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30 New Cases Reported as National E. coli Outbreak Spreads

30 New Cases Reported as National E. coli Outbreak Spreads


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Three new states are now reporting illnesses—here's what you can do to avoid getting sick.

  • The national E. coli outbreak that has been linked to contaminated romaine lettuce has worsened, as more than 30 new cases have been reported.
  • The Centers for Disease Control released a new update on the scale of E. coli infections spreading across the country, with nearly 20 states now reporting illnesses.
  • Multiple national agencies instituted a blanket ban on romaine lettuce nearly a week ago.
  • The CDC says even more cases may be reported still as more E. coli victims come forward to seek treatment, at which point hospitals notify the national agency.

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Health professionals are reeling after a national E. coli outbreak has caused more than 80 people to fall ill after eating tainted romaine lettuce. While headlines have forced national grocery stores and restaurants to ditch salad for the foreseeable future, a new update from the Centers for Disease Control is a reminder that home cooks still need to be wary.

Initially, the CDC only reported 35 cases in 11 different states. But that number has soared to 84 as now 19 different states have reported illnesses related to E. coli poisoning stemming from romaine lettuce.

Those victims aren't living in one particular area of the United States: Alaska, California, Arizona, Washington, Idaho, Montana, Colorado, Louisiana, Missouri, Illinois, Michigan, Ohio, Georgia, Virginia, Pennsylvania, New Jersey, New York, and Connecticut have reported E. coli sicknesses. While no deaths have been reported, the CDC also advised the public that more cases—and increased severity—could be later reported as more and more patients flock to local hospitals.

The issue began when federal inspectors traced the outbreak back to the Yuma, Arizona, region, a robust area of a state that is responsible for a lot of the produce that we eat across the country. Romaine lettuce isn't packaged or sold with clear identification of where it was produced, so unless you have a bed of romaine heads in your backyard, the CDC has asked you not to eat romaine lettuce whatsoever. Grocery stores have followed suit and most national retail outlets have pulled the product from shelves.

What's truly scary about this bout of E. coli sicknesses is that many people have developed a rare kidney disease known as hemolytic uremic syndrome—a phenomena where the kidney fails, and E. coli is the gateway sickness for many of those victims who have since developed what's known as HUS.

We'll update this article with more information as it becomes available, but today's CDC update is a reminder: Stay away from romaine lettuce. This outbreak, which is on its way to becoming one of the worst in American history, is no joke.


Public Health Notice - Outbreak of E. coli infections linked to various flours and flour products

The Public Health Agency of Canada collaborated with federal and provincial public health partners to investigate an outbreak of Escherichia coli, called E. coli O121 that was linked to various flour and flour products produced by Ardent Mills. The Canadian Food Inspection Agency (CFIA) issued food recall warnings advising Canadians of various flours and flour products under various brand names. These food recall warnings were triggered by CFIA findings during its food safety investigation into this outbreak. Given that no new cases have been reported since April 2017, the outbreak appears to be over, and the outbreak investigation has been closed.

Although the outbreak appears to be over, these illnesses and food recall warnings are a reminder that it is not safe to taste or eat raw dough or batter, regardless of the type of flour used as raw flour can be contaminated with harmful bacteria such as E. coli.

Canadians are advised not to use or eat any recalled flour or flour products. For additional food recall details on product brand names and lot codes, please consult CFIA's website for this investigation. Restaurants and retailers are also advised not to sell or serve any recalled products, or any items that may have been prepared or produced using recalled products.

E. coli are bacteria that live naturally in the intestines of cattle, poultry, other animals, and humans. Most E. coli are harmless to humans. However, there are many different strains of E. coli, and some varieties can cause serious illness.

While most people made ill by E. coli experience a few days of upset stomach and then recover fully, infections can sometimes be life threatening.


Outbreak of E. coli Infections – Unknown Source 3

CDC, public health and regulatory officials in several states, and the U.S. Food and Drug Administration (FDA) investigated several multistate outbreaks of E. coli O157:H7 infections. This outbreak is different from two other E. coli O157:H7 outbreaks that occurred at the same time (E. coli outbreak with unknown source 1 and E. coli outbreak linked to leafy greens).

  • As of December 18, 2020, this outbreak is over.
  • A total of 18 people infected with the outbreak strain of E. coli O157:H7 were reported from 9 states.
    • Illnesses started on dates ranging from September 2, 2020, to November 6, 2020.
    • 6 people were hospitalized, and no deaths were reported.
    • On November 6, 2020, Tanimura & Antle recalled external icon its packaged single-head romaine lettuce.

    • Wash your hands after using the restroom or changing diapers, before and after preparing or eating food, and after contact with animals.
    • Cook meats thoroughly. Use a food thermometer to check that the meat has reached a safe internal temperature external icon .
    • Don&rsquot cross-contaminate food preparation areas. Thoroughly wash hands, counters, cutting boards, and utensils after touching raw meat.
    • Wash fruits and vegetables before eating, unless the package says the contents have been washed.
    • Avoid raw milk, other unpasteurized dairy products, and unpasteurized juices.

    • People usually get sick from Shiga toxin-producing E. coli (STEC) 2 to 8 days (average of 3 to 4 days) after swallowing the germ.
    • Symptoms often include severe stomach cramps, diarrhea (often bloody), and vomiting. Some people may have a fever, which usually is not very high (less than 101˚F/38.5˚C).
    • Some people with a STEC infection may get a type of kidney failure called hemolytic uremic syndrome (HUS).
    • Antibiotics are not recommended for patients with suspected E. coli infections until diagnostic testing can be performed and E. coli infection is ruled out. Some studies have shown that administering antibiotics to patients with E. coli infections might increase their risk of developing HUS, and a benefit of treatment has not been clearly demonstrated.
    • For more information, see Symptoms of E. coli Infection.

    December 18, 2020

    CDC, public health and regulatory officials in several states, and the U.S. Food and Drug Administration (FDA) investigated a multistate outbreak of E. coli O157:H7 infections.

    Public health investigators used the PulseNet system to identify illnesses that may have been part of this outbreak. PulseNet is the national subtyping network of public health and food regulatory agency laboratories coordinated by CDC. DNA fingerprinting is performed on E. coli bacteria isolated from ill people by using a standardized laboratory and data analysis method called whole genome sequencing (WGS). CDC PulseNet manages a national database of these sequences that are used to identify possible outbreaks. WGS gives investigators detailed information about the bacteria causing illness. In this investigation, WGS showed that bacteria isolated from ill people were closely related genetically. This means that people in this outbreak were more likely to share a common source of infection.

    As of December 16, 2020, a total of 18 people infected with the outbreak strain of E. coli O157:H7 were reported from nine states. A list of the states and the number of cases in each can be found on the Map of Reported Cases page.

    Illnesses started on dates ranging from September 2, 2020, to November 6, 2020. Ill people ranged in age from 8 to 71 years, with a median age of 28 years, and 72% were female. Of 16 ill people with information available, 6 were hospitalized. No deaths were reported.

    WGS analysis of 15 isolates from ill people and 4 isolates from food did not predict resistance to any antibiotics. Standard antibiotic resistance testing by CDC&rsquos National Antimicrobial Resistance Monitoring System (NARMS) laboratory is currently underway. These findings do not affect treatment guidance since antibiotics are not recommended for patients with E. coli O157:H7 infections.

    Investigation of the Outbreak

    State and local public health officials interviewed ill people to determine what they ate and other exposures in the week before they got sick. Of the 13 people interviewed, all reported eating or maybe eating various types of leafy greens, including romaine lettuce (9), spinach (9), and iceberg lettuce (7).

    Laboratory testing identified the outbreak strain in a sample of Tanimura & Antle romaine lettuce in a single-head package, which was recalled external icon on November 6, 2020. However, investigators were unable to determine if any ill people in this outbreak got sick from eating the recalled product. No one specifically reported eating Tanimura & Antle romaine lettuce, and some people got sick before the &ldquopacked on&rdquo dates for the recalled products.

    FDA conducted traceback investigations and worked with state partners to conduct inspections at several farms. However, none of the findings identified a common source in the distribution chain or linked the farms to the outbreak.

    As of December 18, 2020, this outbreak is over. This outbreak ended before enough information was available for investigators to identify the likely source.


    Gumshoe Work and Luck Helped in E. Coli Case

    The decisive break in tracking down the probable source of the mysterious E. coli bacteria that sickened people across six states came Monday morning, although no one knew it at the time.

    About 10 a.m., Bruce R. Williamson, chief of the Suffolk County Bureau of Public Health Protection, arrived at a Taco Bell in Deer Park, to meet a Taco Bell food safety team that had flown in to collect samples of just about every type of tortilla, tomato and touch of Mexican seasoning in the place.

    A few days earlier, county officials had identified a cluster of E. coli cases linked to the Taco Bell in Deer Park and three others in Suffolk, and a similar cluster was being investigated in New Jersey.

    The county inspectors took samples of 25 items from the Taco Bell in Deer Park, including an eight-ounce plastic bag of cut green onions, also known as scallions, that was about to be thrown out. They sent the samples to the State Health Department laboratory in Albany for sophisticated testing that would take several days.

