Raw spinach will be back on the menu in the San Ramon Valley school district beginning today, as the district’s food supplier lifts its self-imposed ban on the leafy vegetable. The U.S. Food and Drug Administration, according to the school district, issued a consumer alert on Sept. 14 advising consumers not to eat bagged spinach and some related products after incidents involving E. coli bacteria were reported. Sodexho School Services, the district’s food provider, immediately issued a ban on fresh spinach to all school districts it serves throughout the country, but now that ban has been lifted.
This is not Sodexho’s first experience with E. coli-tainted spinach. In October, 2003, the San Mateo County Health Services Agency (SMCHSA) commenced an investigation of an E. coli O157:H7 outbreak among residents and employees of The Sequoias Portola Valley retirement community in San Mateo County. The SMCHSA ultimately linked thirteen confirmed and three probable cases of E. coli O157:H7. Ten persons were hospitalized, and three people died. The SMCHSA’s investigation concluded that the E. coli O157:H7 outbreak and infections were associated with the consumption of food, most likely raw spinach, by the outbreak victims. The food was prepared and served to the facility residents by Sodexho, as a component of meals it prepared and served to residents.
We represented several of the victims of that outbreak. For a full report see www.MarlerClark.com, and continue reading below:
THE SEQUOIAS E. COLI O157:H7 OUTBREAK
The Sequoias is a large, upscale retirement facility that operates in several locations throughout California. One such location is in the Portola Valley in San Mateo County. This Sequoias facility sprawls over forty-two acres, housing a total of 315 people who receive varying levels of assistance. In ascending order of assistance required, 265 residents live in independent living, twenty require assisted living, and thirty require skilled nursing. Each group has its own living area.
Despite living separately, all residents take their meals from the same kitchen. Residents may use one of two dining halls or they may request tray service meals. Those who choose to dine at one of the two designated halls may request table service, but most use the self-service buffet. Food is also available from the kitchen by request, throughout the day.
Sequoias employees, however, are not involved in food service or kitchen management. Instead, the Sequoias contracts with Sodexho, an outside vendor, to perform all food service functions. As a result, it is Sodexho employees exclusively who obtain the food, and prepare and serve meals to Sequoias residents.
On Monday, October 13, 2003, the San Mateo County Health Services Agency (SMCHSA) commenced an investigation based on information that a resident of the Sequoias in Portola Valley had cultured positive for E. coli O157:H7. The resident had become symptomatic on October 9, and had been hospitalized at Stanford Hospital the next day. Several more Sequoias residents reported symptoms consistent with E. coli O157:H7 infections over the next few days.
The epidemiological investigation began with a questionnaire that addressed illness, symptoms, food history, medical care, social contacts, and other risk factors. Interviews of Sequoias residents followed. These were conducted by nurses, epidemiologists, communicable disease investigators, and three UC Berkeley Public Health students. Food service employees also filled out questionnaires, with those who reported illness filling out a more extensive case-control questionnaire.
All employees at the facility, whether Sequoia or Sodexho, submitted stool samples. Ill employees were prohibited from working until they produced two samples, twenty-four hours apart, that tested negative for E. coli O157:H7. Stool samples were also collected from Sequoias residents who reported at least one episode of diarrhea since September 21. The samples were tested, and those with positive E. coli O157 isolates were sent to the California Department of Health Services (CDHS) Microbial Diseases Laboratory for confirmation and serotyping.
The initial case definition was “any resident or employee experiencing two or more episodes of diarrhea in a 24-hour period between 9/21/2003 and 11/3/2003.” During the case-control analysis, the case definition was narrowed to include only laboratory-confirmed cases and probable cases, which were those without laboratory confirmation but that involved bloody diarrhea or hemolytic uremic syndrome. Controls were selected from the frequent dining partners of cases and, alternatively, at random from the resident roster.
The environmental investigation began on October 13. An inspection of the Sequoias kitchen on the same date noted that it met industry standards and was free from violations. Two days later, however, a follow-up investigation noted that several refrigeration units were above 41 degrees Fahrenheit, and a build-up existed on the ice machine. Corrections of these violations were completed by the next inspection, October 27. No food was tested during the investigation because no food samples were left over from the exposure period.
Sixteen confirmed and probable cases were ultimately identified. Of these, thirteen were culture-confirmed. All had onset between October 9 and 17, with 75 percent experiencing onset by October 12, and all cases were residents of “independent living” and “skilled nursing.” The CDHS subtyped all thirteen available isolates using pulsed-field gel electrophoresis (PFGE), and twelve had identical PFGE DNA fingerprint patterns. The lone non-identical pattern differed by just one band.
Analysis done of the sixteen “case” food histories identified only one food item that was associated with illness: raw spinach. The SMCHSA Final Report concludes, “[n]o other common exposures were found. No food handlers were identified with diarrheal illness during the exposure period and no employees cultured positive for enteric pathogens.” The contaminated spinach, which arrived at the facility pre-packaged, was served between October 3 and 5. The spinach was not washed by Sodexho staff in the kitchen prior to serving, thus exposing the vulnerable Sequoias residents to a deadly pathogen.