Since the previous update on November 22, an additional 27 ill people have been reported. As of November 25, 2019, a total of 67 people infected with the outbreak strain of E. coli O157:H7 have been reported from 19 states.

Illnesses started on dates ranging from September 24, 2019, to November 14, 2019. Ill people range in age from 3 to 89 years, with a median age of 25. Sixty-seven percent of ill people are female. Of 50 ill people with information available, 39 hospitalizations have been reported, including six people who developed hemolytic uremic syndrome (HUS), a type of kidney failure. No deaths have been reported.

Epidemiologic, laboratory, and traceback evidence indicate that romaine lettuce from the Salinas, California, growing region is the likely source of this outbreak.

FDA and states continue to trace the source of the romaine lettuce eaten by ill people. Preliminary information indicates that some of the ill people ate lettuce grown in Salinas, California. No common grower, supplier, distributor, or brand of romaine lettuce has been identified.

CDC continues to advise that consumers not eat and retailers not sell any romaine lettuce grown in Salinas, California. The investigation is ongoing to determine the source of contamination and if additional products are linked to illness.

This outbreak is caused by the same strain of E. coli O157:H7 that caused outbreaks linked to leafy greens in 2017 and to romaine lettuce in 2018.

With nearly 450 sickened, 259 hospitalized and 7 deaths, is it time for a Romaine Warning Label?

Or, are the illnesses and deaths simply a cost of doing business?

 2019

41 people sickened, 28 hospitalization and 5 with HUS. A total of 40 people infected with the outbreak strain of E. coli O157:H7 have been reported from 16 states: Arizona, California, Colorado, Idaho, Illinois, Maryland, Michigan, Minnesota, Montana, New Jersey, Ohio, Pennsylvania, Virginia, Washington and Wisconsin. A total of 28 hospitalizations have been reported. Five people have developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported.  Canada has reported one illness.

23 people sickened and 11 hospitalized. The FDA, CDC, along with state and local partners, investigated the illnesses associated with the outbreak. A total of 23 people infected with the outbreak strain of E. coli O157:H7 were reported from 12 states: Arizona, California, Florida, Georgia, Illinois, Maryland, North Carolina, Nevada, New York, Oregon, Pennsylvania  and South Carolina. Eleven people were hospitalized, and no deaths were reported. Illnesses started on dates ranging from July 12, 2019 to Sept. 8, 2019. No illnesses were reported after CDC began investigating the outbreak on Sept. 17, 2019.

2018

218 people sickened, 96 hospitalized, 27 with HUS and 5 deaths. 210 people infected with the outbreak strain were reported from 36 states. 96 people were hospitalized, including 27 people who developed a type of kidney failure called hemolytic uremic syndrome. 5 deaths were reported from Arkansas, California, Minnesota, and New York. In total, there were eight Canadian cases of E. coli O157 that were genetically similar to the U.S. outbreak linked to romaine lettuce coming from the Yuma growing region in the U.S. The eight Canadian illnesses were reported in five provinces: British Columbia, Alberta, Saskatchewan, Ontario, and Quebec. Individuals became sick between March and April 2018. One of the Canadian cases was hospitalized, and no deaths were reported in Canada. Individuals who became ill were between 11 and 76 years of age. The majority of cases (75%) were female.

91 people sickened, 35 hospitalized, 4 with HUS. Sixty-two people infected with the outbreak strain of Shiga toxin-producing E. coli O157:H7 were reported from 16 states and the District of Columbia. Illnesses started on dates ranging from October 7, 2018, to December 4, 2018. Twenty-five people were hospitalized, including two people who developed hemolytic uremic syndrome, a type of kidney failure. No deaths were reported. In Canada, there were a total of 29 confirmed cases of E. coli illness investigated in Ontario, Quebec, New Brunswick, and British Columbia. The illnesses in British Columbia were related to travel to Quebec, Ontario and the United States. Individuals became sick between mid-October and mid-November 2018. Ten individuals were hospitalized, and two individuals suffered from hemolytic-uremic syndrome (HUS), which is a severe complication that can result from an E. coli infection. No deaths were reported. Individuals who became ill were between 2 and 93 years of age. The majority of cases (52%) were female.

