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Tue
24
Feb '15

Salmonella Newport Infections & Cukes

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6406a3.htm?s_cid=mm6406a3_w

Outbreak of Salmonella Newport Infections Linked to Cucumbers — United States, 2014

 Weekly

February 20, 2015 / 64(06);144-147

Kristina M. Angelo, DO1,2, Alvina Chu, MHS3, Madhu Anand, MPH4, Thai-An Nguyen, MPH2, Lyndsay Bottichio, MPH2, Matthew Wise, PhD2, Ian Williams, PhD2, Sharon Seelman, MS, MBA5, Rebecca Bell, PhD5, Marianne Fatica, PhD5, Susan Lance, DVM, PhD5, Deanna Baldwin6, Kyle Shannon3, Hannah Lee, MPH3, Eija Trees, PhD2, Errol Strain, PhD5, Laura Gieraltowski, PhD2 (Author affiliations at end of text)

In August 2014, PulseNet, the national molecular subtyping network for foodborne disease surveillance, detected a multistate cluster of Salmonella enterica serotype Newport infections with an indistinguishable pulse-field gel electrophoresis (PFGE) pattern (XbaI PFGE pattern JJPX01.0061).* Outbreaks of illnesses associated with this PFGE pattern have previously been linked to consumption of tomatoes harvested from Virginia’s Eastern Shore in the Delmarva region and have not been linked to cucumbers or other produce items (1). To identify the contaminated food and find the source of the contamination, CDC, state and local health and agriculture departments and laboratories, and the Food and Drug Administration (FDA) conducted epidemiologic, traceback, and laboratory investigations. A total of 275 patients in 29 states and the District of Columbia were identified, with illness onsets occurring during May 20–September 30, 2014. Whole genome sequencing (WGS), a highly discriminating subtyping method, was used to further characterize PFGE pattern JJPX01.0061 isolates. Epidemiologic, microbiologic, and product traceback evidence suggests that cucumbers were a source of Salmonella Newport infections in this outbreak. The epidemiologic link to a novel outbreak vehicle suggests an environmental reservoir for Salmonella in the Delmarva region that should be identified and mitigated to prevent future outbreaks.

Epidemiologic Investigation

A case was defined as infection with Salmonella Newport with PFGE pattern JJPX01.0061 (the outbreak strain) in a person with illness onset occurring during May 20–September 30, 2014. Initial interviews of ill persons conducted by state and local health officials found that travel to the Delmarva region during the incubation period was commonly reported. A structured, focused supplemental questionnaire was developed to collect detailed information on travel and exposure to restaurants, seafood, fruit, and produce, including tomatoes, in the 7 days before illness onset. Exposure frequencies were compared with the 2006–2007 FoodNet Population Survey, in which healthy persons reported foods consumed in the week before interview.† Information also was collected on illness subclusters, defined as two or more unrelated ill persons who reported eating at the same restaurant, attending the same event, or shopping at the same grocery store in the week before becoming ill.

A total of 275 cases were reported from 29 states and the District of Columbia (Figure 1). An additional 18 suspected cases not meeting the case definition were excluded from the analysis because they were found to be temporal outliers and unlikely to be related. Illness onset dates ranged from May 25 to September 29, 2014 (Figure 2). Median age of patients was 42 years (range = <1–90 years); 66% (174 of 265) were female. Thirty-four percent (48 of 141) were hospitalized; one death was reported in an elderly man with bacteremia. A total of 101 patients were interviewed using the supplemental questionnaire about exposures in the week before illness onset. This questionnaire focused on leafy greens and tomatoes and contained smaller sections on fruit, vegetables, and seafood common to the Delmarva region. Many patients were unreachable and did not receive the supplemental questionnaire. Sixty-two percent (49 of 79) of respondents reported eating cucumbers in the week before becoming ill. Patients were significantly more likely to report consuming cucumbers compared with respondents in the 2006–2007 FoodNet Population Survey, both for national year-round cucumber consumption (46.9% [p=0.002]) and for cucumber consumption in Maryland during the month of July (54.9% [p=0.04]). The proportion of ill persons who reported eating tomatoes, leafy greens, or any other item on the supplemental questionnaire was not significantly higher than expected compared with findings from the FoodNet Population Survey.

