Officials now report that nine hospitalized children have been diagnosed with a complication that causes the kidneys to shut down.

Eleven daycare centers have been closed since Monday. Five of them may be allowed to reopen on Sept. 11 if no illnesses among attendees or staff have been confirmed. The five centers and six with known patients were closed as a cautionary move because they all use a central kitchen.

The Shiga toxin-producing E. Coli involved in the outbreak can also attack other organs and cause widespread organ failure. It is not unusual for children to appear to be recovering and then backslide into a much more severe infection.

Investigators have collected samples of leftovers and frozen food for testing, but those test results are not yet available.

About E. coli infections
Anyone who has developed symptoms of E. coli infection should seek medical attention and tell their doctor about their possible exposure to the bacteria. Specific tests are required to diagnose the infections, which can mimic other illnesses.

Alberta Health Services officials said the outbreak has peaked, though more patients could be identified. There is a chance of secondary infections where sick patients expose others in their families to the bacteria.

The symptoms of E. coli infections vary for each person but often include severe stomach cramps and diarrhea, which is often bloody. Some patients may also have a fever. Most patients recover within five to seven days. According to the Centers for Disease Control and Prevention (CDC), others can develop severe or life-threatening symptoms and complications.

Many people with HUS recover within a few weeks, but some suffer permanent injuries or death. This condition can occur among people of any age but is most common in children younger than five years old because of their immature immune systems, older adults because of deteriorating immune systems, and people with compromised immune systems such as cancer patients. 

About 5 to 10 percent of those diagnosed with E. coli infections develop a potentially life-threatening kidney failure complication known as a hemolytic uremic syndrome (HUS). Symptoms of HUS include fever, abdominal pain, tiredness, decreased frequency of urination, small unexplained bruises or bleeding, and pallor. 

People who experience HUS symptoms should immediately seek emergency medical care. People with HUS will likely be hospitalized because the condition can cause other serious and ongoing problems such as hypertension, chronic kidney disease, brain damage, and neurologic problems.

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Nineteen sick people are aged 63 to 93, including 13 men and six women. Patients have been reported from 10 different regions.

Six people with listeriosis have died. However, it is unclear what role the infection played in their death because most patients had other severe underlying diseases.

People have been sick with the same type of Listeria since autumn 2022, but 15 cases occurred from the end of May this year, said Folkhälsomyndigheten (the Public Health Agency of Sweden).

Of cases with available information, 14 reported eating vacuum-packed salmon from one of two brands before falling sick. Both these brands are produced by Leröy Seafood, and Listeria was detected in products and environmental samples in the firm’s facility.

In most cases, samples have only been analyzed qualitatively so it is unclear if Listeria was above the limit of 100 CFU/g, according to Livsmedelsverket (the Swedish Food Agency).

“For Leröy Smögen Seafood, safe and secure food is our priority, and we take this incident very seriously. We are doing everything we can to ensure this does not happen again. We have a good cooperation and dialogue with the Swedish Food Agency,” said a company statement.

Finding the source of infections
Further analysis of samples from food, the environment, and human cases found the same type of Listeria, which points to the salmon products being the likely source of infection. The company has increased sampling and is carrying out further clean-up measures at the facility.

In early August, the retailer Axfood recalled a batch of Falkenberg Seafood cold smoked salmon 200-grams after low levels of Listeria were found.

The product was available for sale in the majority of Axfood’s stores. Listeria was detected during the retailer’s internal checks.

“The production has not been stopped, but all batches are currently analyzed for the presence of Listeria before release on the market. The company must take action following its HACCP-based procedures. They must also investigate the cause of contaminated products with Listeria monocytogenes and take measures to prevent such contamination. This may involve changes to HACCP-based procedures or other measures,” said Mats Lindblad from Livsmedelsverket.

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Eleven daycare centers in Calgary, Alberta, Canada, have been closed because of the illnesses, which now number 96. During a press conference this afternoon, Dr. Francesco Rizzuti, medical officer of Alberta Health Services Calgary, said 22 patients had been hospitalized. 

Rizzuti said both adults and children have been confirmed sick as outbreak patients. The Alberta Health Services reported that all hospitalized patients are children. Rizzuti declined to say what specific complications the patients suffer, only that some symptoms are severe.

Patients started going to emergency rooms and being admitted to hospitals this past weekend, Rizzuti said. He made the decision Monday to close the 11 daycare centers because they share a common kitchen. On Tuesday morning investigators began collecting samples for testing. Among the samples collected were leftovers and frozen foods.

Parents have reported to Canadian media that they believe meatloaf served to children may be the source of the E. Coli, but Rizzuti would not confirm that.

More than 2,000 stool sample kits have been sent to the implicated daycare centers. Parents and staff can pick up the kits for free. Specific tests are required to diagnose E. Coli infection because it can mimic other illnesses.

Some media reports have said that the central kitchen used by the daycare centers had received non-compliance scores during recent inspections. However, Rizzuti said that is not the case and that the kitchen’s most recent inspections have shown compliance with food safety regulations.

Only some of the daycare centers that have been closed are associated with patients, said Rizzuti. But as a cautionary move he ordered all 11 using the central kitchen to be closed until the situation is resolved.

“We think there is a common source,” Rizzuti said during the press conference this afternoon, adding that it is not unusual for investigators to be unable to determine the source of outbreaks.

He said hospital care for those infected with E. coli can include treatment for dehydration, or, on a more severe scale, monitoring for hemolytic uremic syndrome, a type of kidney failure. Patients are also monitored for sepsis.

Investigators are calling each household with a confirmed illness in addition to collecting and testing samples. Rizzuti said it could take weeks or months to finish the investigation.

The following sites have been issued a closure order until issues are resolved:

• Fueling Brains Braeside
• Fueling Brains West 85th
• Fueling Brains New Brighton
• Fueling Brains Centennial
• Fueling Brains Bridgeland
• Fueling Brains McKnight
• Braineer Academy
• Kidz Space
• Little Oak Early Education (formerly Mangrove)
• Almond Branch School
• Vik Academy in Okotoks

Anyone who works at any of the daycare centers or has a child who attends them should be on the lookout for E. Coli symptoms.

About E. coli infections

Anyone who has developed symptoms of E. coli infection should seek medical attention and tell their doctor about their possible exposure to the bacteria. Specific tests are required to diagnose the infections, which can mimic other illnesses.

The symptoms of E. coli infections vary for each person but often include severe stomach cramps and diarrhea, which is often bloody. Some patients may also have a fever. Most patients recover within five to seven days. Others can develop severe or life-threatening symptoms and complications, according to the Centers for Disease Control and Prevention (CDC).

About 5 to 10 percent of those diagnosed with E. coli infections develop a potentially life-threatening kidney failure complication, known as a hemolytic uremic syndrome (HUS). Symptoms of HUS include fever, abdominal pain, feeling very tired, decreased frequency of urination, small unexplained bruises or bleeding, and pallor. 

Many people with HUS recover within a few weeks, but some suffer permanent injuries or death. This condition can occur among people of any age but is most common in children younger than five years old because of their immature immune systems, older adults because of deteriorating immune systems, and people with compromised immune systems such as cancer patients. 

People who experience HUS symptoms should immediately seek emergency medical care. People with HUS will likely be hospitalized because the condition can cause other serious and ongoing problems such as hypertension, chronic kidney disease, brain damage, and neurologic problems.

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The Directorate-General of Health (DGS) said 209 cases were associated with the consumption of broa de milho (a type of cornbread) in some regions of the country since mid-July.

The clinical symptoms of cases directed a laboratory investigation that considered the short incubation period and duration, the literature, and had contributions from experts.

Patients presented similar symptoms, including a dry mouth, vision issues, dizziness, mental confusion, and decreased muscle strength. Symptoms were observed between 30 minutes to two hours after eating food. In most cases, they were classified as mild, but more than 40 people required hospital care.

Tropane alkaloid findings
In samples taken from flour, bread, and patients, the tropane alkaloids atropine and scopolamine were detected at very high levels.

An investigation found strong evidence of contamination with seeds from the Datura genus, a plant that may be present as weeds in cultivated fields. Such contamination can occur during harvesting.

This work involved regional departments of public health, the Economic and Food Safety Authority (ASAE) and the General Directorate of Food and Veterinary Affairs (DGAV).

Following the incident, DGAV is to release a guide for producers, to ensure better control of this plant in fields and after harvest.

In early August, officials warned people not to eat broa de milho in certain parts of the country but said the product “is, and should continue to be, an integral part of the Portuguese diet.”

Authorities restricted the use of raw materials in the manufacture of the implicated products.

The advice to avoid broa de milho in Leiria, Santarém, Coimbra, and Aveiro has now been lifted.

Authorities said this is due to the lack of new suspected cases and the absence of potentially contaminated products on the market. Businesses and consumers were thanked for following the earlier recommendations.

DGS added that a risk assessment does not justify maintaining the guidance to avoid broa de milho in the identified regions but if new cases arise the situation could change.

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Alberta Health Services reports at least 50 children with symptoms of E. Coli infection have gone to hospitals. There are 17 lab-confirmed patients.

All 11 daycare centers share a common kitchen, according to the health services.

The following sites have been issued a closure order until issues are resolved:

• Fueling Brains Braeside
• Fueling Brains West 85th
• Fueling Brains New Brighton
• Fueling Brains Centennial
• Fueling Brains Bridgeland
• Fueling Brains McKnight
• Braineer Academy
• Kidz Space
• Little Oak Early Education (formerly Mangrove)
• Almond Branch School
• Vik Academy in Okotoks

Families with children attending any of the implicated locations are being sent letters advising of the outbreak and are being asked to monitor for symptoms and present to an emergency department if necessary.

About E. coli infections
Anyone with children at the implicated daycare centers who have developed symptoms of E. coli infection should seek medical attention and tell their doctor about their possible exposure to the bacteria. Specific tests are required to diagnose the infections, which can mimic other illnesses.

The symptoms of E. coli infections vary for each person but often include severe stomach cramps and diarrhea, which is often bloody. Some patients may also have a fever. Most patients recover within five to seven days. Others can develop severe or life-threatening symptoms and complications, according to the Centers for Disease Control and Prevention (CDC).

About 5 to 10 percent of those diagnosed with E. coli infections develop a potentially life-threatening kidney failure complication, known as a hemolytic uremic syndrome (HUS). Symptoms of HUS include fever, abdominal pain, feeling very tired, decreased frequency of urination, small unexplained bruises or bleeding, and pallor. 

Many people with HUS recover within a few weeks, but some suffer permanent injuries or death. This condition can occur among people of any age but is most common in children younger than five years old because of their immature immune systems, older adults because of deteriorating immune systems, and people with compromised immune systems such as cancer patients. 

People who experience HUS symptoms should immediately seek emergency medical care. People with HUS will likely be hospitalized because the condition can cause other serious and ongoing problems such as hypertension, chronic kidney disease, brain damage, and neurologic problems.

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A total of 33 confirmed and one probable case were linked to a pub in Wrexham.

Despite an investigation and testing, the precise source or route of transmission in the Salmonella Infantis outbreak was not identified.

In late July, an Outbreak Control Team (OCT) was established including Public Health Wales, Betsi Cadwaladr University Health Board and Wrexham County Borough Council’s environmental health team.

No details on the age range or gender of patients were released to protect their identity.

Source of outbreak unknown
Richard Firth, consultant in public health at Public Health Wales, and chair of the OCT, said several cases of Salmonella were identified in Wrexham at the end of July.

“We can confirm a total of 33 confirmed, genomically identical, cases of Salmonella infection and one probable case associated with The Nags Head public house on Mount Street, Wrexham, owned by Marston’s PLC,” he said.

