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THE E. COLI O157:H7 BACTERIA

Sources, Characteristics, and Identification

Escherichia coli (E. coli) is an archetypal commensal bacterial species that lives in mammalian intestines. E. coli O157:H7 is one of thousands of serotypes E. coli.[1] The combination of letters and numbers in the name of E. coli O157:H7 refers to the specific antigens (proteins which provoke an antibody response) found on the body, as well as on the tail, or flagellum,[2] and distinguish it from other types of E. coli.[3] Most serotypes of E. coli are harmless and live as normal flora in the intestines of healthy humans and animals.[4]

The E. coli bacterium is among the most extensively studied microorganisms.[5] The testing to distinguish E. coli O157:H7 from its other E. coli counterparts is called serotyping.[6] Pulsed-field gel electrophoresis (PFGE),[7] sometimes also referred to as genetic fingerprinting, is used to compare E. coli O157:H7 isolates to one another to determine if the strains are distinguishable.[8] A technique called multilocus variable number of tandem repeats analysis (MLVA) is used to determine precise classification when it is difficult to differentiate between isolates with indistinguishable or very similar PFGE patterns.[9]

The E. coli O157:H7 Bacteria

E. coli O157:H7 was first recognized as a pathogen in 1982 during an investigation into an outbreak of hemorrhagic colitis[10] associated with consumption of hamburgers from a fast food chain restaurant.[11] Retrospective examination of more than three thousand E. coli cultures obtained between 1973 and 1982 found only one (1) isolation with serotype O157:H7, and that was a case in 1975.[12] In the ten (10) years that followed there were approximately thirty (30) outbreaks recorded in the United States.[13] This number is likely misleading, however, because E. coli O157:H7 infections did not become a reportable disease in any state until 1987, when Washington became the first state to mandate its reporting to public health authorities.[14] As a result, only the most geographically concentrated outbreak would have garnered enough notice to prompt further investigation.[15]

E. coli O157:H7’s ability to induce injury in humans is a result of its ability to produce numerous virulence factors—most notably, Shiga-like toxins (SLT).[16] Shiga toxin (Stx) has multiple variants (e.g. Stx1, Stx2, Stx2c), and acts like the plant toxin ricin by inhibiting protein synthesis in endothelial and other cells.[17] Shiga toxin is one of the most potent toxins known.[18] In addition to Shiga toxins, E. coli O157:H7 produces numerous other putative virulence factors including proteins, which aid in the attachment and colonization of the bacteria in the intestinal wall and that can lyse red blood cells to liberate iron that helps support E. coli metabolism.[19]

E. coli O157:H7 evolved from enteropathogenic E. coli serotype O55:H7, a cause of non-bloody diarrhea, through the sequential acquisition of phage-encoded Stx2, a large virulence plasmid, and additional chromosomal mutations.[20] The rate of genetic mutation of E. coli O157:H7 indicates that the common ancestor of current E. coli O157:H7 clades[21] likely existed some 20,000 years ago.[22] E. coli O157:H7 is a relentlessly evolving organism[23], constantly mutating and acquiring new characteristics, including virulence factors that make the emergence of more dangerous variants a constant threat.[24] The CDC has emphasized the prospect of emerging pathogens as a significant public health threat for some time.[25]

Although foods of a bovine origin are the most common cause of both outbreaks and sporadic cases of E. coli O157:H7 infections,[26] outbreak of illnesses have been linked to a wide variety of food items. For example, produce has, since 1991, been the source of substantial numbers of outbreak-related E. coli O157:H7 infections.[27] Other unusual vehicles for E. coli O157:H7 outbreaks have included unpasteurized juices, yogurt, dried salami, mayonnaise, raw milk, game meats, sprouts, and raw cookie dough.[28]

According to a recent study, an estimated 93,094 illnesses are caused by domestically acquired E. coli O157:H7 each year in the United States.[29] It is estimated that foodborne acquired O157:H7 cases result in 2,138 hospitalizations and 20 deaths annually.[30]

The colitis caused by E. coli O157:H7 is characterized by severe abdominal cramps, diarrhea that typically turns bloody within twenty-four hours, and sometimes fevers.[31] The incubation period—which is to say the time from exposure to the onset of symptoms—in outbreaks is usually reported as three to four days, but may be as short as one day or as long as ten days.[32] Infection can occur in people of all ages but is most common in children.[33] The duration of an uncomplicated illness can range from one to twelve days.[34] Although the rate of death is 0-2 percent in reported outbreaks, in outbreaks that involve the elderly, like those that have occurred in nursing homes, the rate of death can run as high as 16-35%.[35]

What makes E. coli O157:H7 remarkably dangerous is its very low infectious dose,[36] and how relatively difficult it is to kill the bacteria.[37] Unlike Salmonella, for example, which usually requires something approximating an “egregious food handling error, E. coli O157:H7 in ground beef that is only slightly undercooked can result in infection,”[38] as few as twenty organisms may be sufficient to infect a person and, as a result, possibly kill them.[39] And unlike generic E. coli, the O157:H7 serotype multiplies at temperatures up to 44°F, survives freezing and thawing, is heat resistant, grows at temperatures up to 111°F, resists drying, and can survive exposure to acidic environments.[40]

And, finally, to make it even more of a threat, E. coli O157:H7 bacteria are easily transmitted by person-to-person contact.[41] There is also the serious risk of cross-contamination between raw meat and other food items intended to be eaten without cooking. Indeed, a principle and consistent criticism of the USDA E. coli O157:H7 policy is the fact that it has failed to focus on the risks of cross-contamination versus that posed by so-called improper cooking.[42] With this pathogen, there is ultimately no margin of error. It is for this precise reason that the USDA has repeatedly rejected calls from the meat industry to hold consumers primarily responsible for E. coli O157:H7 infections caused, in part, by mistakes in food handling or cooking.[43]

Hemolytic Uremic Syndrome (HUS)

