This Podcast Will Kill You - Ep 99 Salmonella: A hard egg to crack

Episode Date: June 21, 2022

We’ve all been there: doubled over in pain as stomach cramps grip your guts; the panicked shuffle to the nearest bathroom; the waves of nausea and chills as you cry out loud, “oh no, what did I eat??”.  At the very least, food poisoning is a humbling experience, but at the worst, it can be absolutely deadly. In this episode, we take a deep dive into one group of pathogens commonly responsible for outbreaks of food-borne illness, the infamous Salmonella. We start first with an exploration into how and why these bacteria make you sick before turning towards the history of these pathogens, a history which includes a brief jaunt through a bizarre story involving a cult, bioterrorism, and a small Oregon town. Finally, we wrap up the episode with a look at Salmonella by the numbers today. You’ll leave this episode brimming with Salmonella knowledge, thinking twice about how well you cook your chicken or wash your veggies, and contemplating how fast you can get your hands on a food thermometer. Trust us - you’re not gonna want to miss this one! See omnystudio.com/listener for privacy information.

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hang out with the crew at the festival and all of that. So we've been working the festival for a couple of days and spent all Saturday out in the sun all day, grab dinner real quick, hung out with my friends, hopped a couple bars in Cleveland, evening out on the town. And the next morning got up, did the same thing over again. A breakfast, I was at working in the head rig, out in the sun all morning. And again, it's another hot day, but, you know, nothing out of the ordinary. When we took a break for lunch, I noticed that I was really feeling just hot and tired and dehydrated. You know, I sat down in the shade. I grabbed a water bottle, drank a bunch of water. And I just assumed I'd been out in the sun too long. The festival ended that day. I was supposed to get a

ride back to my car so I could go home. The woman that was supposed to give me a ride to my car wasn't there because she'd actually taken a couple of my crewmates to urgent care. Found out later that they were kind of feeling the same thing. They were dehydrated. They were some of the house upset stomachs. I eventually got a ride back to my car and headed home. It's about a 45-minute drive from downtown Cleveland to where I was living at the time. and as I'm driving, all of a sudden it hits me just like stomach cramps, stomach pain. I really felt like I had to fart. And I almost made it.

That last couple miles, well, some parts can't be trusted. So I got home. I had actually pooped my pants a little bit. And so I just took off my clothes, threw them in the washing machine, and started a load of wash, took a shower, put on pajamas, and went to bed. Woke up a couple times in the middle of the night, again, with just an urgent need to go to the bathroom, just watery diarrhea every time. Whatever was inside of my intestines was just on the fast track out.

And that's how I spent Sunday night. That's how I spent Monday. And as I recall, that's how I spent Tuesday, too. I mean, I tried to eat bland food like Cheerios or instant mashed potatoes. But every time I put something in my mouth, it was just on the fast track, clear through. I started getting messages from some of my friends who were on the ship still. And it wasn't just me. It was, at first it was eight or ten of us and then 20 of us and then all of a sudden, almost 40 of us were sick and not getting better.

Probably Tuesday I stopped trying to eat. I'm like, I'll just let my entire digestive system empty out, reset itself and we'll try food again in a day or two. That didn't fix the illness, but it did let me control my. bowels well enough that I could actually go to urgent care. So I did that. They collected a sample and sent it to the lab. And I went back home and lived on Gatorade the next couple of days. Urgent care called me back and they're like, oh, you have salmonella. It should resolve itself. If not, follow up with your primary care doctor. And that's really all they said about it. But, you know, a week into this, I still can't eat solid food. So finally, eight and a half days,

later, I finally got in to see my primary care position. And she walked into the exam room, first thing she says is, you look terrible. And the next question she asked me was, did you finish your antibiotics? And I said, what antibiotics? So it turns out that the lab results from urgent care had actually said you should, you know, treat this patient with this antibiotic. Urgent care never prescribed that. So my doctor started me on the antibiotics four days later, all of a sudden I can eat food again. Like, it was a minor miracle. But in that time, in that as about 10 or 11 days between when I got sick and when I started feeling better, I dropped about 16 pounds.

You know, that took me from being a healthy weight to being underweight. and at the same time this is happening to all of my crewmates too. So we knew that something had gone on in the ship that weekend. When the health department actually started doing surveys and talking to all the people who were and were not sick, we figured out that the people that were sick were not vegetarians and they'd eaten dinner on board the ship on Saturday night. Saturday dinner was Mexican casserole. So there was a version with chicken in it, and there was a version that didn't have chicken in it. An interview with one of the guys that helped in the galley, he says he thinks that chicken had been cooked about six days earlier.

And it was put into a wood stove after dinner one night as the stove cooled off. So the cook goes to start the fire the next morning for breakfast and finds room temperature chicken. and they throws in the refrigerator, and that Saturday night ended up in that casserole. They also, you know, took a look around the equipment and took a lot of, you know, measurements of, you know, how hot the wood stove got, how cold the refrigerator was, how cold the freezer was, things like that.

And one of the things they discovered is there actually was not a food thermometer on board. One of the things about these ships is they have a black water tank. And so whenever you, flush a toilet on the ship. It actually doesn't flush like a toilet. You actually pump the wastewater into the black water tank. That tank gets emptied basically with a septic hauler truck. So those big tank trucks that have the vacuum pumps. So as soon as the ship got back to Erie, they scheduled that truck to come in and empty the black water tank because so many people have been using the heads that the black water tank was full. So first thing on

Monday morning, his first stop of the day was the ship. He, pulls in, hooks up to all the connections so he can suck the poop out. When he emptied the truck the day before, he hadn't flipped the pump from pumping the blackwater out of his truck to sucking it into his truck. So what he actually did was he pushed a bunch of air into the blackwater tank, which pushed salmonella contaminated poo water up through the vent. And all over the place where most of the crew sleeps. And they sanitized what they could, but several of all the people got caught that way too.

So we actually had a little secondary outbreak because the VAC truck was set to blow not suck. At the end of it all, I believe there were 37 of us in the outbreak. It was enough, it was a large enough percentage of the crew that the ship actually had to miss some of our contracted sales and events. but it managed to take a bunch of young, healthy people and pretty much ruin an entire summer for us. Even though you started feeling better because you didn't have uncontroll of diarrhea anymore,

for some of us it was months before you could just eat whatever you wanted without thinking about it. And then a lot of us still to this day, a decade later, don't eat chicken. And several of us have sworn off Gatorade. too, that it's just both of those things are things that remind us of that awful week that we all spent not being able to do anything more than five feet away from a toilet. And that was enough to lead to some regulatory changes in that community. And that's my story. My. Oh, my gosh. I mean, the number of times that I went, what? Right. Are you like, oh, are you kidding me. I'm sorry, what?

That is one of the most outrageous stories. Like, the old chicken. I mean, I can't. I cannot. I don't know that I'm ever going to be able to eat chicken again. I don't know that I'm going to be able to eat like so many things again. Well, thank you, Beth, so much for sharing your story. Like, oh my gosh, what an unbelievable, horrible experience.

Yeah. Hi, I'm Erin Welsh. And I'm Aaron Omen Updike. And this is, this podcast will kill you. Welcome. We're talking about poop today. We are. I love these days.

I truly do. We talk about poop in my house like a lot lately, and so this is just like another day. I mean, I feel like it's an important thing to talk about. And people get real squeamish about it, but literally every person produces. fecal waste. Yeah, everybody poops. Everyone poops. It's important. We have books about it, you know? Yeah. I guess we're not going to get that much into it. Yeah, we're not going to like Bristol stool scale it over here. Okay, adding that to my things to Google later list. We can post a picture of it. Anyways. Anyways. Yeah, this is going to be an interesting episode.

So this is not our first salmonella episode. No, it isn't. It isn't, yeah. But the last time we did salmonella, we did typhoid. Which is different. Very different. And there's a lot of complexity in salmonella and a lot of diversity in salmonella. And it's going to be interesting.