“On July 31, control measures were put in place, which included a voluntary closure and deep clean of the premises, and testing of all staff. No further cases have been identified since the control measures were put in place.

“Whilst all the evidence indicates the exposure site for the infections being The Nags Head, extensive investigation and testing has not identified the precise source or route of transmission for the infections. Public Health Wales would like to extend our sympathies to those affected by this outbreak. We would also like to thank our multi-agency partners as well as the management and staff at both The Nags Head and Marston’s PLC for their proactive support throughout this investigation.”

About Salmonella
Food contaminated with Salmonella bacteria does not usually look, smell, or taste spoiled. Anyone can become sick with a Salmonella infection. Infants, children, seniors, and people with weakened immune systems are at higher risk of serious illness because their immune systems are fragile, according to the CDC.

Anyone who has developed symptoms of Salmonella food poisoning should seek medical attention. Sick people should tell their doctors about the possible exposure to Salmonella bacteria because special tests are necessary to diagnose salmonellosis. Salmonella infection symptoms can mimic other illnesses, frequently leading to misdiagnosis.

Symptoms of Salmonella infection can include diarrhea, abdominal cramps, and fever within 12 to 72 hours after eating contaminated food. Otherwise, healthy adults are usually sick for four to seven days. In some cases, however, diarrhea may be so severe that patients require hospitalization.

Older adults, children, pregnant women, and people with weakened immune systems, such as cancer patients, are more likely to develop a severe illness and serious, sometimes life-threatening conditions. Some people get infected without getting sick or showing any symptoms. However, they may still spread the infections to others.

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The health department told university officials that there haven’t been any new patients since Aug. 25. As of Thursday this week there had been 42 patients identified in the outbreak. Four were hospitalized and two remained in the hospital as of Friday.

The residences of the sick people hasn’t been revealed, but the health department has reported that “it has no reason to believe the outbreak is connected to the university’s public dining facilities.” Some of the patients are residents of sorority houses.

The state health department surveyed 3,200 people during its investigation, according to the university health services department.

“Of that number, 37 are probable cases based on reported E. coli symptoms while five cases have been confirmed with positive tests. The number of individuals impacted may change as the ADH continues to investigate,” according to the university.

“Original estimates of the number of individuals who may have impacted were reduced after those with similar symptoms but no link to the outbreak were sorted out from those with true E. coli symptoms.”

Investigators from the state continue to look for a source of the bacteria while they wait on laboratory results. They believe the outbreak began about two weeks ago. 

“The university has increased its surface cleaning and sanitizing protocols to help mitigate the spread,” according to university officials.

About E. coli infections

Anyone who has developed symptoms of E. coli infection — especially University of Arkansas students who live in sorority or fraternity houses — should seek medical attention and tell their doctor about their possible exposure to the bacteria. Specific tests are required to diagnose the infections, which can mimic other illnesses.

The symptoms of E. coli infections vary for each person but often include severe stomach cramps and diarrhea, which is often bloody. Some patients may also have a fever. Most patients recover within five to seven days. Others can develop severe or life-threatening symptoms and complications, according to the Centers for Disease Control and Prevention (CDC).

About 5 to 10 percent of those diagnosed with E. coli infections develop a potentially life-threatening kidney failure complication, known as a hemolytic uremic syndrome (HUS). Symptoms of HUS include fever, abdominal pain, feeling very tired, decreased frequency of urination, small unexplained bruises or bleeding, and pallor. 

Many people with HUS recover within a few weeks, but some suffer permanent injuries or death. This condition can occur among people of any age but is most common in children younger than five years old because of their immature immune systems, older adults because of deteriorating immune systems, and people with compromised immune systems such as cancer patients. 

People who experience HUS symptoms should immediately seek emergency medical care. People with HUS will likely be hospitalized because the condition can cause other serious and ongoing problems such as hypertension, chronic kidney disease, brain damage, and neurologic problems.

(To sign up for a free subscription to Food Safety News,click here)

 The Minnesota Department of Health urges anyone who recently purchased milk from Healthy Harvest Farm and Kitchen to discard the product and not consume it. The milk may be labeled natural A2 milk, and consumers may be unaware that the milk has not been pasteurized.

The illnesses have been caused by Cryptosporidium parvum, a parasite commonly found in cattle. The cases have related subtypes of Cryptosporidium parvum, suggesting a common source. 

All people who became ill with gastrointestinal symptoms in early August reported purchasing or consuming raw milk from Healthy Harvest Farm and Kitchen before the onset of their illness. Four of them are younger than 10, and one has been hospitalized. One person was infected with Cryptosporidium parvum and E. coli O111:H8 at the same time. Being infected with multiple germs is not uncommon in raw milk outbreaks.

Raw or “natural” milk has not gone through the pasteurization process that heats the milk to a high temperature for a short period of time to kill harmful fecal germs that can contaminate raw milk. These germs can include Cryptosporidium, E. coli, Salmonella, and other viruses, bacteria and parasites, leading to the possibility of getting multiple infections from raw milk. Pasteurization is the only effective method for eliminating germs in raw milk and does not significantly change milk’s nutritional value.

“Cattle can naturally carry Cryptosporidium and E. coli in their digestive system and shed these germs in their manure even though the animal is not sick. Contamination of the milk with manure can occur during the milking process, and if the milk is not pasteurized, the germs will not be killed,” said Carrie Klumb, senior epidemiologist in the Zoonotic Diseases Unit at MDH. “Consuming any unpasteurized milk, no matter how well the animals are cared for and how clean the operation is, puts people at risk for getting sick.”

People infected with Cryptosporidium generally develop watery diarrhea, stomach cramps, loss of appetite, and weight loss approximately a week after consuming contaminated foods or touching infected animals. The illness typically lasts two weeks, but symptoms may go in cycles in which people seem to get better for a few days and then feel worse again before the illness ends.

Symptoms of E. coli infections typically include stomach cramps and diarrhea, including bloody diarrhea. People typically become ill two to five days after consuming contaminated food. In some cases, people may develop severe illness that leads to hospitalization. 

Children under the age of 5, adults over 65, and those with weakened immune systems are most at risk.

The health department is working to identify all people who may have purchased milk from Healthy Harvest Farm and Kitchen to inform them of the risks to prevent additional illnesses. If you or someone you know has experienced gastrointestinal illness after consuming unpasteurized milk from Healthy Harvest Farm and Kitchen, please complete a confidential online survey or email [email protected]. If you are sick, please get in touch with your healthcare provider.

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Earlier this week, the Centre for Health Protection (CHP) of the Department of Health revealed a suspected puffer fish poisoning case and reminded people not to consume puffer fish.

The patient is an 84-year-old man who developed dizziness, finger numbness and shortness of breath about one hour after eating cooked puffer fish, which was caught by himself on the same day in local waters. He was admitted to a hospital for treatment and is in stable condition.

Certain organs of puffer fish have high concentrations of tetrodotoxin, which is a potent neurotoxin that can affect the central nervous system. The toxin is not removed by cooking, boiling, drying or freezing. 

In another incident, suspected neurotoxic shellfish poisoning affected two people.

A 42-year-old female and a 45-year-old male presented with tingling of the tongue, vomiting and diarrhea a few minutes to three hours after consuming steamed snails at home. An initial investigation revealed the snails were bought from a seafood stall at Ap Lei Chau Market.

“Neurotoxic shellfish poisoning toxin is a natural toxin sometimes found in bivalve shellfish. It is heat-stable and cannot be destroyed through cooking,” said a CHP spokesman.

Advice from officials included sourcing shellfish from places where monitoring programs for toxins have been established and to only purchase such products from reliable sources.

Bacterial outbreaks
CHP also investigated two suspected food poisoning clusters affecting five people.

The first cluster had two females, aged 29 and 30, who developed abdominal pain, diarrhea, nausea, vomiting and fever about 15 hours after eating at a restaurant in Tsim Sha Tsui. The other cluster involved three females, aged 22 to 49, who had similar symptoms about 14 hours after having dinner at this restaurant on the same day. Two people were hospitalized.

Initial investigations pointed to pancakes made with eggs as the source of illness that might have been caused by Salmonella.

An imported case of Shiga toxin-producing E. coli (STEC) infection was recorded in mid-August.

A 2-year-old boy was suffering from vomiting in early August, and then had a fever, abdominal pain and diarrhea the next day. He was taken to hospital and admitted before being discharged the next day after his condition became stable. STEC was detected in a stool specimen.

The patient had been to Malaysia from July 29 to August 3. He had consumed yogurt and fresh fruit juice, and had contact with animals. He also swam at the beach and in a swimming pool. Two family members also recorded similar symptoms but had recovered.

The largest outbreak sickened at least 55 people. It involved 24 males and 31 females, aged 7 to 49, who came down with abdominal pain and diarrhea eight to 16 hours after having dinner at a canteen of a campsite in Tai Po.

Officials suspected penne carbonara contaminated with Clostridium perfringens as the source of illness. Initial investigations revealed a possible reason for the incident was improper food holding temperatures. 

Wild plants and bamboo shoot
In mid-August, a 69-year-old woman fell sick after accidentally consuming part of a dangerous plant. CHP reminded the public not to pick or consume wild plants, and to be aware of vegetables containing calcium oxalate raphide.

The patient reported oral numbness, a burning sensation of the mouth and shortness of breath shortly after consuming a wild taro that she was given as a gift from a friend in Tai Po. 

Taro is a popular ingredient used to prepare various dishes and desserts. However, some plants look like taro, such as giant alocasia, but contain toxins that can cause food poisoning.

CHP has also advised people not to consume raw bamboo shoot after a 67-year-old man and a 50-year-old woman fell ill.

The male patient bought fresh bamboo shoots from a shop in Mei Foo and the female patient pressed them into juice at home on the same day. The duo developed headache, dizziness, palpitation, nausea, limb numbness and shortness of breath 10 minutes after drinking the juice. 

“Raw bamboo shoot contain cyanogenic glycosides. Cyanogenic plant products such as bamboo shoot can cause poisoning when eaten raw and in sufficient amounts. Cyanogenic plants should be cut into smaller pieces, soaked in water and cooked thoroughly in boiling water before consumption,” said a CHP spokesman.

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An analysis by the European Centre for Disease Prevention and Control (ECDC) focused on two sub-clusters of Salmonella Enteritidis sequence type (ST) 11 with 134 cases mostly reported between January and August 2023. This Salmonella Enteritidis sequence type is the most frequently detected in Europe.

In one cluster, 97 cases with recent or historical isolates, that were closely related genetically, were reported with 22 cases in Denmark, 19 in France and 12 each in Ireland and the Netherlands. Norway has nine patients, Austria and Belgium both have six, Finland has five, Slovenia has three, Sweden has two, and Germany has one.

Link to meat from Poland
In Denmark, the majority of 19 interviewed cases reported consumption of kebab or pizza that may have had chicken as an ingredient, before developing symptoms. In Austria, two of five interviewed patients reported eating chicken kebabs within seven days before the onset of symptoms and two sick people ate other dishes such as chicken burrito and chicken schnitzel.

Last week, the Danish Veterinary and Food Administration (Fødevarestyrelsen) found Salmonella in a batch of frozen chicken kebab meat from Poland, which was withdrawn from the market. The meat was intended to be further heat-treated before eating.

Further tests found it was the same type of Salmonella that sickened people in Denmark from May to August. Frozen chicken kebab products were mainly sold to restaurants. Salmonella cannot survive heat treatment above 75 degrees C (167 degrees F). Fødevarestyrelsen said it would intensify scrutiny on other batches of chicken products from Poland to ensure they are not contaminated with Salmonella.

In the other cluster, 37 cases were reported with 10 each from France and Germany. Austria has eight patients, Sweden has four, Norway has three, and Slovenia has two.

