a cow-share program. The milk is distributed to shareholders throughout the Kenai Peninsula, in Anchorage, and in Sitka. There is at least one colbert.raw.milksecondary case of an infant who became ill after having close contact with a laboratory-confirmed case.

The Peninsula Clarion reports tate veterinarian Bob Gerlach and Donna Fearey, a nurse epidemiologist for the state, on Tuesday inspected Peninsula Dairy, owned by Kevin Byers. Gerlach said they saw no problems with Byers’ operation.

“In comparison to most dairies, he’s doing a very pretty good job,” Gerlach said.

He said Byers had modern and clean equipment and his cows were healthy and well-fed.

In a 2011 outbreak, 18 people were stricken with Campylobacter that was eventually traced back to a farm owned by Byers’ brother in the Matanuska Valley.

The campylobacter infection was of a different strain, however, and Gerlach said connecting the two outbreaks would be inappropriate.

The department cannot close Byers’ farm as cow-share programs are legal, McLaughlin said. The direct sale of raw milk is, however, illegal, he said.

18 now sick; Campylobacter linked to raw milk in Alaska outbreak

The Alaska Department of Health and Social Services says that 18 people have now been identified with Campylobacter associated with raw-milkconsuming raw milk distributed by a Kenai-based cow-share program.

Two required hospitalization.

All probable and confirmed cases have been linked to consumption of raw milk from a farm on the Kenai Peninsula that operates a cow-share program. The milk is distributed to shareholders throughout the Kenai Peninsula, in Anchorage, and in Sitka. There is at least one secondary case of an infant who became ill after having close contact with a laboratory-confirmed case.

4 sick; Campylobacter linked to raw milk in Alaska outbreak reports the Alaska State Department of Health is investigating an outbreak of a foodborne illness linked to raw milk. Officials have confirmed four cases of Campylobacter infection in people who drank raw milk on the Kenai Peninsula.

Dr. Brian Yablon is a medical epidemiologist with the state. He says the cases colbert.raw.milkhave all been identified by the state lab in the last three weeks:

“When they looked at these strains, they found that the four specimens were all exactly the same type, so that is consistent with a cluster of illnesses and when we found out additional information it seemed that all of the people who developed the infection had consumed raw milk or unpasteurized milk in the proceeding several days before they got sick,” Yablon said.

The state is still working to identify the source of the raw milk. A farmer named Kevin Byers in Kasilof distributes raw milk to families around the state. He did not agree to a recorded interview, but said he doesn’t know if his milk is responsible for the outbreak. He says his customers drink his milk for the perceived health benefits. According to a recent newspaper article, Byers has 150 customers as far away as Sitka.

Selling raw milk is illegal in Alaska. But farmers have found ways to do it legally.

A similar outbreak of Campylobacter bacteria was traced to a Mat-Su Valley farmer in 2011. There were 18 people with probable or confirmed illness in that outbreak. That operation has since gone out of business.

Theatre of the bizarre as North Pole Republican wants to eliminate government regulation of food

A couple of our Alaskan food safety friends sent along updates on the ban food safety regulation movement in the state legislature that looks more like a Second City improv skit.

The Mudflats blog reports Alaska State Rep. Tammie Wilson, a Republican from North Pole, who has taken her quest for deregulation to new and unsanitary heights.

Behold House Bill 202 – Sale of Food by Processors to Consumers. Gone are the days of food inspectors, rules and regulations, requirements for refrigeration, and soap and water. All’s fair at the farmer’s market, no matter what you’re selling.

Most of Rep. Wilson’s testimony came in the form of a skit where the plot focused only on produce and baked goods. She played a beleaguered farmer, just trying to sell her humble wares at the market, and her aide played an uptight, joyless, and unreasonable inspector from the Department of Environmental Conservation (DEC).

The ensuing skit involved a lot of food props, and the committee members had also been given samples of peeled and sliced fruit, and cookies. “I do have a knife,” Wilson demonstrated to the audience, “and I will not use it on anyone, I promise.” (Cue a weirdly awkward moment as Wilson’s aide let forth with a too-loud cackle, and the rest of the room sat in uncomfortable silence).

And thus began the dramatic demonstration. Slicing of tomatoes was not allowed, because that was considered “food preparation.” Orange peeling was forbidden for the same reason. Next, she tried “an apple…one that we know daycares like to do. And I’m sure that they’re able, with no permit or anything, to be able to cut an apple for a snack.” No dice, says the inspector, “And as far as a daycare goes, if you have five or less children, you may cut. Any more than that, you’d be permitted.” (Remember this part for later, because it’s not true).
But we’re not done yet. Next up – a strawberry. Wilson begins to remove the green top.

“This may have seemed ridiculous, but you know, it is ridiculous! Do I want to poison anybody? It’s not a good thing to be a Representative and poison your constituents. I just want to put that on the record.”

