November 17, 2012 [Initial Announcement]: Multistate Outbreak of Shiga Toxin-producing Escherichia coli O157:H7 Infections

This particular outbreak appears to be over. However, E. coli is still an important cause of human illness in the United States. More information about E. coli, and steps people can take to reduce their risk of infection, can be found on the CDC E. coli Web Page.

CDC collaborated with public health officials in several states and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O157:H7 (STEC O157:H7) infections. Results from this investigation linked this outbreak to pre-packaged leafy greens produced by State Garden of Chelsea, Massachusetts.

Public health investigators used DNA “fingerprints” of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that were part of this outbreak. They used data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

The type of bacteria responsible for this outbreak was among those referred to as Shiga toxin-producing E. coli or STEC. STEC bacteria are grouped by serogroups (e.g., O157 or O145). The STEC serogroup found most commonly in U.S. patients is E. coli O157.

A total of 33 ill persons infected with the outbreak strain of STEC O157:H7 were reported from five states. The number of ill people identified in each state with the outbreak strain was as follows: Connecticut (2), Massachusetts (3), New York (26), Pennsylvania (1), and Virginia (1).

Among persons for whom information was available, illness onset dates ranged from October 18, 2012 to November 12, 2012. Ill persons ranged in age from 4 years to 66 years, with a median age of 24 years. Sixty-three percent of ill persons were female. Among 28 ill persons with available information, 13 (46%) were hospitalized. Two ill persons developed hemolytic uremic syndrome (HUS), a type of kidney failure. No deaths were reported.

This particular outbreak appears to be over. However, E. coli is still an important cause of human illness in the United States. More information about E. coli and steps people can take to reduce their risk for infection can be found on the CDC E. coli homepage.

Epidemiologic, laboratory, and traceback investigations conducted by officials in local, state, and federal public health, agriculture, and regulatory agencies linked this outbreak to pre-packaged leafy greens, produced by State Garden of Chelsea, Massachusetts.

State public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Thirty (97%) of 31 ill persons reported eating pre-packaged leafy greens. Fifteen (48%) of 31 ill persons for whom information was available reported eating Wegmans brand Organic Spinach and Spring Mix blend in the week before becoming ill. In total, 25 (81%) of 31 ill persons for whom information was available reported eating a variety of different brands of pre-packaged leafy greens produced by State Garden.

Testing conducted by the New York Department Health Wadsworth Center Laboratories isolated the outbreak strain of STECO157:H7 from four leftover packages of Wegmans brand Organic Spinach and Spring Mix blend collected from four ill persons’ homes.

Traceback investigations of pre-packaged leafy greens purchased by ill persons identified State Garden as a common producer, but a source of contamination was not identified. FDA continues its investigation into the source of the contamination.

On November 2, 2012, Wegmans voluntarily recalled its 5-ounce and 11-ounce clam shell packages of Organic Spinach and Spring Mix blend, a product produced by State Garden. State Garden issued a consumer advisory regarding the product packaged on October 12 and 13, 2012.

A total of 33 persons infected with the outbreak strain of Shiga toxin-producing E. coli O157:H7 were reported from five states. Five new cases were reported from two states: Massachusetts (1) and New York (4).

Among persons for whom information was available, illness onset dates ranged from October 18, 2012 to November 12, 2012. Ill persons ranged in age from 4 years to 66 years, with a median age of 24 years. Sixty-three percent of ill persons were female. Among 28 persons with available information, 13 (46%) patients were hospitalized. Two ill persons developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported.

CDC is collaborating with public health officials in several states and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O157 (STEC O157) infections. Preliminary results from this ongoing investigation indicate that Wegmans brand Organic Spinach and Spring Mix blend produced by State Garden of Chelsea, Massachusetts, is one likely source of this outbreak.

Public health investigators are using DNA “fingerprints” of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that may be part of this outbreak. They are using data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

The type of bacteria responsible for this outbreak is among those referred to as Shiga toxin-producing E. coli or STEC. STEC bacteria are grouped by serogroups (e.g., O157 or O145). The STEC serogroup found most commonly in U.S. patients is E. coli O157.

A total of 28 ill persons infected with the outbreak strain of STEC O157:H7 have been reported from five states. The number of ill people identified in each state with the outbreak strain is as follows: Connecticut (2), Massachusetts (2), New York (22), Pennsylvania (1), and Virginia (1).

Among persons for whom information is available, illness onset dates range from October 18, 2012 to November 3, 2012. Ill persons range in age from 4 years to 66 years, with a median age of 24 years. Sixty-eight percent of ill persons are female. Among 24 ill persons with available information, 10 (42%) reported being hospitalized. Two ill persons have developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported.

This PFGE pattern has very rarely been seen before in PulseNet. It has been seen only 7 times prior to this outbreak. Illnesses that occurred after October 30, 2012 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported. This outbreak can be visually described with a chart showing the number of persons who became ill each day. This chart is called an epi curve. Please see the Timeline for Reporting of E. coli Cases for more details on the reporting process.

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June 10, 2012 [Initial Announcement]: Multistate Outbreak of Shiga Toxin-producing Escherichia coli O145 Infections

This particular outbreak appears to be over. However, E. coli is still an important cause of human illness in the United States. More information about E. coli, and steps people can take to reduce their risk of infection, can be found on the CDC E. coli Web Page.

CDC collaborated with public health officials in 9 states to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli (STEC) O145 infections. Public health investigators used DNA “fingerprints” of STEC bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that may have been part of this outbreak. They used data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

A total of 18 individuals infected with the outbreak strain of STEC O145 were reported from 9 states. The number of ill persons identified in each state with the outbreak strain was as follows: Alabama (2), California (1), Florida (1), Georgia (5), Kentucky (1), Louisiana (5), Maryland (1), Tennessee (1), and Virginia (1).

Among 18 persons for whom information was available, illness onsets ranged from April 15, 2012 to June 12, 2012. Ill persons ranged in age from 1 to 79 years, and the median age was 33 years. Seventy-eight percent of patients were female. Four patients were hospitalized. One death was reported in Louisiana.

CDC initiated an investigation into this outbreak of illnesses on May 14, 2012 when six ill persons had been reported to CDC PulseNet from two states. CDC and state public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Based on interviews of 15 ill persons, a source for these infections was not identified.

A total of 18 persons infected with the outbreak strain of STEC O145 were identified in 9 states: Alabama (2), California (1), Florida (1), Georgia (5), Kentucky (1), Louisiana (5), Maryland (1), Tennessee (1), and Virginia (1). Since the last update 3 new ill persons were identified in 3 states: Kentucky (1), Maryland (1), and Virginia (1).

Among persons for whom information was available, illness onset dates ranged from April 15, 2012 to June 12, 2012. Ill persons ranged in age from 1 year to 79 years, with a median age of 33 years; 78% were female. Four ill persons were hospitalized. One death was reported in Louisiana.

CDC and state public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Based on interviews of 15 ill persons, a source for these infections was not identified.

A total of 15 persons infected with the outbreak strain of STEC O145 infection have been identified in 6 states: Alabama (2), California (1), Florida (1), Georgia (5), Louisiana (5), and Tennessee (1). Since the last update one new ill person has been identified in Louisiana with a reported illness onset of April 21, 2012. This is during the same time period as other ill persons in this outbreak.

Among persons for whom information is available, illness onset dates range from April 15, 2012 to May 12, 2012. Ill persons range in age from 1 year to 79 years old, with a median age of 31 years old; 73% are female. Four ill persons have been hospitalized. One death has been reported in Louisiana.

Illnesses that occurred after May 5, 2012 might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported.

It has been approximately 6 weeks since the last illness onset among reported cases.  Although this indicates that the outbreak could be over, CDC continues to work with state public health officials to identify additional cases and the source of these STEC O145 infections.

State public health officials have been interviewing ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness.  Based on interviews of 12 ill persons to date, a source for these infections has not been identified.

