Some, I am sure are a bit tired of my ranting about the FSIS doing its job and deeming Salmonella that causes human illness an adulterant in meat.

Fact, after E. coli O157:H7 was deemed an adulterant in ground beef in 1994, it took about a decade for E. coli illness cases to drop.  During that time, we saw the same drop in clients seeking our help.  Go figure, the FSIS and the beef industry heeded my call.  It is time to do the same with Salmonella.

Here is a link to a PowerPoint from a presentation I gave a few days ago – https://www.slideshare.net/marlerclark/2021-british-columbia-food-safety-speech

It was in an Op-ed in the Denver Post on August 4, 2002, entitled, “Four steps to safer food.”  Here it is in full:

This summer, scores of Americans, most of them small children or senior citizens, have already or will become deathly ill after eating ground beef boldly labeled “USDA approved.”

The now infamous ConAgra case started with a few sick kids in Colorado and quickly spread coast-to-coast, eventually triggering the recall of 18 million pounds of ground beef tainted with E. coli.

Now we know that this recall came weeks late, after most of that meat had been consumed by innocent consumers from Washington State to New Jersey. Because they trusted government’s food inspections, several kids suffered kidney failure and spent days or weeks hooked up to kidney dialysis machines. For some, the long-term prognosis is grim, with the risk of further kidney failure, dialysis, transplants or worse. I know this because I am a trial lawyer who has built a practice on food pathogens. Many of those kids’ parents have hired me to help them get compensation for hundreds of thousands in medical costs. Which may prompt some readers to consider me a blood-sucking ambulance chaser who exploits other people’s personal tragedies.

If that’s the case, here’s my plea:

Put me out of business. Please.

For this trial lawyer, E. coli has been a successful practice – and a heart-breaking one. I’m tired of visiting with horribly sick kids who did not have to be sick in the first place. I’m outraged with a food industry that allows E. coli and other poisons to reach consumers, and a federal regulatory system that does nothing about it.

Stop making kids sick – and I’ll happily move on. Here’s how:

Actually inspect and sample food. At present, the U.S. Department of Agriculture employs thousands of inspectors across the nation to inspect hundreds of plants that produce millions of pounds of beef at processing plants and retail outlets. The General Accounting Office has warned that the USDA’s food samplings are so scattered and infrequent that there is little chance of detecting microscopic E. coli or any other pathogen.

So hire more inspectors and give them real authority to sample meat and stop its distribution as soon as a pathogen is detected. Implement a sampling system that provides a reasonable chance of preventing another outbreak.

Doing so might add a nickel a pound – maybe less – to the price of hamburger. But it will also cut into my business. And isn’t that the idea?

Consider mandatory recall authority. This authority was required in Sen. Tom Harkin’s Safer Meat, Poultry and Foods Act of 2002. Under the present system of voluntary recalls, no company has actually refused to recall contaminated product. But in its recent report, the GAO did document several instances where companies delayed complying with recall requests. Delays mean tainted product has more time to reach consumers.

Require the meat industry to document where specific lots of food are sold. That way, it can be recalled quickly if a pathogen is detected. In most E. coli outbreaks, there is no recall because retailers don’t know where the meat came from and processors rarely step forward. ConAgra deserves credit for owning up to its responsibility to track down as much of the tainted meat as possible and for covering the medical costs of its victims.

But ConAgra is the exception. Timely online records would allow meat to be efficiently tracked down and recalled as soon as inspectors get a positive test result. Those plastic club cards issued by grocery chains could enable stores to contact specific individuals who have bought suspect ground beef. Merge the two federal agencies responsible for food safety. Right now USDA’s Food Safety Inspection Service and the inspection arm of the Food and Drug Administration share this mission. The system is bifurcated, which leads to turf wars and split responsibilities. We need one independent agency that deals with food-borne pathogens.

None of this will stop E. coli entirely. This invisible poison has been around a long time and is bound to pop up again. But these steps will enable us to detect it far more quickly, to alert stores and families, and to keep our most vulnerable citizens – kids and seniors – out of harm’s way. And, with a little luck, it will force one more damn trial lawyer to find another line of work.

Here is me testifying before Congress in 2008.

Essentially, USDA/FSIS is treating Salmonella as an adulterant in this situation.

I mean, it is not a bad idea to protect school kids, but why the differences?

While you all were sleeping off your “turkey coma,” I was thinking about why Salmonella is not an adulterant by reading, Michael Ollinger, John Bovay, Casiano Benicio, and Joanne Guthrie. Economic Incentives to Supply Safe Chicken to the National School Lunch Program, ERR-202, U.S. Department of Agriculture, Economic Research Service, November 2015.

Here are the highlights:

The U.S. Department of Agriculture’s (USDA) National School Lunch Program (NSLP) provides subsidized and free meals to over 31 million qualified students across the United States each school day (USDA, FNS, 2013). Chicken is a major component of the meals served to students. Some of that chicken is purchased through typical commercial channels, but schools can also obtain it via the Poultry Products Purchase Program, which is administered by USDA’s Agricultural Marketing Service (AMS). The NSLP used about $9 million worth of raw and $240 million worth of processed chicken products in the 2009-10 school year (USDA, FNS, 2012). Most of the processed chicken used in the NSLP was purchased by AMS as raw product and then further processed by State agencies prior to distribution to schools. Like all chicken sold in interstate commerce, the chicken purchased by AMS for the NSLP must meet Federal food safety standards, including tolerances for Salmonella spp. established by the USDA’s Food Safety and Inspection Service (FSIS).

Proper cooking and handling of raw chicken can reduce the risk of foodborne illness by killing Salmonella and other pathogens. Nevertheless, Salmonella remains the second-most common
cause of foodborne illness in the United States, causing an estimated 1 million illnesses, 19,000 hospitalizations, and 380 deaths each year (Scallan et al., 2011). Schools generally use processed (precooked) products such as chicken nuggets, fajita strips, etc., in school meals (Hecht et al., 2008). Processing kills harmful pathogens if it involves cooking the meat to more than 165° Fahrenheit (Burr et al., 2005). Some school systems, however, contend that processing removes some control over the nutritional content of school meals, and purchase the raw commodity (Stanley and Conner, 2013).

Both raw and processed chicken products have been recalled in recent years for food safety reasons. Between 2009 and 2012, there were six recalls of processed chicken due to Salmonella contamination, amounting to nearly 8 million pounds. Processed chicken products have also been recalled due to contamination with Listeria monocytogenes, allergens, and other reasons. Additionally, Foster Farms recently recalled over 1 million pounds of raw chicken products due to excessive Salmonella. However, to our knowledge, there have been no product recalls of raw or processed chicken products purchased by AMS for the NSLP.

