Cyclospora Lawyer & Attorney : Marler Clark : Cyclospora Blog

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April 18, 2006- Incidents of many foodborne illness have declined since statistical collection began in 1996, with rates for some of the most common pathogens falling by up to 32 per cent.

However Listeria infection rates have started to climb again, according to preliminary data published by the federally-funded Foodborne Diseases Active Surveillance Network (FoodNet).

The declines could indicate that efforts by regulatory agencies and by manufacturers are working to combat common foodborne pathogens. Concerns about the safety of the food supply have led to increased regulatory action to cut down the number of illnesses and death caused by pathogens.

FoodNet's data show rates of illnesses caused by Listeria decreased 32 per cent, Campylobacter decreased by 30 per cent, E. coli O157 by 29 per cent and Salmonella by nine per cent in the period to 2005. The data was collected from 10 states, representing about 15 per cent of the US population.

Incidence of infections caused by Campylobacter, Listeria, Salmonella, toxin-producing Escherichia coli O157 (STEC O157), Shigella, and Yersinia has declined, and Campylobacter and Listeria incidences are approaching levels targeted by federal health agencies, the agency concluded.

"Several important food safety initiatives might have contributed to the declines, indicating progress toward meeting the national health objectives," FoodNet stated.

However, most of the declines occurred before 2005, and Vibrio infections have increased, indicating that further measures are needed to prevent foodborne illness, the research unit warned.

Most of the decline in Campylobacter incidence occurred by 2001, with continued small decreases since then. The incidence of Listeria infections in 2005 is higher than its lowest point in 2002. The incidence rate for Listeria infections in 2005 is higher than its lowest point in 2002.

Of the five most common Salmonella serotypes, only Typhimurium has declined, with most of the decline occurring by 2001. Most of the decline in STEC O157 incidences occurred during 2003 and 2004.

The observed sustained increase in Vibrio incidence indicates that additional efforts are needed to prevent Vibrio infections. Oysters are the most important source of human Vibrio infections. Measures that reduce Vibrio contamination of oysters also prevent illness.

FoodNet calculated the rates by comparing data collected in 2005 to the baseline years of 1996 to 1998.

In commenting on the estimates the American Meat Institute (AMI) noted other government figures indicated that the incidence of bacteria on meat and poultry products has also decreased significantly. The incidence of E. coli O157:H7 in ground beef samples tested by USDA has declined by 80 per cent since 1999.

Meanwhile the incidence of Salmonella in ground beef has declined 75 per cent since 1998. The incidence of Listeria monocytogenes on ready-to-eat meat and poultry has declined from 4.5 per cent in 1990 to 0.55 per cent in 2004, the AMI stated.

"These declines in foodborne illness continues to validate the efforts throughout the industry and government to reduce the incidence of foodborne pathogens on meat and poultry products and keep US meat products among the safest in the world," said Patrick Boyle, chief executive and president of the organisation.

In 2005, a total of 16,614 laboratory-confirmed cases of infections were reported to FoodNet in the 10 US states surveyed. Salmonella accounted for 6,471 cases, Campylobacter 5,655 cases, Shigella 2,078 cases, Cryptosporidium 1,313 cases, STEC O157 473 cases, Yersinia 159 cases, STEC non-O157 146 cases, Listeria 135 cases, Vibrio 119 cases and Cyclospora 65 cases.

Overall incidence per 100,000 population was 14.55 for Salmonella, 12.72 for Campylobacter, 4.67 for Shigella, 2.95 for Cryptosporidium, 1.06 for STEC O157, 0.36 for Yersinia, 0.33 for STEC non-O157, 0.30 for Listeria, 0.27 for Vibrio, and 0.15 for Cyclospora.

The Foodborne Diseases Active Surveillance Network (FoodNet) of the Centers for Disease Control and Prevention collects data from 10 US states relating to diseases caused by enteric pathogens transmitted commonly through food.

FoodNet estimates that each year Salmonella infection accounts for 1.4 million cases of illness in the US, 15,000 hospitalizations and 400 deaths. In a separate study, FoodNet estimated that 76 million cases of foodborne disease occur each year in the US.

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On April 28, 2005, the Florida Department of Health announced the ongoing investigation of an upsurge of Florida residents ill with Cyclospora. Over the course of several weeks, Florida residents had complained of intermittent or persistent diarrhea, loss of appetite, substantial weight loss, bloating, increased gas, stomach cramps, nausea, vomiting, muscle aches, low-grade fever, and fatigue.

