Campylobacter Information

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In August 2016, a local public health agency (LPHA) notified the Colorado Department of Public Health and Environment (CDPHE) of two culture-confirmed cases of Campylobacter infection among persons who consumed raw (unpasteurized) milk from the same herdshare dairy.

In Colorado, the sale of raw milk is illegal; however, herdshare programs, in which a member can purchase a share of a herd of cows or goats, are legal and are not regulated by state or local authorities. In coordination with LPHAs, CDPHE conducted an outbreak investigation that identified 12 confirmed and five probable cases of Campylobacter jejuni infection. Pulsed-field gel electrophoresis (PFGE) patterns for the 10 cases with available isolates were identical using the enzyme Sma. In addition, two milk samples (one from the dairy and one obtained from an ill shareholder) also tested positive for the outbreak strain. Five C. jejuni isolates sent to CDC for antimicrobial susceptibility testing were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1).

Although shareholders were notified of the outbreak and cautioned against drinking the milk on multiple occasions, milk distribution was not discontinued. Although its distribution is legal through herdshare programs, drinking raw milk is inherently risky (2). The role of public health in implementing control measures associated with a product that is known to be unsafe remains undefined.

Investigation and Results

On August 23, 2016, El Paso County Public Health notified CDPHE of two culture-confirmed cases of C. jejuni infection; campylobacteriosis is a reportable disease in Colorado. Both patients reported drinking unpasteurized milk from the same herdshare dairy in Pueblo County. Since 2005, obtaining raw milk by joining a herdshare program has been legal for Colorado residents, but selling raw milk is illegal. By purchasing a share of a herd (cows or goats), shareholders are entitled to a portion of the raw milk.

Because the prevalence of consuming unpasteurized milk is low (2.4% in Colorado, 2006–2007 FoodNet Population Survey; 3.1%, 2009 Colorado Behavioral Risk Factor Surveillance System), two cases of enteric illness with a common exposure to raw milk are unlikely to occur by chance (3,4). In this outbreak, a confirmed case was defined as diarrheal illness with onset on or after August 1, 2016, in a person with known consumption of unpasteurized milk from the same herdshare dairy and culture-confirmed C. jejuni infection. A probable case was defined as diarrhea onset on or after August 1, lasting 1 or more days, in a person with either known consumption of milk from the same herdshare dairy or with an epidemiologic link to a confirmed case.

Cases were identified through routine passive reporting with follow-up interviews, a Health Alert Network broadcast to area providers, and attempts to contact all shareholders. A public health order was issued to obtain a list of shareholders with their contact information after it was not provided by the dairy within 5 days of the initial request. CDPHE attempted to contact shareholders to inform them about the outbreak and assess possible illness. Up to three calls were made to each shareholder household. Epidemiologists contacted laboratories to request that isolates from potential outbreak-associated cases be forwarded to the state public health laboratory.

Among 91 (53%) of 171 shareholder households that responded to requests for follow-up interviews, representing 207 persons in five or more Colorado counties, 12 confirmed and five probable cases were identified (Figure). Among confirmed cases, patients ranged in age from 12 to 68 years (median = 58 years); nine were male. Duration of illness ranged from 3 to >10 days. One hospitalization occurred; there were no deaths. In addition to diarrhea, among the 12 confirmed cases, the majority of patients also experienced fever (10), abdominal pain or cramps (eight), headache (eight), and myalgia (seven); vomiting and bloody diarrhea were reported less frequently (in five and four persons, respectively).

Four milk samples were tested for C. jejuni; pathogen identification and PFGE were performed on available isolates from persons epidemiologically linked to the outbreak. C. jejuni with one of two outbreak PFGE patterns (PulseNet DBRS16.0008 using the enzyme Sma and PulseNet DBRK02.1272 or DBRK02.0028 using the enzyme Kpn) was confirmed in 10 isolates that were available at the public health laboratory and two of the four raw milk samples. The National Antimicrobial Resistance Monitoring System performed antimicrobial susceptibility tests on five representative isolates; all were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1).

Public health responses to this outbreak consisted of notifying shareholders about the outbreak on three occasions and requiring the dairy to provide additional written notification about the outbreak at milk distribution points. A press release was issued by two LPHAs in response to detecting at least one infection in a person who was not a shareholder but was given milk by shareholders. In addition, a number of shareholders reported sharing milk with nonshareholders who might have been unaware of the outbreak. Although milk sample results were positive for C. jejuni, CDPHE did not close the dairy or stop distribution of its milk because without pasteurization CDPHE could not create standards for safely reopening the dairy (5). Shareholders were, however, urged to discard raw milk distributed since August 1 and were reminded that Colorado statute prohibits redistribution of raw milk.

