Transcript E. coli

Massachusetts Department of Public Health
Bureau of Infectious Disease
Getting Sick from Food
(…and water)
Patricia Kludt, MPH
Division of Epidemiology and Immunization
Let's Talk

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History and trends of foodborne illness and
outbreaks
Responsible etiologic agents
Causes of foodborne and waterborne illness
The role of the laboratory
A case study
Tips for prevention
2
Foodborne Illness Estimates
2011

Annual toll in US:

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1 out of 6 Americans (or 48M people) sick
128,000 hospitalizations
3,000 deaths
Long term problems
 miscarriages, meningitis, birth defects, kidney failure in
children, paralysis, arthritis, blood infections
A 10% reduction would keep 5M Americans from getting sick
each year.
Preventing one fatal case of E. coli O157 infection would save
an estimated $7M.
3
There are the Bacteria
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Bacillus cereus
Brucella sp.
Campylobacter sp.
Clostridium botulinum
Clostridium perfringens
E. coli
 enterohemorrhagic
 enterotoxigenic
 enteroinvasive
 Listeria monocytogenes

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
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Shigella sp.
Salmonella sp.
Staphylococcus aureus
Group A strep
Vibrio cholerae O1 or O139 and
the rest
 V. vulnificus
 V. parahaemolyticus
 Yersinia enterocolitica
4
…and the viruses, parasites,
toxins and chemicals
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Viruses
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Hepatitis A, E
Norovirus
Astrovirus
Rotavirus
Toxins
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Fungal
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Aflatoxin
Mushroom toxins
Marine

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Ciguatoxin, Scombroid
PSP, Tetradotoxin
Parasites
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Cryptosporidium
Cyclospora
Giardia
Trichinella
Toxoplasma
Chemicals
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Heavy metals
MSG
Pesticides
5
Top 5 Pathogens

Top 5 pathogens
contributing to US
acquired foodborne
illness

Top 5 pathogens
contributing to US
acquired foodborne
illness resulting in death

Norovirus (58%)
Salmonella (11%)
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Salmonella (28%)
T. gondii (24%)
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Clostridium perfringens
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L. monocytogenes
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(10%)
Campylobacter (9%)
S. aureus (3%)
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(19%)
Norovirus (11%)
Campylobacter (6%)
6
1600
1400
1200
1000
800
600
400
200
0
20
12
20
10
20
08
20
06
20
04
Salmonella
Campylobacter
STEC
Listeria
20
02
20
00
# of cases
Enteric Pathogens in
Massachusetts
Year
7
Long Term Trends
2012 data compared to (1996-1998) and (2006-2008)
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The incidence of infection caused by Yersinia, Shiga toxin–producing
Escherichia coli (STEC), Shigella, Listeria, and Campylobacter as a
group was 22% lower than in (1996-1998) but was not significantly
different from (2006-2008).
Salmonella continues to be a challenge. The incidence of some
types of Salmonella infections has increased while others have
decreased.
Vibrio infection was 116% higher compared to 1996-1998 numbers
but only 43% higher compared to 2006-2008.
Overall the 2012 FoodNet data showed a lack of recent progress in
reducing foodborne infections.
8
Foodborne Illness
Microbes +
Mistakes +/or
Poor Choices
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Cross-contamination
Poor food worker hygiene
Poor foodhandling procedures
Contaminated food
Choosing to eat uncooked or undercooked
food
9
Emergence of Foodborne
Illness
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Microbial adaptation
 Increased virulence
 Antibiotic resistance
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Example: Salmonella DT-104
Global trade
 Contact with unfamiliar pathogens
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Example: Raspberries from Guatemala
10
Emergence of Foodborne
Illness
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Food industry demographics
 Increased market size
 Centralized food processing
 Low dose, widely distributed outbreaks
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Example: Shigella in parsley, salmonella in
peanut butter, E. coli O157:H7 in raw cookie
dough
International travel
th century
 Dramatic increases in 20
 Infection by uncommon pathogens

Examples: Typhoid fever and cholera
11
12
Advances
in
technology and
industry
Emergence of Foodborne
Illness

Immigration
 Traditional practices
 Customs, language, social barriers

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Example: salmonella from live bird markets
Social demographics
 Increased life expectancy
 Chronic disease survivors
 Increased susceptibility to enteric pathogens
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Example: Listeria in the elderly
14
Emergence of Foodborne
Illness

