Efforts to prevent Clostridioides difficile infection continue to expand across the health care spectrum in the United States. Whether these efforts are reducing the national burden of C. difficile infection is unclear.
The Emerging Infections Program identified cases of C. difficile infection (stool specimens positive for C. difficile in a person ≥1 year of age with no positive test in the previous 8 weeks) in 10 U.S. sites. We used case and census sampling weights to estimate the national burden of C. difficile infection, first recurrences, hospitalizations, and in-hospital deaths from 2011 through 2017. Health care–associated infections were defined as those with onset in a health care facility or associated with recent admission to a health care facility; all others were classified as community-associated infections. For trend analyses, we used weighted random-intercept models with negative binomial distribution and logistic-regression models to adjust for the higher sensitivity of nucleic acid amplification tests (NAATs) as compared with other test types.
RESULTS
The number of cases of C. difficile infection in the 10 U.S. sites was 15,461 in 2011 (10,177 health care–associated and 5284 community-associated cases) and 15,512 in 2017 (7973 health care–associated and 7539 community-associated cases). The estimated national burden of C. difficile infection was 476,400 cases (95% confidence interval [CI], 419,900 to 532,900) in 2011 and 462,100 cases (95% CI, 428,600 to 495,600) in 2017. With accounting for NAAT use, the adjusted estimate of the total burden of C. difficile infection decreased by 24% (95% CI, 6 to 36) from 2011 through 2017; the adjusted estimate of the national burden of health care–associated C. difficileinfection decreased by 36% (95% CI, 24 to 54), whereas the adjusted estimate of the national burden of community-associated C. difficile infection was unchanged. The adjusted estimate of the burden of hospitalizations for C. difficile infection decreased by 24% (95% CI, 0 to 48), whereas the adjusted estimates of the burden of first recurrences and in-hospital deaths did not change significantly.
CONCLUSIONS
The estimated national burden of C. difficile infection and associated hospitalizations decreased from 2011 through 2017, owing to a decline in health care–associated infections. (Funded by the Centers for Disease Control and Prevention.)
Trends in US burden of clostridioides difficile infection and outcomes, 02 April 2020
New England Journal of Medicine
Alice Y. Guh, M.D., M.P.H., Yi Mu, Ph.D., Lisa G. Winston, M.D., Helen Johnston, M.P.H., Danyel Olson, M.S., M.P.H., Monica M. Farley, M.D., Lucy E. Wilson, M.D., Stacy M. Holzbauer, D.V.M., M.P.H., Erin C. Phipps, D.V.M., M.P.H., Ghinwa K. Dumyati, M.D., Zintars G. Beldavs, M.S., Marion A. Kainer, M.B., B.S., M.P.H., Maria Karlsson, Ph.D., Dale N. Gerding, M.D., and L. Clifford McDonald, M.D.
Enoki mushrooms from South Korea have been recalled and investigators are linking them to a multi-year outbreak of Listeria monocytogenes that has killed four people.
The importer, Sun Hong Foods Inc., Montebello, Calif., recalled the mushrooms March 9 after Michigan Department of Agriculture and Rural Development officials found two samples of the mushrooms were positive for the listeria strain.
According to the Centers for Disease Control and Prevention, public health agencies are using the PulseNet system to identify illnesses linked to the outbreak, using “DNA fingerprinting” through whole genome sequencing.
The agencies did not report when the deaths occurred. Patients in California, Hawaii and New Jersey died.
The cases traced to the mushrooms have a high rate of hospitalization, with 30 of the 36 patients identified requiring hospitalization, according to the Food and Drug Administration, which released a warning to consumers March 10 to not eat any enoki mushrooms from Sun Hong Foods.
Sun Hong Foods, Inc 1105 W Olympic Blvd, Montebello, CA 90640 is recalling All Cases Enoki Mushroom (Product of Korea) Net Wt 7.05/200g because it has the potential to be contaminated with Listeria monocytogenes, a bacterium which can cause life-threatening illness or death. Consumers are warned not to even if it does not look or smell spoiled.
Why did Listeria appear in hard-boiled eggs? Insufficient cooking? Cross-contamination? Dirty pails? This report doesn’t say.
The U.S. Food and Drug Administration, the U.S. Centers for Disease Control, CDC, and state and local partners investigated an outbreak of Listeria monocytogenes infections linked to hard-boiled eggs produced by Almark Foods’ Gainesville, Georgia facility. Almark Foods announced an initial voluntary recall of hard-boiled and peeled eggs in pails on December 20, 2019, and then on December 23, 2019 expanded the recall to include all hard-boiled eggs produced at the Gainesville, Georgia facility. All recalled products are now past their “best by” dates.
CDC has announced this outbreak is over. FDA’s investigational activities, including an inspection, are complete. At this time, the firm is no longer producing products at this facility.
Recommendation
Recalled products are now past their “best by” dates and should be thrown away.
FDA recommends that food processors, restaurants and retailers who received recalled products use extra vigilance in cleaning and sanitizing any surfaces that may have come in contact with these products, to reduce the risk of cross-contamination.
