Multistate outbreak of human Salmonella Muenchen infections linked to contact with pet crested geckos

We were eating dinner on the balcony – as you do in Brisbane – and our neighbor was showing his grandchild the geckos living in the utility box.

creasted-geckos-325There was no contact, but I still see a Salmonella factory.

According to the U.S Centers for Disease Control, as of May 13, 2015, a total of 20 persons infected with the outbreak strain of Salmonella Muenchen have been reported from 16 states since January 1, 2014.

Three (15%) of these ill persons have been hospitalized. No deaths have been reported.

Epidemiologic, laboratory, and traceback findings have linked this outbreak of human Salmonella infections to contact with pet crested geckos purchased from multiple pet stores in different states.

Ten (91%) of 11 ill persons interviewed reported contact with a crested gecko in the week before their illness began.

CDC’S National Antimicrobial Resistance Monitoring System (NARMS) laboratory conducted antibiotic resistance testing on Salmonella Muenchen isolates collected from two ill people infected with the outbreak strain.

Both isolates were susceptible to all antibiotics tested on the NARMS panel.

Antibiotic resistance testing on additional isolates collected from ill people infected with the outbreak strain is ongoing.

Norovirus from swimming in a lake

In July, 2014 a norovirus outbreak linked to a lake near Portland, Oregon sickened 70 people. Those who swam in the lake were 2.3 times more likely to develop vomiting or diarrhea than those who visited the park but didn’t go in the water.

kids.cottage.00More than half of those who got ill were children between 4–10 years old. Experts believe the outbreak began after a swimmer infected with norovirus had diarrhea or vomited in the water and other swimmers swallowed the contaminated water. To prevent other people from getting sick, park officials closed the lake to swimmers for 10 days.

“Children are prime targets for norovirus and other germs that can live in lakes and swimming pools because they’re so much more likely to get the water in their mouths,” said Michael Beach, Ph.D, CDC’s associate director for healthy water. “Keeping germs out of the water in the first place is key to keeping everyone healthy and helping to keep the places we swim open all summer.”

 Norovirus Outbreak Associated with a Natural Lake Used for Recreation — Oregon, 2014


Morbidity and Mortality Weekly Report

Amy Zlot, MPH, Maayan Simckes, MPH, Jennifer Vines, MD, Laura Reynolds, MPH, Amy Sullivan PhD, Magdalena Kendall Scott, MPH, J. Michael McLuckie, Dan Kromer, MPA, Vincent R. Hill, PhD, Jonathan S. Yoder, MPH, Michele C. Hlavsa, MPH


CDC: Reductions in foodborne STEC, some Salmonella, not so much the others in 2014

It’s becoming an annual rite: the U.S. Centers for Disease Control reports progress on some bugs, and no progress on others in the food supply. Batz could probably explain it better than I.

cdc.surveillance.2014But the data is important to focus policy efforts and make improvements.

In 2014, rates of infection from a serious form of E. coli and one of the more common Salmonella serotypes decreased compared with the baseline period of 2006-2008. Meanwhile, some other less common types of Salmonella increased. Campylobacter and Vibrio rose again in 2014, continuing the increase observed during the past few years. Today’s report summarizes the rates of infection per 100,000 population and tracks illness trends for key foodborne illnesses.

Infection with Shiga-toxin producing E. coli O157, which can sometimes lead to kidney failure, decreased 32 percent when compared with 2006-2008 and 19 percent when compared with the most recent three years. These infections are often linked to consumption of undercooked ground beef and raw leafy vegetables. Salmonella Typhimurium, which has been linked to poultry, beef, and other foods, was 27 percent lower than it was in 2006-2008, continuing a downward trend begun in the mid-1980s. Two other less common types of Salmonella, Javiana and Infantis, more than doubled for reasons that are unclear. Salmonella Javiana is concentrated in the southeastern United States, but has been spreading within the Southeast and to other areas of the country. However, when all Salmonella serotypes are combined, there was no change in 2014.

Campylobacter increased 13 percent and Vibrio increased 52 percent compared with 2006-2008. Yersinia has declined enough to meet the Healthy People 2020 goal.

cdc.surv.14The data are from FoodNet, CDC’s active surveillance system that tracks nine common foodborne pathogens in 10 states and monitors trends in foodborne illness in about 15 percent of the U.S. population. Today’s report compares the 2014 frequency of infection with the frequency in the baseline period 2006-2008 and in the three most recent years. Overall in 2014, FoodNet logged just over 19,000 infections, about 4,400 hospitalizations, and 71 deaths from the nine foodborne germs it tracks. Salmonella and Campylobacter were by far the most common– accounting for about 14,000 of the 19,000 infections reported.

