105 sickened, 1 death linked to Salmonella Newport outbreak originating in beef from dairy cattle, 2016-17

Contaminated ground beef was the likely source of a protracted outbreak of 106 Salmonella Newport infections, 42 hospitalizations, and one death in 21 states during October 2016–July 2017. While no direct link was found, whole genome sequencing suggests dairy cows were the ultimate outbreak source.

Foodborne outbreak investigations could be enhanced by improvements in the traceability of cows from their originating farms or sale barns, through slaughter and processing establishments, to ground beef sold to consumers.

In January 2017, the U.S. Centers for Disease Control (CDC) identified a cluster of Salmonella enterica serotype Newport infections with isolates sharing an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern, JJPX01.0010 (pattern 10), through PulseNet, the national molecular subtyping network for foodborne disease surveillance. This report summarizes the investigation by CDC, state and local health and agriculture departments, and the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS) and discusses the possible role of dairy cows as a reservoir for strains of Salmonella that persistently cause human illness. This investigation combined epidemiologic and whole genome sequencing (WGS) data to link the outbreak to contaminated ground beef; dairy cows were hypothesized to be the ultimate source of Salmonella contamination.

A case was defined as infection with Salmonella Newport with PFGE pattern 10 closely related to the outbreak strain by WGS, with bacterial isolation during October 1, 2016, through July 31, 2017. A total of 106 cases were identified in 21 states (Figure 1). Most illnesses ([72%]) were reported from southwestern states, including Arizona (30), California (25), New Mexico (14), and Texas (seven). Illness onset dates ranged from October 4, 2016, through July 19, 2017. Patients ranged in age from <1–88 years (median = 44 years), and 53 (50%) were female. Among 88 (83%) patients with known outcomes, 42 (48%) were hospitalized, and one died.

Initial interviews identified consumption of ground beef as a common exposure among patients. A focused questionnaire was developed to collect detailed information on ground beef exposure and to obtain shopper card information and receipts. Among 65 interviewed patients, 52 (80%) reported eating ground beef at home in the week before illness began. This percentage was significantly higher than the 2006–2007 FoodNet Population Survey, in which 40% of healthy persons reported eating ground beef at home in the week before they were interviewed (p<0.001) (1). Among the 52 patients who ate ground beef at home, 31 (60%) reported that they bought it or maybe bought it from multiple locations of two national grocery chains, and 21 (40%) reported that they bought ground beef from locations of 15 other grocery chains. Specific ground beef information was available for 35 patients. Among these, 15 (43%) purchased ground beef as chubs (rolls) of varying sizes (range = 2–10 lbs), 18 purchased it on a tray wrapped in plastic, and two purchased preformed hamburger patties. Twenty-nine patients reported that they bought fresh ground beef, four bought frozen ground beef, and four did not recall whether it was fresh or frozen when purchased. When asked about ground beef preparation, 12 (36%) of 33 patients reported that they definitely or possibly undercooked it.

Traceback Investigation

USDA-FSIS conducted traceback on ground beef purchased within 3 months of illness onset for 11 patients who provided shopper card records or receipts. Approximately 20 ground beef suppliers belonging to at least 10 corporations were identified; 10 of the 11 records traced back to five company A slaughter/processing establishments, seven of 11 traced back to five company B slaughter/processing establishments, and four of 11 traced back to two company C slaughter/processing establishments.

Product and Animal Testing

Opened, leftover samples of ground beef from three patients’ homes were collected for testing. All were purchased from one of two national grocery chains that had been identified by a majority of patients. One sample, collected from ground beef removed from its original packaging, yielded the outbreak strain. The other two samples did not yield Salmonella.

The outbreak strain was also isolated from four New Mexico dairy cattle. One was collected from a spontaneously aborted fetus in July 2016, and one was isolated from feces from a young calf in November 2016. The third isolate was identified by searching the USDA Animal and Plant Health Inspection Service National Veterinary Services Laboratory (USDA-APHIS NVSL) database for Salmonella Newport isolates collected from cattle in Arizona, California, Texas, New Mexico, and Wisconsin during January 2016–March 2017. Eighteen Salmonella Newport isolates were identified, including 13 from Texas, three from New Mexico, and two from Wisconsin. The only Salmonella Newport pattern 10 isolate identified was from a fecal sample from a New Mexico dairy cow collected during November 2016. The fourth isolate was from a USDA-FSIS routine cattle fecal sample collected at a Texas slaughter establishment in December 2016; USDA-FSIS determined the sample was from a dairy cow and identified the New Mexico farm of origin. Because of confidentiality practices, officials were not able to identify the farm or farms of origin for the dairy cows associated with the other three samples or whether the four dairy cows were associated with a single farm. None of the 11 patients with information for traceback ate ground beef produced at the Texas slaughter establishment.

