An E. coli outbreak traced to chopped romaine lettuce has spread to another five states and public health officials are reporting a hospitalization rate of almost 60 percent, which is twice the usual rate.

There are 53 confirmed cases spread across 16 states, as of Wednesday’s updat from the federal Centers for Disease Control and Prevention. Of the 31 victims who have required hospitalization, five have developed a type of kidney failure called hemolytic uremic syndrome.

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Both the CDC and the Food and Drug Administration renewed their public warnings Wednesday regarding chopped romaine lettuce, specifically from the Yuma, AZ, growing area. The CDC first posted the warning April 13, three days after its initial outbreak report.

“If you cannot confirm the source of the romaine lettuce, do not buy it or eat it. If you have already purchased products containing chopped romaine lettuce, including bagged salads, salad mixes, or prepared salads, throw them away,” the FDA reiterated in its investigation updat Wednesday.

Public health officials across the country have been interviewing sick people in recent weeks after New Jersey officials identified a cluster of E. coli O157H:7 illnesses. In 41 of the 43 completed interviews, the infected people reported eating chopped romaine the week before becoming ill. That’s a 95 percent reporting rate.

Illnesses that occurred after March 29 might not yet be reported because of the time it takes between when a person becomes ill from an E. coli infection and when the illness is lab confirmed and reported. This takes an average of two to three weeks, according to the CDC. Known illnesses began March 13 with the most recent person having become sick on April 6.

Some retailers and restaurants have pulled romaine from their shelves and menus because of the government warnings. However, at least one fresh produce association says it is incorrect to refer to those actions as recalls because specific growers or processors have not been named.

“… the produce industry is asking members of the supply chain to refrain from using ‘recall’ because consumers may assume when they hear the word that the specific product in question has been definitively linked to the outbreak,” according to an April 16 statement to members from Jennifer McEntire, vice president of food safety for the United Fresh Produce Association.

On April 13, United Fresh and four other fresh produce groups — Produce Marketing Association, Arizona Leafy Greens Marketing Agreement, California Leafy Greens Marketing Agreement, and Western Growers — issued a joint statement. They said the industry is cooperating fully with government on the outbreak investigation and stressed that only chopped, bagged romaine from the Yuma, AZ, area has been linked to the outbreak.

The CDC reaffirmed Wednesday that only store-bought chopped romaine and chopped romaine served in restaurants are linked to sick people so far.

Most people reported eating salad at a restaurant, and romaine lettuce was the only common ingredient identified among the salads eaten, the CDC reported. The restaurants reported using bagged, chopped romaine lettuce to make salads. Ill people have not been reporting whole heads or hearts of romaine.

Government and industry are reporting that the risk of additional new infections is decreasing because the growing season in Arizona is wrapping up. As harvest in the Yuma area begins to dro off, usually in mid-March, the romaine growers in California begin shipping. The Arizona Department of Agriculture has confirmed that shipments of romaine from the state started dropping off in recent weeks and the U.S. Department of Agriculture reports shipments out of California are increasing. 

Insight from the FDA’s produce scientist
Jim Gorny, who is back at the FDA after several years with the Produce Marketing Association, has a relatively unique view on the outbreak and investigation. He’s seen these situations from both perspectives and he agrees that the transition from Arizona to California will likely provide a natural interruption in the outbreak. 

The relatively short shelf life of freshcut produce, particularly leafy greens, also provides a kind of self-limiting factor in terms of contaminated product in the supply chain. After it’s harvested, it takes several days for frseshcut romaine and other chopped leafy greens to reach restaurants and grocery stores. Gorny said chopped leafy greens have about 7 to 10 days of shelf life.

“The clock ticks a lot faster once they’re cut,” he said. “Just think of the head of lettuce in your refrigerator. When you chop it up it starts browning on the edges quickly.”

The chopping process also increases the chance for widespread contamination as well as a convenient growth medium. The tanks of water used in fresh processing can spread pathogens from one head of lettuce to an entire lot of bagged lettuce. The cut edges serve as open wounds for pathogens to enter the greens and thrive in a relatively protected environment.

Proper food safety measures reduce the risks associated with freshcut leafy greens, but Gorny said pathogens “shouldn’t be there in the first place.” When foodborne bacteria like E. coli does infiltrate the process and the food, Gorny said warnings and recalls are absolutely necessary. 

But, as senior science advisor for produce safety at the FDA, he wants to make sure the public understands why government posts warnings and why industry recalls products.

“I think people are sometimes missing the point of recalls,” Gorny said earlier this week. 

The number one reason for a recall is to prevent consumption of a product that could cause harm, he said.

The other two reasons for recalls are to alert people about symptoms so they can seek treatment if they consumed the recalled products, and to alert consumers as well as foodservice operators as soon as possible about the possibility of cross contamination from the recalled products.

Quick action helped consumers
Both industry and consumer advocates have praised the FDA and CDC for acting quickly to alert the public to the connection between chopped romaine and the current E. coli outbreak.

“… government agencies, retailers, restaurants and producers quickly acted to do everything possible to remove any product that could possibly have been involved in this outbreak,” the California Leafy Greens Marketing Association said Wednesday in a news release.

Seattle food safety attorney and victim advocate Bill Marler said the FDA and CDC did the right thing by getting on the leading edge of the outbreak instead of waiting to name a specific grower or processor. The decision to alert the public about the link to chopped romaine on April 13 no doubt helped to decrease the scope of the outbreak, but Marler and the CDC investigators expect cases to continue to be /confirm/ied.

“This stuff (chopped romaine) went all over the country,” Marler said. “This outbreak has the potential to be as big as the spinach E. coli outbreak in 2006.”

In that 26-state outbreak, there were 205 confirmed E. coli O157:H7 illnesses, including 31 cases of hemolytic uremic syndrome, 104 hospitalizations, and four deaths.

Marler represented a number of victims on the spinach outbreak. He has already filed a civil case for a 66-year-old woman in New Jersey who became ill after eating a salad at a Panera Bread restaurant. Louise Fraser was hospitalized for more than two weeks with the infection and is till recovering. Her treatment included several blood transfusions, according to the lawsuit.

New Jersey officials began investigating a cluster of E. coli illnesses more than two weeks ago. A county epidemiologist told NJ.com that Panera Bread locations were possibly connected with the illnesses.