The fact the number of confirmed cases of Salmonella Saintpaul continued to rise on Monday was not the big worry for the Centers for Disease Conrol and Prevention (CDC).

It was the fact that the date that people continued to fall ill continues to move forward, now the latest onset date for the illness is June 20th.

That means that in the month sine the U.S. Food and Drug Administration (FDA) took over the investigation into the outbreak that began in New Mexico and Texas; not much has been accomplished. People were warned not to eat certain tomatoes thought to be associated with the outbreak. No tomato field has yet to be named as the source of the outbreak.

And people are still getting sick.

So after last Friday's press conference where FDA and CDC officials acknowledged that the Salmonella Saintpaul outbreak might be due to something other than tomatoes, something had to happen today.

Robert Tauxe, CDC's deputy director for food-borne diseases, told USA Today that "we're broadening the investigation to be sure it encompasses food items that are commonly consumed with tomatoes."  (Tauxe is pictured above)

Indeed there is evidence that CDC has been pulling FDA off the single focus on tomatoes for several days.   And after Friday's CDC/FDA press conference,  USA Today reports:

Over the weekend, the tide of opinion among epidemiologists, produce companies and food safety officials also began to turn in that direction.

Tomatoes couldn't have caused an outbreak that has stretched from early April to late June, says Jim Prevor, editor of Produce Business magazine. "There's not a field in the world" that produces that long, he says.

If not tomatoes, what else? "Something that people find difficult to remember but which is always served with tomatoes," says Tauxe.

That would put salsa, jalapeño peppers, green onions and cilantro at the top of the list of potential culprits, says Doug Powell, director of the International Food Safety Network at Kansas State University in Manhattan, KS.

For the rest of the USA Today story, go here.

In case anyone is concerned that the tomato industry or the larger produce industry does not have a voice in this ongoing Salmonella Saintpaul outbreak, let us introduce you to Jim Prevor's Perishable Pundit.

Through this saga, we’ve largely relied upon “official” sources of information. The states, especially New Mexico and Texas that were impacted early, the Centers for Disease Control & Prevention, and the U.S. Food & Drug Administration.

As the outbreak has dragged on, there’s been an occasional nugget of new information from some of the media covering it. What we’ve really been lacking, however, was for a true expert to speak out and tell us if we were wrong to be thinking this outbreak investigation is inept exercise by federal bureaucrats who couldn’t find a bleeding Elephant in the snow.

Then Mr. Prevor stepped forth with a comprehensive interview with Dr. Michael Osterholm, Director, Center for Infectious Disease Research and Policy, University of Minnesota. He is the true expert, highly respected and just maybe the man who forced FDA and CDC to come clean in their “well maybe its not tomatoes” news conference last Friday.

That’s what Mr. Prevor thinks. We found many of Dr. Osterholm’s quotes so compelling that we are taking the liberty of using a few of them here after questions that are a little shorter than the ones from the conversation between Mr. Prevor and Dr. Osterholm. We strongly encourage you to read the full version at the Perishable Pundit.



Should it make a difference where an outbreak occurs?

In the first instance, all infectious disease is local and only as good as local surveillance. Fortunately, we’ve had states such as Minnesota, Oregon and Tennessee that have really been on the cutting edge of detecting outbreaks because of very good surveillance. Local and state surveillance only works when health laboratories are equipped with the capacity to quickly characterize the bacterial isolates from these patients.

Where did the Salmonella Saintpaul outbreak begin and how did those states do?

New Mexico did a great job in this outbreak. On the whole, Minnesota, Oregon and Tennessee have led the way. The problem is that many states are not geared up to respond. In this outbreak, scores of cases are six weeks old or so. In Texas, many of the “new” cases are not new at all. The Texas Public Health Department is finally catching up in the lab with isolate characterization. The state only has two labs for this kind of fingerprinting.

And how about once the federal government arrives on the scene?

