Today the Oregon Public Health Division, Department of Agriculture and several local Oregon health departments are investigating an outbreak of Escherichia coli O157:H7 – E. coli infections that have left three Portland-area children hospitalized, two with kidney failure (hemolytic uremic syndrome – HUS) – all of whom drank raw milk from the same small farm.

Three children with laboratory-confirmed infections have been hospitalized. A fourth child has lab-confirmed E. coli but has not been hospitalized. All of the children consumed raw unpasteurized milk obtained from Foundation Farm in Clackamas County. The farm has voluntarily ceased its milk distribution.

According to news reports over the last week, Missouri state health officials have confirmed nine cases of E. coli in Missouri.  Missouri Department of Health and Senior Services confirmed cases in Boone, Cooper, Howard, Camden and Jackson counties.

Health officials say a 2-year-old girl a 17-month-old child have developed symptoms of a condition that can cause kidney damage (Hemolytic Uremic Syndrome)

Investigators say consumption of raw dairy products is a “possible” factor in some (actually only four at this time) of the cases.

Raw Milk and Raw Milk Cheese Outbreaks since 2010 (Not including Missouri and Oregon:

Outbreaks 

– 24 raw dairy outbreaks with 309 illnesses, no deaths (22 fluid raw milk, 2 aged raw milk cheese) 

Recalls (no illnesses reported) 

– 14 raw dairy (7 fluid raw milk, 7 aged raw milk cheese)

For more information on the real risks of raw milk, see www.realrawmilkfacts.com.

On April 11, 2012, the USDA announced a recall of 2,057 pounds of ground and tenderized beef products from Town and Country Foods, Inc., after the company confirmed a positive E. coli O157:H7 lab test result.  The following products are subject to the recall:

  • 5- and 10- lb. boxes of 2-, 2.6-, 3-, and 4- oz. “Town & Country Foods XL Hamburg Patties”
  • 5- and 10- lb. boxes of 2-, 2.6-, 3-, and 4- oz. “Town & Country Foods Hamburg Patties”
  • 10- lb. box containing variously weighted bags of “Town & Country Beef for Stewing”
  • 6-, 8-, and 10- oz. “Town & Country Beef Sirloin Filets”
  • 5- and 10- lb. boxes containing variously weighted bags of “Town and Country Hamburg”
  • 5- and 10- lb. boxes containing variously weighted bags of “Town and Country XL Hamburg”

Each case bears a label with the establishment number “EST. 9710” inside the USDA mark of inspection. Additionally, the products contain the following packaging codes: 10952, 10962, 10972, 11002, and 11012. The products subject to recall were produced between April 4, 2012 and April 10, 2012 and were shipped to wholesale and retail establishments in Maine. When available, the retail distribution list(s) will be posted on FSIS’ website at www.fsis.usda.gov/FSIS_Recalls/ Open_Federal_Cases/index.asp.

The problem was discovered through company lab testing which confirmed a positive result for E.coli O157:H7. The company did not hold product pending test results, resulting in this recall. FSIS and the company have received no reports of illnesses associated with consumption of these products. Individuals concerned about an illness should contact a health care provider.

At least 5 raw milk-related E. coli cases have been counted in Missouri since the end of March.  Two children have been hospitalized with hemolytic uremic syndrome, a complication of E. coli infection. 

Missouri public health officials announced Friday that E. coli-contaminated raw milk is the source of an E. coli outbreak that has resulted in 5 E. coli cases, 2 with HUS.  Anyone who has purchased raw milk should dispose of it immediately due to its potential to be contaminated with E. coli bacteria.

E. coli infection is a serious foodborne illness with symptoms including bloody diarrhea.  Individuals who become ill with E. coli – especially the very young and very old – can develop hemolytic uremic syndrome (HUS), which can cause kidney failure and central nervous system impairment.

Raw milk can be contaminated with E. coli during the milking process.  E. coli bacteria live in the intestines of cows and other ruminant animals, and are shed in their feces.  Pasteurization kills E. coli and other bacteria.

