An E. coli O157:H7 outbreak on top of two Cyclospora and two Salmonella outbreaks under investigation makes for a busy Summer for the FDA and its other public health partners. Other active investigations are Salmonella in cookie dough, hepatitis A in strawberries and a deadly Morel Mushroom outbreak in Montana.
Public Health is investigating an outbreak of six people infected with Salmonella Berta, a specific type of Salmonella. All six cases are linked through genetic fingerprinting (whole genome sequencing) which indicates they likely have a common source of infection. These cases were reported from April 14, 2023, to June 12, 2023. Most people who were interviewed reported eating pork (e.g., a variety of pork cuts cooked at home) and different types of seafood (e.g., fish and crab) but no source has been identified. The investigation is ongoing.
Since April 14, 2023, six people from six separate households reported becoming sick. The people who became sick ranged in age from 2 to 65 years old. All the people developed one or more symptoms consistent with salmonellosis, including nausea, vomiting, abdominal cramps, diarrhea, bloody stool, fever, and chills. Their illnesses onset between April 12, 2023, and June 5, 2023.
Public Health conducted interviews with the people sick with salmonellosis to identify potential common exposures and identified that some common exposures were pork and seafood. Environmental Health Investigators began traceback of meat products on June 21, 2023. They collected invoices from different places where some people got food and conducted inspections. A common location or source has not been identified.
All six cases had confirmatory testing for Salmonella and had the same strain of Salmonella Berta based on genetic fingerprinting (whole genome sequencing or WGS) at the Washington State Public Health Laboratory.
In Poisoned, award-winning investigative journalist and #1 New York Times bestselling author Jeff Benedict delivers a jarringly candid narrative of the fast-moving disaster, drawing on access to confidential documents and exclusive interviews with the real-life characters at the center of the drama—the families whose children were infected, the Jack in the Box executives forced to answer for the tragedy, the physicians and scientists who identified E. coli as the culprit, and the legal teams on both sides of the historic lawsuits that ensued. Fast Food Nation meets A Civil Action in this riveting account of how we learned the hard way to truly watch what we eat.
Here is the Netflix trailer:
Harris County Public Health (HCPH), the Houston Health Department and Fort Bend County Health & Human Services, have received reports of an increased number of Cyclospora infections within their jurisdictions and urge people to use caution this summer while cooking and spending time outdoors.
Cyclospora is a non-life-threatening gastrointestinal illness caused by an intestinal parasite. This parasite causes an intestinal infection called cyclosporiasis. People can become infected by consuming contaminated food or water.
In Texas, increased cases of Cyclosporiasis tend to occur seasonally between the months of April and August and symptoms tend to appear between two to 14 days. Cases have been associated with the consumption of – but not limited to – fresh produce, including fresh cilantro, raspberries, basil, snow peas, and mesclun lettuce.
Most individuals recover with no significant health effect; however, those who are immunocompromised, infants, or elderly, may be more affected and potentially require hospitalization for treatment.
Cyclospora infects the small intestine (bowel) and usually causes watery diarrhea, with frequent, sometimes explosive, bowel movements. Other common symptoms include loss of appetite, weight loss, stomach cramps/pain, bloating, increased gas, nausea, and fatigue. Vomiting, body aches, headache, fever, and other flu-like symptoms may be noted.
Some people who are infected with Cyclospora do not have any symptoms. If not treated, the illness may last from a few days to a month or longer. Symptoms may seem to go away and then return one or more times (relapse). It’s common to feel very tired. It is important to note that the disease cannot be transmitted through direct person-to-person contact.
The health departments are investigating the cases and would like to remind people that some gastrointestinal illnesses can spread quickly, especially during the summer.
Here are some prevention tips:
• Wash your hands with soap and water thoroughly for at least 20 seconds before and after preparing food.
• Wash all fruits and vegetables before eating, cutting, or cooking.
• Wash all cutting boards, utensils, and surfaces to avoid cross-contamination.If you or a loved one experience any of these symptoms, please reach out to your healthcare provider.
More than 100 people are sick in a new outbreak of infections caused by the microscopic Cyclospora parasite, but federal officials have not yet determined the source.
As of July 6, the Food and Drug Administration reported 105 patients had been confirmed in the outbreak. The agency has not reported where the patients live.