Previous research (Ollinger et al., 2014) showed that, from 2006 to 2012, ground beef sold to the NSLP performed better on Salmonella spp. tests than ground beef sold to the commercial market. AMS imposes a zero-tolerance standard for Salmonella spp. in ground beef, a higher standard than that required by FSIS for ground beef sold in general commerce. This may have incentivized suppliers of ground beef to the NSLP to be more diligent when fulfilling an AMS contract, but it also likely raised costs, since suppliers may have taken extra precautions to meet FSIS standards.

AMS does not impose stricter Salmonella tolerances for raw chicken sold to AMS for the NSLP relative to the FSIS standard. AMS selects the lowest cost bidder among all AMS-registered suppliers, as long as that bidder meets FSIS standards. The combined effect gives establishments an incentive to invest in food safety up to the point that the establishment just meets the FSIS standard. However, food recalls and other announcements about the safety of food products can affect demand and profit, leading to declines in the stock prices of implicated suppliers (Thomsen and McKenzie, 2001), and in some cases, bankruptcy (Andrews, 2012; Tavernise, 2013). A food safety recall from a school could be particularly costly because the NSLP is a highly visible program and subject to particular scrutiny, potentially resulting in a greater reputation loss than that which would occur in the commercial market for a similar event. Moreover, it may be easier to trace the AMS-purchased chicken served in schools to their suppliers than chicken sold in commercial markets, making a product recall more likely.

Traceability is the ability to identify the supply chain of a product. It enhances food safety because, if a food is linked to a foodborne illness outbreak or other public health threat, then the source can be identified and the producer can be managed by regulators and may be targeted by liability lawsuits. Traceability also helps pinpoint the location of products so they can be removed from the marketplace.

There are fewer AMS suppliers than suppliers in the broader commercial market since not all chicken plants are eligible to bid on AMS contracts. This smaller number of AMS suppliers facili- tates traceability because there are fewer possible sources, and public health officials can inspect shipping records to determine the suppliers most likely responsible for shipping food associated with outbreaks of foodborne illness. Traceability becomes more complicated if the school system buys identical products in the commercial market, since there are more suppliers.

This report investigates the food safety performance of suppliers of raw chicken purchased by
AMS for the NSLP. In particular, we examine whether concerns about reputation for food safety encourage AMS suppliers to outperform commercial-only suppliers on tests for Salmonella spp.
The results could have implications for the AMS purchase specifications and the FSIS food safety program and may help policymakers and private managers better understand the conditions under which stricter standards may be warranted, and those under which private incentives are sufficient to maintain food safety.

Some more recent papers with some interesting tidbits:

Ollinger, Michael, John Bovay. 2018. Pass or Fail: Economic Incentives to Reduce Salmonella Contamination in Ground Beef Sold to the National School Lunch Program. American Journal of Agricultural Economics.100:414–433, doi.org/10.1093/ajae/aax088

“… the incentives generated by the zero-tolerance standard for Salmonella are highly effective: ground beef supplied to the NSLP is 21–22 percentage points more likely to meet a zero-tolerance standard for Salmonella than ground beef tested as part of typical meat-plant inspections.”

Ollinger, Michael, Matthew Houser. 2020. Ground beef recalls and subsequent food safety performance. Food Policy.  97:101971, doi.org/10.1016/j.foodpol.2020.101971.

“The results show that plants have high Salmonella levels before and during the year of the recall and have much lower levels afterward.”

Ollinger, M. and Bovay, J. (2020), Producer Response to Public Disclosure of Food-Safety Information. Amer. J. Agr. Econ., 102: 186-201. doi.org/10.1093/ajae/aaz031

“We find that (1) announcements in 2003 and 2004 were associated with improved performance by the poorest-performing chicken-slaughter plants; (2) the introduction of an easily-understood measure of food-safety quality and the threat of disclosure of the identities of poorly performing plants in 2006 were associated with improved performance by all chicken-slaughter plants; and (3) implementation of a public disclosure program in 2008 was associated with improvements among better-performing chicken-slaughter plants.”

So, why zero-tolerance for Salmonella in ground beef at schools but not at the kids’ homes?

Baby Spinach

According to the CDC, as of November 15, 2021, a total of 10 people infected with the outbreak strain of E. coli O157:H7 have been reported from seven states. Illnesses started on dates ranging from October 15, 2021, to October 27, 2021. Sick people range in age from 2 to 71 years, with a median age of 26, and 70% are female. Of eight people with information available, two have been hospitalized. No deaths have been reported.

According to the NCBI database:

13 Isolates (11 clinical, 2 “Joisie’s Organic Baby Spinach”)

Group:  PDG000000004.2980

Cluster:  PDS000094499.76

Distance between selected isolates: minimum = 0 SNPs, maximum = 2 SNPs, average = 0 SNPs

Target creation date range: 2021-11-04 to 2021-11-19

Onions

According to the CDC, as of November 12, 2021, 892 people infected with the outbreak strain of Salmonella Oranienburg have been reported from 38 states and Puerto Rico. Illnesses started on dates ranging from May 31, 2021, to October 25, 2021. Sick people range in age from less than 1 year to 101 years, with a median age of 37, and 58% are female. Of 571 people with information available, 183 (32%) have been hospitalized.

According to the NCBI database:

961 isolates (960 clinical, 1 “mixed Produce”)

Group:  PDG000000002.2334

Cluster:  PDS000094913.45

Distance between selected isolates: minimum = 0 SNPs, maximum = 8 SNPs, average = 1 SNPs

Target creation date range: 2021-08-20 to 2021-11-19

Seafood

As of October 7, 2021, 102 people infected with the outbreak strain of Salmonella Thompson have been reported from 14 states. Most sick people are either Colorado residents or reported traveling to Colorado in the week before they got sick. Only two people did not report travel to Colorado in the week before they got sick. Illnesses started on dates ranging from May 11, 2021, to September 7, 2021. Sick people range in age from less than 1 to 85 years, with a median age of 39, and 53% are female. Of 89 people with information available, 19 have been hospitalized, and no deaths have been reported.

According the NCBI database:

168 Isolates (155 clinical, 13 “seafood manufacturer”)

Group  PDG000000002.2320

Cluster  PDS000032705.704

Distance between selected isolates: minimum = 0 SNPs, maximum = 4 SNPs, average = 1 SNPs

Target creation date range: 2020-07-07 to 2021-11-08

Remember this as you prepare Thanksgiving for your family and as you read this post – it is Food Safety and Inspection Service (FSIS) Mission Statement: Protecting the public’s health by ensuring the safety of meat, poultry, and processed egg products.

USDA/FSIS has the authority to deem Salmonella and other pathogens adulterants – they just need to use it.

In a few days millions of Americans will bring a food product (a turkey) into their homes that is likely teeming with Salmonella that the manufacturer – by law and with the USDA stamp of approval – knowingly can sell knowing that it may well be tainted with a pathogen that sickens over 1,000,000 yearly.  This is because USDA/FSIS does not consider Salmonella an adulterant.

