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The Hazards of Raw Apple Juice/Cider

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Safe Tables Our Priority



Contents

Why Care About Raw Apple Juice/Cider?

E. coli O157:H7-- A Form of Fecal Contamination

Common Raw Juice Industry Practices-Hazardous Results

Fuel for Epidemics

How to Save Children

What Could the Government Do?

In Conclusion


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Health, Safety, Nutrition and Kids


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E. Coli Infections: What Parents Should Know and Do


Why Care About Raw Apple Juice/Cider?

Whether it is called "fresh cider" on the East Coast or "fresh apple juice" on the West Coast, raw apple beverages have been identified as a repeated source of bacterial contamination that has killed and maimed children in over five states. The bacteria E. coli O157:H7 was the cause of illness in raw apple juice/cider epidemics originating in Massachusetts in 1991, in Connecticut in 1996 and across the Northwest in 1996. Additional outbreaks caused by Cryptosporidium occurred in raw juice/cider in 1993 in Maine and in 1996 in New York.

Pathogenic E. coli represent a particular hazard to children, seniors, the immune impaired and pregnant women. Unfortunately, children are also the primary consumers of apple juice. Parents often begin feeding their children apple juice as early as their first birthday, and the worst devastation of a pathogenic E. coli infection is correlated with younger age.

Many physicians mistakenly dismiss the initial E. coli infection symptoms of frequent watery diarrhea and severe stomach cramps as the flu. Because small children have difficulty in describing their agony, pediatricians and parents are left to interpret what they believe is happening. In a recent raw juice outbreak, two children were turned away from Emergency Rooms because they were not deemed to be sick enough. Health care cost reductions conspire against diagnosis by discouraging physicians from ordering the full panel of foodborne stool and blood tests. As the infection progresses, the diarrhea can turn red with blood.

An estimated 1 in 20 children infected by E. coli O157:H7 go on to develop a catastrophic blood and kidney disorder called "Hemolytic Uremic Syndrome." Deadly toxins produced by E. coli O157:H7 penetrate the blood stream and set up a cascade of damage similar to that of rattlesnake venom. At first, red blood cells and individual platelet are shredded, leaving the victim vulnerable to brain hemorrhaging and uncontrolled bleeding. Preliminary treatment can consist of blood transfusions or plasma replacement. Clots form in the bloodstream, blocking the minute filtration vessels in the kidneys, the middle layer of the heart and the brain. As the kidneys cease to function, the body swells with excess waste fluids, necessitating dialysis. Life threatening complications often involve the cardiopulmonary, neurological and gastrointestinal systems and can appear as strokes, paralysis, heart failure, or intestinal perforations. At any point along the way, the victim can easily die even if he/she receives proper treatment.

Thus, a pathogenic E. coli infection in a child is a devastating illness. Even if a child survives, he/she suffers the life sentence of a host of potential significant long term complications, including the possibility of having kidneys fail before the victim reaches adulthood. Yet, raw juice/cider E. coli O157:H7 poisoning of children is completely preventable.

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E. coli O157:H7-- A Form of Fecal Contamination

For raw apple juice/cider to become contaminated with E. coli O157:H7, the apples or juice must come into contact with animal fecal material or elements of an animal's gastrointestinal tracts. Both cattle and deer are known to be reservoirs of pathogenic E. coli. Less common practices for apple orchards that could result in contamination might involve applying raw cattle manure as a fertilizer or allowing cattle to graze in the orchards where they would then shed feces. Unpotable water used for overhead spray irrigation of an orchard could also be contaminated by either farm or wild animal feces.

For apple orchards, deer present a particular challenge because of their ability to jump fences as high as six feet. Some scientists suspect that if pathogenic E. coli can persist in the lower gastrointestinal tract, the bacteria can easily be found in the upper GI tract or even the mouth of the same animal. Thus, animals such as deer which could easily reach apples on trees might even spread the bacteria to apples with their mouths.

