As much as we love to eat, sometimes the food we put in our mouths ferries microbes that can turn a pleasant meal into a horrifying experience of illness — or worse.
"Carol, oh my God, are you home? Pick up the phone! It’s about those berries you and Mark love. Oh well. Here’s what I heard on NPR. They have hepatitis! You should call Costco. Then text me, okay? I mean, who knew a virus could live in a freezer?!”
— Voicemail message, May 2013
Carol and Mark are retired lawyers who love wholesome, delicious food. They especially love smoothies. For a while, their favorite mauve quaff combined almond milk, protein powder, flaxseed, banana, mango and blueberries. Sixty seconds in the blender and, presto! Instant healthy goodness.
Then, in May 2013, the couple spied a bag of Townsend Farms Organic Antioxidant Blend at their local Costco. This enticing mix contained cherries, berries and pomegranate arils, the fleshy red seeds of the pomegranate fruit. The combo sounded great to my longtime UCLA patients, as they savored the thought of a bright, new breakfast taste.
“We didn’t read the fine print,” Carol acknowledges. (The couple’s full names have been withheld at their request.) “But it probably wouldn’t have stopped us.” Overlooked was the fact that, although packed in Oregon, the frozen pomegranate seeds in the Townsend mix originated from Turkey.
Ten days later came news of the hepatitis outbreak. By then, the icy product had sickened dozens, while other consumers hovered on the brink of hep A’s infamous fevers, flu-like aches, clay-colored stool and glowing, yellow eyes. The next logical question — which ingredient had ferried the virus? — quickly focused on the tangy, red arils. Genetic typing clinched the case. The victims carried a strain of hepatitis A that normally circulates in the Middle East and North Africa. Aside from its pomegranate seeds, Townsend’s other fruits came from South America and Washington State. In June 2013, Townsend recalled all of its implicated lots.
Some backstory: Hepatitis A enters through the mouth, travels to the gut, attacks the liver and passes in stool, at which point it can easily taint water or food. And it is hardy. Hardy, in fact, barely begins to describe the virus’s RNA swirl encased in an icosahedral protein shell. Once in a kitchen, it can live for weeks. It also can tolerate freezing for months. Over decades, if not centuries, food tainted by hep A has infected millions upon millions of people in localized clusters.
But in today’s age of high-speed global transport, infected edibles are no longer limited to specific locales. They are pushing the envelope of their reach, as shown by the following examples of hep A contamination: semi-dried tomatoes sullied in Turkey and eaten in Australia; strawberries frozen in Egypt and then flown to Europe; dehydrated berries of uncertain provenance — Poland? Bulgaria? Authorities still are not sure — dotting a Scandinavian cake mix; and, of course, the frozen arils from Turkey’s Goknur Foodstuffs that were later sold at Costco. Although we’ll never know the full toll of illness and pain, according to the U.S. Centers for Disease Control and Prevention (CDC), Goknur’s glistening, red cubes spawned four times as many infections as our country’s largest hepatitis A outbreak of the previous decade — 35 people sickened by Gulf Coast oysters in 2005. In contrast, 165 people in 10 states became ill from the tainted pomegranate seeds; 69 were hospitalized, two with fulminant infections and one who required an emergency liver transplant. To its credit, Costco quickly notified a quarter-of-a-million buyers about the outbreak, setting a new bar for public-private teamwork to stop a foodborne fiasco dead in its tracks. Some who sampled the berries returned to Costco for post-exposure hep A vaccines. Carol and Mark also got jabbed, thus dodging an ominous bullet. For weeks after, however, they continued to marvel at a hazard they had never before considered, much less expected to find in a frosty bag of fruit at their favorite store.
MODERN FOOD SAFETY IS A GIANT MACHINE with many moving parts and unsung heroes. For starters, consider “traceback,” the process that ultimately nailed the culprit in Townsend’s tainted fruit. Often likened to a painstaking puzzle involving invoices, lot numbers and bills of lading, traceback may also trigger specialized tests performed under furious pressure. At the height of the pomegranate scare, for example, several CDC techs spent Memorial Day pegging the outbreak’s 1B viral genotype.
