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The web site itself may have changed. You can check the current page or check for previous versions at the Internet Archive. Yahoo! is not affiliated with the authors of this page or responsible for its content. Outbreak of Escherichia coli O157:H7 Infection Georgia and Tennessee, June 1995 Outbreak of Escherichia coli O157:H7 Infection Georgia and Tennessee, June 1995 On June 26, 1995, the Division of Public Health, Georgia Department of Human Resources (GDPH), was notified of three cases of Escherichia coli O157:H7 infection among residents of a community in north Georgia who had onsets of illness within a
24-hour period (onset during June 1920); in comparison, during 19931994, only two
cases of this infection had been reported in the same community. Because of the prox-
imity of this community to the Tennessee border, on June 28 GDPH notified the Ten-
nessee Department of Health (TDH) about these cases. TDH subsequently identified
two confirmed cases with onsets of illness during June 2324. Both of these cases
were among persons residing in eastern Tennessee approximately 100 miles from the
community in Georgia, and one occurred in an 11-year-old boy who was hospitalized
with hemolytic uremic syndrome (HUS). This report summarizes the investigation of
this outbreak, which implicated eating hamburgers purchased at a fast-food restau-
rant chain (i.e., chain A) as the source of infection. Active surveillance for additional cases was initiated in hospitals in both states. Cases were defined as laboratory-confirmed E. coli O157:H7 infection among persons who became ill during June 1125, or abdominal cramps and bloody diarrhea of at
least 72 hours duration among persons residing in the same household as a person
with a culture-confirmed case. A matched case-control study was conducted to assess
potential sources of the outbreak. Only the first case (index case) in each household
was included in the study. For each case, two neighborhood controls matched by age
range were selected. Laboratory analyses included O157 and H7 agglutination tests
and pulsed-field gel electrophoresis for DNA analysis of E. coli O157:H7 isolated from stool. Case-patients and controls were interviewed to collect information about food
exposures and potential risk behaviors within 7 days before onset of illness. GDPH and TDH identified 10 case-patients with onset of illness during June 1323. Patients ranged in age from 7 to 89 years (mean: 32 years), and seven were male.
Excluding the HUS case, the median duration of illness was 7 days. All case-patients
had had grossly bloody diarrhea and severe abdominal cramps for >72 hours. Eight of the 10 case-patients were included in the case-control study. One was ex- cluded because his parents declined participation and another because a spouse was
the index patient in the household. Eating hamburgers purchased at one of three
chain A restaurants (two in Tennessee and one in Georgia) during June 1321 was March 29, 1996 / Vol. 45 / No. 12 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / Public Health Service 249 Outbreak of Escherichia coli O157:H7 Infection Georgia
and Tennessee, June 1995 251 Recall of Philip Morris Cigarettes, May 1995March 1996 254 Workshop on the Public Health Response to Nasopharyngeal
Radium Irradiation
September 1995 reported by seven of the eight patients and one of the 16 controls (matched odds
ratio=infinity, 95% confidence interval=2.5infinity). No other exposures were signifi-
cantly associated with E. coli O157:H7 infection. All three restaurants obtained unfro- zen ground beef patties from the same meat processing plant and reported complete
turnover of stock, generally within 3 days. Seven of the eight cases were confirmed by isolation of E. coli O157:H7 from stool specimens; DNA patterns were identical for six of these patients. The single case-
patient for whom the isolate had a different DNA pattern did not recall eating at a
chain A restaurant and had onset of illness on June 13. Inspections of chain A restau-
rants in Georgia and Tennessee did not identify deficiencies in cooking temperature or
procedures, but did identify potential opportunities for cross-contamination from the
