You’ve probably heard of Salmonella and are familiar with the symptoms of salmonellosis, but you may not have heard much about the lesser known foodborne illness listeriosis. Listeriosis is caused by the bacteria Listeria monocytogenes and is a leading cause of hospitalization and death due to foodborne illness, especially in high-income, industrialized countries.

A Brief History

In 1911, G. Hülphers described bacteria that he isolated from the diseased liver of a rabbit. Hülphers named the bacteria Bacillus hepatis, and his description closely matched the findings of E.G.D. Murray 15 years later. In 1926, Murray isolated bacteria from the livers of sick rabbits and guinea pigs and named the bacteria Bacterium monocytogenes. The bacteria went through several more name changes, and in 1940, the name was officially changed to Listeria monocytogenes to honor Joseph Lister, the British surgeon who discovered that sterilizing surgical instruments before operations reduced the risk of infections.

In 1929, A. Nyfeldt reported the first confirmed cases of listeriosis in people. But L. monocytogenes weren’t identified as a major cause of foodborne illness in people until the 1980s when several large outbreaks occurred. Since the 1980s, there have been about 80 recognized outbreaks of listeriosis in people.¹

The Statistics at a Glance

Compared to other foodborne illnesses, listeriosis is rare but very serious. Even with adequate antibiotic treatment, the disease has a high mortality rate of 20 to 30 percent.² Over 90 percent of people with listeriosis are hospitalized, often in intensive care units.^3-5

The World Health Organization estimated that worldwide in 2010, listeriosis sickened 23,150 people, and of these, 5,463 died.⁵ In the U.S., estimates range from 1,600 to 2,500 cases of listeriosis each year, with 260 to 500 deaths.^6-9 The European Union has similar numbers: in 2009, there were 1,645 reported cases of listeriosis, with an estimated 270 deaths.¹⁰

A 2011 outbreak of listeriosis in the U.S. from contaminated cantaloupes sickened 147 people in 28 states, resulting in 33 deaths and 1 miscarriage in a pregnant woman.¹¹ With a mortality rate of over 22%, this was the deadliest recorded outbreak of a foodborne illness in the U.S. since the Centers for Disease Control and Prevention began tracking outbreaks in the 1970s.⁵

In the U.S., the estimated total annual cost of listeriosis—this includes medical expenses, decreased productivity, and premature death—is $2.6 billion, making it the third most costly foodborne illness for Americans, behind salmonellosis and toxoplasmosis (a foodborne illness caused by ingesting a parasite).¹²

Characteristics

L. monocytogenes is widespread in the environment, especially in soil and water. The bacteria can survive in soil for many months. Animals, particularly cattle, can carry L. monocytogenes without appearing sick and shed the bacteria in their feces.

The bacteria are able to live in a wide range of conditions and environments—they can tolerate both acidic and salty conditions, both high and low temperatures, and a fairly low moisture content. These characteristics allow L. monocytogenes to survive a long time in a variety of food products and food processing plants. Because the bacteria can multiply and persist in food processing plants for years—even more than 10 years in one documented case—L. monocytogenes is especially hard to control and can result in intermittent contamination of food.^{2, 5, 13}

Unlike most bacteria, L. monocytogenes can grow and multiply at low temperatures, making the bacteria a potential problem even in properly refrigerated food. One study also found a relatively high percentage of frozen raw beef products contaminated with L. monocytogenes.¹⁴ This finding highlights the ability of the bacteria to thrive in cold environments.

How People Become Infected

People become infected with L. monocytogenes by eating contaminated food. People can also become infected by handling contaminated food, such as contaminated pet food, or touching contaminated surfaces and utensils and then accidentally transferring the bacteria from their hands to their mouths. Babies can become infected in utero or at birth if their mothers ate contaminated food during pregnancy.

The bacteria can contaminate a variety of food, such as:

• Raw meat;
• Ready-to-eat processed meat such as hot dogs and deli meat (both factory-sealed packages and products sold at deli counters);
• Raw vegetables;
• Refrigerated pates;
• Ready-to-eat smoked seafood and raw seafood;
• Prepared or stored salads, including coleslaw and fresh fruit salad;
• Melons;
• Soft cheeses made with unpasteurized milk; and
• Unpasteurized milk and milk products.

Pasteurization, cooking, and most disinfecting agents kill L. monocytogenes. However, in some ready-to-eat food, such as hot dogs and deli meats, contamination may occur after the food is cooked in the factory but before it’s packaged. These products can be safely eaten if reheated until steaming hot.

The U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) maintains a zero-tolerance policy for L. monocytogenes in ready-to-eat meat and poultry products. FSIS continues to strengthen programs and recommendations to reduce or eliminate the bacteria from ready-to-eat products.

