Two long days after word first surfaced about a multi-state outbreak of E. coli tied to raw cookie dough, the CDC has issued information detailing the illnesses.  The outbreak appears to have begun March 1, 2009 and is still ongoing four months later

The CDC reports:

CDC is collaborating with public health officials in many states, the United States Food and Drug Administration (FDA), and the United States Department of Agriculture Food Safety and Inspection Service (FSIS) to investigate an outbreak of E. coli O157:H7 infections.

As of Thursday, June 18, 2009, 65 persons infected with a strain of E. coli O157:H7 with a particular DNA fingerprint have been reported from 29 states. Of these, 23 have been confirmed by an advanced DNA test as having the outbreak strain; these confirmatory test results are pending on the others. The number of ill persons identified in each state is as follows: Arkansas (1), Arizona (2), California (2), Colorado (5), Delaware (1), Hawaii (1), Iowa (2), Illinois (5), Kentucky (1), Massachusetts (4), Maryland (2), Maine (3), Minnesota (5), Missouri (2), Montana (1), North Carolina (1), New Hampshire (2), New Jersey (1), Nevada (2), Ohio (4), Oklahoma (1), Oregon (1), Pennsylvania (2), South Carolina (1), Texas (3), Utah (2), Virginia (2), Washington (5), and Wisconsin (1).

Ill persons range in age from 2 to 57 years; however, more than 70% are less than 19 years old and none are over 60 years old; 75% are female. Twenty-five persons have been hospitalized, 7 developed hemolytic uremic syndrome (HUS); none have died. Reports of these infections increased above the expected baseline in May and continue into June.
Investigation of the Outbreak

In an epidemiologic study, ill persons answered questions about foods consumed during the days before becoming ill and investigators compared their responses to those of persons of similar age and gender previously reported to State Health Departments with other illnesses. Preliminary results of this investigation indicate a strong association with eating raw prepackaged cookie dough. Most patients reported eating refrigerated prepackaged Nestle Toll House cookie dough products raw.

E. coli O157:H7 has not been previously associated with eating raw cookie dough. CDC, the state health departments, and federal regulatory partners are working together in this ongoing investigation.
Clinical Features

Most people infected with E. coli O157:H7 develop diarrhea (often bloody) and abdominal cramps 2-8 days (average of 3-4 days) after swallowing the organism, but some illnesses last longer and are more severe. Infection is usually diagnosed by culture of a stool sample. Most people recover within a week, but some develop a severe infection. A type of kidney failure called hemolytic uremic syndrome (HUS) can begin as the diarrhea is improving; this can occur in people of any age but is most common in children under 5 years old and the elderly.
Advice to Consumers

The Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention are warning consumers not to eat any varieties of prepackaged Nestle Toll House refrigerated cookie dough due to the risk of contamination with E. coli O157:H7. If consumers have any prepackaged, refrigerated Nestle Toll House cookie dough products in their home they should throw them away. Cooking the dough is not recommended because consumers might get the bacteria on their hands and on other cooking surfaces. The recall does not include Nestle Toll House morsels, which are used as an ingredient in many home-made baked goods, or other already baked cookie products.

Individuals who have recently eaten prepackaged, refrigerated Toll House cookie dough and have experienced any of these symptoms should contact their doctor or health care provider immediately. Any such illnesses should be reported to state or local health authorities.

Consumers should be reminded they should not eat raw food products that are intended for cooking or baking before consumption. Consumers should use safe food-handling practices when preparing such products, including following package directions for cooking at proper temperatures; washing hands, surfaces, and utensils after contact with these types of products; avoiding cross contamination; and refrigerating products properly.

Oklahoma State health investigators have confirmed that at least 248 people have become ill as a result of the E. coli O111 outbreak in Northeastern Oklahoma.  Of that number, 202 were adults and 46 were children.  A Pryor man, Chad Ingle, died.  At least 64 people were hospitalized, including 16 who received kidney dialysis treatment.  Of that number, nine were children and seven were adults.  Investigators said the number of reported cases and hospitalizations may change as state investigators continue their investigation into the source of the outbreak.  The common denominator is the Cottage Grove restaurant in Locust Grove, Oklahoma.

