June 2013

Missing my flight to Seattle via London to Amsterdam allowed my to access the internet from a hotel in the old part of the city to upload this post.  It also allowed me to walk the streets and canals taking in a bit of the culture.  As I cruised past the many “coffee shops” that line the canals, it reminded me again that not everyone is as interested in food safety as I might be – well, at least those enjoying the coffee house experience.

Below is a press release (somewhat edited by me) from Townsend Farms that the FDA allows to be placed on its website.  My strong suspicion is that the media and the public think the FDA actually has a hand in it despite the warning:

FDA posts press releases and other notices of recalls and market withdrawals from the firms involved as a service to consumers, the media, and other interested parties. FDA does not endorse either the product or the company.

Townsend Farms, Inc. of Fairview, Oregon, out of an abundance of caution and in cooperation with the FDA is expanding its voluntary recall efforts and is now recalling Townsend Farms Organic Antioxidant Blend, 3 lb. bag with UPC 0 78414 40444 8. The recall codes are located on the back of the package with the words “BEST BY” followed by the code T122114 sequentially through T053115, followed by a letter. All letter designations are included in the voluntary recall. The voluntary recall is occurring because of a potential hepatitis A contamination. The voluntary recall efforts are based on epidemiological and trace-back evidence resulting from an ongoing outbreak investigation conducted by the FDA and the CDC.

Townsend Farms is providing this Update #3 after the FDA and the CDC confirmed that the epidemiological evidence supports a clear association between the hepatitis A illness outbreak and one lot of organic pomegranate seeds used in the Frozen Organic Antioxidant blend subject to the voluntary recall. The implicated lot of pomegranate seeds were imported from Turkey through Goknur and Purely Pomegranate, Inc. The FDA has tested the recalled product and the results to date have not detected hepatitis A.

The FDA has also reported that the epidemiological evidence does not support an association between the illness outbreak and the four other berry products (raspberry, blueberry, strawberry and dark cherry) in the Frozen Organic Antioxidant blend (and which have also been used in other Townsend Farms, Inc. Frozen Organic products) or any other Fresh or Frozen berry products produced by Townsend Farms, Inc.

Finally, as part of the ongoing investigation, the FDA, in cooperation with Townsend Farms, Inc. has completed a directed inspection of the company’s frozen fruit repacking operations. The FDA found no evidence linking either the Townsend Farms, Inc.’s repacking facility or any food handler who had possible contact with the product to the source of the illness outbreak.

This expansion does NOT AFFECT the previous voluntary recall information regarding Harris Teeter Organic Antioxidant Berry Blend, 10 oz. bag UPC 0 72036 70463 4. For additional information regarding the voluntarily recalled Harris Teeter product visit the FDA website http://www.fda.gov/Safety/Recalls/ucm355166.htm.

It does not take much to see that Townsend Farms is attempting to deflect its responsibility for the largest Hepatitis A outbreak in a decade to the supplier of organic pomegranate seeds.  That is legal strategy that will not fly high.  Perhaps someone at Townsend Farms was in one of the coffee shops I passed.

The U.S. Food and Drug Administration will detain shipments of pomegranate seeds from Goknur Gida Maddeleri Ithalat Ihracat Tic [Goknur Foodstuffs Import Export Trading] of Turkey when they are offered for import into the United States.

This action results from an investigation by the FDA, the Centers for Disease Control and Prevention, and state and local health authorities into a multi-state outbreak of Hepatitis A illnesses associated with Townsend Farms Organic Antioxidant Blend, a frozen food blend containing pomegranate seed mix

By combining information gained from the FDA’s traceback and traceforward investigations and the CDC’s epidemiological investigation, the FDA and CDC have determined that the most likely vehicle for the Hepatitis A virus appears to be a common shipment of pomegranate seeds from Goknur used by Townsend Farms to make the Townsend Farms and Harris Teeter Organic Antioxidant Blends that were recalled in June. These seeds were also used by Scenic Fruit Company to make their recently recalled Woodstock Frozen Organic Pomegranate Kernels.

“This outbreak highlights the food safety challenge posed by today’s global food system,” said Michael R. Taylor, deputy commissioner for foods and veterinary medicine. “The presence in a single product of multiple ingredients from multiple countries compounds the difficulty of finding the cause of an illness outbreak. The Hepatitis A outbreak shows how we have improved our ability to investigate and respond to outbreaks, but also why we are working to build a food safety system that more effectively prevents them.”

The FDA reviewed records and determined that the pomegranate seeds from this shipment were the only ingredient common to all of the recalled Townsend Farms and Harris Teeter Organic Antioxidant Blend

FDA will be working with the firms that have distributed pomegranate seeds from this shipment from Turkey to help ensure that all recipients of these seeds are notified.

The CDC reports that as of June 27, 2013, 127 people were exposed to Townsend Farms Organic Antioxidant Blend. The illnesses have been reported in Arizona, California, Colorado, Hawaii, Nevada, New Mexico, Utah, and Wisconsin. The people who were reported ill in Wisconsin were exposed to the product in California.

