587 sick: CDC and FDA try to contain cyclosporiasis outbreak

As the numbers of those sickened with cyclosporiasis reached 495 in the U.S. and 92 in Canada, the only lead appears to be cilantro imported from Mexico.

cilantroCyclospora is a microscopic single-celled parasite that is passed in people’s feces. If it comes in contact with food or water, it can infect the people who consume it. This causes an intestinal illness called cyclosporiasis.

Previous foodborne illness outbreaks of Cyclospora, in Canada and U.S. have been linked to various types of imported fresh produce, such as pre-packaged salad mix, basil, cilantro, berries, mesclun lettuce and snow peas.

To date, no multi-jurisdictional outbreaks have been linked to produce grown in Canada.

NARMS Now: Tool shows changes in foodborne pathogen antibiotic resistance

A new interactive tool from CDC makes it easier and quicker to see how antibiotic resistance for four germs spread commonly through food—Campylobacter, E. coli O157, Salmonella, and Shigella—has changed over the past 18 years.

Each year in the United States, antibiotic-resistant germs cause 2 million illnesses and 23,000 deaths. Antibiotic-resistant infecnarms.now.fbitions from germs spread commonly through food cause an estimated 440,000 of those illnesses.

The NARMS Now: Human Data tool contains information from the National Antimicrobial Resistance Monitoring System (NARMS).

NARMS Now: Human Data allows users to access antibiotic resistance data by bacterial serotype, antibiotic, year (1996-2013), and geographic region. Users can view data on an interactive map or in tables. NARMS Now: Human Data plans to provide access to the most up-to-date antibiotic resistance results by uploading data regularly.

NARMS Now: Human Data can be used to:

-  Inform regulatory agency action.

FDA withdrew approval for Enrofloxacin (a fluoroquinolone) used in poultry after the data showed an increase in fluoroquinolone-resistant Campylobacter infections in humans.

-  Examine the geographic distribution of resistance.

Researchers have used the data to investigate the geographic distribution of multidrug-resistant Salmonella Typhimurium and Newport infections in the United States.

narmsnow-digitaldevices_cropMonitor changing trends in resistance.

Investigators are using NARMS data to help uncover the reason for increasing antibiotic resistance in a type of Salmonella, I 4,[5],12,:i:-, which has emerged recently in the United States.

Timely Access to Data

CDC developed NARMS Now: Human Data in response to requests from Congress, consumer groups, academia, and the public for timely access to data on antibiotic resistance. The tool is an important step towards President Obama’s Open Government Initiative to foster openness in government and establish a culture of transparency, public participation, and collaboration.

The FDA, on behalf of all the NARMS partner agencies, is also making data available online, NARMS Now: Integrated Data. That data helps users to access antibiotic resistance information from isolates from retail meat and animals, and will soon add Campylobacter and non-typhoidal Salmonella from humans.

Foodborne Diseases Active Surveillance Network—2 decades of achievements, 1996–2015

The Foodborne Diseases Active Surveillance Network (FoodNet) provides a foundation for food safety policy and illness prevention in the United States.

FoodNet.pyramid.fbi.OverviewFoodNet conducts active, population-based surveillance at 10 US sites for laboratory-confirmed infections of 9 bacterial and parasitic pathogens transmitted commonly through food and for hemolytic uremic syndrome.

Through FoodNet, state and federal scientists collaborate to monitor trends in enteric illnesses, identify their sources, and implement special studies. FoodNet’s major contributions include establishment of reliable, active population-based surveillance of enteric diseases; development and implementation of epidemiologic studies to determine risk and protective factors for sporadic enteric infections; population and laboratory surveys that describe the features of gastrointestinal illnesses, medical care–seeking behavior, frequency of eating various foods, and laboratory practices; and development of a surveillance and research platform that can be adapted to address emerging issues.

The importance of FoodNet’s ongoing contributions probably will grow as clinical, laboratory, and informatics technologies continue changing rapidly.