2017

76 people sickened, 9 people hospitalized, 2 with HUS and 2 deaths. Twenty-five people infected with the outbreak strain of E. coli O157:H7 were reported from 15 states. Illnesses started on dates ranging from November 5, 2017 to December 12, 2017. Nine people were hospitalized, including two people who developed hemolytic uremic syndrome, a type of kidney failure. One death was reported from California. In total, there were 42 cases of E. coli O157:H7 illness reported in five eastern provinces: Ontario, Quebec, New Brunswick, Nova Scotia, and Newfoundland and Labrador. 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.

E. coli outbreaks associated with lettuce, specifically the “pre-washed” and “ready-to-eat” varieties, are by no means a new phenomenon. In fact, the frequency with which this country’s fresh produce consuming public has been hit by outbreaks of pathogenic bacteria is astonishing. Here is just a sample of E. coli outbreaks based on information gathered by the Center for Science in the Public Interest, Kansas State University, and the Centers for Disease Control and Prevention (CDC ) – NOTE: It is very likely that there or dozens of other outbreaks that the CDC and FDA did not make public:

Date Vehicle Etiology Confirmed
Cases		 States/Provinces
July 1995 Lettuce (leafy green; red; romaine) E. coli O157:H7 74 1:MT
Sept. 1995 Lettuce (romaine) E. coli O157:H7 20 1:ID
Sept. 1995 Lettuce (iceberg) E. coli O157:H7 30 1:ME
Oct. 1995 Lettuce (iceberg; unconfirmed) E. coli O157:H7 11 1:OH
May-June 1996 Lettuce (mesclun; red leaf) E. coli O157:H7 61 3:CT, IL, NY
May 1998 Salad E. coli O157:H7 2 1:CA
Feb.-Mar. 1999 Lettuce (iceberg) E. coli O157:H7 72 1:NE
Oct. 1999 Salad E. coli O157:H7 92 3:OR, PA, OH
Oct. 2000 Lettuce E. coli O157:H7 6 1:IN
Nov. 2001 Lettuce E. coli O157:H7 20 1:TX
July-Aug. 2002 Lettuce (romaine) E. coli O157:H7 29 2:WA, ID
Nov. 2002 Lettuce E. coli O157:H7 13 1:Il
Dec. 2002 Lettuce E. coli O157:H7 3 1:MN
Oct. 2003-May 2004 Lettuce (mixed salad) E. coli O157:H7 57 1:CA
Apr. 2004 Spinach E. coli O157:H7 16 1:CA
Nov. 2004 Lettuce E. coli O157:H7 6 1:NJ
Sept. 2005 Lettuce (romaine) E. coli O157:H7 32 3:MN, WI, OR
Sept. 2006 Spinach (baby) E. coli O157:H7 and other serotypes 205 Multistate and Canada
Nov./Dec. 2006 Lettuce E. coli O157:H7 71 4:NY, NJ, PA, DE
Nov./Dec. 2006 Lettuce E. coli O157:H7 81 3:IA, MN, WI
July 2007 Lettuce E. coli O157:H7 26 1:AL
May 2008 Romaine E. coli O157:H7 9 1:WA
Oct. 2008 Lettuce E. coli O157:H7 59 Multistate and Canada
Nov. 2008 Lettuce E. coli O157:H7 130 Canada
Sept. 2009 Lettuce: Romaine or Iceberg E. coli O157:H7 29 Multistate
Sept. 2009 Lettuce E. coli O157:H7 10 Multistate
April 2010 Romaine E. coli O145 33 5:MI, NY, OH, PA, TN
Oct. 2011 Romaine E. coli O157:H7 60 Multistate
April 2012 Romaine E. coli O157:H7 28