The majority of tested isolates have shown resistance to ciprofloxacin. When antibiotic treatment is required, ciprofloxacin is often used but other antibiotics are needed for these cases.  

More people sick
The two clusters represent only some Salmonella Enteritidis ST11 infections and these strains continue to pose a risk in Europe until sources in the food chain are properly investigated and controlled, said ECDC.

This is shown by information from Austrian authorities, who have recorded 27 sick people in all federal states except Tyrol. One cluster has 14 cases from February to May 2023. Patients are between the ages of 10 and 64.

Another cluster has seven patients aged between 5 and 63 and a 63-year-old man died. Austrian media reported the Klagenfurt public prosecutor’s office is investigating the death. The third cluster, with the latest illness in July, has six cases in Austria aged between 7 and 75.

There were also 65 infections associated with an English outbreak in 2023. For 43 cases linked to a restaurant, the mean age was 32 with a range of 6 to 61 and 17 were female. Epidemiological investigations suggested eggs or chicken as the likely cause.

Thorough cooking of meat and poultry and avoiding cross contamination from uncooked meat to ready-to-eat food are vital to prevent infection with Salmonella.

In 2021, ECDC and the European Food Safety Authority (EFSA) disclosed a multi-country outbreak of Salmonella Enteritidis ST11 linked to poultry products. In 2020 and 2022, two assessments were published on outbreaks of Salmonella Enteritidis ST11 linked to eggs and egg products, showing circulation of the bacteria responsible since 2013.

Meanwhile, a recent control campaign by the National Food Chain Safety Office (Nebih) in Hungary found numerous hygiene problems, Salmonella positive products and one site was temporarily suspended. The seasonal operation looked at outlets selling gyros – a type of sandwich with meat and salad – and other meats.

In late July, Nébih officials conducted inspections in seven gyros distribution units. Proceedings were opened against five sites due to hygiene and traceability deficiencies. The operation of one was suspended. It has since been re-inspected with defects corrected and the required cleaning carried out, allowing it to continue operating.

A total of 19 products were also sampled at eight producers. Tests confirmed Salmonella in seven batches of poultry, so proceedings were brought against the three producers involved. Another two findings of Salmonella in other checks resulted in action including a manufacturer being told to review slaughter hygiene.

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According to the outbreak announcements, the agency has not yet determined the source of the bacteria. 

Food and Drug Administration officials have not revealed where the patients infected with Salmonella Newport live. Nor have they indicated what food or foods are being traced, though they have reported that traceback efforts have begun. So far, there are eight confirmed patients in the outbreak, which is ongoing.

“While the investigation is ongoing to determine what product made people sick, the outbreak appears to be over, and there is likely no ongoing risk to consumers. Additional information will be provided as it becomes available,” according to the outbreak notice from the FDA.

For the outbreak of Cryptosporidium, the FDA is reporting there are 11 patients, all from Minnesota. The FDA is assisting the Minnesota Department of Health and the Minnesota Department of Agriculture in the outbreak investigation. Traceback efforts have begun, but the FDA is not reporting what food or foods are being traced. 

According to the Centers for Disease Control and Prevention, Cryptosporidiosis is a disease that causes watery diarrhea. It is caused by microscopic germs — parasites called Cryptosporidium. Cryptosporidium, or “Crypto” for short, can be found in water, food, soil, surfaces, or dirty hands contaminated with the feces of humans or animals infected with the parasite. Minute amounts of feces not detectable by the human eye can cause infections. 

Testing is the only way to diagnose infection by the parasite as its symptoms can mimic other diseases. Symptoms of Crypto generally begin 2 to 10 days after becoming infected with the parasite. Symptoms include watery diarrhea, stomach cramps or pain, dehydration, nausea, vomiting, fever, and weight loss.

The disease is diagnosed by examining stool samples. People infected with Crypto can shed the parasite irregularly in their poop; for example, one day, they shed the parasite; the next day, they don’t; the third day, they do. Consequently, patients may need to give three samples collected on three different days to help make sure that a negative test result is accurate. Healthcare providers should specifically request testing for Crypto. Routine ova and parasite testing does not normally include Crypto testing.

Symptoms usually last about 1 to 2 weeks, ranging from a few days to 4 or more weeks in people with healthy immune systems. Some people require treatment with antibiotics to recover.

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The recalled products were sold at the Ice Cream House in Brooklyn, NY, and through retail supermarkets in New York, New Jersey, and Ohio, according to the company’s recall notice posted by the Food and Drug Administration this afternoon.

This recall is related to the soft serve On The Go cups previously recalled by Real Kosher Ice Cream Inc., where two cases of illnesses have been reported in this outbreak in New York and Pennsylvania. Both individuals were hospitalized, but no deaths have been reported to date. 

Consumers can use the following information to identify the recalled products:

The company has ceased producing and distributing the products as the investigation is ongoing. 

The newly recalled products include all Ice Cream House branded items currently on the market. This includes all dairy and non-dairy (Parve) products, like ice creams, cakes, logs, and novelty items with the “Ice Cream House” logo. Products are packed in clamshells or cake trays with plastic dome covers in various sizes and styles and have an Ice Cream House label, as seen above. Recalled products are not labeled with lot or date codes.

Products involved in the recall should be discarded or returned to the original point of purchase for a full refund or replacement.

“Ice Cream has a long shelf life and may still be in the freezers of consumers. Consumers should check their freezers and throw away the recalled ice cream products or return it to the place of purchase,” according to the recall notice.

Anyone with questions or concerns can email the company at: [email protected] or call 845-445-7644.

About Listeria infections

Food contaminated with Listeria monocytogenes may not look or smell spoiled but can still cause serious and sometimes life-threatening infections. Anyone who has eaten any recalledproducts and developed symptoms of Listeria infection should seek medical treatment and tell their doctors about the possible Listeria exposure.

Also, anyone who has eaten any of the recalled products should monitor themselves for symptoms during the coming weeks because it can take up to 70 days after exposure to Listeria for symptoms of listeriosis to develop. 

Symptoms of Listeria infection can include vomiting, nausea, persistent fever, muscle aches, severe headache, and neck stiffness. Specific laboratory tests are required to diagnose Listeria infections, which can mimic other illnesses. 

Pregnant women, the elderly, young children, and people such as cancer patients who have weakened immune systems are particularly at risk of serious illnesses, life-threatening infections, and other complications. Although infected pregnant women may experience only mild, flu-like symptoms, their infections can lead to premature delivery, infection of the newborn, or even stillbirth.

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Some main points:

Estimate the loss of 204 that died was at least $240,000,000 US

Hospitalization costs were at least $10,400,000 US

Loss to businesses was at least $15,000,000 US

This does not even account for future medical expenses and/or lost productivity to those that survived and who have life-altering complications. 

And, what about the emotional cost of the survivors?

Here is the abstract:

Periodic outbreaks of foodborne pathogens have resulted in food safety concerns, due to health implications and cost consequences. Occurrence of Listeria monocytogenes in foods and listeriosis have been reported in developed countries; however, documentation of listeriosis in South Africa is limited. In 2017–2018, Listeria was reported on polony (processed deli meat) and listeriosis was observed in South Africa (L. monocytogenes sequence type 6 (ST-6) was identified as the causal agent for listeriosis). Due to its potential effects, we conducted cost estimates to assess the implications of listeriosis outbreak with respect to illnesses, hospitalizations and deaths, and productivity losses. Cost estimates were computed on publicly available data by using USDA-ERS cost computation model for Listeria. Listeriosis had significant impacts, as mortality of 204 individuals with confirmed listeriosis cases was reported, with infants having the highest percent of fatalities (42%). The cost valuation of fatality cases was over US$ 260 million. Hospitalization costs associated with one-month recovery from listeriosis were estimated at US$ 10.4 million. Productivity losses attributed to listeriosis for humans and export value losses for food processors were in excess of US$ 15 million. Increase of food safety measures in South Africa could reduce foodborne disease outbreaks. Pre-emptive pathogen detection, sanitary procedures and bacterial inactivation can enhance control of L. monocytogenes in food processing environments.

Here is what happened and why:

We are now beyond five years from the date that the NICD announced the association between Tiger Brands’ polony products and the outbreak, and the work done by all parties has only generated more evidence that the NICD’s and Tiger Brands’ conclusions are accurate. There is no evidence to the contrary.

In 2017 and 2018, the world’s largest and deadliest outbreak of listeriosis occurred in multiple provinces of South Africa (Figure 1). The outbreak was caused by contaminated polony, a ready-to-eat, processed meat product. Ready-to-eat, processed meats are a well-known vehicle for listeriosis outbreaks (Thomas et al., 2020). The Minister of Health declared that there was an outbreak of listeriosis on December 5, 2017, and, on March 4, 2018, further identified Tiger Brands’ polony products as the cause of the outbreak. The Minister of Health instructed Tiger Brands to recall all polony products the same day. See generally, Minister of Health September 3, 2018, Media Statement. The Ministry of Health based its conclusions on the investigative findings of the Joint Public Health Emergency Co-ordinating Committee, which was established for the specific purpose of identifying the cause of the outbreak and developing measures to prevent further illnesses and other outbreaks associated with processed meat products generally. Id. The relevant epidemiologic findings are set forth in the paragraphs that follow.

Figure 1. Incidence of Laboratory-Confirmed Listeriosis Cases during the Outbreak Period, According to South African Districts (Thomas et al., 2020).

Cases were reported from across the country, with most cases reported from Gauteng Province (58%). Women accounted for 55% of total cases. The ages of cases ranged from birth to 93 years. Neonates (aged £ 28 days) were the most affected age group, accounting for 43% of cases. This was followed by adults of 15 to 49 years of age, accounting for 32% of cases. The disease outcome was known for 806/1,060 (76%) of cases; 27% (216/806) had the known outcome “died” (Smith et al., 2019).

Listeriosis is a serious foodborne infection with a case-fatality rate (“death rate”) of 20-30% (Thomas et al., 2020). People primarily affected by listeriosis have impaired cell-mediated immunity. This includes those who are pregnant, elderly, or immunocompromised from conditions such as HIV, chronic disease, or immunosuppressive therapy (Thomas et al., 2020). The specific outbreak strain associated with the outbreak was Lm ST6. There are two ways that listeriosis can manifest: febrile gastroenteritis and invasive listeriosis (Coulombier). Invasive listeriosis is characterized by bacteraemia, meningitis, pneumonia, endocarditis, and sepsis (Smith et al., 2019).

A total of 1,060 cases were reported during the period of January 11, 2017, to July 17, 2018 (Figure 2)[1]. The outbreak period was defined as a duration of time during which case numbers exceeded and remained above a weekly threshold of five cases per epidemiological week (Thomas et al., 2020). At the peak of the outbreak (mid-November 2017), 41 listeriosis cases were reported in a single week. Prior to this outbreak, listeriosis was not a reportable disease in South Africa; therefore, information is not available on the prevalence, epidemiology, and description of clusters/outbreaks on listeriosis. Due to the lack of surveillance data, the baseline number of listeriosis cases was estimated from counts of listeriosis cases in 2016.

It is known that in 2015 and 2016, clusters of listeriosis occurred in South Africa. The 2015 listeriosis cluster involved 7 cases total, and the predominant strain was Lm ST6. However, researchers did not have sufficient epidemiologic evidence to connect the 2015 cluster to any specific food product (Shuping et al., 2015). For the 2016 cluster, retrospective analysis of Lm cases from the years 2012-2016 was used to calculate the expected case numbers for years 2013, 2014, 2015, and 2016 in the Gauteng province (Mathebula et al., 2016)[2]. Because there were only 3 cases in the 2016 cluster, researchers needed to estimate the baseline number of cases.

