173 | Mystery Poisonings Stalk Citizens | 14 Rules for Bad Quality Managers|
Yes, “The machine is haunted” is an acceptable root cause analysis
This is The Rotten Apple, an inside view on food fraud and food safety for professionals, policy-makers and purveyors. Subscribe for insights, latest news and emerging trends straight to your inbox each Monday.
Mystery Food Poisonings Stalk Citizens;
Bongkrekic acid outbreak insights;
Food Safety News and Resources;
14 rules for bad quality managers;
Food fraud news and recent incidents.
Happy Australia Day if you’re down under and Xīnnián kuàilè" (新年快乐) for those of you celebrating the 🏮lunar new year 🏮this week.
Welcome to Issue 173 of The Rotten Apple, the world’s best independent (and never boring) food safety publication.
South Africa is the scene of a food poisoning national disaster with one source reporting more than 2.6K child poisonings in one province in the past three years. I’ve mentioned various incidents and government responses in our weekly food safety news posts over the past year, but this week it’s time to dive deeper and figure out what is really going on: the cause(s) are definitely not clear-cut.
Also this week, more insights into last year’s deadly bongkrekic acid poisoning outbreak – the second known outbreak linked to rice noodles – and 14 rules for creating quality management mayhem, as well as our usual food fraud news for paying subscribers.
Thanks for being here,
Karen
P.S. This week we’re joined by new paying subscribers from Australia, the United Kingdom and California. Thank you,👋 Cathy, Goupie and Kelley👋 for supporting my work.
Mystery Food Poisonings Stalk Citizens
Reports of multiple deaths - including many children - linked to food but with no obvious cause have been appearing in food safety news outlets and mainstream media for more than a year now. The deaths are occurring in South Africa, and have been accompanied by government warnings to consumers as well as sporadic crackdowns on spaza shops.
One source reports 2,652 child poisonings in the province of Gauteng in three years.
Spaza shops were originally informal, micro-convenience stores, often operated from their owners’ homes, which first appeared during the Apartheid era when black South Africans were restricted from owning formal businesses. They have evolved into more sophisticated businesses, often with foreign owner-operators who use collective purchasing practices to keep prices low.
Multiple illnesses and deaths
Among the dozens of deaths and incidents, here is a selection that have appeared in our weekly Food Safety News Roundups.
September 2023: Ninety children were sickened and three are still in hospital after eating cookies allegedly laced with ‘dagga’ (cannabis) which they purchased from a street vendor (The Citizen)
October 2023: A spate of illnesses and eight deaths in young children are being investigated in South Africa, with foods purchased from local shops near schools thought to be linked to the deaths and illnesses. Officials have issued warnings to parents to purchase snacks for their children and to only do so from reputable sources (Food Safety News).
October 2024: Police in South Africa have arrested four people and discovered a chemical at a food store which they believe is linked to the death of six children in Soweto who died after allegedly eating snacks from the store (MSN.com). A later report suggested that 11 Soweto children had died (Daily Maverick).
October 2024: A child has died and her mother is critically ill from suspected poisoning after eating snacks in Alexandra, South Africa (Times Live)
November 2024: The South African government declares a national disaster, with the president claiming 890 reported incidents of food-borne illnesses between September and mid-November, and at least 22 child deaths. The most populous province in South Africa, Gauteng, which encompasses large cities including Johannesburg and Pretoria, suspends the sale of food at schools after a spate of food poisoning among school children in the region.
What’s causing the deaths?
Much of the media attention around the deaths of children has focussed on the fact that the food implicated in the poisonings was purchased from spaza shops. Many reports discuss the fact that expired food is often found in such shops. Expired snacks such as out-of-date biscuits (cookies) and chips have been linked to the poisonings.
Food safety specialists are puzzled by such allegations, because low-moisture snacks like biscuits and chips are not susceptible to the growth of pathogens, even when they are past their expiry dates.
Such foods can acquire rancid flavours, or become stale when they are old, but these are quality defects, and will not make consumers sick.
A further confounding factor is racial tensions between foreign spaza shop owners and local people. Journalists who attended a raid on a spaza shop in November said the shop owner had the correct immigration papers but all other workers in the shop were not properly documented and appeared to be illegal immigrants.