To date the water in the well used at the restaurant has tested negative for E. coli O111, as has both the surfaces of the restaurant and left over food – REMEMBER – all were tested at least a week or more after people dined at the restaurant.

Outbreak of Severe Diarrheal Illness in Northeastern Oklahoma

The Oklahoma State Department of Health (OSDH) reports today that laboratory analysis of water samples taken from a private well on the property of the Country Cottage restaurant in Locust Grove, OK, has found no disease-causing bacteria. The restaurant has been associated with a large E. coli 0111 outbreak in northeastern Oklahoma.

“The well water is not the source of this outbreak,” said State Epidemiologist Dr. Kristy Bradley. “We are continuing our efforts to conduct microbiological testing of food preparation and serving surfaces in the restaurant, and we continue to interview cases, as we try to establish an association with those who became ill and a potential source.”

At least 206 persons are sick as a result of the outbreak including 149 adults, 53 children, and four whose ages have not yet been confirmed. Cases range in age from 2 months to 88 years. One person has died.

“This appears to be the largest E. coli 0111 outbreak ever reported in the U.S.,” Bradley stated. “The complexity of this outbreak and the necessity to be extremely thorough in our investigation means we still have more questions than answers.”

OSDH disease investigators, along with staff from Tulsa Health Department and area local county health departments, have interviewed more than 500 persons in an effort to identify the source of the outbreak.

The restaurant is closed while the investigation continues. Not all persons who ate at the restaurant have become ill. No other restaurant or food service outlet in the area has been linked to the outbreak.

The Oklahoma State Department of Health (OSDH) reports today that at least 176 persons have become ill as a result of the E. coli O111 outbreak in northeastern Oklahoma. Cases include 128 adults and 48 children. Federal and state health officials say E. coli O111 is a rare type not normally associated with an outbreak this large. OSDH disease investigators, along with staff from Tulsa Health Department and area local county health departments, have interviewed more than 450 persons in an effort to identify the source of the outbreak. Interviews continue this weekend. While the source has not yet been identified, health officials continue to focus on the Country Cottage restaurant in Locust Grove, OK, after interviews with cases indicated most had eaten there during the time period Aug. 15 through Aug. 23.

The restaurant is closed while the investigation continues. Not all persons who ate at the restaurant have become ill. No other restaurant or food service outlet in the area has been linked to the outbreak. OSDH laboratory analysis of water samples taken from a private well on the restaurant property is continuing, however, health officials believe it is unlikely that any well water contamination is the source of the outbreak.

Prior Outbreaks of E. coli O111:

– Community Outbreak of Hemolytic Uremic Syndrome Attributable to Escherichia coli O111:NM — South Australia, 1995

– Outbreak of diarrhoea due to Escherichia coli O111:B4 in schoolchildren and adults: association of Vi antigen-like reactivity

– Escherichia coli O111:H8 Outbreak Among Teenage Campers – Texas, 1999

– Outbreaks of food poisoning in adults due to Escherichia coli O111 and campylobacter associated with coach trips to northern France

The food borne illness outbreak in northeastern Oklahoma that has sickened more than 115, hospitalized 50 and taken one life is the latest emergence of the virulent and highly toxic E. coli bacterium. Most E. coli outbreaks in North America are subtypes of E. coli O157:H7, but the CDC has just revealed that this outbreak is a rare serotype: E. coli O111.

“This is highly unusual,” said food borne illness attorney William Marler. “We have been involved in every major US outbreak in the last 15 years, and we have only seen this serotype twice before—once traced to apple cider in New York, and once connected to water or salad in Texas.”

Although many strains of E. coli can be present in the body with no ill effects, strains like E. coli O111 and E. coli O157:H7 produce a deadly shiga toxin (stx) which ravages the digestive system and kidneys. By the time symptoms emerge—abdominal cramping, vomiting, and bloody diarrhea—the bacteria is already entrenched. Although there is no cure or antidote, immediate health care is critical to support the systems under attack, keep the patient hydrated, and try to alleviate the intense pain that accompanies the illness as the body works to rid itself of the toxic bacteria.

