Escherichia coli O157:H7 Infections Associated With Consumption of Locally Grown Strawberries Contaminated by Deer

Background. An outbreak of Escherichia coli O157:H7 was identified in Oregon through an increase in Shiga toxin–producing E. coli cases with an indistinguishable, novel pulsed-field gel electrophoresis (PFGE) subtyping pattern.

Methods. We defined confirmed cases as persons from whom E. coli O157:H7 with the outbreak PFGE pattern was cultured during July–August 2011, and presumptive cases as persons having a household relationship with a case testing positive for E. coli O157:H7 and coincident diarrheal illness. We conducted an investigation that included structured hypothesis-generating interviews, a matched case-control study, and environmental and traceback investigations.

Results. We identified 15 cases. Six cases were hospitalized, including 4 with hemolytic uremic syndrome (HUS). Two cases with HUS died. Illness was significantly associated with strawberry consumption from roadside stands or farmers’ markets (matched odds ratio, 19.6; 95% confidence interval, 2.9–∞). A single farm was identified as the source of contaminated strawberries. Ten of 111 (9%) initial environmental samples from farm A were positive for E. coli O157:H7. All samples testing positive for E. coli O157:H7 contained deer feces, and 5 tested farm fields had ≥1 sample positive with the outbreak PFGE pattern.

Conclusions. The investigation identified fresh strawberries as a novel vehicle for E. coli O157:H7 infection, implicated deer feces as the source of contamination, and highlights problems concerning produce contamination by wildlife and regulatory exemptions for locally grown produce. A comprehensive hypothesis-generating questionnaire enabled rapid identification of the implicated product. Good agricultural practices are key barriers to wildlife fecal contamination of produce.

9 sick in Snohomish and King counties.  All under the age of 15, except one woman in her 20’s.

Question:  what food items are consumed by kids as young as 1 and someone in their 20’s?

The Snohomish Health District announced Tuesday evening that it has identified two cases of Shiga toxin-producing E. coli (STEC) in Snohomish County residents. Following public health interviews, these cases do appear to be connected to a cluster of STEC cases among seven children in King County.

The local cases involve a woman in her 20s and a child under 10 years of age from separate households. The child has been hospitalized, but no further information will be shared on the cases due to patient privacy.

Seattle King County Public Health is investigating a cluster of seven children infected with Shiga toxin-producing E. coli (also known as STEC) in King County. All cases are currently under 15 years of age, and three are under 5 years of age. Cases have been reported during April 22–May 1, 2021.

All 7 children developed symptoms consistent with STEC, including diarrhea (often bloody), abdominal cramping, nausea, and vomiting. Illness onsets occurred during April 17–29, 2021. Six children have been hospitalized; this includes two children who developed a type of kidney complication called hemolytic uremic syndrome (HUS) and both are recovering.

The investigation is ongoing. They have identified multiple types of fresh produce, mostly organic, in common among the majority of cases but cannot yet rule out other possibilities. They are still uncertain if these cases share the same source of their infection or not. Updates will continue to be posted when more information is available.

Hmm, what fresh produce would a 1 year old eat? Bananas, apples, grapes, small oranges, pears, peaches, blueberries – strawberries perhaps?  Thus far the outbreak seems to be limited to the two counties, so it does beg the question what produce might be available locally this time of year?

It does remind me of a Northwest outbreak of a few years ago.

In 2011 an outbreak of E. coli O157:H7 was linked to eating fresh strawberries produced by Jaquith Strawberry Farm, in Oregon. 15 people were sickened and there was 1 death. The farm sold berries to buyers who in turn distributed them to roadside stands and farmers’ markets in Multnomah, Washington, Clackamas, Yamhill, and Clatsop counties. The berries were sold in unmarked containers and were last distributed on August 1. Confirmed cases included residents of Washington, Clatsop, and Multnomah counties. Strawberries had not previously been implicated in an E. coli O157:H7 outbreak in the U.S. Ten percent of the environmental samples collected at the Jaquith Strawberry Farm tested positive for E. coli O157:H7. Those samples included deer feces; deer were suspected to be the source of the contamination. The outbreak strain was found in samples from fields in three separate locations.

2018 and 2019 were not good years for consumers of romaine lettuce grown in the fields of the southwestern United States, specifically the Yuma growing region of Arizona and the Salinas Valley of California. Although nearly 500 miles apart as the crow flies, the two regions share a notorious history of sickening consumers with a particularly lethal strain of Escherichia coli – O157:H7 – known to strike, and sometimes kill, the most vulnerable among us – children, elderly, and the immunocompromised. The two regions are particularly good at growing romaine lettuce, by virtue of back-to-back growing seasons from Spring to Fall.

