Salmonella Information

As of June 14, 2018, 73 people infected with the outbreak strain of Salmonella Mbandaka have been reported from 31 states. A list of the states and the number of cases in each can be found on the Case Count Map page.

Illnesses started on dates from March 3, 2018, to May 28, 2018. Ill people range in age from less than one year to 87, with a median age of 58. Sixty-five percent are female. Out of 55 people with information available, 24 (44%) have been hospitalized. No deaths have been reported.

Illnesses that occurred after May 22, 2018, 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. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

Epidemiologic evidence indicates that Kellogg’s Honey Smacks cereal is a likely source of this multistate outbreak.

In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Thirty (77%) of 39 people interviewed reported eating cold cereal. In interviews, 14 people specifically reported eating Kellogg’s Honey Smacks cereal. Ill people in this outbreak reported this cereal more often than any other cereals or food items.

On June 14, 2018, the Kellogg Company recalled packages of Kellogg’s Honey Smacks cereal.

As of June 18, 2018, 70 people infected with the outbreak strain of Salmonella Adelaide have been reported from seven states. A list of the states and the number of cases in each can be found on the Case Count Map page.

Illnesses started on dates ranging from April 30, 2018, to June 3, 2018. Ill people range in age from less than 1 year to 97, with a median age of 67. Sixty-seven percent are female. Out of 63 people with information available, 34 (54%) have been hospitalized. No deaths have been reported.

Illnesses that occurred after May 28, 2018, 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. Please see the Timeline for Reporting Cases of Salmonella infection for more details.

Epidemiologic and preliminary traceback evidence indicates that pre-cut melon supplied by Caito Foods, LLC of Indianapolis, Indiana is a likely source of this multistate outbreak. Most of the ill people reported eating pre-cut cantaloupe, watermelon, or a fruit salad mix with melon purchased from grocery stores. Information collected from stores where ill people shopped indicates that Caito Foods, LLC supplied pre-cut melon to these stores.

WHAT IS SALMONELLA?

Salmonella is the second most common intestinal infection in the United States. More than 7,000 cases of Salmonella were confirmed in 2009; however, the majority of cases go unreported. The Centers for Disease Control and Prevention estimates that over 1 million people in the U.S. contract Salmonella each year, and that an average of 20,000 hospitalizations and almost 400 deaths occur from Salmonella poisoning, according to a 2011 report.

Salmonella infection usually occurs when a person eats food contaminated with the feces of animals or humans carrying the bacteria.  Salmonella outbreaks are commonly associated with eggs, meat and poultry, but these bacteria can also contaminate other foods such as fruits and vegetables. Foods that are most likely to contain Salmonella include raw or undercooked eggs, raw milk, contaminated water, and raw or undercooked meats.

Salmonella is generally divided into two categories. Non-typhoidal Salmonella is the most common form and is carried by both humans and animals. Most serotypes of Salmonella, such as Salmonella Javiana and Salmonella Enteritidis cause non-typhoidal Salmonella.  Typhoidal Salmonella, which causes typhoid fever, is rare, and is caused by Salmonella Typhi, which is carried only by humans.

SYMPTOMS OF SALMONELLA INFECTION

Symptoms of Salmonella infection, or Salmonellosis, range widely, and are sometimes absent altogether. The most common symptoms include diarrhea, abdominal cramps, and fever.

Typical Symptoms of Salmonella infection: Appear 6 to 72 hours after eating contaminated food and last for 3 to 7 days without treatment.

  • Diarrhea
  • Abdominal Cramps
  • Fever of 100 F to 102 F

Additional symptoms:

  • Bloody diarrhea
  • Vomiting
  • Headache
  • Body Aches

Typhoid Fever Symptoms: Symptoms of typhoid fever appear between 8 and 14 days after eating contaminated food and last anywhere from 3 to 60 days. They include a fever of 104 F, weakness, lethargy, abdominal pain, coughing, nosebleeds, delirium, and enlarged organs. Typhoid fever is a serious illness that can result in death.

COMPLICATIONS OF SALMONELLA

Complications of Salmonella poisoning are more likely to occur among young children and people age 65 or older. Possible complications include:

Reactive ArthritisReactive arthritis is thought to occur in 2 to 15 percent of Salmonella patients. Symptoms include inflammation of the joints, eyes, or reproductive or urinary organs. On average, symptoms appear 18 days after infection.

Irritable bowel syndrome (IBS): IBS is one disorder in a spectrum of common functional gastrointestinal disorders. Symptoms of IBS can include constipation, diarrhea, alternating diarrhea and constipation, abdominal pain, urgency, bloating, straining at stools, and a sense of incomplete evacuation.

Focal Infection: A focal infection occurs when Salmonella bacteria takes root in body tissue and causes illnesses such as arthritis or endocartitis. It is caused by typhoidal Salmonella only.

SALMONELLA TREATMENT

Salmonella infections generally last 3 to 7 days, and often do not require treatment. People with severe dehydration may need rehydration through an IV.

Antibiotics are recommended for those at risk of invasive disease, including infants under three months old. Typhoid fever is treated with a 14-day course of antibiotics.

Unfortunately, treatment of Salmonella has become more difficult as it has become more resistant to antibiotics. Finding the right antibiotic for a case of Salmonella is crucial to treating this bacterial infection.

