Did health-types get it wrong or a Canberra court: Ricardo’s Café cleared of Salmonella charges

Posted on March 5, 2019 by Douglas Powell

The owner of a popular Canberra cafe has had charges against him dropped, relating to a salmonella outbreak that saw more than 100 people fall ill in 2017, and has also escaped conviction on an unrelated charge.

The owner of Ricardo’s, Rick DeMarco, 32, was cleared of the most serious charges spanning from an investigation in February 2017, which began after customers complained of food poisoning on social media.

The restaurant in Jamison was immediately closed after the reports and, in a statement at the time, Mr DeMarco admitted salmonella was found on a used dishcloth and tea towel, but nothing was found in any food or on any cafe equipment.

Hello? Cross-contamination? Epidemiology?

The ACT chief magistrate Lorraine Walker did not record a conviction against De Marco, after he pleaded guilty to one count of failing to comply with the food standards code.

However, the chief magistrate said there was no correlation between Mr De Marco’s plea of guilty to the individual charge and the salmonella outbreak.

The single charge against Mr De Marco related to breaches discovered by health inspectors. These were uncovered containers of food in a refrigerator and a single-use container being reused.

However, while the food was kept inappropriately, Mr De Marco’s defence barrister Jack Pappas noted the food was kept at the required temperature in the refrigerator.

He added that Mr De Marco’s two businesses, Ricardo’s Cafe and Space Kitchen in Woden, were significant contributors to the local economy by employing about 50 people and training apprentices.

Ms Walker said that the instances were not at the lowest end of offending, “they were pretty close”.

Ms Walker said it was an instance where, due to the nature of the breach and Mr De Marco’s good character, it was appropriate to not record a conviction.

There were 75 cases of salmonella confirmed by ACT Health during the outbreak in February 2017, with some people requiring hospitalisation.

Flour power: NEJM paper on 2016 outbreak

Posted on November 24, 2018 by Ben Chapman

A couple of weeks ago Duncan Hines brand cake mixes were recalled because of Salmonella. Maybe it was the flour. Flour comes from dried wheat that’s milled and not heat treated (because it messes with the gluten). As the Salmonella dries out it gets hardier and survives for months (or longer).

In 2016 pathogenic E. coli (both O121 and O26 serogroups) was the culprit in another raw flour outbreak. The good folks involved with that investigation (Crowe and colleagues) published their findings this week in the New England Journal of Medicine.

The outbreak began in December 2015 and lasted through to September 2016. Fifty-six cases in 22 states were identified.

The biggest takeaway for me was this (such a great explanation of how an investigation works):

Open-ended telephone interviews then were conducted with 10 patients, all of whom stated that they baked frequently or regularly consumed home-baked foods. Five of the patients recalled baking during the week before illness onset, and 3 others reported thatthey might have baked during that period. Of the 5 case patients who remembered baking, 4 reported eating or tasting homemade batter or dough, 3 of whom used brand A flour. The fourth used either brand A or another brand. Two of the patients (a resident of Colorado and a resident of Washington) still had the bags of brand A flour that they had used in the week before illness onset.

Shortly thereafter, state investigators identified 3 ill children who had been exposed to raw flour at restaurants in Maryland, Virginia, and Texas. Restaurant staff had given them raw dough to play with while they waited for their food to be served.

Folks in the media or the hockey arena often ask how these outbreaks get solved. This is how – lots of interviewing, hypothesis generating and then a case-case or case-control analysis. It’s part detective work, part statistics and all science. Sometimes the interviews are messy but this one shows what happens when it works.

Trace-back investigation of the two bags of brand A flour collected from patients in Colorado andWashington revealed that the flour from Colorado was unbleached all-purpose flour manufactured on November 14, 2015, and the flour from Washington was bleached all-purpose flour manufactured on November 15, 2015. The two bags were produced in the same facility. The flour that was used in the raw dough given to the children exposed in the Maryland, Virginia, and Texas restaurants also was from this facility, as was flour from three additional bags collected from case patients residing in Arizona, Califor- nia, and Oklahoma.

