Karen P. Neil

Multistate outbreak of listeriosis associated with cantaloupe.

BACKGROUND Although new pathogen-vehicle combinations are increasingly being identified in produce-related disease outbreaks, fresh produce is a rarely recognized vehicle for listeriosis. We investigated a nationwide listeriosis outbreak that occurred in the United States during 2011. METHODS We defined an outbreak-related case as a laboratory-confirmed infection with any of five outbreak-related subtypes of Listeria monocytogenes isolated during the period from August 1 through October 31, 2011. Multistate epidemiologic, trace-back, and environmental investigations were conducted, and outbreak-related cases were compared with sporadic cases reported previously to the Listeria Initiative, an enhanced surveillance system that routinely collects detailed information about U.S. cases of listeriosis. RESULTS We identified 147 outbreak-related cases in 28 states. The majority of patients (127 of 147, 86%) were 60 years of age or older. Seven infections among pregnant women and newborns and one related miscarriage were reported. Of 145 patients for whom information about hospitalization was available, 143 (99%) were hospitalized. Thirty-three of the 147 patients (22%) died. Patients with outbreak-related illness were significantly more likely to have eaten cantaloupe than were patients 60 years of age or older with sporadic illness (odds ratio, 8.5; 95% confidence interval, 1.3 to ∞). Cantaloupe and environmental samples collected during the investigation yielded isolates matching all five outbreak-related subtypes, confirming that whole cantaloupe produced by a single Colorado farm was the outbreak source. Unsanitary conditions identified in the processing facility operated by the farm probably resulted in contamination of cantaloupes with L. monocytogenes. CONCLUSIONS Raw produce, including cantaloupe, can serve as a vehicle for listeriosis. This outbreak highlights the importance of preventing produce contamination within farm and processing environments.

A Novel Vehicle for Transmission of Escherichia coli O157:H7 to Humans: Multistate Outbreak of E. coli O157:H7 Infections Associated With Consumption of Ready-to-Bake Commercial Prepackaged Cookie Dough—United States, 2009

BACKGROUND  Escherichia coli O157:H7 is a Shiga toxin-producing E. coli (STEC) associated with numerous foodborne outbreaks in the United States and is an important cause of bacterial gastrointestinal illness. In May 2009, we investigated a multistate outbreak of E. coli O157:H7 infections. METHODS  Outbreak-associated cases were identified using serotyping and molecular subtyping procedures. Traceback investigation and product testing were performed. A matched case-control study was conducted to identify exposures associated with illness using age-, sex-, and state-matched controls. RESULTS  Seventy-seven patients with illnesses during the period 16 March-8 July 2009 were identified from 30 states; 35 were hospitalized, 10 developed hemolytic-uremic syndrome, and none died. Sixty-six percent of patients were <19 years; 71% were female. In the case-control study, 33 of 35 case patients (94%) consumed ready-to-bake commercial prepackaged cookie dough, compared with 4 of 36 controls (11%) (matched odds ratio = 41.3; P < .001); no other reported exposures were significantly associated with illness. Among case patients consuming cookie dough, 94% reported brand A. Three nonoutbreak STEC strains were isolated from brand A cookie dough. The investigation led to a recall of 3.6 million packages of brand A cookie dough and a product reformulation. CONCLUSIONS  This is the first reported STEC outbreak associated with consuming ready-to-bake commercial prepackaged cookie dough. Despite instructions to bake brand A cookie dough before eating, case patients consumed the product uncooked. Manufacturers should consider formulating ready-to-bake commercial prepackaged cookie dough to be as safe as a ready-to-eat product. More effective consumer education about the risks of eating unbaked cookie dough is needed.

Foodborne illness outbreaks from microbial contaminants in spices, 1973-2010.

This review identified fourteen reported illness outbreaks attributed to consumption of pathogen-contaminated spice during the period 1973-2010. Countries reporting outbreaks included Canada, Denmark, England and Wales, France, Germany, New Zealand, Norway, Serbia, and the United States. Together, these outbreaks resulted in 1946 reported human illnesses, 128 hospitalizations and two deaths. Infants/children were the primary population segments impacted by 36% (5/14) of spice-attributed outbreaks. Four outbreaks were associated with multiple organisms. Salmonella enterica subspecies enterica was identified as the causative agent in 71% (10/14) of outbreaks, accounting for 87% of reported illnesses. Bacillus spp. was identified as the causative agent in 29% (4/10) of outbreaks, accounting for 13% of illnesses. 71% (10/14) of outbreaks were associated with spices classified as fruits or seeds of the source plant. Consumption of ready-to-eat foods prepared with spices applied after the final food manufacturing pathogen reduction step accounted for 70% of illnesses. Pathogen growth in spiced food is suspected to have played a role in some outbreaks, but it was not likely a contributing factor in three of the larger Salmonella outbreaks, which involved low-moisture foods. Root causes of spice contamination included contributions from both early and late stages of the farm-to-table continuum.

