Tag Archives: Epidemiology

327 sick in prison with Salmonella, 2009

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What’s worse than being in prison? Being in prison in the middle of a Salmonella outbreak (I can think of other things but this is a food safety site).

In September 2009, an outbreak of Salmonella enterica serovar Enteritidis affected 327 of 1419 inmates at a London prison. UK health types report in Epidemiology and Infection they applied a cohort design using aggregated data from the kitchen about portions of food distributed, aligned this with individual food histories from 124 cases (18 confirmed, 106 probable) and deduced the exposures of those remaining well. Results showed that prisoners eating egg cress rolls were 26 times more likely to be ill [risk ratio 25·7, 95% confidence interval (CI) 15·5–42·8, P<0·001]. In a case/non-case multivariable analysis the adjusted odds ratio for egg cress rolls was 41·1 (95% CI 10·3–249·7, P<0·001).

The epidemiological investigation was strengthened by environmental and microbiological investigations. This paper outlines an approach to investigations in large complex settings where aggregate data for exposures may be available, and led to the development of guidelines for the management of future gastrointestinal outbreaks in prison settings.

Clooney and Keibler felled by food poisoning in Italy

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I’m a big George Clooney fan. It’s related to his coolness as Batman and Danny Ocean. It seems like he never makes a bad movie (except for The American). After a week traveling with the kids, Dani and I watched The Descendants, a Clooney movie we had been saving for a while.

George was at his best; the movie was pretty great.

According to Starpulse.com Clooney and his ex-wrestler and prolific tweeter girlfriend Stacy Keibler were not at their best earlier this week in Italy after dealing with what has been reported as food poisoning.

The couple, who were vacationing at Clooney’s Lake Como home, fell sick after a meal in Cernobbio though the manager of the restaurant in question denies all responsibility.

A source told TMZ.com that both Clooney and Keibler are now feeling fine after their brief bout of food poisoning.

Nevertheless, the manager of the restaurant is refusing to accept that it was his food that left the table with upset stomachs, claiming they must have gotten food poisoning elsewhere.

 

Foodborne disease surveillance in France: a foundation for food safety

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The French published their own series of detailed foodborne disease surveillance papers, and did it the day before the Americans.

A special issue of the Bulletin épidémiologique hebdomadaire (BEH) and the Bulletin épidémiologique Anses-DGAL, May 2012, number 50, Microbiological hazards in food products of animal origin: monitoring and evaluation contains 13 research papers.

In an editorial, the author writes foodborne illness surveillance is an important and complex issue. Important because tens of thousands of cases of foodborne outbreaks are still reported each year, complicated by the difficulty in assessing and controlling the risk throughout the supply chain — from the farm to the fork.

Thanks to Albert Amgar for passing along the information and some translation.

The abstracts are available at http://www.anses.fr/bulletin-epidemiologique/Documents/BEP-mg-BE50.pdf and are available in English. They are also available in the daily bites-l listserv and at bites.ksu.edu.

Social media helps investigation of sapovirus gastroenteritis at 2011 Las Vegas Marathon

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The annual Rock ‘n’ Roll Las Vegas Marathon and ½ Marathon was attended by about 44,000 runners on Sunday Dec. 4, 2011. By Tuesday, complaints of illness were trickling in to the Southern Nevada Health District. By Thursday, traditional media reported on increasing complaints of barfing on the event’s Facebook page. An investigation was launched.

Within a week, health-types were able to say it wasn’t the water distributed during the race that made runners sick, quelling a rumor that had already taken on a life of its own.

Below are excerpts from the final report, issued last week, identifying the first outbreak of sapovirus in Nevada and the emerging role of social media in epidemiological investigations.

Links to an epidemiology online survey were shared on the marathon’s Facebook page (with 25,732 followers) by members of the running community on four consecutive days starting on the day of release of the survey, and a total of 42 times within one week as part of a number of discussions among ill runners. Twenty-two people shared the survey link on Twitter, potentially reaching 17,982 followers. A total of 362 responses had been submitted within 12 hours of the release of the survey. After the survey had been posted for 4 days, a total of 1,146 surveys had been submitted. Of the 1,082 completed surveys, 578 (53.4%) were from persons who reported developing diarrhea or vomiting. Of these, 528 (91.3%) met the case definition.

