Frequently Asked Questions About Raw Apple/Juice Cider Contamination

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What has the U.S. government done to prevent future outbreaks of pathogenic E. coli contamination in raw apple juice/cider?

Following two major outbreaks in the fall of 1996, the U.S. FDA held meetings on December 16th and 17th in Washington, D.C. to review the current science and situation and discuss the possibility of pasteurization. They specifically invited many apple juicers from around the country. However, at the meetings, only two people representing consumers were invited and spoke: Caroline Smith-Dewaal of the Center for Science in the Public Interest and Marsha Cohen of Hastings College of Law. The transcripts of the these hearings are available at: http://vm.cfsan.fda.gov/~mow/foodborn.html.

Written public comments were then solicited through February 3, 1997. Since then, the U.S. FDA has been working internally on potential directions. Their initial report is expected to go to the OMB in July, 1997. Note that while U.S. FDA continues to make progress, the states are hesitating to move forward with their own regulations. Due to strict rules about the timing of emergency labeling and receiving feedback on it, the U.S. FDA is not expected to announce changes that can be implemented before the fall, 1997 apple harvesting season.

In the meantime, they have not put in place any outreach campaigns to inform consumers of the risks to children, and no regulations have been put in place.

What has the U.S. Apple Association done to prevent future outbreaks of pathogenic E. coli contamination in raw apple juice/cider?

Since the fall outbreaks of 1996, the U.S. Apple Association has been working on educating cider producers across the country about Good Manufacturing Processes, contamination/sanitation issues, and the benefits of Hazards Analysis and Critical Control Points. They are also drafting their own HACCP plan as an example to benefit their constituents. A HACCP training workshop is planned for January 1998 in Pennsylvania. A workable HACCP plan is under development in Kentucky and expected to be available in the Fall of 1998.

In the meantime, to S.T.O.P.'s knowledge, they have not put in place any outreach campaigns to inform consumers of the risks to children.

For more information on U.S. Apple Association activities, please contact Julia Daly, Director of Communications for the U.S. Apple Association: 703-442-8850.

What have fresh apple juice/cider vendors and/or apple orchards done to reduce the risks to consumers, and particularly children since the fall of 1996?

S.T.O.P. is aware of only one producer of apple juice/cider that has substantially changed its practices. Odwalla has pasteurized all of its fresh apple juice/cider and implemented a producer-to-consumer HACCP program to additionally reduce risks in its other juice products.

The first apple orchard that has substantially changed its practices is McAfee Apple Gardens in Fresno, CA , which has already implemented a full HACCP regimen to reduce the risks in apple produce from farm to fork. They are working aggressively on a partnership campaign which includes the orchard growers, a HACCP-based packing house, the retailer and consumers. Mark McAfee's number is 209-846-9736. Their internet site is www.primuslabs.com/mcafee/home.html.

Which consumers should be most concerned?

An E. coli O157:H7 infection hits children, seniors, the immune impaired and pregnant women most severely. The immune impaired category includes: people who are HIV positive, people undergoing chemotherapy, alcoholics, people with organ transplants, people taking antibiotics, and people taking antacids.

Why should parents and consumers be concerned?

Raw apple juice/cider has been the source of five reported/tracked epidemics since 1991, three of which were related to E. coli O157:H7. Children are the chief consumers of apple juice. Children are also one of the highest risk groups for severe E. coli O157:H7 poisoning. Despite two major outbreaks during the fall of 1996, very little will have changed by the 1997 apple harvesting and raw juice/cider season. Very little has been done to inform consumers of the hazards children face in consuming fresh apple juice/cider. Many consumers may still believe, erroneously, that raw apple juice/cider would be better for their children than pasteurized.

Where can consumers encounter raw apple juice/cider?

Raw apple juice/cider is available direct from manufacturers at orchards or at roadside stands. It is also frequently available on grocery store shelves. If found in grocery stores, it will be in a refrigerated case because the organisms that inhabit raw juice/cider will cause it to ferment or spoil quickly without refrigeration. It may also be sold in specialty retail stores, such as coffee shops or bagel stores, at local farmer's markets, and it may be served in restaurants.

