Tracy Stiles Foodborne Disease Surveillance Laboratories Massachusetts Department of Public Health Listeria Outbreak in Massachusetts y Only the third outbreak in 30 years where pasteurized milk was implicated in human infection with L.monocytogenes Front page of Worcester Telegram and Gazette

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16 Listeria Samples Found at the Whittier Farms Milk Processing Plant

The Massachusetts Department of Public Health (MDPH) continues its investigation into the Listeria outbreak linked to contaminated Whittier Farms milk. According to the MDPH, additional samples of milk products and several environmental samples taken at the Whittier Farms milk processing plant have tested positive for Listeria monocytogenes.

The following is from a MDPH press release regarding this Listeria outbreak.

The processing plant, located in Shrewsbury, Massachusetts remains closed and will not re-open until cleared to do so by the MDPH Food Protection Program and U.S. Food and Drug Administration (FDA) Regional Milk Specialists. Massachusetts public health officials also continue to work with other agencies, including U.S. Food and Drug Administration and the Massachusetts Department of Agricultural Resources to complete the investigation and review whether changes are needed in current state regulations or in the federally mandated inspection and testing processes for dairy farms and plants. Summary of Listeria Positive Laboratory Tests

Sample Description Listeria Strain Coffee flavored milk Glass, Quart A* Coffee flavored milk Glass, Quart A* 1% Chocolate flavored milk Plastic, 8 oz. A* Chocolate flavored milk Plastic, 8 oz. A* Chocolate flavored milk Plastic, Pint A* Vanilla flavored milk Glass, Quart A* Strawberry flavored milk Plastic, 8 oz A* Skim milk Glass, Quart A* 1% Chocolate flavored milk Glass, Quart B** Coffee flavored milk Glass, Quart B** 1% milk Glass, Quart B** 2% milk Glass, Quart C** * Denotes Listeria strain consistent with outbreak strain ** Denotes Listeria strain not consistent with outbreak strain or known human cases Environmental Samples Description Listeria Strain Environmental Swab 1 Floor near homogenizer A* Environmental Swab 2 Drain in fill room D** Environmental Swab 3 Bottle washer washband E** Environmental Swab 4 Empty unwashed bottle F** * Denotes Listeria strain consistent with outbreak strain ** Denotes Listeria strain not consistent with outbreak strain or known human cases Trackbacks (0) Links to blogs that reference this article Trackback URL

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Email Address: Listeria Statistics Massachusetts y MA sees ~30 cases of Listeriosis each year

y In 2007: y 23 isolates were received at SLI y Several isolates not received at lab y 19 different Asc I patterns

y Total Database (MA) y 225 entries of Listeria y 190 different Asc I patterns Listeria 2007 All MA Dice (Opt:1.50%) (Tol 1.5%-1.5%) (H>0.0% S>0.0%) [0.0%-100.0%] PFGE-A PFGE-AscI PFGE-ApaI 100 June 2007 October 2007 November 2007 Patient 1 Patient 2 Unique pattern Match to in MA June No action taken Patient

Both match by PFGE

Per CDC—No other matches Appears to be local cluster

Epi notified Post to Webboard CDC Response: Isolates >120 days apart No Cluster ID Where did it come from? y November 2007 y Family of one patient implicated unpasteurized cider y LBOH visited home y Collected cider (which had been pasteurized) y Also took a bottle of flavored milk y Family reported patient drinks this milk regularly y L. mono isolated from milk y PFGE match to 4 patients y Did the milk contaminate the patient or did the patient contaminate the milk? The Investigation begins…

y November 2007 y MA FPP visited local dairy where milk was processed y Collected 11 milk samples (raw and sealed flavored and non‐flavored) y Also collected environmental swabs y L. mono isolated from one flavored milk sample y Same flavor as from patient’s home y PFGE match to all cases