Public health officers from the FDA have begun sample collection and analysis, but the agency has not reported what food or foods are being tested.
The new outbreak of Cyclospora infections is the third the FDA has reported so far this year. One of the investigations has been closed without the agency determining the source of the microscopic parasite.
The Centers for Disease Control and Prevention is tracking another outbreak that has sickened 210 people across 22 states as of its most recent update in June. Thirty people in the outbreak have been so sick they required hospitalization.
The CDC first reported on the outbreak on May 25. The first date of onset of the infections was April 1. No specific food items have been identified as the source of the parasite.
The other active Cyclospora outbreak investigation underway by the FDA continues to slowly log more patients. As of this week the outbreak sickened 37 people, up one from the past week. The FDA has not discovered the source of the parasite in this outbreak.
Cyclospora infections generally increase in the summer months but can occur at any time. In the past the infections have been traced to fresh produce such as cilantro and lettuce.
Food safety experts say there’s no evidence that washing produce will remove the parasite.
Really, what is the point of not telling the public – “who made the salad?”- with a dash of Cyclospora.
If consumers are left in the dark, how is the “free market” ever going to reward producers that do not poison customers and punish those that do? Isn’t that the point of transparency for consumer products? Let the consumer decide what lettuce to buy based upon knowing facts. Having public servants hide information from the public they serve is simply wrong. The CDC and FDA need to do better.
Here is the full article in todays MMWR.
Cyclosporiasis is a gastrointestinal infection caused by a protozoan parasite, Cyclospora cayetanensis. This species is only known to infect humans and is acquired when oocysts are ingested through food or water contaminated with feces that contain the parasite. The illness was first reported in 1979, and the organism was identified and named in 1994 (1). Historically, infections were typically acquired outside of the United States or from produce that was imported into the United States (1). In recent years, the number of reported U.S. cases has been increasing: cases more than doubled from 537 in 2016 to 1,194 in 2017, and then nearly tripled, to 3,519 cases in 2018; in 2019, 4,703 cyclosporiasis cases were reported.* Recently, the parasite has been found on domestically grown produce (2), and infections have been attributed to these foods (3). Produce washing will decrease but not eliminate the parasite (1).
In Florida, reported numbers of cyclosporiasis cases have been increasing over the last 10 years; 254 cases were reported in Florida in 2021, and the number doubled to 513 in 2022, including 486 (95%) laboratory-confirmed cases and 27 (5%) probable cases. Specimens from 276 (54%) cyclosporiasis patients were submitted to CDC’s Cyclospora genotyping project, including 211 (76%) which were matched to a specific temporal-genetic cluster code§ (4). Among the 513 cases reported in 2022, 469 (91%) patients reported illness onset during May 1–August 31, 2022, with a peak in early July.
The Florida Department of Health required that county public health personnel complete the CDC Cyclosporiasis National Hypothesis Generating Questionnaire (CNHGQ) for all patients with illness onset dates during May 1–August 31, 2022. Among 457 completed questionnaires 330 (72%) respondents reported exposure information with no international travel, including 200 (61%) who reported exposure to bagged salad, a commercially produced package of prewashed salad greens. Among respondents reporting exposure to bagged salad, 85 (43%) noted a specific brand of Caesar salad kit containing only romaine lettuce, from a specific grocery store chain. Onset dates for this case cluster occurred during June 23–July 16, with a median disease onset date of July 1. An additional 76 persons with cyclosporiasis reported exposure to Caesar salad kits, but these persons either could not recall the salad kit brands or had purchased them from a different chain for a total of 161 potentially linked cases. Outbreaks of cyclosporiasis have been previously linked to bagged salads in the past (4). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.
CDC uses a genotyping tool to aid epidemiologic case linkage in near-real time. Among 211 successfully genotyped specimens from Florida, 153 (73%) were assigned to the same temporal genetic cluster (2022_001), including 43 (96%) of 45 genotyped specimens linked to the bagged salad cluster and 30 (39%) of the 76 persons reporting Caesar salad kits with no further identifying information. This information was shared with the Food and Drug Administration along with source information for the implicated product from the grocery store chain to facilitate traceback of the product; however, the source of the likely contaminated product was not identified.