The CDC reports that the outbreak strain of Hepatitis A virus (HAV), belonging to genotype 1B, was found in clinical specimens of 56 people in seven states. This strain is rarely seen in the Americas but circulates in North Africa and the Middle East.

Ouch!

According to London press, Jamie Oliver’s Ministry of Food centre has been temporarily shut down for the “welfare of staff and the public”.

The TV chef opened the flagship Rotherham centre in 2008 as part of a television series of the same name.

It provides regular cooking workshops and also has a cafe.

The local authority said the closure followed health and safety concerns raised by the staff and their trade union.

“There are no issues relating to the safety or quality of the food produced and sold,” a spokesman for Rotherham Borough Council said.

“Five years after the Ministry of Food launched in Rotherham, it is appropriate that this assessment takes place to ensure the service continues to meet its main objectives of encouraging local people to cook and eat healthy food and providing training activities in local communities.”

Say, what is a “Centre?”

Perhaps they are occupied by too much political unrest in Turkey?The CDC reported as of June 27, 2013, 127 people have been confirmed to have become ill from Hepatitis A after eating ‘Townsend Farms Organic Anti-oxidant Blend’ in 8 states: Arizona (17), California (64), Colorado (25), Hawaii (7), New Mexico (5), Nevada (5), Utah (2), and Wisconsin (2). [Note: The cases reported from Wisconsin resulted from exposure to the product in California.]

The outbreak strain of hepatitis A virus, belonging to genotype 1B, was found in clinical specimens of 56 people in seven states: AZ (6), CA (15), CO (22), HI (4), NM (4), NV (4) and WI (1; the person was exposed in California). This subtype is rarely seen in the Americas but circulates in North Africa and the Middle East.  This genotype was identified in a 2013 outbreak in Europe linked to frozen berries and another 2012 outbreak in British Columbia related to a frozen berry blend with pomegranate seeds from Egypt. However, there is no evidence at this time that these outbreaks are related to the ongoing U. S. outbreak.

On June 3, 2013, Townsend Farms, Inc. of Fairview, Oregon voluntarily recalled certain lots of its frozen Organic Antioxidant Blend because it has the potential to be contaminated with hepatitis A virus.  By combining information gained from the FDA’s traceback and trace forward investigations and the CDC’s epidemiological investigation, FDA and CDC have determined that the most likely vehicle for the Hepatitis A virus is appears to be a common shipment of pomegranate seeds from Turkey used by Scenic Fruit Company to make the recalled Woodstock Frozen Organic Pomegranate Kernels and by Townsend Farms to make the recalled Townsend Farms and Harris Teeter Organic Anti-Oxidant Blend.

The FDA reviewed records and determined that the pomegranate seeds from this shipment were the only ingredient common to all of the recalled Townsend Farms and Harris Teeter Organic Anti-Oxidant Blend.  On June 26, 2013, Scenic Fruit Company of Gresham, Oregon recalled specific lots of Woodstock Frozen Organic Pomegranate Kernels.  Combining information gained from the FDA’s traceback and trace forward investigations and the CDC’s epidemiological investigation, it has been determined that the vehicle for the Hepatitis A virus is a common shipment of pomegranate seeds from Turkey used by Scenic Fruit Company in making the recalled Woodstock Frozen Organic Pomegranate Kernels and by Townsend Farms in making Townsend Farms Organic Anti-Oxidant Blend.

According to Lynne Terry of the Oregonian, the seeds originally came from Goknur,  a fruit company based in Ankara, which shipped them to Purely Pomegranate, Inc., in Dana Point, Calif., according to a letter from Purely Pomegranate to its customers. Purely Pomegranate then resold them.  Townsend Farms included the seeds in its Organic Antioxidant Blend, Gaar said. Scenic Fruit Co. in Gresham packaged the frozen seeds for Woodstock Farms in Providence, R.I. under that company’s label, said Ryan Wist,  food safety manager for Scenic.

An Introduction to Hepatitis A.

Exposure to the hepatitis A virus can cause an acute infection of the liver that is typically mild and resolves on its own. [11, 17] The symptoms and duration of illness vary a great deal, with many persons showing no symptoms at all. [11] Fever and jaundice are two of the symptoms most commonly associated with a hepatitis A infection. [17]

It has been written that the “earliest accounts of contagious jaundice are found in ancient China.” [11] According to the CDC:

The first descriptions of hepatitis (epidemic jaundice) are generally attributed to Hippocrates. Outbreaks of jaundice, probably hepatitis A, were reported in the 17th and 18th centuries, particularly in association with military campaigns. Hepatitis A (formerly called infectious hepatitis) was first differentiated epidemiologically from hepatitis B, which has a long incubation period, in the 1940s. Development of serologic tests allowed definitive diagnosis of hepatitis B. In the 1970s, identification of the virus, and development of serologic tests helped differentiate hepatitis A from other types of non-B hepatitis.

