August 2013

Not to be confused with the Spice Girls.

New York Times writer Gardiner Harris wrote last week about the risks of Salmonella in imported spices.  According to Gardiner:

The United States Food and Drug Administration will soon release a comprehensive analysis that pinpoints imported spices, found in just about every kitchen in the Western world, as a surprisingly potent source of Salmonella poisoning.

In a study of more than 20,000 food shipments, the food agency found that nearly 7 percent of spice lots were contaminated with Salmonella, twice the average of all other imported foods. Some 15 percent of coriander and 12 percent of oregano and basil shipments were contaminated, with high contamination levels also found in sesame seeds, curry powder and cumin. Four percent of black pepper shipments were contaminated.

Mexico and India had the highest share of contaminated spices. About 14 percent of the samples from Mexico contained salmonella, the study found, a result Mexican officials disputed.

India’s exports were the second-most contaminated, at approximately 9 percent, but India ships nearly four times the amount of spices to the United States that Mexico does, so its contamination problems are particularly worrisome, officials said. Nearly one-quarter of the spices, oils and food colorings used in the United States comes from India.

The findings, the result of a three-year study that F.D.A. officials have on occasion discussed publicly and recently published in the journal Food Microbiology, form an important part of the spice analysis that will be made public “soon,” agency officials said.

“Salmonella is a widespread problem with respect to imported spices,” Michael Taylor, deputy F.D.A. commissioner for food, said in an interview. “We have decided that spices are one of the significant issues we need to be addressing right now.”

It should have happened earlier.

In early 2009, health departments in several states documents PFGE-matched cases of the rare strain of Salmonella Rissen. As investigations into the apparent outbreak got fully underway, Salmonella Rissen matching the outbreak-strain—that is, the strain isolated from the individuals infected—was isolated from ground white pepper found in three different restaurants in three of the affected states. In each instance, the ground white pepper bore a U.F. Union brand name. This discovery prompted an inspection of the U.F. Union facility in Union City, California. The inspection occurred on March 27, 2009, in accordance with the Domestic Food Safety Inspection Program. At that point, there were 42 confirmed Salmonella infections that had been linked to consumption of U.F. Union’s contaminated white pepper.

My client, Donna Pierce, was born on April 16, 1939 in Antigo, Wisconsin. She died April 9, 2009 of a Salmonella Rissen infection after spending the last month of her life hospitalized. As a family member said:

Shortly after I left the hospital to get something to eat, Donna died. My heart was broken. I could not believe that she was finally gone. She and I were lifelong friends. Especially these past couple of years, we spent all of our time together. We would play board games, talk, eat, shop, and visit family. Not a day goes by that I do not miss her company.

I will always remember Donna for her great sense of humor. She loved to laugh. She believed that laughter would add years to her life. I guess it did not turn out that way for Donna.

I guess not.  Read a bit about the inspection report:

The inspection conducted at U.F. Union included an examination of the facility’s pepper-handling procedures and good manufacturing practices. The inspection turned up a litany of disturbing findings. For example, according to the final FDA 483 report, the owner was cited for six inspection observations:

1. Failure to manufacture, package, and store foods under conditions and controls necessary to minimize the potential growth of microorganisms and contamination.

a. Private laboratory analysis results provided by the hired consultant revealed environmental samples collected from inside the facility were found positive for Salmonella.

b. Ground white pepper was stored in open barrels beneath an unscreened roof vent.

2. Failure to maintain white pepper grinding equipment in an acceptable condition through appropriate cleaning and sanitizing (an accumulation of dust was observed on multiple food contact surfaces).

3. The funnels and unlined barrels were not made of materials that allowed for proper cleaning and maintenance.

4. Failure to clean and sanitize scoops used for repackaging spices in a manner that protected against contamination of food (food residues and a thin film of dust were observed on the scoops).

5. Failure to clean non-food contact surfaces in the white pepper grinding room and the adjacent hallway as frequently as necessary to protect against contamination (accumulations of white pepper dust and brown stains were observed on multiple surfaces in the immediate vicinity of food contact surfaces).