Personally, as I said to the Los Angeles Times some time ago, “I think that anything that can poison or kill a person should be listed as an adulterant [in food].”

Ignoring Salmonella in meat makes little, if any, sense.

Even after the Court’s twisted opinion in Supreme Beef v. USDA, where it found Salmonella “not an adulterant per se, meaning its presence does not require the USDA to refuse to stamp such meat ‘inspected and passed’, ” our government’s failure to confront the reality of Salmonella, especially antibiotic-resistant Salmonella, is inexcusable.

The Wisconsin Supreme Court in Kriefall v Excel called it as it saw it – at least with respect to E. coli – but the analysis is spot on for Salmonella as well:

The E. coli strain that killed Brianna and made the others sick is a “deleterious substance which may render [meat] injurious to health.” There is no dispute about this. Thus, under the first part of 21 U.S.C. § 601(m)(1), meat that either “bears or contains” E. coli O157:H7 (the “deleterious substance”) is “adulterated.” That E. coli O157:H7 contamination can be rendered non-“injurious to health” by cooking thoroughly, as discussed below, does not negate this; Congress used the phrase “may render,” not “in every circumstance renders.” Moreover, if the E. coli bacteria is not considered to be “an added substance,” because it comes from some of the animals themselves and is not either applied or supplied during the slaughtering process (although we do not decide this), it cannot be said that the E. coli strain “does not ordinarily render [the meat on or in which it appears] injurious to health.” Accordingly, meat contaminated by E. coli O157:H7 is also “adulterated” under the second part of § 601(m)(1).

Now, why would Salmonella be different? According to the CDC, it is estimated that 1.4 million cases of salmonellosis occur each year in the United States. Of those cases, 95 percent are related to foodborne causes. Approximately 220 of each 1,000 cases result in hospitalization, and 8 of every 1,000 cases result in death. About 500 to 1,000 deaths – 31 percent of all food-related deaths – are caused by Salmonella infections each year.

So, where do we stand with the existing USDA/FSIS law on adulteration?

Here is the law:

21 U.S.C. § 601(m)(4) – SUBCHAPTER I – INSPECTION REQUIREMENTS; ADULTERATION AND MISBRANDING – CHAPTER 12 – MEAT INSPECTION – TITLE 21—FOOD AND DRUGS

(m) The term “adulterated” shall apply to any carcass, part thereof, meat or meat food product under one or more of the following circumstances:

(1) if it bears or contains any poisonous or deleterious substance which may render it injurious to health; but in case the substance is not an added substance, such article shall not be considered adulterated under this clause if the quantity of such substance in or on such article does not ordinarily render it injurious to health; …

(3) if it consists in whole or in part of any filthy, putrid, or decomposed substance or is for any other reason unsound, unhealthful, unwholesome, or otherwise unfit for human food;

(4) if it has been prepared, packed, or held under insanitary conditions whereby it may have become contaminated with filth, or whereby it may have been rendered injurious to health; …

Here is the law specifically related to poultry:

Title 21 – FOOD AND DRUGS CHAPTER 10 – POULTRY AND POULTRY PRODUCTS INSPECTION

(g) The term “adulterated” shall apply to any poultry product under one or more of the following circumstances:

(1) if it bears or contains any poisonous or deleterious substance which may render it injurious to health; but in case the substance is not an added substance, such article shall not be considered adulterated under this clause if the quantity of such substance in or on such article does not ordinarily render it injurious to health; …

(3) if it consists in whole or in part of any filthy, putrid, or decomposed substance or is for any other reason unsound, unhealthful, unwholesome, or otherwise unfit for human food;

(4) if it has been prepared, packed, or held under insanitary conditions whereby it may have become contaminated with filth, or whereby it may have been rendered injurious to health;

Hmmm. It is hard to read the above and not think that the words equate to all E. coli as well as Salmonella — frankly, all pathogens in food.

I know, I am just a lawyer, but don’t ya think that when food with animal feces (and a dash of E. coli O157:H7) in it is considered an adulterant, that other animal feces (with dashes of other pathogens, like Salmonella) in them, should be considered adulterated too?  But, hey, that is just me.

Another odd governmental fact is that the FDA does not seem to make a distinction between pathogens it considers adulterants or not.

FDA’s enabling legislation – Sec. 402. [21 USC §342] of the Food, Drug & Cosmetic Act also defines “Adulterated Food” as food that is:

(a) Poisonous, insanitary, or deleterious ingredients.

(1) If it bears or contains any poisonous or deleterious substance which may render it injurious to health; but in case the substance is not an added substance such food shall not be considered adulterated under this clause if the quantity of such substance in such food does not ordinarily render it injurious to health;

(2) If it bears or contains any added poisonous or added deleterious substance … that is unsafe within the meaning of section 406;

(3) if it consists in whole or in part of any filthy, putrid, or decomposed substance, or if it is otherwise unfit for food;

(4) if it has been prepared, packed, or held under insanitary conditions whereby it may have become contaminated with filth, or whereby it may have been rendered injurious to health …

It would be interesting, and perhaps entertaining, to have House and Senate hearings focusing on what should and should not be considered adulterants in our food. I can see panels of scientists from various fields, FDA, USDA and FSIS officials, beef, poultry, fish and produce industry representatives, and consumers discussing this.

I would pay to watch it.

And so now onto some history to ruin your appetite.

In 1971 the American Public Health Association (APHA) sued the USDA on the grounds that its mark of inspection (“USDA inspected for wholesomeness”) was misleading because, even though the USDA had put its stamp of approval on meat—literally—it did not, for example, test the meat for bacteria. Moreover, APHA argued that raw meat was commonly contaminated with Salmonella, which posed a risk to the public health. According to APHA, the USDA should instead require that meat carry both a warning label and cooking instructions. The USDA opposed the APHA, helped ably (and predictably) by the meat industry. As quoted by Marion Nestle in her great book, Safe Food, the USDA’s position was that, given how many foods are contaminated with Salmonella, “it would be unjustified to single out the meat industry and ask that the [USDA] require it to identify its raw products as being hazardous to health.” Nestle at 66. (Note to Reader: No, I am really not making this up.)

In 1974, the DC Circuit Court of Appeals upheld the position of the USDA and the meat industry, doing so in a way that was as nonsensical as it was sexist. The court stated that: “The presence of salmonellae on meat does not constitute adulteration within this definition [of ‘adulterated,’ provided in 21 U.S.C. § 601 (m)]….As it said in its letter of August 18, 1971 ‘the American consumer knows that raw meat and poultry are not sterile and, if handled improperly, perhaps could cause illness.” In other words, American housewives and cooks normally are not ignorant or stupid and their methods of preparing and cooking of food do not ordinarily result in salmonellosis.’” APHA v. Butz, 511 F.2d 331, 334 (1974).

