Tag Archives: Going Public

Sushi suspected: multistate outbreak of Salmonella Bareilly infections

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Did health-types mean to go public yesterday about the apparent Salmonella-in-maybe-sushi outbreak? The initial reporting attributed the news to an internal e-mail at the U.S. Food and Drug Administration, but today, the Centers for Disease Control put out the official word.

A total of 93 persons infected with the outbreak strain of Salmonella Bareilly have been reported from 19 states and the District of Columbia.

The number of ill persons identified in each state is as follows: Alabama (2), Arkansas (1), Connecticut (4), District of Columbia (2), Georgia (4), Illinois (8), Louisiana (2), Maryland (8), Massachusetts (4), Mississippi (1), Missouri (1), New Jersey (6), New York (23), North Carolina (2), Pennsylvania (2), Rhode Island (4), South Carolina (3), Texas (3), Virginia (5), and Wisconsin (8).

10 ill persons have been hospitalized, and no deaths have been reported.

Among 93 persons for whom information is available, illness onset dates range from January 28 to March 23, 2012. Ill persons range in age from 4 to 78 years, with a median age of 31. Forty-six percent of patients are female.

Among 51 ill persons for whom information is available, 35 (69%) reported consuming sushi, sashimi, or similar foods in the week before illness onset. This percentage is higher than expected compared with results from a survey of healthy persons in which 5% of persons reported consuming sushi, sashimi, or ceviche made with raw fish or shellfish in the 7 days before they were interviewed. The investigation into specific types of sushi is ongoing.

The investigation has not conclusively identified a food source.

The investigation is ongoing into individual food items and their sources.
CDC and FDA are working together on the investigation and will provide updates as soon as they are available.

If a specific food source is identified for this outbreak, public health officials will alert the public and take further steps to prevent additional illnesses.

Going public: outbreaks should be routinely publicized so others can learn

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Telling produce farmers they need to clean up and pay attention to food safety stuff is a hard sell until there’s an outbreak.

But what if there’s no outbreak?

That was the situation 15 years ago when I started working with Ontario growers; outbreaks related to fresh produce were starting to become reported regularly in the U.S., the Food and Drug Administration was making rumblings about pathogen sampling (which can shut down cross-border trade) and produce exporters, like Ontario greenhouse veggie growers, were cautiously eyeing the situation.

But there hadn’t been any outbreak involving Ontario greenhouse product. Still hasn’t been (that anyone knows of).

Scare stories from other jurisdictions work to a point, pressure from retailers and others in the supply chain works better, but ultimately, when chatting with individual growers, it would usually come down to: I’ve been doing it this way all along and haven’t made anyone sick. So why should I change?

Public health types have adopted their own version of why change? It’s the increasingly heard, there-was-an-outbreak-but-the-product-was-gone-by-the-time-we-figured-it-out-so-there-was-no-ongoing-threat-to-public-health scenario; therefore, we didn’t have to tell anyone, publicly.

It happened with Fresh Express, the salad folks, that had some salmonella issues in 2010 in which people got sick.

It happened in several outbreaks involving Taco Bell, usually referred to as Mystery Restaurant A long after the fact.

According to long-standing policy at the Centers for Disease Control and the Food and Drug Administration, as long as it does not pose an ongoing public health risk, companies that may be the source of dangerous outbreaks are kept out of the headlines.

"Companies voluntarily share information with CDC and FDA, so when we publish company or brand names and there is not a public health need to do, it could have the effect of discouraging such cooperation between our agencies and the food industry," an FDA spokesperson told ABC News.

And now it’s happened in Kansas.

In Jan. 2012, 18 people were sickened by campylobacter in raw goats milk from a dairy in south central Kansas. The sick people attended the same community function so the outbreak was identified and isolated quickly, so no public warning was ever issued – until Friday, in what was supposed to be a statement from state health-types about the dangers of raw milk.