When determining if a cluster of diseases is classified as an outbreak or epidemic, it is essential to know what the baseline number of illnesses is in the population of interest. An epidemic refers to an increase in the number of cases of a disease, above what is normally expected in that population in that area, and an outbreak is defined the same but is often used for a more limited geographic area (Centers for Disease Control and Prevention [CDC], 2012).

Figure 2. Distribution of Laboratory-Confirmed Cases of Listeriosis, According to Outbreak Week and Major Events (January 1, 2017 to August 21, 2018) (Thomas et al., 2020).

Case definitions are used in outbreak investigations to help identify cases who are associated with the outbreak. A case definition includes criteria such as the subject population, implicated location, time, clinical features, and/or laboratory test results if available (CDC, 2012). The initial case definition for the primary listeriosis outbreak included all cases of listeriosis that occurred in South Africa from 2017 to 2018. The initial case definition was appropriate due to the lack of whole-genome sequencing (WGS) data at the beginning of the investigation. Multilocus sequencing typing (MLST) was used later to analyse the WGS results from all viable isolates obtained from case-patients. Researchers discovered that 93% of the clinical isolates collected from cases during the outbreak period were Lm ST6 (Thomas et al., 2020; Gerner-Smidt). The case definition later included sequence typing information to increase the likelihood of identifying a common source (Besser). This finding also showed that the outbreak strain of Listeriosis was definitively the Lm ST6 strain.

Further, we note that investigators thoroughly analysed the theoretical possibility that Lm ST6 was coming from more than just Tiger Brands’ polony products. In short, after conducting environmental investigations at all 157 ready-to-eat meat production facilities in South Africa, there was no Lm ST6 in any other products or facilities except Tiger Brands.

Together with the NCID’s clear statements that Tiger Brands polony products were the source of the outbreak, based on epidemiologic and environmental evidence, the constellation of all evidence conclusively establishes that Tiger Brands’ polony products were in fact the sole source. There is no additional analysis that will materially change these facts.

Based on its investigation findings, the Minister of Health issued a recall of Tiger Brand’s ready-to-eat meat products produced at the Enterprise facility. The Minister of Health also recalled all ready-to-eat meat products produced at Rainbow Foods, but epidemiologic and environmental findings during the investigation showed that this was a precautionary measure only—i.e., the Listeria identified at the Rainbow Foods’ production facility on environmental testing was not Lm ST6, and therefore had no causal association with illness in the outbreak. See Minister of Health March 4, 2017 Statement. Shortly after Tiger Brands’ recall, the outbreak essentially stopped (Figure 3).

Figure 3. Epidemic curve of laboratory-confirmed listeriosis cases by date of clinical specimen collection (n=1 038) and sequence type (ST) (n=564), South Africa, 01 January 2017 to 5 June 2018 (n=1049)

The environmental and epidemiologic investigative findings establish the likely causal nexus between Tiger Brands’ polony products and most all Listeriosis cases that occurred in South Africa before, during, and after the outbreak period. (Coulombier).  As stated above, 93% of clinical isolates that underwent sequencing were shown to be Lm ST6, the strain that was both epidemiologically associated with illness and repeatedly found in the production environment at the Enterprise facility, and nowhere else. But not all isolates could be sequenced, due to the lack of laboratory resources and personnel available (Besser). Based on the high percentage of Lm ST6 clinical isolates, it is highly likely that a similar percentage of non-sequenced isolates would have been Lm ST6 if sequencing could have been done (Coulombier). As further support that there was no difference between the distribution of sequence types among the non-sequenced samples and the distribution of sequence types observed in the sequenced samples, the process of selecting case isolates to be sequenced was not biased. Therefore, it is a statistically valid and provable fact that, in the absence of evidence to the contrary—i.e., sequencing that showed that a clinical isolate was not Lm ST6–a listeriosis patient diagnosed during the outbreak period had a > 90% probability of being related to the outbreak even without confirmed laboratory results (Gerner-Smidt).

After detecting the outbreak, the Centre for Enteric Diseases, a part of the National Institute for Communicable Diseases, conducted a nested case-control study that provided evidence that cases with Lm ST6 infections were more likely to have eaten polony than those with non- Lm ST6 infections (Thomas et. al, 2020). In outbreak investigations, case-control analysis is performed to estimate the odds ratio for the association between specific food items and the outbreak-associated illness. For this nested case-control study, case patients were those with Lm ST6 infections, and control patients were people infected by another strain of LM (i.e., not Lm ST6) during the outbreak period. Results from this study show that the odds ratio was 8.55 with a 95% confidence interval of 1.66 – 43.35. An odds ratio is a measure of association between the odds of becoming ill from consuming a specific food item versus the odds of becoming ill without having consumed the specific food item (Coulombier). An odds ratio of 8.55 signifies that the odds of having eaten polony in Lm ST6 cases is 8.55 times greater than the odds of having eaten polony in non-Lm ST6 cases. Based on the calculated confidence interval, this result is statistically significant because the confidence interval does not include the null value of 1. Therefore, 95% of the time, the true odds ratio fell within this interval.

Prior to the study, food history interviews were conducted to generate a hypothesis as to which food item could have been the source of the outbreak (Coulombier). The food histories were conducted with the use of a standardized questionnaire that inquired as to food consumed by a case-patient over the four weeks prior to onset of symptoms. Open-ended questions were posed to Listeriosis cases to understand each case’s food habits, such as where they purchase food, name of restaurants patronized, and use (and name) of informal food vendors. Closed-ended questions were posed to determine each case’s exposure to specific food items associated with outbreaks in the past and locally consumed foods thought to pose a high risk for listeriosis such as processed meats (e.g., biltong), cold meats (e.g., ham, polony), soft cheeses, raw milk, and raw vegetables. Brand preferences were also captured in the form.  The combination of open and closed-ended questions was and continues to be standard practice for the conduct of epidemiologic investigations internationally and provided investigators with high value data for consideration alongside other epidemiologic and environmental information.

The food history interviews were completed by November 1, 2017. The epidemiologic methods utilized throughout this investigation, including the case-control, were robust and mirrored those used in high-level investigations throughout the world. The investigators’ multi-disciplinary investigative methods were fully appropriate for the outbreak circumstances (Besser).

On January 13, 2018, febrile gastroenteritis developed in 10 children from a nursery in Gauteng Province. Several stool samples were collected from the children, and one yielded Lm ST6. Sandwiches prepared and eaten at the nursery were the only common food exposure, and polony was the common ingredient. Polony was recovered from the nursery refrigerator, and Lm ST6 was identified in the polony produced at Tiger Brands Enterprise Facility in Polokwane (Thomas et al., 2020).

On February 2, 2018, an environmental investigation took place at the Tiger Brands Enterprise Facility in Polokwane following the discovery at the nursery (Gerner-Smidt). Of 317 environmental samples taken from the Polokwane facility, 47 tested positive for Listeria monocytogenes, and of the 47 that tested positive, 34 were subtyped as the outbreak Lm ST6 strain. Additionally, two of 13 samples of unopened polony loaves collected at the facility tested positive for Listeria monocytogenes, and both were subtyped as the outbreak Lm ST6 strain.

These facts stand in stark contrast to the investigations at all other South African ready-to-eat meat producers, during which investigations no Lm ST6 was recovered in any food or environmental sample.

The fact that the public health investigation involved environmental inspections and sampling at the production facilities of other ready-to-eat meat producers is remarkable. Indeed, the public health investigation of this outbreak was unprecedented in scope, even internationally, as it is, in our experience, unprecedented to engage in such robust investigation of producers whose products are not epidemiologically associated with an outbreak. Thus, the only epidemiologic evidence establishes that Tiger Brands, and Tiger Brands alone, produced product contaminated by Lm ST6 during the outbreak period. By incorporating findings from the epidemiologic, environmental, microbiologic, and traceback data, investigators provided conclusive evidence that the source of the outbreak was polony produced fromTiger Brands Enterprise Foods Polokwane production facility, and that there were no other possible causes.

Further, and as set forth previously, the Minister of Health identified Tiger Brands’ polony products as the source of the outbreak on March 4, 2018, and instructed Tiger Brands to recall all its ready-to-eat meat products. At the point in time that Tiger Brands’ polony products were taken off of store shelves and were no longer widely available for purchase and consumption in South Africa, the outbreak ended and listeriosis cases in South Africa shortly returned to their pre-outbreak baseline. As Figure 3 demonstrates, by mid-April 2018 (6 weeks after recall), fewer than 5 cases were reported weekly. Regarding those individuals who became ill between the date of Tiger Brands’ recall and mid-April 2018, listeriosis cases continued to become ill by consumption of Tiger Brands’ polony products that were purchased before the date of the recall, which was to be expected given the lengthy incubation period for listeriosis generally (from 3 days to over one month), or from Tiger Brands’ polony products that were simply not removed from store shelves in time.

Following the findings by the NICD, Tiger Brands conducted its own internal investigation into the outbreak. During this internal investigation, based on information set forth in the discovery conducted to-date and Tiger Brands’ various public statements, Tiger Brands confirmed the presence of the Lm ST6 outbreak strain in both its products and various locations in the production environment at the Enterprise facility. Tiger Brands issued several public statements to this effect.

In a SENS statement dated 19 March 2018, Tiger Brands issued the following public statement:

“On 15 March 2018, Tiger Brands received confirmation from independent laboratory tests corroborating the DoH’s findings of the presence of LST6 in the environment at its Polokwane Enterprise Foods manufacturing Facility. In addition, there was a positive detection of LST6 on the outer casing of two samples.”

On 26 March 2018, Tiger Brands issued a public statement on its website reiterating the independent laboratory results announced in the SENS statement of 19 March 2018 as aforementioned which confirmed the presence Lm ST6 in the Tiger Brands Polokwane Facility. In the 26 March press statement, Tiger Brands CEO, Mr Lawrence Mac Dougall commented on this discovery and, inter alia, stated as follows:

“We are investing all our time and energy into not only understanding the cause of the LST6 detection, but also how it could have come into our facility.”

In a statement to shareholders dated 23 May 2018, Mr Mac Dougall stated that:

“The detection of the presence of Listeria ST6 in our factory in Polokwane was disappointing to us given our compliance with best practices and prevailing standards.”

In a SENS statement dated 25 April 2018, Tiger Brands reported that it had received independent laboratory test results following its own internal investigation which confirmed the presence of the Lm ST6 in samples of ready-to-eat meat products manufactured at the Polokwane Facility:

“The purpose of this announcement is to update shareholders on the results of the independent laboratory re-testing which was carried out in respect of the presence of LST6 in the above samples which were manufactured at the Enterprise Polokwane processing facility. On 24 April 2018, Tiger Brands received confirmation of the presence of LST6 in these samples.”

From both the NICD’s and Tiger Brands’ investigations into the outbreak, there is no evidence that the outbreak had any source other than Tiger Brands’ polony products. There is no epidemiologic support for that proposition, and there is no environmental support for that proposition because NICD found no other positive Lm ST6 samples at any other facility that produces ready-to-eat meat. In fact, Tiger Brands has, in unequivocal terms, admitted to this responsibility. For example, in the request Further Trial Particular, Tiger Brands affirmed its responsibility for Lm ST6 cases:

“Tiger Brands statement of 24 April 2018 was correct. Tiger Brands learnt that laboratory tests had found ST6 in ready-to-eat meat products from its Enterprise Foods manufacturing facility in Polokwane. It accepts that the laboratory findings were correct.”

“Tiger Brands does not know to what products the contamination extended or over what period it occurred. It accepts, however, that ST6 contaminated products from its Polokwane facility probably infected some of the people who suffered from listeriosis during the outbreak.”

“The defendants accept the test results that L. monocytogenes was detected in the polony water coolers at the Polokwane facility.”