This remained the position of the USDA and the meat industry until 1994 when, in an act of both common-sense and bravado, Michael Taylor, then FSIS Administrator, announced that E. coli O157:H7 would be deemed an adulterant in raw ground beef. The Agency did not, however, change its tune with regard to any other pathogens, especially Salmonella. Indeed, in 1999, when FSIS announced it inane distinction between E. coli O157:H7 in “intact” meat versus “non-intact” meat, the Agency continued to focus on how a given meat was “customarily cooked” as a chief determinant of whether it must be treated as an adulterant. Thus, for example, because it decided that “intact steaks and roasts are customarily cooked in a manner that ensures that these products are not contaminated with E. coli O157:H7,” there was no need to treat this deadly pathogen as an adulterant on intact cuts of meat. Of course, this FSIS policy is also one that appears to have been silently jettisoned by the Agency of late.

The Agency’s position on Salmonella and meat came back to haunt it in a big way when FSIS tried to shut down Supreme Beef Processors, Inc. for repeatedly failing Salmonella performance standards that, according to the Agency, was proof that the ground beef being made there was being processed under “insanitary conditions.” Supreme Beef sued the USDA and not only won an injunction, but it succeeded in having the Salmonella regulations struck down as being “beyond the authority granted the Secretary [of the USDA] by the Federal Meat Inspection Act.” Supreme Beef v. USDA, 275 F.3d 432, 434 (5th Cir. 2001). Explaining its holding, the Court wrote:

The difficulty in this case arises, in part, because Salmonella, present in a substantial proportion of meat and poultry products, is not an adulterant per se, 21 meaning its presence does not require the USDA to refuse to stamp such meat “inspected and passed.” 22 This is because normal cooking practices for meat and poultry destroy the Salmonella organism, 23 and therefore the presence of Salmonella in meat products does not render them “injurious to health” 24 for purposes of § 601(m)(1). Salmonella-infected beef is thus routinely labeled “inspected and passed” by USDA inspectors and is legal to sell to the consumer.

Supreme Beef, 275 F.2d at 438-39. And, of course, not surprisingly, the court in this case was quick to cite the decision in APHA v. Butz, and to note that even now the “USDA agrees that Salmonella is not an adulterant per se.” Id. at 439 n. 21.

In my view the Supreme Beef decision is poorly reasoned and ill-informed. (For example, could not someone at the Court figure out that it is impossible for meat to be “infected” with Salmonella, and the proper term here is “contaminated”?) But the real lesson of Supreme Beef is that the USDA was, and continues to be, an Agency that is unable to decide whose side it is on. Sometimes it puts on its public safety hat, and sometimes—actually, most often—it puts on its pro-meat industry hat. And, unfortunately, these roles are too often contradictory. That is why USDA policy when it comes to meat safety is also too often contradictory.

Perhaps it is just time for the FSIS to take the the position that all pathogens that can kill you in meat are adulterants.  You have the authority – you just need to use it.

Let the meat industry sue you.  I know a good lawyer to defend you.

Happy Thanksgiving.

Last week the Camden County New Jersey Health Department reported that it had been notified by a health care provider that a food handler employed at a Starbucks at 1490 Blackwood Clementon Road in Gloucester Township tested positive for hepatitis A and worked through the infectious period. On Wednesday, Nov. 17, the Department of Health was notified that a patient tested positive for hepatitis A and an investigation was instantly commissioned. Based on the investigation and out of an abundance of caution, the Department of Health recommends any member of the public that patronized the Starbucks facility on Nov. 4, 5, 6, 11, 12 and 13 to get the hepatitis A vaccine.

Based on this exposure, the Department of Health will set up a hepatitis A vaccine clinic to administer shots for patrons starting last Saturday at the Camden County Sustainable Facility at 508 Lakeland Road. Tomorrow’s clinic will operate from 3 p.m. to 7 p.m. and on Saturday morning from 9 a.m. to 11:30 a.m. Vaccine appointments will be made on a first come first serve basis.

It was reported today that as many as 4,000 customers may have been exposed.

How soon we forget.

In July 2019, a hepatitis A (HAV) outbreak was discovered in New Jersey linked to Mendham Golf and Tennis Club at 2 Golf Lane in Mendham Township, New Jersey. On July 2, the Morris County Office of Health Management and the New Jersey Department of Health were informed of a positive HAV case who was a food handler at the Mendham Golf and Tennis Club, and an investigation was launched. That day, the club was inspected and documents from Club management were collected. On July 3, it was decided that club members should be notified of potential transmission and asked to seek medical attention if any symptoms were noted.

Cases were notified of their possible exposure on July 5. A total of 26 cases, secondary to the index case, were identified. Symptom onset dates ranged from July 11 to August 7, 2019. Eleven cases were hospitalized – one with a liver transplant, and one case died. Cases were located from three counties and two neighboring states. Cases ranged from 23 to 85 years old (median 54). The majority were male (73%). Eight cases reported dining at the facility multiple times. Only two cases were reported to have received the recommended post-exposure prophylaxis (PEP). No subtype testing was done to analyze the genetic relationship between case infections, so outbreak analyses were primarily based on epidemiological evidence.

The New Jersey Department of Health ultimately ascribed this outbreak to an infected, seasonal food handler at Mendham Golf & Tennis Club. This case’s symptoms started on June 24, 2019, and he was excluded from work on June 30. It was calculated that exposures to this case may have occurred between June 9 and June 30, which would mean that the last date by which affected individuals could receive post-exposure prophylaxis (PEP) would be on July 14, 2019. Unvaccinated cases who dined between June 9 and June 30 were asked to receive PEP by July 14. Patrons who visited the club when the infectious food handler worked were asked to inform any dining companions of the possible exposure to HAV to receive PEP as well. On August 30, 2019, the outbreak was considered over by the New Jersey Department of Health.

Last night the Camden County New Jersey Health Department reported that it had been notified by a health care provider that a food handler employed at a Starbucks at 1490 Blackwood Clementon Road in Gloucester Township tested positive for hepatitis A and worked through the infectious period. On Wednesday, Nov. 17, the Department of Health was notified that a patient tested positive for hepatitis A and an investigation was instantly commissioned. Based on the investigation and out of an abundance of caution, the Department of Health recommends any member of the public that patronized the Starbucks facility on Nov. 4, 5, 6, 11, 12 and 13 to get the hepatitis A vaccine.

Based on this exposure, the Department of Health will set up a hepatitis A vaccine clinic to administer shots for patrons starting tomorrow at the Camden County Sustainable Facility at 508 Lakeland Road. Tomorrow’s clinic will operate from 3 p.m. to 7 p.m. and on Saturday morning from 9 a.m. to 11:30 a.m. Vaccine appointments will be made on a first come first serve basis.

It was reported today that as many as 4,000 customers may have been exposed.

