We investigated an outbreak of listeriosis detected by whole-genome multilocus sequence typing and associated with packaged leafy green salads. Nineteen cases were identified in the United States during July 5, 2015–January 31, 2016; isolates from case-patients were closely related (median difference 3 alleles, range 0–16 alleles). Of 16 case-patients interviewed, all reported salad consumption. Of 9 case-patients who recalled brand information, all reported brands processed at a common US facility.
The Public Health Agency of Canada simultaneously investigated 14 cases of listeriosis associated with this outbreak. Isolates from the processing facility, packaged leafy green salads, and 9 case-patients from Canada were closely related to US clinical isolates (median difference 3 alleles, range 0–16 alleles). This investigation led to a recall of packaged leafy green salads made at the processing facility. Additional research is needed to identify best practices and effective policies to reduce the likelihood of Listeria monocytogenes contamination of fresh produce.
Kristen and Brad Bell felt a little sick after eating the salad last October.
Their two-year-old son soon started to show more severe symptoms. Cooper Bell was vomiting. He developed diarrhea. Then his mother noticed the blood in his diaper.
“I had no idea [what] was happening,” Kristen Bell told CTV News from her home in Stirling, Ont.
“I thought ‘This is not normal.'”
An emergency room doctor thought Cooper might have contracted a bacterial infection. The family’s pediatrician agreed, saying the Bells should keep their son hydrated and bring him back in the morning.
Soon after the Bells returned home, they noticed some worrying changes in Cooper’s behavior.
“He wasn’t responding to me the same as he was earlier. It wasn’t long after that, that he had a seizure in Brad’s arms,” Kristen Bell said.
Seeing their son shaking uncontrollably with his eyes closed, the Bells called an ambulance. He spent a few hours in hospital in nearby Belleville, Ont., and was then airlifted to the Children’s Hospital of Eastern Ontario in Ottawa.
Doctors at CHEO diagnosed Cooper with kidney failure brought on by E. coli. He suffered cardiac arrest and died. The Bells believe it was the romaine lettuce that made Cooper sick, although they were unable to send the lettuce for testing to confirm their belief because it had been thrown out.
There were 29 illnesses and 10 hospitalizations reported across Canada during last fall’s E. coli outbreak, according to the Public Health Agency of Canada. It was one of three outbreaks in North America over the past year all of which were linked to romaine lettuce.
Keith Warriner, a food safety expert and professor at the University of Guelph in Ontario, said in an interview that the food industry has long been slow to improve its testing practices something that could improve overall food safety, but would mean extra costs for their operations.
“The industry itself has known for many years what it needs to do, but it’s just been reluctant to do it,” he said.
The Bells agree. They’re sharing their story of grief with the hope it will help hospital workers and other parents better understand the danger of E. coli, but also because they want to see changes at the food production level.
“E. coli shouldn’t be in our food,” Brad Bell said.
“The way that we’re growing food is dangerous, and something has to change.”
Longtime friend of the barfblog.com, Michéle Samarya-Timm, health educator at the Somerset County Department of Health (that’s in New Jersey, represent) writes:
Baking pumpkin pies with Aunt Kay’s secret recipe. Watching Miracle on 34th Street. Preparing the dining room with the good china. Diffusing political conversations at the dinner table.
Some traditions give a sense of warmth, connection, and continuity, and regularly define a family’s holiday. Unfortunately, there is now a need to add an additional tradition to the season – actively checking for foodborne outbreaks and recalls to prevent folks from getting sick.
Last week, on Tuesday, November 20th at 2pm, (two days before Thanksgiving), the CDC posted a media statement with advice to consumers, restaurants, and retailers:
“CDC is advising that U.S. consumers not eat any romaine lettuce, and retailers and restaurants not serve or sell any, until we learn more about the outbreak.”
The need to release such a notice, right before a major holiday is an unpropitious scenario. It was also very concerning in its specificity to consumers, retailers and restaurants:
“Wash and sanitize drawers or shelves in refrigerators where romaine was stored.”
Such an alert is most effective if it reaches the intended audiences. Folks at my holiday table did not hear about the outbreak. Neither did many local health departments.
