Author: Phyllis Entis

E. coli O104:H4 – How Big Is The Iceberg?

“I believe the HUS cases are the real tip of the iceberg.”

– Dr. Michael T. Osterholm, PhD, MPH, Director of the University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP), the publisher of CIDRAP News.

One puzzling aspect of the E. coli O104:H4 outbreak has been the very high number of cases of hemolytic uremic syndrome (HUS) and the large number of deaths in comparison to the total number of reported infections.

The World Health Organization, as of July 7th, reported a total of 3,941 cases worldwide, including 909 cases of HUS and 52 deaths. This tally actually dropped from the previously reported total (on July 1st) of 4,137 cases. The change was due to a redefinition of outbreak-related cases issued by the European Union.

Determining the actual number of outbreak victims in a foodborne disease investigation is rarely easy. I’ve wondered for some time how many mild and/or asymptomatic illnesses have gone unreported. On July 5th, I gave voice to my suspicion that many cases of E. coli O104:H4 have gone unreported, saying, “It’s likely that an unknown number of milder gastrointestinal illnesses also can be blamed on this outbreak strain.”

It is now clear that my hunch was well-founded. The European Centre for Disease Prevention and Control (ECDC) and the European Food Safety Authority (EFSA) have released an updated “Risk Assessment”which includes the following paragraph:

“The most significant development since June 29 relates to the preliminary results of the screening of children and staff in a school in Kreis Paderborn (Paderborn county), Germany, where three cases of HUS STEC and one case of non-HUS STEC infection have been identified since 13 June 2011 and onwards. In 22 of the 30 children tested (including the three HUS STEC cases, and the non-HUS STEC case), the epidemic strain of E. coli was isolated, indicating a significant level of asymptomatic infection. Asymptomatic carriage of STEC infection was also found in three kitchen workers at the school, in four guardians in four different child care centres in the district, and in three staff members of a supplying catering company. Further investigations of this cluster are ongoing.”

So, how big is the E. coli O104:H4 iceberg? Let’s do the math. First, we must decide on our multiplier. Let’s look at the two extreme cases.

  • The conservative estimate. The ECDC/EFSA report of asymptomatic cases documented a total of 22 children and 10 adults who were carriers of E. coli O104:H4 in its investigation of the Kreis Paderborn cluster of illnesses. Of these 32 carriers, only 4 developed active illnesses – including 3 cases of HUS. This gives us a multiplier of 8 (i.e., each reported case represents 8 actual infections).
  • The opposite extreme. In January 2011, CDC released its latest estimates of foodborne disease illness in the USA. The report details the multipliers that the authors developed for each pathogen to extrapolate actual illnesses from the numbers of reported illnesses. For non-O157 strains of enterohemorrhagic E. coli – the category into which E. coli O104:H4 falls – this multiplier is 106.8 (see Table 2 of report).

Taking these two multipliers and applying them to the most recent numbers reported by the World Health Organization, we arrive at the following:

  • The conservative estimate: 3,941 reported cases worldwide x 8 = 31,528 estimated symptomatic and asymptomatic infections.
  • The opposite extreme: 3,941 reported cases worldwide x 106.8 = 420,899 estimated symptomatic and asymptomatic infections.

The truth, no doubt, lies somewhere in between these two extremes.

Why is this important? Simply, the more people who have been infected – especially those who show no symptoms of illness – the more likely that E. coli O104:H4 will establish itself as thoroughly as E. coli O157:H7 already has done.

As for the “most probable source” of the outbreak, the Egyptian fenugreek seeds have been tracked forward to 25 countries so far – Austria, Belgium, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Italy, Latvia, Lithuania, Luxembourg, the Netherlands, Norway, Poland, Portugal, Slovenia, Spain, Sweden, Switzerland and the United Kingdom.

As for the German outbreak investigation, the Federal Office of Consumer Protection and Food Safety has released its final Task Force report.

The German investigation may be complete, and the present outbreak winding down, but this is not the last we’ve heard from E. coli O104:H4.

Recalls and Alerts: July 13, 2011

Here is today’s list of food safety recalls, product withdrawals, allergy alerts and miscellaneous compliance issues. The live links will take you directly to the official recall notices and company news releases that contain detailed information for each recall and alert.

If you would like to receive automatic email alerts for all new articles posted on eFoodAlert, please submit your request using the sidebar link.

