December 2016

20150506_0831331Food Safety News reports that a Missouri dairy owner is on notice from the FDA for selling unpasteurized, raw camel milk in interstate commerce, with the agency discounting the dairyman’s contention that camel milk is not covered by federal law.

The Food and Drug Administration’s Kansas City district office sent a warning letter to Samuel P. Hostetler, owner of Hump-Back Dairys in Miller, MO, on Dec. 19 related to an inspection at his farm from July 27-29. The federal inspectors found records showing the dairy had distributed unpasteurized, raw camel milk and raw camel milk products across state lines, which is a violation of federal law.

“Such distribution is a violation of  the Public Health Service Act,” according to the warning letter. “…We have reviewed the correspondence letter dated Sept. 19, 2016, from Farm-to-Consumer Legal Defense Fund. The letter, which states that it is written on your behalf, raises questions about whether the regulation in 21 CFR 1240.61(a) applies to products such as yours that are made from the lacteal secretions of camels.

“Under 21 CFR 1240.3(j), the term ‘milk product’ is defined as ‘food products made exclusively or principally from the lacteal secretion obtained from one or more healthy milk-producing animals, e.g., cows, goats, sheep, and water buffalo.’ … Although the definition refers to the examples of cows, goats, sheep, and water buffalo, that list is not exhaustive. The definition thus includes the commercial lacteal secretions from other animals as well, including camels.”

Hostetler is knowingly selling the raw milk in violation of federal law, according to the warning letter, which quoted from labels on the unpasteurized raw milk from the Miller, MO, dairy — “Ingredients: Whole Raw Camel Milk” and “Ingredients: Cultured Whole Raw Camel Milk.”

“You affirmed that products labeled or identified as raw camel milk in your records are not heat treated or pasteurized. Further, the products that you shipped were in final package form and were for direct human consumption,” according to the warning letter.

The FDA letter gave Hostetler the standard 15 days to respond to the agency.

4860A total of 14 patients in eight states were identified, with illness onsets occurring during March 21–April 9, 2016.  Three patients were hospitalized; no deaths were reported.

Epidemiologic evidence indicates Persian cucumbers as the source of Salmonella Oslo infections in this outbreak sold at an unnamed grocery chain. This is the fourth Salmonella outbreak since 2013 associated with cucumbers, with over 1,200 illnesses and 260 hospitalizations included in the previous three outbreaks. Two of these outbreaks were caused by cucumbers sourced from Mexico, whereas the other outbreak identified cucumbers sourced from Maryland as a major cause of illnesses.

State and local public health officials in Minnesota and Michigan initiated an investigation when four persons with Salmonella Oslo infections were identified. A case was defined as infection with Salmonella Oslo with PFGE pattern OSLX01.0090 (the outbreak strain) in a person with illness onset occurring during March 21–April 9, 2016.

FDA, the Canadian Food Inspection Agency, and officials in Minnesota, Massachusetts, and Michigan collaborated to conduct an informational traceback investigation from retail establishments in these states to identify the source of the cucumbers. The investigation identified two Canadian Persian cucumber suppliers during the timeframe of interest, but a single grower was not identified. Growers who could have supplied these cucumbers were located in Canada, Mexico, and the Dominican Republic.

26704718952_9f9580e07e_oIf you are among the Wisconsin residents who consider raw ground beef sandwiches (known as “Cannibal” or “Tiger Meat” sandwiches) a holiday tradition, the Department of Health Services (DHS) wants to remind you that consuming raw or undercooked meat can be dangerous to your health.

Cannibal or Tiger Meat Sandwiches typically consist of raw ground beef topped with salt, pepper and onions, served on rye bread or crackers. Historically in Wisconsin, consumption of these sandwiches has led to outbreaks of E. coli O157:H7 and Salmonella infections, including an outbreak that involved 150 people in 1994. Outbreaks have also been reported in 1986, 1988, 1989, 1990, 1994, 2012 and 2013. Raw beef can also contain other bacteria, including Campylobacter and Listeria. Regardless of where your beef is purchased, eating it raw is always risky.

“We strongly discourage state residents from eating raw or undercooked ground beef. Older adults, pregnant women, children, and people with weakened immune systems are at even greater risk of illness from germs found in raw or undercooked meat”, said State Health Officer Karen McKeown. DHS urges those who are cooking any meat to use a meat thermometer. Color is not a reliable indicator that meat is properly cooked.

