Salmonella Information

This outbreak is one of four separate outbreaks currently under investigation that are linked to imported Maradol papayas from Mexico

This past spring, CDC, public health and regulatory officials in several states, and the U.S. Food and Drug Administration investigated a multistate outbreak of Salmonella Anatum infections.

Fourteen people infected with the outbreak strain of Salmonella Anatum were reported from three states. Illnesses started on dates ranging from December 20, 2016, to April 8, 2017. Five ill people were hospitalized. One death was reported from California.

On September 4, 2017, FDA testing identified the outbreak strain of Salmonella Anatum from a sample taken from an imported papaya at the U.S.-Mexico border. Epidemiologic, laboratory, and traceback evidence indicates that Maradol papayas imported by Bravo Produce Inc. of San Ysidro, California, are the likely source of this multistate outbreak. On September 10, 2017, Bravo Produce Inc. recalled Maradol papayas packed by Frutas Selectas de Tijuana, S. de RL de CV. The papayas were distributed to California from August 10 to August 29, 2017.

WHAT IS SALMONELLA?

It has long been said that, in 1885, pioneering American veterinary scientist, Daniel E. Salmon, discovered the first strain of Salmonella. Actually, though, Theobald Smith, research-assistant to Dr. Salmon, discovered the first strain of SalmonellaSalmonella cholerae suis. But, being in charge, Dr. Salmon received all of the credit. Today, the number of known serotypes of Salmonella bacteria totals over two thousand. Concerns have been raised in recent years, as particular strains of Salmonella have become resistant to traditional antibiotics.

The term Salmonella refers to a group or family of bacteria that variously cause illness in humans. The taxonomy and nomenclature of Salmonella have changed over the years and are still evolving. Currently, the Centers for Disease Control and Prevention (CDC) recognizes two species of Salmonella, which are divided into seven subspecies. These subspecies are divided into over 50 serogroups based on somatic (O) antigens present. The most common Salmonella serogroups are A, B, C, D, E, F, and G. Serogroups are further divided into over 2,500 serotypes, and are typically identified through a series of tests of antigenic formulas listed in a document called the Kauffmann-White Scheme, which is published by the World Health Organization Collaborating Centre for Reference and Research on Salmonella.[1]

Three Salmonella serotypes—Enteritidis, Typhimurium, and Newport—have persisted as the serotypes most often isolated in patients and reported to the CDC over the last decade. In 2009, these three serotypes accounted for 42% of all reported cases of Salmonella.[2]

Where Does Salmonella Come From?

Salmonella is an enteric bacterium, which means that it lives in the intestinal tracts of humans and other animals. Salmonella bacteria are usually transmitted to humans by eating foods contaminated with animal feces, or foods that have been handled by infected food service workers who have practiced poor personal hygiene. Contaminated foods usually look and smell normal and are often of animal origin, such as beef, poultry, milk, or eggs. But all foods, including vegetables, may become contaminated. Many raw foods of animal origin are frequently contaminated, but thorough cooking kills Salmonella. Though, the food handler who neglects to thoroughly wash his or her hands with soap and warm water after using the bathroom may contaminate foods that have otherwise been properly prepared.

What are the Symptoms of Salmonellosis?

Once in the lumen of the small intestine, the bacteria penetrate the epithelium, multiply, and enter the blood within 24 to 72 hours. Variables such as the health and age of the host, and virulence differences among the serotypes, affect the nature of the diagnosis. Infants, the elderly, individuals hospitalized, and the immune-suppressed are the populations that are most susceptible to Salmonellosis and suffer the most severe symptoms.

“The majority of persons infected with Salmonella have diarrhea, fever, and abdominal cramps 12-72 hours after exposure. The illness usually lasts 4-7 days, and the majority of persons recover without treatment.” MMWR Weekly, supra at 684. However, much longer incubation periods of 120 hours to 31 days have been documented in previous Salmonella outbreaks.[3]

The acute symptoms of Salmonella gastroenteritis include the sudden onset of nausea, abdominal cramping, and bloody diarrhea with mucous. As already noted, there is no real cure for a Salmonella infection; treatment, therefore, tends to be palliative – although prescription of antibiotics is common, even if usually contraindicated.

