Multistate Outbreak Research Articles

The characterization of Salmonella enterica serotypes isolated from the scalder tank water of a commercial poultry processing plant: Recovery of a multidrug-resistant Heidelberg strain

The recent multistate outbreak of a multidrug-resistant (MDR) Salmonella Heidelberg strain from commercial poultry production highlights the need to better understand the reservoirs of these zoonotic pathogens within the commercial poultry production and processing environment. As part of a larger study looking at temporal changes in microbial communities within the major water tanks within a commercial processing facility, this paper identifies and characterizes Salmonella enterica isolated from the water in a final scalder tank at 3 times during a typical processing day: prior to the birds entering the tank (start), halfway through the processing day (mid), and after the final birds were scalded (end). Over 3 consecutive processing days, no Salmonella were recovered from start-of-day water samples, while a total of 56 Salmonella isolates were recovered from the mid-day and end-of-day scalder water samples. Traditional and newer PCR-based serotyping methods eventually identified these isolates as either group C3 S. Kentucky (n = 45) and group B S. Heidelberg (n = 11). While none of the S. Kentucky isolates possessed any resistances to the antimicrobials tested, all S. Heidelberg isolates were found to be multidrug resistant to 5 specific antimicrobials representing 3 antimicrobial classes. Due to the potential public health impact of S. Heidelberg and the recent nationwide poultry-associated outbreak of multidrug-resistant S. Heidelberg, future studies should focus on understanding the transmission and environmental growth dynamics of this serotype within the commercial poultry processing plant environment.

Multistate foodborne hepatitis A outbreak among European tourists returning from Egypt– need for reinforced vaccination recommendations, November 2012 to April 2013

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Facing the Increasingly Looming Challenges from Environmental Fungal (Molds and Yeast) Contamination

In an unprecedented and extraordinary case of a deadly multi-state meningitis outbreak in the fall of 2012, 64 people died and 751 cases were treated across 20 states within the USA, according to the Centers for Disease Control and Prevention (CDC)[1]. Exserohilum rostratum , a fungus commonly found in the environment, was identified as the predominant organism in the patients with meningitis and was associated with the growth in the meninges [2]. One of the early patients from the outbreak was infected with Aspergillus fumigatus

Banana infecting fungus, Fusarium musae, is also an opportunistic human pathogen: Are bananas potential carriers and source of fusariosis?

During re-identification of Fusarium strains in the BCCM™/IHEM fungal collection by multilocus sequence-analysis we observed that five strains, previously identified as Fusarium verticillioides, were Fusarium musae, a species described in 2011 from banana fruits. Four strains were isolated from blood samples or biopsies of immune-suppressed patients and one was isolated from the clinical environment, all originating from different hospitals in Belgium or France, 2001–2008. The F. musae identity of our isolates was confirmed by phylogenetic analysis using reference sequences of type material. Absence of the gene cluster necessary for fumonisin biosynthesis, characteristic to F. musae, was also the case for our isolates. In vitro antifungal susceptibility testing revealed no important differences in their susceptibility compared to clinical F. verticillioides strains and terbinafine was the most effective drug. Additional clinical F. musae strains were searched by performing BLAST queries in GenBank. Eight strains were found, of which six were keratitis cases from the U.S. multistate contact lens-associated outbreak in 2005 and 2006. The two other strains were also from the U.S., causing either a skin infection or sinusitis. This report is the first to describe F. musae as causative agent of superficial and opportunistic, disseminated infections in humans. Imported bananas might act as carriers of F. musae spores and be a potential source of infection with F. musae in humans. An alternative hypothesis is that the natural distribution of F. musae is geographically a lot broader than originally suspected and F. musae is present on different plant hosts.

A molecular epidemiological investigation of multistate outbreaks of Salmonella Enteritidis from clinical and environmental samples in Turkey, 2000-2010.