Proximity of animal feces may also play a role. A recent study showed that pathogenic E. coli can survive in soil for at least 18 weeks. Dale Hancock of Washington State University is presently investigating the potential for contamination from windblown dust such that all it would require is that cattle or deer live in proximity to an orchard. Studies have also shown that flies and birds can carry E. coli O157:H7; once again, bacteria from fecal material on the ground or nearby could thus be transferred to apples on a tree. In short, while the exact route of transmission is not defined, it is clear that multiple potential routes increase the likelihood of contamination.

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Common Raw Juice Industry Practices-Hazardous Results

While raw apple juice/cider has been sold for over 200 years in the United States, deadly strains of E. coli bacteria have emerged and been identified only in the last 15 years. The bacteria's virulence is believed to be a result of its rapid mutation. Years ago, it was naively assumed that the bacteria could not survive in raw apple juice/cider because of its high acidity (in the 1991 outbreak, the cider had a pH value of 3.7 to 3.9). Since then, it has been proven that some strains can survive in media with pH as acidic as 2.0 As a result, common juice/cider industry practices that have existed for decades are causing problems that never existed before.

The apple juice industry frequently uses apples that have fallen on the ground in the production of cider/juice despite implications that fallen apples are more likely to become contaminated with dirt and animal waste. These apples are believed to make some of the sweetest juice and usually cannot be sold as individual apples because they appear to be too old or damaged. As a result, turning such apples into juice is a way for apple juice/cider vendors to turn losses into profits. Unfortunately, while pasteurized juice from dropped apples does not represent a particular danger, raw unpasteurized juice produced from grounders does.

Even if grounders are not used, current harvesting, packing and juicing practices aggravate the possibility of contamination. Pickers can track fecal material from soil onto ladders rungs with their shoes and then grab ladder rungs with their hands before picking the fruit. Empty crates and baskets placed on the ground or tipped over can pick up soil and contaminants and transfer it to recently picked fruit. When the apples arrive at an open air packing shed they can be left exposed to fecal material from birds flying in and out. The water in which apples are floated in flumes to be packed can similarly become contaminated by birds, insects or dust.

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Fuel for Epidemics

Because of the virulence of pathogenic E. coli, it takes very few organisms to make a child seriously ill. When contaminated apples are combined in a mash or juice consisting of tens, hundreds or thousands of gallons, the bacteria can be distributed widely to a large number of consumers. Parents may easily misperceive an E. coli infection that clears up quickly as a brief diarrheal episode and not even take their children to see a physician. Physicians may or may not diagnose the disease correctly or order the appropriate tests. Typically, by the time the patient is sick enough to seek medical attention, a short two day window of opportunity exists to successfully isolate the bacterium in a stool culture.

Because so few bacteria may be involved, if a test is not performed at exactly the right period of infection, the bacteria may already have been shed from the body and the test results will come back negative.

It takes a major outbreak for national health authorities to become involved and identify the source of an epidemic. Multiple cases must be identified--usually in children because they are so susceptible to the bacteria. The cases must then be reported to health authorities by doctors who are busy and may or may not perceive an epidemic under way. Epidemiologists must then be sent quickly to investigate the potential sources. Because an E. coli O157:H7 infection incubates for between 3 and 10 days and because it can take even longer for the illness to be diagnosed, by the time consumers speak with epidemiologists, consumers may or may not accurately remember having consumed a specific food product. The end result is that the number of cases of pathogenic E. coli infections is grossly underreported.

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How to Save Children

The Centers for Disease Control and Prevention offers a very basic cautionary statement on raw apple juice/cider:

"Until alternative effective methods can be developed, consumers (especially those at highest risk, which include children and the elderly) can reduce their risk for enteric infections by drinking pasteurized or boiled apple cider and juice."

Safe Tables our Priority, which considers its mission to be one of preventing tragedies before they happen, would go one step further:

To avoid potentially deadly poisoning by raw apple juice/cider, a repeated source of E. coli O157:H7 contamination, children, seniors, the immune impaired and pregnant women should drink only pasteurized apple juice/cider.