Recent Multistate Outbreaks of Human Salmonella Infections Acquired from Turtles: A Continuing Public Health Challenge

The federal ban in the United States on the sale of turtles with shell lengths <4 inches that was established in 1975 has reduced the number of turtle-associated human Salmonella infections during subsequent years, especially among children. Although numerous sporadic turtle-associated Salmonella infections in humans have been reported since the ban went into effect, outbreaks were not reported until recently. Since 2006, 3 multistate outbreaks of turtle-associated Salmonella infections have been documented in the United States. This review examines the history of turtle-associated human Salmonella infections in the United States and discusses reasons why an increase in turtle-associated salmonellosis may be occurring and how challenges in enforcement of the ban affect disease control. Additional steps should be considered by the public health community, state governments, and enforcement agencies to prevent turtle-associated Salmonella infections in humans.

A Large Outbreak of Typhoid Fever Associated With a High Rate of Intestinal Perforation in Kasese District, Uganda, 2008–2009

BACKGROUND Salmonella enterica serovar Typhi (Salmonella Typhi) causes an estimated 22 million typhoid fever cases and 216 000 deaths annually worldwide. In Africa, the lack of laboratory diagnostic capacity limits the ability to recognize endemic typhoid fever and to detect outbreaks. We report a large laboratory-confirmed outbreak of typhoid fever in Uganda with a high proportion of intestinal perforations (IPs). METHODS A suspected case of typhoid fever was defined as fever and abdominal pain in a person with either vomiting, diarrhea, constipation, headache, weakness, arthralgia, poor response to antimalarial medications, or IP. From March 4, 2009 to April 17, 2009, specimens for blood and stool cultures and serology were collected from suspected cases. Antimicrobial susceptibility testing and pulsed-field gel electrophoresis (PFGE) were performed on Salmonella Typhi isolates. Surgical specimens from patients with IP were examined. A community survey was conducted to characterize the extent of the outbreak. RESULTS From December 27, 2007 to July 30, 2009, 577 cases, 289 hospitalizations, 249 IPs, and 47 deaths from typhoid fever occurred; Salmonella Typhi was isolated from 27 (33%) of 81 patients. Isolates demonstrated multiple PFGE patterns and uniform susceptibility to ciprofloxacin. Surgical specimens from 30 patients were consistent with typhoid fever. Estimated typhoid fever incidence in the community survey was 8092 cases per 100 000 persons. CONCLUSIONS This typhoid fever outbreak was detected because of an elevated number of IPs. Underreporting of milder illnesses and delayed and inadequate antimicrobial treatment contributed to the high perforation rate. Enhancing laboratory capacity for detection is critical to improving typhoid fever control.

A Survey of Emergency Department 2009 Pandemic Influenza A (H1N1) Surge Preparedness—Atlanta, Georgia, July–October 2009

During August through September 2009, a surge in emergency department (ED) visits for 2009 pandemic influenza A (pH1N1) illness occurred in Georgia, particularly among children. To understand surge preparedness and capacity, we obtained influenza-like illness (ILI) ED visit data from the Georgia State Electronic Notifiable Disease Surveillance System (SendSS) and conducted a retrospective, Internet-based survey among all 26 metro Atlanta ED managers with reference to the period 1 July-1 October 2009. SendSS detected a marked and progressive increase in mean monthly ILI visits from 1 July-1 October 2009, which more than tripled (from 399 to 2196) for the 2 participating EDs that cared for pediatric patients during this time. ED managers reported patient volume surges, resulting in space and supply limitations, especially at pediatric EDs. Most (92%) of the facilities had current pandemic influenza plans. Pandemic planning can help to ensure preparedness for natural and man-made disasters and for future influenza pandemics.

