The case count in a Salmonella outbreak linked to rice milk formula has increased again, with 26 possible infections in France.

The French National Public Health Agency (Santé publique France) reported 12 confirmed cases of Salmonella Poona and another 14 under investigation. Luxembourg and Belgium also have one case each linked to the outbreak.

Of the 26 cases in France, 18 are boys and eight are girls that live in 10 different regions. They were aged between 2 months and 2 years at the time of symptoms – between late August 2018 and Jan. 27, 2019. All cases had diarrhea, 13 had blood in their stool and 25 had fever. Twelve babies were hospitalized for salmonellosis and have since been released.

Interviews with parents have identified Modilac brand powdered milk formula produced by a factory in Spain as the outbreak source. The company that markets these products, Sodilac, issued a recall in late January. Lactalis recalled Picot AR that was made at the same Spanish site.

Drying tower suspended and rice-based items recalled
Earlier this month, Laboratorios Ordesa S.A. became the third company to recall rice milk formula made at the Industrias Lacteas Asturianas SA (ILAS) factory in Anleo, a municipality in the Spanish province of Asturias.

Tests on products and facilities have so far been negative for Salmonella Poona. One of the drying towers at the factory was suspended and all rice-based items produced in it withdrawn.

In a statement to Food Safety News, ILAS said since onset of the first case in France, the company has been in contact with health authorities.

“From the beginning, the company opened an investigation to find out whether there is a relationship between the product and the cases and, if so, what the origin could be. The investigation is ongoing and a control of all the products is being carried out. To date, no analyses carried out on the product, nor the environmental controls, have detected the presence of Salmonella.

“The company has adopted all control and safety measures established for these cases. Preventively, the complex process to produce rice-based products, which requires special conditions, has been suspended, and the rice-based products have been removed from the market.”

Suspension of the tower wher the product was made will be lifted once safety is /confirm/ied.

“Since 2011, there have been more than 70 million kilos of product without there being any type of incident, and we are working with the best specialists in microbiology to guarantee the quality of our products.”

ILAS only makes the rice-based product for the two companies that have already issued recalls.

Strain related to 2010-2011 outbreak
An outbreak of Salmonella Poona attributed to consumption of powdered milk in infants in Spain between Jan. 8, 2010, and July 12, 2011, sickened 289 infants.

The Spanish factory implicated in the current outbreak is the same as the one in the 2010 and 2011 incident. The Salmonella Poona strains in the two outbreaks are genetically related.

Belgium, Denmark, France, Germany, Italy, Libya, Luxembourg, Morocco, Netherlands, Norway, Portugal, Romania, Spain, Switzerland, Syria, Tunisia, United Kingdom and Vietnam could have implicated products, with online sales led by Amazon.

Peter K. Ben Embarek, INFOSAN management, department of food safety and zoonoses at WHO, told Food Safety News that after the first French recall it checked with France to see what, if any, had been exported to countries outside Europe. Distribution in Europe is led via the RASFF portal.

The International Food Safety Authorities Network (INFOSAN) is managed by the Food and Agriculture Organization (FAO) and World Health Organization (WHO).

“There were five countries that had received products outside Europe: Morocco, Tunisia, Libya, Syria and Vietnam. So we shared details of what had been exported with them and four have made local recalls. The only one wher it is still not clear is Syria, as it is a bit more complicated there,” he said.

“There were much smaller quantities, all were product aimed at allergic kids so a limited market. So far no illnesses reported but we are also facilitating the sharing of sequences from the French cases so other countries can compare and see if they have cases in the outbreak.”

Ben Embarek said the strain in the current outbreak being closely related to that of the 2010-11 incident brings back memories of the Salmonella Agona outbreak last year with Lactalis and the Craon plant.

In that outbreak, recalled formula was distributed to more than 80 countries and an estimated 12 million boxes were affected. Thirty eight babies fell sick in France, two in Spain and one in Greece. It was the same strain that was behind 141 illnesses in 2005 when the Craon site was owned by Célia. Institut Pasteur in France retrospectively identified 25 cases with the same strain between 2006 and 2017.

“A strain is establishing itself in a factory and it stays there for a long time, in that case several years, and creates different outbreaks over time and probably also some sporadic cases in between as was the case with Lactalis last year,” he said.

“That is the new power of whole genome sequencing, it allows us to make this kind of link that would have been impossible in the past and open up a whole new range of issues that we will have to address of how to properly get rid of pathogens in this type of factory environment as normal cleaning and disinfection procedures are obviously not enough.”

Scale of Modilac recall
Recalled Modilac products were produced from summer last year so had a different exposure over a longer period of time, according to Ben Embarek.

“The Lactalis recall is much smaller at 16,000 boxes, while the Modilac one is 400,000 so on a whole different scale. Why are there no cases linked to the two other brands? It is a good question, maybe they will pop up, it is still early days, we don’t know yet if they were produced on the same production line or just the same factory,” he said.

“There could be more cases as it is a product with a long shelf life and there might still be cans in people’s homes but the recall should have a positive effect by making sure we don’t have a sharp rise in the number of cases.”

Ben Embarek said it is not yet known wher the strain could have spread in the factory and what product or production line could have been contaminated.

“From the relatively low number of cases it is probably a low contamination level as authorities and the company have not been able to detect the strain in the processing environment or in the products they looked at and that is probably because of the very low contamination level making it easy to miss,” he said.

“The link so far has only been made through interviewing parents of the babies affected on what products and brands they have bought. Babies are more susceptible and they only consume this, it is 100 percent of their diets so they get continuous exposure to it several times a day and that has a much stronger effect then if they were just eating one contaminated apple or whatever an adult would do as part of their diverse diets.”