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  • South Africa: 2017/2018 Listeriosis

    Source: http://ewn.co.za/2017/12/05/at-least...outbreak-in-sa


    At least 36 dead from Listeria outbreak in SA
    Health Minister Aaron Motsoaledi made the announcement a short while ago in Cape Town.
    Shamiela Fisher | about 4 hours ago

    CAPE TOWN - Health Minister Aaron Motsoaledi says 36 people have died following an outbreak of Listeria in South Africa.

    During a press briefing on Tuesday, Motsoaledi said a total of 557 lab-confirmed Listeriosis cases have been reported.

    The majority of these cases have been reported in Gauteng, followed by the Western Cape and KwaZulu-Natal.

    Motsoaledi says the bacteria is widely distributed in nature and can be found in soil, water and vegetation.

    He explained that Listeriosis is a serious, but treatable and preventable disease caused by the bacterium Listeria Monocytogenes.

    Animal products and fresh produce can be contaminated...

  • #2
    Source: https://www.thesouthafrican.com/list...ow-reaches-61/

    Listeriosis outbreak on the rise as death toll now reaches 61
    The listeriosis outbreak is starting to cause real worry at a national level. Minister of Health, Dr Aaron Motsoaledi has had his say.
    By Nic Andersen -
    2018-01-08

    On Monday afternoon #Listeriosis was the number one trending hashtag on South African Twitter. The death toll for the disease outbreak in the country had reached 61 as of Monday.

    Minister of Health Dr Aaron Motsoaledi announced the news on Monday. He also revealed which provinces have had the most cases and stated that genome sequencing was being carried out to help reveal the source of the outbreak.

    Gauteng continues to host by far the most cases with 442 of the 727 coming from the province. The Western Cape had the second most with 92 confirmed cases. With the recent upswing of the disease, the department of health has added listeriosis to the list of notifiable diseases, before this outbreak it was not on the list...

    Comment


    • #3
      Source: https://www.sowetanlive.co.za/good-l...inues-to-kill/


      Four days? fourteen deaths: fatal listeriosis outbreak continues to kill
      By Wendy Knowler - 18 January 2018 - 17:26

      Fourteen deaths in four days. That's what the National Institute of Communicable Diseases? latest listeriosis outbreak report reveals.

      A total of 81 people have died in South Africa from the disease? contracted from eating food contaminated with the food borne pathogen Listeria? according to the NICD. In early December? the number of dead totalled 36.

      The number of confirmed cases - in what has been described as the biggest listeriosis outbreak - is now 767? up from 748 on January 12. In South Africa? te outbreak is spread across all nine provinces. Scarily? the 235 cases for which the NICD has ?outcome data? reveals the death rate to be an alarming 34%...

      Comment


      • #4
        Source: https://www.businesslive.co.za/bd/na...ak-in-history/

        SA still cannot find source of worst listeriosis outbreak in history
        Most of the 852 cases have been reported in Gauteng? with 13% of cases in the Western Cape and 7% in KwaZulu-Natal
        06 February 2018 - 17:31 Wendy Knowler

        The death count in SA?s listeriosis outbreak ? the worst documented listeriosis outbreak in global history ? has topped 100.

        The National Institute of Communicable Diseases (NICD) announced on Tuesday that the number of confirmed listeriosis cases was now 852? and 107 people had died. The death rate ? based on the outcome data for 355 cases ? was 30%.

        Of those confirmed cases? 42% were babies younger than one month? with pregnant women being 20 times more likely to get listeriosis than other healthy adults.

        Contracted from eating food containing the pathogen listeria? listeriosis is the most deadly of food-borne diseases? the death rate in other documented outbreaks being up to one in four...

        Comment


        • #5
          Source: https://www.zoutnet.co.za/articles/n...limpopo-people

          Listeriosis outbreak affect more and more Limpopo people
          News - Date: 10 February 2018
          Written by: Tracy Ngobeni /

          The Listeriosis outbreak, which has claimed the lives of 61 people in South Africa since 2017, continues to spread and affect more people in all nine provinces.

          This feared disease has also reached the Limpopo Province.

