Everything comes down to poo

My mom said she got foodborne illness a couple of years ago, and it affected her for over a year.

ben.stool.sample.nov.09She didn’t contact the health unit and didn’t go the hospital, because that’s how we roll.

My mom’s like most people I chat with about poop: it’s sorta embarrassing. It’s nerds like Chapman (his kit, right) that get stool samples and find out they’re part of a state-wide outbreak.

The U.S. Centers for Disease Control reports that increased availability and rapid adoption of culture-independent diagnostic tests (CIDTs) is moving clinical detection of bacterial enteric infections away from culture-based methods. These new tests do not yield isolates that are currently needed for further tests to distinguish among strains or subtypes of Salmonella, Campylobacter, Shiga toxin–producing Escherichia coli, and other organisms.

Public health surveillance relies on this detailed characterization of isolates to monitor trends and rapidly detect outbreaks; consequently, the increased use of CIDTs makes prevention and control of these infections more difficult (1–3). During 2012–2013, the Foodborne Diseases Active Surveillance Network (FoodNet*) identified a total of 38,666 culture-confirmed cases and positive CIDT reports of Campylobacter, Salmonella, Shigella, Shiga toxin–producing E. coli, Vibrio, and Yersinia. Among the 5,614 positive CIDT reports, 2,595 (46%) were not confirmed by culture. In addition, a 2014 survey of clinical laboratories serving the FoodNet surveillance area indicated that use of CIDTs by the laboratories varied by pathogen; only CIDT methods were used most often for detection of Campylobacter (10%) and STEC (19%).

Maintaining surveillance of bacterial enteric infections in this period of transition will require enhanced surveillance methods and strategies for obtaining bacterial isolates.

Bacterial enteric infections detected by culture-independent diagnostic tests — FoodNet, United States, 2012–2014

CDC MMWR March 13, 2015 / 64(09);252-257

Martha Iwamoto, Jennifer Y. Huang,. Cronquist, Carlota Medus, Sharon Hurd, Shelley Zansky, John Dunn, Amy M. Woron, Nadine Oosmanally, Patricia M. Griffin, John Besser, Olga L. Henao


Hepatitis A vaccines work: Michigan, 2013

Hepatitis A virus (HAV) infections among persons with developmental disabilities living in institutions were common in the past, but with improvements in care and fewer persons institutionalized, the number of HAV infections has declined in these institutions. However, residents in institutions are still vulnerable if they have not been vaccinated.

hepatitis.AOn April 24, 2013, a resident of a group home (GH) for adults with disabilities in southeast Michigan (GH-A) was diagnosed with hepatitis A and died 2 days later of fulminant liver failure. Four weeks later, a second GH-A resident was diagnosed with hepatitis A. None of the GH-A residents or staff had been vaccinated against hepatitis A. Over the next 3 months, six more cases of hepatitis A were diagnosed in residents in four other Michigan GHs. Three local health departments were involved in case investigation and management, including administration of postexposure prophylaxis (PEP). Serum specimens from seven cases were found to have an identical strain of HAV genotype 1A.

This report describes the outbreak investigation, the challenges of timely delivery of PEP for hepatitis A, and the need for preexposure vaccination against hepatitis A for adults living or working in GHs for the disabled.

CDC MMWR 64(06);148-152

Susan R. Bohm, Keira Wickliffe Berger, Pamela B. Hackert, Richard Renas, Suzanne Brunette, Nicole Parker, Carolyn Padro, Anne Hocking, Mary Hedemark, Renai Edwards, Russell L. Bush, Yury Khudyakov, Noele P. Nelson, Eyasu H. Teshale


Outbreaks from raw milk on the rise in US

The U.S. Centers for Disease Control reports that outbreaks caused by raw milk increased over a six-year period, according to a newly released CDC study. The study reviewed outbreaks caused by raw milk–milk that has not been pasteurized to kill disease-causing germs–in the United States that were reported to CDC from 2007-2012. The study analyzed the number of outbreaks, the legal status of raw milk sales in each state, and the number of illnesses, hospitalizations, and deaths associated with these outbreaks.

colbert.raw.milkMore states are legalizing the sale of raw milk even though this leads to an increase in the number outbreaks.

Findings also showed that the number of states that have legalized the sale of raw milk has also increased. In 2004, there were 22 states where the sale of raw milk was legal in some form; however, this number increased to 30 in 2011. Eighty-one percent of outbreaks were reported in states where the sale of raw milk was legal.