E. coli O157:H7 infections can lead to a severe, life-threatening complication called hemolytic uremic syndrome (“HUS”).[44] HUS accounts for the majority of the acute and chronic illness and death caused by E coli bacteria.[45] HUS occurs in 2-7% of victims who are primarily children, with onset occurring five to ten days after diarrhea begins.[46] HUS is the most common cause of renal failure in children.[47] Approximately half of the children who suffer HUS require dialysis, and at least 5% of those who survive have long-term renal impairment.[48] The same number suffers severe brain damage.[49] While somewhat rare, serious injury to the pancreas, resulting in death or the development of diabetes, can also occur.[50] There is no cure or effective treatment for HUS.[51] And, tragically, as too many parents can attest, children with HUS too often die.[52]

HUS is believed to develop when SLT from the bacteria enters circulation in the body through the inflamed bowel wall.[53] SLT, and most likely other chemical mediators, attach to receptors on the inside surface of blood vessel cells (endothelial cells) and initiate a chemical cascade that results in the formation of tiny thrombi (blood clots) within these vessels.[54] Some organs seem more susceptible, perhaps due to the presence of increased numbers of receptors, and include the kidney, pancreas, and brain.[55] By definition, when fully expressed, HUS presents with the triad of hemolytic anemia (destruction of red blood cells), thrombocytopenia (low platelet count), and renal failure (loss of kidney function).[56]

As already noted, there is no known therapy to halt the progression of HUS. HUS is a frightening complication that even in the best American medical centers has a notable mortality rate.[57] Among survivors, at least five percent will suffer end stage renal disease (ESRD) with the resultant need for dialysis or transplantation.[58] But “[b]ecause renal failure can progress slowly over decades, the eventual incidence of ESRD cannot yet be determined.”[59] Other long-term problems include the risk for hypertension, proteinuria (abnormal amounts of protein in the urine that can portend a decline in renal function), and reduced kidney filtration rate.[60] Since the longest available follow-up studies of HUS victims are twenty-five years, an accurate lifetime prognosis is not really available and remains controversial.[61] All that can be said for certain is that HUS causes permanent injury, including loss of kidney function, and it requires a lifetime of close medical monitoring.

Irritable Bowel Syndrome

A recently-published study surveyed the extant scientific literature and noted that post-infectious irritable bowel syndrome (PI-IBS) is a common clinical phenomenon first-described over five decades ago.[62] The Walkerton Health Study further notes that:

Between 5% and 30% of patients who suffer an acute episode of infectious gastroenteritis develop chronic gastrointestinal symptoms despite clearance of the inciting pathogens.[63]

In terms of its own data, the “study confirm[ed] a strong and significant relationship between acute enteric infection and subsequent IBS symptoms.”[64] The WHS also identified risk-factors for subsequent IBS, including: younger age; female sex; and four features of the acute enteric illness—diarrhea for > 7days, presence of blood in stools, abdominal cramps, and weight loss of at least ten pounds.[65]

Irritable bowel syndrome (IBS) is a chronic disorder characterized by alternating bouts of constipation and diarrhea, both of which are generally accompanied by abdominal cramping and pain.[66] In one recent study, over one-third of IBS sufferers had had IBS for more than ten years, with their symptoms remaining fairly constant over time.[67] IBS sufferers typically experienced symptoms for an average of 8.1 days per month.[68]

As would be expected from a chronic disorder with symptoms of such persistence, IBS sufferers required more time off work, spent more days in bed, and more often cut down on usual activities, when compared with non-IBS sufferers.[69] And even when able to work, a significant majority (67%), felt less productive at work because of their symptoms.[70] IBS symptoms also have a significantly deleterious impact on social well-being and daily social activities, such as undertaking a long drive, going to a restaurant, or taking a vacation.[71] Finally, although a patient’s psychological state may influence the way in which he or she copes with illness and responds to treatment, there is no evidence that supports the theory that psychological disturbances in fact cause IBS or its symptoms.[72]

[1]           E. coli bacteria were discovered in the human colon in 1885 by German bacteriologist Theodor Escherich.  Feng, Peter, Stephen D. Weagant, Michael A. Grant, Enumeration of Escherichia coli and the Coliform Bacteria, in BACTERIOLOGICAL ANALYTICAL MANUAL (8th Ed. 2002), http://www.cfsan.fda.gov/~ebam/bam-4.html. Dr. Escherich also showed that certain strains of the bacteria were responsible for infant diarrhea and gastroenteritis, an important public health discovery. Id. Although the bacteria were initially called Bacterium coli, the name was later changed to Escherichia coli to honor its discoverer. Id.

[2]           Not all E. coli are motile. For example, E. coli O157:H7 which lack flagella are thus E. coli O157:NM for non-motile.

[3]           CDC, Escherichia coli O157:H7, General Information, Frequently Asked Questions: What is Escherichia coli O157:H7?, http://www.cdc.gov/ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm.

[4]           Marion Nestle, Safe Food:  Bacteria, Biotechnology, and Bioterrorism, 40-41 (1st Pub. Ed. 2004).

[5]           James M. Jay, MODERN FOOD MICROBIOLOGY at 21 (6th ed. 2000). (“This is clearly the most widely studied genus of all bacteria.”)

[6]           Beth B. Bell, MD, MPH, et al. A Multistate Outbreak of Escherichia coli O157:H7-Associated Bloody Diarrhea and Hemolytic Uremic Syndrome from Hamburgers:  The Washington Experience, 272 JAMA (No. 17) 1349, 1350 (Nov. 2, 1994) (describing the multiple step testing process used to confirm, during a 1993 outbreak, that the implicated bacteria were E. coli O157:H7).

[7]           Jay, supra note 5, at 220-21 (describing in brief the PFGE testing process).