Yeah, it definitely is. And another thing that's going to be very interesting is that in this episode, we also get to learn how you determine things like the difference between the salmonella that gives you typhoid versus a slightly maybe less scary salmonella saravar. Yeah. We are so excited to be joined later on in this episode by Sarah Zoucha, who is a medical laboratory scientist that's going to give us a behind the scenes look at this fascinating and so important career.

Like, what is medical laboratory science? We've never talked about it on this podcast. So we'll talk about it today, and we'll talk about how you choose which tests to run on various samples and what are some of the strangest samples that have shown up in the lab. But we'll get to all of those questions and more later on in the episode. Oh, I'm so excited. It's going to be so much fun. Yeah, it will be. But first, should we, is it time for quarantinis? For quarantinis? I think so. What are we drinking today, Aaron?

We're drinking the chicken or the egg? Question mark. Get it? Because they could both give you salmonella. Yeah, along with many other things. Yeah. What is in the chicken and the egg? It's a very tasty concoction without any chicken or eggs in it.

Yep, yep. We decided against an egg white foam for this one. Considered and discarded. Mm-hmm. But it has gin and blueberry syrup, lemon juice, some club soda. a little fizz for you. It's fantastic. And if you want to have a foam, there are many different foaming alternatives. One of them is like the water from chickpeas, aqua faba. And you can turn it into a like a foam, a non-eggwhite foam topper for your cocktail. And I don't think that you

can get salmonella from canned beans, maybe just botulism. Yeah. Don't quote us on any of that. I don't know. On any of this. Moving on. Moving on. We'll post the full recipe for that quarantini and our non-alcoholic placebo rita on our website. This podcast will kill you.com and all of our social media channels. We will.

Well, and on our website, I have a Post-it note. Check it out. You can find these sources for all of our episodes. You can find transcripts. You can find links to our bookshop.org affiliate account or our Goodreads list. I'm loving your dramatic pauses here, Aaron. You can find music by Bloodmobile. You can find links to our merch, our Patreon.

Can't read your own handwriting? I can't. I cannot read my own handwriting. And alcohol-free episodes. That'll do it. Fantastic. Well, done. Well, shall we get into this, Erin?

Let's do it. I'm excited about it. Me too. We'll take a quick break first. Dinner shows up every night, whether you're prepared for it or not. And with Blue Apron, you won't need to panic order takeout again. Blue Apron meals are designed by chefs and arrive with pre-portioned ingredients so there's no meal planning and no extra grocery trip.

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Order now at blueapron.com. Get 50% off your first two orders plus free shipping with code this podcast 50. Terms and conditions apply. Visit blueapron.com slash terms for more information. Anyone who works long hours knows the routine. sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keefe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant

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now available in Canada too. That's Q-U-I-N-C-E.com slash this podcast to get free shipping and 365-day returns. Quince.com slash this podcast. Like you said, Aaron, we've already become somewhat familiar with the genus Salmonella during our typhoid fever episode. Today, we're going to focus on all of the other sermons. of salmonella enterica. So you may or may not, listeners, and Erin, remember from our typhoid episode that typhoid fever is caused by a very, very specific bacterium. It's salmonella,

enterica, subspecies, enterica, serovar typhi. Okay. Oh, I forgot about the subspecies part of it. Yeah, exactly. And I also mentioned during that episode that there's another serivar paratyphy. and there's a couple different versions of that. And together, those seravars cause what are known as enteric fevers or the typhoid fevers. Okay. So let's refamiliarize ourselves with salmonella and talk about all of the rest of them, shall we? I'm excited. Let's do it. Let's.

So salmonella enterica is a gram-negative, facultatively intracellular anerobe, which means it can live and grow both inside and outside our cells, and both with or without the presence of oxygen. So it's quite versatile, I guess. And it is present worldwide. It's absolutely everywhere. And today we're focusing on all of the non-enteric fever causing serivars. These are often called NTS, non-typhoid salmonella.

Oh. So there are over 2,500, 2,500 seravars of salmonella. Alaminella Interica that are in six different subspecies. Okay, so quick question. And I don't know if we covered this on typhoid. What makes Asera a Saravar a Saravar? I knew that you were going to ask that, and I still don't really know. Did I ask that on Selwyn?

You might have. You might have. I can't remember. I still don't fully understand because it gets into the, like, very confusing genetics of bacterial species and like how you define a species and how you define a subspecies, I don't know the answer. But we can at least narrow it down a little further. Okay. Because of those six different subspecies of salmonella interica, we're focusing on salmonella enterica, subspecies enterica. So all of the seravars that cause disease in humans

and other animals are in this very specific subspecies. And, And there are over 1,500 different serovars just in this subspecies alone. That's, yeah, wow. Yeah, basically, all of these different serovars have differences between them, obviously, that lead for them to have differential host specificity. So some of these serovars infect and cause illness in a really wide range of host species, and others have a relatively narrow host range, like, for example, typhi, right? which really only causes disease in humans.

But luckily, for what we're talking about today, most of the non-typhoid subspecies, the pathogenic ones, cause pretty similar disease. They cause enterocolitis or diarrhea. So that's why they often get lumped together as the non-typhoid salmonella group. They definitely have a range in their severity, and like I said, their host specificity. So some might really only cause disease in birds or in reptiles and only rarely in humans,

where others are much more common in humans, etc. And they can range in their severity. And they can also differ in their susceptibility to antibiotics for a number of different reasons. We'll get into a little more later. But an important thing to keep in mind is that when characteristics that make a particular serivar more invasive or more likely to cause an invasive disease, a more serious disease, combine with characteristics that confer antibiotic resistance, those two things combined can make for a pretty dangerous seravar.

Yeah. Yeah. Okay. So let's get into how we get this, shall we? I think everybody knows at this point. Just like typhoid, other strains of salmonella and terracca. I might refer to them as just n-te. P.S. or salmonella?

I mean, I say salmonella throughout, I think, the whole time, yeah. These are transmitted primarily fecal-oral in some capacity. Poop is where these bacteria come from, and poop has to somehow make it into your mouth. Salmonella is really a gut pathogen. It's found as a commensal organism in the guts of a lot of different animals. So salmonella can make its way into the soil or the water wherever there is fecal contamination. But even if they're naturally in the gut of an animal, that doesn't mean that they should be in anywhere that they would come into contact with the food supply. Right.

Like, okay, they're in the gut. They shouldn't be in the breast. They shouldn't be in the meat. They shouldn't be in the feathers. They shouldn't be anywhere else except for in the gut. Right. Yeah. And also like salmonella typhi that we talked about.

the other serivars of salmonella do tend to require a relatively large infectious dose upwards of 50,000 bacteria in order to establish an infection. That's a lot. It is a lot, but these bacteria can grow to be in really high numbers, as we'll talk about in just a second. So when you get exposed to a pathogenic syrivar of salmonella, you eat it, right? On your chicken casserole or whatever. It travels through your stomach, through your intestines, and generally establishes an infection in the terminal ilium, which is like the last bit of your small intestine or in your colon, the large intestine. Those are the two areas that salmonella likes.

Asterisk, I'm talking about human infection. I know nothing about the guts of other animals. Why does it like those areas? I think that that's just where it makes a great home in the epithelium. Okay. The epithelium is different throughout your whole rest of your gut and your small intestine. Prior to that has a lot of like villi and all these little things that I don't know exactly why, but that's not where salmonella likes to make its home. Okay.