CDC is collaborating with public health officials in multiple states to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli serogroup O145 (STEC O145) infections. Public health investigators are using DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that may be part of this outbreak. They are using data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

The type of bacteria responsible for this outbreak is among those referred to as Shiga toxin-producing E. coli or STEC.  STEC bacteria are grouped by serogroups (e.g., O157 or O145). The STEC serogroup found most commonly in U.S. patients is E. coli O157. Other E. coli serogroups in the STEC group, including O145, are sometimes called "non-O157 STECs." Some types of STEC frequently cause severe disease, including bloody diarrhea and hemolytic uremic syndrome (HUS) which is a type of kidney failure.  Currently, there are limited public health surveillance data on the occurrence of non-O157 STECs, including STEC O145; many STEC O145 infections may go undiagnosed or unreported. Compared with STEC O157 infections, identification of non-O157 STEC infections is more complex.  First, clinical laboratories must test stool samples for the presence of Shiga toxins. Then, the positive samples must be sent to public health laboratories to look for non-O157 STEC. Clinical laboratories typically cannot identify non-O157 STEC.  The STEC O145 PFGE pattern in this outbreak has not been seen in PulseNet before.

CDC initiated an investigation into this cluster of illnesses on May 14, 2012.  At that time, six ill persons had been reported to CDC PulseNet from two states during May 3, 2012 to May 9, 2012. Although the most recent report of an illness to CDC was on June 4, 2012, their onset of illness occurred before May 10, 2012  and was during same period as other ill persons in this outbreak.

A total of 14 persons infected with the outbreak strain of STEC O145 infection have been identified in 6 states: Alabama (2), California (1), Florida (1), Georgia (5), Louisiana (4), and Tennessee (1).  Among persons for whom information is available, illness onset dates range from April 15, 2012 to May 12, 2012. The time from the beginning of a patient's illness to the confirmation that he or she was part of an outbreak is typically about 2-3 weeks. Please see the E. coli Outbreak Investigations: Timeline for Reporting Cases for more details.  Ill persons range in age from 1 year to 79 years old, with a median age of 33 years old; 79% are female. Three ill persons have been hospitalized; one death has been reported in Louisiana.

It has been approximately 4 weeks since the last illness onset among reported cases.  Although this indicates that the outbreak could be over, CDC continues to work with state public health officials to identify additional cases and the source of these STEC O145 infections.

State public health officials have been interviewing ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness.  Based on interviews of 10 ill persons to date, a source for these infections has not been identified.

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March 29, 2013 [Initial Announcement]: Multistate Outbreak of Shiga toxin-producing Escherichia coli O121 Infections Linked to Farm Rich Brand Frozen Food Products

This particular outbreak appears to be over. However, E. coli is still an important cause of human illness in the United States. More information about E. coli, and steps people can take to reduce their risk of infection, can be found on the CDC E. coli Web Page.

CDC collaborated with public health officials in several states, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O121 (STEC O121) infections linked to Farm Rich brand frozen food products produced by Rich Products Corporation of Buffalo, New York.

Public health investigators used DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis (PFGE) to identify cases of illness that were part of this outbreak. They used data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

A total of 35 individuals infected with the outbreak strain of STEC O121 were reported from 19 states. The number of ill persons identified in each state was as follows: Alabama (1), Arkansas (1), California (1), Colorado (1), Florida (2), Illinois (2), Indiana (2), Michigan (3), Missouri (1), Mississippi (1), New York (4), Ohio (6), Pennsylvania (1), South Dakota (1), Texas (3), Utah (1), Virginia (1), Washington (1), and Wisconsin (2).

Illness onset dates ranged from December 30, 2012 to April 15, 2013. Ill persons ranged in age from less than 1 year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons were 21 years of age or younger. Sixty percent of ill persons were female. Among 29 persons for whom information was available, 9 (31%) were hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported.

This outbreak appears to be over. However, many of these products have a long shelf-life, and they may still be in peoples’ freezers. Consumers unaware of the recall could continue to eat these products and potentially get sick.

E. coli is an important cause of human illness in the United States. More information about E. coli and steps people can take to reduce their risk for infection can be found on the CDC E. coli homepage.

Epidemiologic, laboratory, and traceback investigations conducted by officials in local, state, and federal public health, agriculture, and regulatory agencies linked this outbreak to Farm Rich brand frozen food products.

State and federal public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Twenty-four (100%) of 24 ill persons interviewed reported consuming frozen food products. Thirteen (68%) of 19 ill persons reported consuming Farm Rich brand frozen food products.

The outbreak strain of STEC O121 was identified in two different Farm Rich brand frozen products collected from the homes of two ill persons in New York and Texas.

On April 4, 2013, Rich Products Corporation recalled all of its Farm Rich, Market Day, and Schwan’s brand frozen food products produced at its Waycross, Georgia plant between June 1, 2011 and March 29, 2013 due to possible contamination with E. coli O121.

USDA-FSIS and FDA investigated suppliers of the common ingredients in the various types of Farm Rich brand frozen products consumed by ill persons, but the source of contamination was not identified. Rich Products Corporation is not currently producing products at its Waycross, Georgia plant, while the company continues to work with USDA-FSIS to develop a plan to make food safety improvements.

A total of 35 individuals infected with the outbreak strain of STEC O121 were reported from 19 states. There were no new illnesses reported since the last update.

Illness onset dates ranged from December 30, 2012 to April 15, 2013. Ill persons ranged in age from less than 1 year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons were 21 years of age or younger. Sixty percent of ill persons were female. Among 29 persons for whom information was available, 9 (31%) were hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported.

A total of 35 individuals infected with the outbreak strain of STEC O121 have been reported from 19 states. Three additional ill persons have been reported from Missouri (1) and Ohio (2).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to April 15, 2013. Ill persons range in age from one year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons are 21 years of age or younger. Sixty percent of ill persons are female. Among 29 persons with available information, 9 (31%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after April 10, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Twenty-four (100%) of 24 ill persons interviewed reported consuming frozen food products. Twelve (63%) of 19 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

A total of 32 individuals infected with the outbreak strain of STEC O121 have been reported from 18 states. Five additional ill persons have been reported from California (1), Colorado (1), Florida (2), and Ohio (1).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to April 2, 2013. Ill persons range in age from one year to 75 years, with a median age of 17 years. Eighty-one percent of ill persons are 21 years of age or younger. Fifty-six percent of ill persons are female. Among 26 persons with available information, 9 (35%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after March 30, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

A total of 27 individuals infected with the outbreak strain of STEC O121 have been reported from 15 states. Three new cases have been reported from Illinois (1), Michigan (1) and New York (1).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to March 18, 2013. Ill persons range in age from 2 years to 75 years, with a median age of 17 years. Eighty-one percent of ill persons are 21 years of age or younger. Fifty-six percent of ill persons are female. Among 23 persons with available information, 8 (35%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after March 10, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Twenty (100%) of 20 ill persons interviewed reported consuming frozen food products. Ten (63%) of 16 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

Testing conducted by the Outbreaks Section of the USDA-FSIS Eastern Laboratory identified the outbreak strain of STEC O121 from individually wrapped Farm Rich brand frozen mini pizza slices from an opened package collected from an ill person’s home in Texas. The frozen mini pizza slices were included in the products that were recalled on March 28, 2013.

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CDC is collaborating with public health officials in many states, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O121 (STEC O121) infections. Public health investigators are using DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that could be part of this outbreak. They are using data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

The type of bacteria responsible for this outbreak is among those referred to as Shiga toxin-producing E. coli or STEC. Some types of STEC frequently cause severe disease, including bloody diarrhea and hemolytic uremic syndrome (HUS), which is a type of kidney failure. STEC bacteria are divided into serogroups (e.g., O157 or O121). E. coli O157 is the STEC serogroup found most commonly in U.S. patients. Other E. coli serogroups in the STEC group, including O121, are sometimes called "non-O157 STECs." Because clinical laboratories typically cannot directly identify non-O157 STEC serogroups, they must first test stool samples for the presence of Shiga toxins.  Then, the positive samples must be sent to public health laboratories to look for non-O157 STEC. In recent years, the number of clinical laboratories that test for Shiga toxin has increased greatly, but some laboratories still do not perform these tests. Because of these complexities, many non-O157 STEC infections are probably not identified. The STEC O121 PFGE pattern in this outbreak is rare. In the past it has been seen less than 30 times in PulseNet.

