cilantroAs of August 3, 2015 (4pm EDT), CDC had been notified of 384 ill persons with confirmed Cyclospora infection from 26 states in 2015.

  • Most (226; 59%) ill persons experienced onset of illness on or after May 1, 2015 and did not report international travel prior to symptom onset.
  • Clusters of illness linked to restaurants or events have been identified in Texas, Wisconsin, and Georgia.
  • Cluster investigations are ongoing in Texas and Georgia.
  • Cluster investigations in Wisconsin and Texas have preliminarily identified cilantro as a suspect vehicle.
  • Investigations are ongoing to identify specific food
    item(s) linked to the cases that are not part of the identified clusters.

Previous U.S. outbreaks of cyclosporiasis have been linked to imported fresh produce, including cilantro from the Puebla region of Mexico. Read the related FDA Import Alert issued July 27, 2015.

Bali-Hai-Restaurant-San-DiegoBali Hai Restaurant (Likely Norovirus)

Dozens of people attending a banquet at Bali Hai Restaurant on Shelter Island in San Diego harbor last week were reportedly sickened, and health officials have been busy trying to figure out the source.

The event on July 29, sponsored by the San Diego chapter of the Society of Professional Journalists, drew 170 people, and 55 of them became ill. A few went to the hospital and paramedics reportedly took one there Saturday.

People who attended the banquet were being asked by officials with the San Diego County Department of Environmental Health to fill out a questionnaire about what they had eaten prior to becoming ill.

The restaurant serves Polynesian cuisine and is a popular wedding and banquet venue.

About 35 people were sickened after a wedding reception Friday night in Brewerton, NY, which is about 15 miles north of Syracuse. Nine of the 35 were reportedly taken via ambulance to local hospitals, but all have apparently been released.

As I said to San Diego media:

But food-safety attorney Bill Marler of Seattle said the tag violation could be a sign of a restaurant “cutting corners.”

“They’re called a critical violation for a reason,” Marler said as he prepared to leave Los Angeles for Minnesota. Such violations should have raised management concerns, he said.

Marler has been involved in food-poisoning cases since the 1993 Jack In The Box E. coli outbreak that killed four children and sickened more than 700 people eating undercooked hamburgers.

He said his firm also handled a 2003 case of E. coli bacteria at Pat & Oscar’s restaurants in San Diego County and a 2006 Shigella bacteria case at Filiberto’s in San Diego. His firm has won judgments or settlements totaling more than $600 million, he said.

Bali Hai has a legal problem if the norovirus is traced to an ill worker, Marler said. “Hopefully, they have insurance.”

Lawyer Marler said the Bali Hai outbreak might be considered medium-sized, since just in the past two months he’s seen a salmonella outbreak at a Boise, Idaho, delicatessen that sickened 300, a North Carolina BBQ incident that left 200 ill and a Kenosha, Wisconsin, outbreak that sickened 75.

“I sort of chuckled to myself,” Marler said. “I’m not sure the public is very sympathetic to journalists getting sick.”

Arrowhead-Lodge-banquet-roomArrowhead Lodge at Oneida Shores Park

The reception was being held at Arrowhead Lodge at Oneida Shores Park, where people can rent the facility from Onondaga County and arrange to bring in their own food.

Ann Rooney, Onondaga County deputy county executive, told a Syracuse news outlet that county and state health department officials were investigating the situation and that it had not yet been confirmed whether food was the source of the problem.

Rooney said that ambulances had taken nine people to emergency rooms at Crouse, St. Joseph’s and Upstate University hospitals and at Cortland Regional Medical Center. Two people were kept overnight, and everyone has now been treated and released, she added.

According to one hospital spokesman, the symptoms included diarrhea, vomiting, nausea and cramping.

County health department staff had interviewed 70 of 100 people who attended the event by Saturday afternoon, and half of them reported getting sick at the reception or afterwards, Rooney noted. She would not identify the food vendor at the wedding reception because the cause was still unknown.

e_coli-300x300Likely E. coli O157:H7 cases are being investigated by the Sacramento County Department of Health and Human Services.

Department spokesperson Laura McCasland told Food Safety News that four of the seven who tested positive for E. coli first exhibited symptoms for the pathogen.

McCasland said department investigators do not believe they are dealing with an ongoing outbreak. While the source has not yet been identified, they have no evidence that any retail grocery store is involved.

Food Safety News first learned of the Sacramento County outbreak from a reader who claims to have two children among the infected individuals. That source said that there are three hemolytic uremic syndrome, or HUS, cases among the seven individuals.

