Water water everywhere, but is it safe?

Potable water and the U.S. Centers for Disease Control: two things we take for granted.

CDC reports that during 2013–2014, a total of 42 drinking water–associated outbreaks were reported, resulting in at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was responsible for 57% of outbreaks and 13% of illnesses, and chemicals/toxins and parasites together accounted for 29% of outbreaks and 79% of illnesses. Eight outbreaks caused by parasites resulted in 289 (29%) cases, among which 279 (97%) were caused by Cryptosporidium and 10 (3%) were caused by Giardia duodenalis. Chemicals or toxins were implicated in four outbreaks involving 499 cases, with 13 hospitalizations, including the first outbreaks associated with algal toxins.

To provide information about drinking water–associated waterborne disease outbreaks in the United States in which the first illness occurred in 2013 or 2014 (https://www.cdc.gov/healthywater/surveillance/drinking-surveillance-reports.html), CDC analyzed outbreaks reported to the CDC Waterborne Disease and Outbreak Surveillance System through NORS (https://www.cdc.gov/nors/about.html) as of December 31, 2015. For an event to be defined as a waterborne disease outbreak, two or more cases must be linked epidemiologically by time, location of water exposure, and illness characteristics; and the epidemiologic evidence must implicate water exposure as the probable source of illness. Data requested for each outbreak include 1) the number of cases, hospitalizations, and deaths; 2) the etiologic agent (confirmed or suspected); 3) the implicated water system; 4) the setting of exposure; and 5) relevant epidemiologic and environmental data needed to understand the outbreak occurrences and for determining the deficiency classification.§ One previously unreported outbreak with onset date of first illness in 2012 is presented but is not included in the analysis of outbreaks that occurred during 2013–2014.

Public health officials from 19 states reported 42 outbreaks associated with drinking water during the surveillance period (Table 1) (https://www.cdc.gov/healthywater/surveillance/drinking-water-tables-figures.html).

One outbreak reported during 2013–2014 in an individual system led to 100 estimated illnesses associated with a wedding. The public health challenges highlighted here underscore the need for rapid detection, identification of the cause, and response when drinking water is contaminated by infectious pathogens, chemicals, or toxins to prevent and control waterborne illness and outbreaks.

30 sick: Salmonella linked to tuna

Marissa Harshman of the Spokesman-Review writes Clark County Public Health officials in Washington state were among the first to identify a nationwide salmonella outbreak linked to tuna loins and tuna steaks.

Locally, the case began with five reports of illness to Clark County Public Health in late August. Since then, the outbreak has grown to 30 cases in seven states and led to a recall of a California-based company’s tuna products.

The outbreak includes six confirmed and two presumed cases in Clark County, said Dr. Alan Melnick, Clark County health officer.

The investigation is continuing at the national level by the Food and Drug Administration and the Centers for Disease Control and Prevention.

“The fact that little, old Clark County was able to be one of the first people to pick up on this ongoing outbreak really highlights the strengths of this system we’ve developed,” said Madison Riethman, an applied epidemiology fellow at Clark County Public Health, during a county health board meeting Wednesday.

And what did little old Clark County do to publicize the outbreak, go public to try and prevent others getting sick.

The first rule of public health is, as encapsulated by Riethman, make public health look good.

Local health officials first learned of a possible outbreak on Aug. 29, when local laboratories reported five cases of salmonella, a bacteria that causes illness with symptoms such as diarrhea, fever and abdominal cramps. Typically, the department gets three to eight reports each month, Riethman said.

“The fact that we got five in one day was a big red flag,” she said.

Raw is risky: Ceviche source of V. cholera 01 in Minn

As we drove the five hours yesterday to Sawtell, NSW, for a week of (ice) hockey for Sorenne, and some R&R for me and Amy (mainly me), Amy was telling me about this one time, she went to Senegal (they speak French) in 2005, and the hosts offered her Tang but she didn’t want to drink it because she had been warned about the water.

Turns out there was an on-going cholera outbreak.

I was driving and thought, should I tell her that cholera is a member of the Vibrio genus?

I kept driving.

Today, while Sorenne is working it on the ice, I’m catching up and came across this report from friends at the Minnesota Department of Health (MDH) published by the U.S. Centers for Disease Control.