To analyze interrelated Salmonella Enteritidis strains isolated in Turkey. Fifty-five S. Enteritidis surveillance strains were isolated from human feces and environmental samples from different regions in Turkey between 2000 and 2010. Clinical isolates were selected from different outbreaks in the Turkish National Reference Laboratory. All isolates were submitted to antimicrobial susceptibility test, plasmid profile analysis, and XbaI-digested pulsed-field gel electrophoresis. The strains were scanned against 20 antibiotics and for 3 of them (amikacin, ciprofloxacin, gentamicin), all strains were found to be sensitive. Five isolates had no plasmid. Most of test strains carried the 57-kb plasmid in common and 15 genotypes were identified among the 55 isolates. Six genotypes were related closely, 3 genotypes were undistinguished, and 6 genotypes were unrelated. To our knowledge, this is the first report on the phenotypic and molecular characterization of S. Enteritidis isolates from both environmental samples and clinical isolates in Turkey.

Characterizing zoonotic disease detection in the United States: who detects zoonotic disease outbreaks & how fast are they detected?

There have been many calls for improved detection of zoonoses; research has not yet characterized zoonotic disease detection in the United States, in humans or animals. This research reviewed "who detects" zoonotic disease outbreaks and "how fast" they are detected. Definitions were operationalized based on existing literature and current practice. An outbreak database was created from publicly available records: Morbidity and Mortality Weekly Reports and ProMed-Mail. Univariate and bivariate statistics--including chi-square tests, Kruskal-Wallis tests, and Dunn's method were used for analysis. From an n = 101, results showed that laboratories (human health) detected 32.7% (n = 33) of the outbreaks; physicians/clinicians (human health) detected 18.8% (n = 19). The median time to was 13 days; mean was 31.7 (range = 0-492). There was a relationship between the type of the entity (laboratory, practitioner, or state agency) and how fast the outbreak was detected; state agencies were slower in detection. There was also a significant relationship between how fast an outbreak was detected and whether the outbreak occurred in multiple regions. This research provides important empirical evidence regarding U.S. zoonotic disease outbreak detection, highlighting the difficulty in rapid detection of multi-state outbreaks and the need for rapid, sensitive diagnostic testing and astute practitioners.

Molecular typing of VTEC strains isolated from food, feed and animals

Molecular typing of VTEC strains isolated from food, feed and animals

Prevalence and characterization of Escherichia coli and Salmonella strains isolated from stray dog and coyote feces in a major leafy greens production region at the United States-Mexico border.

In 2010, Romaine lettuce grown in southern Arizona was implicated in a multi-state outbreak of Escherichia coli O145:H28 infections. This was the first known Shiga toxin-producing E. coli (STEC) outbreak traced to the southwest desert leafy green vegetable production region along the United States-Mexico border. Limited information exists on sources of STEC and other enteric zoonotic pathogens in domestic and wild animals in this region. According to local vegetable growers, unleashed or stray domestic dogs and free-roaming coyotes are a significant problem due to intrusions into their crop fields. During the 2010–2011 leafy greens growing season, we conducted a prevalence survey of STEC and Salmonella presence in stray dog and coyote feces. Fresh fecal samples from impounded dogs and coyotes from lands near produce fields were collected and cultured using extended enrichment and serogroup-specific immunomagnetic separation (IMS) followed by serotyping, pulsed-field gel electrophoresis (PFGE), and antimicrobial susceptibility testing. A total of 461 fecal samples were analyzed including 358 domestic dog and 103 coyote fecals. STEC was not detected, but atypical enteropathogenic E. coli (aEPEC) strains comprising 14 different serotypes were isolated from 13 (3.6%) dog and 5 (4.9%) coyote samples. Salmonella was cultured from 33 (9.2%) dog and 33 (32%) coyote samples comprising 29 serovars with 58% from dogs belonging to Senftenberg or Typhimurium. PFGE analysis revealed 17 aEPEC and 27 Salmonella distinct pulsotypes. Four (22.2%) of 18 aEPEC and 4 (6.1%) of 66 Salmonella isolates were resistant to two or more antibiotic classes. Our findings suggest that stray dogs and coyotes in the desert southwest may not be significant sources of STEC, but are potential reservoirs of other pathogenic E. coli and Salmonella. These results underscore the importance of good agriculture practices relating to mitigation of microbial risks from animal fecal deposits in the produce production area.

First Fully Closed Genome Sequence of Salmonella enterica subsp. enterica Serovar Cubana Associated with a Food-Borne Outbreak.

Salmonella enterica subsp. enterica serovar Cubana (Salmonella serovar Cubana) is associated with human and animal disease. Here, we used third-generation, single-molecule, real-time DNA sequencing to determine the first complete genome sequence of Salmonella serovar Cubana CFSAN002050, which was isolated from fresh alfalfa sprouts during a multistate outbreak in 2012.