Ideal growing conditions are what link these two agricultural areas, where most of the romaine lettuce is the United States is now grown. Salinas boasts California’s best weather in the spring and summer, while Yuma claims to be the sunniest populated place in the United States. As Salinas winds down its 4-month growing season every Fall, Yuma’s is just beginning—causing a shift of the same seasonal workers from one region to the other, until the process repeats itself yet again the following spring.[1]

YUMA (Jarboe)

In 2018, the Yuma growing region was responsible for infecting 240 people with E. coli O157:H7 from 37 states in illnesses started on dates ranging from March 13, 2018, to August 22, 2018. Ill people ranged in age from 1 to 93 years, with a median age of 26. Sixty-six percent of ill people were female. Of the more than 201 people with information available, 104 were hospitalized, including 28 people who developed hemolytic uremic syndrome, a type of kidney failure. Five deaths were reported from Arkansas, California, Minnesota (2), and New York.[2]

In addition to this outbreak being unusually large, case-patient clinical course was unusually severe. The proportion of case-patients developing HUS (12.7%) was twice as high as previous outbreaks of Shiga toxin-producing E. coli O157 (6.3%). There were five deaths in this outbreak (2.2%), which is almost four times higher than expected (0.6%). This could be explained by the strain’s Stx2a toxin subtype, which produces more virulent toxins than other types. Outbreaks with Stx2 toxin are more likely to result in increased rates of HUS.


In 2018-2019, the Salinas Valley was responsible for 62 cases in an outbreak of E. coli O157:H7, which were reported from 16 states (CA, CT, FL, GA, IL, LA, MA. MD, MI, NH, NJ, OH, PA, RI, WI) and the District of Columbia.[3]Illnesses occurred from October 7 to December 4, 2018. Cases ranged in age from 1 to 84 years (median age of 25). Sixty-six percent of cases were female. Of 54 cases with information available, 25 (46%) were hospitalized, including two people who developed hemolytic uremic syndrome, a type of kidney failure. No deaths were reported.

Jarboe (Yuma)

8-year-old Makayla Jarboe was one of Yuma’s early victims, becoming sick in April 2018, after consuming romaine lettuce from one of her favorite restaurants. Within a few days, Makayla was admitted to an Arizona hospital with symptoms of bloody diarrhea and rapidly falling platelets, the component of our blood that allows it to clot and stop us from bleeding to death. This is one of the first signs of hemolytic uremic syndrome (HUS), a deadly disease that develops when a toxin associated with the E. coli O157:H7 bacteria attacks the kidneys. For Makayla, the disease also affected her lungs, causing them to fill with fluid, and her entire body began to swell. Because of the effect on her kidneys, she also stopped urinating, which caused her fluid overload to worsen and reduced her ability to breathe adequately. Makayla soon required a chest tube to drain her lungs, and she had to be put on a mechanical ventilator to help her breathe. Because her kidneys failed with worsening HUS, she also had to be put on dialysis to cleanse her blood of toxins usually dealt with by urinating. After almost two weeks in the pediatric intensive care unit (PICU), Makayla was finally able to be taking off the breathing machine, but she continued to need dialysis to assist her failing kidneys. After 3 weeks in the PICU, she began to produce urine again, but it would be almost another month before she was able to be taken off dialysis. As if all that were not enough, Makayla also developed pancreatitis, a painful swelling of the pancreas and had to be fed through a feeding tube for months after she left the hospital. In all, she was in the hospital for 40 days. When she left, she was still on dialysis, but this was able to be continued as an outpatient for a week after she went home.

Makayla survived the initial attack of E. coli O157:H7, but it was not without consequences. She developed high blood pressure, some that can happen when the kidneys are damaged by HUS, and she had to be put on long-term blood pressure medication that she remains on still. She continues to suffer from gastrointestinal difficulties, including food intolerance and bowel issues she did not have before. She suffers from depression and anxiety, as well as cognitive issues, caused by a prolonged stay in the intensive care unit. She now has chronic headaches and possible neurologic damage, caused by another side effect of HUS – “encephalopathy,” which is damage from whole body swelling that did not spare the brain. The HUS encephalopathy is probably the reason for her cognitive impairment, and it is unknown whether this will be permanent.