Whole genome high-quality single nucleotide polymorphism (SNP) analysis* showed that 106 clinical isolates were closely related to each other genetically, to the four dairy cattle isolates, and to the leftover ground beef isolate (range = 0–12 SNP differences), suggesting that the Salmonella bacteria found in patients, ground beef, and dairy cattle all shared a common source. Thirty-nine additional clinical isolates with PFGE pattern 10 were determined to not be closely related and were excluded from the outbreak. No antibiotic resistance was detected among three clinical isolates tested by CDC’s National Antimicrobial Resistance Monitoring Laboratory.

Because the USDA-FSIS traceback investigation did not converge on a common production lot of ground beef or a single slaughter/processing establishment, and no ground beef in the original packaging yielded the outbreak strain, a recall of specific product was not requested. A public warning was not issued to consumers because specific, actionable information was not available (e.g., a specific brand or type of ground beef). Officials in New Mexico visited the dairy farm that was the source of the cow at the Texas establishment and noted no concerns about conditions or practices. However, this visit occurred late in the investigation, and conditions at the time of the visit might not have represented those present immediately before and during the outbreak. No samples from the environment or cows were collected during this visit.

Epidemiologic and laboratory evidence indicated that contaminated ground beef was the likely source of this protracted outbreak of Salmonella Newport infections. A significantly higher percentage of patients than expected ate ground beef at home, and a patient’s leftover ground beef yielded the outbreak strain. Dairy cows colonized or infected with the outbreak strain before slaughter are hypothesized to be the ultimate outbreak source. Most U.S. ground beef is produced from beef cattle; however, 18% is produced from dairy cows (2). Dairy cows are sold for beef production through sale barns or directly to slaughter establishments as they age or if their milk production is insufficient (2). Previous studies have demonstrated long-term persistence of Salmonella Newport in dairy herds (3,4), and a 1987 Salmonella Newport outbreak was linked to contaminated ground beef from slaughtered dairy cows (5). In the current outbreak, as has been observed in previous outbreaks, ground beef purchases traced back to numerous lots and slaughter/processing establishments (6). One possible explanation is that dairy cows carrying a high Salmonella load that overwhelmed antimicrobial interventions could have gone to multiple slaughter/processing establishments (7), resulting in contamination of multiple brands and lots of ground beef. This might explain the reason for failure to identify a single, specific source of contaminated ground beef.

This investigation identified the outbreak strain only in samples from dairy cattle from New Mexico. All four isolates from dairy cattle samples were closely related genetically by WGS to isolates from patients, providing further evidence of a connection between dairy cattle in New Mexico and the outbreak. The disproportionate geographic distribution of cases in the U.S. Southwest, including New Mexico, also suggests a possible regional outbreak source. Although limited in scope, the query of the USDA-APHIS NVSL data identified the outbreak strain only from one New Mexico dairy cow (isolate 3), and the sample collection date was consistent with the timing of illnesses in this outbreak. The overall prevalence and geographic distribution of the outbreak strain in cattle is not known, and it is possible that cattle in states other than New Mexico might have been infected or colonized with the outbreak strain.

This was a complex and challenging investigation for several reasons. First, the PFGE pattern in the outbreak was not uncommon in PulseNet, making it difficult to distinguish outbreak cases from sporadic illnesses associated with the same Salmonella Newport pattern. WGS analysis provided more discriminatory power to refine the outbreak case definition and excluded 39 cases of illness from the outbreak. However, sequencing is not currently performed in real time for Salmonella, thereby slowing the process of determining which cases were likely outbreak-associated. In addition, a direct pathway linking outbreak cases to dairy cows infected with the outbreak strain of Salmonella Newport could not be established. This is because product traceback did not converge on a single contaminated lot of ground beef, and investigators were unable to ascertain a link between the beef slaughter/processing establishments identified during traceback and the farms with dairy cows that yielded the outbreak strain. Tracing back ground beef purchased by patients to slaughter/processing establishments requires documentation such as receipts or shopper card records, and only 10% of patients had this information available. For this outbreak, tracing back cows at slaughter/processing establishments to the farm from which they originated was problematic because cows were not systematically tracked from farm to slaughter/processing establishments.

