In total, 240 people infected with the outbreak strains of E. coli O157:H7 were reported from 37 states. 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.[1]

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.

WGS analysis of isolates from 184 ill people identified antibiotic resistance to chloramphenicol, streptomycin, sulfisoxazole, tetracycline, and trimethoprim-sulfamethoxazole. Standard antibiotic resistance testing of eight clinical isolates by CDC’s National Antimicrobial Resistance Monitoring System (NARMS) laboratory confirmed these findings. Isolates from four of those ill people also contained genes for resistance to ampicillin and ceftriaxone. These findings do not affect treatment guidance since antibiotics are not recommended for patients with E. coli O157 infections. Epidemiologic, laboratory, and traceback evidence indicated that romaine lettuce from the Yuma growing region was the likely source of this outbreak.

The FDA and state and local regulatory officials traced the romaine lettuce to 23 farms and 36 fields in the Yuma growing region. The FDA, along with CDC and state partners, started an environmental assessment in the Yuma growing region and collected samples of water, soil, and manure. CDC laboratory testing identified the outbreak strain of E. coli O157:H7 in water samples taken from a canal in the Yuma growing region. WGS showed that the E. coli O157:H7 found in the canal water is closely related genetically to the E. coli O157:H7 from ill people. Laboratory testing for other environmental samples is continuing. FDA is continuing to investigate to learn more about how the E. coli bacteria could have entered the water and ways this water could have contaminated romaine lettuce in the region.

Certainly, as well cited above, leafy greens have been a source of E. coli-related illnesses for decades, and there have been concerns raised about lettuce grown in the Yuma region. The CDC reports as of May 20, 2010, a total of 26 confirmed and 7 probable cases related to an E. coli O145 outbreak have been reported from 5 states since March 1, 2010 linked to shredded romaine grown in Yuma.[2] In the FDA’s “Environmental Assessment Report in December 2010,” the authors determined:

that the R.V. park is a reasonably likely potential source of the outbreak pathogen based upon the evidence of direct drainage into the lateral irrigation canal; the moist soil in this drainage area; the multiple sewage leach systems on the property; the presence of other STEC found in the lateral irrigation canal and in the growing fields of the suspect farm; and the fact that the section of the lateral canal downstream from the R.V. park supplies water to only one other farm in addition to the suspect farm.

Two pumps are located on the main Wellton canal near the lateral canal split that supplies water to fields of the suspect farm; one gasoline powered pump on a trailer and one permanent electric pump with an attached hose. The electric pump supplies canal water to an attached open-end hose. The site is not secured from vehicles and the hose pump is also unsecured. At the time of this investigation there were people living in recreational vehicles on undeveloped land within one mile of the hose pump. The fact that this area is open to vehicles and the pump and hose are unsecured make it possible for an R.V. owner to dump and rinse out their R.V. septic system into the main Wellton canal at the lateral canal split that supplies the farm. The ground near the hose pump shows erosion evidence of drainage into the Wellton canal. Soil collected from this erosion site tested positive for other Stx2-producing STEC but did not match the outbreak strain.

In a 2009 “Survey of Selected Bacteria in Irrigation Canal Water – Third Year” written by Jorge M. Fonseca, he correctly predicted the human and industry problems that were likely to plague the Yuma lettuce growers:

Despite the fact that no Arizona lettuce grower has been involved in any contaminated-lettuce outbreak, it is of paramount importance to determine the reasons why Arizona lettuce is regarded as safe. This can help lower possibilities of any emerging problem and prevent a catastrophic damage to the industry, as it has occurred in other regions when no control was taken to reduce risks of contaminated product.