ground beef. Meat samples obtained at least 4 days after the case-patients visited the
restaurants were negative for E. coli O157:H7. Based on the epidemiologic and laboratory findings, GDPH and TDH concluded that hamburgers served at chain A restaurants were the source of this outbreak, most
likely as a result of undercooking of or cross-contamination from the ground beef to
the buns or other items on the hamburger. GDPH and TDH recommended a thorough
assessment of food-handling and cooking procedures at chain A restaurants. In addi-
tion, chain A restaurants instituted a training program for workers in proper food-
handling practices. Reported by: M Cannon, H Thomas, Catoosa County Health Dept, Ringgold; W Sellers, MD,
Rome District Health Office, Rome; M Bates, Georgia State Public Health Laboratory, P Blake,
MD, H Stetler, MD, K Toomey, MD, State Epidemiologist, Div of Public Health, Georgia Dept of
Human Resources. J Fowler, S Halford, Knox County Health Dept, Knoxville; G Young, Hamilton
County Health Dept, Chattanooga; S Hall, MD, Knox County Regional Office; P Erwin, MD, East
Tennessee Region; V Boaz, MD, Chattanooga-Hamilton County Regional Office; G Swinger,
DVM, Tennessee Dept of Health. Foodborne and Diarrheal Diseases Br, Div of Bacterial and
Mycotic Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiol-
ogy Program Office, CDC. Editorial Note: E. coli O157:H7 was first recognized as a human pathogen in 1982. Infection with this pathogen may be asymptomatic or associated with a range of
manifestations including mild diarrhea, severe hemorrhagic colitis, HUS, thrombotic
thrombocytopenic purpura, and death ( 1,2 ). From January 1, 1993, through Septem- ber 14, 1995, a total of 63 clusters or outbreaks of E. coli O157:H7 infection were re- ported to CDC by 32 states; these outbreaks accounted for 1734 cases (CDC,
unpublished data). In three U.S. studies conducted during 19851990, E. coli O157:H7 was the third or fourth most common bacterial pathogen isolated from stool speci-
mens ( 2 ) and, among stool cultures at 10 hospitals throughout the United States, E. coli O157:H7 was isolated from 8% of visibly bloody stools (3 ). Ground beef is the most common vehicle for E. coli O157:H7 transmission in inves- tigated outbreaks. Since January 1993, ground beef has been identified as the primary
vehicle of infection in 25 (40%) of the 63 reported outbreaks of this infection. E. coli O157:H7 can be recovered from the intestines of approximately 1% of cattle; because
of processing practices, meat from many animals may comprise one hamburger ( 2 ). Although current U.S. Department of Agriculture regulations specify only gross in-
spection of carcasses, more comprehensive regulationsincluding process controls
that incorporate guidelines for microbiologic testing of meathave been proposed
and already have been implemented by some producers. Complete implementation of Escherichia coli O157:H7 Continued 250 MMWR March 29, 1996 these production practices should decrease E. coli O157:H7 contamination of the meat supply. Ground beef contaminated with E. coli O157:H7 can cause illness when the meat is not thoroughly cooked (to an internal temperature of at least 155 F [68 C]) or when raw
or undercooked meat cross-contaminates other food items. Because the infectious
dose is low, even limited deficiencies in food preparation or handling can result in
exposure and infection ( 2 ). Although this investigation did not identify deficiencies in hamburger cooking temperatures, opportunities for cross-contamination were de-
tected. Measures for preventing cross-contamination include washing hands and sur-
faces after contact with raw ground beef, storing raw ground beef to ensure that
drippings do not contaminate other foods, and using different utensils to handle raw
and cooked meat. As of January 1996, reporting of E. coli O157:H7 infection was required by 38 states (W. Keene, Oregon Department of Human Resources, personal communication, 1996),
including Georgia and Tennessee; neither state had required reporting of E. coli O157:H7 at the time of this outbreak. The outbreak described in this report under-