In this investigation, results from genotyping analysis demonstrated strong agreement between the genotyping and epidemiologic data. The combination of the completed CNHGQ and genetic data strengthens evidence for identifying cases potentially linked to the same source of infection and can guide future investigations.
1. Ortega YR, Sanchez R. Update on Cyclospora cayetanensis, a food-borne and waterborne parasite. Clin Microbiol Rev 2010;23:218–34. https://doi.org/ PMID:20065331
2. Beach C. FDA documents first Cyclospora contamination of U.S. fresh produce. Seattle, WA: Food Safety News; 2018; https://www.foodsafetynews.com/2018/09/fda-documents-first-cyclospora-contamination-of-u-s-fresh-produce/
3. Hoang LMN, Fyfe M, Ong C, et al. Outbreak of cyclosporiasis in British Columbia associated with imported Thai basil. Epidemiol Infect 2005;133:23–7. https://doi.org/ PMID:15724706
4. Barratt J, Ahart L, Rice M, et al. Genotyping Cyclospora cayetanensis from multiple outbreak clusters with an emphasis on a cluster linked to bagged salad mix—United States, 2020. J Infect Dis 2022;225:2176–80. https://doi.org/ PMID:34606577
Rehme P. Notes from the Field: Doubling of Cyclosporiasis Cases Partially Attributable to a Salad Kit — Florida, 2021–2022. MMWR Morb Mortal Wkly Rep 2023;72:751–752. DOI: http://dx.doi.org/10.15585/mmwr.mm7227a3
CDC — Notes from the Field: Doubling of Cyclosporiasis Cases Partially Attributable to a Specific Salad Kit — Florida, 2021–2022
Increase in gastrointestinal illnesses in Florida in 2022 linked to salad kits:
• Cyclosporiasis is a gastrointestinal infection caused by a parasite acquired through ingestion of food or water contaminated with feces that contain the parasite. After the reported number of cases doubled in Florida during 2022, investigators analyzed patient data to identify a common source for the increased number of infections.
• Of the 457 patients who completed questionnaires, 200 (43%) reported exposure to bagged salad, of which 85 (43%) noted a specific brand of Caesar salad kit (containing only Romaine lettuce) from a specific grocery store chain; these data, matched with specimen genotyping, helped identify a particular brand of bagged salad kit as the source of infection. This information was shared with the U.S. Food and Drug Administration and the grocery store chain to facilitate product traceback; however, the source of the contamination was not identified.
Will the FDA and CDC tell us – “Who made the Salad?” And, why are they telling us about a 2021-2022 outbreak in 2023?
Look for it on Netflix in early August.
Also, a good time to order the book – https://www.amazon.com/Poisoned-Deadly-Outbreak-Changed-Americans/dp/B0BPKKCSM3
I guess you liked the T-shirts?
According to the AP:
U.S. health officials will start formally tracking infections caused by the rare but potentially deadly germ that sickened babies and triggered a nationwide shortage of infant formula last year.
A group that advises the Centers for Disease Control and Prevention agreed Thursday to add infections caused by cronobacter to the list of serious conditions reported to the agency. There are about 120 infections and diseases on the national watchlist.
States will be asked, but not required, to notify the CDC about cronobacter infections, although they usually comply. Such infections are required to be reported now in only two states, Minnesota and Michigan. The change will take effect next year, though states may begin reporting earlier.
The action by the Council of State and Territorial Epidemiologists, a nonprofit group, caps months of demands from experts and food safety advocates who called for better surveillance of the deadly infections that typically strike the most vulnerable babies. The move establishes standard criteria for identifying and counting probable and confirmed cronobacter cases and recommends that states require them to be reported.
In April of this year I wrote the following post:
The Abbott infant formula recall could have been prevented. The FDA had reports of safety failures months before the contaminated formula sickened babies and caused two deaths.
Here is what the head of the FDA said in testimony to congress months ago:
The CDC receives reports on foodborne disease outbreaks from state, local, and territorial health departments. On average, CDC receives two to four Cronobacter case reports annually; however, because Cronobacter infection is not reportable in most states, the total number of cases that occur in the United States each year is not known.
Here is a bit of history about why having bacterial infections reportable make a difference.