In addition, Makayla will be bound to kidney doctors and other specialists for life. She now suffers from chronic kidney disease, which is at a “Stage 3” for now. This means that, while her kidneys are damaged and have lost function, they are currently working to detoxify her blood. But since Makayla suffered from such severe HUS and needed prolonged dialysis, the “life” of her own kidneys is limited and it is expected that they will eventually fail entirely, and she will need to have at least one kidney transplant during the rest of her life. Kidney transplantation comes with its own set of problems, not the least of which is needing to be on strong drugs to prevent rejection. Perhaps the saddest consequence of Makayla’s E. coli O157:H7 infection and resultant HUS is the effect on childbearing. Pregnancy in women with chronic kidney disease can be very dangerous, especially if they are on hemodialysis. And pregnancy is considered too high risk and not advised for women who have had a kidney transplant.

Parker (Salinas)

2-year-old Lucas Parker was not as “lucky” as Makayla when, in October 2018, he was sickened with E. coli O157:H7 after consuming romaine lettuce grown in the Salinas Valley. He is now a young child and no longer a toddler, but his life is forever changed and will never be normal.

A resident of British Columbia, Canada, Lucas and his family were on what was supposed to be an exciting and fun trip to Disneyland in Southern California, and he ate the lettuce en route while in a motel eating takeout. After arrival at Disneyland, he showed the first signs of getting sick and was “out of sorts” at the park, but the family went about trying to enjoy it and have some fun with the kids. However, on the road trip back to Canada over the next couple of days, the family did not quite make it back home before they were forced to stop in a hospital in Washington state so Lucas could be seen in the ER. Although in hindsight Lucas probably already had the beginnings of E. coli O157:H7 Shiga toxin associated (STEC) HUS, his bloody diarrhea in the ER was not recognized as such. So, he was given IV fluids and released so the family could continue the rest of the way home.

Within a day after getting there, Lucas was in an ambulance on the way to the hospital, summoned by his worried parents when the otherwise playful and happy little boy grew increasingly lethargic, began vomiting, and had more bloody diarrhea. At first, Lucas seemed to improve with IV fluids and antibiotics, but his platelet count dropped dramatically and it soon became clear he had severe HUS. He was moved from the ER observation suite to pediatric intensive care (PICU), and then he was transferred from the local hospital to a regional medical center with the technology to treat a very sick little boy with HUS.

After transfer, Lucas soon needed dialysis when his kidneys failed and he stopped making urine. He also developed high blood pressure and total body swelling. Then the worst possible thing happened—Lucas’ suddenly deteriorated neurologically and developed seizures and “posturing,” a visible arching of the back and stiffening of the body that signals severe brain damage. Brain damage was confirmed when the doctors did CT scanning of Lucas’ brain. Lucas was no longer responsive and continued to show posturing and more seizures, and he had to be put on a breathing machine to keep him alive.

Over the next few days, Lucas’ brain damage worsened, which the doctors knew because of more imaging (MRI and CT scans), as well as continuous electroencephalograms, which measure the electrical activity of the brain. For his continued kidney failure, he also had to be put on hemodialysis as he was no longer urinating. Lucas’ parents watched helplessly while their little boy remained unresponsive on a ventilator and showed no signs of waking up. Contractures developed in his arms and legs, which is a condition where the muscles do not relax and stiffen, so he was put on medication for that. Although unconscious, Lucas developed “stress gastritis,” or bleeding in the stomach from stress on the body.

Lucas’ condition was dire, and the doctors met with his family to talk about his prognosis. He had suffered severe brain damage, and it was unlikely they would ever see him regain much cognitive ability when he was no longer comatose. The doctors gave Lucas steroids, which helped reduce the brain swelling, in the hopes he would wake up. He was still breathing with the help of the mechanical ventilator, and after two weeks in the PICU, he opened his eyes but did not make eye contact or exhibit any purposeful movements. He began to produce a little urine at this point but remained on dialysis. Lucas was soon able to be removed from the mechanical ventilator, when “weaning” showed he could breathe on his own once again. However, he required frequent suctioning of mucous secretions, as he was unable to clear them on his own by volitional coughing or throat clearing, which conscious persons are able to do.

When more brain scans showed that Lucas was not recovering and in fact suffered even more brain damage (encephalopathy), the doctors talked to his parents about moving him to “palliative care,” which means a facility provides comfort and care without the expectation that the patient will improve enough to regain function and the ability for self-care. On hospital day 17, he was able to be removed from the breathing machine, a requirement to move him to palliative care. Lucas continued to produce urine and was taken off dialysis. But he continued to have seizures and remained unresponsive to meaningful communication (i.e., eye contact, purposeful movement). He was put on anti-convulsant medications to reduce or prevent the seizure activity. He continued to have contractures of his extremities and continued medications for that. Before moving Lucas to palliative care, a PEG tube was operatively inserted into his abdomen so he could be fed without having to use IV nutrition.