1:CA

Canada
June 2012 Romaine E. coli O157:H7 52 Multistate
Sept. 2012 Romaine E. coli O157:H7 9 1:PA
Oct. 2012 Spinach and Spring Mix Blend E. coli O157:H7 33 Multistate
Apr. 2013 Leafy Greens E. coli O157:H7 14 Multistate
Aug. 2013 Leafy Greens E. coli O157:H7 15 1:PA
Oct. 2013 Ready-To-Eat Salads E. coli O157:H7 33 Multistate
Apr. 2014 Romaine E. coli O126 4 1:MN
Apr. 2015 Leafy Greens E. coli O145 7 3:MD, SC, VA
June 2016 Mesclun Mix E. coli O157:H7 11 3:IL, MI, WI
Nov. 2017 Leafy Greens E. coli O157:H7 67 Multistate and Canada
Mar. 2018 Romaine E. coli O157:H7 219 Multistate and Canada
Nov. 2018 Romaine E. coli O157:H7 91 Multistate and Canada
Sept. 2019 Romaine E. coli O157:H7 23 Multistate
Nov. 2019 Romaine E. coli O157:H7 41 Multistate and Canada

We need to take a hard look at the safety of romaine and what we can do to make is safe.

“When in doubt, throw it out,” says William (Bill) Marler, managing partner at the Food Safety Law Firm, Marler Clark.

“It is past time for the leafy green industry to take the safety of greens, especially romaine lettuce, seriously.  The FDA must require, and the industry must implement, better environmental controls and more rigorous testing of products.  There have been too many outbreaks leaving hundreds of consumers with life-long complications,” said Bill Marler.

“Over the last decades, and recently, I have represented the families of people who have died as a result of consuming a product deemed ‘healthy.’  I have also represented dozens of children who face a lifetime of complications – including kidney failure – due to eating leafy greens.  This has to stop,” added Marler.

What to know about the E. coli outbreak:

The FDA, CDC, state and Canadian health authorities are presently investigating an outbreak of illnesses caused by E. coli O157:H7 tainted romaine lettuce in the United States and Canada. Thus far at least 41 people have been sickened in the United States and Canada.  This is in addition to 23 people sickened by E. coli O157:H7 tainted romaine lettuce in September.  Both outbreaks involve romaine lettuce grown in Salinas California.

Epidemiologic, laboratory, and traceback evidence indicates that romaine lettuce from the Salinas, California growing region is a likely source of this outbreak.

Consumers should not eat romaine lettuce harvested from Salinas, California.

Additionally, consumers should not eat products identified in the recall announced by the USDA on November 21, 2019 related to Missa Bay, LLC, products and Ready Pac Bistro Chicken Raised Without Antibiotics Caesar Salad.

Restaurants and retailers should not serve or sell romaine harvested from Salinas, California.  If you do not know the source of your romaine lettuce, and if you cannot obtain that information from your supplier, you should not serve, nor sell it.

Romaine lettuce may be voluntarily labeled with a harvest region. If this voluntary label indicates that the romaine lettuce was grown in “Salinas” (whether alone or with the name of another location) do not eat it. Throw it away or return it to the place of purchase.  If romaine lettuce does not have information about harvest region or does not indicate that it has been grown indoors (i.e., hydroponically- and greenhouse-grown), throw it away or return it to the place of purchase. Consumers ordering salad containing romaine at a restaurant or at a salad bar should ask the staff whether the romaine came from Salinas.  If it did, or they do not know, do not eat it.

What to know about the E. coli:

Shiga toxin–producing E. coli (STEC) cause approximately 100,000 illnesses, 3,000 hospitalizations, and 90 deaths annually in the United States. Most reported STEC infections in the United States are caused by E. coli O157:H7, with an estimated 73,000 cases occurring each year.

What to know about the E. coli complications:

Hemolytic Uremic Syndrome, or HUS, occurs in around 10 percent of hospitalized  E. coli O157:H7 infections. HUS occurs when Shiga toxins get into the bloodstream and cause the part of the kidney that filters toxins out of the blood to break down, causing kidney injury and sometimes kidney failure. Some HUS patients also suffer damage to the pancreas and central nervous system impairment.

