July 2013

The CDC has been notified of 378 cases of Cyclospora infection from the following 16 health departments: Iowa, Texas, Nebraska, Florida, Wisconsin, Illinois, New York City, Georgia, Missouri, Arkansas, Connecticut, Kansas, Minnesota, New Jersey, New York, and Ohio.

Most of the illness onset dates have ranged from mid-June through early July.

At least 21 persons reportedly have been hospitalized in three states.

Nebraska and Iowa have performed investigations within their states and have shared the results of those investigations with CDC. Based on their analysis, Cyclospora infections in their states are linked to a salad mix.

To date, no public health official has announced the manufacturer of the salad mix or where the salad mix was sold.  My thoughts:

Journal Star:

Health officials in Nebraska and Iowa had said Tuesday they had traced the outbreak to prepackaged salad and that the bulk of the threat had passed.  They said the salad was not grown locally, but they did not reveal where it did come from.  That raised concern from those who argue companies should be held accountable for outbreaks and that customers need more information to make smart food choices.

“If you want the free market to work properly, then you need to let people have the information they need to make informed decisions,” said Bill Marler, a Seattle attorney who specializes in class-action food-safety lawsuits.

USA Today:

Seattle food safety lawyer Bill Marler said he understands that the cause of most outbreaks is discovered long after the peak of illnesses has passed. “However, disclosure gives the public information on which companies have a strong or weak food safety record,” he said. Although public health officials shouldn’t name a source until they’re certain, unless it’s a clear threat to the public health, once the product is identified it should be made public.

“The public has a right to know and to use the information as it sees fit, and people — especially government employees — have no right to decide what we should and should not know,” Marler said.

NBC News:

But, critics say, if people knew what brand and manufacturer were behind the outbreak, they wouldn’t have to worry about washing.

“It’s ridiculous,” said Bill Marler, a Seattle lawyer who specializes in food safety cases. “Consumers have a right to know. Presumably, you wouldn’t want to buy produce from a manufacturer that has been poisoning you.”  …

But critics like Marler say that’s still no reason to withhold the name of the product and the manufacturer responsible for those illnesses. Even if the salad mix is not available, consumers could learn whether the company involved has a history of food safety problems and decide whether to continue buying the product or patronizing the places where it was served.

“For the government to make that decision for the public, that we don’t have the right to know to make that decision for our families, it’s wrong,” Marler said. “It appears to most people that that’s really a decision in favor of business instead of the public.”

AP News:

Bill Marler, a Seattle attorney who specializes in class-action food-safety lawsuits, said withholding the information can create general fears that damage the reputation of good actors in food production. Marler said consumers should be allowed to decide for themselves whether to shop and grocery stores or eat at restaurants where tainted produce was sold. Some states also are slow to interview infected people, he said, which reduces the chances that they remember where they ate.

Marler said withholding the information can create general fears that damage the reputation of good actors in food production. He said consumers should be allowed to decide for themselves whether to shop and grocery stores or eat at restaurants where tainted produce was sold.

“If you want the free market to work properly, then you need to let people have the information they need to make informed decisions,” he said.

CIDRAP:

Bill Marler, a foodborne illness attorney based in Seattle, told CIDRAP News that a handful of states have laws like Iowa’s, with language barring the identification of products or sources unless there’s a public health need to know. However, he says laws allow health departments leeway with their disclosure decisions.

Unfortunately, the provisions can unintentionally send the wrong message to the public, that health departments are protecting companies or businesses, Marler said. “Health departments are deciding that they know better about what they should disclose than you do or I do.” He added that health departments are attuned to protecting patient information and privacy, and that default position seems to sometimes extend to businesses, as well.

Marler predicted that the source of the prepackaged lettuce and the outlets that sold or served it will eventually be revealed through the efforts of reporters or lawyers. He said over the last decade of outbreaks linked to leafy greens, there were no instances in which the sources weren’t ultimately revealed.

He said the nearly one dozen patients who have contacted him about the outbreak all had eaten at the same large restaurant chain. Only a handful of companies in the United States produce large quantities of prepackaged salad for restaurants, and some are equipped to pack bagged salad for grocery stores, as well, he added.

“Eventually, it’s going to come out anyway. Health departments should be open and honest with the public,” Marler said.

“As a consumer, I want to know companies’ safety records so that I know in the future if I want to buy the product,” he said, adding that arming consumers with information that guides their buying decisions is a legitimate public health rationale for sharing the information.

