In their recent article in Eurosurveillance, Germinario et al. describe a community-wide outbreak of Shiga toxin 2-producing Escherichia coli (STEC) O26:H11 infections associated with haemolytic uraemic syndrome (HUS) and involving 20 children between 11 and 78 months of age in southern Italy during the summer 2013 . The investigation identified an association between STEC infection and consumption of dairy products from two local milk-processing establishments. We underline striking similarities to a recent multi-country STEC O26 outbreak in Romania and Italy and discuss the challenges that STEC infections and their surveillance pose at the European level.
In March 2016, Peron et al. published, also in Eurosurveillance, early findings of the investigation of a community-wide STEC infection outbreak in southern Romania . As at 29 February 2016, 15 HUS cases with onset of symptoms after 24 January 2016, all but one in children less than two years of age, had been identified, three of whom had died. Aetiological confirmation was retrospectively performed through serological diagnosis and six cases were confirmed with STEC O26 infection. Shortly after this publication, and following the identification of the first epidemiologically-linked case in central Italy, the European Centre for Disease Prevention and Control (ECDC) and the European Food Safety Authority (EFSA) published a joint Rapid Outbreak Assessment . The Italian and Romanian epidemiological, microbiological and environmental investigations implicated products from a milk-processing establishment in southern Romania as a possible source of infection. The dairy plant exported milk products to at least four European Union (EU) countries. The plant was closed in March 2016 and the implicated food products recalled or withdrawn from the retail market.
Pulsed Field Gel Electrophoresis (PFGE) and whole genome sequencing (WGS) analyses did not establish a microbiological link between the Italian (2013) and the Romanian/Italian (2016) outbreaks (personal communication, Stefano Morabito, October 2016). However, the epidemiological similarities between the two community-wide outbreaks associated with HUS and STEC O26 infections, mostly affecting young children and implicating dairy products, are notable. While raw milk and unpasteurised dairy products are well known potential sources of STEC infection, milk products, as highlighted by Germinaro et al. , have been rarely implicated in community-wide STEC outbreaks in the past, emphasising an emerging risk of STEC O26 infection associated with milk products.
Reporting of STEC O26 infections has been steadily increasing in the EU since 2007, partly due to improved diagnostics of non-O157 sero-pathotypes . The attention to non-O157 STEC sero-pathotypes rose considerably after the severe STEC O104 outbreak that took place in Germany and France in 2011 during which almost 4,000 cases and more than 50 deaths were reported . In light of the recently published outbreaks related to dairy products and the simultaneous increased reporting of isolations of STEC O26 from milk and milk products in the EU/European Economic Area (EEA) , strengthening STEC surveillance in humans and food and enhancing HUS surveillance in children less than five years of age is warranted. Paediatric nephrologists should be sensitised to this effect
Community-wide outbreaks of haemolytic uraemic syndrome associated with Shiga-toxin producing Escherichia coli O26 in Italy and Romania: A new challenge for the European Union
Eurosurveillance, Volume 21, Issue 49, 08 December 2016, DOI: http://dx.doi.org/10.2807/1560-7917.ES.2016.21.49.30420
E Severi, F Vial, E Peron, O Mardh, T Niskanen, J Takkinen
National Meat and Provisions, a Reserve, La. establishment, is recalling approximately 2,349 pounds of beef and veal products that may be contaminated with E. coli O26, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today.
