Life-Threatening Food Poisoning
by Kenneth Lyen
INTRODUCTION
In the five months from July to November 2018, there were six major outbreaks of food poisoning in Singapore, affecting about 878 people, and causing one death. According to the Ministry of the Environment, there has been a dramatic increase in the number of reported cases of food poisoning.
SPIZE RESTAURANT (Watch video right at the very end of this blog)
In the case of Spize Restaurant along River Valley Road, 82 diners suffered food poisoning, and there was 1 death. Salmonella typhi was isolated from the blood and stools of 36 symptomatic diners, as well as from some of the food, including the bento set boxes. Four other pathogens were also found. A food handler was positive for norovirus, and another was positive for campylobacter. Faecal coliforms and bacillus cereus were found in the belacan fried rice and a chopping board. Lapses in hygiene were discovered, including leaving food uncovered in a chiller, not providing soap for hand-washing, employing 7 unregistered food handlers, and preparing food outside the licensed kitchen area.
The person who died, Mohamad Fadli, had delayed eating the food delivered to his office in a bento box around 11:30 am on 6 November 2018. Instructions on the box stated that the food had to be eaten within an hour of delivery. Apparently he did not eat the food until 3 or more hours after the delivery, and the food was not refrigerated. This delay enabled the salmonella bacteria to multiply and contributed to the severity of the food poisoning.
According to TodayOnline, that night, "at about 8.30pm, Fadli began experiencing stomach pains. He had multiple bouts of diarrhoea and vomited throughout the night... The following morning (7 November) he had developed a fever of 39.9°C, body aches and nausea. The doctor prescribed him medicine, but advised him to go to the accident and emergency department of a hospital if his symptoms did not improve or if he developed new ones. At 3pm on November 8, two days after eating from the bento box, Fadli fell unconscious and was taken to Sengkang General Hospital by ambulance. He was warded in the intensive care unit from then until Nov 14, when he went into cardiac arrest. He was declared dead at about 7.20pm. His official cause of death was sepsis and multi-organ failure arising from acute gastroenteritis."
Salmonella typhi is the same organism isolated in the infamous New York 19 century outbreak of food poisoning spread by “Typhoid Mary” (see below).
EARLY SYMPTOMS OF FOOD POISONING
Abdominal pain, vomiting and diarrhea are the commonest symptoms of food poisoning. This may be accompanied by headache and fever. There may also be fatigue, sleepiness, aches and pains.
CAUSES OF MASS FOOD POISONING
Mass food poisoning can be due to bacteria, viruses, parasites or toxins. We need to go into each stage from food production to presentation of food on the table.
a) Food Source
Vegetables grown in soil can be contaminated by bacteria. Similarly, raw or poorly cooked foods like sushi, sashimi, raw eggs, and meats can also carry bacteria.
b) Initial Food Storage
According to the Food Safety Council, “the temperature range between 5°C and 60°C is known as Temperature Danger Zone because in this zone food poisoning bacteria can grow to unsafe levels”. Bacteria like Escherichia coli can divide every 20 minutes. In just 7 hours one bacterium can generate 2,097,152 bacteria, in just one more hour the number of bacteria will have risen to 16,777,210, and in 10 hours it will generate a colossal 1 billion cells. Thus food should either be stored below 5°C or above 60°C
c) Food Preparation
Cutting boards, countertops and utensils that are not cleaned and sanitized properly can infect the raw food that are prepared on them.
d) Food Handling
Food handlers carry bacteria on their hands. Hence they should wash their hands frequently. What is sometimes forgotten is that 50 percent of healthy people carry staphylococcus organisms in their nasal passages and throats, as well as their skin and hair. Rubbing a runny nose and then touching food can introduce the bacteria into cooked food.
e) Second Food Storage
Food prepared by caterers or by restaurants for banquets are often kept for some time before they are consumed. Food should either be stored very cold or very hot, but never warm or at room temperature.
Conclusions
A lapse in any of the above stages of food growth, storage and handling can lead to food contamination. The rise in food poisoning in Singapore must therefore be due to carelessness in one or more of these steps. Negligence can result in pain, hospitalisation, and sadly, the occasional death.