Traceback investigation

Officials in Maryland, Delaware, and New York worked with their FDA district offices and FDA and U.S. Department of Agriculture foodborne outbreak rapid response teams to conduct an informational (i.e., nonregulatory) traceback from retail establishments in these states to identify a point of distribution convergence for produce items (i.e., cucumbers, leafy greens, and tomatoes) consumed in nine of 12 subclusters. Each of eight establishments in Maryland and Delaware received cucumbers from a single major distributor. Preliminary traceback from the distributor to several brokers identified a common grower on Maryland’s Eastern Shore in the Delmarva region. Traceback from a New York subcluster led to a different distribution chain than in Maryland and Delaware. Officials from the Maryland Department of Agriculture, the Maryland rapid response team, and the FDA Baltimore District Office visited the Maryland farm. Officials collected 48 environmental samples from areas where cucumbers were grown, harvested, and packed. Sediment and manure samples were taken from the farm. No samples yielded Salmonella; however, sampling was performed several months after the harvest. Records and interviews indicated that the farm applied poultry litter approximately 120 days before harvest, but it was not available for testing.

Laboratory investigation

Twelve distinct illness subclusters were identified across four states, ranging in size from two to six cases. WGS was performed on 58 clinical isolates by state health departments, FDA, and CDC laboratories to further characterize the genetic relatedness of bacteria isolated from patients. Phylogenetic analysis revealed a primary group of highly related clinical isolates from cases in Delaware, Maryland, Ohio, Pennsylvania, and Virginia (median single nucleotide polymorphism distance = 26 [97.5% confidence interval = 1–37]). An additional group of highly related isolates from patients in New York was also identified, but this group was distinct from the primary phylogenetic group, consistent with the epidemiologic and traceback findings (single nucleotide polymorphism distance between the two phylogenetic groups = 102 [97.5% confidence interval = 85–114]). CDC’s National Antimicrobial Resistance Monitoring System laboratory conducted antibiotic resistance testing on three isolates from ill persons with the outbreak strain. All three were susceptible to all antibiotics tested.§

Discussion

The epidemiologic data, traceback investigations, and whole genome sequencing all support the hypothesis that cucumbers were a likely source of Salmonella Newport infections in this outbreak. Cucumbers were the only food eaten by patients significantly more often than expected. Traceback investigations performed using invoices from illness subclusters in Maryland and Delaware identified a common grower of cucumbers in the Delmarva region. This is the first multistate outbreak of Salmonella Newport implicating a fresh produce item grown in the Delmarva region other than tomatoes. Historically, Salmonella Newport outbreaks associated with this PFGE pattern have been linked to red round tomatoes grown on Virginia’s Eastern Shore. These outbreaks occurred in 2002 (333 persons), 2005 (72 persons), 2006 (115 persons), and 2007 (65 persons), with an additional suspected outbreak in 2010 (51 persons) (1). A definitive contamination source has not been found, and Salmonella Newport has not been isolated directly from any Delmarva region tomatoes. Wildlife have been evaluated as a possible source of contamination, but fecal specimens from deer, turtles, and birds have been negative and do not support the hypothesis that animals are a source (2). Other serotypes of Salmonella have been linked to cucumbers; most recently an outbreak of Salmonella Saintpaul infections was linked to imported cucumbers from Mexico in 2013 (3).

Investigating illness subclusters can provide critical clues about the source of an outbreak. Informational traceback can support the epidemiologic investigation by quickly assessing the plausibility of one or more vehicles as the source of the outbreak. Informational traceback generally can be completed much more quickly than regulatory traceback, which requires the collection of specific types of records, such as receipts, invoices, and bills of lading, at each step of the distribution chain. In this investigation, the informational traceback quickly provided a critical clue that suggested cucumbers were a likely source in the outbreak.