Seventeen ill local runners were requested to provide stool specimens; specimens were provided by nine marathon runners and two symptomatic children of a symptomatic marathon runner. Specimens were collected between December 9, 2011 and December 11, 2011 (5-7 days after symptom onset), and all specimens submitted were formed stools. Two were positive by rRT-PCR for sapovirus and negative for all other tested pathogens at CDC and the SNPHL

The findings of this investigation point to the source of the sapovirus outbreak among marathon runners as a common exposure on the morning before the race, most likely at the health and fitness expo. It was not possible to determine which common exposure was responsible for the outbreak. The timing of the exposure and the incubation period of sapovirus resulted in the majority of cases becoming ill during the race or in the hours shortly after; however, exposure during the race was not the cause of the outbreak.

Sapoviruses (genus Sapovirus, family Caliciviridae) are a group of viruses that cause acute gastroenteritis in humans. Sapovirus is not as well-characterized as norovirus, but is thought to be similar to norovirus in that it has a short incubation period (1-2 days), low infectious dose, causes a self-limiting illness that is rarely serious with a significant percentage of asymptomatic infections, and is easily spread from person to person through fecal-oral transmission. Both infections cause diarrhea, although a lesser percentage of sapovirus patients develop vomiting as compared to norovirus patients.

Outbreaks of sapovirus have been reported in the literature, but reports of foodborne outbreaks and outbreaks among adults outside long-term care are rare and the majority of cases occur in children under 5 years of age. This outbreak represents the first outbreak of sapovirus in Southern Nevada and the first time the virus has been identified in the local population. However, sapovirus testing is not available locally and has not been previously ordered during an outbreak. Rather than representing a newly-introduced disease, the identification of the virus likely indicates that sapovirus circulates at low levels in the population but goes unidentified.

This investigation was also the health district’s foray into using social media as an investigative tool, rather than just as a method of disseminating information to the public. Using the active community of runners on Facebook and Twitter allowed for the rapid dissemination of the survey directly to the exposed population without a delay in requesting participant information from the race organizers. Comments posted to social media sites provided ongoing, real-time insight into the needs and concerns of the ill population, and provided a feel for the efficacy of health district investigation efforts. Comments about SNHD were overwhelmingly positive, and indicated a level of trust and willingness to cooperate from the community.

Ill and non-ill runners quickly responded to the survey, which allowed SNHD staff to rapidly identify ill persons for laboratory testing. It also allowed for a preliminary data analysis to be quickly completed, which allowed the water provided by race organizers, an early focus of complaints by runners, to be ruled out as a source of the outbreak. The water provided in the race was the same potable water that is distributed throughout Southern Nevada, and it was important to quickly determine if the general population was at risk of disease.

The ill persons identified by SNHD staff complied very quickly with the request to submit specimens for laboratory testing. The submission of stool samples for testing is often a difficult task due to the type of sample requested and the handling requirements. The ill persons were highly motivated to provide samples that could be used to identify the causative agent of the outbreak.

In the future, several steps should be implemented to improve the investigative process and to prevent disease at similar events. First, although the survey was developed quickly, a standard template should be developed to allow the rapid deployment of standardized surveys for illness. In addition, corresponding standard analytic tools should be developed to allow for the rapid analysis of survey data.

Next, SNHD should consider using social media more frequently to administer surveys given the appropriate audience; in this case, the use of Facebook was effective because there was an active community of marathon frequently posting and reading the marathon’s page. During a large event, it might be appropriate to set up a social media site for the event response. This would provide an additional avenue for SNHD to share information from the public, and following discussions would allow for real-time feedback on the needs and concerns of the public. However, the decision to launch a social media site should be thoroughly discussed prior to launch, as it would place SNHD in the role of moderating the discussion on the topic (for example, removing libelous comments or threats against employees). It would also necessitate the development of policies on the participation in such discussion by staff members on work time or personal time.

The complete report is available at: http://www.southernnevadahealthdistrict.org/download/stats-reports/rocknroll-marathon-sapovirus-outbreak-final-report.pdf.

Incidence of specific Salmonella strain on the risk again in UK; epidemiologists looking for links

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BBC reports that Salmonella Typhimurium DT193 illnesses are on the rise and no one is really sure whether they are linked or what the source might be.