The whole system is flawed. The relationship between FDA and CDC is strained; it’s improved but still lacking. It’s not clear who is really in charge. Authority is split up in a way that decisions get bogged down and you don’t have anyone in command. You need that to effectively launch and oversee an outbreak investigation. I’m not sure who’s in charge. We have people identified as being in charge. We need someone that understands outbreaks, not just manages them. In this case, it appears that instead of experienced professionals, Outbreak Investigation Class 101 was doing the control study.

How did the federal government build upon the good work of the states?

The case control study initiated by New Mexico was important and did provide critical information. It used interviews comparing foods eaten by ill and well persons to identify consumption of raw tomatoes as the likely source of the illnesses. I believe New Mexico did try to do some trace back to the source but didn’t have the information or authority to go all the way back to Mexico.

New Mexico should be applauded for what they did relative to what they could do. CDC supports the overall epidemiological investigation. I know for a fact, however, that the government did not trace back any product reported by the control group. We don’t have a trace back to the source using the information from the control group. That was not done.

Has the investigation worked with tomato growers?

The final piece on this outbreak debacle: several of us have done a lot of work on outbreaks. We went to a wise group in the produce industry with no horse in the race. They looked at the patterns and they knew this market so well. This simple task of eliciting help from industry experts was not done by the investigators to any meaningful extent. We do very a poor job of bringing in the industry to help solve these outbreaks. What does this mean? That straightforward questioning didn’t happen in a way that would have been most helpful.

What about that list of safe growing areas?

Right from the get-go, it was unclear how FDA was coming up with that list; why certain states and countries made the list while others were excluded. If any place not producing in late-April/early-May is safe, why the confusion and piecemeal additions to the list day by day? It appeared there was no rhyme or reason why a state or country was on the list. The logic was lacking. If FDA believed states and countries not in production at time of the outbreak were safe, they should have included all states and countries in that category.

On the other hand, if FDA has the view that a re-packer could be involved, which it now says it does, then it means FDA’s list would have been invalid and in their view putting consumers at risk. Either way, it’s not based in logic. Is it by dates of production, or is it not by dates of production because product could come through a re-packer?

There is a major issue with transparency. Why would you say something is or isn’t involved? First, the formation of the FDA list is disingenuous. It was based on those that screamed the loudest, and from a public health standpoint, that’s not right.

The Centers For Disease Control & Prevention (CDC) added 49 individual cases to the Salmonella Saintpaul outbreak today, bringing the total to 756.   Everyone who has come down with the rare salmonella strain did so before June 13th.  The outbreak continues to involve 34 states and the District of Columbia.

Meanwhile the hunt for the source of the bad tomatoes continues.   Its been a week since the U.S. Food & Drug Administration (FDA) sent teams to specific tomato fields in Mexico and south Florida.  While there's been nothing new from the  FDA investigation, the Palm Beach Post reported this:

Florida Agriculture Commissioner Charles Bronson said Thursday he is "99.99 percent" sure that a national salmonella outbreak was not caused by Florida-grown tomatoes, but that more definitive identification of produce origin would help investigators track down where the infection came from.

Bronson traveled Thursday to Washington to meet with David Acheson, the Food and Drug Administration's associate commissioner for foods, to discuss the labeling issue and others related to the outbreak of Salmonella Saintpaul, which began in April.

The meeting included two Florida congressmen: Adam Putnam, R-Bartow, and Allen Boyd, D-Panama City.  Four Florida counties have yet to be cleared.  Florida's only case of Salmonella Saintpaul involves a man who ate a raw tomato while traveling in New York.

"We know the confusion they are going through," Bronson said of the FDA investigation. "The fact that you have repacking going on across the country with Florida tomatoes puts our label on some product that is not 100 percent Florida product."

Bronson said he recommended to the FDA and the congressmen that repacked tomatoes be better identified.

More from the Post here.

States with persons with the outbreak

strain of Salmonella Saintpaul,

by state of residence.

Since April, 707 persons infected with Salmonella Saintpaul with the same genetic fingerprint have been identified in 34 states and the District of Columbia. These were identified because clinical laboratories in all states send Salmonella strains from ill persons to their State public health laboratory for characterization.