In those with compromised or immature immune systems, E. coli can progress to Hemolytic Uremic Syndrome, or HUS. Children, whose immune systems are not as developed as adults’, are especially vulnerable. HUS is a cascading complication resulting in kidney failure; at the moment several children in Oklahoma are on dialysis. Even when they are able to recover from the potent E. coli toxin (considered by the CDC to be one of the most toxic substances known to man), victims often have permanent kidney damage. It is not unusual for E coli victims infected as children to need multiple kidney transplants over their lifetime.

“Regardless of the strain of toxic E. coli, it produces a devastating illness.” continued Marler. “Under the best circumstances, it can take months to recover. Some victims are affected for the rest of their lives. We need to support the families going through this nightmare, and do everything we can to help them.”

According to Kim Archer of the Tulsa World, Oklahoma state health officials have determined that a relatively rare and virulent form of E. coli infected dozens of patrons of Country Cottage, killing one and sickening more than 73 people.  More than 50 of those who fell ill were hospitalized.  Five children remain in the pediatric intensive care unit at Children’s Hospital at St. Francis.  Four are on dialysis.  Two other children were sent to OU Children’s Hospital.  Ms. Archer quoted State epidemiologist Dr. Kristy Bradley as saying the E. coli strain is not the commonly known E. coli O157:H7.  Non-O157 strains are more common in South America and parts of Europe, according to the Pediatric Infectious Disease Journal.

I could not agree more. Shiga toxin is one of the most potent toxins known to man, so much so that the Centers for Disease Control and Prevention (CDC) lists it as a potential bioterrorist agent (CDC, n.d.). It seems likely that DNA from Shiga toxin-producing Shigella bacteria was transferred by a bacteriophage (a virus that infects bacteria) to otherwise harmless E. coli bacteria, thereby providing them with the genetic material to produce Shiga toxin.

Although E. coli O157:H7 is responsible for the majority of human illnesses attributed to E. coli, there are additional Stx-producing E. coli (e.g., E. coli O121:H19) that can also cause hemorrhagic colitis and post-diarrheal hemolytic uremic syndrome (D+HUS). HUS is a syndrome that is defined by the trilogy of hemolytic anemia (destruction of red blood cells), thrombocytopenia (low platelet count), and acute kidney failure.

Stx-producing E. coli organisms have several characteristics that make them so dangerous. They are hardy organisms that can survive several weeks on surfaces such as counter tops, and up to a year in some materials like compost. They have a very low infectious dose meaning that only a relatively small number of bacteria (< 50) are needed “to set-up housekeeping” in a victim’s intestinal tract and cause infection.

I represented three Hemolytic Uremic Syndrome victims in an outbreak of E. coli O21:H19 linked to a Utah Wendys in 2006. Non-O157:H7 was also likely responsible for some of the illnesses in the Dole Spinach outbreak of 2006.

I also recently gave a speech in front of the USDA/FSIS on making all Shiga-toxin producing E. coli’s adulterants under the US Meat Inspection Act. Here is that text:

Another issue facing, not only the meat industry, but all of us, is the extent to which non-O157 E. coli may be present in food products – FSIS regulated or not. It is clear that Non-O157 Shiga toxin producing E. coli have emerged as a public health issue. Some non-O157 possess the same range of virulence factors as E. coli O157:H7 and are capable of causing serious illnesses, or death. Numerous serotypes, including O26, O103, O111 and O145 have been identified as agents of food borne disease.

I have seen their nasty work in the Dole spinach outbreak and an outbreak in Utah involving Wendy’s. Since 1990, 13 outbreaks of non-O157 E. coli have been reported in the US. While E. coli O157 is the principal strain isolated from implicated food and clinical isolates in the US, non-O157 predominate in other countries, including several of our beef trading partners like Australia, Brazil and Canada.

I will leave this to scientists and public health officials to sort all out. However, perhaps one needs to look no further than the FEDERAL MEAT INSPECTION Act and look at the term ”adulterated" for and answer. A product is adulterated: (1) if it bears or contains any poisonous or deleterious substance which may render it injurious to health." If non-O157 E. coli fits the bill, then to me that answers the question. However, what do we then do about salmonella, listeria, campylobacter, and shigella – especially those with particular virulence or antibiotic resistance?