Screen-shot-2010-10-30-at-10_13_31-PMAs of July 30, 2015, the CDC had been notified of 358 ill persons with confirmed Cyclospora infection from 26 states in 2015.

Most (199; 56%) ill persons experienced onset of illness on or after May 1, 2015 and did not report international travel prior to symptom onset.

Clusters of illness linked to restaurants or events have been identified in Texas, Wisconsin, and Georgia. Cluster investigations are ongoing in Texas and Georgia.

Cluster investigations in Wisconsin and Texas have preliminarily identified cilantro as a suspect vehicle. Investigations are ongoing to identify specific food item(s) linked to the cases that are not part of the identified clusters.

Previous U.S. outbreaks of cyclosporiasis have been linked to imported fresh produce, including cilantro from the Puebla region of Mexico. Read the related FDA Import Alert issued July 27, 2015.

FDA Investigators found:

  • Human feces and toilet paper found in growing fields and around facilities; Inadequately maintained and supplied toilet and hand washing facilities (no soap, no toilet paper, no running water, no paper towels) or a complete lack of toilet and hand washing facilities;
  • Food-contact surfaces (such as plastic crates used to transport cilantro or tables where cilantro was cut and bundled) visibly dirty and not washed;
  • Water used for purposes such as washing cilantro vulnerable to contamination from sewage/septic systems;
  • In addition, at one such firm, water in a holding tank used to provide water to employees to wash their hands at the bathrooms was found to be positive for Cyclospora cayetanensis.

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 each year in the United States. The first outbreak in North America occurred in 1990 from contaminated water. Since then, several outbreaks of cyclosporiasis 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.

We invite you to submit articles or opinion pieces that relate to news topics or to our food safety system in general.  Our goal is to publish articles in their entirety; however, materials that are offensive or inaccurate will not be accepted.  For each article accepted, we will include a link to an author bio page with a one-paragraph biography, photo, and links to your website and Twitter account.

Screenshot-2015-02-01-11.33.16

Please contact us at info@foodsafetynews.com if you are interested in contributing articles to Food Safety News.

Pattegris-Paa-grillThe outbreak of Salmonella infections that may be linked to pork products has grown to 90 cases in several counties around the state. The ongoing outbreak is under investigation by state, local, and federal public health agencies.

With the increase in cases, state health officials have asked the federal Centers for Disease Control and Prevention (CDC) to send a special team to help with the investigation. This team of “disease detectives” will arrive in Washington next week.

ceeb8cb2-37e7-11e5-99e9-6315a5a2a013-1020x1051Disease investigators are searching for possible exposure sources from farm to table. An apparent link to pork consumption or contamination from raw pork is the strongest lead, though no specific source has yet been found. The likely source of exposure for some of the ill people appears to have been whole roasted pigs, cooked and served at private events.

The cases, many of which are in King County, appear to have been caused by the same rare strain of Salmonella bacteria, health officials said. The outbreak is linked to Salmonella I, 4, 5, 12:i:-, a germ that has been emerging nationally but has never before been seen in Washington state.

635699704564741722-Boise-Co-Op-signThe Central District Health Department (CDHD) investigated a Salmonella outbreak associated with the Boise Co-op deli – specifically food purchased from the deli after June 1, 2015.

As of the end of July, approximately 300 cases of Salmonella were associated with the outbreak. Test results showed Salmonella growth in raw turkey, tomatoes and onion.

Salmonella is a bacteria that can cause diarrheal illness in humans. They are microscopic living creatures that pass from the feces of people or animals to other people or other animals. There are many different kinds of Salmonella bacteria.

Salmonella serotype Typhimurium and Salmonella serotype Enteritidis are the most common in the United States.

image002Isn’t this where O.J. Simpson is being held?
Colton Lochhead of the Las Vegas Review-Journal reports that Public health officials are investigating a case of E. coli at the Lovelock Correctional Center, the Nevada Department of Corrections said Thursday.

Besides the confirmed case at the prison about 100 miles northeast of Reno, there are two suspected cases of E. coli being examined, the department said in a news release.

Corrections officials contacted the state’s Division of Public and Behavioral Health to investigate the cause and sent samples to the Centers for Disease Control and Prevention for testing, the release said.

“No other inmates or anyone in the general public have been reported as showing symptoms of or have been suspected of having E. coli in Nevada,” the release said.

donantonios_406x250This is a single outbreak that occurred among patrons who dined at Restaurant A (Don Antonio’s) between March 18, 2015 and March 20, 2015. The agent S. Enteritidis was confirmed by laboratory results. An ill food handler is the likely source of illness.