Going public: Epidemiology works, especially when so many are sick with E. coli O157

Posted on July 17, 2016 by Douglas Powell

With two dead and at least 151 sick with E. coli O157, believed to be from imported rocket (like bagged lettuce), Public Health England (PHE) says the products are still on supermarket shelves because the source of the outbreak had not been confirmed.

Instead, officials are reiterating advice to wash vegetables, including salad leaves, thoroughly before eating them.

Washing is not going to remove much E. coli O157.

Stephen Adams of the Daily Mail writes that children are among those ill.

PHE would not say if the more than 60 patients needing hospital treatment were children or among the fatalities.

Several food wholesalers have been told to ‘stop adding some imported rocket leaves to their mixed salad products while investigations are ongoing,’ said the Food Standards Agency.

Epi works: Over 300 sickened from crypto on pre-cut salad greens in UK, 2012

Posted on May 16, 2016 by Douglas Powell

In May 2012, people in England and Scotland started getting sick with Cryptosporidium. In June, 2012, the UK Health Protection Agency first announced 267 people were sick with Cryptosporidium across four areas of the UK, double the normal rate.

Ten months later, HPA said the crypto that sickened about 300 people was most likely linked to eating pre-cut bagged salad products which were likely to have been labeled as ‘ready-to-eat.’

The outbreak was short lived and the numbers of cases returned to expected seasonal levels within a month of the first cases being reported. Most of those affected had a mild to moderate form of illness and there were no deaths associated with the outbreak.

During the investigation, an initial link was found between illness and pre-cut spinach. When specific retailers were included in the analysis, the strongest association with infection was found to be with consumption of ready to eat pre-cut mixed salad leaves from a major supermarket chain.

In this analysis, exposure to pre-cut spinach only reached conventional levels of significance for one retailer – a second major supermarket chain. A link to spinach from a number of other retailers was also suggested but these were not statistically significant. Together these findings suggest that one or more types of salad vegetables could have been contaminated.

Dr Stephen Morton, regional director of the HPA’s Yorkshire and the Humber region and head of the multi-agency Outbreak Control Team, said, “Our findings suggest that eating mixed leaf bagged salad was the most likely cause of illness. It is however often difficult to identify the source of short lived outbreaks of this type as by the time that the outbreak can be investigated, the affected food and much of the microbiological evidence may no longer be available

Dr Alison Gleadle, director of food safety at the FSA, took the opportunity to further confuse consumers, stating, “We’d like to remind everyone of our usual advice to wash all fruits and vegetables, including salad, before you eat them, unless they are labeled ready-to-eat.”

But wasn’t this outbreak linked to ready-to-eat salads? How is that advice of any use? Could have offered some details, like, additional washing of ready-to-eat products is largely ineffective. FSA is refocusing its efforts on farm management to limit such contamination, before it happens.

A spokesthingy from retailer Morrisons said, rather defensively, “Morrisons is not the source of this outbreak. We have received no complaints of illness and no Morrisons products have tested positive for Cryptosporidia.

“The HPA’s claim is based solely on statistics, not testing. The very same statistics also implicated products from other retailers that the HPA recognize as ‘implausible’.”

Why doesn’t Morrison’s say what they do to enhance the safety of products they sell rather than trash epidemiology?

In the scientific paper on the outbreak, McKerr et. al reported a widespread foodborne outbreak of Cryptosporidium parvum in England and Scotland in May 2012. Cases were more common in female adults, and had no history of foreign travel. Over 300 excess cases were identified during the period of the outbreak. Speciation and microbiological typing revealed the outbreak strain to be C. parvum gp60 subtype IIaA15G2R1.