E. coli outbreaks associated with lettuce, specifically the “pre-washed” and “ready-to-eat” varieties, are by no means a new phenomenon. In fact, the frequency with which this country’s fresh produce consuming public has been hit by outbreaks of pathogenic bacteria is astonishing. Here is just a sample of E. coli outbreaks based on information gathered by the Center for Science in the Public Interest, Kansas State University, and the Centers for Disease Control and Prevention (CDC ) – NOTE: It is very likely that there or dozens of other outbreaks that the CDC and FDA did not make public:

Date Vehicle Etiology Confirmed
Cases		 States/Provinces
July 1995 Lettuce (leafy green; red; romaine) E. coli O157:H7 74 1:MT
Sept. 1995 Lettuce (romaine) E. coli O157:H7 20 1:ID
Sept. 1995 Lettuce (iceberg) E. coli O157:H7 30 1:ME
Oct. 1995 Lettuce (iceberg; unconfirmed) E. coli O157:H7 11 1:OH
May-June 1996 Lettuce (mesclun; red leaf) E. coli O157:H7 61 3:CT, IL, NY
May 1998 Salad E. coli O157:H7 2 1:CA
Feb.-Mar. 1999 Lettuce (iceberg) E. coli O157:H7 72 1:NE
Oct. 1999 Salad E. coli O157:H7 92 3:OR, PA, OH
Oct. 2000 Lettuce E. coli O157:H7 6 1:IN
Nov. 2001 Lettuce E. coli O157:H7 20 1:TX
July-Aug. 2002 Lettuce (romaine) E. coli O157:H7 29 2:WA, ID
Nov. 2002 Lettuce E. coli O157:H7 13 1:Il
Dec. 2002 Lettuce E. coli O157:H7 3 1:MN
Oct. 2003-May 2004 Lettuce (mixed salad) E. coli O157:H7 57 1:CA
Apr. 2004 Spinach E. coli O157:H7 16 1:CA
Nov. 2004 Lettuce E. coli O157:H7 6 1:NJ
Sept. 2005 Lettuce (romaine) E. coli O157:H7 32 3:MN, WI, OR
Sept. 2006 Spinach (baby) E. coli O157:H7 and other serotypes 205 Multistate and Canada
Nov./Dec. 2006 Lettuce E. coli O157:H7 71 4:NY, NJ, PA, DE
Nov./Dec. 2006 Lettuce E. coli O157:H7 81 3:IA, MN, WI
July 2007 Lettuce E. coli O157:H7 26 1:AL
May 2008 Romaine E. coli O157:H7 9 1:WA
Oct. 2008 Lettuce E. coli O157:H7 59 Multistate and Canada
Nov. 2008 Lettuce E. coli O157:H7 130 Canada
Sept. 2009 Lettuce: Romaine or Iceberg E. coli O157:H7 29 Multistate
Sept. 2009 Lettuce E. coli O157:H7 10 Multistate
April 2010 Romaine E. coli O145 33 5:MI, NY, OH, PA, TN
Oct. 2011 Romaine E. coli O157:H7 60 Multistate
April 2012 Romaine E. coli O157:H7 28

1:CA

Canada
June 2012 Romaine E. coli O157:H7 52 Multistate
Sept. 2012 Romaine E. coli O157:H7 9 1:PA
Oct. 2012 Spinach and Spring Mix Blend E. coli O157:H7 33 Multistate
Apr. 2013 Leafy Greens E. coli O157:H7 14 Multistate
Aug. 2013 Leafy Greens E. coli O157:H7 15 1:PA
Oct. 2013 Ready-To-Eat Salads E. coli O157:H7 33 Multistate
Apr. 2014 Romaine E. coli O126 4 1:MN
Apr. 2015 Leafy Greens E. coli O145 7 3:MD, SC, VA
June 2016 Mesclun Mix E. coli O157:H7 11 3:IL, MI, WI
Nov. 2017 Leafy Greens E. coli O157:H7 67 Multistate and Canada
Mar. 2018 Romaine E. coli O157:H7 219 Multistate and Canada
Nov. 2018 Romaine E. coli O157:H7 91 Multistate and Canada
Sept. 2019 Romaine E. coli O157:H7 23 Multistate
Nov. 2018 Romaine E. coli O157:H7 41 Multistate and Canada

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of E. coli outbreaks and hemolytic uremic syndrome (HUS). The E. coli lawyers of Marler Clark have represented thousands of victims of E. coli and other foodborne illness infections and have recovered over $650 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation.  Our E. coli lawyers have litigated E. coli and HUS cases stemming from outbreaks traced to ground beef, raw milk, lettuce, spinach, sprouts, and other food products.  The law firm has brought E. coli lawsuits against such companies as Jack in the Box, Dole, ConAgra, Cargill, and Jimmy John’s.  We have proudly represented such victims as Brianne Kiner, Stephanie Smith and Linda Rivera.