The Missouri E. coli outbreak is one of several raw milk-related E. coli outbreaks that have occurred over the last several years.  E. coli outbreaks in California, Connecticut, and other states have been traced to raw milk produced through both commercial milk producers and cow-share agreements.

The Marler Clark attorneys have represented several children and adults who became ill with E. coli infections or HUS after consuming raw milk in litigation against raw milk dairies and retailers who sold raw milk.  Read more about E. coli cases the law firm has been involved in and cases the Marler Clark attorneys have brought on behalf of Missouri E. coli outbreak victims on the Marler Clark Website.

The Missouri Department of Health and Senior Services (DHSS) is investigating an increase in cases of Shiga toxin-producing Escherichia coli (STEC) in Central Missouri during late March and early April, 2012. Five cases of E. coli O157:H7 have been identified during this time period. Two of the cases, a two-year old child and a seventeen-month old child, reportedly have developed hemolytic uremic syndrome (HUS), a severe, life-threatening condition that may result in permanent kidney damage in some of those who survive.

Marler Clark has been involved with other E. coli cases in Missouri:

The E. coli lawyers of Marler Clark have many years of experience working with clients on E. coli outbreak lawsuits.

E. coli are bacteria that can cause serious, sometimes fatal, infections in humans.  The Centers for Disease Control and Prevention (CDC) estimates that E. coli causes 2,000 hospitalizations in the United States each year.  Ten percent of E. coli victims develop hemolytic uremic syndrome (HUS), which can cause kidney failure, damage to the central nervous system, and ultimately death.

The Marler Clark E. coli lawyers have unmatched experience representing victims of E. coli and HUS.  We have represented hundreds of victims of E. coli outbreaks traced to foods such as hamburgers, spinach, raw milk, water, and food served at restaurants.  The Marler Clark E. coli lawyers are the only lawyers in the nation with a practice focused exclusively on plaintiff foodborne illness litigation.

Our E. coli lawyers have represented victims of notable E. coli outbreaks such as the 2006 Dole Spinach E. coli outbreak, the 2007 Cargill beef E. coli outbreak, and the landmark 1993 Jack in the Box E. coli outbreak. Contact us today to learn more about our services.

Bad Bug Book – Foodborne Pathogenic Microorganisms and Natural Toxins – Second Edition

e_colio157(1).jpg1.         Organism

Like generic E. coli, toxin-producing Shiga- toxigenic Escherichia coli (STEC) are Gram- negative, rod-shaped bacteria, but are characterized by the production of Shiga toxins (Stx). Depending on the reference cited, there are 200 to 400 STEC serotypes, many of which have not been implicated in human illness; however, a subset of STEC called enterohemorrhagic Escherichia coli (EHEC), the topic of this chapter, includes only those that cause serious illness. Serotype O157:H7 is the prototypic EHEC strain.

Although O157:H7 is currently the predominant
strain and accounts for ~75% of the EHEC
infections worldwide, other non-O157 EHEC
serotypes are emerging as a cause of foodborne
illnesses. In the United States a group often
referred to as the “big 6” (O111, O26, O121,
O103, O145, and O45) accounts for the
majority of the non-O157:H7 serotypes isolated
from clinical infections and, therefore, is
currently a focus of concern. However, other
EHEC serotypes, such as O113, O91, and others, also can cause severe illness. As a result, the non-O157 EHEC serotypes of public health concern can change quickly, depending on outbreak incidents, and can vary with countries and geographic regions.

A recent example is the large outbreak, in 2011, that was centered in Germany, but also affected various other countries in the European Union. The pathogen was identified as an E. coli strain of serotype O104:H4 that produced Shiga toxin and, therefore, was thought to be an EHEC. However, genetic analysis showed that this pathogen had 93% genetic homology with a strain of Enteroaggregative E. coli (EAEC), which is known for causing persistent diarrhea in under- developed countries, but has seldom been implicated in major foodborne incidents. Hence, the O104:H4 strain that caused the outbreak appears to be an EAEC strain that acquired the ability to produce Shiga toxin.

