Stew Source of C. perfringens Outbreak at NC Church BBQ

Hundreds of attendees of a church BBQ in North Carolina were stricken with C. perfringens.  Tests indicate that it was the Brunswick stew.  This would indicate that the stew was not held at proper temperatures between the time it was made and the time it was served, allowing the C. perfringens to grow to high number.  Symptoms, including watery diarrhea and mild abdominal cramps occur about 16 hours after consumption of foods containing large numbers (>106 live vegetative cells or >106 spores) of enterotoxin-producing C. perfringens and will last 12 to 24 hours.

Cabarrus Health Alliance

https://www.cabarrushealth.org/CivicAlerts.aspx?AID=108
UPDATE: Poplar Tent Presbyterian Church BBQ
New Update
Update: November 16, 2018

Jambalaya Outbreak - 2 Different Bacterial Pathogens Responsible - Indicates Two Separate Mishandling Issues

A second bacterial pathogen, Clostridium perfringens, has been identified as part of the large outbreak in Louisiana that has been linked to jambalaya served at a softball fundraising event.  Salmonella had already been isolated, but Clostridium perfrigens has now also been identified in patient stool samples.  As of Friday, 125 cases were confirmed with 37 hospitalized.  One death may also be linked.

While Salmonella effects are due to the infection is causes, Clostridium perfringes produces a toxin that causes the symptoms of diarrhea and abdominal cramps.  It usually occurs in less than a day and those symptoms will normally last for 24 hours. 

The issues of contamination will also be different.  Salmonella is not heat resistant, so either the foods are undercooked or it will contaminate foods after cooking through cross contamination.  Clostridium perfringens is a sporeforming pathogen, and its spores are heat resistant and thus can survive normal cooking conditions such as when making jambalaya.  The key to prevention is proper cooling after the product is cooked.  Basically, the spores survive cooking, but need warmer conditions for growth.  In fact, at optimal growth temperature of 109F to 117F, C. perfringens can multiple every 10 minutes or so.

So clearly, the were some issues when people were making jambalaya....and this can be the case when people are cooking large quantities of food.  For Salmonella to be an issue, the cooks either undercooked it, or they had sloppy procedures that allowed cross contamination.  For the second bacterial pathogen - after cooking (or under-cooking), they did not properly cool the food which provided conditions for C. perfrigens growth.  By regulation, foods such as this must be cooled from 135F to 70F within 2 hours, and from 70F to 41F within 4 hours.  These conditions were established for C. perfringens.  And if large quantities were made, cooling can be difficult.

WWL TV.com
http://www.wwltv.com/news/not-just-salmonella-second-bacteria-idd-in-mass-north-louisiana-illness/485166123
Not just salmonella: Second bacteria ID'd in mass North Louisiana illness
WWLTV 10:45 AM. CDT October 22, 2017

C. perfrigens Identified as Cause of Thanksgiving Foodborne Illness Outbreak

Shortly after Thanksgiving, an outbreak of foodborne illness was reported in California that was linked to a Thanksgiving charity event.  There were 3 deaths and another 22 others who were ill.  The causative agent was found to be Clostridium perfringens, a sporeforming pathogen that can grow rapidly when food is temperature abused.

The actual food source of the bacteria was not found, however investigators "found most of the ill people ate turkey and mashed potatoes and they all ate around the same time. Some dishes served at the event, including cooked turkey, were brought to the site after they were prepared in private homes."

A similar scenario occurred in a 2015 outbreak linked to a Thanksgiving luncheon.  In this case, 40 became ill from food contaminated with Clostridium perfrigens.  In this case however, food was prepared by a caterer.