A total of 24 individuals infected with the outbreak strain of STEC O121 have been reported from 15 states. The number of ill persons identified in each state is as follows: Alabama (1), Arkansas (1), Illinois (1), Indiana (2), Michigan (2), Mississippi (1), New York (3), Ohio (3), Pennsylvania (1), South Dakota (1), Texas (3), Utah (1), Virginia (1), Washington (1), and Wisconsin (2).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to March 9, 2013. Ill persons range in age from 2 years to 75 years, with a median age of 17 years. Seventy-eight percent of ill persons are 21 years of age or younger. Sixty-three percent of ill persons are female. Among 21 persons with available information, 7 (33%) reported being hospitalized. One ill person developed HUS, and no deaths have been reported.

The outbreak can be visually described with a chart showing the number of people who became ill each day or week. This chart is called an epi curve. Illnesses that occurred after March 1, 2013 might not be reported yet 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 3 weeks. For more details, please see Timeline for Reporting E. coli Cases.

Epidemiologic, laboratory, and traceback investigations conducted by officials in local, state, and federal public health, agriculture, and regulatory agencies indicate that Farm Rich brand frozen food products are one likely source of this outbreak of STEC O121 infections.

In interviews, ill persons answered questions about food consumed and other exposures during the week before becoming ill. Eighteen (100%) of 18 ill persons interviewed reported consuming frozen food products. Eight (57%) of 14 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

The New York State Department of Health, Wadsworth Center Laboratory, identified the outbreak strain of E. coli O121 in an opened package of Farm Rich brand frozen mini chicken and cheese quesadillas from an ill person’s home.

CDC and state and local public health partners are continuing laboratory surveillance through PulseNet to identify additional ill persons and to interview ill persons about foods eaten before becoming ill. FSIS and FDA are continuing to work closely with CDC and state partners during this investigation.

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June 15, 2011: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

Updated June 15, 2011

As of June 14, 2011, Germany’s Robert Koch Institute (RKI)* reports 784 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing E. coli or STEC infections–and 23 deaths associated with HUS. In the United States, four confirmed cases and one suspect case of STEC O104:H4 infections have been identified. No deaths have been reported. RKI has announced that contaminated raw sprouts were the source of the outbreak. The German public health authorities currently recommend that people in Germany not eat raw sprouts of any origin. Travelers to Germany should be aware that the recommendation not to eat cucumbers, tomatoes and leafy salads in northern Germany has been lifted as of June 10.

CDC is monitoring a large outbreak of Shiga toxin-producing Escherichia coli O104:H4 (STEC O104:H4) infections ongoing in Germany. The responsible strain shares virulence characteristics with enteroaggregative E. coli (EAEC).  As of June 14, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 784 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing E. coli or STEC infections–and 23 HUS-associated deaths.

In the United States, four confirmed cases and one suspect case of STEC O104:H4 infections have been identified. Of these five cases, four recently traveled to Hamburg, Germany, where they were likely exposed. The bacterial isolates from the three HUS cases reported in Massachusetts, Michigan, and Wisconsin and one case with Shiga toxin-positive diarrheal illness in Michigan have been confirmed as matching the outbreak strain. The Michigan case with Shiga toxin-positive diarrheal illness did not travel to Germany, but is a close contact of the Michigan case with HUS.  Their diarrheal illness developed later and was likely acquired through contact with the HUS case.  The suspect case is currently under investigation.

Among U.S. military personnel and their dependents that are stationed in Germany, there are no confirmed cases at this time. Continuous monitoring has shown no increase in visits due to gastrointestinal illness at U.S. military medical treatment facilities in Europe.

CDC has alerted state health departments of the ongoing outbreak and requested information about any persons with either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany and since April 1, 2011. Additionally, CDC is working with state health departments to learn more about suspect cases and obtain bacterial isolates for further characterization. When a report of STEC infection is investigated, every effort is made to identify ill family members or other close contacts to determine if person-to-person spread has occurred. With this outbreak, only one instance of person-to-person spread has been documented.

RKI, the Federal Institute for Risk Assessment and the Federal Office of Consumer Protection and Food Safety have announced there is substantial epidemiologic and traceback evidence indicating that fresh sprouts produced by a farm in Lower Saxony are responsible for the current outbreak in Germany. German public health authorities currently recommend that people in Germany not eat raw sprouts of any origin. Trace back investigations of the food chain indicate that no sprouts or other food items from the implicated farm in Lower Saxony have been exported outside Germany. Travelers to Germany should be aware that the recommendation not to eat cucumbers, tomatoes and leafy salads in northern Germany has been lifted as of June 10.

Although rare, E. coli O104:H4 has been identified before. For example, in 2009 in the Republic of Georgia, culture of specimens from two patients who were part of a cluster of diarrheal illness yielded an E. coli O104:H4 strain that was similar to the current outbreak strain. That strain produced Shiga toxin, but had a different molecular fingerprint and was less resistant to antibiotics than the current outbreak strain in Germany. No clear outbreak was identified in the Republic of Georgia, and no food was identified as a source of infections.

Any person who has recently traveled to Germany or has been in recent contact with an ill person who has recently traveled to Germany and has signs or symptoms of STEC infection or HUS, should seek medical care. He or she should tell the medical provider about the outbreak in Germany and the importance of asking the laboratory to test a stool specimen for STEC. Symptoms of STEC infection include stomach cramps, diarrhea (which is often bloody), and vomiting. If there is fever, it usually is not very high. Most people get better within 5-7 days, but some patients go on to develop HUS—usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color of skin and membranes due to anemia.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with the Food and Drug Administration of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

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* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

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May 30, 2013 [Final Update]: Multistate Outbreak of Shiga toxin-producing Escherichia coli O121 Infections Linked to Farm Rich Brand Frozen Food Products

This particular outbreak appears to be over. However, E. coli is still an important cause of human illness in the United States. More information about E. coli, and steps people can take to reduce their risk of infection, can be found on the CDC E. coli Web Page.

CDC collaborated with public health officials in several states, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O121 (STEC O121) infections linked to Farm Rich brand frozen food products produced by Rich Products Corporation of Buffalo, New York.

Public health investigators used DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis (PFGE) to identify cases of illness that were part of this outbreak. They used data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

A total of 35 individuals infected with the outbreak strain of STEC O121 were reported from 19 states. The number of ill persons identified in each state was as follows: Alabama (1), Arkansas (1), California (1), Colorado (1), Florida (2), Illinois (2), Indiana (2), Michigan (3), Missouri (1), Mississippi (1), New York (4), Ohio (6), Pennsylvania (1), South Dakota (1), Texas (3), Utah (1), Virginia (1), Washington (1), and Wisconsin (2).

Illness onset dates ranged from December 30, 2012 to April 15, 2013. Ill persons ranged in age from less than 1 year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons were 21 years of age or younger. Sixty percent of ill persons were female. Among 29 persons for whom information was available, 9 (31%) were hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported.

This outbreak appears to be over. However, many of these products have a long shelf-life, and they may still be in peoples’ freezers. Consumers unaware of the recall could continue to eat these products and potentially get sick.

E. coli is an important cause of human illness in the United States. More information about E. coli and steps people can take to reduce their risk for infection can be found on the CDC E. coli homepage.

Epidemiologic, laboratory, and traceback investigations conducted by officials in local, state, and federal public health, agriculture, and regulatory agencies linked this outbreak to Farm Rich brand frozen food products.

State and federal public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Twenty-four (100%) of 24 ill persons interviewed reported consuming frozen food products. Thirteen (68%) of 19 ill persons reported consuming Farm Rich brand frozen food products.

The outbreak strain of STEC O121 was identified in two different Farm Rich brand frozen products collected from the homes of two ill persons in New York and Texas.

On April 4, 2013, Rich Products Corporation recalled all of its Farm Rich, Market Day, and Schwan’s brand frozen food products produced at its Waycross, Georgia plant between June 1, 2011 and March 29, 2013 due to possible contamination with E. coli O121.

USDA-FSIS and FDA investigated suppliers of the common ingredients in the various types of Farm Rich brand frozen products consumed by ill persons, but the source of contamination was not identified. Rich Products Corporation is not currently producing products at its Waycross, Georgia plant, while the company continues to work with USDA-FSIS to develop a plan to make food safety improvements.

A total of 35 individuals infected with the outbreak strain of STEC O121 were reported from 19 states. There were no new illnesses reported since the last update.

Illness onset dates ranged from December 30, 2012 to April 15, 2013. Ill persons ranged in age from less than 1 year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons were 21 years of age or younger. Sixty percent of ill persons were female. Among 29 persons for whom information was available, 9 (31%) were hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported.