After a brief return to the hospital when an error in his contracture medication caused a decrease in his heart rate and breathing, Lucas was returned to and stabilized at the palliative care facility and was watched by neurology specialists for signs of improvement, but none occurred. He continued to exhibit signs of severe brain damage and remained obtunded. Lucas could “communicate,” but it was largely by crying in pain or discomfort, and he “responded” by quietening down and crying less.

Despite the best efforts of the neurologists and other specialists, Lucas has remained “obtunded” and unable to meaningfully interact with his parents or others. He continues to require full assistance for all his needs. Lucas was discharged from palliative care in February 2019 after his dad and mom were trained to do his suctioning, feeding, bathing, and all other care he was going to need at home. He was set up for home health care skilled nursing, as well as physical therapy and other skilled services to visit the home without having to transport Lucas to the hospital so frequently.

Lucas’ dad now has a routine he follows to take care of him, having become an expert in doing so as his full time caregiver. Lucas still receive in-home services, but it is never enough. Caring for him is a 24 hour job, with little time to rest. Although his dad sees improvement in his cognition on a day to day basis, Lucas does not have “cognitive ability” in ways the permit him to communicate his needs or participate in his life in any meaningful, volitional way. Lucas life expectancy is unknown, but he is expected to require at least one kidney transplant during his lifetime if he survives to adulthood.


[1]           Salinas and Yuma Are 500 Miles Apart—But Agribusiness Is Growing Them Closer. (2018, November 10). Zócalo Public Square.

[2]           Lyndsay Bottichio, et al., Shiga Toxin-Producing E. coli Infections Associated with Romaine Lettuce – United States, 2018, Clinical Infectious Diseases (December 9, 2019),

[3]           CDC. (2020, November 23). Outbreak of E. coli Infections – Unknown Source 2. Centers for Disease Control and Prevention.

A few days ago, “Down Under” a.k.a. Australia, my friend, food safety guru, and for some strange reason, eater of raw shellfish, Dr. Julian Cox, was speaking about the risk of pregnant women consuming unpasteurized juice or cider and tahini or hummus. The risk to the mother and the baby is Listeria, which can spread from the human digestive tract to the placenta causing miscarriage or birth defects.

It did get me thinking about what risks of foodborne illness women have during pregnancy. Here are my thoughts about what women should avoid while carrying a child.

Bacteria, parasites, and viruses may threaten the health of the mother and the baby, possibly leading to miscarriages or severe neurological illnesses, including intellectual disability, blindness, and epilepsy.

So, what to avoid or at least pay close attention to.

FISH (cooked only)

Fish is a wonderful food. It has lots of good protein and omega-3 fatty acids (omega-3s). Omega-3s are important to your baby’s brain and eye development. You should not eat some types of fish, but it is okay to eat two meals of low mercury fish every week to give you the benefits of omega-3s.

Note: Cook fish by broiling, baking, steaming, or grilling. Remove skin and fat before cooking. Do not eat the fat that drains from the fish while cooking.

Safe Fishes:

  • Farmed salmon (once a month)
  • Albacore tuna (once a week)
  • Shrimp, canned light tuna, canned or wild salmon, pollock, and catfish, cod, anchovies, or flounder (safe to eat up to two meals a week)

Do NOT eat raw fish!

Raw fish can contain parasites (anisakid nematodes, aka “worms”), bacteria (such as Vibrio, Salmonella, or Listeria) or viruses (Hepatitis A or Norovirus):

  • Sushi
  • Sashimi
  • Raw Oysters
  • Raw Clams
  • Raw Scallops
  • Ceviche

High mercury fish, in higher amounts, can be toxic to your nervous system, immune system, and kidneys. It may also cause serious developmental problems in children, with adverse effects even in lower amounts. This can cause brain damage and affect the baby’s hearing and vision.

  • Shark
  • Swordfish
  • King mackerel
  • Tuna (especially bigeye tuna) (Albacore is okay – “white” tuna – once a week only)
  • Marlin
  • Tilefish from the Gulf of Mexico
  • Orange roughy

Deli Meats and Smoked Fish:

Do NOT eat meat spread or pate.

Do NOT eat UNLESS you reheat to steaming hot: Hot dogs, lunch meat, deli meat (such as turkey, salami, and bologna)

Deli-smoked seafood (unless HEATED to steaming hot) can contain Listeria.

