During 2018–2019, CDC, local and state public health partners, the U.S. Department of Agriculture (USDA), and the Food and Drug Administration (FDA) investigated a multistate outbreak of 356 Salmonella Reading infections from 42 states and the District of Columbia (DC) linked to turkey. The outbreak strain was isolated from raw turkey products, raw turkey pet food, and live turkeys. In July 2018, CDC and USDA’s Food Safety and Inspection Service (FSIS) shared outbreak investigation results with representatives from the U.S. turkey industry, engaging with an industry group rather than a specific company for the first time during an outbreak, and CDC issued a public investigation notice. During the investigation, four recalls of turkey products were issued. Evidence suggested that the outbreak strain of Salmonella was widespread in the turkey industry, and therefore, interventions should target all parts of the supply chain, including slaughter and processing facilities and upstream farm sources.
In January 2018, through routine state surveillance, Minnesota Department of Health investigators identified four Salmonella Reading infections with an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern, suggesting they likely shared a common source. One patient had consumed ground turkey, and two lived in the same household where pets in the home ate raw turkey pet food. Minnesota investigators also identified this same strain in one sample of retail ground turkey. This PFGE pattern is the most common subtype of Salmonella Reading; however, the Reading serotype is uncommon, not ranking in the 20 most common types of human Salmonella infections reported in the United States (1). In response to Minnesota’s investigation, PulseNet,* the national laboratory network for foodborne disease surveillance, was queried for additional Salmonella infections with this PFGE pattern. CDC began a multistate cluster investigation, collecting information on patient exposures from local and state health departments and information on food and pet food products from FDA and FSIS.
CDC defined a case as an infection with Salmonella Reading with the outbreak PFGE pattern with illness onset from during November 20, 2017–March 31, 2019. Patients were interviewed to collect information on consumption of turkey and other poultry foods, exposure to raw poultry pet food, and contact with live poultry.
Investigators from DC Health and the Iowa Department of Health identified two illness subclusters of cases in which attendees ate at a common event before becoming ill. The two events occurred in November 2018 and February 2019, and 152 persons became ill, including 51 whose clinical isolates matched the outbreak strain and 101 who had clinically compatible illness without culture confirmation of Salmonella infection. Investigators identified whole turkey and boneless roast turkey as the food items significantly associated with illness at these two events and found that turkey was not handled or prepared in accordance with FSIS guidelines and was not held at proper temperatures to prevent bacterial growth (2).
Overall, 356 outbreak cases from 42 states and DC were identified. Patients ranged in age from <1 to 101 years (median = 42 years), and 175 (52%) of 336 patients for whom information on sex was available were male. Among 300 patients with available information, 132 (44%) were hospitalized, and one died. Among 198 interviewed patients, 132 (67%) reported direct or indirect contact with turkey in the week before illness; 123 reported preparing or eating turkey products that were purchased raw (including whole turkey, turkey pieces, and ground turkey), four became sick after pets in their home ate raw ground turkey pet food, and five worked in a facility that raises or processes turkeys or lived with someone who worked in such a facility. No common type, brand, or source of turkey was identified.
During the investigation, the outbreak strain was identified in 178 samples of raw turkey products from 24 slaughter and 14 processing establishments in 21 states that were collected by FSIS as part of routine testing and in 120 retail turkey samples collected as part of the National Antimicrobial Resistance Monitoring System retail meat sampling program. These samples represented several brands and types of raw turkey products. The outbreak strain was also identified in 10 samples from live turkeys in several states.
Investigators from the Arizona State Public Health Laboratory and the Michigan Department of Agriculture and Rural Development identified the outbreak strain in two of three unopened ground turkey samples collected from two patient homes. These were the same brand of ground turkey but were produced in different facilities. Investigators from the Minnesota Department of Agriculture identified the outbreak strain in samples of two brands of raw turkey pet food that were served to pets in patients’ homes. No commercial connections or common source materials were identified among any of these facilities.
