Had a great opportunity to get on the line with some of my favorite people with one of the very best online sources of everything food.  Here is the interview:

From meat and eggs to leafy greens, four experts weigh in on the safety of the U.S. food supply over the past decade and lay out strategies to improve it.

Listeria in smoked salmon, pieces of metal in chicken strips, undeclared allergens in frozen Chinese food and meatballs, E.coli in ground beef, and mold in corn used for animal feed. This is a partial list of the foods recall in the U.S. from just the last few weeks. In our increasingly consolidated, industrialized food system, stories like these have become commonplace. And yet, unless they are associated with documented illnesses or deaths—such as last year’s two outbreaks of E. coli on Romaine lettuce in Yuma, Arizona, which led to hundreds of illnesses and at least five deaths—they rarely make front page news.

The question of just how safe our food is, and what can be done to make it safer, has been occupying scientists, advocates, lawmakers, and public health officials for decades, and the last 10 years have been especially contentious.

In 2011, President Obama signed into law the most significant piece of food-safety legislation since the 1930s. The Food Safety Modernization Act (FSMA) came in response to a wave of food-borne illnesses and granted the U.S. Food and Drug Administration (FDA) broad new powers to inspect and regulate food products and producers.

At the same time, the country’s food safety system remains complicated—the U.S. Department of Agriculture (USDA) remains responsible for inspecting all meat, poultry, and eggs, while the FDA inspects everything else. Under this situation, a frozen pepperoni pizza would undergo three USDA inspections, while a frozen cheese pizza from the same company would receive just one FDA inspection.

While designed and intended to save lives and protect people, food safety regulations can bring financial and operational burdens to farmers and other food producers, especially those with small- and medium-sized operations. And the growing interest in and demand for cottage food laws and “food sovereignty” bills hint at a grass-roots resistance to what some producers might see as overreaching regulations.

To celebrate Civil Eats’ 10th anniversary, we have been conducting a series of roundtable discussions touching on some of the most important topics we have covered since 2009. In the conversation below, we invited four experts to weigh in on the state of food safety. Marion Nestle is an author and the Paulette Goddard Professor, of Nutrition, Food Studies, and Public Health, Emerita, at New York University; Bill Marler is the managing partner of Marler Clark, a Seattle, Washington, based law firm that specializes in foodborne illness cases and founder and publisher of Food Safety News; Rebecca Spector is the West Coast director for the advocacy nonprofit Center for Food Safety; and Judith McGeary is an attorney, farmer, advocate, and the executive director of the Farm and Ranch Freedom Alliance, a Texas-based organization that advocates for policies to support independent family farmers.

Civil Eats’ editor-in-chief, Naomi Starkman, and associate editor Christina Cooke facilitated the wide-ranging discussion. The conversation has been edited for clarity and brevity.

Here is the full meal deal.

Since the last update on April 26, 2019, 19 more ill people were added to this outbreak.

As of May 13, 2019, 196 people infected with the outbreak strain of E. coli O103 have been reported from 10 states -Florida 5, Georgia 49, Illinois 1, Indiana 1, Kentucky 69, Minnesota 1, Mississippi 1, Ohio 12, Tennessee 55 and Virginia 2. CDC is reporting the 196 illnesses that the PulseNet laboratory network has confirmed are part of this outbreak. States are investigating additional illnesses that might be a part of this outbreak.

Illnesses started on dates from March 1, 2019, to April 19, 2019. Ill people range in age from less than 1 year to 84 years, with a median age of 19. Fifty-two percent are female. Of 174 people with information available, 28 (16%) have been hospitalized. No deaths and two cases of hemolytic uremic syndrome have been reported.

This multistate investigation began on March 28, 2019, when officials in Kentucky and Georgia notified CDC of this outbreak. Epidemiologic and laboratory evidence indicates that ground beef is the 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. Of the 147 people interviewed, 115 (78%) reported eating ground beef. This percentage is significantly higher than results from a survey pdf icon[PDF – 787 KB] of healthy people. Ill people bought or ate ground beef from several different grocery stores and restaurants. Many ill people bought large trays or chubs of ground beef from grocery stores and used the meat to make dishes like spaghetti sauce and sloppy joe.

Officials in Tennessee collected ground beef from a restaurant where ill people reported eating. Laboratory testing identified the outbreak strain of E. coli O103 in the ground beef collected in Tennessee.