Follow these guidelines to avoid illness from the meat you prepare and serve:

  • Wash hands thoroughly with warm water and soap before and after handling raw meat.
  • Cook all meat, poultry and wild game to the proper internal temperature (link is external)
    and use a meat thermometer. Don’t use color as an indicator that meat has reached a safe temperature.

    • Cook ground meat and meat mixtures (e.g., ground beef, pork, veal, lamb) to 160°F.
    • Cook all whole cuts of beef, pork, veal, and lamb to 145°F plus a 3 minute rest.
    • Cook all poultry (e.g., chicken, turkey, duck) and wild game meat to 165°F.
  • Frozen meat should be cooked one and a half times longer than it takes to prepare thawed food. Whole turkey is an exception, as it must be completely thawed before cooking.
  • Eating raw or undercooked wild game meat can also result in illness, including SalmonellaTrichinella, and E. coli infections.
  • Keep raw meat away from other foods that will not be cooked.
  • Wash all work surfaces, cutting boards, and utensils with hot soapy water.
  • Divide leftovers into small portions so they will cool more quickly and put them in the refrigerator as soon as possible. Don’t cool leftovers on the kitchen counter.
  • Cover leftovers to reheat. This helps maintain moisture and ensures the meat is heated all the way through.

Symptoms of foodborne illness can include nausea, vomiting, diarrhea, abdominal cramps, and fever. Contact your healthcare provider if you become ill, especially if you experience diarrhea that lasts more than a few days or is bloody, or if you develop a high fever.

UnknownnmAndrew Oxford of the Santa Fe New Mexican reports that Epidemiologists at the state Department of Health are investigating their agency’s own annual holiday luncheon after dozens of employees reported falling ill after the party last week.

About 70 staff members claim to have experienced gastrointestinal issues following the catered event at the Harold Runnels Building attended by more than 200 employees, according to a spokesman.

Health Secretary Lynn Gallagher wrote in an email to staff Monday that investigators have not identified a specific food from the party that may have caused the outbreak.

A team from the department’s Epidemiology and Response Division “believes that there may have been cross-contamination of menu items served during the luncheon,” she wrote.

Epidemiologists were still waiting for laboratory test results as of Monday, but Gallagher told staff the outbreak appears to have been caused by bacillus cereus or clostridium perfringens, toxins that can cause food-borne illness.

Clostridium perfringens is one of the most common causes of food poisoning in the country, according to the U.S. Department of Health and Human Services. Because cooking kills the bacteria, outbreaks usually occur after foods are prepared in large quantities and kept warm for a long period of time before serving.

Bacillus cereus can be found in foods that have been left to sit at room temperature for too long, according to the U.S. Department of Health and Human Services.

The department cautions that if food is to be stored for longer than two hours, hot foods should be kept hot at over 140 degrees and cold foods kept cold, at least 40 degrees or under.

Cilantro Likely Cause of Outbreak – Sixty-nine confirmed and 37 probable cases

Screen Shot 2016-12-20 at 3.34.40 PMIntroduction. On June 28, 2016, the Chicago Department of Public Health (CDPH) received five reports of Shiga Toxin-producing Escherichia Coli (STEC)1 through routine surveillance. By June 29, routine interviews conducted by the CDPH Communicable Disease (CD) Program revealed that three of the five cases reported consuming food items from Carbon (Restaurant A) within 2-3 days before illness onset. That evening, three separate hospitals reported an increase in the number of patients that presented to the ED with complaints of diarrhea and had preliminary positive STEC diagnostic laboratory tests. By July 1, seven cases reported eating at Restaurant A prior to their illness onset. Carbon Final Outbreak Summary – City of Chicago Dept. of Public Health

Restaurant. Restaurant A has two Chicago locations, one on the south side and another on the west side of the city. The restaurant is open 7 days a week and serves Mexican-style foods. Both locations serve the same menu and use the same food suppliers. The majority of food preparation is performed out of the south side location; most food for the west side location is transported after preparation at the south side kitchen. Catering is also available. Overall, approximately 40% of food orders are placed by phone or through online ordering websites (i.e. GrubHub, Eat24, etc.) for delivery or pickup. Catering and other delivery orders are prepared in the same kitchen and by the same staff as dine-in orders at both locations. Staff members at each location reported regularly consuming restaurant food.

Epidemiological investigation. Case finding was conducted through public messaging and disease surveillance. On June 30, 2016, CDPH issued a health alert to all Chicago hospitals to notify them of the outbreak, to request prompt reporting of STEC cases, and to discourage use of antibiotics and encourage aggressive hydration if suspecting a diagnosis of STEC. Concurrently, the Illinois Department of Public Health (IDPH) issued an alert via the Food borne Outbreak Network to state health departments to notify them of any STEC cases with travel to Chicago and mention of Restaurant A.