A total of 35 individuals infected with the outbreak strain of STEC O121 have been reported from 19 states. Three additional ill persons have been reported from Missouri (1) and Ohio (2).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to April 15, 2013. Ill persons range in age from one year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons are 21 years of age or younger. Sixty percent of ill persons are female. Among 29 persons with available information, 9 (31%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after April 10, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Twenty-four (100%) of 24 ill persons interviewed reported consuming frozen food products. Twelve (63%) of 19 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

A total of 32 individuals infected with the outbreak strain of STEC O121 have been reported from 18 states. Five additional ill persons have been reported from California (1), Colorado (1), Florida (2), and Ohio (1).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to April 2, 2013. Ill persons range in age from one year to 75 years, with a median age of 17 years. Eighty-one percent of ill persons are 21 years of age or younger. Fifty-six percent of ill persons are female. Among 26 persons with available information, 9 (35%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after March 30, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

A total of 27 individuals infected with the outbreak strain of STEC O121 have been reported from 15 states. Three new cases have been reported from Illinois (1), Michigan (1) and New York (1).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to March 18, 2013. Ill persons range in age from 2 years to 75 years, with a median age of 17 years. Eighty-one percent of ill persons are 21 years of age or younger. Fifty-six percent of ill persons are female. Among 23 persons with available information, 8 (35%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after March 10, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Twenty (100%) of 20 ill persons interviewed reported consuming frozen food products. Ten (63%) of 16 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

Testing conducted by the Outbreaks Section of the USDA-FSIS Eastern Laboratory identified the outbreak strain of STEC O121 from individually wrapped Farm Rich brand frozen mini pizza slices from an opened package collected from an ill person’s home in Texas. The frozen mini pizza slices were included in the products that were recalled on March 28, 2013.

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CDC is collaborating with public health officials in many states, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O121 (STEC O121) infections. Public health investigators are using DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that could be part of this outbreak. They are using data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

The type of bacteria responsible for this outbreak is among those referred to as Shiga toxin-producing E. coli or STEC. Some types of STEC frequently cause severe disease, including bloody diarrhea and hemolytic uremic syndrome (HUS), which is a type of kidney failure. STEC bacteria are divided into serogroups (e.g., O157 or O121). E. coli O157 is the STEC serogroup found most commonly in U.S. patients. Other E. coli serogroups in the STEC group, including O121, are sometimes called "non-O157 STECs." Because clinical laboratories typically cannot directly identify non-O157 STEC serogroups, they must first test stool samples for the presence of Shiga toxins.  Then, the positive samples must be sent to public health laboratories to look for non-O157 STEC. In recent years, the number of clinical laboratories that test for Shiga toxin has increased greatly, but some laboratories still do not perform these tests. Because of these complexities, many non-O157 STEC infections are probably not identified. The STEC O121 PFGE pattern in this outbreak is rare. In the past it has been seen less than 30 times in PulseNet.

A total of 24 individuals infected with the outbreak strain of STEC O121 have been reported from 15 states. The number of ill persons identified in each state is as follows: Alabama (1), Arkansas (1), Illinois (1), Indiana (2), Michigan (2), Mississippi (1), New York (3), Ohio (3), Pennsylvania (1), South Dakota (1), Texas (3), Utah (1), Virginia (1), Washington (1), and Wisconsin (2).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to March 9, 2013. Ill persons range in age from 2 years to 75 years, with a median age of 17 years. Seventy-eight percent of ill persons are 21 years of age or younger. Sixty-three percent of ill persons are female. Among 21 persons with available information, 7 (33%) reported being hospitalized. One ill person developed HUS, and no deaths have been reported.

The outbreak can be visually described with a chart showing the number of people who became ill each day or week. This chart is called an epi curve. Illnesses that occurred after March 1, 2013 might not be reported yet 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 3 weeks. For more details, please see Timeline for Reporting E. coli Cases.

Epidemiologic, laboratory, and traceback investigations conducted by officials in local, state, and federal public health, agriculture, and regulatory agencies indicate that Farm Rich brand frozen food products are one likely source of this outbreak of STEC O121 infections.

In interviews, ill persons answered questions about food consumed and other exposures during the week before becoming ill. Eighteen (100%) of 18 ill persons interviewed reported consuming frozen food products. Eight (57%) of 14 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

The New York State Department of Health, Wadsworth Center Laboratory, identified the outbreak strain of E. coli O121 in an opened package of Farm Rich brand frozen mini chicken and cheese quesadillas from an ill person’s home.

CDC and state and local public health partners are continuing laboratory surveillance through PulseNet to identify additional ill persons and to interview ill persons about foods eaten before becoming ill. FSIS and FDA are continuing to work closely with CDC and state partners during this investigation.

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June 7, 2011: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

Updated June 7, 2011

As of June 6, 2011, case counts confirmed by Germany’s Robert Koch Institute* includes 642 patients with hemolytic uremic syndrome (HUS) ? a type of kidney failure that is associated with E. coli or STEC infections ? and 15 deaths associated with STEC O104:H4 infection.In the United States, one confirmed and three suspected cases of STEC O104:H4 infections have been identified in persons who recently traveled to Hamburg, Germany, where they were likely exposed.At this time, a specific food has not been confirmed as the source of the infections. German public health authorities advise against eating raw sprouts, tomatoes, cucumbers, and leafy salads from sources in northern Germany until further notice.

CDC is monitoring a large outbreak of Shiga toxin-producing Escherichia coli O104:H4 (STEC O104:H4) infections ongoing in Germany. The responsible strain shares virulence characteristics with enteroaggregative E. coli (EAEC). As of June 6, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 642 patients with hemolytic uremic syndrome (HUS) – a type of kidney failure that is associated with E. coli or STEC infections – and 15 deaths.

In the United States, one confirmed and three suspected cases of STEC O104:H4 infections have been identified in persons who recently traveled to Hamburg, Germany, where they were likely exposed. One case of HUS in Massachusetts has been confirmed as matching the German outbreak strain. Among the three suspected cases, two are cases of HUS, one case each in Michigan and Wisconsin. The third suspected case, a person with Shiga toxin-positive diarrheal illness, is still under investigation.

CDC is working with state health departments to learn more about these suspected cases and obtain bacterial isolates from them for further characterization. In addition, CDC has alerted state health departments of the ongoing outbreak and requested information about any persons with either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany since April 1, 2011.

At this time, a specific food has not been confirmed as the source of the outbreak. Based on German epidemiologic and traceback investigations, several fresh produce items are currently under further investigation. On June 5, the Lower Saxony Ministry of Agriculture reported that the results of an investigation into the distribution chain of a local producer suggest the consumption of sprouts from a single farm may be associated with the outbreak there. Travelers to Germany should be aware that the German public health authorities have advised against eating raw sprouts, tomatoes, cucumbers, and leafy salads from sources in northern Germany until further notice. United States public health and regulatory authorities currently have no indication that any of these foods have been shipped from Europe to the United States.

The U.S. Department of Defense has been notified of this outbreak because of the presence of U.S. military bases in Germany; there are no known confirmed cases among U.S. military personnel or their dependents at this time. However, reports indicate that a small number of U.S service members in Germany with diarrheal illness are currently under investigation. For travel information related to this outbreak, please view the article on CDC Travelers’ Health Website.

Although rare, E. coli O104:H4 has been identified before. For example, in 2009 in the Republic of Georgia, culture of specimens from two patients who were part of a cluster of diarrheal illness yielded an E. coli O104:H4 strain that was similar to the current outbreak strain. That strain produced Shiga toxin, but had a different molecular fingerprint and was less resistant to antibiotics than the current outbreak strain in Germany. No clear outbreak was identified in the Republic of Georgia, and no food was identified as a source of infections.

Any person who has recently traveled to Germany and has signs or symptoms of STEC infection or HUS should seek medical care and let the medical provider know about the outbreak of STEC infections in Germany and the importance of being tested for STEC. Symptoms of STEC infection include severe stomach cramps, diarrhea (which is often bloody), and vomiting. If there is fever, it usually is not very high. Most people get better within 5-7 days, but some patients go on to develop HUS?usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color to skin and membranes due to anemia.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with the Food and Drug Administration of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

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* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

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July 20, 2012 (Final Update): Multistate Outbreak of Shiga Toxin-producing Escherichia coli O145 Infections

This particular outbreak appears to be over. However, E. coli is still an important cause of human illness in the United States. More information about E. coli, and steps people can take to reduce their risk of infection, can be found on the CDC E. coli Web Page.