Over the course of the next weeks and months, Health Departments, including Sarasota County, worked to locate the cause of the outbreak. Sarasota County focused on the Beanstalk restaurant as the most likely source given the number of ill reporting having eaten there in the incubation period of this intestine burrowing parasite.

According to the Florida Division of Environmental Health, Food and Waterborne Disease Program, the Bean Stalk restaurant was on of two restaurants implicated in Sarasota County. The Bean Stalk was described in a presentation by Roberta Hammond, PhD as "Sarasota #1 - independent restaurant/caterer to several offices" - including Mediserve. Ultimately, ninety one cases were confirmed as having been sourced from the Bean Stalk restaurant.

Due in part due to outbreaks in Canada of Cyclospora illnesses linked to Florida, the Federal Food and Drug Administration (FDA) launched a product "trace-back." This trace-back eventually implicated Country Home SA, Fundo Los Azahares, a manufacturer/shipper in Peru with the sale of contaminated "basil, fresh shredded mixed vegetables for salads and mesculin lettuce."

The reason given for the FDA Alert was:

Fresh (raw) basil was implicated by an investigation of outbreaks of cyclosporiasis infection with the parasite Cyclospora cayetanensis that occurred in the spring of 2005, in multiple counties in Florida. FDA determined that the source of the implicated basil was Country Home, S.A., located in Huaral, Peru. In addition, FDA identified Country Home, S.A. as a possible source of mixed lettuce, called spring mix or mesclun that was implicated by investigations of two outbreaks of cyclosporiasis that occurred in 1997.

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Frequently Asked Questions

Q. What is infectious diarrhea?

A. Infectious diarrhea is an alteration of normal bowel habits, usually characterized by increased stool frequency and liquid consistency, which is caused by infectious bacteria, viruses or protozoa that infect the intestinal tracts of humans and animals. The infectious organisms are normally contracted by ingestion of contaminated water or food. Some of the more well-known organisms causing infectious diarrhea include Campylobacter, enterotoxigenic or Shiga toxin-producing E. coli, Salmonella, Shigella, Clostridium, Cryptosporidium, Giardia, Cyclospora and rotavirus.

Q. How common are infectious diarrheal diseases?

A. Infectious diarrheal diseases are the second leading cause of morbidity and mortality worldwide. There are 3.1 million deaths worldwide due to diarrhea per year (more than 8,400 per day), mostly among children in developing areas. In the United States, an estimated 211-- 357 million episodes of diarrheal illness occur each year resulting in 73 million physician consultations, 1.8 million hospitalizations and 3,100 deaths. The CDC issued a new study November 22, 2002 reporting that outbreaks of waterborne illnesses roughly doubled in the U.S. in a three-year period ending in 2000. Studies have shown that approximately 20 percent of children in the United States are exposed to Cryptosporidium by age 5-7 years. Approximately 9% of all hospitalizations of children younger than 5 years are due to diarrhea

Q. How do diarrheal illnesses affect those suffering from the infection?

A. Most cases of infectious diarrhea are self-limiting in nature resolving spontaneously after a few days. Acute cases of infectious diarrhea can, however, lead to dehydration and even death. Persistent or chronic diarrhea often associated with intestinal protozoan infections can also cause serious long-term consequences, including malnutrition and impairment of physical or cognitive development.

Q. Who is most at-risk of contracting infectious diarrhea?

A. Anyone who is exposed to the causative organism is susceptible to contracting infectious diarrhea. Young children, the elderly and people with weakened immune systems however, are particularly susceptible to infection with a variety of different pathogens and often are more likely to develop illness of greater severity.

Q. Is there a way to prevent or control exposure to these infections?

A. The risk of contracting infectious diarrheal diseases can be reduced by improved sanitary conditions, but they are very difficult to prevent. Efforts to guarantee clean water supplies and food have been successful in reducing the prevalence of infectious diarrhea in developed countries. Still, these organisms cause millions of cases of infectious diarrhea in the United States each year.