Until 2004, hepatitis A was the most frequently reported type of hepatitis in the United States. In the pre-vaccine era, the primary methods used for preventing hepatitis A were hygienic measures and passive protection with immune globulin (IG). Hepatitis A vaccines were licensed in 1995 and 1996. These vaccines provide long-term protection against hepatitis A virus (HAV) infection. [7]

Consequently, hepatitis A is the only common vaccine-preventable foodborne disease in the United States. [7, 12]  This virus is one of five human hepatitis viruses that primarily infect the human liver and cause human illness. [11] Unlike hepatitis B and C, hepatitis A does not develop into chronic hepatitis or cirrhosis, which are both potentially fatal conditions, [7, 11, 17] Nonetheless, infection with the hepatitis A virus (HAV) can lead to acute liver failure and death. [12, 17]

The Incidence of Hepatitis A Infections.

Hepatitis A is much more common in countries with underdeveloped sanitation systems and, thus, is a risk in most of the world. [11, 16]  An increased transmission rate is seen in all countries other than the United States, Canada, Japan, Australia, New Zealand, and the countries of Western Europe. [9] Nevertheless, infections continue to occur in the United States, where approximately one-third of the population has been previously infected with HAV. [6, 12]

Each year, approximately 30,000 to 50,000 cases of hepatitis A occur in the United States. [5, 7] Historically, acute hepatitis A rates have varied cyclically, with nationwide increases every 10 to 15 years. [13] The national rate of HAV infections has declined steadily since the last peak in 1995. [5, 6] Although the national incidence—1.0 cases per 100,000 population—of hepatitis A was the lowest ever recorded in 2007, it is estimated that asymptomatic infections and underreporting kept the documented incidence-rate lower than it actually is. In fact, it is estimated that there were 25,000 new infections in 2007. [6, 22]

Although the rates of HAV infection have declined over the years, rates are twice as high among American Indians and Alaskan Natives. [1] Hispanics are also twice as likely to be infected compared to non-Hispanic Whites in the United States. [19]. Rates among American Indians and Alaskan Natives have decreased dramatically, largely as a result of increased vaccination of children in both urban and rural communities. [1]

In 2007, the CDC reported a total of 2,979 acute symptomatic cases of hepatitis A. [6] Of these, information about food and water exposure was known for 1,047 cases, leading to an estimate that 6.5% of all infections were caused by exposure to contaminated water or food. [6] In 2,500 of the cases, no known risk factor was identified. [6]

Estimates of the annual costs (direct and indirect) of hepatitis A in the United States have ranged from $300 million to $488.8 million in 1997 dollars. [5] In one study conducted in Spokane, Washington, the combined direct and indirect costs for each case of hepatitis A from all sources ranged from $2892 to $3837. [2, 13] In a 2007 Ohio study, each case of HAV infection attributable to contaminated food was estimated to cost at least $10,000, including medical and other non-economic costs. [21] Nationwide, adults who become ill miss an average of 27 workdays per illness, and 11-to-22 percent of those infected are hospitalized. [6, 7] All of these costs are entirely preventable given the effectiveness of a vaccination in providing immunity from infection. [7, 13]

 How is Hepatitis A Transmitted?

Hepatitis A is a communicable (or contagious) disease that often spreads from person to person. [11] Person-to-person transmission occurs via the “fecal-oral route,” while all other exposure is generally attributable to contaminated food or water. [11, 16] Food-related outbreaks are usually associated with contamination of food during preparation by a HAV-infected food handler. [6, 7, 12]  The food handler is generally not ill because the peak time of infectivity—that is, when the most virus is present in the stool of an infected individual—occurs two weeks before illness begins. [12]

Fresh produce contaminated during cultivation, harvesting, processing, and distribution has also been a source of hepatitis A. [12, 25] In 1997, frozen strawberries were the source of a hepatitis A outbreak in five states. [15] Six years later, in 2003, fresh green onions were identified as the source of a hepatitis A outbreak traced to consumption of food at a Pennsylvania restaurant. [25] Other produce, such as blueberries and lettuce, has been associated with hepatitis A outbreaks in the U.S. as well as other developed countries. [3, 4]

HAV is relatively stable and can survive for several hours on fingertips and hands and up to two months on dry surfaces. [11, 17] The virus can be inactivated by heating to 185°F (85°C) or higher for one minute, or disinfecting surfaces with a 1:100 dilution of sodium hypochlorite (household bleach) in tap water. [8, 13, 24]  It must be noted, however, that HAV can still be spread from cooked food if it is contaminated after cooking. [12]

Although ingestion of contaminated food is a common means of spread for hepatitis A, it may also be spread by household contact among families or roommates, sexual contact, or by direct inoculation from persons sharing illicit drugs. [12, 17] Children are often asymptomatic, or have unrecognized infections, and can pass the virus through ordinary play, unknown to their parents, who may later become infected from contact with their children. [11, 18, 22]

Symptoms of Hepatitis A Infection.

