Odwalla E. coli O157 Raw Juice

OUTBREAK SUMMARY
Health officials in the Pacific Northwest identified Odwalla’s unpasteurized apple juice as the source of a multistate outbreak of E. coli O157 infections during 1996. This outbreak lead to industry-wide changes in the use of flash pasteurization, a high temperature, short time processing which maintains the color and taste of the food item. Odwalla was an early adopter and pioneer for using the flash pasteurization which ensures safer foods for consumers and aligning more closely–than traditional pasteurization processes–with the company’s philosophy of social responsibility and providing the freshest products possible.

Documents
Document 1: Odwalla_Ecoli_Questionnaire_First Version
Document 2: Odwalla Questionnaire_UpdatedVersion
Document 3: Odwalla1996 Press Release Voluntary Recall
Document 4: Info Sheet Seattle King County
Document 5: Odwalla Press Release Flash Pasteurization
Document 6: Odwalla Case line listing to identify potential cases
Document 7: FDA Consumer Bulletin: Juice Maker Fined Record Amount
Document 8: Oregon Public Health Division CD Summary: Unpasteurized juices strikes again (and again)
Document 9: CDC MMWR: Outbreak of Escherichia coli O157:H7
Document 10: Odwalla MMWR_JAMA
Document 11: Food Safety News: Odwalla Apple Juice E. coli Outbreak

Media coverage
FDA News Release

NY Times: Juice Poising Case Brings Guilty Plea and a Huge Fine

The Seattle Times: Rotten Fruit, Black Crud And The End Of Odwalla

Forensic Files: Season 4, Episode 10 – Core Evidence – Full Episode

SECURITIES AND EXCHANGE COMMISSION Info: Odwalla

Odwalla Press Release Dated 07-23-1998

SF GATE: Army rejected Odwalla before outbreak

Army letter to Odwalla

Odwalla internal email regarding product pathogen testing

STOP Foodborne Illness: Anna’s story

LA Times: Juice Left in Odwalla : Company Posts Loss, but Sales and Cash Up Despite Recall

CNN: E. coli poisoning leads Odwalla Juice Recall

PBS Frontline: Secret Agent O157: The Evolution of a Killer

California 5 news program

Publications
Annals of Internal Medicine: An Outbreak of Escherichia coli O157:H7 Infection from Unpasteurized Commercial Apple Juice

Introduction
The Odwalla Juice Company was started by a group of health conscious people who wanted to provide organic, fresh juice to customers. The early days of Odwalla started in a backyard shed of one of the founders, who made fresh juice from local produce and sold the product to local restaurants in San Francisco. The company grew and soon became known for supporting the organic food movement, moving away from the large-scale food processing operations that had become ubiquitous in the 1980s. The company’s philosophy of being socially responsible, focusing on community, and providing fresh organic juice to nourish the soul of its consumer underlined Odwalla founders’ belief that pasteurization affected the taste of the juice and removed flavor and nutrients from the natural state of the fruits and vegetables. Instead the company used an acid wash to try to kill harmful bacteria. The lack of pasteurization of apple juice products led to the 1996 Escherichia coli O157:H7 outbreak.

On October 16, 1996, Children’s Hospital in Denver admitted a 1 year old girl with diarrheal illness. She developed hemolytic uremic syndrome (HUS) and battled it for 2 weeks before succumbing on November 8, 1996. The toddler had consumed an Odwalla smoothie before becoming ill. On October 30, 1996, the Seattle-King County Department of Public Health and the Washington State Department of Health reported an outbreak of Escherichia coli O157:H7 infections epidemiologically associated with drinking Odwalla brand unpasteurized apple juice or Odwalla juice mixtures containing apple juice from a coffee shop chain, grocery stores, or other locations. 

Methods
A case was defined as hemolytic uremic syndrome (HUS) or a stool culture yielding E. coli O157:H7 in a person who became ill after September 30, 1996, and drank Odwalla juice within 10 days before illness onset.

CDC advised health departments to find cases in two ways: 1) by interviewing patients reported with E. coli O157 infection or HUS that began in September or October 1996, using a two -page questionnaire that queried about consumption of Odwalla juices; and 2) by contacting pediatric nephrologists and children’s hospitals to ascertain additional cases of HUS and bloody diarrhea of unknown etiology. A rapidly executed case-control study confirmed that consumption of Odwalla juice was very strongly associated with having been recently reported as a case. An identical restriction fragment length polymorphism (RFLP) pattern was seen in patient isolates tested—consistent with a common source.

Results
As of November 6, British Columbia, California, Colorado, and Washington had reported a total of 45  primary cases.  Twenty-five were hospitalized (mostly children) at least 12 developed HUS and 1 died.  The median age of the 28 cases for whom information was reported was 5 years (range: 1—41 years); 15 (54%) were male. One case in Illinois occurred after the child drank Odwalla apple juice  in Washington. One case was acquired via secondary transmission from a patient with a juice-associated infection. 

By the end of the outbreak, more than 65 cases were reported from: California; (26 cases); Colorado; (5), Washington; (29) and British Columbia (10). 

E. coli O157:H7 isolates from a previously unopened container of Odwalla apple juice had a DNA RFLP pattern indistinguishable from case isolates

Lessons learned/historical significance
The use of the extensive, open-ended questionnaire provided epidemiologists the opportunity to identify possible exposures among cases. The questionnaire used in this outbreak ultimately became the foundation for the Oregon shotgun questionnaire that is currently used in many states.

DNA subtyping—in this case, RFLP was instrumental in identifying this outbreak and solving it. Matching the patterns from cases across multiple states allowed the common source be inferred and confirmed. RFLP would later become known by the name of the electrophoretic process used to separate and qualify these DNA fragments: pulsed-field gel electrophoresis (PFGE). 

This outbreak reinforced evidence from previous outbreaks that E. coli O157 is tolerant of acidic foods that would likely kill many other enteric bacteria. The company’s decision to use an acid wash instead of a pasteurization process allowed the bacteria on the apples to survive after they were pressed into juice. Odwalla’s subsequent adoption of flash pasteurization —a high–temperature, short–time process— ultimately saved the company and led to flash pasteurization becoming an industry standard for companies focused on maintaining “natural” but safer foods for their consumers.