Rabies (maybe) from bats living in a sorority house, Indiana, 2017

In February 2017, the Indiana State Department of Health (ISDH) was notified of bat exposures at a university sorority house. The initial complaint was made to ISDH because of concerns for food sanitation. Bats had been routinely sighted in shared living areas and hallways. ISDH, in consultation with the U.S. Centers for Disease Control, collaborated with the university and sorority to assess residents and staff members for potential rabies risk. In 2016, 4.3% of all bats tested in Indiana were positive for rabies. The longest incubation period recorded for indigenously acquired bat rabies is 270 days (1); therefore, out of an abundance of caution, ISDH conducted interviews with 140 students and eight employees who resided or worked in the sorority house during the preceding 12 months, all of whom were considered to have possibly been exposed. A web-based survey was administered in February to collect information about bat exposures, which was used to categorize all respondents into having a low, medium, or high risk for rabies exposure per CDC guidance (2).

Persons who reported a bite, scratch, or direct skin contact with a bat were categorized as having a high risk. Persons were categorized as having moderate risk if they reported waking and finding a bat in the same room where they were sleeping. Persons who reported no bat exposure were categorized as having a low risk. Respondents categorized as having a high or moderate risk had follow-up interviews in person or by telephone.

Among the 148 possibly exposed persons, 100 (68%) responded to the questionnaire, including 92 (66%) students and all eight employees; 94 respondents reported ever having seen a bat in the sorority house. Among those 94 persons, 70 (74%) reported having seen a bat within the previous 12 months, and 34 (36%) reported seeing a bat ≤1 month ago. Among respondents who reported ever having seen a bat in the sorority house, 13 (14%) were identified as having a moderate or high risk for rabies exposure, including 11 sorority members, one university employee, and one nonsorority member student. After follow-up interviews, nine of these 13 persons were reclassified as having a low risk for rabies exposure. The remaining four persons were considered to have a high (three persons) or a moderate (one) risk. All four persons received a recommendation for postexposure prophylaxis (PEP), which consists of human rabies immune globulin and a series of 4 doses of rabies vaccine. Two persons completed the PEP series during March 20–April 18, and two declined PEP because of a perceived lack of risk. No respondent had developed clinical rabies as of February 2018.

ISDH learned that bats had been roosting in the building for approximately 30 years. Commercial wildlife operators conducted an environmental investigation in March and identified multiple small openings between the house’s exterior wall and doorframe, which can serve as points of ingress or egress for bats. In addition, certain students reported hearing scratching behind a wall inside the house’s common space. This wall was scheduled to be removed as part of a house remodel during summer 2017. A commercial wildlife control operator repaired the openings and completed building remediation during this time. Students returned to the house in August 2017. No bat sightings have been reported since students returned.

This is the first reported instance of a mass bat exposure in a fraternity or sorority house. Multiple high-risk rabies exposures occurred in this sorority house, attributable to bat colonization of the building. The initial complaint to ISDH related to concerns for food sanitation, rather than rabies, is consistent with previous reports indicating an underappreciation of the health risks associated with indoor bat exposures (3). ISDH communicated the risk for rabies exposure at meetings with students and university housing directors. All bat exposure events should be reported immediately to public health officials, who can provide advice about rabies risk assessments and determination of the need for PEP.

Notes from the Field: Assessment of Rabies Exposure Risk Among Residents of a University Sorority House — Indiana, February 2017

Morbidity and Mortality Weekly Report; February 9, 2018; 67(5);166

Betsy Schroeder, DVM; Alex Boland, MPH; Emily G. Pieracci, DVM; Jesse D. Blanton, PhD; Brett Peterson, MD; Jennifer Brown, DVM

https://www.cdc.gov/mmwr/volumes/67/wr/mm6705a4.htm?s_cid=mm6705a4_e

Corresponding author: Betsy Schroeder, BSchroeder@cdc.gov, 814-248-5774.

