Investigation of Outbreak of Infections Caused by Salmonella Saintpaul

Update for July 29, 2008 - Case count information as of 9 pm EDT, July 28, 2008

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CDC is collaborating with public health officials in many states, the Indian Health Service, and the U.S. Food and Drug Administration (FDA) to investigate an ongoing multi-state outbreak of human Salmonella serotype Saintpaul infections. An initial epidemiologic investigation in New Mexico and Texas comparing foods eaten by persons who were ill in May to foods eaten by well persons identified consumption of raw tomatoes as strongly linked to illness. A similar but much larger, nationwide study comparing persons who were ill in June to well persons found that ill persons were more likely to have recently consumed raw tomatoes, fresh jalapeño peppers, and fresh cilantro. These items were commonly, though not always, consumed together, so that study could not determine which item(s) caused the illnesses.

Recently, many clusters of illnesses have been identified in several states among persons who ate at restaurants. Most clusters involve fewer than 5 ill persons. Three larger clusters have been intensively investigated. In one, illnesses were linked to consumption of an item containing fresh tomatoes and fresh jalapeño peppers. In the other two, illnesses were linked to an item containing fresh jalapeño peppers and no other of the suspect items. Other clusters are under active investigation. The accumulated data from all investigations indicate that jalapeño peppers are likely to be a major cause of this outbreak. Fresh serrano peppers and fresh tomatoes remain under investigation. Investigators from many agencies are collaborating to track the source of the implicated peppers and other produce items.

An FDA laboratory detected Salmonella Saintpaul with the outbreak strain fingerprint pattern in a sample of jalapeño pepper obtained from a distribution center in McAllen, Texas. The distributor is working with FDA to recall the contaminated product in the United States. The peppers were grown in Mexico; investigators are working to determine where they were contaminated.

The Laboratory Services Division of the Colorado Department of Public Health and Environment detected Salmonella Saintpaul with the outbreak strain fingerprint pattern in a jalapeño pepper provided by an ill individual. The state health department is working with the FDA to determine the origin of the jalapeño pepper.

Since April, 1307 persons infected with Salmonella Saintpaul with the same genetic fingerprint have been identified in 43 states, the District of Columbia, and Canada. These were identified because clinical laboratories in all states send Salmonella strains from ill persons to their State public health laboratory for characterization. The number of ill persons identified in each state is as follows: Alabama (3 persons), Arkansas (19), Arizona (56), California (11), Colorado (16), Connecticut (5), Florida (3), Georgia (40), Idaho (6), Illinois (115), Indiana (20), Iowa (2), Kansas (21), Kentucky (2), Louisiana (2), Maine (1), Maryland (38), Massachusetts (29), Michigan (26), Minnesota (22), Mississippi (2), Missouri (20), Montana (1), New Hampshire (5), Nevada (13), New Jersey (16), New Mexico (106), New York (39), North Carolina (28), Ohio (10), Oklahoma (25), Oregon (11), Pennsylvania (13), Rhode Island (3), South Carolina (2), Tennessee (9), Texas (495), Utah (2), Virginia (31), Vermont (2), Washington (17), West Virginia (1), Wisconsin (13), and the District of Columbia (1). Five ill persons are reported from Canada; four appear to have been infected while traveling in the United States, the travel status of the fifth ill person is unknown.

Among the 1269 persons with information available, illnesses began between April 10 and July 13, 2008, including 38 who became ill on July 1 or later. These numbers include those with estimated onset dates as well as those with reported onset dates. The latest reported onset date is July 12. The latest estimated onset date is July 13. Patients range in age from <1 to 99 years; 50% are female. The rate of illness is highest among persons 20 to 29 years old; the rate of illness is lowest in children 10 to 19 years old and in persons 80 or more years old. At least 253 persons were hospitalized. A man in his eighties who died in Texas from cardiopulmonary failure had an infection with the outbreak strain at the time of his death; the infection may have contributed to his death. A man in his sixties who died in Texas from cancer had an infection with the outbreak strain of at the time of his death; the infection may have contributed to his death.