CDC collaborated with public health officials in 9 states to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli (STEC) O145 infections. Public health investigators used DNA “fingerprints” of STEC bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that may have been part of this outbreak. They used data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

A total of 18 individuals infected with the outbreak strain of STEC O145 were reported from 9 states. The number of ill persons identified in each state with the outbreak strain was as follows: Alabama (2), California (1), Florida (1), Georgia (5), Kentucky (1), Louisiana (5), Maryland (1), Tennessee (1), and Virginia (1).

Among 18 persons for whom information was available, illness onsets ranged from April 15, 2012 to June 12, 2012. Ill persons ranged in age from 1 to 79 years, and the median age was 33 years. Seventy-eight percent of patients were female. Four patients were hospitalized. One death was reported in Louisiana.

CDC initiated an investigation into this outbreak of illnesses on May 14, 2012 when six ill persons had been reported to CDC PulseNet from two states. CDC and state public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Based on interviews of 15 ill persons, a source for these infections was not identified.

A total of 18 persons infected with the outbreak strain of STEC O145 were identified in 9 states: Alabama (2), California (1), Florida (1), Georgia (5), Kentucky (1), Louisiana (5), Maryland (1), Tennessee (1), and Virginia (1). Since the last update 3 new ill persons were identified in 3 states: Kentucky (1), Maryland (1), and Virginia (1).

Among persons for whom information was available, illness onset dates ranged from April 15, 2012 to June 12, 2012. Ill persons ranged in age from 1 year to 79 years, with a median age of 33 years; 78% were female. Four ill persons were hospitalized. One death was reported in Louisiana.

CDC and state public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Based on interviews of 15 ill persons, a source for these infections was not identified.

A total of 15 persons infected with the outbreak strain of STEC O145 infection have been identified in 6 states: Alabama (2), California (1), Florida (1), Georgia (5), Louisiana (5), and Tennessee (1). Since the last update one new ill person has been identified in Louisiana with a reported illness onset of April 21, 2012. This is during the same time period as other ill persons in this outbreak.

Among persons for whom information is available, illness onset dates range from April 15, 2012 to May 12, 2012. Ill persons range in age from 1 year to 79 years old, with a median age of 31 years old; 73% are female. Four ill persons have been hospitalized. One death has been reported in Louisiana.

Illnesses that occurred after May 5, 2012 might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported.

It has been approximately 6 weeks since the last illness onset among reported cases.  Although this indicates that the outbreak could be over, CDC continues to work with state public health officials to identify additional cases and the source of these STEC O145 infections.

State public health officials have been interviewing ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness.  Based on interviews of 12 ill persons to date, a source for these infections has not been identified.

CDC is collaborating with public health officials in multiple states to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli serogroup O145 (STEC O145) infections. Public health investigators are using DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that may be part of this outbreak. They are using data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

The type of bacteria responsible for this outbreak is among those referred to as Shiga toxin-producing E. coli or STEC.  STEC bacteria are grouped by serogroups (e.g., O157 or O145). The STEC serogroup found most commonly in U.S. patients is E. coli O157. Other E. coli serogroups in the STEC group, including O145, are sometimes called "non-O157 STECs." Some types of STEC frequently cause severe disease, including bloody diarrhea and hemolytic uremic syndrome (HUS) which is a type of kidney failure.  Currently, there are limited public health surveillance data on the occurrence of non-O157 STECs, including STEC O145; many STEC O145 infections may go undiagnosed or unreported. Compared with STEC O157 infections, identification of non-O157 STEC infections is more complex.  First, clinical laboratories must test stool samples for the presence of Shiga toxins. Then, the positive samples must be sent to public health laboratories to look for non-O157 STEC. Clinical laboratories typically cannot identify non-O157 STEC.  The STEC O145 PFGE pattern in this outbreak has not been seen in PulseNet before.

CDC initiated an investigation into this cluster of illnesses on May 14, 2012.  At that time, six ill persons had been reported to CDC PulseNet from two states during May 3, 2012 to May 9, 2012. Although the most recent report of an illness to CDC was on June 4, 2012, their onset of illness occurred before May 10, 2012  and was during same period as other ill persons in this outbreak.

A total of 14 persons infected with the outbreak strain of STEC O145 infection have been identified in 6 states: Alabama (2), California (1), Florida (1), Georgia (5), Louisiana (4), and Tennessee (1).  Among persons for whom information is available, illness onset dates range from April 15, 2012 to May 12, 2012. The time from the beginning of a patient's illness to the confirmation that he or she was part of an outbreak is typically about 2-3 weeks. Please see the E. coli Outbreak Investigations: Timeline for Reporting Cases for more details.  Ill persons range in age from 1 year to 79 years old, with a median age of 33 years old; 79% are female. Three ill persons have been hospitalized; one death has been reported in Louisiana.

It has been approximately 4 weeks since the last illness onset among reported cases.  Although this indicates that the outbreak could be over, CDC continues to work with state public health officials to identify additional cases and the source of these STEC O145 infections.

State public health officials have been interviewing ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness.  Based on interviews of 10 ill persons to date, a source for these infections has not been identified.

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April 26, 2013 [Investigative Update]: Multistate Outbreak of Shiga toxin-producing Escherichia coli O121 Infections Linked to Farm Rich Brand Frozen Food Products

This particular outbreak appears to be over. However, E. coli is still an important cause of human illness in the United States. More information about E. coli, and steps people can take to reduce their risk of infection, can be found on the CDC E. coli Web Page.

CDC collaborated with public health officials in several states, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O121 (STEC O121) infections linked to Farm Rich brand frozen food products produced by Rich Products Corporation of Buffalo, New York.

Public health investigators used DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis (PFGE) to identify cases of illness that were part of this outbreak. They used data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

A total of 35 individuals infected with the outbreak strain of STEC O121 were reported from 19 states. The number of ill persons identified in each state was as follows: Alabama (1), Arkansas (1), California (1), Colorado (1), Florida (2), Illinois (2), Indiana (2), Michigan (3), Missouri (1), Mississippi (1), New York (4), Ohio (6), Pennsylvania (1), South Dakota (1), Texas (3), Utah (1), Virginia (1), Washington (1), and Wisconsin (2).

Illness onset dates ranged from December 30, 2012 to April 15, 2013. Ill persons ranged in age from less than 1 year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons were 21 years of age or younger. Sixty percent of ill persons were female. Among 29 persons for whom information was available, 9 (31%) were hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported.

This outbreak appears to be over. However, many of these products have a long shelf-life, and they may still be in peoples’ freezers. Consumers unaware of the recall could continue to eat these products and potentially get sick.

E. coli is an important cause of human illness in the United States. More information about E. coli and steps people can take to reduce their risk for infection can be found on the CDC E. coli homepage.

Epidemiologic, laboratory, and traceback investigations conducted by officials in local, state, and federal public health, agriculture, and regulatory agencies linked this outbreak to Farm Rich brand frozen food products.

State and federal public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Twenty-four (100%) of 24 ill persons interviewed reported consuming frozen food products. Thirteen (68%) of 19 ill persons reported consuming Farm Rich brand frozen food products.

The outbreak strain of STEC O121 was identified in two different Farm Rich brand frozen products collected from the homes of two ill persons in New York and Texas.

On April 4, 2013, Rich Products Corporation recalled all of its Farm Rich, Market Day, and Schwan’s brand frozen food products produced at its Waycross, Georgia plant between June 1, 2011 and March 29, 2013 due to possible contamination with E. coli O121.

USDA-FSIS and FDA investigated suppliers of the common ingredients in the various types of Farm Rich brand frozen products consumed by ill persons, but the source of contamination was not identified. Rich Products Corporation is not currently producing products at its Waycross, Georgia plant, while the company continues to work with USDA-FSIS to develop a plan to make food safety improvements.

A total of 35 individuals infected with the outbreak strain of STEC O121 were reported from 19 states. There were no new illnesses reported since the last update.

Illness onset dates ranged from December 30, 2012 to April 15, 2013. Ill persons ranged in age from less than 1 year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons were 21 years of age or younger. Sixty percent of ill persons were female. Among 29 persons for whom information was available, 9 (31%) were hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported.