  • Nova-style
  • Lox
  • Kippered
  • Smoked
  • Jerky

Dairy Products:

Some cheese may contain bacteria called Listeria. These bacteria can cause a disease called listeriosis which may cause miscarriage, stillbirth, or serious health problems for your baby. In addition to Listeria, raw milk and some raw milk cheeses can contain bacteria like Campylobacter, E. coli, or Salmonella:

  • Brie
  • Feta
  • Camembert
  • Roquefort
  • Queso blanco
  • Queso fresco


Raw and undercooked eggs may have bacteria that can cause food poisoning, especially Salmonella. Do not eat food with raw eggs like Hollandaise sauce and homemade Caesar salad dressing.

 Do NOT consume:

  • Homemade eggnog
  • Raw batter
  • Homemade Caesar salad dressing
  • Tiramisu
  • Eggs Benedict
  • Homemade ice cream
  • Freshly made or homemade hollandaise sauce
  • Soft-scrambled eggs


Premade ham salad, chicken salad, seafood salad may contain Listeria. As described above, luncheon meats may also contain Listeria.

Do NOT eat undercooked poultry, pork, lamb, and beef – Some of the same issues with raw fish affect undercooked meat, too. Eating undercooked or raw meat increases your risk of infection from several bacteria or parasites, including ToxoplasmaE. coliListeria, and Salmonella.

Fruits and Vegetables (and other raw foods):

Like undercooked meats and fishes, raw or undercook sprouts, like alfalfa, clover, mung bean, or radish may contain E. coli or Salmonella. Pregnant women should drink only pasteurized juices.

Raw cookie dough – flour can contain E. coli or Salmonella.

Tap water, though not a “food” can contain bacteria and parasites if untreated or comes from a well. Do not drink any water you are not certain is from a trusted municipal source, or drink only bottled water or water that has been commercially filtered (i.e., some home water filters do not sufficiently remove bacteria, viruses, or sediment) or boiled.

NOTE: washing fruits and vegetables in untreated or “raw” water can contaminate them and cause food poisoning.


Caffeine is absorbed very quickly and passes easily into the placenta. Because babies and their placentas do not have the main enzyme needed to metabolize caffeine, high levels can build up. High caffeine intake during pregnancy has been shown to restrict fetal growth and increase the risk of low birth weight at delivery.

Drinking alcohol during pregnancy can also cause fetal alcohol syndrome, which involves facial deformities, heart defects, and intellectual disability.

I was managing the barbecue last night cooking chicken breasts.

Of course, before they hit the grill, I had carefully removed them from the plastic-covered tray from the store, and placed them into a triple-strength plastic bag to marinate a bit. I washed my hands and counters along the way and dried all with paper towels.

I checked the grill temperature (over 400 °F (204.4 °C), and after carefully removing the chicken with tongs (which I washed before reusing them), I watched them sizzle and waited for the right time to check the internal temperature.

Of course, while I waited I kept thinking how the bird parts were likely teeming with both Salmonella and Campylobacter – don’t get me started on that – see my Petition to ban bugs from chicken.

Well, in the interim, in addition to good hygiene practices, please cook your meats throughly.

Eggs 160 °F (71.1 °C)

Fish & Shellfish 145 °F (62.8 °C)

Whole Beef, Pork, Veal & Lamb Steaks, chops, roasts 145 °F (62.8 °C)

Ground Meats 165 °F (73.9 °C)

All Poultry 165 °F (73.9 °C)

Ground Poultry 165 °F (73.9 °C)

Ham, fresh or smoked (uncooked) 145 °F (62.8 °C)

Fully Cooked Ham 140 °F (60 °C)

Leftovers 165 °F (73.9 °C)

Casseroles 165 °F (73.9 °C)

As Doug Powell says, “stick it in”

In March, the Southern Nevada Health District announced it was working with its federal partners to investigate reports of acute non-viral hepatitis in Clark County.

The Health District initially received reports of five cases of severe acute non-viral hepatitis in children between November 23, 2020, and December 3, 2020. Since its initial investigation, the Health District has identified six additional probable cases (for a total of 11 probable cases) and one suspect case. The newly identified cases are all adults, and the one suspect case meets the clinical criteria but has not been tested for viral hepatitis. The 12 people were hospitalized and have since been released. None of the children or adults required a transplant.

To date, the consumption of “Real Water” brand alkaline water was found to be the only common link between all the identified cases. The FDA is conducting a further investigation into the facility, and the Health District continues to monitor for cases of acute non-viral hepatitis. Fifty additional reports are currently being investigated based on people who self-identified to the Health District, were reported by a health care provider, or because their Real Water subscription was canceled due to health concerns.