To contact Bill Marler, email: bmarler@marlerclark.com or call: 1-206-794-5043.

The U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) is issuing a public health alert due to illnesses caused by E. coli O157:H7 associated with romaine lettuce from the Salinas, California, growing region. FSIS warns against consuming any wraps, sandwiches, prepackaged salad, salad kits, or other product containing romaine lettuce harvested from the Salinas, California, growing region. Additionally, consumers should not eat any salad products identified in a Missa Bay, LLC, recall announced by FSIS on November 21, 2019.

On November 22, 2019, the Centers for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA)advised consumers, retailers, and restaurants not eat or sell any romaine lettuce harvested from the Salinas, California, growing region. Most romaine lettuce products at retail are labeled with a harvest location showing where they were grown. CDC and the FDA are advising that if this voluntary label indicates that the romaine lettuce was grown in “Salinas” (whether alone or with the name of another location) do not eat it. If the romaine does not have information about harvest region or does not indicate that it has been grown indoors (i.e. hydroponically- and greenhouse-grown), throw it away or return it to the place of purchase.

FSIS-regulated establishments are advised not to serve, ship, or sell products that contain romaine lettuce from the Salinas, California, growing region. This advice includes all types of romaine lettuce from the Salinas, California, growing region, such as whole heads of romaine, hearts of romaine, and packages of precut lettuce and salad mixes that contain romaine, including baby romaine, spring mix, and Caesar salad. If you do not know the source of your romaine lettuce, and if you cannot obtain that information from your supplier, you should not serve, ship, or sell the product.

Anyone concerned about an illness should contact a healthcare provider. E. coli O157:H7 is a potentially deadly bacterium that can cause dehydration, bloody diarrhea and abdominal cramps 2–8 days (3–4 days, on average) after exposure the organism. While most people recover within a week, some develop a type of kidney failure called hemolytic uremic syndrome (HUS). This condition can occur among persons of any age but is most common in children under 5-years old and older adults. It is marked by easy bruising, pallor, and decreased urine output. Persons who experience these symptoms should seek emergency medical care immediately.

Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of E. coli outbreaks and hemolytic uremic syndrome (HUS). The E. coli lawyers of Marler Clark have represented thousands of victims of E. coli and other foodborne illness infections and have recovered over $650 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation.  Our E. coli lawyers have litigated E. coli and HUS cases stemming from outbreaks traced to ground beef, raw milk, lettuce, spinach, sprouts, and other food products.  The law firm has brought E. coli lawsuits against such companies as Jack in the Box, Dole, ConAgra, Cargill, and Jimmy John’s.  We have proudly represented such victims as Brianne Kiner, Stephanie Smith and Linda Rivera.

If you or a family member became ill with an E. coli infection or HUS after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark E. coli attorneys for a free case evaluation.

Since the initial investigation notice, 23 additional ill people have been reported. As of November 21, 2019, a total of 40 people infected with the outbreak strain of E. coli O157:H7 have been reported from 16 states.

Illnesses started on dates ranging from September 24, 2019, to November 10, 2019. Ill people range in age from 3 to 89 years, with a median age of 22. Sixty-five percent of ill people are female. Of 39 ill people with information available, 28 hospitalizations have been reported, including 5 people who developed hemolytic uremic syndrome (HUS), a type of kidney failure. No deaths have been reported.

Epidemiologic, laboratory, and traceback evidence indicate that romaine lettuce from the Salinas, California growing region is a likely source of this outbreak.

In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Eight (80%) of 10 people interviewed reported eating romaine lettuce. This percentage is significantly higher than results from a survey of healthy people in which 47% reported eating romaine lettuce in the week before they were interviewed. Ill people in Maryland reported eating Ready Pac Foods Bistro® Chicken Caesar Salad. To date, ill people in other states have not reported eating this particular salad, which contained romaine lettuce from the Salinas, California growing region.