A standard questionnaire was created to collect information about signs and symptoms of illness, food consumption and other potential exposures occurring in the seven days prior to the case’s onset of illness, and meal companions. A case-control study was conducted to determine risk factors for infection with STEC. Case definitions were in accordance with the Centers for Disease Control and Prevention (CDC) and Council of State and Territorial Epidemiologists standards2. A confirmed case was defined as isolation of E. coli O157:H7 (STEC) from a clinical specimen in a person with illness onset between June 3-July 23, 2016, with either reported exposure to Restaurant A or a pulsed-field gel electrophoresis (PFGE) pattern indistinguishable from one of 14 patterns associated with the outbreak. Confirmed cases with reported Restaurant A exposure and onset dates that preceded others within their household were considered confirmed primary cases. A probable case was defined as a person with clinically compatible illness (bloody diarrhea or ~3 days of diarrhea with ~3 stools in a 24-hour period) in the absence of laboratory confirmation, and exposure to Restaurant A or shared household with a primary case. Secondary cases were defined as household contacts of primary confirmed or probable cases, with onset of diarrhea one to eight days after the primary case’s symptom onset date. Case-control analysis was limited to primary confirmed cases and well controls. To identify controls, CD Program staff asked confirmed cases about their meal companions and obtained a list of individuals who placed orders through the online delivery service GrubHub. Controls were frequency matched 4:1 to cases by meal date (June 17th-June 30th) and restaurant location.

Contingency tables were arranged to evaluate the bivariate relationships between case status and individual food items, and odds ratios (OR) with 95% confidence intervals {95% Cl) were estimated for each. Chi-Square tests were performed to identify statistically significant associations, except when expected cell counts were less than or equal to 5, in which case Fisher’s Exact test was used. P-values <0.05 were considered statistically significant. The independent effects of variables found to be significantly associated with disease in the bivariate analyses were further evaluated using multivariable logistic regression, adjusted for age and gender. All statistical analyses were carried out with SAS version 9.3 (SAS Institute, Cary, NC).

Environmental investigation. On July 1, 2016, the Food Protection Division (FPD) conducted an environmental inspection of Restaurant A and collected the following: food samples, initial information about restaurant employees and food preparation, and copies of invoices for food items. Food items collected included steak, chicken, cilantro, elote (corn), elote mix, cheese, sour cream, grilled corn & pineapple salsa, salsa fresca, tequila lime sauce, red and green salsas. CD Program staff performed in depth interviews of the owners of the restaurant and employees. Because employees at both locations often functioned in multiple roles, all on-site restaurant employees were considered food handlers for the purposes of this outbreak investigation. Food handlers were asked to submit stool specimens to screen for STEC.

Laboratory investigation. Clinical culture or polymerase chain reaction tests were performed by hospital and commercial laboratories and results were reported to the CD program. Specimens from cases, food handlers, and food were sent to the Illinois Department of Public Health Division of Laboratories for culture, and for serotyping and PFGE analysis of STEC isolates. PFGE patterns were uploaded to the national Pulse Net database and compared by the Centers of Disease Control (CDC). Sixteen isolates selected to represent all outbreak-associated PFGE patterns and a variety of source patients (primary and secondary cases as well as food handlers), restaurant locations, and meal dates were sent to CDC for characterization by multiple locus variable number of tandem repeats analysis (MLVA).

Epidemiologic findings. Sixty-nine confirmed and 37 probable cases were identified as part of this outbreak. Among the confirmed, 55 met the primary case definition, four were secondary cases, and ten of the confirmed cases matched the outbreak PFGE pattern but their association with the restaurant was not identified (five denied eating at the restaurant and five were unable to locate). One additional case, identified after the restaurant closure and reopening, was unable to be classified due to multiple

Restaurant A meal dates and a PFGE pattern that was similar but not identical to other outbreak patterns. Illness onset dates of the 55 confirmed primary cases ranged from June 19-July 3.

Median age was 29 years (range, 3 to 69 years); 29 (53%) of the cases were female. Median incubation period was 3 days (range 12 hours-5 days). Twenty-one primary and one secondary case were hospitalized. No cases developed hemolytic uremic syndrome, and none died. Among the 55 confirmed primary cases, 50 (91%) ate at the south side location (meal date range 6/17 to 6/30) and 5 (9%) ate at the west side location (meal date range 6/19 to 6/26).