In 2000, I wrote this:

In light of the recent, large-scale Hepatitis A exposure in the San Francisco Bay Area, food safety attorneys of the Seattle-based law firm of Marler Clark, are asking restaurants and food manufacturers to voluntarily vaccinate all workers against Hepatitis A. “In the last six months Hepatitis A exposures have been linked to two Seattle-area Subways, a Carl’s Jr. in Spokane, WA, Hoggsbreath, a Minnesota restaurant, and three restaurants in Northwest Arkansas, IHOP, U.S. Pizza, and Belvedeers. Now more than seven- hundred children are being vaccinated against this potentially deadly virus in California after possible consumption of contaminated strawberries. Furthermore, this isn’t the first time that strawberries have been implicated in the outbreak of a foodborne disease.” Marler continued, “Restaurants and food manufacturers must take action and voluntarily vaccinate all of their employees.”

Sound familiar?

Hardly a week goes by that there is not yet another announcement of a hepatitis A positive employee putting co-workers, customers and the restaurant brand at risk.  There have been illnesses, deaths, thousands of customers have had to stand in long lines to get preventative vaccines, some restaurants have shuttered and there certainly have been lawsuits.  Over that last decades restaurants and insurance companies have paid 10’s of millions of dollars to Marler Clark clients.

In Roanoke, Virginia a month ago, 1 hepatitis A ill employee at Famous Anthony’s restaurant transmitted this human fecal virus that has sickened at least 52, hospitalizing 37, including 1 liver transplant and 3 deaths.

All preventable by a hepatitis A vaccination – the only foodborne illness that is vaccine preventable.

So, here is my offer Starbucks – offer hepatitis A vaccinations to all present and future employees and I will agree to consult with you for $1.00 and conflict Marler Clark from being on the opposite side of the courtroom – forever!

This seems like an “offer you can’t refuse.”

Whether or not you take me up on my offer, consider offering to vaccinate your employees anyway – be a food safety leader.  In addition to being the right thing to do, it is good for your employees, your customers, your brand – and, for taking money out of my pocket.

Hepatitis A is usually spread when a person ingests fecal matter, even in microscopic amounts, from contact with objects, food, or drinks contaminated by the feces or stool of an infected person. Signs and symptoms of hepatitis A can include the following:

  • Fever
  • Fatigue
  • Loss of appetite
  • Nausea
  • Vomiting
  • Abdominal discomfort
  • Dark urine
  • Clay-colored bowel movement
  • Joint pain
  • Jaundice (yellowing of the skin or eyes)

Symptoms of the disease surface two to four weeks after exposure, although they can in some instances occur two to seven weeks after exposure. Children under six years of age with hepatitis A often do not have or show few signs and symptoms.

Hepatitis A is a contagious liver disease that results from infection with the hepatitis A virus. It can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months.

Last week the USDA Food Safety and Inspection Service (FSIS) announced a recall of ground turkey products due to “possible” Salmonella contamination. According to the press release, “Cargill Meat Solutions Corporation, a Springdale, Ark. establishment, is recalling approximately 36 million pounds of ground turkey products that may be contaminated with a multi-drug resistant strain of Salmonella Heidelberg.”

The release goes on: “This recall follows a July 29, 2011 FSIS Public Health Alert that was initiated due to concerns about illnesses caused by Salmonella Heidelberg that may be associated with use and consumption of ground turkey. A total of 79 persons infected with the outbreak strain of Salmonella Heidelberg have been reported from 26 states between March 1 and August 3, 2011. The outbreak strain of Salmonella Heidelberg is resistant to several commonly prescribed antibiotics.”

This recall was, for me, surprising but positive news — surprising, and somewhat inexplicable, given the USDA’s long-held position that Salmonella is not an adulterant per se in raw meat. You see, the meat industry got a court to invalidate Salmonella performance standards that the USDA tried to implement as part of the Pathogen Reduction, HACCP regulations adopted in 1996.

So when I read about this recall, my first thought was to wonder why Cargill agreed to it. (Remember: USDA’s Food Safety and Inspection Service lacks the statutory authority to compel a recall.) And my second thought was: I wonder if the meat industry will sue the USDA to try to prevent the agency from seeking a recall in the future based on possible Salmonella contamination.

I obviously cannot answer either of these questions. But I can provide some useful background information about why this particular recall is so surprising, and so inexplicable. (And, by the way, by inexplicable I mean it is nearly impossible to explain how FSIS could take this action in light of 25 years worth of policy and court decisions that would appear to suggest it has no authority to do what it did. The recall is certainly NOT inexplicable from a public health and safety perspective, which is certainly ironic given the fact that the FSIS has the term “safety” in its name, and doing something in favor of safety should not be inexplicable.)

So now on to some history:

In 1971, the American Public Health Association (APHA) sued the USDA on the grounds that its mark of inspection (“inspected for wholesomeness”) was misleading because, even though the USDA had put its stamp of approval on meat — literally — it did not, for example, test the meat for bacteria. Moreover, APHA argued that raw meat was commonly contaminated with Salmonella, which posed a risk to the public health. According to APHA, the USDA should instead require that meat carry both a warning label and cooking instructions. The USDA opposed the APHA, helped ably (and predictably) by the meat industry. As quoted by Marion Nestle in her great book, “Safe Food,” the USDA’s position was that, given how many foods are contaminated with Salmonella, “it would be unjustified to single out the meat industry and ask that the [USDA] require it to identify its raw products as being hazardous to health.” (Note to readers: No, really, I am not making this up.)

In 1974, the D.C. Circuit Court of Appeals upheld the position of the USDA and the meat industry, doing so in a way that was as nonsensical as it was sexist. The court stated that: “The presence of salmonellae on meat does not constitute adulteration within this definition [of ‘adulterated,’ provided in 21 U.S.C. ¬ß 601 (m)]….As it said in its letter of August 18, 1971 ‘the American consumer knows that raw meat and poultry are not sterile and, if handled improperly, perhaps could cause illness.’ In other words, American housewives and cooks normally are not ignorant or stupid and their methods of preparing and cooking of food do not ordinarily result in salmonellosis.’” APHA v. Butz, 511 F.2d 331, 334 (1974).

This remained the position of the USDA and the meat industry until 1994 when, in an act of both commonsense and bravado, Michael Taylor, then FSIS Administrator, announced that E. coli O157:H7 would be deemed an adulterant in raw ground beef. The Agency did not, however, change its tune with regard to any other pathogens, especially Salmonella. Indeed, in 1999, when FSIS announced its inane distinction between E. coli O157:H7 in “intact” meat versus “non-intact” meat, the Agency continued to focus on how a given meat was “customarily cooked” as a chief determinant of whether the pathogen must be treated as an adulterant. Thus, for example, because it decided that “intact steaks and roasts are customarily cooked in a manner that ensures that these products are not contaminated with E. coli O157:H7,” there was no need to treat this deadly pathogen as an adulterant on intact cuts of meat. Of course, this FSIS policy is also one that appears to have been silently jettisoned by the Agency of late.