MA Press Release 12/27/08

THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF HEALTH AND H UMAN SERVICES DEPARTMENT OF PUBLIC H EALTH 250 WASHINGTON STREET, BOSTON, MA 02108-4619 DEVAL L. PATRICK GOVERNOR

TIMOTHY P. MURRAY LIEUTENANT GOVERNOR

JUDYANN BIGBY, M.D. SECRETARY

JOHN AUERBACH COMMISSIONER

FOR IMMEDIATE RELEASE: December 27, 2007

CONTACT: Donna Rheaume 617-624-5006

DPH ISSUES CONSUMER WARNING FOR MILK PRODUCTS SOLD AT WHITTIER FARMS IN SHREWSBURY DPH Issues Consumer Warning for Milk Products Sold at Whittier Farms in Shrewsbury

Boston — The Department of Public Health (DPH) is issuing a warning to consumers not to drink any milk products from Whittier Farms in Shrewsbury because of listeria bacteria contamination. Investigation y December 2007 y Plant voluntarily recalled all products and ceased operations y Many conference calls held with Lab, Epidemiology, FPP, and DEP y Calls detailed lab reports to date, epi findings to date, and past inspections of the processing plant y Plant was compliant with all regulations y Plant in good repair y Dairy owners in full cooperation with investigators History of the plant y Family owned farm and processing plant y Routinely inspected by MDAR y Compliant with FDA IMS Program y Milk comes from the families own cows y 300 cow herd y Supplemented with another dairy (also compliant with MDAR and IMS program) y Milk is shipped from farm to plant via dedicated milk truck owned by the family y Truck sanitized routinely with “clean in place” procedure y Compliant with all regulations y Process ~3500lbs of milk 3 days/week y Product is distributed to customers via home delivery and 2 retail stores at farm and plant y Bulk cream is distributed out of state for use in baked goods Inspection y FPP visited plant for a full environmental inspection y Cooperation with FDA and LBOH y Inspection occurred over multiple days y Collected more than 100 samples of milk and environmental swabs y Conducted review of all procedures, mandatory recording charts, inspection of facilities, and sanitizing process Full Inspection Day 1 y Focused on pasteurization charts and equipment April 1, 2007‐ December 27, 2007 y Observations included: y tools used to measure and mix flavored syrups on raw side of plant stored open and exposed to air y Condensation was observed on the ceiling in front of 2 raw mixing batching tanks y Dripping to create pooled water on floor y Open‐ended milk bypass piping stored on a wall adjacent to raw milk separator unit y Internal inspection showed sour odor and soil in gasket area y Floor mat in front of raw milk product pump showed residual milk and sour odor underneath Day 2 of Inspection y Inspected piping and processing downstream of processor y Yellow‐brown deposit on internal surface of valve y Rough, raised weld on interior surface of pipe to storage tank y Rubber plug valve on a storage tank pitted in milk contact area y Raised inner weld on discharge pipe from pump supplying milk to filler machine y Floors uneven and cracked in several areas in front of 2 pumps used to transfer pasteurized product to filling machine y Deteriorating floor by floor drain in front of homogenizer Day 3 of Inspection y FPP intended to evaluate bottle washer y Found it to have been disassembled to initiate maintenance y Instead inspected the pasteurizer while bottle washer was reassembled y Continuous HTST milk pasteurizer y High temperature short time y Milk is held at 161°F for 15 sec y Any flavorings are added post‐pasteurization y Milk is then pasteurized again y Equipment compliance testing is done every 90 days y All pasteurization was found to be in compliance with PMO Day 3 (Continued) y Plant Inspection y Condensate observed on day 1 had been repaired y Closed sanitary lubricant for milk contact surfaces was stored in an unclean container y Cracked cement floor with mold on ceiling, upper walls, and plastic strip curtains in milk product cooler y Lower walls in cooler showed wear y Deteriorating floor surface near floor drain next to a raw product tank y Several feet away from pump that is used to transfer pasteurized product to the filler y Deteriorating floor (raised and cracked) directly below glass bottle filler y Pointed wooden stick on cap applicator y Used to unclog caps from cap chute on filler machine Day 3 Plant Inspection (Continued) y Mold formation on walls of bottle washer room y Possibly due to inadequate ventilation y In raw milk room, a hose was observed hanging on the wall y Uncapped, unprotected, cracked y Connected to public water supply y Used for sanitizing equipment y Water sample was collected from hose Day 4 of Inspection y Majority of swabbing and sampling occurred y Dairy had private lab swab duplicate areas y Observations y Dripping water from ceiling y Observed in raw milk storage area y Observed in filling area adjacent to fill milk valves y Plastic milk cases were soiled y Bottle washer had been reassembled y Conveyor “fingers” that move the bottles appeared unclean Final Inspection Day y Bottle washer documentation was reviewed y No violations to sanitizer concentrations or recording y Additional Observations y Bottle washer drains into pipe that terminates in the bottle filling room y Milk cases are cleaned by hand by the bottle washer y New glass bottles stored open in a trailer y Inside was damp with visible mold growth and evidence of rodent droppings y Bottles are all washed prior to use The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health MDPH Press Release 250 Washington Street, Boston, MA 02108-4619