Hepatitis A may cause no symptoms at all when it is contracted, especially in children. [12] Asymptomatic individuals will only know they were infected (and have become immune, given that you can only get hepatitis A once) by getting a blood test later in life. [17] Approximately 10 to 12 days after exposure, HAV is present in blood and is excreted via the biliary system into the feces. [7, 11]  Although the virus is present in the blood, its concentration is much higher in feces. [11] HAV excretion begins to decline at the onset of clinical illness, and decreases significantly by 7 to 10 days after onset of symptoms. [11] Most infected persons no longer excrete virus in the feces by the third week of illness; children may excrete HAV longer than adults. [11, 20]

Seventy percent of hepatitis A infections in children younger than six years of age are asymptomatic; in older children and adults, infection tends to be symptomatic with more than 70% of those infected developing jaundice. [7] Symptoms typically begin about 28 days after contracting HAV, but can begin as early as 15 days or as late as 50 days after exposure. [7, 11, 12] The symptoms include muscle aches, headache, anorexia (loss of appetite), abdominal discomfort, fever, and malaise. [[7, 11, 17]

After a few days of typical symptoms, jaundice (also termed “icterus”) sets in. [11, 17] Jaundice is a yellowing of the skin, eyes and mucous membranes that occurs because bile flows poorly through the liver and backs up into the blood. [17] The urine will also turn dark with bile and the stool light or clay-colored from lack of bile. [7, 11, 17] When jaundice sets in, initial symptoms such as fever and headache begin to subside. [17]

In general, symptoms usually last less than 2 months, although 10% to 15% of symptomatic persons have prolonged or relapsing disease for up to 6 months. [13, 14] It is not unusual, however, for blood tests to remain abnormal for six months or more. [11] The jaundice so commonly associated with hepatitis A can also linger for a prolonged period in some infected persons—sometimes as long as eight months or more. [11, 17] Additionally, pruritus, or severe “itchiness” of the skin, can persist for several months after the onset of symptoms. These conditions are frequently accompanied by diarrhea, anorexia, and fatigue. [7, 17]

Relapse is possible with hepatitis A, typically within three months of the initial onset of symptoms. [14] Although relapse is more common in children, it does occur with some regularity in adults. [11, 14] The vast majority of persons who are infected with hepatitis A fully recover, and do not develop chronic hepatitis. [17] Persons do not carry hepatitis A long-term as with hepatitis B and C. [5, 7]

Fulminant Hepatitis A.

Fulminant hepatitis A is a rare but devastating complication of HAV infection. [10] As many as 50% of individuals with acute liver failure may die or require emergency liver transplantation. [23] Elderly patients and patients with chronic liver disease are at higher risk for fulminant hepatitis A. [11, 23] In parallel with a declining incidence of acute HAV infection in the general population, however, the incidence of fulminant HAV appears to be decreasing. [23]

HAV infects the liver’s parenchymal cells (internal liver cells). [10, 11] Once a cell has been penetrated by the viral particles, the hepatitis A virus releases its own toxins that cause, in essence, a hostile takeover of the host’s cellular system. [11, 22] The cell then produces new viral components that are released into the bile capillaries or tubes that run between the liver’s parenchymal cells. [11] This process results in the death of liver cells, called hepatic necrosis. [11, 23]

The fulminant form of hepatitis occurs when this necrotic process kills so many liver cells—upwards of three-quarters of the liver’s total cell count—that the liver can no longer perform its job. [10, 23] Aside from the loss of liver function, fulminant hepatic failure can lead to encephalopathy and cerebral edema. [10] Encephalopathy is a brain disorder that causes central nervous system depression and abnormal neuromuscular function. [10, 11] Cerebral edema is a swelling of the brain that can result in dangerous intracranial pressure. [10] Intracranial hypertensions leading to brain stem death and sepsis with multiple organ failure are the leading causes of death in individuals with fulminant hepatic failure. [10, 23]

How is Hepatitis A Infection Diagnosed?

The various human hepatitis viruses cause very similar illnesses. [11] Therefore, neither the individual nor the healthcare provider can tell by symptoms or signs if a given individual is suffering from hepatitis A unless laboratory tests are performed. [7, 17]

Fortunately, blood tests are widely available to accurately diagnose hepatitis A, including tests for antibodies, or the affected person’s immune response to hepatitis A proteins. [7] This immune response is conclusively demonstrated by the presence of Immunoglobulin M (IgM) antibodies, indicating acute disease, and immunoglobulin G (IgG), indicating a past infection. [11, 13] The IgG antibodies are present for life, indicating immunity. [13] Following is some guidance for the interpretation of the test results:

  • IgM negative / IgG negative: Most persons with these results have never contracted hepatitis A. Antibodies of the IgM variety develop five to ten days prior to the onset of symptoms.
  • IgM positive / IgG negative: This result indicates acute hepatitis A.
  • IgM positive / IgG positive: This result indicates that acute hepatitis A occurred within the last six months. By six months, the IgM reverts to negative.
  • IgM negative / IgG positive: Persons with this result are immune to hepatitis A. They have either been infected with the virus months or years in the past (with or without symptoms), or they have been vaccinated for hepatitis A. However, if they are currently ill, it is not likely to be due to hepatitis A.

