Epidemiologic Notes and Reports Multi-State Outbreak of Yersiniosis

Between June 11 and July 29, 1982, a large interstate outbreak of enteritis caused by Yersinia enterocolitica occurred. State health departments became aware of a potential problem when hospitals reported increased numbers of Y. enterocolitica isolates. Epidemiologic investigation implicated milk pasteurized at a plant in Memphis, Tennessee, as the vehicle of infection.

One hundred seventy-two culture-positive Y. enterocolitica infections were identified: 67 in the Little Rock, Arkansas, area; 80 in Memphis, Tennessee, and its northern Mississippi suburbs; and 25 in the Greenwood, Mississippi, area. One hundred forty-eight (86%) patients had enteric infections with diarrhea and/or abdominal pain, usually accompanied by fever; 24 patients had extra-intestinal infections of throat, blood, urinary tract, central nervous system, and wounds. Forty-one percent of cases occurred among children less than 5 years of age. Most patients required hospitalization, and 17 underwent appendectomies. The epidemic strain is agglutinated most strongly by antisera to Y. enterocolitica O groups 13 and 18.

Separate case-control studies in each city showed that drinking milk pasteurized by a milk plant in Memphis was associated with illness (in Little Rock, p = 0.03; in Memphis, p = 0.01; in Greenwood, p = 0.004). Overall, 71% of cases and 39% of controls recalled drinking milk from the plant in the 2 weeks before onset of symptoms.

In an effort to estimate the size of the outbreak, a survey was made by telephone of 100 randomly chosen households in Greenwood. Heads of households were queried concerning illness and milk drinking history within the last two months. Eleven cases of yersiniosis-like illness, defined as either 1) fever greater than or equal to 101 F (38.3 C) and diarrhea or 2) fever greater than or equal to 101 F and abdominal pain at any time during the previous 6 weeks, were identified among the 260 members of these households. All patients resided in households that used milk from the implicated plant, and 10 of the 11 (91%) recalled drinking its milk within the previous 2 months. Illness occurred in 6 of 50 (12%) households that used milk from the implicated plant and in none of 50 that did not use its milk (p=0.02, Fisher's exact test). Of those individuals who drank milk from that plant, 8.7% had a yersiniosis-like illness. Based on a census of 20,115 and the number of the Memphis plant milk drinkers in Greenwood, it was estimated that 857 cases (95% confidence limits 363.5-1,351.7) may have occurred in Greenwood where only 3.9% of the plant's milk is sold. The total number of cases in all three states, therefore, would appear to be higher than the 172 cases reported.

The outbreak appeared to end spontaneously. Milk from suspected lots was not available for culture, and Y. enterocolitica was not isolated from subsequent lots. A Food and Drug Administration laboratory isolated Y. enterocolitica of the same serotype found in the outbreak from a milk crate on a hog farm where outdated milk from the implicated plant is fed to hogs. Inspection of the plant identified neither a breach in pasteurizing technique nor an obvious source of contamination. Surveillance for new cases and surveillance of milk for Yersinia have continued. Reported by JP Lofgren, MD, State Epidemiologist, Arkansas State Dept of Health; C Konigsberg, MD, R Rendtorff, MD, V Zee, MPH, Memphis-Shelby County Health Dept, RH Hutcheson, Jr, MD, State Epidemiologist, Tennessee State Dept of Public Health; A Rausa, MD, D Brower, District Health Office, Greenwood, WE Riecken, Jr, MD, State Epidemiologist, Mississippi Dept of Health; Food and Drug Administration; Field Services Div, Epidemiology Program Office, Family Planning Div, Center for Health Promotion and Education, Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: In this investigation pasteurized milk was epidemiologically implicated as the vehicle of transmission of Y. enterocolitica. The temporal and geographic clustering of cases and the negative cultures of subsequent lots of milk are consistent with contamination of a single lot. The mechanism of contamination is unknown.

Y. enterocolitica may be found in raw milk (1,2); contaminated raw milk was responsible for an outbreak of yersiniosis among children in Montreal (3). The organism has also been found in pasteurized milk (1,4) although not associated with illness. Y. enterocolitica generally does not survive standard pasteurization (5); however, if present in large enough numbers, viable Yersinia may persist after pasteurization (4-6). Once present in a pasteurized product, the organism grows well at refrigeration temperature (7). Therefore, pasteurization and proper handling of pasteurized milk may not ensure against enteric disease due to Y. enterocolitica.

Only two other well documented food-borne outbreaks of Y. enterocolitica enteritis have been reported in the United States: one in New York state in 1976 caused by contaminated chocolate milk (8) and one in Washington state in 1982 caused by tofu (9). Food-borne transmission of yersiniosis has also been suspected in other outbreaks (10-12). This is the largest outbreak of yersiniosis ever reported in the United States.

References

1. Schiemann DA. Association of Yersinia enterocolitica with the manufacture of cheese and occurrence in pasteurized milk. Appl Env Microbiol 1978;36:274-7.

2. Vidon DJ, Delmas CL. Incidence of Yersinia enterocolitica in raw milk in eastern France. Appl Environ Microbiol 1981;41:355-9.

3. Yersinia enterocolitica gastroenteritis outbreak--Montreal. Canada Diseases Weekly Report 1976;2:41-4.

4. Hughes D. Isolation of Yersinia enterocolitica from milk and a dairy farm in Australia. J Appl Bacteriol 1979;46:125-30.

5. Francis DW, Spaulding PL, Lovett J. Enterotoxin production and thermal resistance of Yersinia enterocolitica in milk. Appl Environ Microbiol 1980; 40:174-6.

6. Schiemann DA, Toma S. Isolation of Yersinia enterocolitica from raw milk. Appl Environ Microbiol 1978;35:54-8.

7. Morris GK, Feeley JC, Martin WT, Wells JG. Isolation and identification of Yersinia enterocolitica. The Public Health Laboratory 1977;35:217-35.

8. Black RE, Jackson RJ, Tsai T, et al. Epidemic Yersinia enterocolitica infection due to contaminated chocolate milk. N Engl J Med 1978;298:76-9.

9. Washington State Department of Social and Health Services. Unpublished report.

10. Olsovsky Z, Olsakova V, Chobot S, Sviridov V. Mass occurrence of Yersinia enterocolitica in two establishments of collective care of children. J Hyg Epidemiol Microbiol Immunol (Praha) 1975;19:22-9.

11. Asakawa Y, Akahane S, Kagata N, Noguchi M, Sakazaki R, Tamura K. Two community outbreaks of human infection with Yersinia enterocolitica. J Hyg (Lond) 1973;71:715-23.

12. Shayegani M, Morse D, DeForge I, Root T, Parsons LM, Maupin P. Foodborne outbreak of Yersinia enterocolitica in Sullivan County, New York, with pathologic studies of the isolates. Abstracts of the Annual Meeting of the American Society of Microbiology, 1982, No. C175.

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