Q. What can be done to treat infectious diarrhea?

A. The first step in treating diarrhea of any origin is to initiate rehydration therapy, orally or intravenously if necessary. Then, a diagnosis of the causative organism should be made, and where appropriate, antimicrobial therapy should be administered to reduce the duration of diarrhea and prevent potential long-term consequences of the infection. The lack of a specific diagnosis is the most significant obstacle hindering appropriate management and treatment of many infections. For diarrhea lasting more than 7 days, standards of care call for consideration of Cryptosporidium or Giardia infection, especially if the patient is immunocompromised.

Q. Why is it difficult to determine the specific cause of infectious diarrhea?

A. Specific diagnosis of the cause of infectious diarrhea requires the collection of fecal samples (often 2 or 3 samples collected on consecutive days) for microscopic examination or cultures to grow bacteria. The time required to conduct these fecal tests can delay treatment of the patient for several days, and the accuracy of the tests is less than optimal. As a result, many physicians view fecal tests as an unnecessary expense and inconvenience, particularly if the physician believes the infection will ultimately resolve spontaneously. In such cases, the physician either treats empirically with an antimicrobial agent or recommends rehydration therapy until the infection resolves spontaneously.

By questioning a patient about his symptoms and epidemiological risks, a physician can obtain clues that might lead him to suspect a particular infection. Factors suggestive of a particular infection might include recent consumption of unsafe foods, daycare center attendance or employment, swimming in lakes or streams, contact with animals with diarrhea, recent use of certain medications, recent hospitalization, travel to a developing country, blood in the stool, fever, the duration of diarrhea and associated symptoms.

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Friday June 03, 2005 8:53pm

TALLAHASSEE, Fla. (AP) - Contaminated fresh basil is suspected as the most likely cause of an outbreak of the parasitic illness cyclospora that has sickened 300 Floridians, state health officials said Friday. Officials don't know where the basil came from, or where it is being sold, said state Health Secretary John O. Agwunobi.

A spokesman for the Health Department said the federal Food and Drug Administration has agreed to try to trace the product and find out where it came from.

The disease isn't fatal, but can cause severe diarrhea and other painful symptoms.

Cases have been reported in 32 Florida counties in all regions of the state going back to April.

Health officials say people should wash fresh produce to prevent food-borne illnesses, but say that washing may not prevent cyclospora infection.

Cyclospora are microscopic, one-celled organisms that can contaminate fresh produce and burrow in the small intestine.

The illness can be treated with antibiotics or could pass naturally within a period of a few days up to a month.

On the Net:

Florida Department of Health: http://www.doh.state.fl.us/

Federal CDC (website - news) cyclospora page: http://www.cdc.gov/ncidod/dpd/parasites/cyclospora/default.htm

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When diners become ill and blame something they ate, state experts start sleuthing. They interview the victims, conduct food lineups and try to narrow down the suspects.

By Scott Joseph
Sentinel Restaurant Critic
July 20, 2005

Sometimes people think it's just a touch of the flu, a 24-hour bug. Upset stomach, cramps and diarrhea might be some of the discomforts they experience. But on occasion, these are actually indicators of a food-borne illness, and, for epidemiologists such as Dean Bodager, they aren't symptoms, they're clues.

Whenever there is an outbreak of food-borne illnesses, it falls to Bodager and other members of the Florida Department of Health to track down the source. Sometimes it's simple. Most outbreaks occur at the point of preparation -- a restaurant employee who didn't wash his or her hands properly, food that wasn't kept at the correct temperature to prevent bacteria growth, or some sort of cross-contamination.

But sometimes it's more difficult, such as when health officials learn of people who have fallen ill but did not eat at the same restaurant or buy food from the same market. That's when the epidemiologists have to become detectives, interviewing those who have been ill, dissecting their meals and eliminating suspects to find a common thread and, ultimately, the source.

Think of it as CSI: Food.

But unlike the forensic investigations on the CBS franchise "crime scene investigation" series, Bodager says, "It doesn't happen in one hour, and it doesn't happen in seven-minute segments."

Indeed, an investigation has been under way statewide since April involving an outbreak of cyclospora, an uncommon parasite that can be spread through food and water. There are 335 lab-confirmed cases in 35 counties throughout Florida. Cyclospora, which generally causes intense diarrhea and, as a result, weight loss, is completely treatable with antibiotics. There have been no new infections since May 29. The federal Food and Drug Administration is now involved in the tracking.