Now, once it's there, they sort of grab on to that epithelium and they have a number of different virulence factors that what they do is induce a huge amount of inflammation, especially neutrophils, which are often one of our first responders, one of our first white blood cells to like rush into the scene. And they induce a ton of this. So you have tons and tons of neutrophils and other like inflammatory cells, cytokines rushing to the area. And this all starts to happen within one to three hours of an infection. You see massive amounts of inflammation coming in to try and fight off these bacteria. We start making a whole bunch of proteins, we start secreting things to try and fend off these bacteria. And then within a few more hours is when the diarrhea starts. Okay. So symptoms start within like six to 12 hours after

exposure, but after the development of this intense amount of inflammation. Right. So typically, the symptoms are a pretty acute onset of really painful, crampy, crampy, abdominal pain and watery diarrhea. Sometimes this diarrhea can be bloody, especially more common in kids who tend to have even more severe inflammation. And then it's also not uncommon to have a lot of nausea and vomiting because your whole colon and that last part of your small intestine are just full of inflammation. It makes your whole guts really angry. To your body is just like, get everything out of me now. Exactly. And the good news is that. that without any treatment whatsoever, salmonella antarocolitis, salmonella-related diarrhea,

tends to be a self-limited infection that does clear up over the course of about a week, which is a really long time to be having massive diarrhea and nausea and vomiting. Right, and not being able to keep anything down. Yeah. So as long as you can keep something down, as long as you can stay hydrated and avoid electrolyte imbalances from this diarrhea, then you're going to be okay. And in general, antibiotics are actually not recommended, like the CDC, the World Health Organization. It's generally agreed upon that for this type of self-limited diarrhea, you generally don't give antibiotics.

And the only times that you do are if there are specific risk factors that make you think that this is likely to become an invasive infection or you have very high risk of it just being a really severe diarrhea. Like in our first-hand account, if you're not keeping anything down, then, of course, something is wrong. Or if you're very, very young, or very elderly, or immunocompromised, especially with something like HIV. And one of the reasons that it's generally recommended not to use antibiotics in the setting of diarrheal disease is that antibiotic administration, in some cases, can actually prolong the illness and it can prolong the shedding of the infection. bacteria in the stool, which I find absolutely fascinating. But now the question, of course, is how often does this become a more severe infection? And by more severe, what I mean is that while in general these salmonella enterocolitis infections are just limited to this diarrhea, if these bacteria enter through the wall of your colon or your small intestine and make it into

your bloodstream, they can cause a systemic infection. Right? And that can be really severe just like typhoid. What does that systemic infection look like? Great question, Aaron. It looks a lot like typhoid or enteric fever. It can be a really, really high fever. You can see enlargement of the liver and the spleen as the bacteria travel there and begin to replicate within our white blood cells. It can even invade the lungs in some cases. It can cause respiratory symptoms. If these bacteria travel to the heart, and infect the heart or our large arteries, like our aorta, it can cause endocarditis, that's

inflammation of the heart, or end arteritis, that's inflammation of our arteries. This can very quickly become a systemic bacteremia, so people can then go into shock. They can get very sick very quickly. And what's interesting is that often people who end up with invasive salmonella, that's not typhoid, tend to not really have as much of the diarrheal type symptoms. At the beginning? Throughout their infection. Interesting. Yeah.

Because the body is not just like shedding as much or what? Yeah. I don't fully know. And I really tried to get a handle on, first of all, how often does this happen? And from what I can tell, it's actually way more common than I realized because the papers that I found that cited an actual number said that it could be up to 5% of the time, which seems really, really high. Right. And the mortality rate in these invasive infections can be as high as 20 to 25%. So this is interesting because I think it calls into question two things in my mind. Number one is that

the 5%, like how accurate are the estimates that we have of salmonella cases? Number one. Number two, I think that this makes me ask the question about like, I understand that it's sometimes not recommended to give antibiotics for salmonella, but sometimes it is. Like, how do you know? Like, that line seems like suddenly you cross it and this could be really bad, really fast. Yeah. And so what I don't know the answer to, what I didn't quite see in the discussion of the invasive non-typhoidal salmonella infections is whether people tend to have like a salmonella enterocolitis salmonella related diarrhea and then progress to invasive disease or if these are kind of like two different disease processes caused by the same infection or caused by the same bacterium

rather okay and it kind of seems like it's two separate disease processes huh that's very interesting Yeah. But that's not to say that people can't become severely ill from quote unquote just diarrhea, right? You can end up with electrolyte imbalances. You can end up with weight loss. You can end up very, very sick even from just diarrhea. So it's not like nobody should get antibiotics. It's just a matter of like risk stratifying who's more likely to either have a really hard time with it and not be able to tolerate food and just have a really hard time with the infection. And who is likely to go on to potentially have a risk for. invasive disease. And so beyond people who are immune compromised, are there other risk factors for invasive disease? Being very young, so under five, being very old, so over 70 or 75. And interestingly, so, okay, let me back up for a second. Remember how I said that salmonella causes a lot of inflammation in your gut? Yeah. So this is something that's totally different, that's these non-typhoidal salmonellas do that typhoid doesn't do. So typhoid doesn't cause a lot of inflammation in your gut. All of the other syrivaris that cause infection in humans do.

And so one of the things that we have seen is that there are inherited deficiencies in certain inflammatory like systems, specifically, if anyone cares, it's like certain inner lukin systems, IL-12 and IL-23, that people with deficiencies in these systems are at much higher, risk of invasive non-typhoidal salmonella infection. And they're more resistant to typhoid infections. That is fascinating. Uh-huh. Yeah.

The other thing is that salmonella that we're talking about today, these seravars seem to be specifically adapted to survive in a highly inflamed environment. So it's thought that this actually lends it a competitive advantage to establishing an infection in our guts, right? They get into our guts. They stimulate a massive amount of inflammation that makes it harder for a lot of our normal gut flora to thrive. Then ensues massive diarrhea wiping out all of their competitors and then they can kind of flourish and take over. I really enjoy thinking about like the ecology of microbial interactions inside someone. It's so interesting. Yeah. And I wonder too how much could somebody's individual microbiome put this.

them at risk or at less risk for not only having an infection, but having a severe infection or an invasive infection. Yeah, it's really interesting to think about. But also, what about the people who get infected and then don't have any inflammation and the salmonella just hangs out in there? Is that what's going on with carriers? So non-tipotal salmonella, the kind that causes disease, we don't tend to see carriers the way, in humans at least, the way that we see with typhoid. So people tend to shed for like a month after infection. Like there's still salmonella there that they're pooping out. And in kids, it can be as long as seven or eight weeks, which is still a fairly long time to be pooping out salmonella. But we don't see like we do in typhoid this carrier state

of like a year or two years or 10 years or your whole life, which I think is really interesting. And it kind of points to like, this really is a pathogen in humans and not a commensal. Yeah. Huh. Yeah. That's the biology, Aaron. Wow. I mean, that's kind of short.

How much do we know about, I mean, and this is probably like way too much of a rabbit hole question, but how much do we know about different sarovars and the frequency? of them or the intensity of disease that they cause or which ones to keep an eye out for, which ones are associated with which food products, all those things. It's a very good question. So I read a paper that was really diving into that, kind of like the specific epidemiology of all of the different sarovars. It's hard because there's like 1,500, which is so many. Yeah, I feel like we could spend the entire episode just like listing the names of them,

and then we'd be like, okay, that's a two-hour episode. Yeah. So there are a few that kind of stick out as being. the most common worldwide and causing, and therefore, I guess, causing the most infection, not necessarily the most severe infection, but just the most common ones. Those are enterididus, I'm hoping I'm pronouncing that close to right, typhemerium, of which there are like typhemerium A and B, like there's multiple kind of typhemeriums. Of course.

Newport, Javiana, or Javiana, and Infantus. Those are kind of some of the top five. There's also a Kentucky one that I saw. There is a Kentucky one. Yeah. Place name, you know, love it. There are so many serovars. And in general, they do have different pathogenicity.