Discussion

Raw milk from a herdshare dairy was the source of this outbreak of C. jejuni infections, and the investigation highlighted the difficulties inherent in addressing an outbreak related to unpasteurized milk from a herdshare dairy. During three previous herdshare-associated outbreaks in Colorado, public health authorities temporarily took action to stop milk distribution until a series of negative tests were obtained from the milk (Alicia Cronquist, CDPHE, personal communication, December 2017). However, because CDPHE could not ensure that unpasteurized milk would be safe in the future, the decision was made not to close the dairy during this outbreak. In addition, CDPHE’s Division of Environmental Health and Sustainability chose not to make formal recommendations on the dairy’s processes because no protocol improvements short of pasteurization could ensure the product’s safety, even with improved sanitation (5).

All tested isolates’ resistance to three antibiotics was concerning, particularly as fluoroquinolones are frequently used to treat Campylobacter infections in those cases where treatment is indicated. Treatment of antibiotic-resistant Campylobacter infections might be more difficult, of longer duration, and possibly lead to more severe illness than treatment of nonresistant Campylobacter infections (6–8). In 2015, approximately 25.3% of U.S. C. jejuni isolates were resistant to ciprofloxacin, an increase from 21.6% a decade earlier (1).

In collaboration with LPHAs, CDPHE is creating guidelines to address future outbreaks related to raw milk from herdshares. As more states legalize the sale or other distribution of unpasteurized milk, the number of associated outbreaks will likely increase (9,10). The role of public health in responding to raw milk–related outbreaks should be further defined. State-level guidelines might assist with this process.

Corresponding author: Alexis Burakoff, aburakoff@cdc.gov, 303-692-2745.

1Epidemic Intelligence Service, Division of Scientific Education and Professional Development, CDC; 2Colorado Department of Public Health and Environment, Denver, Colorado; 3Pueblo City-County Health Department, Pueblo, Colorado; 4El Paso County Public Health, Colorado Springs, Colorado; 5Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

References

CDC. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): human isolates surveillance report for 2015 (final report). Atlanta, Georgia: US Department of Health and Human Services, CDC; 2018.

CDC. Food safety: raw milk. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/foodsafety/rawmilk/raw-milk-index.html

CDC. Foodborne diseases active surveillance network (FoodNet) population survey atlas of exposures, 2006–2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. https://www.cdc.gov/foodnet/PDFs/FNExpAtl03022011.pdf

Colorado Department of Public Health and Environment. Colorado Behavioral Risk Factor Surveillance System, 2009. [Data on raw milk]. Denver, CO: Colorado Department of Public Health and Environment; 2009. http://www.chd.dphe.state.co.us/Resources/brfss/BRFSS2009results_raw%20milk.pdf

Longenberger AH, Palumbo AJ, Chu AK, Moll ME, Weltman A, Ostroff SM. Campylobacter jejuni infections associated with unpasteurized milk—multiple states, 2012. Clin Infect Dis 2013;57:263–6. CrossRef PubMed

Evans MR, Northey G, Sarvotham TS, Rigby CJ, Hopkins AL, Thomas DR. Short-term and medium-term clinical outcomes of quinolone-resistant Campylobacter infection. Clin Infect Dis 2009;48:1500–6. CrossRef PubMed

Helms M, Simonsen J, Olsen KE, Mølbak K. Adverse health events associated with antimicrobial drug resistance in Campylobacter species: a registry-based cohort study. J Infect Dis 2005;191:1050–5. CrossRef PubMed

Nelson JM, Smith KE, Vugia DJ, et al. Prolonged diarrhea due to ciprofloxacin-resistant Campylobacter infection. J Infect Dis 2004;190:1150–7. CrossRef PubMed

Langer AJ, Ayers T, Grass J, Lynch M, Angulo FJ, Mahon BE. Nonpasteurized dairy products, disease outbreaks, and state laws—United States, 1993–2006. Emerg Infect Dis 2012;18:385–91. CrossRef PubMed

Mungai EA, Behravesh CB, Gould LH. Increased outbreaks associated with nonpasteurized milk, United States, 2007–2012. Emerg Infect Dis 2015;21:119–22. CrossRef PubMed

Outbreak of Fluoroquinolone-Resistant Campylobacter jejuni Infections Associated with Raw Milk Consumption from a Herdshare Dairy — Colorado, 2016

Morbidity and Mortality Weekly Report; February 9, 2018; 67(5);146–148

Alexis Burakoff, MD; Kerri Brown, MSPH; Joyce Knutsen; Christina Hopewell; Shannon Rowe, MPH; Christy Bennett; Alicia Cronquist, MPH

https://www.cdc.gov/mmwr/volumes/67/wr/mm6705a2.htm

According to Poultry World, levels of campylobacter in chicken sold by the UK’s major retailers continue to fall, according to statistics released by the Food Standards Agency on Wednesday 18 October.