1Epidemic Intelligence Service, CDC; 2Indiana State Department of Health; 3Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

References

De Serres G, Dallaire F, Côte M, Skowronski DM. Bat rabies in the United States and Canada from 1950 through 2007: human cases with and without bat contact. Clin Infect Dis 2008;46:1329–37. CrossRef PubMed

CDC. Assessment of risk for exposure to bats in sleeping quarters before and during remediation—Kentucky, 2012. MMWR Morb Mortal Wkly Rep 2013;62:382–4. PubMed

DeMent J, Trevino-Garrison I. Investigation of potential rabies exposure while attending a camp, Barton County, June 2010. Topeka, KS: Kansas Department of Health and Environment; 2010. http://www.kdheks.gov/epi/download/Bats_at_Camp_Final_Report.pdf

Raw is risky: 17 sick with Campylobacter from raw milk in Colorado, 2016

In August 2016, a local public health agency (LPHA) notified the Colorado Department of Public Health and Environment (CDPHE) of two culture-confirmed cases of Campylobacter infection among persons who consumed raw (unpasteurized) milk from the same herdshare dairy.

In Colorado, the sale of raw milk is illegal; however, herdshare programs, in which a member can purchase a share of a herd of cows or goats, are legal and are not regulated by state or local authorities. In coordination with LPHAs, CDPHE conducted an outbreak investigation that identified 12 confirmed and five probable cases of Campylobacter jejuni infection. Pulsed-field gel electrophoresis (PFGE) patterns for the 10 cases with available isolates were identical using the enzyme Sma. In addition, two milk samples (one from the dairy and one obtained from an ill shareholder) also tested positive for the outbreak strain. Five C. jejuni isolates sent to CDC for antimicrobial susceptibility testing were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1).

Although shareholders were notified of the outbreak and cautioned against drinking the milk on multiple occasions, milk distribution was not discontinued. Although its distribution is legal through herdshare programs, drinking raw milk is inherently risky (2). The role of public health in implementing control measures associated with a product that is known to be unsafe remains undefined.

Investigation and Results

On August 23, 2016, El Paso County Public Health notified CDPHE of two culture-confirmed cases of C. jejuni infection; campylobacteriosis is a reportable disease in Colorado. Both patients reported drinking unpasteurized milk from the same herdshare dairy in Pueblo County. Since 2005, obtaining raw milk by joining a herdshare program has been legal for Colorado residents, but selling raw milk is illegal. By purchasing a share of a herd (cows or goats), shareholders are entitled to a portion of the raw milk.

Because the prevalence of consuming unpasteurized milk is low (2.4% in Colorado, 2006–2007 FoodNet Population Survey; 3.1%, 2009 Colorado Behavioral Risk Factor Surveillance System), two cases of enteric illness with a common exposure to raw milk are unlikely to occur by chance (3,4). In this outbreak, a confirmed case was defined as diarrheal illness with onset on or after August 1, 2016, in a person with known consumption of unpasteurized milk from the same herdshare dairy and culture-confirmed C. jejuni infection. A probable case was defined as diarrhea onset on or after August 1, lasting 1 or more days, in a person with either known consumption of milk from the same herdshare dairy or with an epidemiologic link to a confirmed case.

Cases were identified through routine passive reporting with follow-up interviews, a Health Alert Network broadcast to area providers, and attempts to contact all shareholders. A public health order was issued to obtain a list of shareholders with their contact information after it was not provided by the dairy within 5 days of the initial request. CDPHE attempted to contact shareholders to inform them about the outbreak and assess possible illness. Up to three calls were made to each shareholder household. Epidemiologists contacted laboratories to request that isolates from potential outbreak-associated cases be forwarded to the state public health laboratory.

Among 91 (53%) of 171 shareholder households that responded to requests for follow-up interviews, representing 207 persons in five or more Colorado counties, 12 confirmed and five probable cases were identified (Figure). Among confirmed cases, patients ranged in age from 12 to 68 years (median = 58 years); nine were male. Duration of illness ranged from 3 to >10 days. One hospitalization occurred; there were no deaths. In addition to diarrhea, among the 12 confirmed cases, the majority of patients also experienced fever (10), abdominal pain or cramps (eight), headache (eight), and myalgia (seven); vomiting and bloody diarrhea were reported less frequently (in five and four persons, respectively).