Health officials are investigating how to stop a rise in cases of a salmonella strain which can leave patients severely ill, the BBC has learned. Cases of Salmonella Typhimurium DT193, rose 630% from 71 in 2004 to 518 in 2011 in England and Wales, said the Health Protection Agency. A Devon man diagnosed with DT193 poisoning in 2011 spent five days in hospital and is still suffering.

DT193 cases rose in the South West from 14 in 2004 to 73 in 2011. DT193, which is most common in beef and pork, is also found in unpasteurised milk, desserts and sandwiches according to the HPA.

It said in a statement: "The HPA study, which is ongoing, involves people who were ill being questioned about what they ate and activities they were involved in prior to becoming unwell.
"The aims of the study are to find any links between those who were unwell and give insights as to how to stop the increase in cases."

Devon builder Ian Mason, 54, was among eight people who contracted DT193 after attending a hog roast, identified by the HPA as a possible cause of the outbreak, in April 2011.

S. Typhimurium DT193 was linked to a bunch of European outbreaks in the 80s and 90s. Two of the big outbreaks were linked to pork products (in the UK and Italy).
 

Politicians as epidemiologists: local council tries to pull rank on health department

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As accusations of secrecy and confusion continue over the salmonella outbreak at a Ballarat pizza joint (that’s in Australia, state of Victoria), that sickened 18 and killed one, another local council has said an eatery was incorrectly named and shamed by the health department and the Herald Sun for a food poisoning outbreak.

The Warrnambool Standard reports council staff yesterday declared that the Department of Health got it wrong in its attribution of a salmonella outbreak to Warrnambool’s Sushi & Noodle Canteen.

“Our guys don’t believe that place was the source of the outbreak,” council chief executive Bruce Anson said.

“They reckon (Sushi & Noodle Canteen) is the cleanest place in town. It’s where our health guys buy their sushi. Our guys just don’t believe it’s him … and it could put this poor bloke out of business. We’re seriously concerned this bloke’s been unduly blamed when there was no direct evidence.”

Mr Anson called the health department’s reporting of the Sushi & Noodle Canteen a “statistical issue (rather) than an error”, but unfortunately for the eatery’s owners, that report was used as the basis of a story in Saturday’s Herald Sun. The matter stems from an incident in January last year when seven people from one family contracted salmonella and presented at hospital.

As per protocol, the hospital informed the health department and, according to Mr Anson, informed them that three of the seven people had eaten noodles.

“Not all seven had eaten noodles (but) our guys went through the place from top to bottom, tested all this stuff, looked at all his food storage, cooking processes, checked temperatures … but they found no evidence to say it was him,” Mr Anson said.

“This name and shame stuff is fine … when it’s someone who’s done it 27 times … and is clearly crooked. But we think they’re wrong here (and) it affects this guy and his business.”

In an official statement yesterday, Warrnambool council’s health and local laws manager Murray Murfett said “council investigated an outbreak of salmonella in January last year and found no conclusive evidence linking the outbreak to the Sushi & Noodle Canteen.”

“Council advised the Department of Health that it could not establish a link between the outbreak and any local food outlet,” Mr Murfett said.

But health department senior media adviser Graeme Walker yesterday said the department stood by the report.

“Our public health people found there was direct evidence of the place identified being involved in a small cluster of food safety issues,” Mr Walker said.

Sushi & Noodle Canteen owner Steven Wei said he was perplexed by the Herald Sun article.

“In my shop, everything is clean and the council people come here and double check,” Mr Wei said. “They say everything is good. My shop being in the newspaper like that is not good for business.”

Credit card payments helped track German E. coli O104 outbreak in sprouts

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Why bother editing; it’s all below in this letter from the current issue of Emerging Infectious Diseases, Identifying risk factors for shiga toxin–producing Escherichia coli by payment information.

During May and June 2011, a large outbreak of hemolytic uremic syndrome (HUS) and diarrhea caused by Shiga toxin–producing Escherichia coli (STEC) occurred, centered on northern Germany (1,2). Early on, salads and raw vegetables were suspected to be food vehicles (3). Also in May, the staff department of a local company informed the Health Protection Authority in Frankfurt in southwestern Germany about the rapidly increasing number of patients with bloody diarrhea and HUS among employees at 2 company office sites. Both sites were served by cafeterias run by the same caterer. Main dishes were prepared in the cafeterias’ kitchens and differed between the 2 sites. However, in both cafeterias various fresh foods from a salad bar and fruits, desserts, and daily asparagus dishes originated from the caterer’s main kitchen. The salad bar included 30 items. Suspecting that this outbreak was linked to the one in northern Germany, we conducted an outbreak investigation to confirm the epidemiologic link to focus epidemiologic and traceback investigations.