Foodborne Diseases Active Surveillance Network—2 decades of achievements, 1996–2015

Emerging Infectious Diseases, Volume 21, Number 9,  September 2015

Olga L. Henao Comments to Author , Timothy F. Jones, Duc J. Vugia, Patricia M. Griffin, and for the Foodborne Diseases Active Surveillance Network (FoodNet) Workgroup


476 sick with cyclosporiasis in US, 87 in Canada

As of August 17, 2015 (3pm EDT), a total of 476 ill persons with confirmed Cyclospora infection were reported to CDC in 2015. Most of these persons—282 (59%) of 476—experienced onset of illness on or after May 1, 2015, and did not have a history of international travel within 2 weeks before illness onset.

 cilantro.slugs.powell.10These 282 persons were from the following 22 states: Arkansas (2), California (2), Connecticut (3), Florida (10), Georgia (23), Illinois (7), Iowa (1), Kansas (2), Maryland (1), Massachusetts (9), Michigan (2), Missouri (1), Montana (3), Nebraska (1), New Jersey (6), New Mexico (2), New York (excluding NYC) (8), New York City (21), Texas (162), Utah (1), Virginia (3), Washington (2), and Wisconsin (10).

Clusters of illness linked to restaurants or events have been identified in Texas, Wisconsin, and Georgia. Cluster investigations are ongoing in Texas and Georgia. Cluster investigations in Wisconsin and Texas have preliminarily identified cilantro as a suspect vehicle. Investigations are ongoing to identify specific food item(s) linked to the cases that are not part of the identified clusters.

87 cases have been reported in Canada.

Ups and downs in report on drug-resistant foodborne bacteria

CIDRAP reports that an annual federal report released this week on drug resistance in bacterial foodborne illness culprits mainly showed encouraging patterns but raised concerns about multidrug resistance in two Salmonella serotypes.

ab.red.aug.15The findings are from the National Antimicrobial Resistance Monitoring System (NARMS), a collaboration of three federal agencies that between them track resistant bacteria in humans, retail meat, and food animals. The respective agencies include the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the US Department of Agriculture (USDA).

The report focuses on foodborne pathogens that resist antibiotics considered crucial to human medicine and on multidrug resistant bacteria—those that resist agents in three or more antibiotic classes. The system screens for nontyphoidal Salmonella, Campylobacter, Escherichia coli, and Enterococcus; Salmonella and Campylobacter are the leading bacterial causes of foodborne illness.

Methodology and testing changes

This year’s report for the first time covers multiple years, 2012 and 2013, and has a new format that includes 10 interactive graphs to help show resistance patterns in Salmonella and Campylobacter in humans, retail foods, and animals through 2013, the FDA said in a press release yesterday. It added that the report also reflects improvements in NARMS testing. For example, animal testing now includes cecal (intestinal) testing of food-producing animals before slaughter, which may provide a more accurate picture of animals’ microbial status in farm settings.

Also, the FDA said it is using epidemiologic cut-off values that move toward global harmonization of Campylobacter surveillance methods as well as updating measurements for cefepime in response to changes made to best practices for international testing. Cefepime is an antibiotic used to screen for extended-spectrum beta-lactamase (ESBL) production, a mechanism linked to drug resistance.

In encouraging findings, the NARMS study found that overall, Salmonella isolates are holding the line against resistance. About 80% of human Salmonella isolates aren’t resistant to any tested antibiotics, a number that hasn’t changed over the past decade. Resistance to the three most important drugs used to treat human Salmonella isolates—ceftriaxone, azithromycin, and quinolones—remains below 3%.

Similarly, Salmonella multidrug resistance in human, cattle, and chicken isolates hasn’t changed in the last 10 years, remaining at about 10%. Also, the number of multidrug-drug resistant Salmonella isolates in retail chicken has decreased to around 3%, according to the report.

For Campylobacter jejuni, the subtype that causes most human campylobacteriosis cases, resistance to ciprofloxacin, the drug most commonly used for treatment, declined to its lowest level in retail chicken to date (11%).

Among the worrisome findings, multidrug resistance in human isolates of the common Salmonella serotype l 4,[5],12:i:- is still rising, and has doubled from 18% in 2011 to 46% in 2013, according to the FDA.

The report also pointed to another concern, an increase in multidrug resistance and ceftriaxone resistance in Salmonella Dublin subtypes isolated from cattle and humans.