Take Part:

“Consumers have a right to know who poisoned them,” says Bill Marler, a Seattle-based attorney who specializes in foodborne illness outbreaks. “We know it’s a mixed lettuce outbreak. Health officials have given us those details. Isn’t it appropriate for the public to know what happened? Whether it was a failure of an irrigation system, or that the company was buying product from a farm in Mexico? When you hide information from the market, you pervert the free market system. It only works if people have adequate information. “

A total of 385 cases of Cyclospora infection have been reported from 15 states and New York City. The number of cases identified in each area is as follows: Iowa (143), Texas (112), Nebraska (78), Florida (24), Wisconsin (7), Illinois (4), New York City (4), Georgia (3), Kansas (2), Missouri (2), Arkansas (1), Connecticut (1), Minnesota (1), New Jersey (1), New York (1), and Ohio (1).

According to the CDC, Nebraska and Iowa have performed investigations within their states and have shared the results of those investigations with CDC. Based on their analysis, Cyclospora infections in their states are linked to a salad mix. CDC will continue to work with federal, state, and local partners in the investigation to determine whether this conclusion applies to the increase in cases of cyclosporiasis in other states.

Every time one of these outbreaks happen and the CDC, FDA and State Health Departments try to keep public information from the public, I am reminded of one of the most unforgettable scenes in a movie:

As of July 29, 2013, CDC has been notified of 372 cases of Cyclospora infection from the following 16 health departments: Iowa, Texas, Nebraska, Florida, Wisconsin, Illinois, New York City, Georgia, Missouri, Arkansas, Connecticut, Kansas, Minnesota, New Jersey, New York, and Ohio.

Most of the illness onset dates have ranged from mid-June through early July.

At least 21 persons reportedly have been hospitalized in three states.

Nebraska and Iowa have performed investigations within their states and have shared the results of those investigations with CDC. Based on their analysis, Cyclospora infections in their states are linked to a salad mix.

As I said to the Des Moines Register today:

William Marler, a Seattle lawyer who often leads class-action lawsuits on behalf of people who suffered food-poisoning, said that in the age of the Internet, the public eventually will learn who manufactured and sold the tainted salad. “This information is going to come out. It’s just a question of when, not whether,” Marler said. He said consumers have a right to judge for themselves whether to continue shopping at a grocery store or eating at a restaurant that sold tainted produce, especially if the businesses have a history of problems. When public-health officials try to withhold such information, he said, “it makes it look like they care more about the industry than they do about the consumers, and that’s exactly the wrong message to be sending people.”

And, the Omaha World Herald:

Bill Marler, a Seattle attorney who specializes in food safety cases, said the names of the farm where the tainted vegetables originated and the grocery stores and restaurants that sold the salad mix eventually will come out.

Public health officials, he said, “do this so often where they hide the ball, they don’t tell the public, they’re not transparent, even after they know for sure what restaurant it was and who the manufacturer was. It really undercuts public confidence in our public health system.”

The public, he said, has the right to know who produced, distributed and sold the product.

Once again, as Dr. Doug Powell would say, the leafy green cone of silence descends.

As best as I can tell, here are public health’s arguments for disclosure and non-disclosure and my thoughts in italics:

A.  Although there is no written policy, it is the way we have done things for years.

Why do I hear my mom saying, “just because so and so does that does not mean you should too.” Like all government policies – change is good.

B.  Since the outbreak has concluded, there is not an immediate public health threat.

Frankly, that is true in most foodborne illness outbreaks.  In nearly every single outbreak investigated by the CDC the outbreak is figured out far after the peak of the illnesses happened.  However, disclosure gives the public information on which companies have a strong or weak food safety record.

C.  Disclosing the name of the company jeopardizes cooperation from the company in this and future outbreaks; and

If a company will only cooperate if they are placed in a witness protection program and with promises of non-disclosure, it does not say much for our government’s and the company’s commitment to safe food.

D.  Bad publicity may cause economic hardship on the restaurant.

True, but not poisoning your customers is a better business practice.

I would also add a couple more reasons that I have received via email (mostly anonymously):

1.  The source was an unknown supplier, so naming the restaurant might place unfair blame on the restaurant.

This one does make some sense.  However, is this the unnamed restaurants first problem with a faulty supplier, or is this a pattern?  And, even if it is the first time, perhaps some of the unnamed product is still in the market?