A face-to-face survey among hospitalized employees and by email among all other employees was conducted, which included personal details, symptoms, and information about general food eaten at the cafeterias. We defined outbreak cases as infections in employees of the company at 1 of the 2 sites who by May 23, 2011, were either hospitalized with bloody diarrhea or HUS or who self-reported onset of bloody diarrhea from May 8 through May 23. A total of 320 persons responded to the survey, and 285 (89%) of 320 of the responders stated they used the cafeterias; 60 employees fulfilled our case definition. Case-patients’ median age was 33 years (range 22–60 years); 36 (60%) of 60 were female. Thirty case-patients were hospitalized; HUS developed in 18 (30%) (Figure A1). Disease onsets occurred over 9 days. Beginning and magnitude of the outbreak were not different between cafeteria locations. Bacteriologic diagnostics for 11 patients yielded results that are compatible with the outbreak strain (4).

We used billing data from the cafeterias’ obligatory cashless payment system to ascertain risk factors for disease. A nested case–control study design was chosen, limited to a fraction of the cohort to obtain rapid risk estimates. Exposures included were purchases of any fruit, salad bar item, dessert, or asparagus dish in either cafeteria from May 2 through May 13. On the basis of customer identification numbers, the caterer provided billing information for persons with early cases (n = 23). Controls were randomly chosen persons from the caterer’s database whose disease status was checked against the survey information (n = 30) and who did not report symptoms of diarrhea (nonbloody), vomiting, or nausea during the same period. Univariable logistic regression was performed.
In univariable analysis, salad bar purchases were highly associated with illness (odds ratio 5.19; 95% CI 1.28–21.03), and desserts, fruit, and asparagus dishes were not (Table). Three (9%) of the case-patients remained unexposed to salad bar items according to the payment system data. The analysis of main courses purchased in 1 cafeteria revealed that no such meal had been consumed by >5 (22%) of 23 case-patients. Beginning May 23, the cafeterias were closed for 1 week, and salad sales were suspended for a longer period. There were no additional cases.

These results and the identification of the same rare serotype of O104:H4 renders this a satellite outbreak to the larger outbreak in northern Germany, which is the largest outbreak in terms of HUS ever described worldwide. Sprouts are believed to be the food vehicle (5). Sprouts available in the Frankfurt cafeteria salad bars were traced back to a producer of fenugreek sprouts, which appear to be the common source of primary cases in the entire outbreak (5). Sprout consumption could not be studied directly in Frankfurt because of the intense media attention on the sprout hypothesis once it had been announced. Also, it was thought that too much time had passed to successfully recall actually selected salad bar items consumed a few weeks previous.

Cafeteria billing information allowed for a rapid investigation while avoiding exposure misclassification attributable to ill-remembered food purchases (6). Using data sources independent of individual memory is quite useful. In previous studies, similar tools were successfully applied for the detection of outbreak vehicles. Credit card information was used during an investigation on STEC in beef sausages in Denmark (7), supermarket purchase records for STEC in Iceland (8), and grocery store loyalty card records for cyclosporiasis in Canada (9). Shopper card information was used in the United States in an outbreak of Salmonella enterica serovar Montevideo (10). However, billing information also could have introduced exposure misclassification, e.g., purchased food that was left uneaten or brought for colleagues. Analysis on ingredient level is often not possible. This study emphasizes the need for recall-independent investigation methods. In settings where such methods are available, they should be exploited early and relevant data saved from routine deletion.

Hendrik Wilking , Udo Götsch, Helma Meier, Detlef Thiele, Mona Askar, Manuel Dehnert, Christina Frank, Angelika Fruth, Gérard Krause, Rita Prager, Klaus Stark, Boris Böddinghaus, Oswald Bellinger, and René Gottschalk
Author affiliations: Robert Koch Institute, Berlin, Germany (H. Wilking, M. Askar, M. Dehnert, C. Frank, G. Krause, K. Stark); Health Protection Authority, Frankfurt am Main, Germany (U. Götsch, B. Böddinghaus, O. Bellinger, R. Gottschalk); Veterinary Service, Frankfurt am Main (H. Meier, D. Thiele); Robert Koch Institute, Wernigerode, Germany (A. Fruth, R. Prager)

Acknowledgment
We are grateful to the caterer, the employees, and the company management for their cooperation. We thank each member of the Robert Koch Institute HUS Investigation Team for their indispensable work and the coordinators of the German Postgraduate Training for Applied Epidemiology and the European Programme for Intervention Epidemiology Training for their help.