A PowerPoint done by Dr. Fonseca again illustrated the varying risks of lettuce production in Yuma. An example of a few of his points of concern:

And, then the 2018 romaine lettuce E. coli outbreak struck, sickening hundreds in the United States and Canada with dozens suffering from acute kidney failure with five reported deaths. Once again, the Wellton Irrigation Canal was the focus of attention in the “Memorandum to File on the 2018 Environmental Assessment”:

During this EA, three samples of irrigation canal water collected by the team were found to contain E coli O157:H7 with the same rare molecular fingerprint (using whole genome sequencing (WGS)) as the strain that produced human illnesses (the outbreak strain). These samples were collected from an approximate 3.5-mile stretch of an irrigation canal in the Wellton area of Yuma County that delivers water to several of the farms identified in the traceback investigation as shipping romaine lettuce that was potentially contaminated with the outbreak strain. The outbreak strain was not identified in any of the other samples collected during this EA, although other pathogens of public health significance were detected.

Not surprisingly, the FDA in its full “Environmental Assessment of Factors Potentially Contributing to the Contamination of Romaine Lettuce Implicated in a Multi-State Outbreak of E. coli O157:H7,”[3] concluded that the risk of environmental contamination was in fact a well-know and long-standing risk:

Food safety problems related to raw whole and fresh-cut (e.g., bagged salad) leafy greens are a longstanding issue. As far back as 2004, FDA issued letters to the leafy greens industry to express concerns about continuing outbreaks associated with these commodities. FDA and our partners at CDC identified 28 foodborne illness outbreaks of Shiga-toxin producing E. coli (STEC) with a confirmed or suspected link to leafy greens in the United States between 2009 and 2017. This is a time frame that followed industry implementation of measures to address safety concerns after a large 2006 outbreak of E. coli O157:H7 caused by bagged spinach. STEC contamination of leafy greens has been identified by traceback to most likely occur in the farm environment.

Contamination occurring in the farm environment may be amplified during fresh-cut produce manufacturing/processing if appropriate preventive controls are not in place. Unlike other foodborne pathogens, STEC, including E. coli O157:H7, is not considered to be an environmental contaminant in fresh-cut produce manufacturing/processing plants.

Well-established reservoirs for E. coli O157:H7 are the intestinal tract of ruminant animals (e.g., cattle, goats, and deer) that are colonized with STEC and shed the organism in manure. Ruminant animals colonized with STEC typically have no symptoms. In contrast, human infection with E. coli O157:H7 usually produces symptomatic illness often marked by severe, often bloody, diarrhea; severe adverse health outcomes or even death can result. Humans shed E. coli O157:H7 in the stool while ill and sometimes for short periods after symptoms have gone away, but humans are not chronic carriers. Various fresh water sources, including municipal well, and recreational water, have been the source of E. coli O157:H7 infections in humans, as has contact with colonized animals at farms or petting zoos. However, most E. coli O157:H7 infections in humans occur from consuming contaminated food.

In its summary of its environmental findings (also summarized in a November 1, 2018 to public officials) the “FDA [in part] identified the following factors and findings as those that most likely contributed to the contamination of romaine lettuce from the Yuma growing region with E. coli O157:H7 that caused this outbreak”:

• FDA has concluded that the water from the irrigation canal where the outbreak strain was found most likely led to contamination of the romaine lettuce consumed during this outbreak.
• There are several ways that irrigation canal water may have come in contact with the implicated romaine lettuce including direct application to the crop and/or use of irrigation canal water to dilute crop protection chemicals applied to the lettuce crop, either through aerial or ground-based spray applications.
• How and when the irrigation canal became contaminated with the outbreak strain is unknown. A large animal feeding operation is nearby but no obvious route for contamination from this facility to the irrigation canal was identified. Other explanations are possible although the EA team found no evidence to support them.

_______________________

[1] Lyndsay Bottichio, et al., Shiga Toxin-Producing E. coli Infections Associated with Romaine Lettuce – United States, 2018, Clinical Infectious Diseases (December 9, 2019), https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciz1182/5669965.

[2] https://www.cdc.gov/ecoli/2010/shredded-romaine-5-21-10.html

[3] https://www.fda.gov/Food/RecallsOutbreaksEmergencies/Outbreaks/ucm624546.htm

How is this acceptable?

I have spent today reviewing this most interesting study and took the liberty of editing it down for reading “consumption.” https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciz1182/5669965

This outbreak was the largest multistate STEC O157 outbreak in several decades, eclipsing in magnitude a 2006 outbreak linked to fresh spinach. As there are an estimated 26 unreported illnesses for every STEC O157 case reported to PulseNet, the true size of this outbreak was likely much larger than the 240 illnesses reported through PulseNet, suggesting that thousands of people were actually sickened in this outbreak.

