During August-October 2020, United States federal, state, and Canadian partners investigated an outbreak of Salmonella Enteritidis infections, in the U.S. and Canada, linked to fresh, whole peaches packed and supplied by a grower and packer with multiple orchards (Farm A). In the U.S., a total of 101 ill people and 28 hospitalizations were reported in 17 states, while in Canada, 57 ill people and 12 hospitalizations were reported in two Canadian provinces. The U.S. traceback investigation included 14 points of service (POS), representing 18 illnesses in eight states. Multiple distributors, packinghouses, and orchards supplied bagged and loose peaches during the timeframe of interest to identified POS, with peaches and packinghouses linked to Farm A being the primary source. Orchards of interest were identified for peach fruit, orchard tree leaf, and soil-drag swab sample collection using traceback and geospatial analysis. Geospatial analyses showed that several orchards were in proximity to animal operations. While none of the Salmonella isolates recovered matched the outbreak strain, Salmonella Alachua was recovered from peaches and leaf samples, and Salmonella Montevideo was recovered from orchard tree leaves. Whole genome sequencing indicated that these Salmonella isolates were closely related to historical poultry and cattle isolates. Farm A voluntarily recalled loose peaches sold from June 1 to August 3, 2020, and bagged Brand A conventional and organic peaches sold from June 1 to August 19, 2020. Recalled products were likely distributed to at least 14 different countries. Findings suggest that adjacent animal operations may be a potential contributing factor to Salmonella contamination of peaches, with windborne or fugitive dust as a possible route. The findings from this first reported international outbreak of Salmonella linked to peaches grown in the U.S. highlight the importance of grower awareness of adjacent land use.

Foodborne hepatitis A illnesses and outbreaks have been associated with consumption of ready-to-eat foods contaminated with the feces of person(s) shedding hepatitis A virus (HAV). Outbreaks have been linked to fresh and frozen produce imported from countries where HAV is endemic, hygiene and sanitation are inadequate, or food safety standards are lacking or unenforced. In 2022 and 2023, federal, state, and international partners investigated two multijurisdictional outbreaks of infections involving the same HAV genotype IA strain linked to fresh and frozen organic strawberries sourced from a single grower in Baja California, Mexico. These resulted in 39 reported cases in the U.S. and Canada, 21 hospitalizations, and no reported deaths. The United States Food and Drug Administration (FDA), Canadian Food Inspection Agency, and U.S. state partners conducted traceback investigations for fresh strawberries in 2022, while FDA and U.S. state partners traced back frozen strawberries in 2023. Based on the traceback investigations, implicated strawberries were harvested during the 2022 growing season and sold to fresh and frozen berry markets. During a farm inspection in Mexico in 2023, gaps were observed in agricultural practices that could have contributed to contamination of strawberries with HAV. FDA did not detect HAV in the two frozen strawberry samples linked to the recalled lots or environmental water samples collected at the implicated grower in 2023; no samples were collected during the 2022 investigation. Indicator organisms associated with human fecal contamination (male-specific coliphage and crAssphge) were detected in environmental water. Challenges in these investigations included limited recall of food exposures, exposures associated with multiple purchase dates, commingling of strawberries within the frozen market supply chains, and complexities with communicating these outbreak investigations to the public.

Foodborne illness is a continuous public health risk. The recognition of signals indicating a cluster of foodborne illness is key to the detection, mitigation, and prevention of foodborne adverse event incidents and outbreaks. With increased internet availability and access, novel data streams (NDSs) for foodborne illness reports initiated by users outside of the traditional public health framework have emerged. These include, but are not limited to, social media websites, web-based product reviews posted to retailer websites, and private companies that host public-generated notices of foodborne illnesses. Information gathered by these platforms can help identify early signals of foodborne illness clusters or help inform ongoing public health investigations. Here we present an overview of NDSs and 3 investigations of foodborne illness incidents by the US Food and Drug Administration that included the use of NDSs at various stages. Each example demonstrates how these data were collected, integrated into traditional data sources, and used to inform the investigation. NDSs present a unique opportunity for public health agencies to identify clusters that may not have been identified otherwise, due to new or unique etiologies, as shown in the 3 examples. Clusters may also be identified earlier than they would have been through traditional sources. NDSs can further provide investigators supplemental information that may help confirm or rule out a source of illness. However, data collected from NDSs are often incomplete and lack critical details for investigators, such as product information (eg, lot numbers), clinical or medical details (eg, laboratory results of affected individuals), and contact information for report follow-up. In the future, public health agencies may wish to standardize an approach to maximize the potential of NDSs to catalyze and supplement adverse event investigations. Additionally, the collection of essential data elements by NDS platforms and data-sharing processes with public health agencies may aid in the investigation of foodborne illness clusters and inform subsequent public health and regulatory actions.