As reported on November 20, 2019, the Maryland Department of Health identified E. coli O157 in romaine lettuce from an unopened package of Ready Pac Foods Bistro® Chicken Caesar Salad collected from a sick person’s home in Maryland. Whole genome sequencing has been completed and shows that the E. coli strain in the romaine lettuce is closely related genetically to the E. coli found in sick people in this outbreak. This provides additional evidence that people in this outbreak got sick from eating romaine lettuce.

On November 21, 2019, Missa Bay, LLC,  salad products due to possible E. coli contamination.

Do not eat or sell any of the recalled salad products, which were sold under many different brand names.

  • The recalled salad products have “Use By” dates ranging from October 29, 2019, to November 1, 2019.
  • The recalled products have establishment number “EST. 18502B” inside the USDA mark of inspection.

This recall includes salad products that contained contaminated romaine lettuce. The romaine lettuce was tested by the Maryland Department of Health as part of a foodborne illness outbreak in Maryland.

FDA and states are tracing the source of the romaine lettuce eaten by ill people. Preliminary information indicates that some of the ill people ate lettuce grown in Salinas, California. No common grower, supplier, distributor, or brand of romaine lettuce has been identified.

This outbreak is caused by the same strain of E. coli O157:H7 that caused outbreaks linked to leafy greens in 2017 and to romaine lettuce in 2018.

Great that the FDA and the Maryland Department of Health are out early with “Actionable” information.

The Maryland Department of Health is investigating a cluster of Escherichia coli O157:H7 (E. coli O157) infections among seven patients in Maryland. All reported eating Ready Pac Bistro® Bowl Chicken Caesar Salad purchased from various Sam’s Club locations in Maryland. There has been one hospitalization and no deaths associated with these cases.

Consumers are advised not to eat Ready Pac Bistro® Bowl Chicken Caesar Salad, lot #255406963, “Best By” date Oct. 31, 2019. Testing of unopened salad purchased by one of the patients identified the presence of E. coli O157 in the romaine lettuce. In addition to Sam’s Club, these salad bowls are distributed to many other retailers. The investigation is ongoing and additional laboratory testing is pending. There have been prior outbreaks of E. coli O157 linked to romaine lettuce.

And, for some breaking news via tweet – product tested positive:

It is too early to tell if the E. coli cases announced in Wisconsin are linked to the Maryland illnesses.  Since November 13, Wisconsin officials say they are investigating 20 cases, three involving children. They say the cases are scattered across the state and are not isolated in any one region. The source remains a mystery.  However, officials are treating it as an outbreak.

Dr. Larry Lutwick is an infectious disease specialist with the Mayo Clinic in Eau Claire. He said he’s seen three cases of E. coli at his facility and believes they may be linked to the outbreak. He thinks his patients could have contracted the bacteria from lettuce. “In two of the three cases they suspected it was from a salad or salad ingredient,” Lutwick said.

This email notification just dropped into my inbox from Eau Claire, Wisconsin:

Over the past 5 days, our health care facility in northwest Wisconsin,
USA, has seen 3 women hospitalized with E. coli O157 infection. All
presented with significant abdominal pain without fever and watery
diarrhea which in 2 progressed to bloody diarrhea. None of the 3 have
manifested any evidence of hemolytic-uremic syndrome. Both of the
women seen by the Infectious Diseases service stated that their diet
contains a lot of salads.

We would appreciate any reports of upswings in the number of cases of
this process in the upper Midwest USA or elsewhere.

San Antonio Metropolitan Health District commenced a foodborne outbreak investigation in September 2018 after it was bombarded with calls from over 250 ill patrons of Pasha Mediterranean Grill in San Antonio, Texas. 14 patrons were confirmed for Salmonella and a dozen were hospitalized. Those whose stool samples were confirmed at a public health lab tested positive for Salmonella Enteritidis.