References
Frank C, Werber D, Cramer J, Askar M, Faber M, an der Heiden M, Epidemic profile of Shiga-toxin–producing Escherichia coli O104:H4 outbreak in Germany. N Engl J Med. 2011;365:1771–80. DOI PubMed
Wadl M, Rieck T, Nachtnebel M, Greutélaers B, An der Heiden M, Altmann D, Enhanced surveillance during a large outbreak of bloody diarrhoea and haemolytic uraemic syndrome caused by Shiga toxin/verotoxin–producing Escherichia coli in Germany, May to June 2011. Euro Surveill. 2011;16:pii:19893.
Frank C, Faber M, Askar M, Bernard H, Fruth A, Gilsdorf A, Large and ongoing outbreak of haemolytic uraemic syndrome, Germany, May 2011. Euro Surveill. 2011;16:pii:19878.
Bielaszewska M, Mellmann A, Zhang W, Köck R, Fruth A, Bauwens A, Characterisation of the Escherichia coli strain associated with an outbreak of haemolytic uraemic syndrome in Germany, 2011: a microbiological study. Lancet Infect Dis. 2011;11:671–6.PubMed
Buchholz U, Bernard H, Werber D, Böhmer MM, Remschmidt C, Wilking H, German outbreak of Escherichia coli O104:H4 associated with sprouts. N Engl J Med. 2011;365:1763–70. DOI PubMed
Decker MD, Booth AL, Dewey MJ, Fricker RS, Hutcheson RH, Schaffner W. Validity of food consumption histories in a foodborne outbreak investigation. Am J Epidemiol. 1986;124:859–63.PubMed
Ethelberg S, Smith B, Torpdahl M, Lisby M, Boel J, Jensen T, Outbreak of non-O157 Shiga toxin–producing Escherichia coli infection from consumption of beef sausage. Clin Infect Dis. 2009;48:e78–81. DOI PubMed
Sigmundsdottir G, Atladottir A, Hardardottir H, Gudmundsdottir E, Geirsdottir M, Briem H. STEC O157 outbreak in Iceland, September-October 2007. Euro Surveill. 2007;12(11):E071101.2.
Shah L, MacDougall L, Ellis A, Ong C, Shyng S, LeBlanc L. Challenges of investigating community outbreaks of cyclosporiasis, British Columbia, Canada. Emerg Infect Dis. 2009;15:1286–8. DOI PubMed
Centers for Disease Control and Prevention. Salmonella montevideo infections associated with salami products made with contaminated imported black and red pepper—United States, July 2009–April 2010. MMWR Morb Mortal Wkly Rep. 2010;59:1647–50.PubMed

Figure
Figure A1. Patients with Shiga toxin–producing Escherichia coli/hemolytic uremic syndrome (STEC/HUS) by onset of diarrhea and cafeteria visit (location A or B) during STEC/HUS outbreak at a company in Frankfurt, Germany,…
Table
Table. Univariable analysis of risk factors for bloody diarrhea among users of 2 cafeterias in Frankfurt, Germany, 2011
Suggested citation for this article: Wilking H, Götsch U, Meier H, Thiele D, Askar M, Dehnert M, et al. Identifying risk factors for Shiga toxin–producing Escherichia coli by payment information [letter]. Emerg Infect Dis [serial on the Internet] 2012 Jan [date cited]. http://dx.doi.org/10.3201/eid1801.111044
DOI: 10.3201/eid1801.111044

Salad greens likely source of salmonella that sickened 136 in UK in 2010

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From July to Oct. 2010, 136 people in London and east England were sickened by Salmonella Java phage type 3b variant 9. Gobin et al., from the U.K. Health Protection Agency, report in Eurosurveillance today that most cases were female with a median age of 39.5 years and lived in London. Results of epidemiological investigations are compatible with salad vegetables as the potential source, but no common suppliers of salad were identified and no organisms were isolated from environmental and food samples.

