Starfruit Poisoning Update

On April 22, our world food poisoning tour took us to a Chinese hospital, where a Malaysian tourist was lying in a coma after eating starfruit. Sixty-six year old Tang Gon Seang was one of at least 10 victims with similar symptoms.

Now, it has been suggested that the starfruit, which can be toxic to people suffering severe kidney failure, wasn't at fault in this case. A Malaysian naturopath, Professor Dr Dhilip Kumar, claims that Mr. Tang might be suffering from pesticide poisoning.

This past winter, more than 1,000 Japanese consumers fell victim to pesticide poisoning after eating dumplings (gyozo) imported from China, resulting in a massive recall and a major dispute between the two countries. Yesterday, the Japanese government reported finding pesticide in more dumplings produced by the same Chinese company. The report does not state clearly whether these were new, or were left over from the winter recall.

China has a chronic pesticide residue problem. A quick browse through the monthly FDA list of products refused entry into the United States will yield, without fail, at least a few Chinese items.

The Chinese introduced new standards for pesticide manufacturers this year, and are phasing out some of the more highly toxic pesticides, but they still have a long way to go. It's not enough to regulate the manufacture of pesticides. It's equally important to regulate the safe use of these toxic products.

Shigella In South Dakota

The South Dakota Department of Health is warning residents of the state that cases of shigellosis have been reported in Corson and Walworth counties. Corson has experienced 48 cases of Shigella infection so far this year, and Walworth has confirmed 5 cases. Statewide, 57 cases have been reported in 2008. Last year, there were 117 confirmed cases of Shigella infection in the state.

Shigella can be contracted via contaminated food or water, or by direct person-to-person contact (fecal-oral route). The bacterium is shed in the feces of infected individuals and is transmitted as a result of poor personal hygiene, and inadequate hand-washing after using the toilet. Children are especially at risk, as they are often inattentive to correct hand-washing procedures and frequently put their hands, toys or other objects in their mouths.

Shigella has a typical incubation period of 2-3 days, and can spread rapidly in schools and daycare facilities. The state recommends that children and staff at these facilities who have suffered a Shigella infection should be tested for the bacterium and should stay away until they have achieved two negative stool cultures.

Ground Cumin Recalled In Canada - Salmonella

The Canadian Food Inspection Agency has warned consumers in five provinces – Nova Scotia, New Brunswick, Quebec, Ontario and Alberta – that GD Ground Cumin may be contaminated with Salmonella and is being recalled by the manufacturer, Les Aliments G. Dion, of Saint-Jérôme, QC.

The ground cumin is sold in 31-gram packages bearing UPC 6 20383 01038 2. Four different lot numbers (01X22C, 01X29C, 02X07C and 02X13C) are included in this recall. There are no known illnesses associated with the recalled products.

Consumers in need of additional information can call CFIA at 1-800-442-2342, Monday through Friday between 8:00 am and 8:00 pm (eastern time).

Pesto Recalled - Risk of Botulism

According to an Associated Press news release, Bella Cucina is recalling 6-ounce glass jars of porcini and parmesan pesto, identified with lot numbers 0081028 and 0081018.

The pH of the recalled pesto is higher than it should be. Consequently, there is a risk that Clostridium botulinum, if present, could grow and produce its fatal toxin.

The recalled products were sold by mail order and in stores. Consumers can contact Bella Cucina at 678-539-8400 for more information.

San Diego Hepatitis Cases Still On The Rise

The number of victims in the Chipotle-linked hepatitis outbreak now stands at 18, according to a report yesterday on San Diego's Channel 10 News.

It would not be surprising if the number of cases continues to climb. The county is encouraging anyone who ate at the Chipotle Mexican Grill on Fletcher Parkway in La Mesa between March 1st and April 22nd, and who is experiencing symptoms of hepatitis, to see a doctor and be screened for the virus.

Hepatitis A has a very long incubation period – between 10 and 50 days, according to FDA. And some people – especially young children – may be infected without ever experiencing symptoms. Hepatitis A infection produces a range of symptoms, including fever, malaise, nausea, loss of appetite, and abdominal discomfort, followed in several days by jaundice. Symptoms usually last for about 1-2 weeks, but some victims may suffer from chronic fatigue during their convalescence.

Hepatitis A virus is shed in feces even before symptoms appear, while the victim is suffering from gastrointestinal symptoms, and even after jaundice develops. The highest risk time for transmitting the disease is before a victim realizes that he or she is incubating the virus.

Investigators with the county's Department of Environmental Health are no closer to finding the source of the virus. None of the restaurant's 26 employees have tested positive for the disease. Nevertheless, eating at Chipotle's on Fletcher Parkway seems to be the common link for the 18 reported cases.

But, if the source of the virus wasn't an employee, where did it come from? Investigators should be looking into several possibilities.

1. Chipotle may be a false scent – it could be just coincidence that all the victims ate at that location. A thorough case-control epidemiological study might uncover another common link.
2. The virus might have been introduced by a customer. Perhaps someone who was incubating the disease used a washroom and left some virus particles behind on a faucet, door handle or some other surface in the washroom – or even on a table or chair in the eating area of the restaurant.
3. The source of the virus might have been a food ingredient, such as chopped green onions or some other produce item.

Last year, San Diego experienced 82 cases of hepatitis A infection. Including this current outbreak, the 2008 total has already reached 44 cases – and rising.

South African Baby Deaths - Still No Action

I referred last week to an article carried in The Herald Online (Port Elizabeth, South Africa) that reported on nearly 80 baby deaths, which were blamed on contaminated tap water in the Eastern Cape province of South Africa.

The Democratic Alliance (DA), a South African opposition party, is calling for an investigation into the handling of this outbreak and the water contamination that preceded it. The DA is suggesting that charges of criminal negligence might be warranted.

The tap water became contaminated as a result of a breakdown in the system last October – a mechanical problem that has yet to be corrected. Residents served by the municipal water system were never notified of the problem.

But the district municipality apparently is still not convinced that the babies died as a result of drinking the polluted tap water. "There is," said municipal manager Zolile Williams, "currently no conclusive evidence that water is the cause." He added that the municipality believed the children (all between 3 days and 1 year old) had not been exposed to contaminated water, since they had access to boiled water.

The municipal authority still has not issued a public health warning to residents.

Food Poisoning In Hong Kong

The Hong Kong Centre for Health Protection has received reports of two separate incidents of food poisoning, and is investigating both.

Fourteen people, ages 5 to 45, developed symptoms of food poisoning after eating snacks at a school fair on April 26th. Thirteen of them visited a local hospital for treatment; one was admitted and is reported to be in stable condition.

The second outbreak involved 21 men and women who fell ill after eating meals from at "food supplier" at their office on April 25th. While several sought treatment, none of the 21 victims were ill enough to need hospitalization.

China released a draft of its proposed new food safety law earlier this month, and has given the public an opportunity to comment. Among the provisions of this new law are severe penalties – including heavy fines or imprisonment – that may be applied to producers or sellers of unsafe or poor quality food.