The two illness subclusters in this outbreak indicate improper handling and cooking of raw turkey products and highlight the need to reinforce consumer education. A 2017 study found that adherence to food safety practices among persons preparing turkey burgers was low but did improve after watching a USDA video on proper thermometer use (9). This same study also found very low adherence to CDC’s recommended steps for handwashing during food preparation and noted that approximately half of the participants contaminated other kitchen items, such as spice containers, by touching them while preparing turkey (9). These findings underscore the impact that food safety messaging can have on consumer behavior and the importance of proper food safety throughout the food preparation process. Consumers should always thaw turkeys safely (in the refrigerator in a container, in a leak-proof plastic bag in a sink of cold water, or in a microwave oven following the manufacturer’s instructions), avoid the spread of bacteria from raw turkey by keeping it separate from other foods and keeping food surfaces clean, and cook turkey to 165°F (74°C), measured on a food thermometer inserted into the thickest portions of the breast, thigh, and wing joint.† In addition to emphasizing the importance of food safety messaging, this outbreak reinforced the need for awareness of the recommendations against feeding pets a raw meat diet, which can lead to both human and animal illnesses (10). Finally, industries can take steps to provide consumer education through their marketing programs and on product packages. Consumers, public health agencies, and industry officials all play important roles in promoting and implementing Salmonella prevention and control strategies to prevent future illnesses.
Queensland, or maybe all of Australia, has banned single-use plastic bags at supermakets.
No biggie for me, I always have my knapsack.
But it would be more meaningful if Australian retailers could set aside their perverse fetish of wrapping every piece of cut fruit or veggie in plastic.
Fresh-cut presents unique risks and needs to be kept close to 4 C to limit microbial growth.
That ain’t happening at retail.
I have shared my evidence-based concerns with the supermarket, Coles, and they have done, nothing.
The U.S. Centers for Disease Control reports that on December 7, 2019, Tailor Cut Produce recalled its Fruit Luau cut fruit mix as well as cut honeydew melon, cut cantaloupe, and cut pineapple products because they have the potential to be contaminated with Salmonella.
These products were not sold directly to consumers in grocery stores.
These products were sold for use in institutional food service establishments such as hospitals, long-term care facilities, schools, and hotels.
Food service and institutional food operators should not sell or serve the recalled products.
The recalled fruit products were distributed between November 15 and December 1, 2019.
Twenty-seven hospitalizations have been reported. No deaths have been reported.
Since the last update on December 11, 85 additional ill people have been reported from 11 states.
These illnesses started during the same time period as the illnesses reported on December 11, but were not confirmed as part of the outbreak at that time.
Epidemiologic and traceback evidence indicate that cut fruit, including honeydew melon, cantaloupe, pineapple, and grapes, produced by Tailor Cut Produce of North Brunswick, New Jersey, is a likely source of this outbreak.
“Based on the slowed rate of human illness reports, the FDA and CDC are no longer recommending that people avoid purchasing or feeding pig ear pet treats entirely,” FDA officials wrote in a press release.
At the end of July, FDA and CDC recommended no pig ear pet treat sale or use in the United States. With the end of the outbreak, the FDA altered its guidance to pet product retailers and pet owners. The agency now recommends that retailers who wish to re-introduce pig ear pet treats should take appropriate steps to ensure that their suppliers are controlling for pathogens such as Salmonella, and that products are not cross-contaminated after processing. Likewise, the agency advised pet owners to use good hygiene when feeding pig ear pet treats.
Reports of illness from these Salmonella infections started on June 10, 2015 and ran until September 13, 2019. Over the course of the outbreak, official reports tied 154 cases of human infection with exposure to pig ear pet treats in 34 states. Patients ranged in age from less than one year to 90 years. Of 133 cases with info available, 35 people needed hospitalization. Children younger than 5 years were infected in 27 cases.
Public health officials conducted genome sequencing of the Salmonella involved in the outbreak. The researchers revealed that many of the strains were resistant to multiple antibiotics, including ampicillin, streptomycin, tetracycline and ciprofloxacin. Salmonella strains identified were Cerro, Derby, London, Infantis, Newport, Rissen and I 4,,12:i:-.