scores the need for clinical laboratories to screen stool specimens for E. coli O157:H7 on sorbitol-MacConkey (SMAC) agar. In this outbreak, E. coli O157:H7 was detected by a laboratory in Georgia that routinely screened for this pathogen. In a recent survey
of clinical microbiology laboratories in the United states, only 54% screened all bloody
stool specimens on SMAC agar ( 4 ). CDC recommends that laboratories in all states screen at least all bloody stools for E. coli O157:H7. References 1. Boyce TG, Swerdow DL, Griffin PM. Escherichia coli O157:H7 and the hemolytic uremic syn- drome. N Engl J Med 1995;333:3648. 2. Griffin PM. Escherichia coli O157:H7 and other enterohemorrhagic Escherichia coli. In: Blaser MJ, Smith PD, Ravdin JI, Greenberg HB, Guerrant RL, eds. Infections of the gastrointestinal
tract. New York: Raven Press, Ltd., 1995:73961. 3. Ries A, Griffin P, Greene K. Escherichia coli O157:H7 diarrhea in the United States: a 10 center surveillance study. In: Program and abstracts of the 33rd Interscience Conference on Antimi-
crobial Agents and Chemotherapy, New Orleans 1993:385. 4. Boyce TG, Pemberton AG, Wells JG, Griffin PM. Screening for Escherichia coli O157:H7: a nationwide survey of clinical laboratories. J Clin Microbiol 1995;33:32757. Recall of Philip Morris Cigarettes, May 1995March 1996 Cigarette Recall Continued On May 26, 1995, Philip Morris U.S.A.* announced a voluntary recall of 36 cigarette product lines (approximately 8 billion cigarettes) because, during production, the
company detected unusual tastes and peculiar odors and identified methyl isothiocy-
anate (MITC) in the cigarette filters. During June 68, 1995, public health officials in
Minnesota, Oregon, and Texas requested CDCs assistance in investigating consumer
health complaints associated with smoking Philip Morris cigarettes near the time of
the recall. This report summarizes CDCs ongoing investigation, which suggests that
prolonged cigarette smoking caused most of the health complaints; in addition, the
investigation has not identified a distinguishing chemical characteristic of the recalled
cigarettes. Escherichia coli O157:H7 Continued *Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human
Services. Vol. 45 / No. 12 MMWR 251 Reports of cases of illness near the time of the recall were identified through pas- sive surveillance by direct telephone calls to CDC. CDC used a standardized form to
interview persons who reported illness and, when possible, collected cigarette sam-
ples. To verify self-reported data, a medical records review was conducted. Cigarettes
included in the recall had been manufactured during May 1322. Philip Morris U.S.A.
provided CDC with samples of recalled cigarettes (manufactured on May 19, 1995)
and, for comparative analyses, provided samples of cigarettes manufactured before
(on March 3, 1995) and after (on June 12, 1995) the recall. Reports of Illness During JuneJuly 1995, CDC received reports of illness from 72 persons in 27 states who had smoked Philip Morris cigarette brands on or after May 13, 1995. The 72 per-
sons comprised 36 men and 36 women; the mean age of these persons was 40 years
(range: 15 years67 years). A total of 41 (57%) persons reported onsets of illness be-
fore the recall, and 31 (43%) reported onsets after the recall. Of the 72 persons,
51 (71%) reported no preexisting health conditions; 42 (58%) reported experiencing
serious health problems from smoking near the time of the recall. A case definition
could not be developed because no common pattern of symptoms was identified;
however, the most frequently reported manifestation was at least one respiratory or
nasopharyngeal symptom (61 [85%]); other frequently reported symptoms included
headache (18 [25%]), dizziness (15 [21%]), and ophthalmologic problems (15 [21%]). A
total of 59 (82%) persons sought medical treatment for their symptoms; 14 (19%) were
hospitalized. All 72 persons reported smoking cigarettes manufactured by Philip Morris the day they became ill. Most persons (43 [60%]) smoked Marlboro brand cigarettes. The av-
erage duration of smoking was 20 years (range: <1 year45 years), and the average
number of cigarettes smoked per day was 23 (range: <1 cigarette50 cigarettes). Medical Records Review Because a case definition could not be specified, further investigation was re- stricted to 29 persons who reported no preexisting health conditions and who re-