Children were at the highest risk for illness from raw milk. About sixty percent of outbreaks involved at least one child younger than five years of age.

 Raw milk is a risk for human health.

You cannot look at, smell, or taste raw milk to determine if it is safe. Cows and other animals can appear healthy and clean, but can still have germs, like Salmonella and E. coli, which can cause illnesses in humans.

Milk cannot be collected without introducing some bacteria– even under ideal conditions of cleanliness. Unless the milk is pasteurized, these bacteria can multiply.

Even raw milk supplied by “certified,” “organic,” or “local” dairies has no guarantee of being safe. Raw milk from grass-fed animals is not considered safe either. 



Vaccination works: Hepatitis A rates fall in US children, rise in adults

As all children attending two schools in Portsmouth, UK will be vaccinated against Hepatitis A in light of a potential outbreak, researchers at the U.S. Centers for Disease Control report that adults are particularly at risk for Hep A infections.

hepatitis.ABackground. In recent years, few US adults have had exposure and resultant immunity to hepatitis A virus (HAV). Further, persons with liver disease have an increased risk of adverse consequences if they are infected with HAV.

Methods. This study used 1999–2011 National Notifiable Diseases Surveillance System and Multiple Cause of Death data to assess trends in the incidence of HAV infection, HAV-related hospitalization, and HAV-related mortality.

Results. During 1999–2011, the incidence of HAV infection declined from 6.0 cases/100 000 to 0.4 cases/100 000. Similar declines were seen by sex and age, but persons aged ≥80 years had the highest incidence of HAV infection in 2011 (0.22 cases/100 000). HAV-related hospitalizations increased from 7.3% in 1999 to 24.5% in 2011. The mean age of hospitalized cases increased from 36.0 years in 1999 to 45.1 years in 2011. While HAV-related mortality declined, the mean age at death among decedents with HAV infection increased from 48.0 years in 1999 to 76.2 years in 2011. The median age range of decedents who had HAV infection and a liver-related condition was 51.0 to 68.0 years.

Conclusions. Although vaccine-preventable, HAV-related hospitalizations increased greatly, mostly among adults, and liver-related conditions were frequently reported among HAV-infected individuals who died. Public health efforts should focus on the need to assess protection from hepatitis A among adults, including those with liver disease.

Trends in disease and complications of hepatitis A virus infection in the United States, 1999–2011: a new concern for adults

Journal of Infectious Diseases [ahead of print]

Kathleen N. Ly and R. Monina Klevens


Litchi fruit connection? Outbreaks of unexplained neurologic illness in India

The U.S. Centers for Disease Control and Prevention reports that outbreaks of an unexplained acute neurologic illness affecting young children and associated with high case-fatality rates have been reported in the Muzaffarpur district of Bihar state in India since 1995.

he_outbreaks_of_unexplained_neurologic_illnessThe outbreaks generally peak in June and decline weeks later with the onset of monsoon rains. There have been multiple epidemiologic and laboratory investigations of this syndrome, leading to a wide spectrum of proposed causes for the illness, including infectious encephalitis and exposure to pesticides. An association between illness and litchi fruit has been postulated because Muzaffarpur is a litchi fruit–producing region (Figure 1).

To better characterize clinical and epidemiologic features of the illness that might suggest its cause and how it can be prevented, the Indian National Centre for Disease Control (NCDC) and CDC investigated outbreaks in 2013 and 2014. Clinical and laboratory findings in 2013 suggested a noninflammatory encephalopathy, possibly caused by a toxin. A common laboratory finding was low blood glucose (<70 mg/dL) on admission, a finding associated with a poorer outcome; 44% of all cases were fatal. An ongoing 2014 investigation has found no evidence of any infectious etiology and supports the possibility that exposure to a toxin might be the cause. The outbreak period coincides with the month-long litchi harvesting season in Muzaffarpur. Although a specific etiology has not yet been determined, the 2014 investigation has identified the illness as a hypoglycemic encephalopathy and confirmed the importance of ongoing laboratory evaluation of environmental toxins to identify a potential causative agent, including markers for methylenecyclopropylglycine (MCPG), a compound found in litchi seeds known to cause hypoglycemia in animal studies (1–3). Current public health recommendations are focused on reducing mortality by urging affected families to seek prompt medical care, and ensuring rapid assessment and correction of hypoglycemia in ill children.