Nutro News

On April 18th, Lisa Wade McCormick of ConsumerAffairs.com published an article titled "String of Illnesses Afflicts NUTRO-Fed Pets" The subtitle of the article was "Company insists its food is '100% safe' ."

After reading the article, I decided to do some checking of my own. First, I searched the FDAs Center for Veterinary Medicine site for any indication of a safety alert. There was none. Nor was there any information on the Nutro web site. Then, I emailed ConsumerAffairs.com and asked what supporting information they could provide me in addition to the complaints listed on their web site. They never answered.

My next step was to post a query on two Labradoodle boards where I'm a regular lurker and occasional contributor. I asked fellow posters to advise me of any issues they've had recently with Nutro products. I solicited both positive and negative comments.

Four people contacted me by email. An additional 15-18 people replied directly on the discussion boards. Here's a summary of the problems:

• Joy said, "Zorro vomited a couple of times again today. So that's almost every day since I fed that to him. But still its hard to be sure to attribute it to that. He's not vomiting a lot or often & its bile & grass today. So I don't know what to think . Everyone else is fine."
• Kim said, "I put my new foster dog Murray on Nutro MAX chicken and rice because he didn't like my Brand X dog food. Neither did Curly Sue so she also got Nutro MAX. I didn't notice any change in her, but Murray was barfing yesterday all over my back seat and then he had diarrhea last night. Hmmm. Could be the food. I had Murray driving with me a lot yesterday and then we went to the vet, so I thought he was probably car sick. Curly Sue did have a bout withthe big D for a little while. But I started mixing her food with my other food and she seemed to be ok."
• Barb said, " I saw your post and had heard earlier of other people having the same problem I had. I have a 4 month old labradoodle....I started her on Nutro Natural Choice small bites chicken rice and oatmeal...She had very loose stools. I was concerned about how much nutrition she was getting. She had no problems health wise the vet suggested we try a different dog food. I went to a pet store and got samples of Innova, Merrick and Canidae. She didn't like Merrick but did like Innova and Canidae, I have her on Innova Puppy Food and she isn't having any problems...She started gaining weight."
• Stacey said, "I bought a new bag of Nutro about two weeks ago. Since then, both my doodles have developed loose stools ... Here's the pertinent information from the new bag: Nutro Natural Choice Lamb Meal and Rice 44 pound bag (40# bag +10% extra) Expiry: July 2009 Lot#? 15:41 2 BY4 SE."

Most of the people who posted said that they were not having any problems with Nutro, except for difficulty in finding some of the varieties.

Interestingly, Nutro is just one of several pet foods about which complaints have been lodged with ConsumerAffairs.com. Alpo, CANIDAE, Hills, Iams, Ol Roy, Natural Balance, Purina and Science Diet were also the subject of consumer complaints. Some of the complaints relate to last year's melamine contamination; others are more current. Symptoms range from gastrointestinal, to urinary tract, to seizures, to allergies. None of the complaints are documented by lab tests. I would estimate that there are probably as many Nutro complaints as there are for all the other pet foods combined.

A food poisoning blog maintained by the "victim's rights" legal firm Parker & Waichman, LLP, has already picked up on the Nutro issue, with an article titled "NUTRO Pet Food Causing Food Poisoning?" The content of the blog suggests that its author has taken the ConsumerAffairs.com report at face value.

Ms. McCormick was careful to point out in her article that the simple act of switching dog foods can cause temporary gastrointestinal upsets, and that some dogs are naturally sensitive to certain ingredients. Without a proper epidemiological evaluation or lab testing to confirm a problem, it's irresponsible to conclude that one exists.

If you have fed your pet any Nutro products in the last six months, I encourage you to post your experiences – positive or negative – as comments to this article.

'Politically Correct' Cholera

Cholera is certainly in the news lately. There is, of course, the major outbreak which has caused almost 2,500 illnesses in Vietnam since early March. In addition The Times (South Africa) reported last week that two people died as a result of cholera in Tanzania, and China View carried a headline stating that six Filipinos living in Malaysia were admitted to hospital suffering from cholera.

As I was browsing the weekly "Cholera, Diarrhea and Dysentery Update" prepared by the International Society for Infectious Diseases (ISID), I came across a curious statement, which read, "Acute watery diarrhea is often used as a "politically correct" term for cholera."

On that note, here is a capsule summary of the weekly toll of cholera – both the "politically correct" and the incorrect types.

Central Equatoria, Sudan
Cholera has become endemic in this southern Sudan state, and has increased significantly in the past two years. Between March 12th and April 5th, the Yei Civil Hospital has reported 118 cases of cholera or acute watery diarrhea.

Hiraan, Somalia
Medical sources in this part of Somalia are reporting 135 cases of 'politically correct' cholera, with at least 7 confirmed dead.

Gombe, Nigeria
A diagnosis of cholera was reported when 116 female students fell ill. The secondary school students, who attend a boarding school, complained of vomiting and diarrhea after eating a lunch that included some contaminated beans. ISID comments that the reported incubation period and symptoms are not typical of cholera.

Rukwa, Tanzania
In addition to the two deaths reported by The Times, three other people are still undergoing treatment for cholera.

Siraha, Nepal
This district of eastern Nepal has been seeing approximately 25 new cases of diarrhea per day since the onset of a "scorching hot" weather spell. The outbreak is blamed on poor sanitary conditions.

Vietnam
As I reported previously, the current toll is 2,490 illnesses in 20 provinces and cities, mostly in northern Vietnam.

There will most assuredly be more to come, as the monsoon season gets underway in various parts of south and southeast Asia.

San Diego Hepatitis A Toll Rises To 14 Cases

According to a news release from the County of San Diego, there are now 14 cases of hepatitis A that appear to be linked to the La Mesa location of Chipotle's. None of the restaurant's employees have tested positive for the virus so far.

Hepatitis A virus can be transmitted through contaminated food or water, or via the "fecal-oral" route as a result of poor personal hygiene. Individuals who are infected with the virus, but who have not yet started to suffer from symptoms, can shed the virus unknowingly. Those convalescing from an infection may continue to shed the virus for a time after their symptoms have disappeared.

If you have eaten at the La Mesa Chipotle's at any time since March 1st and are experiencing any symptoms of hepatitis A infection, consult your doctor or call the San Diego County Epidemiology Branch at (619) 515-6620. For information on immunization against hepatitis A, check with the HHSA Immunizations Branch at (619) 692-8661.

Evanger's Dog and Cat Food - The Company Replies

Holly Sher, President of Evanger's, posted a comment to my original article. For those who missed the comment it, Ms. Sher wrote,

"The FDA news release is highly inaccurate and misleading. Evanger's Dog and Cat Food Company is not under emergency permit and is currently manufacturing and distributing its products worldwide with FDA approval. There have been no allegations for unsafe product or recalls. Please go to evangersdogfood.com for company statement."

The company's full press release on the subject is available on the Evanger web site. The FDA press release can be read in full on the FDA web site.

Dill Seeds Recalled In UK - Salmonella

The UK Food Standards Agency is advising consumers that East End Foods has recalled one batch of its own brand of dill seeds due to the presence of Salmonella.