ported experiencing serious health problems associated with smoking near the time
of the recall. Of these persons, medical records were obtained for 20. Based on review
of these records, the conditions most frequently diagnosed in these persons near the
time of the recall were pneumonia (four persons), exacerbation of asthma (four), bron-
chitis (three), chronic obstructive pulmonary disease (three), eosinophilic pneumonitis
(two), and laryngitis (two). The review suggested that most (18 [90%]) of these ill-
nesses were associated with cigarette smoking, preexisting medical conditions result-
ing from prolonged cigarette smoking, or infectious agents. Laboratory Analyses CDC analyzed cigarette samples using high-resolution gas chromatography/high- resolution mass spectrometry. MITC was detected in samples of filter and samples of
tobacco and paper obtained from prerecall, recall, and postrecall cigarettes provided
by Philip Morris. MITC levels were higher in cigarettes packaged in hard packs than in
soft packs (e.g., 102 ng per filter versus 15 ng per filter, p<0.01, n=21 [14 hard packs
and seven soft packs]). MITC also was detected in Philip Morris cigarettes produced at
least 1 year before the recall. Seven packs of cigarettes from five other manufacturers
were purchased at local stores in Atlanta; MITC was detected in cigarettes from each
of these packs. 252 MMWR March 29, 1996 Cigarette Recall Continued Cigarettes obtained from Philip Morris were analyzed for the eight compounds re- ported by Philip Morris to have caused the taste and odor problems. Of the eight compounds, three (butyric acid; 1,2-propanediol diacetate; and 2-ethylhexyl acetate)
were detected in prerecall, recall, and postrecall cigarettes; the other five compounds
were not detected. Compared with prerecall and postrecall cigarettes, there was no
distinctive increase in one or more of these compounds in the recall cigarettes. Cigarette samples also were analyzed to identify a unique chemical profile that dis- tinguished the recall cigarettes from the prerecall or postrecall cigarettes. Analysis of
volatile organic compounds from the filter and from the tobacco and paper of these
cigarettes did not identify such a profile. In addition, analysis of cigarette smoke from
recall cigarettes did not contain a unique chemical pattern. Laboratory analysis is ongoing of cigarettes obtained from the 72 persons who re- ported illnesses. However, as of March 22, 1996, no unique chemical pattern had been
identified. Reported by: P Huang, MD, K Hendricks, MD, S Kohout, M Harris, DM Simpson, MD, State
Epidemiologist, Texas Dept of Health. K MacDonald, MD, Minnesota Dept of Health. MA Heu-
mann, MPH, State Health Div, Oregon Dept of Human Resources. Div of Environmental Health
Laboratory Sciences, and Div of Environmental Hazards and Health Effects, National Center for
Environmental Health; Div of Field Epidemiology, Epidemiology Program Office; Office on
Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion,
CDC. Editorial Note: Based on the medical records review and laboratory analyses in this
report, prolonged cigarette smokingrather than smoking contaminated cigarettes
caused most of the health complaints from persons reporting illness associated with
smoking Philip Morris cigarette brands near the time of the recall. Smoking is the lead-
ing preventable cause of diseases associated with premature death in the United
States; in 1990, approximately 419,000 deaths were attributed to smoking ( 1 ). The estimated number of compounds in tobacco smoke exceeds 4000, including many
that are pharmacologically active, toxic, mutagenic, and carcinogenic ( 2 ). Although Philip Morris reportedly recalled cigarettes in part because of the recent detection of MITC, the laboratory analyses in this report indicate that MITC was pre-
sent in cigarettes manufactured by Philip Morris up to 1 year before the recall and in
cigarettes from other manufacturers. MITC is a decomposition product of 3,5-
dimethyl-1,3,5,2H-tetrahydrothiadizine-2-thione, which is used as a preservative in the
manufacture and coating of paperboard