BACKGROUND

On Tuesday, March 24, 2015, the Los Angeles County Department of Public Health (LAC-DPH) received a foodborne illness report via the web (FBIR #23973). The initial complainant, Group A, reported 5 out of 5 ill after eating on Friday, March 20, 2015. Approximately 3 hours later, a second complainant, Group B (FBIR 23974), reported 2 out of 2 ill, and 4 hours later, a third complainant, Group C (FBIR 23978), reported 3 out of 7 ill. The following evening, March 25, 2015, a fourth complainant, Group D (FBIR 23987), reported 1 out of 4 ill. All four groups had eaten on the same date. Initial food items reported were enchiladas, tacos, chile relleno, beans, rice, chips, and salsa. Symptoms included diarrhea, abdominal cramps, fevers, body aches, and headaches. The Acute Communicable Disease Control Program (ACDC) initiated an outbreak investigation to determine the extent of the outbreak, risk factors for the disease, and steps needed to prevent further spread.

METHODS

An outbreak-associated case was defined as a person eating at the restaurant between March 18, 2015 and March 20, 2015 who 1) had a stool, urine, or blood sample taken which grew Salmonella, or 2) had diarrhea and fever, or 3) had diarrhea and two other symptoms. An outbreak-associated control was defined as a person who ate at the restaurant during the same period of time but did not become ill with any gastrointestinal symptoms.

  • LAC-DPH Environmental Health Services (EHS) contacted the parties on the FBIR complaints to obtain contact information and preliminary information for all members.
  • EHS conducted three inspections of the restaurant (3/25/2015, 3/27/2015, 4/1/2015).
  • EHS requested contact information for any other complaints of illness to the restaurant and all reservations made between March 16, 2015 and March 20, 2015.
  • ACDC contacted individuals on YELP who complained about foodborne illnesses after eating at the restaurant and requested that they report to the public health department.
  • ACDC created a food history and illness questionnaire for all the complainants from the FBIR’s and the one reservation group, called all patrons with contact information, and interviewed them via telephone.
  • ACDC collected data in MS Access and calculated frequency and distribution of symptoms among cases. Analyses of food items and combination of food items were also performed. All analyses were conducted using SAS 9.3 analysis software and MS Excel.
  • ACDC sent out a health advisory to hospitals requesting to be notified of salmonellosis patients who could potentially be cases of the outbreak.
  • ACDC created a separate questionnaire to interview employees on job duties, food history, and possible illnesses prior to the outbreak.
  • ACDC, in conjunction with the District Public Health Nurses (PHNs), conducted a site visit on March 27, 2015 to the restaurant to observe food preparation, interview employees, initiate the process of stool collection, and provide education.
  • ACDC and PHNs returned to the restaurant on March 30, 2015 and April 1, 2015 to collect stool samples and provide additional education to the managers and workers.
  • PHNs questioned all routinely reported Salmonella cases to determine if they had any connection to Restaurant A. Any new cases identified by the PHNs were additionally interviewed over the phone by ACDC with the food and illness history questionnaire.
  • PHNs collected any additional stool samples from the employees at their District Health Centers.
  • The Public Health Laboratory (PHL) tested all the employee stool specimens and provided results.
  • PHL serotyped and determined the pulsed-field gel electrophoresis (PFGE) patterns for all the employee and case isolates.

RESULTS

Setting

On Friday, March 20, 2015, multiple small groups gathered separately for meals at an LAC Restaurant. This restaurant is a dine-in Mexican restaurant offering a variety of traditional Mexican dishes, a full bar, and an outdoor seating option. Some food items include burritos, enchiladas, tacos, tamales, taquitos and tostadas. Margaritas and other alcoholic beverages are additionally available upon order. Patrons typically consume their food at the establishment. However, the restaurant also offers a take-out option. Among the four groups, 11 out of 18 people eating at the restaurant reported becoming ill. EHS obtained line lists of the diners and ACDC interviewed patrons via telephone. For Group A, interviews were obtained for 5 individuals (100%). For Group B, two interviews were completed (100%) and for Group C, 2 out of 7 (29%). For Group D, we made contact with 2 out of 5 (40%) members. ACDC emailed electronic copies of the survey to Group D’s controls because only email addresses had been provided. Approximately 3 weeks later (on 4/14/2015), a FBIR was received for Group E reporting 3 ill individuals who ate on 3/19/15. Three out of 3 (100%) case interviews were completed. Collectively, food and illness history questionnaires were completed for 14 out of 22 (64%) individuals.