METHODS: Hypothesis generation questionnaires were administered and an unmatched case control study was undertaken to test the hypotheses raised. Cases and controls were interviewed by telephone. Controls were selected using sequential digit dialling. Information was gathered on demographics, foods consumed and retailers where foods were purchased.

RESULTS: Seventy-four laboratory confirmed cases and 74 controls were included in analyses. Infection was found to be strongly associated with the consumption of pre-cut mixed salad leaves sold by a single retailer. This is the largest documented outbreak of cryptosporidiosis attributed to a food vehicle.

An outbreak of cryptosporidium parvum across England & Scotland associated with consumption of fresh pre-cut salad leaves, May 2012

PubMed

McKerr C1, Adak GK2, Nichols G3, Gorton R4, Chalmers RM5, Kafatos

PLoS One, 2015, doi: 10.1371/journal.pone.0125955. eCollection 2015.

http://www.ncbi.nlm.nih.gov/m/pubmed/26017538/

Bangladesh health officials use traditional media to look for illness clusters

Posted on February 24, 2016 by Ben Chapman

New York City and Chicago have been using social media as a supplemental tool to identify illness clusters and connect with potential victims.

Developing countries, where laboratory-based surveillance infrastructure is low, may use traditional media as an outbreak indicator. The cost is relatively low and it can provide a starting point.

Like in Bangladesh. A study published in EID details how traditional media clips have helped their surveillance activities.

The national rapid response team, consisting of key staff members from IEDCR, received a daily email containing all identified health-related newspaper articles and video clips. The team examined each news item and decided whether it warranted an outbreak response on the basis of expert clinical and epidemiologic knowledge; public health importance (e.g., number of cases and deaths reported, severity of symptoms); and verification by local health officials. For the purposes of this analysis, IEDCR retrospectively created a database of reported events sent by the media scanning company, which included the number of reported events, outbreak etiology, news source, and the outcome of each investigation. The outbreaks reported were classified by media type, etiology, and season.

Key informant interviews consistently indicated that the system was simple, flexible, timely, and acceptable because it used existing media infrastructure and required only minimal costs to contract with a company to compile daily reports of news items. Changes to the system could be implemented effectively through frequent communications between the media scanning company and IEDCR. The system was widely acceptable by all stakeholders and was considered a valuable component of disease surveillance in Bangladesh.

I miss Bill Keene: Museum catalogues food poisoning in Oregon, elsewhere

Posted on August 11, 2015 by Douglas Powell

Lynne Terry of The Oregonian writes that an unusual museum stocked with food packages including everything from ground beef to alfalfa sprouts has gone live on the internet.

The Outbreak Museum, physically located in Portland, showcases the culprits in food poisoning cases.

The museum was the brainchild of Oregon’s star epidemiologist William Keene, who died suddenly at the end of 2013. He cracked dozens, if not hundreds of outbreaks that sickened people from Portland, Oregon to Portland, Maine with food tainted by E. coli, salmonella, norovirus, campylobacter and listeria. He worked with manufacturers and health officials alike with one goal in mind: prevent consumers from getting sick.

He collected packages of tainted items in outbreaks he worked on and other public health officials sent him containers from their investigations. The museum includes items from the 1999 salmonella outbreak traced to alfalfa sprouts, the 2006 E. coli outbreak involving spinach and the 2012 E. coli outbreak traced to raw milk.

Dr. Paul Cieslak, medical director of Oregon’s immunization program, said the museum is designed to educate younger epidemiologists about the significance of past outbreaks and how they influenced public health decisions and epidemiological investigations.

“It’s mainly meant to be instructure,” Cieslak said.

The items are open to public health students and school groups by appointment. The website includes more extensive information on 12 outbreaks.

I believe the epidemiologists: Boise restaurant linked to Salmonella cases

Posted on April 7, 2015 by Ben Chapman

Last week I spent some time with an old friend who owns a funeral home. Fifteen years ago we spent our time and extra money in the local pub drinking pints and talking trash. As we’ve gotten older our taste has changed; we discussed our chosen professions over a bottle of wine.