Three firms recalled product associated with the outbreak: Pet Supplies Plus, Lennox, and Dog Goods USA. A fourth firm, Hollywood Pet, also recalled Salmonella positive pet ear treats that it had sourced from Dog Goods USA, but testing was not sufficient to determine if these treats were connected to illnesses. All of these recalled products originated from suppliers in Argentina, Brazil and Colombia. The importers were placed on Import Alert 72-03 (“Detention Without Physical Examination and Intensified Coverage of Pig Ears And Other Pet Treats Due To The Presence of Salmonella”). These importers were Suarko, SRL (Argentina) and Anabe Industria e Comercio de Proteinas (Brazil), and Custom Pet S.A.S. (Colombia).
The U.S. Centers for Disease Control reports on October 25, 2018, at 2:15 a.m., a woman aged 30 years and her mother, aged 55 years, both of Egyptian descent, arrived at an emergency department in New Jersey in hypotensive shock after 16 hours of abdominal pain, vomiting, and diarrhea. The daughter also reported blurry vision and double vision (diplopia), shortness of breath, chest pain, and difficulty speaking. She appeared lethargic and had ophthalmoplegia and bilateral ptosis. Both women were admitted to the hospital. The mother improved after fluid resuscitation, but the daughter required vasopressor support in the intensive care unit. Although the mother did not have evidence of cranial nerve involvement on admission, during the next 24 hours, she developed dysphagia and autonomic dysfunction with syncope and orthostasis and was transferred to the intensive care unit as her symptoms progressively worsened similar to those of her daughter.
Two days before admission, both women had eaten fesikh, a traditional Egyptian fish dish of uneviscerated gray mullet that is fermented and salt-cured. Fesikh has been linked to foodborne botulism, including a large type E outbreak in Egypt in 1993 (1). The Egyptian Ministry of Health has since issued public health warnings regarding fesikh before Sham el-Nessim, the Egyptian holiday commemorating the beginning of spring, during which fesikh is commonly prepared and eaten.* Foodborne botulism outbreaks associated with fesikh and similar uneviscerated salt-cured fish have also occurred in North America (2); two outbreaks occurred among persons of Egyptian descent in New Jersey in 1992 (3) and 2005 (4).
Botulism, a paralytic illness caused by botulinum neurotoxin (BoNT), was suspected because of the reported exposure to fesikh along with symptoms of ophthalmoplegia, bilateral ptosis, dysarthria, and autonomic dysfunction. Per New Jersey Reporting Regulations (NJAC 8:57),† these suspected illnesses were immediately reported to the New Jersey Department of Health. After consultation with CDC, heptavalent botulism antitoxin was released by CDC and administered to both patients within approximately 24 hours of arrival at the hospital. The daughter’s symptoms improved, and she was weaned off vasopressors. Both patients survived following intensive care for 2 days and total hospitalization of 7 days each.
CDC tested serum obtained before antitoxin administration. Serum from the daughter tested positive for BoNT type E by the BoNT Endopep-MS assay (5); the mother’s serum tested negative. A leftover sample of the consumed fesikh also tested positive for BoNT type E and Clostridium botulinum type E.
Interviews conducted by the Communicable Disease Service at the New Jersey Department of Health revealed that two fresh mullets purchased by the patients’ neighbor at a local Asian market were used to prepare the fesikh. The mother salt-cured and fermented the mullet, leaving the fish uneviscerated and wrapped in plastic in the kitchen for 20 days at ambient temperature. The mother confirmed that she previously used the same method of preparation in Egypt with no deviation in techniques or steps.
These cases illustrate the importance of early recognition and treatment of botulism. Botulism can be fatal, typically from respiratory failure, and treatment delays can result in increased mortality and worsened overall outcomes (6). These cases also highlight the role of uneviscerated, salt-cured fish dishes as potential vehicles for foodborne botulism. C. botulinum spores are ubiquitous in marine environments, and traditional methods of home preparation for these dishes might support conditions that are favorable for toxin production (i.e. anaerobic conditions) (2). Neither of these patients had previously heard of botulism. Risk communication via public awareness campaigns, as has been conducted by the Egyptian Ministry of Health to discourage fesikh consumption, might be indicated in the United States; engagement with Egyptian communities in the United States might provide insights into additional prevention strategies to decrease the risk for foodborne botulism from fesikh and other uneviscerated, salt-cured fish products.