Four points along the “farm to fork” continuum provide opportunities to prevent consumers from becoming ill from contaminated ground beef. First, farms can implement good management practices for cattle health, including vaccination, biosecurity (e.g., controlling movement of persons and animals on farms, keeping a closed herd [so that no animals on the farm are purchased, loaned to other farms, or have contact with other animals], planning introduction of new animals and quarantining them, and performing microbiologic testing of animals), and cleaning and disinfection measures to decrease Salmonella burden in animals and the environments in which they reside, reducing the likelihood that Salmonella will enter beef slaughter/processing establishments (8). Second, slaughter/processing establishments are required to maintain Hazard Analysis and Critical Control Points systems to reduce Salmonella contamination as well as slaughter and sanitary dressing procedures to prevent carcass contamination (9). Third, although Salmonella is not considered an adulterant in not-ready-to eat (NRTE) meat products, USDA-FSIS likely will consider the product to be adulterated when NRTE meat products are associated with an outbreak (9). Finally, consumers are advised to cook ground beef to 160°F (71°C) as measured by a food thermometer to destroy any bacteria that might be present. Consumers are also advised to wash hands, utensils, and surfaces often; separate and not cross-contaminate foods; and refrigerate foods promptly and properly.

This investigation emphasizes the utility of WGS during outbreak investigations and identifies the need for improvements in traceability from the consumer to the farm. It also highlights the importance of continued evaluation of farm practices to help reduce persistent Salmonella contamination on farms, contamination of ground beef, and ultimately human illness.

Protracted outbreak of Salmonella Newport infections linked to ground beef: Possible role of Dairy Cows-21 states, 2016-2017

CDC

https://www.cdc.gov/mmwr/volumes/67/wr/mm6715a2.htm

Kis Robertson Hale, Food Safety and Inspection Service, U.S. Department of Agriculture; territorial, state, city, and county health departments and laboratories; Danya Alvarez, John Crandall, Hillary Berman-Watson, California Department of Public Health Microbial Diseases Laboratory.

 

Flour power: Raw is risky

When I was a kid, I had this multi-colored swim towel that stated Flower Power (right, not exactly as shown).

I should have known that if a 1960s slogan had been co-opted by towel manufacturers in the early 1970s, it was a sign of corporate greed rather than earth-tone sentiment.

For the past decade, raw flour has increasingly come under the food safety microscope.

Flour was suspect in a 2008 outbreak of Salmonella in New Zealand. In June, 2009, an outbreak of shiga-toxin producing E. coli (primarily O157:H7) in Nestle Toll House cookie dough sickened at least 77 people in 30 American states. Thirty-five people were hospitalized – from flour in the cookie dough.

Hemp seed flour sickened 15 Germans in 2010.

There was the U.S. General Mills outbreak of 2016 which sickened at least 56 people with the outbreak strain of E. coli O121 and O26, followed by a separate outbreak of E. coli O121 in Robin Hood flour in Canada in late 2016 going into 2017, that sickened at least 29.

It’s this latter outbreak that has journalist Jim Romahn’s attention.

Romahn writes the release of 759 pages of mostly e-mails indicates there was a massive effort involved in a recall of flour milled in Saskatoon that was contaminated with E. coli O121.

Twenty-two Canadians were identified as sickened by the flour, including one key case where the person consumed raw dough.

With hindsight, health officials were able to determine the first person sickened was Nov. 13, 2016. The others sickened and linked to the flour were between then and Feb. 26, 2017.

Robin Hood flour was identified as the source in March and on March 26 the Canadian Food Inspection Agency began a recall that eventually grew to scores of brand-name products across Canada and even an export shipment to Guyana.

The recall involved a number of major companies, such as Smucker Foods of Toronto and the Sobeys supermarket chain.

There were some unusual difficulties, including the challenge of contacting Mennonites who have no telephones.

The investigation and lab results eventually traced the source to flour milled at Ardent’s Saskatoon plant on Oct. 15, 16 and 17.

A high percentage of packages of flour milled on those dates turned up with E. coli O121.

But even then it’s not clear where the wheat originated.

Ardent Mills said it was probably spring wheat, but it could have also contained soft wheat, and that it probably was from the 2016 harvest, but might have had some wheat from the 2015 harvest.

That’s reflective of the amount of blending that happens both with the wheat used in milling and the flours that are blended into products for sale.

The documents were released under Access to Information at the request of a woman who spent time in a hospital in Medicine Hat, Alta.