Four milk samples were tested for C. jejuni; pathogen identification and PFGE were performed on available isolates from persons epidemiologically linked to the outbreak. C. jejuni with one of two outbreak PFGE patterns (PulseNet DBRS16.0008 using the enzyme Sma and PulseNet DBRK02.1272 or DBRK02.0028 using the enzyme Kpn) was confirmed in 10 isolates that were available at the public health laboratory and two of the four raw milk samples. The National Antimicrobial Resistance Monitoring System performed antimicrobial susceptibility tests on five representative isolates; all were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1).

Public health responses to this outbreak consisted of notifying shareholders about the outbreak on three occasions and requiring the dairy to provide additional written notification about the outbreak at milk distribution points. A press release was issued by two LPHAs in response to detecting at least one infection in a person who was not a shareholder but was given milk by shareholders. In addition, a number of shareholders reported sharing milk with nonshareholders who might have been unaware of the outbreak. Although milk sample results were positive for C. jejuni, CDPHE did not close the dairy or stop distribution of its milk because without pasteurization CDPHE could not create standards for safely reopening the dairy (5). Shareholders were, however, urged to discard raw milk distributed since August 1 and were reminded that Colorado statute prohibits redistribution of raw milk.

Discussion

Raw milk from a herdshare dairy was the source of this outbreak of C. jejuni infections, and the investigation highlighted the difficulties inherent in addressing an outbreak related to unpasteurized milk from a herdshare dairy. During three previous herdshare-associated outbreaks in Colorado, public health authorities temporarily took action to stop milk distribution until a series of negative tests were obtained from the milk (Alicia Cronquist, CDPHE, personal communication, December 2017). However, because CDPHE could not ensure that unpasteurized milk would be safe in the future, the decision was made not to close the dairy during this outbreak. In addition, CDPHE’s Division of Environmental Health and Sustainability chose not to make formal recommendations on the dairy’s processes because no protocol improvements short of pasteurization could ensure the product’s safety, even with improved sanitation (5).

All tested isolates’ resistance to three antibiotics was concerning, particularly as fluoroquinolones are frequently used to treat Campylobacter infections in those cases where treatment is indicated. Treatment of antibiotic-resistant Campylobacter infections might be more difficult, of longer duration, and possibly lead to more severe illness than treatment of nonresistant Campylobacter infections (6–8). In 2015, approximately 25.3% of U.S. C. jejuni isolates were resistant to ciprofloxacin, an increase from 21.6% a decade earlier (1).

In collaboration with LPHAs, CDPHE is creating guidelines to address future outbreaks related to raw milk from herdshares. As more states legalize the sale or other distribution of unpasteurized milk, the number of associated outbreaks will likely increase (9,10). The role of public health in responding to raw milk–related outbreaks should be further defined. State-level guidelines might assist with this process.

 

Corresponding author: Alexis Burakoff, aburakoff@cdc.gov, 303-692-2745.

1Epidemic Intelligence Service, Division of Scientific Education and Professional Development, CDC; 2Colorado Department of Public Health and Environment, Denver, Colorado; 3Pueblo City-County Health Department, Pueblo, Colorado; 4El Paso County Public Health, Colorado Springs, Colorado; 5Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

References

CDC. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): human isolates surveillance report for 2015 (final report). Atlanta, Georgia: US Department of Health and Human Services, CDC; 2018.

CDC. Food safety: raw milk. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/foodsafety/rawmilk/raw-milk-index.html

CDC. Foodborne diseases active surveillance network (FoodNet) population survey atlas of exposures, 2006–2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. https://www.cdc.gov/foodnet/PDFs/FNExpAtl03022011.pdf

Colorado Department of Public Health and Environment. Colorado Behavioral Risk Factor Surveillance System, 2009. [Data on raw milk]. Denver, CO: Colorado Department of Public Health and Environment; 2009. http://www.chd.dphe.state.co.us/Resources/brfss/BRFSS2009results_raw%20milk.pdf

Longenberger AH, Palumbo AJ, Chu AK, Moll ME, Weltman A, Ostroff SM. Campylobacter jejuni infections associated with unpasteurized milk—multiple states, 2012. Clin Infect Dis 2013;57:263–6. CrossRef PubMed

Evans MR, Northey G, Sarvotham TS, Rigby CJ, Hopkins AL, Thomas DR. Short-term and medium-term clinical outcomes of quinolone-resistant Campylobacter infection. Clin Infect Dis 2009;48:1500–6. CrossRef PubMed