    The Taco Bell representatives took their own samples, including some from the same bag, which they sent to an independent lab for a quick test that found green onions contaminated with the E. coli bacteria.

    It was not yet definitive proof, but on Wednesday morning Taco Bell announced a recall of green onions from all 5,800 of its restaurants in the United States.

    Old-fashioned medical gumshoe work, combined with a multilayered tracking system and not a little luck, pinpointed the probable cause of the outbreak two and a half weeks after the first case was reported and apparently prevented it from spreading further. Public health officials said that the system worked.

    But did it work fast enough for this kind of an outbreak, one involving a national fast-food chain, a complex long-distance distribution system and the real possibility that until the onions were removed on Wednesday, contaminated food had remained in the restaurants for more than two weeks after the first case of food poisoning was reported?

    More than 300 confirmed or suspected cases have been reported, including 16 cases added by New Jersey yesterday, bringing its total to 74. New York has at least 221 cases, and a small number have been reported in Pennsylvania, Delaware, South Carolina and Utah.

    Public health officials concede that the system is like a crime scene investigation. It can catch a suspect and prevent that person from doing any more harm, but it cannot prevent the crime from happening in the first place. By the time victims of food poisoning go to doctors' offices and hospitals it is too late, Mr. Williamson said.

    Experts say that it might be possible for officials to react more quickly, but not much more quickly. The real solution, they say, would be to prevent contamination in the first place by tightening regulations on farms where the produce is grown and the livestock is raised.

    Until such measures are taken, public health officials must rely on tried-and-true methods of tracking down diseases and identifying outbreaks of connected illnesses from myriad medical cases that occur every day.

    It all begins with a single case, though that one patient cannot be identified as the sentinel case until well after it is first recorded.

    Food poisoning caused by E. coli is a reportable disease, meaning that any doctor, clinic or hospital that treats someone with it must report it to a county health registry within 24 hours. Notification then moves up the ladder to the state and then federal levels as an outbreak spreads.

    In this investigation, the first reported case of potentially deadly E. coli O157:H7 was in Middlesex County, N.J., on Nov. 17, six days before Thanksgiving. The typical symptoms of nausea and bloody diarrhea were confirmed as E. coli by hospital tests only after someone felt sick enough to see a doctor.

    New Jersey has about 60 confirmed cases of E. coli a year, so a single case did not set off alarms. (And later in the week, state health officials determined that the first case was indeed E. coli but was unrelated to the current outbreak.)

    In the last week of November, more cases were reported, leading Middlesex officials to review the data and look for connections. In this sort of investigation, by interviewing the patients, officials begin to assemble a profile of those who got sick.

    A standard question asked in every interview is whether the patient had eaten out, and if so, where. Symptoms of E. coli infection generally do not appear for three or four days, and in that span the initial patients had collectively been to a number of fast-food restaurants and a local diner, they told officials.

    But as the investigation continued, signals pointed to a specific chain, Taco Bell, and a single restaurant, the one on Stelton Road in South Plainfield, where 9 of 11 reported victims had eaten.

    Several of the victims were vegetarians, leading authorities to focus on produce rather than chopped beef.

    Officials inspected the restaurant on Nov. 27 but found no contaminated food, which is not necessarily surprising. A typical Taco Bell restaurant may have up to 7,000 customers a week, and supplies turn over very quickly. Still, the unusually large number of cases led the county to report the cluster to the New Jersey Department of Health and Senior Services on Nov. 29.

    On Nov. 30, the owners of the Taco Bell in South Plainfield, presented with the evidence from officials, agreed to shut down, dispose of all existing supplies and have the place professionally cleaned.

    On Long Island the next day, Dec. 1, health officials received a frantic phone call from the mother of an 11-year-old boy who had been hospitalized. She thought he might have picked up something exotic from his pet gecko. The boy had all the signs of E. coli infection. It was not the gecko. When health officials confirmed the results of the boy's E. coli test with the hospital, they were surprised to find out that the hospital had two other E. coli cases.

    Later that night, reports of three other cases in Suffolk County came in. Interviews with the victims revealed that all had eaten recently at several local Taco Bell outlets.

    At first, county authorities suspected a worker was somehow to blame, but when four Taco Bells were found to be involved, they knew it had to be something else, probably food that was contaminated before it arrived. Reports coming from New Jersey confirmed their suspicions.

    By the time Taco Bell representatives arrived on Monday, the county had a solid theory. "We showed them the evidence we had with nine patients at that point, and they said, 'Oh, boy, that's pretty compelling,' " recalled Dr. Patricia Dillon, the county director of epidemiology and communicable diseases.

    The Taco Bell delegation huddled, called headquarters and then agreed to close all four restaurants until all possible contamination was eliminated.

    First thing Tuesday morning, at the restaurant on Deer Park Avenue, Mr. Williamson oversaw the disposal of all the food supplies, including the green onions. But before it was thrown into a trash bin, an eight-ounce plastic bag of cut onions was opened and samples were taken. A private lab contracted by Taco Bell found preliminary evidence that onion samples carried the E. coli bacteria.

    Rob Poetsch, a spokesman for Yum! Brands, which owns Taco Bell, said the presumptive evidence was enough for the company to decide to strip green onions from its restaurants and start the process of tracing them through the delivery chain.

    The samples sent to the state laboratory in Albany are undergoing DNA testing that is more extensive and conclusive.

    Although it is still not known how the onions were contaminated, the epidemiological sleuthing that identified the suspected source of the bacteria reflected the kind of response system that authorities have put in place for such emergencies, a system they believe works well.

    "People say, 'Wow, it's like "C.S.I.," ' " Dr. Dillon said, referring to the popular television program about forensic detectives. "It's exciting."

    But it has its limitations, especially when dealing with thousands of fast-food outlets connected by a central distribution system that can send contaminated food rampaging across several states in a few days.

    New Jersey officials at the county and state levels have been criticized for waiting so long after the first case was reported to let the public know there was an outbreak. Officials in both New Jersey and New York have been criticized for allowing Taco Bell restaurants to remain open after they were linked to the outbreak. Most of those that closed did so voluntarily after health officials asked them to.

    And early last week, officials were insisting that the outbreak had been contained because any contaminated food in the restaurants had probably already been consumed. But the green onions were then still in some restaurants.

    "Those statements were somewhat premature," said Dr. Pascal James Imperato, chairman of the department of preventive medicine at the SUNY Downstate Medical Center in Brooklyn and a former New York City health commissioner.

    While additional cases continue to be reported, authorities now say that if the green onions indeed were the source of the bacteria, no one should be getting sick as a result of eating them after Wednesday, the day Taco Bell recalled the onions.

    As news of the outbreak spreads, however, the number of cases reported to authorities is expected to grow exponentially, as people make a connection between how they felt in late November and a meal they may have had at Taco Bell. But after a few weeks, there is no way to collect stool samples to confirm the E. coli, so they will be counted as suspected or probable cases, but not confirmed cases.

    Dr. Imperato said that the best the public health authorities can do is track an outbreak and, with luck, identify the source quickly to keep more people from becoming infected. The real solution, he said, is regulating the farm operations.

    As with the contaminated spinach outbreak earlier this year, doctors became aware of the problem with Taco Bell food only after a noticeable number of people dragged themselves to the doctor or hospital with the classic signs of E. coli infection.

    And that, Dr. Imperato said, is too late.

    "The system is not as good as we would like it to be because there are still holes in our food-safety system," he said. "There's still a lot of room for improvement."

    E. Coli Suspected in Iowa Sicknesses

    A possible E. coli outbreak traced to a taco chain has sickened more than two dozen people in Iowa, but it appears to be unrelated to the illnesses in the Northeast, officials said yesterday.

    The 33 people who got sick in Iowa ate at a Taco John's in Cedar Falls, and 14 have been hospitalized. Tom O'Rourke, director of the Health Department in Black Hawk County, Iowa, said that preliminary tests showed the cause to be E. coli, but there was no evidence to suggest that the contamination is linked to the cases in New York, New Jersey and four other states.

    Brian Dixon, a vice president of marketing at Taco John's, said that the outbreak in Iowa was "baffling."

    "We operate 430 restaurants in 26 states," he said. "This is the only restaurant that has a series of illnesses reported."

    He said that the chain, based in Wyoming, did not serve green onions, the suspected cause of the outbreak in the Northeast.


    Tainted Leaves

    In the spring of 2018, dozens of people across the country began falling sick. Infected with E. coli O157:H7, a Shiga toxin-producing E. coli — symptoms of which include severe stomach cramps, bloody diarrhea, vomiting, and potentially life-threatening kidney failure — the majority of patients shared one thing in common: recently eating romaine lettuce.

    Federal and state health authorities traced the lettuce’s particular strain of E. coli to a 3.5 mile-long stretch of an irrigation canal supplying water to several farms in Arizona’s Yuma growing region, adjacent to a large cattle feedlot, which is often a source of such pathogens. How exactly that particular bacteria found its way into the water and then the lettuce couldn’t be determined, but growers and investigators had a hypothesis, at least: an unusual late-February freeze had damaged the surfaces of leaves, making them vulnerable to the intrusion of pathogenic E. coli, which could have reached the plants via the spraying of canal water or pesticides diluted with the water, or maybe from contaminated dust blown by wind.