Multiple food items were associated with illness on bivariate analysis (Table 1) including consumption of cilantro (odds ratio [OR] 3.5, 95% Cl: 1.5-8.1), salsa fresca (OR 3.1, 95% Cl: 1.6-6.1), chicken taco (OR 3.1, 95% Cl: 1.6-6.0), and lettuce (OR 2.01, 95% Cl: 1.1-3.8). Multivariable analysis using logistic regression (Table 2) revealed that consumption of cilantro (adjusted OR [aOR] 4.64, 95% Cl: 1.87-12.011.6), salsa fresca (aOR 2.85, 95% Cl: 1.31-6.05.4), and lettuce (aOR 2.57, 95% Cl: 1.23-5.26) remained independently associated with illness after adjusting for age and gender. The observed epidemiologic association with chicken tacos may reflect collinearity between chicken tacos and cilantro, meaning that an association was identified because the chicken tacos are prepared and served with raw cilantro. All cases who reported eating a chicken taco also reported eating cilantro. Other chicken-containing items (e.g., chicken burritos, chicken salad bowls) were not associated with illness. Because salsa fresca was known to contain raw cilantro, an additional multivariable logistic regression analysis was performed including a combined variable indicating consumption of either cilantro or salsa fresca. In this model, consumption of cilantro or salsa fresca was associated with an adjusted odds ratio of 6.9 [Cl: 2.0-24.0]

Lettuce was associated with illness in both multivariable models but was consumed by only 44% of cases. In comparison, cilantro was consumed by 87% of cases, and either cilantro or salsa fresca were consumed by 95% of cases.

Environmental findings and food handler interviews. Meats, salsas, and marinades were fully or partially prepared at the south side location and transported daily to the west side location. Most fresh produce items, including cilantro and lettuce, were received by each location in separate deliveries and chopped and prepared on-site. Several critical violations were identified during the sanitarians’ inspection of Restaurant A on July 1, including improper temperatures for several food items (i.e. red & green salsas, tequila lime sauce, raw fish, guacamole, and cheese), and improper hand hygiene practices among food handlers. Because of concern for a potential ongoing public health threat associated with food served by Restaurant A, CDPH recommended that the restaurant voluntarily cease operations and withdraw from a large outdoor food festival until more information about the source of the contamination was known. The owner agreed, and Restaurant A voluntarily closed both locations. CD staff subsequently interviewed and tested forty food handlers from both locations. According to the restaurant owner, there was no cross-over of food handlers at the two locations. Among the forty food handlers interviewed none reported any history of gastrointestinal illness in the two weeks preceding or during the outbreak period, though absenteeism was reported for one. Nearly all food handlers had stool tests performed within one week after the restaurant closure.

Laboratory findings. Specimens from 69 cases and 16/40 (40%) food handlers yielded STEC isolates. From primary case isolates, 10 PFGE patterns were identified. An additional four similar patterns were identified among food handler isolates. The 16 isolates analyzed by MLVA displayed four unique MLVA patterns. One predominant MLVA pattern was shared by 10 isolates. Food handler and case isolates displayed a variety of MLVA patterns, with some food handlers sharing MVLA patterns indistinguishable from restaurant patrons despite differing PFGE patterns. There were no distinct pattern groupings according to restaurant location. None of the 12 food items cultured were positive for STEC.

Food product traceback. In collaboration with CDPH, FPO and IDPH department of Food, Drugs and Dairy, invoices collected from the restaurant for the outbreak period meal dates were reviewed. Cilantro was purchased from a distributor serving multiple other restaurants throughout Illinois. The distributor repackaged cilantro from multiple sources, including suppliers in Mexico and Illinois. Of the five laboratory-confirmed cases who denied Restaurant A exposure, none reported cilantro consumption, although cooperation with re-interview was limited. In the absence of confirmed cases reporting consumption of implicated food items from another restaurant, it was not possible to perform further traceback to assess for a common source of contamination. No other restaurants serviced by the distributor were linked to the outbreak.

Re-inspection and reopening. FPO performed re-inspections at both locations, during which instruction and guidance were provided on hand hygiene and it was ensured that food preparation and storage areas were adequately sanitized. Only food workers who had two consecutive negative tests for STEC were permitted to work at the reopened locations, which delayed reopening of the south side location. After passing FPO re-inspections, the south and west side restaurants re-opened on July 9 and 29, respectively.

