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Chapter 19 - Staphylococcal Food Poisoning

Contents

CHAPTER XIX

Staphylococcal and Streptococcal Food Poisoning and Botulism

G. M. Dack, M. D.1

STAPHYLOCOCCAL FOOD POISONING

Experiences Before World War II

Staphylococcal food poisoning has probably occurred for hundreds of years. From the period of 1870, when the occurrence of cocci in inflammatory processes was first observed, through the first three decades of the 20th century, the cause of these outbreaks was not generally recognized because of the ubiquitous nature of the organism and the failure to demonstrate enterotoxin in implicated foods as well as in cultures of Staphylococci isolated from foods. Many outbreaks of staphylococcal food poisoning have falsely been ascribed to ptomaine poisoning or to products from other bacteria which were toxic when injected parenterally into animals.

Staphylococcal food poisoning is not a reportable disease in our civilian populations, and usually only the large and spectacular outbreaks are reported. The disease has been common in armies. A good illustration of this occurred among the German troops in World War I.2 Although this outbreak was attributed to the bacillus Proteus vulgaris, it was obviously an outbreak of staphylococcal food poisoning since micrococci were found in the product upon bacteriologic examination and since the symptoms and epidemiologic features were characteristic of staphylococcal food poisoning. The following excerpts were translated from this report:

* * * Therefore I am going to report in the following about an extensive sausage poisoning outbreak (approximately 2000 cases) which took place in the spring of 1918 during the siege of Verdun and which could possibly have led to catastrophical military consequences.

In the beginning of June 1918 all of a sudden mass outbreaks which had the appearance of acute gastro-enteritis and which, in some severe cases, were even increased to cholera nostras, spread among the troop surrounding Verdun; with a single blow, whole companies were disabled with the exception of just a few people, and within two days about 2000 men had been attacked. The symptoms were so severe in part of the troops that more

1The author is indebted to Maj. (later Lt. Col.) Everett B. Miller, VC, Office of the Surgeon General, Veterinary Division, for his painstaking work in gathering the source material used in this manuscript.

2 Baerthlein, K.: Ueber ausgedelhnte Wurstvergiftungen, bedingt durch Bacillus proteus vulgaris. München. med. Wchnschr. 69: 155-156, February 1922.


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than 200 sick people had to be transferred to field hospitals. Suspicion of food poisoning arose since, according to statements by the sick people, severe illness set in 2-3 hours (with a smaller part of the sick 6-8 hours) after the ingestion of a certain sausage dish. Only those people among the front troops who had not partaken in the meal were spared, i. e. orderlies of the company who on the same day had gone back to headquarters to receive orders; or soldiers who for other reasons had not eaten the sausages, and those parts of the troops who were in rest billets and had a different diet. However, it was surprising that among the troops behind the front, i. e. the corps butchers, who had eaten from the same sausages though two days earlier, no cases of sickness were observed * * *.

Situation at the Beginning of World War II

At the beginning of World War II, staphylococcal food poisoning was recognized in public health laboratories, but it was not generally known to practicing physicians. Many large outbreaks were reported in civilian defense establishments 3 and in military establishments, including personnel in the Pentagon, as well as among troops in camps and in the field.4

Methods of control.-The control of staphylococcal food poisoning is concerned principally with the refrigeration of perishable foods which furnish a medium for the growth and enterotoxin production of Staphylococci. Where recurrent outbreaks have occurred,5 carriers have been sought among the foodllandlers because in some outbreaks enterotoxic strains of Staphylococci have been demonstrated in pyogenic lesions as well as in the noses and throats of carriers. Other control measures are concerned with scrupulous cleanliness, with particular attention being given to cutting boards and all kinds of cooking utensils.

Research.-Research should be directed toward purification and isolation of the enterotoxin with the hope that this approach will lead to a better method of assaying enterotoxin. If a good assay method were available, progress could be made in processing and protecting foods from staphylococcal food poisoning. Investigation in this field is expensive, and the problem involves such a wide segment of the food industry that no one industry can carry this research load. The Armed Forces and Government agencies should cooperate in this program to hasten the solution of the problem.

