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Why Does CDC Implore Testing for E. coli O111?

Let me start with a story–a true one.  In August, 2008, a large number of people in Mayes County, Oklahoma, began flooding hospitals and physician offices complaining of profuse, bloody diarrhea accompanied by intense, stabbing abdominal pains.  Many of these individuals submitted stool samples that were sent to a lab, cultured, and grew a very dangerous and life-threatening pathogen, E. coli.  

The Oklahoma State Department of Health and the Mayes County Health Department investigated and concluded it was a foodborne point-source outbreak originating from a restaurant, Country Cottage, located in the town of Locust Grove, Oklahoma.  The foodborne transmission of the E. coli bacteria occurred between August 15 and August 24, 2008, and many of those who were unfortunate enough to have dined at the restaurant during this inopportune window became ill–314 known cases, 72 in-patient hospitalizations, and one death.  

Those figures represent just the known victims.  According to the Centers for Disease Control and Prevention (CDC), for every one culture-confirmed, health department-linked illness in an E. coli outbreak, there are approximately 20 additional people who were actually sickened in the outbreak, but for a host of reasons their illnesses are not reported.  Thus it is more accurate to list the number of victims for this outbreak as 6,280–huge.
 
Not only was this outbreak physically and emotionally devastating for those affected by it, but there was an incredible dollar cost as well.  For example, fourteen of the 314 victims in the Country Cottage E. coli outbreak amassed medical bills that cumulatively totaled over two million dollars.

Why am I telling you about this particular outbreak?  Because the bacteria that caused the calamitous results described above was E. coli O111, and, according to the United States Department of Agriculture’s (USDA) Food Safety and Inspection Service (FSIS), this strain of e. coli is NOT an adulterant.  

That’s right, according to the federal agency tasked with overseeing the safety of our nation’s supply of meat, poultry, and processed egg products, this particular strain of E. coli is not an “impurity” or “an additive causing an undesirable effect.”  Excuse me, but if death and permanent bodily injury directly caused by this nasty pathogen does not count as an “undesirable effect,” what does?

Please allow me to explain.  

Escherichia coli O111 belongs to a family of bacteria known as Shiga toxin-producing Escherichia coli (or STEC).  STEC infections are the leading cause of bacterial enteric infections in the United States.  According to the Morbidity and Mortality Weekly Report released by the Centers of Disease Control (CDC) on October 16, 2009, STEC infections cause approximately 100,000 illnesses, 3,000 hospitalizations, and 90 deaths annually in the US.  

The primary symptom of an STEC infection is acute diarrhea that is often bloody.  Further, approximately 8% of people diagnosed with E. coli infections develop a life-threatening condition called hemolytic uremic syndrome (HUS), the most common cause of acute kidney failure in infants and young children–leaving the mildly unlucky ones with future sequelae that may include hypertension, proteinuria, or low glomerular filtration rate.  The severely unlucky are left with long-term extra-renal damage, especially of the pancreas or brain, and severe kidney damage that requires chronic dialysis and future kidney transplant.

In the report, the CDC explicitly recognizes the multifarious significance of properly identifying STEC infections, highlighting that:

Prompt, accurate diagnosis of STEC infection is important because appropriate treatment early in the course of infection might decrease the risk for serious complications such as renal damage and improve overall patient outcome. In addition, prompt laboratory identification of STEC strains is essential for detecting new and emerging serotypes, for effective and timely outbreak responses and control measures, and for monitoring trends in disease epidemiology.

The primary focus of the CDC’s report and recommendations pertain to uniform STEC testing by clinical laboratories, including the recommendation that ALL patients presenting to medical facilities with acute diarrhea be routinely tested for both E. coli O157:H7 and non-O157 STEC.  Doing so would allow 1) identification of additional STEC infections and further detection of other STEC serotypes, 2) early diagnosis and an improved outcome for those infected, and 3) prompt outbreak detection by investigating health agencies.  The CDC recognizes the importance of these benefits, but apparently FSIS does not.

In 1994, following the infamous Jack in the Box E. coli O157:H7 outbreak that killed four children and injured another 700 individuals, FSIS acted boldly and appropriately by declaring E. coli O157:H7 to be an adulterant.  This was a significant policy shift for an agency that had not previously considered pathogens in raw meat and other products under its purview to be adulterants.  Once declared as an adulterant, FSIS had the authority to regulate the presence of this foreign pathogen in the various foods under its authority.

But since that time, despite countless scientific studies, and non-O157 STEC outbreaks and the related devastation they have caused, only one very particular serotype of the larger STEC family, E. coli O157:H7, is considered an adulterant by FSIS.  Declaring E. coli O157:H7 an adulterant while ignoring the more than 150 other STEC serotypes associated with outbreaks and illness is akin to releasing a seasonal flu vaccine that protects against only one influenza virus, while leaving out the other known circulating seasonal flu viruses that are equally as dangerous.  

In other words, it is not a complete waste of effort but certainly devoid of logic and purpose.  This illogical policy stance is especially true given the fact that FSIS went so far as to hold a public meeting in 2007 on the health significance of non-O157 STEC, and stated “growing awareness that STECs other than E. coli O157:H7 cause sporadic and outbreak-associated illnesses.” (emphasis added).

There is a simple truth being ignored by FSIS here:  non-O157 strains of E. coli can and frequently do produce devastating human illnesses that are on par with–or even more severe than–O157:H7 infections.  Declaring those non-O157 strains an adulterant is the only reasonable, thoughtful, and sane response to the growing chorus of voices seeking change.  I implore FSIS to face facts and take the regulatory steps necessary to significantly lessen the chances that yet another non-O157 E. coli outbreak occurs or goes undetected.

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