    By the end of the outbreak, there had been 210 reported illnesses across 36 states. Ninety-six people were hospitalized five died. It was the largest multistate E. coli outbreak in the United States since 2006, when a Shiga toxin-producing E. coli outbreak linked to spinach and to cattle manure in a ranch in California’s San Benito County sickened nearly 200 and caused three deaths.

    Roughly 48 million people in the U.S. get sick, 128,000 are hospitalized, and 3,000 die from foodborne illnesses each year, the Centers for Disease Control and Prevention (CDC) estimates. It’s not perfect, but statistically speaking, “the reality is that we have a pretty safe food supply,” says Lee-Ann Jaykus, a professor in the department of food, bioprocessing and nutrition sciences at North Carolina State University.

    Whether it will remain that way, however, is a different matter, considering the big, flaming, catastrophe-sized elephant in the room: Climate change, food production, and food security are linked, and if we continue down the current trajectory of incremental global warming and everything that entails, the foodborne illness problem is likely going to get worse.

    There’s still a lot that we don’t know yet, admittedly. In 2010, a review of climate change and food safety concluded that climate change “may have an impact on the occurrence of food safety hazards.” Jaykus, one of the co-authors of that paper, says that the keyword “may” is still a good working term. More evidence has emerged in the last decade that points to the potential for more people to get sick from eating food contaminated with harmful microbes as a consequence — both direct and indirect — of climate change.

    These impacts are likely to be felt across the food supply. But among fresh produce, leafy vegetables may be especially worrisome. This commodity grouping was ranked the “highest priority” concern in a 2007 fresh produce microbiological hazard risk assessment meeting by World Health Organization and Food and Agriculture Organization (FAO) experts, who cited the raw consumption of leafy vegetables, as well as the hazards that animals, climate, the weather, flooding, water, and more pose to their specific growing conditions.

    Virtually every one of those hazards — although not solely unique to leafy greens — is vulnerable to the effects of climate change, albeit in complex, interconnected, sometimes uncertain ways. As Jaykus puts it, “It’s like: climate change impacted this factor, which impacted this factor, which impacted this factor.” In other words, think of climate change as both an amplification of existing hazards, as well as a potential trigger for things we can’t foresee.

    To consider the implications of climate change on growing conditions, we have to start from the beginning. E. coli and salmonella, the two pathogens most commonly associated with leafy green-linked foodborne illnesses, live in the intestinal tracts of animals and humans. Their feces can contaminate sources like soil, water, manure, and sewage, which can then reach leafy vegetables via pathways that include irrigation, splash, runoff, direct contact, and more, as summarized in a 2013 International Journal of Food Microbiology paper by researchers in the Netherlands.

    As temperatures and humidity rise, certain pathogens may more readily survive or even proliferate. “Some pathogens exposed to increased temperatures experience faster replication,” says Justin Remais, professor of environmental health sciences at the University of California, Berkeley. Others may see increased virulence, meaning a greater ability to cause damage to the host.

    Rising temperatures have also been associated with increased rates of antimicrobial resistance in pathogenic bacteria, according to a report by the FAO. That means that, as climate change accelerates, it’s possible that there may be more incidences of foodborne pathogens in feed animals not responding to regular amounts of clinical drugs, leading to the use of more antibiotics, which could further compound the problems of antimicrobial resistance.

    More extreme temperatures can also cause cattle — the primary source of E. coli O157:H7 illnesses — to shed higher levels of pathogens into the environment due to stress, says Erin DiCaprio, an assistant cooperative extension specialist in community food safety at the University of California, Davis. Higher temperatures could also result in livestock spending more time outside in warm weather, which may increase pathogen exposure. Climate-related changes will likely result in changes to diet, both to humans and animals, which in turn can change exposure to pathogens, Jaykus posits.

    Once pathogens leave the gut, they’re in a hostile environment and will eventually die off. But some, like, salmonella and E. coli, can actually thrive for a short period of time, up to a few days. “Once these organisms leave the gut, in the feces … they’re trying, evolutionarily, to survive and spread themselves to some other organism or host,” says Jay Graham, an assistant professor in residence of environmental health sciences at Berkeley. Often, they’ll end up in water, where they generally don’t last long, but in certain conditions, they can survive and even grow, like in sterile freshwater with low carbon concentrations and a temperature of 86 degrees Fahrenheit.

    Water is a major area of concern to many experts. “You can’t have a safe and secure food supply if you don’t have a safe and secure water supply,” says Jaykus. Heavy rain or flood events, especially after periods of drought or in arid conditions, can contaminate irrigation water with human and animal waste. There’s a clear link between these weather patterns, which are becoming more prevalent and more extreme due to climate change, and upticks in gastrointestinal infections, according to Graham.

    “Think about all the septic tanks in the United States, all the leaky sewers and all of the livestock waste spread on land,” he says. “Then you have this dry spell, so there can be an accumulation of fecal waste on the land … That rain event basically spreads all that feces out over the environment and contaminates waterways that are then used to irrigate all of our crops.”

    The scale of the problem becomes more serious once you consider how much feces is within the vicinity of the fields where fresh produce is grown. “The way we get rid of animal waste is to apply it to agricultural land,” says Lance Price, a professor of environmental and occupational health at George Washington University. And even when these kinds of soil amendments aren’t used, there may still be fecal matter nearby much of America’s leafy vegetable production takes place in Yuma and the Salinas Valley, where there are also concentrated animal feeding operations (CAFO) that can have upward of 100,000 head of cattle or other livestock.

    “These are animals that are in very close proximity to one another,” is how Jaykus describes CAFOs. “When you have animals very close to each other, you also have a lot of fecal material, and fecal material is close to irrigation in that region.”

    You can imagine where some of that fecal material ends up after heavy downpours. “What you get are little streams of cow and pig shit flowing downstream,” says Price. “They’re just like big fecal wastelands. There’s nothing to really stop the flow of shit and bacteria when there are these heavy rain events.” In some cases, entire fields may be flooded, potentially exposing the edible portions of plants to waste, agrochemicals, and heavy metals, according to FAO food safety officer Vittorio Fattori. Leafy greens, which are grown close to the ground, are more likely to be contaminated compared to other produce under these conditions.

    It doesn’t even have to be flooding. Contaminated runoff could flow into irrigation canals, which are then used to water crops. Dust storms as a result of droughts and dry spells can lead to contaminated dust particles settling on leafy greens. Those vegetables, delicate as they are, could suffer surface damage from unexpected freezes or other unpredictable weather events, creating the potential for bacteria to work its way into the plant.

    Wildlife is another contamination source that could be exacerbated by climate change. “If there are more precipitation events and higher temperatures, you could see this explosion of vegetation and some of these wildlife populations,” says DiCaprio. If the number of pathogen-carrying animals and insects increases, there’s a higher probability that they’ll infiltrate irrigation water, soil sources, or growing fields themselves, potentially leading to more foodborne illnesses.

    Not all of these hazards — just a few among many possibilities, should climate change continue accelerating — are going unchecked. “There have been huge improvements related to irrigation practices, like doing site assessments to make sure there is not a concentrated animal feeding operation in close proximity to a field that’s being used to produce leafy greens,” says DiCaprio, also highlighting irrigation water-quality requirements, soil-amendment regulation, pre-harvest checks for wildlife intrusion, and even more stringent requirements for leafy greens in particular.

    Still, DiCaprio acknowledges, “even with all those tight controls, you can’t control everything.” That’s especially true when you add climate change and all its variables into the mix, complicating the already difficult task of managing food safety.

    “I do think we are going to see more of these events. There are a lot of drivers involved, but it is going to result in more of these kinds of outbreaks,” says Graham.

    While the U.S.’s fairly safe food system may be able to shoulder that burden, the same is not true everywhere. That’s what Graham is primarily concerned with: this “perfect storm” of climate change-related impacts in countries with fewer resources and less developed food safety systems.

    “We’re seeing significant increases in industrial ag in places that don’t even have good human sanitation, so there are very few safeguards against animal waste going into the environment,” he says. “The U.S. does a poor job in managing waste from livestock and poultry, but when I go to these other countries, there’s not the oversight or even local regulations and policies to prevent the spread of any organisms from these farms.”

    Some of those farms with fewer hygiene controls grow fruits and vegetables for export, which poses its own risks for consumers in the U.S. Food imported into this country has steadily increased over the past decades, thanks to higher demand for a wider selection of foods and for produce items year round, according to a 2017 study published in the CDC journal Emerging Infectious Diseases. At the same time, there has been “a small but increasing number of foodborne disease outbreaks associated with imported foods, most commonly fish and produce,” the researchers found. The globalized food supply means that we can’t just focus on our own well-being our problems are shared across oceans, across borders.