In 2022, the U.S. Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), U.S. state and local partners, the Public Health Agency of Canada (PHAC), and the Canadian Food Inspection Agency (CFIA), conducted a bi-national sample-initiated retrospective outbreak investigation (SIROI) of Listeria monocytogenes illnesses linked to enoki mushrooms. The FDA and CDC investigated the first known L. monocytogenes outbreak linked to enoki mushrooms from 2016-2020, making the 2022 outbreak the second time this pathogen-commodity pair was investigated by FDA and CDC. The 2022 outbreak included six ill people, all of whom were hospitalized. Epidemiologic, laboratory, and traceback evidence led to multiple public health actions, including voluntary recalls by firms, public communications about the outbreak, and FDA's country-wide Import Alert for enoki mushrooms from China. This SIROI illustrates the importance of surveillance sampling, national and international coordination of efforts, and rapid information sharing to identify and stop foodborne outbreaks on a global scale. To reduce the risk of listeriosis illnesses linked to contaminated enoki mushrooms, public health and regulatory agencies in the United States and Canada remain committed to conducting comprehensive surveillance for Listeria in foods and in people, efficiently investigating identified outbreaks, and implementing control measures to potentially minimize the impact of future outbreaks.

In 2021, the U.S. Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and state and local health and regulatory partners investigated an outbreak of Salmonella enterica serovar Oranienburg infections linked to bulb onions from Mexico, resulting in 1040 illnesses and 260 hospitalizations across 39 states, the District of Columbia, and Puerto Rico. The Kansas Department of Agriculture recovered the outbreak strain of Salmonella Oranienburg from a sample of condiment collected from an ill person's home. The condiment was made with cilantro, lime, and onions, but, at the time of collection, there were no onions remaining in it. FDA conducted traceback investigations for white, yellow, and red bulb onions, cilantro, limes, tomatoes, and jalapeño peppers. Growers in the state of Chihuahua, Mexico, were identified as supplying the implicated onions that could account for exposure to onions for all illnesses included in the traceback investigation, but investigators could not determine a single source or route of contamination. FDA collected product and environmental samples across the domestic supply chain but did not recover the outbreak strain of Salmonella. Binational collaboration and information sharing supported Mexican authorities in collecting environmental samples from two packing plants and onion, water, and environmental samples from 15 farms and firms in Chihuahua, Mexico identified through FDA's traceback investigation, but did not recover the outbreak strain. Distributors of the implicated onions issued voluntary recalls of red, yellow, and white whole, fresh onions imported from the state of Chihuahua, Mexico. This outbreak showcased how investigators overcame significant traceback and epidemiologic challenges, the need for strengthening the ongoing collaboration between U.S. and Mexican authorities and highlighted the need for identifying practices across the supply chain that can help improve the safety of onions. © 2024

An observational cohort analysis was conducted within the Surveillance, Prevention, and Management of Diabetes Mellitus (SUPREME-DM) DataLink, a consortium of 11 integrated health-care delivery systems with electronic health records in 10 US states. Among nearly 7 million adults aged 20 years or older, we estimated annual diabetes incidence per 1,000 persons overall and by age, sex, race/ethnicity, and body mass index. We identified 289,050 incident cases of diabetes. Age- and sex-adjusted population incidence was stable between 2006 and 2010, ranging from 10.3 per 1,000 adults (95% confidence interval (CI): 9.8, 10.7) to 11.3 per 1,000 adults (95% CI: 11.0, 11.7). Adjusted incidence was significantly higher in 2011 (11.5, 95% CI: 10.9, 12.0) than in the 2 years with the lowest incidence. A similar pattern was observed in most prespecified subgroups, but only the differences for persons who were not white were significant. In 2006, 56% of incident cases had a glycated hemoglobin (hemoglobin A1c) test as one of the pair of events identifying diabetes. By 2011, that number was 74%. In conclusion, overall diabetes incidence in this population did not significantly increase between 2006 and 2010, but increases in hemoglobin A1c testing may have contributed to rising diabetes incidence among nonwhites in 2011.