Currently, it is difficult to determine which serotypes of E. coli are EHEC and equally challenging to predict the emergence of strains that can acquire the genes for Shiga toxin production or other virulence factors and so cause human illness. EHEC are characterized by:

  • production of Stx, including Stx1 and/or Stx2. Stx1 is nearly identical to the toxin produced by Shigella dysenteriae Type I. There are many subtypes of both toxins, and some subtypes of Stx2 appear to be implicated in human illness. Stx2 is most often associated with severe sequelae, such as hemolytic uremic syndrome (HUS), which is characterized by acute renal failure.
  • presence of LEE (“locus for enterocyte effacement”; pathogenicity island that encodes for intimin, a protein that enables bacterial attachment to epithelial cells).

There are also several other putative virulence factors, including enterohemolysin, but the role of these factors in pathogenesis remains undetermined.

2.         Disease

  • Mortality: Patients whose illness progresses to HUS have a mortality rate of 3% to 5%.
  • Infective dose: The infective dose of EHEC O157:H7 is estimated to be very low, in the range of 10 to 100 cells. The infective dose of other EHEC serotypes is suspected to be slightly higher.
  • Onset: Symptoms usually begin 3 to 4 days after exposure, but the time may range from 1 to 9 days.
  • Disease / complications: Infections from EHEC may range from asymptomatic-to-mild diarrhea to severe complications. The acute symptoms are called hemorrhagic colitis (HC), characterized by severe abdominal cramps and bloody diarrhea, which may progress to such life-threatening complications as HUS or thrombotic thrombocytopenia purpura (TTP) – conditions that are most often associated with O157:H7, but that also can occur with other EHEC serotypes. About 3% to 7% of HC cases progress to HUS or TTP. 
Some evidence suggests that Stx2 and intimin are associated with progression to severe disease, such as HUS. Kidney cells have a high concentration of Stx receptors; hence, the kidney is a common site of damage. Some survivors may have permanent disabilities, such as renal insufficiency and neurological deficits. 
Antibiotic therapy for EHEC infection has had mixed results and, in some instances, seems to increase the patient’s risk of HUS. One speculation is that antibiotics lyse EHEC cells, releasing more Stx into the host.
  • Symptoms: Hemorrhagic colitis is characterized by severe cramping (abdominal pain), nausea or vomiting, and diarrhea that initially is watery, but becomes grossly bloody. In some cases, the diarrhea may be extreme, appearing to consist entirely of blood and occurring every 15 to 30 minutes. Fever typically is low-grade or absent.
  • Duration: In uncomplicated cases, duration of symptoms is 2 to 9 days, with an average of 8 days.
  • Route of entry: Oral (e.g., ingestion of contaminated food, water, or fecal particles).
  • Pathway: After ingestion, EHEC attaches to intestinal epithelial cells via LEE-encoded factors and produces Stx that are internalized, activated, and can pass into the bloodstream to become systemic.

3.         Frequency

It is estimated that there are about 63,000 cases of EHEC infections in the U.S. yearly. Ground beef and beef products continue to be implicated in most infections; however, contaminated produce increasingly has been implicated as a vehicle. As for STEC non-O157, the CDC estimates that 112,752 cases, per year, are attributed to foodborne illness in the U.S.

EHEC O157:H7 was first identified in an outbreak, in 1982, in which hamburgers from a fast- food restaurant were the vehicle. In 1991 (sic, 1992-1993), hamburgers from fast-food restaurants were implicated in another outbreak, which affected about 700 people in four states. In the mid 1990s, a large outbreak was traced to unpasteurized juices. The largest O157:H7 outbreak on record took place in Japan; radish sprouts were implicated and about 10,000 people were affected. Since then, O157:H7 has been implicated in numerous outbreaks that involved lettuce, salads, various types of sprouts, and, in 2006, bagged spinach. In 2009, an O157:H7 outbreak in the U.S. was traced to frozen, raw cookie dough.