The increase in reported ill persons since the last update is not thought to be due to a large number of new infections. The number of reported ill persons increased mainly because some states improved surveillance for Salmonella in response to this outbreak and because laboratory identification of many previously submitted strains was completed.

No new states report ill people. The number of ill persons identified in each state is as follows: Arkansas (7 persons), Arizona (36), California (10), Colorado (5), Connecticut (4), Florida (1), Georgia (15), Idaho (3), Illinois (63), Indiana (11), Kansas (11), Kentucky (1), Maryland (25), Massachusetts (17), Michigan (4), Missouri (12), New Hampshire (1), Nevada (4), New Jersey (4), New Mexico (80), New York (18), North Carolina (5), Ohio (3), Oklahoma (17), Oregon (5), Pennsylvania (6), Rhode Island (3), Tennessee (6), Texas (293), Utah (2), Virginia (22), Vermont (1), Washington (5), Wisconsin (6), and the District of Columbia (1).

 Among the 492 persons with information available, illnesses began between April 10 and June 13, 2008. Patients range in age from <1 to 99 years; 50 percent are female. At least 76 persons were hospitalized. No deaths have been officially attributed to this outbreak. However, a man in his sixties who died in Texas from cancer, had an infection with the outbreak strain of Salmonella Saintpaul at the time of his death. The infection may have contributed to his death.

Source: Centers for Disease Control & Prevention, Atlanta

Since April, 613 persons infected with Salmonella Saintpaul with the same genetic fingerprint have been identified in 33 states and the District of Columbia. These were identified because clinical laboratories in all states send Salmonella strains from ill persons to their State public health laboratory for characterization.

The marked increase in reported ill persons since the last update is not thought to be due to a large number of new infections. The number of reported ill persons increased mainly because some states improved surveillance for Salmonella in response to this outbreak and because laboratory identification of many previously submitted strains was completed. In particular, one new state, Massachusetts reported ill persons.

The number of ill persons identified in each state is as follows: Arkansas (3 persons), Arizona (34), California (8), Colorado (4), Connecticut (4), Florida (1), Georgia (14), Idaho (3), Illinois (45), Indiana (9), Kansas (9), Kentucky (1), Maryland (18), Massachusetts (12), Michigan (4), Missouri (12), New Hampshire (1), New Jersey (1), New Mexico (79), New York (18), North Carolina (1), Ohio (3), Oklahoma (17), Oregon (5), Pennsylvania (5), Rhode Island (2), Tennessee (4), Texas (265), Utah (2), Virginia (21), Vermont (1), Washington (1), Wisconsin (5), and the District of Columbia (1).

Among the 316 persons with information available, illnesses began between April 10 and June 13, 2008. Patients range in age from <1 to 99 years; 50percent are female. At least 69 persons were hospitalized. No deaths have been officially attributed to this outbreak. However, a man in his sixties who died in Texas from cancer had an infection with the outbreak strain of Salmonella Saintpaul at the time of his death. The infection may have contributed to his death.

States with persons with the outbreak strain of Salmonella Saintpaul, by state of residence.

Source: Centers for Disease Control & Prevention, Atlanta

This weekend began with news from both the U.S. Food & Drug Administration (FDA) and the Centers for Disease Control & Prevention (CDC).

The FDA gave the impression it was closing in on the source of the contaminated tomatoes, sending teams into areas of both Mexico and Florida to some specific farms that might finally turn up who is responsible for the outbreak.    FDA said:

The FDA is now working to narrow the investigation. As part of this, the agency is sending teams of multi-disciplinary experts to both Mexico and Florida this weekend to conduct joint inspections of the farms and other critical points on the supply chain where the tomatoes may have become contaminated.

The FDA investigators will conduct joint inspections with regulators in Mexico and Florida at the farms and other distribution points. Meanwhile, the FDA will continue to collect samples of tomatoes and conduct traceback activities.