Clostridium perfrigens: 

• Is a gram positive sporeforming anaerobe.
• Is widely distributed in the environment, but can be found in the intestines of animals and humans (but in small numbers).
• Spores are heat resistant and can survive boiling temperatures.  (Dvalues at 100C can range from 0.31min to 17.5min),
• In heat-treated foods that are temperature abused, this organism can divide in as fast as every 10 minutes.  (The heat treatment eliminates any competitive flora.)  Common food sources include cooked meat foods such as stews and casseroles that are temperature abused.
• Symptoms are caused by ingestion of large numbers ( > 106) vegetative cells or >106 spores/g of food. Toxin production in the digestive tract (or in vitro) is associated with sporulation.  This usually occurs about 16 hours after ingestion.  As the organism numbers increase, it produces an enterotoxin, and this entertoxin is responsible for the illness
• The primary symptoms are cramping and diarrhea and usually dissipate within 24 hours.

The cooling procedures in the Food Code and Appendix B for USDA are established taking C. perfringens into account.

This event points out the risk of having volunteers prepare food in their own home.  In many cases, these people have not been trained in preparing large quantities of food and/or preparing food for events outside of their own home.  In the latter, food transportation can be an issue, especially in warmer areas like California.

CBS SF Bay Area News
http://sanfrancisco.cbslocal.com/2016/12/20/common-bacteria-caused-antioch-thanksgiving-dinner-deaths/
Common Bacteria Caused Antioch Thanksgiving Dinner Deaths
December 20, 2016 11:43 AM

ANTIOCH (CBS SF) — A common food-borne bacteria was responsible for three deaths and the illnesses suffered by 22 others following a Thanksgiving meal sponsored by a community church at Antioch’s American Legion auditorium, health officials announced Tuesday.

A 2015 Thanksgiving Luncheon Becomes Scene for C. perfringens Outbreak - A CDC Report

With Thanksgiving leftovers still in the fridge, it is a good time to review a 2015 outbreak that occurred during a Thanksgiving luncheon.  About 40 people who attended a catered company Thanksgiving lunch became ill with diarrhea and abdominal pain the following day (roughly 13 hours later).  C. perfrignes entrotoxin was found in the patient stool samples and C. perfrigens was isolated from the turkey as well as the patients.

According to the CDC report "The caterer had previously maintained a permitted facility, but reported having prepared the lunch food served at this event in an uninspected, residential kitchen. Turkeys were cooked approximately 10 hours before lunch, placed in warming pans, and plated in individual servings. Food was then delivered by automobile, which required multiple trips. After cooking and during transport, food sat either in warming pans or at ambient temperature for up to 8 hours. No temperature monitoring was conducted after cooking."

C. perfringens toxicoinfection is a foodborne illness caused by ingestion of toxin-producing bacteria where then the organism produces the toxin in the gut.  This type of foodborne illness is often associated with consumption of meat that has been improperly prepared and handled.

So store your leftover turkey at the proper temperatures (either below 40F or hot, above 140F).


Notes from the Field: Clostridium perfringens Gastroenteritis Outbreak Associated with a Catered Lunch — North Carolina, November 2015
Weekly / November 25, 2016 / 65(46);1300–1301

Ohio Firm Recalls Salami Due to Inadequate Cooling.

Updated 2/4/15

An Ohio firm is recalling salami products after it was determined that the cooling step in the process appears to have had a deviation in that the product was not cooled enough. This facility operated under state jurisdiction but participated in the Cooperative Interstate Shipment (CIS) program. Under CIS, state-inspected plants can operate like a federally-inspected facility by meeting specific conditions, and then ship their product in interstate commerce and internationally.

The hazard of concern for meat cooling is Clostridium perfringens.    FSIS has requirements that must be met for cooling (also called stabilization) which are defined in Appendix B.

Clostridium perfringens is a sporeforming pathogen that can exist in soil, water, food, meat, spices and vegetables.  The spores are heat resistant and can survive cooking temperatures such as process for cooking processed meat products (Dvalue at 212F ranges from 0.7 min to 38.4 min). If present in the raw materials, the numbers are very low, if present at all.  It only becomes a risk if the cooked product is temperature abused where the number of organisms reach a high number.  It divides very fast in the 90F to 115F range (can be as fast as every 10 minutes or less).

