Outbreak of Salmonella Newport Infections Linked to Cucumbers United States, 2014
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1 Outbreak of Salmonella Newport Infections Linked to Cucumbers United States, 2014 Laura Gieraltowski, PhD, MPH Outbreak Response and Prevention Branch Division of Foodborne, Waterborne, and Environmental Diseases InFORM November 19, 2015 National Center for Emerging and Zoonotic Infectious Diseases Division of Foodborne, Waterborne, and Environmental Diseases
2 Foodborne Salmonellosis Epidemiology 1 million illnesses 20,000 hospitalizations 400 deaths Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson MA, Roy SL, Jones JL, Griffin PM. Foodborne Illness Acquired in the United States Major Pathogens. Emerg Infect Dis, 2011; 17(1):7-15.
3 Geographic Distribution of Salmonella Newport (PFGE Pattern 61) Cases as of August 19, 2014 (n=85) NH(2) OH(4) NY(1) PA(24) VA(7) NC(3) MA(9) CT(1) NJ(6) DE(9) MD(15) GA(1) SC(3) 1-3 cases 4-8 cases >9 cases
4
5 Previous Outbreaks of Salmonella Newport Infections (PFGE Pattern 61) from the Delmarva Peninsula Year Number of Ill Persons Red round tomatoes VA Eastern Shore of the Delmarva Peninsula
6 Case Definition Infection with Salmonella Newport PFGE pattern 61 Illness onset on or after May 20, 2014 Isolation of Salmonella on XLD agar. Source: CDC
7 Hypothesis Generating Questionnaire Included >300 food, animal, and water exposures Administered by state and local health departments
8 Supplemental Questionnaire Emphasized tomatoes and other produce Information on exposures in the 7 days prior to illness onset
9 Travel Questionnaire
10
11 Tomato Exposure Data as of August 27, 2014 (n=13) 9 (69%) reported tomatoes on the supplemental questionnaire Not significant when compared to 68% (p=0.593) Type of Tomato n (%) Red Round 4 (31%) Vine Ripe 3 (23%) Cherry 1 (8%) Grape 1 (8%) Roma 1 (8%) Other 1 (8%) Unknown 1 (8%)
12 Cucumber Exposure Data as of September 3, 2014 (n=32) Ill Persons FoodNet Population Survey p-value Cucumber 21 (66%) 47% 0.026
13 Industry Consultation 3 independent produce industry experts Provided information regarding: Crop production Distribution practices Plausibility of cucumbers as a vehicle
14 Sub-cluster definition Investigating Sub-clusters 2 or more unrelated ill persons Eating at the same restaurant or event, or shopping at the same store Importance of sub-clusters Suggest that the contaminated food item was served or sold there Traceback of suspected food items may be facilitated by onsite records Photo credit: Uptown Magazine
15 Illness Sub-clusters (n=12) Sub-cluster State Type of Establishment # of Ill Persons Traceback Performed Connecticut Restaurant 2 Partial Delaware Restaurant 6 Yes Maryland Restaurant 4 Yes Maryland Restaurant 4 Yes Maryland Restaurant 3 Yes Maryland Restaurant 2 No Maryland Restaurant 2 Yes Maryland Restaurant 2 Yes Maryland Care Facility 2 Yes Maryland Day Camp 4 Yes New York Restaurant 4 Yes Pennsylvania Funeral 3 No
16 Illness Sub-clusters (n=12) Sub-cluster State Type of Establishment # of Ill Persons Traceback Performed Connecticut Restaurant 2 Partial Delaware Restaurant 6 Yes Maryland Restaurant 4 Yes Maryland Restaurant 4 Yes Maryland Restaurant 3 Yes Maryland Restaurant 2 No Maryland Restaurant 2 Yes Maryland Restaurant 2 Yes Maryland Care Facility 2 Yes Maryland Day Camp 4 Yes New York Restaurant 4 Yes Pennsylvania Funeral 3 No
17 Sub-cluster Traceback of Cucumbers Restaurant (NY) Restaurant (DE) Restaurant (MD) Restaurant (MD) Restaurant (MD) Restaurant (MD) Restaurant (MD) Care Facility (MD) Day Camp (MD) 8 of 9 sub-clusters Different Distribution Chain Single Major Distributor Broker Broker Broker Single Family Owned Farm MD Eastern Shore, Delmarva Peninsula
18 16 Salmonella Newport (PFGE Pattern 61) Infections by Date of Illness Onset, May 20 September 30, 2014 (n=275) Farm s Cucumber Harvest Shelf-life & Incubation Period Number of Persons /20 5/27 6/3 6/10 6/17 6/24 7/1 7/8 7/15 7/22 7/29 8/5 8/12 8/19 8/26 9/2 9/9 9/16 9/23 9/30 Date of Illness Onset
19 Number of Persons Infected with Salmonella Newport (PFGE Pattern 61) by State, 2014 (n=275) CA(1) CO(1) ND(1) MN(2) WI(1) MI(1) IA(1) OH(6) IL(1) IN(1) TN(1) VT(3) NY(24) PA(61) VA(23) NC(6) SC(3) ME(2) NH(4) MA(18) RI(1) CT(13) NJ (18) DE(21) MD(55) DC(1) AL(1) GA(2) TX(1) 1-9 cases cases cases >30 cases FL(1)
20 Ill Person Demographic and Clinical Data (n=275) Median age in years (range) 42 (<1 to 90) Female (%) 66% Hospitalizations (%) 34% Deaths (n) 1
