Eight people locked up together eating the same romaine lettuce at the same time is an epidemiologist’s dream – especially when those eight people are linked to some 50 illnesses linked to romaine lettuce in the “lower 48.”  You can be assured that the purchasing office will know who supplied the romaine and that supplier will most assuredly know who processed the romaine and that processor likely knows who grew it in Yuma, Arizona – case closed.

According to a press release, Alaska state officials are responding to an outbreak of acute gastroenteritis caused by Escherichia coli (E.coli) O157:H7 bacteria in the Anvil Mountain Correctional Center in Nome. Eight confirmed cases have been identified to date. The recently discovered cases appear to be connected to a nationwide E. coli outbreak affecting at least 53 persons in 16 states and linked to romaine lettuce grown in Yuma, Arizona.

The state departments of Health and Social Services, Environmental Conservation, and Corrections are working together to investigate and control the outbreak.

Symptoms of E. coli O157:H7 infection include bad stomach cramps, diarrhea (often bloody) and vomiting. Occasionally, more serious complications can occur, including kidney failure and death. Alaskans should talk to a health care provider if they have symptoms of E.coli infection. Cases should be reported to the Department of Health and Social Services by calling (907) 269- 8000.

The investigation has confirmed that the romaine lettuce consumed by the Nome patients was grown in Yuma, Arizona. Because this outbreak involves a strain of E. coli bacteria (O157:H7) that can lead to serious illness including kidney failure, state officials are asking Alaskans to follow CDC recommendations and avoid any romaine lettuce products that could be contaminated.

Restaurants, retailers and consumers should ask suppliers about the source of their lettuce, and if it is from Yuma, Arizona, it should be thrown away and not eaten. This includes both whole head and chopped romaine lettuce.

No additional cases have been identified in Alaska outside of the Anvil Mountain Correctional Center. None of the eight patients identified in the Alaska outbreak have been hospitalized and none have died. Investigations are ongoing, and DHSS will provide updates when more information is available.

As of April 18, 2018, 53 people infected with the outbreak strain of E. coli O157:H7 have been reported from 16 states. Alaska 1, Arizona 3, California 1, Connecticut 2, Idaho, 10, Illinois 1, Louisiana 1, Michigan 2, Missouri 1, Montana 6, New Jersey 7, New York 2, Ohio 2, Pennsylvania, 12, Virginia 1 and Washington 1.

Illnesses started on dates ranging from March 13, 2018 to April 6, 2018. Ill people range in age from 10 to 85 years, with a median age of 34. Seventy percent of ill people are female. Thirty-one ill people have been hospitalized, including five people who developed hemolytic uremic syndrome.

Illnesses that occurred after March 29, 2018, might not yet be reported due to the time it takes between when a person becomes ill with E. coli and when the illness is reported. This takes an average of two to three weeks.

State and local health officials continue to interview ill people to ask about the foods they ate and other exposures before they became ill. Forty-one (95%) of 43 people interviewed reported eating romaine lettuce in the week before their illness started. Most people reported eating a salad at a restaurant, and romaine lettuce was the only common ingredient identified among the salads eaten. The restaurants reported using bagged, chopped romaine lettuce to make salads. At this time, ill people are not reporting whole heads or hearts of romaine. Information collected to date indicates that chopped romaine lettuce from the Yuma, Arizona growing region could be contaminated with E. coli O157:H7 and could make people sick.

I have spoken to and been retained by, people in Idaho, Missouri, Montana, New Jersey, New York and Pennsylvania. Also, I have spoken to people in California and Utah that also may be linked to the outbreak.

On Friday, according to the CDC, as of April 12, 2018, 35 people infected with the outbreak strain of E. coli O157:H7 have been reported from 11 states. Connecticut 2, Idaho 8, Illinois 1, Michigan 1, Missouri 1, New Jersey 7, New York 2, Ohio 2, Pennsylvania 9, Virginia 1 and Washington 1. Illnesses started on dates ranging from March 22, 2018 to March 31, 2018. Ill people range in age from 12 to 84 years, with a median age of 29. Sixty-nine percent of ill people are female. Twenty-two ill people have been hospitalized, including three people who developed hemolytic uremic syndrome, a type of kidney failure.