PREVENTION OF SALMONELLA INFECTION

These safety measures can help prevent Salmonella poisoning:

  • Wash your hands before preparing food and after handling raw meats
  • Cook meat and eggs thoroughly until they reach an internal temperature of 160 F (71 C)
  • Do not eat foods containing raw eggs or milk, such as undercooked French toast
  • Avoid cooking raw meat in the microwave, as it may not reach a high enough internal temperature to kill Salmonella bacteria and may be unevenly cooked
  • Avoid bringing uncooked meat into contact with food that will not be cooked (i.e. salad)
  • Wash hands with soap after handling reptiles or animal feces
  • Always wash your hands after going to the bathroom

ADDITIONAL RESOURCES FOR SALMONELLA

About-Salmonella.com is a comprehensive site with in-depth information about Salmonella bacteria and Salmonellosis.

SalmonellaLitigation.com is a Website that provides information about lawsuits and litigation brought on behalf of victims of Salmonella outbreaks nationwide.  The site provides extensive information about sources of Salmonella outbreaks.

Salmonella Blog provides up-to-date news related to Salmonella outbreaks, research, and more.

On September 30, 2017, the Chincoteague Volunteer Fire Company (CVFC) hosted its 18thAnnual Chili/Chowder Cook-off and Classic Car Show at the carnival grounds in Chincoteague, Virginia. The fire company estimated 2,500 people from multiple states in the region attended the event.

After the event, some attendees developed gastrointestinal (GI) illness. The first complaint of suspected foodborne illness was received by the Accomack County Health Department (ACHD) on October 3. On the same day, ACHD found dozens of reports of GI illness in a conversation (started on October 2) on a social media page for Chincoteague Island residents and visitors. Some of the ill cook-off attendees reported seeking health care and receiving diagnoses of Salmonella infection.

Background: After a chili and chowder cook-off featuring 12 local vendors and attended by ~2,500 people, the Accomack County Health Department received reports of gastrointestinal illness among event attendees. Clinical stool specimens tested positive for Salmonellaserotype Javiana. An investigation was conducted to determine the source of—or practices that might have contributed to—contamination, and provide recommendations to prevent future outbreaks at similar events.

Methods: A cohort study was performed, with event attendees recruited through press releases and subsequent social media posts containing the link to an online survey asking about foods consumed at the cook-off and gastrointestinal illness. A case was defined as three or more episodes of diarrhea in less than 24 hours, or unquantified diarrhea in addition to at least one other symptom (abdominal pain, chills, dehydration, fever, nausea, or vomiting) in someone who consumed cook-off food. In addition to unadjusted relative risks (RRs), Mantel-Haenszel adjusted RRs were calculated to address potential confounding by multiple exposures. Environmental health specialists interviewed food handlers and conducted inspections of restaurants where professional competitors prepared food. Available food samples and stool specimens from ill attendees and asymptomatic food handlers were tested for Salmonella. Primary Salmonellaisolates were subtyped by pulsed-field gel electrophoresis (PFGE) and further characterized by whole-genome sequencing (WGS).

Results: Of 438 survey responses, 171 met the case definition. Of all exposures, Chowder A, prepared for the event by a professional vendor off-site, had the strongest association with illness (RR: 8.9; 95% confidence interval: 5.7–13.7). When stratified by exposure to Chowder A, all other chili or chowder adjusted RRs were less than 1.4. Environmental health inspections and interviews did not identify a specific source of contamination.Salmonella serotype Javiana was identified in stool specimens from 25 ill local and out-of-state attendees and an uneaten sample of Chowder A, but was not identified in the food handler specimens or raw frozen clam strips.

Conclusions: Epidemiologic and laboratory analyses provide evidence Chowder A was the most likely source of illness; however, the original source of Salmonellacould not be identified. Recommendations to prevent future outbreaks included requiring all food to be prepared at the event site and ensuring safe temperatures are maintained during food preparation and service.

Chincoteague Chili Cookoff- VA DOH General Outbreak Report

The Illinois Department of Public Health (IDPH), along with the Centers for Disease Control and Prevention, the Food and Drug Administration, and other state and local health departments, is investigating a recent cluster of Salmonella ser. Montevideo infections.  Two cases have been identified in Illinois residents.  People in Illinois reported becoming ill on December 20 and 26, 2017.  Based on a review of produce, suppliers, and items consumed, investigators believe the most likely source of the infection is sprouts from multiple Jimmy John’s locations.

To reduce the risk to additional customers, IDPH has requested that all Jimmy John’s restaurants in Illinois remove sprouts from their menus until the investigation is complete.  IDPH is also reminding restaurants not to let food handlers with diarrhea work.  If you have developed symptoms of Salmonella infection after eating food at a Jimmy John’s restaurant please contact your health care provider or local health department.

Symptoms of Salmonella may include headache, muscle aches, diarrhea, vomiting, abdominal cramping, chills, fever, nausea, and dehydration.  Symptoms usually appear 6 to 72 hours after ingesting the bacteria, but can be longer.  Most illnesses resolve on their own and do not require treatment other than drinking fluids to stay hydrated.  If your symptoms persist or are severe, promptly contact your health care provider.

Salmonella bacteria live in the intestinal tracts of humans and other animals.  Almost any food can be contaminated with Salmonella.  Person-to-person transmission of Salmonella occurs when an infected person’s feces, from his or her unwashed hands, contaminates food during preparation, or comes into direct contact with another person.

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.