On August 20, 2016, the Minnesota Department of Health (MDH) was notified of a case of Vibrio cholerae infection. The isolate was identified as serogroup O1, serotype Inaba at MDH. CDC determined that the isolate was nontoxigenic. The patient was a previously healthy woman, aged 43 years, with history of gastric bypass surgery. On August 16, she experienced profuse watery diarrhea, vomiting, abdominal cramps, and headache. On August 18, she sought care and submitted the stool specimen that yielded the V. cholerae isolate. She reported no recent travel. However, she had consumed ceviche made with raw shrimp and raw oysters at restaurant A on August 14, 49 hours before illness onset. Her husband had a similar illness with a similar incubation period after eating the same foods at restaurant A.

On August 22, MDH sanitarians visited restaurant A and obtained tags and invoices for oyster and shrimp products; the oysters were a product of the United States, and the shrimp was a product of India. Sanitarians also gathered patron contact information and credit card receipts for August 12–14. Two additional patrons reported experiencing a gastrointestinal illness that met the case definition of three or more episodes of watery stool in a 24-hour period within 5 days of eating at restaurant A; one reported eating ceviche and oysters at restaurant A. Review of complaints to the MDH foodborne illness hotline revealed a previous complaint from two persons who reported experiencing watery diarrhea after eating raw shrimp ceviche (but no oysters) at restaurant A on August 2. These persons did not provide stool specimens, but their gastrointestinal illnesses met the case definition, resulting in a total of six cases, including one laboratory-confirmed case. No other V. cholerae O1 Inaba cases were reported in the United States during this outbreak.

The Minnesota Department of Agriculture facilitated sampling of shrimp at the distributor from the same lots served at restaurant A on August 14, and most likely during August 2–13, and sent them to the Food and Drug Administration for culture. Shrimp samples yielded V. cholerae non-O1, non-O139, but V. cholerae O1 was not isolated. In response to the outbreak results, restaurant A placed consumer warnings on their menus about the risks of consuming raw or undercooked food items and identified raw menu items for consumers. Restaurant A also focused on other actions that might facilitate reduction of V. cholerae, including appropriate freezing of food items, and allowing raw food items to soak in lime juice before being served, rather than serving the items immediately after adding lime juice (1,2).

V. cholera has over 150 serogroups and has been identified in a wide range of aquatic life, including seafood (3). Whereas multiple serogroups can cause vibriosis, only serogroups O1 and O139 that also contain the cholera toxin are classified as causes of cholera (4). Previous studies have documented the presence of nontoxigenic V. cholerae O1 from environmental and shrimp samples in India and Southeast Asia (5–7).

This outbreak of domestically acquired, nontoxigenic V. cholerae infections, likely from shrimp consumption, included the first V. cholerae O1 case identified in a nontraveler in Minnesota since active surveillance for Vibrio began in 1996. Since 1996, MDH has detected 26 V. cholerae infections, 21 (81%) of which were non-O1, non- O139, and five of which were O1. Among the four O1 type cases identified before the current outbreak, all patients had a recent travel history to Micronesia or India. This outbreak demonstrates the importance of investigating all seafood eaten by patients with vibriosis. In addition, investigators should include nontoxigenic V. cholerae as a possible etiology of domestic foodborne outbreaks, particularly when foods eaten include those from V. cholerae O1–endemic areas.

Notes from the field: Vibrio cholerae Serogroup O1, Serotype Inaba — Minnesota, August 2016

CDC MMWR

Victoria Hall, Carlota Medus, George Wahl, Alida Sorenson, Melanie Orth, Monica Santovenia, Erin Burdette, Kirk Smith

https://www.cdc.gov/mmwr/volumes/66/wr/mm6636a6.htm?s_cid=mm6636a6_e

 

1000 sick: As North America turns to Fall, another bumper crop of Cyclospora

CDC reports that as of September 13, 2017 they have been notified of 988 laboratory-confirmed cases of cyclosporiasis in persons who became ill in 2017. This number includes persons who reported international travel as well as persons who did not report travel. The reports have come from 40 states.

