Cantaloupe illnesses and deaths expected to rise (AP)

WASHINGTON � Federal health officials said Wednesday more illnesses and possibly more deaths may be linked to an outbreak of listeria in cantaloupe in coming weeks.

So far, the outbreak has caused at least 72 illnesses � including up to 16 deaths � in 18 states, making it the deadliest food outbreak in the United States in more than a decade.

The heads of the Centers for Disease Control and Prevention and the Food and Drug Administration said consumers who have cantaloupes produced by Jensen Farms in Colorado should throw them out. If they are not sure where the fruit is from, they shouldn't eat it.

Neither the government nor Jensen Farms has supplied a list of retailers who may have sold the fruit. Officials say consumers should ask retailers about the origins of their cantaloupe. If they still aren't sure, they should get rid of it.

"If it's not Jensen Farms, it's OK to eat," said Thomas Frieden, director of the CDC. "But if you can't confirm it's not Jensen Farms, then it's best to throw it out."

Jensen Farms of Holly, Colo. says it shipped cantaloupes to 25 states, though the FDA has said it may be more, and illnesses have been discovered in several states that were not on the shipping list. A spokeswoman for Jensen Farms said the company's product is often sold and resold, so they do not always know where it went.

The recalled cantaloupes may be labeled "Colorado Grown," `'Distributed by Frontera Produce," `'Jensenfarms.com" or "Sweet Rocky Fords." Not all of the recalled cantaloupes are labeled with a sticker, the FDA said. The company said it shipped out more than 300,000 cases of cantaloupes that contained five to 15 melons, meaning the recall involved 1.5 million to 4.5 million pieces of fruit.

The FDA said none of the cantaloupes had been exported, reversing an earlier statement that some of the tainted melons had been shipped abroad.

Frieden and FDA Commissioner Margaret Hamburg said that illnesses are expected for weeks to come because the incubation period for listeria can be a month or even longer. That means that someone who ate contaminated cantaloupe last week may not get sick until next month. Jensen Farms last shipped cantaloupes on Sept. 10. The shelf life is about two weeks.

"We will see more cases likely through October," Hamburg said.

The Food and Drug Administration said state health officials found listeria in cantaloupes taken from Colorado grocery stores and from a victim's home that were grown at Jensen Farms. Matching strains of the disease were found on equipment and cantaloupe samples at Jensen Farms' packing facility in Granada, Colo.

Sherri McGarry, a senior adviser in the FDA's Office of Foods, said the agency is looking at the farm's water supply and possible animal intrusions among other things in trying to figure out how the cantaloupes became contaminated. Listeria bacteria grow in moist, muddy conditions and are often carried by animals.

The health officials said this is the first known outbreak of listeria in cantaloupe. Listeria is generally found in processed meats and unpasteurized milk and cheese, though there have been a growing number of outbreaks in produce. Hamburg called the outbreak a "surprise" and said the agencies are studying it closely to find out how it happened.

Cantaloupe is often the source of outbreaks, however. Frieden said CDC had identified 10 other cantaloupe outbreaks in the last decade, most of them from salmonella.

Listeria is more deadly than well-known pathogens like salmonella and E. coli, though those outbreaks generally cause many more illnesses. Twenty-one people died in an outbreak of listeria poisoning in 1998 traced to contaminated hot dogs and possibly deli meats made by Bil Mar Foods, a subsidiary of Sara Lee Corp. Another large listeria outbreak, in 1985, killed 52 people and was linked to Mexican-style soft cheese.

Listeria generally only sickens the elderly, pregnant women and others with compromised immune systems. The CDC said the median age of those sickened is 78 and that 1 in 5 who contract the disease can die from it. Symptoms include fever and muscle aches, often with other gastrointestinal symptoms.

Unlike many pathogens, listeria bacteria can grow at room temperatures and even refrigerator temperatures. It is hardy and can linger long after the source of the contamination is gone � health officials say people who may have had the contaminated fruit in their kitchens should clean and sanitize any surfaces it may have touched.

The CDC said Tuesday that 13 deaths are linked to the tainted fruit. State and local officials say they are investigating three additional deaths that may be connected.

The death toll released by the CDC Tuesday surpassed the number of deaths linked to an outbreak of salmonella in peanuts almost three years ago. Nine people died in that outbreak. The CDC reported four deaths in New Mexico, two deaths each in Colorado and Texas and one death each in Kansas, Missouri, Nebraska, Oklahoma and Maryland.

New Mexico officials said Tuesday they are investigating a fifth death, while health authorities in Kansas and Wyoming said they too are investigating additional deaths possibly linked to the tainted fruit.

The CDC reported the 72 illnesses and deaths in 18 states. Cases of listeria were reported in California, Colorado, Florida, Illinois, Indiana, Kansas, Maryland, Missouri, Montana, Nebraska, New Mexico, North Dakota, Oklahoma, Texas, Virginia, West Virginia, Wisconsin, and Wyoming. The most illnesses were reported in Colorado, which has seen 15 sickened. Fourteen illnesses were reported in Texas, 10 in New Mexico and eight in Oklahoma.