To further narrow the investigation, the FDA is working with the state of Texas to traceback a cluster of illnesses recently found by the state of Texas. We are hopeful that this will provide additional information to bring the agency closer to the source of the contamination.

The FDA is working jointly with Mexico and Florida and other states to update the list of areas not associated with the outbreak and will continue to post the information on the web site.

While painting a target on Mexico, FDA at the same time added most Mexican states to the
list of "safe" tomato growing areas.

The "safe" areas now include  include the Mexican states of: Aguascalientes, Baja California Norte, Baja California Sur, Campeche, Colima, Chiapas, Chihuahua, Distrito Federal, Durango, Guanajuato, Guerrero, Hidalgo, México, Michoacán, Morelos, Nayarit, Nuevo León, Oaxaca, Puebla, Querétaro, Quintana Roo, San Luis Potosí, Sonora, Tobasco, Tamaulipas, Tlaxcala, Veracruz, Yucatán, Zacatecas.

The only Mexican state bordering on the U.S. not on the "safe" list is Coahuila.

CDC's list of confirmed cases of Salmonella Saintpaul connected to the tainted tomatoes was 552 as the weekend began.   It said 32 states and the District of Columbia were involved.   New Jersey and Rhode Island were the latest states added to the outbreak list.

So, will FDA close the case or be left so befuddled that the agency makes Lou Dobbs look profound?   What will it say about Mexico or Florida if either area is named when the music stops?
How high will CDC's confirmed number of cases go?   Might CDC say something about the liklihood from previous studies that something like 38 people go untreated for every confirmed case of salmonella? 

That, gentle readers, means about 21,000 people are now victims of Salmonella Saintpaul due to bad tomatoes.

Bill's blog has the new official numbers from the Centers on Disease Control & Prevention on the Salmonella Saintpaul tomato outbreak.   Go here for it.  We've got a border-to-border, coast-to-coast outreak here involving 28 states with 277 confirmed cases and the related death of Raul Rivera in Houston.

One state, Oklahoma, has  been added to the "safe" growing areas list.   Many national restaurant chains are returning tomatoes to their menus after making sure they can obtain product from those safe areas.

Since yesterday’s update of the numbers from the Centers for Disease Control, it appears that new cases of Salmonella Saintpaul have turned up in Ohio, Kentucky, and the District of Columbia.

The Columbus Dispatch reports:

Three cases of salmonella have been reported in central Ohio and linked to the national outbreak involving tomatoes, according to Columbus Public Health.

The Ohio story is here.

The Lexington Herald-Leader reports:

The Salmonella outbreak linked to tomatoes has reached Kentucky.

A Louisville woman has been diagnosed with the same strain of Salmonella that has sicked people in 23 other states, the Kentucky Department of Public Health announced Friday.

Go here for more from Kentucky.

And the Washington, D.C. Examiner reports:

The District of Columbia has reported its first case of salmonella linked to the current tomato-related outbreak.

The D.C. Department of Health said a resident tested positive for Salmonella Saintpaul, the uncommon type of salmonella that has sickened at least 228 other people in 23 states.

Officials say the resident appears to have eaten many tomatoes recently.

The D.C. story can be found here.

The official number of confirmed cases of Salmonella Saintpaul now stands at 228, up from 167; and the number of affected states now is 23, up from 17.

Six states added to the outbreak are: Florida, Georgia, Missouri, New York, Tennessee and Vermont. The addition of states in the South and East gives the outbreak, which started out in the West, looking more and more like a border-to-border event

The U.S. Food & Drug Administration remains clueless about the source of the tainted tomato outbreak, nor are they certain all the bad tomatoes are off the market. The latest onset date for a confirmed case is June 1st.

One death has been attributed to Salmonella Saintpaul.   Raul Rivera, 67, of Houston, died June 4th.

State agriculture commissioners just happen to be meeting in Louisville, and they say the U.S. Food & Drug Administration (FDA) is harming innocent tomato producers throughout the South.