Issuing media releases is one way for public health agencies to reach large groups of people. However, distracted by holiday preparations, travel, shopping, family, football and bad weather this advisory was only partially disseminated to the public. A person had to be following news outlets or social media to receive timely notice. I heard about the recall from the woman next to me while I was getting a haircut – not from the CDC or FDA, or any other federal or state agency.
It’s disturbing. The CDC could have sent this info directly to local health departments, or notify them that a news release was issued. This was not the first time as a local public health official that I received delayed – or no – official communication about a national foodborne issue.
Local public health professionals rely on communications systems established by federal and state oversight agencies. Most commonly, if a verified or suspect foodborne contamination or outbreak has occurred, the Centers for Disease Control and Prevention (CDC), the U.S. Department of Agriculture, or the U.S. Food and Drug Administration (FDA) will ascertain the appropriateness of information release. If this information is deemed credible, notification is forwarded individually or en masse to state departments of health. The states, in turn, push this information down to local regulators. Each step in the process contains elements that may delay the rapid dissemination of outbreak information. The ability and willingness of all stakeholders to quickly and readily share incident particulars with fellow responding agencies can enhance effectiveness and amplify response efforts.
Electronically sending this advisory directly to the nearly 3,000 local health departments in the US would provide the opportunity for hundreds of health inspectors, health educators, epidemiologists and other to reach the hospitals, food banks, schools, mom and pop establishments and local residents who may not have otherwise received the alert. This was a missed opportunity, and hopefully one that didn’t cause additional cases of illness.
As I’ve written before, coordinated communication strategies within and between public health agencies is less robust than it should be. As a result, state and local public health officials may hear about foodborne disease issues first from other sources, such as the media, word of mouth, public complaints, or the food industry.
We need to learn how to communicate better with each other. Local public health shouldn’t have to keep an eye on the news media, Twitter or Facebook for information pertinent to protecting the people in our jurisdictions. A multitude of electronic portals exist for purposes of interagency communication, CDC, FDA, and the public health system should collectively define how pertinent information – such as this romaine advisory – rapidly and routinely gets to the grass roots public health workforce. Continuously improving interagency coordination and communication is a goal that is fundamental to increasing the effectiveness of this nation’s food safety systems. I’m putting this out there, because I’m willing to help with the solution. That way, in future years, I can spend my holidays perfecting Aunt Kay’s pie recipe.
This holiday, I’m thankful for public health influencers and amplifiers – like barfblog.com – that act as outbreak aggregators, and push out info to local public health types like me.
Some background information and recommendations on this topic can be found in: Getting the message across: an analysis of foodborne outbreak communications between federal, state, and local health agencies https://calhoun.nps.edu/handle/10945/49379
Scott Gottlieb, FDA Commissioner took to the Twitter this morning while many were buying TVs and Himalayan salt lamps to talk about the Romaine-linked E. coli O157 outbreak.
I imagine there’s lots of pressure out there to lift the blanket statement from CDC to avoid all Romaine. Especially if the dates of harvest/transition from one location to another make it so it’s not likely that lettuce from certain regions would be linked to the outbreak.
Some sort of identification is great – because how would a consumer know what to ask about or how to figure out the source without it.
UPDATE ON OUTBREAK: The romaine implicated in the current outbreak is likely from California based on growing and harvesting patterns. The goal now is to withdraw the product that’s at risk of being contaminated from the market, and then re-stock the market…..
….New romaine from different growing regions, including Florida and Arizona, will soon be harvested. We’re working with growers and distributors on labeling produce for location and harvest date and possibly other ways of informing consumers that the product is “post-purge”….
….We want to help unaffected growers get back into production and enable stores and consumers to re-stock. One goal we’re seeking is to make this type of labeling the new standard rather than a short-term fix; as a way to improve idenfitifaction and traceability in the system.
Escherichia coli are Gram-negative rod-shaped bacteria and part of the normal bacterial flora in the gastrointestinal tract, while diarrhoeagenic E. colipathotypes such as Shiga toxin-producing E. coli (STEC) and enteropathogenic E. coli (EPEC) are able to cause gastrointestinal infections . STEC can lead to a severe disease, such as haemolytic-uraemic syndrome (HUS) . The risk of HUS has been related especially to children under 5 years and to elderly people. HUS is characterised by acute onset of microangiopathic haemolytic anaemia, renal injury and low platelet count.