A total of 35 individuals infected with the outbreak strain of STEC O121 have been reported from 19 states. Three additional ill persons have been reported from Missouri (1) and Ohio (2).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to April 15, 2013. Ill persons range in age from one year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons are 21 years of age or younger. Sixty percent of ill persons are female. Among 29 persons with available information, 9 (31%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after April 10, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Twenty-four (100%) of 24 ill persons interviewed reported consuming frozen food products. Twelve (63%) of 19 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

A total of 32 individuals infected with the outbreak strain of STEC O121 have been reported from 18 states. Five additional ill persons have been reported from California (1), Colorado (1), Florida (2), and Ohio (1).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to April 2, 2013. Ill persons range in age from one year to 75 years, with a median age of 17 years. Eighty-one percent of ill persons are 21 years of age or younger. Fifty-six percent of ill persons are female. Among 26 persons with available information, 9 (35%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after March 30, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

A total of 27 individuals infected with the outbreak strain of STEC O121 have been reported from 15 states. Three new cases have been reported from Illinois (1), Michigan (1) and New York (1).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to March 18, 2013. Ill persons range in age from 2 years to 75 years, with a median age of 17 years. Eighty-one percent of ill persons are 21 years of age or younger. Fifty-six percent of ill persons are female. Among 23 persons with available information, 8 (35%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after March 10, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Twenty (100%) of 20 ill persons interviewed reported consuming frozen food products. Ten (63%) of 16 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

Testing conducted by the Outbreaks Section of the USDA-FSIS Eastern Laboratory identified the outbreak strain of STEC O121 from individually wrapped Farm Rich brand frozen mini pizza slices from an opened package collected from an ill person’s home in Texas. The frozen mini pizza slices were included in the products that were recalled on March 28, 2013.

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CDC is collaborating with public health officials in many states, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O121 (STEC O121) infections. Public health investigators are using DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that could be part of this outbreak. They are using data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

The type of bacteria responsible for this outbreak is among those referred to as Shiga toxin-producing E. coli or STEC. Some types of STEC frequently cause severe disease, including bloody diarrhea and hemolytic uremic syndrome (HUS), which is a type of kidney failure. STEC bacteria are divided into serogroups (e.g., O157 or O121). E. coli O157 is the STEC serogroup found most commonly in U.S. patients. Other E. coli serogroups in the STEC group, including O121, are sometimes called "non-O157 STECs." Because clinical laboratories typically cannot directly identify non-O157 STEC serogroups, they must first test stool samples for the presence of Shiga toxins.  Then, the positive samples must be sent to public health laboratories to look for non-O157 STEC. In recent years, the number of clinical laboratories that test for Shiga toxin has increased greatly, but some laboratories still do not perform these tests. Because of these complexities, many non-O157 STEC infections are probably not identified. The STEC O121 PFGE pattern in this outbreak is rare. In the past it has been seen less than 30 times in PulseNet.

A total of 24 individuals infected with the outbreak strain of STEC O121 have been reported from 15 states. The number of ill persons identified in each state is as follows: Alabama (1), Arkansas (1), Illinois (1), Indiana (2), Michigan (2), Mississippi (1), New York (3), Ohio (3), Pennsylvania (1), South Dakota (1), Texas (3), Utah (1), Virginia (1), Washington (1), and Wisconsin (2).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to March 9, 2013. Ill persons range in age from 2 years to 75 years, with a median age of 17 years. Seventy-eight percent of ill persons are 21 years of age or younger. Sixty-three percent of ill persons are female. Among 21 persons with available information, 7 (33%) reported being hospitalized. One ill person developed HUS, and no deaths have been reported.

The outbreak can be visually described with a chart showing the number of people who became ill each day or week. This chart is called an epi curve. Illnesses that occurred after March 1, 2013 might not be reported yet 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 3 weeks. For more details, please see Timeline for Reporting E. coli Cases.

Epidemiologic, laboratory, and traceback investigations conducted by officials in local, state, and federal public health, agriculture, and regulatory agencies indicate that Farm Rich brand frozen food products are one likely source of this outbreak of STEC O121 infections.

In interviews, ill persons answered questions about food consumed and other exposures during the week before becoming ill. Eighteen (100%) of 18 ill persons interviewed reported consuming frozen food products. Eight (57%) of 14 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

The New York State Department of Health, Wadsworth Center Laboratory, identified the outbreak strain of E. coli O121 in an opened package of Farm Rich brand frozen mini chicken and cheese quesadillas from an ill person’s home.

CDC and state and local public health partners are continuing laboratory surveillance through PulseNet to identify additional ill persons and to interview ill persons about foods eaten before becoming ill. FSIS and FDA are continuing to work closely with CDC and state partners during this investigation.

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May 10, 2013 [Investigative Update]: Multistate Outbreak of Shiga toxin-producing Escherichia coli O121 Infections Linked to Farm Rich Brand Frozen Food Products

This particular outbreak appears to be over. However, E. coli is still an important cause of human illness in the United States. More information about E. coli, and steps people can take to reduce their risk of infection, can be found on the CDC E. coli Web Page.

CDC collaborated with public health officials in several states, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O121 (STEC O121) infections linked to Farm Rich brand frozen food products produced by Rich Products Corporation of Buffalo, New York.

Public health investigators used DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis (PFGE) to identify cases of illness that were part of this outbreak. They used data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

A total of 35 individuals infected with the outbreak strain of STEC O121 were reported from 19 states. The number of ill persons identified in each state was as follows: Alabama (1), Arkansas (1), California (1), Colorado (1), Florida (2), Illinois (2), Indiana (2), Michigan (3), Missouri (1), Mississippi (1), New York (4), Ohio (6), Pennsylvania (1), South Dakota (1), Texas (3), Utah (1), Virginia (1), Washington (1), and Wisconsin (2).

Illness onset dates ranged from December 30, 2012 to April 15, 2013. Ill persons ranged in age from less than 1 year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons were 21 years of age or younger. Sixty percent of ill persons were female. Among 29 persons for whom information was available, 9 (31%) were hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported.

This outbreak appears to be over. However, many of these products have a long shelf-life, and they may still be in peoples’ freezers. Consumers unaware of the recall could continue to eat these products and potentially get sick.

E. coli is an important cause of human illness in the United States. More information about E. coli and steps people can take to reduce their risk for infection can be found on the CDC E. coli homepage.

Epidemiologic, laboratory, and traceback investigations conducted by officials in local, state, and federal public health, agriculture, and regulatory agencies linked this outbreak to Farm Rich brand frozen food products.

State and federal public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Twenty-four (100%) of 24 ill persons interviewed reported consuming frozen food products. Thirteen (68%) of 19 ill persons reported consuming Farm Rich brand frozen food products.

The outbreak strain of STEC O121 was identified in two different Farm Rich brand frozen products collected from the homes of two ill persons in New York and Texas.

On April 4, 2013, Rich Products Corporation recalled all of its Farm Rich, Market Day, and Schwan’s brand frozen food products produced at its Waycross, Georgia plant between June 1, 2011 and March 29, 2013 due to possible contamination with E. coli O121.

USDA-FSIS and FDA investigated suppliers of the common ingredients in the various types of Farm Rich brand frozen products consumed by ill persons, but the source of contamination was not identified. Rich Products Corporation is not currently producing products at its Waycross, Georgia plant, while the company continues to work with USDA-FSIS to develop a plan to make food safety improvements.

A total of 35 individuals infected with the outbreak strain of STEC O121 were reported from 19 states. There were no new illnesses reported since the last update.

Illness onset dates ranged from December 30, 2012 to April 15, 2013. Ill persons ranged in age from less than 1 year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons were 21 years of age or younger. Sixty percent of ill persons were female. Among 29 persons for whom information was available, 9 (31%) were hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths were reported.