Medical treatment is acutely important, though, if the patient becomes severely dehydrated or if the infection spreads from the intestines. Persons with severe diarrhea often require re-hydration, usually with intravenous (IV) fluids. But antibiotics are not necessary or indicated unless the infection spreads from the intestines, at which time the infection can be treated with ampicillin, gentamicin, trimethoprim/sulfamethoxazole, or ciprofloxacin. Unfortunately, though, some Salmonella bacteria have become resistant to antibiotics, largely as a result of the use of antibiotics to promote the growth of feed animals.

MEDICAL COMPLICATIONS

Reactive Arthritis

The term reactive arthritis refers to an inflammation of one or more joints, following an infection localized at a site distant from the affected joints. The predominant site of the infection is the gastrointestinal tract. And reactive arthritis can be post infection, meaning that the infection may not be active when diagnosed. Several bacteria, including Salmonella, can reactive arthritis.[4]  And although the resulting joint pain and inflammation can resolve completely over time, permanent joint damage can occur.[5]

Reiter’s syndrome, a form of reactive arthritis, is an uncommon but debilitating syndrome caused by gastrointestinal or genitourinary infections. The reactive arthritis associated with Reiter’s may develop after a person eats food that has been tainted with bacteria. In a small number of persons, the joint inflammation is accompanied by conjunctivitis (inflammation of the eyes), and uveitis (painful urination). Id. This triad of symptoms is called Reiter’s Syndrome.[6]    Salmonella is one of the most common gastrointestinal bacteria involved with Reiter’s Syndrome. And although Reiter’s syndrome is characterized by a triad of arthritis, conjunctivitis, and urethritis, not all three symptoms occur in all affected individuals.[7]

Even though the initial infection may not be recognized, reactive arthritis can still occur. Reactive arthritis typically involves inflammation of one joint (monoarthritis), or four or fewer joints (oligoarthritis), preferentially affecting those of the lower extremities; the pattern of joint involvement is usually asymmetric. Inflammation is common at the places where ligaments and tendons attach to bone (enthuses), especially the knee and the ankle.

Salmonella has been the most frequently studied bacteria associated with reactive arthritis. Overall, studies have found rates of Salmonella-associated reactive arthritis to vary between six and thirty percent.[8] The frequency of post-infectious Reiter’s Syndrome, however, has not been well described. In a Washington State study, while twenty-nine percent of research participants developed arthritis, only three percent developed the triad of symptoms associated with Reiter’s syndrome.[9] In addition, individuals of Caucasian descent were found to be potentially more likely than those of Asian descent to develop reactive arthritis,[10] and children potentially less susceptible than adults to reactive arthritis following infection with Salmonella.[11]

A clear association has been made between reactive arthritis and a genetic factor called the human leukocyte antigen (HLA) B27 genotype. HLA is the major histocompatibility complex in humans; these are proteins present on the surface of all body cells that contain a nucleus, and are in especially high concentrations in white blood cells (leukocytes). It is thought that HLA-B27 may affect the elimination of the infecting bacteria or an individual’s immune response.[12]  HLA-B27 has been shown to be a predisposing factor in one-half to over two-thirds of individuals with reactive arthritis.[13] While HLA-B27 does not appear to predispose to the initial infection itself, it increases the risk of developing arthritis that is more likely to be severe and prolonged. This risk may be slightly greater for Salmonella and Yersinia-associated arthritis than with Campylobacter, but more research is required to clarify this.[14]

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a chronic disorder characterized by alternating bouts of constipation and diarrhea, both of which are generally accompanied by abdominal cramping and pain.[15] In one recent study, over one-third of IBS sufferers had lived with IBS for more than ten years, and their symptoms remained fairly constant over time.[16] The study found that IBS sufferers typically experienced symptoms for an average of 8.1 days per month.[17]