2.  Since the outbreak involves a perishable item, by the time the CDC announces the outbreak, the tainted product has long been consumed.

This one I have heard a “bunch” of times – especially in leafy green outbreaks.  However, why should the public be left in the dark about the type of product that sickens as well as the likely grower and shipper so they can make future decision who to buy from?

3.  Going public with the name of the restaurant compromises the epidemiologic investigation by suggesting the source of the outbreak before the investigation is complete.

I completely agree with this one.  This is a tough call, and one that must create the most angst for public health officials – they decide the balance between having enough data to go forward to protect the public health or wait for more data.  The point is do not go forward until the investigation is complete.

4.  Public health is concerned of making an investigation mistake like, it’s the tomatoes, err, I mean peppers.

See my answer to 3 above.  This is why under the law; public health officials are immune for liability for the decisions that they make in good faith to protect the public.

5.  Public health – especially surveillance – is under budgetary pressures and there are simply not the resources to complete investigations.

There is no question that this is true.  I have seen it in dropped investigations over the last few years.  Labs are not doing genetic fingerprinting to help reveal links between ill people.  And, many trace backs are stopped by the lack of people power to do the research necessary to find the “root cause” of an outbreak.

For me it is easy – the public has a right to know and to use the information as it sees fit, and people – especially government employees – have no right to decide what we should and should not know.  CDC, FDA and the state health departments of health should just do their jobs.

After talking to more that a few people who seem to be part of this nationwide and ongoing Cyclospora outbreak, perhaps a common vegetable is not becoming clear – yet, but it is becoming more evident that there is a common restaurant chain that links they vast majority of those sickened.

Question is – will public health announce it?

As I said last night, according to CIDRAP, the Cyclospora illness total has reached 373 as opposed to the 353 reported by the CDC to date.  According to the CDC, as of July 26, 2013, the CDC has been notified of 353 cases of Cyclospora infection from the following 15 health departments: Iowa, Texas, Nebraska, Florida, Wisconsin, Illinois, New York City, Georgia, Missouri, Arkansas, Connecticut, Kansas, Minnesota, New Jersey, and Ohio.

21 patients from three states have been hospitalized, but no deaths have been reported.

CIDRAP reports that Iowa, Nebraska, and Texas have reported more cases since the July 26 announcement.

The Iowa Department of Public Health (IDPH) reported 5 more cases, boosting its total to 145. The Nebraska Department of Health and Human Services (DHHS) announced 6 more cases, raising its total to 77.  Texas Department of State Health Services (TDSHS) said on Jul 26 that a total of 101 Cyclospora infections have been reported in that state so far, 9 more than reflected in the CDC update.

According to CIDRAP, the Cyclospora illness total has reached 373 as opposed to the 353 reported by the CDC to date.  According to the CDC, as of July 26, 2013, the CDC has been notified of 353 cases of Cyclospora infection from the following 15 health departments: Iowa, Texas, Nebraska, Florida, Wisconsin, Illinois, New York City, Georgia, Missouri, Arkansas, Connecticut, Kansas, Minnesota, New Jersey, and Ohio.

21 patients from three states have been hospitalized, but no deaths have been reported.

CIDRAP reports that Iowa, Nebraska, and Texas have reported more cases since the July 26 announcement.

The Iowa Department of Public Health (IDPH) reported 5 more cases, boosting its total to 145. The Nebraska Department of Health and Human Services (DHHS) announced 6 more cases, raising its total to 77.  Texas Department of State Health Services (TDSHS) said on Jul 26 that a total of 101 Cyclospora infections have been reported in that state so far, 9 more than reflected in the CDC update.

CDC reports as of July 26, 2013 (5pm EDT), CDC has been notified of 353 cases of Cyclospora infection from the following 15 health departments: IowaTexasNebraska, Florida, Wisconsin, Illinois, New York City, Georgia, Missouri, Arkansas, Connecticut, Kansas, Minnesota, New Jersey, and Ohio.

Most of the illness onset dates have ranged from mid-June through early July.

At least 21 persons reportedly have been hospitalized in three states.

No food items have been implicated to date, but public health authorities are pursuing all leads. Previous outbreak investigations have implicated various types of fresh produce.

