MMWR article on salmonella outbreak linked to oat cereal

[Kuester, Sarah]

Hello.  Below is the MMWR article regarding a multistate outbreak 
of Salmonella linked to Toasted Oats Cereal.  Please refer to the 
original website at http://www.cdc.gov/epo/mmwr/mmwr_wk.html 
for an official copy of the article.

Thank you,
Sarah Kuester
Public Health Nutritionist
Centers for Disease Control and Prevention
sak2 at cdc.gov

 -----------------------------------------------------
From: Morbidity and Mortality Weekly Report, Vol. 47
(22):462-4, June 12, 1998.

Multistate Outbreak of Salmonella Serotype Agona Infections
Linked to Toasted Oats Cereal -- United States, April-May, 1998

     During April-May 1998, a total of 11 states reported an increase in
cases of Salmonella serotype Agona infections; as of June 8, a total of
209
cases have been reported and at least 47 persons have been hospitalized,
representing an eightfold increase over the median number of cases
reported
in those states during 1993-1997. The states reporting increases were
Illinois (49 cases), Indiana (30), Ohio (29), New York (24), Missouri
(22),
Pennsylvania (20), Michigan (15), Iowa (eight), Wisconsin (six), Kansas
(four), and West Virginia (two). This report summarizes the outbreak
investigation by local, state, and federal public health officials,
which
implicated Millville brand plain Toasted Oats cereal manufactured by
Malt-O-Meal, Inc. as the cause of illness.
     Among 162 patients in this outbreak for whom information was
available, 85 (52%) were female. Most cases occurred in children and the
elderly (47% in persons aged less than 10 years and 21% in persons aged
greater than 70 years). Most illnesses began in May.
     Officials in the 11 state health departments, in collaboration with
CDC, conducted a matched case-control study comparing persons with cases
of
S. Agona infection in April and May with well household members
(controls);
conditional linear logistic regression was used to examine the relation
between consumption of cereal and illness. As of June 8, information
from
55 households has been analyzed; 46 (84%) of these 55 households shopped
at
an Aldi supermarket. During the 3 days before onset of illness, 31 (66%)
of
47 patients and 32 (36%) of 89 household controls consumed Millville
brand
plain Toasted Oats cereal purchased at an Aldi supermarket (matched odds
ratio=22; p=0.003). This association remained significant when
controlled
for age (pless than 0.05). When average daily consumption of Millville
brand plain Toasted Oats cereal purchased from an Aldi supermarket was
categorized into three groups (no consumption, less than or equal to 1
cup,
and greater than 1 cup), a significant dose response relation was found
(p=0.003).
     Culture of an open box of Millville brand plain Toasted Oats cereal
obtained from the home of a case-patient yielded Salmonella Agona at
CDC.
The pulsed-field gel electrophoresis (PFGE) pattern of this isolate was
indistinguishable from the predominant PFGE pattern among
outbreak-associated clinical isolates. The Food and Drug Administration
(FDA) isolated Salmonella Agona from two separate composite samples from
unopened boxes. Clinical isolates were susceptible to all antimicrobial
agents tested (i.e., ampicillin, trimethoprim-sulfamethoxazole, and
ciprofloxacin).
     The Minnesota Department of Health, the Minnesota Department of
Agriculture, FDA, and CDC are collaborating in the investigation of the
Malt-O-Meal, Inc. plant that manufactured the implicated cereal to
determine the source of contamination. At this plant on the same
production
line, multiple brands of plain Toasted Oats are manufactured at
different
times. Malt-O-Meal has issued a voluntary recall of all plain Toasted
Oats
cereal produced on the same production line. Investigation is ongoing to
determine whether other plain Toasted Oats cereal brands produced by the
same company were contaminated. Cases of Salmonella Agona infection
occurring during the same time have now been reported in California
(11),
Washington (nine), New Jersey (five), Tennessee (three), Oklahoma
(three),
Idaho (two), Maryland (two), Minnesota (two), Nebraska (one), and
Connecticut (one). These cases are being investigated to determine
possible
links to this outbreak. CDC recommends that consumers not eat plain
Toasted
Oats cereal produced by Malt-O-Meal until further investigation has
identified the scope, magnitude, and cause of the contamination.
Questions
about plain Toasted Oats cereals manufactured by Malt-O-Meal should be
directed to the company, telephone (800) 590-1810.

Reported by: State and local health depts. Office of Regulatory Affairs,
and Center for Food Safety and Applied Nutrition, Food and Drug
Administration. Foodborne and Diarrheal Diseases Br, Div of Bacterial
and
Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note: Salmonella Agona is one of approximately 2000 Salmonella
serotypes that can cause illness in humans. An estimated 2-4 million
cases
of salmonellosis occur in the United States each year, resulting in
greater
than or equal to 500 deaths (1). Approximately 40,000 of these
infections
are culture confirmed, serotyped, and reported to CDC by state health
departments (1). Salmonella infections usually resolve in 5-7 days and
do
not require antibiotic treatment. Persons with severe diarrhea may
require
rehydration with intravenous fluids. Antibiotics are required when
infection spreads from the intestinal tract. Salmonella Agona is an
uncommon serotype of Salmonella, accounting for approximately 1.5% of
human
isolates reported to the Public Health Laboratory Information System
(PHLIS) (2). Like most other Salmonella serotypes, Salmonella Agona is
found in a variety of animal reservoirs including poultry, cattle, pigs,
and animal feed. The first reported U.S. outbreak of Salmonella Agona
infections was traced to animal feed made with contaminated imported
fishmeal in 1972 (3); other outbreaks have been attributed to dried milk
(4) and to a commercial peanut-flavored snack (5). This outbreak
represents
the first time a commercial cereal product has been implicated in a
Salmonella outbreak, although an infant cereal product was implicated in
an
outbreak of Salmonella senftenberg in the United Kingdom (6). Salmonella
spp. are relatively resistant to desiccation and can survive for long
periods in dry environments such as cereal (7).
     Timely communication among the states and CDC about unexplained
local
increases in Salmonella Agona infections, and the relative rarity of
this
serotype, led to the identification of this multistate outbreak.
Electronic
national laboratory-based reporting of Salmonella infections facilitated
prompt recognition of the extent of the outbreak. Cooperative
investigations among federal, state, and local agencies, coordination by
CDC, electronic reporting through PHLIS, and the rapid identification of
related isolates using PulseNet (the national network of public health
laboratories that perform DNA "fingerprinting" on foodborne bacteria)
are
critical components in the recognition and investigation of multistate
foodborne outbreaks.


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international
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