 An Outbreak of Shiga Toxin–Producing Escherichia coli O121 Infections Associated with Flour – Canada, 2016–2017

MMWR Morb Mortal Wkly Rep 2017; 66: 705–706

Morton V, Cheng JM, Sharma D, Kearney A.

Waiter, is that romaine from Yuma? At least 53 sick across 16 US states with outbreak strain of E. coli O157:H7 linked to lettuce

David Meyer of Fortune magazine reports the U.S.’s mysterious E. coli outbreak now has a likely culprit: romaine lettuce grown around Yuma, Arizona. And consumers are being given conflicting advice on what to do to protect themselves.

The Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) said Wednesday that any consumers in the U.S. who have store-bought chopped romaine lettuce should throw it away. If they want to buy romaine lettuce from now on, they should first check with the store or restaurant that it wasn’t grown in the Yuma region, the agencies said.

However, Consumer Reports has gone a step further, advising people to avoid all romaine lettuce for the time being. Why? Because people may find it difficult to establish for sure that their lettuce does not come from the growing region that’s suspected to be the source.

Niraj Chokshi of the New York Times reported that CDC said in a statement, “If you do not know if the lettuce is romaine, do not eat it and throw it away,” the C.D.C..

The agency was first alerted to the outbreak by health officials in New Jersey, who had noticed an increase in E. coli cases in the state, said Dr. Laura Gieraltowski, an epidemiologist at the C.D.C. After some discussion, it became clear that many of those infected had eaten chopped romaine lettuce at restaurants before getting sick.

Concerned, the agency looked for related cases by checking PulseNet, a national network of laboratories that catalog samples of harmful bacteria from infected patients.

“When we looked back into our PulseNet system we saw that there were other cases in other states with the same DNA fingerprint,” Dr. Gieraltowski said.

The C.D.C. learned that the others infected by that particular strain, E. coli O157:H7, had also eaten chopped romaine lettuce at restaurants before getting sick, she said. It turned over the information to the Food and Drug Administration, which helped trace the outbreak to Yuma, Ariz.

To pinpoint the exact source, though, investigators would need samples of the tainted lettuce. But because of the short shelf life of lettuce and the time it takes for an outbreak to be identified, obtaining such a sample may prove difficult.

However, a cluster of eight illnesses in an Alaska prison may help pinpoint the source.

Dr. Joe McLaughlin, with the Epidemiology Section at the state Department of Health and Social Services, said health officials had responded last week to an outbreak of E. coli O157:H7 bacteria at the Anvil Mountain Correctional Center in Nome, Alaska.

None of the eight patients have died or been hospitalized, in cases which were noticed between April 5 and April 15. All ate “significantly higher” numbers of salads than other people at Anvil Mountain, however, and have shown the same symptoms.

“Our outbreak is the first one I know of that’s been associated nationally with the consumption of whole heads of lettuce rather than chopped lettuce,” McLaughlin said. “What this outbreak suggests is that the source of contamination may actually be at the farm rather than the actual processing of the lettuce.”

Duh.

CDC reports in its latest outbreak update  that information collected to date indicates that chopped romaine lettuce from the Yuma, Arizona growing region could be contaminated with E. coli O157:H7 and could make people sick.

At this time, no common grower, supplier, distributor, or brand has been identified.

Consumers anywhere in the United States who have store-bought chopped romaine lettuce at home, including salads and salad mixes containing chopped romaine lettuce, should not eat it and should throw it away, even if some of it was eaten and no one has gotten sick. If you do not know if the lettuce is romaine, do not eat it and throw it away.

Before purchasing romaine lettuce at a grocery store or eating it at a restaurant, confirm with the store or restaurant that it is not chopped romaine lettuce from the Yuma, Arizona growing region. If you cannot confirm the source of the romaine lettuce, do not buy it or eat it.

Restaurants and retailers should ask their suppliers about the source of their chopped romaine lettuce.

35 in 11 states sick with E. coli from Romaine lettuce grown in Arizona

It’s time to end the leafy greens cone of silence.

Top view of romaine lettuce that has been sliced on a wood cutting board.

This time it has made people unnecessarily sick.

I wouldn’t touch their product.

But how would I know?

On Sept. 14, 2006, the U.S. Food and Drug Administration announced that an outbreak of E. coli O157: H7 had killed a 77-year-old woman and sickened 49 others. The FDA learned from the Centers for Disease Control and Wisconsin health officials that the outbreak may have been linked to the consumption of produce and identified bagged fresh spinach as a possible cause.

Eventually, four would die and at least 200 sickened.