An additional case of STEC was subsequently identified with a meal date of July 11, 2016 at the reopened west side location, prompting imposed restriction of all food handlers who had been involved with preparation of the case’s meal. All of these food handlers and the case’s meal companions were tested for STEC, with negative results. The case had also eaten food from the restaurant on June 21 with a household member, prior to the restaurant’s closing; neither reported symptoms of illness at that time. PFGE analysis revealed an additional pattern not previously identified in this outbreak, but which appeared related to other outbreak patterns. Because of the multiple meal dates, negative test results of all meal companions and involved food handlers, and absence of additional reported restaurant-associated cases after the re-opening, we could not definitively determine if the case was primary, secondary or unrelated. Food handlers were permitted to return to work after repeated negative test results. No additional complaints were received in association with the restaurant in the two months following this case’s illness onset

Conclusion. This was a large restaurant-associated outbreak of Shiga toxin-producing E. coli O157:H7 infections. Closure of the restaurant during the early stage of the investigation prevented additional cases of illness from occurring. Cilantro was the most likely food-vehicle causing this outbreak, based on the strong statistical association of raw cilantro consumption with illness, and the high percentage of cases explained by cilantro consumption. The large number of PFGE patterns associated with the outbreak was suggestive of a heavily contaminated food item rather than introduction from a point source such as an ill food worker at the restaurant. However, STEC was not isolated from cilantro or cilantro-containing food items collected from the restaurant or the restaurant’s distributor. Inability to isolate STEC from food samples may have been hindered by imperfect sensitivity of testing, imperfect representativeness of food samples, or turnover of produce items through the distribution chain leading to items no longer being contaminated at the time of collection. Additionally, cross-contamination during food preparation and transmission by food handlers who were found to have STEC infection likely contributed to the outbreak.

8 x 10 in. (1)Arcadia Trading Inc. of Brooklyn, NY, is recalling 34 cartons of Lizard Fish because they have the potential to be contaminated with Clostridium botulinum, a bacterium which can cause life-threatening illness or death.  Consumers are warned not to consume the product even if it does not look or smell spoiled.

Botulism, a potentially fatal form of food poisoning, can cause the following symptoms: general weakness, dizziness, double- vision, and trouble with speaking or swallowing.  Difficulty in breathing, weakness of other muscles, abdominal distension and constipation may also be common symptoms.  People experiencing these problems should seek immediate medical attention.

The Lizard Fish was distributed nationwide to supermarkets between 2/11/2014 and 7/8/2016.

The product was imported from Vietnam and is packed in uncoded bulk 15 kg boxes.

No illnesses have been reported to date in connection with this problem.

The potential for the contamination was noted by an FDA Investigator during a follow-up inspection.  Subsequent FDA analysis of the product confirmed that the fish was not properly eviscerated prior to processing.  The company has ceased distribution of the product.

One of the great things about being a lawyer is that you can, if you want, continue to learn every day, even if you have been doing the same or similar thing for over 20 years.  I also get to reach out to the best experts in the world to ask for help in educating myself.  Thanks to to very good food safety people at NC State for updating the risk of Hepatitis A in shellfish.  Importers, be forewarned.

Hepatitis A outbreaks associated with shellfish, worldwide, from 1956 to 2016.  Adapted and expanded from Richards et al., 1985, Portnoy et al., 1975, and Fiore et al., 2004.  Outbreaks that were poorly investigated or had fewer than 30 cases were omitted.  Italics indicate the seafood was locally sourced with respect to the cases.  Asterisks denote outbreaks of “infectious hepatitis” before hepatitis A virus was specifically identified, and may have not been caused by hepatitis A virus.

Year # Cases Implicated food Location of cases Source of implicated food Suspected cause of contamination Reference
1956 629 Oysters Sweden Havstenssund Harbor, Sweden Oysters stored in polluted water Roos, 1956*; Pintó et al., 2009; Portnoy et al., 1975
1961 80