          The Limpopo Department of Health (DoH) confirmed that 60 leaners from the Bosele School for the Blind in the Sekhukhune area were infected during January. They were rushed to different health facilities after complaining of severe stomach aches and diarrhoea. After receiving treatment, they were discharged on Friday, 26 January.

          A spokesperson for the DoH, Mr Thabiso Teffo, said 40 cases of Listeriosis were reported on 29 January across Limpopo. Of these cases, 21 were female patients while 16 were male patients. The gender of the remaining three patients could not be confirmed by the time of our going to press. Teffo confirmed that 28 cases were reported by private hospitals and 12 by state hospitals.

          According to information made available by the National Institute for Communicable Diseases (NICD), Listeriosis is food poisoning caused by eating foods contaminated with Listeria monocytogenes bacterium. Nationally, a total of 767 confirmed listeriosis cases have been reported to the National Institute of Communicable Disease between January 2017 and January 2018...

          Comment


          • #6
            Outbreaks and Emergencies Bulletin, Week 6: 3 - 9 February 2018

            Listeriosis South Africa

            852
            Cases
            107
            Deaths
            12.6%
            CFR

            EVENT DESCRIPTION
            The outbreak of listeriosis in South Africa continues, with a decreasing
            trend in the number of cases since Week 50 of 2017. As of 5 February
            2018, 852 laboratory confirmed cases have been reported since 1
            January 2017, with a total of 107 deaths (case fatality rate 12.6%).
            Most cases have been reported from Gauteng Province (59%,
            505/852), followed by Western Cape (13%, 107/852) and KwaZuluNatal
            (7%, 63/852). Cases have been diagnosed in the public (66%,
            558/852) and private (34%, 294/852) healthcare sectors. Diagnosis
            was most frequently based on isolation of Listeria monocytogenes in
            blood culture (71%, 609/852), followed by cerebrospinal fluid (CSF)
            (22%, 191/852). Where age was reported (n=823), ages ranged from
            birth to 93 years (median 19 years) and 42% are neonates aged 28
            days or younger. Of neonatal cases, 96% had early-onset disease
            (birth to less than 7 days). Females accounted for 55% of cases for
            whom gender was reported. Final outcome data are available for 42%
            of cases, of which 30% (107/355) have died. The elderly and neonates are at increased risk for listeriosis; additional risk factors include pregnancy,
            immunocompromise and cancer. An investigation team continues to work on what is considered a strong lead between human cases and a food item;
            laboratory results are pending.
            ...


            The World Health Organization (WHO) is building a better future for people everywhere. The Organization aims to provide every child, woman and man with the best chance to lead a healthier, longer life.
            "Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
            -Nelson Mandela

            Comment


            • #7
              Source: http://townpress.co.za/live/2018/02/...a-doubles-172/


              Death toll from listeria outbreak in South Africa more than doubles to 172
              by Town Press
              February 22, 2018

              JOHANNESBURG ? The death toll from an outbreak of the food-borne disease listeria in South Africa has more than doubled from previous numbers given in January to 172 deaths, the government said on Thursday.

              A street trader sells fruit from a shopping trolley at a taxi and bus rank in Pin

              The National Institute of Communicable Diseases (NICD) said 915 cases of the disease have been confirmed since January last year, up from the previous figures given last month of 61 deaths and 720 confirmed outbreaks.

              The government said the source of the outbreak was still unknown...

              Comment


              • #8
                Minister Aaron Motsoaledi: Update on the Listeriosis outbreak in South Africa


                4 Mar 2018

                Good morning ladies and gentlemen.

                Let me take this opportunity to thank you for joining us this morning.

                Firstly, let me introduce the team that is here. We have Dr Juno Thomas, Head of the Centre for Enteric Diseases from the National Institute for Communicable Diseases (NICD); Mme Precious Matsoso (Director-General of Health) and her team; Mr Lionel October (Director General for the Department of Trade and Industry (DTI) and his team; Dr Rufaro Chatora (Country Representative from the World Health Organization (WHO)); the Acting from the Department of Agriculture, Forestry and Fisheries (DAFF) DG Mr Ramasodi and his team; the team from the National Consumer Commission (NCC); as well as the representative from the National Regulator for Compulsory Specifications (NRCS), .

