Multistate Outbreak of Salmonella Infections Linked to Imported Maradol Papayas

Case Count Update

Since the last update on August 18, 2017, 28 more ill people from 12 states were added to this investigation.

As of August 30, 2017, a total of 201 people infected with the outbreak strains of Salmonella Thompson (131), Salmonella Kiambu (57), Salmonella Agona (8), or Salmonella Gaminara (5) have been reported from 23 states. A list of the states and the number of cases in each can be found on the Case Count Map page.

Illnesses started on dates ranging from May 17, 2017 to August 20, 2017. Ill people range in age from less than 1 year to 95, with a median age of 37. Some information is not available for all of the ill people. Among 196 ill people, 118 (60%) are female. Among 153 people, 101 (66%) are of Hispanic ethnicity. Among 158 people, 65 (41%) have been hospitalized. One death was reported from New York City.

Illnesses that occurred after August 1, 2017, 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 4 weeks.

Investigation Update

As a result of this outbreak investigation, FDA has increased testing of papayas from Mexico to see if papayas from other farms are contaminated with Salmonella. Through this increased testing, FDA identified other types of Salmonella not linked to this outbreak on papayas from Caraveo Produce in Tecomán, Mexico and El Zapotanio in La Huerta, Mexico. FDA reports that the shipments of papayas found to be contaminated were destroyed and were not distributed for sale in the United States.  Papayas from these farms were distributed in the United States earlier this year, but FDA reports that no shipments of papayas from either farm are on the market in the United States because they are past their shelf life.

Through a review of the PulseNet database, CDC identified two more outbreaks of people infected with Salmonella with the same DNA fingerprints as the Salmonella found on papayas from these two other farms. Available information indicates that illnesses in these two outbreaks are not linked to papayas from the Carica de Campeche farm and are being investigated separately. Summaries of the two outbreaks are provided below.

Outbreak of Salmonella Newport and Salmonella Infantis Infections

FDA testing identified Salmonella Newport and Salmonella Infantis in an imported papaya sample collected from Caraveo Produce in Tecomán, Mexico. CDC identified three people in the PulseNet database who were infected with the same DNA fingerprint of Salmonella Newport (2 people) or Salmonella Infantis (1 person). The ill people were reported from three states: Illinois, Massachusetts, and Michigan. All three people (100%) reported eating or possibly eating papayas in the week before illness started.

Outbreak of Salmonella Urbana Infections

FDA testing identified Salmonella Urbana in an imported papaya sample collected from El Zapotanio in La Huerta, Mexico. CDC identified six people in the PulseNet database who were infected with the same DNA fingerprint of Salmonella Urbana. The ill people were reported from three states: New Jersey (4), New York (1), and Pennsylvania (1). Of four people with information available, three (75%) reported eating or possibly eating papayas in the week before illness started.

Because three separate outbreaks linked to papayas from different farms have been identified, CDC is concerned that papayas from several other farms in Mexico might be contaminated with Salmonella and have made people sick. FDA continues testing papayas from Mexico to see if other papayas from other farms are contaminated with Salmonella. Investigations are ongoing to determine if additional consumer warnings are needed beyond the advice not to eat papayas from specific farms that is given in this update. Updates will be provided when more information is available.

Introduction

Since the last update on August 11, 2017, 34 more ill people were added to this investigation from 11 states.

As of August 16, 2017, 173 people infected with the outbreak strains of Salmonella Kiambu (51), Salmonella Thompson (111), Salmonella Agona (7), or Salmonella Gaminara (4) have been reported from 21 states. A list of the states and the number of cases in each can be found on the Case Count Map page.

Illnesses started on dates ranging from May 17, 2017 to July 31, 2017. Ill people range in age from less than 1 year to 95, with a median age of 38. Some information is not available for all of the ill people. Among 169 ill people, 101 (60%) are female. Among 135 people, 91 (67%) are of Hispanic ethnicity. Among 136 people, 58 (43%) have been hospitalized. One death was reported from New York City.

Illnesses that occurred after July 18, 2017, 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 4 weeks.