Consumers who have purchase a 250-gram package size of East End Dill Seeds labeled with batch code 7353L2A and Best Before date of 20/12/2009 should return it to the store for a refund.

Malt-O-Meal Update From CDC

The CDC has updated its status report on the Salmonella Agona outbreak that has been linked to Malt-O-Meal puffed cereals. As of April 22nd, according to CDC, there are a total of 21 confirmed victims in 13 states. Specifically,

As of April 22, 2008, state and city health departments from 12 states have identified 21 ill persons infected with same genetic fingerprint of Salmonella Agona. Ill persons with the outbreak strain have been identified from Colorado (1), Delaware (1), Maine (3), Massachusetts (2), Minnesota (1), North Dakota (1), New Hampshire (2), New Jersey (4), New York (3), Pennsylvania (1), Rhode Island (1), and Vermont (1). Onset dates, which are known for 13 patients, ranged from January 22 to March 8, 2008. Patients’ ages ranged from 4 months to 95 years with a median age of 66 years. Five hospitalizations and no deaths have been reported.

There is a bit of a discrepancy between the CDC tally and an April 14th report from FDA. In its report, FDA cited 23 illnesses in 14 states. Perhaps two of those suspected illnesses turned out to be due to another microbe or from a different source.

The good news is that this outbreak appears to be contained. No new cases have been reported in the last two weeks. The bad news, for Malt-O-Meal, is that the lawsuits are only just beginning.

Hepatitis Update - San Diego Chipotle's

The number of cases of hepatitis A infection linked to a Chipotle's Mexican Grill outlet in La Mesa (San Diego) has risen to 12, according to the Union Tribune.

The county's Department of Environmental Health is still investigating the source of the outbreak. None of the restaurant's 25 employees have tested positive for the virus so far.

Bill Marler (food safety attorney and blogger) has long advocated that all food handlers should receive hepatitis A vaccine. Now, only St. Louis County in Missouri and Clark County, Nevada mandate this.

The CDC Advisory Committee on Immunization Practices (ACIP) has this to say about hepatitis A and food handlers:

"Foodborne hepatitis A outbreaks are recognized relatively infrequently in the United States. Outbreaks typically are associated with contamination of food during preparation by an HAV-infected food handler; a single infected food handler can transmit HAV to dozens or even hundreds of persons (34,36,37,78--81). However, the majority of food handlers with hepatitis A do not transmit HAV. Food handlers are not at increased risk for hepatitis A because of their occupation. However, among the approximately 40,000 adults with hepatitis A reported during 1992--2000 for whom an occupation was known, 8% were identified as food handlers, reflecting the large number of persons employed in the food service industry (34). Evaluating HAV-infected food handlers is a common and labor-intensive task for public health departments. In a 1992 common-source outbreak involving 43 persons, the estimated total medical and disease control cost was approximately $800,000 (82)."

Nevertheless, ACIP does not recommend routine vaccination of food handlers, on the grounds that this is not an occupation that presents increased risk of becoming infected with the virus. They don't appear to consider the potential benefits or cost-savings to the general public that food handler vaccination would bring.

Current CDC recommendations for hepatitis A vaccination include:

• all children under one year of age;
• adults who live in a community with a high rate of hepatitis A infection;
• males who have sex with other men;
• users of street drugs;
• those who work in or travel to countries with a high rate of hepatitis A infection;
• people with long-term liver disease;
• people who receive agents to help their blood clot; and
• people who work with hepatitis A virus-infected animals or who work with the virus in a research setting.

Roughly one-third (31% in 2006) of US residents already have long-term immunity to hepatitis A, either through prior infection or as a result of having been vaccinated. This proportion should continue to rise, if parents follow CDC recommendations and have their children immunized.

Meanwhile, the two-thirds of the public without immunity to hepatitis A are at risk of infection from the occasional asymptomatic – and symptomatic – carrier working as a food handler. Perhaps it's time for one of the major restaurant food chains to take the lead and require that its employees be tested for hepatitis A immunity and, if necessary, be vaccinated. Are you listening, Chipotle?

Safety Warning on Evanger's Dog And Cat Food

FDA has found that the processing procedures at Evanger's Dog & Cat Food Company, Inc. in Wheeling, IL leave something to be desired. The agency has issued a notice to the company that it must obtain an emergency permit from FDA before it can sell its canned pet foods interstate.

Evanger's canned pet food is all-meat, grain-free, and even kosher. It has received the approval of the Chicago Rabbinical Council, but not of the FDA, which answers to a different authority.

According to the FDA order, Evanger's processing documentation has been inadequate, leading to the possibility that Clostridium botulinum might be able to survive in the canned pet foods. While the types of botulism toxin that are dangerous to humans – A, B, and E – usually don't affect dogs or cats, types C and D can be dangerous to both cats and dogs.

Simply handling contaminated pet food that contains Clostridium botulinum or its toxin may also be risky. The microbe can infect open sores, producing "wound botulism". Or, a miniscule amount of toxin may be transferred onto the handler's skin and, inadvertently, be ingested. It takes very little toxin to make someone ill.

FDA appears to be of the opinion that the product does not present any immediate risk. Nevertheless, it is requiring the company to bring its documentation and processing practices into line with federal requirements. Otherwise, Evanger's will not be permitted to sell their products outside of the state of Illinois.

Fennel Seeds Recalled In UK - Salmonella

The UK Food Standards Agency is advising that Natco Foods Ltd. has recalled one batch of its fennel seeds after Salmonella was detected in the product.

The affected seeds carry batch code 4538 and an expiry date of 12/2009. The seeds are packaged in 20 x 400g and 6 x 1kg packs.

It appears from the wording of the notice that this product has not been sold at retail stores.

Malaysia's National Dish - Food Poisoning

What is it with nasi lemak? This national dish of Malaysia has been linked to yet another food poisoning outbreak among school children.

The New Straits Times reported yesterday that 120 students at Sekolah Kebagsaan Taman Dato Harun 1 school became ill after eating nasi lemak from the school's canteen. The students, who ranged from 10 to 12 years of age, complained of stomach pain – some within minutes of having eaten the nasi lemak. One girl, who vomited after her recess snack, said that the dish "...tasted terrible."

This is the second outbreak linked to nasi lemak in less than two weeks. I reported on April 15th that more than 100 Malaysian students were stricken with food poisoning after eating a snack of nasi lemak. In that outbreak, also, the incubation period was described as being just a few minutes.

The very short incubation period experienced by victims of both outbreaks may be due to one of two possibilities – a toxic chemical or Bacillus cereus in the rice. Some strains of B. cereus produce a toxin that causes a very rapid reaction. Known as "Chinese restaurant syndrome", it is usually associated with rice that has been cooked, then held at room temperature before being reheated or served.

Nasi lemak consists of rice, which has been cooked in coconut milk. Typically it is served with a garnish, such as cooked eggs, cucumber or nuts and sometimes with a sauce. It is a perfect feeding ground for bacteria.

The Education Department is investigating the most recent outbreak and will issue a "warning" to the canteen operator if he is found to have been negligent. The operator's contract may also be reviewed.

I would add one more element to the canteen operator's "punishment". He should be forced to eat his own nasi lemak.