What people eat
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Where people eat
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Changes in food preferences
Fresh fruits and vegetables
Undercooked foods
Fast foods and salad bars
Food preparation skills
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Few opportunities for home instruction
No “home-ec” in schools
Foodborne illness in the home
15
Leafy Greens
Healthy or high-risk!
Trends in Foodborne
Outbreaks in Massachusetts
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We are still seeing “event” driven outbreaks
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Weddings, birthday parties, potluck dinners
Why?
But also we seeing more and more nationwide
outbreaks
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Peanut butter, raw cookie dough, veggie booty,
spinach, parsley, orange juice, pet food, etc.
Why?
17
Foodborne Surveillance
or how we find out what is going on
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Passive surveillance (state and local)
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FoodNet (national)
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Database with DNA "fingerprints"
NARMS (national)
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Surveillance for E. coli O157:H7, Campy, Listeria, Salmonella,
Shigella, Yersinia, Vibrio, Cryptosporidium and Cyclospora
PulseNet (national)
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Over 15 enteric diseases are reportable to the state and local
health departments in Massachusetts and every other state
National antimicrobial resistance monitoring system
NORS (national)
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National outbreak reporting system
18
CSI:
The Public Health Laboratory
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The past
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Genus
Species
Serotyping/serogrouping
The present
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DNA testing
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PFGE testing, PCR, MLVA
The future (?)
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Rapid testing with no available isolates
19
Fingerprinting bacteria
PFGE and MLVA
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PFGE: Pulsed-field gel electrophoresis
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Gel electrophoresis differentiates between the different
fragments of the DNA, making it suitable for comparison and
family relationship testing.
Can be used to distinguish strains of E. coli O157:H7,
Salmonella, Shigella, Listeria, or Campylobacter at the DNA
level
1st used in a foodborne outbreak investigation in 1993 for the
E. coli O157:H7 in the western US. PFGE patterns from case
isolates had the same pattern as isolates grown from
hamburger patties consumed by cases.
20
Fingerprinting bacteria
PFGE and MLVA
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MLVA: Multiple Locus Variable-number
Tandem Repeat Analysis
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MLVA is another technique used by scientists to generate a
DNA fingerprint for a bacterial isolate. Scientists usually
perform MLVA after PFGE to find out more specific details
about the type of bacteria that may be causing an outbreak.
It can also be used instead of PFGE when time if of the
essence.
Not yet able to be used on all organisms
21
PFGE Pattern
22
PulseNet
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Is an electronic database of "DNA fingerprints" identified at
local, state or federal laboratories
Was created as a result of the E. coli outbreak
Plays a vital role in surveillance and the investigation of
foodborne outbreaks
Is instrumental in the identification and resolution of
outbreaks where the cases are geographically dispersed
Allows for outbreaks to be identified in hours rather than
days or even weeks
23
The Process
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Isolates recovered in clinical laboratories by conventional
means are sent to public health laboratories for:
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Conventional confirmation
Serotyping/serogrouping
PFGE and/or MLVA analysis
Patterns are entered into an electronic database of "DNA
fingerprints" at the state public health laboratory and then
uploaded to PulseNet.
24
The Process (cont.)
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CDC performs regular searches, looking for clusters of
matching patterns.
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The results are reported back to state health department
laboratories and epidemiologists.
The public health laboratorians also perform regular
searches on their local databases, looking for clusters of
matching patterns.
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Anything suspicious gets reported to the epidemiologists and to
CDC.
25
Multi-state Outbreaks
Bug
Food
Year
Campylobacter
Unpast. milk/cheese
2007
Salmonella
Veggie booty
2007
Salmonella
Live poultry
2007
Salmonella
Frozen pot pies
2007
E. coli O157:H7
Beef
2008
Salmonella
Multiple raw produce
2008
Salmonella
Pet turtles
2008
Salmonella
Peanut Butter
2008-09
Salmonella
Salami (black & red pepper)
2009-10
26
Multi-state Outbreaks (cont.)
Bug
Food
Year
Salmonella
Aquatic frogs
2009
E. coli O157:H7
Raw cookie dough
2009
Salmonella
Alfalfa sprouts
2009
E. coli O157:H7
Beef & Poultry
2010
Salmonella
Alfalfa sprouts
2010
Salmonella
Eggs
2010
E. coli O145
Shredded romaine lettuce
2010
Salmonella
Turkey Burgers
2011
Salmonella
Cantaloupe
2011
E. coli O157:H7
Bologna
2011
27
Multi-state Outbreaks (cont.)
Bug
Food
Year
Salmonella
Peanut Butter
2012
Salmonella
Hedgehogs
2012
Salmonella
Mangoes
2012
E. coli O26
Raw clover sprouts
2012
Salmonella
Raw scraped ground tuna
2012
Salmonella
Dry dog food
2012
Salmonella
Small turtles
2012
Listeria
Ricotta cheese
2012
Salmonella
Cantaloupes
2012
Salmonella
Live poultry
2012
E. coli O157:H7
Spinach and Spring Mix
2012
28
Real Life Problems
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Illnesses are not reported - by consumers or
healthcare
Healthcare doesn't test
When tests are done, isolates are not sent to public
health laboratories for further testing
The process of illness to testing to reporting to
investigation is too long
People don't remember what they ate
29
Typical incubation periods
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< 8 hours
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B. cereus (short incubation)
S. aureus
Ciguatoxin
Scombroid
PSP
Tetrodotoxin
Heavy Metals
MSG
Short-acting mushrooms
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8 - 48 hours
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B. cereus (long incubation)
C. perfringens
Salmonella sp. (not typhi)
V. parahaemolyticus
Botulism
Caliciviruses
Astroviruses
Long acting mushrooms
30
Typical incubation periods
(cont.)
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48 - 96 hours
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Campylobacter
E. coli O157:H7
Shigella
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Group A strep
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V. cholerae
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> 14 Days
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Brucella (>30d)
Listeria
Trichinella
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Hepatitis A (and E)
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5 - 14 Days
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Y. enterocolitica
Salmonella typhi
Cryptosporidium
Cyclospora
Giardia
31
Problems in Recognition
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Day 1: undercooked hamburger consumed
Day 5: bloody diarrhea begins and a decision is made that it
must have been what was eaten the night before (on day 4)
Day 6-8: still sick
Day 9: seen by HCP, stool sent to lab
Day 10:
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positive for E. coli O157:H7
reported to public health & specimen sent to public health laboratory
Day 11: patient contacted and asked for food history;
patient reports what they ate on day 4
Day 13: PFGE results available & posted to PulseNet
32
What about the water?
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Drinking water
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Problems with drinking water has largely been
controlled in the US
Understand your source and how it is treated
Recreational water - another story
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Pools
Ponds
Lakes
33
A Word about Coliforms
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Group of bacteria which includes normal flora
of humans and other animals
Not all are fecal organisms
Not usually considered important causes of
disease
Fecal coliforms serve as reasonable, efficient
surrogates of fecal contamination not
necessarily for the presence of pathogens
34
Sources of pathogens
found in water
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shed in human feces
can enter lakes, rivers, reservoirs or other
bodies of water from sewage treatment plants
or discharge from boats
feces from pets, farm animals, or wild animals
directly or from storm run-off
well water usually safe except if directly
affected by surface water or septic tank
discharge
35
Waterborne Pathogens