Treatment for Acute Hepatitis A Infections.

Once a clinical infection is established, there is no specific treatment for hepatitis A.  Affected individuals generally suffer from loss of appetite, so the main concern is ensuring a patient receives adequate nutrition and avoids permanent liver damage. [7, 17] An individual’s perception of the severity of fatigue or malaise is the best determinant of the need for rest. [17]

Treatment of those suffering from fulminant hepatic failure depends largely on the affected person’s status.  [23, 26] Those who have not become encephalopathic generally undergo an intense course of supportive treatment.  [10, 23] But for those whose liver failure is so complete that it has lead to encephalopathy or cerebral edema, timely liver transplantation is often the only option. [10, 14] Unfortunately, many individuals with irreversible liver failure do not receive a transplant because of contraindications or the unavailability of donor livers. [11, 23]

Real Life Impacts.

The number of acute hepatitis A infections in the U.S. drastically fell in the first part of the 21st Century, largely in part because hepatitis A vaccination was recommended for persons in groups shown to be at high risk for infection and children living in communities with high rates of disease beginning in 1996.   By 2006, hepatitis A vaccine had been incorporated into the Advisory Committee on Immunization Practices’ recommended childhood vaccination schedule. [27]

Despite a decrease in the number of hepatitis A cases reported annually, anyone who has not been vaccinated is at increased risk for contracting hepatitis A infection.  Persons over the age of 50, those with chronic liver disease, and immunocompromised individuals who have not been vaccinated against hepatitis A remain most at risk for developing fulminant hepatitis, a rare but devastating complication of a hepatitis A infection that can lead to the need for a liver transplant, or death.

How to Prevent Hepatitis A .

Hepatitis A is totally and completely preventable. [12] Although outbreaks continue to occur in the United States, no one should ever get infected if preventive measures are taken. [7, 12] For example, food handlers must always wash their hands with soap and water after using the bathroom, changing a diaper, and certainly before preparing food. [12, 24] Food handlers should always wear gloves when handling or preparing ready-to-eat foods, although gloves are not a substitute for good hand washing. Ill food-handlers should be excluded from work. [14, 24]

After exposure, immune globulin (IG) is 80% to 90% effective in preventing clinical hepatitis A when administered within 2 weeks of last exposure. [9] Although efficacy is greatest when IG is administered early in the incubation period, when administered later, IG is still likely to make the symptoms less severe. [9, 11] Given the lack of appropriately designed studies comparing the postexposure efficacy of vaccine with that of IG, the Advisory Committee on Immunization Practices (ACIP) recommends IG exclusively for post-exposure. [9] Hepatitis A vaccine, if recommended for other reasons, could be given at the same time. [9, 13]

In 2006, the ACIP recommended routine hepatitis A vaccination for all children ages 12-23 months, that hepatitis A vaccination be integrated into the routine childhood vaccination schedule, and that children not vaccinated by two years of age be vaccinated subsequently. [9, 13] The vaccine is recommended for the following persons:

  • Travelers to areas with increased rates of hepatitis A
  • Men who have sex with men
  • Injecting and non-injecting drug users
  • Persons with clotting factor disorders (e.g. hemophilia)
  • Persons with chronic liver disease
  • Persons with occupational risk of infection (e.g. those who work with hepatitis A-infected primates or with hepatitis A virus in a laboratory setting)
  • Children living in regions of the U.S. with increased rates of hepatitis A
  • Household members and other close personal contacts (such as regular babysitters) of adopted children newly arriving from countries with high or intermediate rates of hepatitis A. [9]

The vaccine may also help protect household contacts of those persons infected with hepatitis A. [9, 20] Although generally not a legal requirement at this time, vaccination of food handlers would be expected to substantially diminish the incidence of hepatitis A outbreaks. [12] Persons traveling to a high-risk area less than four weeks after receiving the initial dose of hepatitis A vaccine, or travelers who choose not to be vaccinated against hepatitis A should receive a single dose of Immune Globulin, which provides protection against hepatitis A infection for up to three months. [9, 11, 18]

References.

1.         Bialek, Stephanie, et al., “Hepatitis A Incidence and Hepatitis A Vaccination among American Indians and Alaska Natives, 1990–2001,” American Journal of Public Health.Vol. 94, No. 6, pp. 996-1001 (2004). Full text of article is available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448379/pdf/0940996.pdf.