Two companies recalled raw ground beef products because they may be contaminated with E. coli. Grant Park Packing in Franklin Park, Ill., recalled approximately 53,200 pounds of raw ground beef products on April 24, 2019. K2D Foods, doing business as Colorado Premium Foods, in Carrollton, Ga., recalled approximately 113,424 pounds of raw ground beef products on April 23, 2019. These products were sold to restaurants and institutions.

USDA-FSIS and state regulatory officials continue to collect products for testing and continue their traceback investigations to determine the source of ground beef supplied to grocery stores and restaurants where ill people ate. At this time, no common supplier, distributor, or brand of ground beef has been identified that could account for the whole outbreak.

Almost 70 people have fallen ill in New Zealand with Salmonella infections from alfalfa sprouts.

GSF Fresh New Zealand recalled some of its Pams, Sproutman and Fresh Harvest branded sprout products because of a “production process concern” at the end of March.

Recalled Pams brand sprouts

“Salmonella Typhimurium phage type 108/170 was the causative pathogen identified from cases, sprouts and spent irrigation water tested in this outbreak. Subtyping using Multiple Locus Variable-Number Tandem Repeat Analysis (MLVA) and whole genome sequencing methods were performed on isolates to confirm cases in the outbreak as well as the outbreak source,” said the spokesman.

Analysis of information from people who got sick and test results confirmed the strain of Salmonella was identical to a strain detected in alfalfa sprouts and indicates the product is the likely source of illness.

There were only four cases of this phage type identified in 2018, 13 in 2017 and 19 in 2016.

Recalled sprouts had best before dates of March 31 to April 4. GSF New Zealand is one of the largest produce manufacturers in New Zealand, according to the firm’s website. The company operates a plant in Auckland which manufactures fresh produce for restaurants throughout the country.

Recalled Fresh Harvest brand sprouts

Fresh Harvest brand products were sold in Countdown, Fresh Choice and SuperValue supermarkets throughout the North Island. Pams Superfoods Super Salad Mix was sold in supermarkets across New Zealand. Other Pams brand sprouts affected by the recall were only sold in supermarkets around the North Island. Sproutman brand products were sold in stores and retail outlets across the country.

Pams brand sprouts sold in the South Island are made by a different supplier, Southern Alps Sprouts Ltd, and were not affected by the recall.

Onset date of the first known case was Dec. 23, 2018. The most recent case was reported on April 1, 2019. Between that period there were 67 confirmed and two probable infections. The majority of cases – 66 – fell ill between Jan. 23 to 25. No deaths were reported, but 17 people needed hospital treatment.

Cases were predominantly in the North Island and from the following District Health Boards: Waitemata (13 cases), Counties Manukau (8), Waikato, MidCentral and Hutt Valley (6 each), Capital and Coast (5), Wairarapa (4), Northland, Auckland and Hawke’s Bay (3 each), Lakes, Tairawhiti, Taranaki and Southern (2 each), Bay of Plenty, Whanganui, Nelson Marlborough and Canterbury (1 each).

The people affected ranged in age from 2 to 92 years old and almost two-thirds were women.

MPI advises consumers that the only way to make all varieties of sprouts safe is to cook them thoroughly.

The agency also recommends not to serve raw sprouts to young children and babies, the frail elderly, pregnant women, people who’ve recently had an operation and those who have a chronic illness or have been advised to take extra care with food safety.

The CDC and public health and regulatory officials in California, Nevada, Alaska, Illinois and New Hampshire are investigating a multistate outbreak of Vibrio parahaemolyticus, Shigella flexneri, STEC non-O157, Vibrio albensis, Campylobacter lari, and norovirus genogroup 1 illnesses linked to raw oysters harvested from Estero El Cardon estuary in Baja California Sur, Mexico. On May 6, one U.S. distributor of oysters harvested from Estero El Cardon issued a voluntary recall  On May 7, Estero El Cardon was closed to further oyster harvesting pending investigation.

Epidemiologic and traceback evidence for these cases indicated people ate raw oysters harvested from Estero El Cardon in Baja California Sur, Mexico. State public health officials identified additional illnesses among people who also ate raw oysters from the same harvest area.

As of May 10, 2019, 16 ill people have been reported from five states. Ill people in this outbreak have been infected with multiple pathogens causing illness, including Vibrio parahaemolyticus, Shigella flexneri, STEC non-O157, Vibrio albensis, Campylobacter lari, and norovirus genogroup 1.

In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. All 15 people who were interviewed reported eating raw oysters from different restaurants in California and Nevada. State health officials collected traceback information for 15 cases and found that oysters were shipped by SOL AZUL, S.A. DE C.V. (MX 01 SS) and harvested from Estero El Cardon (an estuary).