Outbreaks During World War II

Staphylococcal food-poisoning outbreaks are cosmopolitan and have occurred among troops in all the war theaters, as well as on the homefronts. Since staphylococcal food poisoning is not generally reported even in the Army, there is no accurate information as to its magnitude. A survey of the outbreaks of food poisoning reported in the Army in World War II was tabulated under the following headings: Code, unit, location and date, epidemiology, case

3 Getting, V. A., Rubenstein, A. D., and Foley, G. E.: Staphylococcus and Streptococcus Carriers: Sources of Food-borne Outbreaks in War Industry. Am. J. Pub. Health 34: 833-840, August 1944.

4 Williams, G. C., Swift, S., Vollum, R. L., and Wilson, G. S.: Three Outbreaks of Staphylococcal Food Poisoning Due to lce-Cream. Month. Bull. Min. Health & Emerg. Pub. Health Lab. Serv. 5: 17-25, January 1946.

5 See footnotes 2, p. 433, and 4.


435

history, food, laboratory findings, remarks, and document. Under this method of tabulation, 190 outbreaks involving 22,364 cases were reported for all causes. In this tabulated summary, much of the information was not available, and in some instances not even the number of cases was reported. Of the 190 outbreaks reported, 76 were chosen in which the epidemiologic data, together with the laboratory findings, suggested staphylococcal food poisoning. These 76 outbreaks involved 14,214 men. In addition to these 76 outbreaks, many of the others may very well have been staphylococcal food poisoning, but the information available was inadequate to establish them definitely as such. From a study of the data, staphylococcal food poisoning was without doubt the most important cause of the illnesses.

These 76 outbreaks of staphylococcal food poisoning occurred during the following months of the 4-year period from 1942 through 1945:

Month

Number of outbreaks

January

2

February

6

March

8

April

6

May

9

June

12

July

10

August

2

September

5

October

7

November

6

December

3


More outbreaks occurred in each of the months May, June, and July than in the other months of the year. The seasonal incidence may have less meaning in view of the fact that Army personnel were scattered in many parts of the world where the prevailing temperatures differed for the separate geographic areas according to months. The inconstant and shifting Army populations in these different areas, together with the fact that the reported outbreaks probably are only a small part of the total, make this information unsuitable for statistical analysis. Furthermore, in many outbreaks epidemiologic and laboratory studies either were not done or were inadequate to permit the drawing of conclusions.

The number of outbreaks reached a peak in 1944 (41 of the 76 selected outbreaks). This number was far greater than reported in the two preceding years (5 and 8) and almost twice as great as reported for the following year (22). This yearly incidence is subject to the same variables mentioned for the seasonal incidence. Although the yearly average of the strength of the, Army reached a peak in 1944, there is not a direct relationship between the yearly number of outbreaks and the number of men at risk for that period. Furthermore, information disseminated through Army regulations, training manuals,


436

and training courses may also have influenced recognition and reporting of outbreaks. 6 With the better understanding of the causes of staphylococcal food poisoning, more care may have been utilized in the use of leftovers and in the provision for more adequate refrigeration of perishable foods, thus influencing the yearly incidence of the disease.

A list of foods involved in the staphylococcal food-poisoning outbreaks comprises some 43 different food items, the most common of which are as follows:

Foods involved

Number of outbreaks

Bread pudding

11

Ham

9

Potato salad

6

Rice pudding

3

Ice cream

3

Turkey

3

Roast veal

3

Ham salad

2

Macaroni and chicken

2

Ham sandwich

2


Foods which were involved in 76 staphylococcal food-poisoning outbreaks comprising a total of 14,214 cases were as follows:

Food

Number of times

Food

Number of times

Meat

Desserts

Canned pork sausage

1

Rice pudding

3

Canned corned beef or tongue

1

Ice cream

3

Corned-beef stew

1

Bread pudding

11

Frankfurters

1

Tapioca pudding

1

Hamburger

1

Fruit pudding

1

Roast veal

2

Pumpkin pie

1

Ham salad

2

Cream filler of layer cake

1

Beef

1

Peanut-butter pie

1

Ham

9

Boston cream pie

1

Roast beef

1

Vegetables

Liver-sausage sandwich

1

Canned corn

1

Ham sandwich

2

Potato salad

6

Ham omelet

1

Fried potatoes

1

Hash

1

Poultry

Miscellaneous

Turkey

3

Turkey dressing

1

Chicken a la king

1

Thanksgiving meal

1

Chicken fricassee

1

Egg or roast-beef sandwiches

1

Chicken salad

1

Macaroni salad

1

Chicken pie

1

Cream

1

Turkey a la king

1

Egg salad sandwich

1

Creamed chicken

1

Vegetable soup

1

Macaroni and chicken salad

2

Liver cheese

1

Unknown

1


6 (1)AR 40-205, 31 Dec. 1942. (2) AR 40-210, 25 Apr. 1945.
(3) TM 8-227, 11 Oct. 1946. (4) TM 8-210, 20 Mar. 1942,
(5) TM 8-227, 17 Oct. 1941.


437

Of the 76 outbreaks, 21 were selected for which the data were most complete. Of these 21 outbreaks, involving 5,370 men, 8 occurred in the European theater, 1 in the Mediterranean theater, 9 in the Zone of Interior, 1 aboard ship, and 2 in the Caribbean Defense Command. Of the 5,370 men ill, 1,059 were hospitalized. There was one death which occurred in a patient hospitalized with coronary heart disease. Of these 21 outbreaks, there was I in which only 17 men were involved, whereas the largest involved 1,637 men. The onset of illnesses following the incriminated meals was reported as varying from 15 minutes to as long as 8 hours. In all instances, the duration of illness varied from 6 to 48 hours and was followed by weakness and diarrhea which lasted as long as 48 hours. From 13 of the 21 outbreaks, laboratory studies were made, and Staphylococci were isolated from the incriminated foods.

In the 21 selected outbreaks, the time of onset following a specific meal and the symptoms of illness were typical of those which characterize staphylococcal food poisoning and set it apart from other types of gastrointestinal illnesses. The average period of onset of illness following a meal was slightly less than 3 hours. The symptoms included one or all of the following: Nausea, vomiting, abdominal cramping, and diarrhea. In severe cases, prostration occurred and the patients developed shock. Such cases were treated with fluids parenterally and made rapid recoveries. Fever or subnormal temperatures were rarely reported.

A history of the implicated food is given for 15 of these outbreaks, and in each of these the food stood for several hours at a warm temperature before being served. In two cases, the food item was stored in a warming oven for 7 hours before serving. One outbreak involving ham salad illustrates the folly of attempting to refrigerate large volumes of food. In this outbreak, ground ham was packed in 12-gallon containers and placed in the refrigerator. It is obvious that if the ham was warm when placed in such containers, it would require hours for the ground ham in the center of the container to reach refrigeration temperature. In two outbreaks, frozen ham was cooked and served the same day with no illnesses; the leftover portions were kept out of the refrigerator and served the following morning, causing severe illness. In 1 of these 2 outbreaks, 10 hours elapsed between servings.

Ice cream was involved in two outbreaks. A history of preparation was given in only one. In this incident, a portion of the mix was frozen in the hospital in which it was prepared and served to 30 to 40 people without causing any illnesses. The largest portion of the same mix, however, was kept at room temperature before it was frozen. There were 399 men made, ill from the later preparation of ice cream.

One of these 15 outbreaks illustrates the thermostability of the enterotoxin. This outbreak involved chicken pie in which the chicken was cooked and stored at room temperature for 16 hours before being made into the pie which was served immediately after cooking. Apparently, the cooking of the chicken pie did not destroy the enterotoxin which was probably formed during the 16-hour period in which the chicken was out of refrigeration.