2.         Bownds, Lynne, et al., “Economic Impact of a Hepatitis A Epidemic in a Mid-Sized Urban Community: The Case of Spokane, Washington,” Journal of Community Health, Vol. 28, No. 4, pp. 233-246 (2003). Abstract available online at http://www.ncbi.nlm.nih.gov/pubmed/12856793

3.         Butot S, et al., “Effects of Sanitation, Freezing and Frozen Storage on Enteric Viruses in Berries and Herbs,” International Journal of Food Microbiology, Vol. 126, pp. 30-35 (2008). Full text of article is available at http://www.prograd.uff.br/virologia/sites/default/files/bulot_et_al_2008_inactivation.pdf

4.         Calder, L, et al., “An Outbreak of Hepatitis A Associated with Consumption of Raw Blueberries,” Epidemiology and Infection, Vol. 131, No. 1, 745-751 (2003) at  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870016/pdf/12948375.pdf

5.         CDC Summary, “Disease Burden from Viral Hepatitis A, B, and C in the United States, 2004-2009, at http://www.cdc.gov/hepatitis/pdfs/disease_burden.pdf

6.         CDC, “Surveillance for Acute Viral Hepatitis — United States, 2007, Morbidity and Mortality Weekly Report, Surveillance Summaries, Vol. 58, No. SS03 (May 22, 2009) at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5803a1.htm

7.         CDC, “Hepatitis A,” in EPIDEMIOLOGY AND PREVENTION OF VACCINE-PREVENTABLE DISEASES (also known as “The Pink Book”), Atkinson W, Wolfe S, Hamborsky J, McIntyre L, editors, 12th edition. Chapter available online at http://www.cdc.gov/vaccines/pubs/pinkbook/hepa.html

8.         CDC, “Updated recommendations from Advisory Committee on Immunization Practices (ACIP) for use of hepatitis A vaccine in close contacts of newly arriving international adoptees,” Morbidity and Mortality Weekly Report, Vol. 58, No. 36, (Sept. 18, 2009), http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5836a4.htm

9.         CDC, “Update: Prevention of Hepatitis A after Exposure to Hepatitis A Virus and in International Travelers, Updated ACIP Recommendations,” Morbidity and Mortality Weekly Report, Vol. 56, No. 41, pp. 1080-84 (Oct. 19, 2007), online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a3.htm.

10.       Detry, Oliver, et al., “Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure:  Pathophysiology and Management,” World Journal of Gastroenterology, Vol. 12, No. 46, pp. 7405-7412 (Dec. 14, 2006). Full article is available online at http://www.wjgnet.com/1007-9327/12/7405.pdf

11.       Feinstone, Stephen and Gust, Ian, “Hepatitis A Virus,” in Mandell, Douglas, & Bennett’s PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES, Fifth Edition, Chap. 161, pp. 1920-40 (2000).

12.       Fiore, Anthony, Division of Viral Hepatitis, CDC, “Hepatitis A Transmitted by Food,” Clinical Infectious Diseases, Vol. 38, 705-715 (March 1, 2004). Full text online at http://www.cdc.gov/hepatitis/PDFs/fiore_ha_transmitted_by_food.pdf

13.       Fiore, Anthony, et al., Advisory Committee on Immunization Practices (ACIP), Prevention of Hepatitis-A Through Active or Passive Immunization: Recommendations, Morbidity & Mortality Weekly Review, Vol. 55, Report 407, (May 19, 2006) at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm

14.       Gilkson Miryam, et al., “Relapsing Hepatitis A. Review of 14 cases and literature survey,”  Medicine, Vol. 71, No. 1, 14-23 ( Jan. 1992). Abstract of article online at http://www.ncbi.nlm.nih.gov/pubmed/1312659

15.       Hutin YJF, et al., “A Multistate, Foodborne Outbreak of Hepatitis A,” New England Journal of Medincine, Vol. 340, pp. 595–602 (1999). Full text of article is online at http://www.nejm.org/doi/full/10.1056/NEJM199902253400802

16.       Jaykus Lee Ann, “Epidemiology and Detection as Options for Control of Viral and Parasitic Foodborne Disease,” Emerging Infectious Diseases, Vol. 3, No. 4, pp. 529-39 (October-December 1997). Full text of the article is available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640072/pdf/9366607.pdf

17.       Mayo Clinic Staff, “Hepatitis A,” (last updated Sept. 1, 2011). Articles available online at http://www.mayoclinic.com/health/hepatitis-a/DS00397 .

