Three Lettuce E. coli Outbreaks in 11 Months

Eight days ago, federal health officials announced that romaine lettuce had been linked to a multistate E. coli outbreak, the third such outbreak to occur within the last 11 months, according to the Centers for Disease Control and Prevention (CDC). The two prior outbreaks were both deadly.

“Many of our recent E. coli cases have been linked to contaminated lettuce,” said Ryan Osterholm, one of the lead E. coli attorneys at the national food safety law firm Pritzker Hageman. As he recently told Bloomberg News, tainted produce is responsible for almost half of all food poisoning illnesses. And, while leafy greens have been a long been a top offender, E.coli outbreaks linked to lettuce are on the rise.

Ryan Osterholm
Attorney Ryan Osterholm

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In March 2018, an E. coli outbreak linked to romaine lettuce grown in Yuma, Arizona began,  It struck 36 states sickening 210 people before the CDC declared its end on June 28, 2018. Ninety-six people were hospitalized including 27 people who developed hemolytic uremic syndrome (HUS), a life-threatening form of kidney failure that affects between 5 percent and 10 percent of people with E. coli infections. Five people died.

Just a few months before that, an E. coli outbreak linked to leafy greens was announced. That outbreak, which began in November 2017 and ended in January 2018, sickened 25 people in 15 states. Nine people were hospitalized including two who developed HUS. One person died.

Health officials were never able to determine the brand or even the specific kind of lettuce responsible. But a simultaneously occurring E. coli outbreak in Canada was linked to romaine lettuce. And health investigators did determine that the genetic fingerprint of the E. coli strain in that outbreak, which sickened 42 people in five Canadian provinces, was closely related to the strain linked to the leafy greens outbreak in the U.S.  And just as virulent.  In Canada, 17 people were hospitalized and one person died.

Romaine Lettuce E. coli

Tracking E. coli Source: Mixed Bags, Handwritten Records

The investigation of the deadly Yuma-grown romaine outbreak that followed was also plagued with unresolved questions.  Health officials narrowed it down to romaine lettuce grown in Yuma, AZ.  But at that time of year, almost all of the romaine lettuce produced in the U.S. is grown in that region. And the U.S. Food and Drug Administration (FDA) was never able to determine a common grower or distributor.

So, the CDC and FDA warned consumers not to eat and restaurants and retailers not to sell romaine lettuce unless they knew it wasn’t grown in Yuma. The problem is, labels on most romaine products sold at grocery stores don’t state where it was grown. Things got more confusing when some stores issued romaine recalls, some restaurants stopped serving romaine and some romaine producers issued statements saying their lettuce wasn’t linked to the outbreak, including one company based in Yuma, AZ.

California and Arizona produce about 95 percent of lettuce grown in the U.S.,  dividing the year seasonally.  Each November, production shifts to Arizona where the bulk of our leafy greens until April when production shifts back to California.

Tracing back the source of an outbreak linked to a highly perishable commodity is always a challenge. But three things made it even more difficult for FDA investigators. The first was that the season had ended. The second was that the implicated finished romaine product contained romaine from various farms. And the third was that the majority of the records were on paper or handwritten.

As confusion swirled, the case count mounted.

E. coli Deaths, A Tragic Backdrop

That is the tragic backdrop for this outbreak. And likely explains why the CDC and the FDA took a different, more cautious approach when they, again, found themselves with unresolved questions. Again unable to identify a common supplier or distributor, the agencies warned consumers to avoid all romaine when they announced the outbreak on November 20, 2018. They have since been able to identify the growing region and have now modified the warning to avoid romaine produced in central and northern California.

But what about the label problem?

During the pause of all romaine sales, producers agreed to begin including the harvest location and date on their labels. The CDC says it may take some time before this information begins to appear and that consumers should not buy any romaine lettuce unless they are sure it was not grown in central or northern California.

Just as the Yuma-grown outbreak was tied to the end of the winter growing season when most romaine is grown in Arizona, this outbreak is tied to the end of the romaine growing season in California  As of November 26, 2018,  43 people in 12 states had been sickened. Sixteen people have been hospitalized including one who has HUS.

Romaine E. coli Outbreak Timeline

October 8, 2018
The first case-patient develops symptoms of an E.coli infection including diarrhea which can be bloody and abdominal cramps.

October 31, 2018
Symptoms for the most recent case-patient begin.

November 20, 2018
The CDC announces the outbreak. Thirty-two people in 11 states have been sickened by an E.coli strain that closely resembles the one linked to deadly leafy greens outbreak. Thirteen people have been hospitalized. One person has developed HUS. Because they can’t identify a common grower, supplier or distributor, the CDC and FDA warn consumers not to eat romaine lettuce of any kind.

November 23, 2018
CDC Director DR Robert Redfield takes the unusual step of issuing a public statement about the outbreak in which he Americans that they must follow CDC guidance to throw away all romaine lettuce or products containing it. No exceptions.

A Key Finding

November 26, 2018
FDA Commissioner Dr. Scott Gottlieb issues a lengthy public statement about the outbreak saying that over the Thanksgiving weekend investigators made a key finding about the origin of the contaminated lettuce. The agency revises its romaine warning to apply only to romaine grown in central and northern California.
There are three main points:

  • The outbreak has expanded to include 43 people in 12 states.
  • The agency has determined the romaine linked to this outbreak was grown in California’s Central Coast regions where production has ended for the season.
  • Romaine producers will now include harvest location and dates on their labels.

The CDC issues a public statement about the outbreak.
In addition the Gottlieb’s points, it includes:

  • Romaine that was not grown in the Central Coastal growing regions of northern and central California or that was grown hydroponically or in greenhouses is not implicated in this outbreak.
  • Consumers should not buy romaine that isn’t labeled with information about where it was grown.
  • Sixteen people have been hospitalized, one of them has HUS.

FDA Issues and Outbreak Update
In addition to the above information, the FDA update includes:

  • Symptoms for the most recent case began October 31, 2018.
  • Cases reported by state are: CA (11), CT (1), IL (2), MA (2), MD (1), MI (7), NH (2), NJ (9), NY (5), OH (1), RI (1), WI (1).

CDC Issues an Outbreak Update
In addition to the above information, the CDC update includes:

  • Eighty-eight percent of the case-patients interviewed reported eating romaine lettuce in the week before they became ill.
  • “Onset-of-illness” days ranging from October 8, 2018, to October 31, 2018.
  • Case-patients range in age from less than 1 to 84 years old.

November 28, 2018
The FDA identifies counties where romaine was grown. The agency says romaine lettuce grown in the following six counties is not safe to eat: Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz and Ventura. Other counties may be added