Surveillance for waterborne disease outbreaks associated with drinking water – United States, 2011-2012

The U.S. Centers for Disease Control reports in Morbidity and Mortality Weekly that advances in water management and sanitation have substantially reduced waterborne disease in the United States, although outbreaks continue to occur (1). Public health agencies in the U.S. states and territories* report information on waterborne disease outbreaks to the CDC Waterborne Disease and Outbreak Surveillance System (http://www.cdc.gov/healthywater/surveillance/index.html).

water.wellFor 2011–2012, 32 drinking water–associated outbreaks were reported, accounting for at least 431 cases of illness, 102 hospitalizations, and 14 deaths. Legionella was responsible for 66% of outbreaks and 26% of illnesses, and viruses and non-Legionella bacteria together accounted for 16% of outbreaks and 53% of illnesses. The two most commonly identified deficiencies† leading to drinking water–associated outbreaks were Legionella in building plumbing§ systems (66%) and untreated groundwater (13%). Continued vigilance by public health, regulatory, and industry professionals to identify and correct deficiencies associated with building plumbing systems and groundwater systems could prevent most reported outbreaks and illnesses associated with drinking water systems.

This report provides information on drinking water–associated¶ waterborne disease outbreaks in which the first illness occurred in 2011 or 2012** (http://www.cdc.gov/healthywater/surveillance/drinking-surveillance-reports.html), and summarizes outbreaks reported to the Waterborne Disease and Outbreak Surveillance System through the electronic National Outbreak Reporting System (http://www.cdc.gov/nors/about.html) as of October 30, 2014. For an event to be defined as a waterborne disease outbreak, two or more persons must be linked epidemiologically by time, location of water exposure, and case illness characteristics; and the epidemiologic evidence must implicate water as the probable source of illness. Data submitted 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) contributing factors in the outbreak; and 5) the setting of exposure.

Karlyn D. Beer, PhD1,2; Julia W. Gargano, PhD2; Virginia A. Roberts, MSPH2; Vincent R. Hill, PhD2; Laurel E. Garrison, MPH3; Preeta K. Kutty, MD3; Elizabeth D. Hilborn, DVM4; Timothy J. Wade, PhD4; Kathleen E. Fullerton, MPH2; Jonathan S. Yoder, MPH, MSW2

Salmonella cases tied to pork jump to 90

Be really careful with whole pigs.

JoNel Aleccia of The Seattle Times writes that the number of people sickened in a Salmonella outbreak in Washington state –has apparently linked to whole pigs – has jumped from 56 to 90.

whole.pig.roastThe U.S. Department of Agriculture (USDA)’s Food Safety and Inspection Service (FSIS) has issued a public-health alert because of concerns that the Washington salmonella infections might be tied to whole pigs used in pig roasts.

The sharp uptick in cases in less than a week and the lack of a clear source has led state health officials to ask the federal Centers for Disease Control and Prevention to send in a special team to help with the investigation. The so-called Epi-Aid group is expected to be in Washington next week, a state Department of Health spokesman said. The U.S. Department of Agriculture is also involved in the probe.

Investigators say many of the cases appear to be linked to eating pork, or to exposure to raw pork, particularly roasted pigs cooked and served at private events.

The cases appear to have been caused by the same rare strain of bacteria, health officials, Salmonella I, 4, 5, 12:i:-, a germ that has been emerging nationally but has never before been seen in Washington state.

“Roasting a pig is a complex undertaking with numerous potential food handling issues,” FSIS officials said in a statement.


Probably cilantro: Cyclosporiasis outbreak hits 358

The stories we could – and will — tell about implementing on-farm food safety programs for the past 15 years.

cilantro.slugs_.powell.10-300x225Don’t have a shit around fresh produce; don’t make the worker incentives such that they crap in the fields because they lose money if they go to the bathroom; provide decent handwashing facilities, and stop with nonsensical soundbites.

As of July 30, 2015 (11am EDT), the U.S. Centers for Disease Control and Prevention had been notified of 358 ill persons with confirmed Cyclospora infection from 26 states in 2015.

Most (199; 56%) ill persons experienced onset of illness on or after May 1, 2015 and did not report international travel prior to symptom onset.

Clusters of illness linked to restaurants or events have been identified in Texas, Wisconsin, and Georgia.

Cluster investigations are ongoing in Texas and Georgia.

Cluster investigations in Wisconsin and Texas have preliminarily identified cilantro as a suspect vehicle.

Investigations are ongoing to identify specific food item(s) linked to the cases that are not part of the identified clusters.