Diagnostic Laboratory Practices Tool: Find out how diagnostic testing practices in FoodNet’s surveillance area have changed over time for 10 pathogens: Campylobacter, Cryptosporidium *, Cyclospora, Listeria, norovirus, Salmonella, STEC, Shigella, Vibrio, and Yersinia.
Hemolytic Uremic Syndrome (HUS) Surveillance Tool: HUS is a life-threatening condition, most often triggered by STEC infection. See how rates of pediatric HUS and STEC infection have changed in FoodNet’s surveillance area since 1997.
I love Mondays in Australia because it’s Sunday in the U.S., football and hockey are on TV for background, the kid is at school when not in France, and I write (Sorenne painting in France).
Fourteen years ago, me and Chapman went on a road trip to Prince George (where Ben thought he would be eaten by bears) to Seattle, then to Manhattan, Kansas, where in the first week I met a girl, got a job, and then spinach happened.
Leafy greens are still covered in shit.
I am drowning in nostalgia, but things haven’t changed, and, as John Prine wrote, all the news just repeats itself.
Same with relationships.
Former U.S. Food and Drug Administration food safety chief, David Acheson, writes that on October 31, 2019, FDA announced a romaine lettuce E. coli O157:H7 outbreak for which the active investigation had ended and the outbreak appeared to be over. As such FDA stated there was no “current or ongoing risk to the public” and no avoidance of the produce was recommended.
Since that announcement, however, I have seen a number of articles condemning FDA and CDC. Why? Because the traceback investigation of the outbreak began in mid-September when CDC notified FDA of an illness cluster that had sickened 23 people across 12 states. So why the delay in announcing it to the public?
Despite the critical (and rather self-serving; always self-serving) stance on the “inexcusable” delay taken by a prominent foodborne illness attorney and his Food Safety “News” publication – which blasted a headline FDA “hid” the outbreak – my stance, having been an FDA official myself involved in outbreak investigations, is that the delay was practical and sensible.
Why? As FDA states right in its announcement:
When romaine lettuce was identified as the likely source, the available data indicated that the outbreak was not ongoing and romaine lettuce eaten by sick people was past its shelf life and no longer available for sale.
Even once romaine was identified as the likely cause, no common source or point of contamination was identified that could be used to further protect the public.
During the traceback investigation, the outbreak strain was not detected in any of the samples collected from farms, and there were no new cases.
Thus, neither FDA nor CDC identified any actionable information for consumers.
So, if it is not in consumers’ best interest to publicize an issue that no longer exists, why should they be driven away from a healthy food alternative? Why should unfounded unease be generated that will damage the industry, providing no benefit for consumers but ultimately impacting their pockets? There is just no upside to making an allegation without information. We’ve seen the impact on consumers and the industry when an announcement of a suspected food turns out to be incorrect; specifically “don’t eat the tomatoes” when it turned out to be jalapeno and serrano peppers. Having learned from such incidents, FDA’s approach is: If we don’t have a message that will help protect the public, then there is no message to be imparted.
So, rather than condemn FDA and CDC, I would commend them for getting the balance correct. And, perhaps, instead of any condemning, we should be working together to get the answers faster, to get outbreak data through better, faster, more efficient and coordinated traceability. Our entire system is too slow – a topic we have discussed many times in these newsletters.
The public and the scientific community need to be informed to prevent additional people from barfing.
I also rarely eat lettuce of any sort because it is overrated and the hygiene controls are not adequate.
Greek salad without lettuce is my fave.