Achieving modern food safety also requires front-line clinicians, who, when confronted with troubling symptoms, “think” foodborne infection and then order appropriate tests.
Although diagnosing hepatitis A requires bloodwork, most foodborne foes lurk in stool. Which leads to another modern twist. Once the sine qua non of enteric detection, cultures are no longer the only Sherlock Holmes-ian path to unmasking villains like norovirus, Salmonella, Campylobacter and E. coli 0157:H7, the toxin-bearing bug that first made headlines when fast-food hamburgers sickened hundreds in the 1990s. Today, rapid molecular tests also can identify these and other perps in 60 minutes flat.
To David A. Bruckner, Sc.D., professor emeritus of pathology and laboratory medicine and of microbiology and immunology, the new “multiplex” tests equal a stunning advance. The former COO of UCLA’s clinical labs, Dr. Bruckner still works three days a week at Olive View-UCLA Medical Center and UCLA’s microbiology hub in Brentwood.
“When you looked at what the [stool] panels offered, it was so extensive, it blew your mind away,” says the veteran microbiologist, recalling his initial reaction to the cutting-edge assays. “I began to think about all the things we previously couldn’t culture or for which we depended on a physician’s clinical judgment to diagnose. Now we can pinpoint the cause of a lot more infections.”
UCLA Health and Olive View introduced multiplex tests in 2017. According to Dr. Bruckner, they’ve proved especially useful in Olive View’s busy ER or when trying to link a group of sufferers to a shared exposure. “With this kind of laboratory diagnostic,” he explains, “information goes to public health so fast, they can track things much more quickly than before.”
PREVENTION, RATHER THAN DIAGNOSIS, REMAINS THE HOLY GRAIL — especially since every year, one-in-six Americans still suffers a foodborne blight. Now picture the infections’ most vulnerable targets — the “canaries in the coal mine,” if you will: folks whose immune systems are hobbled by anti-rejection drugs for transplanted organs or by hefty doses of steroids or treatments for cancer. Theoretically, even acid-fighting pills heighten one’s risk. As a result, ensuring the safety of every meal that is served in UCLA’s hospitals — both in patients’ rooms and in cafeterias — is a serious job. At UCLA, that mandate falls to Patti Oliver, RDN, MBA, UCLA Health’s long-time director of nutrition services. Oliver not only supervises 300 employees who produce 10,000 meals a day, but also in 2017 she won a major tribute — the “Silver Plate Award” from the International Foodservice Manufacturers Association — for her commitment to wellness, sustainability and UCLA’s “Signature Dining,” which often wins exclamations of “Wow! This is not your usual hospital food!” from both patients and visitors.
When Oliver first trained as a dietitian, there were gaps in knowledge and practice. “Back then, we had food science and food management classes, but they barely touched on food safety,” Oliver says, as Medicare inspectors conduct a routine, unannounced audit just yards from her office. “Looking back, if I knew the responsibility [I would someday shoulder], it might have scared me off. Then, as the process became more regulated and surveys became more and more brutal, my thought was: ‘Poor me, why is this happening?’ But now I’m glad. Because the truth is, the worst thing that can happen is a foodborne outbreak. So, yes, it’s a lot of work, and sometimes it’s tiresome, and you only have X amount of resources, but food safety and patient safety remain our highest priorities,” she says.
Here’s a snapshot of Oliver’s daily operation. In addition to receiving and storing food, cooking, serving and cleaning, some of her staff must, every two hours, check and log the temperatures of dish-washing machines, refrigerators, freezers, hot food, salad bars and blast chillers. Managers regularly inspect the dining commons, catering kitchens and meal service to patients. Finally, all of Oliver’s staff are constantly refreshing their food-safety knowledge.
