French authorities are investigating more than a dozen cases of Salmonella infection in babies less than 19 months old. The illnesses are linked to a rice milk formula made in Spain.

Of the 14 babies involved in the investigation, the French National Public Health Agency (Santé publique France) reports five have been confirmed and nine are under investigation. Seven of the babies were hospitalized for salmonellosis but have since recovered.

Luxembourg and Belgium have reported one case each linked to the outbreak.

The Salmonella National Reference Center (CNR) at the Institut Pasteur in France has found five infections of Salmonella Poona in infants whose strains belong to the same genomic cluster. CNR has identified nine other babies who had Salmonella Poona. The strains from these babies are being analyzed to see if they belong to the same cluster.

Nine of the babies are boys and five are girls. They live in 10 different regions of France. They were aged 2 months to 19 months at the time of symptoms. Illness onset dates range from late August 2018 to Jan. 23, 2019.

Santé publique France is interviewing parents of sick babies about symptoms and feeding history before they got ill. Investigations so far have highlighted consumption, in the days before symptoms, of Modilac brand powdered milk produced by a single plant in Spain.

Sodilac, the company that markets the items and is a subsidiary of Savencia SA, withdrew and recalled its range of infant nutrition products based on rice proteins and all infant formula made at the Spanish production site.

Lactalis later recalled 16,300 boxes of Picot AR milk because it was made at the same Spanish site. No illnesses in this outbreak have been linked to any Lactalis products.

Belgium officials reported a case of Salmonella infection in an infant linked to the outbreak in France despite implicated Modilac products not being distributed on the market in the country.

Luxembourg had one Salmonella Poona infection in January this year in a child who consumed the same brand of infant formula ordered on the internet.

Italian authorities said French officials informed them that some of the products subject to the alert had been sold via Amazon. In Italy, Amazon sold 48 packs online through 15 orders.

Distribution includes Belgium, Denmark, France, Germany, Italy, Libya, Luxembourg, Morocco, Netherlands, Norway, Portugal, Romania, Spain, Switzerland, Syria, Tunisia, United Kingdom and Vietnam, according to an alert on the RASFF portal.

The Czech Republic detected four cases of Salmonella Poona in 2018. In January this year it identified one infection in a 17-month-old child who did not consume the suspected infant formula.

Germany has reported two cases in infants since the beginning of 2018. The Netherlands recorded one case in a 1-year-old child in 2018. Switzerland has one case in an infant with sampling dates ranging from December 2017 to March 2018. No exposure information was available for Germany, the Netherlands and Switzerland. Sequencing is ongoing in Belgium, Germany and the Netherlands to determine the specific strain of Salmonella involved.

The European Centre for Disease Prevention and Control (ECDC) has asked the European Food Safety Authority (EFSA) to do a joint rapid outbreak assessment on the incident.