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Background: Botulism is a rare and potentially fatal paralytic disease caused by botulinum neurotoxin (BoNT). In April 2017, 4 California residents from 2 adjacent counties were hospitalized with suspected foodborne botulism, precipitating an investigation by state and local public health departments in California., Methods: We interviewed suspected botulism patients and their families, inspected the suspect establishment, and collected suspect food. We tested patient sera, stool, and gastric aspirates using mouse bioassay for BoNT and/or culture for Clostridium botulinum. We tested suspect food and environmental samples for BoNT and confirmed presumptive positives using direct mouse bioassay and culture. We performed whole-genome sequencing on food and clinical isolates., Results: From April 2017 through May 2017, 10 patients in the Sacramento area were hospitalized with laboratory-confirmed botulism; 7 required mechanical ventilation, and 1 died. Of 9 patients with information, all had visited Gas Station X before illness onset, where 8 reported consuming a commercial cheese sauce. BoNT/A and/or BoNT/A-producing C. botulinum were detected from each patient and from leftover cheese sauce. Clostridium botulinum isolates from 4 patients were closely related to cheese sauce isolates by whole-genome high-quality single-nucleotide polymorphism analysis. No other botulism cases associated with this cheese sauce were reported elsewhere in the United States., Conclusions: This large foodborne botulism outbreak in California was caused by consumption of commercial cheese sauce dispensed at a gas station market. The epidemiologic and laboratory evidence confirmed the cheese sauce as the outbreak source. The cheese sauce was likely locally contaminated, although the mechanism is unclear., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

During September 29-October 6, 2017, the County of San Diego Public Health Services (COSD) was notified of two patients with suspected wound botulism and a history of using black tar heroin. On October 9, COSD, which had reported an average of one wound botulism case per year during 2001-2016, sent a health alert through the California Health Alert Network, notifying Southern California providers of these two patients, including their signs and symptoms and black tar heroin exposure. In collaboration with the California Department of Public Health, COSD conducted an investigation to identify additional cases, determine risk factors for illness, estimate cost of medical care, and develop recommendations to prevent further illness. By April 18, 2018, nine (eight confirmed and one probable) patients with wound botulism were identified, all of whom were hospitalized; one of the nine died. All nine were persons who inject drugs; seven specifically reported using black tar heroin and six practiced subcutaneous injection known as skin popping. Clinically compatible signs and symptoms included muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, difficulty breathing, loss of facial expression, or descending paralysis. All patients were treated with heptavalent botulism antitoxin (BAT). Wound botulism is likely underrecognized because of its rarity and the overlapping signs and symptoms with opioid intoxication, overdose, and other neurologic syndromes including Guillain-Barré syndrome, the Miller Fisher variant of Guillain-Barré syndrome, and myasthenia gravis. Prompt diagnosis, administration of BAT, and provision of supportive care can help stop the progression of paralysis and be lifesaving., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Objectives: To assess hospitalisation risk factors and economic effects associated with a multistate hepatitis A outbreak in 2013., Study Design: Retrospective case series., Methods: Eligible outbreak-related cases confirmed by September 1, 2013, were defined as acute hepatitis symptoms and positive IgM anti-hepatitis A during March 15-August 12 among patients who consumed the food vehicle or had the outbreak genotype. We reviewed medical records, comparing demographic and clinical characteristics among hospitalized and non-hospitalized patients; we used logistic regression analysis to identify factors associated with hospitalization. We interviewed patients regarding symptom duration and healthcare usage and estimated per-patient and total costs. Health departments reported outbreak-related personnel hours., Results: Medical records were reviewed for 147/159 (92%) eligible patients; median age was 48 (range: 1-84) years, and 64 (44%) patients were hospitalized. Having any chronic medical condition was independently associated with hospitalisation (odds ratio, 3.80; 95% confidence interval, 1.68-8.62). Interviews were completed for 114 (72%) eligible patients; estimated per-patient cost of healthcare and productivity loss was $13,467 for hospitalized and $2138 for non-hospitalized patients and $1,304,648 for all 165 outbreak-related cases. State and local public health personnel expenditures included 82 h and $3221/outbreak-related case., Conclusions: Hospitalisations in this outbreak were associated with chronic medical conditions and resulted in substantial healthcare usage and lost productivity. These data can be used to inform future evaluation of expansion of hepatitis A vaccination recommendations to include adults with chronic medical conditions., (Published by Elsevier Ltd.)