“When we hire them, every employee has to verbalize that he or she cannot come to work with certain symptoms or diagnoses: vomiting, diarrhea, jaundice, sore throat, fever or infected burns or cuts,” she says.
For audits, they also have to know the names and symptoms of bugs like Salmonella, norovirus and hepatitis A.” Oliver concluded by describing her department’s monthly infection-control rounds, which involve five teams touring every nook and cranny of the food service domain and recording their findings. In short, it is a continuous cycle of monitoring, evaluation and improvement.
DANIEL Z. USLAN, MD, LOVES DIVERSE CUISINE, BUT HE ALSO KNOWS ITS RISKS. Several years ago, Dr. Uslan, associate clinical chief of UCLA’s Adult Division of Infectious Diseases, voiced concern about drug-resistant bacteria in modern farm-to-fork chains. Not long after, a Los Angeles Times headline — “UCLA hospitals serve antibiotic-free meat in fight against superbugs”— marked Oliver’s response. At the school of medicine’s Café Med courtyard, Dr. Uslan recounts the story.
“Most people are aware of active foodborne outbreaks — E. coli in sprouts, Salmonella in chicken or whatever the latest problem is,” he says. “Not a month goes by when something isn’t brewing somewhere, and most of those events get pretty good media attention. On the other hand, what’s not on many people’s radar is the potential — perhaps unquantifiable — for transmission of antibiotic-resistant bacteria through food.
“So, back in 2014, when the cafeteria got rid of trans fats and fried foods — French fries, chicken fingers, things like that — at one point I said to Patti: ‘You know, if we’re really trying to promote healthy eating, and we’re a responsible organization, we should be purchasing antibiotic-free meat and poultry.’”
“Much to my surprise and appreciation—and despite the increased cost—she agreed! Four years later, I still believe we made the right decision, not just for public health, but for moral reasons as well.”
Of course, Oliver and Dr. Uslan both know that UCLA’s stand is partly symbolic. What happens in a hospital doesn’t address the larger problem, namely that the U.S. overuses antibiotics in farms and feedlots. But, for now, targeting drug-resistant flora in food can still advance health, Dr. Uslan says. “Even if they’re not making us sick today,” he warns, “in the future, if we’re ill or immunosuppressed or taking other antibiotics, those silent, resistant bacteria in our intestines can suddenly flare and cause us harm.”
A final chilling statistic: Each year, the CDC estimates, 400,000 Americans are sickened by antibiotic-resistant bugs in food. This represents one-fifth of our nation’s annual toll of serious drug-resistant infections.
ON A FOUR-LANE BOULEVARD IN SAN GABRIEL, nestled among stucco and ranch-style houses, an occasional picket fence and palms, oleanders and pines, there’s a family-run market, Howie’s, that has been a staple of the community since the 1950s and still evokes the feel of a bygone era. Today, its owners are Mike and Denise Milazo. In 1994, the Milazos’s teenage daughter Kirsten was traveling through the California Low Desert when she suddenly felt hot. Her sudden illness soon spiraled into meningococcal sepsis, one of the most deadly infections in the world. For her first two weeks in the ICU of a Palm Springs hospital, she was put into a medically induced coma, placed on a ventilator and underwent dialysis. Three months later, surgeons had amputated Kirsten’s right leg below the knee; she also had lost all of her remaining digits with the exception of two stump-like thumbs; and, worst of all, her kidneys still were not working. The following year, she received her first kidney transplant, with an organ donated by her mother. Twenty years later, she received a second transplant, from her father.
Today, Kirsten Milazo Nolan is a vibrant and conversational woman. When I spoke with her at Howie’s, where she is co-manager, she wore black sneakers, khaki pants, an embroidered Mexican top and a beautiful diamond ring on a chain around her neck. “Transplant dietitians barely existed the first time around,” she recalls. “But with the second transplant, at UCLA, they were very specific. No sushi, no raw fish. No sliced turkey or processed deli meats.” During the first few months after her second transplant, when the risk of infection is highest, Kirsten also eliminated fresh produce, a special hardship in light of her love of “luscious green vegetables.”