A total of 35 individuals infected with the outbreak strain of STEC O121 have been reported from 19 states. Three additional ill persons have been reported from Missouri (1) and Ohio (2).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to April 15, 2013. Ill persons range in age from one year to 75 years, with a median age of 17 years. Eighty-two percent of ill persons are 21 years of age or younger. Sixty percent of ill persons are female. Among 29 persons with available information, 9 (31%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after April 10, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Twenty-four (100%) of 24 ill persons interviewed reported consuming frozen food products. Twelve (63%) of 19 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

A total of 32 individuals infected with the outbreak strain of STEC O121 have been reported from 18 states. Five additional ill persons have been reported from California (1), Colorado (1), Florida (2), and Ohio (1).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to April 2, 2013. Ill persons range in age from one year to 75 years, with a median age of 17 years. Eighty-one percent of ill persons are 21 years of age or younger. Fifty-six percent of ill persons are female. Among 26 persons with available information, 9 (35%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after March 30, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

A total of 27 individuals infected with the outbreak strain of STEC O121 have been reported from 15 states. Three new cases have been reported from Illinois (1), Michigan (1) and New York (1).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to March 18, 2013. Ill persons range in age from 2 years to 75 years, with a median age of 17 years. Eighty-one percent of ill persons are 21 years of age or younger. Fifty-six percent of ill persons are female. Among 23 persons with available information, 8 (35%) reported being hospitalized. Two ill people developed hemolytic uremic syndrome (HUS), a type of kidney failure, and no deaths have been reported.

Illnesses that occurred after March 10, 2013 might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Twenty (100%) of 20 ill persons interviewed reported consuming frozen food products. Ten (63%) of 16 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

Testing conducted by the Outbreaks Section of the USDA-FSIS Eastern Laboratory identified the outbreak strain of STEC O121 from individually wrapped Farm Rich brand frozen mini pizza slices from an opened package collected from an ill person’s home in Texas. The frozen mini pizza slices were included in the products that were recalled on March 28, 2013.

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CDC is collaborating with public health officials in many states, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O121 (STEC O121) infections. Public health investigators are using DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that could be part of this outbreak. They are using data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

The type of bacteria responsible for this outbreak is among those referred to as Shiga toxin-producing E. coli or STEC. Some types of STEC frequently cause severe disease, including bloody diarrhea and hemolytic uremic syndrome (HUS), which is a type of kidney failure. STEC bacteria are divided into serogroups (e.g., O157 or O121). E. coli O157 is the STEC serogroup found most commonly in U.S. patients. Other E. coli serogroups in the STEC group, including O121, are sometimes called "non-O157 STECs." Because clinical laboratories typically cannot directly identify non-O157 STEC serogroups, they must first test stool samples for the presence of Shiga toxins.  Then, the positive samples must be sent to public health laboratories to look for non-O157 STEC. In recent years, the number of clinical laboratories that test for Shiga toxin has increased greatly, but some laboratories still do not perform these tests. Because of these complexities, many non-O157 STEC infections are probably not identified. The STEC O121 PFGE pattern in this outbreak is rare. In the past it has been seen less than 30 times in PulseNet.

A total of 24 individuals infected with the outbreak strain of STEC O121 have been reported from 15 states. The number of ill persons identified in each state is as follows: Alabama (1), Arkansas (1), Illinois (1), Indiana (2), Michigan (2), Mississippi (1), New York (3), Ohio (3), Pennsylvania (1), South Dakota (1), Texas (3), Utah (1), Virginia (1), Washington (1), and Wisconsin (2).

Among persons for whom information is available, illness onset dates range from December 30, 2012 to March 9, 2013. Ill persons range in age from 2 years to 75 years, with a median age of 17 years. Seventy-eight percent of ill persons are 21 years of age or younger. Sixty-three percent of ill persons are female. Among 21 persons with available information, 7 (33%) reported being hospitalized. One ill person developed HUS, and no deaths have been reported.

The outbreak can be visually described with a chart showing the number of people who became ill each day or week. This chart is called an epi curve. Illnesses that occurred after March 1, 2013 might not be reported yet 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 3 weeks. For more details, please see Timeline for Reporting E. coli Cases.

Epidemiologic, laboratory, and traceback investigations conducted by officials in local, state, and federal public health, agriculture, and regulatory agencies indicate that Farm Rich brand frozen food products are one likely source of this outbreak of STEC O121 infections.

In interviews, ill persons answered questions about food consumed and other exposures during the week before becoming ill. Eighteen (100%) of 18 ill persons interviewed reported consuming frozen food products. Eight (57%) of 14 ill persons reported consuming Farm Rich brand frozen food products. Investigations are ongoing to determine the specific types and sources of frozen food that might be linked with illness, as well as to determine which particular ingredients or components of these products may be contaminated.

The New York State Department of Health, Wadsworth Center Laboratory, identified the outbreak strain of E. coli O121 in an opened package of Farm Rich brand frozen mini chicken and cheese quesadillas from an ill person’s home.

CDC and state and local public health partners are continuing laboratory surveillance through PulseNet to identify additional ill persons and to interview ill persons about foods eaten before becoming ill. FSIS and FDA are continuing to work closely with CDC and state partners during this investigation.

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June 23, 2011: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

Updated July 8, 2011 (FINAL Update)

As of July 5, 2011, Germany’s Robert Koch Institute (RKI)* reports 852 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing Escherichia coli, or STEC, infections–and 32 deaths associated with HUS. In the United States, six confirmed cases of STEC O104:H4 infections have been identified. Among these six cases, one death has been reported in an Arizona resident who traveled to Germany before becoming ill.On June 10, 2011, RKI announced that contaminated raw sprouts from one farm in Germany are the likely source of the outbreak. This farm has been closed and the sprouts produced there are no longer in restaurants or store shelves in Germany. Over the past few weeks, the number of cases associated with this outbreak has markedly decreased. On June 24, 2011, France identified a cluster of E. coli O104:H4 infections among attendees of an event in Bordeaux, France; attendees reported consuming sprouts produced locally in Bordeaux.On July 5, 2011, the European Food Safety Authority issued a report identifying a single lot of fenugreek seeds, from an exporter in Egypt, as the most likely source of the sprouts linked with E. coli O104:H4 outbreaks in Germany and France.

CDC is monitoring a large outbreak of Shiga toxin-producing Escherichia coli O104:H4 (STEC O104:H4) infections ongoing in Germany. The responsible strain shares virulence characteristics with enteroaggregative E. coli (EAEC).  As of July 5, 2011, case counts confirmed by Germany’s Robert Koch Institute* include 852 patients with hemolytic uremic syndrome (HUS)–a type of kidney failure that is associated with Shiga toxin-producing E. coli, or STEC, infections–and 32 HUS-associated deaths.

In the United States, six confirmed cases of STEC O104:H4 infections have been identified. Of these six cases, five recently traveled to Germany, where they were likely exposed. Bacterial isolates from four HUS cases reported in Arizona (1), Massachusetts (1), Michigan (1) and Wisconsin (1), and two cases with diarrheal illness reported in Michigan (1) and North Carolina (1), have all been confirmed as matching the outbreak strain. One death has been reported in the Arizona resident with HUS who traveled to Germany before becoming ill. The Michigan resident with diarrheal illness did not travel to Germany, but likely acquired this infection through close contact with the Michigan resident with HUS. 

Among U.S. military personnel and their dependents that are stationed in Germany, there are no confirmed cases at this time. Continuous monitoring has shown no increase in visits due to gastrointestinal illness at U.S. military medical treatment facilities in Europe.

CDC has alerted state health departments of the ongoing outbreak and requested information about any persons with either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany and since April 1, 2011. Additionally, CDC is working with state health departments to learn more about suspect cases and obtain bacterial isolates for further characterization. When a report of STEC infection is investigated, every effort is made to identify ill family members or other close contacts to determine if person-to-person spread has occurred. With this outbreak, only one instance of person-to-person spread has been documented in the United States.

RKI, the Federal Institute for Risk Assessment, and the Federal Office of Consumer Protection and Food Safety have found substantial epidemiologic and traceback evidence indicating that fresh sprouts produced by a farm in Lower Saxony are responsible for the current outbreak in Germany. German public health authorities currently recommend that people in Germany not eat raw sprouts of any origin. Traceback investigations of the food chain indicate that no sprouts or other food items from the implicated farm in Lower Saxony have been exported outside Germany. Travelers to Germany should be aware that the recommendation not to eat cucumbers, tomatoes and leafy salads in northern Germany was lifted. On June 10, 2011, RKI announced that contaminated raw sprouts from one farm in Germany are the likely source of the outbreak. This farm has been closed and the sprouts produced there are no longer in restaurants or store shelves in Germany. Over the past few weeks, the number of cases associated with this outbreak has markedly decreased. While some cases may still occur because of the time it takes between when a person becomes ill and when the illness is reported, it is likely that the number of cases will continue to decrease until the outbreak is over.

