Outbreak of Human Typhoid Fever Infections in Nevada and California Associated with Frozen Mamey Fruit Pulp

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News Release

Public Health Update - Salmonella Typhi (Typhoid Fever)
August 12, 2010

The Southern Nevada Health District has confirmed four cases of Salmonella Typhi, the bacterium that causes Typhoid Fever, as part of a two-state outbreak (California currently has five confirmed cases). The local patients, all of whom have recovered, are under age 30. The illness was likely contracted from consuming a frozen fruit product known as mamey fruit pulp. The situation is under investigation by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA), working in conjunction with public health authorities from two affected states.

Currently, the health district and the CDC recommend that consumers do not eat or drink food items containing frozen Goya brand mamey fruit pulp. A voluntary product recall has been issued. Individuals who believe they might have become ill after consuming frozen mamey fruit pulp should consult their healthcare providers.

Mamey fruit pulp, sometimes called zapote or sapote, is a tropical fruit grown in Central and South America and is commonly found in markets nationwide, particularly in Hispanic communities. The product is often used in shakes and smoothies.

Typhoid Fever is a serious bacterial infection that can be treated with antibiotics. There are approximately 400 cases in the United States annually, 70 percent of which are acquired while traveling internationally. Infection occurs when a patient eats or drinks food or beverages handled by a person who is ?shedding? the Salmonella Typhi bacterium in his stool, or if sewage is contaminated with the bacterium and the water is used for drinking or washing food. The illness can last up to three or four weeks. It is recommended that people who will visit locations where Typhoid Fever is common receive the appropriate immunization from their healthcare provider or at the health district?s immunization clinic.

Symptoms occur within three days and up to three months after consuming contaminated food or water and include a sustained fever as high as 103 F to 104 F as well as stomach pains, a headache, anorexia, a slow heart rate, malaise, constipation or diarrhea, or a non-productive cough. People are the only host for the Salmonella Typhi bacterium, which is carried in the bloodstream and intestinal tract. Ten percent of untreated patients can remain infectious for as many as three months after the onset of symptoms, and 2 to 5 percent of these patients can become permanent carriers.

The Southern Nevada Health District investigates more than 100 cases of Salmonellosis annually; there have been no reported cases of Typhoid Fever, a distinct type of Salmonella infection, through 2009.

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http://www.southernnevadahealthdistr...s10/081210.php

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Re: Southern Nevada Health District has confirmed four cases of Typhoid Fever

CDC: Fruit pulp linked to rare US typhoid cases

<!-- google_ad_section_start(name=article) --> By MIKE STOBBE (AP) ? 5 hours ago
ATLANTA ? A rare U.S. outbreak of typhoid fever has been linked to a frozen tropical fruit product used to make smoothies, health officials reported Thursday. The victims range in age from 4 to 31, said CDC spokeswoman Arleen Porcell-Pharr.
Seven cases have been confirmed ? three in California and four in Nevada. Two more California cases are being investigated. Five people were hospitalized, according to the Centers for Disease Control and Prevention said.
The CDC said five of the victims drank milkshakes or smoothies made with frozen mamey (ma-MAY') fruit pulp. Four of them used pulp sold by Goya Foods Inc. of Secaucus, N.J.
. . .

The company has recalled packages of the pulp, sold in mostly western states. A sample from one package found in Las Vegas tested positive for the bacteria that causes typhoid, the Food and Drug Administration reported Wednesday.
. . .

Three food-related outbreaks have been reported in the last 12 years. One, also linked to frozen mamey pulp, caused three illnesses in Florida in 1999. One, linked to Gulf Coast oysters, sickened six in Texas in 2006. The third, linked to a Maryland restaurant, caused four illnesses.
Symptoms include a sustained fever as high as 103 to 104 degrees, along with headache. weakness, stomach pains or loss of appetite. Some patients have a rash of flat, rose-colored spots. It can be treated with antibiotics.
It's not clear if there will be additional cases, said Dr. Ezra Barzilay, the CDC epidemiologist supervising the investigation. It can take between three days to eight weeks for an infected person to develop symptoms, he noted.
. . . .
The recalled mamey pulp was sold in 14-ounce plastic packages in Alaska, Arizona, California, Colorado, Hawaii, New Mexico, Nevada, Oregon, Texas, Utah and Washington.

http://www.google.com/hostednews/ap/article/ALeqM5hUdZFMg1oMUG0uTsbkU36GjU_mDgD9HI6AB01

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Outbreak of Human Typhoid Fever Infections in Nevada and California Associated with Frozen Mamey Fruit Pulp

Investigation Announcement: Multistate Outbreak of Human Typhoid Fever Infections Associated with Frozen Mamey Fruit Pulp

<!-- mobile syndication block 1 end -->August 12, 2010
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<!-- Insert Secondary Body Navigation Here -->Persons Infected with the Outbreak Strain of Salmonella Typhi, by State, United States

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<!-- epi curve -->Infections with the Outbreak Strain of Salmonella Typhi, by Week of Illness Onset

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CDC is collaborating with public health officials in two states and the U.S. Food and Drug Administration (FDA) to investigate an outbreak of Salmonella infections, serotype Typhi. Salmonella Typhi is the bacterium that causes typhoid fever. Typhoid fever is a very rare illness in the United States among non-international travelers and can cause serious symptoms, often times requiring hospitalization. Typhoid fever is contracted when food and water are contaminated by an infected individual and are then consumed by other people. Investigators are using DNA analysis of Salmonella bacteria obtained through diagnostic testing to identify cases of illness that may be part of this outbreak.