Distribution and Diversity of Salmonella Strains in Shipments of Hatchling Poultry, United States, 2013.

Multistate outbreaks of salmonellosis associated with live poultry contact have been occurring with increasing frequency. In 2013, multistate outbreaks of salmonellosis were traced back to exposure to live poultry, some of which were purchased at a national chain of farm stores (Farm store chain Y). This study was conducted at 36 stores of Farm store chain Y and was concurrent with the timing of exposure for the human outbreaks of salmonellosis in 2013. We used environmental swabs of arriving shipment boxes of hatchling poultry and shipment tracking information to examine the distribution, diversity and anti-microbial resistance of non-typhoidal Salmonella (NTS) across farm stores and hatcheries. Isolates recovered from shipment boxes underwent serotyping, anti-microbial resistance (AMR) testing and pulsed-field gel electrophoresis (PFGE). Postal service tracking codes from the shipment boxes were used to determine the hatchery of origin. The PFGE patterns were compared with the PFGE patterns of NTS causing outbreaks of salmonellosis in 2013. A total of 219 hatchling boxes from 36 stores in 13 states were swabbed between 15 March 2013 and 18 April 2013. NTS were recovered from 59 (27%) of 219 hatchling boxes. Recovery was not significantly associated with species of hatchlings, number of birds in the shipment box, or the presence of dead, injured or sick birds. Four of the 23 PFGE patterns and 23 of 50 isolates were indistinguishable from strains causing human outbreaks in 2013. For serotypes associated with human illnesses, PFGE patterns most frequently recovered from shipment boxes were also more frequent causes of human illness. Boxes positive for the same PFGE pattern most frequently originated from the same mail-order hatchery. Only one of 59 isolates was resistant to anti-microbials used to treat Salmonella infections in people. This study provides critical information to address recurrent human outbreaks of salmonellosis associated with mail-order hatchling poultry.

Tracking an Escherichia coli O157:H7–Contaminated Batch of Leafy Greens through a Pilot-Scale Fresh-Cut Processing Line

Cross-contamination of fresh-cut leafy greens with residual Escherichia coli O157:H7-contaminated product during commercial processing was likely a contributing factor in several recent multistate outbreaks. Consequently, radicchio was used as a visual marker to track the spread of the contaminated product to iceberg lettuce in a pilot-scale processing line that included a commercial shredder, step conveyor, flume tank, shaker table, and centrifugal dryer. Uninoculated iceberg lettuce (45 kg) was processed, followed by 9.1 kg of radicchio (dip inoculated to contain a four-strain, green fluorescent protein-labeled nontoxigenic E. coli O157:H7 cocktail at 10(6) CFU/g) and 907 kg (2,000 lb) of uninoculated iceberg lettuce. After collecting the lettuce and radicchio in about 40 bags (∼22.7 kg per bag) along with water and equipment surface samples, all visible shreds of radicchio were retrieved from the bags of shredded product, the equipment, and the floor. E. coli O157:H7 populations were quantified in the lettuce, water, and equipment samples by direct plating with or without prior membrane filtration on Trypticase soy agar containing 0.6% yeast extract and 100 ppm of ampicillin. Based on triplicate experiments, the weight of radicchio in the shredded lettuce averaged 614.9 g (93.6%), 6.9 g (1.3%), 5.0 g (0.8%), and 2.8 g (0.5%) for bags 1 to 10, 11 to 20, 21 to 30, and 31 to 40, respectively, with mean E. coli O157:H7 populations of 1.7, 1.2, 1.1, and 1.1 log CFU/g in radicchio-free lettuce. After processing, more radicchio remained on the conveyor (9.8 g; P < 0.05), compared with the shredder (8.3 g), flume tank (3.5 g), and shaker table (0.1 g), with similar E. coli O157:H7 populations (P > 0.05) recovered from all equipment surfaces after processing. These findings clearly demonstrate both the potential for the continuous spread of contaminated lettuce to multiple batches of product during processing and the need for improved equipment designs that minimize the buildup of residual product during processing.

Multistate foodborne disease outbreaks associated with raw tomatoes, United States, 1990-2010: a recurring public health problem.