                At the last media briefing held on 08 January 2018, I reported that a total of 727 laboratory-confirmed cases of listeriosis had occurred since 01 January 2017.
                Of these 727 cases, there was final outcome data for 134 patients. This means that 134 actual patients were traced to their health facilities, i.e as to what eventually happened to them. Unfortunately, 61 of them had died.


                I had then promised that we would have a media briefing every month. However, we could not have a media briefing in February because the NICD asked for a bit of more time to finalise certain laboratory tests. We are now ready because those test results they have been waiting for were finalised. That is why we have called you here to brief you.

                The situation now is as follows:

                As of 02 March 2018, a total of laboratory-confirmed cases have risen to 948, still counting from January 2017. Of these 948, a total 659 patients have been traced and 180 of them have unfortunately died. This constitutes 27% case fatality rate.

                In our constant search for the source of the outbreak and the treatment of people who are affected, a team from the NICD has interviewed 109 ill people to obtain details about foods they had eaten in the month before falling ill. Ninety three (85%) people reported eating ready-to-eat (RTE) processed meat products, of which polony was the most common followed by viennas/sausages and then other ‘cold meats’.

                On Friday 12th January, nine children under the age of 5 years presented to Chris Hani Baragwanath Hospital with febrile gastro-enteritis. The paediatrician suspected foodborne disease, including listeriosis, as a possible cause. The environmental health practitioners (EHPs) were informed and on the same day visited the cr?che, and obtained samples from two unrelated polony brands(manufactured by Enterprise and Rainbow Chicken Limited (RCL) respectively) and submitted these to the laboratory for testing.

                Listeria monocytogenes was isolated from stool collected from one of the ill children, and from both of the polony specimens collected from the cr?che. These isolates were sent to the NICD Centre for Enteric Diseases, and underwent whole genome sequencing and genomic analysis. The ST6 sequence type was confirmed on all three isolates on Saturday 27th January. Remember that in the last press conference I informed you that from clinical isolates obtained from patients (patient blood), 9 sequence types of Listeria monocytogenes were isolated and 91% were of sequence type 6 (ST6). We had then concluded that time that this outbreak is driven by ST6.

                I wish to further remind you that we had then taken a decision to visit all food-processing sites, food-packaging sites, as well as food production sites where possible.

                Following the lead from the tests performed on these children from Soweto and the food they had ingested, the EHPs (Environmental Health Practitioners), together with the NICD and DAFF representatives, accompanied by 3 technical advisors from the World Health Organisation in Geneva, visited a food-production site in Polokwane and conducted an extensive food product and environmental sampling.

                Listeria monocytogenes was isolated from over 30% of the environmental samples collected from this site, which happens to be the Enterprise factory in Polokwane.

                To conclude the investigation, whole genome sequencing analysis was performed from this Enterprise factory and the results became available midnight or last night. The outbreak strain, ST6, was confirmed in at least 16 environmental samples collected from this Enterprise facility.

                THE CONCLUSION FROM THIS IS THAT THE SOURCE OF THE PRESENT OUTBREAK CAN BE CONFIRMED TO BE THE ENTERPRISE FOOD-PRODUCTION FACILITY IN POLOKWANE

                Additionally, preliminary results show that several ready-to-eat processed meat products from the Enterprise facility located in Germiston contain L. monocytogenes, but the sequence type is not known as yet.

                Investigation of the RCL Wolwehoek production facility is also underway. Polony products have tested positive for L. monocytogenes, but the sequence types of the isolates are NOT ST6. However, such contamination of ready-to-eat processed meat products constitutes a health risk. Also, over 10% of environmental samples collected by EHPs at this facility have tested positive for L. monocytogenes. The sequence types of these isolates are not known as yet.

                With the information at our disposal, we have decided on the following course of action:
                1. The National Consumer Commission (NCC) has in terms of Section 60(2) of the Consumer Protection Act this morning issued the manufacturers concerned with safety recall notices.