The ages of the children identified during the initial investigation range from 7 months to 5 years. The ages of the newly identified probable and suspect cases range from 32 to 71 years of age. The most common symptoms reported by the patients included nausea and vomiting, fatigue, loss of appetite, and dizziness.

The FDA has recommended that consumers, restaurants, and retailers discontinue drinking, cooking with, selling, or serving “Real Water” alkaline water. More information on the investigation is available on the FDA’s website.

Acute non-viral hepatitis is an inflammation of the liver that can be caused by exposure to toxins, autoimmune disease, or drinking too much alcohol. Though hepatitis can have many causes, symptoms often include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-colored stools, joint pain, and yellow skin or eyes. Anyone who is experiencing these symptoms should contact their health care provider.

Several years ago I spent several weeks in Australia and New Zealand giving a series of speeches on food safety – “why it is a bad idea to poison your customers.” One of the many sayings from “down under” that I learned to enjoy was “good on ya” when someone did some especially well.

LGMA, “good on ya.”

Written by April Ward

Last week the California LGMA Board endorsed new Pre-Harvest Testing guidance in an effort to prevent foodborne illness outbreaks associated with leafy greens. The guidance calls for pre-harvest testing of leafy greens products when risk assessments deem it necessary, specifically when grown in proximity to animals.

Farmers Acting Quickly to Protect Public Health

“We are endorsing pre-harvest testing in direct response to FDA’s recent report on E. coli outbreaks associated with lettuce in 2020, which identified the recurring E. coli strain implicated in this outbreak to be a reasonably foreseeable hazard. We want to send a clear message to FDA that our industry is, in fact, taking additional measures to prevent outbreaks.” – Dan Sutton, Chairman of the California LGMA

Focused on Risk and Adjacent Lands

In addition to the Pre-Harvest Testing Guidance document, the LGMA Board endorsed several other updates to the food safety standards that are currently being developed by the LGMA Technical Committee and expected to become a requirement in the coming months. Projects currently under development include:

  • An adjacent land risk assessment tool
  • Root cause analysis requirement for high-risk food safety incidents
  • Major revision to existing standards for soil amendments and crop inputs

These important tools and revisions have been in development for several months and they represent input from food safety experts and researchers throughout the industry.

“None of this could have happened without the tremendous work done by the LGMA’s Technical Committee to rapidly develop guidance for pre-harvesting testing and all efforts currently underway. Nor could this be accomplished without the commitment of LGMA members and farmers to produce safe food by implementing LGMA’s standards.” – Dan Sutton, Chairman of California LGMA.

The Produce Buyers Role

The LGMA provides a unique system to enforce food safety practices on California and Arizona farms that produce over 90% of the leafy greens consumed in the U.S.

“When produce buyers require LGMA certification of their suppliers they reinforce best practices on leafy greens farms. Simply put, when buyers support the LGMA, they support a system that offers the fastest and best means to reduce incidents of foodborne illness.” – Tim York, California LGMA CEO

According to the USDA ERS: Foodborne illnesses from different pathogens (bacteria, viruses, and parasites) cause a variety of health effects, ranging from a few days of diarrhea to more serious outcomes such as kidney failure, cognitive impairment, and even death. Since the mid-1990s, the USDA, Economic Research Service (ERS) has estimated the economic cost of 15 major foodborne illnesses. Monetary measures of these health effects provide a common metric to compare impacts of various pathogens, a way to aggregate impacts across illnesses, and a means of comparing the costs of experiencing those illnesses with the costs of preventing them. Government agencies and private industries rely on cost estimates for foodborne illness as they set priorities, make policies, and develop management initiatives. They also use the ERS estimates to help the public understand the importance of preventing foodborne disease.

ERS last estimated the total cost of the leading U.S. foodborne illnesses at $15.5 billion in 2013 dollars. While overall inflation in the United States has been low in recent years, inflation in the healthcare sector has not been low. ERS recently released revised cost estimates for these illnesses showing inflation and income growth alone increased the economic cost of these pathogens by $2 billion, to $17.6 billion in 2018 dollars, holding the number of cases constant.

Inflation in Hospitalization Costs Drove Increases in Medical Care Costs

To determine the economic cost of foodborne illness, ERS looked at the costs of medical care, the value of lost earnings, and a monetary measure of death linked to how much people are willing to pay to reduce risk of dying from foodborne illness (see blue box below). ERS used the Centers for Disease Control and Prevention’s (CDC) foodborne illness incidence rates from 2011—the agency’s most recent data—to develop the economic cost estimates.