Listeriosis in People

Listeriosis occurs almost exclusively in pregnant women, newborns, the elderly, and people with weakened immune systems (such as those with cancer or other diseases). After a person ingests L. monocytogenes, the bacteria grow quickly in the liver and then move into the bloodstream and can invade many places in the body, including the:

• Brain;
• Membranes surrounding the brain and spinal cord (called the “meninges”);
• Gastrointestinal, or digestive, tract (the stomach and intestines); and
• Bloodstream.

Pregnant Women and Newborns

Pregnant women are 18 times more likely to get listeriosis than other healthy adults, and 16 to 27% of all L. monocytogenes infections are in pregnant women.¹⁵ Scientists don’t know why pregnant women are so susceptible to the disease. It usually affects pregnant women who are healthy and don’t have other risk factors.

Diagnosing listeriosis in pregnant women is difficult because they usually don’t have the gastrointestinal symptoms—such as vomiting and diarrhea—that are normally seen with a foodborne illness. The most common, and sometimes only, symptom of listeriosis in pregnant women is fever. They often have a flu-like illness with non-specific symptoms, such as fatigue and muscle aches, which are often temporary and go away on their own. Some pregnant women show no symptoms. In a series of 191 cases of listeriosis in pregnancy, over one-quarter (29%) of the women had no symptoms.¹⁵

Compared to listeriosis in non-pregnant people, the disease in pregnant women has a longer incubation period—the length of time between when a person ingests the bacteria and first shows symptoms. In one study, the median incubation period in pregnant women was 27.5 days, with a range of 17 to 67 days.¹⁶ This long incubation period adds to the difficulty in diagnosing listeriosis in pregnant women.

Food Safety for Moms-to-Be: While You’re Pregnant – Listeria (En español)
Food Safety for Pregnant Women (En español)

While listeriosis in the mother is mild, infection in the fetus and newborn can be severe. Listeriosis can develop at any time during pregnancy, and the disease causes miscarriage, stillbirth, premature birth, and life-threatening infection of the newborn, such as a blood infection, respiratory distress or pneumonia, and meningitis (inflammation of the membranes surrounding the brain and spinal cord). Listeriosis is one of the most common causes of meningitis in newborns.¹⁵

With a mortality rate of 20 to 30%, newborns suffer the most serious consequences of listeriosis.¹⁵ They have either early- or late-onset disease depending on when their symptoms first appear.

Non-pregnant People

Healthy children and adults occasionally get listeriosis, but rarely become seriously ill. In healthy, non-pregnant people, listeriosis can cause gastroenteritis—mainly diarrhea—accompanied by a fever. Other symptoms may include vomiting, joint pain, headache, and body pain. This form of listeriosis has a much shorter incubation period, with symptoms typically occurring within 24 hours after a person ingests a high number of the bacteria. The illness is usually mild and goes away on its own. The diarrhea can last up to 5 days.^{2, 3, 13}

The elderly and people with weakened immune systems have a higher risk of getting a more severe form of listeriosis, including:

• Inflammation of the brain (encephalitis)
• Inflammation of the membranes surrounding the brain and spinal cord (meningitis); and
• Infection of the blood.

In a joint risk assessment report on L. monocytogenes in ready-to-eat food, FAO/WHO found that the elderly (people 60 years and older) were 2.6 times more likely to get listeriosis than the general healthy population.²⁰ In the U.S. in 2011, the median age of non-pregnant people diagnosed with a severe form of listeriosis was 71 years.¹³

Symptoms of listeriosis vary depending on the form and can come on suddenly. Symptoms may include fever, muscle aches, severe headache, nausea, vomiting, stiff neck, confusion, loss of balance, and convulsions.^{3, 19}

In contrast to the incubation period for other, more common foodborne illnesses, like salmonellosis, the incubation period for listeriosis can be long and also varies depending on the form. Cases involving a blood infection have a fairly short incubation period, with a median of 2 days. For cases involving encephalitis or meningitis, the incubation period is longer, with a median of 9 days.¹⁶

There is also a skin form of listeriosis that results from intact skin coming into direct contact with the bacteria. The skin form is rare and mostly seen in people with at-risk jobs, such as veterinarians or farmers, who are exposed to sick animals or diseased tissues, especially after an animal has a pregnancy loss caused by L. monocytogenes.^{2, 13}

Update: November 28, 2018

The FDA, along with CDC, state and local agencies, is investigating a multistate outbreak of E. coli O157:H7 illnesses likely linked to romaine lettuce grown in California this fall. The Public Health Agency of Canada (PHAC) and Canadian Food Inspection Agency are also coordinating with U.S. agencies as they investigate a similar outbreak in Canada.

The FDA has been conducting a traceback investigation, reviewing shipping records and invoices to trace the supply of romaine from the place where ill people were exposed to the place where that romaine was grown.