  • At least 553 (56%) of these persons did not report international travel (i.e., likely were infected in the United States) and became ill on or after May 1, 2017 (a date after which cases tend to increase each year). These 553 persons were from the following 36 states: Arizona (1), California (10), Colorado (6), Connecticut (23), Florida (68), Georgia (10), Illinois (17), Indiana (4), Iowa (14), Kansas (2), Louisiana (7), Maryland (12), Massachusetts (13), Michigan (3), Minnesota (11), Mississippi (1), Missouri (13), Montana (2), Nebraska (5), New Hampshire (4), New Jersey (19), New Mexico (1), New York (excluding NYC) (15), New York City (30), North Carolina (45), Ohio (16), Pennsylvania (2), Rhode Island (2), South Carolina (7), South Dakota (4), Tennessee (3), Texas (163), Utah (1), Virginia (7), Washington (1), West Virginia (2), and Wisconsin (9).
  • At this time, no specific vehicle of interest has been identified, and investigations to identify a potential source (or sources) of infection are ongoing. It is too early to say whether cases of Cyclosporainfection in different states are related to each other or to the same food item(s).

Previous U.S. outbreaks of cyclosporiasis have been linked to various types of imported fresh produce (e.g., basil, cilantro, mesclun lettuce, raspberries, snow peas). Consumers should continue to enjoy the health benefits of eating fresh fruits and vegetables as part of a well-balanced diet.

1 dead, over 200 sick: Salmonella Anatum infections linked to imported maradol papayas

This outbreak is one of four separate outbreaks currently under investigation that are linked to imported Maradol papayas from Mexico.

The Centers for Disease Control, public health and regulatory officials in several states, and the U.S. Food and Drug Administration (FDA) are investigating a multistate outbreak of Salmonella Anatum infections.

Public health investigators are using the PulseNet system to identify illnesses that may be part of this outbreak. PulseNet is the national subtyping network of public health and food regulatory agency laboratories coordinated by CDC. DNA fingerprinting is performed on Salmonella bacteria isolated from ill people by using techniques called pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). CDC PulseNet manages a national database of these DNA fingerprints to identify possible outbreaks. WGS gives a more detailed DNA fingerprint than PFGE.

This past spring, CDC investigated a multistate outbreak of Salmonella Anatum infections. Fourteen people infected with the outbreak strain of Salmonella Anatum were reported from three states. A list of the states and the number of cases in each can be found on the Case Count Map page. WGS showed that isolates from people infected with Salmonella Anatum were closely related genetically. This close genetic relationship meant that people in this outbreak were more likely to share a common source of infection.

Illnesses started on dates ranging from December 20, 2016, to April 8, 2017. Ill people ranged in age from less than 1 year to 85, with a median age of 38. Ninety-two percent were female. Among 11 people with available information, 10 (91%) were of Hispanic ethnicity. Among those 11 people, 5 (45%) were hospitalized. One death was reported from California.

In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Seven (88%) of eight people interviewed reported eating papayas. This proportion was significantly higher than results from a survey of healthy Hispanic people in which 22% reported eating papayas in the week before they were interviewed. In addition, four of these seven people reported buying papayas from the same grocery store chain.

While the epidemiologic information indicated that papayas were the likely source of this outbreak at the time, investigators could not determine the specific source of contaminated papayas and the outbreak investigation ended after illnesses stopped.

FDA informed CDC that a sample from an imported papaya identified Salmonella Anatum on September 4, 2017. This sample came from a papaya from a grower in Mexico named Productores y Exportadores de Carica Papaya  de Tecomán y Costa Alegre in Tijuana, Mexico. WGS showed that the isolate from the papaya and the isolates from the 14 people infected with Salmonella Anatum this past spring were closely related. Bravo Produce Inc. was a supplier of Maradol papayas to the grocery store chain where four of seven ill people reported buying papayas. After receiving FDA’s recent Salmonella isolate from papayas, CDC reviewed the PulseNet database to look for matching DNA fingerprints in bacteria from people who got sick after the investigation closed in the spring of 2017. Six more ill people have been identified and CDC is investigating to determine if these more recent illnesses are also linked to Maradol papayas imported by Bravo Produce Inc.