From 2013 to 2018, inflation for the entire U.S. economy was 7.8 percent. During this period, income growth, measured in terms of real per capita Gross Domestic Product (GDP), was 8.8 percent. At the same time, inpatient hospital costs rose 25 percent, outpatient hospital costs grew 22.5 percent, and costs of prescription drugs and medical supplies increased 19.3 percent.

The cost of inpatient hospital services accounted for 74 percent of the inflation of medical care costs for foodborne illness between 2013 and 2018, ERS researchers found. The cost of medical care as a whole care accounted for only 21 percent of inflation in the total cost of foodborne illnesses.

Value of Preventing Death Accounted for Most Inflation for Foodborne Illness Costs

The 15 foodborne pathogens in ERS’s cost-of-illness estimates accounted for more than 95 percent of the cases, hospitalizations, and deaths from foodborne illnesses for which the CDC can determine a specific pathogen cause. The CDC estimated the 15 major foodborne pathogens cause roughly 8.9 million cases of illness and 54,000 hospitalizations each year. ERS estimated these pathogens and their chronic health outcomes led to nearly 1,480 deaths each year. This estimate of deaths reflects CDC estimated number of deaths from acute illnesses plus ERS estimation of deaths from chronic health outcomes from these acute illnesses.

Economists usually measure the value of preventing death in terms of people’s willingness to pay for reduced risk of death, a measure of demand for reduction in mortality risk. Based on a meta-analysis of previous studies, ERS approximated the value of each life saved in the United States at $8.7 million in 2013 dollars, which increased to $9.7 million in 2018 dollars when adjusted for inflation and income growth. Based on the ERS estimate of 1,480 deaths in 2018, the total value of preventing deaths from the major foodborne pathogens was $14.4 billion in 2018 dollars, a 12-percent increase from $12.8 billion in 2013 dollars.

This $1.6 billion increase was 76 percent of the $2 billion inflation in the total cost of these foodborne illnesses between 2013 and 2018. So, even though the mortality risk from foodborne disease was relatively low and the increase in the value of preventing deaths was lower than inflation in healthcare costs, the high value people place on reducing deaths made it the largest component of the costs of these 15 foodborne illnesses.

The proportion of total costs of the 15 leading foodborne illnesses due to medical care increased 1 percentage point, from 13 percent to 14 percent, while the percentage of costs attributed to preventing deaths dropped nearly 1 percentage point, from 82.6 percent to 81.9 percent.

Most of the Economic Cost of Foodborne Illnesses Was Caused by a Handful of Pathogens

The number of cases of illness and their health outcomes varied across the different bacteria, viruses, and parasites that cause foodborne illnesses. ERS researchers found this led to significant variation in the change in costs of the 15 foodborne illnesses from 2013 to 2018, ranging from a $270,095 change for Cyclospora to a $475,579,129 change for Salmonella.

Five of the pathogens accounted for about 90 percent of the total costs from these foodborne pathogens ($15.7 billion in 2018 dollars). Three pathogens, Salmonella, Toxoplasma, and Listeria, were responsible for more than 60 percent of the total economic cost from major foodborne illnesses in 2018 dollars.

When someone talks about having “the stomach flu,” they are probably describing acute-onset gastroenteritis caused by one of the noroviruses. 

The Centers for Disease Control and Prevention (CDC) estimates that noroviruses cause nearly 21 million cases of acute gastroenteritis annually, making noroviruses the leading cause of gastroenteritis in adults in the United States. Norovirus is highly contagious and transmitted by infected individuals at an enormous rate. According to CDC estimates, this translates into about 2,500 reported norovirus outbreaks in the United States each year. Norovirus outbreaks have been reported in many settings, including healthcare facilities, restaurants and catered events, schools, and childcare centers. Cruise ships account for a small percentage (1%) of reported norovirus outbreaks overall. Norovirus outbreaks occur throughout the year but are most common from November to April. The most common symptoms are sudden onset of vomiting and watery diarrhea, although stomach cramps and pain also often occur. Some people experience fever and body aches. Symptoms usually start 12 to 48 hours after being exposed and typically last about 1 to 3 days.

Guillain-Barré syndrome (GBS) is a disorder in which the body’s immune response, typically to an infection, causes nerve damage. The syndrome is rare, affecting about one to two people in 100,000 each year. It can present as a very mild case of brief weakness to devastating paralysis, affecting the muscles that allow a person to breathe on their own. Fortunately, most people eventually recover from even the most severe cases of Guillain-Barré, although some are left with some level of weakness. Guillain-Barré syndrome is not contagious.


However, according to the CDC, outbreaks of associated pathogenic viruses and bacteria, including Campylobacter, can lead to clusters of people with Guillain-Barré syndrome. About one in every 1,000 reported Campylobacter illnesses leads to Guillain-Barré syndrome. As many as 40 percent of cases in the United States are thought to be triggered by Campylobacter infection.