Helms M, Simonsen J, Olsen KE, Mølbak K. Adverse health events associated with antimicrobial drug resistance in Campylobacter species: a registry-based cohort study. J Infect Dis 2005;191:1050–5. CrossRef PubMed

Nelson JM, Smith KE, Vugia DJ, et al. Prolonged diarrhea due to ciprofloxacin-resistant Campylobacter infection. J Infect Dis 2004;190:1150–7. CrossRef PubMed

Langer AJ, Ayers T, Grass J, Lynch M, Angulo FJ, Mahon BE. Nonpasteurized dairy products, disease outbreaks, and state laws—United States, 1993–2006. Emerg Infect Dis 2012;18:385–91. CrossRef PubMed

Mungai EA, Behravesh CB, Gould LH. Increased outbreaks associated with nonpasteurized milk, United States, 2007–2012. Emerg Infect Dis 2015;21:119–22. CrossRef PubMed

Outbreak of Fluoroquinolone-Resistant Campylobacter jejuni Infections Associated with Raw Milk Consumption from a Herdshare Dairy — Colorado, 2016

Morbidity and Mortality Weekly Report; February 9, 2018; 67(5);146–148

Alexis Burakoff, MD; Kerri Brown, MSPH; Joyce Knutsen; Christina Hopewell; Shannon Rowe, MPH; Christy Bennett; Alicia Cronquist, MPH

https://www.cdc.gov/mmwr/volumes/67/wr/mm6705a2.htm

113 sick with Campylobacter from Petland puppies

The U.S. Centers for Disease Control, several states, and the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service (USDA-APHIS) investigated a multistate outbreak of multidrug-resistant Campylobacter infections. Epidemiologic and laboratory evidence indicated that contact with puppies sold through Petland stores were a likely source of this outbreak. This outbreak investigation is over. Illnesses could continue to occur because people may be unaware of the risk of Campylobacter infections from puppies and dogs.

Cute puppies

A total of 113 people with laboratory-confirmed infections or symptoms consistent with Campylobacter infection were linked to this outbreak. Illnesses were reported from 17 states. Illnesses started on dates ranging from January 12, 2016 to January 7, 2018. Ill people ranged in age from less than 1 year to 86, with a median age of 27. Sixty-three percent of ill people were female. Of 103 people with available information, 23 (22%) were hospitalized. No deaths were reported. Whole genome sequencing (WGS) showed that isolates from people infected with Campylobacter were closely related genetically. This close genetic relationship means that people in this outbreak were more likely to share a common source of infection.

Campylobacter bacteria isolated from clinical samples from people sickened in this outbreak were resistant to commonly recommended, first-line antibiotics. This means it may be difficult to treat these infections with the antibiotics usually prescribed for Campylobacter infections. Antibiotic resistance may be associated with increased risk of hospitalization, development of a bloodstream infection, or treatment failure in patients. Using WGS, we identified multiple antimicrobial resistance genes and mutations in most isolates from 38 ill people and 10 puppies in this outbreak. This finding matched results from standard antibiotic susceptibility testing methods used by CDC’s National Antimicrobial Resistance Monitoring System laboratory on isolates from five ill people and seven puppies in this outbreak. The 12 isolates tested by standard methods were resistant to azithromycin, ciprofloxacin, clindamycin, erythromycin, nalidixic acid, telithromycin, and tetracycline. In addition, 10 were resistant to gentamicin, and 2 were resistant to florfenicol.

In interviews, ill people answered questions about the foods they ate and any animal contact in the week before they became ill. Ninety-nine percent of people reported contact with a puppy in the week before illness started, and 87% reported they had contact with a puppy from Petland stores, or had contact with a person who became sick after contact with a puppy from a Petland store. Twenty-five ill people worked at Petland stores.

During the investigation, officials collected samples from pet store puppies for laboratory testing and identified the outbreak strain of Campylobacter in the samples. WGS showed that the Campylobacter isolates from sick people in this outbreak and isolates from pet store puppies were closely related genetically, providing additional evidence that people got sick from contact with pet store puppies.

Ill people reported contact with different breeds of puppies at different store locations in several states. The investigation did not identify a common breeder where puppies infected with the outbreak strain of Campylobacter originated. Puppies in this outbreak may have become infected at various points along the distribution chain when they had contact with infected puppies from other breeders or distributors during transport to pet store locations. Enhanced infection prevention measures throughout the distribution chain may help reduce the spread of Campylobacter infections among puppies.