Oysters Mississippi, Alabama Pascagoula River, Mississippi Polluted harvesting areas Mason and McLean, 1962*
1961 459 Clams New Jersey Raritan Bay, New Jersey Polluted harvesting areas Dougherty and Altman, 1962*
1964 123 Clams Connecticut Multiple US sources, primarily Rhode Island Unknown Ruddy et al., 1969*
1973 281 Oysters Texas, Georgia, Louisiana Louisiana Stormwater runoff; investigated possible illegal harvesting Mackowiak et al., 1976; Portnoy et al., 1976
1980 312 Oysters Singapore Philippines Suspect contaminated harvesting waters Lee et al., 2011; Goh, 1981
1981 132 Cockles, whelks, mussels, prawns Southeast England United Kingdom Sewage discharge near harvesting beds, insufficient processing O’Mahoney et al., 1983
1982 225 Oysters Hondo City, Japan Ariake Bay, Japan Unknown Fujiyama et al., 1985
1984 75 Mussels and clams Livorno, Italy Livorno, Italy; Venice, Italy Sewage discharge near harvesting beds, improper handling at point of sale Mele et al., 1989
1988 61 Oysters Alabama, Georgia, Florida, Tennessee, Hawaii Florida Untreated sewage from residents and boats, possible illegal harvesting Descenclos et al., 1991
1988 292,301 Clams Shanghai, China Qi-Dong, China Untreated sewage Halliday et al., 1991
1992 800 Raw shellfish Western France Loire-Atlantique and Morbihan, France Unknown Apaire-Marchais et al., 1995
1996, 1997 5673,


Mussels and clams Puglia, Italy Italy Unknown Chironna et al., 2002
1997 444


Oysters New South Wales, Australia Wallis Lake, Australia Untreated sewage; stormwater runoff Conaty et al., 2000
1999 184 Coquina clams Valencia, Spain Peru Unknown Sanchez et al., 2002; Bosch et al., 2001
1999 32 Raw shellfish Bretagne, France Bay of Pampiol, France Unknown, harvesting sites near a busy tourist port Costa-Mattioli et al., 2000
2004 882 Mussels and clams Campania, Italy Primarily Campania, also other areas of Italy, Turkey Illegal storage of shellfish in contaminated seawater at point of purchase Pontrelli et al., 2008
2005 39 Oysters Alabama, Florida, South Carolina, Tennessee Louisiana Untreated sewage, possibly from recreational and other boats Bialek et al., 2007; Shieh et al., 2007
2007 111 Oysters Côtes d’Armor, France Côtes d’Armor, France Suspect contaminated water in tanks used on a shellfish farm, nearby untreated sewage Guillois-Bécel et al., 2009
2008 100 Coquina clams Spain Peru Unknown Pintó et al., 2009; Polo et al., 2010
2013 117 Suspect raw foods, especially seafood Taiwan Unknown Unknown Lung and Kay, 2013
2014 30 Raw bivalves: oysters, clams Taiwan Unknown Unknown Taiwan CDC, 2014
2016 292 Scallops Hawaii Philippines Unknown CDC, 2016; HI DOH, 2016



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Bosch, A., Sánchez, G., Le Guyader, F., Vanaclocha, H., Haugarreau, L., Pintó, R. M. (2001). Human enteric viruses in Coquina clams associated with a large hepatitis A outbreak. Water Science and Technology, 43(12): 61–65.

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Conaty, S., Bird, P., Bell, G., Kraa, E., Grohmann, G., McAnulty, J. M., et al. (2000). Hepatitis A in New South Wales, Australia from consumption of oysters: the first reported outbreak. Epidemiol Infect, 124: 121–130.

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Pontrelli, G., Boccia, D., Di Renzi, M., Massari, M., Giugliano, F., Celentano, L. P., … & Rapicetta, M. (2008). Epidemiological and virological characterization of a large community-wide outbreak of hepatitis A in southern Italy. Epidemiology and infection, 136(08): 1027-1034.

Portnoy, B. L., Mackowiak, P. A., Caraway, C. T., Walker, J. A., McKinley, T. W., Klein, C. A. (1975). Oyster-associated hepatitis: failure of shellfish certification programs to prevent outbreaks. JAMA, 233: 1065–1068.

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Shieh, Y. C., Khudyakov, Y. E., Xia, G., Ganova-Raeva, L. M., Khambaty, F. M., et al. (2007) Molecular confirmation of oysters as the vector for hepatitis A in a 2005 multistate outbreak. J Food Prot, 70: 145–150.

Taiwan Centers for Disease Control. (2014). As Taiwan CDC confirms cluster of hepatitis A cases due to consumption of raw bivalves using genetic sequencing for the first time, public urged to pay attention to food safety. Press Release. Published December 8, 2014. Available at Also available on ProMED Mail at

10_notomatoes_lgToday the 4th Circuit Court of Appeals affirmed the December 15, 2015, District Court dismissal of a lawsuit brought by tomato grower, Seaside Farm, Inc.  Seaside alleged that the Food and Drug Administration negligently issued a contamination warning in response to an outbreak of Salmonella Saintpaul that devalued Seaside’s tomato crop by $15,036,293.95.

