August 1999
SEATTLE - Health officials in two Pacific Northwest states have reported at least 162 cases of Salmonella muenchen infection linked to unpasteurized orange juice.
There have been no deaths linked to the outbreaks, but 17 people have required hospitalization. Cases have been reported in Washington (103 cases with eight hospitalizations), Oregon (60 cases with nine hospitalizations) and in a New York resident who developed salmonellosis while staying in a northern California hotel. As of July 13, 66 other cases have been reported in people in 13 other states and two Canadian provinces, according to the Centers for Disease Control and Prevention.
Both children and adults have been infected in Washington, said John Kobayashi, MD, communicable disease epidemiologist at the Washington State Department of Health. However, the most severe case to date occurred in an 88-year-old man who suffered a stroke after he became infected.
"I am not aware of any children who are that severely ill, although some kids have been quite sick," said Kobayashi. Twenty-three of the 103 cases occurred in people younger than 19.
In neighboring Oregon, an 84-year-old woman developed septicemia and required hospitalization, and one of the 12 reported pediatric cases required hospitalization, according to epidemiologist Emilio Debess, MD, Oregon State Department of Health. "Most people who became ill were between their 20s and 40s, and some people in retirement homes also became infected," he said.
Results from 10 additional cases of potential salmonellosis in Oregon are pending. "There are 2000 serotypes of Salmonella, so these 10 cases could be anything," said Debess, but it is possible that they are related to this outbreak. "The 45 cases in Washington have occurred so far, and these numbers will probably increase."
Investigations revealed the two clusters of cases were related; Salmonella muenchen isolates from Oregon and Washington shared the same DNA fingerprint. This subsequently led to a national recall of the unpasteurized orange juice.
"We called the different distributors of this juice and found the single supplier, Sun Orchard Inc.," said Debess.
Kobayashi added that there are preliminary case reports from other parts of the United States, but that it is too early to tell which of these cases are related to this outbreak.
Children's Hospital and Regional Medical Center in Seattle first reported the problem to the Washington State Department of Health, said Kobayashi, after three Salmonella serogroup C2 cases were identified there within a few days. All three people drank a mixed fruit drink that contained several fruits and orange juice. After an epidemiologic investigation, the original hypothesis regarding orange juice was developed. Public Health Seattle King County conducted a more extensive investigation and then implicated orange juice as the cause of the Salmonella outbreak, explained Kobayashi.
At the same time, a case of restaurant-related salmonellosis was reported after someone drank juice from a buffet in Portland, Ore. Epidemiologists there were also investigating a Salmonella outbreak among people who attended a birthday party. S. muenchen which is rare in Oregon, was confirmed in both, said Debess.
"We called other states and found that Washington was having the same problem," he said. It was then determined that the four people who attended the birthday party and drank orange juice were infected, while six people who attended but did not drink orange juice were not infected.
Because both states worked together, epidemiologists were able to pin down a source, Debess said.
"This emphasizes the importance of close collaboration between microbiology laboratories and infectious disease specialists with public health departments," said Kobayashi. "If there was not the initial report from the Children's Hospital and Regional Medical Center, this investigation would have been delayed."
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The contaminated juice was distributed to Arizona, California, Colorado, New Mexico, Nevada, Oregon, Texas, Utah, Washington, Wisconsin and in the Candadian provinces of Alberta and British Columbia, said Jennifer Geiger, sales department, Sun Orchard Inc.
Public Health Seattle King County notified the company after the three initial Salmonella cases were discovered, said Jim Kurtz, vice-president of administration at Sun Orchard Inc. "They notified us that they had identified an epidemiological thread, in that the three people drank fruit drinks containing strawberries, bananas, sherbet and our orange juice."
A few days later, said Kurtz, the reported cases totaled eight, six of which were in people who drank the same fruit drink as the initial three cases. They were also notified about the Portland outbreak. "Without further information, we voluntarily recalled the orange juice," said Kurtz.
The recalled juice was packaged in clear-plastic gallon containers, as well as half gallon, quart, pint, 12 oz and half-pint containers with a July 7 expiration date.
In regard to infection control efforts within the company, Kurtz said "Sun Orchard has fully met federal requirements for a 5log (99.99%) reduction of potentially harmful micro-organisms in fresh juice. To achieve this 5log reduction, we use innovative fruit surface treatment processes including a chlorinating bath and a steam tunnel."
Most people develop diarrhea, fever and abdominal cramps within 12 to 72 hours after infection, according to the Centers for Disease Control and Prevention (CDC). Foods contaminated with animal feces are usually the cause of infection and are often of animal origin such as beef, poultry, milk or eggs, but all foods may become contaminated.
Infection usually resolves in five to seven days, and people who develop diarrhea usually recover completely. Rehydration with intravenous fluids may be required for those with severe diarrhea, according to the CDC.
If a patient becomes severely dehydrated or the infection spreads from their intestines, the CDC recommends treatment with antibiotics. A small number of people infected develop joint pain, eye irritation and painful urination, known as Reiter's syndrome, that can last for months or years and lead to chronic arthritis. Antibiotic treatment does not effect whether or not they develop arthritis later in life, according to the CDC.
Raw or undercooked eggs, poultry and meat should be avoided and poultry and meat should be well-cooked.
For more information:
- CDC. Outbreak of Salmonella serotype muenchen infections associated with unpasteurized orange juice - United States and Canada, June 1999. MMWR.1999;48(27):582-585.
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