Shiga toxins (Stx) are primarily associated with Shiga toxin-producing Escherichia coli and Shigella dysenteriae serotype 1. Stx production by other shigellae is uncommon, but in 2014, Stx1-producing S. sonnei infections were detected in California. Surveillance was enhanced to test S. sonnei isolates for the presence and expression of stx genes, perform DNA subtyping, describe clinical and epidemiologic characteristics of case-patients, and investigate for sources of infection. During June 2014-April 2015, we identified 56 cases of Stx1-producing S. sonnei, in 2 clusters. All isolates encoded stx1 and produced active Stx1. Multiple pulsed-field gel electrophoresis patterns were identified. Bloody diarrhea was reported by 71% of case-patients; none had hemolytic uremic syndrome. Some initial cases were epidemiologically linked to travel to Mexico, but subsequent infections were transmitted domestically. Continued surveillance of Stx1-producing S. sonnei in California is necessary to characterize its features and plan for reduction of its spread in the United States.

Background: In May, 2013, an outbreak of symptomatic hepatitis A virus infections occurred in the USA. Federal, state, and local public health officials investigated the cause of the outbreak and instituted actions to control its spread. We investigated the source of the outbreak and assessed the public health measures used., Methods: We interviewed patients, obtained their shopping information, and did genetic analysis of hepatitis A virus recovered from patients' serum and stool samples. We tested products for the virus and traced supply chains., Findings: Of 165 patients identified from ten states, 69 (42%) were admitted to hospital, two developed fulminant hepatitis, and one needed a liver transplant; none died. Illness onset occurred from March 31 to Aug 12, 2013. The median age of patients was 47 years (IQR 35-58) and 91 (55%) were women. 153 patients (93%) reported consuming product B from retailer A. 40 patients (24%) had product B in their freezers, and 113 (68%) bought it according to data from retailer A. Hepatitis A virus genotype IB, uncommon in the Americas, was recovered from specimens from 117 people with hepatitis A virus illness. Pomegranate arils that were imported from Turkey--where genotype IB is common--were identified in product B. No hepatitis A virus was detected in product B., Interpretation: Imported frozen pomegranate arils were identified as the vehicle early in the investigation by combining epidemiology--with data from several sources--genetic analysis of patient samples, and product tracing. Product B was removed from store shelves, the public were warned not to eat product B, product recalls took place, and postexposure prophylaxis with both hepatitis A virus vaccine and immunoglobulin was provided. Our findings show that modern public health actions can help rapidly detect and control hepatitis A virus illness caused by imported food. Our findings show that postexposure prophylaxis can successfully prevent hepatitis A illness when a specific product is identified. Imported food products combined with waning immunity in some adult populations might make this type of intervention necessary in the future., Funding: US Centers for Disease Control and Prevention, US Food and Drug Administration, and US state and local public health departments., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Hispanics are less likely to receive the influenza vaccine compared to other racial and ethnic groups in the US. Hispanic residents of the US-Mexico border region may have differing health beliefs and behaviors, and their cross-border mobility impacts disease control. To assess beliefs and behaviors regarding influenza prevention and control among border populations, surveys were conducted at border clinics. Of 197 respondents, 34 % reported conditions for which vaccination is indicated, and travel to Mexico was common. Few (35 %) believed influenza could make them 'very sick', and 76 % believed they should take antibiotics to treat influenza. Influenza vaccine awareness was high, and considered important, but only 36 % reported recent vaccination. The belief that influenza vaccination is 'very important' was strongly associated with recent vaccination; "Didn't think about it" was the most common reason for being un-vaccinated. Misconceptions about influenza risk, prevention and treatment were common in this Hispanic border population; improved educational efforts and reminder systems could impact vaccination behaviors.

In 2010, 41 patients ill with Escherichia coli O157:H7 isolates determined to be indistinguishable by pulsed-field gel electrophoresis were identified among residents of five Southwestern U.S. states. A majority of patients reported consuming complimentary samples of aged raw-milk Gouda cheese at national warehouse chain store locations; sampling Gouda cheese was significantly associated with illness (odds ratio, 9.0; 95 % confidence interval, 1.7 to 47). Several Gouda samples yielded the O157:H7 outbreak strain, confirming the food vehicle and source of infections. Implicated retail food-sampling operations were inconsistently regulated among affected states, and sanitation deficiencies were common among sampling venues. Inspection of the cheese manufacturer indicated deficient sanitation practices and insufficient cheese curing times. Policymakers should continue to reexamine the adequacy and enforcement of existing rules intended to ensure the safety of raw-milk cheeses and retail food sampling. Additional research is necessary to clarify the food safety hazards posed to patrons who consume free food samples while shopping.