The outbreak can be visually described with a chart showing the number of persons who became ill each day. This chart is called an epidemic curve or epi curve. Please see Interpretation of Epidemic Curves During an Active Outbreak. It shows that the number of persons who became ill peaked during May and decreased in June. The average number of persons who became ill between May 20 and June 10 was 33 per day. The average number of persons who became ill between June 11 and June 20 was 19 per day. The outbreak appears to be ongoing, but with fewer new illnesses reported each day. Illnesses that occurred recently may not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 2-3 weeks. Please see the Salmonella Outbreak Investigations: Timeline for Reporting Cases for more details regarding the 2-3 week time period.

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

Health officials have worked continuously since late May to investigate this outbreak. CDC has sent 39 people to the field, which includes seven epi-aid investigations, to work with other public health officials. The investigation is complex and difficult. One difficult aspect is that people often have difficulty remembering exactly what foods they ate, and remembering specific ingredients in those foods is even more difficult. Although laboratory testing of foods might help identify the source, perishable foods that were consumed by ill persons are often not available to test. When food items are mixed together and consumed in the same dish, all the items may be statistically linked to illness. In that case, determining by statistical means which item caused the illness can be difficult or impossible. Tracing suspect produce items back to processors and growers is an integral part of the effort to identify a single source and a possible means of contamination.

Clinical features of Salmonella Infection

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

Advice to consumers

FDA is advising consumers that they should avoid raw jalapeño peppers and foods that contain them if they were grown, harvested, or packed in Mexico. Jalapeño and serrano peppers grown in the United States are not connected with this outbreak. Commercially canned, pickled, and cooked jalapeño peppers are also not connected with the outbreak.

This new advisory is based on evidence gathered during a multi-week, intensive investigation conducted in partnership with FDA and several states to find the source of the contamination which led to the outbreak.

FDA continues to advise persons in high risk populations, such as the elderly , infants, and those with impaired immune systems to avoid eating raw serrano peppers from Mexico or food made from raw serrano peppers from Mexico until further notice.

FDA has indicated that tomatoes on the market today are safe to consume.

Consumers everywhere are advised to follow the general food safety guidelines below:

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

Consumers are reminded that vegetables are an important part of a healthy diet and that cooking vegetables kills bacteria, including Salmonella.

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

More information about Salmonella and this investigation can be found at:

• Salmonella FAQ
• Timeline for Reporting of Cases
• New Mexico Department of Health (PDF – 191 KB)
• Arizona Department of Health Services News Release - Tomatoes: Caution Urged*
• Texas Department of State Health Services - News Update, June 13, 2008*
• Kansas Identifies 3 Cases Linked to Multi-State Salmonella Outbreak*
• Kentucky Cabinet for Health and Family Services Press Release
• Indiana State Department of Health Media Update on Salmonella Outbreak*
• Maryland Department of Health and Mental Hygiene News Release
• New Jersey Department of Health and Human Services: NJ Reports Four Salmonella Cases Linked to Multi-State Outbreak
• Public Health Agency of Canada: Update of Salmonella SaintPaul Situation in Canada*
• Utah Department of Health: Health News

Information on the safe handling of produce can be found at: www.cfsan.fda.gov/~dms/prodsafe.html.*

Previous Updates on this Outbreak

• July 28, 2008
• July 25, 2008
• July 24, 2008
• July 23, 2008
• July 22, 2008
• July 21, 2008
• July 18, 2008
• July 17, 2008
• July 16, 2008
• July 15, 2008
• July 14, 2008
• July 11, 2008
• July 10, 2008
• July 9, 2008
• July 8, 2008
• July 7, 2008
• July 4, 2008

• July 3, 2008
• July 2, 2008
• July 1, 2008
• June 30, 2008
• June 27, 2008
• June 26, 2008
• June 25, 2008
• June 24, 2008
• June 23, 2008
• June 20, 2008
• June 18, 2008
• June 16, 2008
• June 12, 2008
• June 9, 2008
• June 7, 2008
• June 5, 2008
• June 2, 2008

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