The Agency’s position on Salmonella and meat came back to haunt it in a big way when FSIS tried to shut down Supreme Beef Processors, Inc. for repeatedly failing Salmonella performance standards that, according to the Agency, were proof that the ground beef being made there was being processed under “insanitary conditions.” Supreme Beef sued the USDA and not only won an injunction, but it succeeded in having the Salmonella regulations struck down as being “beyond the authority granted the Secretary [of the USDA] by the Federal Meat Inspection Act.” Supreme Beef v. USDA, 275 F.3d 432, 434 (5th Cir. 2001).

Explaining its holding, the Court wrote:

The difficulty in this case arises, in part, because Salmonella, present in a substantial proportion of meat and poultry products, is not an adulterant per se, meaning its presence does not require the USDA to refuse to stamp such meat “inspected and passed.” This is because normal cooking practices for meat and poultry destroy the Salmonella organism, and therefore the presence of Salmonella in meat products does not render them “injurious to health” for purposes under the law. Salmonella-infected beef is thus routinely labeled “inspected and passed” by USDA inspectors and is legal to sell to the consumer.

Not surprisingly, the court in this case was quick to cite the decision in APHA v. Butz, and to note that even now the “USDA agrees that Salmonella is not an adulterant per se.”

In my view, the Supreme Beef decision is poorly reasoned and ill-informed. (For example, it is impossible for meat to be “infected” with Salmonella; the proper term here is “contaminated.”) But the real lesson of Supreme Beef is that the USDA was, and continues to be, an Agency that is unable to decide whose side it is on. Sometimes it puts on its public safety hat, and sometimes — actually, most often — it puts on its pro-meat industry hat. And, unfortunately, these roles are too often contradictory. That is why USDA policy, when it comes to meat safety, is also too often contradictory.

So how does the USDA square last week’s recall of Salmonella-contaminated meat with the last 25 years of Agency policy on meat adulteration standards? It cannot. But let us hope that if the meat industry decides to sue to scuttle what appears to be a new and better policy on Salmonella in meat, that this time the USDA decides to stand with the public on the side of meat safety.

Or, perhaps it is just time for the FSIS to take the position that all pathogens in meat that can kill are adulterants.  Let the meat industry sue you.  I know a good lawyer to defend you.

Or, as I have said before:

Personally, as I said to the Los Angeles Times some time ago, “I think that anything that can poison or kill a person should be listed as an adulterant [in food].”

Ignoring Salmonella in meat makes little, if any, sense. Even after the Court’s twisted opinion in Supreme Beef v. USDA, where it found Salmonella “not an adulterant per se, meaning its presence does not require the USDA to refuse to stamp such meat ‘inspected and passed’, ” our government’s failure to confront the reality of Salmonella, especially antibiotic-resistant Salmonella, is inexcusable.

The Wisconsin Supreme Court in Kriefall v Excel called it as it saw it:

The E. coli strain that killed Brianna and made the others sick is a “deleterious substance which may render [meat] injurious to health.” There is no dispute about this. Thus, under the first part of 21 U.S.C. § 601(m)(1), meat that either “bears or contains” E. coli O157:H7 (the “deleterious substance”) is “adulterated.” That E. coli O157:H7 contamination can be rendered non-“injurious to health” by cooking thoroughly, as discussed below, does not negate this; Congress used the phrase “may render,” not “in every circumstance renders.” Moreover, if the E. coli bacteria is not considered to be “an added substance,” because it comes from some of the animals themselves and is not either applied or supplied during the slaughtering process (although we do not decide this), it cannot be said that the E. coli strain “does not ordinarily render [the meat on or in which it appears] injurious to health.” Accordingly, meat contaminated by E. coli O157:H7 is also “adulterated” under the second part of § 601(m)(1).

Now, why would Salmonella be different? According to the CDC, it is estimated that 1.4 million cases of salmonellosis occur each year in the United States. Of those cases, 95 percent are related to foodborne causes. Approximately 220 of each 1,000 cases result in hospitalization, and 8 of every 1,000 cases result in death. About 500 to 1,000 deaths – 31 percent of all food-related deaths – are caused by Salmonella infections each year.

So, where do we stand with the existing USDA/FSIS law on adulteration?  Here is the law:

21 U.S.C. § 601(m)(4) – SUBCHAPTER I – INSPECTION REQUIREMENTS; ADULTERATION AND MISBRANDING – CHAPTER 12 – MEAT INSPECTION – TITLE 21—FOOD AND DRUGS

(m) The term “adulterated” shall apply to any carcass, part thereof, meat or meat food product under one or more of the following circumstances:

(1) if it bears or contains any poisonous or deleterious substance which may render it injurious to health; but in case the substance is not an added substance, such article shall not be considered adulterated under this clause if the quantity of such substance in or on such article does not ordinarily render it injurious to health; …

(3) if it consists in whole or in part of any filthyputrid, or decomposed substance or is for any other reason unsound, unhealthfulunwholesome, or otherwise unfit for human food;

(4) if it has been prepared, packed, or held under insanitary conditions whereby it may have become contaminated with filth, or whereby it may have been rendered injurious to health; …

Hmmm. It is hard to read the above and not think that the words in bold equate to all E. coli and Salmonella — frankly, all pathogens in food. I know, I am just a lawyer, but don’t ya think that when food with animal feces (and a dash of E. coli O157:H7) in it is considered an adulterant, that other animal feces (with dashes of other pathogens, like Salmonella) in them, should be considered adulterated too?  But, hey, that is just me. Another odd governmental fact is that the FDA does not seem to make a distinction between pathogens it considers adulterants or not. FDA’s enabling legislation – Sec. 402. [21 USC §342] of the Food, Drug & Cosmetic Act also defines “Adulterated Food” as food that is: 

(a) Poisonous, insanitary, or deleterious ingredients.

(1) If it bears or contains any poisonous or deleterious substance which may render it injurious to health; but in case the substance is not an added substance such food shall not be considered adulterated under this clause if the quantity of such substance in such food does not ordinarily render it injurious to health;

(2) If it bears or contains any added poisonous or added deleterious substance … that is unsafe within the meaning of section 406;

(3) if it consists in whole or in part of any filthy, putrid, or decomposed substance, or if it is otherwise unfit for food;

(4) if it has been prepared, packed, or held under insanitary conditions whereby it may have become contaminated with filth, or whereby it may have been rendered injurious to health …

It would be interesting, and perhaps entertaining, to have House and Senate hearings focusing on what should and should not be considered adulterants in our food. I can see panels of scientists from various fields, FDA, USDA and FSIS officials, beef and produce industry representatives, and consumers discussing this. I would pay to watch it.

Being in Washing D. C. for a week made me wonder – what the hell have we been doing for the last decade?