“We’re cautiously optimistic that changes in food safety practice are having an impact in decreasing E. coli and we know that without all the food safety work to fight Salmonella that more people would be getting sick with Salmonella than we are seeing now,,” said Robert Tauxe, M.D., deputy director of CDC’s Division of Foodborne Waterborne and Environmental Diseases. “The increasing use of whole genome sequencing to track foodborne illness cases will also help; however, much more needs to be done to protect people from foodborne illness.” 

The recent decline in the incidence of Shiga toxin-producing E. coli (STEC) O157 follows several years of increasing scrutiny for beef products. Since 1994, the Food Safety and Inspection Service of the U.S. Department of Agriculture has taken STEC O157:H7 extremely seriously and made a number of changes in its regulatory oversight of the beef industry to protect public health.”We are encouraged by the reduction of STEC O157:H7 illnesses, which reflects our science-based approach to beef inspection, and we look forward to seeing further reductions in Salmonella and Campylobacter infections as our improved standards for poultry take effect later this year, ” said Al Almanza, Deputy Under Secretary for Food Safety at USDA. “Data sources like FoodNet allow us to be strategic in developing our food safety policies, and we will do everything within our power to keep reducing cases of foodborne illness from all meat and poultry products.”

Under the provisions of the FDA Food Safety Modernization Act, the U.S. Food and Drug Administration is planning to publish major new regulations in 2015. The regulations are geared toward ensuring produce safety, implementing preventive controls on processed foods, and improving the safety of imported foods.

“Prevention of illness is the fundamental goal of our new rules under the FDA Food Safety Modernization Act,” said Michael Taylor, deputy commissioner for Foods and Veterinary Medicine at FDA.  “We have worked with a wide range of stakeholders to devise rules that will be effective for food safety and practical for the many diverse elements of our food system. Once the rules are fully implemented, FoodNet will help us evaluate their impact.”

The FoodNet report also includes results of culture-independent diagnostic tests (a new method for diagnosing intestinal illnesses without needing to grow the bacteria) done in the many hospital laboratories in the FoodNet sites. In 2014, the results of more than 1,500 such tests were reported. More than two-thirds of the tests were for Campylobacter. Other tests performed were for STEC, Salmonella, Shigella and Vibrio. Some of the tests had a positive result. However, the infections were not confirmed by culture, and so CDC experts did not include them in the overall FoodNet results for 2014.

Public health has better things to do: Increased outbreaks associated with nonpasteurized milk

The number of US outbreaks caused by nonpasteurized milk increased from 30 during 2007-2009 to 51 during 2010-2012. Most outbreaks were caused by Campylobacter spp. (77%) and by nonpasteurized milk purchased from states in which nonpasteurized milk sale was legal (81%).

rw.milk.outbreaks.2Regulations to prevent distribution of nonpasteurized milk should be enforced.

Increased outbreaks associated with nonpasteurized milk, United States, 2007-2012.

Emerging Infectious Diseases, 2015 Jan;21(1):119-22. doi: 10.3201/eid2101.140447.

Mungai EA, Behravesh CB, Gould LH.

Beaver fever: Giardiasis surveillance, US 2011–2012

Problem/Condition: Giardiasis is a nationally notifiable gastrointestinal illness caused by the protozoan parasite Giardia intestinalis.

Reporting Period: 2011–2012.

beaver.feverDescription of System: Forty-four states, the District of Columbia, New York City, the Commonwealth of Puerto Rico, and Guam voluntarily reported cases of giardiasis to CDC through the National Notifiable Diseases Surveillance System (NNDSS).

Results: For 2011, a total of 16,868 giardiasis cases (98.8% confirmed and 1.2% nonconfirmed) were reported; for 2012, a total of 15,223 cases (98.8% confirmed and 1.3% nonconfirmed) were reported. In 2011 and 2012, 1.5% and 1.3% of cases, respectively, were associated with a detected outbreak. The incidence rates of all reported cases were 6.4 per 100,000 population in 2011 and 5.8 per 100,000 population in 2012. This represents a slight decline from the relatively steady rates observed during 2005–2010 (range: 7.1–7.9 cases per 100,000 population). In both 2011 and 2012, cases were most frequently reported in children aged 1–4 years, followed by those aged 5–9 years and adults aged 45–49 years. Incidence of giardiasis was highest in Northwest states. Peak onset of illness occurred annually during early summer through early fall.

Interpretation: For the first time since 2002, giardiasis rates appear to be decreasing. Possible reasons for the decrease in rates during 2011–2012 could include changes in transmission patterns, a recent change in surveillance case definition, increased uptake of strategies to reduce waterborne transmission, or a combination of these factors. Transmission of giardiasis occurs throughout the United States, with more frequent diagnosis or reporting occurring in northern states. Geographical differences might suggest actual regional differences in giardiasis transmission or variation in surveillance capacity across states. Six states did not report giardiasis cases in 2011–2012, representing the largest number of nonreporting states since giardiasis became nationally notifiable in 2002. Giardiasis is reported more frequently in young children, which might reflect increased contact with contaminated water or ill persons, or a lack of immunity.