Instead, it’s another example of outbreaks not being publicly disclosed. And if they aren’t disclosed, how is the public, or farmers or others to know there are problems? How can people become informed without access to information?

People are instead doing it themselves.

The Internet, social media, smartphones, and a host of other tools are providing increasing access to public information, and the private experiences of individuals. Because who doesn’t want to share stories of barfing or bad hookups on the Internet. The information will, increasingly, get out.

In California, there are recurring reports of at least nine children being sickened by campylobacter, in raw milk, from Claravale Farm. No word from public health.

Public health types have a tough job, separating the wheat from the chaff, the meaningful noise from background chatter; resources are diminishing. But establishing some ground rules – and publicizing those rules – would help quell conspiracy theories and perhaps rebuild some public trust.

If people get sick, let it be known, sooner rather than later. Those stories are essential to support statistics. Otherwise I’m just another propeller-head who don’t know nothing about farming and food.

Going public: Del Monte drops lawsuit against Oregon public health over cantaloupe

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Fresh Del Monte is ending its lawsuit against Oregon health officials who linked a salmonella outbreak to its Guatemalan cantaloupe.

In August, Coral Gables, Fla.-based Del Monte Fresh Produce NA Inc. said it would sue the Oregon Health Authority’s Public Health Division and the agency’s top scientist over how it handled the investigation of the February and March 2011 outbreak that sickened 20 people in the western U.S. and Pennsylvania and Maryland.

Lynne Terry of The Oregonian reported yesterday that Del Monte Fresh Produce said in a letter e-mailed to the state earlier this month that it would not act on its notice to sue William Keene and Oregon Public Health.

"Obviously, it’s a relief for us that that’s withdrawn so now we can focus on the job we’re supposed to do which is to protect the public’s health," said Dr. Katrina Hedberg, state epidemiologist. The tort claim filed last August had gobbled up time of state scientists and lawyers dealing with it, she said.

The claim was unprecedented. State epidemiologists investigate dozens of foodborne illness outbreaks every year and name the culprits to prevent more people from getting sick. No other company has ever filed a suit or threatened to sue Oregon over one of those investigations.

"There have been lots of outbreaks," Hedberg said. "Why some companies choose to work with public health and others want to fight it — I can’t answer that."

Del Monte Fresh Produce wouldn’t either. A spokesman said the company "does not comment on ongoing or closed investigations."

The company’s letter said the withdrawal marked "a show of good faith" in its discussions with Oregon Public Health over food safety. It asked for another meeting with Oregon’s top food safety detectives.

The state agreed to a meeting in Portland.

"I’m not sure why they want it," Hedberg said. "We work with businesses and companies but that does not preclude us from notifying the general public if we find a food item that’s been responsible for an outbreak or cluster of illnesses."

The saga dates to January 2011 when people started getting sick. In March, the company recalled nearly 60,000 whole cantaloupes imported from its facility in Guatemala. The recall notice, published on the Food and Drug Administration website, said the melons could be contaminated with Salmonella Panama, the strain involved in the outbreak.

In July, the FDA imposed an import alert, effectively banning the sale of the Guatemalan melons until the company demonstrated they were safe. Located in Coral Gables, Fla., Del Monte Fresh Produce is a major importer of cantaloupe. A third of its supply comes from Guatemala.

The company, which is not part of the Del Monte Foods conglomerate, responded to the alert by filing suit against the FDA. Then in August, it filed the tort claim against Keene and Oregon Public Health along with a separate ethics complaint against Keene.

The documents said Keene conducted a shoddy investigation. They said he never found salmonella in its cantaloupes but named the company anyway. Del Monte Fresh Produce also blamed Keene for the recall, saying he pushed the FDA to take action.

But Keene was not the only epidemiologist who concluded that Del Monte Fresh Produce was to blame in that outbreak. His peers in Washington state reached the same conclusion.