[8]           Id.  Through PFGE testing, isolates obtained from the stool cultures of probable outbreak cases can be compared to the genetic fingerprint of the outbreak strain, confirming that the person was in fact part of the outbreak. Bell, supra note 6, at 1351-52. Because PFGE testing soon proved to be such a powerful outbreak investigation tool, PulseNet, a national database of PFGE test results was created.  Bala Swaminathan, et al.  PulseNet:  The Molecular Subtyping Network for Foodborne Bacterial Disease Surveillance, United States, 7 Emerging Infect. Dis. (No. 3) 382, 382-89 (May-June 2001) (recounting the history of PulseNet and its effectiveness in outbreak investigation).

[9]           Konno T. et al.  Application of a multilocus variable number of tandem repeats analysis to regional outbreak surveillance of Enterohemorrhagic Escherichia coli O157:H7 infections. Jpn J Infect Dis. 2011 Jan; 64(1): 63-5.

[10]          “[A] type of gastroenteritis in which certain strains of the bacterium Escherichia coli (E. coli) infect the large intestine and produce a toxin that causes bloody diarrhea and other serious complications.”  The Merck Manual of Medical Information, 2nd Home Ed. Online, http://www.merck.com/mmhe/sec09/ch122/ch122b.html.

[11]          L. Riley, et al.  Hemorrhagic Colitis Associated with a Rare Escherichia coli Serotype, 308 New. Eng. J. Med. 681, 684-85 (1983) (describing investigation of two outbreaks affecting at least 47 people in Oregon and Michigan both linked to apparently undercooked ground beef).  Chinyu Su, MD & Lawrence J. Brandt, MD, Escherichia coli O157:H7 Infection in Humans, 123 Annals Intern.  Med. (Issue 9), 698-707 (describing the epidemiology of the bacteria, including an account of its initial discovery).

[12]          Riley, supra note 11 at 684. See also Patricia M. Griffin & Robert V. Tauxe, The Epidemiology of Infections Caused by Escherichia coli O157:H7, Other Enterohemorrhagic E. coli, and the Associated Hemolytic Uremic Syndrome, 13 Epidemiologic Reviews 60, 73 (1991).

[13]          Peter Feng, Escherichia coli Serotype O157:H7:  Novel Vehicles of Infection and Emergence of Phenotypic Variants, 1 Emerging Infect. Dis. (No. 2), 47, 47 (April-June 1995) (noting that, despite these earlier outbreaks, the bacteria did not receive any considerable attention until ten years later when an outbreak occurred 1993 that involved four deaths and over 700 persons infected).

[14]          William E. Keene, et al.  A Swimming-Associated Outbreak of Hemorrhagic Colitis Caused by Escherichia coli O157:H7 and Shigella Sonnei, 331 New Eng. J. Med. 579 (Sept. 1, 1994).  See also Stephen M. Ostroff, MD, John M. Kobayashi, MD, MPH, and Jay H. Lewis, Infections with Escherichia coli O157:H7 in Washington State:  The First Year of Statewide Disease Surveillance, 262 JAMA (No. 3) 355, 355 (July 21, 1989).  (“It was anticipated the reporting requirement would stimulate practitioners and laboratories to screen for the organism.”)

[15]          See Keene, supra note 14 at 583. (“With cases scattered over four counties, the outbreak would probably have gone unnoticed had the cases not been routinely reported to public health agencies and investigated by them.”)  With improved surveillance, mandatory reporting in 48 states, and the broad recognition by public health officials that E. coli O157:H7 was an important and threatening pathogen, there were a total of 350 reported outbreaks from 1982-2002. Josef M. Rangel, et al.  Epidemiology of Escherichia coli O157:H7 Outbreaks, United States, 1982-2002, 11 Emerging Infect. Dis. (No. 4) 603, 604 (April 2005).

[16]          Griffin & Tauxe supra note 12, at 61-62 (noting that the nomenclature came about because of the resemblance to toxins produced by Shigella dysenteries).

[17]          Sanding K, Pathways followed by ricin and Shiga toxin into cells, Histochemistry and Cell Biology, vol. 117, no. 2:131-141 (2002). Endothelial cells line the interior surface of blood vessels.  They are known to be extremely sensitive to E. coli O157:H7, which is cytotoxigenic to these cells making them a primary target during STEC infections.

[18]          Johannes L, Shiga toxins—from cell biology to biomedical applications.  Nat Rev Microbiol 8, 105-116 (February 2010).  Suh JK, et al.  Shiga Toxin Attacks Bacterial Ribosomes as Effectively as Eucaryotic Ribosomes, Biochemistry, 37 (26); 9394–9398 (1998).

[19]          Welinder-Olsson C, Kaijser B.  Enterohemorrhagic Escherichia coli (EHEC).  Scand J. Infect Dis. 37(6-7): 405-16 (2005).  See also USDA Food Safety Research Information Office E. coli O157:H7 Technical Fact Sheet:  Role of 60-Megadalton Plasmid (p0157) and Potential Virulence Factors, http://fsrio.nal.usda.gov/document_fsheet.php?product_id=225.

[20]          Kaper JB and Karmali MA.  The Continuing Evolution of a Bacterial Pathogen.  PNAS vol. 105 no. 12 4535-4536 (March 2008).  Wick LM, et al.  Evolution of genomic content in the stepwise emergence of Escherichia coli O157:H7.  J Bacteriol 187:1783–1791(2005).

[21]          A group of biological taxa (as species) that includes all descendants of one common ancestor.

[22]          Zhang W, et al.  Probing genomic diversity and evolution of Escherichia coli O157 by single nucleotide polymorphisms. Genome Res 16:757–767 (2006).

[23]          Robins-Browne RM. The relentless evolution of pathogenic Escherichia coli.  Clin Infec Dis. 41:793–794 (2005).

[24]          Manning SD, et al. Variation in virulence among clades of Escherichia coli O157:H7 associated with disease outbreaks. PNAS vol. 105 no. 12 4868-4873 (2008).  (“These results support the hypothesis that the clade 8 lineage has recently acquired novel factors that contribute to enhanced virulence.  Evolutionary changes in the clade 8 subpopulation could explain its emergence in several recent foodborne outbreaks; however, it is not clear why this virulent subpopulation is increasing in prevalence.”)