Guillain-Barré syndrome initially causes weakness and “pins and needles” sensations that begin in the legs. These symptoms can progress up the body and become more severe, leading to paralysis of the arms and legs. There may be weakness of the face muscles, of the muscles that enable a person to swallow, or of the muscles in charge of moving the eyes. Breathing muscles may be involved, and 10-30% of patients with Guillain-Barré syndrome will need a ventilator to breathe. Blood pressure or heart rate can vary from high to low, often unexpectedly, and the patient may not be able to empty their bladder or may be constipated. Pain in the back, arms, or legs is common.

Hemolytic uremic syndrome was first described in 1955, but it was not known to be secondary to Escherichia coli (E. coli) infections until 1983. HUS is now recognized as a cause of acute kidney failure in infants and young children. Adolescents and adults are also susceptible, as are the elderly, who often have severe disease and are at significant risk of death from the disease. The bowel inflammation that occurs prior to the onset of HUS is generally referred to as the “prodrome.”

During the prodromal phase of HUS, the initial diagnosis is often acute surgical abdomen, acute appendicitis, or ulcerative colitis. After several days of diarrhea, thrombocytopenia, hemolytic anemia (secondary to the destruction of red blood cells), and acute kidney injury converge to form the trilogy that defines HUS. Physical findings on admission to the hospital may include lethargy, abdominal tenderness, blood spots or skin hemorrhages (purpura), swelling, or dehydration.

Features on admission that portend a severe or fatal outcome include coma, rectal prolapse, decreased or absent urine output, or an elevated white blood cell count (WBC)—one greater than 20 x 10^9/L (i.e. greater than 20,000 per liter). Children with HUS average about two weeks in the hospital, with a range of three days to three months. Approximately two-thirds require dialysis during the acute phase of the disease. Adults with HUS are typically in the hospital longer because their course of illness tends to be more severe.

There is no effective therapy for HUS—it cannot be stopped with medications or other therapies. Instead, treatment is supportive, which includes meticulous attention to fluid and electrolyte balance—the cornerstone of survival.

Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract. The hallmark symptoms of IBS are abdominal pain and altered bowel habits. Abdominal pain is usually crampy in nature, but character and sites can vary. In some patients, the pain is relieved by defecation but, in others, defecation may worsen the pain. Additional symptoms may include bloating, straining at stools, and a sense of incomplete evacuation.


Altered bowel habits range from constipation to diarrhea, or alternating diarrhea and constipation. The symptoms of IBS may be daily but, more frequently, are episodic. Symptoms may be triggered by specific foods or by stress. Often, however, no specific triggers can be identified. It is estimated that 10-15% of the Western population has symptoms consistent with IBS, although most (75-80%) never seek medical care.

Although researchers and clinicians have not yet identified any actual anatomic changes, it is likely that some people with IBS have dysregulation in the motor function (also called “motility” or “peristalsis”) of their gastrointestinal tracts. Others develop visceral hypersensitivity, an increased sensation in response to stimuli. For example, persons with IBS will experience pain with distension of a balloon in the rectum at a smaller volume than that experienced in people without IBS. Finally, for some people, IBS affects their gut microbiome or causes intestinal inflammation, dyspepsia (i.e. indigestion), or gastroparesis (i.e. a condition in which stomach emptying is delayed, resulting in nausea, vomiting, early satiety, and weight loss).

Reactive arthritis (ReA) is joint inflammation that occurs after a bacterial infection originating outside the joints (“extra-articular”). These infections are either gastrointestinal (e.g., SalmonellaCampylobacterYersiniaShigella, and sometimes E. coli) or urogenital (most commonly Chlamydia trachomatis, but also Neisseria gonorrhea and Mycoplasma).

Typically, symptoms last for 3-5 months, and most resolve by a year. However, 15-20% may involve a more chronic persistent arthritis, with joint damage and deformity in some. Those who are HLA-B27 positive are more likely to have a worse course, as are those who have hip involvement, those who do not respond to nonsteroidal anti-inflammatory drugs (NSAIDs), and those who have elevated inflammatory markers (i.e., ESR greater than 30).Acute ReA occurs several days or weeks after the antecedent infection. It is typically monoarticular (involving one joint) or oligoarticular (involving just a few joints, usually less than six). The lower extremities are most commonly involved, but it can also involve the arms and spine. A small subset of patients with ReA may have two additional symptoms: conjunctivitis (redness and eye pain) and urethritis (burning and pain with urination).