The raw non-intact beef and veal items were produced and packaged on Sept. 14-15, 2016. The following products are subject to recall: [View Labels (PDF Only)]
51.40-lb. of VACUUM-PACKED “BEEF GROUND COMPANY BURGER BLEND,” packed on 9/14/2016 with a lot number of “00028584” and case codes of 53085/CB136 in the upper left-hand corner of the label
50.00-lb. of VACUUM-PACKED “BEEF GROUND COURSE STEAK TRIM,” packed on 9/14/2016 with a lot number of “00028582” and case codes of 53080/02300H in the upper left-hand corner of the label
10.00-lb. of VACUUM-PACKED “BEEF GROUND FRESH,” packed on 9/14/2016 with a lot number of “00028583” and case codes of 53110/02300P in the upper left-hand corner of the label
50.00-lb. VACUUM-PACKED “BEEF GROUND CHIMES FINE,” packed on 9/14/2016 with a lot number of “00028581” and case codes of 56660/02300C in the upper left-hand corner of the label
51.46-lb. VACUUM-PACKED “BEEF GROUND COMPANY BURGER BLEND,” packed on 9/15/2016 with a lot number of “00028597” and case codes of 53085/CB136 in the upper left-hand corner of the label
10.00-lb. VACUUM-PACKED “BEEF FAT OF RIB CAP,” packed on 9/15/2016, with a lot number of “00028595,” and case codes of 50010/1138 in the upper left-hand corner of the label
10.83-lb. VACUUM-PACKED “BEEF GROUND CHUCK DAT DOG,” packed on 9/15/2016, with a lot number of “00028593,” and case codes of 56135/02150 in the upper left-hand corner of the label
10.23-lb. VACUUM-PACKED “BEEF GROUND CHUCK BRISKET BURGER,” packed on 9/15/2016 with a lot number of “00028596,” and case codes of 53060/208116120 in the upper left-hand corner of the label
5.00-lb. VACUUM-PACKED “BEEF STEAK CUBED 5#,” packed on 9/15/2016, with a lot number of “00028594,” and case codes of 50565/04902 in the upper left-hand corner of the label
10.00-lb. VACUUM-PACKED “BEEF GROUND CHUCK 10#,” packed on 9/15/2016, with a lot number of “00028592,” and case codes of 53015/02100 in the upper left-hand corner of the label
10.11-lb. VACUUM-PACKED “BEEF STEAK CUBED,” packed on 9/15/2016, with a lot number of “00028591,” and case codes of 50555/1100GJ in the upper left-hand corner of the label
10.32-lb. VACUUM-PACKED “BEEF GROUND CHUCK BRISKET 8 oz.,” packed on 9/15/2016, with a lot number of “00028585,” and case codes of 53050/05M8 in the upper left-hand corner of the label
9.98-lb. VACUUM-PACKED “VEAL SIRLOIN CUBED POLY BAGED,” packed on 9/15/2016, with a lot number of “00028590,” and case codes of 56070/0776 in the upper left-hand corner of the label
The products subject to recall bear establishment number “EST. M-22022” inside the USDA mark of inspection. These items were shipped to a distributor, as well as hotels, restaurants and institutions in Louisiana.
The problem was discovered when the establishment received a positive STEC sample during their quarterly E. coli testing program on Sept. 29, 2016. There have been no confirmed reports of adverse reactions due to consumption of these products.
Many clinical laboratories do not test for non-O157 Shiga toxin-producing E. coli (STEC), such as STEC O26 because it is harder to identify than STEC O157. People can become ill from STECs 2–8 days (average of 3–4 days) after consuming the organism. Most people infected with STEC O26 develop diarrhea (often bloody), and vomiting. Some illnesses last longer and can be more severe. Infection is usually diagnosed by testing of a stool sample. Vigorous rehydration and other supportive care is the usual treatment; antibiotic treatment is generally not recommended.
A case–control study was conducted to identify the source of the outbreak. STEC O26 infection was identified in 20 children (median age 17 months) with HUS, two of whom reported severe neurological sequelae. No cases in adults were detected. Molecular typing showed that two distinct STEC O26:H11 strains were involved. The case–control study showed an association between STEC O26 infection and consumption of dairy products from two local plants, but not with specific ready-to-eat products. E.coli O26:H11 strains lacking the stx genes were isolated from bulk milk and curd samples, but their PFGE profiles did not match those of the outbreak isolates.
This outbreak supports the view that infections with Stx2-producing E. coli O26 in children have a high probability of progressing to HUS and represent an emerging public health problem in Europe.
Community-wide outbreak of hemolytic uraemic syndrome associated with Shiga toxin 2-producing Escherichia coli O26:H11 in southern Italy, summer 2013
Eurosurveillance, Volume 21, Issue 38, 22 September 2016
Four more ill people have been reported from two states. The most recent illness started on June 25, 2016.
An infection with another serotype, Shiga toxin-producing Escherichia coli (STEC O26), has been added to this outbreak investigation. STEC O26 was isolated from a sample of General Mills flour (pic, left, from 2011; Sorenne did not eat the flour and awareness of cross-contamination was robust).
One person has developed hemolytic uremic syndrome, a type of kidney failure.
The U.S. Centers for Disease Control, multiple states, and the U.S. Food and Drug Administration(FDA) are investigating a multistate outbreak of Shiga toxin-producing Escherichia coli (STEC) infections.
46 people infected with the outbreak strains of STEC O121 or STEC O26 have been reported from 21 states.
Thirteen ill people have been hospitalized. One person developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported.
Epidemiologic, laboratory, and traceback evidence indicate that flour produced at the General Mills facility in Kansas City, Missouri is a likely source of this outbreak.
Several recalls and recall expansions have been announced as a result of this investigation.