In September, the FDA lifted its import alert and Oregon’s Government Ethics Commission dismissed the ethics claim against Keene.

At the time, Kirk Smith, epidemiology supervisor for the Minnesota Department of Health, told the Washington Post it’s rare for scientists investigating foodborne illness outbreaks to test the exact food suspected of carrying pathogens. By the time symptoms occur and a foodborne illness is reported and confirmed, the product in question has likely been consumed or has exceeded its shelf-life and been thrown away.

Instead, scientists, like detectives, interview victims, collect data, analyze patterns and match food “fingerprints” to determine the likely source of an outbreak.

“The majority of outbreaks, we don’t have the food to test,” Smith said. “Laboratory confirmation of the food should never be a requisite to implicating a food item as the vehicle of an outbreak.

Epidemiology is actually a much faster and more powerful tool than is laboratory confirmation.”

Going public Italian style: I tell you but you tell I sue

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As Americans grapple with the public health implications about going public either too early or too late, the Italians have added an unique variation: a company issued a public warning, then prohibited people from speaking or writing about it.

A food safety friend based in Italy who has followed the machinations of Taco-Restaurant-A-Bell and a recent salmonella outbreak, noted that going public with a food safety recall is an exception in Italy. Companies have plans for disseminating information to the public in their recall procedures, but are reluctant to put them into practice. National authorities don’t insist on much. A recall for foreign bodies is also exceptional as officials don’t mind foreign bodies much. What is typically Italian is the threatening message at the end: we tell the public because we have to, but we will sue you if you talk about it to anyone, or you link to our page.

The press release, translated from Italian, says, “Leaf Italia informs its consumers of the possible presence of foreign bodies inside some boxes of chocolate pralines "Sperlari Granperle plain chocolate with crushed nougat" gr. 160 which belong only to production lots L11284 – L11285 – L11287 – L11294 – L11296 – L11300 as indicated on the package.

“As a precautionary measure, it is therefore recommended not to consume the product in the image and to call the toll free number 800829008 for more information.

“This information is owned by LEAF. The information is intended for exclusive use for the purposes covered by this statement and any different use must be authorized in writing by LEAF: in the absence of such authorization, any dissemination and reproduction is forbidden."

Going public: Mexican-style restaurant chain A will look bad in salmonella outbreak; if consumers knew, they could better choose

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When government health officials wrapped up a three-month investigation of a Salmonella Enteritidis outbreak that sickened 68 people in 10 states, the final report on Jan. 19 included nearly every detail — except the name of the place that sold the food.

JoNel Aleccia of msnbc.com writes the U.S. Centers for Disease Control and Prevention has refused to identify the source, other than as “Restaurant Chain A,” a Mexican-style fast-food chain.

“It will eventually come out and it will be the company that looks bad,” said Doug Powell, a professor of food safety at Kansas State University and author of a food safety blog. “A lot of these problems could be reduced if government agencies were more transparent about how they decide when to go public.”

Dr. Robert Tauxe, a top CDC official, defended the agency’s practice of withholding company identities, which he said aims to protect not only public health, but also the bottom line of businesses that could be hurt by bad publicity.

“The longstanding policy is we publicly identify a company only when people can use that information to take specific action to protect their health,” said Tauxe, the CDC’s deputy director of the Division of Foodborne, Waterborne and Environmental Diseases. “On the other hand, if there’s not an important public health reason to use the name publicly, CDC doesn’t use the name publicly.”

The trouble, say food safety advocates, is that it’s not clear when or why CDC officials decide to withhold the identity of firms involved in outbreaks and when they decide to go public.

"No one is happy, and that’s largely because there are no guidelines people can at least point to, whether they agree with the guidance or no," Powell said.

Tauxe acknowledged there’s no written policy or checklist that governs that decision, only decades of precedent.

“It’s a case-by-case thing and all the way back, as far as people can remember, there’s discussions of ‘hotel X’ or ‘cruise ship Y,” he said.