FOR IMMEDIATE RELEASE: Update DEVAL L. PATRICK GOVERNOR January 2, 2008 TIMOTHY P. MURRAY 1/2/08 LIEUTENANT GOVERNOR FURTHER INFORMATION: JUDYANN BIGBY, MD Tom Lyons (617) 624-5275, or SECRETARY Donna Rheaume (617) 624-5006 JOHN AUERBACH COMMISSIONER **UPDATE**

MDPH CONTINUES LISTERIA INVESTIGATION Whittier Farms Dairy Processing Plant remains closed while state and federal health officials continue to investigate the source of contamination

BOSTON – The Massachusetts Department of Public Health (MDPH) is continuing its public health investigation of listeria contamination in milk products from Whittier Farms Dairy. Whittier Farms operates a dairy farm in West Sutton, Massachusetts, as well as a dairy processing plant and retail outlets at the farm and in Shrewsbury, Massachusetts. A source of contamination at the processing plant has not yet been identified.

Four cases of listeriosis infection have been identified by DPH. The cases occurred in June, October and two in November. The four cases involved three elderly individuals and a pregnant woman. Two elderly men have died as a result.

DNAthese infectionsfingerprinting came conducted from a common by the Statesource. Laboratory Whittier InstituteFarms milk showed product that samplesthe bacteria collected causing from a patient’s home and from Whittier Farms showed listeria contamination. The DNA fingerprints of the listeria found in the milk samples and in the patients were the same.

There have been no new cases of listeriosis confirmed as linked to this outbreak.

“State and federal regulatory health officials have initiated an environmental investigation at the facility that includes a thorough examination of the plant and its production equipment, as well as their pasteurization, packaging, cleaning and sanitization procedures. The state will also be conducting environmental and product testing for listeria before the dairy is allowed to begin operations again.” said Suzanne Condon, Director of MDPH’s Environmental Health Bureau. Whittier Farms has voluntarily suspended operations and distribution until the source of contamination is identified and corrected. The company has contacted all known customers and distributors of its products and informed them about the situation. A public health advisory was released by MDPH on December 27 to warn non-home delivery customers who may have purchased products in retail outlets and retained them at home to discard these products immediately.