It is time to take the gloves off – FSIS, the petition to deem 31 Salmonella as adulterants is long past due – FSIS-2020-0007-0001_attachment_1

The alternative is a lawsuit that you will lose – Letter to Ms. Eskin 11.12.21 – FINAL

Well, my flight to DC was delayed – no pilots – and this press release landed in my inbox.  I have known Dr, Esteban for a long time and look forward to his leadership.

WASHINGTON, Nov. 12, 2021 — “Dr. Esteban has a deep understanding of USDA’s commitment to protect the health of the public by providing food safety. Having held several leadership roles in USDA’s Food Safety and Inspection Service (FSIS), he has a proven, and extensive, track record on this key issue.

Dr. Esteban started his tenure at USDA FSIS in 2001 and held the roles of Laboratory Director for the Western Laboratory, Scientific Advisor for Laboratory Services and Research Coordination, and Executive Associate for Laboratory Services. In 2018, he was appointed Chief Scientist of the Food Safety and Inspection Service. In his role, Dr. Esteban provides scientific advice to support Agency policies including the disciplines of microbiology, chemistry, and pathology. Prior to joining USDA, Dr. Esteban worked at the Centers for Disease Control and Prevention as an Epidemic Intelligence Service Officer, Staff Epidemiologist, and Assistant Director of the Food Safety Office.

He currently serves as the Chair for the Codex Alimentarius Commission Committee on Food Hygiene, the committee where international food hygiene standards are defined for international trade. He is also currently vice president of the International Association for Food Protection (IAFP).

Trained as a veterinarian in Mexico, Dr. Esteban supplemented his training with an MBA, a master’s degree in Preventive Veterinary Medicine, and a PhD in Epidemiology from University of California, Davis.

As we continue to push forward our commitment to create a safe, sustainable, competitive U.S. food and fiber system, Dr. Esteban’s leadership will be invaluable to our team.”

Dr. J. Emilio Esteban was appointed as Chief Scientist of the U.S. Department of Agriculture Food Safety and Inspection Service (FSIS) in August 2018. In this capacity, Dr. Esteban serves as the primary scientific advisor on matters of public health and food safety that affect the mission of the Agency, with primary responsibility for scientific initiatives within the Office of Public Health Science (OPHS). Dr. Esteban’s efforts directly support FSIS’ Strategic Goals 1: Prevent Foodborne Illness and Protect Public Health, and 2: Modernize Inspection Systems, Policies, and the Use of Scientific Approaches.

In 2002, Dr. Esteban joined OPHS as the Director of the Western Laboratory. In this role, he directed the implementation of the sampling program and was responsible for the physical plant, equipment and personnel infrastructure. In 2008, he was appointed as the FSIS Science Advisor for Laboratory Services, where he harmonized the operation of all three FSIS laboratories, maintained operations to meet with the ISO17025 standard and coordinated emergency response.

Prior to joining FSIS, Dr. Esteban worked in several positions at the Centers for Disease Control and Prevention (CDC). From 1994 to 2002, he was as an Epidemic Intelligence Service Officer; a Staff Epidemiologist in the National Center for Environmental Health; and an Assistant Director for the CDC Food Safety Office.

He received his Doctorate in Veterinary Medicine from Mexico’s National University, a Master of Business Administration Degree from the Panamerican Institute, and a Master of Preventive Veterinary Medicine Degree, as well as a Doctorate in Epidemiology from the University of California at Davis.

Alison Graham and the Roanoke Times told a story of an unnecessary hepatitis A outbreak.  Thanks for doing the story.

The Vests spent the last few weeks of their 40-year marriage in and out of the hospital.

At first, Larry Vest, 77, ran a low fever and felt tired. After a few tests at his doctor, he went to the emergency room and was diagnosed with hepatitis A. He stayed at Carilion Roanoke Memorial Hospital for 19 days while his wife Dianne, 78, visited him and cared for their home.

When Larry left the hospital, he spent one day with his wife before she started to experience the same symptoms and left for the hospital in an ambulance.

She went into a coma-like state within a few days and died Oct. 26.

“The family survived the pandemic with no major issues only to be devastated by a public health issue that could have just been avoided,” Dianne’s son Tim O’Leary said.

The Vests are just one local family affected by the recent hepatitis A outbreak in the Roanoke Valley, which has been linked to three Famous Anthony’s restaurants — on Grandin Road Extension, Williamson Road and Crystal Spring Avenue.

An employee who worked at all three locations tested positive for the virus. So far, there have been 52 confirmed cases, 31 hospitalizations and three deaths. James Hamlin, a Roanoke County man, died Oct. 8 from hepatitis A complications.

Like the Hamlins, Larry and Dianne Vest ate at Famous Anthony’s frequently. They visited the Williamson Road location, across the street from their church, two times during the period the employee was contagious.

Larry is currently recovering and doing well, but O’Leary said the family will be forever changed.

“What we had, two months ago, were two healthy parents enjoying their life together and doing the things they like to do,” he said. “And that all came to a screeching halt because someone did not want to practice basic hygiene.”

Disease spreads

Hepatitis A is a virus that causes liver inflammation, which can prevent the organ from functioning normally.

The liver is responsible for turning food and drink into energy and nutrients. It also removes harmful substances from the blood and helps fight off infections.

According to the American Liver Foundation, hepatitis A is most commonly spread by not washing hands before preparing or eating food or not washing hands after using the bathroom or changing a diaper.

The virus is spread through fecal to oral transmission, which means a person ingests fecal matter, usually in microscopic amounts invisible to the eye. People can also contract the virus from using drugs with others, certain types of sexual contact or caring for someone who has the virus.

When someone contracts hepatitis A, they can experience fatigue, nausea, vomiting, abdominal pain, clay-colored bowel movements, loss of appetite, low grade fever, dark urine, joint pain, intense itching and jaundice, or yellowing of the skin and eyes.

Symptoms can take weeks to develop after the initial exposure, which means people sometimes don’t know they are contagious or have the virus before spreading it. Roanoke City and Alleghany Health Districts director Cynthia Morrow said because of how long it takes for patients to show symptoms, the infectious period is often over before the health department is aware that someone is infected.

That happened in the case of Famous Anthony’s. Morrow said it’s hard to know for certain where any one individual was infected outside of an outbreak, but the department had no reason to believe that wherever the employee was initially exposed is a public threat.

She said once the department suspected the restaurant could be implicated in the transmission of the virus, officials completed an inspection. She said there was nothing that raised any alarms or would require a closure or cleaning.

Attorney Sean Workowski issued the following statement on behalf of Famous Anthony’s: “The Famous Anthony’s staff and employees wish to express their most heartfelt concern and sympathy to all the families and individuals in our community that have been affected by this unforeseen, lamentable event. Upon notification by the Roanoke and Alleghany Health District officials of a possible hepatitis A exposure … we have cooperated fully with the health department’s investigation and adhered to all recommendations to ensure the continued safe and healthy operation of all locations for our many loyal customers.”