“We understand that the FDA has a big responsibility, but it is necessary for them to open the lines of communication with the public as well as the states,” said Kentucky Agriculture Commissioner Richie Farmer, president of the Southern Association of State Departments of Agriculture (SASDA), during SASDA’s annual conference in Lexington, Ky. “The FDA needs to work with the states to pinpoint the source of the outbreak and eradicate it without unnecessarily harming producers whose products are not affected by the outbreak.”

Other Ag commissioners piled on:

• Florida Agriculture Commissioner Charles Bronson said the FDA’s statements on the salmonella outbreak “have basically shut down the southern tomato growers.” 
• Commissioner Bronson said no FDA official has been to Florida or asked his state’s government to help trace the outbreak. 
• Alabama Agriculture Commissioner Ron Sparks pointed out that his state, which borders Florida, is on the FDA’s list of unaffected states. “It doesn’t make good sense,” he said.
• Tennessee Agriculture Commissioner Ken Givens said the decision of some national restaurant chains to take tomatoes off their products comes at a time when U.S. hamburger consumption is at an all-time high. “This couldn’t come at a worse time,” he said
• West Virginia Agriculture Commissioner Gus Douglass said the FDA’s statements on the outbreak are affecting sales of hydroponically grown tomatoes from states farther north that are not on the FDA’s list of unaffected states.

Late Tuesday, FDA added much of Florida to the list of tomato growing areas found not to be responsible for the current 17-state outbreak of Salmonella Saintpaul in tomatoes.  What everybody has been waiting for, however, is for FDA to say where the tainted tomatoes actually came from.  Mexico is No. 1 on the suspect list, but FDA has gone through a lengthy process of naming the innocent before finding the guilty.

We think we just heard a radio network news report saying that the Centers for Disease Control & Prevention now lists the death of 67-year old Paul Rivera of Houston as the first official fatality of the outbreak of Salmonella Saintpaul in tomatoes.

Mr. Rivera died June 4th after he and most of his family dined on pico de gallo, a tomato-based condiment, at a Mexican restaurant in late May and were stricken with Salmonella Saintpaul.

Like many a fatal victim of food-borne illnesses like Salmonella, Mr. Rivera had a weakened immune system as he was being treated for lymphoma, a cancer that does impair the immune system.  People with weakened immune systems, the elderly, and younger children are always most at risk during outbreaks like the one we are now experiencing.

Death certificates usually are written from the most recent to the contributing factors.   Had he not had the fatal serving of pico de gallo, would Mr. Rivera not be alive today?  From the family's statements, we think he would be.

Bob Drobatz is president of operations for Petaluma Market in Santa Rosa, CA.  He told the Santa Rosa Press Democrat that the tomatoes he was pulling from grocery shelves came from Mexico.

Mexico is one of the biggest suppliers of red round tomatoes and the country was conspicuously absent from the FDA  “safe” list,  Drobatz said.

“I assume it must be Mexico where the suspect tomatoes are from,” he said.

Yesterday we reported Dr. Michael Landen, deputy state epidemiologist with the New Mexico Department of Health, said  “Preliminary data indicates the tomatoes we are having problems with are from Mexico."

How much longer must we wait for FDA to come out with the Unsafe List?  Bill Marler asked the same question on the Marler blog.

So, where the Hell did the Salmonella Tomatoes and E. coli Romain Lettuce come from?

He also asks:  In the days of the risk of bio-terrorism, and with the advent of computer technology to pin-point where our books from Amazon are, you would think we would be able to trace-back contaminated tomatoes and lettuce a bit quicker?

Consumers got an expanded warnings today (06/07/08) from the U.S. Food & Drug Administration NOT to eat Red Plum or Red Roma nor Round Red raw tomatoes.

The expanded warning comes as the Salmonella Saintpaul outbreak blamed on red raw tomatoes spreads to 16 states with at least 145 people sick and 23 in hospitals.

From the official statement:

At this time, FDA is advising consumers to limit their consumption of tomatoes to the following types of tomatoes. The following types of tomatoes listed below are NOT likely to be the source of this outbreak.