So all of the different seravars that cause disease in humans and other animals have some similar, like, virulence factors that tend to be clustered on what are often called these like pathogenicity islands, which I think is. is a hilarious term. But it basically is just in their genome, they have these little clusters of genes that encode a number of different things like flagella and capsules and like type three transport systems that like blah, blah, blah, help them to infect us. But there are also a number of different plasmids that they have that encode not only other virulence factors that might make them more likely to say be able to infect a bird or your bearded dragon or your frog and other ones that might make it easier to infect humans. But also a lot of these plasmids are what end up conferring antibiotic resistance, which of course is a huge problem when it comes to salmonella.

And I'll talk a lot more about it at the end of this episode. But that's kind of the like, Burm-brum-br-b-b-b-what happens next. Yeah. Because even though we don't use antibiotics to treat all human infections, you have to have antibiotics that work to be able to treat the severe infections. Yeah. Yep. But now. Yeah.

So, Erin, can you tell me a little bit about this bug? I can. Let's take a quick break and then we'll get started on that. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keefe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant hand washing and harsh conditions. Working hands creates a protective layer on the skin that locks in moisture. It's non-greasy, unscented, and absorbs quickly. A little goes a long way. Moisturization that lasts up to 48 hours. It's made for people whose hands take a beating at work, from health care and food service to salon, lab, and caregiving environments. It's been relied on for decades by people who wash their hands constantly

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Nibbles would have loved you like a brother. Connecting homeowners with skilled pros for over 30 years. Angie, the one you trust to find the ones you trust. Find pros for all your home projects at Angie.com. You know, like we've talked about, we've covered Salmonella before in the context of typhoid. And even though that was, I feel like that was a pretty big episode. It was. And we covered a lot of ground in that.

There really isn't that much overlap between that history and the story and the history of general salmonella food poisoning, or at least like in terms of what I decided to talk about today. And I have to say that I'm really excited about it because it is, I think, such a fascinating look into how food preparation and consumption has changed over the past 100 years or so and how food poisoning kind of grew as a concept during that time. But the thing that I'm most thrilled to talk about is how salmonella was involved in the first act of bioterrorism in the U.S. Stop it. What?

Yeah. I am, oh, I'm so glad. I'm so glad you don't know anything about this because it's going to be fun. I know nothing about anything, Aaron. I love it. Okay. So let's get started. So in terms of evolutionary history stuff, the salmonella group that has been linked to food poisoning,

like we talked about, is incredibly diverse. and the number of seravars and all of that is just, I'm not going to go into the details about the origins of this or that sarovar, because there's just too much ground to cover. But I will say that understanding the evolutionary origins of certain seravars that are associated with food poisoning and which types of food poisoning, that's incredibly important in preventing outbreaks because that knowledge can influence control strategies. For instance, if one serivar is only present in the guts of diseased animals, animals that are actively showing that they are diseased, you might use a different strategy than if a sarovar was a natural commensal of the guts of all cows or all pigs or something like that. And it can also help with identifying the source of contamination.

So if you're dealing with a diseased animal-only sarovar and you find it in a bunch of meat, that could point towards fecal contamination in the meat. processing aspect of it, which is like really bad. And I mean, really, in a sense, finding salmon in any part of like an animal product is bad. But I also think that like it might be dependent upon the seravar when you're like, oh, that is really alarming. How did it get all over here? Whereas there might be ones that you more commonly see. Yeah. And especially because there are ones that infect different animals. So if you have one that's more common in chickens and it's all over your beef. Right. How did it get there? What happened here? Yeah. Yeah. Okay. So salmonella food poisoning

seems kind of ubiquitous nowadays, and probably most people either know someone who has had it or has had it themselves. But has it always been this ubiquitous food poisoning presence, right? I mean, probably. It seems kind of tricky to get estimates of the timing of when salmonella started infected. people based on like molecular clock info, but people have probably been getting sick with salmonella and other foodborne pathogens forever. And I think that this probably ramped up somewhat with the agricultural revolution. But even though the widespread practice of keeping livestock would have increased exposure to salmonella, the big outbreaks that we see today were still a ways away. Unlike in the typhoid episode, where I talked about the plague of Athens and the 400s BCE and the impact of typhoid on the residents of Jamestown in like the 1600s, for more general salmonella food poisoning, I'm going to jump ahead to the mid to late 1800s. So around the time germ theory was more or less established as a thing.

By this point in history, people had, of course, long recognized for hundreds of years. that foods could make you sick with fever or diarrhea or vomiting. But before germ theory, it seemed to generally be ascribed to chemical changes in the food as it decomposed, or like some element of rotting food specifically. It was around the early 1880s that people began to realize that food could look perfectly fine and unspoiled and smell fine, but could contain microbes that would make you sick in it. if you ate it. And one, or rather many, I guess, of those microbes, happened to be salmonella.

In 1885, researchers Daniel Salman or Salmon, I don't know, because I'm realizing that we say salmonella, but not sam, you know, anyway, Daniel Salman and Theobald Smith were the first to identify salmonella causing salmonellosis in pigs that were sick with hog cholera. And they thought that this microbe that they had found was responsible for hog cholera, which it wasn't, but they named it hog cholera bacillus. In 1900, it and several other microbes were reclassified and renamed salmonella in order of salmon. But even though this taxonomy was a complete mess, the important thing was that there was now a name for these cases of food poisoning, and it also kind of provided the ability to trace its source via

microbiological techniques. Pretty soon after the first identification of salmonella in those pigs in the 1880s, people began finding the bacteria in many different foods, especially pork, chicken, beef, and milk, and also in people who fell ill after eating those foods, right? Like making the link between food and illness. And this period marks a huge turning point in the history of food safety, not just because salmonella had been identified, but also because it represents a shift in the way that people viewed foods that made you sick. So previously, it had been specific foods themselves. Oh, this one is spoiled.

This one has undergone a chemical change. But the recognition of salmonella and other microbes as directly causing those illnesses meant that any food could be contaminated without a piece. to be, and more optimistically, that those sources of contamination could mostly be eliminated through the way you handled the food. You know, you could kill the bacteria through methods of cooking or preparation, especially heat. Food poisoning as a general term, like the term itself, came into use around this time, which I think is so interesting because it kind of represents this shift in thinking about microbes spoiling food rather than food just being spoiled on its own. Yeah, I never thought about that.

Yeah, and I think this whole period also called for an infrastructure change in regulation of food safety, especially through testing, notification, and better food handling practices. But that was still a long way away, and there was a lot left to be desired. because as the global population continued to grow and people continued to leave the rural countryside for cities, the way that people interacted with food increasingly changed. Food was traveling larger distances. Refrigeration wasn't really necessarily a thing yet. And hand hygiene was far from universally practiced.

Yeah. As these things were going on, the rate of food poisoning just continued to increase. right, like our knowledge of this group of bacteria way outpaced our ability to do anything about it. Yeah. But it wasn't really until the first few decades of the 20th century that people began to realize the true extent of just how prevalent these pathogens were. And that's simply because people weren't monitoring foodborne illnesses. The primary salmonella-related focus throughout the late 1800s and early 1900s was typhoid.

And so a lot of the efforts were centered more on improving water quality and identifying human carriers of the disease, as we well remember from our typhoid episode. But salmonellosis kind of was just like waiting for its moment to shine. In the first few decades of the 20th century, salmonella seemed to be on the rise. And this was shown to be the case by the 1930s or the 1940s, which is around the time several countries had a doctor. adopted foodborne illness reporting systems. What these early reporting systems were finding was more and more salmonella. But was there an actual increase? Always an important question to ask. And it seems to be somewhat debated because screening tools weren't the greatest, although they did improve in the 1930s and the 1940s when phage typing began to be used to

distinguish among salmonella seravars. And so it's possible that one big point, part of the apparent increase in cases was due to improvements in screening or our increased ability to trace outbreaks or even that more mild illnesses like foodborne illnesses were finally coming into view as more deadly diseases were being treated or vaccinated against. But I also feel like it's hard to chalk all of the increase up to just those things. Because like I mentioned earlier, the way people were handling food and eating food was changing. especially during World War II and the years immediately after. So during World War II, we saw a huge rise in communal feeding spots.

