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An apple a day may keep the doctor away--but not if it is juiced.  That seems to be the most obvious message from the recent outbreak of E. coli food poisoning that has been laid at the door of the Odwalla Juice Company.  By now almost everyone has heard about the severe dysentery that afflicted over 60 American children, one of whom died.  There were 10 cases in Seattle a day before Halloween and six of the patients said they had drunk an Odwalla apple juice product.  The county environmental health director was in a quandary about what to do.  On the one hand he lacked direct evidence that the E. coli O157 bacteria had actually come from Odwalla juice.  So he called FDA and initiated a bureaucratic conference involving 40 health officials nationwide in a massive conference that went on until past 3:00 AM. 

This committee of experts agreed that it was prudent to notify the public and initiate a recall of the suspected Odwalla products.  “Better safe than sorry” makes sense in this case, in light of the Jack in the Box hamburger disaster that afflicted more than 700 persons and caused 4 deaths just three years ago due to “undercooked” meat.  Since then fast-food restaurants are under orders to cook their burgers well done, no red juices at all.  That is what it takes to kill the bacteria.  Unfortunately, it also destroys some of the food value, even the amino acids and especially the fats.  And heat is not the only antidote: proper food handling, especially the maintenance of refrigeration, is even more important. 

While meat is usually free of pathogenic bacteria in the interior, the surface may have been contaminated in transportation or cutting.  Thus, it is unwise to allow meat to stand at room temperature or even to thaw slowly.  However the risk of heavy bacterial infection is much greater with ground meats than with steaks and filets.  The very act of grinding meat necessarily spreads bacterial contamination over the surface of the myriad of globules.  No wonder hamburger can be dangerous.  Even a minor number of virulent bacteria on the meat, which there often is, will reproduce and can reach astronomic levels in just a few hours.  In fact, E. coli are known to reproduce themselves, to undergo cell division, in about 20 minutes at room temperature.  That means a single organism can generate a million progeny in about 7 hours and that is almost certainly sufficient to be an infective dose! 

But when food is contaminated it usually means thousands or millions of organisms per gram to begin with; and so a much shorter incubation period can be dangerous.  As little as two or three hours at room temperature can catapult the bacterial load from a sub-clinical to severely toxic degree of infection.  How many children drink juice from a bottle that is left at room temperature or perhaps never put back into the refrigerator?  From what I have seen, it is commonplace to allow a child to carry a nipple bottle for long periods of time.  Sometimes the bottle doesn’t get emptied at all and the remnants are dumped at the end of the day.  Many babies have a bottle in bed all through the night as a pacifier.  What a dangerous pacifier!  Luckily, juices with acid pH, below 4.4, i.e. similar to vinegar, inhibit growth of E. coli.  Organic acids, such as benzoic, propionic and citric acids are commonly used food preservatives for this reason.  Apples, citrus and cranberries are usually acid, pH 3.0 to 4.5, and thus protected against E. coli--until the 157:H7 strain came along.

After the 1993 hamburger disaster, the FDA issued a Medical Bulletin for health professionals.  In addition to the recommendation about cooking ground beef to 155º, i.e. well done, the bulletin also mentioned apple cider as a source of infection.  This was because “fresh pressed apple cider was part of the title of a 1991 report of an outbreak of E. coli 0157:H7 in apple cider, with diarrhea, blood cell destruction, and kidney damage.  The FDA also reported person-to-person transmission of the disease and now in 1996 there is a report of thousands of sick school-children in Japan: same bug, same miserable symptoms.  Only they got sick from eating Japanese radish sprouts.  Evidently this bacterium really gets around.  It is not an apple juice problem.  It is a fecal contamination problem.

What’s going on here?  Back in the 1950’s, during my training years, E. Coli was thought of as a normal flora in the intestinal tract.  The virulent strain, called 0157-H7 was not even recognized until 1982.  Evidently we have a new mutation here.  FDA researcher Thomas Cebula explains that the E. coli microbes mutate rapidly and repair their own damaged DNA by taking up DNA stands from other bacteria, even from other species, such as Salmonella, which cause severe diarrhea in their own right.  It seems likely that this is an unpleasant consequence of 50 years of antibiotics.  Whatever the cause, the fact remains that virulent and resistant bacteria are making an increasing appearance.  E. coli 0157 is one of these bad bugs.  Is there anything we can do about it?  Let’s consult an impartial expert.  Let me quote from a review of the subject in Science magazine (15 Nov 96), Dr. Miroslav Radman of the Institut Jacques Monod in Paris has this to say: “I would never promise people that even if we do find a trick to kill the mutators, the bacteria won’t find another trick to avoid it.  And then we’ll have to find another.  And so on.  That’s life.”  In other words, there is going to be ongoing exposure to this and other virulent bacteria. 