CAUSES OF LIFE-THREATENING FOOD POISONING
DEHYDRATION
Worldwide, diarrhoea is the second leading cause of death in children under 5 years old. Over 2,000 children die every day. In Singapore, the commonest organism responsible for the diarrhea is E. Coli. When you lose too much fluids, your blood pressure drops, and blood flow to the liver, kidneys and intestines declines. The organs are damaged because of the diminished supply of oxygen and nutrients. This results in liver and kidney failure, and ultimately, death. Treatment is by rehydration, either orally or by intravenous drip.
HAEMOLYTIC-URAEMIC SYNDROME
In 2011, I was booked to attend a pediatric course in London when there was an outbreak of food poisoning affecting 3,902 people with 53 deaths in Europe, Canada and the USA. The culpable organism for this outbreak was a new strain of the bacterium Escherichia coli 0104:H4.
Spanish cucumbers, raw tomatoes, lettuce and bean sprouts were blamed as the source of this bacterial outbreak, but they all turned out to be negative. Eventually the organism was traced to fengreek seeds from Egypt, although the Egyptian Minister for Agriculture denies this.
Symptoms included abdominal cramps, bloody diarrhea, fever and vomiting. Most of the deaths were from kidney failure due to a disease known as hemolytic uremic syndrome (HUS). Treatment is by kidney dialysis, platelet transfusion.
There was no way I was going to London in summer and not eat salads. So I took life in my own hands.
Some 7 years later, on 28 November 2018, the US Centre for Communicable Diseases issued a warning not to eat romaine lettuce because they found an outbreak of E Coli 0157:H7 food poisoning affecting 43 persons to date. One of them developed haemolytic uraemic syndrome.
SEPTICAEMIA
When bacteria enters the bloodstream, it can spread everywhere can cause widespread inflammatory response resulting in lowered blood pressure and shock. The mortality from septic shock is almost 50%, One of the commoner organisms is salmonella, and this can be found in uncooked eggs and meats.
TOXIC MEGACOLON
One of the complications of salmonella infection is toxic megacolon, which causes abdominal bloating and pain, and if untreated, will lead to shock and death. Treatment is the use of steroids, antibiotics, and possibly surgical removal of the affected colon.
MENINGITIS
Listeria is a bacteria that can be ingested with uncooked meats, vegetables, apples and rock melon. In April 2018, the World Health Organisation confirmed that rock melons from Australia were contaminated with listeria, which caused 6 deaths.
HEPATITIS
Hepatitis A can be found in oysters and scallops. It causes hepatitis which is characterized by fever, fatigue, loss of appetite, nausea and vomiting, abdominal pain, jaundice and dark urine. In severe cases it can cause liver failure and death. Hepatitis A can be prevented by vaccination.
PARALYSIS AND SEIZURES
The puffer fish or fugu is a rather idiosyncratic and slightly bizarre Japanese delicacy. Because if incorrectly prepared it can kill you. Last year I was invited by a good friend to try this delicacy in a Singapore Japanese restaurant, and it was very tasty, and luckily I survived. The poison is tetrodotoxin, a sodium channel blocker which inhibits the firing of action potentials in nerve cells by binding to the voltage-gated sodium channels in the membranes. This stops the nervous system from carrying messages and leads to muscle paralysis. If the diaphragm is paralysed, one cannot breathe, and ultimately it can result in seizures and death.
REYE SYNDROME
In October 1988, I received a phone call from the Ministry of Health in Malaysia asking if I were available to fly to Perak to help them investigate a mysterious outbreak of vomiting, fever, diarrhea, abdominal pain, seizures, and coma, that had affected 16 children and one adult. Initial laboratory findings suggested a pediatric condition called Reye Syndrome, which affects children’s brain and liver.
Ultimately 13 children died, and postmortem confirmed the encephalopathy of the brain, necrosis of the liver and the kidneys. No infection was isolated, and there was no trace of aspirin. However toxicology subsequently showed abnormally high levels of boric acid, a banned food additive, and aflatoxin, a poison produced by a fungus that must have contaminated the stored ingredients.
HOW TO PREVENT MASS FOOD POISONING?
There were many lapses in food hygiene and storage discovered after the Spize Restauarant food poisoning, and the authorities were asked how come these slip-ups were not discovered earlier? The official replied that there were too many food preparation establishments to inspect.
I do not buy this explanation. Take medical clinics, for example. They are tightly regulated and they are regularly inspected by nurses. I think the relevant authorities need to tighten up on regular inspections of food joints.