Although investigators have not yet zeroed in on the source of the contamination, they think they have the culprit, the vehicle that carried the pathogen: basil.

How the epidemiologists were able to narrow their search to a single ingredient, one that held a parasite that typically can take up to a week to make a person ill, is as intriguing as any network crime show.

Precise questions

It takes only two complaints of a suspected food-borne illness to launch Bodager and his colleagues into action. Two cases with a common association with a place or a product in time.

"In other words," says Bodager, "if we got a call, and someone said they were in XYZ restaurant, and, if someone else said the same thing, that would prompt us to do an investigation."

But, in a perverse sort of way, the more cases the better. A larger sample can help investigators pinpoint the source. But remember a lot of victims may not even know that their illness is the result of something they ate. So the health department might make phone calls, send faxes or e-mail alerts to health-care providers whose patients have complained of illness and hospital labs whose technicians may be seeing a pattern of infection.

Catherine Harwood of Merritt Island had to insist that her doctor test her for cyclospora. She and her husband, Bill, became sick several days after a rare dinner out at a Brevard County restaurant with their two small children, who were not affected.

Harwood, a former reporter for a Palm Beach television station and now a stay-at-home mom, suspected cyclospora because she had covered another widespread outbreak in the late '90s, one that involved raspberries. Still, it didn't dawn on her that it was the same parasite until a friend mentioned seeing a report about a new outbreak of infections. Coincidentally, she had an appointment with her family doctor that same day. She says her doctor was reluctant to test her for cyclospora but she persuaded him.

An epidemiologist from the Brevard County office of the state health department, who had been alerted with the test results from the lab, called her with the test results before her doctor's office could contact her. Just like any television detective, he had a few questions he wanted to ask.

Bodager says the questions investigators ask are carefully tailored to the specific type of infection. Bacteria have different profiles and each takes a specific length of time to cause illness. Hepatitis takes about 30 days, E. coli three to five days, salmonella poisoning one to three, sometimes five, days. Cyclospora can take up to a week and a half. By knowing the type of parasite or bacteria and when the person got ill, investigators know what period of time to look at to determine the point of infection.

But most people have a hard time remembering what they had for breakfast the same day. Getting someone to remember what they ate a couple of weeks ago takes patience and precision questioning.

"The best are those in a special occasion, like a wedding," says Bodager. But, barring something apparent, he tries to take them back by putting a calendar in front of them or going through credit-card receipts with them. A menu from a restaurant is a handy visual for prodding the memory, and sometimes investigators will use photos of foods, a sort of culinary lineup.

The bruschetta! That's it!

For Harwood, her visit to a restaurant was like a special occasion because her family rarely goes out to eat. And with two young children, she says her home meals feature a lot of frozen foods or prepared dinners. She was certain it was the restaurant meal. Her kids did not get sick, she says, because they did not eat the same things she and her husband had. Further, she was convinced she had digested the parasite from the salad because it was the only thing she could think of that would have included uncooked foods.

She had forgotten about the bruschetta until the investigator dug deeper.

Often served as an appetizer, bruschetta features slices of toasted bread topped with a mixture of chopped tomatoes and garlic . . . and basil.

For other victims who dine out more often, Bodager says, more rooting is needed. The protocol is to establish a three-day food history.

"We're going to ask them what we call exposure variables," he says. "We ask about their food: What kinds of foods did you eat, when did you eat them, who did you eat them with?" Even the time the food was consumed might be important.

Some questions may involve nonfood exposures, such as with other infected humans or with animals, as was the case with the recent outbreak of E. coli from a children's petting zoo.

But the search for the source of a food-borne illness might take a widespread dragnet. Produce, seafood and meats are shipped from throughout the world, and, as Bodager says, "It can be contaminated anywhere from the farm to the fork."

But just as important as talking with anyone who is ill or experienced symptoms is the questioning of those who were in the same place and ate the same foods but who didn't get sick.

Bodager says if you have an outbreak and you talk to 10 sick people who ate strawberries you might start to think strawberries are the cause. But then if you talk to 10 others who also ate strawberries but didn't get sick, you may be looking at the wrong suspect.

It's fairly easy to find those who are ill because they often present themselves to a healthcare provider or call the health department directly with a complaint. No one calls to report they are fine.