We examined multistate outbreaks attributed to raw tomatoes in the United States from 1990 to 2010. We summarized the demographic and epidemiological characteristics of 15 outbreaks resulting in 1959 illnesses, 384 hospitalizations, and three deaths. Most (80%) outbreaks were reported during 2000-2010; 73% occurred May-September. Outbreaks commonly affected adult (median age 34 years) women (median 58% of outbreak cases). All outbreaks were caused by Salmonella [serotypes Newport (n = 6 outbreaks), Braenderup (n = 2), Baildon, Enteritidis, Javiana, Montevideo, Thompson, Typhimurium (n = 1 each); multiple serotypes (n = 1)]. Red, round (69% of outbreaks), Roma (23%), and grape (8%) tomatoes were implicated. Most (93%) outbreaks were associated with tomatoes served predominantly in restaurants. However, traceback investigations suggested that contamination occurred on farms, at packinghouses, or at fresh-cut processing facilities. Government agencies, academia, trade associations, and the fresh tomato industry should consider further efforts to identify interventions to reduce contamination of tomatoes during production and processing.

Reply to "not over yet: fungal infections following methyl prednisolone injections smoulder on".

The multistate outbreak of fungal infections in the United States following contaminated methyl prednisolone injection has been well reported ([1][1]). Meningitis was the most frequent consequence, but other infections included arachnoiditis, with local spinal infection and peripheral joint

Methylprednisolone impairs conidial phagocytosis but does not attenuate hyphal damage by neutrophils against Exserohilum rostratum.

Exserohilum rostratum caused a multistate fungal meningitis outbreak following iatrogenic inoculation of contaminated methylprednisolone in the United States. To gain insight into the immunopathogenesis of this infection, we studied the innate host responses of human neutrophils against E. rostratum conidia and hyphae with or without methylprednisolone. The neutrophil-induced percentage fungal damage against conidia and hyphae was effector-to-target ratio dependent (≤55%). While methylprednisolone did not affect neutrophil-induced fungal damage by treatment of Exserohilum or neutrophils, it compromised phagocytosis of conidia (P < 0.05). These findings suggest that methylprednisolone-treated neutrophils may have altered phagocytic clearance of Exserohilum conidia, reducing host capacity to contain the invasive process.

Plasma fluoride level as a predictor of voriconazole-induced periostitis in patients with skeletal pain.

Voriconazole is a triazole antifungal medication used for prophylaxis or to treat invasive fungal infections. Inflammation of the periosteum resulting in skeletal pain, known as periostitis, is a reported side effect of long-term voriconazole therapy. The trifluorinated molecular structure of voriconazole suggests a possible link between excess fluoride and periostitis, as elevated blood fluoride has been reported among patients with periostitis who received voriconazole. Two hundred sixty-four patients from Michigan were impacted by the multistate outbreak of fungal infections as a result of contaminated methylprednisolone injections. A retrospective study was conducted among 195 patients who received voriconazole therapy at St Joseph Mercy Hospital during this outbreak. Twenty-eight patients who received both bone scan and plasma fluoride measurements for skeletal pain were included in the statistical analyses. Increased tracer uptake on bone scan was considered positive for periostitis. The primary outcome measure was the correlation between plasma fluoride and bone scan results. Blood fluoride (P < .001), alkaline phosphatase (P = .020), daily voriconazole dose (P < .001), and cumulative voriconazole dose (P = .027) were significantly elevated in patients who had periostitis compared with those who did not. Discontinuation or dose reduction of voriconazole resulted in improvement of pain in 89% of patients. High plasma fluoride levels coupled with skeletal pain among patients who are on long-term voriconazole therapy is highly suggestive of periostitis. Initial measurement of fluoride may be considered when bone scan is not readily available. Early detection should be sought, as discontinuation of voriconazole is effective at reversing the disease.

The drug quality and security act.