In July 2016, laboratory testing by General Mills and FDA isolated STEC O26 from a sample of General Mills flour. Whole genome sequencing (WGS) showed that the STEC O26 isolated from the flour sample was closely related genetically to isolates from an ill person. The flour tested was not included in the earlier General Mills recalls.
On July 25, 2016, General Mills further expanded its flour recall to include additional lots.
CDC recommends that consumers, restaurants, and retailers do not use, serve, or sell the recalled flours.
Do not eat raw dough or batter, whether made from recalled flour or any other flour. Flour or other ingredients used to make raw dough or batter can be contaminated with STEC and other pathogens.
Consumers should bake all items made with raw dough or batter before eating them. Do not taste raw dough or batter.
Restaurants and retailers should not serve raw dough to customers or allow children and other guests to play with raw dough.
This investigation is ongoing, and we will update the public when more information becomes available.
Eight cases of the E. coli O26 infection have been identified in children who attend the nursery.
The Public Health Agency (PHA) is investigating and confirmed that preliminary test results suggest there may be additional cases.
Dr Neil Irvine, consultant in health protection at the PHA, said: “We are working with colleagues in environmental health and staff in the nursery to identify the source of infection and to help prevent transmission to other children.
“As a precautionary measure, the nursery has been closed for a deep clean and samples taken from all children. The children will be excluded from nursery until negative samples are provided.”
Dr Irvine said people should follow some simple rules to help prevent the spread of E. coli, such as washing hands after using the toilet and before eating or preparing food. He said people with vomiting or diarrhoea should remain at home for 48 hours after last symptoms appear.
If it was so bloody simple, then why do so many get sick?
Serogroup O26 strains are categorized mainly into two groups: enteropathogenic (EPEC) O26, carrying a locus of enterocyte effacement (LEE) and mostly causing mild diarrhea, and Shiga-toxigenic (STEC) O26, which carries the Shiga toxin (STX) gene (stx), responsible for more severe outcomes. stx-negative O26 strains can be further split into two groups. One O26 group differs significantly from O26 EHEC, while the other O26 EHEC-like group shows all the characteristics of EHEC O26 except production of STX.
In order to determine the different populations of O26 E. coli present in U.S. cattle, we sequenced 42 O26:H11 strains isolated from feedlot cattle and compared them to 37 O26:H11 genomes available in GenBank. Phylogenetic analysis by whole-genome multilocus sequence typing (wgMLST) showed that O26:H11/H− strains in U.S. cattle were highly diverse. Most strains were sequence type 29 (ST29). By wgMLST, two clear lineages could be distinguished among cattle strains. Lineage 1 consisted of O26:H11 EHEC-like strains (ST29) (4 strains) and O26:H11 EHEC strains (ST21) (2 strains), and lineage 2 (36 strains) consisted of O26:H11 EPEC strains (ST29).
Overall, our analysis showed U.S. cattle carried pathogenic (ST21; stx1+ ehxA+ toxB+) and also potentially pathogenic (ST29; ehxA+ toxB+) O26:H11 E. coli strains. Furthermore, in silico analysis showed that 70% of the cattle strains carried at least one antimicrobial resistance gene.
Our results showed that whole-genome sequence analysis is a robust and valid approach to identify and genetically characterize E. coli O26:H11, which is of importance for food safety and public health.
Virulence gene profiles and clonal relationships of Escherichia coli O26:H11 isolates from feedlot cattle as determined by whole-genome sequencing
At the same time, The National Veterinary Authority for Food Safety (ANSVSA) sent a press release by which they said that on 25 February joint teams made up of inspectors from Arges and Dolj started the action of taking samples which were sent to be analysed to the Institute for Public Health (IISPV).
According to the results of the inquiry, in which 194 samples analysed up to that date, E.coli O26 was found in a chicken sample taken from the fridge of one of the persons under inquiry. The meat came from chickens raised in the household of the respective person (Bacau county).
At the same time, the bacteria was discovered in samples taken from 25 kg of cottage cheese produced by a dairy unit in Arges (Lactate Bradet).
With six outbreaks now associated with Chipotle since July, the burrito chain is under scrutiny from the public and food safety folks for being heavy on promises to be 20 years ahead of everyone else and light on details. A couple of weeks ago they talked about switching their tomato handling from largely an in-store process to a centralized commissary with controls.
Onions will be dipped in boiling water to kill germs before they’re chopped. Raw chicken will be marinated in re-sealable plastic bags, rather than in bowls. Cilantro will be added to freshly cooked rice so the heat gets rid of microbes in the garnish.
“When you’re given a project like this, you look at the universe of hazards,” said Mansour Samadpour, CEO of IEH Laboratories, which was hired by Chipotle to tighten its procedures.
