A Fateful Purchase
At the start of Thanksgiving week in 2007, John and his wife, Regina, were overjoyed, looking forward to spending time with their children and grandchildren. Their son, Johnny, and his family, who live in California, usually came to visit at Christmas; but in 2007, they were coming to Thanksgiving instead. John and Regina loaded up on a wide variety of food items, making sure that their pantry was completely stocked for the holidays.
Johnny's ritual during the holidays, whether Thanksgiving or Christmas, was to pick up some fresh, homemade eggnog at Shady Oaks Farm in Medway, Mass. Not wanting to break with tradition, on Tuesday, November 20, he stopped by the farm to purchase the eggnog. In a cruel twist of fate, Johnny decided to buy some chocolate and coffee milk instead. His father consumed the milk on multiple occasions over the course of the next several days.
John's Illness
Although he had a number of comorbidities, John was fully independent, living at home, and still sharp as a tack at 87 years old. As late as the day before Thanksgiving 2007, his daughter Nancy recalls witnessing her nieces and nephews doubled over in laughter from the stories and jokes their granddad loved to tell. Indeed, family and friends recall John as a man in excellent condition, sharp, strong, and vibrant.
At noon on Friday, November 23, Regina was shocked to find John barely responsive. He had developed severe gastrointestinal symptoms, including nausea, vomiting, weakness, and fever. The family immediately called an ambulance, which rushed John to the Milford Regional Medical Center Emergency Room.
Upon arrival at the emergency room, the treating physician noted that John's vital signs were normal, but that he was mildly confused. The doctor ordered a stool test to determine the source of John's illness, and immediately started him on intravenous fluids to combat the already severe dehydration.
John's elevated white blood cell count indicated that he was suffering from an infection. He was also suffering from severe kidney disease--stage IV kidney failure, in fact--and the blood flow to his heart was restricted, consistent with heart failure. John continued to deteriorate overnight, and blood tests done at 6 a.m. on November 24 showed a further decline in kidney function. John's nurse noted that he continued to have loose, sometimes bloody, stools.
Over the course of the next two days, John's condition continued to slowly deteriorate. A cardiology consultation revealed that his lungs were overloaded, making breathing difficult. And by mid-afternoon on November 25, John had become shaky and had begun to stutter.
Finally, on November 26, doctors discovered the cause of John's rapid decline: a blood sample had tested positive for Listeria monocytogenes. John was immediately seen by an infectious disease specialist, whose impression was that John had Listeria-induced gastroenteritis with bacteremia (bacteria in the blood).
Regina vividly recalls learning of the diagnosis and the frenzy of events that followed: "After hearing the diagnosis, Johnny--my son--suggested that I take what was left of the coffee milk that John had consumed to the Medway Board of Health. My daughter and I did this; they in turn forwarded it to the Massachusetts Department of Public Health to be tested."
"We were informed by watching the 6 p.m. news that two men had died from drinking tainted milk from Whittier Farms and another was seriously ill. My daughter called Robert Briggs from Shady Oaks Farm to ask if he purchased milk from Whittier Farms and he confirmed our worst fears."
The Investigation
In 2007, Whittier Farms had operated a milk product pasteurizing, bottling, and processing facility for nearly 50 years. Raw milk was transported by tanker truck to the Whittier Farms processing facility from the company's own farm of nearly 300 cows and from another, independent farm located 25 miles away.
Whittier Farms produced various milk and non-milk beverage products in glass and plastic bottles, including several varieties of flavored milk. Retail outlets were located at the dairy and the farm; however, the bulk of the dairy's milk products was sold through home delivery and at various retail establishments in Massachusetts, including Shady Oaks Farm in Medway.
The Massachusetts Department of Public Health identified five people who had consumed milk produced by Whittier Farms during the six weeks before becoming ill with listeriosis with matching pulsed field gel electrophoresis (PFGE) patterns, or "DNA fingerprints," indicating milk produced by Whittier Farms was the source of their Listeria infections.
