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Marler Blog Providing Commentary on Food Poisoning Outbreaks & Litigation

Dr. Richard Besser (acting head of CDC), Swine Flu (H1N1), E. coli O157:H7, Apple Cider and Bill Marler have what in Common?

OK, it is 2:00 AM and the power is out after a wind a rain and storm on Bainbridge Island. Fortunately, my laptop has batteries and I have a wireless card. I am also wondering where my passport is since I leave for Canada in 12 hours. But, hopefully the morning will find it – somewhere.

So, I was reading up on the recent pronouncements about Swine Flu (politically correct H1N1 virus) and kept bumping into Dr. Richard Besser, acting head of CDC. Doing a little research on him at 2:00 AM uncovered this article about his research into an E. coli O157:H7 outbreak linked to unpasteurized apple juice, two years before the outbreak of E. coli O157:H7 linked to Jack in the Box restaurants. There began my connection.

Back to unpasteurized juice – Interesting to note that the CONCLUSIONS below show how we learn – a bit slowly – to protect ourselves from the next outbreak by actually investigating and learning from past outbreaks. Goes to show why surveillance of foodborne illness outbreaks is so important in preventing the next one. Now, if only we can do the same with the Flu.

An outbreak of diarrhea and hemolytic uremic syndrome from Escherichia coli O157:H7 in fresh-pressed apple cider.  Besser RE, Lett SM, Weber JT, Doyle MP, Barrett TJ, Wells JG, Griffin PM.

Escherichia coli O157:H7 causes hemorrhagic colitis and the hemolytic uremic syndrome. In the fall of 1991, an outbreak of E coli O157:H7 infections in southeastern Massachusetts provided an opportunity to identify transmission by a seemingly unlikely vehicle.  Case-control study to determine the vehicle of infection. New England cider producers were surveyed to assess production practices and determined the survival time of E coli O157:H7 organisms in apple cider.  Illness was significantly associated with drinking one brand of apple cider. Thirteen (72%) of 18 patients but only 16 (33%) of 49 controls reported drinking apple cider in the week before illness began (odds ratio [OR], 8.3; 95% confidence interval [CI], 1.8 to 39.7). Among those who drank cider, 12 (92%) of 13 patients compared with two (13%) of 16 controls drank cider from cider mill A (lower 95% CI, 2.9; P < .01). This mill pressed cider in a manner similar to that used by other small cider producers: apples were not washed, cider was not pasteurized, and no preservatives were added. In the laboratory, E coli O157:H7 organisms survived for 20 days in unpreserved refrigerated apple cider. Addition of sodium benzoate 0.1% reduced survival to less than 7 days.

CONCLUSIONS–Fresh-pressed, unpreserved apple cider can transmit E coli O157:H7 organisms, which cause severe infections. Risk of transmission can be reduced by washing and brushing apples before pressing, and preserving cider with sodium benzoate.  Consumers can reduce their risk by only drinking cider made from apples that have been washed and brushed.

An outbreak of Escherichia coli O157:H7 infections and haemolytic uraemic syndrome associated with consumption of unpasteurized apple cider.  Hilborn ED, Mshar PA, Fiorentino TR, Dembek ZF, Barrett TJ, Howard RT, Cartter ML.

During October 1996, an outbreak of Escherichia coli O157:H7 infections among Connecticut residents occurred. An epidemiologic investigation included enhanced surveillance and a case-control study. Clinical isolates of Escherichia coli O157:H7 were typed by pulsed-field gel electrophoresis (PFGE). Implicated cider samples were analysed by culture and polymerase chain reaction (PCR). Consumption of implicated cider was associated with illness; (matched odds ratio = undefined, 95 % confidence interval = 3.5-infinity). Ultimately, a total of 14 outbreak-associated patients were identified. All isolates analysed by PFGE yielded the outbreak-associated subtype. Escherichia coli O157:H7 was not cultured from three cider samples; PCR analysis detected DNA fragments consistent with Escherichia coli O157:H7 in one. This outbreak was associated with drinking one brand of unpasteurized apple cider. PFGE subtyping supported the epidemiologic association. PCR analysis detected microbial contaminants in the absence of live organisms.

CONCLUSIONS – Washing and brushing apples did not prevent cider contamination.

An outbreak of Escherichia coli O157:H7 infection from unpasteurized commercial apple juice.  Cody SH, Glynn MK, Farrar JA, Cairns KL, Griffin PM, Kobayashi J, Fyfe M, Hoffman R, King AS, Lewis JH, Swaminathan B, Bryant RG, Vugia DJ.

Escherichia coli O157:H7 infections have traditionally been associated with animal products, but outbreaks associated with produce have been reported with increasing frequency. In fall 1996, a small cluster of E. coli O157:H7 infections was epidemiologically linked to a particular brand (brand A) of unpasteurized apple juice.  To define the extent of the outbreak, confirm the source, and determine how the apple juice became contaminated.  Descriptive epidemiologic study and traceback investigation.  Western United States and British Columbia, Canada.  Patients with E. coli O157:H7 infection who were exposed to brand A apple juice.  Clinical outcome and juice exposure histories of case-patients, pulsed-field gel electrophoresis of case and juice isolates, and juice production practices.  Seventy persons with E. coli O157:H7 infection and exposure to brand A unpasteurized apple juice were identified. Of these persons, 25 (36%) were hospitalized, 14 (20%) developed the hemolytic uremic syndrome, and 1 (1%) died. Recalled apple juice that was produced on 7 October 1996 grew E. coli O157:H7 with a pulsed-field gel electrophoresis pattern indistinguishable from that of case isolates. Apple juice produced on 7 October 1996 accounted for almost all of the cases, and the source of contamination was suspected to be incoming apples. Three lots of apples could explain contamination of the juice: Two lots originated from an orchard frequented by deer that were subsequently shown to carry E. coli O157:H7, and one lot contained decayed apples that had been waxed.

CONCLUSIONS – Standard procedures at a state-of-the-art plant that produced unpasteurized juices were inadequate to eliminate contamination with E. coli O157:H7.  This outbreak demonstrated that unpasteurized juices must be considered a potentially hazardous food and led to widespread changes in the fresh juice industry.

My connection, I represented most of the hemolytic uremic syndrome cases in the Jack in the Box E. coli Outbreak and the "Commercial" (a.k.a Odwalla) E. coli Outbreak.  Well, I wish Dr. Besser well and I hope I find my passport.