240 case-patients (not 210) from 37 states; 104 were hospitalized, 28 developed hemolytic uremic syndrome, and five died. Of 179 people who were interviewed, 152 reported consuming romaine lettuce in the week before illness onset. Twenty sub-clusters were identified.

Product traceback from sub-cluster restaurants identified numerous romaine lettuce distributors and growers; all lettuce originated from the Yuma growing region.

Water samples collected from an irrigation canal in the region yielded the outbreak strain of E. coli O157.

One case-patient was co-infected with E. coli O157 and E. coli O61, and two case-patients were infected with only E. coli O61. Case-patients were 1–93 years (median 26 years), and 66% (158/239) were female. All outbreak isolates were related genetically by WGS (0–40 SNP differences). Two distinct sub-clades that included the majority of outbreak isolates, which had isolates with 0–19 SNP differences.

In April 2018, the New Jersey Department of Health and the Pennsylvania Department of Health notified the Centers for Disease Control and Prevention of two E. coli infection clusters. Before becoming ill, people in both clusters reported eating salads at a national restaurant chain. Pulsed- field gel electrophoresis showed that the E. coli O157 isolated from ill people in both states had the same, rare PFGE pattern combination.

Product traceback efforts by local health jurisdictions, state health departments, and FDA could not identify a single product lot, processor, or farm as the source of the entire outbreak. In total, 36 fields on 23 farms were identified during the traceback investigation. Only the Alaska correctional facility sub-cluster could be traced to a single farm. All of the romaine lettuce identified was traced to farms in the Yuma growing region. FDA, CDC and state partners conducted an EA in the growing region, which consisted of farms in Imperial County, CA and Yuma County, AZ.

In June 2018, E. coli O157 with PFGE patterns indistinguishable from clinical outbreak isolates and closely related genetically to clinical isolates in both main clades were detected in irrigation water from the Yuma growing region. The outbreak strains were detected in three separate water samples from sites along a 3.5-mile section of the Wellton irrigation canal that runs adjacent to romaine lettuce farms identified during traceback and next to a concentrated animal feeding operation (CAFO) with approximately 105,000 cattle. No E. coli O61 was identified from the environmental assessment or water samples collected. No romaine lettuce was available for sampling during this outbreak since harvesting had ended in this region by the time the environmental assessment began.

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 STEC 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.

The ultimate source of E. coli O157 for this outbreak is unknown, but reasonable hypotheses exist that explain how romaine lettuce could have become contaminated. The E. coli O157 outbreak strain was detected at multiple points in a Yuma growing region irrigation canal, and the contaminated canal water may have subsequently contacted romaine lettuce in several ways, including direct application to the crop through aerial or land-based spray chemicals diluted with canal water.

However, how and when E. coli O157 was introduced into the irrigation canal is unknown, as well as why the majority of illnesses were associated with romaine when other types of lettuce were grown in the same area during the time of interest. A CAFO was located adjacent to the irrigation canal where the outbreak strain was found, but no obvious route for contamination from the facility was identified. Environmental contamination could have been caused by the adjacent CAFO, as cattle are a well-documented reservoir for pathogenic E. coli O157.