18.       Piazza, M, et al., “Safety and Immunogenicity of Hepatitis A Vaccine in Infants: A Candidate for Inclusion in Childhood Vaccination Program,” Vaccine. Vol. 17, pp. 585-588 (1999). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/10075165

19.       Rawls, R.A. and Vega, K.J., “Viral Hepatitis in Minority America,” Journal of Clinical Gastroenterology, Vol. 39, No. 2, pp. 144–151 (Feb. 2005). Abstract is at  http://www.ncbi.nlm.nih.gov/pubmed/15681912

20.       Sagliocca, Luciano, et al., “Efficacy of Hepatitis A Vaccine in Prevention of Secondary Hepatitis A Infection: A Randomized Trial,” Lancet, Vol. 353, 1136-39 (1999). Abstract at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)08139-2/abstract

21.       Scharff, RL, et al., “Economic Cost of Foodborne Illness in Ohio,” Journal of Food Protection, Vol. 72, No. 1, pp. 128-136 (2009). Abstract available online at http://www.ingentaconnect.com/content/iafp/jfp/2009/00000072/00000001/art00018

22.       Schiff, E.R., “Atypical Manifestations of hepatitis-A,” Vaccine, Vol. 10, Suppl. 1, pp. 18-20 (1992). Abstract at http://www.ncbi.nlm.nih.gov/pubmed/1475999

23.       Taylor, Ryan, et al., “Fulminant Hepatitis A Virus Infection in the United States: Incidence, Prognosis, and Outcomes,” Hepatology, Vol. 44, 1589-1597 (2006). Full text http://deepblue.lib.umich.edu/bitstream/2027.42/55879/1/21439_ftp.pdf

24.       Todd, Ewan C. D., et al., “Outbreaks Where Food Workers Have Been Implicated in the Spread of Foodborne Disease. Part 6. Transmission and Survival of Pathogens in the Food Processing and Preparation-environment,” Journal of Food Protection, Vol. 72, 202-219 (2009). Full text of the article is available online at http://courses.washington.edu/eh451/articles/Todd_2009_food%20processing.pdf

25.       Wheeler, C, et al., “An Outbreak of Hepatitis A Associated with Green Onions,” New England Journal of Medicine, Vol. 353, 890-897 (2005). Full text of article available at http://www.nejm.org/doi/full/10.1056/NEJMoa050855

26.       Willner, IR, et al., “Serious Hepatitis A: An Analysis of Patients Hospitalized During an Urban Epidemic in the United States,” Annals of Internal Medicine, Vol. 128, No. 2, pp. 111-114 (Jan. 15, 1998). Full text of the article is available at http://www.annals.org/content/128/2/111.full.pdf+html

27.       CDC. “Prevention of Hepatitis A through Active or Passive Immunization:  Recommendations of the Advisory Committee on Immunization Practices (ACIP),”  Morbidity and Mortality Weekly Report, Vol. 55, (RR07), pp. 1-23 (May 29, 2006) online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm.

Tiffany Craig of KHOU reports that the Harris County Texas Health Department has temporarily closed Humble’s Iguana Joe’s after multiple patrons reported being sickened over Father’s Day weekend.

The health department said it warned Iguana Joe’s about critical violations and how to fix them, but the restaurant didn’t listen so it had no choice but to close the place down at 9 a.m. Tuesday.

The patrons blamed the restaurant for making them sick.

“I think it was a good decision until they find out what has made so many people sick,” said Debbie Rodriguez.  Her son ended up in the hospital with Salmonella after eating at Iguana Joe’s. 9-year old Ashton is now out of the hospital.  “I think now they understand that the story was a lot bigger than they initially thought,” Rodriguez said.

Allison Duhon Hill and six other people in her family got sick too.  “We were all trying to decide was it the fajitas, was it the sour cream, was it the salsa because we all kind of ate different things,” Hill said. “I’m sure after this incident they will probably be the safest place to eat.”

Nick and Ashley Howe visited on Father’s Day and suffered similar symptoms.  “I went to work the next day and made it though half a day before I was told go home because I was literally in the restroom all day long,” admitted Nick Howe.  A few hours later, Ashley Howe was in the same boat.

I found the Broad Street Pump today (although, I am not sure it is in the same location as the original) – famous because John Snow (a.k.a., father of Epidemiology) figured out that is was the water from the pump that was the vector in the 1854 Cholera outbreak. Inside the cover of Steven Johnson’s “The Ghost Map” reads:

It is the summer of 1854. Cholera has seized London with unprecedented intensity. A metropolis of more than 2 million people, London is just emerging as a one of the first modern cities in the world. But lacking the infrastructure necessary to support its dense population – garbage removal, clean water, sewers – the city has become the perfect breeding ground for a terrifying disease no one knows how to cure.

Thank you John Snow for also lending your name to the nearby pub where I was able to find a pint.  Rumor has it that in 1854 the local beer from the brewery that used the same water source that the pump tapped sickened no one.  Cheers!

I want to also thank Marler Clark’s senior (not in age) Epi-goddess, Patti Waller, for bringing a bit of John Snow to the office every day.