“In the hospital, transplant patients cannot eat salads because our guidelines dictate a ‘low bacteria diet,’” Patti Oliver had told me, and her comment echoed in my head. “Even their bread comes in pre-packaged, individual servings.”
But, paradoxically, Milazo Nolan relished her early post-op meals at UCLA. “I was so happy to add things [to my diet],” she says, referring, in particular, to peanut butter and cooked broccoli, foods she had eliminated while on dialysis. On the other hand, Milazo Nolan was quickly brought to her feet when a hospital dietitian admonished against the natural aloe vera juice she was privately sipping for severe, post-transplant heartburn. Now that she’s largely back on her usual fare, the grocery maven, who loves finding “new and exciting products” for customers at Howie’s, often discusses food with a long-time friend who is also post-transplant. “We go back and forth about certain things we can and cannot eat,” she says. “When either of us gets a sick stomach, it’s like, ‘What were you eating? What did you do?’”
This illustrates the ongoing challenge of counseling transplant patients about how to eat “safely,” not just for a while, but for the rest of their lives. Even for an infectious diseases or public health specialist, predicting the next food that will harbor an occult infectious threat is far from easy. In 2011, for example, there was a 28-state conflagration in which 147 people were seriously harmed, and 33 died after eating cantaloupe contaminated with Listeria monocytogenes, a ubiquitous, damp-loving bacterium that had never before laced a melon’s rind. Moreover, almost 90 percent of the people who were affected were in some way immunosuppressed, according to a study later published in The New England Journal of Medicine. Today, UCLA Health’s food service workers wash all whole cantaloupes under running water before they are cut up to be served.
“Do transplant patients need more education around their heightened risk of serious foodborne illness?” I ask Dr. Uslan. “The care of transplant patients requires so much,” he says. “There’s all the pharmacy issues with medications and drug interactions. There’s surgical issues — everything from post-op wound care to complications. And then there’s travel. Not surprisingly, if you’ve got people who’ve been chained to a dialysis machine who can suddenly take a cruise, they’re going to do it!
“But, yes, especially living in a cosmopolitan place like Southern California, I worry that some transplant patients are just going out and eating without being aware of potential risks. While I don’t want people to live in fear, I think we could all do a lot more teaching about what’s safe and appropriate and what’s not.”
Who wouldn’t second that motion? At the same time, perhaps all of us — not just transplant recipients and other, extra-vulnerable people — should learn from modern foodborne outbreaks that regularly splash across the media.
In 2018, first there was E. coli 0157:H7 in romaine lettuce from Yuma, Arizona, and then again from California’s Central Coast; Cyclospora in McDonald’s salads and Del Monte vegetable trays; Salmonella in Jimmy John’s sprouts, Fareway chicken salad, Rose Acre shell eggs and Kellogg’s Honey Smacks cereal; Vibrio parahemolyticus — a kinder, gentler relative of cholera — in imported crab from Venezuela. And the list goes on.
In 2018, frozen foods also made the list: frozen vegetables laced with Listeria were in more than 100 countries, including the U.S. and Canada. The tracebacks and recalls were daunting. And so, as an infectious diseases professional, I have some simple advice. When making Kermit-colored smoothies, do not toss uncooked frozen veggies into your blender. Greenyard International (the manufacturer of the frozen Listeria-tainted fare) advises heating their edibles to 160 degrees Fahrenheit and then cooking them for another couple of minutes. The same amount of boiling also will quash unseen viral invaders in other manufacturers’ frozen vegetables and fruit — with or without juicy and tart pomegranate arils.
Dr. Claire Panosian Dunavan is an infectious diseases specialist, a clinical professor of medicine (recalled) in the David Geffen School of Medicine at UCLA and a medical journalist. Her writing has been published in the Los Angeles Times, The New York Times, The Washington Post, Discover magazine and Scientific American, among others. She currently is writing a book about modern foodborne infections.