References

1. Rangel JM, Sparling PH, Crowe C, Griffin PM, Swerdlow DL. Epidemiology of Escherichia coli O157:H7 outbreaks, United States, 1982-2002. Emerging Infectious Diseases, 2005; 11(4): 603-9.
2. Dewey-Mattia D, Manikonda K, Hall AJ, Wise ME, Crowe SJ. Surveillance for Foodborne Disease Outbreaks – United States, 2009-2015. Morbidity and Mortality Weekly Report Surveillance Summaries, 2018; 67(10): 1-11.
3. Sharapov UM, Wendel AM, Davis JP, et al. Multistate Outbreak of Escherichia coli O157:H7 Infections Associated with Consumption of Fresh Spinach: United States, 2006. Journal of Food Protection, 2016; (12): 2024.
4. Food Bill Aims to Improve Safety. FDA Consumer Health Information 2010.
5. Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne illness acquired in the United States– 
major pathogens. Emerging Infectious Diseases, 2011; 17(1): 7-15.
6. Heiman KE, Mody RK, Johnson SD, Griffin PM, Gould LH. Escherichia coli O157 Outbreaks in the United States, 2003-2012. Emerging Infectious Diseases, 2015; 21(8): 1293-301.
7. National Shiga toxin-producing Escherichia coli (STEC) Surveillance Overview. Atlanta, Georgia: CDC, 2012.
8. General information: Escherichia coli. Available at: https://www.cdc.gov/ecoli/general/index.html.
9. PulseNet home page. Available at: https://www.cdc.gov/pulsenet/.
10. Katz L.S., Griswold T., Williams-Newkirk A.J., et al. . A Comparative Analysis of the Lyve-SET 
Phylogenomics Pipeline for Genomic Epidemiology of Foodborne Pathogens. Frontiers in 
Microbiology, 2017; 8:375.
11. Foodborne Diseases Active Surveillance Network (FoodNet): population survey. Available at: https://www.cdc.gov/foodnet/surveys/population.html.
12. Environmental Assessment; Yuma 2018 E. coli O157:H7 Outbreak Associated with Romaine Lettuce. US Food and Drug Administration, October 24, 2018.
13. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS). Available at: https://www.cdc.gov/narms/antibiotics-tested.html.
14. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): Human Isolates Surviellance Report for 2015 (Final Report). Atlanta, Georgia: CDC, 2018.
15. National Outbreak Reporting System (NORS) Dashboard. Available at: https://wwwn.cdc.gov/norsdashboard/.
16. Gould LH, Demma L, Jones TF, et al. Hemolytic Uremic Syndrome and Death in Persons with Escherichia coli O157:H7 Infection, Foodborne Diseases Active Surveillance Network Sites, 2000– 2006. Clinical Infectious Diseases, 2009; 49(10): 1480-5.
17. Food Safety Modernization Act (FSMA) Final Rule on Produce Safety. Available at: https://www.fda.gov/Food/GuidanceRegulation/FSMA/ucm334114.htm.
18. Beauvais W, Gart EV, Bean M, et al. The prevalence of Escherichia coli O157:H7 fecal shedding in feedlot pens is affected by the water-to-cattle ratio: A randomized controlled trial. PloS One, 2018; 13(2): e0192149-e.
19. Karmali MA. Factors in the emergence of serious human infections associated with highly pathogenic strains of shiga toxin-producing Escherichia coli. International Journal of Medical Microbiology, 2018; 308(8): 1067-72.
20. Wilson D, Dolan G, Aird H, et al. Farm-to-fork investigation of an outbreak of Shiga toxin- producing Escherichia coli O157. Microbial Genomics, 2018; 4(3): e000160.

It is likely that these numbers will be old in the next few minutes.

A total of 102 people infected with the outbreak strain of E. coli O157:H7 have been reported from 23 states. Two illnesses are reported in Canada. A total of 58 hospitalizations have been reported. Ten people have developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported. Epidemiologic, laboratory, and traceback evidence collected to date indicate that romaine lettuce from the Salinas, California, growing region may be contaminated with E. coli O157:H7 and is making people sick. Missa Bay, LLC Recalls Salad Products Due to Possible E. coli O157:H7 Contamination, Consumers advised not to eat Ready Pac Bistro® Bowl Chicken Caesar Salad, lot #255406963, “Best By” date Oct. 31, 2019 Do not eat or sell Fresh Express Sunflower Crisp Chopped Salad Kits with this identifying information: UPC 0 71279 30906 4, beginning with lot code Z, and a best-before date up to and including 07DEC19.