6. Failure to maintain pipes used to convey oil (food product) in a manner that protected against contamination (oil was observed collected in pans below pipes and in a plastic bag tied around a pipe in the sauce and oil bottling room).

Additionally, of 116 environmental-swab samples collected, 46 tested positive for Salmonella (40%), while 14 of 18 in-process white pepper samples (78%), and 2 finished-product composite samples (100%) tested positive. By June 4, 2009, the U.F. Union Salmonella outbreak encompassed a total of 87 PFGE-matched cases of Salmonella Rissen in California, Nevada, Oregon, Washington, and Idaho.

Also as part of the outbreak investigation, samples of whole white pepper were collected at U.F. Union’s facility from sealed, intact bags purchased from Harris Freeman. A sample collected from one of the Harris Freeman bags, on April 7, 2009, was positive for Salmonella Rissen, and was a genetic match to the unique outbreak strain.

FDA, better late than never.

Last Report was 90 – Several earlier reports show risky practices.

14-Feb-2013       Inspection Type: Routine           Score: 90
Violation Type Risk Category
Other low risk violation Low Risk
Unclean unmaintained or improperly constructed toilet facilities Low Risk
Wiping cloths not clean or properly stored or inadequate sanitizer Low Risk
Inadequately cleaned or sanitized food contact surfaces Moderate Risk

Latest Official Data

See Inspection Reports back to 2005

Joe Vazquez, @joenewsman, San Francisco Journalist at CBS5 TV, tweeted that 1 of 14 developed hemolytic uremic syndrome.

The San Francisco Chronicle reports that the San Francisco’s Department of Public Health is investigating an E. coli outbreak that infected 14 people earlier this month, many after they dined at the Burma Superstar restaurant on Clement Street.

Investigators said in a statement Friday that they believe nine of the 14 infected people were exposed to the bacteria when they visited the restaurant in the Inner Richmond neighborhood on Aug. 16 or 17. There have been no fatalities.

The origin of the outbreak is still unknown. Investigators said there have been no new cases since mid-August and they do not think there is an ongoing public health risk.

Burma Superstar, located on Clement Street near Fourth Avenue, will remain open during the investigation, but owner Desmond Tan said he will close it voluntarily for the weekend voluntarily and reopen Monday.

The Division of Public Health Services (DPHS) is investigating a second case of hepatitis A in a food service worker. This individual also worked at the Covered Bridge Restaurant in Contoocook, NH. DPHS’ estimates between 100 and 200 people might have been exposed to the illness.

The infected food service worker, worked at the Covered Bridge Restaurant on August 13th and 20th. If you were at the Covered Bridge Restaurant on August 13th, it is too late for you to receive prophylaxis but you should be alert to potential symptoms of hepatitis A. If you were at the Covered Bridge Restaurant on August 20th DPHS is recommending you receive either the vaccine or immune globulin at this time. If you have previously been vaccinated or if you have had hepatitis A infection you do not need any further vaccine for this situation.

Although there is no cure for hepatitis A, there is a vaccine and immune globulin can help prevent someone who has been exposed from getting sick. Anyone from 12 months of age to age 40 can receive the vaccine. People over 40 and under 12 months it is recommended to receive immune globulin (an antibody preparation).

DPHS is working with the Capital Area Public Health Network to conduct vaccination clinics for anyone who may have been exposed to the virus. Clinics are being held Friday, August 30th from 5PM – 8 PM and Saturday, August 31st from 9AM – 12 PM. Clinics will be held at Bow High School, 32 White Rock Hill Rd, Bow, NH.

Nearly 7,000 exposed.

The Suffolk County Department of Health Services is investigating a case of Hepatitis A virus in an individual who worked at the Driver’s Seat Restaurant, in, Southampton, New York.

Patrons who consumed food or beverage at this establishment between August 6th and August 20th may have been exposed to Hepatitis A. Preventive treatment for Hepatitis A virus can help to prevent or lessen the severity of illness when given within two weeks of exposure.

SCDHS will offer free Hepatitis A vaccine or immune globulin (IG) to individuals who dined at this establishment between August 16th and August 20th . Treatment is offered at the 3rd Floor Teaching Center, Southampton Hospital, 240 Meeting House Lane, Southampton, at the following times:

Friday, August 30 3:00 p.m. – 6:00 p.m.