Investigation Update

As was reported in the update on August 4, FDA tested other papayas imported from Mexico and isolated several types of Salmonella bacteria, including Salmonella Agona, Salmonella Kiambu, Salmonella Gaminara, Salmonella Thompson, and Salmonella Senftenberg. Investigators compared pulsed-field gel electrophoresis and whole genome sequencing results of Salmonella isolates from the papayas to isolates from ill people in the CDC PulseNet database. CDC has now identified 11 people infected with the same strains of either Salmonella Agona (7) or Salmonella Gaminara (4). These 11 illnesses have been added to the case count for this outbreak. Among 5 for whom information was available, all 5 (100%) reported eating or possibly eating papayas in the week before becoming ill.

This investigation is ongoing. Updates will be provided when more information is available.

Introduction

Since the last update on August 4, 2017, 32 more ill people were added to this investigation from 15 states.

As of August 9, 2017, 141 people infected with the outbreak strains of Salmonella Kiambu (51) or Salmonella Thompson (90) have been reported from 19 states. A list of the states and the number of cases in each can be found on the Case Count Map page.

Illnesses started on dates ranging from May 17, 2017 to July 27, 2017. Ill people range in age from less than 1 year to 95, with a median age of 39. Among 136 ill people with available information, 83 (61%) are female. Among 98 people with available information, 66 (67%) are of Hispanic ethnicity. Among 103 people with available information, 45 (44%) have been hospitalized. One death was reported from New York City.

Illnesses that occurred after July 14, 2017, 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 4 weeks.

Investigation Update

Based on information collected to date, CDC is now recommending that consumers not eat Maradol papayas from the Carica de Campeche farm in Mexico. If consumers aren’t sure if their Maradol papaya came from the Carica de Campeche farm, they should ask the place of purchase. When in doubt, don’t eat it; just throw it out. Restaurants and retailers should not serve or sell Maradol papayas from the Carica de Campeche farm.

As was reported in the last update on August 4, FDA tested other papayas imported from Mexico and isolated several types of Salmonella bacteria, including Salmonella Agona, Salmonella Kiambu, Salmonella Gaminara, Salmonella Thompson, and Salmonella Senftenberg. CDC is working to determine if there are any illnesses with these other types of Salmonella linked to this outbreak.

This investigation is ongoing. Updates will be provided when more information is available.

Introduction

Since the last update on July 21, 2017, 64 more ill people were added to this investigation from 15 states.

As of August 3, 2017, 109 people infected with the outbreak strains of Salmonella Kiambu (48) and Salmonella Thompson (61) have been reported from 16 states. A list of the states and the number of cases in each can be found on the Case Count Map page.

Illnesses started on dates ranging from May 17, 2017 to July 22, 2017. Ill people range in age from less than 1 year to 95, with a median age of 36. Among ill people, 63% are female. Among 74 people with available information, 50 (68%) are of Hispanic ethnicity. Among 76 people with available information, 35 (46%) were  hospitalized. One death was reported from New York City.

This outbreak can be illustrated with a chart showing the number of people who became ill each day. This chart is called an epidemic curve or epi curve. Illnesses that occurred after July 10, 2017 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 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

Investigation Update

In ongoing interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Of the 59 interviewed, 28 (47%) reported eating papayas. This proportion was significantly higher than results from a survey [PDF – 29 pages] of healthy Hispanic people in which 16% reported eating papayas in the months of May and June in the week before they were interviewed.

Investigators used whole genome sequencing (WGS) to learn more about the DNA fingerprint of the strains of Salmonella isolated from Maradol papayas that Maryland health officials collected from a grocery store in that state. Samples from these papayas yielded outbreak strains of Salmonella Kiambu and Salmonella Thompson. Both samples were from Caribeña brand Maradol papayas imported from Mexico. Investigators compared WGS results of Salmonella isolates from the papayas to clinical isolates from ill people in the PulseNet database.

WGS showed that the Salmonella Kiambu papaya isolate is closely related genetically to Salmonella Kiambu isolates from ill people. WGS also showed that the Salmonella Thompson papaya isolate is closely related genetically to Salmonella Thompson isolates from ill people. This result provides more evidence that people in this outbreak got sick from eating contaminated Maradol papayas imported from Mexico.

FDA tested other papayas imported from Mexico and isolated several types of Salmonella, including Salmonella Agona, Salmonella Kiambu, Salmonella Gaminara, Salmonella Thompson, and Salmonella Senftenberg. Through this testing, the FDA has also identified Maradol papayas from the Carica de Campeche papaya farm in Mexico as a likely source of the outbreak.