Eight people infected with the outbreak strain of E. coli O157:H7 have been reported from three states.  Minnesota reports that there are nine in total. Three people have been hospitalized.  One person has developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported. Information collected to date indicates that Fresh Express Sunflower Crisp chopped salad kits are a likely source of this outbreak.  Also, As of December 11, 2019, there are 24 cases of E. coli O157 illness linked to this outbreak in the following provinces: Ontario (11), Quebec (3), New Brunswick (4), Nova Scotia (4), Prince Edward Island (1), and Newfoundland and Labrador (1). Individuals became sick between November 5 and November 23, 2019. Six individuals have been hospitalized, including one person who developed hemolytic uremic syndrome, a type of kidney failure.

Then there is Seattle/King County Public Health investigating an outbreak of Shiga toxin-producing E. coli (STEC) potentially associated with four Evergreens restaurants in Seattle. Twelve of Thirteen people who became ill during November 10–15, 2019, ate dishes containing raw vegetables, including leafy greens, from Evergreens restaurants during November 5–11, 2019. The Thirteenth person did not report having eaten at Evergreens, but genetic testing showed they were infected with the same strain of E. coli as three people who did eat at Evergreens and became ill. Genetic testing on isolates from four of the seven people (three who reported eating at Evergreens before they became ill and one who did not report eating at Evergreens) identified the same strain of E. coli, suggesting they have a common source of infection. This strain of E. coli is different from the strain currently causing a national outbreak associated with romaine lettuce grown in Salinas, California, which the U.S. Centers for Disease Control and Prevention (CDC) announced on November 22, 2019.

2019 – 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.

However, as of last night we learned that these numbers above were in fact higher – 240 case-patients from 37 states (238 of them were infected with STEC O157; 1 was co-infected with STEC O157 and STEC O61, and 2 were infected with only STEC O61). 104 hospitalizations 28 victims with hemolytic uremic syndrome

2018 – 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.

If the recent phone calls to my office of people recently sick with E. coli, I would say soon.

In the last few days, the CDC, public health and regulatory officials in several states, and FDA reported that they are investigating a multistate outbreak of E. coli O157:H7 infections. A total of eight people infected with the outbreak strain of E. coli O157:H7 have been reported from North Dakota, Minnesota and Wisconsin. Three of the nine  ill people have been hospitalized, including one person who developed hemolytic uremic syndrome.  A day earlier, Canadian health authorities reported 16 confirmed cases of E. coli O157:H7 illness linked to the same product in the following provinces: Ontario, Quebec, New Brunswick, Nova Scotia, Newfoundland and Labrador. Four individuals have been hospitalized. Information collected to date indicates that Fresh Express Sunflower Crisp chopped salad kits are a likely source of this outbreak. The investigation is ongoing to determine which ingredient in the salad was contaminated. Romaine lettuce is one of the ingredients in the salad kit.

Then there is this one – Seattle Public Health is investigating an outbreak of E. coli potentially associated with four Evergreens restaurants in Seattle. Thirteen people who became ill during November 10–15, 2019, ate dishes containing raw vegetables, including leafy greens, from Evergreens restaurants during November 5 to 11. Genetic testing on isolates from the people identified the same strain of E. coli, suggesting they have a common source of infection. This strain of E. coli is different from the strain currently causing a national outbreak associated with romaine lettuce grown in Salinas, California, which the CDC announced on November 22.

Here is a bit(e) of history:

In 2017 in Canada, a total, of 42 cases of E. coli O157 illness were reported in five eastern provinces: Ontario (8), Quebec (15), New Brunswick (5), Nova Scotia (1), Newfoundland and Labrador (13). 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.

In 2017 in the United States, 25 people infected with the outbreak strain of STEC O157: H7 had been reported from 15 states. Ill people ranged in age from 1 to 95 years, with a median age of 26. Among ill people, 67% were female. Nine ill people were hospitalized, including two people who developed the hemolytic uremic syndrome. One death was reported from California.

In the Spring of 2018 in Canada, there were eight Canadian illnesses of E. coli O157 with a similar genetic fingerprint to illnesses reported in the U.S. investigation.

In the United States as of June 27, 2018, 210 people infected with the outbreak strain of E. coli O157: H7 were reported from 36 states. Ill people ranged in age from 1 to 88 years, with a median age of 28. Sixty-seven percent of ill people were female. Of 201 people with information available, 96 (48%) were hospitalized, including 27 people who developed the hemolytic uremic syndrome. Five deaths were reported from Arkansas, California, Minnesota (2), and New York.