21 Final Exposure Data, May 20 September 30, 2014 Food Item n Ill Persons FoodNet Population Survey p-value Cucumber (62%) 47% Tomato (any) (69%) 68% Leafy Greens (72%) 86% 0.999
22 Final Exposure Data, May 20 September 30, 2014 Food Item n Ill Persons FoodNet Population Survey p-value Cucumber (62%) 47% Tomato (any) (69%) 68% Leafy Greens (72%) 86% 0.999
23 Dendrogram of Isolates with Whole Genome Sequencing (WGS) Performed Performed on 58 (PFGE pattern 61) clinical isolates Revealed 2 groups of highly related isolates Primary Group Secondary Group MD and DE sub-clusters NY su b -cluster * 10 SNPs
24 Investigation Summary First outbreak of Salmonella Newport PFGE pattern 61 from the Delmarva Peninsula not linked to red round tomatoes
25 Investigation Summary First outbreak of Salmonella Newport PFGE pattern 61 from the Delmarva Peninsula not linked to red round tomatoes Cucumbers were a major source of illness Only item consumed more often by ill persons than healthy persons Traceback of the MD and DE sub-clusters led to a single farm
26 Investigation Summary First outbreak of Salmonella Newport PFGE pattern 61 from the Delmarva Peninsula not linked to red round tomatoes Cucumbers were a major source of illness Only item consumed by ill persons greater than expected Traceback of the MD and DE sub-clusters led to a single farm WGS Supported traceback findings Demonstrated genetic relatedness between isolates
27 Acknowledgements CDC Outbreak Response and Prevention Branch Enteric Diseases Laboratory Branch Food and Drug Administration CORE Response Team 1 Baltimore District Office New York District Office Departments of Agriculture Maryland Department of Agriculture New York State Department of Agriculture and Markets State Health Departments Maryland Department of Health and Mental Hygiene New York State Department of Health Delaware Department of Health and Social Services Virginia Department of Health Minnesota Department of Health Connecticut Department of Public Health Ohio Department of Health
28 Thank you! For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone: CDC-INFO ( )/TTY: Visit: Contact CDC at: CDC-INFO or The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Foodborne, Waterborne, and Environmental Diseases
29 PulseNet Data Analysis: Searching for Clusters CDC monitors the database for similar PFGE patterns Patterns visually compared PulseNet team notifies epidemiologists Outbreak investigation begins Cluster of indistinguishable patterns
30 25 Salmonella Newport Infections by Upload Date, May 20 October 31, 2014 (n=275) Farm s Cucumber Harvest Shelf Life & Incubation Period 20 Number of Persons Upload Date to PulseNet USA
31 Salmonella Newport Infections by Illness Onset Date and Upload Date, May 20 October 31, 2014 (n=275) Number of Persons * 25 Date of Illness Onset 20 Number of Persons * 0 Upload Date to PulseNet USA
32 Expected Cases of Salmonella Newport Pattern 61 by Month* Number of Cases Outbreak Time Frame Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Month *Compilation of background data from 1998 to 2014
33 Number of Persons Infected with Salmonella Newport (PFGE Pattern 61) by State, August 20 September 30, 2014 (n=57) CO(1) ND(1) MN(1) IA(1) WI(1) IL(1) VT(1) NY(5) PA(9) VA(7) ME(1) NH(1) RI(1) CT(4) NJ (3) DE(3) MD(6) MA(6) TN(1) AL(1) GA(2) 1-2 cases 3-4 cases >4 cases
34 Final Exposure Data, May 20 September 30, 2014 Ill Persons Percent of Ill Persons National FoodNet Population Survey p-value Cucumber 49/79 62% 47% Tomato (any) 88/127 69% 68% Red Round 27/101 27% N/A Cherry 19/101 19% N/A Vine Ripe 12/101 12% N/A Roma 9/101 9% N/A Grape 8/101 8% N/A Leafy Greens (any) 64/88 72% 86% Iceberg 33/81 41% 46% Romaine 28/78 36% 47% Spinach 20/87 23% 23% 0.543
35 WGS Methodology Determines the complete DNA sequence of an organism's genome at a single time Single Nucleotide Polymorphism (SNP) Analysis Evolutionally informative differences o Confer the most recent likely ancestor ATGTTCCTC ATGTTGCTC = test sequence = reference sequence
36
37 Investigation Timeline 2014 Aug 11 PulseNet detects the cluster Aug 22 Distributed supplemental questionnaire Sep 11 Industry Consultation Mid to Late Sept Traceback Completed Aug 2014 Sep 2014 Oct 2014 Nov 2014 Aug 19 First multi-state conference call Late Aug -Cucumbers become of interest -Multiple sub-clusters identified Late Oct Farm Visit
38 25 Salmonella Newport Infections by Illness Onset Date and Upload Date, May 20 October 31, 2014 (n=275) Farm s Cucumber Harvest Shelf Life & Incubation Period 20 Number of Persons Illness Onset Date Upload Date to PulseNet USA 5 * 0 Date
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