Saturday, August 31 10:00 a.m. – 1:00 p.m.

Monday, September 2 10:00 a.m. – 1:00 p.m.

Tuesday, September 3 3:00 p.m. – 6:00 p.m.

Treatment will also be offered at SCDHS offices, 3500 Sunrise Hwy, Suite 124, Great River on:

Friday, August 30 9:00 a.m. – 4:00 p.m.

Tuesday, September 3 9:00 a.m. – 4:00 p.m.

Potentially exposed individuals may also receive preventive treatment from their health care provider. Preventive treatment is not recommended for individuals potentially exposed before August 16, 2013. Those individuals should be aware of the signs and symptoms of Hepatitis A and contact their health care provider if they become ill.

Hepatitis A is an inflammation of the liver caused by the Hepatitis A virus. The virus may be spread by consuming food or drink that has been handled by an infected person. It may also be spread from person to person by putting in the mouth something that has been contaminated with fecal material of a person with hepatitis A. Casual contact, as in an office or school setting, does not spread the virus.

The symptoms of Hepatitis A range from mild to severe and include fever, fatigue, poor appetite, nausea, stomach pain, dark-colored urine and jaundice (a yellowing of the skin and whites of the eyes). Most people recover in a few weeks without any complications. The symptoms commonly appear within 28 days of exposure, with a range of 15-50 days. There is no specific treatment for Hepatitis A. Treatment is supportive care. Thorough hand washing after bathroom use and before, during and after food preparation can help to prevent the spread of this and other intestinal illnesses.

The CDC reported today a total of 616 cases of Cyclospora infection have been reported from 22 states and New York City. The number of cases identified in each area is as follows: Texas (263), Iowa (156), Nebraska (86), Florida (32), Wisconsin (16), Illinois (11), Arkansas (10), Georgia (5), Missouri (5), New York City (5), Kansas (4), New Jersey (4), Louisiana (3), Virginia (3), Connecticut (2), Minnesota (2), New York (2), Ohio (2), California (1), New Hampshire (1), South Dakota (1), Tennessee (1), and Wyoming (1).

However, Texas has now reported a total of 302 cases of Cyclospora infection in Texas in 2013 with the vast majority having onsets in June and July. Most Texas cases are reported from the Dallas/Fort Worth area.

That raises the total to 655.

I was struck in reading (at 3:25 AM) the FDA’s update of the Cyclospora outbreak that has sickened nearly 650 in 22 states this summer, that we still do not know exactly how the outbreak happened and the source of all, or most of the illnesses.  Although “[e]pidemiologic and traceback investigations by the states of Iowa and Nebraska, the CDC and the FDA had linked salad mix supplied by [Taylor Farms de Mexico, S. de R.L. de C.V.,] to Olive Garden and Red Lobster restaurants, which are owned by Darden Restaurants,” those account for only 242 of the illnesses.  Texas, which has nearly 300 of the illnesses, has not linked those illnesses to the same source – neither have the other 19 states.  As the CDC said, “[t]he preliminary analysis of results from an investigation into a cluster of cases that ate at a Texas restaurant does not show a connection to Taylor Farms de Mexico. This investigation is ongoing.”

It does beg the question (well, actually several), if Taylor Farms de Mexico, S. de R.L. de C.V., is not the source of nearly 400 of the illnesses, what is?  Assuming that health officials in Iowa and Nebraska and at the CDC and FDA are correct on the source of the illnesses in those states, what accounts for illnesses that run from at least June 1 to August 6 in all the other states?  It is hard to imagine salad mix lasting that long – because it would not.  Is there some component of the salad mix with a longer shelf life that is the common denominator?  Or, given the long Epi Curve, is there an environmental part of this outbreak that has sustained the illnesses in other products grown in the same region of Mexico?