Likewise, it is critical that parents understand that it is unacceptable to bring raw apple juice/cider to school, religious and other functions where it may be unwittingly served to children who would then be poisoned by it. Unfortunately, as the fall of 1997 approaches, many consumers remain completely in the dark about the facts about raw apple juice/cider and naively assume that raw apple juice/cider might actually be healthier for children than pasteurized juice. They are wrong. Dead wrong. Only products that have been specifically treated to eliminate pathogenic E. coli can be considered safe enough. The safest apple juices available today have been pasteurized.

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What Could the Government Do?

While there are many steps the government could take, there are two which are unlikely. First, the government could outlaw the practice of using grounders or dropped apples in unpasteurized apple juice/cider. Unfortunately, as has already been described, it is quite possible that tree-borne fruit could become contaminated. Indeed, in a recent outbreak, the juice processor had legally specified in its contracts that none of the fruit supplied to it should be grounders. Thus, the government knows, and consumers need to know, that just because a raw juice processor "promises" that its raw apple juice/cider is safe, safety cannot be guaranteed.

A second step would be to mandate pasteurization of all apple juice/cider. This would be the safest possible step the government could take. Yet, it would put some raw apple juice/cider suppliers out of business and eliminate a product from the market which some adults can drink with minimal impact.

Safe Tables Our Priority believes that two critical steps must be taken. The first is an education campaign which would notify parents in particular of the hazards of raw apple juice/cider. No child should be unwittingly poisoned by raw apple juice/cider without his parent having been adequately informed of the risks--this is simply the worst possible case of ďcaveat emptor.Ē No parent should have to worry whether raw apple cider/juice might be served at a party his child attends. The least expensive education campaign would be a warning label on raw apple juice/cider.

The second is the institution of HACCP (Hazards Analysis and Critical Control Point) practices throughout the apple industry to dramatically reduce the likelihood of any E. coli contamination. As already described, a person can be poisoned by pathogenic E. coli contamination on a single apple. Apple harvesting practices cannot continue as they have for the last 200 years.

In the production of raw apple juice/cider, reducing risks of contamination through HACCP would be a significant step forward, but no HACCP program by itself would eliminate risks in juice without what is commonly known as a "kill step." HACCP programs must be instituted by management and require a complete commitment on the part of an entire organization "from farm to fork." Because of the folds of an apple, bacteria can easily "hide" around the stem of the fruit and avoid contact with brushing, scrubbing or washing.

Within HACCP, one absolutely critical step to help ensure risk reduction is that of testing the product at various points along the way for potential contamination. A positive test result indicating contamination raises a red flag that the contamination has occurred since a previous test point and identifies places where processes need to be more stringent. However, a negative does not mean that the product is guaranteed to be pathogen free. If a scientist samples the skin of an apple, he may miss the bacteria on the other side or on a different apple. If a scientist pulls a juice sample that within two days appears to be free of contamination, he may have completely missed hundreds or even thousands of E. coli bacteria that resided in a different section of the same batch. Consumers should therefore demand raw products that have been HACCP risk reduced, but understand that only products that have been put through a kill step have been specifically treated to eliminate pathogens.

In juice, a kill step typically consists of a process in which the juice/cider is sterilized at a temperature and for a time that science indicates kills living microbes. While other methods are presently under investigation throughout the industry, including additives, irradiation, high pressure treatment, light treatment and others, for children, the critical kill step today for apple juice/cider is pasteurization.

Unfortunately, the time has grown short for implementation of either a national consumer education awareness campaign or HACCP standards for raw apple juice/cider. Few producers have made the necessary changes to eliminate contamination from their products since the fall of 1996. Safe Tables Our Priority's concern is that children may pay the price.

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In Conclusion

Safe Tables Our Priority advises that children, seniors, pregnant women and the immune impaired drink only pasteurized apple juice/cider. Hard apple juice/cider, e.g. cider, which has been fermented and which should generally not be served to children because of its alcohol content, is speculated to be safer than raw, unfermented apple juice/cider because the alcohol content is believed to kill off bacteria.

Visit S.T.O.P.'s website for further information

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