Consultation with independent industry experts early in an outbreak investigation also can provide important clues to help focus the investigation on certain suspected foods. Because of the suspicion that this outbreak was caused by a novel vehicle for this Salmonella Newport PFGE pattern, an industry consultation was held on September 11, 2014, with three independent experts from the produce industry to obtain information regarding cucumber harvesting and distribution on the Delmarva region. The consultants provided information regarding crop production and distribution practices that also helped assess the plausibility of cucumbers as an outbreak vehicle.

Advanced molecular detection methods, including WGS, might improve discrimination of subclusters during outbreak investigations. WGS data from the subclusters in this investigation demonstrated a phylogenetic link between clinical isolates from the eight Maryland and Delaware subclusters, in addition to differentiating these clusters from a subcluster in New York. The significance of this differentiation remains unclear at this time but might suggest that some of the illnesses in New York were not related to consumption of cucumbers from the Delmarva region. This is also supported by the informational traceback from the New York establishment, which led to a different distribution chain than those of the Maryland and Delaware establishments.

The findings in this report are subject to at least two limitations. First, no case-control study was performed because illness subclusters were small. Second, not all patients in the subclusters were systematically asked about cucumber consumption.

This outbreak supports the continued evaluation of farm practices by FDA as a part of the development of a Produce Safety Rule.¶ These evaluations include conducting a risk assessment and working with the U.S. Department of Agriculture and other stakeholders. It also includes performing research to strengthen scientific support for determining appropriate intervals between application of raw manure fertilizer and harvest. The Maryland Department of Agriculture plans additional assessments in the Delmarva region before the 2015 planting season to determine whether additional or alternative “best practices” can be implemented.

Given the typical shelf life of cucumbers is 10–14 days, cucumbers from the implicated grower are no longer available for purchase or in person’s homes. Consumers and retailers should always follow safe produce handling recommendations.** Cucumbers, like all produce, should be washed thoroughly, scrubbed with a clean produce brush before peeling or cutting, and refrigerated as soon as possible to prevent multiplication of bacteria such as Salmonella.

Acknowledgments

William Wolfgang, PhD, David Nicholas, MPH, New York State Department of Health. David Blythe, MD, Maryland Department of Mental Health and Hygiene. Kate Heiman, MPH, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

1Epidemic Intelligence Service, CDC; 2Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 3Maryland Department of Health and Mental Hygiene; 4New York State Department of Health; 5Food and Drug Administration; 6Maryland Department of Agriculture (Corresponding author: Kristina M. Angelo, kangelo@cdc.gov, 404-718-4876404-718-4876)

References

  1. Bennett SD, Litterell KW, Hill TA, Mahovic M, Behravesh CB. Multistate foodborne disease outbreaks associated with raw tomatoes, United States, 1990–2010: a recurring public health problem. Epidemiol Infect 2014;August 28:1–8 [Epub ahead of print].
  2. Gruszynski K, Pao S, Kim C, et al. Evaluating wildlife as a potential source of Salmonella serotype Newport (JJPX01.0061) contamination for tomatoes on the Eastern Shore of Virginia. Zoonoses Public Health 2014;61:202–7.
  3. CDC. Multistate outbreak of Salmonella Saintpaul infections linked to imported cucumbers (final update). Available at http://www.cdc.gov/salmonella/saintpaul-04-13/index.html.

* Additional information available at http://www.cdc.gov/pulsenet.

† Additional information available at http://www.cdc.gov/foodnet/studies/population-surveys.html.

§ Additional information available at http://www.cdc.gov/narms/about/index.html.

¶ Available at http://www.fda.gov/food/guidanceregulation/fsma/ucm334114.htmExternal Web Site Icon.

** Available at http://www.foodsafety.gov/keep/types/fruits/tipsfreshprodsafety.htmlExternal Web Site Icon.

 

What is already known on this topic?

Salmonella is the most common bacterial cause of foodborne disease in the United States and results in the highest number of hospitalizations and deaths among foodborne pathogens. Salmonella Newport has historically been a common cause of tomato-associated outbreaks in the United States. The Virginia Eastern Shore in the Delmarva region has been the site of multiple outbreaks of Salmonella Newport infection in recent years.