Hepatitis A in San Diego County

San Diego County health authorities are investigating a possible outbreak of hepatitis A that may be linked to a Chipotle Mexican Grill outlet in La Mesa, according to a press release issued by the county Department of Environmental Health earlier today.

Six cases of hepatitis A infection have been reported so far, and investigators are working with the restaurant's management to try and determine the source of the virus. Health authorities are recommending that individuals who ate at the La Mesa Chipotle's between March 1st and April 22nd, and who are experiencing symptoms of hepatitis A infection should contact their doctors.

Hepatitis A has a relatively long incubation period (10-50 days), so it's very possible that more cases will pop up. Customers of the La Mesa restaurant who are still asymptomatic should consider obtaining a gamma globulin injection to boost their immune systems and help ward off the illness.

Anyone who has been potentially exposed to hepatitis A should take pay scrupulous attention to personal hygiene and take extra precautions when preparing or handling food, especially for other people. Infected individuals can transmit the virus before symptoms of the infection begin to show themselves.

San Diego residents who need more information can contact the County Epidemiology Branch at (619) 515-6620, or the HHSA Immunizations Branch at (619) 692-8661.

Soy Sprouts Recall Update

FDA has issued a notice advising that Chang Farms has recalled its soy sprouts due to the presence of Listeria monocytogenes. The company, based in Whately, Massachusetts, announced the recall last week, but didn't specify the species of Listeria that had been found in the sprouts.

Listeria monocytogenes can cause a variety of symptoms, ranging from mild flu-like symptoms or gastroenteritis to life-threatening illness. Pregnant women who become infected with this bacterium are at risk of miscarriage.

If you have purchased the recalled sprouts, either discard them or return them to the store for a refund.

Houmous Recalled Due To Salmonella

Waitrose and Tesco have recalled a number of their own brands of houmous (chick pea paste) due to the presence of Salmonella in the products, according to an announcement issued today by the UK Food Standards Agency.

Waitrose recalled two package sizes of houmous with a date code of 23 April after finding Salmonella in the product. As a precaution, the company also recalled 11 different products that were made using the contaminated houmous. The recall covers all date codes up to and including April 29th.

Tesco has recalled two batches of houmous – Chicken Topped Red Pepper Pesto Houmous (205g pack) with a date code of 23 April 2008, and Red Pepper Pesto Houmous (200g pack) with a date code of 24 April 2008.

Customers who purchased the recalled products are asked to return them to the store for a refund.

A Busy Little Virus

Ohio health officials now know what caused the food poisoning event last week at the Chipotle Mexican Grill located across the street from the Kent State University campus. An employee of the fast food restaurant was ill with Norovirus and transmitted it to more than 400 customers.

Norovirus hasn't limited its activities to Ohio, though. It has also made appearances in the last few days in Indiana and Maine – to the detriment of those who came into contact with it.

Approximately 100 people have reported gastrointestinal symptoms after attending a tennis tournament held last week in western Illinois. Victims include residents of the area as well as visitors who traveled from Wisconsin to watch the tournament.

A two-day conference in Lincoln, Maine was also a venue for Norovirus. More than 20 of the 36+ hospital employees who attended the meeting – a customer service training program – began complaining of nausea, headache, dizziness, vomiting and diarrhea the day after the conference. A hospital spokesperson described the symptoms as "sudden and severe", but most of the victims had recovered by the following day. Norovirus was recovered from the stool sample of at least one victim of the outbreak.

Norovirus is a problem wherever large numbers of people congregate – cruise ships, nursing homes, daycare facilities, restaurants and resorts. It can be transmitted on food, in water, or by contact with contaminated surfaces. The only defense is constant attention to good sanitation, safe food handling practices, and scrupulous personal hygiene.

South Africa's Dirty LIttle Secret

Last week, I wrote about the lack of clean water and toilet facilities in Die Gaatjie, an "unofficial" community of 200 families near the tourist township of Sedgefield, South Africa. A report in today's "The Herald Online" leaves no doubt that the situation in Die Gaatjie is far from unique.

According to the report, 80 babies in the Eastern Cape province of South Africa have died of waterborne diseases in the last few months. The total includes at least 15 victims in Barkly East and 62 in Sterkspruit. Other towns in the Ukhahlamba district municipality may also be affected.

The babies died from "...diarrhea and other complications..." after drinking contaminated tap water. There was a breakdown in the municipal water purification system last October, according to an official health report, but no actions were taken to correct the problem. Nor were residents alerted to the breakdown.

Meanwhile, officials appear to be spending their time playing the Blame Game instead of addressing the emergency. The Municipal Manager claims that the local hospital was dilatory in reporting the deaths; hospital officials reply that they reported the deaths to the municipality after seven babies died of gastroenteritis, but that municipal officials took no action.

And while "health" officials play, babies die.

Food Poisoning Around The World - April 22nd Edition

On today's leg of our continuing journey, we'll be making stops on three continents – Asia, Africa and Europe.

Hong Kong
Our first stop is this former British Crown Colony, which is now a "special" part of China. But there was nothing special about a Guilin restaurant on April 17, except for the aftereffects of the meal. Twelve restaurant patrons (part of a tour group) came down with symptoms of food poisoning, which appeared 18-40 hours after they dined at the restaurant. One of the victims was admitted to hospital and is reported to be in stable condition.

Japan
From Hong Kong, we take a short hop to Saitama Prefecture in Japan, where we visit with students who live and study at the Musashino Academia Musicae. Sixty of high school-aged students fell ill with gastroenteritis after eating at the dormitory cafeteria on April 15th and 16th. The local health center was able to confirm Norovirus in 8 of the ill students and in 3 cafeteria workers. As punishment, Saitama Prefecture ordered the cafeteria to remain closed for three days.

Kuala Lumpur, Malaysia (ex China)
A 66-year old Malaysian man, Tang Gon Seang, is in a coma in a Chinese hospital after eating starfruit. He is just one of at least 10 patients who were admitted to the hospital with similar symptoms. Starfruit is known to contain one or more toxins, depending on the variety, and can cause severe neurological symptoms in patients who are suffering from severe kidney disease. But according to his family, Mr. Tang was in excellent health when he embarked on his trip to China.

Gombe State, Nigeria
Our next stop is Doma in Gombe State, where approximately 125 students at a girls school are undergoing treatment for food poisoning. The girls began complaining of "excessive" vomiting, stomach pain and diarrhea after eating a meal of beans. More than 100 of the students have been treated in hospital and released. Ten have been admitted to hospital and are said to be in critical condition. The government is testing the beans to determine whether they are the cause of the illnesses.

Tuzla, Bosnia
A local fast food restaurant, "Bos Burger", is suspected of being the source of a food poisoning outbreak that has struck 131 people so far. The victims are complaining of nausea and severe stomach pain. Four of the 131 victims have been hospitalized in serious condition, and local officials have closed the restaurant until their investigation into the cause of the outbreak is complete. Local media appear to be pointing the finger at "bad mayonnaise", but this is pure speculation on their part.