One of the responses was to form the Leafy Greens Marketing Agreement (LGMA) which apparently overseas most of the leafy greens production in the U.S.

They are known primarily for self-aggrandizing press releases.

And lots of rumors about how they inhibit epidemiological investigations into outbreaks of foodborne illness linked to their products (search ‘cone of silence’ on barfblog.com for plenty of examples)

According to the U.S. Centers for Disease Control, since the last update on April 10, 2018, 18 more people from 9 states were added to this outbreak.

How many of those could have been prevented if CDC or State health types fingered chopped Romaine lettuce when rumors started circulating? Is the goal of LGMA really to forego epi and demand absolute proof before going public?

As of April 12, 2018, 35 people infected with the outbreak strain of E. coli O157:H7 have been reported from 11 states. Illnesses started on dates ranging from March 22, 2018 to March 31, 2018. Ill people range in age from 12 to 84 years, with a median age of 29. Sixty-nine percent of ill people are female. Twenty-two ill people have been hospitalized, including three people who developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported.

Illnesses that occurred after March 27, 2018, might not yet be reported due to the time it takes between when a person becomes ill with E. coli and when the illness is reported. This takes an average of two to three weeks.

Epidemiologic evidence collected to date indicates that chopped romaine lettuce is the likely source of this outbreak. Twenty-six (93%) of 28 people interviewed reported consuming romaine lettuce in the week before their illness started. This percentage is significantly higher than results from a survey[787 KB] of healthy people in which 46% reported eating romaine lettuce in the week before they were interviewed. Most people reported eating a salad at a restaurant, and romaine lettuce was the only common ingredient identified among the salads eaten. The restaurants reported using bagged, chopped romaine lettuce to make salads. At this time, ill people are not reporting whole heads or hearts of romaine.

Traceback investigations are ongoing to determine the source of chopped romaine lettuce supplied to restaurant locations where ill people ate. At this time, no common grower, supplier, distributor, or brand has been identified. However, preliminary information indicates that the chopped romaine lettuce was from the Yuma, Arizona growing region.

Information collected to date indicates that chopped romaine lettuce from the Yuma, Arizona growing region could be contaminated with E. coli O157:H7 and could make people sick.

Advice to Restaurants and Retailers:

  • Restaurants and retailers should not serve or sell any chopped romaine lettuce, including salads and salad mixes containing chopped romaine lettuce, from the Yuma, Arizona growing region.
  • Restaurants and retailers should ask their suppliers about the source of their chopped romaine lettuce.

That’s right, consumers, it’s up to you.

It should be up to the restaurant or retailer, who markets food safety at point-of-purchase.

And LGMA, which covers Yuma growing, should be forthcoming about risks, rather than blowing themselves in nonsensical tweets.

17 sick in 7 states with E. coli O157:H7: Source not yet identified

CDC, several states, the U.S. Food and Drug Administration, and the U.S. Department of Agriculture’s Food Safety and Inspection Service are investigating a multistate outbreak of Shiga toxin-producing E. coli O157:H7 infections. The investigation is still ongoing and a specific food item, grocery store, or restaurant chain has not been identified as the source of infections. CDC is not recommending that consumers avoid any particular food at this time. Restaurants and retailers are not advised to avoid serving or selling any particular food. CDC will provide more information as it becomes available.

As of April 9, 2018, 17 people infected with the outbreak strain of E. coli O157:H7 have been reported from 7 states. A list of the states and the number of cases in each can be found on the Case Count Map page. Illnesses started on dates ranging from March 22, 2018 to March 31, 2018. Ill people range in age from 12 to 84 years, with a median age of 41. Among ill people, 65% are female. Six ill people have been hospitalized, including one person who developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported.

Kids, kids, the FoodNet data is back

The incidence of infections transmitted commonly through food has remained largely unchanged for many years. Culture-independent diagnostic tests (CIDTs) are increasingly used by clinical laboratories to detect enteric infections. CIDTs benefit public health surveillance by identifying illnesses caused by pathogens not captured routinely by previous laboratory methods.

Decreases in incidence of infection of Shiga toxin–producing Escherichia coli (STEC) O157 and Salmonella serotypes Typhimurium and Heidelberg have been observed over the past 10 years. These declines parallel findings of decreased Salmonella contamination of poultry meat and decreased STEC O157 contamination of ground beef.

As use of CIDTs continues to increase, higher, more accurate incidence rates might be observed. However, without isolates, public health laboratories are unable to subtype pathogens, determine antimicrobial susceptibility, and detect outbreaks. Further prevention measures are needed to decrease the incidence of infection by pathogens transmitted commonly through food.