One of the benefits of being awake while the USA is sleeping is that I get to read the FDA recalls that are sent out in the middle of the night.Scenic Fruit Company of Gresham, Oregon today announced it is voluntarily recalling 5,091 cases (61,092 eight ounce bags) of Woodstock Frozen Organic Pomegranate Kernels. Based on an ongoing epidemiological and traceback investigation by the Food and Drug Administration (FDA) and the Centers for Disease Control (CDC) of an illness outbreak, the kernels have the potential to be contaminated with Hepatitis A virus.No illnesses are currently associated with Woodstock Frozen Organic Pomegranate Kernels and product testing to date shows no presence of Hepatitis A virus in Woodstock Frozen Organic Pomegranate Kernels. The company’s decision to voluntarily recall products is made from an abundance of caution in response to an ongoing outbreak investigation by the FDA and CDC. The organic pomegranates are imported from Turkey.

Products were shipped from February 2013 through May 2013 to UNFI distribution centers in California, Colorado, Connecticut, Florida, Georgia, Indiana, Iowa, New Hampshire, Pennsylvania, Rhode Island, Texas, and Washington State. UNFI distribution centers may have further distributed products to retail stores in other states.

Woodstock Organic Pomegranate Kernels are sold in eight-ounce (227 gram) resealable plastic pouches (see image) with UPC Code 0 42563 01628 9. Specific coding information to identify the product can be found on the back portion of these pouches below the zip-lock seal. The following lots are subject to this recall:

C 0129 (A,B, or C) 035 with a best by date of 02/04/2015

C 0388 (A,B, or C) 087 with a best by date of 03/28/2015

C 0490 (A,B, or C) 109 with a best by date of 04/19/2015

I do not thank enough the good folks at state health departments for counting, and the CDC for compiling, all the outbreak data that I often steal whole cloth for my blog.  Thanks.

So, when the CDC quietly announced that a few recent outbreaks were officially over, I thought I would give them a “shout out,” or whatever the corollary is here in London.

Salmonella Tahini – A total of 16 persons infected with the outbreak strains of Salmonella Montevideo or Salmonella Mbandaka were reported from nine states.

The number of ill persons identified in each state was as follows: California (1), Georgia (1), Iowa (1), Louisiana (1), Minnesota (2), New York (1), North Dakota (1), Texas (7), and Wisconsin (1). One ill person was hospitalized and died.

Collaborative investigation efforts of state, local, and federal public health and regulatory agencies indicated that tahini sesame paste distributed by Krinos Foods, LLC of Long Island City, New York was the source of this outbreak.

Salmonella Cucumbers – A total of 84 persons infected with the outbreak strain of Salmonella Saintpaul were reported from 18 states. 28% of ill persons were hospitalized, and no deaths were reported.

Collaborative investigative efforts of local, state, and federal public health and regulatory agencies indicated that imported cucumbers supplied by Daniel Cardenas Izabal and Miracle Greenhouse of Culiacán, Mexico were the source of this outbreak.

Now for the question – When an outbreak is “over” does the CDC or state health departments that have done the counting and compiling, tell the counted that they were part of a recognized outbreak?  Perhaps, yes?  Perhaps, no?

Certainly, those of the counted who were sickened at the end of the outbreak – as it is being announced – likely know.  However, what about an outbreak that has a long Epi curve – an outbreak like the Wright County Salmonella egg outbreak that limped along for nearly a year before it is recognized?

From May 1 to November 30, 2010, a total of 3,578 illnesses were reported. However, some cases from this period may not have been reported yet, and some of these cases may not be related to this outbreak. Based on the previous 5 years of reports to PulseNet, we would expect approximately 1,639 total illnesses to occur during this same period. This means there are approximately 1,939 reported illnesses that are likely to be associated with this outbreak.

It has been my experience that many of the people who are in fact counted as part of an outbreak never know that they are – they are never told.  True, they likely know that they had Salmonella, E. coli, Listeria, etc., but are not told of the vector that got them that way.

OK, I can hear it now – “Marler, you want to know so you can sue the poor, grower, manufacturer, importer, shipper, retailer!”  Well, true enough, but shouldn’t the counted know what caused their illness, or the death of a family member?  Perhaps even in knowing they do not hire me or another want to be food poison ambulance chasers?  Perhaps knowing causes simply causes people to change behaviors and stop buying that particular product or brand of product?  And, perhaps that provides the incentive for better food safety decisions?

Isn’t that how the free market is supposed to work anyway?

Bill, reporting from London – arguably, the birthplace of capitalism.

Hello from London.  I arrived about six hours ago – just in time to shower, shave and head to my speech at the Royal Institute of Public Health.  Now it is a pint in a pub with WiFi.

Looking back across the pond, the CDC continues to compile Hepatitis A numbers.  As of June 25, 2013, 122 people have been confirmed to have become ill from Hepatitis A after eating ‘Townsend Farms Organic Anti-oxidant Blend’ in 8 states: Arizona (17), California (62), Colorado (25), Hawaii (5), New Mexico (5), Nevada (5), Utah (2), and Wisconsin (1). [Note: The one case reported from Wisconsin resulted from exposure to the product in California.]