Large numbers of people were being fed in canteens and cafeterias, and so there was a greater potential for larger outbreaks rather than sporadic cases. And this communal feeding and rationing also led to people reheating food more often, which, when done improperly, can, of course, lead to food poisoning. So there were more opportunities for a larger number of people to get sick if the salmonella was there. But was salmonella itself growing in its presence or prevalence? And that also seems likely. So let's consider things from the food production side, especially in the scaling up and the industrialization of many food products.

That's the key. It is the key. So whereas previously people would mostly consume food that had had been. been grown or produced in their near vicinity, like even just within a town or city, the growth of cities and a demand for more food and a greater variety of food meant that every step along the way in food production, the operation had to expand. It had to grow larger and it had to become more specialized in a way, right? In the years after World War II, especially when wartime rationing restrictions were lifted, meat consumption increased in a big way. And to keep up with that,

farming expanded and intensified. Small chicken ranches or dairy farms grew into or were largely replaced by huge industrial operations. And with bigger populations of livestock, salmonella could spread more easily and infect more animals. And it would become much more difficult to control or identify. not to mention that around the same time post-World War II is when widespread antibiotic use started to come into play. And antibiotic resistance was not far behind. And that also grew and grew and grew and grew. And to be honest, it's one of the most terrifying parts of this whole story that that's all I'm going to mention about it. Yeah. Listen to our antibiotic resistance episode from season three for more. Three, yeah. Yeah, season three. But another place where contamination

became increasingly likely to occur, again thinking about sort of this chain of food production, is in slaughterhouses. Yeah. So slaughtering shifted from being mostly at or near the farms where these animals were raised to happening farther away because, like, oh, you needed to have more equipment to process more animals. You need to have more specific equipment. equipment. Like it was difficult to have, to be a jack of all trades as a farmer and do and make a living the way you used to. Like it just, it became less and less feasible. Right. And so slaughtering began to be done mostly at these large slaughterhouses that processed many different types of meats in many different ways. So you can see how literally every step along the way of food

production or preparation or consumption increased the potential for salmonella to spread. And in some cases, these changes in practices led to some increase in virulence or difficulty in treating like we talked about with antibiotic resistance. And also, it's important to point out, as I'm sure you will later on, that salmonella was not and is not limited to just the pork or poultry or beef industries. It's everywhere. It's everywhere. And an increase in salmonella in one area

frequently leads to an increase in salmonella in all areas. The mid-20th century did see several new regulations put into place, and testing had also become more refined. But the cat was out of the bag. Spiratic cases or outbreaks of salmonellosis had just become. kind of like almost a regular thing, wasn't that unexpected. So in September of 1984, when residents of a small community in Oregon began experiencing painful stomach cramps, diarrhea, nausea, fever, fatigue, after eating at several restaurants in the area, local public health officials suspected salmonella was to blame, naturally. And it was.

Samples from several people who had sought care at hospitals in the area confirmed the presence of salmonella typhemerium, which is, like you said, one of the most common causes of salmonellosis associated with the consumption of contaminated animal products. So by the end of that first week of cases, 13 of 28 employees at Shakey's Pizza, one of the restaurants suspected to be a source, had come down with food poisoning.

and dozens of customers had called the restaurant complaining that they had gotten sick after eating there. And that wasn't the only restaurant affected. By the time the outbreak was over at the end of September, nearly 1,000 people had reported symptoms of food poisoning, and 751 cases of salmonella had been confirmed. That's a lot. It's a lot. It was, and I think remains, the largest.

outbreak in Oregon's history. But fortunately, this Salmonella did seem to resolve for a lot of people pretty, like, easily or pretty well, or was treatable with antibiotics. But people had missed work. They had these large medical bills, and their bodies had obviously been put through the ringer with this illness. And they were left with questions. What happened? Where did this come from? Why me? The big guns were called and to help the local public health department trace the source of the outbreak, and EIS officers from the CDC arrived later that month. And they went around interviewing hundreds of patients and their families about what they had eaten, where and when, and also they went to every restaurant in the area, testing food, surfaces, and employees for trace of salmonella. They evaluated thermometers and ovens for any inconsumbrance. consistencies or faults. They tested cows, milk, septic tanks, city water, pond water, produce,

literally everything they could think of for salmonella, expecting to find a common source, linking all of these cases. The fact that the outbreak seemed tied to many different restaurants pointed towards a particular food item that was served at all of them, but they couldn't pinpoint it. They couldn't find it. There was no single factor linking all of these cases. Which isn't to say that they didn't find salmonella because they did find it in a few places, like in the coffee creamer at one restaurant and in the blue cheese dressing and another, but those items weren't eaten by everyone who had gotten sick. And the blue cheese dressing was contaminated during its preparation,

not like before it got to the restaurant, which pointed towards a human source, but no one person worked at all of the restaurants. As the investigation went on, cases dwindled and leads dried up, and the CDC was left with the unsatisfying conclusion that the outbreak was, I don't know, likely caused by employees at these different restaurants, and, you know, a lot of them lived together or were roommates, and so maybe that's what happened. And, you know, that's kind of how it goes sometimes with food poisoning outbreaks, there's no neat answer. But the people of Wasco County, Oregon would get their neat answer. They just had to wait about a year for it. Oh my God. I'm loving this. And when they got it,

it was not the answer that they were expecting, although at least a few people had had their suspicions all along. The reason that the food poisoning investigation had such a hard time linking all the cases to one food or one person was because it was actually many foods, poisoned by many people. People belonging to the Rajneeshi, some say movement, some say cult. So there was one common source for the salmonella cases all along, but the CDC investigators did not expect it to be intentional poisoning by a cult. Okay, so what? Why?

What? What? What? I'm sorry. This is a cult podcast now? I know. I know. Let's get into it. And this is why, so this is why I asked you whether you had seen Wild Wild Country, that documentary series. Oh, no, I haven't. It's so interesting. And everyone who's listening and hasn't seen it yet, go check it out. And everyone who has already seen it, and I suspect a great number of you out there have already seen it. Watch it again. Or, you know, like this is just a, refresher, so I don't know. I hope you enjoy it. I'm excited. Okay. So to get into the what and the why and the how of this massive salmonella poisoning, which this is the, like I said, the first bioterrorism attack in the U.S., we have to go back to around 1981. That year, a group of people from this religious movement, including its founder, Bhagwan Sri Rajdish, moved to Wasco County, Oregon, which is about 90 or so miles east of Portland, to a 64,000-acre ranch they had purchased.

The group had left Puna, India, for Oregon, after a lot of political pressure and reports suggesting that the cult was basically a money-making scheme, which exploited not only its wealthy members, but also did other illegal things to make money. I don't know if it's been confirmed or not, but they wanted out and they wanted to establish a utopia elsewhere. Ma Anand Sheila, the personal secretary and right-hand woman of the cult's leader Rajneesh, was charged with finding a place where they could build this utopia, where the followers, known as Sanyasins or Rajneeshis, could freely practice Rajneesh's teachings, which involved a lot

of love, beauty, guiltless sex, and capitalism. There was a store where you could live. like become more enlightened by spending money. It's kind of genius. And so this is how she decided on this ranch, right? The 64,000 acres, plenty of space to grow, beautiful land, all of that stuff. Their arrival was not really met with open arms by the people living in Wasco County, especially those living in the small town of Antelope. And when I say small, I mean like population a few dozen. Okay. small that was that you know located really near the ranch and tensions between the townspeople

of antelope and the ranch continued to mount as the rajneeshisys built up their community to essentially be a mini city complete with dozens of modular buildings and mobile homes and a frames a 2.2 acre meeting hall a 160 room hotel a two block long shopping mall a casino and a disco, a medical lab, a dam and a lake, water, sewage and transportation systems, an airstrip for the five private jet planes and helicopter owned by the cult, new roads. I mean, you get the picture. It was... Wow. They built a whole city. A whole city. It was a massive undertaking. It's, yeah. And this happened within a very short time frame, like in just a matter of a couple of years, which was terrifying for the people of Antelope,

who started to look for ways to kick these people out of the town or ideally out of the country. And when the legal way of doing things didn't look like it was going to work to get them gone, some open threats began to be made with a lot of gun carrying around town. It was, yeah. And the Rajneeshis, they met fire with fire.