So the investigators have to do more detective work, which might include obtaining the credit-card receipts for a restaurant and calling the patrons. That can get you some well people, but it can also lead to more cases of people with the infection.

Often, says Bodager, they will call someone to say they're investigating an outbreak of food-borne illnesses and the person on the phone will ask, "How did you know I was sick?"

Just good detective work.

Scott Joseph can be reached
at sjoseph@orlandosentinel.com
or 407-420-5514.

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By Thomas Caywood
Tuesday, July 19, 2005

Boston public health officials are probing an intestinal parasite outbreak at a swanky Back Bay private club.

A handful of people attending a dinner lecture at the exclusive Chilton Club on Commonwealth Avenue in April were infected with cyclospora, a nasty bug that causes severe diarrhea, cramping and vomiting. Cyclospora is spread when people eat food or drink water that has come in contact with infected feces.

The Boston Public Health Commission found out about the outbreak in May and has been tracking down all the club members and guests who attended the dinner lecture to determine exactly how many got sick, spokesman Tom Lyons said.

``We believe this is a food borne illness at this point,'' Lyons said. ``Produce and berries can sometimes be the way people get this infection.''

The tony Chilton Club, named for Mayflower passenger Mary Chilton, is a stop on the Boston Women's Heritage Trail. The club was founded in 1910 by a group of women who chafed at the restrictions placed on women by the exclusive men's clubs of the day, according to the trail's Web site.

General manager Robert Wood couldn't be reached for comment yesterday. A person familiar with the situation said more than a dozen club members, guests and employees got sick.

Lyons said the number of cyclospora cases nationally has been increasing, but such outbreaks remain rare in the United States. He said there's no risk to the general public and likely no longer any risk to club members.

``We haven't completely locked down what the source was, but we believe the source was food mostly because everyone that was ill came from that one event,'' Lyons said.

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7/01/2005
High number of cases cited of parasite that causes persistent diarrhea
EDWARD J. CROWDER, ecrowder@ctpost.com
Connecticut Post

Health officials are on the lookout for a nasty food-borne bug that causes persistent diarrhea after eight cases turned up over the last week in New Haven County.

The state Department of Public Health is asking doctors to be on the lookout for symptoms of the parasitic infection, known as cyclosporiasis.

All of the cases were identified since June 22, state officials said. Normally, the whole state gets just four cases in a year.

"We assume there are others and we're looking for them," said Dr. Matthew L. Cartter, coordinator of the department's Epidemiology and Emerging Infectious Diseases Program.

Cartter said the cases were found in half a dozen communities, but declined to say which ones. The department Wednesday alerted local health departments and doctors of the outbreak. As additional cases are diagnosed, Cartter said, it will help health officials trace the source of the outbreak.

Cyclosporiasis is caused by the cyclospora bacterium, a parasite that infects the small intestine and is spread by contaminated produce.

Victims typically suffer persistent or on-and-off watery diarrhea ó sometimes explosive ó that can last weeks if it's not treated with antibiotics. Other symptoms include bloating, stomach cramps, aches and low-grade fever.

In severe cases, the diarrhea can lead to dehydration or malnutrition, health officials said.

The state health department asked doctors to keep cyclosporiasis in mind as they diagnose patients with typical symptoms.

Cyclosporiasis can be identified in the laboratory by testing stool samples, but most labs look for it only if they're specifically asked.

"This might not be something that a doctor thinks of, but if they think of it then they can test for this," Cartter said.

The first known cases of cyclosporiasis were reported in 1979 and there have been sporadic outbreaks since.

An outbreak in Florida earlier this year sickened nearly 300; public health officials suspected a batch of fresh basil.

According to the U.S. Centers for Disease Control and Prevention, cyclosporiasis is spread through food or water infected with contaminated stool.

However, according to the CDC it's probably not passed directly from person to person ó for example, from someone who didn't wash after using the bathroom ó because it takes the germs several days to become infectious after being passed in a bowel movement.

"It's not something that's passed person to person; this is something that's going to be passed by something you eat," agreed Dr. Joanne Passalacqua of St. Vincent's Medical Center's Division of Infectious Diseases in Bridgeport.

"You make sure that the foods that you eat, particularly fresh produce ó fruits and vegetables ó is thoroughly washed before consuming it."

Several hospital and local health department officials did not return calls late Thursday afternoon.

