More than 300 people from 16 countries have been sickened in a Salmonella outbreak linked to Kinder chocolate made by Ferrero in Belgium.

A total of 324 cases have been reported from Austria, Belgium, Denmark, France, Germany, Ireland, Italy, Luxembourg, Netherlands, Norway, Spain, Switzerland, Sweden and the United Kingdom. Canada and the United States are also affected.

The number of people sick has more than doubled since a previous assessment in April by the European Centre for Disease Control and Prevention (ECDC) and European Food Safety Authority (EFSA).

Hundreds of people, mainly children, sick
The UK is the main country affected with 109 monophasic Salmonella Typhimurium patients, France has 81, Belgium has 64 and Switzerland has 43. The United States and Canada both have one each. The Canadian case is a child under the age of 10 with a symptom onset date of Feb. 19. The U.S. patient was reported from the state of Illinois.

Almost 200 people have been interviewed and 170 reported consumption of chocolate products made by Ferrero.

However, eight cases cannot be explained by chocolates manufactured at the Arlon, Belgium factory, suggesting there may be other sources of infection, said ECDC and EFSA. These patients did eat different products made by Ferrero but it is not known wher they were made.

Most cases are children under the age of 10 and females are more affected than males. From those with available data, almost half have been hospitalized but no deaths have been recorded.

Positive Salmonella results
Belgian authorities reported 81 samples from finished and semi-finished products, intermediate products, raw materials, environmental swabs and rinse oil samples taken in company checks at the plant from early December 2021 to late January 2022 tested positive for Salmonella. In April, seven samples from finished products tested positive for Salmonella.

Production was stopped on Dec. 16, restarted on Jan. 3, stopped again on Jan. 7 and resumed a few days later.

Belgian officials stopped production at the facility in early April but it could reopen next month with provisional authorization which would be evaluated after three months.

Salmonella positive items were destroyed, the production line was cleaned and an internal investigation launched. Production restarted after negative tests for Salmonella, and all final products were released after a negative result of the tested batch.

A recall has been issued but potentially contaminated products have still been found on sale. Cost of the Ferrero recall could exceed $60 million, according to insurance firm Lockton.

Buttermilk from Italian company
The average time from production to retail is 60 days so the first sampled case in the UK on Dec. 21, 2021, is very unlikely to be explained by contamination detected in the plant in December 2021. This suggests that contamination in the factory occurred earlier than December 2021, said EFSA and ECDC.

Two types of monophasic Salmonella Typhimurium matching the outbreak strains were identified in the buttermilk line at Ferrero’s plant between December 2021 and January 2022. Buttermilk was provided by an Italian supplier wher Salmonella was not detected. This firm also sent buttermilk to other plants of Ferrero and Salmonella has not been detected.

There are two Salmonella strains involved, both are multidrug-resistant, and some isolates carry resistance to disinfectants based on quaternary ammonium compounds and hydrogen peroxide, but remain susceptible to azithromycin, ciprofloxacin, meropenem, and third generation cephalosporins.

Chocolate produced in Belgium was distributed to at least 113 countries.

The first patient was reported in the UK on Jan. 7, with a sampling date of Dec. 21, 2021. The UK issued a notice on a European platform on Feb. 17 and another alert on March 25. It notified the WHO about the cluster of monophasic Salmonella Typhimurium on March 27.