They were beginning. to stockpile weapons, make threats to the town people. And they also used the legal routes available to them. They ran for town council. Oh, okay. And they won handedly. Yeah. Because the Rajneeshishe's greatly outnumbered the other residents of Antelope. This meant that the cult now controlled everything in the town, like everything. The roads, the water, the police force, they renamed the town Rajneishi. And this, of course, further escalated things because then residents of Wascoe County and Antelope ramped up their fight to get rid of the cult. On both sides, there was violence, there was threats of violence.

It's a story of like constantly mounting tensions where cause and effect is really difficult or almost impossible to disentangle. Yeah. And a big reason for this constantly mounting tension was, at least in terms of the cult, Ma Anan Shila. So Sheila, who was spokesperson for the cult and effectively its leader during Rajneesh's four-year vow of public silence, she was determined to win, to just gain more power. And that's what she viewed as her life's mission. This movement and making sure this movement had whatever it needed to grow and expand and any threat to the movement was a threat to her directly.

So she announced that she wasn't going to stop at taking over Antelope. She had set her sights next on Wasco County, the entire county, after that Oregon, and then the world. The only problem was that the cult members who numbered like 2,000 to 3,000, estimates vary. They didn't have the numbers to outvote the other Wasco. County residents, which is around 20,000 at this time. Okay. But luckily, Sheila had a strategy. She coordinated the busing in of thousands of people who were experiencing homelessness

into the ranch to then get them to register to vote so that in the next Wasco County election, in the fall of 1984, they would have stronger representation. But that didn't work out as planned, again with legal battles. At this point, though, Sheila's position was getting to be. a bit tenuous within the cult. And she felt increasingly threatened and desperate to not lose her status as like the de facto cult leader. She had to win this.

Registering thousands of recently arrived people to try to win an election didn't seem to be working out. But that's okay. Sheila had another plan. Oh, no. In the spring of 1984, Sheila and one of her top lieutenants, Ma Anand Puja, who was a nurse in charge of the Rajneesh Medical Corporation, they had a brainstorming session

about ways they could, you know, ensure that they won the election. One of the ideas floated was poisoning people to make them too sick to vote, but make them sick with what? That was the question. Sheila and Pooja began reading books like, I kid you not, how to kill volumes one through four. Stop. And the handbook of poisons.

Which, like, I'm sure that, like, based on what we do for this podcast, our Google search history is also quite bizarre. Yeah, but still. But still. And they also visited a local urologist to ask which poisons and bacteria would be difficult to trace, but deadly. And they were like, oh, well, we're worried about people poisoning the cult, so we want to know what we should keep an eye out for. And he was like, salmonella. Like, well, it's kind of easy to trace, but okay. It seems like they were more concerned about, like, the logistics of it.

And, like, how do we best do this? Sheila had tried to coordinate the assassinations of political enemies of the cult, and she had also poisoned people who had wronged her within the cult. Naturally. Pooja was apparently known by some in a cult as Nurse Mengley because of her obsession with using poisons and pathogens as a weapon. with one report of her trying to weaponize HIV. So, you know, it's, I'm sorry, what?

I know. It's horrifying. And there's so much more to the story that's like, this is just scratching the surface. It's kind of unbelievable. So at the ranch, there grew to be increasing conflict between the Rajneeshishe's and these people that had been bust in. And so Pujas and Sheila's solution was to tranquilize. the people, the new arrivals, either with sneak injections or by putting it in the beer that they were given every day. But for their sick in the public to prevent voting scheme,

they also toyed with the idea of hepatitis viruses, typhoid, and putting beavers for Guardia or just dead rats and mice into the public water system, just dropping it in there to make everyone sick. But salmonella seemed the most promising, not to mention accessible. Because where do you get salmonella, right? You order it. You can order it? I don't know if regulations have changed, but because back then they had a medical corporation and a lab, all they had to do was order samples from companies. Salmonella typhemerium wasn't the only one they ordered. They also got causative agents for typhoid. gonorrhea, tularemia,

Ooh, Shigella, and others. Yeah, I mean, you're supposed to have a medical lab that is biosafety licensed of a certain level to deal with certain pathogens, and those are supposed to be inspected, however often to maintain their status. They're supposed to be checks and balances in place here. Well, but I think the thing is they had been inspected by the public health officials. Their operation, their medical lab operation was big. Like, they had legit equipment and everything.

So it, which makes it all the more scary, I think. I know. But to make sure that salmonella typhemerium was the one, they had to test it out, of course. The perfect opportunity presented itself with a planned visit in late August 1984 by Judge William Hulse, Wosco County Executive, and Raymond Matthew, Woscoe County. commissioner. They got a flat tire during their inspection of the ranch, and while changing the tire, they were offered some cups of water, which they drank. Oh my goodness. Within about eight hours, they were both violently ill, and Hulse nearly died. Like, he went to the hospital and was like, it was touch and go. Wow. And the cause? Salmonella. So now we arrive at the big

moment. The poisoning of Hulse and Matthew showed that those samples could make people sick, but would it work on a big scale? For that, a bunch of members from the cult dressed up in disguise. They put on wigs, and they changed out their bright red clothes and robes for more neutral-toned outfits. And they went around to restaurants and grocery stores in the dolls, mostly, sprinkling, salmonella on salad bars, in coffee creamers, in dressings, over produce departments, and so on, like everywhere. They just literally ceded everything with salmonella. Okay. How did it come to light, Erin? Okay. So at the time, like I said, the CDC concluded that, well, we don't really know exactly what happened, but we suspect it was this person. There were

people who did suspect that it was the cult. It was the Rajneeshis that were behind it. But there was no apparent evidence at the time linking the Rajneeshis to the outbreak. The poisoning, which that was just sort of like a dry run, I guess, because this was in September and the actual voting happened later on. And so when it came time to the actual election, there was, as far as I'm aware, no salmonella poisoning, and the Rajneeshi candidates in this election lost by a landslide. There was a record 93% voter turnout. Wow. It's really high.

Sheila's position, I think with this loss, continued to slip and her paranoia grew. And on September 13th, 1985, which is about a year after that salmonella attack began, Sheila and a few others fled to Europe. A few days later, Rajneesh broke his four-year vow of public silence. He came out on stage and was like, I denounce Sheila and her allies. They betrayed my faith. They were responsible for all these criminal things. They're horrible people.

They're no longer in the light, et cetera. You know, she attempted murder of followers who challenged her authority. She mismanaged my money and left this commune $55 million in debt, and so I have to sell my 90 Rolls Royces. She tried to poison my doctor and dentist. She did incredibly intensive wiretapping, experimented with different lethal poisons on mice to try to find ones that were untraceable, and had coordinated this salmonella attack. And so in the midst of all of this denouncing of Sheila, Rajneesh was like, I demand a government investigation. This is on you now. You need to investigate what's going, what happened. And the investigation found glass vials containing salmonella backtroll discs that had been ordered from VWR scientific. And sure enough, that salmonella was the same as the one that had made those hundreds of people sick in the DALs. And Rajneesh, of course, denied knowing. any of it. He was like, I knew nothing. So was Sheila just a scapegoat for all of this? I mean,

she clearly was responsible for like a lot. And she clearly was completely without morals. But yeah. So how does the story end? The story ends with a few of these key players getting some jail time, about four years and had to pay some fines. So Sheila, if you are curious, now runs a couple of care homes in Switzerland for seniors and people with degenerative disorders. Your face. I know. Oh, no. Mm-hmm.