Sprouts still suck; another outbreak sickens at least 115 with Salmonella

The prison warden told Paul Newman’s Cool Hand Luke in the 1967 film that “what we have here is a failure to communicate.”

coolhandlukeIt’s based on an authoritarian model and is the oldest excuse out there; all kinds of problems could be solved if everyone just communicated better, especially scientists and others.

The anti-authoritarian heros of great American movies like One Flew Over the Cuckoo’s Nest, The Blues Brothers and Stripes all found different ways to communicate, in unconventional ways.

The U.S. Centers for Disease Control reports a total of 115 persons infected with the outbreak strains were reported from 12 states. The number of ill people identified in each state was as follows: Connecticut (8), Maine (4), Maryland (6), Massachusetts (36), Montana (1), New Hampshire (6), New York (22), Ohio (3), Pennsylvania (18), Rhode Island (7), Vermont (3), and Virginia (1). The one ill person from Montana traveled to the Eastern United States during the period when exposure likely occurred. Since the last update on December 16, 2014, four additional cases were reported from Maryland (1), Massachusetts (1), New York (1), and Pennsylvania (1).

Illness onset dates ranged from September 30, 2014, to December 15, 2014. Ill persons ranged in age from younger than 1 year to 83 years, with a median age of 32 years. Sixty-four percent of ill persons were female. Among 75 persons with available information, 19 (25%) were hospitalized, and no deaths were reported.

This outbreak appears to be over. However, sprouts are a known source of foodborne illness. CDC recommends that consumers, restaurants, and other retailers always follow food safety practices to avoid illness from eating sprouts.

Erdozain, M.S., Allen, K.J., Morley, K.A. and Powell, D.A. 2012. Failures in sprouts-related risk communication. Food Control. 10.1016/j.foodcont.2012.08.022



Nutritional and perceived health benefits have contributed to the increasing popularity of raw sprouted seed products. In the past two decades, sprouted seeds have been a recurring food safety concern, with at least 55 documented foodborne outbreaks affecting more than 15,000 people. A compilation of selected publications was used to yield an analysis of the evolving safety and risk communication related to raw sprouts, including microbiological safety, efforts to improve production practices, and effectiveness of communication prior to, during, and after sprout-related outbreaks.

amy.sprouts.guelph.05Scientific investigation and media coverage of sprout-related outbreaks has led to improved production guidelines and public health enforcement actions, yet continued outbreaks call into question the effectiveness of risk management strategies and producer compliance. Raw sprouts remain a high-risk product and avoidance or thorough cooking are the only ways that consumers can reduce risk; even thorough cooking messages fail to acknowledge the risk of cross-contamination. Risk communication messages have been inconsistent over time with Canadian and U.S. governments finally aligning their messages in the past five years, telling consumers to avoid sprouts. Yet consumer and industry awareness of risk remains low. To minimize health risks linked to the consumption of sprout products, local and national public health agencies, restaurants, retailers and producers need validated, consistent and repeated risk messaging through a variety of sources.

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

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.

American Samoa.schoolBased 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.

american.samoa.peopleShigella 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.

Who doesn’t? Working when sick

Surveillance data indicate that handling of food by an ill worker is a cause of almost half of all restaurant-related outbreaks. The U.S. Food and Drug Administration (FDA) Food Code contains recommendations for food service establishments, including restaurants, aimed at reducing the frequency with which food workers work while ill. However, few data exist on the extent to which restaurants have implemented FDA recommendations.

sick.rest.workerThe Centers for Disease Control and Prevention’s Environmental Health Specialists Network (EHS-Net) conducted a study on the topic of ill food workers in restaurants. We interviewed restaurant managers (n = 426) in nine EHS-Net sites. We found that many restaurant policies concerning ill food workers do not follow FDA recommendations. For example, one-third of the restaurants’ policies did not specifically address the circumstances under which ill food workers should be excluded from work (i.e., not be allowed to work). We also found that, in many restaurants, managers are not actively involved in decisions about whether ill food workers should work. Additionally, almost 70% of managers said they had worked while ill; 10% said they had worked while having nausea or “stomach flu,” possible symptoms of foodborne illness.