Chipotle spokesman Chris Arnold said many of changes will be implemented in coming weeks, but that the company doesn’t expect the taste of its food to suffer. Among the tweaks the company is making:
—Cheese will now arrive in restaurants shredded.
—Ingredients like onions will be macerated with lemon or lime juice to kill germs.
—60 samples of every 2,000 pounds of steak will be tested before it’s sent to stores. A similar testing program will be implemented for chicken in coming weeks. Pork and barbacoa beef are already delivered cooked in sealed bags.
—Tomatoes, cilantro and other ingredients will be chopped in centralized locations, rather than in stores, so they can be tested. Chipotle has said in the past that tomatoes taste better when freshly diced in restaurants. After the outbreak, Chipotle co-CEO Steve Ells changed tunes: “If I’m eating a burrito that had tomatoes that were chopped in a central kitchen in the salsa or one that was chopped in house, I probably couldn’t tell the difference,” he said in an interview on CNBC last week.
Not all chopping will be moved to centralized locations. Onions, for instance, would oxidize and smell bad if they were chopped days in advance, Samadpour said. So they will remain chopped in restaurants, along with lemons, limes and jalapenos. All will now be blanched to kill germs.
These are some good steps, I’d love to see the validation data that shows onions macerated with high-acid juice will take care of pathogens. Salmonella has been shown to be pretty hardy in the ceviche-type setting (resulting in a 1-2 log reduction according to some work done by barfblog friend and podcast buddy Don Schaffner).
I’d love to see the data associated with adding-cilantro-to-hot-rice – sounds like a good idea, but what is the heat transfer like and what does it do to the pathogens?
Sealed bags vs open bowls for marination is good – but those bags still need to be opened and the juices controlled.
He and his wife are conscientious about their food: They eat organic, local produce and ethically raised animals. Collins liked to have a meal at Chipotle once a week. On Friday evening, Oct. 23, he ordered his regular chicken bowl at his usual Chipotle in Lake Oswego. His dinner was made of 21 ingredients, including toasted cumin, sautéed garlic, fresh organic cilantro, finely diced tomatoes, two kinds of onion, romaine lettuce, and kosher salt. It tasted as good as always.
By the next night, Collins’s body was aching and his stomach was upset. Then he began experiencing cramping and diarrhea. His stomach bloated. “Moving gave me excruciating pain,” he says, “and anytime I ate or drank it got worse.” His diarrhea turned bloody. “All I was doing was pooping blood. It was incredibly scary.” After five days, he went to an urgent-care clinic near his home; the nurse sent him to an emergency room. He feared he might have colon cancer.
On Halloween, the ER doctor called him at home: Collins had Shiga-toxin-producing E. coli 026, and he’d likely gotten it from one of those 21 ingredients in his meal at Chipotle. (This was later confirmed by public-health officials.) The doctor warned him that kidney failure was possible; intensive treatment, including dialysis, could be necessary. His kidneys held up, but it took an additional five days for the worst of Collins’s symptoms to ease and nearly six weeks for him to recover. He still doesn’t have as much physical strength as he used to, and he feels emotionally shaky, too. “Before, I was doing the P90X workouts. For a long time after, I couldn’t even walk a few blocks,” he says. “It made me feel old and weak and anxious.” On Nov. 6, Collins sued Chipotle, seeking unspecified damages.
Collins was among 53 people in nine states who were sickened with the same strain of E. coli. “I trusted they were providing me with ‘food with integrity,’ ” Collins says, sarcastically repeating the company motto. “We fell for their branding.” Chipotle’s public stance during the outbreak irritated him, too. The company closed all 43 of its restaurants in Oregon and Washington in early November to try to identify the source of the E. coli and sanitize the spaces. Notices on restaurant doors generally referred to problems with the supply chain or equipment. But local media reported that at least one restaurant in Portland put up a note that said, “Don’t panic … order should be restored to the universe in the very near future.” “That felt so snarky,” Collins says. “People could die from this, and they were so smug.”
For a long time, smug worked pretty well for Chipotle Mexican Grill. It’s grown into a chain of more than 1,900 locations, thanks in part to marketing—including short animated films about the evils of industrial agriculture—that reminds customers that its fresh ingredients and naturally raised meat are better than rivals’ and better for the world. The implication: If you eat Chipotle, you’re doing the right thing, and maybe you’re better, too. It helped the company, charging about $7 for a burrito, reach a market valuation of nearly $24 billion. Its executives seemed to have done the impossible and made a national fast-food chain feel healthy.
