Winter is the hottest time for hospitals, retirement residences, cruise ships and restaurants when it comes to norovirus outbreaks. Here in North Carolina, the Department of Public Health distributed a press release referencing recent outbreaks that has made the rounds on local TV and in small town papers.

With as little as just a few virus particles needed for infection and a high rate of secondary illnesses, a noro problem can escalate quickly (just ask Heston Blumenthal).

And everyone is looking for quick solutions to replace handwashing with soap and water, including the ever-present alcohol-based hand sanitizer. They just don’t exist.

Recent research, the first to evaluate alcohol-based hand sanitizers against a human strain of norovirus, shows that the squirtable and ubiquitous-in-public liquid isn’t a magic bullet. A report in the January Applied and Environmental Microbiology (76:394-399) by Liu et al demonstrates that commonly available alcohol-based sanitizers are less-than ideal against noro (despite many of the sanitizer producers proclaiming magic with Tom-Cruise-on-Oprah’s-couch-like exuberance).

As David C. Holzman of the American Society for Microbiology's Microbe says:

Moe, Liu, and their collaborators (including my friend Lee-Ann Jaykus) compared the effectiveness of liquid soap and alcohol hand sanitizers in removing or killing viruses on finger pads, following methods developed by the American Society for Testing and Materials.

After finger pads were inoculated with norovirus and then washed, the researchers used quantitative reverse transcriptase PCR to measure viruses that remained. In another set of tests, sodium hypochlorite (bleach) eliminated virus, while ethanol, regardless of concentration, did little to reduce virus titer. In vivo rinsing either with water or with antibacterial, triclosan-containing soap proved about equally effective in reducing viruses on finger pads.

These results suggest that protection comes from mechanically removing the virus from the hands, rather than from inactivating the virus, says Stuart Levy of Tufts University in Boston, Massachusetts.

Here’s the rub (no pun intended): sanitizer alone isn’t even close to being effective as handwashing on noro but what happens in systems (like kitchens) where handwashing compliance is consistently shown to be less than 20 per cent (and other pathogens also exist). In a study we completed, to be published soon, we report that handwashing attempts can be close to zero at busy times. Best practice, until a better option is found is, soap and water but, as barfblog-favorite Don Schaffner has suggested, there might be a public health benefit by providing sanitizer in low-handwashing compliance situations as replacements for handwashing.
 

WRAL is reporting that 5 students have been hospitalized and more than 150 students fell ill after eating a common meal on Friday February 12.  All of the ill were attending a YMCA leadership event at the Raleigh Sheraton and attended a banquet at the Raleigh Convention Center.

Some attendees reported stomach discomfort, vomiting and diarrhea early Saturday morning, Perry said. As the reports increased, conference leaders called emergency personnel.

Most of the sick students were isolated, treated and returned to conference activities, Perry said. By early afternoon, about 150 students had been treated. Five had to be taken to the hospital.

Students came from across the state to attend. Conference leaders called the parents of students who got sick, and some parents had started to arrive at the Sheraton by Saturday afternoon. Organizers have provided a phone line at 1-800-834-2105 for concerned parents to call for more information.

“At this time, we don’t know the cause of the illness,” said Wake County EMS Medical Director Brent Myers. “We are working with the Wake County epidemiological team to investigate the cause of this illness. It is important that parents of the young people attending the conference know that we are taking good care of everyone.”

Perry said food poisoning could be a possibility. All the students attended a banquet at the Raleigh Convention Center Friday night, he said.

Listeria is bad news for some folks. The elderly and pregnant women are hit much harder than the rest of the population (with mortality rate for listerosis infections in the elderly somewhere around 20-30%).

I gave a talk earlier this year to a bunch of food service operators and gave a few examples on why Listeria is a problem for certain groups of people, focusing on the Maple Leaf outbreak (In 2008, 43 individuals became ill and 22 died during the outbreak linked to Listeria-contaminated deli meat; the average age of victims was 77).

One of the participants, who had his food handlers’ food safety certification, came up to me afterwards and wanted to know more about Listeria and the elderly. He told me that after running institutional foodservice operations for 20 years he had never really connected how big of an issue Listeria is for him and that he had some responsibility for keeping it out of kitchen. He was really freaked out because his residents had recently demanded he provide them with a sandwich bar. So he did.

Research with foodservice personnel in long-term care/assisted living facilities shows that operators can demonstrate general food safety knowledge and generally good attitude towards food safety. Operators’ concern tended to focus on personal hygiene-related issues and little on Listeria-specific risks such as the avoidance of RTE foods susceptible for contamination and risk reduction practices. Cross-contamination and sanitation issues, specifically with food contact surfaces (including cutting boards and counters) have been shown to be problematic for operators in long term care or assisted living facilities.

This week’s food safety infosheet focuses on Listeria-related risks in the food service kitchen and uses an example of a senior’s program facility in Ohio being shut down. The closure was due to fallout from a Listeria monocytogenes positive sample from a meal served there.