Results y L.mono grew out of 8 milks and one environmental swab y Positive swab was taken from floor drain near a homogenizer unit y Close proximity to where raw milk equipment was cleaned y Inspection showed floor surface around the drain was pitted and had pooled water y PFGE matched all cases y An additional 4 milks and 2 swabs grew Listeria (L.mono and other species) that did not match cases by PFGE y Positive swabs from shield in bottle washer and fill room floor drain Enumeration Results

Most probable State Inspect Type of Date of number, Lab ID or Sample contain initial organisms/ number number description er Code/date dilution mL

1% chocolate, JH Whittier plastic, 08F028 4928 Farm 8 oz 1/6/2008 1/11/2008 460

chocolate milk, JH Whittier plastic, 08F029 4929 Farm pint 12/31/2007 1/11/2008 >1100

vanilla milk, JH Whittier glass, 08F030 4930 Farm quart 12/31/2007 1/11/2008 >1100

JH chocolate plastic, 08F034 4934 milk 8 oz 1/3/2008 1/11/2008 >1100

JH 1% quart 08F007 4906 chocolate glass 12/31/2007 1/11/2008 >1100

JH quart 08F017 4917 coffee milk glass 1/10/2008 1/11/2008 >1100

JH quart 08F003 4902 1% milk glass 1/3/2008 1/11/2008 >1100

JH quart 08F004 4903 2% milk glass 12/31/2007 1/11/2008 >1100

JH quart 08F016 4916 skim** glass 1/10/2008 1/15/2008 46,000

JH quart 08F017 4917 coffee milk glass 1/10/2008 1/15/2008 460,000 Dic e (O p t:1 .5 0% ) (To l 1 .5 %-1 .5 %) ( H>0 .0% S>0 .0 %) [0 .0 %- 10 0. 0% ] PFGE-AscI PFGE-AscI 50 100 E NV I RO NMEN TA L SW AB E NV I RO NMEN TA L SW AB E NV I RO NMEN TA L SW AB -- CO OLE R F AN ENVIRONMENTAL SW AB--CENTRAL COOLER FAN#2 ENVIRONMENTAL SWAB-FLOOR DRAIN, RAW MILK TANK OF HTST PROCESSOR ENVIRONMENTAL SWAB-FLOOR DRAIN, RAW MILK TANK OF HTST PROCESSOR E NV I RO NMEN TA L SW AB ENVIRONMENTAL SWAB-FLOOR DRAIN, RAW MILK TANK OF HTST PROCESSOR E NV I RO NMEN TA L SW AB -- B OT TLE WA SH ER E NV I RO NMEN TA L SW AB -- B OT TLE WA SH ER ENVIRONMEN TAL SW AB-- POOLING WATER IN FR ONT OF RAW TANK COFFEE ENVIRONMENTAL SW AB--FILL ROOM FLOOR DR AIN ENVIRONMENTAL SW AB--FILL ROOM FLOOR DR AIN 1% CHOC OLATE CHOCOLATE MILK VANILLA MILK CHOCOLATE MILK E NV I RO NMEN TA L SW AB -- FLO OR E NV I RO NMEN TA L SW AB SKIM MILK SKIM MILK SKIM MILK SKIM MILK STRAWBERRY MILK STRAWBERRY MILK STRAWBERRY MILK STRAWBERRY MILK STRAWBERRY MILK 1% CHOC OLATE COFFEE MILK 2% MILK, QT. GLASS 2% MILK, QT. GLASS 1% MILK STRAWBERRY MILK

MDPH Press Release Update #3 T HE C OMMONWEALTH OF M ASSACHUSETTS E XECUTIVE O FFICE OF H EALTH AND H UMAN S ERVICES 1/17/08 D EPARTMENT OF P UBLIC H EALTH 250 W ASHINGTON S TREET , B OSTON , MA 02108-4619 DEVAL L. PATRICK GOVERNOR TIMOTHY P. MURRAY LIEUTENANT GOVERNOR JUDYANN BIGBY, M.D. SECRETARY JOHN AUERBACH COMMISSIONER FOR IMMEDIATE RELEASE: January 17, 2008 CONTACT: Donna Rheaume 617-624-5006 ** UPDATE NO. 3** STATE RELEASES WHITTIER FARMS LABORATORY SAMPLE RESULTS Environmental and milk products test positive for Listeria. Milk processing plant will remain closed until cleared by health officials. BOSTON — As part of its on-going investigation of a Listeria monocytogenes (Listeria) outbreak linked to contaminated milk, the Massachusetts Department of Public Health (MDPH) said today that additional samples of milk products and several environmental samples taken at the Whittier Farms milk processing plant have tested positive for Listeria. The processing plant, located in Shrewsbury, Massachusetts remains closed and will not re-open until cleared to do so by the MDPH Food Protection Program and U.S. Food and Drug Administration (FDA) Regional Milk Specialists.