A spokesman for Yale-New Haven Hospital, after consulting with an epidemiology expert there, said the hospital has not seen "many" cyclosporiasis infections recently, but could not immediately elaborate.

According to Cartter, the widespread importation of produce has introduced public health challenges not faced by generations past.

"Certainly, how food is distributed today is very different than 25 or 30 years ago, and that is probably a component not just for [the spread of] cyclospora but for other food-borne illnesses as well," he said.

Public health authorities offer the following advice (some of it painfully obvious) to avoid contracting cyclosporiasis:

l wash fruits and vegetables before eating them.

l avoid drinking untreated water from lakes, streams, springs or other untreated sources.

l avoid touching human or animal feces.

l wash hands after using the toilet, after changing diapers and before handling food or eating.

Edward J. Crowder, who covers regional issues, can be reached at 330-6326.

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By Carole Sugarman

My daughter never met a chicken tender she didn't like. But during a recent family vacation in Florida, 9-year-old Anna was struck with a bad case of salmonellosis -- disease caused by salmonella. And while we'll never know for sure, we strongly suspect it was caused by contaminated, undercooked poultry at one of her daily restaurant chicken meals.

There is more than a little irony in this tale of excruciating stomach pains, bathroom vigils and hospital emergency rooms.

As a food writer for 25 years, I've interviewed numerous victims of food-borne diseases and parents of children who've died from them. I've attended scores of conferences and hearings where food safety issues are debated among government officials, industry and activist groups.

But this was the first time I got to see firsthand how devastating full-blown food-borne illness can be. Believe me, we're not talking about a bad tummy ache.

And while the experience illuminated many of the food safety issues that I have long covered, I was still surprised and overwhelmed by Anna's illness. Surprised at the nonchalant attitude of doctors toward food-borne disease and the uneven follow-through of the public health system. Surprised at the gap between the bureaucratic rhetoric and the reality of the problem. And overwhelmed by a very sick daughter, whose condition she accurately described as "having my butt on full blast."

The Centers for Disease Control and Prevention (CDC) estimates that there are 76 million cases of food-borne illness a year in the United States. (We're dealing here only with sickness caused by a bacteria or virus in a contaminated food. The CDC estimate does not include the untold millions of upset stomachs caused by overeating, rich foods and such that many people mistake for food-borne illness.) The problem sends nearly 325,000 people a year to the hospital; 5,000 a year die from it. The young, the old and the immune-compromised are hit hardest.

Some progress is being made, however. In April, when Anna was home sick, the CDC announced its latest food-borne diseases surveillance figures -- a story I (ironically) had to cover.

The good news: Infections caused by five hard-to-spell bacteria -- E. coli O157:H7, campylobacter, cryptosporidium, listeria and yersinia -- underwent significant declines in 2004, compared with 1996-1998. The bad news: Salmonella infections showed the smallest decline. Of 15,806 laboratory-diagnosed cases of food-borne infections from the 10 states under CDC surveillance, more cases -- 6,464 -- were from salmonella than any other bug.

In what may be the most surreal exchange of my career, I asked Agriculture Secretary Mike Johanns during a telephone press conference why there hadn't been more progress made in combating salmonellosis -- and what the U.S. Department of Agriculture (USDA) planned to do about it. Johanns passed the question to another USDA official, who said that the agency was committed to developing policies to address the problem. Somehow, with my salmonella-infected daughter groaning in the next room, I didn't find this answer adequate.

Even CDC surveillance data don't get at the real scope of the problem. Most food-borne infections go undiagnosed and unreported because many sick people don't seek attention. Of those who do, many are not tested. In the case of salmonellosis, the CDC estimates that 38 cases occur for every one that's actually reported.

I can certainly see why.

When we brought Anna to the hospital with severe stomach pains, diarrhea and dehydration, the doctor -- who seemed intent on diagnosing appendicitis -- ordered a sonogram, an X-ray and finally a CT (computed tomography) scan, which shows the most detailed images. But a stool culture -- the standard diagnostic test for food-borne illness and a cinch to collect while your child is perennially on the pot -- was not even mentioned, even though frequent diarrhea and stomach pains are hallmarks of the illness.

While it was prudent to rule out appendicitis, you might think food poisoning would have been high on the list of next suspects. But my requests for a culture were ignored.