Today the Arizona Department of Health Services (ADHS) is advising residents to not eat and dispose of store-bought chopped romaine lettuce, including salads and salad mixes containing chopped romaine lettuce. The Centers for Disease Control and Prevention and the Food and Drug Administration indicated a multi-state outbreak of E. coli O157 is likely associated with chopped romaine lettuce from the Yuma, Arizona growing region. Three cases of E. coli in Arizona have been linked to this multistate outbreak.

Also, today the Montana Department of Health announced that there has been an increase in reports of STEC O157 cases in Montana, with onset dates between 3/28 and 4/7. These cases are linked to a multi-state outbreak of STEC O157 sickening at least 29 individuals in 11 states. This total includes three confirmed STEC O157 cases (2 in Missoula, 1 in Ravalli) with patterns matching the national outbreak strain. An additional five PCR positive cases are pending culture confirmation with the state laboratory (3 in Flathead, 1 in Lincoln, and 1 in Gallatin). Further analysis will be needed to determine if they part of the outbreak. Please see the information below for recommendations.

According to the CDC, epidemiologic evidence collected to date indicates that chopped romaine lettuce is the likely source of this outbreak. Most people reported eating a salad at a restaurant, and romaine lettuce was the only common ingredient identified among the salads eaten. The restaurants reported using bagged, chopped romaine lettuce to make salads.

Traceback investigations are ongoing to determine the source of chopped romaine lettuce supplied to restaurant locations where ill people ate. At this time, no common grower, supplier, distributor, or brand has been identified. However, preliminary information indicates that the chopped romaine lettuce was from the Yuma, Arizona growing region. Information collected to date indicates that chopped romaine lettuce from the Yuma, Arizona growing region could be contaminated with E. coli O157:H7 and could make people sick.

ADHS Advises Residents to Not Eat and Throw Away Chopped Romaine Lettuce
Three Arizona Residents Are Confirmed with E. coli Related to a Multi-State Outbreak

The Arizona Department of Health Services (ADHS) is advising residents to not eat and dispose of store-bought chopped romaine lettuce, including salads and salad mixes containing chopped romaine lettuce. The Centers for Disease Control and Prevention and the Food and Drug Administration indicated a multi-state outbreak of E. coli O157 is likely associated with chopped romaine lettuce from the Yuma, Arizona growing region. Three cases of E. coli in Arizona have been linked to this multistate outbreak.

E. coli can cause serious illness, so it is critical that everyone take precautions by not eating store-bought chopped romaine lettuce, even if you or someone from you family has consumed the product and did not get sick,” said Dr. Cara Christ, director of the Arizona Department of Health Services. “If you or someone from your family recently ate store-bought chopped romaine lettuce and are experiencing symptoms, please seek medical treatment immediately.”

Symptoms of E. coli O157 include diarrhea (sometimes bloody), and abdominal pain. E. coli O157 infection ranges from mild to severe, with symptoms lasting about five to seven days in most people. Young children, the elderly, and the immune-compromised are at risk of developing Hemolytic Uremic Syndrome (HUS), a potentially life-threatening illness that can cause kidney failure.

The CDC and the FDA are also advising people that before they eat lettuce from a restaurant to confirm that the product used to prepare the meal is not chopped romaine lettuce from the Yuma, Arizona growing region. ADHS is working with local health departments, the CDC, and the FDA to confirm the source of the E. coli O157 infections, to identify additional cases, and to prevent the spread of the disease.

To prevent foodborne illness, ADHS advises everyone to thoroughly wash hands with soap and water prior to food preparation or consumption, and after using the toilet. Wash fruits and vegetables before eating or handling. Avoid cross-contamination of food during preparation by washing hands, cutting boards, utensils, and any food preparation surfaces.

Advisory from the Montana Health Alert Network

Subject: Multi-state outbreak of E. coli O157:H7 (STEC O157), including Montana.

Background: There has been an increase in reports of STEC O157 cases in Montana, with onset dates between 3/28 and 4/7. These cases are linked to a multi-state outbreak of STEC O157 sickening at least 29 individuals in 11 states.

This total includes three confirmed STEC O157 cases (2 in Missoula, 1 in Ravalli) with patterns matching the national outbreak strain. An additional five PCR positive cases are pending culture confirmation with the state laboratory (3 in Flathead, 1 in Lincoln, and 1 in Gallatin). Further analysis will be needed to determine if they part of the outbreak. Please see the information below for recommendations.