According to the 4th Circuit, “the district court reasoned that FDA had broad discretion to warn the public about a contaminated food supply, and that Seaside failed to allege any statute, regulation, or policy that required FDA to proceed in a particular manner. The district court also acknowledged that contamination warnings implicate competing policy considerations of protecting the public from serious health risks and minimizing any adverse economic impact on associated industries.

On May 22, 2008, the New Mexico Department of Health notified the Centers for Disease Control and Prevention that a number of local residents had been infected with Salmonella Saintpaul. Similar reports soon arrived at CDC from Texas. After interviewing patients, CDC discovered a “strong statistical association” between the infections and eating raw tomatoes. This observation was supported by a “historical association” between Salmonella and tomatoes generally. CDC subsequently notified FDA that tomatoes were the “leading hypothosis” for the source of the outbreak. On June 7, 2008, FDA issued an updated contamination warning titled, “FDA Warns Consumers Nationwide Not to Eat Certain Types of Raw Red Tomatoes.” The contamination warning explained the nature of Salmonella Saintpaul and specified certain types of tomato as the likely vehicles for the bacteria. It also provided a list of countries and seven states, including South Carolina, whose tomatoes remained unassociated with the outbreak. The media, however, reported the contamination warning without mentioning that some tomatoes were not implicated. FDA officials also stressed the magnitude and national scope of the outbreak but likewise failed to mention any “safe” tomatoes. Eventually, the CDC accumulated enough data to trace Salmonella Saintpaul to jalapeño and serrano peppers imported from Mexico. FDA withdrew the contamination warning as a result and announced that fresh tomatoes were no longer associated with the outbreak.

According to the CDC as of April 2008, 1442 persons infected with Salmonella Saintpaul with the same genetic fingerprint have been identified in 43 states, the District of Columbia, and Canada. The number of ill persons identified in each state is as follows: Alabama (8 persons), Arkansas (21), Arizona (59), California (16), Colorado (17), Connecticut (5), Florida (4), Georgia (42), Idaho (6), Illinois (120), Indiana (21), Iowa (2), Kansas (21), Kentucky (2), Louisiana (3), Maine (1), Maryland (39), Massachusetts (31), Michigan (28), Minnesota (31), Mississippi (2), Missouri (20), Montana (1), New Hampshire (6), Nevada (14), New Jersey (16), New Mexico (115), New York (41), North Carolina (28), Ohio (10), Oklahoma (38), Oregon (11), Pennsylvania (15), Rhode Island (3), South Carolina (2), Tennessee (10), Texas (559), Utah (3), Virginia (31), Vermont (2), Washington (18), West Virginia (1), Wisconsin (13), and the District of Columbia (1). Five ill persons are reported from Canada. Four appear to have been infected while traveling in the United States; the travel status of the fifth ill person is unknown. Among the 1414 persons with information available, illnesses began between April 16 and August 11, 2008 with most becoming ill during May or June. At least 286 persons were hospitalized, and the infection might have contributed to two deaths.

So, bottom line, doing your job protecting public health is the right thing to do.

Front-line staff, such as servers in restaurants, are often trusted with providing customers with food safety information regarding their meals. A challenge to the food-service industry is that these positions have high turnover, relatively low wages and servers are focused primarily on providing patrons with a positive experience. And new research shows that this poses a problem.

A recent study finds restaurants don’t do an effective job of communicating with customers when it comes to addressing risks associated with eating undercooked meat – specifically hamburgers. Inaccurate information provided by servers often contradicts science-based information customers need to make informed food safety decisions.

All 50 states in the U.S. have adopted some version of the Food & Drug Administration’s Model Food Code, which requires restaurants to tell customers about risks associated with undercooked meat and poultry products.

“We wanted to know how well restaurant servers and menus communicated with customers about these risks, specifically in the context of beef hamburgers,” says Ben Chapman, co-author of a study on the work and an associate professor at North Carolina State University whose research program is aimed at improving food safety.

The researchers focused on beef hamburgers because consuming undercooked ground beef has been linked to a lot of foodborne illness outbreaks, including outbreaks related primarily to Shiga toxin-producing E. coli.

For this study, the researchers sent trained “secret shoppers” into 265 full-service, sit-down restaurants in seven different regions around the U.S. At each restaurant, the patrons ordered one well-done hamburger and one medium-rare hamburger to go. The shoppers then recorded how, if at all, the restaurant communicated about risk.