The PHNs were notified of the outbreak and 9 additional cases connected to the restaurant were discovered. These cases had eaten at the restaurant between 3/18/15 and 3/20/15. ACDC made contact with 8 out of the 9 cases (89%). One case did not want to return the phone calls from ACDC. However, the District Nurse was able to gather some preliminary food and illness history during her standard Salmonella surveillance interview.

From these 9 confirmed cases, 5 controls were identified. One eating partner of a confirmed case reported illness but did not meet the case definition. Many controls were non-responsive and could not be included in the analysis. In total, 23 cases and 6 controls were identified. Stool and blood samples were collected by the private medical facilities the cases visited. Isolates from these cases are routinely forwarded to the PHL for PFGE testing. Therefore, ACDC did not need cases to submit stools to the PHL for confirmation.

Cases – Restaurant Patrons

The median age of cases was 37 years, ranging from 3-83 years (Table 1). Cases were both male (40%) and female (60%). The controls also included males (33%) and females (67%) with a median age of 30 years (range: 17-47 years) (Table 2). Main symptoms of cases included diarrhea (100%), abdominal cramps (95%), nausea (77%), fever (68%), and chills (64%) (Table 3). Illness onsets occurred between March 20, 2015 and March 25, 2015 (Figure 1). The median incubation period was 26.5 hours (range: 2 to 122 hours). The duration for cases was approximated due to several cases still experiencing major symptoms at the time of the interview. The median duration was at least 5 days (range: at least 3 days to at least 11 days). Thirteen restaurant patrons had confirmed positive Salmonella Enteritidis laboratory cultures with the PFGE pattern JEGX01.0002. This includes the party of the fifth complainant, FBIR 24085, who reported on 4/14/2015. Two case isolates were submitted to CDC for whole genome sequencing.

Food Analysis

The results of the analysis of food items eaten by the patrons are shown in Table 4. All groups were combined for food analysis because many food items were shared across parties. Each party also had a limited number of individuals or respondents. Since only a few groups ate with people who did not report illness, these controls could also be compared to cases from other groups. No food items were found to be significantly associated with illness. The most common food items eaten by cases were rice (78%), chips (78%) and beans (67%). For controls, it was chips (78%), rice (78%), beans (67%) and salsa (67%). These foods are commonly served to all patrons as an appetizer or sides to the main dish. Also, because they were eaten by both ill and non-ill individuals, they are unlikely to be the source of illness.

Restaurant A

Inspection

Restaurant A is a casual dining restaurant open 7 days a week for lunch and dinner. It is frequented by families and friends who gather to share a meal or to celebrate special events. Employees are responsible for all the preparation and service of the food. Some patrons reported consuming items at the establishment and others had consumed the food elsewhere. The inspection by EHS on March 25, 2015 revealed violations such as improper holding temperatures, unapproved equipment usage, and the need for sanitization of utensils. During the inspection on March 27, 2015, EHS noticed failure to clean a cutting board after pounding raw chicken and an unapproved immersion blender paddle in use. The possibility for cross contamination during preparation of chile rellenos from raw shell eggs was also observed. The restaurant voluntarily closed that weekend (March 27-March 28, 2015) for terminal cleaning.

On April 1, 2015, EHS conducted a third inspection of the restaurant. All violations that were noted on the prior two inspections had been abated. The District Inspector followed up within two weeks with a standard graded inspection.

Employees

There were 36 employees reported to ACDC. Contact was made with all 36 employees (100%). One food server admitted to gastrointestinal symptoms which began on 3/23/2015 and lasted for 5 days. This individual took time off while sick and tested negative for Salmonella/Shigella. Like the rest of the restaurant staff, this employee frequently eats at the restaurant and did not admit to any ill contacts. All other employees denied symptoms of gastrointestinal illnesses in themselves and members of their household during the month preceding the outbreak. Stool samples were collected from the entire staff, 36 out of 36 employees (100%). The PHL performed the test for results. Nine employees had positive culture for S. Enteritidis, with PFGE pattern JEGX01.0002. These are identical to the serotypes and PFGE patterns of the patrons. One employee isolate was submitted to CDC for whole genome sequencing.

ACDC worked with the restaurant owner to ensure that these nine employees were either removed from the restaurant until they were cleared by standard procedures or were placed in duties that did not involve food handling. No employee tested positive for Shigella. All other workers yielded negative test results for both Salmonella and Shigella.