What is added by this report?

In August 2014, a multistate cluster of Salmonella enterica serotype Newport infections with an indistinguishable pulse-field gel electrophoresis (PFGE) pattern (XbaI PFGE pattern JJPX01.0061) was detected, involving 275 patients in 29 states and the District of Columbia with illness onsets occurring during May 20 and September 30. Epidemiologic, product traceback, and laboratory evidence implicated cucumbers. Whole genome sequencing, used to subtype the isolates, and the traceback investigation suggested that some, but not all, of the contaminated cucumbers were from a farm in Maryland. No Salmonella was isolated from environmental samples taken at the farm.

What are the implications for public health practice?

The epidemiologic link to a novel outbreak vehicle from the Delmarva region, cucumbers, suggests an environmental reservoir for Salmonella that might also include both the Virginia and Maryland portions of the Delmarva region. Federal, state, and local public health and regulatory authorities should focus on identifying and mitigating this potential environmental reservoir to prevent future outbreaks.

FIGURE 1. Number of persons (N = 275) infected with the outbreak strain of Salmonella Newport, by state — United States, May 20–September 30, 2014The figure above is a map of the United States showing the number of persons infected with the outbreak strain of Salmonella Newport, by state, in the United States during May 20- September 30, 2014. A total of 275 cases were reported from 29 states and the District of Columbia.Alternate Text: The figure above is a map of the United States showing the number of persons infected with the outbreak strain of Salmonella Newport, by state, in the United States during May 20- September 30, 2014. A total of 275 cases were reported from 29 states and the District of Columbia.
FIGURE 2. Number of persons (N = 275) infected with the outbreak strain of Salmonella Newport, by estimated date of illness onset — United States, May 20–September 30, 2014  The figure above is a histogram showing the number of persons (N = 275) infected with the outbreak strain of Salmonella Newport, by estimated date of illness onset, in the United States during May 20-September 30, 2014. Alternate Text: The figure above is a histogram showing the number of persons (N = 275) infected with the outbreak strain of Salmonella Newport, by estimated date of illness onset, in the United States during May 20-September 30, 2014.
Sun
22
Feb '15

Number of persons (N = 275) infected with the outbreak strain of Salmonella Newport, by state — United States, May 20–September 30, 2014

The figure above is a map of the United States showing the number of persons infected with the outbreak strain of Salmonella Newport, by state, in the United States during May 20- September 30, 2014. A total of 275 cases were reported from 29 states and the District of Columbia.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6406a3.htm

Thu
18
Dec '14

Damn Sprouts: Persons infected with the outbreak strains of Salmonella Enteritidis, by state of residence, as of December 16, 2014 (n=111)

Map of persons infected with the outbreak strains of Samonella Enteritidis, by state of residence, as of December 15, 2014 (n-111)

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Sat
6
Dec '14

Multistate Outbreak of Salmonella Enteritidis Infections Linked to Bean Sprouts

Case count map, December 4, 2014

Epi Curve, December 4, 2014

 

 

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Wed
24
Sep '14

While the American food supply is among the safest in the world, an estimated 1 in 6 Americans is sickened by foodborne illness annually, resulting in about 3,000 deaths, according to the CDC. Salmonella is the leading cause of deaths and of hospitalizations related to foodborne illness, estimated to cause 380 deaths and 19,000 hospitalizations in the United States each year.

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm415831.htm

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Sat
23
Aug '14

Multistate Outbreak of Salmonella Braenderup Infections Linked to Nut Butter Manufactured by nSpired Natural Foods, Inc.

http://www.cdc.gov/salmonella/braenderup-08-14/index.html

Persons infected with the outbreak strain of Salmonella Braenderup, by State as of August 20, 2014