    With food safety, as with climate change, there’s no magic bullet that can fix everything. “Our world is so complex now, and the problems we face are so fundamental and big, that we can’t use a reductionist approach,” says Max Teplitski, chief science officer of the Produce Marketing Association. Addressing all the components — sustainability, labor, hygiene and health, soil quality, environmental protection, wildlife management — will take a systems approach rather than a siloed one. That means getting all the right people to the table: farmers, the scientific community, and the government, which Teplitski finally feels hopeful about, thanks to the new administration. Collaboration needs to happen on local, national, and global levels.

    “A few months ago, we had this conversation about how essential food industry workers are, and I think we also realized that the food industry itself is essential,” he says. “If we say that food production is essential for life on this planet, then we must treat this industry as essential.” To him, that means investing in agricultural research and practices that foster sustainability and produce safety, whether that’s incentivizing carbon soil sequestration or the protection of soil health.

    “The health of people, animals, plants, and the environment are inextricably linked” under the umbrella of the One Health paradigm, says Fattori. That’s a lesson we should have learned from the coronavirus pandemic: fundamentally, public health is collective. The only way we can protect ourselves — and the planet — is to put in the work to protect each other.

    Yadi Liu is an award-winning visual artist who is passionate about finding the optimum balance between illustration and modern art.
    Fact checked by Andrea López Cruzado
    Copy edited by Rachel P. Kreiter


    Multistate Outbreak of Salmonella Poona Infections Linked to Imported Cucumbers (Final Update)

    This outbreak appears to be over. However, Salmonella remains an important cause of human illness in the United States. For more information about Salmonella and steps that people can take to reduce their risk of infection, visit CDC&rsquos Salmonella webpage.

    • This outbreak appears to be over. However, Salmonella remains an important cause of human illness in the United States. For more information about Salmonella and steps that people can take to reduce their risk of infection, visit CDC&rsquos Salmonella webpage.
    • CDC, multiple states, and the U.S. Food and Drug Administration External (FDA) investigated a multistate outbreak of Salmonella Poona infections.
      • A total of 907 people infected with the outbreak strains of Salmonella Poona were reported from 40 states.
      • A total of 204 ill people were hospitalized, and six deaths were reported from Arizona (1), California (3), Oklahoma (1), and Texas (1). Salmonella infection was not considered to be a contributing factor in two of the three deaths in California.

      Introduction

      CDC collaborated with public health officials in many states and the U.S. Food and Drug Administration External (FDA) to investigate a multistate outbreak of Salmonella Poona infections.

      Public health investigators used the PulseNet system to identify illnesses that were part of this outbreak. PulseNet, coordinated by CDC, is the national subtyping network of public health and food regulatory agency laboratories. PulseNet performs DNA fingerprinting on Salmonella bacteria isolated from ill people by using techniques called pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). CDC PulseNet manages a national database of these DNA fingerprints to identify possible outbreaks.

      A total of 907 people infected with the outbreak strains of Salmonella Poona were reported from 40 states. A list of states and the number of cases in each can be found on the Case Count Map page.

      Among people for whom information was available, illnesses started on dates ranging from July 3, 2015 to February 29, 2016. Ill people ranged in age from less than 1 year to 99, with a median age of 18. Forty-nine percent of ill people were children younger than 18 years. Fifty-six percent of ill people were female. Among 720 people with available information, 204 (28%) were hospitalized. Six deaths were reported from Arizona (1), California (3), Oklahoma (1), and Texas (1). According to the California Department of Public Health, Salmonella infection was not considered to be a contributing factor in two of the three deaths in California.

      WGS showed that isolates from ill people were closely related genetically. These results also included isolates from people who became ill in October, November and January after the outbreak&rsquos peak. This close genetic relationship means that people in this outbreak were more likely to share a common source of infection, such as a contaminated food.

      Investigation of the Outbreak

      Epidemiologic, laboratory, and traceback investigations identified imported cucumbers from Mexico and distributed by Andrew & Williamson Fresh Produce as the likely source of the infections in this outbreak.

      Epidemiologic Investigation

      State and local public health officials interviewed ill people to obtain information about foods they might have eaten and other exposures in the week before their illness began. In interviews, 391 (75%) of 519 people reported eating cucumbers. This proportion was significantly higher than results from a survey of healthy people Cdc-pdf [PDF &ndash 29 pages] in which 47% reported eating cucumbers in the week before they were interviewed.

      Also, many ill people were identified as part of illness clusters. An illness cluster is defined as two or more people who do not live in the same household who report eating at the same restaurant location, attending a common event, or shopping at the same location of a grocery store in the week before becoming ill. Investigating illness clusters can provide critical clues about the source of an outbreak. If several unrelated ill persons ate or shopped at the same location of a restaurant or store within several days of each other, it suggests that the contaminated food item was served or sold there. Eleven illness clusters were identified in seven states. In all of these clusters, interviews found that cucumbers were a common item eaten by ill people. Epidemiologic studies that compare foods eaten by both ill and well people were conducted in two of these clusters. Results of these studies indicated that a food item containing cucumbers was associated with illness.

      CDC&rsquos National Antimicrobial Resistance Monitoring System (NARMS) laboratory conducted antibiotic resistance testing on clinical isolates collected from 30 ill people infected with one of the outbreak strains. Of the 30 isolates tested, 2 (7%) were drug resistant (resistance to one or more antibiotics), and the other 28 (93%) isolates were not resistant to any of the antibiotics tested by NARMS. One drug-resistant isolate was resistant to tetracycline. The other isolate was resistant to nalidixic acid and nonsusceptible to ciprofloxacin. Nonsusceptible means an antibiotic cannot completely kill bacteria or stop their growth. Ciprofloxacin is commonly used to treat serious Salmonella infections in adults but is not routinely used in children. Antibiotic resistance may be associated with increased risk of hospitalization, development of a bloodstream infection, or treatment failure.

      Laboratory Investigation

      Several state health and agriculture departments collected and tested cucumbers from retail locations and isolated the outbreak strains of Salmonella Poona. Information indicated that these cucumbers were distributed by Andrew & Williamson Fresh Produce. Additionally, testing of cucumbers collected from the Andrew & Williamson Fresh Produce facility isolated the outbreak strains of Salmonella Poona.

      WGS of Salmonella Poona isolates from ill people and from contaminated cucumbers distributed by Andrew & Williamson Fresh Produce showed that the strains were closely related genetically. This close genetic relationship provided additional evidence that ill people in this outbreak became ill from consuming cucumbers distributed by Andrew & Williamson.

      Traceback and Regulatory Investigation

      Early in an outbreak investigation, consultation with independent industry experts can provide important clues to help focus the investigation on certain suspected foods. An industry consultation was held on August 26, 2015, with four independent experts from the produce industry to obtain information regarding fresh produce harvesting and distribution in the areas where ill people were being reported. The consultants provided information regarding crop production and distribution practices that helped assess the plausibility of cucumbers and other produce items as possible outbreak sources.

      Traceback information collected from the 11 illness clusters indicated that cucumbers eaten by ill people were imported from Mexico and distributed by Andrew & Williamson Fresh Produce.

      Two recalls of garden variety cucumbers distributed by Andrew & Williamson Fresh Produce were announced because the cucumbers were likely contaminated with Salmonella. Recalled cucumbers were grown in Baja California, Mexico and distributed to many U.S. states. On September 4, 2015, Andrew & Williamson Fresh Produce voluntarily recalled External all cucumbers sold under the Limited Edition brand label from August 1, 2015 through September 3, 2015. On September 11, 2015, Custom Produce Sales voluntarily recalled External all cucumbers sold under the Fat Boy brand label starting August 1, 2015. These cucumbers were sent to Custom Produce Sales from Andrew & Williamson Fresh Produce.

      Illnesses Occurring after September 24, 2015

      The number of reported illnesses declined substantially after the peak of illnesses in August and September however, illnesses did not return to the expected number for several months afterwards for this DNA fingerprint (typically, about one illness is expected every month from November through January). Instead, 127 illnesses started after September 24, 2015, when recalled cucumbers should have no longer been available in stores or restaurants. If any of the recalled cucumbers were still available, they would have spoiled by that time.

      WGS results from illnesses which occurred after the end of September 2015 suggested they shared a common source with the illnesses during the peak of the outbreak in August and September. State and local public health officials interviewed 46 of these ill people. Of that group, 29 (63%) reported eating cucumbers in the week before their illness started. Interviews did not identify any additional food items potentially linked with illness. Investigations were unable to determine if the illnesses could be explained by cross-contamination within the distribution chain for the recalled cucumbers, such as in shipping containers or at retail locations. This outbreak appears to be over.

      Final Case Count Update

      This outbreak appears to be over. Since the last update on January 26, 2016, 19 more ill people were reported from eight states.

      A total of 907 people infected with the outbreak strains of Salmonella Poona were reported from 40 states. A list of states and the number of cases in each can be found on the Case Count Map page.

      Among people for whom information was available, illnesses started on dates ranging from July 3, 2015 to February 29, 2016. Ill people ranged in age from less than 1 year to 99, with a median age of 18. Forty-nine percent of ill people were children younger than 18 years. Fifty-six percent of ill people were female. Among 720 people with available information, 204 (28%) were hospitalized. Six deaths were reported from Arizona (1), California (3), Oklahoma (1), and Texas (1). According to the California Department of Public Health, Salmonella infection was not considered to be a contributing factor in two of the three deaths in California.