Just 5.9% of chickens had high levels of campylobacter in the survey – which sampled 1,437 birds between April and July – down from 20.1% for the same period in 2014.

The FSA announced last month that it was changing its annual campylobacter retail survey with the top 9 retailers publishing their own results. Instead, the Agency would concentrate on smaller retailers, independent traders and markets stalls where levels of campylobacter have been stubbornly high.

Full results from the third annual retail survey, running from August 2016 to July 2017, showed:

  • The figure for high-level campylobacter prevalence (more than 1,000 cfu/g) among the top nine retailers (based on market share) was 5.6%
  • The ‘Others’ group, consisting of smaller retailers and butchers, had a significantly higher prevalence at 17.1%
  • The retailers with significantly lower prevalence than the average among all retailers were Morrisons (2.9%), Tesco (4.2%) and Waitrose (2.7%)
  • There was a significant fall in the percentage of chickens positive for campylobacter at any level – down from 73.2% in 2014/5 to 54% in 2016/7.

According to the CDC, at least 39 people across seven states have confirmed or suspected cases of Campylobacter bacteria, which can cause diarrhea, abdominal pain and fever. While the investigation is ongoing, federal officials have linked it to contact with puppies sold by Petland, a chain of pet stores based in Ohio.

Twelve of the confirmed cases are in Petland employees, and 27 other people who fell ill either visited a Petland, recently purchased a puppy there, or visited or live in a home with a Petland puppy. According to the CDC’s announcement, nine people have been hospitalized and there are no reported deaths.

The State Department of Agriculture and Markets announced Monday that milk from Martin Yoder Farm, 2594 Murdock Rd., was contaminated by Campylobacter jejuni, a bacteria that is a common cause of food poisoning, in samples conducted last week.

Ag & Markets Commissioner Richard A. Ball warned consumers in Orleans County and the surrounding area not to consume unpasteurized raw milk from the farm, but noted that no illnesses have been associated with the product.

“The Department recommends that any consumers who purchased raw milk from the Martin Yoder Farm immediately dispose of it,” the department said in a statement.

According to Ag & Markets, symptoms from Campylobacter jejuni exposure typically develop within two to five days after exposure and include abdominal pain, diarrhea, fever and malaise. These symptoms generally last about seven days but Campylobacter jejuni has been linked to incidents of Guillain-Barre syndrome, which may occur weeks after exposure.

Inspectors discovered the bacteria in a preliminary test completed on Sept. 13, and the farm immediately voluntarily suspended sales of the product. Further laboratory testing, completed on Friday, confirmed the presence of Campylobacter jejuni in the raw milk sample.

The farm, founded by the late Martin Yoder, is part of an Amish community that came to northwestern Orleans County from families in Ohio. Yoder’s farm, as of 2013, had 45-head of grazing cows on a fully-organic operation.

Consumers were able to purchase raw milk directly from the farm, but those sales have been prohibited until additional sampling is completed that confirms the product is bacteria-free.

Unpasteurized raw milk is supported by some consumers as a healthier and less industrial product, but skipping the heating process does not eliminate the possibility for bacteria. Consumers who may have purchased this product and have questions may call the Department at (518) 457-1772.

Raw milk can harbor dangerous bacteria, even when routine testing results show it to be uncontaminated, says a report from Utah on a 2014 outbreak of confirmed or suspected campylobacteriosis in 99 individuals. The report appears in today’s issue of Morbidity Mortality Weekly Report (MMWR).

The outbreak began in May 2014 with three patients who tested positive on pulsed field gel electrophoresis for Campylobacter jejuni. They had all consumed raw milk from an unnamed dairy in Weber County in northern Utah. The dairy’s routine testing, which is required monthly of dairies selling raw milk in Utah and consists of somatic cell and coliform counts, had yielded results within acceptable levels (<400,000 somatic cells/mL and <10 coliform colony forming units/mL).

Enhanced testing after the illnesses were identified showed C jejuni in the dairy’s milk.