Preliminary traceback information indicates that ill people in several areas across the country were exposed to romaine lettuce harvested in California. Specifically, current evidence indicates this romaine was harvested in the Central Coast growing regions of northern and central California.  

[New Information as of November 28, 2018]

The specific California counties FDA identified in the traceback investigation are:

• Monterey
• San Benito
• San Luis Obispo
• Santa Barbara
• Santa Cruz
• Ventura 

Romaine harvested from locations outside of the California regions identified by the traceback investigation does not appear to be related to the current outbreak.

There is no recommendation for consumers or retailers to avoid using romaine lettuce that is certain to have been harvested from areas outside of the Central Coast growing regions of northern and central California. For example, romaine lettuce harvested from areas that include, but are not limited to the desert growing region near Yuma, the California desert growing region near Imperial County and Riverside County, the state of Florida, and Mexico, does not appear to be related to the current outbreak. Additionally, there is no evidence hydroponically- and greenhouse-grown romaine is related to the current outbreak.

During this new stage of the investigation, it is vital that consumers and retailers have an easy way to identify romaine lettuce by both harvest date and harvest location. Labeling with this information on each bag of romaine or signage in stores where labels are not an option would easily differentiate for consumers romaine from unaffected growing regions.

Recommendation:

Based on discussions with producers and distributors, romaine lettuce entering the market will now be labeled with a harvest location and a harvest date or labeled as being hydroponically- or greenhouse-grown. If it does not have this information, you should not eat or use it.

If romaine lettuce does have this labeling information, we advise avoiding any product from the Central Coast growing regions of northern and central California. Romaine lettuce from outside those regions need not be avoided.

Romaine lettuce that was harvested outside of the Central Coast growing regions of northern and central California does not appear to be related to the current outbreak. Hydroponically- and greenhouse-grown romaine also does not appear to be related to the current outbreak. There is no recommendation for consumers or retailers to avoid using romaine harvested from these sources.