      Case Count Update

      Since the last update on November 19, 2015, 50 more ill people have been reported from 16 states. Illnesses that occurred after December 21, 2015 might not be reported yet. A series of events occurs between the time a person is infected and the time public health officials can determine that the person is part of an outbreak. This means that there will be a delay between when a person gets sick and confirmation that he or she is part of an outbreak. This takes an average of 2 to 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

      As of January 21, 2016, 888 people infected with the outbreak strains of Salmonella Poona have been reported from 39 states. The number of ill people reported from each state is as follows: Alabama (1), Alaska (19), Arizona (134), Arkansas (13), California (241), Colorado (21), Connecticut (1), Florida (1), Hawaii (1), Idaho (26), Illinois (11), Indiana (5), Iowa (7), Kansas (2), Kentucky (1), Louisiana (5), Maryland (1), Minnesota (43), Missouri (15), Montana (16), Nebraska (8), Nevada (17), New Hampshire (1), New Mexico (35), New York (6), North Dakota (8), Ohio (3), Oklahoma (13), Oregon (23), Pennsylvania (2), South Carolina (10), South Dakota (3), Tennessee (1), Texas (52), Utah (62), Virginia (1), Washington (26), Wisconsin (46), and Wyoming (7).

      Among people for whom information is available, illnesses started on dates ranging from July 3, 2015 to January 6, 2016. Ill people range in age from less than 1 year to 99, with a median age of 18. Forty-nine percent of ill people are children younger than 18 years. Fifty-six percent of ill people are female. Among 686 people with available information, 191 (28%) report being hospitalized. Six deaths have been reported from Arizona (1), California (3), Oklahoma (1), and Texas (1). According to the California Department of Public Health, Salmonella infection was not considered to be a contributing factor in two of the three deaths in California.

      Investigation Update

      Whole genome sequencing (WGS) of Salmonella Poona isolates from ill people and from contaminated cucumbers distributed by Andrew & Williamson Fresh Produce showed that the strains are closely related genetically. These results also included isolates from people who became ill in October and November.

      The number of reported illnesses has declined substantially since the peak of illnesses in August and September however, it has not returned to the number of reported illnesses that we would expect to see (about 1 every month during this time of year).

      One hundred and six illnesses started after September 24, 2015, when recalled cucumbers should have no longer been available in stores or restaurants. If any of the recalled cucumbers were still available, they would have spoiled by that time. State and local public health officials have interviewed 38 of these ill people. Twenty-four (63%) of them reported eating cucumbers in the week before their illness started. Interviews have not identified any additional food items potentially linked with illness. The investigation into the source of these recent illnesses is ongoing.

      The source of contamination for cucumbers distributed by Andrew & Williamson Fresh Produce has not been identified. WGS results from recent illnesses suggest they share a common source with the illnesses during the peak of the outbreak in August and September. Investigations are under way to determine if cross-contamination within the distribution chain for the recalled cucumbers could explain recent illnesses.

      This investigation is ongoing. CDC will provide updates when more information is available.

      Case Count Update

      Since the last update on October 14, 2015, 71 more ill people have been reported from 23 states. Illnesses that occurred after October 21, 2015 might not be reported yet. A series of events occurs between the time a person is infected and the time public health officials can determine that the person is part of an outbreak. This means that there will be a delay between when a person gets sick and confirmation that he or she is part of an outbreak. This takes an average of 2 to 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

      As of November 18, 2015, 838 people infected with the outbreak strains of Salmonella Poona have been reported from 38 states. The number of ill people reported from each state is as follows: Alabama (1), Alaska (17), Arizona (129), Arkansas (13), California (232), Colorado (19), Connecticut (1), Florida (1), Hawaii (1), Idaho (24), Illinois (9), Indiana (5), Iowa (7), Kansas (2), Kentucky (1), Louisiana (5), Maryland (1), Minnesota (40), Missouri (14), Montana (16), Nebraska (8), Nevada (16), New Hampshire (1), New Mexico (32), New York (6), North Dakota (8), Ohio (3), Oklahoma (13), Oregon (22), Pennsylvania (2), South Carolina (10), South Dakota (3), Texas (42), Utah (58), Virginia (1), Washington (25), Wisconsin (43), and Wyoming (7).

      Among people for whom information is available, illnesses started on dates ranging from July 3, 2015 to November 1, 2015. Ill people range in age from less than 1 year to 99, with a median age of 18. Fifty percent of ill people are children younger than 18 years. Fifty-seven percent of ill people are female. Among 601 people with available information, 165 (27%) report being hospitalized. Four deaths have been reported from Arizona (1), California (1), Oklahoma (1), and Texas (1).

      The number of reported illnesses has declined substantially since the peak of illnesses in August and September however, it has not returned to the number of reported illnesses that we would expect to see (about 5 every month). The investigation into the source of these recent illnesses is ongoing.

      Case Count Update

      Since the last update on October 6, 2015, 35 more ill people have been reported from 14 states. Illnesses that occurred after September 15, 2015 might not be reported yet. A series of events occurs between the time a person is infected and the time public health officials can determine that the person is part of an outbreak. This means that there will be a delay between when a person gets sick and confirmation that he or she is part of an outbreak. This takes an average of 2 to 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details. Also, cucumbers have a shelf life of up to 14 days. Some people may not have known about the recall and eaten the contaminated cucumbers after the recall.

      As of October 13, 2015, 767 people infected with the outbreak strains of Salmonella Poona have been reported from 36 states. The number of ill people reported from each state is as follows: Alabama (1), Alaska (16), Arizona (118), Arkansas (11), California (205), Colorado (18), Florida (1), Hawaii (1), Idaho (24), Illinois (9), Indiana (4), Iowa (6), Kansas (2), Kentucky (1), Louisiana (5), Maryland (1), Minnesota (38), Missouri (12), Montana (15), Nebraska (7), Nevada (14), New Mexico (31), New York (6), North Dakota (6), Ohio (3), Oklahoma (12), Oregon (21), Pennsylvania (2), South Carolina (9), South Dakota (3), Texas (38), Utah (53), Virginia (1), Washington (24), Wisconsin (42), and Wyoming (7).

      Among people for whom information is available, illnesses started on dates ranging from July 3, 2015 to September 29, 2015. Ill people range in age from less than 1 year to 99, with a median age of 17. Fifty percent of ill people are children younger than 18 years. Fifty-five percent of ill people are female. Among 561 people with available information, 157 (28%) report being hospitalized. Four deaths have been reported from Arizona (1), California (1), Oklahoma (1), and Texas (1).

      Case Count Update

      Since the last update on September 29, 2015, 61 new ill people have been reported from 24 states. It can take up to a week from the time people eat food contaminated with Salmonella before they get sick. Also, cucumbers have a shelf life of up to 14 days. It is not unexpected to continue to see illnesses reported after the recalls. Some people may not have known about the recall and eaten the contaminated cucumbers after the recall.

      As of October 5, 2015, 732 people infected with the outbreak strains of Salmonella Poona have been reported from 35 states. The number of ill people reported from each state is as follows: Alabama (1), Alaska (14), Arizona (114), Arkansas (11), California (192), Colorado (18), Hawaii (1), Idaho (24), Illinois (9), Indiana (3), Iowa (6), Kansas (2), Kentucky (1), Louisiana (5), Maryland (1), Minnesota (37), Missouri (11), Montana (14), Nebraska (6), Nevada (14), New Mexico (31), New York (6), North Dakota (6), Ohio (2), Oklahoma (12), Oregon (20), Pennsylvania (2), South Carolina (9), South Dakota (3), Texas (34), Utah (53), Virginia (1), Washington (22), Wisconsin (40), and Wyoming (7).

      Among people for whom information is available, illnesses started on dates ranging from July 3, 2015 to September 25, 2015. Ill people range in age from less than 1 year to 99, with a median age of 17. Fifty percent of ill people are children younger than 18 years. Fifty-five percent of ill people are female. Among 536 people with available information, 150 (28%) report being hospitalized. Four deaths have been reported from Arizona (1), California (1), Oklahoma (1), and Texas (1).
      Illnesses that occurred after September 8, 2015 might not be reported yet. A series of events occurs between the time a person is infected and the time public health officials can determine that the person is part of an outbreak. This means that there will be a delay between when a person gets sick and confirmation that he or she is part of an outbreak. This takes an average of 2 to 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

      Case Count Update

      Since the last update on September 22, 2015, 113 new ill people have been reported from 19 states. It can take up to a week from the time people eat food contaminated with Salmonella before they get sick. Also, cucumbers have a shelf life of up to 14 days. It is not unexpected to continue to see illnesses reported after the recalls. Some people may not have known about the recall and eaten the contaminated cucumbers after the recall.