Further, and following the Supreme Court of Appeal’s ruling in the third-party subpoena’s litigation, Tiger Brands issued the following statement to the press:

“On Friday, 4 February 2022, the Supreme Court of Appeal overturned the earlier order of the Gauteng Division of the High Court, Johannesburg which required various third parties to hand over epidemiological information relating to the listeriosis outbreak.”

“The 2018 listeriosis outbreak affected many South Africans. We are saddened by the impact it has had on the lives of the victims and those who have lost loved ones from the outbreak. Tiger Brands reiterates its commitment to ensure that a resolution of the matter is reached in the shortest possible time, in the interest of all parties, particularly the victims of listeriosis.”

That Tiger Brands is liable for the manufacture and sale of contaminated polony products that injured people is beyond doubt; the scientific findings from the multi-disciplinary investigation allow only this conclusion, and the functional life of the outbreak ended when Tiger Brands was ordered to withdraw its products from the market. The epidemiologic implications of NICD’s sequencing effort are conclusive, which is the preliminary point made by SAAFOsT, in which organization Tiger Brands is a custodian member, in its December 2017 statement that:

“This is undoubtedly one of the worst listeriosis cases in global history. A large percentage (74%) of all the clinical isolates belong to the same sequence type i.e. ST6—this means that these isolates originate from a single source, most likely a food product on the market.”

What SAAFOsT did not have the benefit of then knowing, however, was that sampling at Tiger Brands’ Polokwane facility would validate in every respect the epidemiologic implications from NICD’s sequencing efforts on human isolates.

We are now beyond four years from the date that the NICD announced the association between Tiger Brands’ polony products and the outbreak, and the work done by all parties has only generated more evidence that the NICD’s and Tiger Brands’ conclusions are accurate. There is no evidence to the contrary.

_____________________

[1]  Note: 23 October 2016 to 3 September 2018 is the “Outbreak Period” in the Certification Order.

[2] The oldest South African CT4148 isolates date from September 2015 and are related to a cluster of three cases of listeriosis in Western Cape Province28; this finding suggests a potential epidemiologic link to the 2017–2018 outbreak. Thomas, et al., 2020

References

Besser, J. (2020). Expert Opinion Regarding a Listeria Outbreak in South Africa Involving Tiger Brands Limited.

Coulombier, D. (2020). Expert Opinion Regarding a Listeria Outbreak in South Africa Involving Tiger Brands Limited.

Gerner-Smidt, P. (2020). Expert Opinion on Subtyping Aspects of the Listeria Outbreak in South Africa Involving Tiger Brands Limited.

Smith, A. M., et al. (2019). Outbreak of Listeria monocytogenes in South Africa, 2017-2018: Laboratory Activities and Experiences Associated with Whole-Genome Sequencing Analysis of Isolates. Foodborne Pathog. Dis. 16(7): 524-530. doi:10.1089/fpd.2018.2586

Thomas, J., et al. (2020). Outbreak of Listeriosis in South Africa Associated with Processed Meat. N. Engl. J. Med. 382: 632-643. doi:10.1056/NEJMoa1907462

Tiger Brands SENS statement dated 19 March 2018, “Financial Impact of Product Recall and Suspension of Operations at the Polokwane, Germiston, Pretoria and Clayville Processing facilities of Value-Added Meat Products (“VAMP”); Institution of Class Action; and Results of Independent Tests carried out in respect of the presence of Listeria monocytogenes ST6 type (“LST6”)”

Tiger Brands Public Statement dated 26 March 2018, “Tiger Brands Listeria Update”

Tiger Brands SENS Statement dated 23 May 2018, “Unaudited group results and dividend declaration for the six months ended 31 March 2018.

Tiger Brands SENS Statement dated 25 April 2018, ‘Results of Independent Tests carried out in respect of the presence of Lister monocytogenes ST6 type (“LST6”)’

Tiger Brands response to Plaintiff’s Further Particulars

Rose, “Tiger Brands Tall Tale”. Financial Mail, 10 February 2022.

Shuping, L., et al. (2015). Investigating a cluster of Listeria monocytogenes cases in the Western Cape province of South Africa, September 2015.

NICD. (2016). Investigation of Listeria monocytogenes cases at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, December 2016.

NICD, Listeriosis Outbreak Situation Report. Dated 11 June 2018.

SAAFOST, “Listeriosis Outbreak in South Africa – Latest! By Dr Lucia Anelich, SAAFoST President”. Dated 20 December 2017.

During a news conference this afternoon, a spokesman from the Arkansas Department of Health said four people were hospitalized. Also, about 100 students from the university responded to an email saying they currently have or have recently had symptoms.

The total number of confirmed outbreak patients has not been released.

The spokesman said the outbreak seems limited to the Northeast part of the state. He also said the state department and university officials are working with the U.S. Centers for Disease Control and Prevention to investigate the outbreak.

The spokesman said health officials believe the outbreak started about a week ago.

About E. coli infections
Anyone who has developed symptoms of E. coli infection should seek medical attention and tell their doctor about their possible exposure to the bacteria. Specific tests are required to diagnose the infections, which can mimic other illnesses.

Students and the public are being asked to monitor themselves for symptoms of E. Coli infections and report any illnesses to their doctors or go to emergency rooms if the symptoms are severe.

“This outbreak does not appear to be related to a couple of others on the West Coast being investigated by the CDC,” according to the state spokesman.

The symptoms of E. coli infections vary for each person but often include severe stomach cramps and diarrhea, which is often bloody. Some patients may also have a fever. Most patients recover within five to seven days. According to the Centers for Disease Control and Prevention (CDC), others can develop severe or life-threatening symptoms and complications.

About 5 to 10 percent of those diagnosed with E. coli infections develop a potentially life-threatening kidney failure complication known as a hemolytic uremic syndrome (HUS). Symptoms of HUS include fever, abdominal pain, tiredness, decreased frequency of urination, small unexplained bruises or bleeding, and pallor. 

Many people with HUS recover within a few weeks, but some suffer permanent injuries or death. This condition can occur among people of any age but is most common in children younger than five years old because of their immature immune systems, older adults because of deteriorating immune systems, and people with compromised immune systems such as cancer patients. 

People who experience HUS symptoms should immediately seek emergency medical care. People with HUS will likely be hospitalized because the condition can cause other serious and ongoing problems such as hypertension, chronic kidney disease, brain damage, and neurologic problems.

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The Governor’s announcement comes after the New York State Department of Health issued comprehensive guidelines to healthcare providers, outlining optimal practices for identifying and treating patients related to such bacterial infections.

Fatal cases of vibriosis have also been identified in Connecticut, prompting authorities to alert the public and bolster healthcare vigilance. The deaths were linked to swimming in contaminated water. Governor Hochul stressed the importance of awareness and preventive steps, emphasizing that New Yorkers should be informed about minimizing exposure risks.

“While rare, the vibrio bacteria has unfortunately made it to this region and can be extraordinarily dangerous,” Governor Hochul cautioned. “As we investigate further, it is critical that all New Yorkers stay vigilant and take responsible precautions to keep themselves and their loved ones safe, including protecting open wounds from seawater and, for those with compromised immune systems, avoiding raw or undercooked shellfish which may carry the bacteria.”

The spectrum of vibriosis encompasses various bacterial strains, with Vibrio vulnificus prominently occurring in saltwater coastal environments. The prevalence of this bacterium surges from May to October, coinciding with warmer weather conditions. Ingesting the bacteria can lead to symptoms such as diarrhea, stomach cramps, vomiting, fever, and chills. Additionally, exposure can result in ear infections, sepsis, and life-threatening wound infections.

Authorities are currently investigating the death in Suffolk County to ascertain whether the bacteria was contracted from New York waters or from elsewhere. In the interim, the New York State Department of Health has communicated with healthcare providers, urging them to remain vigilant and consider vibrio vulnificus when diagnosing cases of severe wound infections or sepsis with or without associated wound infections.

Dr. James McDonald, New York State Health Commissioner, highlighted the need for heightened awareness, stating, “We are reminding providers to be on the lookout for cases of vibriosis, which is not often the first diagnosis that comes to mind. We are also suggesting to New Yorkers that if you have wounds, you should avoid swimming in warm seawater. And, if you have a compromised immune system, you should also avoid handling or eating raw seafood that could also carry the bacteria.”

Suffolk County Executive Steve Bellone underscored the importance of staying informed and cautious, “While we continue to investigate the source of this rare infection, it is important for residents to remain aware and vigilant on precautions that can be taken. As always, if any residents have health concerns we encourage them to contact their healthcare provider.”

It’s worth noting that while anyone can contract vibriosis, individuals with liver disease, cancer, weakened immune systems, or those taking medication to reduce stomach acid levels may be more susceptible to infection or complications arising from infection.

To mitigate the risk of vibriosis, individuals with open wounds, recent piercings, or tattoos are advised to avoid exposing the affected area to warm seawater in coastal regions. Alternatively, these wounds should be covered with waterproof bandages. Moreover, individuals with compromised immune systems are cautioned against consuming raw or undercooked shellfish, such as oysters, known to harbor the bacteria. Practicing safe handling techniques and thorough handwashing is recommended after touching raw shellfish.

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Investigators linked the outbreak to ground beef sold at ShopRite stores in the Northeast, according to a notice from the Centers for Disease Control and Prevention.

Of the 18 patients, seven were so sick they had to be hospitalized. Patients were from four states. No one died. The patients lived in New York, New Jersey, Connecticut and Maryland.

“WGS (Whole Genome Sequencing) showed that bacteria from sick people’s samples were closely related genetically. This suggested that people in this outbreak may have gotten sick from the same food,” according to the CDC’s report.

“. . . The outbreak strain was identified in a routine ground beef surveillance sample collected by USDA-FSIS in March 2023.”

State and local public health officials interviewed patients about the foods they ate in the week before they got sick. Of the 16 people interviewed, 10 reported eating ground beef. Nine sick people reported purchasing the ground beef from ShopRite locations in Connecticut, New Jersey, and New York. Seven of these people specifically reported purchasing 80 percent lean ground beef products. Two people reported purchasing ground beef products from ShopRite but could not remember the type of ground beef.

As of Aug. 23, a total of 18 people infected with the outbreak strain of Salmonella were reported. Illnesses started on dates ranging from April 27 through July 6.

“The true number of sick people in this outbreak was likely much higher than the number reported, and the outbreak may not have been limited to the states with known illnesses. This is because many people recover without medical care and are not tested for Salmonella. In addition, recent illnesses may not yet be reported as it usually takes 3 to 4 weeks to determine if a sick person is part an outbreak,” according to the CDC outbreak notice.

Although this outbreak has ended, the CDC is reminding consumers to cook ground beef to an internal temperature of 160 degrees F to kill pathogens.

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Researchers analyzed the cause of household foodborne disease outbreaks from 2010 to 2020 using data from the National Foodborne Disease Surveillance System.

A total of 17,985 outbreaks, which resulted in 73,252 illnesses, 38,829 hospitalizations, and 1,269 deaths, were reported. Most episodes were from May to October, and the highest number occurred in July.

A similar study, published in China CDC Weekly, looked at outbreaks in catering facilities in the country using data from the same time period.

Wild mushroom problem
Fungi, mainly poisonous mushrooms, were the most implicated food category, with 8,873 household outbreaks. The second was toxic plants and their products, with 1,552. These include aconite, potherb, tung seed or oil, bitter bottle gourd, and Masang fruit. Fungi were the primary etiologic agent, with 31,125 illnesses and 736 deaths.

Household outbreaks rose from 118 in 2010 to 4,140 in 2020. Almost 700 outbreaks were from unknown food. Alcohol products caused the highest case fatality rate, found in the study published in the Foodborne Pathogens and Disease journal.

