Tag Archives: Epidemiology

Pull back the curtain; it’s only 7 people with a rare subtype of E. coli O157 in California, so it’s a ‘small cluster’

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There’s seven people in California that have been barfing from a rare strain of E. coli O157:H7 as determined by PFGE subtyping.

Those folks may not like being referred to as a “small cluster” of illness while hanging out with the goddess of porcelain.

The California Department of Public Health (CDPH) identified six patients with illness onset dates between April 8 and June 18, 2010 and after further review, CDPH added another patient from February to the case count, bringing the count to seven.

The U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) became aware of the problem on July 15, 2010, and eventually – early this morning, Aug, 6, 2010 – convinced Valley Meat Company, a Modesto, Calif. establishment to recall approximately one million pounds of frozen ground beef patties and bulk ground beef products that may be contaminated with E. coli O157:H7.

FSIS and the establishment are concerned that some product may still be frozen and in consumers’ freezers.

But not so concerned to issue a warning earlier. Who knew what when? Maybe it’s time to pull back the curtain on epidemiological investigations and when to go public with information that could prevent others from barfing.
 

Guidelines for foodborne disease outbreak response

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Proving there is a Council for everything, the Council to Improve Foodborne Outbreak Response released its Guidelines for Foodborne Disease Outbreak Response today.

The guidelines in this document are targeted to local, state and federal agencies and provide model practices used in foodborne disease outbreaks, including planning, detection, investigation, control and prevention. Local and state agencies vary in their approach to, experience with, and capacity to respond to foodborne disease outbreaks. The guidelines are intended to give all agencies a common foundation from which to work and to provide examples of the key activities that should occur during the response to outbreaks of foodborne disease. The guidelines were developed by a broad range of contributors from local, state and federal agencies with expertise in epidemiology, environmental health, laboratory science and communications. The document has gone through a public review and comment process.

The Guidelines document is not intended to replace current procedure manuals for responding to outbreaks. Instead, it is designed to be used as a reference document for comparison with existing procedures; to fill in gaps and update site-specific procedures; to provide models for new procedures where they do not exist; and to provide training to program staff. The document is available in electronic and hard-copy formats for state and local health departments.

 

Local is not safer

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Spring has sprung in Kansas. We all worked in the yard yesterday, and after a couple of cool nights later in the week, the first leafy greens will be going into the garden.

With spring comes the mantra, local is safer.

The idea food that is grown and consumed locally is somehow safer than other food, either because it contacts fewer hands or any outbreaks would be contained, is sorta soothing, like a mild hallucinogen, and has absolutely no basis in reality.

Foodborne illness is vastly underreported — it’s known as the burden of reporting foodborne illness. Someone has to get sick enough to go to a doctor, go to a doctor that is bright enough to order the right test, live in a state that has the known foodborne illnesses as a reportable disease, and then it gets registered by the feds. For every known case of foodborne illness, there are 10 -300 other cases, depending on the severity of the bug.

Most foodborne illness is never detected. It’s almost never the last meal someone ate, or whatever other mythologies are out there. A stool sample linked with some epidemiology or food testing is required to make associations with specific foods.

Robert Brackett, senior vice president of the Grocery Manufacturers Association, and a darn fine scientist, told USA Today most foodborne illnesses don’t get noticed because not enough people get sick to alert officials that an outbreak is underway. Undetected outbreaks are more likely with "local" products delivered in small quantities and sold in a small area.

Comparing local with all that other food brings in more tenuous links and numerous erroneous assumptions. To accurately compare local and other food, a database would have to somehow be constructed so that a comparison of illnesses on a per capita meal or even ingredient basis could be made.

But the absence of data doesn’t stop doctrine. JoLynn Montgomery, director of the Michigan Center for Public Health Preparedness at the University of Michigan told the Detroit Free Press today that one solution that is catching on is buying locally grown foods.

"The less distance the food has to travel, the fewer people who touch the food, the less risk you have.”

Local can be microbiologically safe. But repeating ‘local’ while in some sorta peyote buzz doesn’t take care of the dangerous bugs. So wherever food is purchased or even grown, ask some questions:

• how are pathogenic microorganisms managed;
• is wash and irrigation water tested for dangerous bacteria;

• how is fresh produce protected from animal poop;
• what kind of soil amendments are being used and are they microbiologically safe; and,
• are you or your suppliers practicing great handwashing?

That’s a start.
 