Consumers and particularly parents need to be made aware that their children may also be served raw apple juice/cider at events such as birthday parties, school potlucks, and church gatherings. As recently as the fall of 1996, raw apple juice/cider was even available in some hospital cafeterias.

What about Juice Bars? Could a person get an E. coli O157:H7 infection from a Juice Bar?

Quite possibly. At many juice bars, carrots and other produce such as wheat grass are ground up into a blended juice without having been subjected to a killstep. Once again, any fruit or vegetables which have not been sterilized and can come into contact with fecal matter in any way can harbor microbial contamination. Washing and scrubbing are insufficient practices to eliminate harmful pathogens. Safe Tables Our Priority advises that consumers at highest risk from pathogenic E. coli infections (children, seniors, the immune impaired, pregnant women) not drink juice bar beverages that have not been completely pasteurized.

What can consumers do to reduce their risk of poisoning from E. coli O157:H7 by raw apple juice/cider?

To prevent future tragedies, Safe Tables Our Priority strictly recommends that the groups most likely to be affected by E. coli O157:H7(children, seniors, the immune impaired and pregnant women) purchase and drink only pasteurized apple juice/cider. To reduce their risks, consumers outside of these high risk groups should either:

• drink only pasteurized apple juice/cider;
  
  
• purchase raw apple cider/juice made from HACCP certified, cross-contamination-free fruit;
  
  
• or boil raw cider.
  
  

Allowing the raw juice/cider to ferment may help to reduce the risk of infection as scientists speculate that a certain level of alcohol is believed to kill off bacteria.

When you say a juice must be "pasteurized," what do you mean? What is the correct level of pasteurization?

Webster's defines pasteurization as :

...a method devised by Pasteur to check fermentation (as in wine or milk) involving the partial sterilization of a substance (as a fluid) at a temperature and for a length of time that does not greatly change its chemical composition but does destroy many pathogenic organisms and other undesirable bacteria though spores and thermoduric organisms (as lactic acid bacteria) survive.

Loosely, scientists sometimes refer to other processes that achieve the same effects as pasteurization processes as well.

The adequacy of any pasteurization process is based on a combination of:

• the temperature to which a product is heated;
  
  
• the length of time to which the product is subjected to that heat; and
  
  
• the number and type of organisms intended to be eliminated.
  
  

Thus, if 161 degrees for 15 seconds is adequate to kill an organism, it is possible that heating it to 200 degrees, if only briefly, may also kill the organism. A specific level of pasteurization is usually measured in terms of the number of "log kills" that are achieved; typically, for a microbiologist, a 5 or 6 log kill step is considered sufficiently conservative to eliminate presently identified bacteria that would seriously sicken a human being. The combinations of adequately conservative time and temperature are known as "thermal curves."

However, such a process does not eliminate all bacteria. Specifically, certain bacteria and fungi form spores which are resistant at "lower" temperatures. These often play a role in spoilage of products rather than in illness. Thus, a distinction might be made between juices that have been "only" pasteurized and juices that have been truly sterilized to create shelf stable products. Juice packed in popular children's juice boxes, for example, will be heated to even higher temperatures and packaged under more sterile conditions than juice that is simply pasteurized.

For consumers to be confident that their products have been through a killstep, they should look for the word "pasteurized" on the label. As of the summer of 1997, use of the word "pasteurized" on labels is strictly voluntary.

Can a juice vendor really guarantee that its pasteurized juice is pathogen free?

In truth, while a juice producer might put juice through a pasteurization killstep and seal the product at that time to ensure its safety, it is possible that the product could be subsequently contaminated in transportation or at the time of its opening. Thus, pasteurized juice producers are reluctant to guarantee that their products are 100% safe.

What can consumers do to reduce their risk of poisoning from E. coli O157:H7 by individual apples?

Consumers should insist that their retail stores provide them with fruit that has been certified as having gone through a strict, farm-to-fork HACCP program. As of July, 1997, the only orchard S.T.O.P. knows that has put this type of program in place is McAfee Apple Gardens in Fresno, CA.

Who is resistant to a warning label that accurately informs consumers of the risks of E. coli O157:H7 infection?

Raw apple juice/cider vendors are resistant to a consumer education plan that would include warning labels.

Why would raw apple juice/cider vendors not want to have a warning label placed on their products?