As we chatted food safety and death he wanted to know how the disease detectives connected the dots in an outbreak. I gave him a rudimentary explanation of PFGE, genome sequencing, Pulsenet and told him about Bill Keene’s contribution to foodborne epidemiology. He was genuinely interested in learning about how epi folks do their magic, or it may have been the wine.

Here’s today’s example of a cluster of illnesses linked to a restaurant, without a smoking gun, that is garnering further investigation (via the Idaho Statesman).

Five people have reported getting sick from Salmonella poisoning since late February after eating at a Boise restaurant, according to the Central District Health Department.

The agency did not publicly name the eatery Monday, but the owner of Pho Tam on North Orchard Street confirmed to the Idaho Statesman that her Vietnamese restaurant is the one in question.

“I don’t know what happened,” owner Long Doan said. “We try to be careful.”

The most recent sickness took place in mid-March, but wasn’t reported to health officials until Thursday, Health Department spokeswoman Christine Myron said.

Health inspectors last week tested food at the restaurant and did not find any traces of Salmonella or other harmful bacteria, Myron said.

“The cultures that they grew did not come back with any Salmonella, so they’ve not determined a definite source for the Salmonella,” Myron said. “We don’t know exactly how it may have gotten into the food at this point.”

I trust the epi folks.

Problems public health investigators face: It’s a tough job (but we love ya for it)

Posted on March 26, 2015 by Douglas Powell

In Ontario, Canada (that’s in Canada), enteric case investigators perform a number of functions when conducting telephone interviews including providing health education, collecting data for regulatory purposes ultimately to prevent further illness, enforcement, illness source attribution and outbreak detection. Information collected must be of high quality as it may be used to inform decisions about public health actions that could have significant consequences such as excluding a person from work, recalling a food item that is deemed to be a health hazard, and/or litigations. The purpose of this study was to describe, from the perspectives of expert investigators, barriers experienced and the techniques used to overcome these barriers during investigation of enteric disease cases (that’s Sider, right, exactly as shown).

Methods

Twenty eight expert enteric investigators participated in one of four focus groups via teleconference. Expert investigators were identified based on their ability to 1) consistently obtain high quality data from cases 2) achieve a high rate of completion of case investigation questionnaires, 3) identify the most likely source of the disease-causing agent, and 4) identify any possible links between cases. Qualitative data analysis was used to identify themes pertaining to successful techniques used and barriers experienced in interviewing enteric cases.

Results

Numerous barriers and strategies were identified under the following categories: case investigation preparation and case communication, establishing rapport, source identification, education to prevent disease transmission, exclusion, and linking cases. Unique challenges experienced by interviewers were how to collect accurate exposure data and educate cases in the face of misconceptions about enteric illness, as well as how to address tensions created by their enforcement role. Various strategies were used by interviewers to build rapport and to enhance the quality of data collected.

Conclusions

To our knowledge, this is the first study to examine the perspectives of expert enteric disease case investigators on successful interview techniques and barriers experienced during enteric case investigation. A number of recommendations could improve the process of enteric case investigation in the Ontario context which include formal training and development of resource materials pertaining to interviewing, standardized interviewing tools, strategies to address cultural and language barriers, and the implementation of the single interviewer approach.

A focus group study of enteric disease case investigation: successful techniques utilized and barriers experienced from the perspective of expert disease investigators

BMC Public Health, Disease epidemiology- infectious, Volume 14, doi:10.1186/1471-2458-14-1302

Stanley Ing, Christina Lee, Dean Middleton, Rachel D Savage, Stephen Moore and Doug Sider

http://www.biomedcentral.com/1471-2458/14/1302

To the importer who says there’s no proven link, I say, epidemiology still works: 18 confirmed sick with hep A from frozen Chinese berries

Posted on February 23, 2015 by Douglas Powell

As the number of confirmed hepatitis A cases in Australia from frozen berries grown in China rose to 18 over the weekend, as political rhetoric about imports and local food reached staggering new heights, the company continued to insist there’s no firm link between a national hepatitis A outbreak and its recalled berries.