Fascinating, Erin. Aaron. I know. It's so interesting because I was trying to figure out, like, what is the legacy of this bioterrorism attack? This was the first time when we were doing this episode that I had read about it, and I was like, what on earth? There's so much more to the story than I had any idea. This seems like it would have been huge news. And of course, it was in Oregon. But from what I read, it doesn't seem like it got a ton of national attention. And I think that part of the reason for that is because

public health officials were like, oh my gosh, this was so easy for. for them to do, we don't want people to know that this is possible. Oh dear. We don't want any copycats. This is disturbing. And so as far as I could tell, it didn't really immediately result in any changes to regulations about who could order germs or for what purpose. I imagine, I hope that that has changed somewhat by this point.

Interesting. In any case, the 1984 Wasco County Salmonella attack was not the last time that Salmonella attack was not the last time that Salmonella made headlines. There have been many unintentional outbreaks since, including a huge one in Chicago, from contamination at a milk processing plant, and it led to 16,000 confirmed cases. 16,000 confirmed? That's what it said in a news report I read, yeah. Oh, my God, that's got to be a lot more than that actual cases.

Uh-huh. Oh, boy. Yeah. And reports in the late 80s revealed the incredible extent to which salmonella is present on eggs, which was also, I think, the first time that food hygiene as it related to salmonella gained more widespread awareness. But I'm really curious, Aaron, what has happened in the years since. I know antibiotic resistance is an issue, and reporting and tracing outbreaks is still problematic. Can you bring me up to speed? How many people are you? How many people are you? I know, get sick, what's the biggest problems, all that stuff? I can't wait to. Let's take a break first. So I thought for this one, I'd start like as broad as possible and then dig down to more narrow. All right? Okay. That's my plan. Sure. So globally, if we just look at foodborne illness in general, the World Health Organization estimates over 600 million infections and 420,000.

deaths associated with foodborne illness specifically. If we look just at the diarrheal foodborne infections, those cause an estimated 230,000 deaths worldwide. So over half. And salmonella is one of these principal agents that cause death among those foodborne diarrheal illnesses. So it's estimated, if we now just look more. specifically at salmonella, that salmonella enteritis itself in 2017 is estimated to have caused over 95 million infections worldwide. And there's a really wide margin of error on that estimate. Of course. And over 50,000 deaths. Again, wide margin of error. If we now get even more specific and turn to invasive disease, so invasive salmonella, not typhoid salmonella.

salmonella, it's estimated that there were in 2017 over 535,000 cases of invasive non-typhoidal salmonella, with the highest incidence in sub-Saharan Africa. And they estimated over 34 cases per 100,000 happened in children under age 5. So a huge burden in children, and they are, of course, some of the highest risk for severe illness and invasive disease. And this paper also estimated over 77,000 deaths in 2017 just from invasive salmonella. So that's separate from the salmonella enteritis. Oh, wow. I know.

Yeah. The all-age case fatality rate for invasive salmonella was 14.5% on average, 14% death toll from invasive salmonella. That is, I had no idea. how severe an invasive salmonella infection. And so when you get an invasive salmonella infection, is it just that antibiotics don't always get there in time, or is it antibiotic-resistant infections?

Like, what's contributing to that high death toll? Yeah, it's a good question. I think it's a lot of things. I think it's probably a combination of all of that. It's also that, so the case fatality rate is even higher if you look at just the elderly or look at just those under age five or just those living with HIV. So that's even just the average.

But I think it's a lot of things. I think it's how overwhelming the infection can be, maybe by the time you identify it. I think it's that a lot of these are happening in areas that have a lack of access to good medical care or to rapid medical care with identification and quick treatment and that sort of thing. So I think it's a lot of factors that play into it.

In the U.S. alone, the CDC estimates that there are, over 1.35 million cases of salminalosis every year, over 26,000 hospitalizations, and 420 deaths in the U.S. And now here's where it gets even scarier. And this data I really only have for the U.S., but this isn't specific to the U.S., but this data is from the U.S. Of those 1.35 million cases, it's estimated that over 200,000 of them are due to antibiotic-resistant salmonella. Wow. Including an estimated 20,000, at least cases a year that are resistant to three or more of the essential antibiotics that we would use to treat salmonella. Antibiotic resistance, it's a really big problem, obviously when it comes to so many infections, not just salmonella.

But in salmonella, I think part of the reason that it's a particular problem is because, of the way that antibiotic resistance can develop in our food system and then spread through that food system. Yeah. Right? So because salmonella can be found in so many guts of so many animals, especially domestic animals that we use for food, it can then, like you were saying, Aaron, enter our food system from a number of different ways from the processing to the water supply. It can end up on the boots of a farmer and then be transferred between locations. It can end up in the soil.

It can be carried by rodents or even insects potentially. It can persist on shared equipment. Like you mentioned, it can be in these tanks where they're cleaning things that just then get filled with salmonella. It can be everywhere. It has a lot of points of entry into our food system, right? That's just salmonella. Now, antibiotic resistance genes are present. not just in bacteria of pathogen potential, but antibiotic resistance genes are present in a lot of

environmental microorganisms. So there's what's often called like an environmental resistome that exists. And these genes can then also make their way into bacteria of pathogen potential. It doesn't have to be that these salmonella making their way into our food system have to evolve these resistance genes de novo. A lot of the times these genes already exist and in many cases are present on plasmids or if, let's say, other like lactic acid bacteria in the soil, like break open. Now these genes are in the environment. So bacteria like salmonella can then come into contact and pick them up via conjugation or transformation. See our antibiotic resistance episode for more.

And that too is one of the reasons why like the wide. spread use of antibiotics, especially in our farm system and our domestic animal, like animal for meat production and things is so concerning and such a big part of the problem that contributes to antibiotic resistance, right? Because you're selecting for these resistance genes, not just in the pathogens, but in the environmental bacteria as a whole. It is nightmarish. It really is. It is, yeah. Speaking of nightmareish, great. Yeah. Love that segue. Right? That was a good one. Thanks for handing it to me. I want to give a shout out to a very great and thorough article that, Erin, you sent me over. This article was published in ProPublica. It dives very deeply into an outbreak that perhaps is still evolving, perhaps has waned. It's hard to

say, but an outbreak of salmonella, a seravar called Infantis, which I mentioned at the top, that started in 2018, and this is a particularly multi-drug resistant and particularly infectious and tends to cause relatively severe disease, Sarovar, that really ran rampant and was found at extremely high prevalence in meat and poultry samples. And throughout this outbreak, according to the article, the CDC estimated that for every confirmed case of salmonella, an additional 30 are never reported. So this outbreak likely had infected nearly 3,000 people. I had never heard of it. No. Yeah. This was like 2018, 2019. Like this just happened. And this article does a really great job

of kind of highlighting some of the major flaws. And this is U.S. specific. And they kind of compare to the way the regulatory system works in the U.S. versus Canada and Europe and other countries. But we have in the U.S. some pretty massive holes in how our regulatory system works in terms of what the CDC can do and require and investigate and what their investigations can then produce as like a recommendation or product versus the FDA versus the USDA who oversees meat and poultry. and that is separate from the FDA that does all of the rest of the food. Mm-hmm.

Right? And essentially, just like this system, which probably comes as no surprise to anyone who's listened to this podcast, is not designed to protect the consumer. No. It's designed to protect the industry. You might hear about salmonella in your bag of spinach every once in a while. You might hear about it every once in a while in chicken from this one farm. But the problem is so much bigger than that. And to really get a handle on it, we have to truly, in this country, revamp the way that our food system works and the power that regulatory government bodies actually have to regulate that industry, which essentially doesn't exist right now.