Public Health Action: Educational efforts to decrease exposure to unsafe drinking and recreational water and prevent person-to-person transmission have the potential to reduce giardiasis transmission. The continual decrease in jurisdictions opting to report giardiasis cases could negatively impact the ability to interpret national surveillance data; thus, further investigation is needed to identify barriers to and facilitators of giardiasis case reporting. Existing state and local public health infrastructure supported through CDC (e.g., Epidemiology and Laboratory Capacity grants and CDC-sponsored Council of State and Territorial Epidemiologists Applied Epidemiology Fellows) could provide resources to enhance understanding of giardiasis epidemiology.

Multistate outbreak of multiple Salmonella serotype infections linked to sprouted chia seed powder – United States, 2014

To be presented at the U.S. Centers for Disease Control and Prevention’s 64th Annual Epidemic Intelligence Service (EIS) conference April 20-23 in Atlanta. Salmonella causes 1.2 million infections and 380 deaths annually in the United States. On 5/6/2014, PulseNet, the national molecular subtyping network for foodborne disease surveillance, identified a cluster of Salmonella Newport infections with the same novel outbreak strain. US states, FDA, Canada, and CDC investigated to identify the source and prevent additional illnesses.

Methods: We defined a case as infection with an outbreak strain with onset 1/1/2014–7/22/2014. We conducted open-ended interviews to identify common exposures in the week prior to onset, administered supplemental questionnaires to refine hypotheses, collected products for testing, and performed traceback investigations.

Results: We identified 31 case-patients in 16 states; 22% (5/23) were hospitalized. Ninety percent (19/21) of case-patients reported consuming chia seeds or powder; 79% (15/19) of those specifically reported consuming chia seed powder of variable brand names. Traceback identified a Canadian firm as the common supplier for the sprouted chia seed powder. Multiple products containing sprouted chia seed powder from this firm were recalled and FDA denied admission of these products into the US until testing could confirm the products were no longer contaminated. During the investigation, testing of chia-containing products yielded two more Salmonella strains (Hartford and Oranienburg) that also caused illnesses; these were included in the outbreak.

Conclusions: Epidemiologic, traceback, and laboratory evidence identified sprouted chia seed powder processed at a single firm as the outbreak source. Although sprouted chia seeds are a novel Salmonella outbreak vehicle, this investigation highlights the well-documented risks for foodborne illness associated with the sprouting process. Firms choosing to produce sprouted seed products should follow available guidance to reduce the risk of bacterial contamination.

Listeria monocytogenes linked to whole apples used in commercially produced, prepackaged caramel apples – United States, 2014-2015

To be presented at the U.S. Centers for Disease Control and Prevention’s 64th Annual Epidemic Intelligence Service (EIS) conference April 20-23 in Atlanta.

caramel.appleBackground: Listeria monocytogenes (Lm) infection is the third leading cause of death from foodborne illness in the United States. Lm isolates undergo pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS) to identify disease clusters. In November 2014, two multistate clusters of Lm infections with distinct PFGE patterns were detected. Due to geographic and temporal overlap and a case with co-infection, they were investigated together to identify the source and prevent illnesses.

Methods: Cases were defined as illnesses with highly related Lm strains by WGS reported to PulseNet, the national molecular subtyping network for foodborne disease surveillance, with onset from 10/17/2014 to 2/12/2015. Information was collected on foods consumed in the weeks before illness onset using hypothesis-generating questionnaires and open-ended interviews. Case-patient food exposures were compared with data from listeriosis patients with genetically unrelated Lm using Fisher’s exact test. Traceback was performed to identify the suspect food source. WGS was performed on all case-patient, produce, and environmental isolates.

Results: Thirty-five cases from 12 states and 1 from Canada were identified; 34 patients were hospitalized and seven died. Three cases of meningitis occurred among healthy children. Twenty-eight (90%) of 31 patients reported consuming prepackaged caramel apples (multiple brands) compared with 1 (2.8%) of 36 patients with unrelated Lm isolates (p<0.001). Environmental and produce samples from a common apple supplier were highly related to clinical isolates by WGS. Three caramel apple producers and the apple supplier issued voluntary recalls.

Conclusions: Whole apples used in prepackaged caramel apples were the outbreak source. This is a new vehicle for Lm infections. Research is needed to understand factors specific to caramel apple production to prevent further contamination and illness.