S. Java is present in poultry flocks in the European Union and is the most common serovar reported in poultry in the Netherlands. Outbreaks of S. Java have been reported in the past, associated with salad vegetables, goat’s milk cheese, poultry, reptiles and tropical fish aquariums. S. Java is an uncommon cause of salmonellosis in the United Kingdom (UK), with 151, 112 and 130 cases reported in 2007, 2008 and 2009 respectively according to the national database.

In 2007, a multi-country outbreak of S. Java phage type (PT) 3b variant 9 (var9) involved cases in Denmark, Finland, the Netherlands, Norway, the UK and the U.S. Epidemiological evidence suggested an association with salad vegetables.

The results of the case–case study confirmed a significant association between symptomatic infection of S. Java PT 3b var9 and eating out at restaurants, eating pre-packaged mixed salad leaves at home, consumption of salad leaves from takeaway restaurants and eating any salad leaves either at home or purchased from commercial catering settings. Since salad is often used as a garnish in meals eaten in commercial catering settings, it is possible that the model underestimated the proportion of cases who consumed salad leaves away from home.

We cannot exclude the possibility that the study may have missed the right vehicle of the outbreak such as sprouted seeds which have been implicated in two recent outbreaks in Europe. It is likely that the consumption of smaller food items (seeds, sprouted seeds and herbs) in salads prepared by commercial caterers was not remembered or was not noticed by cases. None of the smaller salad items were found to be associated with cases during the hypothesis generation. It is possible that salad leaves were a confounding factor in this investigation and smaller, less memorable items should be considered in outbreaks where salad vegetables appear to be implicated.

Environmental investigations did not identify common suppliers of salad vegetables and the short shelf life of salad vegetables limited the ability to acquire any suspect foods for microbiological analysis.

The contamination of salad leaves and salad vegetables during their production and processing has been implicated in a number of geographically widespread outbreaks. High risk practices during production and processing include the use of contaminated water either to irrigate the crops, to apply pesticides or other dressings, or to wash the crop once harvested; the use of human or animal sewage as a crop fertilizer; and the transport of the harvested crop in a contaminated vehicle/storage system, e.g. trucks previously used for transporting waste. Crops growing in the field are also vulnerable to contamination from sources such as wild animals and birds

Gastrointestinal infection associated with salad vegetables may also be the result of cross-contamination from poultry, meat or meat products or contamination by the food handler during food preparation in the home or in catering establishments. A review of more than 2,000 general foodborne outbreaks from 1992 to 2006 undertaken by the HPA found that 4% of them were associated with prepared salads. The review found that most of the outbreaks linked to salads occurred in the catering sector and were associated with infected food handlers, cross-contamination and poor storage.

The increase in illness and outbreaks associated with the consumption of fresh ready to eat salad vegetables indicates the ongoing need to improve methods in the production and preparation of these foods to reduce the potential for contamination with Salmonella and other enteric pathogens.

The complete epidemiological write-up, with a full discussion of limitations, is available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20023.

Anyone can armchair quarterback; dealing with uncertainty in real-time during foodborne outbreaks

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It’s not easy being a food safety investigator in the face of deep uncertainty.

So says Ron Doering, a past president of the Canadian Food Inspection Agency who practices food law in the Ottawa offices of Gowling Lafleur Henderson, in his latest Food Law column.

In the U.S., the largest foodborne outbreak in the last decade involved a rare strain of Salmonella Saintpaul thought to originate from tomatoes. The Food and Drug Administration (FDA) acted quickly, providing a public warning to avoid eating tomatoes until its investigation was complete. After several weeks and hundreds of tests and interviews, the FDA concluded that the problem was likely not tomatoes but rather hot peppers. Politicians rushed to microphones attacking the FDA for “destroying” the tomato industry. Of course, these are the same people who would have been outraged if tomatoes had been the source of the Salmonella and the FDA had not acted quickly.

While the FDA probably did the right things in the face of so much uncertainty, they should have communicated better. Tracing the source of foodborne illnesses is very complicated, especially for produce like tomatoes where there are no bar codes, no packages, and they are quickly consumed, often with other produce.

In the EU, the largest foodborne illness outbreak in the last decade, and one of the developed world’s most severe in modern times, took place this summer when a very rare strain of E. coli (O104:H4) got into the European food supply.