The symptoms of the illness occur within 6 to 24 hours after eating the contaminated food and these symptoms include diarrhea and acute abdominal pain.  The illness occurs when the food contains large numbers of bacteria, that once consumed, sporulate in the intestines and thus releasing the toxin.  Toxin can also be preformed in the food.

It is interesting to note that this is a cured meat, and being a cured meat, Clostridium pathogens are controlled by nitrite.

Dr. Bruce Tompkin provided a comment on this topic, which I wanted to add here:

 

This recall reminds me of the long, unfinished debate about whether C. perfringens is a significant hazard and for that reason chilling should be a CCP in the HACCP plan for cooked cured meat products.

This recall also is unfortunate because it is not likely to have any public health benefit because cured meats have not been associated with C. perfringens illness with one notable exception.

That exception is corned beef that has been cooked in water in a home or food service establishment and subsequently held at time-temperatures that permit germination and outgrowth. Long cooking in water likely reduces the salt and nitrite levels to non-inhibitory levels.

Otherwise, “there is no history of C. perfringens diarrhea associated with cured meat products since the bacillus is relatively sensitive to sodium chloride and nitrite” (ICMSF Book 5. 1996. page 116). Similar statements can be found elsewhere in the literature.

We investigated chilling deviations and conducted other research to better understand why the risk of C. perfringens illness from commercially processed RTE meat and poultry products is very low (Kalinowski et al. 2003. JFP 66:1227-1232). That research investigated both cured and non-cured products.

The publications of Jackson et al in 2011 (JFP 74:410-416 and 417-424) are among the more recent studies that lead to the conclusion that C. perfringens should not be considered a significant hazard in “conventionally cured” meats.

The risk assessment by Crouch et al in 2009 (JFP 72:1376-1384) led to the conclusions that ”Improper retail and consumer refrigeration accounted for the majority of the predicted C. perfringens illnesses, while stabilization accounted for less than 1% of illnesses. Therefore, efforts to reduce illnesses in RTE/PC meat and poultry products should focus on retail and consumer storage and preparation methods.” This agrees with experience in the UK and Australia as mentioned in Kalinowski et al. 2003.

Yes, cooked cured products are now chilled faster and more orderly but I do not recall any instance of C. perfringens illness occurring from an improperly chilled cured RTE product between 1964 when I started in the industry, 1988 when the initial chilling guidelines were implemented and 1999 when FSIS finalized its stricter chilling/stabilization regulations.

Bruce Tompkin


 FSIS Recall Notice
http://www.fsis.usda.gov/wps/portal/fsis/topics/recalls-and-public-health-alerts/recall-case-archive/archive/2015/recall-024-2015-release
Ohio Firm Recalls Salami Products Due To Possible Temperature Abuse
Class I Recall 024-2015
Health Risk: High Jan 30, 2015
Congressional and Public Affairs Whitney Joy (202) 720-9113
 
WASHINGTON, Jan. 30, 2015 – Great Lakes Smoked Meats, a Lorain, Ohio establishment, is recalling approximately 2,863 pounds of smoked salami product, which may have experienced temperature abuse and may contain Clostridium perfringens, the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) announced today.

Investigative Report on Foodborne Outbreak at Food Safety Conference in Baltimore

 An investigation of an foodborne illness outbreak occurring at the Food Safety Summit's Conference in Baltimore this past April indicates that the cause of the illness was Clostridium perfrignens associated with the Chicken Marsala dish.  In all, some 216 illnesses were reported with 146 reporting that they ate the Chicken Marsala dish.

While there was no smoking gun, there were a number of issues that may have led to the outgrowth of this sporeforming pathogen.  As you know, spores of Clostridium perfringens will survive cooking, and if that product is temperature abused, the spores will germinate and the organism will multiply very rapidly.

The issues revolved around temperature measurements during holding of the food.  The recommendations in the report provide good guidance for operations to prevent such outbreaks.