United States

  • Food Safety Recall: Food City advises that Food Club Red Enchilada Sauce, 10 oz has been recalled.
  • Outbreak Alert: barfblog reports that Manatee County Health Department is investigating a case of Vibrio vulnificus infection contracted from eating oysters.

Canada

  • Allergy Alert: CFIA warns the public that Healthy Times brand Brown Rice Cereal for Baby (6 oz/170g pkg; Product of USA; Lot 02711; Use by 15 JAN 2013) contains undeclared gluten, and is being recalled by the Canadian importers of the product. One allergic reaction has been reported. The recalled product was distributed in Ontario and may have been distributed nationally.
  • Personal Hygiene Product Safety Recall: Procter & Gamble recalls Oral B Anti-Cavity Dental Rinse – Alcohol Free, and Oral-B Anti-Bacterial with Fluoride – Alcohol Free Daily Use Mouthrinse, due to possible microbial contamination.

Europe

  • Food Recall (Belgium): Quality Nuts BVBA recalls pine nuts (sold from October 2010 through December 2010) after the bitter variety Pinus Armandii was found in certain packages.
  • Food Safety Recall (Denmark): Econova Garden AB (Sweden) recalls Weibull Mix Spire Mixture (seeds for sprouting; Product code number 7651), after the Swedish firm learns that the seed mixture contains fenugreek seeds from the batch implicated in the E. coli O104:H4 outbreak.
  • Outbreak Alert Update (Switzerland): Norovirus has been confirmed as the cause of an outbreak of acute gastroenteritis that sickened a total of 60 military recruits last week.

Asia, Africa and the Pacific Islands

  • Food Safety Recall (Hong Kong): The distributor and importer were warned by the Centre for Food Safety to recall San Bu Bridge Kaiping Preserved Bean Curd (1,000g per bottle; Product of China; Best Before July 29, 2012 and November 29, 2012), manufactured by Kaiping Chuang Feng Trading Company Limited of Guangdong, after the Centre for Food Safety found elevated numbers of Bacillus cereus in samples drawn from the two recalled production lots.
  • Proprietary Medicine Safety Recall (Hong Kong): The Department of Health instructs Chaisentomg Pharmaceutical Factory Limited to recall five powdered medicines, as they were found to exceed the stated product weight.

Some supermarket chains post recall notices on their web sites for the convenience of customers. To see whether a recalled food was carried by your favorite supermarket, follow the live link to the supermarket’s recall web site.

Recalls and Alerts: July 12, 2011

Here is today’s list of food safety recalls, product withdrawals, allergy alerts and miscellaneous compliance issues. The live links will take you directly to the official recall notices and company news releases that contain detailed information for each recall and alert.

If you would like to receive automatic email alerts for all new articles posted on eFoodAlert, please submit your request using the sidebar link.

United States

  • Allergy Alert: B&G Foods, Inc. recalls Las Palmas Green Enchilada Sauce (19-ounce; All sell-by dates on or prior to December 13, 2013), because the product may contain an undeclared allergen, according to a report by Giant Eagle.
  • Allergy Alert Update: Posh Bakery (Santa Clara, CA) recalls Butter Mini Croissants and Chocolate Mini-Croissants (12-pack, 12-ounce clear plastic clamshell containers with Whole Foods Market labels; all best-buy dates prior to and up until July 6, 2011) due to an undeclared egg wash. One allergy reaction has been reported. The recalled baked goods were sold in 26 Whole Foods Market stores in Northern California.
  • Food Safety Recall Update: USDA posts retail distribution list for boneless, fully cooked ham products recalled by Carolina Pride Foods, Inc. due to possible contamination with Listeria monocytogenes.
  • FDA Warning Letter: FDA warns Sogo Foods Inc. (San Jose, CA) that a September/October 2010 inspection of the company’s food manufacturing facility revealed misbranding of two products and also determined that products were prepared, packed, or held under insanitary conditions whereby they may have become contaminated with filth, or whereby they may have been rendered injurious to heath.
  • FDA Warning Letter: FDA warns Mai’s Bakery, Corp. (Monterey Park, CA) that a March 2011 inspection of the company’s manufacturing facility revealed serious violations of FDA’s Current Good Manufacturing Practice (CGMP) regulation for manufacturing, packing, or holding human food.
  • FDA Warning Letter: FDA warns First Commercial Kitchen, L.L.C. (Waipahu, HI) that a December 2010 – February 2011 inspection of the company’s food processing facility determined that your facility produced acidified foods and revealed that you have significant deviations from the requirements of the Acidified Food regulations, causing the company’s acidified food products to be adulterated, in that they have been prepared, packed, or held under unsanitary conditions whereby they may have become contaminated with filth, or whereby they may have been rendered injurious to heath.
  • FDA Warning Letter: FDA warns BioSan Laboratories, Inc. (Derry, NH) that a December 2010 – January 2011 inspection of the company revealed significant violations of Current Good Manufacturing Practice (cGMP) regulations in Manufacturing, Packaging, Labeling, or Holding Operations for Dietary Supplements.