Utility of Combining Whole Genome Sequencing with Traditional Investigational Methods To Solve Foodborne Outbreaks of Salmonella Infections Associated with Chicken: A New Tool for Tackling This Challenging Food Vehicle

High consumption rates and a multitude of brands make multistate foodborne outbreaks of Salmonella infections associated with chicken challenging to investigate, but whole genome sequencing is a powerful tool that can be used to assist investigators. Whole genome sequencing of pathogens isolated from clinical, environmental, and food samples is increasingly being used in multistate foodborne outbreak investigations to determine with unprecedented resolution how closely related these isolates are to one another genetically. In 2014, federal and state health officials investigated an outbreak of 146 Salmonella Heidelberg infections in 24 states. A follow-up analysis was conducted after the conclusion of the investigation in which 27 clinical and 24 food isolates from the outbreak underwent whole genome sequencing. These isolates formed seven clades, the largest of which contained clinical isolates from a subcluster of case patients who attended a catered party. One isolate from a chicken processed by a large producer was closely related genetically (zero to three single-nucleotide polymorphism differences) to the clinical isolates from these subcluster case patients. Chicken from this large producer was also present in the kitchen of the caterer on the day before the event, thus providing additional evidence that the chicken from this producer was the outbreak source. This investigation highlights how whole genome sequencing can be used with epidemiologic and traceback evidence to identify chicken sources of foodborne outbreaks.

Shiga Toxin–Producing E. coli Infections Associated with Flour

BACKGROUND In 2016, a multijurisdictional team investigated an outbreak of Shiga toxin–producing Escherichia coli (STEC) serogroup O121 and O26 infections linked to contaminated flour from a large domestic producer. METHODS A case was defined as infection with an outbreak strain in which illness onset was between December 21, 2015, and September 5, 2016. To identify exposures associated with the outbreak, outbreak cases were compared with non‐STEC enteric illness cases, matched according to age group, sex, and state of residence. Products suspected to be related to the outbreak were collected for STEC testing, and a common point of contamination was sought. Whole‐genome sequencing was performed on isolates from clinical and food samples. RESULTS A total of 56 cases were identified in 24 states. Univariable exact conditional logistic‐regression models of 22 matched sets showed that infection was significantly associated with the use of one brand of flour (odds ratio, 21.04; 95% confidence interval [CI], 4.69 to 94.37) and with tasting unbaked homemade dough or batter (odds ratio, 36.02; 95% CI, 4.63 to 280.17). Laboratory testing isolated the outbreak strains from flour samples, and whole‐genome sequencing revealed that the isolates from clinical and food samples were closely related to one another genetically. Trace‐back investigation identified a common flour‐production facility. CONCLUSIONS This investigation implicated raw flour as the source of an outbreak of STEC infections. Although it is a low‐moisture food, raw flour can be a vehicle for foodborne pathogens.

A Multistate Outbreak of Human Salmonella Agona Infections Associated With Consumption of Fresh, Whole Papayas Imported From Mexico—United States, 2011

Background Nontyphoidal Salmonella causes ~1 million food-borne infections annually in the United States. We began investigating a multistate outbreak of Salmonella serotype Agona infections in April 2011. Methods A case was defined as infection with the outbreak strain of Salmonella Agona occurring between 1 January and 25 August 2011. We developed hypotheses through iterative interviews. Product distribution analyses and traceback investigations were conducted. The Food and Drug Administration (FDA) tested papayas from Mexico for Salmonella. Results We identified 106 case patients from 25 states. Their median age was 21 years (range, 1-91). Thirty-nine of 61 case patients (64%) reported Hispanic/Latino ethnicity; 11 of 65 (17%) travelled to Mexico before illness. Thirty-two of 56 case patients (57%) reported papaya consumption. Distribution analyses revealed that three firms, including Distributor A, distributed papaya to geographic areas that aligned with both the location and timing of illnesses. Traceback of papayas purchased by ill persons in four states identified Distributor A as the common supplier. FDA testing isolated the outbreak strain from a papaya sample collected at distributor A and from another sample collected at the US-Mexico border, destined for distributor A. FDA isolated Salmonella species from 62 of 388 papaya import samples (16%). The investigation led to a recall of fresh, whole papayas from Distributor A and an FDA import alert for all papayas from Mexico. Conclusions This is the first reported Salmonella outbreak in the United States linked to fresh, whole papayas. The outbreak highlights important issues regarding the safety of imported produce.