Going public: Early disclosure of food risks for the benefit of public health
NEHA, Volume 79.7, Pages 8-14
Benjamin Chapman, Maria Sol Erdozaim, Douglas Powell
Often during an outbreak of foodborne illness, there are health officials who have data indicating that there is a risk prior to notifying the public. During the lag period between the first public health signal and some release of public information, there are decision makers who are weighing evidence with the impacts of going public. Multiple agencies and analysts have lamented that there is not a common playbook or decision tree for how public health agencies determine what information to release and when. Regularly, health authorities suggest that how and when public information is released is evaluated on a case-by-case basis without sharing the steps and criteria used to make decisions. Information provision on its own is not enough. Risk communication, to be effective and grounded in behavior theory, should provide control measure options for risk management decisions. There is no indication in the literature that consumers benefit from paternalistic protection decisions to guard against information overload. A review of the risk communication literature related to outbreaks, as well as case studies of actual incidents, are explored and a blueprint for health authorities to follow is provided.
I’ll leave the summary of two antimicrobial resistance reports to my friend and hockey colleague (and he’s a professor/veterinarian) Scott Weese of the Worms & Germs Blog (he’s the semi-bald dude behind me in this 15-year-old pic; I’m the goalie; too many pucks to the head):
Two reports came out this week, both detailing the scourge of antibiotic resistance.
They’re both comprehensive, with a combined >400 pages explaining that this is a big problem.
I’m not going try to summarize the reports. I’ll just pick out a few interesting tidbits.
From the CCA report (Canada):
According to their modelling, first-line antimicrobials (those most commonly used to treat routine infections) helped save at least 17,000 lives in 2018 while generating $6.1 billion in economic activity in Canada. “This contribution is at risk because the number of effective antimicrobials are running out.”
Antimicrobial resistance was estimated to reduce Canada’s GDP by $2 billion in 2018. That’s only going to get worse unless we get our act together. It’s estimated that by 2050, if resistance rates remain unchanged, the impact will be $13 billion per year. If rates continue to increase, that stretches to $21 billion. Remember, that’s just for Canada, a relatively small country from a population standpoint.
Healthcare costs due to resistance (e.g. drugs, increased length of stay in hospital) accounted for $1.4 billion in 2018. But remember that people who die from resistant infections can actually cost less. If I get a serious resistant infection and die quickly, my healthcare costs are pretty low since I didn’t get prolonged care. All that to say that dollar costs alone don’t capture all the human aspects. Regardless, this cost will likely increase to $20-40 billion per year by 2050.
In terms of human health, resistant infections were estimated to contribute to 14,000 deaths in Canada in 2018, with 5,400 of those directly attributable to the resistant infection (i.e. those deaths would not have occurred if the bug was susceptible to first line drugs). That makes resistance a leading killer, and it’s only going to get worse.
The document’s dedication says a lot. “This report is dedicated to the 48,700 families who lose a loved one each year to antibiotic resistance or Clostridioides difficile, and the countless healthcare providers, public health experts, innovators, and others who are fighting back with everything they have.”
The forward has some great messages too:
To stop antibiotic resistance, our nation must:
Stop referring to a coming post-antibiotic era—it’s already here. You and I are living in a time when some miracle drugs no longer perform miracles and families are being ripped apart by a microscopic enemy. The time for action is now and we can be part of the solution.
Stop playing the blame game. Each person, industry, and country can affect the development of antibiotic resistance. We each have a role to play and should be held accountable to make meaningful progress against this threat.
Stop relying only on new antibiotics that are slow getting to market and that, sadly, these germs will one day render ineffective. We need to adopt aggressive strategies that keep the germs away and infections from occurring in the first place.
Stop believing that antibiotic resistance is a problem “over there” in someone else’s hospital, state, or country—and not in our own backyard. Antibiotic resistance has been found in every U.S. state and in every country across the globe. There is no safe place from antibiotic resistance, but everyone can take action against it. Take action where you can, from handwashing to improving antibiotic use.