Salmonella was the top bacterial pathogen with 437 outbreaks, and the principal chemical agent was nitrite, causing 476 outbreaks. Pupal toxicants, tetrodotoxin (TTX), and saxitoxin were the leading poisonous animal toxins. Norovirus was the primary virus, with 13 outbreaks. The cause was unknown for more than 4,200 outbreaks with 75 deaths.

Plant saponin toxicants were mainly found in vegetables. Eggs and egg products were mostly contaminated by Salmonella, followed by meat and meat products with the same pathogen. Chemical pesticides were primarily found in vegetables.

Tackling the issues
Researchers said most poisonous mushroom outbreaks occurred in southwest China, including Yunnan, Hunan, and Guizhou provinces.

Outbreaks from vegetable products were mainly caused by improper processing. Inedibility and misuse, especially wrong identification, were the top contributing factors to illnesses related to poisonous mushrooms, mainly in southwest China. The leading cause of Salmonella contamination in meat and meat products was improper processing and poor storage.

“The reason is that wild poisonous mushrooms are similar in appearance to edible mushrooms, and it is difficult for ordinary people to distinguish edible mushrooms from poisonous mushrooms without proper equipment. This study showed that targeted interventions to reduce mushroom poisoning are critical in China,” said researchers.

“Severe and even fatal aconite root poisoning may occur after consuming herbal soups and foods prepared from aconite roots. If the raw preparations and large amounts of aconite root are used, even prolonged boiling may not have a protective effect.

“All regions should strengthen market surveillance and improve laboratory surveillance of pathogenic bacteria such as Salmonella in meat. Residents should raise their awareness of food safety and ensure meat safety by processing meat and raw foods separately and storing them safely.” 

Public health agencies should also boost the supervision of foodborne diseases to reduce the risks.

“Governments should strengthen supervision for provinces with a high incidence of foodborne diseases, especially during peak seasons. In addition, health education for household food handlers, such as proper food handling behavior and emphasis on kitchen hygiene, should be strengthened to improve residents’ awareness of food safety and effectively reduce the occurrence of foodborne diseases among families,” said researchers.

Scientists said it was necessary to change understanding around aconitum plants. Aconite roots are used to prepare herbal soups and meals for their beneficial health effects.

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Although investigators identified the cause of the outbreak, the Food and Drug Administration is not reporting what brand of Pico de Gallo was implicated. The agency reported that 37 people were sickened in the outbreak, but did not report where they live. The FDA first reported the outbreak on June 14.

“For the outbreak of Salmonella Paratyphi B var. L(+) tartrate+ the outbreak has ended and FDA’s investigation has closed. CDC, FDA, and state and local partners conducted epidemiologic and traceback investigations and identified Pico de Gallo as the source of the outbreak,” according to an FDA report released Wednesday.

The FDA reported that its investigators took samples of the product as well as environmental samples of the production facility, but all of the samples came back negative for the outbreak strain. The agency’s statement says there is no risk to consumers.

“Due to the lack of additional supporting evidence, investigators were unable to determine a specific ingredient within the Pico de Gallo or contributing factors as the source of the contamination. Additionally, once investigators had enough information to confirm Pico de Gallo as the source of this outbreak, the products were past their shelf life and no longer available for sale,” the FDA reported.

Cyclospora outbreak
In an outbreak of infections from the microscopic cyclospora parasite, the FDA is reporting that the patient count is 72, up from 69 a week ago. The FDA has not released any patient information and is not reporting where the sick people live. The agency first reported the outbreak on June 14.

FDA investigators have begun traceback efforts as well as onsite inspections and sample analysis. However, the agency has not reported what food is being traced or what location is being inspected.

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There is a link between patients and different packaged brands of Spanish omelet (tortilla de patata), which is made with potatoes and eggs, purchased in various supermarkets in different regions.

The Norwegian cases stayed in Barcelona between July 10 and 23.

The first case, a 38-year-old man, was confirmed with onset of symptoms on July 23. He consumed the suspected product between July 17 and 23. The man required hospitalization on August 10, admission to the ICU on August 12, and treatment with botulinum antitoxin.

The second is a probable case; a 38-year-old woman, with onset of botulism symptoms on July 22. She reported eating the implicated product between July 14 and 20 but did not need hospitalization or specific treatment.

Eleven people sick

Five confirmed and four probable cases of botulism had previously been reported from June 21 to July 22. Sick people ranged from 23 to 63 years old with a median age of 49. Four confirmed patients required medical attention in intensive care units but no deaths have been reported.

Italy recorded two cases of botulism linked to omelets eaten in Spain. The patients are a 23-year-old woman and her 61-year-old father who returned home from Valladolid on July 1, having consumed the suspected item on June 30.

The other three confirmed patients live in Madrid, Galicia and Asturias and are aged 43, 49 and 50. Four probable patients are from Valencia, Andalusia and Madrid and are aged 49, 27, 63 and 48.

According to information from the Spanish Agency for Food Safety and Nutrition (AESAN), all brands of Spanish omelets consumed by the cases were made by a single company. Items were also distributed to Andorra, France, and Portugal.

All items with a batch number equal to or greater than 10001 and an expiration date later than September 2 are safe to eat. Spanish omelets with lot numbers between 5426 and 5563 should not be consumed.

Restart of operations

Earlier this month, the firm linked to the outbreak restarted production after being given the all-clear.

Grupo Empresarial Palacios Alimentación said the production line at the Mudrián factory had been reopened after approval from authorities. Production was stopped and products were removed from sale in July.

All official and internal analyses carried out on the products and manufacturing processes were negative for Clostridium botulinum and botulinum toxin, according to the company.

Palacios Alimentación said it was important to always follow the recommendations for use and conservation instructions on the labeling of such products, which should have been kept refrigerated.

Botulinum poisoning is a rare but life-threatening condition, caused by toxins produced by Clostridium botulinum bacteria. In foodborne botulism, symptoms generally begin 18 to 36 hours after eating contaminated food. However, they can occur as soon as six hours or up to 10 days later. Symptoms may include double or blurred vision, drooping eyelids, slurred speech, difficulty swallowing or breathing, paralysis, a thick-feeling tongue, dry mouth, and muscle weakness.

Anyone who has eaten suspect products and developed symptoms should immediately seek medical attention.

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The ice cream, made by Real Kosher Ice Cream of Brooklyn, NY, has been found to be contaminated with the same strain of Listeria monocytogenes as that found in samples from two patients. Both patients, one in New York and the other in Pennsylvania, have been so sick that they required hospitalization.

The company issued a recall of certain ice cream products earlier this month after a link was established between the sick people and its products.

In information released yesterday, the FDA confirmed that Listeria Monocytogenes matching the sick people’s samples was found in an unopened sample of the implicated ice cream during testing by the Pennsylvania Department of Agriculture.

Also, the New York Department of Agriculture and Markets found the outbreak strain of Listeria Monocytogenes in five finished samples of “Soft Serve On the Go” ice cream cups collected from the company’s manufacturing facility.

The ice cream was distributed in California, Colorado, Connecticut, Washington D.C., Delaware, Florida, Illinois, Massacheassetts, Maryland, Michigan, Minnesota, North Carolina, New Hampshire, New Jersey, New York, Ohio, Oregon, Pennsylvania, Virginia and West Virginia.

The company is recalling all flavors of its Soft Serve On The Go 8-ounce ice cream cups”

• Soft Serve On The Go Vanilla Chocolate 
• Soft Serve On The Go Razzle
• Soft Serve On The Go Caramel 
• Soft Serve On The Go Parve Vanilla Chocolate
• Soft Serve On The Go Sorbet Strawberry Mango
• Soft Serve On The Go Lite Peanut Butter

The FDA is continuing to investigate the outbreak along with state officials and the U.S. Centers for Disease Control and Prevention. 

Additional patients are likely part of the outbreak because of the lag time between when people become ill and when testing, confirmation testing and reporting are done. Also, it can take up to 70 days for symptoms of Listeria infections to develop. 

About Listeria infections
Food contaminated with Listeria monocytogenes may not look or smell spoiled but can still cause serious and sometimes life-threatening infections. Anyone who has eaten any of the recalled ice cream and developed symptoms of Listeria infection should seek medical treatment and tell their doctors about the possible Listeria exposure.

Also, anyone who has eaten any of the recalled products should monitor themselves for symptoms during the coming weeks because it can take up to 70 days after exposure to Listeria for symptoms of listeriosis to develop. 

Symptoms of Listeria infection can include vomiting, nausea, persistent fever, muscle aches, severe headache, and neck stiffness. Specific laboratory tests are required to diagnose Listeria infections, which can mimic other illnesses. 

Pregnant women, the elderly, young children, and people such as cancer patients who have weakened immune systems are particularly at risk of serious illnesses, life-threatening infections, and other complications. Although infected pregnant women may experience only mild, flu-like symptoms, their infections can lead to premature delivery, infection of the newborn, or even stillbirth.

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This past week, officials from the city of Mikkeli sent a questionnaire to parents of students and staff about symptoms that occurred during or after school meals on Aug. 16. As of Monday morning, answers had been received from nearly 3,800 parents and 350 employees.

All schools in Mikkeli have had at least a few patients. The incident is being investigated with the Finnish Food Authority (Ruokavirasto) and National Institute of Health and Welfare (THL).

Samples taken from different foods and raw materials are being examined to find out the cause of the epidemic. Results of laboratory tests are expected later this week.

Mainly mild illnesses
Most sick people had mild symptoms, which they have now recovered from, and as yet no serious illnesses have come to the attention of authorities.

About half of the students had symptom onset within an hour of eating, and 75 percent within six hours. About 16 percent came down with symptoms 12 hours after eating. The most common symptom was stomach pain, followed by nausea, headache, vomiting, diarrhea, fever, muscle or joint pain, and a few reported blood in their stool.

Ill staff reported stomach pain, nausea, headache, diarrhea, vomiting, fever, joint pain, and one person had blood in their stool.

Initial findings point to vegetable tortillas as the source, because there have been sick people at all schools where they were available.

Several students mentioned the tortillas were “bad” with some saying they tasted like soap or detergent.

The tortillas came ready-made for all kitchens, from the same place. Vegetable filling was done for schools in four different kitchens.

In 2021, a large Salmonella outbreak in Finland affected more than 700 people, with children making up the majority of patients. The implicated food was a salad with iceberg lettuce, cucumber, and peas served in several education establishments. Officials in the city of Jyväskylä investigated the incident with the help of THL.

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Editor’s note: This column was originally published by MEDPAGETODAY and is reposted here with permission.

In August 2006, Ruby Trautz of Omaha, Nebraska was the first person of several to die in a foodborne outbreak after eating uncooked baby spinach laced with E. coli 0157:H7, a pathogen that makes a deadly toxin not unlike the infamous poison ricin. Not that Trautz’s doctors knew it at the time. The truth is, when the lively 81-year old first passed bloody stool, then became uremic and seized, her doctors assumed (despite her negative test) that Trautz had a terrible case of colitis due to C. difficile.

Soon after Trautz expired, however, her son-in-law Ken Costello also suffered diarrhea and agonizing abdominal pain. His doctor diagnosed diverticulitis.

Finally, in mid-September, the multi-state outbreak linked to bagged, pre-washed Dole-brand spinach packed by California’s Natural Selection Foods made national headlines. When Costello and his wife learned this news, they quickly returned to the home they had previously shared with Trautz. Sure enough, still in the fridge was an open package of spinach eaten by the entire family that was later sent to a lab where a slurry was cultured. That specimen grew the outbreak strain.

The final toll of illness for 225 infected people residing in 27 states? Although there were only five confirmed deaths, more than half were hospitalized, and 39 suffered life-threatening hemolytic-uremic syndrome.