On September 10, 2017, Bravo Produce Inc. recalled Maradol papayas packed by Frutas Selectas de Tijuana, S. de RL de CV. The grower of the recalled Maradol papayas is Productores y Exportadores de Carica Papaya de Tecoman y Costa Alegre in Tijuana, Mexico. The papayas were distributed to California from August 10 to August 29, 2017. The recalled papayas can be identified by the label on the fruit from the packing company, Frutas Selectas de Tijuana.

This investigation is ongoing. CDC and state and local public health partners are continuing laboratory surveillance through PulseNet to identify additional ill people and to interview them. FDA continues testing papayas from Mexico to see if other papayas from other farms are contaminated with Salmonella. Investigations are ongoing to determine if additional consumer warnings are needed beyond the advice not to eat papayas from specific importers or farms. Updates will be provided when more information is available.

39 sick: You’re a cute puppy, yes you are, but you have Campylobacter

The Ohio Department of Health, several other states, the U.S. Centers for Disease Control, and USDA-APHIS are investigating a multistate outbreak of human Campylobacter infections linked to puppies sold through Petland stores.

Investigators are looking for the source of infections in people and puppies so they can recommend how to stop the outbreak and prevent more illnesses in order to protect human and animal health.

As of September 11, 2017, the outbreak includes 39 cases in 7 states (Florida, Kansas, Missouri, Ohio, Pennsylvania, Tennessee, and Wisconsin).

Illnesses began on dates ranging from September 15, 2016 through August 12, 2017. The most recent illness was reported on September 1, 2017.

Ill people range in age from <1 year to 64 years, with a median age of 22 years; 28 (72%) are female; and 9 (23%) report being hospitalized. No deaths have been reported.

Epidemiologic and laboratory findings have linked the outbreak to contact with puppies sold through Petland stores. Among the 39 ill people, 12 are Petland employees from 4 states and 27 either recently purchased a puppy at Petland, visited a Petland, or visited or live in a home with a puppy sold through Petland before illness began.

Whole genome sequencing showed samples of Campylobacter isolated from the stool of puppies sold through Petland in Florida were closely related to Campylobacter isolated from the stool of an ill person in Ohio. Additional laboratory results from people and dogs are pending.

Regardless of where they are from, any puppies and dogs may carry Campylobacter germs.

 

Raw milk is risky

I have friends who grew up on the farm their entire lives and insist on drinking raw milk as they feel that pasteurization completing devoid the milk of nutrients. I can preach about the dangers of consuming raw milk supported with scientific facts but that’s not going to change their minds. They’re adults, they can make their own choices; just don’t impose your choice on a child. When I was younger I was courting a girl who lived on a dairy farm in rural Manitoba (Canada). She insisted on drinking raw milk and offered some to me. I was aware that raw milk was risky but this way before my food safety days. So like many boys courting women, you sometimes make foolish mistakes and so I drank the milk. Puked it up. Not because of microbial reasons, just tasted horrible, maybe it was that batch, not sure.

Kristi Rosa reports
The Centers for Disease Control and Prevention (CDC) have issued an official health advisory regarding a rifampin/penicillin-resistant strain of RB51 Brucella that has been linked with the consumption of raw milk; this follows a alert issued by the Texas Department of State Health Services (DSHS) that was issued back in mid-August.

The DSHS defines raw milk as “milk from cows or other animals that has not been pasteurized to kill harmful bacteria.” Raw milk can be contaminated with several different bacteria, including Listeria, Salmonella, Escherichia coli, and Campylobacter—all bacteria that are known to be responsible for countless disease outbreaks.

The individual who contracted brucellosis is a Texas resident who was exhibiting fever, muscle and joint pain, as well as fatigue. The DSHS reports that blood culture revealed the bacteria responsible for these symptoms was, in fact, Brucella. Further investigation tracked the infection back to a potential source: a licensed raw milk dairy based in Paradise, Texas, called K-Bar Dairy.

The CDC stresses that any individuals who have consumed raw milk from this dairy between June 1, 2017 and August 7, 2017 should “receive appropriate post-exposure prophylaxis (PEP).” These individuals are thus at increased risk for infection and should contact their healthcare providers to inquire about PEP and undergo potential diagnostic testing.

K-Bar Dairy has fully cooperated with the CDC’s investigation and has contacted customers and advised them to dispose of any milk that may be contaminated. However, the dairy does not have a record of all customers, therefore, the DSHS alerted the public about the recall on August 14, 2017.

