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National Center for Emerging and Zoonotic Infectious Diseases
Multistate Outbreak of E. coli O157:H7 Infections Linked to Romaine Lettuce- United States, October – December 2018
Colin Schwensohn, MPHOutbreak Response and Prevention BranchDivision of Foodborne, Waterborne, & Environmental DiseasesCenters for Disease Control and Prevention
Outbreak Detection
October 29, 2018: PulseNet codes STEC cluster (1810MLEXH-1)
– Ten E. coli O157:H7 infections from 3 states
– Three very similar PFGE Xbal/Blnl pattern combinations
NCBI pathogen detection pipeline query
– Isolates are highly related to historical leafy green STEC outbreak 1712MLEXH-1
CDC and state colleagues initiated a multistate investigation to identify the outbreak source
Hypothesis GenerationActivities during 11/1/2018 to 11/19/2018:
34 cases from 11 states
– Case definition now includes 6 PFGE pattern combinations
– cgMLST indicate cluster isolates are within 0-2 alleles
– Highly related cases in Canada
– NHGQ and state routine enteric forms used to assess exposures
Notable exposures reported by ill people:
– 24/25 (96%) report consuming any leafy greens
– 13/16 (81%) report consuming romaine lettuce specifically
– Two restaurant sub-clusters identified in MI and CA with some reporting romaine salad exposure
FDA and state partners worked to traceback romaine lettuce exposures to the farm level
Romaine Traceback Investigation
Traceback information from the FDA indicated ill people in this outbreak ate romaine lettuce harvested from the Central Coastal growing regions of northern and central California
Adam Bros. Farming, Inc. in Santa Maria was one of the farms identified in the traceback investigation
November 20, 2018: First CDC Food Safety Alert
Late November, 2018: Environmental Investigation
FDA, CDC, and state partners investigated farms and cooling facilities in California that were identified in romaine traceback
CDC analyzed water and sediment samples from an Adam Bros. Farming, Inc. farm, one of the farms identified during romaine traceback
E. coli O157:H7 found in an Adam Bros Farm agricultural water reservoir highly related by WGS to outbreak strain
Canadian isolates
Historical isolates
wgmlst_v4 (Core)
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CDC__2018C-5284g
CDC__2018C-5284b
CDC__2018C-5284f
18-9566
NY___IDR1800050410.
CDC__2018C-5284c
CDC__2018C-5284a
CDC__2018C-5284i
CDC__2018C-5284e
CDC__2018C-5284h
CDC__2018C-5284d
NJ___182262
RI___18P201
CA___M18F03488
VA___R171213076
NY___IDR1800047567.
LAC__F23658_O157
CAOC_SB182330280
NJ___182181
LAC__H64098_O157
NYC__NYC18-200876.
NJ___182151
NYC__NYC18-200876.
LAC__F23661_O157
MI___CL18-167744
MI___CL18-167741
LAC__F23659_O157
NJ___182263
NYC__NYC18-200881.
NH___1811140017
LAC__T9049_O157
MA___18EN7737
18-9643
MI___CL18-167740
CT___806453001
RI___18P202
NH___1810250005
MI___CL18-167742
OH___2018005225
NJ___182302
PA___M18014521-1
LAC__M41817_O157
PA___M18014968-1
IL___C18EN001516
CAOC_SB182810049
MI___CL18-167739
MD___MDA18102222
NJ___182149
NY___IDR1800049021.
LAC__M40000_O157
PA___M18014243-1
CA___M18F03389
NH___1811140016
PA___M18014485-1
18-9440
LAC__T10719_O157
NJ___182300
NJ___182283
MI___CL18-167747
CAOC_SB182300044
LAC__T9060_O157
NJ___182286
FL___JBE18001015
PA___M18015652-1
NH___1810250004
GA___19C0074864
ia___736178
NY___IDR1800050491.