Another recently-published study—The Walkerton Health Study (WHS)—surveyed the extant scientific literature and noted that post-infectious irritable bowel syndrome (PI-IBS) is a common clinical phenomenon first-described over five decades ago.[18] The WHS further notes that between five and thirty percent of patients who suffer an acute episode of infectious gastroenteritis develop chronic gastrointestinal symptoms, despite clearance of the inciting pathogens.[19] In terms of its own data, the WHS “confirm[ed] a strong and significant relationship between acute enteric infection and subsequent IBS symptoms.”[20] The WHS also identified risk-factors for subsequent IBS including: younger age; female sex; and four features of the acute enteric illness—diarrhea for > 7days, presence of blood in stools, abdominal cramps, and weight loss of at least ten pounds.[21]

As would be expected from a chronic disorder with symptoms of such persistence, IBS sufferers were found to require more time off work, spend more days in bed, and to more often cut down on usual activities, when compared with non-IBS sufferers.[22] And even when able to work, a significant majority (67%) of IBS sufferers felt less productive at work because of their symptoms.[23] IBS symptoms also have a significantly deleterious impact on social well-being and daily social activities, such as undertaking a long drive, going to a restaurant, or taking a vacation.[24] And finally, although a patient’s psychological state may influence the way in which he or she copes with illness and responds to treatment, there is no evidence to supports the theory that psychological disturbances in fact cause IBS or its symptoms.[25]

[1]     Grimont, PAD, Weill, F.  Antigenic formulae of the Salmonella serovars, 2007, 9th Edition. WHO Collaborating Centre for Reference and Research on Salmonella. Paris: Pasteur Institute.  http://www.pasteur.fr/ip/portal/action/WebdriveActionEvent/oid/01S-000036-089.

[2]     http://www.cdc.gov/ncezid/dfwed/PDFs/SalmonellaAnnualSummaryTables2009.pdf, Table 1.

[3]     O’ Mahony, et al.  An outbreak of Salmonella Heidelberg infection associated with a long incubation period.  J. Public Health (1990) 12 (1): 19-21;  Abe, et al.  Prolonged Incubation Period of Salmonellosis Associated with Low Bacterial Doses.  J. Food Protection (2004) Vol. 67, No. 12; 2735-2740.

[4]     See Reactive Arthritis. “Questions and Answers About.” N.p., n.d. Web. 12 Nov. 2015.

[5]     Id.

[6]     IdSee also, Dworkin, et al.  “Reactive Arthritis and Reiter’s Syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis,” Clin. Infect. Dis., 2001 Oct. 1;33(7): 1010-4; Barth, W. and Segal, K.  “Reactive Arthritis (Reiter’s Syndrome),” American Family Physician, Aug. 1999, online at www.aafp.org/afp/990800ap/499.html.

[7]     Hill Gaston JS, Lillicrap MS.  (2003).  Arthritis associated with enteric infection.  Best Practices & Research Clinical Rheumatology.  17(2):219-239.

[8]     Id.

[9]     Dworkin MS, Shoemaker PC, Goldoft MJ, Kobayashi JM.  “Reactive arthritis and Reiter’s syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis.”  Clin. Infect. Dis. 33(7):1010-1014.

[10]    McColl GJ, Diviney MB, Holdsworth RF, McNair PD, Carnie J, Hart W, McCluskey J.  “HLA-B27 expression and reactive arthritis susceptibility in two patient cohorts infected with Salmonella Typhimurium,” Australian and New Zealand Journal of Medicine.  30(1):28-32 (2001).

[11]    Rudwaleit M, Richter S, Braun J, Sieper J.  “Low incidence of reactive arthritis in children following a Salmonella outbreak,” Annals of the Rheumatic Diseases, 60(11):1055-1057 (2001).

[12]    Hill Gaston and Lillicrap, supra Note 7.