As of July 25, 2013, CDC has been notified of 321 cases of Cyclospora infection in residents of 14 states and one city, including Iowa, Nebraska, Texas, Florida, New York City, Wisconsin, Georgia, Missouri, Arkansas, Connecticut, Minnesota, New Jersey, and Ohio. Illinois and Kansas have also notified CDC of one case each that may have been acquired out of state but in the United States.

Most of the illness onset dates have ranged from mid-June through early July.

At least 18 persons reportedly have been hospitalized in three states.

No food items have been implicated to date, but public health authorities are pursuing all leads. Previous outbreak investigations have implicated various types of fresh produce.  See also, www.outbreakdatabase.com.

My bet is an imported leafy green.

Cyclospora outbreak going on since June 1 and we do not know the source.

Did you hear the joke about the two doctors and a trial lawyer?

I am sure there might be something funny here if it were not that part of the story involves 321 sick with Cyclospora in 15 states and me getting a bit between Dr. Patricia Quinlisk, medical director for the Iowa Department of Public Health and Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, in an recent article by Tony Leys of the Des Moines Register entitled: “Iowa’s Cyclospora response criticized – Expert: Source should have been pinpointed quickly.”

In a nutshell the unfunny joke goes something like:

“If this same number of cases had happened in Minnesota as happened in Iowa, this would have been solved weeks ago.”  Dr. Osterholm

“I guess it’s easy to be critical if you’re not involved in the investigation.”  Dr. Quinlisk

“It seems to me that by now the health departments and the CDC and the FDA should have identified the products.” “[I] don’t know all the details of the investigation, [but I agree] with Osterholm that the Minnesota health department, along with the one in Oregon, often manages to quickly track down the source of tainted food.”  Ambulance Chaser Marler

The reality is that Minnesota’s and Oregon’s foodborne illness surveillance works and works well.  They work in large part because of the people and the commitment to good epidemiology.  The goal for both is to find the source of the outbreak fast so illnesses are stopped as quickly as possible and that the correct food product gets off the shelves.  There is a misconception that you must go slowly to confirm that the right product is implicated.  In 20 years of following foodborne illness outbreaks worldwide, I have not seen Minnesota’s and Oregon’s prompt responses name a wrong product or manufacturer.

Beyond stopping an outbreak is the traceback to the source so lessons can be learned to prevent another outbreak.  Minnesota and Oregon do not wait for the FDA or FSIS to do a product traceback.  Certainly, the Feds play a role, but there have been times in the past where federal traceback was unusually slow and manufacturers, shippers and retailers were left unnamed.

In Minnesota, Team D (D for diarrhea) is a squad of graduate students at the University of Minnesota School of Public Health and epidemiologists at the Minnesota Department of Health (MDH) performing epidemiological interviews in trace back investigations. Armed with a tantalizing knowledge of the gastrointestinal system, telephones, and a lot of gumption, the work of Team D gives Minnesota an unusual prowess in cracking some of the most infamous foodborne illness cases in the U.S.

By Minnesota state law (oddly, only 35 states in the U.S. mandate Cyclospora as reportable), doctors must send stool cultures believed to be from cases of foodborne illness to the MDH laboratory where they are pulsed field gel electrophoresis (PFGE) tested to create DNA finger printing – which tell investigators if different samples likely came from a common host.  Team D gets to work immediately, interviewing the victims, often as they are suffering symptoms, looking for commonalities in what, where, and when they ate. Whereas some states may take weeks to perform the interview portion of an investigation, it is this real-time history gathering that adds an invaluable level of depth to trace back investigations, something it seems that this Cyclospora outbreak desperately needs.

Team D is a model that all states should emulate.

Of course, you cannot do without individual knowledge.  Dr. William Keene, senior epidemiologist is the top foodborne illness investigator at Oregon’s Division of Public Health. Keene has been unraveling the path of pathogens from victims to the source for over 30 years, and has an impressive list of solved cases under his belt.  One of his most valuable contributions to the food safety world is the shotgun questionnaire, which lists hundreds of foods for foodborne illness victims to choose from to help them recall what they recently ate.

But, do not take it just from me.

In 2011, the Center for Science in the Public Interest released a nationwide report card grading the 50 states and the District of Columbia on how well they detect, investigate, and report outbreaks of foodborne illness (See Report). The report shows that there is a need for improvement. CSPI assigned a letter grade and created an outbreak profile for each state.