As a rule however, these microbes are not even diagnosed.  It is hard to diagnose new diseases.  For example, only a handful of laboratories are set up to identify the 0157 strain of E. coli.  In addition, diarrhea is such a common symptom that most E. coli cases are not even seen by the doctor.  One might say: E. coli 0157 causes the runs and then runs its own course.  It does not usually cause high fever, seldom above 102º F.  The complicated cases get the attention because they cause bleeding--bloody diarrhea-- and destruction of blood cells that then can clog the kidneys with blood cell waste.  This is the hemolytic-uremic-syndrome and it can cause kidney failure and death.  Fortunately it only occurs in about 2 cases in a hundred.  In the current series, there was only 1 death and another close call, both in young children, who often are at greater risk due to nutrient deficiencies, weak secretion of stomach acid and low levels of vitamin A and Carnitine.

The 1993 FDA Bulletin actually ends with some very good rules for safe eating of ground meat and poultry: 1) keep it cold; 2) keep it clean; and 3) cook it thoroughly.  Right there you have an implied warning, one that tells us there is no guarantee that E. coli contamination can be prevented.  In fact, no matter how stringent the rules may be at the processing plant, infection with E. coli 1057 is inevitable.  There are so many sources of infection that some or all of us are exposed to this bacterium on a regular basis.  E. coil is a coliform, bacteria, an organism found in the colon.  There is not a one of us who does not have daily contact with colon bacteria.  That is why we should ALWAYS wash our hands, or at least rinse them under running water, after using the toilet.

However many people fail to perform this simple health ritual and yet seldom get sick anyway. Why not?  It comes down to basic things like: 1) the number of bad bacteria ingested; 2) the potency of the stomach acid of the individual; 3) the nutrition status of the individual; 4) the immune status of the individual; 5) the intestinal health of the individual.

The greatest error in the entire E. coli tragedy is the false expectation that any food product can be 100 percent uncontaminated.  This leads to the dangerous expectation that perishable foods can be left out of the refrigerator for hours at a time.  E. coli divide about every 20 minutes and a single coliform bacillus can multiply by a million in just 7 hours.  Given enough time at room temperature, food spoilage can be very dangerous if there is a virulent microbe aboard.  That is why we have refrigeration.

This tragic epidemic of bacterial food poisoning has clearly attracted attention from the media and the public.  This attention should be used to educate the public to expect all food to be contaminated, not only at the factory but especially in the kitchen.  E. coli was not found in the Odwalla factory and only one bottle in the warehouse had E. coli--and that might have come from the inspectors or from laboratory error.  It is more likely that the E. coli came from household sources, such as unclean hands, diapers, floors, pets--or the children themselves.  Pasteurization will not kill all E. coli and cannot protect against the inevitable contamination at the point of consumption.  This is not a manufacturing problem.  It is a public health education problem.  Odwalla officials could perform a public service by making this point.  Because they have maintained high standards of cleanliness in their plant, they are in a position to set the record straight, something that the FDA appears unprepared to do at this time!

Here are a few rules that you can use to protect yourself:

1) Accept the fact that food contamination is inevitable.  Be on guard.

2) Don’t eat food that has been left at room temperature for more than two hours (three if it is cold to begin with).

3) Don’t eat left-overs that are more than 3 days old.

4) Never eat under-cooked hamburger unless you know it has been freshly ground and immediately refrigerated.

5) Never eat deviled eggs, egg salad or potato salad at a buffet or picnic--unless you know that it has been refrigerated continuously.

6) Never use warm cream in your coffee or tea at a restaurant.  If it is not cold it is not safe.

7) Be especially careful if you have weak stomach acid.  Acid is the first line of defense against microbes in food.  That is why a cocktail, wine, coffee or hot spices, taken with meals, can diminish the extent of food poisoning.  All of these are known to stimulate acid production.  On the other hand, antacids, particularly the H3 blockers and omeprazole, can breach the acid barrier and set the stage for infection.  Because people with vitamin B12 deficiency usually have weak acid secretion, and B12 patients usually are troubled by anemia, they should be particularly careful about food poisoning.  The use of acid supplements may be useful in that case. 


© Richard A. Kunin, M.D. 2010


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