[25]          Robert A. Tauxe, Emerging Foodborne Diseases: An Evolving Public Health Challenge, 3 Emerging Infect. Dis. (No. 4) 425, 427 (Oct.-Dec. 1997).  (“After 15 years of research, we know a great deal about infections with E. coli O157:H7, but we still do not know how best to treat the infection, nor how the cattle (the principal source of infection for humans) themselves become infected.”)

[26]          CDC, Multistate Outbreak of Escherichia coli O157:H7 Infections Associated with Eating Ground Beef—United States, June-July 2002, 51 MMWR 637, 638 (2002) reprinted in 288 JAMA (No. 6) 690 (Aug. 14, 2002).

[27]          Rangel, supra note 15, at 605.

[28]          Feng, supra note 13, at 49. See also USDA Bad Bug Book, Escherichia coli O157:H7, http://www.fda.gov/food/foodsafety/foodborneillness/foodborneillnessfoodbornepathogensnaturaltoxins/badbugbook/ucm071284.htm.

[29]          Scallan E, et al.  Foodborne illness acquired in the United States –major pathogens, Emerging Infect. Dis. Jan. (2011), http://www.cdc.gov/EID/content/17/1/7.htm.

[30]          Id., Table 3.

[31]          Griffin & Tauxe supra note 12, at 63.

[32]          Centers for Disease Control, Division of Foodborne, Bacterial and Mycotic Diseases, Escherichia coli general information, http://www.cdc.gov/nczved/dfbmd/disease_listing/stec_gi.htmlSee also PROCEDURES TO INVESTIGATE FOODBORNE ILLNESS, 107 (IAFP 5th Ed. 1999) (identifying incubation period for E. coli O157:H7 as “1 to 10 days, typically 2 to 5”).

[33]          Su & Brandt, supra note 11 (“the young are most often affected”).

[34]          Tauxe, supra note 25, at 1152.

[35]          Id.

[36]          Griffin & Tauxe supra note 12, at 72. (“The general patterns of transmission in these outbreaks suggest that the infectious dose is low.”)

[37]          V.K. Juneja, O.P. Snyder, A.C. Williams, and B.S. Marmer, Thermal Destruction of Escherichia coli O157:H7 in Hamburger, 60 J. Food Prot. (vol. 10). 1163-1166 (1997) (demonstrating that, if hamburger does not get to 130°F, there is no bacterial destruction, and at 140°F, there is only a 2-log reduction of E. coli present).

[38]          Griffin & Tauxe supra note 12, at 72 (noting that, as a result, “fewer bacteria are needed to cause illness that for outbreaks of salmonellosis”). Nestle, supra note 4, at 41. (“Foods containing E. coli O17:H7 must be at temperatures high enough to kill all of them.”) (italics in original)

[39]          Patricia M. Griffin, et al.  Large Outbreak of Escherichia coli O157:H7 Infections in the Western United States:  The Big Picture, in RECENT ADVANCES IN VEROCYTOTOXIN-PRODUCING ESCHERICHIA COLI INFECTIONS, at 7 (M.A. Karmali & A. G. Goglio eds. 1994).  (“The most probable number of E. coli O157:H7 was less than 20 organisms per gram.”)  There is some inconsistency with regard to the reported infectious dose.  Compare Chryssa V. Deliganis, Death by Apple Juice:  The Problem of Foodborne Illness, the Regulatory Response, and Further Suggestions for Reform, 53 Food Drug L.J. 681, 683 (1998) (“as few as ten”) with Nestle, supra note 4, at 41 (“less than 50”). Regardless of these inconsistencies, everyone agrees that the infectious dose is, as Dr. Nestle has put it, “a miniscule number in bacterial terms.”  Id.

[40]          Nestle, supra note 4, at 41.

[41]          Griffin & Tauxe supra note 12, at 72. The apparent “ease of person-to-person transmission…is reminiscent of Shigella, an organism that can be transmitted by exposure to extremely few organisms.”  Id.  As a result, outbreaks in places like daycare centers have proven relatively common.  Rangel, supra note 15, at 605-06 (finding that 80% of the 50 reported person-to-person outbreak from 1982-2002 occurred in daycare centers).

[42]          See, e.g. National Academy of Science, Escherichia coli O157:H7 in Ground Beef: Review of a Draft Risk Assessment, Executive Summary, at 7 (noting that the lack of data concerning the impact of cross-contamination of E. coli O157:H7 during food preparation was a flaw in the Agency’s risk-assessment), http://www.nap.edu/books/0309086272/html/.

[43]          Kriefall v. Excel, 265 Wis.2d 476, 506, 665 N.W.2d 417, 433 (2003).  (“Given the realities of what it saw as consumers’ food-handling patterns, the [USDA] bored in on the only effective way to reduce or eliminate food-borne illness”—i.e., making sure that “the pathogen had not been present on the raw product in the first place.”)  (Citing Pathogen Reduction, 61 Fed. Reg. at 38966).

[44]          Griffin & Tauxe, supra note 10, at 65-68. See also Josefa M. Rangel, et al., Epidemiology of Escherichia coli O157:H7 Outbreaks, United States, 1982-2002, 11 Emerging Infect. Dis. (No. 4) 603 (April 2005) (noting that HUS is characterized by the diagnostic triad of hemolytic anemia—destruction of red blood cells, thrombocytopenia—low platelet count, and renal injury—destruction of nephrons often leading to kidney failure); Richard L. Siegler, MD, The Hemolytic Uremic Syndrome, 42 Ped. Nephrology, 1505 (Dec. 1995) (noting that the diagnostic triad of hemolytic anemia, thrombocytopenia, and acute renal failure was first described in 1955).

