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Yersinia enterocolitica Gastroenteritis Among Infants Exposed to Chitterlings --- Chicago, Illinois, 2002

During December 2002--January 2003, the Chicago Department of Public Health (CDPH) investigated a cluster of Yersinia enterocolitica infections reported during a 10-week period among nine Chicago infants aged <1 year. This report summarizes the investigation of these cases and underscores the continuing risks for enteric infection among infants exposed to chitterlings (i.e., pork intestines), and the need for health-care providers to be aware of Y. enterocolitica as a cause of gastroenteritis, particularly in black children during traditional winter holiday celebrations.

CDPH defined a case of Y. enterocolitica gastroenteritis as diarrhea in an infant, with accompanying isolation of Y. enterocolitica from stool culture. CDPH alerted hospitals and health-care providers of the cases and requested reports of all laboratory-confirmed cases. Caretakers of the affected infants were interviewed by using a standard case investigation form. Questions were added to determine the source of the chitterlings, brand name, and preparation techniques. CDPH acquired chitterlings from several identified retail outlets for microbiologic testing.

During November--December 2002, nine infants had illness onset; the median age of the infants was 8 months (range: 7 weeks--13 months). Of the nine infants, eight were black and had either eaten chitterlings or spent time in a household in which the dish had been prepared. The one case not associated with chitterlings occurred in a Hispanic infant aged 1 year. All eight infants who were exposed to chitterlings had a history of contact with caretakers who prepared chitterlings, and one had a history of eating chitterlings. For seven infants for whom information about time of exposure to chitterlings was available, all had direct or indirect contact with chitterlings within 2 weeks of illness onset (median: 4 days; range: 1--12 days).

Caretakers of six infants purchased chitterlings from the same grocery store chain but from three separate locations. Two infants were exposed to the same brand of chitterlings. Caretakers reported different preparation techniques, and preparation times ranged from 2 to 12 hours. No chitterlings or lot numbers associated with the cases were available.

Y. enterocolitica isolates from two infants were serotyped; both were serotype O:3. Samples of chitterlings obtained for testing yielded Y. enterocolitica serotype O:3 and Salmonella serotype Derby. One infant with chitterlings-associated Y. enterocolitica also had S. Typhimurium isolated from stool culture. All nine infants recovered, and clinical illness was limited to gastroenteritis. Six infants were hospitalized; median duration of hospitalization was 5 days (range: 3--6 days). The infant who also had coinfection with S. Typhimurium required 6 days of hospitalization because of possible intussusception.

Reported by: RC Jones, MPH, JR Fernandez, SI Gerber, MD, W Paul, MD, Chicago Dept of Public Health; L Williams, Environmental Svcs, Illinois Dept of Public Health. R Turner, DVM, Food Safety and Inspection Svc, US Dept of Agriculture. JT Watson, MD, EIS Officer, CDC.

Editorial Note:

This report describes nine cases of Y. enterocolitica gastroenteritis among Chicago infants, eight of whom were exposed to chitterlings prepared in their homes during the winter holidays. Chitterlings are a known cause of Y. enterocolitica gastroenteritis, particularly among black children (1,2). Y. enterocolitica, a gram-negative enteric organism commonly present in swine, can cause illness characterized by fever, occasional bloody diarrhea, and abdominal pain. Bacteremia also can occur, especially in infants aged <3 months (3). Chitterlings are traditional winter holiday food in certain black families and are readily available in the United States. Y. enterocolitica is transferred from raw chitterlings to infants, particularly to bottle-fed infants, through contact with the hands of food preparers (1,2). In Fulton County, Georgia, nearly half of all child caretakers enrolled in an epidemiologic investigation to determine risk factors for Y. enterocolitica infection reported household preparation of chitterlings for holiday meals (1). In 2002, Y. enterocolitica gastroenteritis was reported by active surveillance in FoodNet sites at an incidence of 0.44 per 100,000 population. Incidence has been decreasing for years for undetermined reasons (4).

Prevention of yersiniosis should focus primarily on increased consumer awareness of the inherent bacterial contamination of chitterlings as a food product and the risks associated with their preparation and consumption. The Food Safety and Inspection Service of the U.S. Department of Agriculture regulates inspection of chitterlings produced in federally inspected establishments. Preparation of chitterlings requires thorough cleaning before cooking, an extensive process usually performed at home. Special care should be taken when handling raw chitterlings, including careful hand washing by persons cleaning chitterlings before touching children or anything used by children (5). Public health officials and clinicians should be alert to the possibility of Y. enterocolitica as a cause of gastroenteritis, particularly in black communities during the winter holiday season. Information regarding safe preparation of chitterlings is available at http://www.ph.dhr.state.ga.us/epi/news/oct02/103102.shtml.

References

  1. Lee LA, Gerber AR, Lonsway DR, et al. Yersinia enterocolitica O:3 infections in infants and children, associated with the household preparation of chitterlings. N Engl J Med 1990;322:984--7.
  2. Lee LA, Taylor J, Carter GP, Quinn B, Farmer JJ 3rd, Tauxe RV. Yersinia enterocolitica O:3: an emerging cause of pediatric gastroenteritis in the United States. J Infect Dis 1991;163:660--3.
  3. Abdel-Haq NM, Asmar BI, Abuhammour WM, Brown WJ. Yersinia enterocolitica infection in children. Pediatr Infect Dis J 2000;19:954--8.
  4. CDC. Preliminary FoodNet data on the incidence of foodborne illness---selected sites, United States, 2002. MMWR 2003;52:340--3.
  5. CDC. Topics in minority health: Yersinia enterocolitica infections during the holidays in black families---Georgia. MMWR 1990;39: 819--20.



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