SEATTLE Two outbreaks of Escherichia coli O157:H7 traced to apples, one on each coast, has state and federal food and drug officials questioning the safety of all widely distributed fresh fruit juices, according to the Centers for Disease Control and Prevention (CDC).
An outbreak of E. coli O157:H7 in the Pacific Northwest resulted in 61 CDC-confirmed cases linked to unpasteurized apple juice manufactured by Odwalla Inc., based in Half Moon Bay, Calif.
The cases were reported in Washington (25), California (20), Colorado (5) and British Columbia (11). The ages of those infected ranged from 1 to 41 years of age, with a median age of 4½. Of these cases, 13 children developed hemolytic uremic syndrome (HUS), resulting in one death.
A 16-month-old Colorado child, who drank the manufacturer's apple juice, died from HUS, which officials suspect is related to E. coli O157:H7, but at press time the CDC tests were incomplete.
The CDC and the Food and Drug Administration (FDA) are investigating how the product became contaminated, as well as exactly how many people contracted the disease, said Tom Skinner, public affairs specialist for the CDC.
Odwalla built its reputation on selling fresh, unpasteurized juice as part of the fresh fruit juice craze, and markets products in seven states and British Columbia.
Investigators said Odwalla has a state-of-the-art facility and likely produced a single bad lot of apple juice, possibly the reason why only four of the eight localities where the juice is sold reported the illness.
The Odwalla plant was inspected by the FDA in July and showed no significant problems of any kind, said FDA spokesman Arthur Witmore.
"E. coli is a 'slippery organism.' It only takes a few microbes to reproduce under the right circumstances," Witmore said.
"The juice could've been contaminated through production, packaging or shipping. No one knows yet," Skinner added.
"The jury just isn't in yet (on the method of contamination)," said John Kobayashi, a senior epidemiologist with the Washington State Health Department. "There is no indication, so far, as to the method of contamination."
A similar outbreak in Massachusetts in 1991 was attributed to apple cider made from fallen apples that had been exposed to manure from cows and were not thoroughly washed or brushed.
The FDA has positively matched the contents of a recalled Odwalla juice bottle returned by a consumer with the DNA fingerprints from stools of confirmed E. coli patients, Witmore explained.
"We now have a direct link," he added.
Witmore said it would be weeks before a final decision on contamination is made, but the next step for the FDA is to begin with the Odwalla plant and continue the investigation in the orchards and with the suppliers, producers and packing houses.
"We are looking at everything," Witmore said. "We start at the plant and work our way out."
Taking into consideration the 1991 Massachusetts outbreak, paired with the recent outbreaks in Connecticut and the western states, Skinner said there are increasing concerns about unpasteurized juices.
"The whole issue of juice manufacturing is being looked at by the California State Health Department and FDA," according to Kobayashi. "A big part of the concern is related to this and many other cases that may go overlooked."
But, consumers must remember, Kobayashi added, "The two juice-related E. coli outbreaks which occurred are fairly uncommon considering the amount of juice consumed. It's important to keep all this in perspective."
Another outbreak occurred in Connecticut in October when 10 cases of E. coli were reported, three of which involved children. Although there have been no deaths, four cases of HUS were discovered. However, two patients hospitalized with HUS were not confirmed by culture for E. coli 0157:H7, but both had a history of drinking the same cider as the confirmed case patients.
"The investigation is still preliminary," said Matthew Cartter, MD, chief epidemiologist in the Connecticut State Department of Public Health. "The case numbers could still change."
The exact cause for this E. coli outbreak is still undetermined, but the improperly washed apples are suspected.
"This raises the question of what are the best ways to produce cider to contain the problem. It's a tradition in the New England area, so no one wants to see it disappear," Cartter said.
Cooking destroys the bacteria, Cartter said, but cider is generally not pasteurized.
"Cider is not sterile, so a potential for contamination exists," Cartter added. "It's probably occurred more often than we realize."
After the 1991 Massachusetts outbreak, an investigation published in the Journal of the American Medical Association (JAMA) uncovered that E. coli 0157:H7 organisms can survive in refrigerated unpreserved apple cider for up to 20 days. However, the addition of sodium benzoate reduced survival of the organisms to less than seven days.
The CDC and FDA were aware of the Connecticut outbreak, and the CDC is providing laboratory assistance.
These outbreaks have raised concern with the FDA concerning fresh-food products. The FDA is planning to meet with E. coli experts, industry and consumer representatives and the CDC to address the issue, according to Witmore.
You can express your views on this article, or other relevant themes, in the Infectious Diseases in Children Specialty Forums.