[45]          Siegler, supra note 35 at 1505. (“[HUS] is now recognized as the most frequent cause of acute renal failure in infants and young children.”) See also Beth P. Bell, MD, MPH, et al., Predictors of Hemolytic Uremic Syndrome in Children During a Large Outbreak of Escherichia coli O157:H7 Infections, 100 Pediatrics 1, 1 (July 1, 1997), at http://www.pediatrics.org/cgi/content/full/100/1/e12.

[46]          Tauxe, supra note 17, at 1152. See also Nasia Safdar, MD, et al., Risk of Hemolytic Uremic Syndrome After Treatment of Escherichia coli O157:H7 Enteritis: A Meta-analysis, 288 JAMA (No. 8) 996, 996 (Aug. 28, 2002).  (“E. coli serotype O157:H7 infection has been recognized as the most common cause of HUS in the United States, with 6% of patients developing HUS within 2 to 14 days of onset of diarrhea.”); Amit X. Garg, MD, MA, et al., Long-term Renal Prognosis of Diarrhea-Associated Hemolytic Uremic Syndrome: A Systematic Review, Meta-Analysis, and Meta-regression, 290 JAMA (No. 10) 1360, 1360 (Sept. 10, 2003). (“Ninety percent of childhood cases of HUS are…due to Shiga-toxin producing Escherichia coli.”)

[47]          Su & Brandt, supra note 9.

[48]          Safdar, supra note 37, at 996 (going on to conclude that administration of antibiotics to children with E. coli O157:H7 appeared to put them at higher risk for developing HUS).

[49]          Richard L. Siegler, MD, Postdiarrheal Shiga Toxin-Mediated Hemolytic Uremic Syndrome, 290 JAMA (No. 10) 1379, 1379 (Sept. 10, 2003).

[50]          Pierre Robitaille, et al., Pancreatic Injury in the Hemolytic Uremic Syndrome, 11 Pediatric Nephrology 631, 632 (1997) (“although mild pancreas involvement in the acute phase of HUS can be frequent”).

[51]          Safdar, supra note 37, at 996; see also Siegler, supra note 35, at 1379. (“There are no treatments of proven value, and care during the acute phase of the illness, which is merely supportive, has not changed substantially during the past 30 years.”)

[52]          Su & Brandt, supra note 9 (“the mortality rate is 5-10%”). See also Kriefall, 265 N.W.2d at 483 (“three-year old Brianna Kriefall died from food that everyone party to this appeal…recognize was cross-contaminated by E. coli O157:H7 bacteria from meat sold by Excel.”)

[53]          Garg, supra note 46 at 1360.

[54]          Id. Siegler, supra note, at 1509-11 (describing what Dr. Siegler refers to as the “pathogenic cascade” that results in the progression from colitis to HUS).

[55]          Garg, supra note 46 at 1360. See also Su & Brandt, supra note 11, at 700.

[56]          Garg, supra note 46 at 1360. See also Su & Brandt, supra note 11, at 700.

[57]          Siegler, supra note, at 1519 (noting that in a “20-year Utah-based population study, 5% dies, and an equal number of survivors were left with end-stage renal disease (ESRD) or chronic brain damage.”)

[58]          Garg, supra note 46 at 1366-67.

[59]          Siegler, supra note, at 1519.

[60]          Id. at 1519-20. See also Garg, supra at 1366-67.

[61]          Garg, supra note 46 at 1368.

[62]          J. Marshall, et al., Incidence and Epidemiology of Irritable Bowel Syndrome After a Large Waterborne Outbreak of Bacterial Dysentery, Gastro., 2006; 131;445-50 (hereinafter “Walkerton Health Study” or “WHS”). The WHS followed one of the largest E. coli O157:H7 outbreaks in the history of North America. Contaminated drinking water caused over 2,300 people to be infected with E. coli O157:H7, resulting in 27 recognized cases of HUS, and 7 deaths. Id. at 445.  The WHS followed 2,069 eligible study participants. Id.  For Salmonella specific references, see Smith, J.L., Bayles, D.O., Post-Infectious Irritable Bowel Syndrome: A Long Term Consequence of Bacterial Gastroenteritis, Journal of Food Protection. 2007:70(7);1762-1769.

[63]          Id. at 445 (citing multiple sources).

[64]          WHS, supra note 34, at 449.

[65]          Id. at 447.

[66]          A.P.S. Hungin, et al., Irritable Bowel Syndrome in the United States: Prevalence, Symptom Patterns and Impact, Aliment Pharmacol. Ther. 2005:21 (11); 1365-75.

[67]          Id.at 1367.

[68]          Id.

[69]          Id. at 1368.

[70]          Id.

[71]          Id.

[72]          Amy Foxx-Orenstein, DO, FACG, FACP, IBS—Review and What’s New, General Medicine 2006:8(3) (Medscape 2006) (collecting and citing studies). Indeed, PI-IBS has been found to be characterized by more diarrhea but less psychiatric illness with regard to its pathogenesis. See Nicholas J. Talley, MD, PhD, Irritable Bowel Syndrome: From Epidemiology to Treatment, from American College of Gastroenterology 68th Annual Scientific Meeting and Postgraduate Course (Medscape 2003).

11 with E. coli with 2 Dead in Utah

According to Food Safety News, the E. coli outbreak in southwest Utah that has already killed two is growing, and public health officials there have warned people to avoid consuming raw milk or recently purchased ground beef.

Officials with the Southwest Utah Public Health Department initially reported six victims in a July 3 health alert. As of Tuesday, 11 victims had been confirmed. The first victim was a 3-year-old boy who died in June. He and the other fatality, a 6-year-old girl, were not related but they lived in the same apartment building in Hildale.

The source of the outbreak in Hildale, UT, remains under investigation, according to health department spokesman David Heaton who is quoted in local media reports.

Heaton told the Salt Lake Tribune newspaper on Tuesday that the public alert about raw milk and “recently purchased ground beef” is a standard warning and that there is not a confirmed link to such products. He also told the newspaper there could be multiple sources for the E. coli, or the original patient could have contaminated food or surfaces, resulting in additional people becoming infected.