A’s: Oregon, Minnesota, Florida, Hawaii, Maryland, Washington, and Wyoming.

B’s: Colorado, Illinois, Kansas, Maine, Michigan, Ohio, and Vermont.

C’s: Alabama, Alaska, California, Connecticut, Iowa, New Hampshire, North Dakota, and Wisconsin.

D’s: Delaware, the District of Columbia, Georgia, Idaho, Massachusetts, Montana, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, South Dakota, Tennessee, Utah and Virginia.

F’s: Arizona, Arkansas, Indiana, Kentucky, Louisiana, Mississippi, Missouri, Nebraska, Nevada, New Mexico, Oklahoma, South Carolina, Texas, and West Virginia.

In addition to states being committed quickly and accurately seeking the source of a foodborne illness outbreak, perhaps too the answer to the low grades and the lack of a source in this Cyclospora outbreak may lie in overlooked Sec. 205 of the Food Safety Modernization Act.  The Section should:

– Coordinate Federal, State and local systems, including complaint systems and networks of public health, food regulatory agencies and labs;

– Facilitate sharing of findings between FDA, USDA, State and local agencies, and the public;

– Develop improved epidemiological tools;

– Improve systems that attribute an outbreak to a specific food;

– Expand fingerprinting and other detection strategies for food-borne agents;

– Allow public access to aggregated, de-identified surveillance data;

– Publish findings at least yearly;

– Rapidly initiate scientific research by academic institutions;

– Integrate surveillance systems and data with other bio surveillance and public health entities.

Also, is the creation of “PARTNERSHIPS,” which appears to actually be a “working group of experts and stakeholders from Federal, State and local food safety and health agencies, the food industry, consumer organizations and academia.”  In addition, Sec. 205 (c) adds “strengthen[ing] the capacity of State and local agencies to carry out inspections and enforce safety standards” and, “the Secretary to (within a year) complete a review of State and local capacities, including staffing levels, laboratory capacity, outbreak response, inspection and enforcement functions.”

Stopping outbreaks sooner, means less ill people.  Honestly, that is not good for my business.  Tracing it to the source gives everyone a better understanding of how the outbreak happened and what can be done to prevent the next one.  Hmm, that does not help my bottom line as well.

So, if the states and the federal government did a better job of figuring out foodborne illness outbreaks there would be less ill people and fewer outbreaks?

Wait, I just figured out, this joke could well be on me!

The Iowa Department of Public Health reported that it has received 26 reports of illness linked to a relatively uncommon strain of the Salmonella bacteria. The department said Salmonella cases had been confirmed in Allamakee, Black Hawk, Buena Vista, Cerro Gordo, Des Moines, Humboldt, Jasper, Kossuth, Madison, Mahaska, Marshall, Muscatine, Polk, Scott, Sioux, Story, Union, Webster and Woodbury counties.

Iowa already is investigating an outbreak of food poisoning caused by a rare parasite, Cyclospora, which has sickened at least 138 Iowans in recent weeks.

Also today, the department notified health officials statewide to be on the lookout for Cryptosporidium, a microscopic parasite that also can cause diarrhea. The department said it has recently been notified of 76 confirmed cases of Cryptosporidium infections. The parasite can be spread from person to person, through contaminated food or through recreational water, such as swimming pools.

The CDC reports as of July 25, 2013 (5pm EDT), CDC has been notified of 321 cases of Cyclospora infection in residents of multiple states and one city, including Iowa, Nebraska, Texas, Florida, New York City, Wisconsin, Georgia, Missouri, Arkansas, Connecticut, Minnesota, New Jersey, and Ohio. Illinois and Kansas have also notified CDC of one case each that may have been acquired out of state but in the United States.

Most of the illness onset dates have ranged from mid-June through early July.

  • At least 18 persons reportedly have been hospitalized in three states.
  • No food items have been implicated to date, but public health authorities are pursuing all leads. Previous outbreak investigations have implicated various types of fresh produce.
  • It is not yet clear whether the cases from all of the states are part of the same outbreak.
  • No common events (e.g., social gatherings) have been identified among the case patients.
  • Additional cases are currently under investigation and will be included on this page as states confirm them. Cases in this outbreak are defined as laboratory-confirmed Cyclospora infection in a person who became ill in June or July, 2013, and had no history of travel outside of the United States or Canada during the 14 days prior to onset of illness.