Botulism is a severe neurological disease caused by the complex family of botulinum neurotoxins (BoNT). Based on the different serotypes known today, a classification of serotype variants termed subtypes has been proposed according to sequence diversity and immunological properties. However, the relevance of BoNT subtypes is currently not well understood. Here we describe the isolation of a novel Clostridium botulinum strain from a food-borne botulism outbreak near Chemnitz, Germany. Comparison of its botulinum neurotoxin gene sequence with published sequences identified it to be a novel subtype within the BoNT/A serotype designated BoNT/A8. The neurotoxin gene is located within an ha-orfX+ cluster and showed highest homology to BoNT/A1, A2, A5, and A6. Unexpectedly, we found an arginine insertion located in the HC domain of the heavy chain, which is unique compared to all other BoNT/A subtypes known so far. Functional characterization revealed that the binding characteristics to its main neuronal protein receptor SV2C seemed unaffected, whereas binding to membrane-incorporated gangliosides was reduced in comparison to BoNT/A1. Moreover, we found significantly lower enzymatic activity of the natural, full-length neurotoxin and the recombinant light chain of BoNT/A8 compared to BoNT/A1 in different endopeptidase assays. Both reduced ganglioside binding and enzymatic activity may contribute to the considerably lower biological activity of BoNT/A8 as measured in a mouse phrenic nerve hemidiaphragm assay. Despite its reduced activity the novel BoNT/A8 subtype caused severe botulism in a 63-year-old male. To our knowledge, this is the first description and a comprehensive characterization of a novel BoNT/A subtype which combines genetic information on the neurotoxin gene cluster with an in-depth functional analysis using different technical approaches. Our results show that subtyping of BoNT is highly relevant and that understanding of the detailed toxin function might pave the way for the development of novel therapeutics and tailor-made antitoxins.

We read with interest the recent report by Kirchner et al [1] in BJR, which describes the results of the International Labour Office (ILO) classifications of routine digital chest radiographs as well as readings of contrast-enhanced chest CT images among a convenience-based sample of 85 tobacco smokers who were clinically referred for chest imaging, primarily for known or suspected cancer. Chest radiographs for the study were obtained using a storage phosphor digital system, and hard copies were printed from the digital image files via a laser printer. Transparencies were then displayed and classified by two board-certified radiologists. It was not described whether or not the classifications were made independently, and if so, how the readings were summarised. The data were presented as a correlation (see Figure 2) between pack-years and the ILO classification scores, which was found to be significant. Only slightly more than half of the data points were visible in this figure, leaving the reader to infer that some of the points presented represented more than one value. However, the actual distribution of the data cannot be inferred with the presentation of the results in this format. Additionally, there was no mention of how recognised confounding factors, such as age or occupational exposures, were accounted for in the correlation. | A number of previous studies have shown that, in the absence of occupational dust exposures, cigarette smoking and increasing age may lead to a one- or two-subcategory increase in the profusion of irregular type opacities. However, our reading of this report raised a number of concerns regarding study methods, including image acquisition and classification, as well as conclusions.

Botulinum neurotoxins (BoNTs) cause the disease botulism, which can be lethal if untreated. There are seven known serotypes of BoNT, A-G, defined by their response to antisera. Many serotypes are distinguished into differing subtypes based on amino acid sequence, and many subtypes are further differentiated into toxin variants. Previous work in our laboratory described the use of a proteomics approach to distinguish subtype BoNT/A1 from BoNT/A2 where BoNT identities were confirmed after searching data against a database containing protein sequences of all known BoNT/A subtypes. We now describe here a similar approach to differentiate subtypes BoNT/B1, /B2, /B3, /B4, and /B5. Additionally, to identify new subtypes or hitherto unpublished amino acid substitutions, we created an amino acid substitution database covering every possible amino acid change. We used this database to differentiate multiple toxin variants within subtypes of BoNT/B1 and B2. More importantly, with our amino acid substitution database, we were able to identify a novel BoNT/B subtype, designated here as BoNT/B7. These techniques allow for subtype and strain level identification of both known and unknown BoNT/B rapidly with no DNA required.