Illnesses started on dates ranging from December 16, 2018 to April 4, 2019. Among 15 people with information available, ages range from 26 to 80 years, with a median age of 38. Sixty-seven percent are male. Of 15 people with clinical information available, 2 (13%) hospitalizations were reported. Illnesses might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported. This can take 4 or more weeks.

CDC, public health and regulatory officials in multiple states, and the U.S. Food and Drug Administration (FDA) investigated a multistate outbreak of Cyclospora cayetanensis infections.

As of September 11, 2018, CDC was notified of 511 laboratory-confirmed cases of Cyclospora infections in people from 15 states and New York City who reported consuming a variety of salads from McDonald’s restaurants in the Midwest.

Twenty-four (24) people were hospitalized. No deaths were reported.

Epidemiologic and traceback evidence indicated that salads purchased from McDonald’s restaurants were one likely source of this outbreak.

On July 13, 2018, McDonald’s voluntarily stopped selling salads at over 3,000 locations in 14 states. The company has since reportedExternal that it has replaced the supplier of salad mix in those states.

On July 26, 2018, the FDA completed final analysis of an unused package of romaine lettuce and carrot mix distributed to McDonald’s by the Fresh Express processor in Streamwood, IL. The analysis confirmed the presence of Cyclospora in that sample.

What is cyclospora? Cyclospora is a parasite composed of one cell, too small to be seen without a microscope. The organism was previously thought to be a blue-green alga or a large form of cryptosporidium. Cyclospora cayetanensis is the only species of this organism found in humans. The first known human cases of illness caused by cyclospora infection (that is, cyclosporiasis) were first discovered in 1977. An increase in the number of cases being reported began in the mid-1980s, in part due to the availability of better diagnostic techniques. Over 15,000 cases are estimated to occur in the United States each year. The first recorded cyclospora outbreak in North America occurred in 1990 and was linked to contaminated water. Since then, several cyclosporiasis outbreaks have been reported in the U.S. and Canada, many associated with eating fresh fruits or vegetables. In some developing countries, cyclosporiasis is common among the population and travelers to those areas have become infected as well.

Where does cyclospora come from? Cyclospora is spread when people ingest water or food contaminated with infected stool. For example, exposure to contaminated water among farm workers may have been the original source of the parasite in raspberry-associated outbreaks in North America. Cyclospora needs time (one to several weeks) after being passed in a bowel movement to become infectious. Therefore, it is unlikely that cyclospora is passed directly from one person to another. It is not known whether or not animals can be infected and pass infection to people.

What are the typical symptoms of Cyclospora infection? Cyclospora infects the small intestine (bowel) and usually causes watery diarrhea, bloating, increased gas, stomach cramps, loss of appetite, nausea, low-grade fever, and fatigue. In some cases, vomiting, explosive diarrhea, muscle aches, and substantial weight loss can occur. Some people who are infected with cyclospora do not have any symptoms. Symptoms generally appear about a week after infection. If not treated, the illness may last from a few days up to six weeks. Symptoms may also recur one or more times. In addition, people who have previously been infected with cyclospora can become infected again.

What are the serious and long-term risks of cyclospora infection? Cyclospora has been associated with a variety of chronic complications such as Guillain-Barre syndrome, reactive arthritis or Reiter’s syndrome, biliary disease, and acalculous cholecystitis. Since cyclospora infections tend to respond to the appropriate treatment, complications are more likely to occur in individuals who are not treated or not treated promptly. Extraintestinal infection also appears to occur more commonly in individuals with a compromised immune system.

How is cyclospora infection detected? Your health care provider may ask you to submit stool specimen for analysis. Because testing for cyclospora infection can be difficult, you may be asked to submit several stool specimens over several days. Identification of this parasite in stool requires special laboratory tests that are not routinely done. Therefore, your health care provider should specifically request testing for cyclospora if it is suspected. Your health care provider might have your stool checked for other organisms that can cause similar symptoms.

How is cyclospora infection treated? The recommended treatment for infection with cyclospora is a combination of two antibiotics, trimethoprim-sulfamethoxazole, also known as Bactrim, Septra, or Cotrim. People who have diarrhea should rest and drink plenty of fluids. No alternative drugs have been identified yet for people with cyclospora infection who are unable to take sulfa drugs. Some experimental studies, however, have suggested that ciprofloxacin or nitazoxanide may be effective, although to a lesser degree than trimethoprim-sulfamethoxazole. See your health care provider to discuss alternative treatment options.