Despite ongoing food safety measures in the United States, foodborne illness continues to be a substantial health burden. The 10 U.S. sites of the Foodborne Diseases Active Surveillance Network (FoodNet)* monitor cases of laboratory-diagnosed infections caused by nine pathogens transmitted commonly through food. This report summarizes preliminary 2017 data and describes changes in incidence since 2006.

In 2017, FoodNet reported 24,484 infections, 5,677 hospitalizations, and 122 deaths. Compared with 2014–2016, the 2017 incidence of infections with Campylobacter, Listeria, non-O157 Shiga toxin–producing Escherichia coli (STEC), Yersinia, Vibrio, and Cyclospora increased. The increased incidences of pathogens for which testing was previously limited might have resulted from the increased use and sensitivity of culture-independent diagnostic tests (CIDTs), which can improve incidence estimates (1). Compared with 2006–2008, the 2017 incidence of infections with Salmonella serotypes Typhimurium and Heidelberg decreased, and the incidence of serotypes Javiana, Infantis, and Thompson increased. New regulatory requirements that include enhanced testing of poultry products for Salmonella† might have contributed to the decreases.

The incidence of STEC O157 infections during 2017 also decreased compared with 2006–2008, which parallels reductions in isolations from ground beef.§ The declines in two Salmonella serotypes and STEC O157 infections provide supportive evidence that targeted control measures are effective. The marked increases in infections caused by some Salmonella serotypes provide an opportunity to investigate food and nonfood sources of infection and to design specific interventions.

FoodNet conducts active, population-based surveillance for laboratory-diagnosed infections caused by Campylobacter, Cryptosporidium, Cyclospora, Listeria, Salmonella, STEC, Shigella, Vibrio, and Yersinia in 10 sites that account for approximately 15% of the U.S. population (an estimated 49 million persons in 2016). FoodNet is a collaboration among CDC, 10 state health departments, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the Food and Drug Administration (FDA). Laboratory-diagnosed bacterial infections are defined as isolation of bacteria from a clinical specimen by culture or detection by a CIDT. CIDTs detect bacterial antigens, nucleic acid sequences, or, for STEC, Shiga toxin or Shiga toxin genes.¶ A CIDT-positive–only bacterial infection is a positive CIDT result without culture confirmation. Listeria cases are defined as isolation of L. monocytogenes or detection by a CIDT from a normally sterile site or from placental or fetal tissue in the instance of miscarriage or stillbirth. Laboratory-diagnosed parasitic infections are defined as detection of the parasite from a clinical specimen. Hospitalizations and deaths within 7 days of specimen collection are attributed to the infection. Surveillance for physician-diagnosed postdiarrheal hemolytic uremic syndrome (HUS) is conducted through a network of nephrologists and infection preventionists and hospital discharge data review. This report includes pediatric HUS cases identified during 2016, the most recent year for which data are available.

Incidence per 100,000 population was calculated by dividing the number of infections in 2017 by the U.S. Census estimates of the surveillance area population for 2016. Incidence measures include all laboratory-diagnosed infections reported. A negative binomial model with 95% confidence intervals (CIs) was used to estimate change in incidence during 2017 compared with that during 2014–2016 and 2006–2008. Because of large changes in testing practices since 2006, incidence comparisons with 2006–2008 used only culture-confirmed bacterial infections, and comparisons with 2014–2016 used culture-confirmed and CIDT-positive–only cases combined. For HUS, 2016 incidence was compared with that during 2013–2015.

Preliminary incidence and trends of infections with pathogens transmitted commonly through food-foodborne diseases active surveillance network, 10 U.S. sites, 2006-2017

CDC

Ellyn Marder

https://www.cdc.gov/mmwr/volumes/67/wr/mm6711a3.htm

Acknowledgments

Workgroup members, Foodborne Diseases Active Surveillance Network (FoodNet), Emerging Infections Program, CDC; Brittany Behm, Staci Dixon, Elizabeth Greene, Logan Ray, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Neal Golden, Steven Mamber, and Joanna Zablotsky Kufel, U.S. Department of Agriculture’s Food Safety and Inspection Service.

87 now sick from this kratom stuff in the U.S.

The investigation has expanded to include outbreak strains from three additional serotypes of Salmonella: Salmonella Javiana, Salmonella Okatie, and Salmonella Thompson.

The same strains of Salmonella Okatie and Salmonella Thompson were found in samples collected from kratom and from ill people.