438

Summary of Experiences

Staphylococcal food poisoning frequently occurs in the Army. It is conceivable that its untimely appearance in troops may lose battles, as was pointed out in the case of the Battle of Verdun in World War I. The incidence of staphylococcal food poisoning in World War II is not known, since many outbreaks are not reported and since some of those reported may have been caused by Staphylococci but were not so classified because of insufficient data. From the study of 190 tabulated outbreaks involving 22,364 cases of illness, 76 outbreaks were selected where sufficient data were available to classify them as staphylococcal food poisoning. The 76 outbreaks involved 14,214 men. The illnesses usually appeared within from 3 to 4 hours following a meal and were characterized by nausea, vomiting, diarrhea, and, in the acute cases, prostration.The acute symptoms lasted only a few hours, and in general men returned to duty within from 24 to 48 hours.The outbreaks of food poisoning due to Staphylococci were reported for all months of the year but were highest in the warm months, May, June, and July.

Forty-two different food items were involved comprising meat, poultry, desserts, vegetables, dairy products, and miscellaneous items. Of the 76 outbreaks attributed to Staphylococci, 21, for which the data were most complete, were selected for study. For 15 of these 21 outbreaks, a history of the handling of the implicated food was available, and in all cases the food had stood for several hours at a warm temperature before being served. The danger inherent in the use of leftovers was demonstrated repeatedly in the series of incidents under study. Examples were cited emphasizing (1) the length of time for enterotoxin production; (2) the failure to obtain rapid chilling in food refrigerated in large containers; and (3) an example of perishable food stored at room temperature and then cooked before serving, thus illustrating the thermostability of enterotoxin.

Although the danger of staphylococcal food poisoning had been emphasized in Army regulations and other written communications in the Army, outbreaks continued to occur. It is important that information such as detailed here be made available to all personnel responsible for handling perishable foods.

STREPTOCOCCAL FOOD POISONING

Outbreaks of gastrointestinal illnesses caused by Streptococcus faecalis have been reported.7 Human volunteers, who were fed large numbers of Str. faecalis which had been recently isolated from implicated foods, developed illnesses identical to those described in the outbreaks. Knowledge of this type of food poisoning is incomplete. In food poisoning attributable to Str. faecalis, the living organisms are responsible for illness and not preformed toxins as in staphylococcal food poisoning or botulism.

7 Dack, G. M.: Food Poisoning.Chicago: The University of Chicago Press, 1949.


439

In outbreaks occurring in the Army, little or no effort was made to look for Str. faecalis in the incriminated items of food.Several of the 190 outbreaks tabulated in this series were suggestive of Str. faecalis food poisoning. In only 1 of the 6 outbreaks was Str. faecalis demonstrated in the implicated food. In the others, there were either no samples of the food available or laboratory tests were not made.

These 6 outbreaks involved 1,015 men. Two were reported for the European theater, one from the Panama Canal Zone, and three from the Zone of Interior. The food items were turkey, lamb, canned meat and vegetable stew, canned creamed corn, veal dressing, and meat-hash sandwiches. The onset varied from 4 hours to 18 hours. The illnesses were usually mild, with little or no vomiting, and were characterized principally by abdominal cramps, nausea, and diarrhea. In general, recovery was complete in from 16 to 24 hours.

In all six outbreaks, perishable foods were kept out of refrigeration for varying periods of time. In the case of the turkey outbreak, 140 turkeys were cooked on an afternoon and evening with facilities that accommodated 8 turkeys at a time. The following morning, the turkeys were sliced and placed in pans and stored in the refrigerator for 24 hours. The meat was served at noon. Alpha-type streptococci were isolated from the turkey in this outbreak, which involved 266 men. The lamb outbreak followed the use of leftover lamb that was kept out of refrigeration for 24 hours. In the meat and vegetable stew outbreak, several of the cans contained gas, and the contents were reported to have had a strong odor, when they were opened. It was suggested that one or two of the spoiled cans may have been used in preparing the meal. The outbreak traceable to creamed corn resulted from use of a product which had been left over from a previous meal. The veal dressing was prepared from chopped frankfurters left over from a meal 5 days previously, stale bread, onions, cheese and macaroni left over from a meal 24 hours before, and scrambled eggs left over from breakfast of the day on which the dressing was prepared. A very pertinent remark for the last outbreak is made by the surgeon reporting it: "* * * so far as health is concerned, food wastage is preferable, to food poisoning * * *." The meat-hash sandwiches were prepared a day previous to serving, although they were refrigerated after preparation. There is no statement of the time required for the preparation and the length of time before refrigeration.

