Friday, August 30, 2013

Let the Alarmism Begin on The Safety of Spices

Earlier this week, we commented on the New York Times report regarding an FDA study on the safety of spices ( . We indicated that there is essentially no risk for consumers when buying spices from the grocery store. Brand label spices are produced by reputable companies, such as McCormick, have extensive food safety systems in place that minimize the risk.

But unfortunately, major media outlets can’t help themselves from jumping on this study and spreading some fear. At least, the NY Times article’s title ‘Spices’ Link to Food Ills Prompts Changes in Farming’ wasn’t overly misleading. But from that article, other news outlets had their own spin in order to ‘one-up’ the other. Let’s take a look at these titles. 

From NPR, we have ‘ Your Kitchen Spices Can Often Harbor Salmonella’. The title suggests something that is completely inaccurate. Even the reader’s comments at the bottom of the article (you can connect to the link on the article below to read) indicate that these readers know that this is over-the-top fear mongering.

NPR is not the only one. LA Weekly has an article “Spices a Potent Source of Food Poisoning”. Not to be outdone MSN News has - Rumor: Common kitchen spices contain salmonella’ and goes on to state that this rumor is true. No it is not.

Certainly there have been a few incidents that contaminated spices have resulted in illnesses, but these were extremely isolated and due to unique circumstances. Going back to look at the original study, there are few things we can see in this FDA study which was published in Food Microbiology that warrant comment :

  • The sampling in the study primarily evaluated untreated spices which had a higher level of contamination…as we would expect. Will those spices be treated at some point during further processing….probably yes?
  • We don’t know the type of importer for the spices that were found positive. Were the major spice companies, or smaller importers? Companies with familiar brands names must protect those brands, and thus will have solid quality and safety programs including preventive control measures. But unfortunately, this study does not indicate they type of company. And the news articles then lump all spice companies together.

This is not to say that these companies representing major brands will not have the occasional issue, but they are few and far between. So as I put pepper on my pizza tonight, I will not worry about Salmonella contamination. Will you worry about the spices in your cabinet? Probably not.

The real take home from the FDA study is that companies who import spices need to have preventive controls in place to ensure the safety of those items.

Your Kitchen Spices Can Often Harbor Salmonella
by Nancy Shute
August 29, 2013 3:16 PM
NPR – The Salt

 Spice may be nice, but spices also can carry very bad bugs. About 7 percent of spices tested by Food and Drug Administration researchers were contaminated with salmonella, which can cause serious illness and death. Because of this finding and others, the FDA and international food safety organizations are putting more effort into how to reduce the risk.
A New York Times
article this week really brought the issue to everyone's attention. Here are some of the questions we've been asking about spices and salmonella here at The Salt:

Wednesday, August 28, 2013

Safety of Imported Foods - Spices and FSMA

A NY Times article released today (below with link) details the high contamination Salmonella rate of spices and the challenges that exist in importing products. Primarily, these spices are produced in tropical zones in ‘rustic’ conditions. Because of this, these items have a high risk of becoming contaminated with Salmonella (from birds, animal manure, reptiles, etc) and then, that organism can survive in these dried spices for months or longer.

Spices have been processed this way it has been since the time of the spice trade, thousands of years ago. But as consumers, do we generally worry about the safety of spices? Generally not. Companies that have been involved in buying and selling spices have secured their supply chains and where needed, have added interventions such as irradiation to eliminate these bacterial hazards. So there is no risk to the consumer, when you look at the vast quantities of spice consumed each day in this country.

This is not to say there have not been issues, but primarily those issues were linked to food companies using less than reliable sources for their spices. In the small number of cases where there have been issues, importers of spice did not have adequate control measures in place.

So what is the point of the NY Times article? It is directed at the Foreign Supplier Verification Program (FSVP) component of FSMA. In this proposed regulation, emphasis is put on the companies who import food to ensure the safety of those foods. It defines the importer as the person in the US who has purchased the item, and in many cases, this can be the retailer or the distributor. 

The NY Times piece provides ammunition for those who feel that the federal government should have a heavier hand in determining the safety of those imported food items. This would necessitate a heavy testing program conducted by the government agencies at the border for incoming foods and having FDA inspectors inspect foreign companies.

With about 15% of the food consumed in this country being imported, it is not financially feasible to have FDA take on that responsibility. The concept proposed in FSVP is better…making companies responsible for the foods they import. We just have to look at companies like McCormick who have practiced the safe importation and processing of spices for more than a century.  

For those identified as importers, FSVP provides the elements of a supplier verification program that these companies will need to establish for each suppler, including verifying that he supplier has a HACCP type system in place and conducting verification, corrective action, and record keeping activities.

In the long run, FSVP will create a stronger food supply system. Companies who sell imported foods will either be forced out of selling if they are not willing or capable of implementing such an adequate supplier contol system, or will need to align with an importer who does have the necessary capabilities.

NY Times
Spices’ Link to Food Ills Prompts Changes in Farming
Published: August 27, 2013

IDUKKI, India — Spices grown in the mist-shrouded Western Ghats here have fueled wars, fortunes and even the discovery of continents, and for thousands of years farmers harvested them in the same traditional ways. Until now.

Science has revealed what ancient kings and sultans never knew: instead of improving health, spices sometimes make people very sick, so Indian government officials are quietly pushing some of the most far-reaching changes ever in the way farmers here pick, dry and thresh their rich bounty.