Epidemiology, like humans, is flawed. But it’s better than astrology. The more that public health folks can articulate when to go public and why, the more confidence in the system. Past risk communication research has demonstrated that if people have confidence in the decision-making process they will have more confidence in the decision. People may not agree about when to go public, but if the assumptions are laid on the table, and value judgments are acknowledged, then maybe the focus can be on fewer sick people.

I understand the flexibility public health types require to do their jobs effectively, but much of the public outrage surrounding various outbreaks – salmonella in tomatoes/jalapenos, 2008, listeria in Maple Leaf deli meats, 2008, the various leafy green recalls and outbreaks of 2010, and the delay in clamping down on Iowa eggs – can be traced to screw ups in going public.

It’s long been a tenet of risk communication that it is better to default to early public information rather than later. People can handle all kinds of information, especially when they are informed in an honest and forthright manner.

Public health should protect public health and name names; Victoria health types resort to blame the consumer defense

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After the belated public notification about a salmonella outbreak linked to Rizzo’s Pizza in Ballarat, Australia, the Herald-Sun uncovered a bunch of other incidents of people barfing in the state of Victoria that were never or belatedly made public.

A poisoning outbreak at a sushi bar that left 84 people sick and 19 in hospital is among serious food safety incidents kept quiet by authorities.

Other cases uncovered include 17 diners who fell acutely ill after eating Vietnamese chicken and pork rolls; 10 people struck down after eating eggs Benedict at a cafe; and 13 people who fell crook from chicken parmigiana at a hotel.

Health department figures show a significant rise in salmonella cases in the past two years, many of them linked to eggs (a table of raw-egg related outbreaks in Australia is available at http://bites.ksu.edu/raw-egg-related-outbreaks-australia).

Brooke Dellavedova, a principal at Maurice Blackburn, said she often heard about food poisoning outbreaks, but new laws meant class actions were difficult to mount on behalf of victims.

"So the proprietors get a slap on the wrist, if that, and that’s the end of the story," she said.

Department of Health spokesman Graeme Walker said the department did not routinely reveal the names of businesses because its role was to identify and remove the source and investigate the cause.

Acting chief health officer Dr Rosemary Lester said the information was not being kept secret and salmonella was common adding, "We do know that many cases of salmonella arise in the home and other outlets.”

This isn’t about where salmonella happens: this is about accountability by publicly-funded health types.

Listeria in cantaloupe; 146 sick including 30 dead 1 miscarriage; will talk of change translate into action with meaningful verification?

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For those counting – which seems like a bizarrely gruesome fetish – the final tally for the listeria-in-cantaloupe outbreak of 2011 is 146 persons sick from 28 states, including 30 dead and one miscarriage.

Far more important is – will the cantaloupe industry in Colorado and elsewhere become overtly proactive, seeking the best research on the causes, prevention, and how to translate guidelines into actual actions in the field – where contamination starts.

The U.S. Centers for Disease Control today issued its final report on the Multistate Outbreak of Listeriosis Linked to Whole Cantaloupes from Jensen Farms, Colorado—United States, 2011.

(Sidenote: In the E. coli O157:H7 outbreak linked to Romaine lettuce served at Schnucks, CDC spokeswoman Lola Russell told The Packer yesterday the agency leaves announcements regarding names of growers and distributors to the regulatory agencies – state health departments and the U.S. Food and Drug Administration. But it had no problem fingering Jensen Farms? Maybe because the Food and Drug Administration named Jensen Farms on Sept. 14 it was open season after that. Maybe CDC was trying to protect other cantaloupe growers. Maybe they’d like to protect other Romaine lettuce growers? Is there a written policy on when to finger a farm? Consistency in communications helps build trust.)

From the CDC cantaloupe report:

A total of 146 persons infected with any of the four outbreak-associated strains of Listeria monocytogenes were reported to CDC from 28 states.