Vietnam
Finally, we find ourselves back in Asia for an update on Vietnam's cholera epidemic. According to the World Health Organization, the country has logged 2,490 cases of acute, watery diarrhea between March 5th and April 22nd. Of these, 377 were positive for Vibrio cholerae, serotype O1 Ogawa. This outbreak, which has now spread to 20 municipalities and provinces, is showing no signs of abating.

And that's our world tour for today.

Chang Farms Soy Sprouts Recalled

Soy sprouts produced by Chang Farms of Whately, MA have been recalled due to the presence of Listeria. The 12-ounce packages of sprouts, which were sold in Stop & Shop, Market Basket and Whole Foods Market stores, are labeled with a "sell-by" date of April 19th.

Consumer alerts have been issued by Stop and Shop, the Connecticut Department of Consumer Protection, the Rhode Island Department of Health and the Massachusetts Department of Health. FDA has not yet posted a recall advisory on its web site, but I expect that they will follow suit.

Except for Listeria monocytogenes, most species of Listeria are not human pathogens. There have been no illnesses associated with this recall so far.

If you have purchased the recalled sprouts, either discard them or return them to the store for a refund.

Chipotle's Secret Ingredient?

Students of Kent State University in Ohio thought they were being rewarded for participating in an on-campus blood donor clinic last week. According to a report on Barfblog, blood donors were given a coupon for a free food at the Chipotle's Mexican Grill located across the street from the university's campus.

But the reward turned out to have an unintended consequence. At last count, 432 customers of Chipotle's have reported suffering from "...severe vomiting, diarrhea, nausea and cramping..." – symptoms consistent with a Norovirus infection.

According to a statement from Chipotle spokesman Chris Arnold, all Chipotle outlets receive their food from the same source, and no other location has reported any illnesses.

The restaurant closed for thorough disinfection and was allowed to reopen on Saturday. Chipotle also rotated out the employees who were working in the restaurant at the time of the outbreak, in case one of them was the source of the food poisoning. The county health department is in the process of testing samples and hopes to determine the cause of the outbreak once those results are available.

There have been no additional cases of illness reported since Chipotle's reopened.

Vietnam's Cholera Outbreak - A Structural Problem

It's no secret that Vietnam is suffering from a serious, and spreading outbreak of cholera. According to the latest report, the outbreak now has spread to 19 cities and provinces – mainly, but not exclusively in the northern part of the country. Of the more than 1,800 people who have fallen ill from diarrheal diseases since March 5th, 326 have been confirmed to be infected with cholera.

Vietnam's health agencies blame the outbreak on contaminated or unhygienic food – dog meat, shrimp paste, uncooked vegetables – and water. Lakes and ponds have been dredged and disinfected in an attempt to contain the spread of cholera and other acute diarrheal diseases.

But a report presented last Friday at a conference held in Hanoi on "Clean Vegetable Growth in the Red River Delta" illustrated the magnitude of the problem. Produce grown in many areas of northern Vietnam, including supposedly "safe" areas, is often contaminated with heavy metals, toxins, and E. coli. Irrigation water used on crops contains E. coli more often than not.

The problem goes beyond water. Fecal pathogens such as E. coli also find their way into the soil when farmers use fresh manure as fertilizer. Proper composting greatly reduces the pathogen content of manure, but Vietnam does not provide its farmers with clear guidelines for fertilizing with compost.

On our recent trip to Southeast Asia, we had a chance to visit local farming villages in Myanmar and to see how manure is composted. The process is simple – it's collected in a heap until it is needed. There is no method or timetable to its accumulation or use.

A chicken foraging for it's midday snack at the edge of a manure heap in a typical village

Southeast Asia's food and water safety issues are well-entrenched, and they will only be solved when the countries in the region manage to put the necessary infrastructure in place, including a reliable supply of clean drinking water, adequate facilities for handling human waste, basic education and training for farmers in how to fertilize cropland safely.

Funeral Hazardous To Mourners' Health

Mourners at a funeral held in northern Thailand last Friday had an extra reason for sadness, according to a report in the Bangkok Post. The soup that they were served at the funeral contained fish balls made using puffer fish.

More than 300 villagers who attended the funeral complained of "...numb tongues, breathing difficulty and diarrhoea..." after eating the fish balls. Ninety of the victims taken to hospital for treatment; 32 remain hospitalized.

Importation, raising and sale of puffer fish is banned in Thailand. Nevertheless, it is still used on occasion – albeit illegally – to make fish balls, since it is less expensive than most other types of fish.

Puffer fish, also known as fugu, is considered a delicacy in Japan, but can be deadly if not prepared correctly. The toxin it contains is not damaged or inactivated by heating.

All of the victims of this incident are expected to recover.

Extreme Diet - An Update

On March 27th, the FDA issued a recall advisory for several flavors of "Total Body Formula" and "Total Body Mega Formula" after receiving a number of illness complaints by consumers of these products. At the time, FDA suspected that the illnesses were due to excessive levels of selenium in the products, but hadn't yet completed lab analysis.

The agency's fears were confirmed on April 9th, and in a report posted on the CDC web site last week. FDA labs have found levels of selenium that are up to 200 times higher than the concentrations claimed on the product labels; chromium levels are also excessive - up to 17 times greater than the amounts shown on the labels.

The recalled products were sold through distribution channels and also directly over the Internet. Illnesses consistent with excessive intake of selenium have been reported by consumers of the dietary supplements in ten states as of April 17th.

As I reported on March 28th, symptoms of excessive selenium consumption begin 7-10 days following ingestion of the dietary supplement, and may include significant hair loss, muscle cramps, diarrhea, joint pain and fatigue.

A full list of the recalled dietary supplements can be found on the CDC web site. Anyone who has used one of the recalled products and is experiencing any unusual symptoms should contact his or her doctor. Patients and doctors can also report adverse reactions directly to FDA's MedWatch program at 800-FDA-1088.

Alamosa Water Was Never Chlorinated

The Alamosa water system has been flushed, disinfected and declared safe. The outbreak has ended, but not the investigation into its origins.

The Denver Post, in an article on April 11th, reported that the Alamosa water system was never chlorinated prior to this outbreak. According to Post reporter Katy Human, the water for the municipal supply was drawn from "...deep groundwater wells..." that were thought to be protected from contamination and, therefore, wasn't required to be chlorinated.

Apparently, no one considered the possibility of contamination after the water left the wells. In fact, the water that issued from the taps of Alamosa residents contained not just Salmonella, but also parasites such as Cryptosporidium and Giardia.

It's been eight years since the town of Walkerton, Ontario was hit by a major outbreak of E. coli O157:H7 illnesses due to a contaminated municipal water supply. The Walkerton water system was supposed to be chlorinated, but that responsibility was sadly – even criminally – neglected. Those responsible for maintaining the water system mislabeled samples and falsified chlorination records rather than doing their job. Municipal officials believed their groundwater wells to be protected from contamination, and turned a blind eye to the mismanagement and malfeasance – with fatal results.

Now, it appears that the Alamosa outbreak might also have cost a life. Attorney and fellow blogger Bill Marler, citing an article in The Pueblo Chieftain, reports that one person has died after contracting an infection with the same strain of Salmonella that had contaminated the Alamosa water supply. Marler also reports that the outbreak tally now stands at 411 reported cases of salmonellosis (112 confirmed by laboratory testing), and 18 hospitalizations.

