Several months before this date 30 years ago, a Black Swan event occurred in Japan.

The 67-year-old president of the United States, George H.W. Bush while at a state dinner in his honor hosted by the Prime Minister of Japan, leaned forward and then fell on to his side hurling projectile vomit into the lap of PM Kiichi Miyazawa.

Black Swan events are said to be unpredictable with severe and widespread consequences, usually negative.

Thirty years ago today, six-year-old Lauren Beth Rudolph died in southern California from complications from an E. coli O157:H7 infection. She was the first fatality in the Jack-in-the-Box outbreak. We mark the 30th anniversary of that tragic event today that also took the young lives of two-year-olds Michael Nole of Tacoma, and Celina Shribbs of Mount Lake Terrace, WA; and 17-month-old Riley Detwiler of Bellingham.

While the president’s bout with foodborne illness, might have been foretelling in a Black Swan sort of way, his embarrassing bout of gastroenteritis soon passed. Those stricken later the same year by E. coli O157:H7 from Jack-in-the-Box hamburgers would experience more severe and lasting illnesses, and deaths.

This strain of E. coli did not have a public profile before the Jack-in-the-Box outbreak. Hamburgers contaminated with the previously unknown O157:H7 bacteria would sicken 732 Jack-in-the-Box customers before the outbreak was over, causing 178 severe illnesses and those four deaths. The poisoned beef patties were purchased at 73 Jack-in-the-Box restaurants in California, Idaho, Washington State, and Nevada.

Most of the victims were less than 10 years old and in addition to four deaths, another 178 were left with permanent injuries including brain and kidney damage. It was the severity of those outcomes that made Jack-in-the-Box the most infamous food-borne outbreak in contemporary history.

Brianne Kiner, 9 years old at the time, survived the Jack-in-the-Box outbreak, but with its most severe and permanent damages. Seattle attorney Bill Marler sued on her behalf, winning a $15.8 million settlement for Kiner. Her story includes diabetes, asthma, and brain and kidney damage from Hemolytic Uremic Syndrome (HUS), which caused the need for a transplant.

During the past 30 years, Marler has become the nation’s best-known attorney for victims of foodborne illness. He is also the publisher of Food Safety News.

The public may never have heard of it before, but the meat industry knew about E. coli O157:H7. Undercooked hamburgers sold by McDonald’s in Oregon and Michigan were contaminated with O157:H7 in 1982, causing an outbreak that did not get the attention it deserved. Before 1992, O157:H7 had indeed caused 35 deaths in 22 scattered outbreaks.

The Jack-in-the-Box outbreak, however, would have sweeping ramifications, including:

• USDA’s reclassification of E. coli O157:H7 as an adulterant in ground beef, making it illegal to sell ground beef contaminated with it.

• USDA’s Food Safety and Inspection Service began testing for E. coli O157:H7 in ground meat.

• Infection by E. coli O157H7 was made a reportable disease by all state health departments.

• FDA increased the recommended internal cooking temperature for hamburgers to 155 degrees Fahrenheit, up from 140.

• USDA adopted Pathogen Reduction and Hazard Analysis and Critical Control Point programs originally created for NASA.

As it happened, Jack-in-the-Box restaurants were in the middle of a promotion for “Monster Burger” sold under the slogan “So good, it’s scary!” And the promotion was keeping demand high, overwhelming the outlets. The promotion was so popular that it contributed to problems by speeding the line and not keeping the hamburgers at high enough temperatures to kill the bacteria.

Jack-in-the-Box was named as the source of the E. coli O157:H7 outbreak on Jan. 18, 1993. Through Foodmaker, its parent company, the burger chain agreed to stop serving hamburgers and quarantine beef. The San Diego-based company blamed Vons Companies, it’s beef supplier, for the outbreak.

Jack-in-the-Box knew about, but choose to ignore, Washington State’s higher cooking temperature for hamburgers. The state’s 155-degree Fahrenheit requirement was 15 degrees higher than FDA’s 140. Had Jack-in-the-Box adhered to the Washington State Health Department regulation, it’s unlikely the outbreak would have occurred.

With an expanding probe by President Bill Clinton’s new administration, five slaughterhouses in the United States and another one in Canada were found to be the likely sources of the contaminated beef. Foodmaker agreed to a $58.5 million settlement from Vons and eight other beef suppliers.

Later in 1993, Jack-in-the-Box hired food safety expert Dave Theno, who implemented “test and hold” to clear before use, higher cooking temperatures, and numerous other food safety measures. Theno carried a picture of outbreak victim Lauren Beth Rudolph until his own death in 2017.

The Jack-in-the-Box outbreak was the first time Dr. Phillip Tarr, then pediatric gastroenterologist at the University of Washington and Seattle’s Children’s Hospital had seen E. coli-caused HUS with bloody diarrhea in a cluster of children. When he told Dr. John Kobayashi, Washington State Epidemiologist about it, Kobayashi knew immediately that he had a “big red flag” on his hands.

The Jack-in-the-Box outbreak is now seen as only second to the Upton Sinclair book, The Jungle, for its effect on the beef industry and its regulators. To be a Black Swan event, it could not have been predicted. But probably was inevitable.