Information for Clinicians

Clinicians are encouraged to consider E. coli infection in clinically compatible patients and order appropriate laboratory testing. Laboratories are reminded to submit specimens, as required by state rules, for surveillance purposes to the Montana Public Health Laboratory. Advanced testing will be conducted at no expense to the provider/patient that will enable us to compare the isolate to others at the state and national level.

Local public health officials will interview cases or proxies to assess exposures and the potential for additional transmission using a standardized data collection tool. Prompt reporting to local public health officials is essential.

Reporting: Reporting of suspected and confirmed cases of STEC (O157 and others) is required by state reporting rules. Prompt reporting by clinicians is essential to break the disease transmission cycle and identify potential sources.

Local Health Authorities

  • Please interview the patient using the general STEC investigation tool and outbreak specific tools distributed through a separate email. We request that the tools be used on any locally confirmed cases and returned via confidential fax to the CD/Epi program for analysis.
  • Review the information in this HAN with key surveillance partners, particularly laboratories, who may be processing enteric samples.

Resources

As of  April 13, 2018, Marler Clark represents E. coli victims in Idaho, Missouri, New Jersey and Pennsylvania.

As of April 12, 2018, 35 people infected with the outbreak strain of E. coli O157:H7 have been reported from 11 states. Connecticut 2, Idaho 8, Illinois 1, Michigan 1, Missouri 1, New Jersey 7, New York 2, Ohio 2, Pennsylvania 9, Virginia 1 and Washington 1.  (CDC Report)

Illnesses started on dates ranging from March 22, 2018 to March 31, 2018. Ill people range in age from 12 to 84 years, with a median age of 29. Sixty-nine percent of ill people are female. Twenty-two ill people have been hospitalized, including three people who developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported.

The current outbreak is not related to a recent multistate outbreak of E. coli O157:H7 infections linked to leafy greens. People in the previous outbreak were infected with a different DNA fingerprint of E. coli O157:H7 bacteria.

Epidemiologic evidence collected to date indicates that chopped romaine lettuce is the likely source of this outbreak. Most people reported eating a salad at a restaurant, and romaine lettuce was the only common ingredient identified among the salads eaten. The restaurants reported using bagged, chopped romaine lettuce to make salads.

Traceback investigations are ongoing to determine the source of chopped romaine lettuce supplied to restaurant locations where ill people ate. At this time, no common grower, supplier, distributor, or brand has been identified. However, preliminary information indicates that the chopped romaine lettuce was from the Yuma, Arizona growing region. Information collected to date indicates that chopped romaine lettuce from the Yuma, Arizona growing region could be contaminated with E. coli O157:H7 and could make people sick.

The CDC, several states, the U.S. Food and Drug Administration, and the U.S. Department of Agriculture’s Food Safety and Inspection Service are investigating a multistate outbreak of Shiga toxin-producing E. coli O157:H7 infections. This investigation includes E. coli O157:H7 infections recently reported by the New Jersey Department of Health.  Illnesses reported by investigators in New Jersey also included ill people who had a diagnostic test showing they were infected with E. coli bacteria. Laboratory testing is ongoing to link their illnesses to the outbreak using DNA fingerprinting. Some people may not be included in CDC’s case count because no bacterial isolates are available for the DNA fingerprinting needed to link them to the outbreak.

As of April 9, 2018, 17 people infected with the outbreak strain of E. coli O157:H7 have been reported from 7 states. The 7 states are : Connecticut (2), Idaho (4), Missouri (1), New Jersey (6), Ohio (1), Pennsylvania (2), and Washington (1). Illnesses started on dates ranging from March 22, 2018 to March 31, 2018. Ill people range in age from 12 to 84 years, with a median age of 41. Among ill people, 65% are female. Six ill people have been hospitalized, including one person who developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported.

The investigation is still ongoing, and a specific food item, grocery store, or restaurant chain has not been identified as the source of infections.  State and local public health officials are interviewing ill people to determine what they ate and other exposures in the week before their illness started.

I have thought a lot over the last 25 years about what lessons can be drawn from the tragedy that was the 1993 Jack in the Box E. coli O157:H7 outbreak. Knowing the children—many who are now nearing 35—who still bear the scars of eating a hamburger, and knowing the parents of those who died, makes it difficult for me to see the benefit of those losses.