		November 26, 2018  Dear Colleagues,  “The U.S. Food and Drug Administration, along with the Centers for Disease Control and Prevention and state authorities, continues to investigate a multistate outbreak of E. coliO157:H7 infections associated with consumption of romaine lettuce in the U.S. As of Nov. 26, 2018, this outbreak has resulted in 43 people becoming ill in 12 states, with the last reported illness onset date being Oct. 31, 2018. An additional 22 people in Canada have become ill, and the FDA and our partners are also coordinating the investigation with Canadian health and food safety authorities. As we continue to investigate this outbreak, today the FDA is announcing new steps to help consumers better identify where their romaine is grown through voluntary labeling. To prevent additional cases of E. coli O157:H7, on Nov. 20, 2018 the CDC advised the public not to consume romaine lettuce and to destroy any romaine lettuce in their homes. At the same time, the FDA requested that all romaine lettuce on the market, including in restaurants and other commercial establishments, should be withdrawn and destroyed. The FDA made this request because initial information available at that time had not identified a likely source for the outbreak that would allow a targeted request, it was likely romaine lettuce contaminated with E. coli O157:H7 that could cause illness was still available on the market, and a market withdrawal was the fastest way to remove potentially contaminated product. The romaine lettuce industry agreed to comply with the FDA’s request to withdraw any romaine lettuce on the market on that date, and available information suggests this action was effective in removing potentially contaminated romaine lettuce from retail establishments.   Over the Thanksgiving holiday, the FDA continued to investigate the outbreak. Our investigation at this point suggests that romaine lettuce associated with the outbreak comes from areas of California that grow romaine lettuce over the summer months, and that the outbreak appears to be related to “end of season” romaine lettuce harvested from these areas. The involved areas include the Central Coast growing regions of central and northern California. The FDA is continuing tracebacks of romaine lettuce from locations where impacted consumers purchased or consumed romaine lettuce before they became ill in order to identify specific locations that are the likely source of the outbreak and to determine the factors that resulted in contamination. Through laboratory studies we have identified that the E. coli O157:H7 strain causing the outbreak is similar to one that produced an outbreak of E. coli O157:H7 in the fall of 2017 that also occurred in the U.S. and Canada, which was associated with consumption of leafy greens in the U.S. and specifically romaine lettuce in Canada. Based on further discussions with the leafy greens industry and with agricultural authorities, we have begun to narrow the location in which we believe the contaminated romaine in the current outbreak was grown. At the time of the outbreak, the vast majority of the romaine on the market was being grown in the Central Coast region of California. Since, then harvesting of romaine lettuce from this region has ended for the year. Growing and harvesting of romaine lettuce is now shifting to the winter growing regions of the U.S., which include mainly the California desert region of the Imperial Valley, the desert region of Arizona in and around Yuma, and Florida. Romaine lettuce grown in Mexico is exported to the U.S. during the winter months. Smaller quantities of romaine lettuce are grown in other states. At this time, the FDA has no information to suggest any of these growing areas are involved in the current outbreak, which began well before any romaine lettuce from these winter growing locations was available for harvest. In addition, hydroponic romaine lettuce and romaine lettuce grown in green-houses is also marketed in the U.S., but there is no information to suggest these products are implicated in any identified E. coli O157:H7 outbreak.   The FDA believes it was critically important to have a “clean break” in the romaine supply available to consumers in the U.S. in order to purge the market of potentially contaminated romaine lettuce related to the current outbreak. This appears to have been accomplished through the market withdrawal request of Nov. 20, 2018. Knowing the growing origin of produce will continue to play an important role in allowing consumers to avoid contaminated products and facilitating market withdrawals and tracebacks. That’s why we previously called on the romaine lettuce industry to provide unambiguous and clear information to consumers regarding where their lettuce was grown and when it was harvested. To this end, the FDA recently participated in discussions with the major producers and distributors of romaine lettuce in the U.S. and with the major trade associations representing the produce industry regarding product labeling and dating to assure consumers that any romaine lettuce that will come onto the market is not associated with the current outbreak of E. coli O157:H7. The labeling will identify the origin of the romaine based on harvest region, along with the date of harvest. This can improve the ability of the FDA to provide more targeted information to consumers in the event of a future outbreak of illness. The FDA also has commitments from the romaine lettuce industry that such labeling will continue into the future and become the standard for their products.  In addition, the leafy greens industry has agreed to establish a task force to find solutions for long term labeling of romaine lettuce and other leafy greens for helping to identify products and to put in place standards for traceability of product. The task force will also examine information from this outbreak to identify measures that led to its occurrence and how to prevent ongoing safety problems with romaine lettuce. One outcome could be to extend the commitment for labeling for origin and date of harvest to other leafy greens. Therefore, the FDA is issuing the following updated advice as part of our investigation and public warning: Based on discussions with major producers and distributors, romaine lettuce entering the market will now be labeled with a harvest location and a harvest date. Romaine lettuce entering the market can also be labeled as being hydroponically or greenhouse grown. If it does not have this information, you should not eat or use it. If consumers, retailers, and food service facilities are unable to identify that romaine lettuce products are not affected – which means determining that the products were grown outside the California regions that appear to be implicated in the current outbreak investigation — we urge that these products not be purchased, or if purchased, be discarded or returned to the place of purchase. Romaine lettuce that was harvested outside of the Central Coast growing regions of northern and central California does not appear to be related to the current outbreak. Hydroponically- and greenhouse-grown romaine also does not appear to be related to the current outbreak. There is no recommendation for consumers or retailers to avoid using romaine harvested from these sources.   The FDA has urged growers, processors, distributors and retailers to: ·         clearly and prominently label all individually packaged romaine products to identify growing region and harvest date for romaine; and ·         clearly and prominently label at the point of sale the growing region when it is not possible for romaine lettuce suppliers to label the package (e.g. individual unwrapped whole heads of romaine lettuce available in retail stores). We hope that growers, processors, distributors and retailers will join us in our effort to protect consumers by applying these labeling recommendations to their products. We remain committed to identifying ways to decrease the incidence and impact of foodborne illness outbreaks, and will continue to provide updates on our investigation and changes to our advice on romaine lettuce as more information becomes available.” The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products This message is being broadcast by the Division of Communications in FDA’s Office of Regulatory Affairs (ORA). Thank you,

 

Tianeptine is a substance that does not meet the statutory definition of a dietary ingredient and is an unsafe food additive.

Under the Federal Food, Drug, and Cosmetic Act (the Act), dietary supplements must contain at least one “dietary ingredient” but can also contain non-dietary ingredients, subject to applicable requirements. A “dietary ingredient” is a vitamin; mineral; herb or other botanical; amino acid; dietary substance for use by man to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of the preceding substances. Non-dietary ingredients intended for use in dietary supplements must be used in accordance with a food additive regulation or be generally recognized as safe (GRAS). Because tianeptine does not qualify as a dietary ingredient, is not an approved food additive, and is not GRAS, dietary supplements containing tianeptine are adulterated under the Act.

Tianeptine is used as a prescription drug in some European, Asian, and Latin American countries, but it is not approved as a drug in the U.S. The FDA is aware of several serious adverse event reports associated with tianeptine.

Tianeptine is also known as:

• Tianeptine sulfate
• Tianeptine sodium powder
• Tianaa
• Tianna Green
• Tianna Red
• Tianna White

Consumers may inadvertently find themselves addicted to tianeptine and should avoid all products containing tianeptine, especially those claiming to treat opioid use disorder (OUD). Reliance on products with unsubstantiated claims may delay those who suffer from OUD from entering recovery and may put them at greater risk of overdose and death. Consumers with OUD should consult their healthcare provider for treatment options.

By Coral Beach on  November 21, 2018