Despite E. coli cases, Oklahoma restaurant kept serving customers; not so in North Bay

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A Harvey’s restaurant in North Bay, Ontario, Canada,  remains closed as the number of confirmed and suspected sick with E. coli O157:H7 climbed to 159 today.

The public health folks in North Bay must be going nuts, but they, along with the operators of Harvey’s, have put public health first and closed the restaurant until more is known.

Locust Grove, Oklahoma, was also hammered by an E. coli outbreak, E. coli O111, linked to dining at the Country Cottage restaurant in August.. One person died, 72 were hospitalized and 241 others got sick before the outbreak was contained.

Today it was revealed that State Health Department officials allowed the Country Cottage to stay open temporarily — even after confirming six of eight initial food poisoning victims had eaten its food, internal documents show. That decision may have resulted in additional people getting sick.

Health Department officials admitted last week there is no set threshold in such cases for closing a restaurant suspected of being the source of an outbreak.

There are no guidelines. Epidemiological investigations are full of uncertainty. So is most of what is known about foodborne illness. But after the Salmonella-in-tomatoes-jalapenos outbreak this summer, public health officials are seemingly reluctant to go public. Industry has attempted to take matters into their own hands – which they should have been doing anyway – and is increasingly challenging public health investigations with its own test results, and unfortunately overstating the value of their own tests.

Listeria in Maple Leaf deli meats, Salmonella in produce, E. coli in Ontario and Oklahoma. There are no guidelines on when to go public. Federal agencies like the U.S. Food and Drug Administration and the Canadian Food Inspection Agency must come clean with the public and industry and articulate the basis for public notification, or even restaurant closures, during outbreaks of foodborne illness. Until then local health units are left cleaning up the mess.
 

More of the same from Maple Leaf, CFIA

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Maple Leaf Foods president and CEO Michael McCain said last night that “consistent with normal findings and practices” listeria continues to be found at the same facility that produced cold-cuts linked to at least 20 deaths and 50 illnesses in Canada.

“Listeriosis is an exceptionally rare illness,” he said, “but we are taking every precaution possible.”

I’m sure the illness didn’t feel exceptionally rare to the sick and the dead.

Mr. McCain also reiterated that,

“Listeria exists in all food plants, all supermarkets and presumably in all kitchens,”

which is exactly why my pregnant wife and Ben’s pregnant wife didn’t go near Maple Leaf or any other cold cuts during their pregnancies. So I’m sure Mr. McCain will put as much energy and resources into advising vulnerable populations to stay away from Maple Leaf cold-cuts and other refrigerated ready-to-eat foods as he is into re-opening the Toronto plant.

And if Maple Leaf is now “behaving in the most conservative way possible,” what were they doing before the listeria outbreak became public knowledge on Aug. 20, 2008?

Confidential data obtained by the Toronto Star and  CBC and reported last night revealed that two-thirds of Maple Leaf meat samples collected from Toronto hospitals and nursing homes tested positive for a virulent strain of listeria just before the country’s largest food recall.

The test results show a dramatically high percentage of bacteria-laced ham, corned beef, turkey, and roast beef was being served to hundreds of vulnerable hospital patients and seniors. Experts say it’s more contamination than they have seen and further evidence of a health risk that should have reached the public’s attention sooner.

“There shouldn’t be any positives,” says Rick Holley, a food safety expert at the University of Manitoba. “The reality is if you did a survey in the market, you might find one or two at most out of this sample that are positive … And it is a particularly virulent strain of listeria. It’s one of the bad ones.” …

“I’d never seen anything like this,” said Dr. Vinita Dubey, Toronto’s associate medical officer of health. “The fact that so many came back positive shows how contaminated the source was.”

So given the high level of contamination, what did the Canadian Food Inspection Agency do? Insist on more testing, because epidemiology is not enough to protect the health of Canadians.

In a conference call with members of the Canadian Food Inspection Agency on Aug. 14, Toronto officials told the agency they had enough evidence to make a connection and pressed the CFIA to warn the public about Maple Leaf products.

CFIA officials, however, said they needed to wait for one more set of test results from unopened meat packages.

While the CFIA had identified listeria bacteria at the Maple Leaf Foods meat processing plant in Toronto and even begun an investigation of the company by that time, the federal agency said it wanted definitive test results to see whether it was the same strain as the one responsible for the outbreak.

The CFIA declined a request for an interview with CBC News. The agency maintained that it requires hard scientific proof before it can recall food or issue warnings to the public.