The rest of the story can be found here.

19 sickened: Temperatures matter; C. perfringens outbreak at a catered lunch Connecticut, 2016

The U.S. Centers for Disease Control reports in September 2016, the Connecticut Department of Public Health was notified of a cluster of gastrointestinal illnesses among persons who shared a catered lunch.

The Connecticut Department of Public Health worked with the local health department to investigate the outbreak and recommend control measures. Information about symptoms and foods eaten was gathered using an online survey. A case was defined as the onset of abdominal pain or diarrhea in a lunch attendee <24 hours after the lunch. Risk ratios (RRs), 95% confidence intervals (CIs), and Fisher’s exact p-values were calculated for all food and beverages consumed. Associations of food exposures with illness were considered statistically significant at p<0.05. Among approximately 50 attendees, 30 (60%) completed the survey; 19 (63%) respondents met the case definition. The majority of commonly reported symptoms included diarrhea (17 of 18), abdominal pain (15 of 16), and headache (7 of 15).

The median interval from lunch to illness onset was 5.3 hours (range = 0.4–15.5 hours) for any symptom and 7 hours (range = 2.5–13 hours) for diarrhea. Analysis of food exposures reported by 16 ill and 10 well respondents (four respondents did not provide food exposure information) found illness to be associated with the beef dish (RR = undefined; CI = 1.06–∞; p = 0.046) (Table). All 16 ill respondents reported eating the beef. Coffee was also associated with illness; however, all 13 coffee drinkers who became ill also ate the beef. Eating cake approached significance (p = 0.051); all 10 cake eaters who became ill also ate the beef.The caterer had begun preparing all dishes the day before the lunch. Meats were partially cooked and then marinated in the refrigerator overnight. In the morning, they were sautéed 2 hours before lunch. Inspection of the facility found the limited refrigerator space to be full of stacked containers that were completely filled with cooked food, disposable gloves that appeared to have been washed for reuse, and a porous wooden chopping block.

The caterer’s four food workers reported no recent illness. Stool specimens from the food workers and from four ill attendees all tested negative for norovirus, Campylobacter, Escherichia coli O157, Salmonella, and Shigella at the Connecticut State Public Health Laboratory. All eight specimens were sent to the Minnesota Department of Health Public Health Laboratory, where additional testing was available. Two specimens from food workers were positive for enterotoxigenic Escherichia coli by polymerase chain reaction, but no enterotoxigenic E. coli colonies were isolated. Seven specimens (four from food workers and three from attendees) were culture-positive for Clostridium perfringens, and specimens from all attendees contained C. perfringens enterotoxin. Pulsed-field gel electrophoresis of 29 C. perfringens isolates from the culture-positive specimens found no matches among attendee isolates, but demonstrated a single matching pattern between two food worker specimens. No leftover food items were available for testing.

C. perfringens, a gram-positive, rod-shaped bacterium, forms spores allowing survival at normal cooking temperatures and germination during slow cooling or storage at ambient temperature (1). Diarrhea and other gastrointestinal symptoms are caused by C. perfringens enterotoxin production in the intestines. Vomiting is rare and illness is usually self-limited, although type C strains can cause necrotizing enteritis (1).

Symptoms reported were consistent with C. perfringens infection, with a predominance of diarrhea, and median diarrhea onset time was at the lower end of the typical C. perfringens incubation period (6–24 hours) (1). C. perfringens enterotoxin detection in the stool of two or more ill persons confirms C. perfringens as the outbreak etiology (2). Both C. perfringens and enterotoxigenic E. coli can colonize asymptomatic persons (3,4), which might explain the presence of these pathogens in the stools of asymptomatic food workers. Pulsed-field gel electrophoresis did not identify the C. perfringens strain responsible for the outbreak, but findings add to the evidence for a wide variety of C. perfringens strains, not all producing C. perfringens enterotoxin (5).

C. perfringens outbreaks are typically associated with improper cooling or inadequate reheating of contaminated meats (1), which might have occurred with the beef dish. The restaurant was advised about the need for adequate refrigeration and best practices for cooling foods, including using stainless steel rather than plastic containers, avoiding filling containers to depths exceeding two inches, avoiding stacking containers, and ventilating hot food. Upon follow-up inspection, staff members discarded disposable gloves after one use, used only food-grade cutting boards, and maintained proper food temperatures for hot holding, cold holding, cooling, and reheating, as outlined in the Food and Drug Administration Food Code.