Objective: Human outbreaks of Salmonella infection have been attributed to a variety of food vehicles. Processed snack foods are increasingly consumed by children. In May 2007, state and local health departments and the Centers for Disease Control and Prevention investigated human infections from Salmonella Wandsworth, an extremely rare serotype., Materials and Methods: Serotyping and pulsed-field gel electrophoresis were used to identify outbreak-associated illnesses. Food history questionnaires and open-ended interviews were used to generate exposure hypotheses. A nationwide case-control study was conducted to epidemiologically implicate a source. Public health laboratories cultured implicated product from patient homes and retail stores., Results: Sixty-nine patients from 23 states were identified; 93% were aged 10 months to 3 years. Eighty-one percent of child patients had bloody diarrhea; 6 were hospitalized. No deaths were reported. The case-control study strongly associated illness with a commercial puffed vegetable-coated ready-to-eat snack food (mOR = 23.3, P = 0.0001), leading to a nationwide recall. Parents of 92% of interviewed case-children reported that children consumed the food during the week before their illness began; 43% reported daily consumption. Salmonella Wandsworth, 3 additional Salmonella serotypes and Chronobacter (formerly Enterobacter) sakazaki were all cultured from this product, leading to the identification of 18 human outbreak-related Salmonella Typhimurium illnesses., Conclusions: This report documents a nationwide outbreak associated with a commercial processed ready-to-eat snack food. Cases occurred primarily in infants and toddlers, many of whom frequently consumed the food. Measures are needed to ensure that ingredients added to ready-to-eat foods after the final lethal processing step are free of pathogens.

Objectives: We examined barriers to influenza vaccination among long-term care facility (LTCF) health care workers in Southern California and developed simple, effective interventions to improve influenza vaccine coverage of these workers., Methods: In 2002, health care workers at LTCFs were surveyed regarding their knowledge and attitudes about influenza and the influenza vaccine. Results were used to develop 2 interventions, an educational campaign and Vaccine Day (a well-publicized day for free influenza vaccination of all employees at the worksite). Seventy facilities were recruited to participate in an intervention trial and randomly assigned to 4 study groups., Results: The combination of Vaccine Day and an educational campaign was most effective in increasing vaccine coverage (53% coverage; prevalence ratio [PR]=1.45; 95% confidence interval [CI]=1.24, 1.71, compared with 27% coverage in the control group). Vaccine Day alone was also effective (46% coverage; PR= 1.41; 95% CI=1.17, 1.71). The educational campaign alone was not effective in improving coverage levels (34% coverage; PR=1.18; 95% CI=0.93, 1.50)., Conclusion: Influenza vaccine coverage of LTCF health care workers can be improved by providing free vaccinations at the worksite with a well-publicized Vaccine Day.

Background: In June 1996, an outbreak of chronic diarrhea was reported to the Texas Department of Health (Austin)., Methods: We initiated active case finding, performed 2 case-control studies, and conducted an extensive laboratory and environmental investigation., Results: We identified 114 persons with diarrhea that lasted > or = 4 weeks. Symptoms among 102 patients who were studied included urgency (87%), fatigue (86%), fecal incontinence (74%), and weight loss (73%); the median maximum 24-h stool frequency was 15 stools. Diarrhea persisted for > 6 months in 87% and for > 1 year in 70% of patients who were observed. Fifty-one (89%) of 57 ill persons had eaten at a particular restaurant within 4 weeks before onset, compared with 8 (14%) of 59 matched control subjects (matched odds ratio [OR], undefined; 95% confidence interval [CI], 11.2-infinity). At the restaurant, patients were more likely than their unaffected dining companions to have drunk tap water (OR, 2.8; 95% CI, 1.0-9.9) and to have eaten several specific food items, and they were less likely to have drunk iced tea made from boiled water and store-bought ice (OR, 0.3; 95% CI, 0.05-1.0). A multivariable model that included consumption of tap water and salad bar tomatoes best fit the data. The restaurant had multiple sanitary and plumbing deficiencies. Extensive laboratory and environmental testing for bacterial, parasitic, mycotic, and viral agents did not identify an etiologic agent., Conclusions: The clinical, laboratory, and epidemiologic findings are consistent with those of previous outbreaks of Brainerd diarrhea. To our knowledge, this is the largest reported outbreak of Brainerd diarrhea associated with a restaurant.