Highlights

  • As of August 20, 2014, a total of four persons infected with the  outbreak strain of Salmonella Braenderup have been reported from four states  since January 1, 2014.
    • The number of        ill persons identified in each state is as follows: Connecticut (1),        Iowa (1), Tennessee (1), and Texas (1).
    • One ill person        has been hospitalized. No deaths have been reported.
  • Collaborative       investigation efforts of state, local, and federal public health and       regulatory agencies indicate that almond and peanut       butter manufactured       by nSpired Natural Foods, Inc. is the likely source       of this outbreak.
    • The U.S. Food        and Drug Administration (FDA) isolated the same strain of Salmonella Braenderup from environmental        samples collected from an nSpired Natural Foods facility during routine inspections        in January and July 2014.
  • On  August 19, 2014, nSpired Natural Foods, Inc. voluntarily recalledExternal Web Site Icon certain lots of almond  and peanut butters because of potential contamination with Salmonella.
    • The  recalled brands include Arrowhead Mills, MaraNatha, Trader Joe’s, Whole Foods,  Safeway, and Kroger.
    • A  complete listing of all of the recalled products is available on the FDA websiteExternal Web Site Icon.
  • CDC  recommends that consumers do not eat any of the recalled almond and peanut butter products  and discard any remaining product.
    • This  product has a long shelf life, and it may still be in people’s homes.

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Tue
12
Aug '14

As of August 5, 2014, a total of 300 persons infected with the outbreak strains of Salmonella Infantis, Salmonella Newport, or Salmonella Hadar have been reported from 42 states and Puerto Rico.

http://www.cdc.gov/salmonella/live-poultry-05-14/index.html

Persons infected with the outbreak strains of Salmonella Hadar, Infantis, or Newport by state as of August 5, 2014

  • As of August  5, 2014, a total of 300 persons infected with the outbreak strains of Salmonella Infantis, Salmonella Newport, or Salmonella Hadar have been reported from  42 states and Puerto Rico.
    • 31% of  ill persons have been hospitalized, and no deaths have been reported.
  • Epidemiologic,  laboratory, and traceback findings have linked this outbreak of human Salmonella infections to contact with chicks, ducklings, and other live poultry from Mt.  Healthy Hatcheries in Ohio.
    • 80% of  ill people reported contact with live poultry in the week before their illness  began.
  • Findings  of multiple traceback investigations of live baby poultry from homes of ill  persons have identified Mt. Healthy Hatcheries in Ohio as the source of chicks  and ducklings. This is the same mail-order hatchery that has been associated  with multiple outbreaks of Salmonella infections linked to live poultry in past years, including in 2012 and 2013.
  • CDC’s National  Antimicrobial Resistance Monitoring System (NARMS) laboratory conducted antibiotic resistance  testing on Salmonella isolates collected from 11 ill persons infected  with the outbreak strains of Salmonella Infantis or Newport. Of the 11 isolates tested:
    • Two (18%) were drug resistant  (defined as resistance to one or more antibiotics).
    • Nine (82%) were pansusceptible  (susceptible to all antibiotics tested).
  • Mail-order  hatcheries, agricultural feed stores, and others that sell or display chicks,  ducklings, and other live poultry should provide health-related information to owners and potential purchasers of  these birds prior to selling them. This should include information about the  risk of acquiring a Salmonella infection from contact with live poultry.
  • Consumers who own live poultry should take steps to  protect themselves:
    • Always wash your hands thoroughly with soap and water  right after touching live poultry or anything in the area where these birds  live and roam.
    • Do not let live poultry inside  the house.
    • Learn about additional recommendations to protect yourself and your  family from Salmonella infections. These recommendations are important and apply  to all live poultry, regardless of the age of the birds or where they were  purchased.