How can Cyclospora infection be prevented? Avoiding water or food that may be contaminated is advisable when traveling. Drinking bottled or boiled water and avoiding fresh ready-to-eat produce should help to reduce the risk of infection in regions with high rates of infection. Improving sanitary conditions in developing regions with poor environmental and economic conditions is likely to help to reduce exposure. Washing fresh fruits and vegetables at home may help to remove some of the organisms, but cyclospora may remain on produce even after washing.

Now that is a mouthful of some pathogens.

The California Department of Public Health (CDPH) today recommended that consumers avoid eating raw oysters harvested from Estero El Cardon in Baja California Sur, Mexico, because they are linked to an outbreak of gastrointestinal illnesses in California.

In California, 12 individuals have reported illness in February, March, and April after consuming raw oysters sold by restaurants and retailers located in Los Angeles, Orange, Santa Barbara and San Diego Counties. The raw oysters have been distributed throughout the state. Laboratory testing was performed for eight cases and multiple pathogens were identified: Vibrio parahaemolyticus (3), Vibrio albensis (1), Vibrio species unidentified (1), Shigella flexneri serotype 1 (2), and norovirus (1). One of the Vibrio parahaemolyticus cases was co-infected with non-O157 Shiga toxin-producing E. coli. The investigation is ongoing.

CDPH continues to work closely with local health jurisdictions to collect information about the cases. Traceback evidence collected to date confirms that the oysters were harvested from Estero El Cardon. Shellfish authorities in Mexico have been notified about the outbreak and are investigating. Restaurants and retailers can protect customers by checking their inventory and shellfish tags that are required to identify the source to avoid any raw oysters harvested from Estero El Cardon in Baja California Sur, Mexico. This will ensure that potentially contaminated raw oysters are not available for purchase, and any leftover contaminated products are discarded. Consumers should ask the retailer or restaurant about the source if the product is not labeled or identified.

California residents should visit their doctors if they become ill after eating raw oysters. Any illness should also be reported to the local health department. Some tips to remember include:

Avoid eating raw and undercooked shellfish, including oysters, to reduce the risk of illness.
If you do eat shellfish, cook it until it reaches an internal temperature of at least 145°F. Quick steaming isn’t sufficient to prevent gastrointestinal illness from these pathogens.”

This year marks the 25th anniversary of a massive E. coli outbreak, which hit 73 Jack in the Box restaurants in Washington, Idaho, Oregon and California; sickened 700 people; sent 171 to the hospital; and killed four. The anniversary is a somber but noteworthy milestone for accomplished food safety attorney Bill Marler ’87.

“It’s the 25th anniversary of the outbreak, but it’s also the 20th anniversary of our law firm,” he said. Seattle-based Marler Clark, which he co-founded with fellow Seattle University School of Law alumnus Bruce Clark ’84, was the nation’s first law firm to focus solely on helping victims of foodborne illnesses and grew directly from both attorneys’ experience with the 1993 outbreak.

As milestones like this come and go, Marler, who recently turned 60, wonders whether it’s time to retire. A few of his colleagues from the law firm’s early days have already done so.

“But I really love my job,” he said. “I get to make a huge difference in people’s lives, people who have lost their kidneys, lost their large intestines, are brain-injured, families that are facing millions and millions and millions of dollars in medical expenses, or a husband who’s never going to work again. And I get to help them. That’s a reason to get up and go to work every day.”

In the last two decades, Marler Clark has been involved in the aftermath of every major and minor outbreak of foodborne illness in the United States, working not only with victims but also with scientists and public health officials to make the food supply safer. Author Jeff Benedict, who chronicled the Jack in the Box story in his 2011 book, “Poisoned,” wrote that “no individual has had more influence on the shape and direction of food safety policy in the U.S.” than Marler.

Back in 1993, just a few years out of law school, he became the lead lawyer for the plaintiffs through an effective combination of hustle, hard work, personal connections, and media savvy.

His first E. coli client was a Tacoma family referred to him by a woman he had helped with a worker’s compensation claim. He rushed from his office in downtown Seattle to his old law school hangout in Tacoma (the law school was formerly affiliated with University of Puget Sound), the Poodle Dog Restaurant, met with the family, and convinced them to hire him.

“I went from obscurity to being sort of the legal face of the outbreak. I went from having one client to five clients to 10 clients to hundreds,” he said. Two years into the class-action lawsuit, when the end was finally in sight, Marler settled $25 million worth of cases in two days of mediation.