The second doctor on duty finally agreed to take a stool sample, but said she doubted the problem was linked to anything Anna had eaten. She said that Anna probably had a gastrointestinal virus -- like the other five kids in the ER that night. I don't know how many (if any) of them were tested for a food-borne infection.

Patricia Griffin, chief of the food-borne disease branch of the CDC, said that an emergency room physician recently told her that she doesn't take stool cultures anymore since the results generally don't come back for a couple of days -- after the patient has been discharged. Plus, she said, a positive result wouldn't affect treatment: Although the type and severity of food-borne disease determines the specific therapy, many infections are not treated with antibiotics or anti-diarrhea medications. That's because antibiotics can complicate the condition and possibly lead to drug resistance, and anti-diarrheals keep the disease-causing bacteria in the system rather than help get it out. Since in many cases, there's no treatment other than keeping hydrated, doctors may figure it's fruitless to take a culture. "In their minds, they're not going to do anything different," Griffin said.

But there are good public health arguments for testing for food-borne disease.

"It's hard to talk about it in our society, which is so focused on health care for the individual person," said Griffin. "But from the societal point of view, that's the way we find outbreaks. It's the main way we find things wrong with our food system."

Although state procedures vary somewhat, the basic protocol for responding to a suspected food-borne illness is this: If a stool sample tests positive for food-borne bacteria, the results are supposed to be reported to the state, which then alerts the CDC. The hospital or private lab is urged to send a sample of the bacteria to the state, which does further testing to determine the serotype -- the specific strain of the bacteria identified. Knowing the serotype may help identify the food that caused the problem, since certain serotypes are more common to specific foods. Monitoring serotypes also helps the CDC keep tabs on which strains are increasing in prevalence and which are decreasing.

The state labs may also take a genetic fingerprint of the bacteria and enter it into a CDC database, to see if there are any matches. Since food processors distribute their food nationwide, people in Maine and California could get sick from the same firm's hamburgers. DNA matches could help spot outbreaks and stop them from spreading.

In my daughter's case, the state never received her bacteria sample from the hospital, so her salmonella was never serotyped, and a genetic fingerprint was never sent to the CDC. I know this from Holly Conners, a nurse with the epidemiology and surveillance branch of the Montgomery County Health Department and the bright light of this whole ordeal. Conners ran interference for me to get this information, as I learned that protocol and privacy acts make it difficult to get it yourself -- even when it's your own kid.

All we know from the lab report is that Anna had salmonella Group D, which consists of nearly 200 strains, but that it was not the kind that can lead to typhoid fever.

Figuring out what made an individual person get sick often is impossible. "Sometimes you can, sometimes you can't," said Donna Rosenbaum, a food safety consultant and the first executive director of Safe Tables Our Priority (STOP), an advocacy group for victims of food-borne disease. "Occasionally you get lucky."

Sometimes, too much time has elapsed to find evidence, such as a suspect food item or a food service worker who failed to wash hands or follow sanitary procedures. When a lot of people at a wedding reception or restaurant get sick, the chances are greater that a link will be uncovered. But what are the chances that one cooking error or contaminated turkey sandwich will ever be tracked down?

Trying to piece the puzzle together yourself can become practically a full-time job. All while your child is screaming her head off on the toilet.

It took five days after my daughter got sick in Florida for her to be diagnosed with salmonellosis. (By that time she'd been flown back to Maryland and was hospitalized.) Then it took another day to reconstruct exactly what she ate during our week-long vacation, and where she ate it.

While we will never be sure of the meal that did it, several factors point to the chicken tenders Anna ate in a restaurant 10 hours before she made her first beeline to the bathroom.

For one, when we told her that she probably got sick from something she ate, she immediately said, "I know where." With no prompting, she told us that parts of the chicken tenders tasted cold and hard. For another, it seemed obvious that the busy restaurant had a doneness problem: My fish was dry and overcooked. When I called the restaurant to inquire further into the situation, the owner said he believed the tenders were purchased partially cooked and frozen. Perhaps, I suggested, the fry cook didn't fully cook them? If the tenders were contaminated with salmonella, undercooking them might not kill the bacteria.

The restaurant owner, who appeared to listen sympathetically, told me he would check with the kitchen staff and get back to me. He never did. Concerned about the possibility of further illnesses, I reported the restaurant to the Florida authorities -- the county department of business regulation, not the health department.