My first reaction is, “Why does it always seem to take a tragedy before we seem to be able to act?” Whether it was reinforcing the cockpit doors after the horror of 9/11, or now finally having a dialogue about automatic weapons post-Newtown, we have seemed nearly incapable of preventing a tragedy before it has happened multiple times, or with such force that ignoring it any longer is impossible. Frankly, not being able to look ahead to prevent disasters seems so ingrained in human DNA that I am not sure of a ready fix.

Human evolution aside, I think there are lessons that can be learned from Jack in the Box that have meaning in the food safety world both in the past and in the future. First, like all food safety failures, and the outbreaks that stem from them, the Jack in the Box outbreak was completely preventable—in other words, Jack in the Box had warnings enough to have prevented the outbreak. And second, after the outbreak there will always be facts—and documents—that prove it.

In March of 1992 the Washington State Board of Health mandated that the internal cook temperature for ground beef should be 155 degrees, not the 140 degrees that all other of the 49 states used based on the Federal Food Code. Washington was ahead of the curve because health officials had investigated an earlier outbreak linked to undercooked ground beef. Officials reached out to all restaurants in the State with the new standards. Although Jack in the Box leaders initially claimed that they knew nothing of the changes—and perhaps they did not directly—but the new standards were found in files in corporate headquarters in San Diego.

Finding the Washington State Food Code in the bottom drawer of a cabinet was certainly not the best “find” in the litigation. Far from it; a bit of context might be in order.

Although the outbreak was announced in mid-January 1993, aggressive litigation and discovery did not really commence until late 1993. It lasted through the end of 1994. During that time, I received nearly 50 boxes of paper from the lawyers representing Jack in the Box and its meat suppliers. From those documents and the dozens of depositions taken, it became clear that Jack in the Box had more than just the new cook temperatures in its desk drawer. Scattered (on purpose) within the boxes were documents that showed that Jack in the Box knew of the new cook-temperature guidelines and simply chose to ignore them.

On June 18, 1992—five months before the Jack in the Box E. coli outbreak struck its hometown of San Diego and seven months before it would hit the Pacific Northwest—Wendy Cochinella, the shift leader at the Arlington, Washington restaurant faxed the below “IN THE SUGGESTION BOX” to Jack in the Box corporate headquarters in San Diego:

She wrote:

“I think regular patties should cook longer. They don’t get done and we have customer complaints.”

“If we change this we will be making our burgers done and edible.”

After just over a month, Wendy (and most of the Jack in the Box food safety team) received the below response from corporate headquarters. Wendy also received a pen highlighter (I always thought they should have made her at least Vice-President):

It reads:

We have received your suggestion regarding increasing the cook time for our regular patties.

Your suggestion is currently being researched within the corporate offices. You will again be notified with more detail as soon as a decision has been made regarding this suggestion.

We would like to acknowledge the time and effort you have taken to contribute to the success of JACK IN THE BOX by enclosing this pen/highlighter. Each person submitting suggestions is eligible to receive one gift per quarter with their first suggestion.

But it did not end there. No, Jack in the Box wanted to see if they could make “[their] burgers done and edible.” What they found in their corporate kitchen was that sometimes they could reach internal temperatures of 155 degrees and above on new grills with the two-minute cook time, but often—too often—internal temperatures of 140 degrees or below were reached on older grills with the two-minute cook time. E. coli O157:H7 bacteria can survive at 140 degrees for two minutes, but not at 155.

So, what was the response?

Yes, you guessed it, the two-minute cook time was more important than having “burgers done and edible.” Wendy’s next communication from corporate headquarters indicated that a cook time longer than two minutes made burgers “tough.”

Wendy and the Jack in the Box food safety team received the following communication from superiors:

We have researched your suggestion and determined that with the variability of our grill temperatures (350° – 400°) the two-minute cook time is appropriate. If the patties are cooked longer than two minutes, they tend to become tough. To ensure that you are meeting quality expectations for regular patties, please ensure that the grill temperature is correct and grill personnel are using proper procedures.”

And, as they say, the rest is history—a tragic history.  Weeks after the outbreak was announced Jack in the Box changed the cook time from two minutes to two minutes and fifteen seconds – yes, fifteen seconds.