The web site itself may have changed. You can check the current page or check for previous versions at the Internet Archive. Yahoo! is not affiliated with the authors of this page or responsible for its content. Outbreak of Escherichia coli O157:H7 Infection Georgia and Tennessee, June 1995 Outbreak of Escherichia coli O157:H7 Infection Georgia and Tennessee, June 1995 On June 26, 1995, the Division of Public Health, Georgia Department of Human Resources (GDPH), was notified of three cases of Escherichia coli O157:H7 infection among residents of a community in north Georgia who had onsets of illness within a
24-hour period (onset during June 1920); in comparison, during 19931994, only two
cases of this infection had been reported in the same community. Because of the prox-
imity of this community to the Tennessee border, on June 28 GDPH notified the Ten-
nessee Department of Health (TDH) about these cases. TDH subsequently identified
two confirmed cases with onsets of illness during June 2324. Both of these cases
were among persons residing in eastern Tennessee approximately 100 miles from the
community in Georgia, and one occurred in an 11-year-old boy who was hospitalized
with hemolytic uremic syndrome (HUS). This report summarizes the investigation of
this outbreak, which implicated eating hamburgers purchased at a fast-food restau-
rant chain (i.e., chain A) as the source of infection. Active surveillance for additional cases was initiated in hospitals in both states. Cases were defined as laboratory-confirmed E. coli O157:H7 infection among persons who became ill during June 1125, or abdominal cramps and bloody diarrhea of at
least 72 hours duration among persons residing in the same household as a person
with a culture-confirmed case. A matched case-control study was conducted to assess
potential sources of the outbreak. Only the first case (index case) in each household
was included in the study. For each case, two neighborhood controls matched by age
range were selected. Laboratory analyses included O157 and H7 agglutination tests
and pulsed-field gel electrophoresis for DNA analysis of E. coli O157:H7 isolated from stool. Case-patients and controls were interviewed to collect information about food
exposures and potential risk behaviors within 7 days before onset of illness. GDPH and TDH identified 10 case-patients with onset of illness during June 1323. Patients ranged in age from 7 to 89 years (mean: 32 years), and seven were male.
Excluding the HUS case, the median duration of illness was 7 days. All case-patients
had had grossly bloody diarrhea and severe abdominal cramps for >72 hours. Eight of the 10 case-patients were included in the case-control study. One was ex- cluded because his parents declined participation and another because a spouse was
the index patient in the household. Eating hamburgers purchased at one of three
chain A restaurants (two in Tennessee and one in Georgia) during June 1321 was March 29, 1996 / Vol. 45 / No. 12 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / Public Health Service 249 Outbreak of Escherichia coli O157:H7 Infection Georgia
and Tennessee, June 1995 251 Recall of Philip Morris Cigarettes, May 1995March 1996 254 Workshop on the Public Health Response to Nasopharyngeal
Radium Irradiation
September 1995 reported by seven of the eight patients and one of the 16 controls (matched odds
ratio=infinity, 95% confidence interval=2.5infinity). No other exposures were signifi-
cantly associated with E. coli O157:H7 infection. All three restaurants obtained unfro- zen ground beef patties from the same meat processing plant and reported complete
turnover of stock, generally within 3 days. Seven of the eight cases were confirmed by isolation of E. coli O157:H7 from stool specimens; DNA patterns were identical for six of these patients. The single case-
patient for whom the isolate had a different DNA pattern did not recall eating at a
chain A restaurant and had onset of illness on June 13. Inspections of chain A restau-
rants in Georgia and Tennessee did not identify deficiencies in cooking temperature or
procedures, but did identify potential opportunities for cross-contamination from the