While most healthy adults can consume listeria with no ill effects, it can kill the elderly and those with compromised immune systems. It is also dangerous to pregnant women because it easily passes through to the fetus. The CDC's Frieden said that two of those sickened were pregnant women but they have since recovered.

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Online:

CDC on cantaloupe outbreak: http://www.cdc.gov/listeria/index.html

FDA on cantaloupe recall: http://www.fda.gov/Food/FoodSafety/CORENetwork/ucm272372.htm

Center for Science and the Public Interest, "Super Safe Your Kitchen": http://www.cspinet.org/new/pdf/safekitchen.pdf

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Find Mary Clare Jalonick on Twitter at http://twitter.com/MCJalonick

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Dementia patients suffer dubious hospitalizations (AP)

One-fifth of Medicare nursing home patients with advanced Alzheimer's or other dementias were sent to hospitals or other nursing homes for questionable reasons in their final months, often enduring tube feeding and intensive care that prolonged their demise, a new study found.

Nursing homes may feel hospital care is warranted when a frail, elderly patient develops swallowing problems, pneumonia or a serious infection, but researchers suspect a different motive for many transfers: money. Medicare pays about three times the normal daily rate for nursing homes to take patients back after a brief hospitalization.

"I think that's unfortunately a factor in what's happening here," said Dr. Joan Teno, a palliative care physician and health policy professor at Brown University. "A lot of this care just feels like in and out, in and out. You really have to question, is the health care system doing a good job or not."

She is a co-author of the study, published in Thursday's New England Journal of Medicine and done with researchers from Harvard University and Dartmouth Medical School.

Among the nearly 475,000 patients studied, 19 percent were moved for questionable reasons. The study provided no evidence that money motivated such transfers or that there was wrongdoing involved. However, the large variation that researchers saw from state to state suggests money may be playing a role.

Rates of such transfers varied from 2 percent in Alaska to more than 37 percent in Louisiana. In McAllen, Texas, 26 percent of study participants had multiple hospitalizations for urinary infections, pneumonia or dehydration � conditions that usually can be treated in a nursing home. That compares to just 1 percent of patients in Grand Junction, Colo.

The researchers used Medicare records from 2000 through 2007 to identify "burdensome" transitions of care: moving patients in the last three days of life, moving them multiple times in the last three months of life, or moving them so they landed in a new nursing home afterward.

Medicaid pays on average $175 per day, depending on the state, for long-term care, but Medicare will pay three times that for skilled nursing care after a patient returns from three days or more in a hospital.

"If you have a nursing home that is operating on a margin, it adds up. It can be a tremendous incentive to hospitalize these people," Teno said.

Researchers found that patients who had a dubious transfer were more likely to have a feeding tube inserted, to spend time in intensive care in the last month of life, to have a severe bedsore or to be enrolled in hospice late (three days or less before they died).

Dubious transfers were more common with black patients, Hispanics and those without advance directives, legal documents spelling out care wishes.

The National Institute on Aging sponsored the study. One author consults for a nursing home system and owns stock in a long-term care information services company.

The study is important because more than 1.6 million Americans live in nursing homes, and nearly one-quarter of people admitted to one after hospitalization wind up back in the hospital within a month, Dr. Joseph Ouslander of Florida Atlantic University in Boca Raton and Dr. Robert Berenson of the Urban Institute in Washington, D.C., wrote in an editorial in the journal. Nursing homes may fear legal liability if they don't hospitalize a very sick patient, they wrote.

However, people with advanced dementia have a terminal condition.

"These are people who are unable to recognize their relatives, they're bed-bound and they're now usually having problems with swallowing. This is a population where the burdens of hospitalization often outweigh the possible benefits," Teno said. "These patients actually do better when they stay in a nursing home," where caregivers and surroundings are familiar, she said.

For families and nursing homes, "it may be difficult to recognize that in fact, this person is in the dying process," said Dr. Michael Malone, medical director of senior services for Aurora Health Care, a network of 15 hospitals in eastern Wisconsin. His 87-year-old father, Wendell Malone, died in January of advanced dementia in a nursing home that managed his care without frequent hospitalizations.

"It provided dignity, it provided comfort for the family," and let him stay in a place and with caregivers he knew, Malone said.

Beth Kallmyer, who runs programs for caregivers for the Alzheimer's Association, said the most important thing is to have a plan in place, with legal documents like "do not hospitalize" directives, before a nursing home has to make a decision about whether to hospitalize someone or instead focus on comfort care and not try to prolong life.

"When the time comes, the family will be able to say `This is what dad wanted,'" Kallmyer said.

She and other experts offered these tips:

_Involve patients in planning their care while they're still able to do so, and make sure wishes like "do not resuscitate" or "do not call 911" are spelled out in legal documents.

_Develop good relationships with nursing home staff and attending physicians so they understand the family's goals of care.

_Consider hospice care when seniors with advanced dementia are admitted.

_Revisit and review the plan whenever there is a change in a loved one's status. Someone may not be end-stage when they enter a nursing home but that can change.

_Seek advice. The Alzheimer's Association has a 24-hour toll-free number, 1-800-272-3900, with counselors to help families.

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Online:

Medical journal: http://www.nejm.org

State reports: http://www.LTCFocUS.org

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Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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