Officials suspended the dairy’s permit in August and then reinstated it Oct 1 after follow-up cultures were negative. However, seven more C jejuni cases occurred by Nov 4, and the permit was permanently revoked Dec 1.

It total, 99 people in Utah, 85 (86%) of them from northern counties, were identified through lab testing and patient interviews as having confirmed (59) or probable (40) cases of campylobacteriosis from May 9 to Nov 6, 2014. Patients ranged in age from 1 to 74 years; 10 were hospitalized, and 1 died.

Of the 98 patients for whom exposure history was available, 53 reported drinking raw milk, 52 of them milk from the Weber Country dairy; 4 drank raw milk but could not name the dairy where it was purchased, and 14 bought raw milk at the dairy but did not report drinking it.

The authors point out that “Current raw milk testing standards do not readily detect contamination.” They recommend more education of consumers about the dangers associated with consuming unpasteurized milk, and they conclude, “The safest alternative is to consume pasteurized milk.”

Orange County has confirmed three cases of campylobacteriosis infection associated with consumption of raw goat milk distributed by Claravale Farm of San Benito County, California.  All three patients are young children less than 5 years of age.  One patient was hospitalized, and all of them are expected to recover.

The raw goat milk was distributed throughout the state, and the California Department of Public Health (CDPH) is leading an investigation to determine if there are additional cases.  While the CDPH investigation is ongoing the Health Care Agency advises against consuming Claravale Farm raw goat milk.

There is always a risk of illness associated with consumption of raw, or unpasteurized, milk products.  The risk of getting sick from drinking raw milk is greatest for infants and young children, the elderly, pregnant women, and people with weakened immune systems, such as people with cancer or HIV/AIDS. But, it is important to remember that healthy people of any age can get very sick if they drink raw milk contaminated with harmful germs.

Campylobacteriosis is an infectious disease caused by the Campylobacter bacteria. Outbreaks of Campylobacter disease have most often been associated with unpasteurized dairy products, contaminated water, poultry, and produce. Most people who become ill with campylobacteriosis get diarrhea, cramping, abdominal pain, and fever within two to five days after exposure to the organism.

The Food Standards Agency’s (FSA) released its “Name and Shame” Report this morning.  The idea of testing retail chicken and publishing the results had been the focus of much discussion over the last few months.  Some UK retailers were not very happy that the public would actually know how tainted the chicken really is.

If this had been the US equivalent, FSIS, we would be wondering why would the report be released on Thanksgiving Day.  My guess is that in the UK Thanksgiving does not have the same meaning as it does over here.

Retailers had tried to block the study’s release.

Well, back to the study; Campylobacter was found in 70 per cent of chicken tested up from 59 per cent of chickens in August.  Almost a fifth of all chickens (18 per cent) tested positive for Campylobacter above the highest level of contamination, while six per cent of packaging tested positive – a rise of four per cent since August.

The FSA also revealed that Asda sold the highest percentage of chickens contaminated with the bug.  Campylobacter was present in 78 per cent of chickens from the supermarket, with 28 per cent above the highest level of contamination.

Packaging testing showed 12 per cent was contaminated.  Don’t forget the recent “chicken juice” report.

Almost three-quarters of chickens (73 per cent) sold by the Co-operative tested positive, followed by Morrisons, Sainsbury’s and Waitrose (69 per cent), Marks & Spencer (67 per cent) and Tesco (64 per cent).

Perhaps it is time to redo our 2011 testing of contamination levels in chicken purchased in Seattle.  Here were some of the results:

The study showed that up to 80% of Seattle area raw chicken could be contaminated with some form of potentially harmful bacteria.

Testing done by IEH Laboratories in Lake Forest Park, Washington showed that 80 of 100 raw chickens purchased at various Seattle area grocery stores contained at least one potentially harmful pathogen.

The test was comprised of 18 brands of chicken purchased at 18 different Seattle area stores including chain grocery stores, Safeway (3 locations), Albertsons (2), QFC (4), Fred Meyer (2), Thriftway (1); warehouse clubs Costco (2) and Sam’s Club (1); natural foods stores Whole Foods (1) and PCC (1), and one small market, Ken’s Market (1).

In the study local and organic chicken did not prove to be safer than other samples. In terms of origination, 59 chicken samples originated from Washington, while 13 samples came from other states and 28 were of unknown origin. Regardless of place, chicken from every state tested was confirmed to contain potentially harmful bacteria.  Of the 14 samples of organic chicken 12 contained harmful bacteria.