All five patients were hospitalized. Three were male, ages 75 to 87, and two were pregnant females, ages 31 and 34. All three men, including John Powers, died from sepsis attributed to Listeria; the 31-year-old woman gave birth to a healthy but premature infant at 36 weeks gestation, and the 34-year-old woman experienced a stillbirth at 37 weeks gestation.
On December 17, evidence of Listeria growth was reported from a coffee-flavored milk sample retrieved from John and Regina Powers' home, prompting the Massachusetts Food Protection Program (MFPP) to inspect Whittier Farms.
Eleven samples of unopened, flavored and unflavored milk products were collected for testing on December 18. The same unique PFGE pattern was identified within Whittier Farms milk products, four PFGE-confirmed cases associated with the outbreak, and the milk from the Powers' fridge.
The Pathogen
The Centers for Disease Control and Prevention (CDC) attributes approximately 2,500 illnesses and 500 deaths to listeriosis every year.
Listeria is everywhere, and can be isolated from wild and domestic animals, birds, insects, soil, wastewater, and vegetation. The bacterium easily comes into contact with farm animals, as it has been found to be present in grazing areas, stale water, and poorly prepared animal feed.
Several segments of the population, including pregnant women, the elderly, and those with compromised immune systems, are particularly at risk for listeriosis.
It is believed that the ingestion of fewer than one thousand Listeria bacteria can cause human illness.
A person with listeriosis usually experiences fever, muscle aches, and gastrointestinal symptoms such as nausea or diarrhea. Listeria bacteria can invade all body areas, including the central nervous system, heart, and eyes. If the infection spreads to the nervous system, symptoms such as headache, stiff neck, loss of balance, confusion, reduced alertness, and convulsions can occur. With brain involvement, listeriosis sometimes mimics a stroke.
In the context of dairy production, post-pasteurization Listeria contamination is a constant threat. Dairy products are particularly susceptible to Listeria growth since Listeria bacteria thrive at refrigeration-level temperatures.
In light of the serious risk to health and public safety that Listeria represents, regular environmental testing is recommended to pinpoint possible Listeria contamination threats before products leave dairy-production facilities.
A Recall and Dairy Closure
MFPP returned to Whittier Farms on December 26 and collected environmental swab samples from inside the processing facility. On December 27, the State Laboratory Institute of MDPH reported a presumptive positive Listeria specimen in a sample of unopened, coffee-flavored milk that had been collected from Whittier Farms on December 19.
Whittier Farms was asked to voluntarily cease all operations and recall its dairy products. The dairy complied with this request on December 27; on December 30, the State Laboratory Institute confirmed that Listeria monocytogenes with a PFGE pattern indistinguishable from the outbreak strain had been isolated from a sample of unopened, coffee-flavored milk.
From December 28, 2007, to January 3, 2008, MFPP conducted a full environmental investigation in conjunction with the U.S. Food and Drug Administration and the local board of health.
On January 2, 2008, after the closure of Whittier Farms and the recall of its dairy products, approximately 100 additional environmental and product samples were collected by MFPP. One environmental swab from a floor drain in the finished product area, one skim milk sample, and seven flavored milk samples tested positive for Listeria monocytogenes and matched the outbreak strain by PFGE analysis.
Two additional environmental swabs and four additional samples of milk, both flavored and non-flavored, tested positive for seven distinct strains of Listeria, including three different Listeria species and three strains of Listeria monocytogenes with PFGE patterns that differed from those of the outbreak strain.
On February 1, 2008, Whittier Farms decided to permanently close the milk processing facility, citing an inability to invest the money necessary to make the facility safe.
The Beginning of the End
Between November 26 and December 2, John's condition neither worsened nor improved. He continued to suffer loose stools, intermittent confusion, and occasional fevers. He repeatedly tested positive for Listeria monocytogenes.
John's symptoms slowly continued to worsen. Between December 3 and 5, his test results demonstrated that his kidney function had continued to deteriorate as well. X-rays of John's chest indicated worsening congestive heart failure and possible pneumonia. Also, because Listeria monocytogenes can invade the central nervous system, causing confusion and seizures, John underwent a brain scan to rule out meningitis.