47 more ill people from 25 states were added to this investigation since the last update on March 2, 2018.

At this time, CDC recommends that people not consume any brand of kratom in any form because it could be contaminated with Salmonella.

Kratom is also known as Thang, Kakuam, Thom, Ketom, and Biak.

Kratom is a plant consumed for its stimulant effects and as an opioid substitute.

CDC, public health and regulatory officials in several states, and the U.S. Food and Drug Administration are investigating a multistate outbreak of Salmonella infections.

Epidemiologic and laboratory evidence indicates that kratom is the likely source of this multistate outbreak.

No common brands or suppliers of kratom products have been identified at this time.

Because no common source of Salmonella-contaminated kratom has been identified, CDC is recommending against consuming any kratom.

Since the last update on March 2, 2018, investigators identified ill people infected with other types of Salmonella, including Salmonella Okatie, Salmonella Javiana, and Salmonella Thompson. Epidemiologic and laboratory evidence has linked these additional Salmonella illnesses to consuming kratom.

Health officials continue to collect various leftover and unopened kratom products to test for Salmonella contamination. Investigators in California collected leftover Phytoextractum brand kratom powder from an ill person in that state. The outbreak strain of Salmonella I 4,[5],12:b:- was identified in this sample. As a result of these findings, PDX Aromatics recalled kratom powder sold online between January 18, 2018 and February 18, 2018.

Investigators in Oregon and Utah collected kratom powder from retail locations and online retailers where ill people reported purchasing kratom. Outbreak strains of Salmonella Okatie and Salmonella Thompson were identified in these samples. No brand information was available for the kratom products collected in Oregon. The ill person in Utah purchased kratom powder from the website kratoma.com.

State and local health officials continue to interview ill people to ask about the foods they ate and other exposures before they became ill. Forty (73%) of 55 people interviewed reported consuming kratom in pills, powder, or tea. Most people report consuming the powder form of kratom. People who reported consuming kratom purchased it from retail locations in several states and from various online retailers.

Despite the information collected to date about where ill people purchased kratom, a single common brand or supplier of kratom has not been linked to the outbreak. At this time, CDC recommends that people not consume any brand of kratom in any form because it could be contaminated with Salmonella and could make people sick. This investigation is ongoing and we will provide updates as needed.

Raw is risky: Brucellosis from unpasteurized milk in Texas

In July 2017, the Texas Department of State Health Services (DSHS) Region 2/3 office reported a human case of brucellosis associated with the consumption of raw (unpasteurized) cow’s milk purchased from a dairy in Paradise, Texas. CDC’s Bacterial Special Pathogens Branch (BSPB) confirmed the isolate as Brucella abortus vaccine strain RB51 (RB51).

Brucellosis is a zoonotic bacterial disease that affects humans and many animal species. In humans, the disease is characterized by fever and nonspecific influenza-like symptoms that frequently include myalgia, arthralgia, and night sweats. Without appropriate treatment, brucellosis can become chronic, and life-threatening complications can arise. Human brucellosis transmitted by cattle was once common in the United States. Control strategies have focused on elimination of brucellosis through vaccination and surveillance of cattle herds, in addition to milk pasteurization. Because of these measures, domestically acquired human cases are now rare (1).

RB51, a live-attenuated vaccine used to prevent B. abortus infection in cattle, has been documented to cause human disease, most commonly through occupational exposures such as needle sticks (2). Importantly, unlike wild strains of B. abortus, RB51 does not stimulate an antibody response detectable by routine serological assays, requiring culture for confirmation. Additionally, RB51 is resistant to rifampin, a common treatment choice for human brucellosis (2,3). This case represents the first documented instance of human brucellosis caused by RB51 through consumption of raw milk acquired in the United States.

Following isolation of RB51 from the patient’s blood, bulk milk tank samples from the farm tested positive for RB51 by polymerase chain reaction and bacterial culture. Culture of individual milk samples from all 43 cows in the herd identified two RB51 culture-positive cows. Subsequent whole genome sequencing indicated genetic relatedness between the cow and human isolate.

In Texas, farm sales of raw milk products to the public are legal with a “Grade ‘A’ Raw for Retail” license, regulated by the DSHS Milk and Dairy Group. By the end of August, through correspondence with the dairy, DSHS had identified approximately 800 persons who might have visited the farm during June 1–August 7. On September 1, Texas DSHS and BSPB began notification calls to these households, recommending that all exposed persons (i.e., those who consumed raw milk products from the farm during June 1–August 7) seek medical attention and begin 3 weeks of postexposure prophylaxis, even if asymptomatic (4).