Str. faecalis food-poisoning outbreaks occur in the Army, although this type of food poisoning is not generally recognized. Laboratory and epidemiologic studies are necessary to establish the diagnosis.

In 6 selected outbreaks from the group of 190 studied, Str. faecalis was considered the probable etiologic agent. In 5 of the 6 outbreaks, there was a definite history of perishable food items having been kept out of refrigeration for several hours.


440

BOTULISM

There are records of civilian outbreaks of botulism in the United States and Canada dating back to 1899,8 and from then until 1918 the number of outbreaks reported yearly varied from none to seven. However, beginning with 1918, when 16 outbreaks were reported, and following through to include 1947, the annual number of outbreaks has varied from 3 to 25, with an average of 13.9 per year. The highest incidence of botulism from canned goods packed in the United States occurred in 1920 (6 outbreaks). Since 1925, with one possible exception, no cases have occurred from commercially canned goods packed in the United States.The sharp rise beginning in 1918 may have been caused by the increase in preservation of foods because of the war. The publicity and better recognition of the disease after 1918 may explain why the number of outbreaks has not decreased since that time.

The control of botulism has been effectively developed by the canning industry in the United States. This disease occurred among only 23 men in the United States Army in World War II, with 9 deaths, giving a case fatality rate of 39 percent. The 23 cases were represented in 4 outbreaks. The first occurred from commercially canned beets packed in Australia in November 1942. In this outbreak, there were 16 cases and 7 deaths, with a case fatality rate of 44 percent. The other three incidents involved home-preserved products. In August 1944, an outbreak occurred in the European theater from home-canned ravioli which was sent to one of the enlisted men by his parents in the United States. There were 3 cases with 1 death. In January 1945, in the United States, a family had sent their son home-canned mushrooms, which caused 7 cases with 1 death among non-Army personnel as well as 1 nonfatal case in a soldier. The fourth outbreak, causing 3 cases with 1 death, occurred in April 1945 in Germany and was due to pickles and preserves found in a cellar of a home.

Since the Army uses commercially canned products and the canning industry in the United States is keenly aware of the botulism hazard, there are no recommendations necessary in this direction. During World War II, the author evaluated a botulism hazard from dehydrated meats, and the industry and using agencies for these products were apprised of the hazard. Instructions were issued for preventing botulism from the use of these products. In recent years, the Quartermaster Corps has been developing canned bread, which is a nonsterile product, and the hazard involved has been investigated under experimental conditions, in the author's laboratory. The specifications for the manufacture of canned bread have been rigidly set to safeguard this product from botulism. If new nonsterile items are introduced, the foodpoisoning risk should be considered for each item and control measures instituted before the item is placed in production. Since 3 of the 4 outbreaks were from home-preserved items consumed by soldiers, in theory it might

8 See footnote 7, p. 438.


441

seem desirable to prohibit the sending of food items in which there may be a hazard from botulism, but such selective regulation of items is obviously a practical impossibility. Data for United States Army personnel only indicate that in 3 of the 4 outbreaks antitoxin was administered to 6 cases, 1 of whom died, representing a case fatality rate of 17 percent. Three outbreaks occurred between August 1944 and April 1945. In the other outbreak, which occurred in November 1942 in Australia, there were 16 cases with 7 deaths among United States troops. No mention is made as to whether antitoxin was available or given, and the case fatality rate was 44 percent. The food was of Australian manufacture, and, prior to the arrival of United States troops, both New Zealand and Australia had done very little commercial canning of foods. Under lend-lease agreement, these countries undertook to supply huge quantities of canned food to United States Armed Forces with resulting need for tremendous and rapid expansion of their canning industry. Despite assistance by technical experts from the United States, it was inevitable that time would be required to bring productive methods to a level equal to United States standards. Although the incidence of botulism in the United States Army is small, it is suggested that supplies of botulinus antitoxin be available to take care of emergencies, such as the occasional outbreaks reported here. Furthermore, thought should be given to having available a supply of antitoxin in the event that botulinus toxin is used as an agent in biologic warfare.