Background

On April 19, 2019, the Minnesota Department of Health (MDH) Public Health Laboratory (PHL) determined that two clinical Salmonella Braenderup isolates submitted through routine surveillance had indistinguishable pulsed-field gel electrophoresis (PFGE) patterns (Minnesota designation BR134). Initial interviews with these cases revealed that both had eaten food from the Green Mill in Bloomington in the week before their illness onset. City of Bloomington Environmental Health Division (CBEH) was notified, and an investigation was initiated.

Methods

Cases were defined as individuals who tested positive for S. Braenderup with PFGE pattern BR134, or a Green Mill – Bloomington patron who developed diarrhea (≥3 stools in a 24-hour period) that was at least 3 days in duration or was accompanied by a fever, after eating food from the restaurant. Stool samples collected from consenting individuals were submitted to the MDH PHL for bacterial and viral testing. PFGE and whole genome sequencing (WGS) was performed on isolates.

MDH staff collected online orders, information for catering groups, and receipts from April 5, 8, 9, and 10, and patrons were called to find additional cases and controls.

All restaurant employees were required to submit two stool samples to the MDH PHL for Salmonella testing. Any employee reporting illness on or after March 15 was excluded from work in food service until two consecutive stool samples tested negative for Salmonella by culture. Employees who tested positive for Salmonella by culture were excluded until two consecutive stool samples tested negative.

Results

Eighty-nine restaurant patrons and 18 additional catered training event attendees were interviewed. Seven cases (7%) were identified, including five laboratory-confirmed cases. Two patrons reported illness but did not meet the case definition and were excluded from further analysis. Cases reported meal dates of March 22 (n=1), April 5 (n=3), April 8 (n=4), April 9 (n=3), April 10 (n=3). Four cases had 2 to 3 meal dates. Onsets of illness ranged from March 29 to April 16. The median age of cases was 39 years (range, 6 to 65 years), and four (57%) cases were male. All seven cases reported diarrhea and cramps, five (71%) fever, one (14%) vomiting, and one (14%) bloody stool. Four (57%) cases visited a healthcare provider, but none were hospitalized or died. The median incubation for the three cases with only one meal date was 115 hours (range, 1.5 to 175 hours).

Three laboratory-confirmed cases attended the same training event catered by the Green Mill restaurant on April 8, 9, and 10. All other cases were sit-down restaurant patrons or had take-out. One case tested negative for Salmonella, and the other case did not return a stool kit. In a univariate analysis including all laboratory-confirmed cases and controls from the catered training event and restaurant patrons from April 5 and 8, there were no significant findings. At the ingredient level, consumption of diced tomatoes (5 of 5 cases vs. 18 of 60 controls; odds ratio [OR], undefined; p = 0.004), any tomatoes (5 of 5 cases vs. 21 of 60 controls; OR, undefined; p < 0.008) and romaine lettuce (5 of 5 cases vs. 23 of 60 controls; OR, undefined; p < 0.012) were significantly associated with illness. In a multivariable analysis, no items remained independently associated with illness, likely because of the high degree of collinearity between tomatoes and romaine lettuce.

CBEH sanitarians visited Green Mill on April 19. All 53 employees were interviewed, and 5 employees were excluded because they reported vomiting, diarrhea, or fever since March 17. The illness onset dates for employees were April 1, April 9, April 11, April 19, and April 24. All five of these employees negative twice for Salmonella on their first two samples.

Two employees who did not initially report any gastrointestinal symptoms tested positive for S. Braenderup that matched by PFGE and whole genome sequencing to patron isolates. Both positive employees were banquet servers. One positive employee reported not having any gastrointestinal symptoms, and worked on April 5, 8, 9, and 10. The second positive employee, who initially reported having no illness, later reported diarrhea, chills, and abdominal pain but was unable to identify an onset date. This employee worked on April 5.

Sanitarians identified numerous issues. The Victory produce wash was plumbed to the 3-compartment sink. The paper towel dispenser was empty on the cook line. An employee was observed touching pizza with bare hands. An employee was observed rinsing the pizza cutter in the hand sink. The pressure gauge was not functional on the dish washing machine.

Fresh produce, including tomatoes and romaine lettuce, were delivered on the morning of April 5. Tomatoes are rinsed with Victory wash in the sink, diced or sliced, and then stored in the walk-in cooler and line flip top cooler. The romaine lettuce is delivered pre-cut and pre-shredded. Food for catered banquets and restaurant patrons are prepared in different areas.

Conclusion

This was an outbreak of S. Braenderup infections associated with the Green Mill restaurant in Bloomington and identified through routine disease surveillance. Tomato and romaine lettuce consumption were statistically associated with illness. Two banquet servers tested positive for the outbreak strain of S. Braenderup. Food workers infected with Salmonella may have been the source of contamination, but other sources of contamination could not be ruled out.