Nevertheless, despite his weakened condition, John had made some mild improvements by December 5, and his doctors even began to plan for his discharge from the hospital. By December 6, his white blood cell count had normalized, indicating resolution of his infection, and although his kidney function remained a concern and he exhibited signs of worsening congestive heart failure, by this point the Listeria infection seemed to be resolving.
Accordingly, John began physical therapy and weight training in anticipation of going home.
Rehab
On December 10, John was no longer suffering from diarrhea, abdominal pain, or fever, so he was transferred to a rehabilitation hospital. His treatment plan included physical and occupational therapy, and further management of his underlying conditions, which included worsening kidney function secondary to heart failure and volume overload, delirium secondary to blood infection, congestive heart failure exacerbation, and deconditioning due to acute prolonged hospitalization.
Over the course of the next few days, John's condition remained relatively stable, though he remained restless, couldn't sleep, and required oxygen therapy. He was, however, slowly regaining some mobility and had finished taking the antibiotics prescribed to treat his underlying Listeria infection.
Despite certain signs of improvement, John remained anxious and confused, with shallow breathing. An infectious disease consultant's impression was that John was suffering from possible persistent listeriosis with mental status changes. He remained confused and restless.
Worsening Kidney Function
Test results on December 18 indicated that John's kidney insufficiency was continuing. He was, as a result, transferred to the University of Massachusetts, where he could undergo dialysis therapy. Tests over the course of the first two days of his stay at UMASS Hospital revealed that John's kidney function was worsening again. As a result, doctors ordered that dialysis begin immediately.
Despite treatment, John became increasingly confused and agitated each night, pulling at his IV, being uncooperative at times, and yelling. The outbursts became so severe that wrist restraints had to be applied to prevent this eighty-seven-year-old man from hurting himself or others.
By December 21, John was no longer the man that his family had always known. And shortly after starting his dialysis treatment that day, he became very agitated and began screaming again. Regina recalls, "It was evident that the infection affected him neurologically. He went from a cooperative patient to an extremely agitated and delirious one. It was painful to hear this kind of behavior."
In the days leading up to Christmas, John's condition stabilized and his renal function again improved. His vital signs were all stable and he had no new complaints. Although he was still noticeably sleepy, he was markedly less confused.
Christmas in the Hospital
December 25, 2007 was a significant day for John and the rest of the Powers family. Not only was it Christmas Day--a significant day for John, a devout Catholic--but it marked his 88th birthday. After 88 years on this planet and a lifetime of memories, braving severe illness and enduring such a long hospitalization was the last thing John's family wanted for him.
His daughter Nancy vividly recalls Christmas Day 2007: "We had given Dad a snapshot of him and Ma and all five grandchildren taken on Thanksgiving Day. He held that photograph in his hands and wouldn't let go of it. We showed him some videos of when the kids were little and he watched as best he could.
"[My daughter] and I had made a handmade throw, which had the Red Sox on one side and the Patriots on the other. We lugged that gift with us for the next few days trying to find him in the right frame of mind to give it to him. Regrettably, we never had the chance."
At this point, John's condition was stable, but not improving. His speech was slurred, and he wheezed as he struggled with each breath. His treating physicians were doing all they possibly could to help him, but the heart and kidney failure and impaired cognitive function were not improving.
A Turn for the Worse
As the New Year approached, John's white blood cell count began to rise, indicating infection, and tests showed ever-worsening kidney failure. Daily dialysis was again started on December 26. John continued to have difficulty sleeping at night.
"During all of our visits, I sat beside him, stroking his head and trying to calm him as he shouted incoherently. He prayed audibly, repeating Hail Mary over and over. There are no words to describe the suffering and anguish he endured," Regina recalls.
John's condition continued to decline over the next several days despite the continuation of dialysis treatments. He died January 3, 2008, with his wife and daughter by his side.