      As of September 28, 2015, 671 people infected with the outbreak strains of Salmonella Poona have been reported from 34 states. The number of ill people reported from each state is as follows: Alabama (1), Alaska (13), Arizona (112), Arkansas (9), California (164), Colorado (17), Hawaii (1), Idaho (22), Illinois (8), Indiana (2), Iowa (5), Kansas (2), Kentucky (1), Louisiana (5), Minnesota (34), Missouri (10), Montana (14), Nebraska (5), Nevada (13), New Mexico (30), New York (5), North Dakota (3), Ohio (2), Oklahoma (12), Oregon (19), Pennsylvania (2), South Carolina (9), South Dakota (1), Texas (33), Utah (51), Virginia (1), Washington (21), Wisconsin (38), and Wyoming (6).

      Among people for whom information is available, illnesses started on dates ranging from July 3, 2015 to September 21, 2015. Ill people range in age from less than 1 year to 99, with a median age of 17. Fifty-one percent of ill people are children younger than 18 years. Fifty-four percent of ill people are female. Among 459 people with available information, 131 (29%) report being hospitalized. Three deaths have been reported from Arizona (1), California (1) and Texas (1).

      Illnesses that occurred after September 2, 2015 might not be reported yet. A series of events occurs between the time a person is infected and the time public health officials can determine that the person is part of an outbreak. This means that there will be a delay between when a person gets sick and confirmation that he or she is part of an outbreak. This takes an average of 2 to 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

      Case Count Update

      Since the last update on September 15, 2015, 140 new ill people have been reported from Alaska (2), Arizona (23), Arkansas (2), California (31), Colorado (1), Idaho (6), Illinois (2), Iowa (1), Kansas (1), Minnesota (9), Missouri (1), Montana (1), Nebraska (3), Nevada (2), New Mexico (5), New York (1), North Dakota (1), Oklahoma (2), Oregon (9), South Dakota (1), Texas (4), Utah (9), Washington (3), and Wisconsin (20).

      As of September 21, 2015, a total of 558 people infected with the outbreak strains of Salmonella Poona have been reported from 33 states. The number of ill people reported from each state is as follows: Alaska (12), Arizona (95), Arkansas (8), California (120), Colorado (17), Hawaii (1), Idaho (20), Illinois (8), Indiana (2), Iowa (1), Kansas (2), Kentucky (1), Louisiana (4), Minnesota (29), Missouri (9), Montana (14), Nebraska (5), Nevada (11), New Mexico (27), New York (5), North Dakota (3), Ohio (2), Oklahoma (12), Oregon (17), Pennsylvania (2), South Carolina (8), South Dakota (1), Texas (24), Utah (46), Virginia (1), Washington (18), Wisconsin (29), and Wyoming (4).

      Among people for whom information is available, illnesses started on dates ranging from July 3, 2015 to September 11, 2015. Ill people range in age from less than 1 year to 99, with a median age of 16. Fifty-two percent of ill people are children younger than 18 years. Fifty-four percent of ill people are female. Among 387 people with available information, 112 (29%) report being hospitalized. Three deaths have been reported from Arizona (1), California (1) and Texas (1).

      Illnesses that occurred after August 28, 2015 might not be reported yet. A series of events occurs between the time a person is infected and the time public health officials can determine that the person is part of an outbreak. This means that there will be a delay between when a person gets sick and confirmation that he or she is part of an outbreak. This takes an average of 2 to 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

      Investigation Update

      CDC&rsquos National Antimicrobial Resistance Monitoring System (NARMS) laboratory conducted antibiotic resistance testing on clinical isolates collected from 6 ill people infected with one of the outbreak strains. Of the 6 isolates tested, all (100%) were susceptible to all antibiotics tested on the NARMS panel. CDC&rsquos NARMS laboratory continues to conduct antibiotic resistance testing on additional clinical isolates collected from ill persons infected with the outbreak strains. Results will be reported when they become available.

      Case Count Update

      Since the last update on September 9, 2015, 77 new ill people have been reported from Alaska (1), Arizona (6), California (17), Colorado (2), Idaho (6), Indiana (2), Minnesota (8), Montana (3), Nevada (2), New Mexico (4), North Dakota (1), Oklahoma (2), South Carolina (1), Texas (2), Utah (7), Washington (5), Wisconsin (7), and Wyoming (1).

      As of September 15, 2015, a total of 418 people infected with the outbreak strains of Salmonella Poona have been reported from 31 states. The number of ill people reported from each state is as follows: Alaska (10), Arizona (72), Arkansas (6), California (89), Colorado (16), Hawaii (1), Idaho (14), Illinois (6), Indiana (2), Kansas (1), Kentucky (1), Louisiana (4), Minnesota (20), Missouri (8), Montana (13), Nebraska (2), Nevada (9), New Mexico (22), New York (4), North Dakota (2), Ohio (2), Oklahoma (10), Oregon (8), Pennsylvania (2), South Carolina (8), Texas (20), Utah (37), Virginia (1), Washington (15), Wisconsin (9), and Wyoming (4).

      Among people for whom information is available, illnesses started on dates ranging from July 3, 2015 to September 3, 2015. Ill people range in age from less than 1 year to 99, with a median age of 17. Fifty-two percent of ill people are children younger than 18 years. Fifty-three percent of ill people are female. Among 290 people with available information, 91 (31%) report being hospitalized. Two deaths have been reported from California (1) and Texas (1).

      Illnesses that occurred after August 22, 2015 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2 to 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

      Investigation Update

      On September 11, 2015, Custom Produce Sales voluntarily recalled External all cucumbers sold under the Fat Boy label starting August 1, 2015 because they may be contaminated with Salmonella. These cucumbers were sent to Custom Produce Sales from Andrew & Williamson Fresh Produce. Fat Boy label cucumbers were produced in Baja California, Mexico and distributed in the states of California, Colorado, Illinois, Iowa, Nevada, North Dakota, Oklahoma, and Texas. Unlabeled cucumbers packed into a black reusable plastic container, and sold in Nevada as of August 1, 2015, are also covered by this recall. The type of cucumber is often referred to as a &ldquoslicer&rdquo or &ldquoAmerican&rdquo cucumber. It is dark green in color and typical length is 7 to 10 inches. In retail locations it is typically sold in a bulk display without any individual packaging or plastic wrapping. These cucumbers are shipped in a black, green, and red cardboard box which reads &ldquoFat Boy Fresh Produce.&rdquo Photos of the packing cartons are available.

      Several state health and agriculture departments are collecting and testing cucumbers from retail locations for the presence of Salmonella. Since the last update on September 9, 2015, the Arizona Department of Health Services and the Montana Department of Public Health and Human Services isolated one of the outbreak strains of Salmonella Poona from cucumbers collected from retail locations. Preliminary information indicates that these cucumbers were distributed by Andrew & Williamson Fresh Produce. The San Diego County Health and Human Services Agency isolated one of the outbreak strains of Salmonella Poona from cucumbers collected from the Andrew & Williamson Fresh Produce facility.

      The National Antimicrobial Resistance Monitoring System External (NARMS) is a U.S. public health surveillance system that tracks antibiotic resistance in foodborne and other enteric bacteria found in people, raw meat and poultry, and food-producing animals. NARMS is a partnership among the CDC, the U.S. Food and Drug Administration (FDA), USDA, and state and local health departments.

      The NARMS human surveillance program at CDC monitors antibiotic resistance in Salmonella and other bacteria isolated from clinical specimens submitted to NARMS by public health laboratories. CDC&rsquos NARMS laboratory conducted antibiotic resistance testing on clinical isolates collected from 3 ill people infected with one of the outbreak strains. Of the 3 isolates tested, all (100%) were susceptible to all antibiotics tested on the NARMS panel. CDC&rsquos NARMS laboratory continues to conduct antibiotic resistance testing on additional clinical isolates collected from ill persons infected with the outbreak strains. Results will be reported when they become available.

      Case Count Update

      Since the last update on September 4, 2015, 56 new ill people have been reported from Alaska (1), Arizona (6), California (21), Hawaii (1), Illinois (1), Louisiana (1), Missouri (1), New Mexico (3), Oklahoma (3), Oregon (5), Pennsylvania (2), South Carolina (1), Texas (9), and Washington (1).

      As of September 8, 2015, a total of 341 people infected with the outbreak strains of Salmonella Poona have been reported from 30 states. The number of ill people reported from each state is as follows: Alaska (9), Arizona (66), Arkansas (6), California (72), Colorado (14), Hawaii (1), Idaho (8), Illinois (6), Kansas (1), Kentucky (1), Louisiana (4), Minnesota (12), Missouri (8), Montana (10), Nebraska (2), Nevada (7), New Mexico (18), New York (4), North Dakota (1), Ohio (2), Oklahoma (8), Oregon (8), Pennsylvania (2), South Carolina (7), Texas (18), Utah (30), Virginia (1), Washington (10), Wisconsin (2), and Wyoming (3).

      Among people for whom information is available, illnesses started on dates ranging from July 3, 2015 to August 30, 2015. Ill people range in age from less than 1 year to 99, with a median age of 15. Fifty-three percent of ill people are children younger than 18 years. Fifty-eight percent of ill people are female. Among 214 people with available information, 70 (33%) report being hospitalized. Two deaths have been reported from California (1) and Texas (1).