  • Multistate Salmonella Outbreak, Jimmy John’s Restaurants Sprouts 2018

As of January 18, 2018, eight people infected with the outbreak strain of Salmonella Montevideo have been reported from Illinois, Wisconsin and Minnesota. Illnesses started on dates ranging from December 20, 2017 to January 3, 2018. Ill people range in age from 26 to 50, with a median age of 34. All 8 (100%) are female. No hospitalizations and no deaths have been reported.  Evidence indicates that raw sprouts served at Jimmy John’s restaurants are a likely source of this multistate outbreak.

Federal, state, and local health and regulatory officials are conducting traceback investigations from the six Jimmy John’s locations where ill people ate raw sprouts. These investigations are ongoing to determine where the sprouts were distributed, and to learn more about the potential route of contamination. 

  • Multistate E. coli O121 Outbreak, Jimmy John’s Restaurants Alfalfa Sprouts 2014

19 Sickened – Public health officials in California, Idaho, Michigan, Montana, Utah and Washington collaborated with their federal partners at the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) to investigate an outbreak of E. coli O121 that occurred in May 2014.  A total of 19 persons with the outbreak strain, identified by PulseNet PFGE Pattern Identification Numbers EXKX01.0011/EXKA26.0001, were reported.  Among persons for whom information was available, dates of illness onset ranged from May 1, 2014 to May 20, 2014.  Ill persons ranged from 11 years to 52 years.  Seven of 16 persons for whom information was available were hospitalized.  No ill person developed hemolytic uremic syndrome and no deaths were reported.

Epidemiologic and traceback investigations conducted by public health officials implicated raw clover sprouts produced by Evergreen Fresh Sprouts, LLC of Hayden, Idaho as the likely source of this outbreak.  Thirteen (81%) of 16 ill persons reported eating raw clover sprouts in the week before becoming ill.  Ill persons in Washington and Idaho reported eating sprouts in sandwiches at several local food establishments including several Jimmy John’s Gourmet Sandwiches locations, the Pita Pit, and Daanen’s Deli.

As part of the investigation the FDA performed a traceback analysis and determined that Evergreen Fresh Sprouts supplied sprouts to seven restaurants with outbreak associated cases.  This analysis used documents collected directly from the distributors and the grower, Evergreen Fresh Sprouts, as well as documents collected by the states from the points of service.

The FDA conducted several inspections at the Evergreen Fresh Sprouts facility in May and June.  During the inspections FDA investigators observed a number of unsanitary conditions, including condensate and irrigation water dripping from rusty valves, a rusty and corroded watering system in the mung bean room, tennis rackets (used to scoop mung bean sprouts) that had scratches, chips and frayed plastic; a pitchfork (used to transfer mung bean sprouts) that had corroded metal, and a squeegee (used to agitate mung bean sprouts inside a soak vat) that had visible corroded metal and non-treated wood.

On June 26, 2014 the FDA and CDC held a meeting with the owner of Evergreen Fresh Sprouts to advise the firm of FDA’s concerns that the seed lot used to row clover sprouts linked to this outbreak might be contaminated and to encourage Evergreen Fresh Sprouts to discontinue using that seed lot.  The owner of Evergreen Fresh Sprouts agreed to stop using the suspected lot of seeds.

  • Multistate E. coli O26 Outbreak, Jimmy John’s Restaurants Alfalfa Sprouts 2012

29 Sickened – A total of 29 individuals infected with the outbreak strain of E. coli O26 were reported from 11 states, including:  Alabama (1), Arkansas (1), Iowa (5), Kansas (2), Michigan (10), Missouri (3), Ohio (3), Pennsylvania (1), Washington (1), Wisconsin (1), and West Virginia (1).

Of the 27 ill persons with available information, 23 (85%) reported consuming sprouts at Jimmy John’s restaurants in the 7 days preceding illness.  Among 29 ill persons, illness onset dates ranged from December 25, 2011 to March 3, 2012.  Ill persons range in age from 9 years to 57 years old, with a median age of 26 years.  89% of ill persons are female.  Among the 29 ill persons, 7 (24%) were hospitalized. None developed HUS, and no deaths were reported.

Preliminary traceback information identified a common lot of clover seeds used to grow clover sprouts served at Jimmy John’s restaurant locations where ill persons ate.  FDA and states conducted a traceback that identified two separate sprouting facilities; both used the same lot of seed to grow clover sprouts served at these Jimmy John’s restaurant locations.  On February 10, 2012, the seed supplier-initiated notification of sprouting facilities that received this lot of clover seed to stop using it.

