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CDC Salmonella Saintpaul Investigation

1423 Salmonella Saintpaul cases have been confirmed in 43 states, including New Mexico and Texas, where the outbreak began, and the District of Columbia. Read the FDA Warning. We also have information on the Minnesota Salmonella Saintpaul cases associated with the Good Earth restaurant in Roseville, Minnesota. Read about the Minnesota Salmonella outbreak associated with the Good Earth restaurant in Roseville, Minnesota.

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Investigation of Outbreak of Infections
Caused by Salmonella Saintpaul

CDC is collaborating with public health officials in many states, the Indian Health Service, and the U.S. Food and Drug Administration (FDA) to investigate an ongoing multi-state outbreak of human Salmonella serotype Saintpaul infections. An initial epidemiologic investigation in New Mexico and Texas comparing foods eaten by persons who were ill in May to foods eaten by well persons identified consumption of raw tomatoes as strongly linked to illness. This was a strong epidemiologic association, and tomatoes from that time period remain under investigation. After the public warning concerning tomatoes on June 7, cases continued to occur, though at a lower rate.

A similar but much larger, nationwide study comparing persons who were ill in June to well persons found that ill persons were more likely to have recently consumed raw tomatoes, raw jalapeño peppers, and raw cilantro. These items were commonly, though not always, consumed together, so that study could not determine which item(s) caused the illnesses.

After the first case-control study was conducted, clusters of infection were detected that were associated with specific restaurants. Most clusters involve fewer than 5 ill persons. As of July 1, three large clusters were investigated. In one, illnesses were linked to consumption of an item containing raw tomatoes and raw jalapeño peppers. In the other two, illnesses were linked to an item containing raw jalapeño peppers and no other of the suspect items. More recently, three additional large clusters were investigated. Detailed investigations of these clusters indicate that jalapeño peppers do not explain all illnesses. In two of these investigations, illnesses were linked to an item containing raw serrano peppers and raw tomatoes, but not jalapeño peppers. In the third, illnesses were linked to an item that contained raw jalapeños and tomatoes. Other clusters are still under active investigation.

These epidemiological studies indicate that more than one food vehicle is involved in this outbreak. No one food item can explain the entire outbreak. By themselves, tomatoes cannot explain the entire outbreak, nor do jalapeño peppers explain all the clusters. Although rare, there have been outbreaks in the past in which more than one food source has been implicated.

At present, information indicates that jalapeño and serrano peppers grown, harvested, or packed in Mexico are the cause of some clusters and are major food vehicles for the outbreak. Although tomatoes currently on the market are safe, raw tomatoes consumed early in the outbreak are still under investigation. The outbreak strain Salmonella Saintpaul has been isolated twice from jalapeño peppers and once from serrano peppers. These foods were sampled as the result of traceback investigations based on the epidemiologic investigations of clusters. An FDA laboratory detected the outbreak strain Salmonella Saintpaul in a sample of a jalapeño pepper obtained from a distribution center in McAllen, Texas. The distributor is working with FDA to recall the contaminated product in the United States. The peppers were grown in Mexico. An FDA laboratory detected the outbreak strain Salmonella Saintpaul in a sample of a serrano pepper and an agricultural water sample collected on a farm in Mexico that supplied peppers to the distribution center in McAllen, Texas. Results from the FDA laboratory therefore confirm that this outbreak was caused by at least two produce items, raw jalapeño and raw serrano peppers. In addition, the Laboratory Services Division of the Colorado Department of Public Health and Environment detected the outbreak strain Salmonella Saintpaul in a jalapeño pepper provided by an ill individual. The state health department is working with the FDA to determine the origin of the jalapeño pepper.

Since April,1423 persons infected with Salmonella Saintpaul with the same genetic fingerprint have been identified in 43 states, the District of Columbia, and Canada. These were identified because clinical laboratories in all states send Salmonella strains from ill persons to their State public health laboratory for characterization. The number of ill persons identified in each state is as follows: Alabama (5 persons), Arkansas (21), Arizona (59), California (13), Colorado (17), Connecticut (5), Florida (4), Georgia (42), Idaho (6), Illinois (119), Indiana (21), Iowa (2), Kansas (21), Kentucky (2), Louisiana (3), Maine (1), Maryland (39), Massachusetts (30), Michigan (26), Minnesota (31), Mississippi (2), Missouri (20), Montana (1), New Hampshire (5), Nevada (14), New Jersey (16), New Mexico (113), New York (41), North Carolina (28), Ohio (10), Oklahoma (38), Oregon (11), Pennsylvania (15), Rhode Island (3), South Carolina (2), Tennessee (10), Texas (554), Utah (2), Virginia (31), Vermont (2), Washington (18), West Virginia (1), Wisconsin (13), and the District of Columbia (1). Five ill persons are reported from Canada. Four appear to have been infected while traveling in the United States; the travel status of the fifth ill person is unknown.