You can download the food safety infosheet here.

An updated version of the classic kids game Clue might now have a food safety bent on it: the home chef did it, in the retail store, with the aioli. Following an investigation into a recent aoili/Salmonella-linked outbreak which caused over 130 illnesses, NSW (Australia) Primary Industries Minister Steve Whan was cited as saying in a press release:

'Eggs are a delicious and nutritious food that can be enjoyed as part of a healthy, balanced diet but it is vital people are aware of how to prepare them safely.

'Eggs can sometimes carry Salmonella bacteria and eating raw egg product, like any raw foods from animals can present a risk of food poisoning.

'The risk does tend to increase when restaurants and cafes prepare large batches of raw egg deserts such as mousses or tiramisu, or sauces such as aioli, hollandaise and mayonnaise,' Minister Whan said.

'It is important for business to understand the risk of these products and be extra careful when preparing them.'

The NSW Food Authority strongly recommends businesses:

• offer safer alternatives such as commercially manufactured mayonnaises and sauces,or
• use pasteurised egg products for preparation of such foods as an alternative to raw egg.

Raw eggs have been linked to outbreaks in mayonnaise, Caesar salad dressing, hollandaise, mousses, icings and homemade ice cream. Check out our raw egg food safety infosheet here.

U.S. Centers for Disease Control and Prevention has announced that they are currently investigating a national outbreak of Salmonella Montevideo. Illnesses have been seen in 38 states and DNA analysis on the pathogen is underway to confirm whether all of the illnesses are connected to a common source (nothing has been identified yet). Illnesses associated with this outbreak go back as far as July 2009 (with the most recent illness reported on January 1 of this year).

CDC is collaborating with public health officials in many states, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS), and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Salmonella serotype Montevideo infections. Investigators are using DNA analysis of Salmonella bacteria obtained through diagnostic testing to identify cases of illness that may be part of this outbreak.

As of 12:00 pm EST on January 22, 2010, a total of 184 individuals infected with a matching strain of Salmonella Montevideo have been reported from 38 states since July 1, 2009.  The number of ill persons identified in each state with this strain is as follows:  AL (2), AZ (5), CA (30), CO (2), CT (4), DE (2), FL (2), GA (3), IA (1),  IL (11), IN (3), KS (3), LA (1), MA (12), MD (1), ME (1), MI (1), MN (4), NC (9), ND (1), NE (1), NH (1), NJ (7), NY (15), OH (9), OK (1), OR (8), PA (3),  RI (2), SC (1), SD (3), TN (3), TX (7), UT (7), VA (1), WA (14), WV (1), and WY (2). Because this is a commonly occurring strain, public health investigators may determine that some of the illnesses are not part of this outbreak.

Initially reported as an outbreak of foodborne illness among 30 patrons, WRAL reports tonight that up to 280 people have reported becoming ill after eating at Raleigh's 42 St. Oyster Bar in late December. Health authorities also believe that illnesses also might not have been linked to oysters as initially reported. As Norovirus is easily transmissible and needs only a few particles to infect, it will be difficult for investigators to pinpoint the initial source. Health authorities tested eight employees for norovirus and all have been negative for the virus.

42nd Street owner Brad Hurley initially thought the culprit was oysters from Louisiana. As a precaution, the restaurant immediately stopped serving the Louisiana oysters and started using only oysters from North Carolina.

Tests of the remaining Louisiana oysters have come back negative, Andre Pierce, Wake County's environmental health and safety director said.

The restaurant has also worked with the health department to take other precautions, such as eliminating bare hand contact with food and changing from an ammonia sanitizer to chlorine.

Pierce said they may never know the exact source.

"Norovirus is probably one of the most unreported food illnesses out there. It's hard to detect. It's hard to find a source. We spend a lot of time and resources trying to track it down. And it is frustrating to us and it is frustrating to the public that you can't just put a finger on it, but it is very present and I think it's a lot more out there than we realize."

Public vomiting is particularly a problem as the act of spewing can cause particles to spread. Norovirus particles can also stay viable on surfaces for weeks. Pathogens can be passed on by someone even if they aren’t feeling ill. In 2008 a foodhandler who did not show symptoms or test positive for Norovirus caused an outbreak leading to over 30 illnesses. It's believed that the foodhandler, who was caring for ill family members at home, introduced the norovirus into the kitchen by practicing poor personal hygiene.

It might look good today, but by cleaning up is the Aramark-managed Capitol cafeteria the "safest restaurant in the city of Harrisburg"?

PennLive.com reports that after being closed by Pennsylvania officials on December 17th following an inspection that revealed rodent droppings, underheated dishwashing water and poor food handling procedures, Capitol is trying to clean up their image. Bruce Walton, vice president for operations of Aramark was cited as saying that prior to the closing, more than 1,500 customers ate at the Capitol cafeteria on busy weekdays and that rebuilding that steady clientele will take time.

