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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
Schiemann DA. Association of Yersinia enterocolitica with the
manufacture of cheese and occurrence in pasteurized milk. Appl
Env Microbiol 1978;36:274-7.
Vidon DJ, Delmas CL. Incidence of Yersinia enterocolitica in
raw
milk in eastern France. Appl Environ Microbiol 1981;41:355-9.
Yersinia enterocolitica gastroenteritis outbreak--Montreal.
Canada Diseases Weekly Report 1976;2:41-4.
Hughes D. Isolation of Yersinia enterocolitica from milk and a
dairy farm in Australia. J Appl Bacteriol 1979;46:125-30.
Francis DW, Spaulding PL, Lovett J. Enterotoxin production and
thermal resistance of Yersinia enterocolitica in milk. Appl
Environ Microbiol 1980; 40:174-6.
Schiemann DA, Toma S. Isolation of Yersinia enterocolitica
from
raw milk. Appl Environ Microbiol 1978;35:54-8.
Morris GK, Feeley JC, Martin WT, Wells JG. Isolation and
identification of Yersinia enterocolitica. The Public Health
Laboratory 1977;35:217-35.
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.
Washington State Department of Social and Health Services.
Unpublished report.
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.
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.
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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