Canada

  • Outbreak Alert (Ontario): One patient at the Guelph General Hospital has died after suffering from a hospital-acquired infection with Clostridium difficile. The hospital declared a C. difficile outbreak on July 5th, after discovering 11 cases in May and June. The outbreak total now stands at 15 cases.

Europe

  • Food Safety Recall (Denmark): Select Salmon A/S recalls Smoked Halibut (Lot #17411; Best before 15.07.2011), due to evidence of Listeria monocytogenes contamination.
  • Food Safety Recall (Denmark): Biogan A/S recalls Organic fenugreek seeds (1-kg bags; Best before 05-10-2012, 21-02-2013 and 16-04-2013) because the seeds came from Egypt and may be contaminated with E. coli O104:H4.
  • Food Safety Recall (Denmark): Fausol A/S recalls Hornum Sprouts, Asia-Mix (30g; Item #1328), because the product contains fenugreek from Egypt and may be contaminated with E. coli O104:H4.
  • Food Safety Recall Expanded (Finland): Raisio Nutrition Ltd. expands its previous recall of Oat Oats, Organic Wheat Paahtopalat product, 260g pack. The recall was expanded to include the Best before date 08/20/2011 and batch ID #L02.25. The recalled packages have been buckling and may be contaminated.
  • Food Supplement Safety Notification (EU #2011.0909): Metal strips in calcium tablets with vitamin D3 from Germany, processed in Hungary; distributed to the Czech Republic, Germany and Hungary.
  • Food Safety Notification (EU #2011.0910): Salmonella in frozen pork meat from France; distributed to Sweden.
  • Food Safety Notification (EU #2011.0912): Undeclared sulphite in frozen prawns from Spain; distributed to Italy.
  • Allergy Alert Notification (EU #2011.0915): Undeclared milk ingredient in bread-crumbed fish fillets from France; distributed to Ireland and the United Kingdom.
  • Animal Feed Safety Notification (EU #2011.0917): Aflatoxins in maize gluten with raw material from China; distributed in Switzerland.
  • Food Safety Notification (EU #2011.0920): Mercury in sliced swordfish from Spain; distributed to Italy.

Asia, Africa and the Pacific Islands

  • Food Safety Alert (Taiwan): Taipei City health officials report that 5.6% (3 out of 54 samples) of iced snack and beverage ingredients failed tests for “problematic” food additives. Officials have ordered the three offending items – marble-sized black tapioca balls, taro beads, and konyaku – off the market.
  • Pharmaceutical Product Safety Recall (Hong Kong): Orient Europharma Co. Ltd. recalls Navelbine Injection 10mg/1ml (Batch 1P109), and Navelbine Injection 50mg/5ml (Batches P507 and P508), as part of a worldwide recall due to and out-of-trend result in content of an active ingredient.
  • Outbreak Alert (PRC): Spoiled leftovers served at an unlicensed kindergarten has been blamed for an episode of food poisoning that hospitalized 42 children in east Zhejiang Province.

Australia and New Zealand

  • Food Safety Recall (Australia): Haigh’s Manufacturing Pty Ltd recalls Haigh’s Aprichoc Chocolates (300g cardboard gift box; Best before 29 OCT 11), due to the possible presence of undeclared nuts. The recalled chocolates were sold in Haigh’s Chocolate Shops in New South Wales, South Australia and Victoria.

Some supermarket chains post recall notices on their web sites for the convenience of customers. To see whether a recalled food was carried by your favorite supermarket, follow the live link to the supermarket’s recall web site.