Famous Anthony’s attorneys declined a request to interview the restaurant’s owner or answer any further questions due to pending litigation.

Hepatitis A is vaccine preventable. The U.S. Food and Drug Administration has licensed two hepatitis A vaccines and one combination vaccine that protects against both Hepatitis A and B. The first vaccine was licensed in 1995, and since then, rates of hepatitis A have declined dramatically in the U.S. Since 2006, the hepatitis A vaccine has been recommended for all children at age one and is sometimes required by schools. But this means many adults have not been vaccinated.

The Centers for Disease Control and Prevention identified unprecedented widespread outbreaks of hepatitis A in the U.S. in 2016. Since then, more than 40,000 cases have been reported and at least 400 deaths. Many of the cases have been among people who are the most at risk, including those who use drugs or people who are experiencing homelessness.

Morrow said the district has seen an uptick in vaccines since the local outbreak and vaccinated as many as 45 people in one day.

O’Leary said when his stepfather Larry Vest went to the hospital with symptoms, no one told his mother she should get vaccinated or asked if she was potentially exposed. He said he wished someone had asked her questions or told her to see a doctor. But soon enough, it was too late.

“This family has been wrecked,” he said. “It’s simple handwashing that has caused devastation to at least 50 families.”

Outbreaks across Virginia

Mindy Perdue, 40, made many memories at Famous Anthony’s. She and her parents used to eat at the Williamson Road location every Saturday before she went bowling. Occasionally, they hosted family gatherings there and on other days, she visited the restaurant with her husband of 13 years.

In August, she ordered a gravy biscuit combo from the Famous Anthony’s on Grandin Road Extension. Within a few weeks, a migraine and fever set in. She started to throw up and went to the emergency room. They suspected it might be COVID-19, gave her fluids and sent her home.

Eventually, she threw up again and saw blood. She went to work and her temperature hit 100 degrees. She went home and spent a few days resting, but when she returned, her coworkers said she looked yellow. She drove herself straight to the emergency room and spent four days in the hospital.

Perdue became the first person to file a lawsuit with Seattle attorney Bill Marler, who is now representing 25 families, including the Vests and the Hamlins.

Perdue said she was out of work for weeks and has hospital and lab bills stacking up that she needs to pay. She has since returned to work, but still experiences residual pain and is waiting for her body to return to normal.

“I didn’t have to get sick,” Perdue said. “I almost died because of it. It changed my life and it still has.”

Marler has represented hundreds of people across the country in hepatitis A outbreaks. He represented about 50 people, some from Virginia, in an outbreak linked to strawberries at a Tropical Smoothie Café in 2016. The frozen strawberries, imported from Egypt, infected 143 people in nine states. More than 50 were hospitalized, but there were no deaths, according to the Centers for Disease Control and Prevention. Virginia accounted for the majority of cases with 109 people infected.

The Mount Rogers Health District, which includes Galax and Carroll, Grayson, Bland and Wythe counties in southwestern Virginia, has reported the most hepatitis A cases in the state — more than 150 cases since January 2019.

In 2019, an employee at Cheddar’s Scratch Kitchen in Bristol was diagnosed with hepatitis A. And in 2020, an employee at Taco Bell in Chilhowie was also diagnosed with the virus.

Breanne Forbes Hubbard, population health manager at the health district, said those two restaurant-related outbreaks caused many cases in her district, but there have also been increases among the substance use community. The area has been hit hard by the opioid epidemic and the department has worked to do contact tracing in that population.

The health district offered vaccine clinics and worked with local restaurants on proper protocols to stop the spread.

She said food service workers are not at a greater risk of contracting the virus, but they are at a higher risk of spreading it. She said handwashing is the best way to stop the spread beyond vaccination.

“We were telling people you shouldn’t eat at a restaurant if you’re not vaccinated against hepatitis A,” she said. “All it takes is one time of someone not washing their hands well.”

Slow recovery

LouAnn and Harvey Howell set out on a mission to get healthier. They joined Weight Watchers and started going to Famous Anthony’s every week to order salads.

They ate at the restaurant seven Fridays in a row — three times during the period when the employee was contagious. LouAnn ordered a taco salad and Harvey ordered a chef salad.

In mid-September, Harvey ran a high fever and felt incredibly sick. He went to an urgent care clinic and they gave him a COVID-19 test, which came back negative. A few days later, his fever still raged on and he started dry heaving. He called his wife to come home from work and they went to the hospital.

By then, Harvey’s eyes and skin had turned yellow and the hospital staff issued a sepsis alert and rushed him into the emergency room, he said. Within a few hours, they had diagnosed him with hepatitis A and made plans to transfer him to another hospital where he could get a liver transplant.

“There’s not much I could focus on, but when I heard that it scared me,” he said. “That’s when I realized this is really serious.”

For days, Harvey hallucinated. He insisted to the doctors that he had previously had a lung transplant, which is not true. And in one case, he thought he saw a bug on the wall that wasn’t there and was adamant when his wife and the nurses told him he was wrong.

His wife LouAnn packed a bag and kept it in her car in case he was transferred to a different hospital for an organ transplant. But eventually, he started to stabilize and a transplant was no longer necessary. He spent a week in the hospital before he returned home.

Since then, his recovery has been slow. Even small tasks take all of his energy and he can hardly eat anything. He’s on short term disability while he waits out the symptoms and for his liver to fully recover. He lost almost 40 pounds in a matter of weeks.

“I feel like I’ve been sick for seven months, not seven weeks,” he said. “It’s incredibly depressing and weighs heavy on you. You think about all the stuff you’re supposed to be doing, need to be doing, but you can’t do any of it.”

His doctor said he might have long-term scarring or damage to his liver, but he will eventually be able to carry on a normal life. LouAnn said she spends most of her days making sure he continues to eat, stay hydrated and gets to his doctor appointments.

Every two weeks, he goes to get blood drawn and they hold their breath waiting for the results. They’ve been told that a full recovery could take six to nine months.

“I’m nothing like I was before this,” Harvey said. “It’s just gonna be different from now on. Lord willing I will recover and get back to some semblance of life someday.”

The National Center for Biotechnology Information (NCBI) shows:

Seafood

168 Isolates (155 clinical, 13 “seafood manufacturer”)

Distance between selected isolates: minimum = 0 SNPs, maximum = 4 SNPs, average = 1 SNPs

Target creation date range: 2020-07-07 to 2021-11-08

seafood 11_10_2021 – Full Tree

Onions

872 isolates (871 clinical, 1 “mixed produce”)

Group: PDG000000002.2326

Cluster: PDS000094913.38

Distance between selected isolates: minimum = 0 SNPs, maximum = 8 SNPs, average = 1 SNPs

Target creation date range: 2021-08-20 to 2021-11-08

mixed produce – Full Tree