ground beef. Meat samples obtained at least 4 days after the case-patients visited the
restaurants were negative for E. coli O157:H7. Based on the epidemiologic and laboratory findings, GDPH and TDH concluded that hamburgers served at chain A restaurants were the source of this outbreak, most
likely as a result of undercooking of or cross-contamination from the ground beef to
the buns or other items on the hamburger. GDPH and TDH recommended a thorough
assessment of food-handling and cooking procedures at chain A restaurants. In addi-
tion, chain A restaurants instituted a training program for workers in proper food-
handling practices. Reported by: M Cannon, H Thomas, Catoosa County Health Dept, Ringgold; W Sellers, MD,
Rome District Health Office, Rome; M Bates, Georgia State Public Health Laboratory, P Blake,
MD, H Stetler, MD, K Toomey, MD, State Epidemiologist, Div of Public Health, Georgia Dept of
Human Resources. J Fowler, S Halford, Knox County Health Dept, Knoxville; G Young, Hamilton
County Health Dept, Chattanooga; S Hall, MD, Knox County Regional Office; P Erwin, MD, East
Tennessee Region; V Boaz, MD, Chattanooga-Hamilton County Regional Office; G Swinger,
DVM, Tennessee Dept of Health. Foodborne and Diarrheal Diseases Br, Div of Bacterial and
Mycotic Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiol-
ogy Program Office, CDC. Editorial Note: E. coli O157:H7 was first recognized as a human pathogen in 1982. Infection with this pathogen may be asymptomatic or associated with a range of
manifestations including mild diarrhea, severe hemorrhagic colitis, HUS, thrombotic
thrombocytopenic purpura, and death ( 1,2 ). From January 1, 1993, through Septem- ber 14, 1995, a total of 63 clusters or outbreaks of E. coli O157:H7 infection were re- ported to CDC by 32 states; these outbreaks accounted for 1734 cases (CDC,
unpublished data). In three U.S. studies conducted during 19851990, E. coli O157:H7 was the third or fourth most common bacterial pathogen isolated from stool speci-
mens ( 2 ) and, among stool cultures at 10 hospitals throughout the United States, E. coli O157:H7 was isolated from 8% of visibly bloody stools (3 ). Ground beef is the most common vehicle for E. coli O157:H7 transmission in inves- tigated outbreaks. Since January 1993, ground beef has been identified as the primary
vehicle of infection in 25 (40%) of the 63 reported outbreaks of this infection. E. coli O157:H7 can be recovered from the intestines of approximately 1% of cattle; because
of processing practices, meat from many animals may comprise one hamburger ( 2 ). Although current U.S. Department of Agriculture regulations specify only gross in-
spection of carcasses, more comprehensive regulationsincluding process controls
that incorporate guidelines for microbiologic testing of meathave been proposed
and already have been implemented by some producers. Complete implementation of Escherichia coli O157:H7 Continued 250 MMWR March 29, 1996 these production practices should decrease E. coli O157:H7 contamination of the meat supply. Ground beef contaminated with E. coli O157:H7 can cause illness when the meat is not thoroughly cooked (to an internal temperature of at least 155 F [68 C]) or when raw
or undercooked meat cross-contaminates other food items. Because the infectious
dose is low, even limited deficiencies in food preparation or handling can result in
exposure and infection ( 2 ). Although this investigation did not identify deficiencies in hamburger cooking temperatures, opportunities for cross-contamination were de-
tected. Measures for preventing cross-contamination include washing hands and sur-
faces after contact with raw ground beef, storing raw ground beef to ensure that
drippings do not contaminate other foods, and using different utensils to handle raw
and cooked meat. As of January 1996, reporting of E. coli O157:H7 infection was required by 38 states (W. Keene, Oregon Department of Human Resources, personal communication, 1996),
including Georgia and Tennessee; neither state had required reporting of E. coli O157:H7 at the time of this outbreak. The outbreak described in this report under-