This multidrug-resistant outbreak highlights the need for responsible use of antibiotics in pets. Education about best practices for Campylobacter disease prevention, diarrhea management in puppies, and responsible antibiotic use is essential throughout the distribution chain to help prevent the emergence and spread of antibiotic resistance. Pet owners should be aware that any puppy or dog, regardless of where it is purchased or adopted, may carry germs like Campylobacterthat can make people sick. Always wash your hands thoroughly with soap and water right after touching puppies and dogs or after picking up their poop. Work with your veterinarian to keep your animal healthy to prevent disease. More information about how to prevent illness when handling puppies and dogs is available for pet owners.

Lettuce grazers rejoice: Consumer Reports says it’s ok to eat romaine lettuce again

Actually, it was the U.S.  Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) who jointly declared an end to the E coli O157 outbreak after nearly two months of investigation. At least 66 people across the U.S and Canada became ill, 22 were hospitalized, and 2 died during November and December, all linked to consumption of romaine lettuce.

Consumer Reports went along for the ride.

What’s been missing is any response from the leafy greens marketing agency types.

Silence – the LGMA cone of silence — is golden, I guess.

CDC announced on January 25, 2018, that this outbreak appears to be over, because the last case became ill on December 12, 2017. This indicates that the food causing illness is no longer available in the marketplace or consumers’ homes.

Although this outbreak appears to be over, the FDA’s outbreak investigation team is continuing to work with federal, state and local partners to determine what leafy greens made people ill, what people ate, where they bought it, and identify the distribution chain — all with the goal of identifying any common food or points where the food might have become contaminated. To date, no common link has been identified.

Because whole genome sequencing showed that the E. coli O157:H7 strain that resulted in the U.S. illnesses was closely related genetically to the strain that caused illnesses in Canada, the FDA and CDC have been in contact with Canadian food safety authorities throughout this outbreak.

 

26 sick: Multistate outbreak of Salmonella infections linked to Coconut Tree brand frozen shredded coconut

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

As of January 12, 2018, 25 people infected with the outbreak strains of Salmonella I 4,[5],12:b:- (24 people) or Salmonella Newport (1 person) have been reported from 9 states. One more ill person infected with the outbreak strain of Salmonella I 4,[5],12:b:- has been reported from Canada.

WGS showed that isolates from people infected with Salmonella I 4,[5],12:b:- are closely related genetically. This close genetic relationship means that people in this outbreak are more likely to share a common source of infection.

Illnesses started on dates ranging from May 11, 2017 to November 4, 2017. Ill people range in age from 1 year to 82, with a median age of 19. Among ill people, 19 (76%) are male. Six people (24%) report being hospitalized. No deaths have been reported.

Epidemiologic, laboratory, and traceback evidence indicates that Coconut Tree Brand frozen Shredded Coconut is the likely source of this multistate outbreak. This investigation is ongoing.

In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Ten (63%) of 16 people interviewed reported eating or maybe eating coconut. Of these 10 people, 8 (80%) reported having an Asian-style dessert drink that contained frozen shredded coconut.

Throughout the outbreak investigation, state and local health officials have collected different food items from restaurants where ill people consumed Asian-style dessert drinks. In November 2017, laboratory testing of a sample from coconut milk made in one restaurant in New York did not identify the outbreak strain of Salmonella I 4,[5],12:b:-, but did identify a strain of SalmonellaNewport. This sample was from coconut milk made with Coconut Tree Brand frozen Shredded Coconut, as well as other ingredients. WGS showed that the Salmonella Newport isolated from the coconut milk was closely related genetically to a Salmonella Newport isolate from an ill person from Massachusetts who had consumed an Asian-style dessert drink.

In December 2017, officials in Massachusetts collected food items from a restaurant where that ill person had consumed Asian-style dessert drinks. One sample from frozen shredded coconut identified a strain of Salmonella that was new to the PulseNet database and has not been linked to any illnesses. This sample was from an unopened package of Coconut Tree Brand Frozen Shredded Coconut. As a result, on January 3, 2018, Evershing International Trading Company recalled all Coconut Tree Brand Frozen Shredded Coconut. The recalled product was packaged in 16-ounce plastic bags.