[13]    Id.; Barth WF, Segal K., “Reactive arthritis (Reiter’s syndrome).” American Family Physician, 60(2):499-503, 507 (1999).

[14]    Hill Gaston and Lillicrap, supra Note 7.

[15]    A.P.S. Hungin, et al.  Irritable Bowel Syndrome in the United States: Prevalence, Symptom Patterns and Impact, Aliment Pharmacol. Ther., 2005:21 (11); 1365-75.

[16]    Id. at 1367.

[17]    Id.

[18]    J. Marshall, et al.  Incidence and Epidemiology of Irritable Bowel Syndrome After a Large Waterborne Outbreak of Bacterial Dysentery, Gastro., 2006; 131;445-50 (hereinafter “Walkerton Health Study” or “WHS”).  The WHS followed one of the largest E. coli O157:H7 outbreaks in the history of North America.  Contaminated drinking water caused over 2,300 people to be infected with E. coli O157:H7, resulting in 27 recognized cases of HUS, and 7 deaths.  Id. at 445.  The WHS followed 2,069 eligible study participants.  Id.  For Salmonella specific references, see Smith, J.L., Bayles, D.O., Post-Infectious Irritable Bowel Syndrome: A Long Term Consequence of Bacterial Gastroenteritis.  Journal of Food Protection, 2007:70(7);1762-1769.

[19]    Id. at 445 (citing multiple sources).

[20]    WHS, supra note 34, at 449.

[21]    Id. at 447.

[22]    Id. at 1368.

[23]    Id.

[24]    Id.

[25]    Amy Foxx-Orenstein, DO, FACG, FACP.  IBS—Review and What’s New.  General Medicine, 2006:8(3) (Medscape 2006) (collecting and citing studies).  Indeed, PI-IBS has been found to be characterized by more diarrhea but less psychiatric illness with regard to its pathogenesis.  See Nicholas J. Talley, MD, PhD.  Irritable Bowel Syndrome: From Epidemiology to Treatment, from American College of Gastroenterology 68th Annual Scientific Meeting and Postgraduate Course (Medscape 2003).

Unknown1After multiple serious health code violations were discovered by Boston health inspectors, two restaurants in the city’s Back Bay neighborhood have been closed to allow for corrective measures.

Health inspectors were called to Cafe Med and Back Bay Sandwich on St. James Avenue after nine confirmed cases of salmonella, Channel 7 reports.

Inside Back Bay Sandwich, health inspectors reported finding 19 violatins, including “rodent activity and droppings” as well as food stored at unsafe temperatures and unsanitary refrigerators.

Chicken was found to be sitting a a “green liquor” inside Cafe Med’s kitchen.

The Boston Inspectional Services Department and the Boston Public Health Commission said the management of both eateries are working to “ensure compliance of all applicable codes,” according to a statement issued by the ISD. “This is an ongoing investigation into the cause of the illness and the health permits for both establishments will be suspended until further notice.”

Both restaurants will be closed until the health investigation is complete.

Screen Shot 2016-06-14 at 10.53.07 PMAccording to Food Safety News, at least eleven people, including seven employees of Ajuua’s Mexican Restaurant, are confirmed with Salmonella infections related to the restaurant.

The root cause of the outbreak was still unknown, but that fresh tomatoes and/or salsa made and served at the restaurant in Odessa, Texas.

It is not known if the employees who tested positive for Salmonella carried the pathogen into the restaurant or picked it up there.

Three of the restaurant’s patrons required hospitalization because their symptoms were so severe.

As many as 23 other possible outbreak victims had been identified as of Monday.

Most people infected with Salmonella develop abdominal cramps, fever and diarrhea 12 to 72 hours after being exposed to the bacteria, according to the Centers for Disease Control and Prevention. Children under the age of 5, adults older than 65, and people with weakened immune systems are at increased risk of severe symptoms and death.

A total of 907 people infected with the outbreak strains of Salmonella Poona were reported from 40 states. A list of states and the number of cases in each can be found on the Case Count Map page.