More than 400 STEC serotypes have been recognised, of which the best-known serotype is O157:H7 . The most common non-O157:H7 serotypes causing human infections are O26, O103, O111 and O145 . The virulence of STEC is largely based on the production of Shiga toxin 1 or 2 and is identified by detecting the presence of stx1 or stx2 genes [1,4]. The virulence of EPEC is caused by its capability to form attaching and effacing (A/E) lesions in the small intestine. This capability requires the presence of virulence genes called the locus of enterocyte effacement (LEE) in a pathogenity island (PAI) that encodes intimin . Unlike STEC, EPEC do not produce Shiga toxin. EPEC are divided into two distinct groups by the presence of EPEC adherence factor plasmid (pEAF) expressing bundle-forming pili (BFP), which is a virulence determinant of typical EPEC (tEPEC) . Thus atypical EPEC (aEPEC) are defined as E. coli that produce A/E lesions but do not express BFP. Typical EPEC are best known as a cause of infantile diarrhoea, especially in developing countries . Diarrhoea-causing aEPEC have been shown to be separate group without a close relation to tEPEC, but some serotypes are genetically related to STEC . The pathogenity of aEPEC has been questioned but their involvement with diarrhoeal outbreaks supports the idea that certain strains are diarrhoeagenic [1,7].
Both STEC and EPEC are transmitted through the faecal-oral route, and outbreaks caused by STEC and aEPEC have been described after ingestion of contaminated food or water [7,8]. STEC is common in ruminants and can be found in foods contaminated by ruminant faeces . Most studies on STEC have focused on the serotype O157:H7, but infections and outbreaks caused by non-O157 strains are increasingly reported in Europe and elsewhere [10–13]. Atypical EPEC strains are found in animals used for food production, such as cattle, sheep, goat, pig and poultry, in contrast to tEPEC that has been found only in humans [1,14].
Since 1995, clinicians and clinical microbiology laboratories have been obliged to report culture-confirmed STEC infections to the Finnish Infectious Disease Registry (FIDR) maintained by the National Institute for Health and Welfare (THL) in Finland. EPEC infections are not reportable. Since PCR instead of culture became the standard for screening of diarrhoeal patients in 2013, the incidence of reported STEC infections has increased in Finland to 1.2–1.8 per 100,000 population between 2013 and 2015 compared with 0.2–0.6 per 100,000 between 2000 and 2012. From 1997 to 2015, six food- or waterborne STEC outbreaks were detected in Finland (Table 1).
Outbreak of multiple strains of non-O157 Shiga toxin-producing and enteropathogenic Escherichia coli associated with rocket salad, Finland, autumn 2016
Elizabeth Shogren and Susie Neilson of Reveal write that William Whitt suffered violent diarrhea for days. But once he began vomiting blood, he knew it was time to rush to the hospital. His body swelled up so much that his wife thought he looked like the Michelin Man, and on the inside, his intestines were inflamed and bleeding.
For four days last spring, doctors struggled to control the infection that was ravaging Whitt, a father of three in western Idaho. The pain was excruciating, even though he was given opioid painkillers intravenously every 10 minutes for days.
His family feared they would lose him.
“I was terrified. I wouldn’t leave the hospital because I wasn’t sure he was still going to be there when I got back,” said Whitt’s wife, Melinda.
Whitt and his family were baffled: How could a healthy 37-year-old suddenly get so sick? While he was fighting for his life, the U.S. Centers for Disease Control and Prevention quizzed Whitt, seeking information about what had sickened him.
Finally, the agency’s second call offered a clue: “They kept drilling me about salad,” Whitt recalled. Before he fell ill, he had eaten two salads from a pizza shop.
William Whitt and wife Melinda say it is irresponsible for the Food and Drug Administration to postpone water-testing requirements for produce growers. “People should be able to know that the food they’re buying is not going to harm them and their loved ones,” Melinda Whitt said.
The culprit turned out to be E. coli, a powerful pathogen that had contaminated romaine lettuce grown in Yuma, Arizona, and distributed nationwide. At least 210 people in 36 states were sickened. Five died and 27 suffered kidney failure. The same strain of E. coli that sickened them was detected in a Yuma canal used to irrigate some crops.