Officials in Massachusetts returned to the restaurant and collected more Coconut Tree Brand frozen Shredded Coconut in January 2018. On January 12, laboratory testing confirmed that samples from that frozen shredded coconut identified the outbreak strain of Salmonella I 4,[5],12:b:-. Laboratory testing of other samples identified several types of Salmonella bacteria, including Salmonella Javiana, Salmonella Rissen, and Salmonella Thompson. These samples were from unopened packages of Coconut Tree Brand Frozen Shredded Coconut sold before January 3, 2018. CDC is reviewing the PulseNet database to determine if the other Salmonella isolates from the frozen shredded coconut are linked to any illnesses.

Frozen shredded coconut can last for several months if kept frozen and may still be in retail stores or in people’s homes. CDC recommends that retailers not sell, restaurants not serve, and consumers not eat recalled Coconut Tree Brand frozen Shredded Coconut.

Confused consumers: Canadians say E. coli in romaine outbreak is over; U.S. says it’s leafy greens

Outbreaks of foodborne illness are fraught with uncertainties.

It’s OK to admit, to do the best with the info available, and get on with things.

On January 10, 2018, the Public Health Agency of Canada reported that an outbreak of Shiga toxin-producing E. coli O157:H7 infections (STEC O157:H7) they had identified was linked to romaine lettuce appears to be over.

As of January 10, 2018, there were 42 cases of E. coli O157 illness reported in five eastern provinces. Individuals became sick in November and early December 2017. Seventeen individuals were hospitalized. One individual died.

In the United States, the Centers for Disease Control, several states, and the U.S. Food and Drug Administration continue to investigate a multistate outbreak of 24 STEC O157:H7 infections in 15 states. Since CDC’s initial media statement on December 28, seven more illnesses have been added to this investigation. The last reported illness started on December 12, 2017.

The likely source of the outbreak in the United States appears to be leafy greens, but officials have not specifically identified a type of leafy greens eaten by people who became ill.  Leafy greens typically have a short shelf life, and since the last illness started a month ago, it is likely that contaminated leafy greens linked to this outbreak are no longer available for sale. Canada identified romaine lettuce as the source of illnesses there, but the source of the romaine lettuce or where it became contaminated is unknown.

Whole genome sequencing (WGS) showed that the STEC O157:H7 strain from ill people in the United States is closely related genetically to the STEC O157:H7 strain from ill people in Canada. WGS data alone are not sufficient to prove a link; health officials rely on other sources of data, such as interviews from ill people, to support the WGS link. This investigation is ongoing. Because CDC has not identified a specific type of leafy greens linked to the U.S. infections, and because of the short shelf life of leafy greens, CDC is not recommending that U.S. residents avoid any particular food at this time.

In the United States, a total of 24 STEC O157:H7 infections have been reported. Among the 18 ill people for whom CDC has information, nine were hospitalized, including one person in California who died. Two people developed hemolytic uremic syndrome, a type of kidney failure.

The Public Health Agency of Canada identified romaine lettuce as the source of the outbreak in Canada. In the United States, the likely source of the outbreak appears to be leafy greens, but health officials have not identified a specific type of leafy greens that sick people ate in common.

State and local public health officials continue to interview sick people in the United States to determine what they ate in the week before their illness started. Of 13 people interviewed, all 13 reported eating leafy greens. Five (56%) of nine ill people specifically reported eating romaine lettuce. This percentage was not significantly higher than results from a survey of healthy people in which 46% reported eating romaine lettuce in the week before they were interviewed.  Based on this information, U.S. health officials concluded that ill people in this outbreak were not more likely than healthy people to have eaten romaine lettuce.  Ill people also reported eating different types and brands of romaine lettuce. Currently, no common supplier, distributor, or retailer of leafy greens has been identified as a possible source of the outbreak. CDC continues to work with regulatory partners in several states, at the U.S. Food and Drug Administration, and the Canadian Food Inspection Agency to identify the source.

Although the most recent illness started on December 12, there is a delay between when someone gets sick and when the illness is reported to CDC. For STEC O157:H7 infections, this period can be two to three weeks. Holidays can increase this delay. Because of these reporting delays, more time is needed before CDC can say the outbreak in the United Stated is over. This investigation is ongoing.