A national spotlight was shone on the safety of compounded pharmaceutical products with the 2012 multistate outbreak of fungal meningitis and other infections due to contaminated steroid injections produced by the New England Compounding Center (NECC) in Framingham, Massachusetts.1 To date, 751 cases and 64 deaths in 20 states have been linked to tainted NECC steroid injections. As a direct result of this outbreak, Congress passed the Drug Quality and Security Act, which was signed into law by President Obama in November 2013.2–4 The Drug Quality and Security Act consists of 2 Titles: Title I covers drug compounding and Title II relates to drug supply chain security.4 There are 2 major compounding-related changes to current law within Title I of the Drug Quality and Security Act. One change involves Section 503A of the Food, Drug, and Cosmetics Act (FDCA).2,4 Section 503A creates a “safe harbor” for traditional pharmacy compounding performed for a specific patient prescription and generally overseen by state boards of pharmacy.2,3 This section exempts this type of compounding from FDCA requirements including compliance with current good manufacturing practices (cGMP), appropriate labeling, and US Food and Drug Administration (FDA) approval prior to marketing.2 The Drug Quality and Security Act removes wording regarding a prohibition on advertising of compounded products from Section 503A that was deemed to be unconstitutional by the Supreme Court in 2002.2,4 By deleting these unconstitutional provisions, the Act “removes uncertainty regarding the validity” of 503A. 2 Another major new provision is the creation of a novel section of the FDCA, Section 503B.2,5 Under Section 503B, a pharmaceutical compounder can voluntarily register on an annual basis with the FDA as an “outsourcing facility.” An outsourcing facility must adhere to cGMP, but does not need to receive FDA approval for its compounded products prior to marketing and can qualify for exemptions regarding labeling products with adequate directions for use.2 In addition, outsourcing facilities: are not required to be licensed pharmacies, must compound under the supervision of a licensed pharmacist or physician, may or may not obtain patient-specific prescriptions, may use only drugs from a bulk ingredients list, are not allowed to compound products already commercially available unless the products are on shortage, must undergo regular FDA inspections on a riskbased schedule, must submit information about products compounded within the facility to the FDA every 6 months, must report product-related adverse events to the FDA, and must pay an annual fee of $15,000 to the FDA to cover inspection costs.2,4,5 Pharmaceutical compounders who choose not to register with the FDA as an outsourcing facility, and are not traditional compounders under 503A, are subject to the same requirements as conventional manufacturers under the FDCA.4 As of May 28, 2014, 42 compounding centers have registered as outsourcing facilities.6 The FDA is encouraging health care systems and providers to buy compounded medications from registered outsourcing facilities when needed. 4 Title II of the Drug Quality and Security Act has received less attention thanTitle 1. This Title focuses on drug supply chain security. Specifically, Title II mandates the development of a national “track and trace” electronic system for prescription medications. The goal of this legislation is to protect consumers from potentially harmful drug exposures such as those experienced with the NECC crisis. Implementation of this system over the next 10 years should allow for verification of the legitimacy of a drug product identifier down to the individual package level, enhance detection of illegitimate drug products in the supply chain, and improve drug product recall mechanisms. Pharmaceutical manufactures, wholesale distributors, and drug repackagers and dispensers will all be involved in the development of this system over the coming decade. Although full implementation of the Drug Quality and Security Act will take years, unresolved questions remain regarding legislative intent, and gaps in the Act have been identified, this law is an important step forward in improving the safety of the national drug supply.

Molecular identification of isolated fungi from unopened containers of greek yogurt by DNA sequencing of internal transcribed spacer region.

In our previous study, we described the development of an internal transcribed spacer (ITS)1 sequencing method, and used this protocol in species-identification of isolated fungi collected from the manufacturing areas of a compounding company known to have caused the multistate fungal meningitis outbreak in the United States. In this follow-up study, we have analyzed the unopened vials of Greek yogurt from the recalled batch to determine the possible cause of microbial contamination in the product. A total of 15 unopened vials of Greek yogurt belonging to the recalled batch were examined for the detection of fungi in these samples known to cause foodborne illness following conventional microbiological protocols. Fungi were isolated from all of the 15 Greek yogurt samples analyzed. The isolated fungi were genetically typed by DNA sequencing of PCR-amplified ITS1 region of rRNA gene. Analysis of data confirmed all of the isolated fungal isolates from the Greek yogurt to be Rhizomucor variabilis. The generated ITS1 sequences matched 100% with the published sequences available in GenBank. In addition, these yogurt samples were also tested for the presence of five types of bacteria (Salmonella, Listeria, Staphylococcus, Bacillus and Escherichia coli) causing foodborne disease in humans, and found negative for all of them.