Previous U.S. outbreaks of cyclosporiasis have been linked to imported fresh produce, including cilantro from the Puebla region of Mexico. Read the related FDA Import Alert issued July 27, 2015.

The U.S. Food and Drug Administration, the Centers for Disease Control and Prevention (CDC) and state public health officials have identified annually recurring outbreaks (in 2012, 2013, and 2014) of cyclosporiasis in the United States which have been associated with fresh cilantro from the state of Puebla, Mexico. There is currently (in July 2015) another ongoing outbreak of cyclosporiasis in the United States in which both the Texas Department of State Health Services and the Wisconsin Department of Health Services and the Wisconsin Department of Agriculture, Trade and Consumer Protection have identified cilantro from the Mexican state of Puebla as a suspect vehicle with respect to separate illness clusters.

From 2013 to 2015, FDA, SENASICA, and COFEPRIS inspected 11 farms and packing houses that produce cilantro in the state of Puebla, 5 of them linked to the US C. cayetanensis illnesses, and observed objectionable conditions at 8 of them, including all five of the firms linked through traceback to the U.S. illnesses.

Conditions observed at multiple such firms in the state of Puebla included human feces and toilet paper found in growing fields and around facilities; inadequately maintained and supplied toilet and hand washing facilities (no soap, no toilet paper, no running water, no paper towels) or a complete lack of toilet and hand washing facilities; food-contact surfaces (such as plastic crates used to transport cilantro or tables where cilantro was cut and bundled) visibly dirty and not washed; and water used for purposes such as washing cilantro vulnerable to contamination from sewage/septic systems. In addition, at one such firm, water in a holding tank used to provide water to employees to wash their hands at the bathrooms was found to be positive for C. cayetanensis.

Based on those joint investigations, FDA considers that the most likely routes of contamination of fresh cilantro are contact with the parasite shed from the intestinal tract of humans affecting the growing fields, harvesting, processing or packing activities or contamination with the parasite through contaminated irrigation water, contaminated crop protectant sprays, or contaminated wash waters.


Largest botulism outbreak in 40 years in US: Botulism at church potluck in Ohio, 2015

The U.S. Centers for Disease Control reports that on April 21, 2015, the Fairfield Medical Center (FMC) and Fairfield Department of Health contacted the Ohio Department of Health (ODH) about a patient suspected of having botulism in Fairfield County, Ohio.

cannedpotatoes20091-300x214Botulism is a severe, potentially fatal neuroparalytic illness.* A single case is a public health emergency, because it can signal an outbreak (1). Within 2 hours of health department notification, four more patients with similar clinical features arrived at FMC’s emergency department. Later that afternoon, one patient died of respiratory failure shortly after arriving at the emergency department. All affected persons had eaten at the same widely attended church potluck meal on April 19. CDC’s Strategic National Stockpile sent 50 doses of botulinum antitoxin to Ohio. FMC, the Fairfield Department of Health, ODH, and CDC rapidly responded to confirm the diagnosis, identify and treat additional patients, and determine the source.

A confirmed case of botulism was defined as clinically compatible illness in a person who ate food from the potluck meal and had 1) laboratory-confirmed botulism or 2) two or more signs of botulism or one sign and two or more symptoms† of botulism. A probable case was a compatible illness that did not meet the confirmed case definition in a person who ate food from the potluck meal.

Among 77 persons who consumed potluck food, 25 (33%) met the confirmed case definition, and four (5%) met the probable case definition. The median age of patients was 64 years (range = 9–87 years); 17 (59%) were female. Among 26 (90%) patients who reported onset dates, illness began a median of 2 days after the potluck (range = 1–6 days).

Twenty-seven of the 29 patients initially went to FMC. Twenty-two (76%) patients were transferred from FMC to six hospitals in the Columbus metropolitan area approximately 30 miles away; these transfers required substantial and rapid coordination. Twenty-five (86%) patients received botulinum antitoxin, and 11 (38%) required endotracheal intubation and mechanical ventilation; no other patients died. Within 1 week of the first patient’s arrival at the emergency department, 16 patients (55%) had been discharged. Among 19 cases that were laboratory-confirmed, serum and stool specimens were positive for botulinum neurotoxin type A or Clostridium botulinum type A.