On June 24, 2011, France reported a cluster of E. coli O104:H4infections among persons who attended an event in Bordeaux, France. Attendees reported eating sprouts served at the event. The sprouts were privately produced in small quantities by the organizer of the event from seeds purchased locally in Bordeaux.

The European Food Safety Authority (EFSA) initiated a comprehensive investigation to identify the source of the two outbreaks. On July 5, 2011, EFSA issued a report of its findings. Comparison of information from the outbreak investigations led to the identification of a single lot of fenugreek seeds, from an exporter in Egypt, as the most likely source of the sprouts linked with the two outbreaks. Given the possible severe health impact of exposure to a small quantity of contaminated material, and in the absence of information regarding the source and means of contamination and possible cross-contamination, all lots of fenugreek seeds from the identified exporter should be considered suspect.

Although rare, E. coli O104:H4 has been identified before. For example, in 2009 in the Republic of Georgia, culture of specimens from two patients who were part of a cluster of diarrheal illness yielded an E. coli O104:H4 strain that was similar to the current outbreak strain. That strain produced Shiga toxin, but had a different molecular fingerprint and was less resistant to antibiotics than the current outbreak strain in Germany. No clear outbreak was identified in the Republic of Georgia, and no food was identified as a source of infections.

The STEC O104:H4 responsible for the German outbreak has several genetic factors that contribute to its ability to cause illness. One is its ability to stick to cells in the intestine and another is its ability to make Shiga toxin. These factors are already well known and occur in various strains of E. coli in nature. E. coli, like many other bacteria, exchange genetic material and there is no evidence to think that this strain has been modified intentionally. Because of minimal person-to-person transmission associated with this strain, there is also no evidence to indicate that it will cause a pandemic or spread around the world. More information about the characteristics of the STEC O104:H4 strain can be found in The Lancet (abstract) - “Characterisation of the Escherichia coli strain associated with an outbreak of haemolytic uraemic syndrome in Germany, 2011: a microbiological study” and in The New England Journal of Medicine - "Epidemic Profile of Shiga-Toxin–Producing Escherichia coli O104:H4 Outbreak in Germany — Preliminary Report".

Any person who has recently traveled to Germany or has been in recent contact with an ill person who has recently traveled to Germany and has signs or symptoms of STEC infection or HUS, should seek medical care. He or she should tell the medical provider about the outbreak in Germany and the importance of asking the laboratory to test a stool specimen for STEC. Symptoms of STEC infection include stomach cramps, diarrhea (which is often bloody), and vomiting. If there is fever, it usually is not very high. Most people get better within 5-7 days, but some patients go on to develop HUS—usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color of skin and membranes due to anemia.

CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular, with the Food and Drug Administration of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture. CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.

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June 22, 2012 (Investigation Update): Multistate Outbreak of Shiga Toxin-producing Escherichia coli O145 Infections

This particular outbreak appears to be over. However, E. coli is still an important cause of human illness in the United States. More information about E. coli, and steps people can take to reduce their risk of infection, can be found on the CDC E. coli Web Page.

CDC collaborated with public health officials in 9 states to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli (STEC) O145 infections. Public health investigators used DNA “fingerprints” of STEC bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that may have been part of this outbreak. They used data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

A total of 18 individuals infected with the outbreak strain of STEC O145 were reported from 9 states. The number of ill persons identified in each state with the outbreak strain was as follows: Alabama (2), California (1), Florida (1), Georgia (5), Kentucky (1), Louisiana (5), Maryland (1), Tennessee (1), and Virginia (1).

Among 18 persons for whom information was available, illness onsets ranged from April 15, 2012 to June 12, 2012. Ill persons ranged in age from 1 to 79 years, and the median age was 33 years. Seventy-eight percent of patients were female. Four patients were hospitalized. One death was reported in Louisiana.

CDC initiated an investigation into this outbreak of illnesses on May 14, 2012 when six ill persons had been reported to CDC PulseNet from two states. CDC and state public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Based on interviews of 15 ill persons, a source for these infections was not identified.

A total of 18 persons infected with the outbreak strain of STEC O145 were identified in 9 states: Alabama (2), California (1), Florida (1), Georgia (5), Kentucky (1), Louisiana (5), Maryland (1), Tennessee (1), and Virginia (1). Since the last update 3 new ill persons were identified in 3 states: Kentucky (1), Maryland (1), and Virginia (1).

Among persons for whom information was available, illness onset dates ranged from April 15, 2012 to June 12, 2012. Ill persons ranged in age from 1 year to 79 years, with a median age of 33 years; 78% were female. Four ill persons were hospitalized. One death was reported in Louisiana.

CDC and state public health officials interviewed ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness. Based on interviews of 15 ill persons, a source for these infections was not identified.

A total of 15 persons infected with the outbreak strain of STEC O145 infection have been identified in 6 states: Alabama (2), California (1), Florida (1), Georgia (5), Louisiana (5), and Tennessee (1). Since the last update one new ill person has been identified in Louisiana with a reported illness onset of April 21, 2012. This is during the same time period as other ill persons in this outbreak.

Among persons for whom information is available, illness onset dates range from April 15, 2012 to May 12, 2012. Ill persons range in age from 1 year to 79 years old, with a median age of 31 years old; 73% are female. Four ill persons have been hospitalized. One death has been reported in Louisiana.

Illnesses that occurred after May 5, 2012 might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported.

It has been approximately 6 weeks since the last illness onset among reported cases.  Although this indicates that the outbreak could be over, CDC continues to work with state public health officials to identify additional cases and the source of these STEC O145 infections.

State public health officials have been interviewing ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness.  Based on interviews of 12 ill persons to date, a source for these infections has not been identified.

CDC is collaborating with public health officials in multiple states to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli serogroup O145 (STEC O145) infections. Public health investigators are using DNA "fingerprints" of E. coli bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that may be part of this outbreak. They are using data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections.

The type of bacteria responsible for this outbreak is among those referred to as Shiga toxin-producing E. coli or STEC.  STEC bacteria are grouped by serogroups (e.g., O157 or O145). The STEC serogroup found most commonly in U.S. patients is E. coli O157. Other E. coli serogroups in the STEC group, including O145, are sometimes called "non-O157 STECs." Some types of STEC frequently cause severe disease, including bloody diarrhea and hemolytic uremic syndrome (HUS) which is a type of kidney failure.  Currently, there are limited public health surveillance data on the occurrence of non-O157 STECs, including STEC O145; many STEC O145 infections may go undiagnosed or unreported. Compared with STEC O157 infections, identification of non-O157 STEC infections is more complex.  First, clinical laboratories must test stool samples for the presence of Shiga toxins. Then, the positive samples must be sent to public health laboratories to look for non-O157 STEC. Clinical laboratories typically cannot identify non-O157 STEC.  The STEC O145 PFGE pattern in this outbreak has not been seen in PulseNet before.

CDC initiated an investigation into this cluster of illnesses on May 14, 2012.  At that time, six ill persons had been reported to CDC PulseNet from two states during May 3, 2012 to May 9, 2012. Although the most recent report of an illness to CDC was on June 4, 2012, their onset of illness occurred before May 10, 2012  and was during same period as other ill persons in this outbreak.

A total of 14 persons infected with the outbreak strain of STEC O145 infection have been identified in 6 states: Alabama (2), California (1), Florida (1), Georgia (5), Louisiana (4), and Tennessee (1).  Among persons for whom information is available, illness onset dates range from April 15, 2012 to May 12, 2012. The time from the beginning of a patient's illness to the confirmation that he or she was part of an outbreak is typically about 2-3 weeks. Please see the E. coli Outbreak Investigations: Timeline for Reporting Cases for more details.  Ill persons range in age from 1 year to 79 years old, with a median age of 33 years old; 79% are female. Three ill persons have been hospitalized; one death has been reported in Louisiana.

It has been approximately 4 weeks since the last illness onset among reported cases.  Although this indicates that the outbreak could be over, CDC continues to work with state public health officials to identify additional cases and the source of these STEC O145 infections.

State public health officials have been interviewing ill persons to obtain information regarding foods they might have eaten and other exposures in the week before illness.  Based on interviews of 10 ill persons to date, a source for these infections has not been identified.

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