After a thorough clean-up, a new pest control program with Ecolab and contracting with a company to provide surprise audits, Aramark district manager Andre Obendorfer was quoted as saying "This is the safest restaurant to eat in in the city of Harrisburg."

Ah, the safest food/safest restaurant comment; impossible to back-up with evidence and leaves everyone who eats there with a warm and fuzzy feeling.

Walton, by not disclosing any firings or discipline, downplayed what might be the most important change -- personnel. He was quoted as saying that they "did make changes in our team." Rodent control and a cold dishwasher can lead to public health issues, but other violations found on December 17th including indirect cross-contamination (handling potentially contaminated equipment and then going to clean equipment, possibly leaving pathogens for the next person) and not having paper towels, demonstrate a lack of a food safety culture. A personnel and management issue.

Food safety culture is a set of values wherein food safety risks are openly identified, discussed, and addressed. What this means is that anyone who works there -- from manager to dishwasher -- knows that paper towels can reduce risks so they refill the dispenser. Food safety is supported from the organization but it's the front-line folks who hold the health of patrons in their hands. An organization like Aramark needs to be building the food safety culture capacity behind the scenes, not just touting how clean everything looks now.

To assure patrons of their commitment to food safety, the article reports that Aramark will have staff on site to answer questions, use guest chefs and in the most bizarre step, revamp cafeteria stations such as turning the pizza station into an "Italian zone." I guess visitors to the Capitol Complex have the perception that Italian food is safer than pizza?

Salmonella in nuts strikes again. Nuts and seeds seem to be prone to Salmonella contamination. This year alone peanuts, pistchios, sesame and sunflower seeds, pecans and now hazelnuts from two Oregon companies have been recalled due to Salmonella contamination.

Kunze Farms of Dayton, OR is recalling 32,950 lbs. of hazelnut kernels distributed to several different processors and wholesaler’s in the following areas:  

Dayton, OR; , Milton-Freewater, OR; Hauppauge, NY; Mesa, AZ; Cottonwood, AZ; Seattle, WA; Ogden, UT;  San Antonio, TX.; and Parker, CO. The product was packed in 25 lb cartons, under our product brand name of Kunze Farms, ‘Select Shelled Hazelnuts’ Dayton, Oregon with the code numbers 289091A or 299091A.

Willamette Filbert Growers of Newberg, OR is recalling 29,861 lbs of Shelled Hazelnuts and Shelled Organic Hazelnuts.

After product sampling, Salmonella was found on one production lot at the facility where Willamette Filbert Grower's hazelnuts were shelled. To ensure consumer safety, Willamette Filbert Growers has decided to recall all shelled hazelnuts and shelled organic hazelnuts processed from October 12th 2009 through November 25th 2009. Shelled Hazelnuts and Shelled Organic Hazelnuts were distributed in Oregon and California through wholesale distributors and direct delivery. Unshelled hazelnuts are not subject to this recall. All products subject to recall were packed in 25 lbs. corrugated boxes bearing Willamette Filbert Growers or Meridian Organic Hazelnuts labeled with lot code numbers 289091A and 311091A.

Two Salmonella outbreaks linked to peanut butter, and an additional two Salmonella outbreaks linked to almonds earlier in the decade demonstrate how resilient Salmonella can be on and in dried nut products. At IAFP in August 2005, I co-moderated a symposium at which Robert Tauxe of the CDC said sesame seeds and Salmonella was the next big thing on the international food safety horizon.  His prediction is still looking pretty good.

ESPN reported today that Mark Fistric of the Dallas Stars missed last Saturday night's game vs Los Angeles after being hospitalized with symptoms consistent with a foodborne illness. In an effort to step out of hockey and into epidemiology, Fistric (below, left side of the Blackhawk sandwich), who has 3 points and 14 penalty minutes this season, reported that he believes the illness was caused by a pregame meal on Friday.

"The last thing I ate was a pregame meal in San Jose, and everyone ate it and no one got it," Fistric said. "I felt fine during the game. But when I was getting on the bus, it started hitting me. It was the most pain I'd ever felt in my stomach and they took me right to the hospital [when the plane landed]."
Fistric said he was put on antibiotics and got plenty of sleep the last few days.

Although most pathogens will create symptoms within a couple of days, Fistric might have been exposed up to ten days before feeling ill. While it might make a reappearance, it's usually not as simple as blaming the most recent meal for the illness.

As I dug up some stats on Mark Fistric, I came across some info on his dad, Boris, who was drafted by the Detroit Red Wings in 1979 and spent his professional career in the minor leagues. Boris was a bit of a bad ass, racking up 460 penalty minutes in 64 games as a junior (that's about three fights every two games) and breaking 390 minutes twice while with Kalamazoo of the International League. Wow.