From the report:

Recommendations for event A and all event organizers and Caterer A and all foodservice facilities:1.) Ensure that internal food temperatures are measured at the conclusion of cooking and during the hot holding process.
 a. Temperatures should be taken while the food remains inside the hot holding cabinets at one hour intervals and from multiple locations of the food trays on different shelves.
b. Food handlers should record the range of temperatures (versus a single temperature) as observed on log sheets. Food must maintain 135°F at all times after cooking and prior to service.
c. Obtain representative (multiple sites, mix of locations on tray, such as center, corners, edges) temperature measurements of all food trays before serving time.

2.) Report immediately to management or the person in charge when any food temperatures are below the required holding temperatures.

3.) Corrective action, as specified in the facility’s approved HACCP plan, must be taken when food measures less than the 135°F critical limit.

4.) Maintain detailed temperature logs.
a. Retain detailed internal temperature logs of any cold and hot held food every hour for all locations and all serving lines;
b. Log both internal and external temperature readings for all refrigeration units every 2‐4 hours to ensure that potentially hazardous foods do not exceed regulated time and temperature requirements.

Maryland Department of Health
http://dhmh.maryland.gov/docs/Outbreak%202014-119%20FINAL_with%20Attachments_v3.pdf
SUMMARY REPORT
OUTBREAK 2014-119

September 2014

Office of Infectious Disease Epidemiology and Outbreak Response
Prevention and Health Promotion Administration
Maryland Department of Health and Mental Hygiene

INTRODUCTION
On April 11, 2014, the Baltimore City 311 system received 3 reports of illness from attendees of Conference A. A 4th report was received on April 15. All of the reports were from conference attendees who also worked in the same building at another work location. The reporters stated that they, and several coworkers who also attended Conference A, became ill with diarrhea between April 8 and April 10. The attendees suspected that lunch served on April 9 was the source of the illnesses. All 4 reports were assigned in the 311 system to Baltimore City Health Department’s (BCHD), Bureau of Environmental Health, Environmental Inspection Services (EIS) Food Control Section. On April 16, BCHD, EIS identified that these reports were related and informed BCHD’s Office of Acute Communicable Diseases (ACD). An outbreak investigation was initiated on April 16 by BCHD. BCHD notified the  Maryland Department of Health and Mental Hygiene (DHMH) Division of Outbreak Investigation on April 16. Subsequently, the response proceeded as a joint state‐local outbreak investigation.

Outbreaks in the News this week (2/7/12)

There have been some interesting foodborne illness outbreaks in the news this week (Feb 7, 2012).  Here is a quick summary.

Clostridium perfrigens outbreak due to taco meat served at N.D. basketball game.  How it probably happened - the spore-forming organism survived the heat treatment and then grew in the taco meat when that cooked meat was not held at the proper temperature.  Temperature control of cooked food can be an issue  in venues like this.  Unfortunately, people are not willing to question servers when they receive meat products that are not hot.  People preparing and handling food may not have been trained.

http://www.ksfy.com/story/16689309/clostridium-perfringens-cause-of-pierre-outbreak

Watermelon the likely source for Salmonella outbreak – Over 35 people became ill (it occurred in England, so they became unwell) from eating ready-to-eat (pre-sliced) watermelon.  How it probably happened - during the watermelon slicing operation Salmonella was transferred from the outer surface to the interior surface.  This Salmonella could have originated on the raw fruit, and then been spread through the wash water.  If the sliced water melon was not refrigerated, Salmonella could grow on the more pH neutral fruit, making the situation worse.

http://www.telegraph.co.uk/news/uknews/9056645/One-person-dies-after-salmonella-outbreak-linked-to-watermelons.html

Update – Outbreak of Campylobacter from consumption of contaminated raw milk affects 43 people in 4 states.  The dairy has resumed sales. (That raw milk group is a dedicated bunch).

http://www.therecordherald.com/news/x962217783/Raw-milk-sales-resume-at-The-Family-Cow-in-Chambersburg

3 cruise ships disinfected after norovirus outbreak

http://www.washingtonpost.com/lifestyle/travel/ship-with-stomach-virus-outbreak-sets-sail-from-port-everglades-with-new-passengers/2012/02/06/gIQAc8aztQ_story.html?tid=pm_lifestyle_pop