Shigella
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Giardia
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Milwaukee 1993 - 403,000 sick, 69 deaths
Swimming pools
Legionella pneumophila
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Recreational waters or person-to person
Cryptosporidium
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Problems in or by the shores of recreational waters
Cooling towers, decorative fountains, spas, vegetable misters, etc.
Vibrio sp., noroviruses, hepatitis A
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Raw shellfish, swimming in contaminated ocean water
36
High-Risk Populations
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Very old
Very young
Immunocompromised
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cancer patients receiving chemotherapy
AIDS/HIV infected
Organ transplant recipients
Persons on steroid therapy
Other chronic conditions
37
Giardia and Cryptosporidium in
Massachusetts
# of cases
800
700
600
500
400
Crypto
Giardia
Legionella
300
200
100
0
2009 2010 2011 2012 2013 2014
Year reported
38
Waterborne Outbreaks in
Massachusetts

Shigella sonnei
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9 cases - community sprinkler fountain
5 cases - beach and lake
68 cases - beach and lake
12+ - beach and lake
Giardia lamblia
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1998
2005
2010
2013
1999 13 cases - probable recreational water
2003 149 cases - pool
2007 9 cases - pool
Cryptosporidium sp.
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2002 767 cases - pool
2007 6 cases - camp and pond
39
More waterborne outbreaks in
Massachusetts
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Vibrio parahemolyticus
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2012 7 cases (oysters)
Norovirus
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2013 50+ (oysters)
40
Two Case Studies
…..or what happens when things
go terribly wrong
A hot case - solved
42
Norovirus from the sea
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1st report on a Monday: 30+ attendees ill
after a catered rehearsal dinner in a private
home on Friday and wedding on Saturday
Raw oysters were served at rehearsal dinner,
full buffet at wedding
Symptoms consistent with norovirus
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Onsets reported early Sunday morning
Vomiting with duration 24-48 hours
43
The investigation
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Rehearsal dinner or wedding?
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Looking for sick attendees from wedding
who did not attend rehearsal
Found groomsman who arrived on
Wednesday symptomatic
Postulated that groomsman arrived with
norovirus and got everyone else sick