Most notably, he secured a $15.6 million settlement – the largest of its kind at the time – on behalf of Brianne Kiner, the Seattle girl who was the most severely injured victim of the outbreak, which was traced to undercooked hamburgers at 73 Jack in the Box restaurant locations. Just 9 years old, she spent several weeks in a coma, followed by a long and painful recovery. She still struggles with lifelong health effects such as infertility, asthma, and diabetes.

When the case concluded, Marler figured he would return to a general personal injury practice, possibly specializing in medical malpractice. But then another E. coli outbreak hit, again centered in Washington state. In 1996, a tainted batch of apple juice, from a juice company called Odwalla, killed one toddler and sickened 66 people. The families called Marler for help, thanks to his high profile in the Jack in the Box litigation.

“It really was at that point that I thought, ‘Hmm, clearly people think I know what I’m doing,'” Marler joked. “But candidly, I had worked really hard. I knew the law and I knew the medicine really well. I started wondering if you could create an entire practice around this.”

You could. Or rather, he could. Marler and Clark partnered with lawyers Denis Stearns and Andy Weisbecker to create the firm in 1998. (Both Clark and Stearns essentially switched sides, having represented Jack in the Box during the earlier litigation.) Two of the firm’s most recent hires are also Seattle U Law graduates – Anthony Marangon ’15 and Josh Fensterbush ’17. Stearns and Drew Falkenstein ’02 are of counsel at the firm.

Over the years, Marler has secured more than $600 million for victims of E. coli, salmonella, and other foodborne illnesses. While lawsuits often spur companies to make important changes – Jack in the Box developed the industry’s toughest safety standards after its outbreak – Marler knows there’s more to it than litigation. So he also devotes his energy and expertise to advocate for stronger food safety laws and regulations.

He petitioned the U.S. Department of Agriculture to better regulate pathogenic E. coli and successfully advocated for the passage of the 2010-2011 FDA Food Safety Modernization Act. He has spoken to countless industry groups and journalists, established science scholarships, and written extensively on all manner of foodborne pathogens.

What motivated Bill Marler back in 1993 is what continues to motivate him today. Many people who suffer the most from foodborne illness are children, and the money he earns for them is intended to take care of them for the rest of their lives.

Marler has three daughters of his own – one is a graduate of Seattle University and two are current students. The oldest was just an infant when he took on Jack in the Box.

“When you’re representing little children and you see how injured they are,” he said, “it doesn’t take much to look at your own kids and realize just how important your job is.”

(This story originally appeared in Lawyer, Spring 2018.)

It is said that it is always hard to get the first olive out of the jar and it is the same in settlements.  It was hard fought, but the resolutions of the cases were fair and my hope is that these corporate defendants and their insurers see that it is in everyone’s best interest to take care of customers who were sickened by their product sooner rather than later.

Although litigation is always my preferred option, resolving cases that are backed up by solid epidemiology and genetic fingerprinting of both E. coli and Salmonella, makes the most economic sense for the defendants and insurers and it is far fairer  to the injured.

Here was the case lineup:

The Spring 2018 E. coli O157:H7 Romaine Lettuce Outbreak:  In 2018 in the United Sates, 210 people infected with the outbreak strain of E. coli O157 were reported from 36 states. 96 people were hospitalized, including 27 people who developed a type of kidney failure called hemolytic uremic syndrome (HUS). 5 deaths were reported from Arkansas, California, Minnesota (2), and New York. In Canada, 8 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 8 Canadian illnesses were reported in 5 provinces: British Columbia, Alberta, Saskatchewan, Ontario and Quebec. 1 of the Canadian cases was hospitalized with HUS and no deaths were reported in Canada. Through our own traceback, we have uncovered numbers restaurant clusters which have led to processor clusters, and in some instances, farms.

The Summer 2018 E. coli O26 Ground Beef Outbreak:  As of September 19, 2018, 18 people infected with the outbreak strain of E. coli O26 were reported from 4 states. Illnesses started on dates ranging from July 5, 2018 to July 25, 2018. Ill people ranged in age from one year to 75, with a median age of 16. Sixty-seven percent of ill people were male. Of 18 people with information available, 6 (33%) were hospitalized, including one person who died in Florida. Epidemiologic, laboratory, and traceback evidence indicates that ground beef from Cargill Meat Solutions was a likely source of this outbreak.