One thing to remember, whether a product is considered to be an adulterant under the FMI or not, if a food product contains a bacteria or virus that sickens or kills, civil liability can, and often will attach. My vote is to simply get pathogens out of your product.

As Tim Hay of the San Mateo County Times reported today, a multinational food company and a Salinas vegetable farm have been ordered to pay an undisclosed amount to an elderly woman who was sickened in an outbreak of E. coli in a local retirement home, as well the son of a woman who died after eating the same tainted spinach in October 2003.
Marler Clark sued Sodexho USA and River Ranch Fresh Foods after an outbreak of the food-borne illness sickened at least 16 people and caused the deaths of two others at the Sequoias Portola Valley retirement community.
County health officials said the outbreak was most likely caused by pre-packaged spinach that Sodexho bought from River Ranch and served at the 315-bed home.
Marler Clark represented Keith McWalter, whose 85-year-old mother, Alice McWalter, died when the E. coli caused kidney failure. Mrs. McWalter was hospitalized on Oct. 14, and suffered 12 days of fever and nausea before she died.
The other Marler Clark client was Sequoias resident Sarah Ish. She was hospitalized with severe nausea during the outbreak, but pulled through.

As the The Salinas Californian reports, legal consequences of two food-borne illness outbreaks that sickened at least 63 people and killed one in 2003 have returned to the Salinas Valley, where state investigators say lettuce and spinach — contaminated at an unknown point before they were eaten — were grown.
Beginning with those infected with E. coli 0157:H7 by the tainted produce, lawsuits have blossomed throughout the food-growing and distribution chain. Now River Ranch Fresh Foods and Diamond Produce, the two companies said to have grown the contaminated lettuce and spinach, have taken preliminary steps toward suing Monterey County.
Lawyers for the two Salinas-area companies say the Monterey County Water Resources Agency failed to maintain Santa Rita Creek, resulting in flooding in 2003 that spread waste across a field where produce was grown.
From the article:

Forty of the customers sickened at Pat & Oscar’s sued the restaurant chain and settled their claims just before Christmas, said Bill Marler, a Seattle attorney who represented 29 of them.
Marler also represents the family of McWalter and Sarah Ish, another sickened Sequoias resident, in lawsuits against Sodexho USA, he said.

As the Herald Salinas Bureau reports, Marler Clark clients who were victims of an E. coli outbreak involving contaminated vegetables grown in Salinas Valley are settling their claims against the restaurants serving tainted produce in 2003.
But the legal cases continue while the restaurant owners attempt to pin the blame on Salinas Valley produce companies, and operators of those produce companies blame the Monterey County Water Resources Agency.
Terms of the settlement agreement between the restaurants and the approximately 49 victims of the outbreak are confidential. Not all those claims have been settled, but most have.

So far eight families have contacted Marler Clark, and one lawsuit has been filed, over the Wendy’s ground beef E. coli outbreak in Marion County.
One family was hit twice when the two sons, a 4-year-old and a 23-month-old, became sick from E. coli. The 4-year-old was released last week from Oregon Health Sciences University Hospital, and the 23-month-old remained in fair condition Saturday night. Both had been on dialysis, after which patients can either recover or require transplants, depending on the severity of the condition.
As the Statesman Journal reports, three weeks after the largest E. coli outbreak in Marion County history, the investigation focuses on Wendy’s ground beef, said Dr. Paul Cieslak of the Oregon Health Division. The connection was made after a second Wendy’s restaurant in Tualatin was linked to the outbreak when an adult female was confirmed Sept. 2 as an E. coli victim. The DNA of the E. coli matched that of the Salem outbreak, confirming a common contamination source.
The lettuce link can be explained by cross contamination, which may have occurred because of improper food handling.
From interviews with Wendy’s employees, officials determined that a few workers had washed lettuce in a sink that had not been sanitized and previously contained utensils that had touched raw meat.