Epidemiologic evidence indicates that contact with pig ear dog treats is the likely source of this outbreak.

In interviews, ill people answered questions about animal contact in the week before they became ill. Thirty-four (89%) of 38 ill people reported contact with a dog before getting sick. Of 24 people with available information, 17 (71%) reported contact with pig ear dog treats or with dogs who were fed pig ear dog treats. Both of these proportions are significantly higher than the results from a survey of healthy people who reported contact with dogs (61%) or handling dog treats, such as pig ears (16%), in the week before interview.

Officials from the Michigan Department of Agriculture and Rural Development gathered pig ear dog treats at retail locations where ill people reported buying the products. They sampled pig ears for Salmonella. Although the outbreak strain was not identified, other strains of Salmonella were. Investigators are checking to see if any human illnesses are linked to those strains. Retail locations where sampling occurred have removed pig ears from shelves.

A common supplier of pig ear dog treats has not been identified.

CDC, public health and regulatory officials in several states, and the U.S. Food and Drug Administration (FDA) are investigating a multistate outbreak of multidrug-resistant Salmonella I 4,[5],12:i:- infections linked to contact with pig ear dog treats.

As of July 2, 2019, a total of 45 people infected with the outbreak strain of Salmonella I 4,[5],12:i:- have been reported from 13 states.

California – 1

Illinois – 3

Indiana – 3

Iowa – 12

Kansas – 3

Massachusetts – 2

Michigan – 7

Missouri – 3

New York – 6

North Dakota – 1

Pennsylvania – 2

South Carolina – 1

Wisconsin – 1

Total – 45

Illnesses started on dates ranging from November 18, 2018, to June 13, 2019. Ill people range in age from less than 1 year to 81 years, with a median age of 23. Half (50%) of ill people are female. Of 39 ill people with information available, 12 (31%) have been hospitalized. No deaths have been reported.

Illnesses might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2 to 4 weeks.

CDC, public health and regulatory officials in several states, and the U.S. Food and Drug Administration are investigating a multistate papaya outbreak of Salmonella Uganda infections.

As of June 26, 2019, a total of 62 people infected with the outbreak strain of Salmonella Uganda have been reported from 8 states – Texas, Florida, New York, Pennsylvania, New Jersey, Massachusetts, Connecticut and Rhode Island.

Illnesses started on dates ranging from January 14, 2019, to June 8, 2019. Most illnesses have occurred since April 2019. Ill people range in age from 1 to 86 years, with a median age of 60. Fifty-three percent of ill people are female. Of 35 people with available information, 23 (66%) have been hospitalized. No deaths attributed too Salmonella have been reported. Of 33 ill people with available information, 22 (67%) reported being of Hispanic ethnicity.

Epidemiologic evidence and early product distribution information indicate that whole, fresh papayas imported from Mexico and sold in Connecticut, Massachusetts, New Jersey, New York, Pennsylvania, and Rhode Island, are a likely source of this outbreak.

In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Of 21 people who were interviewed, 16 (76%) reported eating papayas. This proportion was significantly higher than results from a survey pdf icon[PDF – 787 KB] of healthy Hispanic people in the months of January through June in which 13% reported eating papayas in the week before they were interviewed.

Two people who lived in different households got sick in Connecticut after eating papayas purchased from the same grocery store location in the week before becoming ill. This provides additional evidence that papayas are a likely source of this outbreak. One ill person in Florida had traveled to Connecticut in the week before they got sick. Officials are working to gather more information about an ill person in Texas.

The gene that makes salmonella resistant to antibiotics of last resort has finally made its way from Asia to the United States, a new study says.

Researchers isolated the gene mcr-3.1 in a patient who had traveled to China two weeks before falling ill to salmonella, according to research published in the June edition of the Journal of Medical Microbiology.

They found the gene after genome sequencing 100 human stool samples collected between 2014 and 2016.

“This gene was already in the USA since 2016, which is surprising,” Siddhartha Thakur, the director of global public health at North Carolina State University, told UPI. “Colistin is the last resort drug and if the gene for resistance jumps on a plasmid then it spreads faster.”

According to Thakur, the gene made its way from a chromosome to a plasmid in China. This illustrated the possibility it could move back and forth between organisms.

So far, the gene has spread to 30 different countries, Thakur says, illustrating its transmission capability. Of the more than 2,500 salmonella serotypes in existence, Salmonella enterica causes much of the sickness related to the disease in the United States.

“This is exactly what we have seen in our study. It is possible that this gene has spread even more than what we had imagined,” Thakur said. “The major consequence is that we are running out of drugs to treat multi-drug resistant infections. This will lead to higher mortality.”