Among people for whom information was available, illnesses started on dates ranging from July 3, 2015 to February 29, 2016. Ill people ranged in age from less than 1 year to 99, with a median age of 18. Forty-nine percent of ill people were children younger than 18 years. Fifty-six percent of ill people were female. Among 720 people with available information, 204 (28%) were hospitalized. Six deaths were reported from Arizona (1), California (3), Oklahoma (1), and Texas (1).

Epidemiologic, laboratory, and traceback investigations identified imported cucumbers from Mexico and distributed by Andrew & Williamson Fresh Produce as the likely source of the infections in this outbreak.

Several state health and agriculture departments collected and tested cucumbers from retail locations and isolated the outbreak strains of Salmonella Poona. Information indicated that these cucumbers were distributed by Andrew & Williamson Fresh Produce. Additionally, testing of cucumbers collected from the Andrew & Williamson Fresh Produce facility isolated the outbreak strains of Salmonella Poona.

Traceback information collected from the 11 illness clusters indicated that cucumbers eaten by ill people were imported from Mexico and distributed by Andrew & Williamson Fresh Produce.

Two recalls of garden variety cucumbers distributed by Andrew & Williamson Fresh Produce were announced because the cucumbers were likely contaminated with Salmonella. Recalled cucumbers were grown in Baja California, Mexico and distributed to many U.S. states. On September 4, 2015, Andrew & Williamson Fresh Produce voluntarily recalled all cucumbers sold under the Limited Edition brand label from August 1, 2015 through September 3, 2015. On September 11, 2015, Custom Produce Sales voluntarily recalled all cucumbers sold under the Fat Boy brand label starting August 1, 2015. These cucumbers were sent to Custom Produce Sales from Andrew & Williamson Fresh Produce.

Sid Wainer and Son of New Bedford, MA, is voluntarily recalling Jansal Valley brand Raw Macadamia Nuts because the product has the potential to be contaminated with Salmonella. 

The product is packaged in a plastic bag labeled as Jansal Valley Raw Macadamia Nuts and is packaged in both a one-pound and eight-ounce size with Lot code 469566.

The Raw Macadamia Nuts were distributed nationwide in retail stores and through mail orders.

No illnesses have been reported to date in connection with this problem.

Random third-party testing found presence of Salmonella in the one-pound package of Jansal Valley Raw Macadamia Nuts.

pork-chopsWashington State health officials are working with state and local partners to investigate several cases and clusters of Salmonella infections that appear to be linked to eating pork. The ongoing investigation of at least 56 cases in eight counties around the state includes food served at a variety of events.

Disease investigators continue to explore several sources from farm to table, and are focused on an apparent link to pork consumption or contamination from raw pork. Salmonellosis, the illness caused by infection with Salmonella, can cause severe and even bloody diarrhea, fever, chills, abdominal discomfort, and vomiting. Serious bloodstream infections may also occur.

As of July 23, the 56 cases include residents of King (44), Snohomish (4), Mason (2), Thurston (2), Pierce (1), Grays Harbor (1), Yakima (1), and Clark (1) counties. Five of the cases were hospitalized; no deaths have been reported. All were infected with the same strain of Salmonella bacteria. The disease investigation shows a potential exposure source for several cases was whole roasted pigs, cooked and served at private events. The source of contamination remains under investigation by state and local health officials and federal partners.

The outbreaks are a reminder of the importance of proper food care, handling, preparation, and cooking to prevent illness. State health officials recommend these food safety strategies broadly, and specifically advise against eating raw or undercooked pork.

Following food safety guidance can help prevent food-borne illness. Health officials warn consumers who handle and/or eat pork to cook the meat to a safe internal temperature, using a meat thermometer; whole cuts of pork should be cooked to 145 degrees. Meat thermometers should be placed in the thickest part of the meat, avoiding bone, fat, and cartilage.