This study is the latest in a long line of real-world research that Chapman and his collaborators have conducted.

“We try to actually match what people do versus what they say they do because people will say anything on a survey,” Chapman says. “We’ve looked at cooking shows; observed handwashing and cross-contamination in commercial kitchens; examined hand hygiene during a norovirus outbreaks and others. What people actually do is the difference between an enjoyable meal and a foodborne illness.

“For example,” Chapman says, “did the server mention risks associated with undercooked meat when the shopper ordered? If not, the shopper would ask about the risk of getting sick, and then record whether the wait staff responded with clear, accurate information.”

The shoppers also looked to see whether restaurants included clear, accurate risk information on their menus.

The study found that 25 percent of restaurants wouldn’t even sell an undercooked hamburger to secret shoppers. However, at restaurants that would sell a medium-rare hamburger, the majority of servers – 77 percent – gave customers unreliable information about food safety.

“Servers said that meat was safe because it was cooked until ‘until the juices ran clear’ – which is totally unreliable,” says Ellen Thomas, a food safety scientist at RTI International and lead author of the study who worked on the project while a Ph.D. student at NC State. “Those 77 percent didn’t mention things like cooking meat to the appropriate temperature – either 155°F for 15 seconds, or 160°F for instant kill.

“The indicator of safety most widely reported by servers was the color of the burger, and that’s also not a reliable indicator at all,” Thomas says “Time and temperature are all that matter. An undercooked, unsafe burger can be brown in the middle, and a safely cooked burger can still be red or pink in the center.”

Meanwhile, almost all of the menus complied with FDA guidance. But what servers told customers often contradicted the information on the menu.

“If a menu says something is risky but a server says that it isn’t, that can downplay the risks for consumers and impact a customer’s decisions,” Chapman says. “It’s confusing, leaving the patron to choose which message to believe”

The researchers also found that chain restaurants fared much better than independent restaurants at having servers offer reliable risk information. See this related blog post for an example.

“That’s not surprising,” Chapman says. “Large chains implement standardized training across all outlets for servers in order to protect their brand and reduce the likelihood of being implicated in a foodborne illness outbreak. That’s bad for business.

“This study tells us that servers aren’t good risk communicators,” Chapman says. “We encourage consumers to ask food-safety questions, but they should probably ask a manager.

“It also tells us that we need to work on addressing the widespread – and wrong – belief that color is a reliable indicator of food safety in meat,” Chapman adds. “Restaurants are in a position to help us share this information with consumers, but many servers are currently sharing incorrect information.”

The paper, “Assessment of Risk Communication about Undercooked Hamburgers by Restaurant Servers,” is published in the Journal of Food Protection. The paper was co-authored by Andrew Binder, Anne McLaughlin, Lee-Ann Jaykus, and Dana Hanson of NC State; and by Doug Powell of The research was supported by Agriculture and Food Research Initiative Competitive Grant no. 2012-68003-30155 from the USDA National Institute of Food and Agriculture.

Note to Editors: The study abstract follows.

“Assessment of Risk Communication about Undercooked Hamburgers by Restaurant Servers”

Authors: Ellen M. Thomas, RTI International; Andrew Binder, Anne McLaughlin, Lee-Ann Jaykus, Dana Hanson, and Benjamin Chapman, North Carolina State University; and Doug Powell, Powell Food Safety

Published: Dec. 1, Journal of Food Protection

DOI: 10.4315/0362-028X.JFP-16-065

Abstract: According to the U.S. Food and Drug Administration 2013 Model Food Code, it is the duty of a food establishment to disclose and remind consumers of risk when ordering undercooked food such as ground beef. The purpose of this study was to explore actual risk communication activities of food establishment servers. Secret shoppers visited restaurants (n=265) in seven geographic locations across the U.S., ordered medium rare burgers, and collected and coded risk information from chain and independent restaurant menus and from server responses. The majority of servers reported an unreliable method of doneness (77%) or other incorrect information (66%) related to burger doneness and safety. These results indicate major gaps in server knowledge and risk communication, and the current risk communication language in the Model Food Code does not sufficiently fill these gaps. Furthermore, should servers even be acting as risk communicators? There are numerous challenges associated with this practice including high turnover rates, limited education, and the high stress environment based on pleasing a customer. If it is determined that servers should be risk communicators, food establishment staff should be adequately equipped with consumer advisory messages that are accurate, audience-appropriate, and delivered in a professional manner so as to help their customers make more informed food safety decisions.