About a dozen non-O157:H7 EHEC outbreaks have been recorded in the U.S., but incidences may be underestimated due to lack of routine testing and appropriate testing methods.

4.         Sources

Raw or undercooked ground beef and beef products are the vehicles most often implicated in O157:H7 outbreaks. Earlier outbreaks also implicated consumption of raw milk. O157:H7 can develop acid tolerance, as evidenced by infections in which acid foods (<pH4.6) were implicated, such as yogurt, mayonnaise, fermented sausages, cheeses, and unpasteurized fruit juices.

Various water sources, including potable, well, and recreational water, also have caused EHEC infections, as has contact with animals at farms or petting zoos.

Produce, including bagged lettuce, spinach, and alfalfa sprouts, increasingly is being implicated in O157:H7 infections.

Interestingly, infections in the U.S. by non-O157:H7 EHEC has been caused by many of these same vehicles, but, as of this writing, beef products have seldom been implicated.

Person-to-person transmission of infection is well documented.

Additional information is available from “Escherichia coli Serotype O157:H7: Novel Vehicles of Infection and Emergence of Phenotypic Variants,” by Dr. Peter Feng, FDA. Emerging Infectious Diseases (1995) 1(2)

5.         Diagnosis

Unlike generic E. coli, EHEC O157:H7 do not ferment the sugar sorbitol, so an effective method is to plate patient’s bloody diarrhea samples onto sorbitol MacConkey medium to screen for sorbitol non-fermenting isolates. These are then typed serologically using antibodies to the O157 and the H7 antigens. However, as other EHEC serotypes are increasingly causing illness, clinical samples are now simultaneously tested for the presence of Stx using commercially-available antibody kits. Any STEC strains found are then serotyped and identified. There are also many PCR assays specific for Stx genes that may be used for screening clinical samples.

6.         Target Populations

All people are believed to be susceptible to hemorrhagic colitis, but young children and the elderly are more susceptible and at higher risk for the illness to progress to more severe complications. Others with weak immune systems also are at risk, such as people with some chronic diseases or AIDS, and people on immunosuppressive medications; for example, some drugs used for arthritis and cancer chemotherapy.

7.         Food Analysis

Presence of EHEC O157:H7 in foods can be determined by plating culture enrichment of food samples onto selective and differential media. Unlike typical E. coli, O157:H7 do not ferment sorbitol and are negative with the MUG assay, so these tests are commonly used to distinguish O157:H7 strains from other E. coli prior to serological testing for the O157 and H7 antigens and also for the presence of Stx genes by PCR. Molecular assays also exist that can specifically detect O157:H7 strains using unique mutational markers.

Detection of non-O157:H7 EHEC, however, is more complex, due to the lack of unique traits. For non-O157 EHEC, food enrichment is first screened for Shiga toxin using an antibody assay or for Stx genes by PCR. Enrichment cultures that are positive for Stx are plated on agar media, and multiple isolates are then tested for Stx genes, in order to obtain a pure culture isolate. These putative STEC isolates are then retested for virulence genes and their serotype determined. This process is both time-consuming and labor-intensive and may require screening hundreds of isolates.

There are numerous commercially-available kits to test for Stx, O157, and a few other EHEC serotypes. However, there are several Stx subtypes and many EHEC serotypes, and not all of these can be detected by commercial test kits. The Escherichia coli link to the FDA Bacteriological Analytical Manual, Chapter 4, provides a description of methods to test for common E. coli. Methods for EHEC and O157:H7 are described in Chapter 4a.

8.         Examples of Outbreaks

For more information about recent outbreaks see the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Reports.

9.         Other Resources

More information is available from the following sources.