Contact information was available for 582 households. The notification was issued successfully to 397 (68.2%) households. Among these notified households, 324 (81.6%) identified at least one exposed household member. Contacted persons referred 34 additional potentially exposed households, including households from seven other states.* A nationwide press release and Health Alert Network Health Advisory were issued in September to facilitate further identification of exposed persons (5).

To date, there are no other confirmed cases associated with this investigation. CDC and Texas DSHS continue measures to increase awareness among health care providers and the public regarding unique challenges associated with treatment and diagnosis of RB51 in humans and the risks of consuming raw milk.

Notes from the Field: Brucella abortus vaccine strain RB51 infection and exposures associated with raw milk consumption

09.mar.18

CDC

Caitlin Cossaboom

https://www.cdc.gov/mmwr/volumes/67/wr/mm6709a4.htm?s_cid=mm6709a4_w

I love science: 28 sick from Salmonella in kratom

I go to group therapy most Fridays, because it keeps me humble.

Half are regulars, half are newbies, usually on some opioid path, of late.

The U.S. Centers for Disease Control along with public health and regulatory officials in several states, and the U.S. Food and Drug Administration (FDA) are investigating a multistate outbreak of Salmonella I 4,[5],12:b:- infections.

As of February 16, 2018, 28 people infected with the outbreak strain of Salmonella I 4,[5],12:b:- have been reported from 20 states. A list of the states and the number of cases in each can be found on the Case Count Map page. WGS performed on isolates from ill people were closely relatedly genetically. This means that people in this outbreak are more likely to share a common source of infection.

Illnesses started on dates ranging from October 13, 2017 to January 30, 2018. Ill people range in age from 6 to 67 years, with a median age of 41. Sixteen people are male. Eleven hospitalizations have been reported. No deaths have been reported.

WGS analysis did not identify any predicted antimicrobial resistance in isolates from five ill people. Testing of outbreak isolates using standard antibiotic susceptibility testing methods is currently underway in CDC’s National Antimicrobial Resistance Monitoring System (NARMS) laboratory.

Epidemiologic evidence indicates that kratom is a likely source of this multistate outbreak. Kratom is a plant consumed for its stimulant effects and as an opioid substitute. Kratom is also known as Thang, Kakuam, Thom, Ketom, and Biak.

In interviews, ill people answered questions about the foods they ate and other exposures in the months before they became ill. Eight (73%) of 11 people interviewed reported consuming kratom in pills, powder, or tea. No common brands or suppliers of kratom have been identified at this time.

At this time, CDC recommends that people not consume kratom in any form. The investigation indicates that kratom products could be contaminated with Salmonella and could make people sick. CDC’s recommendation may change as more information becomes available. This investigation is ongoing and we will provide updates as needed.

Multistate outbreak of salmonella I 4,[5],12:b- infections linked to Kratom

20.feb.18

CDC

https://www.cdc.gov/salmonella/kratom-02-18/index.html

Why we had don’t eat poop shirts in 4 languages: CDC Emergency partners and limited English proficiency

According to the U.S. Centers for Disease Control there are at least 350 languages spoken in U.S. homes (2009-2013 data).

People who have limited English proficiency can be found in all 50 states (2014 data).

About 65,00 people in the U.S. who have limited English proficiency speak Navajo or another native North American Language (2009-2013 data).

    Effective communication during an emergency can sometimes mean the difference between life and death. This is true whether communicating with those whose primary language is English or with people who have limited English proficiency. People who are limited English proficient (LEP) are those who “do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English” (https://www.lep.gov/faqs/faqs.html#OneQ1).

People who are LEP can be found throughout the United States and when it comes to planning for, responding to, and recovering from disasters, considering their needs can help ensure a better emergency response. Below are some tips from our colleagues at the U.S. Department of Justice (DOJ) for reaching LEP communities in emergency preparedness, response, and recovery.

Establish policies and procedures that include language access in your emergency plan.

Identify the language groups in your area.

Ensure LEP individuals can access your programs and services.

Conduct outreach efforts.

Include LEP individuals and language access issues in training,

Provide notifications, warnings, and other information in the languages of the affected communities.

Plan for language access needs as part of survivor care.

Do not rely upon children as interpreters and translators.

For more information on how to carry out these recommendations and where to find tools to help take action, see Tips and Tools for Reaching Limited English Proficient Communities in Emergency Preparedness, Response, and Recovery.