The FDA update raises other questions as well.  Over a month and a half after the first reported illness, “[f]rom August 11-19, 2013, the FDA with the cooperation of Mexican government authorities and Taylor Farms de Mexico, S. de R.L. de C.V., conducted a thorough environmental assessment at Taylor Farms de Mexico’s processing facility and five farms identified through the Cyclospora outbreak’s traceback investigation.”  Not surprisingly, “[t]he team found that conditions and practices observed at these facilities at the time of the assessment were in accordance with known food safety protocols.”  As the FDA pointed out, the likely reason that things looked good at Taylor Farms was because “[t]he last date that someone who had eaten in one of these restaurants in those states reportedly became ill with cycloporiasis was on July 2, more than five weeks prior to start of the Environmental Assessment.”

Based upon the FDA’s review, “Taylor Farms de Mexico, S. de R.L. de C.V., resumed production and shipment of salad mix, leafy greens, and salad mix components from its operations in Mexico to the United States.”  It appears that the FDA’s decision was based in part on “the recent environmental assessment [AND] FDA’s thorough review of a product sampling plan for Cyclospora put in place by Taylor Farms de Mexico, S. de R.L. de C.V.”

It does beg the question, what if any Cyclospora sampling plan did Taylor Farms have before the FDA arrived and before the outbreak that they have in part been linked to?

Clearly, more questions than answers, and, although I have been retained by dozens of ill, it is why I have held off in the lawsuit filling frenzy that we have seen.  It is more important to get it right than be first.  That is as true in lawsuits as it is in Epi surveillance.

I’ll go back to bed and sleep on it.

A total of 125 persons infected with the outbreak strains of Salmonella Infantis, Salmonella Lille, Salmonella Newport, or Salmonella Mbandaka have been reported from 26 states.

The number of ill persons identified in each state is as follows: Alabama (3), Arizona (3), California (1), Colorado (2), Connecticut (3), Delaware (1), Georgia (1), Illinois (4), Indiana (1), Kentucky (4), Maine (1), Maryland (1), Massachusetts (7), Minnesota (3), Mississippi (2), Nebraska (1), New Jersey (2), New York (10), North Carolina (10), Ohio (19), Pennsylvania (8), Tennessee (12), Vermont (2), Virginia (3), West Virginia (15), and Wisconsin (6).

29% of ill persons have been hospitalized, and no deaths have been reported.

41% of ill persons are children 10 years of age or younger.

Epidemiologic, laboratory, and traceback findings have linked this outbreak of human Salmonella Infantis, Salmonella Lille, Salmonella Newport, and Salmonella Mbandaka infections to contact with chicks, ducklings, and other live baby poultry from Mt. Healthy Hatchery in Ohio.

Toronto’s public health department says a food poisoning outbreak at the Canadian National Exhibition was caused by a contaminated topping put on cronut burgers.

An investigation into the outbreak that sickened more than 220 people last week found samples of the cronut burger — a cheeseburger with a hybrid croissant-donut bun — were contaminated by a bacterium.

Officials say lab results show the staphylococcus aureus toxin — a recognized cause of food-borne illness — was found in the maple bacon jam put on top of the burgers.

The public health investigation is focusing on Le Dolci, the supplier of the bacon jam, to determine how the contamination occurred.

Public health officials say Le Dolci has stopped production of the product voluntarily and its food products will not be distributed until further investigation.

Last week it was Guinea Pigs causing Salmonella in Minneapolis and this week Russian Health officials fear an outbreak of bubonic plague in central Asia after a teenage boy died from the disease and three more were admitted to hospital in Kyrgyzstan.

Temirbek Isakunov, a 15-year-old from a mountain village near the border with Kazakhstan, reportedly died from the disease last week after eating an infected barbecued marmot. Kyrgyzstan’s emergency ministry said a young woman and two children from a different village who came into contact with Isakunov were hospitalized on Tuesday with the high fever and swelling around the neck and armpits characteristic of bubonic plague, local news outlets reported.

A total of 131 people, including 33 medical personnel, have been quarantined, although none of them have yet exhibited symptoms of the disease, the newspaper Komsomolskaya Pravda in Kyrgyzstan reported. The health ministry continues to find and quarantine people who came into contact with the teenager, according to its director.

The bacteria that cause bubonic plague are typically transmitted from rodents to humans via flea bites but can also be contracted through direct contact with infected tissue.