  • USDA (August 11 1998) – USDA Urges Consumers to Use Food Thermometer When Cooking Ground Beef Patties
  • CDC – General information about Escherichia coli O157:H7           
  • Produce Handling and Processing Practices, from Emerging Infectious Diseases, CDC
  • Risk assessment of E. coli O157:H7 in ground beef, from the USDA Food Safety and Inspection Service

Continue Reading Bad Bug Book – Foodborne Pathogenic Microorganisms and Natural Toxins – Second Edition – Enterohemorrhagic Escherichia coli (EHEC) – E. coli

dhss_logo.gifThe Missouri Department of Health and Senior Services (DHSS) is investigating an increase in cases of Shiga toxin-producing Escherichia coli (STEC) in Central Missouri during late March and early April, 2012. Five cases of E. coli O157:H7 have been identified during this time period. Two of the cases, a two-year old child and a seventeen-month old child, reportedly have developed hemolytic uremic syndrome (HUS), a severe, life-threatening condition that may result in permanent kidney damage in some of those who survive.

The investigation is ongoing and the source of the infections has not been identified.

DHSS recommends that any person who has signs or symptoms of STEC infection should seek medical care. Health care providers should determine if testing for STEC infection is warranted.

Symptoms of STEC infection include severe stomach cramps, diarrhea (which is often bloody), and vomiting. If there is fever, it usually is not very high. Most patients’ symptoms improve within 5–7 days, but some patients go on to develop HUS, usually about a week after the diarrhea starts. The classic triad of findings in HUS is acute renal damage, microangiopathic hemolytic anemia, and thrombocytopenia.

A total of 29 individuals infected with the outbreak strain of E. coli O26 have been reported from 11 states. JimmyJohns-map.jpgThe number of ill persons identified in each state is as follows: Alabama (1), Arkansas (1), Iowa (5), Kansas (2), Michigan (10), Missouri (3), Ohio (3), Pennsylvania (1), Washington (1), Wisconsin (1), and West Virginia (1). Of the 27 ill persons with available information, 23 (85%) reported consuming sprouts at Jimmy John’s restaurants in the 7 days preceding illness.

Among 29 ill persons, illness onset dates ranged from December 25, 2011 to March 3, 2012. Ill persons range in age from 9 years to 57 years old, with a median age of 26 years. Eighty-nine percent of ill persons are female. Among the 29 ill persons, 7 (24%) were hospitalized. None have developed HUS, and no deaths have been reported.

Sysco Seattle Inc. is recalling approximately 16,800 pounds of ground beef patties distributed to restaurants in Colorado, Arizona, Texas and Washington because of possible E. coli contamination according to the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS).

The producer, New Food Classics of Burlington, Ontario, notified Sysco Seattle of the possible contamination earlier this month.

The following products are subject to recall:

•10 lb. boxes of PRIME RIB BEEF PATTIES 8 oz, with product code 55317, and production code 11 NO 22.

•10 lb. boxes of PRIME RIB BEEF PATTIES 71g, with product code 55391 and bearing a production code of 11 SE 01 or 12 JA 04.

Sysco Seattle Inc., a Seattle, Wash. firm, is recalling approximately 16,800 pounds of ground beef patties imported from Canada because they may have been contaminated with E. coli O157:H7, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today.

Screen Shot 2012-03-24 at 8.05.37 PM.png The following products are subject to recall:

  • 10 lb. boxes of PRIME RIB BEEF PATTIES 8 oz, with product code 55317, and production code 11 NO 22
  • 10 lb boxes of PRIME RIB BEEF PATTIES 71g, with product code 55391 and bearing a production code of 11 SE 01 or 12 JA 04

Since the issuance of the Public Health Alert, FSIS has learned that Sysco was contacted by the Canadian firm and began notifying their customers on March 20. FSIS was unaware of the firm’s actions and proceeded with the Public Health Alert out of an abundance of caution.

Imported products were produced by New Food Classics of Burlington, Ontario and were imported by Sysco Seattle Inc., for distribution to restaurants in Arizona, Colorado, Texas and Washington.