Toronto Public Health said it had gathered plenty of evidence during July and August that linked Maple Leaf meat products to the outbreak, including:
    * two deaths linked to listeriosis
    * more cases being reported
    * meat samples from sandwiches tested positive
    * samples from opened meat packages were taken

During a 2005 outbreak of salmonella found in bean sprouts in Kingston, Ont., regional health officials didn’t wait for definitive proof to issue their own recall.

"I think it’s a less desirable approach, from the point of view of the people we serve, to say, ‘We’ll have to wait and have confirmation before we can intervene,’" said Dr. Ian Gemmill, the medical officer of health for the Kingston Area Health Unit.

The locals sound increasingly frustrated with CFIA. Until there is a clear policy on when to go public, expect more failures and frustration in the future.

Asked for the listeria test results leading up to the outbreak, the Maple Leaf spokesthingy said last week that, in the spirit of open and transparent co-operation and a genuine desire to improve the safety of refrigerated, ready-to-eat foods, the company would not release them publicly.
 

Cantaloupes and Salmonella: epidemiology is the proof?

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On June 12, 1996, Ontario, Canada’s chief medical officer, Dr. Richard Schabas, issued a public health advisory on the presumed link between consumption of California strawberries and an outbreak of diarrheal illness among some 40 people in the Metro Toronto area. The announcement followed a similar statement from the Department of Health and Human Services in Houston, Texas, which was investigating a cluster of 18 cases of cyclospora illness among oil executives.

Turns out it was Guatemalan raspberries, and no one was happy.

Last month, the U.S. Food and Drug Administration and the Canadian Food Inspection Agency warned consumers to stay away from Honduran cantaloupes because of a salmonella outbreak that has sickened at least 50 Americans and nine Canadians.

The president of Honduras is furious. So is the agriculture minister who is demanding millions in reparations, saying the U.S. has not scientifically proven the fruit was infected in Honduras.

But proof is rare.

The initial, and subsequent, links between cyclospora and strawberries or raspberries in 1996 was based on epidemiology, a statistical association between consumption of a particular food and the onset of disease. The Toronto outbreak was first identified because some 35 guests attending a May 11, 1996 wedding reception developed the same severe, intestinal illness, seven to 10 days after the wedding, and subsequently tested positive for cyclospora. Based on interviews with those stricken, health authorities in Toronto and Texas concluded that California strawberries were the most likely source. However, attempts to remember exactly what one ate two weeks earlier is an extremely difficult task; and larger foods, like strawberries, are recalled more frequently than smaller foods, like raspberries.

By July 18, 1996, the CDC declared that raspberries from Guatemala — which had been sprayed with pesticides mixed with water that could have been contaminated with human sewage containing cyclospora — were the likely source of the cyclospora outbreak, which ultimately sickened about 1,000 people across North America. Guatemalan health authorities and producers vigorously refuted the charges. The California Strawberry Commission estimated it lost $15 million to $20 million in reduced strawberry sales.

Once epidemiology identifies a probable link between a food and some dangerous bug, health officials have to decide whether it makes sense to warn the public. In retrospect, the decision seems straightforward, but there are several possibilities that must be weighed at the time.

Back in 1996, when the Ontario Ministry of Health decided to warn people that eating imported strawberries might be connected to cyclospora infection, two outcomes were possible: if it turned out that strawberries were implicated, the ministry made a smart decision, warning people against something that could hurt them; if strawberries were not implicated, then the ministry made a bad decision with the result that strawberry growers and sellers lost money and people stopped eating something that was good for them.

If the ministry decided not to warn people, another two outcomes were possible: if strawberries were implicated, then the ministry made a bad decision and people could have acquired a parasitic infection they could have avoided had they been given the information (lawsuits usually follow); if strawberries were definitely not implicated then nothing happens, the industry does not suffer and the ministry does not get in trouble for not telling people.

These scenarios apply to cantaloupes and salmonella, raw milk and E. coli, and any other combination of food and pathogen.

It’s often not fair. Any hosehead can come along and say, "Hey, I found a mouse in my beer bottle, give me a free case of beer." Or a syringe in some soda. Or I barfed from eating some food. The best producers or manufacturers can do is diligently manage and mitigate risks and be able to prove such diligence in the court of public opinion.

Douglas Powell is scientific director of the International Food Safety Network at Kansas State University. A video on preparing cantaloupe — and some nasty comments which highlight the trade and economic issues at stake — is available here .