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ARTICLE |

An Outbreak of Diarrhea and Hemolytic Uremic Syndrome From Escherichia coli O157:H7 in Fresh-Pressed Apple Cider

Richard E. Besser, MD; Susan M. Lett, MD, MPH; J. Todd Weber, MD; Michael P. Doyle, PhD; Timothy J. Barrett, PhD; Joy G. Wells, MS; Patricia M. Griffin, MD
JAMA. 1993;269(17):2217-2220. doi:10.1001/jama.1993.03500170047032.
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Objective.  Esherichia coli O157:H7 causes hemorrhagic colitis and the hemolytic uremic syndrome. In the fall of 1991, an outbreak of E coli O157:H7 infections in southeastern Massachusetts provided an opportunity to identify transmission by a seemingly unlikely vehicle.

Design.  —Case-control study to determine the vehicle of infection. New England cider producers were surveyed to assess production practices and determined the survival time of E coli O157:H7 organisms in apple cider.

Results.  —Illness was significantly associated with drinking one brand of apple cider. Thirteen (72%) of 18 patients but only 16 (33%) of 49 controls reported drinking apple cider in the week before illness began (odds ratio [OR], 8.3; 95% confidence interval [CI], 1.8 to 39.7). Among those who drank cider, 12 (92%) of 13 patients compared with two (13%) of 16 controls drank cider from cider mill A (lower 95% CI, 2.9; P<.01). This mill pressed cider in a manner similar to that used by other small cider producers: apples were not washed, cider was not pasteurized, and no preservatives were added. In the laboratory, E coli O1 57:H7 organisms survived for 20 days in unpreserved refrigerated apple cider. Addition of sodium benzoate 0.1% reduced survival to less than 7 days.

Conclusions.  —Fresh-pressed, unpreserved apple cider can transmit E coli O157:H7 organisms, which cause severe infections. Risk of transmission can be reduced by washing and brushing apples before pressing, and preserving cider with sodium benzoate. Consumers can reduce their risk by only drinking cider made from apples that have been washed and brushed.(JAMA. 1993;269:2217-2220)

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