Outbreak of Salmonella Newport infections linked to cucumbers – United States, 2014

To be presented at the U.S. Centers for Disease Control and Prevention’s 64th Annual Epidemic Intelligence Service (EIS) conference April 20-23 in Atlanta. (1)Background: Salmonella causes approximately 1 million foodborne infections and 400 deaths annually in the United States. In August 2014, PulseNet, the national molecular subtyping network for foodborne disease surveillance, detected a multistate cluster of Salmonella Newport (SN) infections with an indistinguishable pulse-field gel electrophoresis pattern. This strain has previously been linked to tomatoes from the Delmarva Peninsula of the Eastern US. We investigated to identify the source and prevent further illnesses. Methods: A case was defined as an illness with the outbreak strain with onset from 5/20/2014- 9/30/2014. Information was collected on travel, restaurant, and food exposures in the 7 days before illness onset using a structured questionnaire. Reported food frequencies were compared to the 2006-2007 FoodNet Population Survey. A non-regulatory traceback was performed to identify the source of food items consumed in illness sub-clusters. Whole genome sequencing (WGS) was conducted to further characterize relatedness of Salmonella isolates.

Results: A total of 275 cases from 29 states and DC were identified; 34% (48/141) were hospitalized and 1 death was reported. A significantly higher percentage of ill persons consumed cucumbers in the week before illness onset than expected, (62% vs. 46.9%, p=0.002). Traceback of 8 illness subclusters led to a common cucumber grower in the Delmarva region of Maryland. WGS analysis showed that genetic sequences of clinical isolates from MD and DE were highly related but distinct from a NY sub-cluster.

Conclusions: Epidemiologic and traceback evidence suggest cucumbers were a major source of illness in this outbreak. This is the first multistate outbreak of SN infections linked to a produce item from the Delmarva Peninsula other than tomatoes, suggesting an environmental reservoir may be responsible for recurring outbreaks.

Campylobacter jejuni infection associated with raw milk consumption – Utah, 2014

To be presented at the U.S. Centers for Disease Control and Prevention’s 64th Annual Epidemic Intelligence Service (EIS) conference April 20-23 in Atlanta.

colbert.raw.milkSummary: Despite routine testing, raw milk from a Utah dairy sickened 99 people with Campylobacter; 1 died and 10 were hospitalized. A 2-month shutdown failed to stop the outbreak and the dairy’s raw milk permit was revoked.


Background: In Utah, raw milk sales are legal from farm to consumer. Despite routine bacterial and coliform

counts by the Utah Department of Agriculture and Food (UDAF), raw milk-related illnesses occur. In May 2014, the Utah Department of Health (UDOH) identified a cluster of 3 Campylobacter jejuni infections with indistinguishable pulsed-field gel electrophoresis (PFGE) patterns. All patients reported consuming Dairy A’s raw milk. Routine testing of UDAF-licensed Dairy A’s raw milk was acceptable. We investigated to identify a source and prevent additional infections.

Methods: UDAF used onsite milk neutralization technique to preserve C. jejuni during testing. Utah’s electronic disease surveillance system identified cases. Confirmed illness was defined as diarrhea caused by C. jejuni matching the cluster PFGE pattern. Probable illness was diarrhea and contact with a confirmed patient or raw milk purchased from Dairy A. Confirmed patients were interviewed by using a standardized questionnaire.

Results: During May 9–July 31, a total of 89 (52 confirmed and 37 probable) cases were identified. Eleven (21.2%) confirmed patients were hospitalized; 1 died. Twenty-five (48.1%) confirmed patients reported having consumed Dairy A raw milk. Fifteen (28.8%) confirmed patients reported having eaten queso fresco. Dairy A’s raw milk yielded C. jejuni with the cluster PFGE pattern. UDAF suspended Dairy A’s raw milk permit on August 4 for 2 months. Additional cases occurred in November; UDAF revoked Dairy A’s raw milk permit on December 1.

Conclusions: Routine testing of raw milk does not ensure its safety. Mandatory reporting, timely sample collection, pathogen testing, and onsite milk neutralization likely led to C. jejuni detection. Linking case and raw milk PFGE patterns might identify the source and allow implementation of control measures.

100 sick onboard Celebrity cruise ship

Up to 100 passengers have are being reported as sick from a possible Norovirus outbreak onboard the Celebrity Infinity.

vomit cruiseAccording to the Centre for Disease Control (CDC) 95 out of 2,117 passengers along with 5 crew members have been reported sick from gastrointestinal illness. The CDC has not yet confirmed that it’s Norovirus but in most outbreaks onboard it usually is. Passengers and crew have been having vomiting and diarrhea.

The CDC has also stated that 8 stool specimens from passenger and crew have been collected for testing. A CDC Vessel Sanitation Program environmental health officer and one epidemiologist are to board the 91,000 gross ton ship once it arrives in San Diego, CA on April 13. The Celebrity Infinity began the voyage on March 29th from Fort Lauderdale, Florida on a 15 night Panama Canal cruise.