DISCUSSION

This is a laboratory confirmed S. Enteritidis outbreak. The PHL, in conjunction with private labs, yielded a total of 22 positive Salmonella tests. The nine positive employees included managers, cooks, waiters, bartenders and cleaning staff. Patrons who tested positive were from separate groups and had eaten at different times or dates. Several cases were identified from routine Salmonella surveillance rather than foodborne illness reporting. Presumptive cases also reported severe symptoms such as ongoing diarrhea, fever, headaches and body aches. No food item was found to be significantly associated with illness.

According to the Centers for Disease Control and Prevention, Salmonella results in symptoms of diarrhea, fever and abdominal cramps. Individuals generally become symptomatic 12 to 72 hours after being infected and remain so for approximately 4-7 days. Children, the elderly, those immunocompromised, and individuals with severe symptoms may require hospitalization. Salmonella infections are more commonly seen in the summer. Certain food items and meats are known to cause Salmonellosis when not properly heated. Such products served at this restaurant include eggs, pork, beef and chicken. When undercooked, these foods can be the source of bacterial infections. Raw fruits and vegetables such as lettuce, tomatoes and radishes could also be contaminated by the drippings of these products, while in the field, or during packaging and shipping1.

The spread of Salmonella in this restaurant could have been through employees, cross contamination or an undercooked or raw ingredient that infected both patrons and the employees. Infected individuals can excrete the bacteria in their feces for a few days or several weeks, depending on how quickly their bodies are able to get rid of the illness2 (Heymann). Salmonella can remain in a person’s system even after symptoms have resolved. Food handlers are possible sources of Salmonella due to the nature of their work2,3,4. Appropriate measures were taken to prevent additional spread. No cases occurred after Salmonella positive employees were removed and thorough cleaning and sanitizing of the kitchen.

LIMITATIONS

The food analysis is limited by the small number of controls available for the analysis. Having few cases and even fewer controls reduces statistical power and decreases the likelihood of calculated p-values being statistically significant. A small number of groups had controls. Due to a low response rate, attempts to get controls through reservations, take-out orders, and online solicitation were not successful.

Cases that are found through routine Salmonella surveillance occasionally have difficulties recalling when and what they ate at the restaurant. Persons may eat out frequently and the restaurant is one of many exposures. More time has also passed for these cases compared to the individuals who report foodborne illness. As a result, it is also harder to remember the date and time their symptoms first began. These are individuals who have already been diagnosed and may be several days out from their symptoms.

PREVENTION

EHS educated restaurant owners and managers about sanitization and ways to prevent future Salmonella infections. Some recommendations included using separate preparation surfaces for raw foods and produce, methods to properly rid surfaces of contamination and buying pasteurized products to eliminate risk. Additional recommendations include proper hand washing after using the restroom and monitoring employees for signs of illnesses3. The PHNs and ACDC educated all the restaurant workers and individual salmonellosis cases on the spread of Salmonella and the importance of staying home when ill to prevent spreading sickness.

CONCLUSION

This is a single outbreak that occurred among patrons who dined at Restaurant A between March 18, 2015 and March 20, 2015. The agent S. Enteritidis was confirmed by laboratory results. An ill food handler is the likely source of illness. No additional complaints or illnesses have been reported for Restaurant A since the restaurant has taken appropriate measures to remove all potential causes of this outbreak. ACDC in conjunction with EHS will monitor for future reports of foodborne illness from Restaurant A.

Full Report is Linked Here – includes all attachments, charts and references.  I am not sure why the report says “Restaurant A.”

tarheelThe Salmonella outbreak connected with the Tarheel Q restaurant in Lexington, NC, has been deemed over with at least 280 people sickened, according to a July 28 case count. One person died.

The designation was announced after two incubation periods (six days for most Salmonella cases) had passed without new illnesses since the restaurant reopened. Local health departments will no longer accept additional reports of illness.

The 280 cases were distributed across 21 North Carolina counties and 6 states. Of the North Carolina cases, 77 percent were residents of Davidson County and Davie County.

Laboratory testing indicated that the BBQ sample and a sample from a patient who became ill during the beginning of the outbreak were both positive for Salmonella species. The serogroup was Typhimurium, and both samples had the same PFGE pattern (DNA fingerprint). Three additional patients had a different PFGE pattern.

Fifty-eight percent of those sickened were male, 42 percent were between the ages of 20 and 49, and 9 percent had been hospitalized. Most cases had illness onset dates between June 16 and June 21.