An estimated 1 million illnesses in the United States each year are attributable to C. perfringens, but fewer than 1,200 illnesses are reported annually with C. perfringens outbreaks (6). C. perfringens testing is not routine for foodborne outbreaks; even if testing is unavailable, C. perfringens should be considered when improper cooling, inadequate reheating, and improper temperature maintenance of meat are identified.

37 sick from Salmonella in turtles

Turtles in the 1960s and 1970s were inexpensive, popular, and low maintenance pets, with an array of groovy pre-molded plastic housing designs to choose from. Invariably they would escape, only to be found days later behind the couch along with the skeleton of the class bunny my younger sister brought home from kindergarten one weekend.

Maybe I got sick from my turtle.

Maybe I picked up my turtle, rolled around on the carpet with it, pet it a bit, and then stuck my finger in my mouth. Maybe in my emotionally vacant adolescence I kissed my turtle. Who can remember?

The U.S. Centers for Disease Control reports there are now – in yet another turtle outbreak – 37 people sick with Salmonella Agbeni in 13 states.

Illnesses started on dates ranging from March 1, 2017 to August 3, 2017

Of 33 people with available information, 16 have been hospitalized. No deaths have been reported.

Twelve (32%) ill people are children 5 years of age or younger.

Epidemiologic and laboratory findings link the outbreak of human Salmonella Agbeni infections to contact with turtles or their environments, such as water from a turtle habitat.

In interviews, ill people answered questions about contact with animals during the week before becoming ill. Fifteen (45%) of the 33 people interviewed reported contact with turtles or their environments, such as water from a turtle habitat, before getting sick.

In interviews with 9 ill people about where their turtles came from, 6 reported buying a turtle from a flea market or street vendor, or receiving the turtle as a gift.

In 2015, state and local health officials collected samples from turtles at a street vendor. Whole genome sequencing showed that the Salmonella Agbeni isolated from ill people in this outbreak is closely related genetically to the Salmonella Agbeni isolates from turtles. This close genetic relationship means that people in this outbreak are more likely to share a common source of infection.

Do not buy small turtles as pets or give them as gifts.

Since 1975, the FDA has banned selling and distributing turtles with shells less than 4 inches long as pets because they are often linked to Salmonella infections, especially in young children.

All turtles, regardless of size, can carry Salmonella bacteria even if they look healthy and clean. These outbreaks are a reminder to follow simple steps to enjoy pet reptiles and keep your family healthy.

This outbreak is expected to continue since consumers might be unaware of the risk of Salmonella infection from small turtles. If properly cared for, turtles have a long-life expectancy.

 

961 sick with Salmonella: About those chicks, stop kissing them

The U.S. Centers for Disease Control reports that since the last update on July 13, 2017, 172 more ill people have been reported. The most recent illness began on July 31, 2017.

CDC and multiple states are investigating 10 separate multistate outbreaks of Salmonella infections in people who had contact with live poultry in backyard flocks.

These outbreaks are caused by several DNA fingerprints of different Salmonella bacteria: Salmonella Braenderup, Salmonella Enteritidis, Salmonella Hadar, Salmonella I 4,[5],12:i-, Salmonella Indiana, Salmonella Infantis, Salmonella Litchfield, Salmonella Mbandaka, Salmonella Muenchen, and Salmonella Typhimurium.

The outbreak strains of Salmonella have infected a reported 961 people in 48 states and the District of Columbia.

Illnesses started on dates ranging from January 4, 2017 to July 31, 2017.

215 ill people have been hospitalized. One death has been reported.

Epidemiologic, traceback, and laboratory findings link the 10 outbreaks to contact with live poultry, such as chicks and ducklings, from multiple hatcheries.

In interviews, 498 (74%) of 672 ill people reported contact with live poultry in the week before illness started.

Contact with live poultry or their environment can make people sick with Salmonella infections. Live poultry can be carrying Salmonella bacteria but appear healthy and clean, with no sign of illness.