Patrons who fell ill were presumed to have dined at Pasha over Labor Day weekend. Investigations began on September 3, 2018. That day, numerous violations were noted, including two ill employees who worked the previous week. Testing results for these employees are not known. Other violations included improper temperature holding, improper glove use, and poor employee hand hygiene. Previously, Pasha had been given several violations of public health importance by public health inspectors. The most recent violations previous to the outbreak were recorded in May 2018.

The owner of the restaurant reportedly closed the location implicated in the outbreak after a refrigerator was found shorted following a lightning strike on September 3. While the location was re-opened the following day, it closed again two days later due to temperature issues with the same refrigerator. To date, San Antonio Metropolitan Health District has not published a final summary of the investigations. It is unclear what would have caused the outbreak, although contaminated hummus was suspected by public health officials.

Outbreak

On August 14, 2018, the Oregon Health Authority (OHA) and Yamhill County Health and Human Services (YCHHS) independently received reports of persons with gastrointestinal illness days after attending a wedding and reception in Yamhill County on August 11. Over the next two days, additional wedding attendees reported gastrointestinal illness. OHA notified the Multnomah County Health Department (MCHD), and the agencies initiated an investigation to determine the cause of the outbreak and to prevent additional cases. YCHHS contacted the Oregon Department of Agriculture (ODA), which regulates some food-service establishments in Oregon.

By August 15, 10 cases had been reported to OHA. A Health Alert Network notice was sent to the ORCD1 group advising them to ask patients with gastrointestinal illness whether they had attended a wedding in Yamhill County and, if they were willing, to submit a still sample.

Fecal samples from patients were cultured and isolates serotyped at the Oregon State Public Health Laboratory. On August 20, Shigella flexneri type 3a was first identified from a patient specimen. OHA consulted with subject matter experts at the Centers for Disease Control and Prevention (CDC) for information on this Shigella serotype.

Methods

YCHHS public health investigators obtained contact information for attendees and the caterer. The caterer is based in Multnomah County. MCHD officials contacted the caterer to obtain a menu of foods served at the wedding. Using this information, on August 16 OHA epidemiologists emailed to wedding attendees a link to an online survey asking them to identify foods they had eaten and to determine whether they had illnesses meeting the case definition.

Information from the first survey indicated that there was a cocktail hour between the wedding ceremony and the reception. Because S. flexneri infections have been associated with international travel, and there were additional food exposures, OHA invited wedding attendees to complete a second online survey on August 24. OHA asked respondents about their illness on this survey, too.

A confirmed case had S. flexneri cultured from a clinical specimen and attended the wedding reception. A presumptive case was reported diarrhea or vomiting in a person who attended the wedding reception.

An ODA environmental health specialist inspected the venue, collected water samples and leftover strawberries and cucumbers, and examined general biosecurity. Yamhill County environmental health specialists collected leftover potatoes. Well-water samples were tested using the Colilert® test for total coliforms. Food samples were tested for Shigella species using polymerase chain reaction testing. Multnomah County environmental health specialists inspected the caterer. They observed hygiene practices and asked that people who prepared food for the reception submit stool samples for testing.

Results

Among 263 wedding attendees and reception venue staff, 192 were represented on the first survey and 128 on the second survey; some people completed the survey for their children, spouses, or other relatives. In total, 200 people were represented by the two surveys combined.

One hundred twelve cases were identified;23 (21%) were confirmed. Eighty-seven (78%) of the cases were Oregon residents; the remainder were residents of 11 other states. Oregon cases resided in 11 different counties.

Cases by time of illness onset are shown in Figure 1. Of the 95 cases with onset information, 92 (97%) were reported to have started on the two days between midnight on August 12 and midnight August 14 .

The median age of ill people was 30 years. Of 112 female attendees, 62 (55%) became ill. Of 88 male attendees, 49 (56%) became ill. Of 18 persons ≤18 years of age, 5 (28%) were ill. Of 181 persons >18 years of age, 107 (58%) were ill (Table 1). Persons ≤18 years of age were significantly less likely to become ill (p = 0.03).

Table 2 shows the symptoms reported by ill people.

Of ill people, 74/105 (70%) missed school or work, 57/106 (54%) saw a clinician, 38/105 (36%) visited the emergency room, and 10/106 (9%) were hospitalized overnight.