All meats and fish should be cooked to a safe internal temperature, using a food thermometer; guidance can be found on the Department of Health website. Other food safety tips include washing hands thoroughly with soap and water before and after preparing food, especially raw meats. To avoid cross-contamination, don’t place cooked food on a plate that previously held raw meat of any kind.

It’s also important to sanitize cutting boards, knives, and countertops that come into contact with raw meat by using a solution of bleach water (1 teaspoon bleach per gallon of water) or antibacterial cleaner.

Food Safety News reports that Massachusetts state and local health department officials are investigating 19 Salmonella cases linked to a restaurant in Holyoke,  Brian Fitzgerald, Holyoke’s health director, told a local TV station that officials were trying to figure out why people were apparently sickened after eating at the Delaney House in Holyoke between Nov. 11 and 15, 2014.

Investigative reports from the Massachusetts Department of Public Health indicate that 19 confirmed Salmonella cases and additional potential cases were traced back to 10 different events held at the Delaney House.

The restaurant has not been shut down, although the state asked local health officials to order the management to comply with several alleged food code violations.

Five food handlers and one non-food handling employee at the restaurant also tested positive for Salmonella. Some of the infected food handlers reportedly worked at events outside of the Delaney House, including the Log Cabin, a take-out restaurant, and various catered events.

Lundberg Family Farms announced that it is voluntarily recalling specific bags of Brown Rice Flour because they have the potential to be contaminated with Salmonella, an organism which can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems if consumed raw. Healthy persons infected with Salmonella often experience fever, diarrhea (which may be bloody), nausea, vomiting and abdominal pain.

The recalled Eco-Farmed Brown Rice Flour (UPC# 0 73416 00550 1) and Organic Brown Rice Flour (UPC # 073416 00500 6) were distributed in retail store bulk bins, and 25lb bulk bags, between November 4th and November 12th, 2014 in the following states: CA, HI, MA, AZ, NV, and through mail order.

The affected 25lb bulk bags contain the following lot numbers 141027, 141028, 141029, 141030 located on the bottom seam of the bag.

No serious illnesses have been reported to date from the consumption of the product. The potential for contamination was identified after routine testing and immediate corrective action has been taken. Distributors and retailers have been notified and requested to discard the affected products in stock. The company notified the U.S. Food and Drug Administration, and is cooperating fully with the agency.

Friday the CDC updated its ongoing reporting of a Salmonella outbreak linked to baby chickens and ducks.  Now a total of 300 persons infected with the outbreak strains of Salmonella Infantis,Salmonella Newport, or SalmonellaHadar have been reported from 42 states and Puerto Rico. The number of ill persons identified in each state is as follows:  Alabama (8), Arizona (2), Arkansas (3), California (3), Colorado (5), Connecticut (1), Florida (1), Georgia (16), Idaho (4), Illinois (5), Iowa (3), Indiana (4), Kansas (1), Kentucky (11), Maine (9), Maryland (3), Massachusetts (1), Michigan (1), Minnesota (1), Mississippi (2), Missouri (1), Montana (3), Nebraska (3), New Hampshire (3), New Jersey (2), New Mexico (2), New York (30), North Carolina (28), Ohio (24), Oregon (1), Pennsylvania (29), Puerto Rico (1), South Carolina (6), South Dakota (3), Tennessee (17), Texas (2), Utah (1), Vermont (7), Virginia (25), Washington (8), West Virginia (18) Wisconsin (1), and Wyoming (1).

31% of ill persons have been hospitalized, and no deaths have been reported.

Epidemiologic, laboratory, and traceback findings have linked this outbreak of humanSalmonella infections to contact with chicks, ducklings, and other live poultry from Mt. Healthy Hatcheries in Ohio.  80% of ill people reported contact with live poultry in the week before their illness began.

Findings of multiple traceback investigations of live baby poultry from homes of ill persons have identified Mt. Healthy Hatcheries in Ohio as the source of chicks and ducklings. This is the same mail-order hatchery that has been associated with multiple outbreaks of Salmonella infections linked to live poultry in past years, including in 2012 and 2013.