Background: Ralstonia pickettii is a Gram-negative bacillus commonly found in soil and moist environments; however, R. pickettii is rarely isolated from clinical specimens. In August 2001, a cluster of R. pickettii bacteremia occurred among neonatal intensive care unit (NICU) infants at a California hospital., Methods: A case-control study was conducted to determine risk factors for infection. A case was a NICU patient with R. pickettii bacteremia. Controls were NICU infants with negative blood cultures drawn during the same time period. A detailed environmental investigation was also conducted., Results: We identified 18 patients with 19 distinct episodes of R. pickettii bacteremia from July 30 through August 30, 2001. All cases had intravascular access at the time of bacteremia. Although the case-control study did not implicate any statistically significant risk factors, the most likely source of the outbreak was the heparin flush prepared in the hospital pharmacy. This is supported by the following: (1) the heparin flush was the only substance introduced directly into the bloodstream of all case infants; (2) the heparin flush was used exclusively by the NICU; and (3) no further cases were identified after the heparin flush was discontinued. Cultures of remaining heparin flush and environmental cultures from the NICU were negative for R. pickettii., Conclusions: This unusual outbreak of R. pickettii bacteremia was most likely caused by contaminated heparin flush and ended after the heparin flush was discontinued.

We investigated a multistate cluster of Escherichia coli O157:H7 isolates; pulsed-field gel electrophoresis subtyping, using a single enzyme, suggested an epidemiologic association. An investigation and additional subtyping, however, did not support the association. Confirmating E. coli O157 clusters with two or more restriction endonucleases is necessary before public health resources are allocated to follow-up investigations.

In 2000, shigellosis traced to a commercially prepared dip developed in 406 persons nationwide. An ill employee may have inadvertently contaminated processing equipment. This outbreak demonstrates the vulnerability of the food supply and how infectious organisms can rapidly disseminate through point-source contamination of a widely distributed food item.

In California, black tar heroin (BTH) use among injection drug users (IDUs) has resulted in an increased number of cases of wound botulism due to Clostridium botulinum, tetanus due to Clostridium tetani, and necrotizing soft-tissue infections due to a variety of clostridia. From December 1999 to April 2000, nine IDUs in Ventura County, California, developed necrotizing fasciitis; 4 died. Cultures of wound specimens from 6 case patients yielded Clostridium sordellii. Some of the patients appeared to have the toxic shock syndrome previously reported to be characteristic of toxin-mediated C. sordellii infection, which is characterized by hypotension, marked leukocytosis, and hemoconcentration. The suspected source of this outbreak was contaminated BTH that was injected subcutaneously or intramuscularly ("skin popped"). This outbreak of C. sordellii infection serves as another example of how BTH can potentially serve as a vehicle for transmitting severe and often deadly clostridial infections, and reinforces the need to educate IDUs and clinicians about the risks associated with skin popping of BTH.

The sources of sporadic Salmonella enterica serotype Enteritidis (SE) infections in the United States are unclear. To determine risk factors for sporadic SE infection, we conducted a population-based case-control study in 5 Foodborne Disease Active Surveillance Network surveillance areas. During the 12-month study, 396 cases of SE infection were ascertained. Among the 182 case patients and 345 controls, SE infection was univariately associated with international travel (matched odds ratio [MOR], 61; 95% confidence interval [CI], 8-447), eating undercooked eggs (MOR, 2.2; 95%CI, 1-5), and eating chicken prepared outside of the home (MOR, 2.2; 95% CI, 1.3-3.4). Multivariate analysis revealed that eating chicken outside of the home remained the only significant risk factor for illness (MOR, 2.0; 95% CI, 1.1-3.6). Chicken consumption has not previously been identified in the United States as a risk factor for SE infection. Measures to prevent SE infections include educating consumers and food handlers about food safety and interventions to decrease contamination of eggs and poultry.

Introduction: Our purpose was to review the clinical features of head and neck cellulitis in hospitalized patients., Material and Methods: A retrospective review was undertaken of 147 cases of head and neck cellulitis seen over a 15-year period at a community Hawaiian hospital., Results: Otologic cellulitis was mainly related to otitis externa, caused by Pseudomonas aeruginosa, although some cases had infected pierced ears or ear cysts. Cervical cellulitis was associated with malignancy, dental infection, or lymphadenitis; these patients often had positive blood cultures. Facial cellulitis was almost always caused by Staphylococci and Streptococci, usually preceded by dental infections, traumatic abscesses, or sinusitis. All study patients recovered completely, except for one patient who developed cavernous vein thrombosis and oculomotor palsy. Seventy-five percent of the patients recovered with parenteral antibiotics alone; the other patients required abscess drainage and/or other surgical procedures, especially if neck infection was present., Conclusion: Although head and neck cellulitis cases have grave potential consequences, most patients do very well with proper antibiotics and appropriate surgical drainage.