The TV cameras were rolling, but there was no audio hookup yet. This happens so people don’t embarrass themselves by saying something stupid into a “hot mic” that they weren’t intending to say in public. In this particular case, that didn’t matter. Behold our food-prepping farmer, who beautifully illustrates the hazards of her own bill during the ten minutes before the meeting started:
Who could object to dirty cutlery, snotty carrots, unrefrigerated egg custard, and the underside of Tammy Wilson’s germy fingernails in their strawberries? Ridiculous. As long as there was no willful attempt to poison, that should be enough.

Kristin Ryan, Director for the DEC, identified the Food Safety and Sanitation program as “the main target of Rep. Wilson’s bill” and began her testimony by stating what really should be the obvious:

“The DEC recognizes the interest from small food business owners throughout the state to sell products. Provisions in HB202 could cause significant risks for the general public, and increase foodborne illness outbreaks.

When you purchase food to eat, you assume it is safe. While no one intends to harm their customers, food-borne illnesses are common, and can easily happen. Precautionary measures are important to make and serve safe food. At a minimum, you need a sanitary environment, employees to wash their hands, and proper temperature control.”

The Republican bill would eliminate the ability of the DEC to investigate if an outbreak of food-borne illness was occurring. The agency would not be allowed to inspect, test, or stop the sale of a food product that is making people sick.

Because Republicans love freedom. And food safety inspectors don’t.

We don’t need no stinkin’ regs; Alaska Rep. sponsors bill to do away with most safe food regulations

The Daily News-Miner reports a bill introduced by North Pole Republican Rep. Tammie Wilson would do away with much of the state’s safety regulations for food sold directly to consumers in an attempt to grow Alaska’s local food industry and farmers markets.

That has health officials worried. House Bill 202, which was heard in the House Labor and Commerce Committee this week, would remove safety regulations not only for the traditional farmers market fare but also for potentially hazardous foods like seafood, shellfish, poultry, meat, dairy and any other processed foods.
Currently, the Department of Environmental Conservation has no regulations for direct-to-consumer food sales for raw fruits and vegetables, syrup, honey and jam. But the state does have safety regulations on most other processed foods and raw foods where there’s a potential for dangerous bacteria to make it to the consumer.

But Wilson feels that expenses like permits and equipment are stifling the development of local food. Instead, she said the consumer should take responsibility for the food they eat.

“We just think that there’s something called responsibility that is here,” she said during the committee hearing. “I don’t think government is there to keep us safe from absolutely everything, you can’t protect everybody from everything.”

She said, instead, that the state should take an education-based approach to food safety.

Wilson’s bill would require sellers to provide a card that alerts the consumer that “This product has not been inspected by any governmental agency and may be harmful to your health.”

Environmental Health Director Kristin Ryan who testified against the bill’s sweeping changes, said, “People buy food under the assumption that it’s safe to eat. Yes, people should have personal responsibility. But when there’s some clear risk, it’s our responsibility to protect against that risk.”

18 sick from campylobacter linked to raw milk in Alaska

The Anchorage Daily News reports that an outbreak of a serious gastrointestinal illness connected to consumption of raw milk from an Alaska dairy is ongoing, with seven confirmed cases and 11 more that are suspected, state health officials said in a bulletin published Thursday.

The outbreak connected to unpasteurized milk began in May and has continued into July, the report said.

The same rare strain of the Campylobacter pathogen was found in all seven cases confirmed in laboratory tests. And it also was confirmed in manure samples from the unnamed Mat-Su farm.

The lab report, combined with the fact everyone who got sick drank raw milk from the same dairy, "affirms the conclusion that this outbreak is due to consumption of Farm A raw dairy products," the state bulletin said.

But tests didn’t find the pathogen in milk from the farm’s bulk tanks.

That’s not surprising, said state epidemiologist Joe McLaughlin. Campylobacter jejuni "is notoriously difficult to culture from environmental specimens other than raw stool," Thursday’s epidemiology bulletin said.

Alaska investigating 4 cases of raw milk contamination

KTUU reports the Alaska Department of Health and Social Services is investigating four cases of people who became sick after drinking bacteria-contaminated raw milk from a Mat-Su Valley farm.

??According to DHSS spokesperson Greg Wilkinson, state law doesn’t allow the sale of raw milk, but does permit owning shares of an animal to receive its milk — which doesn’t have to be tested or pasteurized it’s distributed.??

The four people infected with Campylobacter jejuni bacteria from May 7 through June 4 were Southcentral Alaska residents ranging in age from 1 to 81 years old. All four experienced severe stomach flu after drinking raw milk from one of the unnamed farm’s cows, and two said family members also experienced symptoms but did not seek medical attention.