For more than a decade, it’s been clear that there’s a gaping hole in American food safety: Growers aren’t required to test their irrigation water for pathogens such as E. coli. As a result, contaminated water can end up on fruits and vegetables.
After several high-profile disease outbreaks linked to food, Congress in 2011 ordered a fix, and produce growers this year would have begun testing their water under rules crafted by the Obama administration’s Food and Drug Administration.
But six months before people were sickened by the contaminated romaine, President Donald Trump’s FDA – responding to pressure from the farm industry and Trump’s order to eliminate regulations – shelved the water-testing rules for at least four years.
Despite this deadly outbreak, the FDA has shown no sign of reconsidering its plan to postpone the rules. The agency also is considering major changes, such as allowing some produce growers to test less frequently or find alternatives to water testing to ensure the safety of their crops.
“Mystifying, isn’t it?” said Trevor Suslow, a food safety expert at the University of California, Davis. “If the risk factor associated with agricultural water use is that closely tied to contamination and outbreaks, there needs to be something now. … I can’t think of a reason to justify waiting four to six to eight years to get started.”
The deadly Yuma outbreak underscores that irrigation water is a prime source of foodborne illnesses. In some cases, the feces of livestock or wild animals flow into a creek. Then the tainted water seeps into wells or is sprayed onto produce, which is then harvested, processed and sold at stores and restaurants. Salad greens are particularly vulnerable because they often are eaten raw and can harbor bacteria when torn.
After an E. coli outbreak killed three people who ate spinach grown in California’s Salinas Valley in 2006, most California and Arizona growers of leafy greens signed agreements to voluntarily test their irrigation water.
Whitt’s lettuce would have been covered by those agreements. But his story illustrates the limits of a voluntary safety program and how lethal E. coli can be even when precautions are taken by farms and processors.
Farm groups contend that water testing is too expensive and should not apply to produce such as apples or onions, which are less likely to carry pathogens.
“I think the whole thing is an overblown attempt to exert government power over us,” said Bob Allen, a Washington state apple farmer.
While postponing the water-testing rules would save growers $12 million per year, it also would cost consumers $108 million per year in medical expenses, according to an FDA analysis.
“The Yuma outbreak does indeed emphasize the urgency of putting agricultural water standards in place, but it is important that they be the right standards, ones that both meet our public health mission and are feasible for growers to meet,” FDA spokeswoman Juli Putnam said in response to written questions.
In addition, the FDA did not sample water in a Yuma irrigation canal until seven weeks after the area’s lettuce was identified as the cause of last spring’s outbreak. And university scientists trying to learn from the outbreak say farmers have not shared water data with them as they try to figure out how it occurred and avoid future ones.
My wife does a better Minnosotan accent, spending her yute in Albert Lea, eh?
He didn’t like the photo, right, made by the creative couple of Heather and Christian, who used to work in my lab, and opened the conversation with, “How could you print that?”
I said it was an accurate description of what had been publically known about the leafy greens folks since the E. coli O157 spinach outbreak of 2006 (I’m old, waiting for news on the birth of my third grandson).
I said great, make it public, so people can judge on their own.
Fresh Express has now been linked to 395 cases of Cyclospora through their lettuce served at McDonalds.
U.S. Rep. Rosa DeLauro, D-Conn., is pressing Food and Drug Administration Commissioner Scott Gottlieb for specifics about the investigation of the cyclosporaoutbreak linked to product sold by Fresh Express.
In an Aug. 3 letter her office released to the media, DeLauro said she wrote the letter “out of concern about the current outbreak of cyclosporiasis as well as the transparency and timeliness of your agency’s ongoing investigation.”
“Although once rare in the United States, parasitic outbreaks caused by cyclospora have become more common over the last several decades,” she said in the letter. “Many of these outbreaks have continually been found to be associated with imported fruits and vegetables.”
The recent outbreak is currently responsible for 395 infections — including 16 hospitalizations — across 15 states.
The parasite was first found when the FDA conducted testing on an unused package of Fresh Express salad mix, distributed to a McDonald’s restaurant, containing romaine lettuce and carrots.