California – 34 ill: From mid-November to mid-January, 9 cases of E. coli O157:H7-associated bloody diarrhea and the hemolytic-uremic syndrome had been reported in San Diego County, California and 1 child died. A total of 34 persons had bloody diarrhea, the hemolytic-uremic syndrome, or E. coli O157:H7 organisms isolated from stool during the period November 15, 1992, through January 31, 1993. E. coli O157:H7 was ultimately identified from 6 persons were indistinguishable from those of the Washington outbreak strain linked to Jack in the Box restaurants in Washington, Idaho, Nevada and California. All the pre-formed frozen hamburgers were produced by Von’s in California and shipped to those restaurants in those states.
According to public health officials:
Improved surveillance by mandating laboratory – and physician – based reporting of cases of E coli O157:H7 infection and the hemolytic uremic syndrome might have alerted health officials to this outbreak sooner, which could have resulted in earlier investigation and the institution of measures to prevent more cases.
Clearly, had E. coli O157:H7 been reportable, public health officials in California would have caught the illnesses and most likely prevented the hamburgers from being shipped to other states. Hundreds of people – specifically children – would not have been sickened and three would likely not have died.
The final outbreak report by the CDC found that nearly all illnesses in states other than California occurred AFTER the cluster of 34 cases that went unreported in California.
Washington – 602: On January 13, 1993, a physician reported to the Washington Department of Health a cluster of children with hemolytic uremic syndrome (HUS) and an increase in emergency room visits for bloody diarrhea. During January-February 1993, 602 patients with bloody diarrhea or HUS were reported to the state health department. 144 were hospitalized, 30 developed HUS and three died.
Idaho – 14: Following the outbreak report from Washington, the Division of Health, Idaho Department of Health and Welfare, identified 14 persons with culture-confirmed E. coli O157:H7 infection. 1 developed hemolytic uremic syndrome (HUS).
Nevada – 58: On January 22, after receiving a report of a child with HUS who had eaten at a local chain A restaurant, the Clark County (Las Vegas) Health District issued a press release requesting that persons with recent bloody diarrhea contact the health department. Of 58 persons whose illnesses met the case definition 9 were hospitalized and 3 developed hemolytic uremic syndrome (HUS).
So, do something to prevent the next Cronobacter Sakazakii outbreak from being larger than necessary.
Key Points:
Each year, infections from major foodborne pathogens are responsible for an estimated 9.4 million illnesses, 56,000 hospitalizations, and 1,350 deaths in the United States. (All foodborne illnesses account for over 40 million illnesses, 125, 000 hospitalizations and 3,000 deaths).
During 2022, annual incidences of illnesses caused by the pathogens Campylobacter, Salmonella, Shigella, and Listeria were similar to average annual incidences during 2016–2018; however, incidences of Shiga toxin-producing Escherichia coli (STEC), Yersinia, Vibrio, and Cyclospora illnesses were higher.
This report highlights lack of progress in reducing enteric infection incidence. The incidence of Salmonella infections during 2022 was above the Healthy People 2030 target. Also during 2022, the incidence of the most common domestically acquired infections, those caused by Campylobacter (17.4 per 100,000 population), was above the Healthy People 2030 target of 10.9. Poultry meat has been the most commonly identified source of Campylobacter infections in many countries for many years and is also estimated to be the most common U.S. source of Salmonella infections.
Further efforts to reduce contamination during poultry slaughter and processing are needed to reduce the incidence of Campylobacter, Salmonella, and other foodborne pathogens. In 2021, FSIS published new guidelines for poultry slaughter and processing establishments to control Campylobacter in raw poultry. Recommendations aim to reduce the incidence of pathogen colonization in birds (e.g., poultry vaccination and use of prebiotics and probiotics) and minimize contamination of poultry water, feed, and bedding. In 2022, FSIS proposed a new regulatory framework to control Salmonella in poultry products. In 2023, FSIS released a proposed notice of determination to declare Salmonella an adulterant in not-ready-to-eat breaded and stuffed chicken products. Reducing leafy green contamination by improving agricultural water safety, as promoted by FDA and the Food Safety Modernization Act, could also reduce Salmonella, STEC, Listeria, and other pathogens that cause foodborne illnesses.