The Wisconsin Department of Health Services, Wisconsin Department of Agriculture, Trade and Consumer Protection, Minnesota Department of Health, and Wisconsin local health departments are working with the Food and Drug Administration and Centers for Disease Control and Prevention to investigate an ongoing multi-state outbreak of salmonellosis linked to consumption of certain Del Monte vegetable trays. To date, all ill patients associated with this outbreak, three in Wisconsin and one in Minnesota, have reported consuming a Del Monte vegetable tray purchased from a Wisconsin or Minnesota Kwik Trip location prior to their illness.  Kwik Trip is cooperating with regulatory officials and has removed all Del Monte vegetable trays from their stores. These patients reported becoming ill between April 13 and April 27, 2019. It is possible additional illnesses will be reported due to the delay from when a person becomes ill to when it is reported to public health agencies.

The Del Monte vegetable trays associated with the investigation contain broccoli, cauliflower, carrots, and dill dip. Del Monte vegetable trays may also have been distributed to other retailers in Wisconsin. Investigation for product distribution is ongoing. Consumers are advised to not eat the following products:

Del Monte Vegetable Tray (containing broccoli, cauliflower, carrots, and dill dip) 6 oz.
Del Monte Vegetable Tray (containing broccoli, cauliflower, carrots, and dill dip) 12 oz.

Salmonellosis is caused by consuming food or water contaminated with Salmonella bacteria, or by direct or indirect contact with fecal matter from infected people or animals. Symptoms include diarrhea, abdominal pains, fever, and vomiting that lasts for several days. Bloodstream infections are rare, but can be quite serious in young children, older adults, and people with weakened immune systems. Most people recover from salmonellosis on their own, but may require extra fluids to prevent dehydration. It is important to wash fruits and vegetables before eating them to prevent illness from Salmonella and other bacteria.

The United States Food and Drug Administration, along with the Centers for Disease Control and Prevention (CDC), and state and local partners, are investigating a multistate outbreak of Salmonella Concord illnesses linked to “Karawan Tahini and Halva” brand tahini imported from Israel.

The FDA has been working with the state of New York and New York City. The New York City Department of Health and Mental Hygiene tested samples of Karawan tahini and found that the product contained Salmonella.

Case Counts

Total Illnesses: 4
Hospitalizations: 1
Deaths: 0
Last illness onset: March 23, 2019
States with Cases: New York (2), Massachusetts (1), Texas (1)

Based on the positive product sample, the available epidemiological data, and traceback data from the investigation, the FDA has requested that the product be voluntarily recalled. Discussions with the U.S. agent for the firm, as well as foreign public health partners are ongoing and additional information will be provided as it becomes available.

The label of the product that tested positive for Salmonella identified Brodt Zenatti Holdings, LLC, of Jupiter, Fla., as the importer of that specific tahini, however, other importers may have also imported “Karawan Tahini and Halva” branded tahini. The investigation is ongoing, but at this time the current outbreak does not appear to be related to the previous 2018-2019 outbreak of Salmonella Concord linked to tahini.

The tahini of concern may be labelled as either “Karawan Tahini” or as “El Karawan Tahini.”  Consumers should avoid eating this tahini. This tahini was sold in bulk to retailers and restaurants and was also available to consumers at retail locations and online. It may have also been used in other food products sold to consumers. Consumers should be aware that this product has a shelf life of two years and should check their homes for tahini with either label. Consumers with this tahini in their home should not eat it and should discard it. Consumers with concerns about tahini consumed outside the home should ask their restaurant or retailer if the product they have purchased contains this tahini. Retailers and restaurants should throw the product out and sanitize any surfaces that may have come in contact with this tahini.

Tahini is made from sesame seeds and can be served on its own or used as an ingredient in Mediterranean and Middle Eastern style dishes, such as hummus, falafel, and baba ganoush.

On December 11, 2017, the King County Public Health Department (“DOH”) announced that they were investigating an outbreak of salmonellosis associated with the Miller’s Guild restaurant in Seattle, Washington. Six persons from four separate meal parties became ill after eating at the restaurant on different dates from August 15, 2017, to November 3, 2017. One of the ill persons was hospitalized and has since recovered.

Laboratory testing and genetic identification has indicated that three of the ill persons were infected with the same strain of Salmonella bacteria—Salmonella Braenderup—thereby strongly suggesting a common source of infection.

As part of the DOH investigation, Environmental Health investigators visited and closed the restaurant on November 21, 2017. During the field inspection, potential risk factors, such as practices that contribute to the risk of cross contamination, were identified, and several environmental samples were collected for. Salmonella was not found in environmental samples collected form the restaurant on November 21. However, epidemiologic and laboratory evidence from ill persons indicated that food served at Miller’s guild was the likely source of the outbreak.