Among persons for whom information was available, reported illness onset ranged from July 31, 2011 through October 27, 2011. Ages ranged from <1 to 96 years, with a median age of 77 years. Most ill persons were over 60 years old. Fifty-eight percent of ill persons were female. Among the 144 ill persons with available information on whether they were hospitalized, 142 (99%) were hospitalized.

Thirty deaths were reported: Colorado (8), Indiana (1), Kansas (3), Louisiana (2), Maryland (1), Missouri (3), Nebraska (1), New Mexico (5), New York (2), Oklahoma (1), Texas (2), and Wyoming (1). Among persons who died, ages ranged from 48 to 96 years, with a median age of 82.5 years. In addition, one woman pregnant at the time of illness had a miscarriage.

Seven of the illnesses were related to a pregnancy; three were diagnosed in newborns and four were diagnosed in pregnant women. One miscarriage was reported.

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.

When to go public? First salmonella-in-Del-Monte cantaloupe illnesses IDed in Albany in Feb. public not told

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Alex Paul of the Albany Democrat-Herald reports the first confirmed victims of a February outbreak of Salmonella Panama that eventually affected 20 people in 10 states and was traced to cantaloupe that came from a single farm in Guatemala, was in Albany, Oregon.

“We found one person confirmed and two others presumed with a pretty rare form of salmonella,” said Jane Fleischbein of the Linn County Public Health Department.

Fleischbein said the public wasn’t notified because Costco immediately pulled the product from its shelves.

“It all depends on timing,” Fleischbein said. “Sometimes it takes a while to track down and by the time the source has been identified, the product has already been consumed or taken off the shelves.”

Fleischbein said her office gets news of at least one recall per week.

“If local public health departments sent a notice about every recall, we would be awfully busy,” Fleischbein said. “There are many recalls that go under the radar.”

The three in Albany were among six people statewide who became sick. The investigation concluded they had eaten cantaloupe served at a church supper.

Will Del Monte’s lawsuit against Oregon health succeed in setting poisonous tone for outbreak investigations?

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Del Monte Fresh Produce, a company that recalled its cantaloupes in March after health investigators in several states linked them to a Salmonella Panama outbreak, said yesterday that is plans to sue Oregon Health Authority and, Dr William Keene, one of the nation’s most well-known disease outbreak investigators (right, exactly as shown), claiming that the company’s products were wrongly singled out.

Lisa Schnirring of CIDRAP news at the University of Minnesota interviewed several public health types, who say the company’s suit is unprecedented, and some worry that it may inhibit future foodborne illness investigations.

Lon Kightlinger, MPH, PhD, state epidemiologist with the South Dakota Department of Health, said some of his department’s disease investigations have involved legal tug-of-wars. "Although we do have some worries of legal threats, that does not drive our investigation, but causes us to do a better job," he said.

In Iowa, laws require public health officials to treat the names of entities such as restaurants or companies the same as people, said Patricia Quinlisk, MD, MPH, medical director and state epidemiologist for the Iowa Department of Public Health.

She said that, before going public with names, health officials must discuss the issue with the state attorney general’s office to make sure the action complies with a "necessary for public health" clause. "Thus something like this might have more scrutiny here than other places," she said, adding that she’s never seen a legal threat like Del Monte’s.

Tim Jones, MD, MPH, state epidemiologist for the Tennessee Department of Health, said he’s been bullied and subjected to implied threats in the course of epidemiologic investigations. "I’ve never taken them seriously, and legally I’ve never been worried," he said.

Though Del Monte’s legal threat could create an inhibitory effect, epidemiologists take pride in being able to respond to outbreaks faster and freer than federal agencies, which are often bound by legal restrictions, Jones said.

"Our job is to protect people."

Some measure of immunity is needed for investigators, Jones said. "If anyone in public health is nervous about getting sued, it could be dangerously inhibitory."