The FDA states as of July 13, McDonald’s decided to stop selling the salads at restaurants impacted in Illinois, Iowa, Indiana, Wisconsin, Michigan. Ohio, Minnesota, Nebraska, South Dakota. Montana, North Dakota, Kentucky, West Virginia and Missouri.
In a July 20, statement, McDonald’s said the health and safety of their customers is their top priority.
“The health and safety of our customers and the people who work in McDonald’s restaurants is always our top priority. The additional states identified by the FDA and CDC are among the same states where a week ago we proactively decided to remove our lettuce blend in impacted restaurants and replace it through a different supplier. McDonald’s is committed to the highest standards of food safety and quality and we continue to cooperate and support regulatory and public health officials in their investigations. For those seeking additional information about Cyclospora, we encourage them to visit the CDC and FDA websites.”
Cyclospora sucks. My aunt, my mom’s sister, got it in Florida from basil, about a decade ago.
(Doesn’t she look amazing at 80, left.)
Cyclospora isn’t one of those things doctors routinely check for. Then you’re sick for about six weeks until some bright doc figures it out.
The U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) issued an alert to the public on “beef, pork and poultry salad and wrap products potentially contaminated with Cyclospora that were distributed by Caito Foods LLC, of Indianapolis,” Indiana.
USDA also released a public health alert after Indianapolis-based food distributor Caito Foods “received notification from their lettuce supplier, Fresh Express, that the chopped romaine that is used to manufacture some of their salads and wraps was being recalled.”
“Fresh Express follows rigid food safety requirements and preventive controls throughout our supply chain that are carefully designed to mitigate against potential health risks. Working together with public health officials, we are hopeful a definitive source of the outbreak clusters will be identified soon.”
Still here, Mike. You can call me in Australia through Google voice 785-532-1925 and tell me what Fresh Express is doing, and why they are importing lettuce in the middle of North American summer.
Lettuce has been implicated in human norovirus (HuNoV) outbreaks. The virus is stable on the leaf surface for at least 2 weeks; however, the dynamics of virus internalization have not been fully investigated. The purpose of this study was to assess the internalization and distribution of HuNoV and two surrogate viruses, porcine sapovirus (SaV) and Tulane virus (TV), in lettuce and spinach.
Viral inoculations through the roots of seedlings and the petiole of leaves from mature plants were performed, and the viruses were tracked on days 1 and 6 post-root inoculation and at 16 h and 72 h post-petiole inoculation. Confocal microscopy was used to visualize root-internalized HuNoV.
In both lettuce and spinach, (i) HuNoV was internalized into the roots and leaves at similar RNA titers, whereas surrogate viruses were more restricted to the roots, (ii) all three viruses were stable inside the roots and leaves for at least 6 days, and (iii) HuNoV disseminated similarly inside the central veins and leaf lamina, whereas surrogate viruses were more restricted to the central veins. Infectious TV, but not SaV, was detectable in all tissues, suggesting that TV has greater stability than SaV. HuNoV was visualized inside the roots’ vascular bundle and the leaf mesophyll of both plants.
In conclusion, using surrogate viruses may underestimate the level of HuNoV internalization into edible leaves. The internalization of HuNoV through roots and cut leaves and the dissemination into various spinach and lettuce tissues raise concerns of internal contamination through irrigation and/or wash water.
IMPORTANCE Human noroviruses are the leading cause of foodborne outbreaks, with lettuce being implicated in the majority of outbreaks. The virus causes acute gastroenteritis in all age groups, with more severe symptoms in children, the elderly, and immunocompromised patients, contributing to over 200,000 deaths worldwide annually. The majority of deaths due to HuNoV occur in the developing world, where limited sanitation exists along with poor wastewater treatment facilities, resulting in the contamination of water resources that are often used for irrigation.
Our study confirms the ability of lettuce and spinach to internalize HuNoV from contaminated water through the roots into the edible leaves. Since these leafy greens are consumed with minimal processing that targets only surface pathogens, the internalized HuNoV presents an added risk to consumers. Thus, preventive measures should be in place to limit the contamination of irrigation water. In addition, better processing technologies are needed to inactivate internalized viral pathogens.
Tissue distribution and visualization of internalized norovirus in leafy greens