It happens a lot!
44
The plot thickens or sickens
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2nd report: sick attendees at a birthday
party held on Saturday in adjacent town
to the wedding (restaurant B)
Symptoms consistent with norovirus
Raw oysters served
45
Oyster background
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All oysters harvested must be labelled
with who, where and when
These tags must follow the oyster to
wherever they go and kept for 90 days
Most states have strict harvesting
requirements and issue licenses for
specific beds
46
Oyster investigation

Oysters consumed at rehearsal dinner (caterer A)
and Restaurant B were harvested from the same
oyster bed by Company Y.
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Both the caterer and restaurant were asked to hold all
remaining oysters
The president and chief oyster harvester at
Company Y also reported illness the prior
weekend.

He reported that he eats many of his own oysters
47
The investigation
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3rd report: two couples became ill after
eating ray oysters Monday following
wedding at Restaurant C
Oysters came from same oyster bed as
rehearsal dinner (caterer A) and
birthday party (restaurant B) oysters
Remaining oysters requested to be held
48
The investigation

Clinical specimens were obtained from the oyster
harvester, foodhandlers at restaurant B and
attendees at the rehearsal dinner
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Birthday party attendees and couples at restaurant C
declined to submit specimens
Foodhandlers at restaurant B reported symptoms
Leftover oysters from caterer A, restaurant B & C
were sent to FDA testing facility in Alabama
Division of Marine Fisheries collected water and
oyster samples from implicated bed
49
Results
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The oyster harvester, 4 foodhandlers, and
5 wedding attendees were positive for
norovirus G1.4
All oysters submitted for testing were also
positive for norovirus G1.4
Additional oysters and water samples
obtained from implicated bed had high
coliform counts
50
Actions


The Division of Marine Fisheries closed the implicated oyster
bed and one adjacent harvest area
Positive foodhandlers were restricted from working until 72h
after symptom resolution

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Foodhandlers from restaurant C had eaten oysters that were being
held and then became ill
All oysters harvested from the implicated bed during the 11
days prior to the date of bed closure were recalled
Over 25,000 oysters had been collected from the implicated
bed during identified time period

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app. 2000 were destroyed, 10,000 were consumed
over 13,000 were successfully recalled and returned to the sea
51
Food Trucks:
Delicious or Deadly?
52
The New Cool Kid on the Block

From Roach Coach to Cultural Phenomena

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Evolving customer base: liked by hipsters,
yuppies, hippies and regular people
More diverse menu and better food
Unique marketing strategy via social media

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Creates a sense of community and brand loyalty
Low marketing and operational costs
Chefs laud as more rewarding and
financially feasible than brick and mortar
53
How cool is it?


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
Boston: 54 total licensed food
trucks
Dallas: 91
New York City: >500
$1Billion in sales in 2012
54
55
The saga of one Boston area
"cool kid"

7/10/13: 10 Salmonella javiana
isolates identified in our PFGE
laboratory with identical pattern

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Cases from 4 MA counties
Ages: 20-65 yrs
Specimen dates: 7/2-7/6
Pattern last seen in MA in 2011
Pattern not seen outside of MA
56
Case investigation

By 7/12, a total of 12 cases had
been identified. Of the 7
interviewed all had eaten at a
restaurant or food truck owned by
Company A
57
Common foods among cases


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Chickpea fritters
Egg and eggplant sandwiches
Hummus
Various side dishes
No one food item in common
58
Company A's operation

Brick and Mortar Retail (aka restaurant)



Commissary


4 sites operational, 1 site pending
4 MA cities/towns
Shares space with a retail site
4 trucks move to 8-9 locations



Loaded at commissary in the morning
Restocked from “re-stocking vans” throughout the day
Leftover food returned to commissary and re-used
59
60
Problems common to most
food trucks

Cold holding


Cross contamination



Hard to maintain separation in small spaces
Adequate water supply


Small fridges on trucks and re-supply vans cannot
maintain proper temps
Handwashing, cleaning
Location of bathrooms
Leftover food disposition
61
Problems with these food trucks



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
Some trucks had run out of water for handwashing and
general use.
PHF from trucks were returned to the commissary out of
temperature and then placed in walk-ins to be distributed
the next day to trucks and/or restaurants.
Re-supply van not chilled to proper temperature before
loading and distribution.
Inadequate resources to get food cold enough quickly
enough.
Inadequate recording of temperatures.
A general lack of appropriate SOPs.
62
Our first response?