scores the need for clinical laboratories to screen stool specimens for E. coli O157:H7 on sorbitol-MacConkey (SMAC) agar. In this outbreak, E. coli O157:H7 was detected by a laboratory in Georgia that routinely screened for this pathogen. In a recent survey
of clinical microbiology laboratories in the United states, only 54% screened all bloody
stool specimens on SMAC agar ( 4 ). CDC recommends that laboratories in all states screen at least all bloody stools for E. coli O157:H7. References 1. Boyce TG, Swerdow DL, Griffin PM. Escherichia coli O157:H7 and the hemolytic uremic syn- drome. N Engl J Med 1995;333:3648. 2. Griffin PM. Escherichia coli O157:H7 and other enterohemorrhagic Escherichia coli. In: Blaser MJ, Smith PD, Ravdin JI, Greenberg HB, Guerrant RL, eds. Infections of the gastrointestinal
tract. New York: Raven Press, Ltd., 1995:73961. 3. Ries A, Griffin P, Greene K. Escherichia coli O157:H7 diarrhea in the United States: a 10 center surveillance study. In: Program and abstracts of the 33rd Interscience Conference on Antimi-
crobial Agents and Chemotherapy, New Orleans 1993:385. 4. Boyce TG, Pemberton AG, Wells JG, Griffin PM. Screening for Escherichia coli O157:H7: a nationwide survey of clinical laboratories. J Clin Microbiol 1995;33:32757. Recall of Philip Morris Cigarettes, May 1995March 1996 Cigarette Recall Continued On May 26, 1995, Philip Morris U.S.A.* announced a voluntary recall of 36 cigarette product lines (approximately 8 billion cigarettes) because, during production, the
company detected unusual tastes and peculiar odors and identified methyl isothiocy-
anate (MITC) in the cigarette filters. During June 68, 1995, public health officials in
Minnesota, Oregon, and Texas requested CDCs assistance in investigating consumer
health complaints associated with smoking Philip Morris cigarettes near the time of
the recall. This report summarizes CDCs ongoing investigation, which suggests that
prolonged cigarette smoking caused most of the health complaints; in addition, the
investigation has not identified a distinguishing chemical characteristic of the recalled
cigarettes. Escherichia coli O157:H7 Continued *Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human
Services. Vol. 45 / No. 12 MMWR 251 Reports of cases of illness near the time of the recall were identified through pas- sive surveillance by direct telephone calls to CDC. CDC used a standardized form to
interview persons who reported illness and, when possible, collected cigarette sam-
ples. To verify self-reported data, a medical records review was conducted. Cigarettes
included in the recall had been manufactured during May 1322. Philip Morris U.S.A.
provided CDC with samples of recalled cigarettes (manufactured on May 19, 1995)
and, for comparative analyses, provided samples of cigarettes manufactured before
(on March 3, 1995) and after (on June 12, 1995) the recall. Reports of Illness During JuneJuly 1995, CDC received reports of illness from 72 persons in 27 states who had smoked Philip Morris cigarette brands on or after May 13, 1995. The 72 per-
sons comprised 36 men and 36 women; the mean age of these persons was 40 years
(range: 15 years67 years). A total of 41 (57%) persons reported onsets of illness be-
fore the recall, and 31 (43%) reported onsets after the recall. Of the 72 persons,
51 (71%) reported no preexisting health conditions; 42 (58%) reported experiencing
serious health problems from smoking near the time of the recall. A case definition
could not be developed because no common pattern of symptoms was identified;
however, the most frequently reported manifestation was at least one respiratory or
nasopharyngeal symptom (61 [85%]); other frequently reported symptoms included
headache (18 [25%]), dizziness (15 [21%]), and ophthalmologic problems (15 [21%]). A
total of 59 (82%) persons sought medical treatment for their symptoms; 14 (19%) were
hospitalized. All 72 persons reported smoking cigarettes manufactured by Philip Morris the day they became ill. Most persons (43 [60%]) smoked Marlboro brand cigarettes. The av-
erage duration of smoking was 20 years (range: <1 year45 years), and the average
number of cigarettes smoked per day was 23 (range: <1 cigarette50 cigarettes). Medical Records Review Because a case definition could not be specified, further investigation was re- stricted to 29 persons who reported no preexisting health conditions and who re-