In some cases, it is possible raw apple juice/cider vendors believe they personally will not be responsible for another outbreak; therefore, despite the fact that they may not have changed their processes, they believe that a warning label will either reduce their sales or cause an image problem or a combination of both. In other cases, they would like to believe that not enough evidence is yet in to support warning consumers. In either case, should another outbreak occur, the entire industry will suffer from lack of consumer confidence, and every individual within the raw apple juice/cider industry should be held responsible for knowing that they could have prevented another tragedy, but didn't.

Where are the next E. coli O157:H7 in raw apple cider/juice outbreaks likely to occur?

It is impossible to accurately predict where an outbreak is likely to occur. However, certain criteria should be considered when looking for the next potentially reported outbreak. These criteria include:

• a past history of raw apple cider related outbreaks,
  
  
• a density of small raw juice/cider vendors,
  
  
• changes or lack of changes that vendors have put in place,
  
  
• ignorance on the part of consumers,
  
  
• a medical establishment with the experience to identify the symptoms and illnesses that develop, and
  
  
• the presence of national foodborne illness surveillance centers.
  
  

As a result, S.T.O.P. considers the next epidemics related to E. coli O157:H7 tainted raw apple juice/cider will be most likely to be identified in the states of California and Washington and the region of New England.

What are the key initial symptoms of an E. coli O157:H7 infection in a child?

Severe abdominal cramps and frequent watery diarrhea. The diarrhea may or may not appear bloody and often arises with no fever or a very mild, brief fever. Additional symptoms include vomiting. Because these symptoms are often erroneously associated with the flu, parents needs to be cautious in accepting a diagnosis of flu from a pediatrician. The loss of fluids is so substantial that children can easily lose 10% or more of their body weight in a few days. Many of these children appear to doctors for administration of IV fluids for dehydration even before they are diagnosed.

What complications may arise from such an infection?

Statistically, 1 in 20 cases of pathogenic E. coli infections go on to become full-blown Hemolytic Uremic Syndrome, for which treatment is merely supportive, not curative. If a child is diagnosed with HUS, ideally they should immediately be transferred to a hospital with a full array of pediatric subspecialists on staff, preferably one with a pediatric intensive care unit. This blood disorder can attack all organ systems in an unpredictable, insidious manner. Typically, the first organs to fail are the kidneys. Careful fluid management and dialysis provide supportive care. Plasma exchange therapy may be indicated if damage is not restricted to renal involvement. Additional disease complications that can arise include: strokes, paralysis, heart failure, respiratory distress, intestinal perforations, pancreatic damage and death. Should a child survive, he or she often sustains major physical impairment or faces a lifetime risk of developing renal failure or diabetes.

What medical tests can help determine whether a person has an E. coli O157:H7 infection?

The most frequently used test for O157:H7 is known as the MacConkey-Sorbitol test and is performed as a stool culture requiring 24 to 48 hours before results. Unfortunately, in many cases, 48 hours is too long. By refining the E. coli O157:H7 grown from such a stool culture, research labs can then examine the genetic material of the bacteria through DNA fingerprinting and isolate whether it is similar to the genetic material of other cases and is therefore common to an epidemic.

There are two, slightly more expensive, stool tests available:

• Meridian's Premier EHEC EIA, which requires 16 hours of stool culture, but works on both stools and meat; and
  
  
• MicroCarb's VeroTest, which requires 3 hours.
  
  

These tests look to identify the toxin produced by the bacteria rather than the bacteria itself. As a result, these tests will more accurately pinpoint toxic E. coli strains other than O157:H7 as well.

There is also a blood test available through reference laboratories such as the Centers for Disease Control and Prevention. Known as the "Antibodies to O157 lipopolysaccharide" test, this test checks for antibodies that are developed after a person is exposed to E. coli O157:H7. It can prove that the person once had an E. coli O157:H7 infection but will not help identify when the infection occurred or whether there was common source with other infections.

The timing of these tests is absolutely critical; they must be performed before the bacteria are shed from the body. Unfortunately, many physicians are unaware of the newer tests, and the frequent, preliminary misdiagnosis of these infections means that by the time the tests are performed the bacteria are already shed from the body.