                Section 60(2) of the Consumer Protection Act states that:
                If the NCC has reasonable grounds to believe that any goods may be unsafe, or that there is a potential risk to the public from the continued use of or exposure to the goods, and the producer or importer of those goods has not taken any steps required by an applicable code contemplated in subsection the Commission, by written notice, may require that producer to—
                (a) conduct an investigation contemplated in subsection (1); or
                (b) carry out a recall programme on any terms required by the Commission.
                The NCC will prepare a recall strategy in conjunction with the manufacturers and make further announcements to the public in due course.
                The safety recall will affect the manufacturers’ entire distribution networks, both domestic and international.
                2. Compliance notices will be issued to facilities in terms of the National Health Act.
                Environmental Health Practitioners appointed in terms of section 80(1) of the Act and duly registered as such in terms of section 83(5) of the National Health Amendment Act, 2013 (Act No. 12 of 2013) should upon finding that there are in terms of section 83 (1) and (2), existing conditions which-
                (a) constitutes a violation of the right contained in section 24(a) of the Constitution;
                (b) constitutes pollution detrimental to health;
                (c) is likely to cause a health nuisance; or
                (d) constitutes a health nuisance,
                3. In terms of registration for exports by the Department of Agriculture, Forestry and Fisheries (DAFF), the respective processing or manufacturing establishments namely RCL Foods with an export registration number ZA32 and Enterprise Foods with an export registration number ZA 33 have been temporarily suspected till further notice.
                4. We advise members of the public to avoid all processed meat products that are sold as ready-to-eat. While we know that polony is definitely implicated, there is a risk of cross-contamination of other ready-to-eat processed meat products, either at production, distribution or retail. This is because Listeria on the exterior casing (packaging) of polony can be transferred to other products it comes into contact with, including viennas, russians, frankfurters, other sausages, and other ‘cold meat’ products that are typically not cooked before eating.

                Just a reminder that people at high risk for listeriosis include:
                • pregnant women
                • neonates (first 28 days of life)
                • very young infants
                • elderly persons >65 years of age, and
                • anyone with a weakened immune system (due to HIV infection, cancer, diabetes, kidney disease, liver disease, people with transplants and those on immunosuppressive therapy such as oral corticosteroids, chemotherapy, or anti-TNF therapy for auto-immune disease).
                The recall of these products does not mean that members of the public must now relax and stop the 5 food-safety rules which we have recited many times have to be abandoned, i.e washing your hands before handling food or when coming back from the bathroom; making sure that food is well cooked; isolating raw food from cooked food; making sure that food is at an appropriate temperature; and washing non-cooked food with clean running water; as well as using only pasteurised or boiled milk products.

                It means that the general status of hygiene of the population must still be a matter of priority to society as a whole, and must remain like that forever.

                I thank you
                For media enquiries, please contact:
                Mr Popo Maja
                Head of Communications
                Cell: 0725853219
                Tel: 012 395 9591

                Foster Mohale
                Director: Media Relations
                Cell: 0724323792
                Tel: 012 395 8180

                Email: Foster.mohale@health.go




                Issued by:
                Department of Health



                More from:
                Department of Health



                More on:
                Health

                https://www.gov.za/speeches/minister...-mar-2018-0000










                "Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
                -Nelson Mandela

                Comment


                • #9
                  Outbreaks and Emergencies Bulletin, Week 10: 3 - 9 March 2018