As of 9:00am EDT on August 12, 2010, a total of 7 confirmed and 2 probable individuals infected with a matching strain of Salmonella serotype Typhi have been reported from 2 states since May 25, 2010. Confirmed cases are persons with illness on or after January 1, 2010 and a DNA fingerprint matching the outbreak strain. Probable cases are persons with a Salmonella Typhi infection and a strong epidemiologic link to the outbreak. The number of ill persons identified in each state with this strain is as follows: CA (3 confirmed and 2 probable) and NV (4 confirmed).

Among persons with reported illness onset dates available, illnesses began between April 10, 2010, and July 23, 2010. Infected individuals range in age from 4 to 31 years old and the median age is 21 years. Sixty-seven percent (67%) of cases are female and 100 percent report Hispanic ethnicity. Among 7 patients with available clinical information, 5 (71%) were hospitalized. Five (83%) of 6 patients interviewed reported no international travel in the 60 days prior to illness onset. As of August 12, 2010, no deaths attributed to this infection have been reported.

The outbreak can be visually described with a chart showing the number of persons who became ill each day. This chart is called an epidemic curve or epi curve. Illnesses that occurred after May 30, 2010, might not yet be reported due to the time it takes between when a person becomes ill, when laboratory testing is completed, when the diagnosis is confirmed, and when the illness is reported. For typhoid fever outbreaks, this takes an average of 8-10 weeks. This delay is denoted by the gray box on the epi curve.
Investigation of the Outbreak

CDC and public health officials in two states conducted an epidemiologic study comparing foods eaten by ill and well persons. Among interviewed ill persons, 5 (71%) of 7 reported consuming frozen mamey fruit pulp in a milkshake or smoothie, also called a ?batido? or ?licuado.? Upon further investigation, it was found that 4 (80%) of 5 ill persons consumed Goya brand frozen mamey fruit pulp. Among well persons, 0 (0%) of 33 reported exposure to frozen mamey fruit pulp. No other food was found to be associated with illness. These results suggest that eating frozen mamey fruit pulp is a likely source of these illnesses. This investigation is ongoing. CDC and its public health partners will update the public on the progress of this investigation as information becomes available.

Mamey, also called ?zapote? or ?sapote,? is a tropical fruit grown primarily in Central and South America. It is prepared by removing the inner seed and consuming the flesh raw, or adding it to milkshakes, jellies, or other foods or beverages. When preparing frozen mamey fruit pulp, it is peeled and mashed, and then consumed as a shake or smoothie. Frozen mamey fruit pulp can be purchased in grocery stores throughout the U.S., and packages have a 2-3 year shelf life.
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Clinical Features/Signs and Symptoms

Most persons infected with Salmonella Typhi develop high and sustained fever, headache, constipation, malaise, chills, and myalgia 2 to 5 weeks after infection. Infection is usually diagnosed by a blood culture. The illness can last from 3 to 4 weeks and infections may be severe or fatal if untreated. Typhoid fever should be treated with appropriate antimicrobial medications. More general information about Salmonella Typhi can be found here.
Advice to Consumers

• Until further notice, do not eat or drink Goya brand frozen mamey fruit pulp.
• Individuals who think they might have become ill from eating frozen mamey fruit pulp should consult their health care providers.

General Information

• Typhoid Fever
• Description of the Steps In a Foodborne Outbreak Investigation
• CDC's Role During a Multi-State Foodborne Outbreak Investigation

CDC's Role in Food Safety

As an agency within the U.S. Department of Health and Human Services (HHS), CDC leads federal efforts to gather data on foodborne illnesses, investigate foodborne illnesses and outbreaks, and monitor the effectiveness of prevention and control efforts. CDC is not a food safety regulatory agency but works closely with the food safety regulatory agencies, in particular with HHS's U.S. Food and Drug Administration (FDA) and the Food Safety and Inspection Service within the United States Department of Agriculture (USDA). CDC also plays a key role in building state and local health department epidemiology, laboratory, and environmental health capacity to support foodborne disease surveillance and outbreak response. Notably, CDC data can be used to help document the effectiveness of regulatory interventions.
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Page last modified: August 12, 2010

Content source: Centers for Disease Control and Prevention
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
Division of Foodborne, Waterborne,and Environmental Diseases (DFWED)

http://www.cdc.gov/salmonella/typhoidfever/index.html