The study tested for five pathogens.  While some findings were typical, other results were more surprising.  Previous studies have found on average that 33 to 53% of chicken is contaminated with Campylobacter.  In Seattle 65% of the chicken tested positive for Campylobacter.  Salmonella was isolated in 19% of the chicken purchased at retail stores in the Seattle area, slightly higher than the expected average of 16%.  Staphylococcus aureus was found in 42% of the chicken sampled; 10 of these samples were Methicillan-resistant, commonly known as MRSA.  One sample cultured positive for Listeria monocytogenes and one sample cultured positive for E. coli O26, a bacteria often found in beef.

Campylobacter:  Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Campylobacter outbreaks. The Campylobacter lawyers of Marler Clark have represented thousands of victims of Campylobacter and other foodborne illness outbreaks and have recovered over $600 million for clients.  Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation.  Our Campylobacter lawyers have litigated Campylobacter cases stemming from outbreaks traced to a variety of sources, such as raw milk and municipal water.

Food safety experts plan to “superfreeze” chickens to halt the rise of campylobacter food poisoning. The Food Standards Agency is currently looking into a procedure which involves exposing the surface of slaughtered chickens to extreme cold, known as rapid surface chilling.

The radical process is currently being considered to help curb the rampant levels of the food poisoning bacteria commonly found in uncooked poultry products.

Around two-thirds of fresh, raw chicken sold by retailers is believed to be contaminated with campylobacter, which can cause sever stomach upsets.

The FSA aims to reduce the proportion of birds in the highest category of contamination at UK poultry houses from 27 per cent to 10 per cent by 2015.

Read full article: “Chickens to be ‘superfrozen’ to kill food bug.”

New Zealand Health officials are warning liver lovers to cook their offal properly, after more than two dozen cases of food poisoning in Wellington.  They are also working with restaurants and cafes, where use of organs and other cheap cuts of meat have had a resurgence, to ensure would-be chefs are cooking their grandmother’s lamb’s fry recipes to today’s food safety standards.

Campylobacter, a bacterium that causes stomach bugs, was found in undercooked poultry and lamb’s liver, Margot McLean of Regional Public Health said. Symptoms included diarrhoea, abdominal pain, fever, headache and vomiting.

Like chicken meat, lamb liver needs to be cooked long enough to kill any bacteria.

Most campylobacter victims are fine after a week, but some develop arthritis and on rare occasions people can develop the rare disease Guillain-Barre syndrome, which involves the immune system attacking the body’s nerves, resulting in paralysis that can last several weeks.

Researchers at the Institute of Food Research have discovered why the micronutrient selenium is important to the survival of Campylobacter bacteria, which are responsible for an estimated half a million cases of food poisoning annually in the UK alone. Knowing how and why Campylobacter uses selenium could help develop ways of controlling it, benefitting public health and the food industry.

Converting nutrients into energy is essential to all forms of life, and without this process, known as respiration, life would not exist in harsh and hostile conditions. This holds true for the foodborne bacterial pathogen Campylobacter, which colonises the intestines of poultry. In this environment it uses organic acids produced by other bacteria to respire and thrive. Campylobacter needs selenium to make the formate dehydrogenase enzyme required for this respiration, but it is not known how selenium is acquired or metabolised by Campylobacter or many other bacteria.

New research from the group of Dr Arnoud van Vliet at the Institute of Food Research, strategically funded by the Biotechnology and Biological Sciences Research Council, has resulted in the identification of two Campylobacter genes which are required for the formation of the formate dehydrogenase enzyme. Inactivation of these two genes blocked the formation of the formate dehydrogenase enzyme, but when the bacteria were supplemented with extra selenium, they were able to synthesize the enzyme again, suggesting that the two Campylobacter genes are involved in selenium metabolism. As it was previously shown that the lack of formate dehydrogenase affects the ability of Campylobacter to colonise the chicken gut, this may open up possibilities to target this pathway for antimicrobial purposes. In addition, as these selenium metabolism genes and the formate dehydrogenase enzyme are also present in other important foodborne pathogens like Salmonella and E. coli, it may be possible to extend such investigations to other areas of food safety.

“Selenium metabolism is still poorly understood in bacteria, and its role in important foodborne pathogens like Campylobacter is not yet appreciated fully”, said Dr van Vliet. “With the identification of these two genes essential for formate respiration, we now hope to have a tool to generate knowledge that helps us get a better understanding of what makes Campylobacter so good in colonising the chicken gut and cause disease in humans. Such knowledge is essential if we want to achieve the ultimate goal of reducing the impact of Campylobacter in the food industry.”

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