      Illnesses that occurred after August 16, 2015 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2 to 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

      Investigation Update

      Several state health and agriculture departments are collecting and testing leftover cucumbers from retail locations for the presence of Salmonella. Since the last update on September 4, 2015, the Nevada Department of Health and Human Services isolated one of the outbreak strains of Salmonella Poona from a cucumber collected from a retail location. Additionally, the Arizona Department of Health Services and the Montana Department of Public Health and Human Services isolated Salmonella from cucumbers collected from retail locations. Preliminary information indicates that these cucumbers were distributed by Andrew & Williamson Fresh Produce. DNA &ldquofingerprinting&rdquo is being conducted to determine the pulsed-field gel electrophoresis (PFGE) pattern of the Salmonella isolated from the cucumbers in Arizona and Montana. DNA &ldquofingerprinting&rdquo is still ongoing for the Salmonella isolated from cucumbers collected from the Andrew & Williamson Fresh Produce facility by the San Diego County Health and Human Services Agency. Results of additional product testing will be reported when available.

      September 4, 2015

      CDC, multiple states, and the U.S. Food and Drug Administration (FDA) are investigating a multistate outbreak of Salmonella Poona infections linked to imported cucumbers from Mexico and distributed by Andrew & Williamson Fresh Produce.

      Public health investigators are using the PulseNet system to identify illnesses that may be part of this outbreak. PulseNet, the national subtyping network of public health and food regulatory agency laboratories, is coordinated by CDC. DNA &ldquofingerprinting&rdquo is performed on Salmonella bacteria isolated from ill people by using a technique called pulsed-field gel electrophoresis, or PFGE. PulseNet manages a national database of these DNA &ldquofingerprints&rdquo to identify possible outbreaks. Three DNA &ldquofingerprints&rdquo (outbreak strains) are included in this investigation.

      As of September 3, 2015, 285 people infected with the outbreak strains of Salmonella Poona have been reported from 27 states. The number of ill people reported from each state is as follows: Alaska (8), Arizona (60), Arkansas (6), California (51), Colorado (14), Idaho (8), Illinois (5), Kansas (1), Louisiana (3), Minnesota (12), Missouri (7), Montana (11), Nebraska (2), Nevada (7), New Mexico (15), New York (4), North Dakota (1), Ohio (2), Oklahoma (5), Oregon (3), South Carolina (6), Texas (9), Utah (30), Virginia (1), Washington (9), Wisconsin (2), and Wyoming (3).

      Among people for whom information is available, illnesses started on dates ranging from July 3, 2015 to August 26, 2015. Ill people range in age from less than 1 year to 99, with a median age of 13. Fifty-four percent of ill people are children younger than 18 years. Fifty-seven percent of ill people are female. Among 160 people with available information, 53 (33%) report being hospitalized. One death has been reported from California.

      This outbreak can be illustrated with a chart showing the number of people who became ill each day. This chart is called an epidemic curve or epi curve. Illnesses that occurred after August 14, 2015 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2 to 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

      Investigation of the Outbreak

      Epidemiologic, laboratory, and traceback investigations have identified imported cucumbers from Mexico and distributed by Andrew & Williamson Fresh Produce as a likely source of the infections in this outbreak. The investigation is ongoing.

      State and local public health officials are interviewing ill people to obtain information about foods they might have eaten and other exposures in the week before their illness began. In interviews, ill people answered questions about foods eaten and other exposures in the week before their illness began. Fifty-eight (73%) of 80 people interviewed reported eating cucumbers. This proportion was significantly higher than results from a survey Cdc-pdf [PDF &ndash 29 pages] of healthy people in which 55% reported eating cucumbers in the month of July in the week before they were interviewed.

      In addition, numerous ill people were identified as part of illness clusters. An illness cluster is defined as two or more people who do not live in the same household who report eating at the same restaurant location, attending a common event, or shopping at the same location of a grocery store in the week before becoming ill. Investigating illness clusters can provide critical clues about the source of an outbreak. If several unrelated ill persons ate or shopped at the same location of a restaurant or store within several days of each other, it suggests that the contaminated food item was served or sold there. Eleven illness clusters have been identified in seven states. In all of these clusters, interviews found that cucumbers were a food item eaten in common by ill people. Epidemiologic studies that compare foods eaten by both ill and well people are being conducted in two of these clusters. Preliminary results of these studies indicate that a food item containing cucumbers was associated with illness. Preliminary traceback information indicates that cucumbers eaten by ill people in these clusters were imported from Mexico and distributed by Andrew & Williamson Fresh Produce.

      Several state health and agriculture departments are collecting leftover cucumbers from restaurants and grocery stores where ill people reported eating or shopping to test for the presence of Salmonella. The San Diego County Health and Human Services Agency isolated Salmonella from cucumbers collected during a visit to the Andrew & Williamson Fresh Produce facility. DNA &ldquofingerprinting&rdquo is being conducted to determine the PFGE pattern of the Salmonella isolated from these cucumbers. Results of additional product testing will be reported when available.

      Consultation with independent industry experts early in an outbreak investigation also can provide important clues to help focus the investigation on certain suspected foods. An industry consultation was held on August 26, 2015, with four independent experts from the produce industry to obtain information regarding fresh produce harvesting and distribution in the affected region. The consultants provided information regarding crop production and distribution practices that helped assess the plausibility of cucumbers and other produce items as possible outbreak sources.

      On September 4, 2015, Andrew & Williamson Fresh Produce voluntarily recalled External all cucumbers sold under the &ldquoLimited Edition&rdquo brand label during the period from August 1, 2015 through September 3, 2015 because they may be contaminated with Salmonella. The type of cucumber is often referred to as a &ldquoslicer&rdquo or &ldquoAmerican&rdquo cucumber. It is dark green in color and typical length is 7 to 10 inches. In retail locations it is typically sold in a bulk display without any individual packaging or plastic wrapping. Limited Edition cucumbers were distributed in the states of Alaska, Arizona, Arkansas, California, Colorado, Florida, Idaho, Illinois, Kansas, Kentucky, Louisiana, Minnesota, Mississippi, Montana, Nevada, New Jersey, New Mexico, Oklahoma, Oregon, South Carolina, Texas, and Utah and reached customers through retail, food service companies, wholesalers, and brokers. Further distribution to other states may have occurred.

      These cucumbers are shipped in a black, green, yellow, and craft colored carton which reads &ldquoLimited Edition Pole Grown Cucumbers.&rdquo Labeling on the cases of recalled cucumbers indicates the product was grown and packed by Rancho Don Juanito in Mexico. Domestically produced cucumbers are not believed to be involved in this outbreak.

      CDC&rsquos National Antimicrobial Resistance Monitoring System (NARMS) laboratory is conducting antibiotic resistance testing on clinical isolates collected from ill people infected with the outbreak strains results will be reported when they become available.

      This investigation is rapidly evolving. CDC and state and local public health partners are continuing laboratory surveillance through PulseNet to identify additional ill people and to interview them. Updates will be provided when more information is available.


      An Arizona connection

      Federal health officials named Harrison Farms in Yuma last month as the source of whole heads of tainted romaine lettuce sold to a prison in Nome, Alaska, where eight inmates became ill.

      They confirmed the lettuce matched the other E. coli cases, but said Harrison Farms could not be tied to those through their trace-back efforts.

      The CDC said in its update that 64 people have been hospitalized and 17 people have developed kidney failure.

      The CDC continues to warn consumers against eating or buying romaine lettuce from the Yuma growing region.

      Farms in the Yuma region supply North America with the vast majority of its leafy greens from January through March every year.

      "Romaine lettuce has a shelf life of several weeks, and contaminated lettuce could still be in homes, stores, and restaurants," according to the CDC.

      Farm industry representatives and the Arizona Department of Agriculture say the romaine lettuce growing season ended weeks ago and is no longer being harvested. But health officials say they "cannot be certain that romaine lettuce from this region is no longer in the supply chain."


      Death Toll Rises to 13 in E.coli Outbreak

      BRUSSELS — The health authorities in Europe stepped up efforts on Monday to halt a deadly outbreak of a virulent form of E. coli bacteria in cucumbers as a dispute broke out between Spain and Germany over the source of the illness.

      The federal and state authorities in Germany — where effects are by far most severe — said the death toll climbed to 13 by Monday, from 10 on Sunday, in one of the largest outbreaks its kind reported worldwide.

      Hundreds of people have been struck down across the European Union with symptoms like bloody diarrhea and stomach cramps. Vegetables were pulled from shelves in a number of countries, though no official Continent-wide bans were announced. The effects of the outbreak were being felt as far away as the United States, where two people who had recently been traveling in Germany, and a third person, had fallen sick with the illness, the European Commission said.

      The German-Spanish dispute highlighted tensions that the outbreak has created between nations in the bloc, where there is a single market in goods and most citizens move freely across borders, but where health policy and disease control mainly remain in the hands of national governments. In fact, the commission, the European Union’s executive arm, could confirm only three deaths from the bacteria on Monday, saying it was awaiting formal notification from Germany.

      Last week, the German authorities had identified fresh Spanish cucumbers from Málaga and Almería as one of the possible sources for the outbreak. That prompted a furious reaction in Spain.