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Tue
8
Jul '14

Multidrug-Resistant Salmonella Heidelberg Infections Linked to Foster Farms Brand Chicken

http://www.cdc.gov/salmonella/heidelberg-10-13/index.html

Persons infected with the outbreak strain of Salmonella Heidelberg, by State as of July 2, 2014

  • This outbreak investigation is ongoing; however, since an increase in illnesses noted in February and March, there has been a decline in the weekly number of illnesses occurring. The number of illnesses is now approaching the expected number for this time of year.
  • As of July 2, 2014, a total of 621 persons infected with seven outbreak strains of Salmonella Heidelberg have been reported from 29 states and Puerto Rico, since March 1, 2013.
    • 36% of ill persons have been hospitalized, and no deaths have been reported.
    • Most ill persons (77%) have been reported from California.
  • Epidemiologic, laboratory, and traceback investigations conducted by local, state, and federal officials indicate that consumption of Foster Farms brand chicken is the likely source of this outbreak of Salmonella Heidelberg infections.
  • On July 3, 2014, Foster Farms recalledExternal Web Site Icon an undetermined amount of chicken products that may be contaminated with a particular strain of Salmonella Heidelberg.
    • The recall resulted from USDA-FSIS identifying one of the outbreak strains of Salmonella Heidelberg in an intact sample of Foster Farms brand chicken with labeling information collected from the home of a person infected with the same strain in California.
    • Although the recalled chicken had production dates of March 7 through March 13, 2014, USDA-FSIS and CDC are concerned that the recalled chicken could still be in people’s freezers.
    • Consumers should check their freezers for the recalled chicken and should not eat it.
  • The outbreak strains of Salmonella Heidelberg are resistant to several commonly prescribed antibiotics. Although these antibiotics are not typically used to treat Salmonella bloodstream infections or other severe Salmonella infections, antibiotic resistance can be associated with increased risk of hospitalization in infected individuals.
  • It is not unusual for raw poultry from any producer to have Salmonella bacteria. CDC and USDA-FSIS recommend all consumers follow food safety tipsExternal Web Site Icon to prevent Salmonella infection from any raw poultry produced by Foster Farms or any other brand.

 

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Sat
28
Jun '14

As of June 25, 2014, a total of 251 persons infected with the outbreak strains of Salmonella Infantis, Salmonella Newport, or Salmonella Hadar have been reported from 37 states.

http://www.cdc.gov/salmonella/live-poultry-05-14/index.html

 

**  32% of ill persons have been hospitalized, and no deaths have  been reported.

**  Epidemiologic,  laboratory, and traceback findings have linked this outbreak of human Salmonella infections to contact with chicks, ducklings, and other live poultry from Mt.  Healthy Hatcheries in Ohio.

Persons infected with the outbreak strains of Salmonella Infantis or Newport, by state as of June 25, 2014

 

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Sun
15
Jun '14

CDC is warning the public about an ongoing outbreak of Salmonella infections linked to products containing chia powder

http://www.cdc.gov/media/releases/2014/a0613-chia-products.html

CDC Investigates Ongoing Salmonella Outbreak Linked to Chia Products

What

The Centers for Disease Control and Prevention (CDC) is warning the public  about an ongoing outbreak of Salmonella infections linked to products containing  chia powder. Chia powder is made  from small chia seeds that are sprouted and ground into powder. It is often added to health foods  like smoothies for its nutritional value. It is sold at many different stores,  including specialty health food stores, and online.

Multiple  recalls of different brands of products containing chia powder and chia seeds  have been issued by companies in the U.S. and Canada.

Where

As of  June 9, 2014, 21 illnesses have been reported in 12 U.S. states. Canada has  reported similar cases of Salmonella in several provinces. Two patients have been hospitalized.

Why

The recalled chia products linked to illness have  a long shelf-life so may still be in people’s pantries without them knowing it.

Consumers  should check to see if they have the recalled products in their homes. CDC  urges people who have purchased any of the recalled products to not eat them,  and either throw them away or return them to the place of purchase. Links and  images for the recalled products are available on the CDC website at: http://www.cdc.gov/salmonella/newport-05-14/advice-consumers.html.

Salmonella  causes diarrhea, fever and abdominal cramps 12 to 72 hours after infection.  Most people recover within four to seven days without treatment. Children  younger than five, older adults and people with weakened immune systems are more  likely to have a severe illness from Salmonella infection.

Please contact the CDC Media Office,  if you have questions or would like to request an interview.

For up-to-date information about  the outbreak, visit http://www.cdc.gov/salmonella/newport-05-14/index.html.

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