This leafy-green fiasco was just another milestone in the story of a hazardous microbe that still thrives in many U.S. livestock. Thirteen years earlier, after surfacing in undercooked Jack in the Box hamburgers, the same toxic bug launched the career of a leading plaintiffs’ attorney featured in a new Netflix documentary called “Poisoned: The Dirty Truth About Our Food.”

Not only has “Poisoned” won kudos for its frank depiction of a “broken system that often places profit over public health” the film has much to teach doctors about growing threats along American farm-to-fork chains plus modern loopholes and legislative inertia surrounding the safety of American food.

The Story of Bill Marler

In the world of foodborne illness and food safety, Seattle attorney Bill Marler, JD, is a hero to many people. For more about his one-of-a-kind passion and style, take a look at a 2015 story in The New Yorker that covers his present-day campaign against Salmonella. But back in 1993, when Jack in the Box fare started to sicken and kill, Marler had not yet found his calling.

Then came an SOS about 9-year-old Brianne Kiner, a desperately ill child who had already spent 40 days in a coma and 5 months in a hospital connected to wires and tubes. “She was just so vulnerable, and she just ate a fricking hamburger,” was Marler’s characteristic comment in “Poisoned.”

After meeting Brianne and forcing back tears, the 35-year-old lawyer then went to work, ultimately winning the largest personal injury pay-out ($15.6 million) awarded in his state to date. It wouldn’t restore her health, but at least it would cover care for the rest of Brianne’s life.

For Marler, lawsuit upon lawsuit then followed, some stemming from further outbreaks of E. coli 0157, others involving different foodborne perps such as Salmonella, Campylobacter, hepatitis A, and Listeria. But perhaps Marler’s proudest (non-monetary) 1990s win came when Michael Taylor, JD, then a senior lawyer at the U.S. Department of Agriculture (USDA), announced that raw ground beef contaminated with E. coli 0157 would henceforth be deemed “adulterated.”

The industry reforms that followed now mean that eating a fast-food hamburger in the U.S. poses only a fraction of the risk of fresh produce, as shown by the outbreak that killed Trautz.

“Poisoned” advances this theme by educating viewers about the proximity of massive cattle feedlots and agricultural lands in Yuma, Arizona, and California’s Central Valley, a modern recipe for disaster that periodically allows animal feces to enter irrigation canals and contaminate downstream crops like romaine lettuce. Or the blatant disregard for crowding of animals and on-site sanitation in other factory farms that fuels Salmonella-laced filth that can ultimately taint poultry and eggs.

Egregious violations have even prompted criminal prosecution. The most dramatic example? The 28-year prison sentence meted out to Stewart Parnell, former CEO of the Peanut Corporation of America, after Parnell repeatedly instructed certain employees to cover up positive Salmonella tests in 2008 to 2009. The final outcome of this wanton falsification was a multistate outbreak of Salmonella typhimurium that killed at least nine people and sickened many hundreds more who consumed a slew of peanut-containing items sold in 46 states.

A Medical Call to Action

What is more relatable than food? After all, everyone eats, and everyone occasionally suffers a foodborne illness. However, some U.S. doctors tend to discount foodborne illnesses because — despite our food supply’s many imperfections — Americans suffer fewer such incidents and related deaths than residents of most other countries. Oft-cited statistics from a seminal CDC study published in 2011 concluded that, at that time, one in six Americans — roughly 48 million people — suffered a foodborne illness each year, 128,000 were hospitalized, and 3,000 died.

These data stand in stark contrast to a WHO study published in 2015. In their first-ever analysis of the global burden of foodborne disease, the authors assessed 31 individual “hazards” and reached a final estimate of 420,000 foodborne illness deaths per year — 40% in children under 5. Not surprisingly, the study listed some risks most U.S. doctors and medical students rarely if ever consider. For example, hepatotoxic aflatoxins contaminating moldy grain, or cysticercosis — larval infection with pork tapeworm — which underlies many cases of epilepsy in low- and middle-income countries.

At the same time, a universal risk both here and abroad, is non-typhoid Salmonella, which consistently ranks as the top cause of foodborne death worldwide.

My concern is that foodborne diseases and food safety are rarely covered in medical school curricula and that even seasoned MDs often lack knowledge about changing trends, contributory factors, and the messy web of government agencies and regulations (don’t get me started about the weird jurisdictions and different mindsets of the USDA and the FDA). The list goes on.

Weaving case studies involving real people, outbreaks, and regulatory policies into continuing medical education would be one way to start (for example, do most readers even know their state’s stance on the legal sale of unpasteurized milk?). Having medical students watch “Poisoned” is another.

At the end of the day, why shouldn’t doctors and other healthcare professionals join the ranks of lobbyists, advocates, and educators around ongoing farm-to-fork reform? After all, the microbes aren’t going away anytime soon, they’re only traveling farther (and becoming more antibiotic-resistant) as our food supply grows ever more global.

About the author: Claire Panosian Dunavan, MD, is a professor of medicine and infectious diseases at the David Geffen School of Medicine at UCLA and a past-president of the American Society of Tropical Medicine and Hygiene. You can read more of her writing in the “Of Parasites and Plaguesopens” column.

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The Washington State Health Department reports that between February 27 and July 22, 2023, six Washington State residents (five from Pierce County and one from Thurston County) developed severe illness due to Listeria bacteria (listeriosis) infection.

All six people had conditions that made their immune systems less able to fight disease. Three of the individuals died. Genetic fingerprinting (whole genome sequencing) of the bacteria indicated that the same food was likely responsible for making all six people sick.

The restaurant discontinued the use of its two milkshake machines on August 8. The milkshake machines will be kept out of service until the Tacoma-Pierce County Health Department determines they are free of Listeria contamination and no longer pose a danger to the public.

Because milkshakes and ice cream have caused listeria outbreaks, the Tacoma-Pierce County Health Department collected milkshake samples from the restaurant on August 8, 2023. On August 18, 2023, all flavors of the milkshakes were found to be contaminated with the same strain of Listeria that caused the outbreak.

Two people infected with listeriosis reported consuming milkshakes from Frugals restaurant at 10727 Pacific Ave: S., Tacoma, WA, 98444, before becoming sick.

Also, anyone who has eaten recalled products should monitor themselves for symptoms during the coming weeks because it can take up to 70 days after exposure to Listeria for symptoms of listeriosis to develop. 

The state Department of Health is working with Pierce and Thurston County local health jurisdictions to gather information from interviews with patients and their families to help identify any common exposures.

About Listeria infections

Food contaminated with Listeria monocytogenes may not look or smell spoiled but can still cause severe and sometimes life-threatening infections. Anyone who has eaten any recalled product and developed symptoms of Listeria infection should seek medical treatment and tell their doctors about possible Listeria exposure.

Symptoms of Listeria infection can include vomiting, nausea, persistent fever, muscle aches, severe headache, and neck stiffness. Specific laboratory tests are required to diagnose Listeria infections, which can mimic other illnesses. 

Listeria bacteria are found in the environment and can spread from contaminated food to surfaces. Listeria can grow on foods kept in the refrigerator for several days. The bacteria are easily killed by heating food to a high temperature (165°F).

Although healthy, non-pregnant individuals may suffer only short-term symptoms such as fever, muscle aches, nausea, abdominal pain and diarrhea, Listeria monocytogenes is especially harmful to some people:

• For pregnant womenListeria infection can cause pregnancy loss, premature birth, or life-threatening infection in the newborn.
• Listeria infection often results in hospitalization and sometimes death for people with a weakened immune system (those (who have health problems or take medicines that lower the body’s ability to fight germs and sickness).
• For people 65 years or older, Listeria infection often results in hospitalization and sometimes death.

Pregnant women, the elderly, young children, and cancer patients with weakened immune systems are particularly at risk of serious illnesses, life-threatening infections, and other complications. Although infected pregnant women may experience only mild, flu-like symptoms, their infections can lead to premature delivery, infection of the newborn, or even stillbirth.

People who are not pregnant usually have a fever, muscle aches, and tiredness. They may also get a headache, stiff neck, confusion, loss of balance, or seizures.

Symptoms usually start within two weeks after eating food contaminated with Listeria monocytogenes but may begin as early as the same day or as late as ten weeks after exposure.

Pregnant people usually have a fever, muscle aches, and tiredness.

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The Kansas Department of Health and Environment and the Southeast Kansas Multi-County Health Department announced that the outbreak is associated with the Trade Winds Bar and Grill in Garnett, KS, in Anderson County. The town is about 70 miles southwest of the Kansas City metro area.

The health departments are asking anyone who ate at the restaurant between July 14 and Aug. 9 and who later experienced symptoms of diarrhea, bloody diarrhea, abdominal pain, nausea or vomiting to complete an online survey.

The survey is anonymous and will help health officials confirm the source and scope of the outbreak.

Health officials say the cause of such infections is usually traced back to the consumption of raw or undercooked poultry or poultry that has not been held at the proper temperature or by food that was contaminated by such items.

Additional information about the outbreak and help for those who would like to complete a phone-based version of the survey can call 785-448-6559 for residents in Anderson County or 877-427-7317 for those living outside of Anderson County.

The health departments did not report the number of sick people. Still, the U.S. Centers for Disease Control and Prevention says there are usually more sick people than are reported in campylobacter outbreaks because many people do not seek medical attention.

Many people recover in a week, but Campylobacter infection can result in long-term consequences, such as arthritis, irritable bowel syndrome (IBS), and Guillain-Barré syndrome (GBS).

About campylobacter infections
According to the U.S. Centers for Disease Control and Prevention, outbreaks have been associated with unpasteurized dairy products, contaminated water, poultry, and produce. People also can become infected from contact with dog or cat feces. Person-to-person spread of Campylobacter is uncommon.

Azithromycin and fluoroquinolones, such as ciprofloxacin, are commonly used for treatment, but resistance to fluoroquinolones is common.

Campylobacter infection symptoms usually begin two to five days after exposure and are characterized by diarrhea (frequently bloody), abdominal pain, fever, nausea, and sometimes vomiting. More severe illnesses can occur, including bloodstream infection and symptoms mimicking acute appendicitis or ulcerative colitis.

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In its Morbidity and Mortality Weekly Report released yesterday the Centers for Disease Control and Prevention describes the outbreak in Tazewell County Illinois that occurred during 2022 from Nov. 19 through 26.

Among the 268 interviewed patients with information on illness onset date, symptoms commenced during Nov. 20 to 28, with 114 cases occurring on Nov. 24 

Sick people who were residents of 10 other counties were reported. Some secondary cases were reported within the households of restaurant patrons and were not included in the total of 317 case-patients.

Norovirus outbreaks typically have many more sick people that are included in official counts because many people do not seek medical attention.

“After the release of news stories by the press, the number of reported ill persons doubled,” according to the CDC report.

Based on interviews with sick people the suspected food vehicle was salad, according to the report. 

Nearly one third of the illnesses, 32 percent, occurred in people aged 20 to 49 years. The overall age range was from 6 months to 83 years. Signs and symptoms reported by 317 case-patients through an online questionnaire included vomiting, nausea, diarrhea, myalgias, chills, abdominal cramps and fever. 

“Preparation with ungloved hands by a food handler who had vomiting on Nov. 22, and worked during Nov. 21-23, likely served as a main contributor to the outbreak. The restaurant voluntarily closed on Nov. 26 for disinfection and reopened on Nov. 29, after a health inspection,” the CDC reported. 

“Because a large number of persons had patronized the restaurant over the Thanksgiving holiday, the ability to identify exact numbers of ill and well patrons was limited, and the number of cases is likely underreported.