Case Counts
Total Illnesses: 8 Illnesses in 2019: 5 Hospitalizations: 5 Deaths: 1 Last illness isolation date: December 7, 2019 States with Cases: FL (1), ME (2), PA (1), SC (2), TX (2) States with Cases in 2019: FL (1), ME (2), SC (2), TX (1) Product Distribution*: Nationwide *Distribution has been confirmed for states list, but at this time we believe the product was distributed nationwide. Updates will be provided as more information becomes available.
What Products are Recalled?
Recalled products include bulk product sold in pails, as well as products sold at retail. Companies who received recalled product from Almark Foods have initiated recalls of products containing these eggs. A list of all these recalls is available on the FDA website.
I’ll say it again, as a comic in all seriousness: Lettuce is overrated.
My favorite salad is a Greek one with all those veggies and no lettuce.
The U.S. Food and Drug Administration announced last week that between 2009 and 2018, FDA and the Centers for Disease Control and Prevention (CDC) identified 40 foodborne outbreaks of Shiga toxin-producing E. coli (STEC) infections in the U.S. with a confirmed or suspected link to leafy greens.
Holy shit.
This is why The Tragically Hip were so great, and why they never appealed much beyond Canada.
I feel the same about academia.
And why Osterholm called me 15 years ago as a consultant for Fresh Express, and asked me how dare I the lettuce and skull picture, and I said because I can and it was fairly apt given there have been 40 outbreaks.
Holy shit (this is me echoing my John Oliver voice).
Coronavirus is just confirming: Go public, go often, go hard.
It’s the only way people will pay attention.
And as this story in the N.Y. Times points out, there have been spectacular public health failures by people who tell others, just shut the fuck up.
According to the FDA, it has an unwavering commitment to advancing the safety of fresh leafy greens. Leafy greens are among the most widely consumed vegetables and an important part of an overall healthy diet. While millions of servings are consumed safely every day, this produce commodity has been implicated too often in outbreaks of foodborne illness, and we believe that FDA, along with leafy greens sector stakeholders, can do more.
Between 2009 and 2018, FDA and Centers for Disease Control and Prevention (CDC) identified 40 foodborne outbreaks of Shiga toxin-producing E. coli (STEC) infections in the U.S. with a confirmed or suspected link to leafy greens. While most strains of E. coli are harmless, STEC can cause bloody diarrhea, anemia, blood-clotting problems, and kidney failure – conditions that are potentially life-threatening. The most common STEC, E. coli O157:H7, is the type most often associated with outbreaks.
Most leafy greens are grown outdoors, where they are exposed to soil, animals, and water, all of which can be a source of pathogen contamination. In addition, leafy greens are mostly consumed raw, without cooking or other processing steps to eliminate microbial hazards. The Produce Safety Rule under the FDA Food Safety Modernization Act (FSMA) sets science-based standards to help ensure that water, soil amendments (e.g., fertilizer or compost), food contact surfaces and other materials that touch produce during growing, harvesting, packing, and holding do not contribute to produce contamination. The Produce Safety Rule also addresses animal intrusion into fields and worker hygiene.
Due to the recurring nature of outbreaks associated with leafy greens, FDA has developed this commodity-specific action plan. What follows is an overview of the actions FDA plans to take in 2020 to advance work in three areas: (1) prevention, (2) response, and (3) addressing knowledge gaps.
The Princess Cruises’ Caribbean Princess Ship left the U.S. on Feb 2 — and after more than a week at sea, was forced to turn back to the U.S. early when it was denied entry to the Caribbean.
The Caribbean Princess was set to have a 14-day trip around the Caribbean, but was forced to turn back to the U.S.
The cruise’s early return comes after it was denied entry to Trinidad and Tobago by the Government of Barbados due to the outbreak on board, according to a statement from the Ministry of Health.
Princess Cruises said in a statement to The Sun that the ship, which was on a 14-day cruise in the Caribbean, is now on its way back to the Port of Everglades in Fort Lauderdale.
The Caribbean Princess ship is scheduled to dock at 7 a.m. on Thursday, three days ahead of its previous Feb. 16 return.
A total of 299 passengers and 22 crew members of the 4,196 people on board got sick with a gastrointestinal bug, causing vomiting and diarrhea.
Princess Cruises said the cruise has “curtailed its voyage out of an abundance of caution due to guests reporting symptoms due to a mild gastrointestinal illness,” in a statement to The Sun.
The ship will undergo a “super sanitation cleaning” when it reaches the Florida port, according to a statement from the CDC.
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,[5],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.
The Emerging Infections Program identified cases of C. difficile infection (stool specimens positive for C. difficile in a person ≥1 year of age with no positive test in the previous 8 weeks) in 10 U.S. sites. We used case and census sampling weights to estimate the national burden of C. difficile infection, first recurrences, hospitalizations, and in-hospital deaths from 2011 through 2017. Health care–associated infections were defined as those with onset in a health care facility or associated with recent admission to a health care facility; all others were classified as community-associated infections. For trend analyses, we used weighted random-intercept models with negative binomial distribution and logistic-regression models to adjust for the higher sensitivity of nucleic acid amplification tests (NAATs) as compared with other test types.