The first death was reported on May 24. The next day, the Robert Koch Institute announced that the early epidemiology indicated that the likely culprit was cucumbers, tomatoes or green salads. And later that day German officials announced that the rare strain had been found in the stools of five of the sick patients. The following day a German state-level agency announced triumphantly that it had found E. coli on Spanish cucumbers, though it had not yet tested for the strain.

On May 31, after testing for the strain, it was announced that the cucumbers were not to blame, by which time, of course, the Spanish cucumber industry was destroyed and German vegetable growers were suffering losses of $2.8 million per day as consumers quit eating all salads. Finally, on June 5 it was reported that “initial tests” (it was not tests, it was the result of epidemiological tracing) revealed that sprouts grown on an organic farm in Germany were “likely” the source of the problem, even though they couldn’t find a smoking sprout on the farm. Then on June 12 several victims of the O104 strain fell ill in France. They had no connection to the German organic farm. Attention turned to seeds, with the French blaming the British (I’m not making this up). Finally, on June 29 tracing determined the source of the problem as sprout seeds imported from Egypt in 2009. By this time there had been more than 50 deaths and well over 4,300 people seriously ill, including approximately 900 cases of patients with permanent kidney damage.

In both cases, with the benefit of hindsight, academics and the media roundly criticized the regulators as incompetent.

In a detailed review of the EU sprouts case, Peter Sandman, an expert on risk communication, concluded that the main failure of the regulators was in not being more forceful in proclaiming in their risk messaging the level of uncertainty in the case.

To me it seems there is a more basic problem, and it flows from the use of the language of risk, because “risk” disguises the deep uncertainty inherent in complex cases like these. These regulators were dealing with uncertainty, not risk — they were engaged in crisis management, not risk management.

‘I guess I did eat cantaloupe’ Grocery loyalty cards help trace foodborne illness source

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Elizabeth Weise writes in USA Today an outbreak of salmonella in five Eastern states has sickened 42 people so far this year, with two hospitalizations. Dozens more might have been struck down were it not for a strikingly successful new tool used by public health officials to quickly figure out what was making all those people sick: the lowly shopper-loyalty card.

Food safety officials are increasingly finding value in plumbing shoppers’ food buying habits through these loyalty cards when they’re faced with foodborne illness outbreaks across communities and even states that seem to have no obvious links.

"It’s very helpful because it’s very hard for people to remember what they ate a couple of days before, not to mention a couple of weeks ago," says Casey Barton Behravesh, with the Centers for Disease Control and Prevention.

Supermarket loyalty-card programs were introduced in 1987. By the 1990s, they were widely used. In return for discounts on some items, they allow companies to track shopping habits. For epidemiologists, who study disease outbreaks, they’re a complete record of everything shoppers bought at the store going back for years.

Privacy is a huge concern in using cards to track food-borne illness outbreaks, officials say. All health departments are required to get permission to use them, Hammond says. "This is voluntary: People are not required to consent to having the grocery chain release their shopper-card history," he says.

In the salmonella outbreak among Eastern states, New York state and local health officials noticed an increased number of salmonella cases and started conducting routine interviews.

When they realized that all the patients shopped at Wegmans, a local supermarket chain, it was a "red flag," Behravesh says. Given permission by patients to check their shopper club card data, officials found "a lot of these people were buying bulk Turkish pine nuts," or foods that contained them, Behravesh says.

Other recent cases include:
•An outbreak of E. coli O157:H7 that sickened 33 people and led to 15 hospitalizations in five Western states in 2010 was quickly traced to raw milk Gouda cheese produced by Bravo Farms in Traver, Calif., using Costco purchasing data.

•A puzzling outbreak of salmonella Montevideo that sickened 272 people in 44 states in 2009 was finally cracked when health officials examined shopper records from Costco and saw that almost everyone who had gotten sick had purchased salami from Daniele Inc. Testing showed it was not the sausage but the black and red pepper it was coated in that carried the bacteria.

The shopper loyalty cards also can help public health workers when consumers misremember what they ate. "One person swore she didn’t eat cantaloupe, she only ate honeydew melons," says William Keene, a senior epidemiologist with Oregon Public Health Services. "When we pulled her records, we found that she only bought cantaloupe, not honeydew. When we showed her that, she said ‘Oh, I guess I did eat cantaloupe.’ "