On August 5, Agroson’s LLC recalled certain Cavi brand Maradol papayas grown and packed by Carica de Campeche. The Cavi brand carries a purple, green and black sticker with the words “cavi MEXICO 4395” in white. Only certain lot codes of Cavi brand Maradol papayas were recalled, because they were known to come from Carica de Campeche. Boxes provided to wholesalers are stamped with CARICA DE CAMPECHE on the upper left side of the box. Other Cavi papayas, sourced from other farms, were not recalled.

FDA is working to identify other brands of papayas that may have originated from Carica de Campeche and facilitate recalls. More information is available on FDA’s website.

CDC and state and local public health partners are continuing laboratory surveillance through PulseNet to identify additional ill people and to interview them. Further investigation by FDA and regulatory officials is under way to determine the point in the supply chain where the papayas were contaminated. Updates will be provided when more information is available.

Introduction

CDC, public health and regulatory officials in several states, and the U.S. Food and Drug Administration (FDA) are investigating a multistate outbreak of Salmonella Kiambu infections.

Public health investigators are using the PulseNet system to identify illnesses that may be part of this outbreak. PulseNet is the national subtyping network of public health and food regulatory agency laboratories coordinated by CDC. DNA fingerprinting is performed on Salmonella bacteria isolated from ill people by using techniques called pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). CDC PulseNet manages a national database of these DNA fingerprints to identify possible outbreaks. WGS gives a more detailed DNA fingerprint than PFGE.

As of July 21, 2017, 47 people infected with the outbreak strain of Salmonella Kiambu have been reported from 12 states. A list of the states and the number of cases in each can be found on the Case Count Map page. WGS showed that isolates from people infected with Salmonella Kiambu are closely related genetically. This close genetic relationship means that people in this outbreak are more likely to share a common source of infection.

Illnesses started on dates ranging from May 17, 2017 to June 28, 2017. Ill people range in age from less than 1 year to 95, with a median age of 27. Among ill people, 67% are female. Among 31 people with available information, 18 (58%) are of Hispanic ethnicity. Among 33 people with available information, 12 (36%) report being hospitalized. One death was reported from New York City.

This outbreak can be illustrated with a chart showing the number of people who became ill each day. This chart is called an epidemic curve or epi curve. Illnesses that occurred after June 23, 2017 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 4 weeks. Please see the Timeline for Reporting Cases of Salmonella Infection for more details.

Investigation of the Outbreak

Epidemiologic and laboratory evidence collected to date indicate that Maradol papayas imported from Mexico are a likely source of this multistate outbreak. This investigation is ongoing.

In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Eleven (44%) of 25 people interviewed reported eating papayas. This proportion was significantly higher than results from a survey [PDF – 29 pages] of healthy Hispanic people in which 16% reported eating papayas in the months of May and June in the week before they were interviewed.

An illness cluster in Maryland was identified. An illness cluster is defined as two or more people who do not live in the same household who report eating at the same restaurant location, attending a common event, or shopping at the same location of a grocery store in the week before becoming ill. In Maryland, several ill people reported eating papayas purchased from the same location of a grocery store. Salmonella Kiambu and Salmonella Thompson were isolated from samples collected from ill people. Investigating illness clusters provides critical clues about the source of an outbreak. If several unrelated ill people ate or shopped at the same location of a restaurant or store within several days of each other, it suggests that the contaminated food item was served or sold there.

The Maryland Department of Health collected papayas from the grocery store associated with the illness cluster to test for Salmonella. One sample yielded the outbreak strain of Salmonella Kiambu and another sample yielded Salmonella Thompson. Both samples were from Caribeña brand Maradol papayas imported from Mexico. WGS showed that the Salmonella Kiambu papaya isolate is closely related genetically to the Salmonella Kiambu isolates from ill people. This result provides more evidence that people in this outbreak got sick from eating contaminated Maradol papayas. CDC is working to collect additional information to determine whether the recent Salmonella Thompson illness in Maryland is part of this multistate outbreak.

On July 26, Grande Produce recalled Caribeña brand Maradol papayas that were distributed between July 10 and July 19, 2017. Based on the available evidence, CDC recommends that consumers not eat, restaurants not serve, and retailers not sell Maradol papayas from Mexico until we learn more about other possible brands that might be linked to this outbreak.

CDC and state and local public health partners are continuing laboratory surveillance through PulseNet to identify additional ill people and to interview them. Further investigation by FDA and regulatory officials is under way to determine the point in the supply chain where the papayas were contaminated. Updates will be provided when more information is available.