Interviews were conducted with 75 of 77 persons who ate any of the 52 potluck foods. Consumption of any potato salad (homemade or commercial) yielded the highest association with probable or confirmed case status (risk ratio [RR] = 13.9; 95% confidence interval [CI] = 4.6–41.8), followed by homemade potato salad (RR = 9.1; CI = 3.9–21.2). Of 12 food specimens collected from the church dumpster, six were positive for botulinum neurotoxin type A; five contained potato salad and one contained macaroni and cheese that might have been contaminated after being discarded.

The attendee who prepared the potato salad with home-canned potatoes reported using a boiling water canner, which does not kill C. botulinum spores, rather than a pressure canner, which does eliminate spores (2). In addition, the potatoes were not heated after removal from the can, a step that can inactivate botulinum toxin. The combined evidence implicated potato salad prepared with improperly home-canned potatoes, a known vehicle for botulism (3).

This was the largest botulism outbreak in the United States in nearly 40 years (Table). Early recognition of the outbreak by an astute clinician and a rapid, coordinated response likely reduced illness severity and facilitated early hospital discharge. This outbreak response illustrates the benefits of coordination among responders during botulism outbreaks. Close adherence to established home-canning guidelines can prevent botulism and enable safe sharing of home-canned produce (2).


Fairfield Medical Center, Lancaster, Ohio; Fairfield Department of Health, Lancaster, Ohio; Ohio Department of Health (ODH) Bureau of Infectious Diseases, Columbus, Ohio; ODH Bureau of Public Health Laboratory, Reynoldsburg, Ohio; ODH Office of Preparedness, Columbus, Ohio; Franklin County Public Health, Columbus, Ohio; Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Strategic National Stockpile, Office of Public Health Preparedness and Response, CDC; Office of Regulatory Affairs, CDC.

1Ohio Department of Health; 2Epidemic Intelligence Service, CDC; 3Division of Foodborne, Waterborne, and Infectious Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 4Fairfield Department of Health; 5Fairfield Medical Center.

Corresponding author: Carolyn L. McCarty, wmw8@cdc.gov, 614-728-6941.


Sobel J. Botulism. Clin Infect Dis 2005;41:1167–73.

National Center for Home Food Preservation, US Department of Agriculture. USDA complete guide to home canning, 2009 revision. Washington, DC: US Department of Agriculture; 2009. Available at http://nchfp.uga.edu/publications/publications_usda.htmlExternal Web Site Icon.

Sobel J, Tucker N, Sulka A, McLaughlin J, Maslanka S. Foodborne botulism in the United States, 1990–2000. Emerg Infect Dis 2004;10:1606–11.

*Botulinum neurotoxin and botulinum neurotoxin–containing species of Clostridium are subject to the select agent regulations (42 CFR Part 73).

†Symptoms of botulism include blurred vision, diplopia (double vision), dizziness, slurred speech, thick-feeling tongue, change in sound of voice, hoarseness, dry mouth, and dysphagia (difficulty swallowing). Signs of botulism include extraocular palsy (paralysis of eye muscles), ptosis, sluggishly reactive pupils, facial paralysis, palatal weakness, impaired gag reflex, musculoskeletal weakness or paralysis, and objective evidence of declining respiratory function.

Escherichia coli O157 outbreaks in the United States, 2003–2012

Infections with the Shiga toxin–producing bacterium Escherichia coli O157 can cause severe illness and death.

e.coli.O157.strawberryWe summarized reported outbreaks of E. coli O157 infections in the United States during 2003–2012, including demographic characteristics of patients and epidemiologic findings by transmission mode and food category.

We identified 390 outbreaks, which included 4,928 illnesses, 1,272 hospitalizations, and 33 deaths. Transmission was through food (255 outbreaks, 65%), person-to-person contact (39, 10%), indirect or direct contact with animals (39, 10%), and water (15, 4%); 42 (11%) had a different or unknown mode of transmission. Beef and leafy vegetables, combined, were the source of >25% of all reported E. coli outbreaks and of >40% of related illnesses.

Outbreaks attributed to foods generally consumed raw caused higher hospitalization rates than those attributed to foods generally consumed cooked (35% vs. 28%). Most (87%) waterborne E. coli outbreaks occurred in states bordering the Mississippi River.