Among the 58 cases whose illness had resolved when they completed the survey, illness duration ranged from 3 to 14 (median, 5) days. Forty-four cases were still ill when they completed their survey. No deaths were reported.

Persons (n = 55) who attended the rehearsal dinner were no more likely to become ill than those who did not attend it (RR 1.2, p= 0.51); therefore, the epidemiologic investigation focused on food exposures at the wedding reception. Food was served buffet-style. Six food items were each associated with a significantly increased risk of illness: asparagus, au gratin potatoes, bread, butter, the aioli that was served with the asparagus, and salad. Asparagus was most strongly associated with illness: of those who ate asparagus, 66% became ill, compared to 12.5% of those who denied eating asparagus (RR 5.3, 95% CI 2.1–13.3). Asparagus consumption also accounted for a higher percentage of cases (96%) than any other exposure (Table 3). In further analysis of these six foods, including stratified and multivariable analyses, asparagus consumption was the only exposure significantly associated with increased likelihood of becoming ill.

There was a children’s buffet. Some persons aged <10 years old ate food from the rest of the buffet, and some adults ate food from the children’s buffet. Persons aged <10 years old were significantly more likely to have eaten from the kid’s buffet (p < 0.01) and significantly less likely to have eaten any adult food (p < 0.01).

When visiting the caterer, Multnomah County inspectors did not observe any food-handling violations. Stool samples were submitted by some of the food-handling staff; none were positive for Shigella. Food preparers were primarily responsible for specific dishes. When analyzing attendees’ exposures by who was responsible for the foods they consumed, illness rates did not differ significantly by food preparer. Catering records revealed that the caterer served some of the same foods, including the grilled asparagus dish, at multiple events that same weekend. The asparagus was sourced domestically. No illnesses related to those other events were reported to OHA.

The ODA inspector concluded that biosecurity on the venue’s water supply was sufficient to protect against intentional contamination. The water tested negative for bacterial contamination. The leftover strawberries, cucumbers and potatoes tested negative on bacterial culture; no asparagus had been left over for testing.

Conclusions

An outbreak of Shigella flexneri type 3a infections was most likely caused by contaminated asparagus consumed by people who attended a wedding reception in Yamhill County on August 11, 2018. Bread was also associated with illness, but it is less likely to be the cause of the outbreak. Asparagus accounts for a higher proportion of cases, and the age breakdown of illness is better explained by asparagus consumption patterns.

This is the second-largest foodborne outbreak of S. flexneri infections reported in the U.S. since 1988. The source of the contamination was not definitively identified. Because humans are the natural reservoir for Shigella species, and there were no concurrent outbreaks to suggest upstream contamination, poor food-handler hygiene is the most likely cause.

Updated Outbreak report

According to South African press reports, it seems that there’s no coming back from the Listeria crisis that rocked Tiger Brands last year.

The unit’s revenues slid 79 percent in the six months ending in March, resulting in an operating loss of over R200-million.

The company now says it’s looking to sell its processed meats business.

Tiger Brands owns the likes of Enterprise Foods and Mielie Kip.

The division was temporarily closed last year following the world’s largest-ever listeria outbreak.

Over 1,000 people were sickened with over 200 deaths were linked to the outbreak.

The particular strain of listeria bacteria was traced back to an Enterprise Foods factory. But Tiger Brands says the review of its processed meats business started long before that.

While Tiger Brands is exploring the sale of its value-added meat products business, the company can still be held liable for the 2017’s listeria outbreak says attorney at Richard Spoor Attorneys Catherine Marcus (we are working with Richard and his team on the case – See https://listeriaclassaction.co.za/).

Marcus says Tiger Brands Limited and Tiger Consumer Brands, who are the main defenders along with Enterprise Foods in a class-action lawsuit, must still answer to any negligence or any intentional harm that may have occurred as a result of their action or inaction at the time.

She adds that whoever takes control of Enterprise Foods would also be taking on the liability.

If Enterprise Foods is sold, Enterprise will still be jointly responsible for any liability related to the outbreak and whoever or whatever entity takes ownership of Enterprise will also be taking up that liability.

Catherine Marcus, Attorney – Richard Spoor Attorneys