•  cherry tomatoes
•  grape tomatoes
•  tomatoes sold with the vine still attached
•  tomatoes grown at home

FDA has issued a list of states and countries believed not to have grown the bad tomatoes, but there were no additions to it today.

FDA did note the risk consumers take in consuming food containing tomatoes.  FDA says:

Consumers should also be aware that raw tomatoes are often used in  the preparation of fresh salsa, guacamole, and pico de gallo, are  part of fillings for tortillas, and are used in other dishes.

Restaurants, grocery stores, and food service operators have been advised by the FDA not to offer for sale or service raw red plum, Roma, or red tomatoes and products made from these types of tomatoes unless they are from one of the areas listed above.

Raul Rivera ate pico de gallo during a family celebration at a Houston area Mexican restaurant. He died and was laid to rest today.   Health officials are investigating whether his death becomes this outbreak's first fatality.

The U.S. Food & Drug Administration is out with a list of states and countries that have been eliminated  as sources for the Salmonella Saintpaul-tainted tomatoes.  States and countries on the list below were eliminated based on  FDA traceback review and production and distribution patterns. The sources  not associated with the outbreak are:

* Arkansas
* California
* Georgia
* North Carolina
* South Carolina
* Tennessee
* Texas
* Belgium
* Canada
* Dominican Republic
* Guatemala
* Israel
* Netherlands
* Puerto Rico

Florida, the nation's largest grower of fresh tomatoes,  remains a suspect for the 11-state outbreak of the rare Saintpaul strain of Salmonella.  Mexico also hasn't been cleared.    The hunt continues.

The Centers for Disease Control, along with several state health agencies and the federal Indian Health Service says the investigation into the Salmonella Saintpaul outbreak has identified consumption of raw tomatoes as the likely source of the illnesses in New Mexico and Texas.

The specific type and source of tomatoes is under investigation; however, preliminary data suggest that large tomatoes, including Roma and red round are the source.

Here from CDC are the official numbers, as of yesterday (6/4/08):

Since late April, 57 persons infected with Salmonella Saintpaul with the same genetic fingerprint have been identified in Texas (24 persons) and New Mexico (33 persons). These were identified because clinical laboratories in all states send Salmonella strains from ill persons to their State public health laboratory for characterization. Among the 38 persons who have been interviewed, illnesses began between April 23 and May 27, 2008. Patients range in age from 3 to 82 years; 48% are female. At least 17 persons were hospitalized. No deaths have been reported.

In addition, 29 persons with the outbreak strain of Salmonella Saintpaul have been reported since mid-April in residents of Arizona (6 persons), Colorado (1), Idaho (2), Illinois (12), Indiana (1), Kansas (3), Utah (1), Virginia (1), and Wisconsin (2). Investigations are underway to determine if consumption of raw tomatoes is also associated with illness in these states.

CDC's consumer and other information on the outbreak can be found here.

CDC Salmonella Saintpaul Outbreak Map

Persons infected with the outbreak strain of Salmonella Saintpaul, United States, by state, April 15 to June 4, 2008

Here's tomato update from the Marler blog:

The Food and Drug Administration (FDA) is alerting consumers in New Mexico and Texas that a salmonellosis outbreak appears to be linked to consumption of certain types of raw red tomatoes and products containing raw red tomatoes. The bacteria causing the illnesses are Salmonella serotype Saintpaul, an uncommon type of Salmonella.

Preliminary data suggest that raw red plum, red Roma, or round red tomatoes are the cause. At this time, consumers in New Mexico and Texas should limit their tomato consumption to tomatoes that have not been implicated in the outbreak. These include cherry tomatoes, grape tomatoes, tomatoes sold with the vine still attached, and tomatoes grown at home.

From April 23 though June 1, 2008, there have been 57 reported cases of salmonellosis caused by Salmonella Saintpaul in New Mexico and Texas, including 17 hospitalizations. Approximately 30 reports of illness in Arizona, Colorado, Idaho, Illinois, Indiana, Kansas, and Utah are currently being investigated to determine whether they are also linked to tomatoes.