Salmonella is pretty easy to kill. It's not like some of the bacteria that we've talked about that have like very environmentally hardy spores or anything. Mm-hmm. So cooking your food properly does kill the bacteria. And it does have a really high infectious dose. So that's also good. Yeah, it is also, though, really easy to contaminate other parts of the kitchen. So I think, like, yeah, the knives, the cutting boards, the counter, your hands, everything has to be really well cleaned,

including things that you aren't going to cook like salad greens or fruits. These things need to be washed. And that can really be a challenge sometimes. It can. It really can. One of the biggest tools that we have to use in understanding the extent to which salmonella poses a public health problem is, of course, through testing. But not just testing of environmental samples or of meat products or produce, but also testing of humans when we get sick. Because while a lot of salmonella cases are never reported, because the person who got sick, maybe. didn't get sick enough to actually go to the hospital or clinic. But there are a lot of people who do. So if, for example, you get quite sick, you have really bad stomach cramps, you absolutely can't stop pooping, and you decide to go to the hospital or a doctor's office. Once you're there, what's very likely going to happen is that you might get asked to provide a sample of said poop

or stool to figure out what the cause is of your symptoms. But the question, is how exactly does all that information come to light? Like where does that stool sample go? Who is the person who's having to sort through it and test it? And what else are they working with? We are really happy to have the help of medical laboratory scientist and TPWKY listener Sarah Zoucha to help us answer some of these questions and to shine a light on a sometimes very overlooked but crucial field in health care, medical laboratory science. We'll let Sarah introduce herself right after this break. Hi, I'm Sarah Zoucha. I'm a medical laboratory scientist. I have been working in the field for about 12 years. I am ASCP certified as a generalist, which means I can

work in all areas of the clinical laboratory, including blood bank, hematology, chemistry, and microbiology, which is my primary focus, and where I have been working for the past 10 or so years. Awesome. Thank you so much for being here. Can you walk me through what happens in foodborne illness testing in general? Like, what's the process from the doctors, office to test results, and what are the other common pathogens that you look for? In any kind of laboratory testing, there are three phases. There's the pre-analytic phase, which is what happens with the specimen before it gets to the lab, the analytic phase, which would be the actual laboratory testing, and then the post-analytical phase. So starting in the

pre-analytic phase, that's, you know, when the patient goes to the doctor, they're not feeling well. And the doctor will be asking about patient symptoms when they began, what their symptoms are. Specifically, if they're suspecting a foodborne illness, of course, where did they eat, what did they eat, any travel history, things like that. The next thing they will do is they'll collect the specimen from the patient. So the doctor will give the patient everything that that they need to do that. And in the case of food-borne testing, they're going to need a stool sample. So the analytical phase of testing is when the specimen is actually received into the lab. So the specimen is processed for testing, and there's a couple of different ways that this can be done.

Right now, a lot of labs are moving to a more rapid kind of testing versus traditional culture. In traditional culture, you have to wait 24 hours for the bacteria to grow before you can really do anything with it. With the new molecular test, it's a panel that will test for the most likely suspects in foodborne illness. So it will give you a preliminary result right away. So the doctor kind of has a heads up the day that the specimen is received into the lab. And these panels typically test for salmonella, chigella, ecoli, aromonas, pleicomonas, vibrio, campelobacter, and ursinia enterococalitica. You can also get expanded panels for other things like parasites and certain viruses that may cause

gastrointestinal discomfort, depending upon, you know, the hospital and what they determine their needs are. So once this molecular panel is run, if there is something that is identified in this panel, what will then happen is that specimen is cultured out and grown in traditional bacterial culture for confirmation. and then this is done by different biochemical testing and other commercial laboratory instrumentation that will confirm the ID. Once this bacteria is identified, then it is typically sent out to the local department of health

or other state reporting agencies so they can do kind of their follow-up. investigation. And then this kind of leads us into the last phase, which is post-analytical, where the results are reported out to the patient's chart, call to the clinician if it's considered a critical value, and then any contact tracing or patient follow-up is performed. So with cases of food poisoning, you have your usual suspects that you're looking for. But what if you don't know exactly what you might be looking for in a suspected infection. Like, where do you start your search in that case? Actually, how it works is we're supposed to be totally blind when we have a

sample come into the lab. We're not supposed to really know too much about the patient in their history because that can bias the results. So when the specimen comes into the lab, all we know is that that the doctor wants this kind of test. So like in the case of suspected foodborne illness, they're just going to send a stool culture. So we would just set up the testing and basically we have a list of what we're looking for and we're ruling everything out. If the culture is negative, we're going to send out those results. But if the doctor does suspect that there is still something going on, then that's when they would order more testing so like they would know, okay, this patient is exhibiting GI symptoms. It's not bacterial. Well, maybe it's viral.

So let me order a viral panel. You know, if that's negative, then they'll be like, all right, parasitic. Let me order an ova and parasite panel. You know, so it's really up to the doctor to kind of make that determination. We in the lab aren't really authorized to order testing as that constitutes treatment and diagnosis, which is out of our scope. The only time we're able to order extra testing to rule things out is if it's something that's predetermined

by the medical director in the clinician team where a test would automatically reflux. As a medical laboratory scientist or technician, what are some of the places you can work? And what does the current job market look like for these careers? So the current job market is super excellent right now. There is a severe shortage. I went on the Bureau of Labor Statistics to find out how short we actually are.

So according to the Bureau of Labor Statistics, job growth between 2020 and 2030 is 11% faster than the national average for most other jobs. What's going on right now, if you graduate from college, you can get a job anywhere. Like anywhere you want, any city, any hospital, I mean, everybody is hiring. So some of the places that people normally work, hospital labs are the most common, but also there's reference labs like LabCore, Quest, Arup. A lot of times doctors' offices or urgent cares will employ an MLS to run their small in-house laboratory, point of care, which point of care is kind of maintaining the devices that the nurses would use at a patient's bedside like glucometers, public health labs, pharmaceutical companies, medical device companies, and research are other areas that do employ clinical laboratory or medical laboratory scientist.

However, I feel like those are a little bit less popular and also harder to get a job in those industries. What is the most unusual sample you've ever worked with? The most unusual sample I've ever worked with. Probably any like amputated body part when you're testing something like that, you're generally, it's a tissue culture. Like, let's say somebody has gang green, and so, you know, you're trying to figure out the cause of the infection.

So what's really supposed to happen? The doctor's supposed to cut off a piece of the tissue and deliver it to the lab that way. But there's been times where it's, I remember one time we got something, it was like a Tupperware container, and I open it up and it's like half a foot. and, you know, we've gotten fingers.

We've gotten tips of penises. Yeah. So those would be, yeah, some of probably, like, my more memorable ones where I'm just like, did they really just do that? Oh, my goodness. I really. cannot get over it. That is amazing. Amazing and hilarious. Thank you so much, Sarah, for taking the time to chat. Yes, thank you. Well, should we do sources? Sources, definitely. I will shout out a few.

There were a couple papers by Hardy, one from 1999, one from 2003, that kind of looked at this bigger picture of salmonella and the way that like food production changed. And of course, the documentary Wild Wild Country. I had a number of papers. If you want to know more about the differences in the epidemiology of the serovars. There was a paper in Applied and Environmental Microbiology from 2019 that went into a lot of detail on it. I really enjoyed a paper from Frontiers in microbiology 2014 that was like comparing and contrasting typhoidal and non-typhoidal salmonella serovars. There was a bunch of really good ones. And I will also link to that ProPublica article if you want to read more about that outbreak that happened in the U.S. recently.

Thank you again so much, Beth, for sharing your story. We really appreciate it. Thank you. Thank you also to Bloodmobile for providing the music for this episode and all of our episodes. And thank you to you, listeners. We hope that you enjoyed this poopie episode. Poopie episode. Yeah. Not poopie. It actually wasn't. Yeah. And a special thank you to our patrons. We love you. We love you. Okay, well, until next week, my gosh, please wash your hands and your fruits and vegetables and use a thermometer. And your knives and your cutting. boards and your kitchen counters and your, what do you do about sponges? Aye, you filthy animals.

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