One environmental swab, one sample of skim milk and seven flavored milk samples tested p ositive for the same strain of Listeria found in four of the five cases linked to this outbreak. No sample was available to test in the fifth case linked to the outbreak — a 31 year-old pregnant woman from Middlesex County who drank Whittier milk products and was diagnosed with Corrective Action y Letter requesting corrective action was sent to the plant y Outlined all observed violations y February 1, 2008 y Dairy announced publicly it would not reopen the processing plant y Attributed to the financial burden of making necessary corrections Epidemiology y 4 lab confirmed cases June‐November y Age range 31‐87 years y 3 males, one female y June patient consumed skim milk from this dairy regularly y October patient had no obvious exposure to milk y 1 November patient regularly drank flavored milk from this dairy y 1 November patient was unable to be interviewed (numerous attempts were made) Epidemiology y Epidemiology Investigation identified one additional case in September y Pregnant woman presented with listeriosis y L. mono was isolated y Isolate never sent to lab y Patient reported milk consumption from this dairy y Epi‐linked not PFGE‐linked Summary of Cases

y Cases range June‐November y 5 cases y 3 adult deaths y 1 late term miscarriage y 1 premature c‐section resulting in healthy baby Laboratory Strengths

y MA PFGE Lab is Rock Solid! y Diligent in finding match even though it was >120 days y Followed all protocols including epi notification, posting to webboard y Continued to monitor for this strain y Great teamwork among all labs y PFGE, Food, Dairy, Enteric, Reference Labs y All staff ready and willing to help out wherever needed Laboratory Weaknesses y MA Food Lab needed help y The “forgotten lab” in Massachusetts y Lab tested ~100 samples/year y Mainly extraneous materials, little pathogen testing y Protocols had been altered y Results improperly documented y More testing done for this outbreak than any of the previous years y After 1st set of samples, BT‐FERN staff was enlisted to assist (Assisted in the 100+ samples) y Much potential for the future Lessons Learned‐Epidemiology y What about case in September? y If it had been sent to lab, would we have identified the outbreak sooner? y MA will begin focusing on re‐education of the local labs y MA Regulations now state all isolates of L.mono are to be forwarded to the state lab immediately (within 48 hours) y MA Regulations are being updated to make all submissions required y Up to now, it is not mandatory y Still difficulty in getting interviews from this population Lessons learned‐Inspection y Several distinct strains of Listeria were found in product samples and environmental samples y Suggests post‐pasteurization contamination can go undetected y Facility design likely contributed to intermittent post‐pasteurization contamination from equipment and environment y Equipment met FDA standards for time, temp, and flow for pasteurization y Is this enough to ensure a safe milk supply? y Plant had no environmental monitoring program for L.monocytogenes y Not required, but should it be? y Often done at larger facilities y Special concern for ready‐to‐eat foods with a longer shelf life y Listeria will multiply at refrigeration temperatures y Is a physical inspection of the plant part of routine inspections? Acknowledgments y Massachusetts Lab Staff y PFGE Lab y BT‐FERN Staff y Media Room Staff y Reference Lab Staff y Massachusetts Epidemiologists y Massachusetts Food Protection Program y Massachusetts DEP y Massachusetts Hospital Labs y If they had not submitted the isolates we would never have found the outbreak! y Local Board of Health