In November, when the situation reached a crisis point, the president, Cyril Ramaphosa, addressed the nation and provided a reason for the deaths. He said the group of six children who died in Soweto in 2024 were found to have been exposed to an organophosphate pesticide Terbufos and their deaths could be “directly attributed” to Terbufos.
Terbufos is extremely toxic. It is not approved for residential use, but is registered for agricultural use in South Africa. However, it is sold illegally to residents of townships - areas with high density, poor infrastructure and extreme poverty - who use it to kill rats.
Another toxic pesticide, Aldicarb, which is also used against rats, was blamed by President Ramaphosa for the deaths of six other children in 2023. Aldicarb—commonly known as two-step—is banned in South Africa but sold illegally in small packets in some spaza shops.
Since the president’s address, attention appears to be squarely focused on pesticides as the cause of the deaths. Media outlets have reported that hazardous chemicals are commonly stored alongside foods, and food safety inspectors have confiscated illegal pesticides from spaza shops while investigating some of the deaths.
However, deaths continue to occur, with a five year old boy dying after reportedly consuming snacks from a spaza shop just a few days after the president’s address. Another was rushed to hospital the following day.
Although the official line seems to be that these poisonings are the result of accidental contamination with pesticides, something doesn’t seem right.
What’s missing from both government sources and media reports is a plausible explanation for how these pesticides are so frequently getting into the packaged foods that have been linked to the deaths.
And here’s a real kicker. Although the president stated in his address “The investigations… do not suggest any deliberate campaign to poison children in our country” he also mentioned, in the briefest of sentences, that the pesticide Terbufos had been found on both the outside and the inside of a packet of chips found on one of the children who had died in Soweto.
Is food fraud part of the problem?
Video footage published by eNCA showed foods such as savoury crackers in transparent inner packs but without their outer packaging or labels in a spaza shop store room. Because they are missing traceability elements such as outers and labels it’s quite possible these foods are from non-legitimate food supply chains. For example, they could have been diverted from waste.
A report about the multi-country anti-food-fraud operation Opson XIII in October 2024 said: “Researchers across Europe noticed a continuing trend in the sale of expired food, after attracting waste disposal companies, they have masses of food in their hands to be destroyed, which subsequently erase and reprint the expiration dates and attach the new labels reintroducing the expired products into the supply chain again.” El Dia de La Rioja (translation from Spanish)
The crackers in the eNCA video could have originated in another country, perhaps sent for disposal by a supermarket because they had passed their sell-by dates but stolen or diverted from waste disposal by criminals. This would explain why their outer packs and labels are missing - such elements are sometimes removed before disposal, or to prevent easy tracing of diverted products.
Over the past few years, a number of criminal operations in which expired foods were relabelled or over-stickered with new expiry dates have been exposed, including a multi-year, million-Euro operation based in Lithuania.
President Ramaphosa did not directly mention illegal supply chains in his address about the poisonings, but he did promise to strengthen controls for foods coming into South Africa. This makes me think that illegal imports have been making their way into spaza shops.
Counterfeit foods could also be part of the mix. South African police found two warehouses containing counterfeit clothing and foods including canned fish, fizzy drinks, soya beans, baby food and spices along with pesticides, counterfeit prescription medication, body lotion and expired alcoholic beverages near Durban in November.
Counterfeit foods are manufactured without food safety inspections and so the possibility of contamination of foods and packaging materials is high.
Something more sinister?
We live in an age where innocent people are attacked by religious and political extremists for unfathomable reasons: men drive cars into shoppers at Christmas markets, religious schools hire bodyguards to protect their students from hate crimes, and nightclub patrons are executed during a night out.
It makes no sense to me that anyone would set out to deliberately poison children with snack foods. But none of those other crimes make any sense to me either.
It’s not out of the question that some of the poisonings in South Africa could have been perpetrated for malicious purposes; perhaps to besmirch the reputations of foreign spaza shop owners and stir up racial hatred, perhaps for some other reason.
Highly toxic illegal pesticides appear to be readily available in the townships where many of the deaths have occurred, and this is likely a contributing factor to the deaths, whether they are the result of accidental contamination or deliberate adulteration.
What is being done?