Multistate outbreak of Shiga toxin-producing E. coli O157:H7 infections (STEC O157:H7) in 13 states

Eastern Canada has been experiencing an outbreak of E. coli O157:H7 infections linked to romaine lettuce. Since the lettuce is eaten raw, this increases the likelihood of acquiring the infection. It appears now that the states are experiencing a similar outbreak. The CDC is performing whole genome sequencing to determine if this outbreak is related to the Canadian romaine lettuce outbreak.

CDC, several states, and the U.S. Food and Drug Administration are
investigating a multistate outbreak of Shiga toxin-producing E. coli O157:H7 infections (STEC O157:H7) in 13 states. Seventeen illnesses have been reported from California (3), Connecticut (2), Illinois (1), Indiana (1), Michigan (1), Nebraska (1), New Hampshire (2), New York (1), Ohio (1), Pennsylvania (1), Virginia (1), Vermont (1) and Washington (1). Illnesses started on dates from November 15 through December 8, 2017. The Public Health Agency of Canada also is investigating an outbreak of STEC O157:H7 infections in several provinces.
CDC is performing whole genome sequencing on samples of bacteria making people sick in the United States to give us information about whether these illnesses are related to the illnesses in Canada. Preliminary results show that the type of E. coli making people sick in both countries is closely related genetically, meaning the ill people are more likely to share a common source of infection.
The Public Health Agency of Canada has identified romaine lettuce as the source of the outbreak in Canada. In the United States, state and local public health officials are interviewing sick people to determine what they ate in the week before their illness started. CDC is still collecting information to determine whether there is a food item in common among sick people, including leafy greens and romaine.
Because we have not identified a source of the infections, CDC is unable to recommend whether U.S. residents should avoid a particular food. This investigation is ongoing, and more information will be released as it becomes available.

54 sick: Salmonella from contact with dairy calves

The U.S. Centers for Disease Control reports an on-going outbreak of multidrug-resistant Salmonella Heidelberg infections from contact with dairy calves:

  • Since the last update on August 2, 2017, eight more ill people have been reported from six states.
  • CDC, several states, and the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service (USDA-APHIS) are investigating a multistate outbreak of multidrug-resistant SalmonellaHeidelberg infections.
  • A total of 54 people infected with the outbreak strains of SalmonellaHeidelberg have been reported from 15 states.
    • Seventeen (35%) people have been hospitalized. No deaths have been reported.
    • Illnesses started on dates ranging from January 27, 2015 to October 15, 2017.
    • Eighteen (33%) people in this outbreak are children under the age of 5.
  • Epidemiologic and laboratory investigations linked ill people in this outbreak to contact with calves, including dairy calves.
    • In interviews, ill people answered questions about contact with animals and foods eaten in the week before becoming ill. Of the 54 people interviewed, 34 (63%) reported contact with dairy calves or other cattle. Some of the ill people interviewed reported that they became sick after their dairy calves became sick or died.
    • Ongoing surveillance in veterinary diagnostic laboratories showed that calves in several states continue to get sick with the outbreak strains of multidrug resistant Salmonella ‎
    • Information collected earlier in the outbreak indicated that most of the calves came from Wisconsin. Regulatory officials in several states are now tracing the origin of the calves that are linked to the newer illnesses.
    • Whole genome sequencing has identified multiple antimicrobial resistance genes in outbreak-associated isolates from 43 ill people, 87 isolates from cattle, and 11 isolates from animal environments.
    • These findings match results from standard antibiotic resistance testingmethods used by CDC’s National Antimicrobial Resistance Monitoring System (NARMS) laboratory on clinical isolates from eight ill people in this outbreak.
    • All eight isolates from ill people were resistant to amoxicillin-clavulanic acid, ampicillin, cefoxitin, ceftriaxone, streptomycin, sulfisoxazole, and tetracycline, and had reduced susceptibility to ciprofloxacin. Seven isolates were also resistant to trimethoprim-sulfamethoxazole. Five were also resistant to nalidixic acid. Three were also resistant to chloramphenicol. All eight isolates tested were susceptible to azithromycin and meropenem.

 

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.