Among the 1385 persons with information available, illnesses began between April 10 and July 29, 2008, including 94 who became ill on July 1 or later. These numbers include those with estimated onset dates as well as those with reported onset dates. The latest reported onset date is July 24. The latest estimated onset date is July 29. Patients range in age from <1 to 99 years; 50% are female. The rate of illness is highest among persons 20 to 29 years old; the rate of illness is lowest in children 10 to 19 years old and in persons 80 or more years old. At least 272 persons were hospitalized. A man in his eighties who died in Texas from cardiopulmonary failure had an infection with the outbreak strain at the time of his death; the infection may have contributed to his death. A man in his sixties who died in Texas from cancer had an infection with the outbreak strain of at the time of his death; the infection may have contributed to his death.

The outbreak can be visually described with a chart showing the number of persons who became ill each day. This chart is called an epidemic curve or epi curve. Please see Interpretation of Epidemic Curves During an Active Outbreak. It shows that the number of persons who became ill peaked during May and decreased in June. The average number of persons who became ill in recent weeks continues to decrease, indicating that the outbreak is ending. The average number of persons who became ill each day between May 21 and June 1 was 38, between June 13 and 23 was 24, and between July 5 and July 15 was 4. More recent illnesses may not yet be reported because it takes an average of 2-3 weeks. between when a person becomes ill and when the illness is reported. (see the Salmonella Outbreak Investigations: Timeline for Reporting Cases).

Only 18 persons infected with this strain of Salmonella Saintpaul were identified in the country during April through August of 2007. The previous rarity of this strain and the distribution of illnesses in all U.S. regions suggest that the implicated food is distributed throughout much of the country. Because many persons with Salmonella illness do not have a stool specimen tested, it is likely that many more illnesses have occurred than those reported. Some of these unreported illnesses may be in states that are not on today's map.

Only 6 persons infected with this strain of Salmonella Saintpaul were identified in the country during April through June of 2007. The previous rarity of this strain and the distribution of illnesses in all U.S. regions suggest that the implicated food is distributed throughout much of the country. Because many persons with Salmonella illness do not have a stool specimen tested, it is likely that many more illnesses have occurred than those reported. Some of these unreported illnesses may be in states that are not on today's map.

Clinical features of Salmonella Infection

Most persons infected with Salmonella develop diarrhea, fever, and abdominal cramps 12–72 hours after infection. Infection is usually diagnosed by culture of a stool sample. The illness usually lasts 4 – 7 days. Although most people recover without treatment, severe infections may occur. Infants, elderly persons, and those with impaired immune systems are more likely than others to develop severe illness. When severe infection occurs, Salmonella may spread from the intestines to the bloodstream and then to other body sites, and can cause death. In these severe cases, antibiotic treatment may be necessary.

Advice to consumers

At this time, FDA is advising U.S. consumers to limit their tomato consumption to those that are not the likely source of this outbreak. These include cherry tomatoes; grape tomatoes; tomatoes sold with the vine still attached; tomatoes grown at home; and red plum, red Roma, and round red tomatoes from specific sources listed at: http://www.fda.gov/oc/opacom/hottopics/tomatoes.html*. Consumers should 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 many other dishes.

Consumers everywhere are advised to:

• Refrigerate within 2 hours or discard cut, peeled, or cooked tomatoes.
• Avoid purchasing bruised or damaged tomatoes and discard any that appear spoiled.
• Thoroughly wash all tomatoes under running water.
• Keep tomatoes that will be consumed raw separate from raw meats, raw seafood, and raw produce items.
• Wash cutting boards, dishes, utensils, and counter tops with hot water and soap when switching between types of food products.

FDA recommends that U.S. retail outlets, restaurants, and food service operators offer only fresh and fresh cut red plum, red Roma, and round red tomatoes and food products made from these tomatoes from specific sources listed at: http://www.fda.gov/oc/opacom/hottopics/tomatoes.html#retailers*. Cherry tomatoes, grape tomatoes, and tomatoes sold with the vine still attached from any source may be offered.

FDA information on this investigation can be found at: http://www.fda.gov/oc/opacom/hottopics/tomatoes.html*

If someone was sickened by tomatoes, a Salmonella lawyer should be contacted immediately.  If someone has been sickened, do not discard any uneaten tomatoes until you speak with a Salmonella lawyer.

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