Caterers and restaurants should be reminded that they should not leave food around uncovered and unrefrigerated for inordinately long periods. Education is important, and food handlers must be taught how to be extremely meticulous in handwashing, especially after visiting the toilet. They need to know how to recognize raw or undercooked food, and how to store food properly. All surfaces, containers, plates, bowls, utensils need to be washed carefully and kept clean. Only licensed and trained handlers should be allowed to prepare and handle food. They should also be regularly checked to see if they are carrying any organisms.
TYPHOID MARY (1869-1938)
Perhaps the most famous infectious disease carrier is Mary Mallon, nicknamed “Typhoid Mary”. She was an asymptomatic carrier of salmonella typhi, the bacterium that causes typhoid fever. She is said to have infected 51 people, of whom 3 died. Emigrating from Ireland to the United States, she found work as a cook. Mary was working at Manhattan’s Sloan Maternity Hospital when 25 people developed typhoid fever and 2 died. The epidemic was traced to the hospital’s cook, “Typhoid Mary”. However, she changed her name to Mary Brown and managed to disappear. The New York health department was unable to trace her. In the meantime she worked at hotels, restaurants and institutions. Finally they caught up with her and quarantined her. Mary spent her final 23 years as a virtual prisoner in forced isolation.
THE HYGIENE HYPOTHESIS RECONCEIVED
The Hygiene Hypothesis was originally expounded by Dr David Strachan in 1989, and it stated that the increase in allergies in recent decades is related to the excessive cleanliness and hygiene in both diet and environment. Unfortunately there has been no evidence to support this relationship, and so the hypothesis is being abandoned.
But let us not throw the baby out with the bathwater. Let us reconceive this Hygiene Hypothesis and borrow it to explain the recent rise in mass food poisoning. In the past, our diet and our environment was dirtier, and our food was contaminated by many bacteria, viruses, parasites and even toxins. The benefits of early exposure to these organisms and toxins, it is hypothesized, has helped us generate some immunity to many of these germs. This enabled us to tolerate food poisonings, or perhaps develop milder symptoms.
In recent decades, especially in the more developed countries, there has been an increase in excessive cleanliness and hygiene, and thus we have not been exposed to so many organisms. Our resistance has remained low, and when we are suddenly exposed to pathogens, we are more prone to develop serious symptoms.
If this hypothesis proves correct, then perhaps we should judiciously recommend probiotic prophylaxis, and increase the types of organisms to include benign strains of E Coli, salmonella, campylobacter, etc.
Just a thought!
LAST WORD
Perhaps one of the most famous person who died of food poisoning, according to legend, is Buddha. Some claim that he accepted an offering of spoilt pork, which killed him, but others claim that it was poisonous mushrooms. While the legend may not be true, I would like to say that nobody is immune from food poisoning.
MANDARIN HOTEL ORCHARD ROAD
In December 2018, 315 people got food poisoning in 5 separate events held at the Mandarin Hotel Orchard banquet hall. Although they found norovirus in some of the people who fell ill, they also discovered E. coli and Bacillus cereus in swabs taken from surfaces of utensils and door handles. One of the patients consulted my colleague at the hospital opposite this hotel. The symptoms of food poisoning occurred within half an hour after the dinner. This suggests that the cause of the food poisoning in this instance is due to a toxin. Hence there seems to be a variety of organisms and toxins causing food poisoning. This pre-Christmas holiday period is a popular time for large parties and festivities and in the rush to prepare food for these banquets, kitchen staff probably let down their guard, resulting in lapses in food hygiene. Hopefully more care will be taken in future!
REFERENCES
Tracking an outbreak of romaine lettuce E Coli: https://lmtribune.com/northwest/tracking-an-outbreak-of-e-coli-in-lettuce/article_edcb489a-9dd6-5b23-a3ce-b7e39f962a24.htmlTop of Form
Singapore: no definitive link among recent cases of food poisoning
https://www.channelnewsasia.com/news/singapore/food-poisoning-can-you-really-avoid-it-10984370
Food poisoning: can you really avoid it?
https://www.channelnewsasia.com/news/singapore/food-poisoning-can-you-really-avoid-it-10984370
Five deadliest food-borne illnesses and how to prevent them
Rat tailed noodle food poisoning
http://kenlyen.wixsite.com/website/rat-tail-noodle
Written by Kenneth Lyen
7 January 2019, updated 24 August 2019