The Summer 2018 Salmonella Adelaide Cut Fruit Outbreak: As of July 24, 2018, 77 people infected with the outbreak strain of Salmonella Adelaide were reported from nine states – Arkansas 1, Florida 1, Illinois 7, Indiana 14, Kentucky 1, Michigan 39, Missouri 11, Ohio 2, Tennessee 1. Illnesses started on dates ranging from April 30, 2018, to July 2, 2018. Ill people ranged in age from less than 1 year to 97, with a median age of 67. Among ill people, 67% were female. Out of 70 people with information available, 36 (51%) were hospitalized. No deaths were reported. Epidemiologic and traceback evidence indicated that pre-cut melon supplied by the Caito Foods, LLC of Indianapolis, Indiana was the likely source of this multistate outbreak.

And, I get to fly home on my birthday.

The CDC warns:

Place chicken in a disposable bag before putting in your shopping cart or refrigerator to prevent raw juices from getting onto other foods.

Wash hands with warm soapy water for 20 seconds before and after handling chicken.

Do not wash raw chicken. During washing, chicken juices can spread in the kitchen and contaminate other foods, utensils, and countertops.

Use a separate cutting board for raw chicken.

Never place cooked food or fresh produce on a plate, cutting board, or other surface that previously held raw chicken.

Wash cutting boards, utensils, dishes, and countertops with hot soapy water after preparing chicken and before you prepare the next item.

Use a food thermometerExternal to make sure chicken is cooked to a safe internal temperature of 165°F.

If cooking frozen raw chicken in a microwavable meal, handle it as you would fresh raw chicken. Follow cooking directions carefully to prevent food poisoning.

If you think the chicken you are served at a restaurant or anywhere else is not fully cooked, send it back for more cooking.

Refrigerate or freeze leftover chicken within 2 hours (or within 1 hour if the temperature outside is higher than 90°F).

Summary

Public Health investigated an outbreak of Shiga toxin-producing E. coli (STEC) associated with I Love Sushi and Café Mario at Nintendo of America campus in Redmond. Café Mario is operated by Sodexo and is not open to the public. I Love Sushi is a food establishment that operates out of Café Mario once a week.

This outbreak appears to be over. After a thorough investigation, we do not have enough evidence to connect I Love Sushi to this outbreak.. No single food item prepared by Café Mario has been identified as the source of the illnesses. Everyone who reported illness has recovered.

Illnesses

Since July 2, 2018, we have learned of 22 people in WA (20 in King County and 2 in Snohomish County) who developed symptoms consistent with an STEC illness, including diarrhea (bloody or non-bloody) and abdominal cramps. All 22 of these ill people are adults who work at the Nintendo of America campus in Redmond. Illness onsets occurred during June 11-July 5, 2018.

The 22 people who got sick all ate food from Café Mario on multiple days before becoming ill. Only four people who got sick also ate at I Love Sushi.

We learned of two additional people from King County who tested positive for E. coli infections with the same bacterial strain as the cases associated with Café Mario. However, these two people had no known connection to Café Mario or Nintendo, and we could not identify any other potential sources of exposure in common with any of the other people who got sick. We are not including these two people in the overall case count of this outbreak.

Public Health actions

On July 3, 2018, Environmental Health investigators visited Café Mario. Inspections were completed for both Café Mario and I Love Sushi.

At Café Mario, investigators identified possible risk factors for cross contamination and spread of bacteria, including improper hand washing practices and improper cold holding temperatures of food; corrective actions were addressed with Café Mario’s management. At I Love Sushi, possible risk factors were also identified and discussed, including improper temperature storage of foods. Both restaurants were not open on the July 4 holiday.

On July 5, 2018, investigators closed Café Mario and the onsite I Love Sushi food services. Investigators revisited both food establishments on July 11, 2018, and both were allowed to reopen the same day. Café Mario and I Love Sushi both completed a thorough cleaning and disinfection of their facilities before reopening, and any remaining processed ready-to-eat food products were discarded.

We did not identify any employees of either restaurant who had a recent diarrheal illness. Investigators also reviewed with management of both food establishments the Washington State Retail Food Code requirement that staff are not allowed to work while having vomiting or diarrhea.

Laboratory testing

Four of the 22 people who got sick tested positive for STEC O26 with the same genetic fingerprint, suggesting that they have a common source of infection. The remaining people who got sick were not tested for STEC, but their symptoms are suggestive of STEC.

Environmental swabs were collected from both I Love Sushi and Café Mario for laboratory testing and all came back negative for STEC at the Washington State Public Health Laboratory.