CA___M16X06654
CA___M18F02022
2018C-5284g
2018C-5284b
2018C-5284f
18-9566
PNUSAE020608
2018C-5284c
2018C-5284a
2018C-5284i
2018C-5284e
2018C-5284h
2018C-5284d
PNUSAE020560
PNUSAE020211
PNUSAE021027
PNUSAE011627
PNUSAE020169
PNUSAE020063
PNUSAE018389
PNUSAE020519
PNUSAE020510
PNUSAE020220
PNUSAE020068
PNUSAE020218
PNUSAE020065
PNUSAE020071
PNUSAE019892
PNUSAE020064
PNUSAE020561
PNUSAE020442
PNUSAE020636
PNUSAE020513
PNUSAE020254
18-9643
PNUSAE019891
PNUSAE019911
PNUSAE020212
PNUSAE020516
PNUSAE020069
PNUSAE020042
PNUSAE020565
PNUSAE020675
PNUSAE020511
PNUSAE021000
PNUSAE020518
PNUSAE019880
PNUSAE019890
PNUSAE019983
PNUSAE020067
PNUSAE020363
PNUSAE020066
PNUSAE020740
PNUSAE020509
PNUSAE020635
PNUSAE020742
18-9440
PNUSAE020512
PNUSAE020564
PNUSAE020562
PNUSAE020121
PNUSAE017885
PNUSAE020514
PNUSAE020563
PNUSAE020815
PNUSAE021237
PNUSAE020515
PNUSAE020195
PNUSAE020365
PNUSAE021009
PNUSAE005370
PNUSAE017176
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1811ECMLVA1QC-WGS
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1712MLEXH-1
1810MLEXH-1
1810MLEXH-1
NOT1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1811ECMLVA1QC-WGS
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1811ECMLVA1QC-WGS
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
NOT1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1810MLEXH-1
1611MLEXH-1
1808CAEXH-1
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WGS Results
0-4 alleles
Historical isolates
• cgMLST tree of highly related STEC isolates within 0-4 alleles
• Includes 2016, 2017, and 2018 clinical isolates
• Environmental isolates from Adam Bros. Farm
Environmental isolate
Legend:
WGS Clade of Concern: A Timeline
1611MLEXH-1 • 20 cases• Vehicle: unknown
1712MLEXH-1 • 25 cases• Vehicle: leafy greens
1810MLEXH-1 • 62 cases• Vehicle: romaine lettuce
Case Definition Infection with E. coli O157:H7
Isolation date during 10/1/2018 to 1/9/2019
PFGE XbaI/BlnI pattern combination– EXHX01.7535/ EXHA26.5334– EXHX01.7220/ EXHA26.5597– EXHX01.7535/ EXHA26.5597– EXHX01.7220 /EXHA26.5334 – EXHX01.7549 /EXHA26.5334 – EXHX01.7551 /EXHA26.5334 – EXHX01.2382 /EXHA26.5334 – EXHX01.7572 /EXHA26.5334 – EXHX01.7581/EXHA26.5334 – EXHX01.7580 /EXHA26.5334
62 cases from 16 states and DC
Onset dates ranged from October 7, 2018 to December 4, 2018
Patient ages ranged from 1 to 84 (median 25 years)
66% of patients female
46% of patients were hospitalized, 2 developed HUS, and no deaths were reported
Outbreak Summary
Conclusions
Role of WGS in the investigation
– Linked current outbreak to a cluster in 2016 and an outbreak in 2017 associated with leafy greens in the U.S.
– WGS link to 2017 leafy green outbreak informed the investigation, hypothesis generation, and traceback strategy with a focus on romaine lettuce
– Confirmed genetic relatedness of 10 different PFGE pattern combinations
FDA/CDC/CA farm investigation and isolation of the WGS outbreak strain
– Key to identifying one of the farm level sources for reoccurring STEC outbreaks of the same WGS strain
– Provides additional evidence that water contamination may be an important factor in STEC outbreaks associated with romaine lettuce
Acknowledgments CDC ORPB
– Laura Gieraltowski
– Natasha Dowell
CDC EDLB– Kane Patel
CDC WDPB– Mia Mattioli
– Amy Kahler
US Food & Drug Administration (FDA)– Sharon Seelman
– Allison Wellman
– Alvin Crosby
– Johnson Nsubuga
Public Health Agency of Canada– Ashley Kerr
California Department of Public Health– Vi Peralta
– Jeff Higa
Michigan Department of Health and Human Services
– Katie Arends
Illinois Department of Public Health– Julie Dow
– Shana Altman
Ohio Department of Health– Scott Nowicki
New Jersey Department of Health – Deepam Thomas
New York State Department of Health– Kadri Ajileye
– David Nicholas
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Contact:Colin Schwensohn
Thank you