                  Listeriosis South Africa


                  967
                  Cases
                  183
                  Deaths
                  27.4%
                  CFR

                  EVENT DESCRIPTION
                  The outbreak of listeriosis in South Africa is ongoing, and the new
                  development is that the source of the outbreak has been identified.
                  As of 8 March 2018 there have been 967 laboratory-confirmed cases
                  reported to the National Institute for Communicable Diseases (NICD)
                  since 1 January 2017. Of these, 749 cases were reported in 2017 and
                  218 cases in 2018. Of the 669 confirmed cases for whom outcome data
                  are available, 183 died, giving a case fatality rate of 27.4%. Gauteng
                  Province has reported the most cases (59.1%; 572/967) followed by
                  Western Cape (11.9%, 115/967) and KwaZulu-Natal (7.0%, 68/967).
                  The majority (85.3%; 93/109) of infected people interviewed by an NICD
                  team reported eating ready-to-eat processed meat products, most
                  commonly polony, followed by viennas/sausages and other ?cold
                  meats?. On 12 January 2018, nine children under the age of 5 years
                  from the same cr?che presented to Chris Hani Baragwanath Hospital
                  in Johannesburg with febrile gastroenteritis. A food-borne illness was
                  suspected, with listeriosis as a possible cause. Environmental Health
                  Practitioners (EHPs) visited the cr?che and obtained samples from two
                  unrelated brands of polony (Enterprise and Rainbow Chicken Limited
                  (RCL)), which were submitted for testing. Listeria monocytogenes was
                  isolated from the stool of one ill child and from both polony specimens.
                  Whole genome sequencing and genomic analysis by the NICD Centre for
                  Enteric Diseases confirmed the ST6 sequence type on all three isolates on
                  27 January 2018. Whole genome sequencing analysis was performed on
                  environmental samples collected from the Enterprise factory, confirming
                  the outbreak strain ST6, and showing the source of the outbreak to be
                  the Enterprise food production facility in Polokwane, Limpopo Province.
                  ...
                  SITUATION INTERPRETATION
                  The identification of the source of this outbreak is an important milestone in the control of this event. Strong risk communication and information about potentially
                  contaminated food products is required, as well as public information about what to do if they have eaten these products. The disease is now notifiable and a strong
                  surveillance system is required for early reporting, case investigation and detection. Food safety and inspection mechanisms need to be strengthened by public health
                  authorities.



                  The WHO Health Emergencies Programme is currently monitoring 50 events in the region. This week’s edition covers key new and ongoing events, including: Listeriosis in South Africa Rift Valley fever in South Sudan Lassa fever in Nigeria Cholera in Uganda Humanitarian crisis in Democratic Republic of the Congo    
                  "Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
                  -Nelson Mandela

                  Comment


                  • #10
                    Source: http://www.who.int/csr/don/28-march-...uth-africa/en/
                    Listeriosis ? South Africa

                    Disease outbreak news
                    28 March 2018

                    In South Africa, an outbreak of listeriosis, a serious foodborne disease, has been ongoing since the start of 2017. Between 1 January 2017 through 14 March 2018, 978 laboratory-confirmed listeriosis cases have been reported to the National Institute for Communicable Diseases (NICD) from all provinces. The majority of cases have come from three provinces: 581 (59%) from Gauteng, 118 (12%) from Western Cape and 70 (7%) from KwaZulu-Natal provinces, with the remaining cases coming from the other provinces in South Africa. The outcome of illness is known for 674 patients, of whom 183 (27%) of them died; this case fatality rate is comparable to other recorded listeriosis outbreaks worldwide. Most of the cases are persons who have higher risks for a severe disease outcome, such as neonates, pregnant women, the elderly and immunocompromised persons. In this outbreak, 42% of the cases are neonates who were infected during pregnancy or delivery.
                    Whole genome sequencing was performed on isolates from a large subset of patients. Ninety one percent of the strains belonged to Listeria monocytogenes Sequence Type 6 (ST6). The same ST6 sequence type was identified in a widely consumed ready-to-eat processed meat product called ?Polony?. The same strain was also found in the processing environment of the manufacturer of the implicated product. On 4 March 2018, the Ministry of Health, announced that this product was believed to be the source of the outbreak.
                    The food processing company and three of its retailers export to 15 countries1 in the African region . All of these countries have issued recalls for the implicated products. Environmental samples from other food production companies in South Africa have also tested positive for Listeria but with strains different from the outbreak strain. These companies have also issued food recalls. Some of their products have been exported to some of the countries mentioned above.
                    Nine percent of the reported cases in the present outbreak in South Africa were infected with different strains of Listeria than the predominant ST6 outbreak strain. This may indicate that more than one outbreak is ongoing. Comprehensive investigations to identify the source of infection of these cases should be conducted.
                    Number of Laboratory-Confirmed Cases of Listeriosis by Week of Sample Collection and Province, South Africa, 01 January 2017 to 12 March 2018 (n=978)



                    Source: National Institute for Communicable Diseases (NICD), South Africa2.
                    Public health response

                    The country has activated a national multisectoral task force to coordinate investigation and response activities:
                    • The Minister of Health, South Africa, held a press conference on 4 March 2018 to announce the source of the outbreak.
                    • Following the source identification, the national authorities have taken measures to limit further infections and associated mortality, including but not limited to the issuance of safety recall notices, compliance notices, and measures related to exportation of implicated products and risk communication with vulnerable groups.
                    • The Southern African Development Community (SADC) Health Ministers held a meeting in Johannesburg on 15 March 2018, to share information and to enhance preparedness and response for listeriosis. Health Ministers were further reminded about their rights and obligations under the International Health Regulations (IHR) with regards to additional health measures for international travel and trade.
                    • Listeriosis has been made a notifiable medical condition in South Africa Since December 2017.
                    • National risk communication activities have been initiated since December 2017 around the ?WHO five keys to safer food messages?.