Results of the epidemiologic and traceback investigations indicated eating raw clover sprouts at Jimmy John’s restaurants was the likely cause of this outbreak.

  • Sprouters Northwest, Jimmy John’s Restaurants Clover Salmonella Sprouts Outbreak 2010

7 Sickened – Sprouters Northwest of Kent, Washington, issued a product recall after the company’s clover sprouts had been implicated in an outbreak of Salmonella Newport in Oregon and Washington. At least some of the cases had consumed clover sprouts while at a Jimmy John’s restaurant. Jimmy John’s Restaurants are a restaurant chain that sells sandwiches. Concurrent with this outbreak, a separate Salmonella outbreak (Salmonella, serotype I 4,5,12,i- ; see Multistate Outbreak, Tiny Greens Organic Farm, Jimmy John’s Restaurants), involving alfalfa sprouts served at Jimmy John’s restaurants was under investigation. The recall of Northwest Sprouters products included: clover; clover & onion; spicy sprouts; and deli sprouts. The Sprouters Northwest products had been sold to grocery stores and wholesale operations in Washington, Oregon, Idaho, Alaska, British Columbia, Saskatchewan, and Alberta. The FDA inspection found serious sanitary violations.

  • Multistate Salmonella Outbreak, Tiny Greens Organic Farm, Jimmy John’s Restaurants Alfalfa Sprouts 2010

140 Sickened – On December 17, the Illinois Department of Health announced that an investigation was underway into an outbreak of Salmonella, serotype I4,[5],12:i:-. Many of the Illinois cases had eaten alfalfa sprouts at various Jimmy John’s restaurants in the Illinois counties of: Adams, Champaign, Cook, DuPage, Kankakee, Macon, McHenry, McLean, Peoria, and Will counties. The sprouts were suspected to be the cause of the illnesses. On December 21, Jimmy John Liautaud, the owner of the franchised restaurant chain, requested that all franchisees remove sprouts from the menu as a “precautionary” measure. On December 23, the Centers for Disease Control revealed that outbreak cases had been detected in other states and that the outbreak was linked with eating alfalfa sprouts while at a nationwide sandwich chain. On December 26, preliminary results of the investigation indicated a link to eating Tiny Greens’ Alfalfa Sprouts at Jimmy John’s restaurant outlets. The FDA subsequently advised consumers and restaurants to avoid Tiny Greens Brand Alfalfa Sprouts and Spicy Sprouts produced by Tiny Greens Organic Farm of Urbana, Illinois. The Spicy Sprouts contained alfalfa, radish and clover sprouts. On January 14, 2011, it was revealed that the FDA had isolated Salmonella serotype I4,[5],12:i:- from a water runoff sample collected from Tiny Greens Organic Farm; the Salmonella isolated was indistinguishable from the outbreak strain. The several FDA inspections of the sprout growing facility revealed factors that likely led to contamination of the sprouts.

  • CW Sprouts, Inc., SunSprout Sprouts, “restaurant chain (Chain A),” a.k.a. Jimmy John’s Salmonella Outbreak 2009

256 Sickened – In February, Nebraska Department of Health and Human Services officials identified six isolates of Salmonella Saintpaul. Although this is a common strain of Salmonella, during 2008, only three cases had been detected in Nebraska and only four subtypes of this outbreak strain had been identified in 2008 in the entire USA. As additional reports were made, a case control study was conducted; alfalfa sprout consumption was found to be significantly related to illness. The initial tracebacks of the sprouts indicated that although the sprouts had been distributed by various companies, the sprouts from the first cases originated from the same sprouting facility in Omaha, Nebraska. Forty-two of the illnesses beginning on March 15 were attributed to sprout growing facilities in other states; these facilities had obtained seed from the same seed producer, Caudill Seed Company of Kentucky. The implicated seeds had been sold in many states. On April 26, the FDA and CDC recommended that consumers not eat raw alfalfa sprouts, including sprout blends containing alfalfa sprouts. In May, FDA alerted sprout growers and retailers that a seed supplier, Caudill Seed Company of Kentucky, was withdrawing all alfalfa seeds with a specific three-digit prefix.  Many of the illnesses occurred at “restaurant chain (Chain A).”