30 with E. coli prompt larger flour recall in Canada

E-COLI-300x200There are now 30 cases of E. coli O121 under investigation.

The Canadian Food Inspection Agency (CFIA) has added more brands to its recall list of flour and flour based products, over further fears of E. coli contamination.

“It is not safe to taste or eat raw dough or batter regardless of the type of flour used, as raw flour can be contaminated with harmful bacteria such as E. coli O121,” wrote the CFIA in a news release.

The latest recall includes durum atta flour, a flour used to make South Asian flatbreads, and sooji flour, which is used in Indian and Pakistani desserts.

Also added to the list are bread flours, including whole wheat and multigrain bread flours.

Although the bacteria may not cause contaminated food to look or smell spoiled, the CFIA says it can still make you sick.

Possible symptoms include nausea, vomiting, mild to severe abdominal cramps, and watery to bloody diarrhea.

The flour recall has been ongoing since April.

Ardent Mills has issued a recall on the following products:

– Creative Baker, all purpose flour, 10 kg: Lot codes containing: 6 285 SK and 2017 OC 11; 6 286 SK,and 2017 OC 12; 6 312 SK and 2017 NO 07; 6 313 SK and 2017 NO 08.

– Creative Baker, all purpose flour, 20 kg: Lot codes containing: 6 293 SK and 2017 OC 19; 6 309 SK and 2017 NO 04.

– Creative Baker, whole wheat flour, 20 kg: Lot codes containing: 6 280 SK and 2017 AL 06; 6 307 SK and 2017 MA 02; 6 308 SK and 2017 MA 03; 6 28622 10131 0

– Brodie, self raising cake & pastry flour, 1 kg: Lot codes containing: 6 313 548 and 2018 FB 08; 6 314 548 and 2018 FB 09.

– Brodie, self raising cake & pastry flour, 2.5 kg: Lot codes containing: 6 294 548 and 2018 JA 20; 6 294 548 and 2018 JA 21.

– Golden Temple, No. 1 fine durum atta flour blend, 9 kg: Lot codes containing: 6 286 548 and 2018 JA 12; 6 287 548 and 2018 JA 13; 6 299 548 and 2018 JA 25; 6 300 548 and 2018 JA 26.

– Golden Temple, durum atta flour blend, 9 kg: Lot codes containing: 6 286 548 and 2018 JA 12; 6 287 548 and 2018 JA 13; 6 299 548 and 2018 JA 25; 6 300 548 and 2018 JA 26.

– Golden Temple, atta wheat flour, 9 kg: Lot codes containing: 6 279 548 and 2018 JA 05; 6 280 548 and 2018 JA 06; 6 292 548 and 2018 JA; 18 6 293 548 and 2018 JA 19.

– Golden Temple, sooji creamy wheat, 2 kg: Lot codes containing: 6 293 548 and 2018 JA 19; 6 312 548 and 2018 FE 07; 6 313 548 and 2018 FE 08.

– Purity, wheatlets, 550 g: Lot codes containing: 6 317 548 and 2018 FE 12; 6 318 548 and 2018 FE 13.

– Robin Hood, all purpose flour, original, 1 kg: Lot codes containing: 6 312 548 and 2018 MA 07; 6 313 548 and 2018 MA 08.

– Robin Hood, all purpose flour, original, 2.5 kg: Lot codes containing: 6 278 548 and 2018 AL 04; 6 279 548 and 2018 AL 05; 6 280 548 and 2018 AL 06; 6 296 548 and 2018 AL 22; 6 297 548 and 2018 AL 23; 6 298 548 and 2018 AL 24; 6 310 548 and 2018 MA 05; 6 311 548 and 2018 MA 06 6 319 548 and 2018 MA 14.

– Robin Hood, all purpose flour, original, 5 kg: Lot codes containing: 6 305 548 and 2018 AL 30; 6 306 548 and 2018 MA 01; 6 317 548 and 2018 MA 12; 6 318 548 and 2018 MA 13.

– Robin Hood, all purpose flour, original, 10 kg: Lot codes containing: 6 292 548 and 2018 AL 18; 6 295 548 and 2018 AL 21; 6 298 548 and 2018 AL 24; 6 301 548 and 2018 AL 27; 6 305 548 and 2018 AL 30; 6 306 548 and 2018 MA 01; 6 308 548 and 2018 MA 03; 6 309 548 and 2018 MA 04; 6 312 548 and 2018 MA 07; 6 313 548 and 2018 MA 08; 6 314 548 and 2018 MA 09; 6 319 548 and 2018 MA 14.

– Robin Hood, all purpose flour, unbleached, 2.5 kg: Lot codes containing: 6 297 548 and 2018 AL 23; 6 298 548 and 2018 AL 24; 6 308 548 and 2018 MA 03; 6 309 548 and 2018 MA 04.

– Robin Hood, all purpose flour, unbleached, 5 kg: Lot codes containing: 6 302 548 and 2018 AL 28; 6 303 548 and 2018 AL 29; 6 304 548 and 2018 AL 30; 6 317 548 and 2018 MA 12.

– Robin Hood, all purpose flour, whole wheat, 2.5 kg: Lot codes containing: 6 285 548 and 2018 JA 11; 6 286 548 and 2018 JA 12; 6 295 548 and 2018 JA 21; 6 296 548 and 2018 JA 22; 6 309 548 and 2018 FE 04; 6 310 548 and 2018 FE 05.

– Robin Hood, best for bread flour homestyle, white, 5 kg: Lot codes containing: 6 303 548 and 2018 AL 29; 6 314 548 and 2018 MA 09; 6 316 548 and 2018 MA 11; 6 317 548 and 2018 MA 12.