I find it difficult to understand the logic of feeding untreated, unchlorinated well water through a municipal water supply, especially after Walkerton provided such a graphic illustration of the risks associated with this approach. I have seen no information so far on how often – if ever – Alamosa tested its drinking water. A regular testing program, properly conceived and carried out, could have provided an early warning and given the water management authorities a chance to prevent the outbreak.

Canada doesn't seem to have learned the Walkerton lessons very well, either. According to a recent study by the Canadian Medical Association, there are 1,775 "boil water" advisories in effect in communities across the country – most of them in Ontario (679), British Columbia (530) and Newfoundland (228). Some of those advisories have been in effect for more than five years.

It's scandalous that so many people and agencies who are responsible for public health and safety cling to old habits instead of updating their policies and practices regularly. The Alamosa outbreak should ring alarm bells in the offices of every municipal and county water authority. We cannot afford to take clean water for granted.

Food Poisoning Around The World - This Week's Itinerary

This week, our tour of food poisoning venues includes stops in the United States, England, Hong Kong, Bangladesh and Vietnam.

Alabama, USA
Some attendees at a church lunch in Dothan, AL experienced nausea, vomiting and lethargy after their meal. The 28 individuals reported eating "...chicken and rice, green beans and a brownie..." according to a report on WTVY, a local CBS affiliate. The local health department is investigating, and hopes to have some test results within the next 48 hours.

Shropshire, England
A second boy has been diagnosed with an E. coli O157:H7 infection in the last few weeks. Doctors suspected appendicitis at first, but then determined that he was suffering from a severe case of E. coli O157:H7. The victim, whose kidneys have been affected, is being treated in Birmingham Children's Hospital. Health officials are of the opinion that this case is not connected with an earlier case of E. coli O157:H7 in the same part of the country.

Hong Kong (via Cambodia)
Ten members of a tour group developed symptoms of dysentery after returning from a trip to Cambodia. The five men and five women, aged 26 to 65, complained of fever, abdominal pain and diarrhea. Hong Kong's Centre for Health Protection is contacting other tour participants to determine whether there were any more victims.

Bangladesh
Warm weather is exacerbating an outbreak of diarrhea in this country. The International Center for Diarrhea Disease Research in Dakka received 418 patients on April 17th, and an additional 221 by 3pm on April 18th. The situation is not expected to improve as long as the weather remains hot.

Vietnam
Finally, we return to Vietnam for an update on this Southeast Asian country's cholera outbreak. Health authorities have received reports of more than 1,800 cases of acute diarrhea in 19 cities and provinces since March 5th. Cholera has been confirmed in 326 patients. The outbreak is still confined mostly to the northern part of Vietnam, including the cities of Hanoi and Hai Phong.

The country is trying to address the underlying causes of the outbreak. The Health Ministry has announced that it will spend US$80 million on six new food safety programs, and the government has been dredging and disinfecting contaminated waterways in an effort to control the spread of the cholera.

That's this week's whistle-stop tour. Watch for the next installment in a few days.

Salmonella Triple Crown - A Recap

The first quarter of 2008 has witnessed a trio of Salmonella outbreaks. Each one burst onto the scene, enjoyed its 15 minutes of fame, and then disappeared from public view. Here's a recap on the background and status of each outbreak.

Salmonella Litchfield in Honduran Cantaloupe
This story began with an "import alert" issued by FDA on March 22nd. The agency warned that cantaloupes from Agropecuaria Montelibano, a Honduran grower/packer, appeared to be implicated in a Salmonella Litchfield outbreak. As news of the alert was transmitted to processors and distributors, the number of recall notices grew.

The outbreak, according to CDC's most recent update (dated April 2), comprised 51 illnesses in 16 US states, plus an additional 9 illnesses in Canada. At least 16 people were hospitalized. Fortunately, there were no deaths.

FDA has sent a team of investigators to Honduras to help determine the source of the contamination. But if past history is anything to go by, they face a daunting task. At best, it will take months before their investigation is complete and the results are known.

Salmonella Contaminates Alamosa Drinking Water
Hard on the heels of the cantaloupe outbreak came the news of a Salmonella outbreak in Alamosa, CO. The contaminant, eventually identified as Salmonella Typhimurium, caused at least 380 illnesses and forced residents served by the municipal water system to rely solely on bottled water for more than two weeks while the system was flushed and disinfected.

The Colorado Department of Public Health and Environment has not yet posted – if it ever intends to do so – a final tally of illnesses on its web site. The last official news update was on March 24th.

Malt-O-Meal Breakfast Cereals Recalled
For the second time in ten years, Malt-O-Meal cereals have been implicated in an outbreak of Salmonella Agona. On April 5th, the company announced a recall of its unsweetened Puffed Rice and unsweetened Puffed Wheat cereals after detecting Salmonella in a sample. At the time, they were unaware (according to their press release) of any illnesses associated with the recalled products.

But that soon changed. Maine announced on April 10th that it was investigating three illness reports linked to the recalled cereals, and CDC posted its own investigation report on April 11th. The most recent tally of the scope of the outbreak, published on April 14th by FDA, is 23 illnesses in 14 states. It's too soon to tell whether that number will grow.


It can be frustrating to see these outbreaks fade from the news without anyone announcing "it's over", or giving a final tally of the number of victims – much less a summary of the results of the investigation. Anyone for a nice Honduran cantaloupe?

South Africa's Great Sanitation Divide

Wikipedia describes South Africa as having "...a two-tiered economy; one rivaling other developed countries and the other with only the most basic infrastructure." The country is well-endowed with natural resources, is a net food exporter, and has been working to diversify its economy.

But there is another side to South Africa – one that belies the modern images presented by its major cities of Johannesburg and Cape Town. The "informal" settlement of Die Gaatjie, near the tourist town of Sedgefield is an example of the other South Africa – poor, crowded and unsanitary.

Die Gaatjie is a community consisting of 200 families, and was built on an old dumping ground. It is served by three communal water taps and just five toilets – one for every 40 families. Residents complain that the overflow and smell from the toilets make people ill.

Cholera is endemic in South Africa, and can spread easily in conditions such as exist in Die Gaatjie – as it did in 2001. Just yesterday, two confirmed cases of cholera were reported in Soweto, a poor township near Johannesburg.

James Booysen, a local community leader in Die Gaatjie, told visiting government officials that the settlement needed decent housing, water, electricity and toilet facilities. That doesn't seem like too much to ask for.

Why I Don't Eat Sushi Or Sashimi

Ten patrons of a restaurant in Kisai, Japan were diagnosed with cholera after eating sashimi at the Shozaburo restaurant last week, according to an item in the Mainichi Daily News. Eight of the victims needed treatment for their diarrhea and nausea; three were hospitalized.

My initial exposure to sushi and sashimi was in 1981, when I visited Japan for the first time. I have eaten sushi on several occasions since then, usually when dining with Japanese colleagues either in the United States or Canada, but have never felt comfortable with the dish – except in Japan.