Fewer people associate Chipotle with “healthy” now. Three months before Collins was infected with E. coli, five people fell ill eating at a Seattle-area restaurant. By the time local health officials had confirmed a link, the outbreak was over, so no one said anything. In August, 234 customers and employees contracted norovirus at a Chipotle in Simi Valley, Calif., where another worker was infected. Salmonella-tainted tomatoes at 22 outlets in Minnesota sickened 64 people in August and September; nine had to be hospitalized. Norovirus struck again in late November: More than 140 Boston College students picked up the highly contagious virus from a nearby Chipotle, including half of the men’s basketball team. An additional 16 students and three health-care staff picked it up from the victims. The source? A sick worker who wasn’t sent home although Chipotle began offering paid sick leave in June. In the second week of December, when Chipotle should have been on highest alert, a Seattle restaurant had to be briefly shut down after a health inspection found that cooked meat on the takeout line wasn’t being kept at a high enough temperature. And in the most recent case, on Dec. 21, the CDC announced it was investigating an outbreak of what seems to be a different and rare version of E. coli 026 that’s sickened five people in two states who ate at Chipotle in mid-November. The company says it had expected to see additional cases. It still doesn’t know which ingredients made people ill.
Almost 500 people around the country have become sick from Chipotle food since July, according to public-health officials. And those are just the ones who went to a doctor, gave a stool sample, and were properly diagnosed. Food-safety experts say they believe with any outbreak the total number of people affected is at least 10 times the reported number. The CDC estimates that 48 million Americans get sick from contaminated food every year.
At Chipotle, three different pathogens caused the five known outbreaks. That wasn’t inevitable or coincidental. “There’s a problem within the company,” says Michael Doyle, the director of the center for food safety at the University of Georgia. Chipotle has gotten big selling food that’s unprocessed, free of antibiotics and GMOs, sometimes organic, sometimes local. “Blah, blah, blah,” says Doug Powell, a retired (I’m not dead yet) food-safety professor and the publisher of barfblog.com. “They were paying attention to all that stuff, but they weren’t paying attention to microbial safety.” Whatever its provenance, if food is contaminated it can still make us sick—or even kill. Millennials may discriminate when they eat, but bacteria are agnostic.
“Food with integrity,” a promise to Chipotle’s customers and a rebuke to its competitors, has become the source of much schadenfreude among both. Chipotle’s stock has lost about 30 percent of its value since August. Sales at established stores dropped 16 percent in November, and executives expect a decline of 8 percent to 11 percent in comparable-store sales for the last three months of the year. That would be the first quarterly decline for Chipotle as a public company.
Steve Ells, Chipotle’s founder and co-chief executive, went on the Today show on Dec. 10, apologized to everyone who’d fallen ill, and announced a comprehensive food-safety program that he said would far exceed industry norms. He didn’t address why a company that had challenged quality standards with such gusto hadn’t taken on safety standards as well.
On Dec. 17, speaking by phone in New York, he’s still on message, describing the Seattle restaurants he visited as clean and organized. “I ate delicious food there,” he says. “Traffic was slow, but we’re ready for people to come back. There is no E. coli in Chipotle. ” To hear Ells tell it, the company is witnessing an outbreak of excitement. He says the chain’s suppliers are excited to participate in the new safety programs; employees at headquarters in Denver are excited to contribute however they can; it’s “a very, very exciting time for us to be pushing the boundaries” on food safety. “We’re embracing this as an opportunity.”
Ells studied art history in college, trained as a chef at the Culinary Institute of America, and opened the first Chipotle in Denver in 1993 with a loan from his father. He set up a model—open kitchen, fresh ingredients, real cooking in the back, and an assembly line in front, allowing customization and speed—that’s become its own industry standard. Chipotle grew from 489 restaurants and revenue of $628 million in 2006, when it went public, to about 1,800 restaurants and $4.1 billion in revenue in 2014. Net profit increased 60 percent from 2012 to 2014. Ells and his co-CEO, Montgomery Moran, together earned more than $140 million in total compensation during that time. And Michael Pollan, the good-food arbiter, said that Chipotle was his favorite fast-food chain and that he didn’t have a second.
The company was influenced in ways it doesn’t always admit by the biggest, most industrialized chain of them all: McDonald’s. The company invested about $340 million in Chipotle from 1998, when it had 13 restaurants in Colorado, until 2006, when the two parted ways. McDonald’s taught Chipotle supply-chain economics. Chipotle often derides fast-food chains and their factory farms, enlisting the likes of Willie Nelson to make plaintive music videos about crop chemicals and steroidal cattle. But Ells respects McDonald’s size. In an interview with Bloomberg in 2014, he said Chipotle could one day be “bigger than McDonald’s in the U.S. I mean, that’s not an unreasonable way to think about this.”