On November 27, 2017, the DOH was notified of an additional ill person infected with Salmonella after eating at Miller’s Guild restaurant between October 15 and 21, 2017. The ill person was an employee at Miller’s Guild, but there was no evidence indicating that the person was the source of the outbreak.

salmonella

An outbreak of Salmonella Javiana occurred in August of 2018 among patrons of La Luz restaurant in Fort Collins, Colorado.  Thirty-one laboratory confirmed caseswere included in the outbreak, including 6 employees of the restaurant. Analysis of data did not determine a food-specific cause for the outbreak.

The Larimer County Department of Health & Environment (LCDHE) received a complaint on Thursday, August 16, 2018 from an individual that reported dining at the restaurant on Friday, August 10, 2018. The complainant indicated that she/he dined with two employees from that restaurant. The complainant reported becoming ill approximately 15 hours after eatingat the restaurant and reported that theemployees with whom she/he had dined also become ill.

On Friday, August 17, 2018,routine follow-up of a reported Salmonellacase from the Colorado Department of Public Health and Environment communicable disease reporting system identified that this case had dined at the restaurant on August 9, 2018. Also on August 17,LCDHE staff conducted an on-site investigation/inspection at the restaurant. Therestaurant’s management reported that four employees had beenill with the “stomach flu” on Thursday, August 9, 2018 and thatthese employees were still out sick and had not returned to work as of August 17, 2018. LCDHE noted several food safetyviolations, including improper cooling and cold storage, employee drinkingcups in food preparation areas, no hand soap at hand washing sinks, flies in the kitchen, soiled kitchen utensils and storage areas, a dirty anddisconnected copper pipe on a shelf above clean dishes, old food containers used for food storage, and an unshielded glass flood light.

On Monday, August 20, 2018, LCDHE staff made a second on-site visit to the restaurant. The operator was notified that all of the establishment’s employees would need to be interviewed to determine scope of duties at the restaurant and to provide information on recent health status; employees were instructed to submit rectal swabs to testfor Salmonella. By Tuesday, August 21, 2018, five laboratory confirmed Salmonellacases had beenidentified, and all reported eating at the restaurant between Thursday, August 9, 2018 and Sunday, August 12, 2018. All five cases had been hospitalized. LCDHE staff conducted a third site visit that afternoon, and the establishment was requested to voluntarily close and discontinue all food preparation and sale of food; it closed late that afternoon.

An illness questionnaire was developed by CDPHE Epi Division, and 85 individuals completed the questionnaire. All individuals who completed the questionnaire reportedeating food from the restaurant,and 61of those peoplereported symptoms of gastrointestinalillness. Of the 61 individuals, 30 (49%) were female and 31 (51%) were males. Ages ranged from 4 years to 72 years of age with the median age of 36 years. Onset of illness ranged from 2 hours to 243.5 hours with an average of 59.6 hours. Duration of symptoms ranged from 1 day to 17 days with median of 6 days (mean of 6 days). Despite an analysis of foods consumed by the people interviewed, no specific food was noted to be associated with illness.

Overall, 31 individuals were laboratory confirmed positive for Salmonella Javiana, including six of 20 restaurant employees. Cases were confirmed through culture and/or PCR; all cases had matching PFGE patterns. Five cases reported being hospitalized and no deaths were associated with this outbreak. On September 6, 2018, LCDHE approved the establishment to reopen to the public. The establishment reopened to the public on September 11, 2018, only to close for business permanently shortly after.

Jensen Tuna of Louisiana is recalling frozen ground raw tuna sourced from JK Fish of Vietnam due to possible Salmonella contamination. The recalled tuna was individually packaged in one-pound bags and sold in 20-pound boxes under lot numbers z266, z271, and z272

The product was sold to wholesalers in Connecticut, Iowa, Illinois, Minnesota, North Dakota, New York, and Washington. These wholesalers further distribute the product to restaurants and retail locations. The product was distributed from November 30, 2018 to March 15, 2019.

Restaurants and retailers should check with their suppliers and not sell or serve recalled frozen ground tuna and should wash and sanitize locations where recalled ground tuna was stored. Consumers with concerns should ask their restaurants and retailers whether the tuna dish they are purchasing contained the recalled ground tuna.

The voluntary recall is in response to the CDC and FDA’s investigation of 13 illnesses caused by Salmonella, confirmed to date. As of today, the ground tuna samples were found negative for Salmonella.

Salmonella is an organism that can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems. Most people infected with Salmonella develop symptoms within 12 to 72 hours after infections, according to the FDA. The illness, marked by diarrhea, fever and abdominal cramps, usually lasts 4 to 7 days.