E. coli O111 Recall Linked to Veal

Screen Shot 2017-05-04 at 5.36.09 PMMarcho Farms, Inc., a Souderton, Pa. establishment, is recalling approximately 5,620 pounds of boneless veal, and ground veal, beef and pork products that may be adulterated withnon-O157 Shiga toxin-producing E. coli (STEC) O111, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today.

The veal, beef and pork products were produced on April 11 and April 14, 2017. The following products are subject to recall: [View Labels (PDF Only)]

  • 60-lb.cases of “VEAL BONELESS TRIMMINGS HALAL” with case code “5398” and “MANFU. DATE” of “04/11/2017.”
  • 60-lb. cases of “VEAL TRIMMINGS USDA CHOICE” with case code “98” and “MANFU. DATE” of “04/11/17.”
  • 9-lb. cases of “VEAL, BEEF, PORK GROUND FOR MEATLOAF” with case code “3122” and “Sell By” date “05/05/17.”
  • 10-lb. cases of “VEAL, BEEF, PORK GROUND FOR MEATLOAF BULK PACK” with case code “3125.”

These items were distributed to retail stores and food service locations in Illinois, New York, North Carolina, Pennsylvania, South Carolina and Virginia.

The problem was discovered when the Illinois State Meat Inspection Service notified FSIS on May 2, 2017, about positive non-O157 Shiga toxin-producing E. coli (STEC) samples made with source material produced by Marcho Farms, Inc. There have been no confirmed reports of adverse reactions due to consumption of these products.

Non-O157 Shiga toxin-producing E. coli (STEC) outbreaks are rare, but tend to primarily be due to contaminated food and person-to-person transmission. Like E. coli O157:H7, non-O157 Shiga toxin-producing E. coli (STEC) is a potentially deadly bacterium that can cause dehydration, bloody diarrhea and abdominal cramps 2–8 days (3–4 days, on average) after exposure the organism. While most people recover within a week, some develop a type of kidney failure called hemolytic uremic syndrome (HUS). This condition can occur among persons of any age but is most common in children under 5-years old and older adults. It is marked by easy bruising, pallor, and decreased urine output. Persons who experience these symptoms should seek emergency medical care immediately.

FSIS and the company are concerned that some product may be frozen and in consumers’ freezers.

Consumers who have purchased these products are urged not to consume them.

Chicken & Rice Guys E. coli Outbreak Hits 15

The Boston Globe reported last night reported that an E. coli O157: H7 outbreak had shuttered three locations of the Chicken & Rice Guys, as well as its fleet of Middle Eastern food trucks, Boston health inspectors said Tuesday.

Today, that number jumped to 15 with at least 10 people hospitalized.

The department confirmed 15 cases of E. coli O157: H7 stemming from the Chicken & Rice Guys Allston location, which supplies food to the chain’s other outposts. The problems led to the suspension of its operating license.

The company’s four food trucks, which rotate locations around Greater Boston, were taken off the road Tuesday afternoon.

According to Boston Inspectional Services, the city received an anonymous complaint and opened an investigation Tuesday. Public health officials remained at the Allston site throughout the afternoon trying to determine a specific source of the outbreak.

E. coli Outbreak Linked to Soy Nut Butter Expands

Twenty-nine people infected with the outbreak strains of STEC O157:H7 have been reported from 12 states. Arizona 4, California 5, Florida 1, Illinois 1, Massachusetts 1, Maryland 1, Missouri 1, New Jersey 1, Oregon 9, Virginia, 2, Washington 2, and Wisconsin 1.

Illnesses started on dates ranging from January 4, 2017, to March 13, 2017. Ill people range in age from 1 to 57 years, with a median age of 8. Twenty-four (83%) of the 29 ill people are younger than 18 years. Among ill people, 59% are male. Twelve ill people have been hospitalized, and nine people developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported.

Laboratory testing found the outbreak strains of STEC O157:H7 in I.M. Healthy brand SoyNut Butter collected from the homes of ill people and from retail locations.

soynut-butter-productOn March 7, 2017, The SoyNut Butter Company recalled all varieties of I.M. Healthy SoyNut Butters and all varieties of I.M. Healthy Granola products. On March 10, 2017, The SoyNut Butter Company expanded its recall to include Dixie Diner’s Club brand Carb Not Beanit Butter. On March 23, 20/20 Lifestyle Yogurt Peanut Crunch Bars were recalled because they contain a recalled ingredient.

CDC recommends that consumers do not eat, and childcare centers, schools, and other institutions do not serve, any variety or size of I.M. Healthy brand SoyNut Butter, I.M. Healthy brand granola, Dixie Diner’s Club brand Carb Not Beanit Butter, or 20/20 Lifestyle Yogurt Peanut Crunch Bars, regardless of the date of purchase or the date listed on the container. Even if some of the product was eaten or served and no one got sick, throw the rest of it away. Put it in a sealed bag in the trash so that children, pets, or other animals can’t eat it.

Canada Health Announced E. coli Outbreak Tied to Flour

The Public Health Agency of Canada is collaborating with federal and provincial public health partners to investigate an outbreak of Escherichia coli, called E. coli O121 that has now been linked to Robin Hood All Purpose Flour, Original. The Canadian Food Inspection Agency (CFIA) has issued a food recall warning advising Canadians of the recalled product that has been distributed in British Columbia, Alberta, Saskatchewan, and Manitoba. The investigation is ongoing and it is possible that additional products linked to the outbreak investigation may be identified.

Canadians are advised not to use or eat any Robin Hood All Purpose Flour, Original sold in 10 kilogram bags with a code containing BB/MA 2018 AL 17 and 6 291 548 as these products may be contaminated with E. coli. For additional recall details, please consult CFIA’s recall notice. Restaurants and retailers are also advised not to sell or serve the recalled product, or any items that may have been prepared or produced using the recalled product.

This outbreak is a reminder that it is not safe to taste or eat raw dough or batter, regardless of the type of flour used as raw flour can be contaminated with harmful bacteria such as E. coli.