ported experiencing serious health problems associated with smoking near the time
of the recall. Of these persons, medical records were obtained for 20. Based on review
of these records, the conditions most frequently diagnosed in these persons near the
time of the recall were pneumonia (four persons), exacerbation of asthma (four), bron-
chitis (three), chronic obstructive pulmonary disease (three), eosinophilic pneumonitis
(two), and laryngitis (two). The review suggested that most (18 [90%]) of these ill-
nesses were associated with cigarette smoking, preexisting medical conditions result-
ing from prolonged cigarette smoking, or infectious agents. Laboratory Analyses CDC analyzed cigarette samples using high-resolution gas chromatography/high- resolution mass spectrometry. MITC was detected in samples of filter and samples of
tobacco and paper obtained from prerecall, recall, and postrecall cigarettes provided
by Philip Morris. MITC levels were higher in cigarettes packaged in hard packs than in
soft packs (e.g., 102 ng per filter versus 15 ng per filter, p<0.01, n=21 [14 hard packs
and seven soft packs]). MITC also was detected in Philip Morris cigarettes produced at
least 1 year before the recall. Seven packs of cigarettes from five other manufacturers
were purchased at local stores in Atlanta; MITC was detected in cigarettes from each
of these packs. 252 MMWR March 29, 1996 Cigarette Recall Continued Cigarettes obtained from Philip Morris were analyzed for the eight compounds re- ported by Philip Morris to have caused the taste and odor problems. Of the eight compounds, three (butyric acid; 1,2-propanediol diacetate; and 2-ethylhexyl acetate)
were detected in prerecall, recall, and postrecall cigarettes; the other five compounds
were not detected. Compared with prerecall and postrecall cigarettes, there was no
distinctive increase in one or more of these compounds in the recall cigarettes. Cigarette samples also were analyzed to identify a unique chemical profile that dis- tinguished the recall cigarettes from the prerecall or postrecall cigarettes. Analysis of
volatile organic compounds from the filter and from the tobacco and paper of these
cigarettes did not identify such a profile. In addition, analysis of cigarette smoke from
recall cigarettes did not contain a unique chemical pattern. Laboratory analysis is ongoing of cigarettes obtained from the 72 persons who re- ported illnesses. However, as of March 22, 1996, no unique chemical pattern had been
identified. Reported by: P Huang, MD, K Hendricks, MD, S Kohout, M Harris, DM Simpson, MD, State
Epidemiologist, Texas Dept of Health. K MacDonald, MD, Minnesota Dept of Health. MA Heu-
mann, MPH, State Health Div, Oregon Dept of Human Resources. Div of Environmental Health
Laboratory Sciences, and Div of Environmental Hazards and Health Effects, National Center for
Environmental Health; Div of Field Epidemiology, Epidemiology Program Office; Office on
Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion,
CDC. Editorial Note: Based on the medical records review and laboratory analyses in this
report, prolonged cigarette smokingrather than smoking contaminated cigarettes
caused most of the health complaints from persons reporting illness associated with
smoking Philip Morris cigarette brands near the time of the recall. Smoking is the lead-
ing preventable cause of diseases associated with premature death in the United
States; in 1990, approximately 419,000 deaths were attributed to smoking ( 1 ). The estimated number of compounds in tobacco smoke exceeds 4000, including many
that are pharmacologically active, toxic, mutagenic, and carcinogenic ( 2 ). Although Philip Morris reportedly recalled cigarettes in part because of the recent detection of MITC, the laboratory analyses in this report indicate that MITC was pre-
sent in cigarettes manufactured by Philip Morris up to 1 year before the recall and in
cigarettes from other manufacturers. MITC is a decomposition product of 3,5-
dimethyl-1,3,5,2H-tetrahydrothiadizine-2-thione, which is used as a preservative in the
manufacture and coating of paperboard
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