The rest of the world apparently doesn't share my qualms. Sushi is everywhere – including the local supermarket fish counter.

Last month, chefs at an international restaurant summit in Tokyo warned about the dangers of the sushi craze. They are worried that "amateur" sushi chefs are not handling raw fish correctly, and are exposing sushi bar patrons to the risk of food poisoning from bacteria and parasitic worms.

This problem is not new. In 2003, the Australian government analyzed 55 samples of sushi from 14 different establishments. They found marginal or unsatisfactory levels of Staphylococcus aureus in 8 of the samples, excessive E. coli in 4, Listeria monocytogenes in 7, and marginal or unsatisfactory numbers of Bacillus cereus in 9 samples.

Much of the risk associated with sushi and sashimi appears to relate to improper handling and inattention to good sanitation practices. This month's Journal of Food Protection carries a research report from Germany that compares fresh sushi prepared in sushi bars with frozen sushi available in supermarket freezer aisles.

The frozen sushi won the comparison hands-down – at least as far as microbiological safety was concerned. Staphylococcus aureus, E. coli and Listeria monocytogenes were all found more often in the fresh items from sushi bars than in the frozen sushi.

I have no plans to return to Japan in the near future. But when I do, I'll probably give the sushi a miss – even in its place of birth.

Clean At Last: Alamosa Water Safe To Drink

It's been a long, slow process, but residents of Alamosa, CO were given the go-ahead last Friday to use their tap water for drinking and cooking.

The problem with the town's water supply came to light almost four weeks ago, when health officials were alerted to a cluster of 33 confirmed cases of Salmonella gastroenteritis linked to the town's tap water. Officials instructed residents to avoid using their tap water for any purposes – drinking, cooking, and even bathing – until the water system was purged, disinfected and retested for safety.

By April 9th, with the disinfection well underway, the number of gastroenteritis cases had risen to 379, 106 of them confirmed as being due to Salmonella. Fifteen people were hospitalized as a result of the severity of their symptoms.

While the tap water is now potable, there is no guarantee that the underlying problem has been solved. Health authorities still haven't found the source of the contamination. Nevertheless, residents of Alamosa must be breathing more easily now the their water is flowing freely once more.

Put Children's Health First

Malaysia's New Straits Times published an article in honor of World Health Day on April 7th. The story cited improvements in infant and child mortality statistics in Malaysia, but indicated that there is significant room for improvement. Preventable diseases such as diarrhea still claim the lives of roughly 7,000 children under the age of five each year.

Since late March, there have been three separate outbreaks of food poisoning among Malaysian school children.

• Sixty-eight students suffered from food poisoning in two separate outbreaks in northern Penang state at the end of March. Four (out of 43) ill students from one school were hospitalized; 25 students from a second school were treated as out-patients and released.
• Students of SK Bukit Tembakau primary school who took part in a parade last week received an unexpected ingredient in their morning snack. The nasi lemak contained boiled egg that one student described as "slimy and smelly". One hundred and eight students began vomiting within a few minutes of having eaten their snack.
• Thirty-nine students from SK Sri Indah primary school were the victims of a food poisoning incident yesterday, after eating food from the school canteen. The students were taken to Penang Hospital for examination.

And the name of that April 7th article in the New Straits Times?

Put Children's Health First

Malt-O-Meal: Add Illinois To The List

We can add Illinois to the list of states reporting Salmonella illness that may be tied to the Malt-O-Meal cereal recall.

The state's director of public health, Dr. Damon T. Arnold, reminded consumers today to avoid eating the recalled cereals. He also announced that Illinois is investigating one illness that could be linked to the cereal. Test results are still pending.

Once again, please check your pantry for any of the cereal brands and batches included in the list of recalled products. You can find this information at the Malt-O-Meal web site.

Safe Water In The Developing World

Sometimes it seems as though safe drinking water is like the weather – everyone talks about it, but no one does anything. In this International Year of Sanitation, we are seeing some evidence of action.

China's pre-Olympics environmental and sanitation face lift is contributing to the improvements. Earlier this month, Chen Lei – the Minister of Water Resources – revealed that the PRC government spent 24 billion yuan (US$3.4 billion) between 2001 and 2007 to make safe drinking water available in rural areas. This investment, which was supplemented by contributions of 22.7 billion yuan from local governments, provided drinking water to an additional 128 million Chinese. The government's goal is to solve the rural drinking water access problem by 2015.

The government of Tibet is undertaking its own infrastructure improvement program, as well. The regional water resources department began its program in 2005, and has spent 450 million yuan so far – delivering safe drinking water to more than 600,000 rural residents. An additional 230,000 yuan have been budgeted for 2008 to provide drinking water to another 230,000 people.

It's not only governments who have the power to make a difference. Individuals are weighing in as well.

Muhammad Yunus – a Nobel laureate who was recognized for his efforts in providing micro-loans to entrepreneurs in underdeveloped countries – announced on March 31st a program to bring clean drinking water to 100,000 rural residents of Bangladesh. The joint venture between Yunus' Grameen bank and France's Veolia Environment group will build and operate water treatment plants in several Bangladeshi villages.

Feliciano dos Santos, a Mozambiquan singer, is using his musical talent and his local celebrity status to further the goal of clean water and improved sanitation. Dos Santos incorporates messages that promote hand washing and the use of slab latrines into the lyrics of his songs. Several years ago, he wrote to the Prime Minister of Mozambique to enlist him in a campaign to promote hand-washing. After being rebuffed by government officials, dos Santos used the occasion of an official dinner to shame the Prime Minister into cooperation.

One has only to read the Cholera, Diarrhea & Dysentery Update, published weekly by the International Society for Infectious Diseases, to realize the importance of clean drinking water to public health. Until this basic need is met, gastrointestinal diseases will continue to be part of the daily life of residents of the underdeveloped world.

Vietnam's Cholera Epidemic

Vietnam has been struggling with a major outbreak of acute diarrheal disease since March 5th. As of April 11th, more than 1,300 individuals have been hospitalized as a result of acute diarrhea, according to a report in today's Thanh Nien Daily. Of those, 136 people – 44 of them in Hanoi – have been diagnosed with cholera.

According to a Ministry spokesperson, most of the victims have fallen ill after eating contaminated foods, including items such as dog meat, shrimp paste, uncooked vegetables and raw blood soup.

The Ministry of Health has been working to contain the epidemic, but their efforts are hampered by a lack of clean water – samples from 18 rivers and canals and other waterways in northern Vietnam contained high levels of Vibrio cholerae – and by an abundance of unregulated food stands.

The government has ordered that more than 30 lakes be dredged or decontaminated, and has suspended the licenses of 15 food stalls in the Hanoi area after they failed to meet hygiene standards.

While this outbreak has been confined mostly to the north of the country, cholera has also made an appearance in Ho Chi Minh City (formerly Saigon). A 71 year-old woman complained of diarrhea after eating food purchased from a street vendor in the city. She has since been diagnosed with cholera and has been hospitalized. Ho Chi Minh City health officials are warning citizens to maintain high standards of hygiene and to avoid eating shrimp paste.