There have been 25 cases of E. coli O121 with a matching genetic fingerprint reported in four provinces: British Columbia (12), Saskatchewan (4), Alberta (4) and Newfoundland and Labrador (5). The illness onset dates range from November 2016 to late February 2017. Six individuals have been hospitalized. These individuals have recovered or are recovering. No deaths have been reported. The majority (54%) of the individuals who became ill are male with an average age of 24 years.

The Canadian Food Inspection Agency has issued a food recall warning for Robin Hood All Purpose Flour, Original linked to this outbreak. During the food safety investigation, samples of Robin Hood flour were collected and did test positive for E. coli O121. Several individuals who became ill reported having contact with Robin Hood flour. The investigation is ongoing and it is possible that additional products linked to the outbreak investigation may be identified.

Update: Soy Nut Butter E. coli Outbreak

The CDC this morning updated the E. coli O157:H7 outbreak linked to I.M. Healthy and Dixie Dew Soy Nut Butter to twenty-three people infected with the outbreak strains of E. coli O157:H7 from nine states. Arizona 4, California 5, Maryland 1, Missouri 1, New Jersey 1, Oregon 6, Virginia 2, Washington 2, Wisconsin 1.

Illnesses started on dates ranging from January 4, 2017, to March 5, 2017. Ill people range in age from 1 to 48 years, with a median age of 8. Twenty (87%) of the 23 ill people are younger than 18 years. Among ill people, 61% are male. Ten ill people have been hospitalized and seven people developed hemolytic uremic syndrome (HUS), a type of kidney failure. No deaths have been reported. Illnesses that occurred after February 24, 2017, might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported.

In interviews, ill people or their family members answered questions about the foods they ate and other exposures in the week before they became ill. Twenty (87%) of the 23 people reached for interview reported either eating I.M. Healthy brand SoyNut Butter at home (14 people) in the week before they became ill, attending a facility that served I.M. Healthy brand SoyNut Butter (2 people), or attending childcare centers that served I.M. Healthy brand SoyNut Butter and I.M. Healthy brand granola coated with SoyNut Butter (4 people). SoyNut Butter is a nut-free substitute for peanut butter. Investigators have reported to CDC two more ill people who either developed HUS or had test showing they were infected with the E. coli O157:H7 bacteria.

Laboratory testing identified E. coli O157:H7 in opened containers of I.M. Healthy brand SoyNut Butter collected from the homes of ill people in California, Oregon, and Washington. Officials in California also isolated E. coli O157:H7 in unopened containers of I.M. Healthy brand SoyNut Butter collected from retail locations. Further testing using pulsed-field gel electrophoresis (PFGE) showed that the E. coli O157:H7 in all of these containers of SoyNut Butter had the same DNA fingerprints as the E. coli O157:H7 isolates from ill people.

Boneless Beef Recalled Over E. coli

H & B Packing Co., Inc., a Waco, Texas establishment, is recalling approximately 73,742 pounds of boneless beef products that may be contaminated with E. coli O103, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today.

The boneless beef items were produced on March 6, 2017. The following products are subject to recall:

  • 60-lb. box containing boneless beef with case code 69029 and production date 03/06/17.
  • Multiple combo bins containing 73,682-lbs of boneless beef with case code 69029 and production date 03/06/17.

The products subject to recall bear establishment number “EST. M13054” inside the USDA mark of inspection. These items were shipped to food manufacturers within the state of Texas.

The problem was discovered when FSIS was notified by the State of Texas’ Meat Safety Assurance Unit about a positive non-O157 Shiga toxin-producing E. coli sample.

There have been no confirmed reports of illnesses due to consumption of these products.

Many clinical laboratories do not test for non-O157 Shiga toxin-producing E. coli (STEC), such as STEC O103 because it is harder to identify than STEC O157. People can become ill from STECs 2–8 days (average of 3–4 days) after consuming the organism. Most people infected with STEC O103 develop diarrhea (often bloody), and vomiting. Some illnesses last longer and can be more severe. Infection is usually diagnosed by testing of a stool sample. Vigorous rehydration and other supportive care is the usual treatment; antibiotic treatment is generally not recommended.

Most people recover within a week, but, rarely, some develop a more severe infection. Hemolytic uremic syndrome (HUS) is uncommon with STEC O103 infection. HUS can occur in people of any age but is most common in children under 5 years old, older adults and persons with weakened immune systems. It is marked by easy bruising, pallor, and decreased urine output. Persons who experience these symptoms should seek emergency medical care immediately.

FSIS and the company are concerned that some product may be frozen and in customers’ freezers.

Customers who have purchased these products are urged not to use them.

16 with E. coli in 9 States

CDC, multiple states, and the U.S. Food and Drug Administration (FDA) are investigating a multistate outbreak of Shiga toxin-producing Escherichia coliO157:H7 (STEC O157:H7) infections.

Sixteen people infected with the outbreak strains of STEC O157:H7 have been reported from nine states.

Eight ill people have been hospitalized. Five people developed hemolytic uremic syndrome, a type of kidney failure, and no deaths have been reported.

Fourteen of the 16 ill people in this outbreak are younger than 18 years old.

Epidemiologic evidence indicates that I.M. Healthy brand SoyNut Butter is a likely source of this outbreak. I.M. Healthy brand SoyNut Butter may be contaminated with E. coli O157:H7 and could make people sick.

On March 7, 2017, The SoyNut Butter Company recalled all varieties of I.M. Healthy SoyNut Butters and all varieties of I.M. Healthy Granola products.

CDC recommends that consumers do not eat, and childcare centers, schools, and other institutions do not serve, any variety or size of I.M. Healthy brand SoyNut Butter, or I.M. Healthy granola coated with SoyNut Butter, regardless of the date of purchase or the date listed on the container.

Even if some of the SoyNut Butter or granola was eaten or served and no one got sick, throw the rest of the product away. Put it in a sealed bag in the trash so that children, pets, or other animals can’t eat it.