When asked why they had worked when ill, a third of the managers said they felt obligated to work or their strong work ethic compelled them to work. Other reasons cited were that the restaurant was understaffed or no one was available to replace them (26%), they felt that their symptoms were mild or not contagious (19%), they had special managerial responsibilities that no one else could fulfill (11%), there was non–food handling work they could do (7%), and they would not get paid if they did not work or the restaurant had no sick leave policy (5%).

Data from this study can inform future research and help policy makers target interventions designed to reduce the frequency with which food workers work while ill.

 Managerial practices regarding workers working while ill

Journal of Food Protection, Number 1, January 2015, pp. 4-234, pp. 187-195(9)

Norton, D. M.; Brown, L. G.; Frick, R.; Carpenter, L. R.; Green, A. L.; Tobin-D’Angelo, M.; Reimann, D. W.; Blade, H.; Nicholas, D. C.; Egan, J. S.; Everstine, K.


6 dead, 28 sick in outbreak of listeriosis linked to commercially produced, prepackaged caramel apples

The U.S. Centers for Disease Control and Prevention reports:

  • CDC is collaborating with public health officials in several states and with the U.S. Food and Drug Administration (FDA) to investigate an outbreak of Listeria monocytogenes infections (listeriosis) linked to commercially produced, prepackaged caramel apples. Listeria can cause a serious, life-threatening illness.
  • caramel.appleOn January 6, 2015, Bidart Bros. of Bakersfield, California voluntarily recalled Granny Smith and Gala apples because environmental testing revealed contamination with Listeria monocytogenes at the firm’s apple-packing facility.
  • Consumers should not eat any recalled Granny Smith and Gala apples produced by Bidart Bros., and retailers should not sell or serve them.
  • Consumers who are buying or have recently bought Granny Smith or Gala apples can ask their retailers if the apples came from Bidart Bros.
  • The information CDC has at this time indicates that commercially produced, prepackaged caramel apples may be contaminated with Listeria and may be causing this outbreak.
  • Happy Apples, California Snack Foods, and Merb’s Candies each announced a voluntary recall of commercially produced, prepackaged caramel apples after hearing from Bidart Bros., an apple supplier, that there may be a connection between Bidart Bros. apples and this listeriosis outbreak.
  • Investigators are continuing to work to determine if any other brands or types of commercially produced, prepackaged caramel apples are linked to illnesses.
  • CDC continues to recommend that U.S. consumers do not eat any commercially produced, prepackaged caramel apples, including plain caramel apples as well as those containing nuts, sprinkles, chocolate, or other toppings, until more specific guidance can be provided.
  • Although caramel apples are often a fall seasonal product, contaminated commercially produced, prepackaged caramel apples may still be for sale at grocery stores and other retailers nationwide or may be in consumers’ homes.
  • As of January 8, 2015, a total of 32 people infected with the outbreak strains of Listeria monocytogenes had been reported from 11 states.
  • Thirty-one ill people have been hospitalized, and six deaths have been reported. Listeriosis contributed to at least three of these deaths.
  • Ten illnesses were pregnancy-related (occurred in a pregnant woman or her newborn infant), with one illness resulting in a fetal loss.
  • Three invasive illnesses (meningitis) were among otherwise healthy children aged 5–15 years.
  • To date, 23 (88%) of the 26 ill people interviewed reported eating commercially produced, prepackaged caramel apples before becoming ill.
  • The Public Health Agency of Canada (PHAC) has identified 2 cases of listeriosis in Canada with the same pulsed-field gel electrophoresis (PFGE) patterns as seen in the U.S. outbreak.
  • PHAC is working with its provincial and territorial partners to determine the source of these illnesses.
  • This investigation is rapidly evolving, and new information will be provided as it becomes available.

Cruise ship sickness/norovirus outbreaks lowest in 14 years

The number of gastrointestinal illness (GI) outbreaks, including norovirus and enterotoxigenic E. coli, on cruise ships fell to the lowest level in 14 years in 2014.

vomit cruiseThe CDC (Centers for Disease Control and Prevention) website contains detailed reports about the outbreaks on cruise ships from 1994 to 2015. The CDC considers it an outbreak anytime 3% or more of the passengers and crew members report diarrheal symptoms onboard a vessel of at least 100 passengers on sailings that are 3 days or longer.

There were nine reported outbreaks of GI on 7 different cruise ships in 2014, tying 2013 with the lowest number of outbreaks since 2001. When you take into consideration that the number of cruise ships is at a record high, this past year saw the lowest percentage of outbreaks on cruise ships since 2001.