      It was “an irresponsibility and an atrocity” to put in question the whole of Spanish agricultural exports, Josep Puxeu, secretary of state for rural affairs, said Sunday. “You cannot use speculation to demonize a production system that is absolutely serious, reliable and controlled.”

      A key question was whether the disease could have developed on delivery routes between Spain and Germany, or in storage areas, after the cucumbers left the Spanish farms.

      Farming is one of Spain’s biggest export sectors, with about 20,000 tons of fruit and vegetables leaving the country daily. Asaja, a Spanish agricultural cooperative, estimated over the weekend that the damaged reputation from the E. coli outbreak would cost Spanish farmers €6 million, or about $8.5 million, a day in lost revenue.

      In Germany, 329 people had severe forms of the infection by Monday afternoon, the European Commission said.

      “We hope that the number of cases will go down, but we fear that it will worsen,” said Oliver Grieve, a spokesman for the University Medical Center Schleswig-Holstein, in northern Germany, where many of those afflicted are being treated.

      Sweden had reported 30 cases, with 13 of those with the more severe form of the illness, the commission said. Denmark had reported 11 cases, 5 of them with the more severe form, and Britain had reported 3 cases, with 2 of those the most severe form, it said. There was one Dutch case of the most severe form of the disease while Austria had reported 2 cases, but none were the severe variety, it said.

      The Spanish authorities on Monday were examining soil and water and other relevant materials from two cucumber farms in Málaga and Almería. Those results are expected this week, possibly as soon as Wednesday, Pia Ahrenkilde Hansen, a spokeswoman for the European Commission, told a news conference Monday.

      “We are very much trying to keep everything under control by exactly pinning down where there is an outbreak of this bacteria,” Ms. Ahrenkilde Hansen said.

      The “situation remains very different across the European Union on the ground,” she said.

      Health experts at an E.U.-financed laboratory in Rome were developing a faster method of detecting bacteria in food to help stop its spread. Any diagnosis would be carried out in national laboratories, said commission officials who spoke on the condition of anonymity because talks were continuing between governments. Those tests would take 48 hours for a result rather than five to seven days, which is now the case.

      Ms. Ahrenkilde Hansen said the outbreak was mainly affecting northern Germany and an area around Hamburg, and that most of the cases outside Germany concerned German nationals visiting abroad or other people visiting Germany.

      As nervousness spread, the Austrian authorities sent inspectors to 33 organic supermarkets on Monday to ensure that Spanish vegetables suspected of contamination with the potentially fatal bacteria had been taken off shelves, The Associated Press reported from Vienna. “If anything is found to be left over, it will be tested and taken off the market,” said Fabian Fusseis, a spokesman for the Health Ministry.

      The Danish authorities had pulled a “suspect consignment” of cucumbers from the market there, Ms. Ahrenkilde Hansen said. But the E.U. and national authorities were still trying to trace other suspect batches in Hungary, Austria, France, Luxembourg and the Czech Republic, she said.

      Another batch of cucumbers shipped from either the Netherlands and Denmark, and sold in Germany, was also being investigated, she said.

      Judy Dempsey contributed reporting from Berlin and Raphael Minder from Madrid.


      First death reported from E. coli-contaminated romaine lettuce as outbreak spreads

      The nationwide food poisoning outbreak from E. coli-contaminated romaine lettuce has claimed its first fatality, an unidentified person in California, and the contagion has sickened a total of 121 people in 25 states, the U.S. Centers for Disease Control and Prevention announced Wednesday.

      That's an increase of 23 people and three states - Kentucky, Massachusetts and Utah - since the most recent CDC update on Friday. With the numbers ratcheting up every week, this outbreak is approaching the scale of the 2006 baby spinach E. coli outbreak, in which 205 people became sick and five of them died.

      This strain of E. coli produces a toxin that causes vomiting and diarrhea and potentially other severe symptoms, including in some cases kidney failure. Of the people sickened, 52 have been hospitalized, 14 of them with kidney failure.

      The bacteria normally live in the intestines of animals, including cows and pigs, and in the 1990s, most E. coli cases were associated with contaminated hamburger. Reforms in the livestock industry have sharply reduced the number of outbreaks involving meat, but that has been offset by a surge in E. coli contamination of leafy greens.

      Bill Marler, a Seattle-based food safety lawyer who has been involved in food-borne illness lawsuits for decades, said it's striking that federal investigators still have not explained how, when and where the bacteria contaminated the romaine and spread to so many people and places. He said an outbreak of this size typically is easier to trace because there are more people providing clues to the origin of the pathogen.

      "It's 2018, and we're basically a month into this outbreak, and they can't link it to a farmer or a farm or a processor? I mean, candidly, that's ridiculous," Marler said. He said the leafy greens industry and government regulators made traceability a high priority after the 2006 baby spinach cases.

      "They're now 12 years post-spinach, and traceability was supposed to be one of the big things that came out of that disaster. And it just doesn't seem to be getting there," he said.

      One farm in Yuma, Arizona has been identified so far as supplying the whole-head lettuce linked to a cluster of E. coli cases among prisoners in Nome, Alaska. But investigators have not specified when and where that lettuce became contaminated with the dangerous bacteria, and the farm has not been linked to other cases. Many of the people sickened across the country consumed chopped lettuce that had been sold in bagged form to restaurants. The bacteria could have contaminated the lettuce somewhere in the production stream beyond the original farm.

      The Yuma region - which includes farms across the Colorado River in southeastern California - grows the overwhelming majority of the lettuce and other leafy greens consumed in the United States in the winter months, but the industry begins shifting to California's Central Valley and Salinas Valley in the second half of March and early April. Lettuce has a shelf life of only a couple of weeks at most, and any romaine lettuce on sale in stores today is likely not from Yuma and is not implicated in this outbreak.

      But the CDC continues to emphasize that consumers should confirm that any lettuce they buy or eat did not originate in the Yuma region. This includes romaine in any form, including in a salad mix.

      California now leads the nation with 24 cases, followed by Pennsylvania with 20 and Idaho with 11. The first two cases in this outbreak involved people who reported becoming sick on March 13, according to the CDC. The most recent case was April 21. There are delays in reporting and confirming cases linked to this specific strain of E. coli, and the CDC noted that cases involving people who became sick on or after April 11 may not be reported.


      Deadly E. coli outbreak tied to romaine spreads

      An outbreak of E. coli linked to romaine lettuce from the Yuma, Arizona, growing region has spread to four additional.

      An outbreak of E. coli linked to romaine lettuce from the Yuma, Arizona, growing region has spread to four additional states, the US Centers for Disease Control and Prevention announced Wednesday. Florida, Minnesota, North Dakota and Texas are the latest states to report illnesses, bringing the total to 29.

      The CDC also reported 28 additional cases of illness, bringing the total to 149 since the outbreak began in March. Symptoms of the most recent illnesses reported began April 25. However, the CDC warned that due to a lag in reporting, any illness that occurred in the past two to three weeks may not have been counted in this update.

      An additional four states have reported E. coli illness connected to romaine lettuce

      Over a third of all people affected have been hospitalized one person has died

      Last week, the CDC announced that one person had died the death, in California, was the first known fatality. Previously, the CDC warned that the strain of E. coli identified, O157:H7, is particularly virulent and known to be associated with higher hospitalization and complication rates.

      Sixty-four people have been hospitalized, the CDC said, and 17 of those have developed hemolytic uremic syndrome, a form of kidney failure that can be life-threatening, although most people recover in a few weeks.

      Symptoms of E. coli begin on average three to four days after the bacteria are consumed. They include severe stomach cramps, diarrhea and vomiting. Most people recover in five to seven days with supportive treatment.

      The CDC cautions against the use of antibiotics when dealing with this strain of E. coli because studies have connected antibiotic use with an increased risk for hemolytic uremic syndrome in both children and adults.

      "Antibiotics are not recommended for patients with suspected E. coli O157 infections until diagnostic testing can be performed and E. coli O157 infection is ruled out," the CDC said.

      The US Food and Drug Administration said it received confirmation from the Arizona Department of Agriculture that romaine lettuce is no longer being grown or shipped from the Yuma area. But there is a 21-day shelf life for romaine, the agency says, so there might still be lettuce in the supply chain.

      However, the agency confirmed that no other types of lettuce or any other growing region for romaine are involved in the outbreak.

      To explain the diverse geographical spread of this outbreak, the FDA said it is still investigating multiple points of origin and distribution. Last week, it identified Harrison Farms as the source of a single outbreak at a correctional facility in Nome, Alaska, that sickened eight inmates.

      The growing season at that farm has ended, and the shelf life of the lettuce from there has passed. Therefore, it is not being sold or served anymore.

      Because labels on romaine lettuce do not often list growing regions, it can be difficult for a consumer to tell whether the lettuce they are purchasing is part of the outbreak. The CDC warns consumers not to buy romaine unless they can verify the region of production.

      "This advice includes whole heads and hearts of romaine, chopped romaine, baby romaine, organic romaine, and salads and salad mixes containing romaine lettuce," the CDC said. "If you do not know if the lettuce in a salad mix is romaine, do not eat it."



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