The government of South Africa is taking steps to halt the poisonings, with a range of initiatives, announced, including new rules for spaza shops, which were not previously regulated or inspected.
There are wider calls for better hygiene infrastructure in townships so that residents do not need to purchase highly toxic products to control rats. And plans to provide more food safety education for schools and business owners.
Deaths of children under 12 have become notifiable within the country’s medical surveillance system, and this should enable better investigations of any future incidents.
Final thoughts
My thoughts go out to the parents and citizens of South Africa who are dealing with almost daily tragedies linked to food poisoning. It’s a complicated situation, with unlicensed food sellers, questionable food sources and highly toxic pesticides sold illegally in food outlets.
Pesticide contamination of food has been blamed for the illnesses and deaths, but I doubt that accounts for the whole story. Accidental contamination of legitimate, pre-packaged foods is an inadequate explanation for the (perhaps) thousands of cases of poisoning that have occurred in recent years.
With enforcement agencies now investigating illegal food supply chains, imposing stricter controls on spaza shops, and implementing better surveillance of child deaths, I hope that more information comes to light. And that it leads to an end to the epidemic of poisonings.
…
Thank you to Arlene and Ellenor, food safety professionals from South Africa, for encouraging me to write about this issue, and providing sources.
Follow up: Bongkrekic acid poisoning
In Issue 134 I wrote about a fatal outbreak of bongkrekic acid poisoning which sickened and killed diners in Taiwan in March 2024. New information has been revealed by prosecutors who investigated the outbreak.
Reminder: Bongkrekic acid is a toxin produced by the bacterium Burkholderia gladioli pathovar cocovenenans. It is odourless, tasteless and heat-stable.
The toxin causes abdominal pain, diarrhoea, vomiting, weakness, palpitations and death. There is no antidote. Outbreaks have mortality rates of about 50%. That is, half the people who have eaten contaminated foods have died.
Poisonings caused by bongkrekic acid are rare, despite B. cocovenenans being ubiquitous in plants and soil, because the bacterium requires specific fatty acids to produce the toxin. Bongkrekic acid poisonings are usually caused by fermented coconut tempe – bongkrek - which is considered such a risky food that it is banned in some countries.
In the Taiwan outbreak last year, 34 people were affected, mostly young or middle-aged adults. Six people died. All had eaten cooked wet rice noodles in the same shopping mall restaurant.
Until the Taiwan outbreak there had only been one other reported outbreak of bongkrekic acid poisoning from rice noodles.
The people allegedly responsible for the outbreak have now been charged by prosecutors in Taiwan, with prison sentences sought for the franchise owner, head chef, substitute cook and store manager.
Victims tested positive for bongkrekic acid and it was detected in samples from one of the chef’s hands. However, it was not found in food samples from the restaurant or its suppliers.
Prosecutors allege the noodles used to produce the deadly dish had been left unrefrigerated in a basket for “a few days” before being used in meals served at the restaurant.
Takeaways for food professionals
Bongkrekic acid poisoning is a rare but frequently fatal form of food poisoning.
Previously thought to affect mainly fermented corn and coconut products, the outbreak in Taiwan in 2024 has been attributed to non-fermented flat rice noodles which were allegedly left unrefrigerated for a few days before being used to make rice noodle dishes in a restaurant.
The toxin, which is odourless, tasteless and heat-stable is produced at temperatures of 22 – 30 degrees Celsius and in foods of a neutral pH and low salt content by the bacterium B. cocovenenans, which is ubiquitous in plants and soil and has been isolated from both developing and developed nations including the United States.
High-risk foods are those with a fatty acid composition that promotes toxin formation (rich in oleic acid), including coconut-based and corn-based fermented foods.
Control methods include the careful control of fermentations, keeping pH low during fermentation and storing high-risk foods in the refrigerator.