The company says its imported Chinese berries were recalled on health department advice despite a lack of proof from accredited laboratories of a link to the hepatitis A virus (HAV).

“At this point, we have not been provided any remaining consumer product to test from the 13 confirmed HAV cases to clinically verify there is indeed a link with the Nanna’s Mixed Berries,” managing director and chief executive Stephen Chaur said in a statement on Friday.

Mr Chaur said the company had rigorous testing that went beyond the Australian standards requirement that five per cent of imported fruit containers be tested.

“Patties Foods’ documented test regime is among the highest, testing 20 per cent of all the containers when they arrive in Australia,” he said.

But Mr Chaur said sample testing for microbial and viral markers had been increased to 100 per cent of imported frozen berries from all countries.

The company has checked quality control testing documents back to June 2014 and says they’re satisfied no biological indicators outside Australian guidelines have been detected.

Great. Prove it and make the data public.

Importance of epi: Outbreak of diarrheal illness caused by Shigella flexneri — American Samoa, May–June 2014

Posted on January 17, 2015 by Douglas Powell

The U.S. Centers for Disease Control reports that on May 9, 2014, a physician at hospital A in American Samoa noticed an abnormally high number of children presenting to the emergency department with bloody diarrhea.

Based on preliminary testing of stool specimens, Entamoeba histolytica infection was suspected as a possible cause. Shigella was also suspected in a subset of samples. On May 22, the American Samoa Department of Health requested assistance from CDC with the outbreak investigation. The goals of the investigation were to establish the presence of an outbreak, characterize its epidemiology and etiology, and recommend control measures. The CDC field team reviewed the emergency department log book for cases of diarrheal illness during April 15–June 13, 2014. During this period, 280 cases of diarrheal illness were recorded, with a peak occurring on May 10. Twice as many cases occurred during this period in 2014 compared with the same period in 2011, the most recent year for which comparable surveillance data were available. Cases were widely distributed across the island. The highest number of cases occurred in children aged 0–9 years. Across age groups, cases were similarly distributed among males and females. These patterns are not consistent with the epidemiology of disease caused by E. histolytica, which tends to cause more cases in males of all ages.

Hypothesis-generating interviews with families of 13 patients did not reveal any common water, food, sewage, or event exposures. Eight participants reported having ill household contacts, with family contacts often becoming ill within 1–3 days after the participant’s illness onset. Six stool specimens were sent to CDC. All were negative for ameba, including E. histolytica, by multiple laboratory methods. All six specimens were also negative for Cryptosporidium and Giardia by a polymerase chain reaction test. However, an invasion plasmid antigen H (ipaH) gene sequence, a genetic marker of Shigella, was identified in four specimens. Additionally, seven Shigella isolates sent to the Hawaii Department of Health and CDC were identified as Shigella flexneri serotype 7 (proposed; also referred to as provisional 88-893 or 1c), and five shared an indistinguishable pulsed-field gel electrophoresis pattern.

Shigella causes an estimated 500,000 cases of shigellosis per year in the United States (1). Most persons infected with Shigella develop diarrhea (sometimes bloody), fever, and stomach cramps 1–2 days after they are exposed to the bacteria. The illness usually resolves in 5–7 days. Careful and frequent hand washing and strict adherence to standard food and water safety precautions are the best defense against shigellosis (2).

Together, epidemiologic and laboratory data suggest this was a shigellosis outbreak with person-to-person transmission. This investigation highlights the importance of building epidemiologic and laboratory capacity for enteric illnesses and enhancing basic hand hygiene and prevention strategies in U.S. territories.

barfblog

safe food from farm to fork

Tag Archives: Epidemiology