E Coli O157:H7 Outbreak Alert November 2019

IN THE NEWS

For the third holiday season in a row (2017, -18, -19), Consumers, Stores & Restaurants, Healthcare Personnel, National, State and Local Public Health Authorities, and Healthcare Facilities are being warned about an outbreak of E. Coli O157:H7.  This is one of the E. Coli strains that is associated with a Shiga-toxin (STEC), can make people sick, cause severe illness, and even death.  Through an investigation, lab testing and traceback information, the outbreak has been linked to romaine lettuce from the Salinas, California growing region; and is considered likely to be the source of this outbreak. Testing is ongoing to identify all contaminated product(s).  A recall and safety notice have been put out by the FDA and was first announced on 11/21/19.  The FDA and CDC will continue to provide updates as more info and cases present, until an end to the outbreak is declared.  Links & Resources, including from Canada, can be found in an attached page on this site.

Canada has also received these Salinas, CA growing region romaine lettuce products.  They do not have an outbreak, but there is one patient from Manitoba, with a genetic footprint consistent with the US strain of E. Coli.  PHAC and other governmental agencies have put measures into place to prevent more potentially contaminated lettuce from entering Canada at the border and have guidelines in place to assist in helping its citizens check for the implicated lettuce, disposing of it, as well as being on the lookout for signs of infection, and consulting with their HCPs if they do appear.

As of November 25, a total of 67 positive cases have been reported from 19 states.  Illnesses started between 9/24/19 and 11/14/19 with an age range of 3 to 89 years old (median age 25); 67% are female.  More cases will likely be reported since it takes about 2 – 4 weeks from the time of illness to reporting to the CDC.  So far, with complete info on only 50 people available, 39 patients have been hospitalized and six (6) have developed hemolytic uremic syndrome (HUS).  HUS is a type of kidney failure which can occur with this type of E. Coli infection.  There have been no deaths.

The CDC has issued a Safety Alert advising ALL Consumers to not eat any romaine lettuce that is either labeled as coming from the Salinas, California growing region, where the growing region is not identified, and/or Salinas cannot be ruled out.  Grocery stores (or other retailers) and restaurants should not sell or serve any romaine lettuce from the Salinas region, where the growing region is not indicated, or the Salinas region cannot be ruled out. 

This includes all forms of romaine lettuce (whole heads, leaves, and hearts of romaine, packages/boxes of precut romaine lettuce, as well as salad mixes that contain any romaine such as baby or regular, spring mix, or Caesar salad.  If you cannot be sure that a lettuce is not romaine or that a salad mix doesn’t contain it, it should be considered a risk and part of this alert.  The Public Health Agency of Canada is advising its citizens and visitors to avoid eating ANY romaine lettuce and any salad mixes containing romaine lettuce from the Salinas, California growing region and follow the U.S. CDC’s public health advice.  Check for updates at the PHAC link included in the attached page.

The CDC provides this advice about any product containing romaine lettuce from the Salinas, CA growing region or where the growing region is unknown/unconfirmed.  The bag/box/package should be labeled with the growing region:

1. Consumers who have any implicated romaine lettuce in their homes should discard it, even if some of it has been eaten and no one is ill.
2. Restaurants and stores (retailers) should not sell or serve any implicated romaine lettuce, including mixes containing romaine.
3. Wash and sanitize any shelves, drawers, counters, or other areas/devices where the implicated romaine lettuce was kept or had any contact.
4. If you have symptoms (see below) of E. Coli infection:
5. Talk to your healthcare provider
6. Log what you ate for the week before you started getting sick
7. Report (or assure your HCP does) your illness to the local health department and assist them by answering questions about your illness and food log; provide specimens as requested.
8. Assist public health investigators by answering their questions if you are ill.
9. WASH YOUR HANDS WELL each time you go to the bathroom, after changing diapers, and both before and after preparing any food to prevent spread to others, after touching any animals or the area and items surrounding them.

See the CDC Prevention URL link in the attached Links and Resources page for more recommendations to protect yourself, your family, and your patients from E. Coli.

First Responder Specific Recommendations (follow your Agency’s Policy & Procedures):

1. As soon as your Unit knows that a patient is having a diarrheal illness, use Standard and Contract Precautions to avoid possible contact with fecal contamination from the patient, the patient’s clothes or bedding, or other items that might have been contaminated but are not readily apparent. Following HIPAA and allowing for other privacy/dignity concerns, alert other responding/arriving units of a need to consider protecting themselves.
2. Patients with STEC (Shiga Toxin E. Coli) may be seriously ill, with dehydration, electrolyte imbalance, kidney failure, and/or exacerbating chronic conditions (i.e. heart disease, diabetes, immunosuppression, etc.). Watch for a worsening condition, provide supportive care as indicated per Protocol.
3. Try to avoid contaminating non-disposable equipment and/or identify and segregate the equipment and place in a red bag for decontamination before the next call.
4. If transporting, consider providing an impermeable or fluid resistant barrier for the cot.
5. Report the patient’s condition and symptoms to the receiving hospital personnel (considering HIPAA and other privacy concerns).
6. At the completion of the call, according to your Agency’s guidelines, clean and disinfect (a two-step procedure) contaminated reusable equipment as well as areas surrounding the patient that may have been unknowingly contaminated (stretcher, walls, floor, etc.). Use an EPA registered appropriate disinfectant that kills E. Coli.
7. Report any exposure(s) to your Designated Infection Control Officer for any appropriate follow-up.

All Shiga toxin-positive E. Coli, diarrheal illness, or HUS should be reported to local health department.  That is typically done via the physician, lab or hospital identifying it, but a call to the health department if that information is reported to your Agency is appropriate, particularly if the patient is one of your first responders.  If there were multiple agencies involved, anyone who had exposure should be notified via official channels while honoring HIPAA.  This is usually done by the Designated Infection Control Officer or their designee.

Incubation period (the time from exposure to signs of illness):  most begin to feel sick in 3 to 4 days after eating or drinking something with the E. Coli bacteria, but it can actually occur from 1 to 10 days after exposure.

Symptoms:  vary from person to person but severe stomach/intestinal cramps, diarrhea (which may be bloody), and/or vomiting.  There may be a fever but it is usually less than 101^o F (38.5^o C).

Infections may range from mild to severe and some may be life-threatening.  The illness usually lasts 5-7 days but visit your HCP, Urgent Care, hospital ER, or call 911 if the diarrhea lasts more than 3 days or is combined with a high fever (102^oF), blood in the stool, or continuous vomiting that prevents liquids from staying down or results in very little urine output.

5-10% of those with Shiga-toxin E. Coli, will develop the complication of hemolytic uremic syndrome approximately a week after symptoms first begin and when the diarrhea is getting better.  Signs of HUS include decreased urination, fatigue, and/or becoming pale in the cheeks and lower eyelids.  Anyone with these signs should be evaluated by a HCP, often in an emergency department and, if diagnosed with HUS, will typically be admitted.  Renal failure or other problems may occur and supportive therapy is usually needed.  Most people will recover in a few weeks but some have permanent damage or die.

Download the pdf