In Canada, as of November 23, 2018, there had been 22 confirmed cases of E. coli illness investigated in Ontario (4), Quebec (17), and New Brunswick (1). Eight individuals were hospitalized, and one individual suffered from the hemolytic-uremic syndrome. Individuals who became ill were between 5 and 93 years of age. The cases are evenly distributed among male and female individuals.

In November 2018, 66 people infected with the outbreak strain of Shiga toxin-producing E. coli O157:H7 were reported from 12 states. Illnesses started on dates ranging from October 8, 2018 to October 31, 2018. Sixteen people were hospitalized, including one person who developed hemolytic uremic syndrome, a type of kidney failure. Epidemiologic and traceback evidence from the United States and Canada indicates that romaine lettuce harvested from the Central Coastal growing regions of northern and central California is a likely source of the outbreak.

In November 2019, the CDC notified the FDA of this illness cluster in mid-September 2019 and the agency promptly initiated a traceback investigation. 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 (3), California (8), Florida (1), Georgia (1), Illinois (2), Maryland (1), North Carolina (1), Nevada (1), New York (1), Oregon (1), Pennsylvania (2) and South Carolina (1). 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.

As of December 2, 2019, 102 people infected with E. coli O157:H7 have been reported from 23 states. There have been over 50 hospitalizations, with at least 10 with acute kidney failure. Illnesses started on dates ranging from September 24 to November 18. As of December 6, the Public Health Agency of Canada has reported two illnesses related to the U.S. outbreak. Based on available traceback data, the FDA requested that industry voluntarily withdraw romaine lettuce grown in Salinas, California from the market and is requesting that the industry withhold distribution of romaine for the remainder of the growing season in Salinas. Consumers are still advised to not eat, and retailers and food service establishments to not sell or serve, any romaine lettuce harvested from the Salinas growing region.

Since 2017 there been over 500 people in the U.S. and Canada who have suffered E. coli O157:H7 illnesses linked to leafy greens grown in the U.S.  Of these, nearly 200 have been hospitalized with 50 suffering hemolytic uremic syndrome (acute kidney failure).  There have been seven reported deaths.

E. coli O157:H7 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:

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	88	Multistate and Canada
Sept. 2019	Romaine	E. coli O157:H7	23	Multistate
Nov. 2019	Romaine	E. coli O157:H7	104	Multistate and Canada

Additional Resources

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 $700 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.

• About E. coli – a complete online resource with information on symptoms and risks of E. coli infection
• Marler Clark E. coli Lawsuits and Litigation
• A downloadable Family Health Guide on E. coli (PDF)
• About Hemolytic Uremic Syndrome

Since the previous update on November 26, an additional 35 ill people have been reported. As of December 2, 2019, a total of 102 people infected with the outbreak strain of E. coli O157:H7 have been reported from 23 states. AZ (3), CA (4), CO (6), FL (1), IA (1), ID (3), IL (1), MD (4), MI (1), MN (3), MT (1), NE (1), NJ (7), NC (1), NM (2), OH (12), OR (1), PA (8), SD (1), TX (4), VA (4), WA (2), WI (31).

Illnesses started on dates ranging from September 24, 2019, to November 18, 2019. Ill people range in age from less than 1 to 89 years, with a median age of 25. Sixty-five percent of ill people are female. Of 98 ill people with information available, 58 hospitalizations have been reported, including 10 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.

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

At this time, there is no outbreak of E. coli occurring in Canada. There is one Canadian illness related to the U.S. outbreak that has been identified in the province of Manitoba. This individual became ill in mid-October.

A bit of recent problems with romaine:

 2019

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.

Additional Resources

• About E. coli – a complete online resource with information on symptoms and risks of E. coli infection
• Marler Clark E. coli Lawsuits and Litigation
• A downloadable Family Health Guide on E. coli (PDF)
• About Hemolytic Uremic Syndrome
• E. coli Information Video