All operations on all food trucks and
retail restaurants were shut down
by 7/13
63
The company's 1st response?

The day they were notified of their
connection to the outbreak, the
company owner starting blogging on
their website.
64
The “posts”



The daily blogs started on 7/13
He talked about every step of the
investigation, over and over again and even
discussed employee test results
Went through every hypothesis and
discounted them

“We think it UNLIKELY it was introduced by our food
handlers as they follow safe practices. They wash
their hands after breaks/ eating/ bathroom/ between
tasks/ when changing gloves.”
65
.. the "responses"



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
“With these posts, you’re a model of grace under
pressure. I look forward to my next meal after you
guys are back up and running”
“You continue to amaze me with your standard of
doing the right thing.”
“You guys are amazing. Thank you so much for
being so transparent and honest with all of this.”
“I’m a loyal customer and so sad to hear about what
you’re going through.”
“Fate has called your bluff here, but you’re walking
the walk.”
66
Final Case Tally – S. Javiana

18 consumers



17 linked to Company A
 3 restaurants, 3 trucks
1 consumer ate at a restaurant next door to
one of the implicated restaurants
11 foodhandlers


136 tested
3 of the positive foodhandlers reported
symptoms
67
Cases
68
# of cases
Outbreak cases by onset date
8
7
6
5
4
3
2
1
0
Symptomatic
foodhandler
Consumer
6/
25
6/
26
/2
01
3
6/
27
/2
01
3
6/
28
/2
01
3
6/
29
/2
01
3
6/
30
/2
01
7/
1/
7/
2/
7/
3/
7/
4/
7/
5/
7/
6/
7/
7/
7/
8/
7/
9/
2
2
2
2
2
2
2
2
2
/2
01 013 013 013 013 013 013 013 013 013
3
3
date of onset
N=21
69
What was different about this
investigation?


Food trucks are very popular both with consumers
and politicians
The owner went public from the day of closing until
they re-opened




Was this good or bad, did it help or hurt?
How did it affect the investigation?
The outbreak involved the state and 4 different
local jurisdictions
The outbreak highlighted gaps in permitting. When
does a retail operation turn into a food processing
facility and who keeps watch?
70
Conclusions and lessons
learned

We do not know what happened







It affected all aspects of the operation
Might have started with a foodhandler
No further cases after closure
We suspect they were overwhelmed with two openings
in one week
The weather was HOT!
We need to get on board the social media train or be
left behind.
We need a better way to track growing industries and
be clearer on who is in charge of what
71
Lesson not learned
One of his last posts on the subject
was on 8/22: “ServSafe certified”
“The interesting thing is that the test and the
FDA’s guidelines and requirements work
together to ruin food quality. One of my
favorites: [consider using pasteurized eggs for
all dishes that will not be cooked to high
temperature]. Pasteurized eggs!?! Do you
know what those are? They come in a milk
carton, enough said.”
72
What’s the Answer







Collaboration of regulatory agencies and industry
 FDA, USDA-FSIS, CDC, EPA, Homeland Security,
Department of Justice
Hazard Analysis and Critical Control Points from farm to
fork
Ensuring the safety of imported foods
Extending Pasteurization & Irradiation
Research for better testing methods
Increasing educational efforts
Supporting public health infrastructure
73
How to prevent/eliminate
contamination?





Close waters to shellfish harvesters
Vaccinations/depopulation/egg diversion/changing
feeds/Farm sanitation
Hazard Analysis and Critical Control Point
Educate food workers, sanitation, temperature control,
good hygiene, exclude sick employees, prevent bare hand
contact with RTE foods
Educate consumers- cook, chill, clean, separate
74
Personal Tips

Ground Beef


Egg eating:



Order hamburgers well-done
Order over-easy
Avoid french toast, runny omelets or scrambled eggs
unless using pasteurized egg product or cooking for
yourself
Fresh fruits and vegetables


Wash or at least rinse all fresh fruits and vegetables that
cannot be peeled
Wash or rinse off outside of whole melons before cutting
75
Other considerations





Cook more at home
Know where your food comes from
Plant something edible
Wash your hands
Support local agriculture
76
Keep in mind….
"…we can make a lot of people
sick from just being stupid,
careless, cheap, and greedy."*
*Pat Kludt, Lucky Peach, Issue 6: The
Apocalypse, page 40