It took three weeks and lots of follow-up calls to confirm that an inspector had been dispatched to the restaurant. By then, of course, none of the implicated food was available. But I was told that the inspector found no refrigeration or cooking temperature violations, no sick employees who could have transmitted the infection, and no other reported food-borne illnesses from the day we ate there.

"It's tough to catch these things," a state official told me.

I am happy to report that after missing two full weeks of school and spending several weeks on the BRAT diet (bananas, rice, applesauce and toast), Anna is fully recovered. She isn't squeamish about eating at restaurants, but sometimes asks me to examine her food to make sure it's fully cooked. At home, she has the opposite concern, berating me for cooking her chicken and hamburgers to death. But Anna has definitely broadened her dining-out repertoire. Now she mostly orders grilled cheese.

Carole Sugarman, a former Washington Post food reporter, now covers the Agriculture Department for Food Chemical News.

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Breaking News on Food Development in the US

08/06/2005 - Fresh basil, the most probable source of an outbreak of gastrointestinal illness in Florida earlier this year, is now the target of an FDA traceback operation, writes Anthony Fletcher.

The US Food and Drug Administration (FDA) is determined to identify the source of several clusters of gastrointestinal illness known as cyclosporiasis that occurred in the state during mid-March through mid-April.
The investigation began last week after the Florida Department of Health's epidemiological investigation implicated fresh basil as the source of the illness. Most cases were reported on the west coast and central areas.

"FDA is aggressively working with our federal and state partners to determine the source of the contaminated product and taking appropriate action to protect the public," said Dr. Robert Brackett, director of the FDA's Center for Food Safety and Applied Nutrition.

It is not known how this outbreak will effect Florida's burgeoning basil sector. There has been a dramatic increase in herb production in Florida in the last decade, from virtually none in 1991 to nearly 17 acres by 2001.

Herbs now rank third in greenhouse food crops, accounting for 18 percent of the state's greenhouse acreage, with the major herb being basil. Fresh-cut herbs grown in Florida account for over $1 million in sales, and the demand for fresh-cut herbs is expected in increase in part due to health-conscious consumers and increasing consumption of ethnic cuisine.

The FDA has been swift in its implementation of traceback since the identification of basil as the probable source of the outbreak. Since the passage of the Public Health Security and Bioterrorism Preparedness Act, the agency has unprecedented authority over domestic and imported food products.

All food facilities are required to register with the FDA. In addition, the FDA requires all food facilities to maintain records to allow the agency to identify the immediate previous sources and the immediate subsequent recipients of food products.

The agency says that the speed at which these "one-step forward, one-step back" records can be accessed in case of potential food contamination is critical in diminishing the impact on consumers.

If companies are unable to trace and isolate the source of a possible food contamination problem within 24 to 48 hours, the potential of serious damage increases exponentially. The FDA is therefore determined to push through with great rapidity its traceback operation in Florida.

Cyclosporiasis is caused by the ingestion of the Cyclospora parasite and results in the infection of the small intestine. It causes watery diarrhea with frequent, sometimes explosive, bowel movements.

Other symptoms include loss of appetite, substantial weight loss, stomach cramps, nausea, vomiting, muscle aches, low-grade fever and fatigue. Symptoms usually develop about a week after consuming the contaminated food. Cyclospora infection can be treated with appropriate antibiotic therapy. Individuals experiencing these symptoms after consuming basil products are advised to consult their physicians and notify their local health departments.

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June 4, 2005

TALLAHASSEE, Fla. - Contaminated fresh basil is suspected as the most likely cause of an outbreak of the parasitic illness cyclospora that has sickened 300 Floridians, state health officials said Friday.

Officials don't know where the basil came from, or where it is being sold, said state Health Secretary John O. Agwunobi.

A spokesman for the Health Department said the federal Food and Drug Administration has agreed to try to trace the product and find out where it came from.

The disease isn't fatal, but can cause severe diarrhea and other painful symptoms.

Cases have been reported in 32 Florida counties in all regions of the state going back to April.

Health officials say people should wash fresh produce to prevent food-borne illnesses, but say that washing may not prevent cyclospora infection.

Cyclospora are microscopic, one-celled organisms that can contaminate fresh produce and burrow in the small intestine.

The illness can be treated with antibiotics or could pass naturally within a period of a few days up to a month.

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