“The Food and Drug Administration’s 2022 Food Code cites noroviruses as the leading cause of foodborne illness in the United States, and proper hand hygiene and exclusion of symptomatic employees are essential for preventing outbreaks”

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The agency reports that the outbreak has ended with 13 patients having been identified. The FDA did not reveal any patient information, such as where the patients lived.

According to the agency’s most recent update, it first reported the outbreak to the public on July 26. The FDA initiated traceback efforts but did not report what food or foods were being traced as part of the investigation.

The Centers for Disease Control and Prevention did not post any information about the outbreak, as is the agency’s practice when a source of the pathogen is not found.

In other outbreak news, FDA has ended its investigation into an outbreak of infections from the microscopic Cyclospora parasite. According to the agency’s update yesterday the outbreak has ended with a patient count of 59, which is up from 55 a week ago. 

For the Cyclospora outbreak, the FDA initiated traceback, sample testing and onsite inspections. However the agency did not report what food was being traced or what was being tested. The agency also did not report what location had been inspected. The FDA first reported the outbreak on July 26.

In an ongoing investigation of illnesses caused by Listeria monocytogenes the FDA confirmed an ice cream product is likely the cause of the infections. The agency first reported the outbreak on Aug. 9, before the source of the pathogen was known.

On Aug. 10 the FDA posted an advisory stating that the outbreak was linked “Soft Serve On The Go” ice cream cups produced by Real Kosher Ice Cream of Brooklyn, NY. Two people have been confirmed as outbreak patients and both have required hospitalization.

The ice cream was distributed to California, Colorado, Connecticut, Washington D.C., Delaware, Florida, Illinois, Massachusetts, Maryland, Michigan, Minnesota, North Carolina, New Hampshire, New Jersey, New York, Ohio, Oregon, Pennsylvania, Virginia and West Virginia.

The ice cream has been recalled. For packaging codes and photos of the recalled products, click here.

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By their convictions and sentencing, Stewart Parnell, 69, and brother Michael Parnell, 64, respectfully still have 15 and 8 years before their prison release dates.

Their jury convictions and trial judge rulings were all upheld by the Appellate Court in 2018.

Nine deaths were associated with the outbreak.

Those nine had families that miss them to this day. Those families see Stewart Parnell as a despicable character whose reckless disregard for life caused the death of their loved ones.

But for now, about to start its fifth year, Stewart Parnell has played the last card he has left. It’s been called the “Great Writ” of habeas corpus. It is a fundamental right in the Constitution that protects against unlawful and indefinite imprisonment. In Latin, it means “show me the body.” Habeas corpus is supposed to safeguard individual freedom against arbitrary executive power.

Stewart Parnell’s Habeas corpus petition was filed on Sept. 6, 2019. After being denied on. Sept. 23, 2022, by the trial judge for the federal District Court, the 11th Circuit took up Parnell’s Habeas petition on appeal.

And the Appellate Court has issued Parnell a “certificate of appealability” on two issues. Those are jury prejudice and ineffective assistance of counsel. With deep experience in federal appeals, Savannah Attorney Amy Lee Copeland has recently filed a 68-page appellate brief for Stewart Parnell and followed it with a few hundred pages of appendix.

The Parnell appeal includes mounds of local, state, and national media stories to illustrate the climate from the outbreak through the trial.  Copeland said about 8,000 were in the jury pool in the Court’s Albany Division at the time of the trial.   

This is a lot to digest, but it all boils the case down.

“The nine deaths did not come into evidence at trial,” Attorney Copeland writes.  “The government agreed not to introduce that evidence.” Two who knew about the deaths entered the jury and into juror deliberations.

It breaks down into whether those nine deaths couldn’t be put aside in a community with the peanut industry too damaged by the Salmonella outbreak blamed entirely on Stewart Parnell’s Peanut Corporation of America. 

Criminal charges were not brought for four years after the outbreak, but .jury selection showed that 60 percent of the prospective jurors knew about the case.

In testimony two years ago, an Albany peanut broker said the Salmonella outbreak at PCA “devastated” the industry. “The sentiment in the local community was ‘under attack by the media,’ especially after reports of death resulting from the salmonella ‘hit the fan,’ ” according to the appellate brief.

Parnell’s trial attorneys did not seek a change of venue for the original jury trial. His defense team members all testified at an evidentiary hearing two years ago. They thought Albany would be the friendliest venue for the PCA trial, but they may have misread the public badly.

The 2014 jury trial was held in Albany, GA, where 60 percent of America’s peanuts are grown within a 150-mile radius. PCA’s peanut processing plant in Blakely, GA, was 65 miles away.

A change of venue is not required if prospective jurors are merely exposed to facts of a case, but only if “inflammatory, prejudicial pretrial publicity “ pervades or saturates the community making a fair trial “virtually impossible.”

Parnell has established “a presumption of jury prejudice,” according to Copeland. “The Sixth Amendment secures criminal defendants the right to trial by an impartial jury,” she said.

And when the deaths were not allowed to be even mentioned at trial, Copeland says jurors were using terms like “fry them” and “hang” and “exact a pound of flesh” as they convicted Parnell on 67 of 68 counts against him.

Many of us remember from our Civil War history that President Lincoln suspended the Writ so certain Rebels could not escape the military’s jurisdiction. The Lincoln suspension ended after four years when the Civil War was over. Parnell’s Writ, however, will go on a bit longer.

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The UK Health Security Agency (UKHSA) said it has identified an increase of Cyclospora cayetanensis in travelers returning from Mexico. The microscopic parasite is transmitted through contaminated food or drinks.

Between May 12 and Aug. 14, 74 cases were reported in England, Wales, and Scotland. Slightly more than half of patients are female and overall patients have a median age of 44. 

Travel information is known for 52 cases, of which 48 reported going to Mexico. Of these, 42 stayed in different hotels in the Riviera Maya and Cancún regions, and most reported having a variety of food and drink within their resort as part of an all-inclusive holiday package.

Seasonal outbreaks of cyclosporiasis in people returning from Mexico have been reported since 2015, except in 2020 and 2021 during the COVID-19 pandemic, although case numbers have varied with 79 in 2015, 359 in 2016, 82 in 2017, 61 in 2018, 67 in 2019, and 36 in 2022.

“Travelers to Mexico are strongly advised to maintain good food and water hygiene at all times even if staying in high-end all-inclusive resorts. If possible, they should choose freshly prepared food that is thoroughly cooked and served piping hot. Certain foods should be avoided such as fresh uncooked berries and herbs, unpeeled fruit and salad items as these can be difficult to clean,” said the UKHSA.

UKHSA is investigating the clusters of illnesses with the UK trade association for travel agents (ABTA) and Mexican public health authorities.

Wider problem
At the end of July, the U.S. Centers for Disease Control and Prevention (CDC) reported there are 1,063 patients identified as part of multiple outbreaks from April 2023. Sick people range in age from 2 to 96 and live in 34 states and New York City. A total of 79 people have been admitted to hospital but no one has died.

The Public Health Agency of Canada (PHAC) has recorded 260 illnesses with 230 in Ontario as of August. Patients range in age from 1 to 97 years old. Six people were hospitalized but no one died.

The British Columbia Centre for Disease Control (BCCDC) said 43 cases had been reported to the agency in 2023 and at least nine of these were locally acquired, as they did not travel outside of Canada and the United States.

About Cyclospora
Anyone who has developed symptoms of Cyclospora infection, and has reason to believe they have been exposed to the parasite, should seek medical attention. Specific tests are required and antibiotics are used to fight the parasite.

Cyclospora infection can cause severe abdominal pain, watery diarrhea, nausea, vomiting, body aches, and fatigue. Symptoms can develop between two and 14 days after exposure. Though symptoms can be severe enough to send people to the hospital, it’s rare for people to die from Cyclospora infections. 

Cyclospora is a type of protozoa, which is a tiny, single-celled organism. It is transmitted when people somehow ingest contaminated feces, typically through contaminated food or water. It can be spread only through human waste, unlike E. coli and Salmonella, which can also be spread from animal fecal matter. 

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A total of 27 people have fallen sick and one has died in the trio of Salmonella Enteritidis incidents.

Investigation of the outbreaks is being carried out by the Austrian Agency for Health and Food Safety (AGES), the Ministry of Health and the relevant provincial authorities. Initial surveys point to poultry meat from Poland, which was used to produce kebab skewers, as the vehicle of infection.

First outbreak details
Since February, 14 people in Austria have become ill with a specific type of Salmonella Enteritidis. Patients with this strain have also been reported in Denmark, Germany, France, the Netherlands, Norway and the United Kingdom.

From May to July, Statens Serum Institut (SSI) in Denmark recorded 15 people infected with the same type of Salmonella Enteritidis. Patients are seven men and eight women and live across the country. They are between 15 and 99 years old with a median age of 30.

Whole genome sequencing of bacteria isolated from patients showed they were very closely related and all belonged to sequence type 11, which is the most frequently detected Salmonella type in Denmark and the rest of Europe.

In Germany, there are six patients with five of these confirmed. Patients range in age from 9 to 58 years old. Five are male and the other is female. The first date of illness onset is December 2022. The latest reported date is mid-June 2023.

There were 65 infections associated with an English outbreak in 2023. For 43 cases linked to a restaurant, the mean age was 32 with a range of 6 to 61 and 17 were female. Epidemiological investigations suggested eggs or chicken as the likely cause.

The Netherlands has two cases that were notified in March 2022 and April 2023. Both are male and aged between 20 and 40 years old.

Norway has identified one patient, a female younger than 5, with a sampling date in March 2023. There is no information on travel history or possible exposures.

Other outbreaks
The second Austrian outbreak involves another cluster type of Salmonella Enteritidis. A total of seven people have fallen sick since April and one has died.

Investigations into the second incident uncovered another Salmonella Enteritidis outbreak that was responsible for a further six cases in Austria. Related infections have also been reported in Ireland, Belgium, the Netherlands, and France.

In the Netherlands, there are eight patients aged 16 to 68 with a median age of 56. Three are male and five are female. People fell sick between September 2020 and July 2023.

In Belgium, there are eight patients possibly related to the outbreak reference strain. The most recent case was isolated in January 2023 from a 49-year old man; the other seven were isolated between January and September 2022 and ranged from 6 to 79 years old. Three were male and four were female.

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The Directorate-General of Health (DGS) said 187 suspected cases of food poisoning have been recorded associated with the consumption of broa de milho (a type of cornbread) in certain areas of the country between July 21 and August 9. Affected regions are Leiria, Santarém, Coimbra, and Aveiro.

“Broa de milho is, and should continue to be, an integral part of the Portuguese diet. However, in the context of suspected food poisoning, it is recommended that the consumption of this food be stopped in the geographical areas identified above, pending an investigation by the authorities,” said the DGS.

Patients presented similar symptoms including a dry mouth, visual changes, dizziness, mental confusion and decreased muscle strength. Symptoms were observed between 30 minutes to two hours after eating food. In most cases, symptoms were classed as mild but 43 suspected patients required hospital care. However, the agent responsible has not been revealed.

Focus on flour
An epidemiological investigation is in progress and involves regional departments of public health, the Economic and Food Safety Authority (ASAE) and the General Directorate of Food and Veterinary Affairs (DGAV).

Authorities have restricted the raw materials used in the manufacture of broa de milho that is suspected to be involved and are monitoring the situation.

Those affected had consumed broa de milho produced and distributed in the districts of Santarém, Leiria, Coimbra and Aveiro. Initial suspicions have fallen on the flour used to make the product.

To deal with the existing uncertainty, officials are carrying out tests on food and raw materials as well as inspecting businesses to identify the batches of raw materials used.

DGS said the recommendation to avoid broa de milho in the four regions listed is a preventive measure that would remain in place until there is a guarantee that all potentially contaminated foods have been removed from the market and the investigation has been completed.

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