In short: 🍏 A rare pathogenic bacterium, Burkholderia gladioli pv. cocovenenans caused serious illnesses and deaths among Taiwanese diners via the heat-stable and highly toxic bacterial toxin bongkrekic acid, thought to have been present in flat rice noodles 🍏 Prosecutors allege the rice noodles were left unrefrigerated for a “few days” before being used in noodle dishes served to diners 🍏 They are seeking prison sentences for kitchen workers and restaurant management 🍏
Information for consumers: Bongkrekic Acid: Safety of Fermented Corn and Coconut Products | Singapore Food Safety Agency
Sources:
Lai, C.-C., Wang, J.-L. and Hsueh, P.-R. (2024). Burkholderia gladioli and bongkrekic acid: An under-recognized foodborne poisoning outbreak. Journal of Infection, [online] 89(1), p.106182. doi:https://doi.org/10.1016/j.jinf.2024.106182.
Newsdesk. (2025). Food Safety News. Food Safety News. [online] https://www.foodsafetynews.com/2025/01/five-charged-after-deadly-bongkrekic-acid-outbreak/.
Food Safety News and Resources
Our news and resources section has not-boring food safety news plus links to free webinars and guidance documents: no ads, no sponsored content, only resources that I believe will be genuinely helpful for you.
This week’s food safety news has some interesting pet food-related stories, plus more.
Click the preview below to access it.
14 Rules for Bad Quality Managers (just for fun)
Yes, “The machine is haunted” is an acceptable root cause analysis
This tongue-in-cheek advice is from Ekaterina Potemkina, a quality expert with a wicked sense of humour. Follow Ekaterina on LinkedIn or subscribe to her newsletter Quality All In, for insights, tips and practical formulas in quality.
If you want to make headlines for all the wrong reasons in your quality management role, follow these 14 tips:
1. Make Decisions Based on Vibes, Not Data
Gut feeling is the backbone of quality management, right?
2. Always Wing It During Audits
Preparation is for amateurs. Real pros rely on their charm and spontaneous storytelling to explain missing documentation.
3. Procrastinate on That Non-Conformity Report
Why fix it today when you can let it snowball into a full-blown scandal tomorrow? After all, everyone loves a good corporate drama.
4. Turn Your Management Review into a Nap-Worthy Lecture
Nothing says “I care about quality” like 100 slides of jargon and a room full of glazed-over executives.
5. Skip Training — People Learn Best by Failing Publicly
Let your team figure out compliance through trial, error and front-page news.
6. Ignore Customer Complaints Until They Go Viral on Social Media
The best way to gauge urgency is a trending hashtag.
7. Run Every Change Past Ten Layers of Approval
Who needs agility? Bog down improvement efforts in bureaucracy and enjoy the thrilling pace of snail-like progress.
8. Use Sticky Notes for Document Control
SOP updates? Scribble them on a sticky note. It’s eco-friendly (until it blows away).
9. If you don’t document it, it didn’t happen.
Hide Problems Under the Rug. Denial is the secret to short-term success (and long-term disaster).
10. Turn CAPAs into a Never-Ending Saga
Drag corrective actions out like a Netflix series — so much suspense, so little resolution.
11. Replace Root Cause Analysis with Wild Guessing
“The machine is haunted” is a perfectly acceptable explanation for recurring defects. Who needs evidence?
12. Promise the Impossible
“Zero defects forever!” Who needs realistic commitments when you’ve got boundless optimism?
13. Assume Your Team Reads Your Mind
Skip explaining the processes — your team should just know what you want. Telepathy is a leadership skill, right?
14. Always Say Yes to Everything
Overcommit, underdeliver and let the chaos unfold. You’re just one person; how bad can it get?
Despite the irony, some of these chaos-triggers might be quite realistic for many Quality Folks. Are you "guilty" of any?😎
By Ekaterina Potemkina of Quality All In, a newsletter for quality professionals.
Below for paying subscribers: Food fraud news and incident reports
📌 Food Fraud News 📌
In this week’s food fraud news:
📌 Amber alert from a food crime unit;
📌 Wine;
📌 Canned tuna;
📌 Misleading pastries.
Amber Alert Issued by Food Crime Unit
Food businesses should be on the lookout for fraudulent laboratory test results, which could be used to facilitate food fraud, says a national authority, which has noticed an increase in the use of false test results by perpetrators of food crimes.
Falsified test results can lead to unsafe food being deemed safe, putting consumers at risk of illness and death.
False test results have appeared in three forms:
1. Altered versions of genuine laboratory documents in which results or dates have been altered;
2. Results presented…
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