  • Jimmy John’s Restaurant Alfalfa Sprouts and Iceberg Lettuce E. coli Outbreak 2008

28 Sickened – Several University of Colorado students from one sorority became ill with symptoms of bloody diarrhea and cramping. Additional illnesses were reported. E. coli O157:NM(H-) was determined to be the cause. Consumption of alfalfa sprouts at the Jimmy John’s Restaurants in Boulder County and Adams County were risk factors for illness. In addition, the environmental investigation identified Boulder Jimmy John’s food handlers who were infected with E. coli and who had worked while ill. The health department investigation found a number of critical food handling violations, including inadequate handwashing. The fourteen isolates from confirmed cases were a genetic match to one another.

E. coli bacteria

In the United States, CDC, several states, and the U.S. Food and Drug Administration continue to investigate a multistate outbreak of 24 STEC O157:H7 infections in 15 states. Since CDC’s initial media statement on December 28, seven more illnesses have been added to this investigation. The last reported illness started on December 12, 2017.

The likely source of the outbreak in the United States appears to be leafy greens, but officials have not specifically identified a type of leafy greens eaten by people who became ill.  Leafy greens typically have a short shelf life, and since the last illness started a month ago, it is likely that contaminated leafy greens linked to this outbreak are no longer available for sale. Canada identified romaine lettuce as the source of illnesses there, but the source of the romaine lettuce or where it became contaminated is unknown.

Whole genome sequencing (WGS) showed that the STEC O157:H7 strain from ill people in the United States is closely related genetically to the STEC O157:H7 strain from ill people in Canada. WGS data alone are not sufficient to prove a link; health officials rely on other sources of data, such as interviews from ill people, to support the WGS link. This investigation is ongoing. Because CDC has not identified a specific type of leafy greens linked to the U.S. infections, and because of the short shelf life of leafy greens, CDC is not recommending that U.S. residents avoid any particular food at this time.

In the United States, a total of 24 STEC O157:H7 infections have been reported from California (4), Connecticut (2), Illinois (1), Indiana (2), Maryland (3), Michigan (1), Nebraska (1), New Hampshire (2), New Jersey (1), New York (1), Ohio (1), Pennsylvania (2), Vermont (1), Virginia (1), and Washington (1). Illnesses started on dates from November 15 through December 12, 2017. Among the 18 ill people for whom CDC has information, nine were hospitalized, including one person in California who died. Two people developed hemolytic uremic syndrome, a type of kidney failure.

The Public Health Agency of Canada identified romaine lettuce as the source of the outbreak in Canada. In the United States, the likely source of the outbreak appears to be leafy greens, but health officials have not identified a specific type of leafy greens that sick people ate in common.

State and local public health officials continue to interview sick people in the United States to determine what they ate in the week before their illness started. Of 13 people interviewed, all 13 reported eating leafy greens. Five (56%) of nine ill people specifically reported eating romaine lettuce. This percentage was not significantly higher than results from a survey of healthy people in which 46% reported eating romaine lettuce in the week before they were interviewed.  Based on this information, U.S. health officials concluded that ill people in this outbreak were not more likely than healthy people to have eaten romaine lettuce.  Ill people also reported eating different types and brands of romaine lettuce. Currently, no common supplier, distributor, or retailer of leafy greens has been identified as a possible source of the outbreak. CDC continues to work with regulatory partners in several states, at the U.S. Food and Drug Administration, and the Canadian Food Inspection Agency to identify the source.

Although the most recent illness started on December 12, there is a delay between when someone gets sick and when the illness is reported to CDC. For STEC O157:H7 infections, this period can be two to three weeks. Holidays can increase this delay. Because of these reporting delays, more time is needed before CDC can say the outbreak in the United Stated is over. This investigation is ongoing.

On January 10, 2018, the Public Health Agency of Canada reported that an outbreak of Shiga toxin-producing E. coli O157:H7 infections (STEC O157:H7) they had identified was linked to romaine lettuce appears to be over. As of January 10, 2018, there were 42 cases of E. coli O157 illness reported in five eastern provinces: Ontario (8), Quebec (15), New Brunswick (5), Nova Scotia (1), and Newfoundland and Labrador (13). Individuals became sick in November and early December 2017. Seventeen individuals were hospitalized. One individual died. Individuals who became ill were between the ages of 3 and 85 years of age. The majority of cases (74%) were female. It urged the public to avoid eating romaine lettuce until more is known about the contamination.