Alopecia and nail changes associated with voriconazole therapy.

Voriconazole was 1 of 2 antifungal agents recommended for treatment of fungal infections associated with injection of contaminated methylprednisolone. Alopecia and nail changes are not commonly reported side effects of voriconazole. Having noted increasing hair loss among our patients treated with voriconazole, we sought to determine the prevalence and characteristics of alopecia associated with this agent. Patients who received voriconazole for at least 1 month for probable or confirmed fungal infection were eligible to complete a survey regarding alopecia and nail changes. For those patients who reported alopecia, additional questions about reversal of hair loss were asked after voriconazole had been stopped for at least 3 months. A total of 152 of 175 eligible patients (87%) completed the survey. One hundred twenty-five (82%) reported alopecia. Hair loss on the scalp was noted in 120 (96%), arms and legs in 52 (42%), and eyebrows and eyelashes in 47 each (38%). Nineteen patients (15%) reported wearing a wig or hat because of extensive hair loss. Alopecia developed a mean (standard deviation) of 75 (54) days after initiation of voriconazole. Of 114 patients who were off voriconazole for at least 3 months, hair loss had stopped in 94 (82%) and regrowth had begun in 79 (69%), including those who were changed to either itraconazole or posaconazole. Nail changes or loss occurred in 106 (70%) patients. Alopecia and nail changes were common adverse effects associated with voriconazole therapy during the multistate fungal outbreak.

Comparative study of thermal inactivation kinetics of Salmonella spp. in peanut butter and peanut butter spread

Peanut butter has been implicated in multi-state outbreaks of salmonellosis in recent years. Studies have shown that Salmonella exhibited increased thermal resistance in peanut butter. However, little is known about the effect of product formulation on the kinetics of survival of Salmonella during thermal treatment. Therefore, the objective of this research was to compare the thermal resistance of Salmonella in four commercially available peanut butter and spread products, and evaluate the effect of product formulation on the survival of this pathogen during heating. Four peanut butter and spread samples, including Omega 3 (A), regular fat (B), reduced sugar (C), and reduced fat (D), inoculated with a 6-strain cocktail of Salmonella spp., were heated at 70, 75, 80, 85, and 90 °C. Experimental results showed that the highest thermal resistance of Salmonella was found in the samples with reduced fat, while the least in the samples with Omega 3 formulation. No significant difference in the bacterial thermal resistance was observed in the regular fat and reduced sugar formulations. The Weibull survival model was used to describe the survival curves. Results showed that the average exponent (shape factor) of the model ranged from 0.38 to 0.662, suggesting progressively decreased rate of inactivation during heating. The scale (rate) coefficients of the model increased linearly with temperature. The calculated minimum lethal temperature for Salmonella was 54.8, 59.8, 59.5, and 63.9 °C in samples A, B, C, and D, respectively. No tail effect was observed. The results of this study suggest that proper formulation of peanut butter and spread may enhance thermal inactivation of Salmonella.

Evaluation of monkeypox virus infection of black-tailed prairie dogs (Cynomys ludovicianus) using in vivo bioluminescent imaging.

Monkeypox (MPX) is a re-emerging zoonotic disease that is endemic in Central and West Africa, where it can cause a smallpox-like disease in humans. Despite many epidemiologic and field investigations of MPX, no definitive reservoir species has been identified. Using recombinant viruses expressing the firefly luciferase (luc) gene, we previously demonstrated the suitability of in vivo bioluminescent imaging (BLI) to study the pathogenesis of MPX in animal models. Here, we evaluated BLI as a novel approach for tracking MPX virus infection in black-tailed prairie dogs (Cynomys ludovicianus). Prairie dogs were affected during a multistate outbreak of MPX in the US in 2003 and have since been used as an animal model of this disease. Our BLI results were compared with PCR and virus isolation from tissues collected postmortem. Virus was easily detected and quantified in skin and superficial tissues by BLI before and during clinical phases, as well as in subclinical secondary cases, but was not reliably detected in deep tissues such as the lung. Although there are limitations to viral detection in larger wild rodent species, BLI can enhance the use of prairie dogs as an animal model of MPX and can be used for the study of infection, disease progression, and transmission in potential wild rodent reservoirs.