Some might say it’s alarmist. However, I don’t think it’s alarmist when someone really should be raising the alarm. We need to talk about it more, not less. We need to get people (including the general public, healthcare workers, farmers, veterinarians, policymakers) on board, to realize it’s a big issue that needs to be addressed now. “Short term pain for long-term gain” certainly applies here. We can keep delaying and the numbers will keep going up, or we can invest in solutions.
The numbers are scary but specific numbers don’t really matter in many ways. “Lots” is all we should have to know to get motivated. However, decision-makers like numbers, so these numbers hopefully will be useful to show the impact and potential benefits of investing in this problem, and motivate them to put money into antimicrobial stewardship. Saving lives should be enough, but that often doesn’t cut it. Antibiotic resistance doesn’t have a good marketing campaign. Everyone knows why people were wearing pink last month and why there are some pretty dodgy moustaches this month. Those are important issues, for sure. However, considering the overall impact, antibiotic stewardship needs to get more people behind it if we’re going to effect change.
In an ongoing effort to understand sources of foodborne illness in the United States, the Interagency Food Safety Analytics Collaboration (IFSAC) collects and analyzes outbreak data to produce an annual report with estimates of foods responsible for foodborne illnesses caused by pathogens. The report estimates the degree to which four pathogens – Salmonella, E. coli O157, Listeria monocytogenes, and Campylobacter – and specific foods and food categories are responsible for foodborne illnesses.
The Centers for Disease Control and Prevention (CDC) estimates that, together, these four pathogens cause 1.9 million foodborne illnesses in the United States each year. The newest report (PDF), entitled “Foodborne illness source attribution estimates for 2017 for Salmonella, Escherichia coli O157, Listeria monocytogenes, and Campylobacter using multi-year outbreak surveillance data, United States,” can be found on the IFSAC website.
The updated estimates, combined with other data, may help shape agency priorities and inform the creation of targeted interventions that can help to reduce foodborne illnesses caused by these pathogens. As more data become available and methods evolve, attribution estimates may improve. These estimates are intended to inform and engage stakeholders and to improve federal agencies’ abilities to assess whether prevention measures are working.
Foodborne illness source attribution estimates for 2017 for salmonella, Escherichia coli O157, listeria monocytogenes, and campylobacter using multi-year outbreak surveillance data, United States, Sept.2019
In interviews, 12 (71%) of 17 ill people reported contact with a turtle.
This investigation is ongoing and CDC will provide updates when more information is available.
Turtles can carry Salmonella germs in their droppings while appearing healthy and clean. These germs can easily spread to their bodies, tank water, and habitats. People can get sick after they touch a turtle or anything in their habitats.
Always wash hands thoroughly with soap and water right after touching, feeding, or caring for a turtle or cleaning its habitat.
Adults should supervise handwashing for young children.
Don’t kiss or snuggle turtles, because this can spread Salmonella germs to your face and mouth and make you sick.
Don’t let turtles roam freely in areas where food is prepared or stored, such as kitchens.
Clean habitats, toys, and pet supplies outside the house when possible.
Avoid cleaning these items in the kitchen or any other location where food is prepared, served, or stored.
Pick the right pet for your family.
CDC and public health officials in several states are investigating a multistate outbreak of human Salmonella Oranienburg infections linked to contact with pet turtles.
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 a standardized laboratory and data analysis method called whole genome sequencing (WGS). CDC PulseNet manages a national database of these sequences that are used to identify possible outbreaks. WGS gives investigators detailed information about the bacteria causing illness. In this investigation, WGS showed that bacteria isolated from ill people were closely related genetically. This means that people in this outbreak are more likely to share a common source of infection.
Ill people reported contact with red-eared sliders and other turtles that were larger than four inches in length. Previous Salmonella outbreaks have been linked to turtles with a shell length less than four inches. Due to the amount of Salmonella illnesses related to these small turtles, the U.S. Food and Drug Administration banned the sale and distributionexternal icon of turtles with shells less than four inches long as pets.
Regardless of where turtles are purchased or their size, turtles can carry Salmonella germs that can make people sick. Pet owners should always follow steps to stay healthy around their pet.
This investigation is ongoing, and CDC will provide updates when more information becomes available.