But practicing good hygiene is near impossible in the absence of adequate toilet facilities. Ho Chi Minh City's residents have been complaining for years about the lack of public restrooms. These facilities are few and far between. They usually are dirty, foul-smelling, closed after 6pm, and expensive to use. The fee is more than many workers are prepared to pay. As a result, the city streets often become the latrines of last resort.

The 8 million residents of Ho Chi Minh City had better hope that the Ministry of Health succeeds in preventing the cholera epidemic from spreading. Otherwise, the city will be in for a very long, very hot, and extremely unhealthy summer.

Malt-O-Meal: The Latest Tally

FDA has just announced that the number of victims of the Salmonella-contaminated Malt-O-Meal cereals has risen to 23 people, in 14 states. The agency is reminding consumers to check their pantries and discard all recalled unsweetened Puffed Rice and unsweetened Puffed Wheat cereals.

A complete list of recalled items is available on the Malt-O-Meal web site. FDA is working with CDC and state agencies to find the source of the contamination and to limit the extent of the Salmonella outbreak.

Malt-O-Meal Salmonella Outbreak - An Update

In 1998, Malt-O-Meal Toasted Oats cereal sickened more than 200 individuals in 11 US states. That cereal, which was contaminated with Salmonella Agona, was manufactured in the company's Northfield, MN plant (Omaha World - Herald. Jun 5, 1998). The source of the contamination was never found.

On April 5th, Malt-O-Meal recalled all of its unsweetened Puffed Rice and unsweetened Puffed Wheat cereals after finding Salmonella in a sample of product that was manufactured on March 24th. The cereals were produced in the company's Northfield, MN facility and the contaminant was Salmonella Agona. The genetic fingerprint of this strain appears to be the same as the 1998 strain.

As of yesterday, state health officials, working with CDC and FDA investigators, have identified 21 individuals in 13 states who have been infected with Salmonella Agona as a result of eating the recalled Puffed Rice and Puffed Wheat cereals. That total will almost certainly increase as the investigation continues.

This new outbreak raises some questions about Malt-O-Meal, its quality assurance programs, and FDA follow-up inspections as the Northfield plant in the years after the 1998 outbreak.

• Was Malt-O-Meal sampling its production environment regularly for Salmonella? The Malt-O-Meal recall notice stated that Salmonella was found in a sample of product. Finding Salmonella in finished product is at least as difficult as finding a needle in an entire field of hay. If the microbe has been lurking in and around the plant for 10 years, it should have been found as a result of routine sampling of the plant environment (production lines, drains, air intake vents, etc.).
• Has Malt-O-Meal ever found Salmonella in its Northfield production environment since it re-started operations after the 1998 outbreak? If so, what did management do about the finding?
• What testing methods was Malt-O-Meal using to look for Salmonella? The choice of methods and sample size makes an enormous difference to the chances of finding the microbe.
• Why has the recall been limited to just the Puffed Rice and Puffed Wheat? Are these the only cereals manufactured in the Northfield plant?
• How often and how thoroughly did FDA inspect the Northfield plant in the years after the 1998 outbreak?

I'll be watching for answers to these questions as further details become available.

Breakfast Cereal Salmonella Outbreak Puffs Up

According to a news release issued late today by the Minnesota Department of Health, the number of Salmonella Agona cases linked to Malt-O-Meal's Puffed Rice and Puffed Wheat has grown to 21 illnesses in 13 states – including one case in Minnesota.

In case you missed the beginning of the story, Malt-O-Meal announced a recall of its unsweetened Puffed Rice and unsweetened Puffed Wheat cereals on April 5th, after finding Salmonella in a product sample. At the time of their announcement, the company was unaware of any illnesses associated with the products. But that situation has changed as state health officials, together with CDC, continue their review of past reports of Salmonella illnesses.

The specific strain of Salmonella Agona that is responsible for the present outbreak has the same fingerprint as the one associated with Malt-O-Meal's 1998 Salmonella outbreak and recall. In that earlier outbreak, 209 people became ill after eating Salmonella-contaminated Toasted Oats cereal produced by Malt-O-Meal. The source of the contamination was never found.

The evolution of this story is somewhat atypical. Usually, health officials first realize that an outbreak of food-borne disease is in progress when they notice a spike in the number of cases due to a specific microbe, and they begin their search for the cause. This time, they are tracing the outbreak in the other direction – from the food to the victims.

Have We Taken The Wrong Fork In The Road To Food Safety?

Yesterday, the CDC released its annual preliminary FoodNet report on the incidence of food-borne diseases. The agency concluded that reported food-borne illnesses in the United States, which had decreased annually until 2004, has plateaued. In fact, illnesses due to Cryptosporidium actually increased by 44% in 2007.

In 1999, researchers at CDC published their estimates of the overall incidence of food-borne disease in the US population. They examined available statistics on reported illnesses and calculated (based on the proportion of illness that are actually reported) that the annual toll of food-borne diseases was approximately 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths.

The 76 million illnesses, when divided by the US population at the time of the study of approximately 270 million, equated to about 28% of the population – more than one person in four.

The United States is not alone in experiencing this high rate of food-borne disease. As I pointed out last fall in Lies, Damn Lies and Statistics, both Canada and the UK suffer from similar levels of disease.

Even without knowing the true incidence of food-borne illness, consumers can often sense that there is something rotten in the food supply. A third of Australians surveyed by Food Standards Australia and New Zealand believed that they had suffered from food poisoning in the previous year.

New Zealanders are even more aware of their tummies. A survey of 3,500 New Zealanders, published last month in the New Zealand Weekend Herald, determined that 9% of those surveyed had experienced a bout of diarrhea or vomiting in the four weeks prior to the survey. That translates to 4.6 million bouts of illness a year – in a country of fewer than 4.3 million people. The New Zealand survey didn't distinguish between food-borne and water-borne disease.

It's easy to think of food-borne disease as a Third World phenomenon. But it's clearly just as prevalent in the "developed" world. And it will remain a serious problem until we retrace our steps back to that fork in the road and choose a better path to achieving a safer food and water supply.

Malt-O-Meal Déja Vu

According to a news release just issued by the Oregon Department of Human Services, Malt-O-Meal cereal has been identified as the source of a multi-state Salmonella outbreak. Most of the cases appear to be concentrated in the east.

Notwithstanding the manufacturer's earlier assurances that it had found the source of the problem and had corrected it, the Company has suspended production at its Northfield, MN facility "pending further investigation."

The Oregon news release reports that the strain of Salmonella responsible for the current outbreak appears to be very similar to the one that caused the 1998 Malt-O-Meal outbreak. Both outbreak strains are Salmonella Agona and both have the same molecular marker.

This could mean that we are in for a fairly severe outbreak. In the 1998 incident, 47 out of 209 victims were ill enough to need hospitalization. Two of the three cases being investigated so far in Maine resulted in hospital admission. On the plus side, maybe investigators will finally discover and eliminate the source of the contamination.

If you have eaten unsweetened Puffed Rice or Puffed Wheat cereal and are experiencing severe diarrhea or diarrhea with fever, please consult your doctor. And be sure that your illness is reported to the appropriate health authorities.