                    WHO risk assessment

                    Globally, this is the largest outbreak of listeriosis that has been detected. Due to the potentially long incubation period of listeriosis (one to three weeks and up to 70 days) further cases are expected before the impact of the food recall is observed.
                    Following the identification of the source of this outbreak, WHO is now concerned that the export of implicated products may have resulted in listeriosis cases in other countries. Detailed information on the implicated product batches exported to each of the identified 15 countries should be shared with WHO and the International Food Safety Authorities Network (INFOSAN) Secretariat. This will help to facilitate efficient recalls of these products.
                    Recently, Namibia reported a confirmed case of listeriosis. It is important that this case and other possible cases be properly investigated and the implicated food sources identified. The isolated Listeria strains should be sequenced to determine potential links to the outbreak in South Africa. Some of these countries may not have well-established surveillance systems and laboratory diagnostic services in place to detect cases of listeriosis. In such cases, WHO is ready to provide support and has reached out to 16 African nations (two West African countries and 14 members of SADC) to provide support for preparedness and response.
                    An increase in public concern about the outbreak has been reflected in media reports and discussions in various social media platforms.
                    WHO advice

                    Countries should strengthen national food safety and disease surveillance systems as a prerequisite to prevent similar events in the future and to ensure a safe food supply for their populations. Additionally, countries are urged to pay closer attention to common foodborne pathogens such as Salmonella species, Campylobacter jejuni, Escherichia coli and Listeria monocytogenes, to make listeriosis a notifiable disease if not yet done, to make the best use of a new ?WHO manual to strengthen surveillance of and response to foodborne diseases?, which was published on November 2017 and to refer to the ?WHO Factsheet on Listeriosis?. See below, in the "Further Information" section for links to these documents.
                    Responsible authorities are encouraged to proactively provide public health advice on the prevention and control of listeriosis, including, strengthened risk communication, to address public concerns and promote outbreak control measures .
                    WHO does not currently recommend any travel or trade restrictions in relation to this outbreak, other than the recall of processed meat products indicated by the South African Government.
                    While WHO understands the desire by sovereign governments to take measures to protect the health of their populations, States Parties to the IHR have obligations not to take actions that significantly interfere with international travel and trade which are not based on scientific principles and which may be viewed as excessive. Indeed such measures contravene the spirit and purpose of the IHR, and can impede public health objectives.
                    Currently, 12 out of 15 countries have recalled the implicated processed meat products, and banned imports of the same, while three out of these countries have additionally banned imports of other food products. WHO continues to monitor the travel and trade measures taken by countries in relation to this outbreak and their compliance with requirements under the IHR.
                    For travellers, it is advisable to practice good food hygiene, such as avoiding uncooked food, avoiding food that has been kept at room temperature for several hours, and always washing hands thoroughly with soap and water before preparing or consuming food.
                    1The 15 countries include: Angola, Botswana, Democratic Republic of the Congo, Ghana, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Nigeria, Swaziland, Uganda, Zambia, and Zimbabwe.
                    2The provinces are: Western Cape (WC), North West (NW), Northern Cape (NC), Mpumalanga (MP), Limpopo (LP), KwaZulu-Natal (KZ), Gauteng (GA), Free State (FS) and Eastern Cape (EC).
                    Further information:

                    Comment


                    • #11
                      Source: https://www.aol.com/article/news/201...tory/23472938/


                      212 people are dead and hundreds more are seriously ill in the largest listeria outbreak in history
                      Business Insider
                      Kate Taylor
                      Jul 2nd 2018 11:48AM

                      A food-poisoning outbreak has killed 189 people and sickened hundreds more.
                      A South African meat-production plant was the root of the listeria outbreak.
                      The incident is the largest listeria outbreak ever detected, according to the World Health Organization...

                      Comment

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