The United States Food and Drug Administration will soon release a comprehensive analysis that pinpoints imported spices, found in just about every kitchen in the Western world, as a surprisingly potent source of salmonella poisoning.

Tuesday, August 27, 2013

Cyclospora cases now over 600, Texas cases not linked to Taylor bagged salad

As of August 26th, CDC is reporting that there are 610 cases of Cyclospora infection in 22 states. While many of the illnesses in IA and NB were linked to bagged salad mix produced by Taylor Farms de Mexico, CDC indicates that a number of cases in Texas are unrelated to the cases in IA and NB, but rather originated with people eating at the same restaurant..

CDC is investigating the Texas cases as well as the cases seen in other states to see how any of them might be related and what might be the source (CDC release below).

The Taylor Farms facility in Mexico that was linked to the IA and NB cases has resumed production after undergoing an extensive FDA audit. (story and link below).

CDC News
Investigation of an Outbreak of Cyclosporiasis in the United States

Case counts are updated Mondays, Wednesdays, and Fridays
On June 28, 2013, CDC was notified of 2 laboratory-confirmed cases of Cyclospora infection in Iowa residents who had become ill in June and did not have a history of international travel during the 14 days before the onset of illness. Since that date, CDC has been collaborating with public health officials in multiple states and the U.S. Food and Drug Administration (FDA) to investigate an outbreak of cyclosporiasis.

Read the Advice to Consumers
Read the Guidance for Laboratories
Cyclospora cayetanensis is a single-celled parasite that causes an intestinal infection called cyclosporiasis.
As of August 23, 2013 (5pm EDT), CDC has been notified of 610 ill persons with Cyclospora infection from 22 states: Arkansas, California, Connecticut, Florida, Georgia, Illinois, Iowa, Kansas, Louisiana, Minnesota, Missouri, Nebraska, New Jersey, New Hampshire, New York (including New York City), Ohio, South Dakota, Tennessee, Texas, Virginia, Wisconsin, and Wyoming.
Most of the illness onset dates have ranged from mid-June through mid-July.
Among 581 ill persons with available information, 43 (7%) have reported being hospitalized. No deaths have been reported.
Public health officials in Iowa and Nebraska performed investigations within their states and concluded that restaurant-associated cases of Cyclospora infection in their states were linked to a salad mix produced by Taylor Farms de Mexico.
On August 12, 2013, Taylor Farms de Mexico informed FDA that the company had voluntarily suspended production and shipment of any salad mix, leafy green, or salad mix components from its operations in Mexico to the United States.
On August 25, 2013, Taylor Farms de Mexico, with FDA concurrence , resumed production and shipment of salad mix, leafy greens, and salad mix components to the United States.
Currently, CDC is collaborating with the Texas Department of Health and Human Services and local public health departments to investigate cases of cyclosporiasis reported among people in Texas.
The preliminary analysis of results from an investigation into a cluster of cases that ate at a Texas restaurant does not show a connection to Taylor Farms de Mexico. This investigation is ongoing.
Although the investigation of cases continues, available evidence suggests that not all of the cases of cyclosporiasis in the various states are directly related to each other.

Friday, August 16, 2013

What is Gluten Free - FDA sets a standard

FDA established a standard that defines “Gluten Free”. Gluten free is a food that does not contain an a gluten containing grain such as wheat, does not contain an ingredient that is derived from a gluten containing grain, and does not contain an ingredient derived from a gluten containing grain that has been processed to remove the protein (such as wheat starch) where that ingredient has more than 20 ppm of gluten. And is produced so that the food will not be contaminated with the unavoidable presence of gluten to a level of no more than 20 ppm.

Foods that are free of gluten by their nature can be labeled as gluten free, however they do not have to be labeled as such if they are gluten free. It is voluntary. Manufacturers are not required to test for the presence of gluten, but are required to meet the requirements of the law, so manufacturers can use a number of tools to meet the standard.

Establishing this set standard allows uniform labeling thus making it easier for those with the celiac disease to make informed decisions regarding food items.

Gluten is protein that is found in wheat, rye, barley. In people with celiac disease, gluten triggers an immune reaction that results in antibodies attacking the intestinal lining. It can be painful for those individuals who inadvertently ingest gluten. It can also impact absorption of nutrients from the intestines. This condition is especially problematic in children where it can lead to growth problems, and weight loss. For adults, in addition to the stomach issues, it can lead to long term effects such as malnutrition, liver disease, and cancer of the intestines. It is estimated that roughly 1 in 100 people have the disease (whether they know it or not).

It is important to remember that gluten is an important part of the diet and a gluten free diet is not recommended for the general public

For Immediate Release: August 2, 2013

Media Inquiries: Shelly Burgess 301-796-4651,
Consumer Inquiries: 888-INFO-FDA
En EspaƱol1

FDA defines “gluten-free” for food labeling
New rule provides standard definition to protect the health of Americans with celiac disease

The U.S. Food and Drug Administration today published a new regulation defining the term "gluten-free" for voluntary food labeling. This will provide a uniform standard definition to help the up to 3 million Americans who have celiac disease, an autoimmune digestive condition that can be effectively managed only by eating a gluten free diet.

“Adherence to a gluten-free diet is the key to treating celiac disease, which can be very disruptive to everyday life,” said FDA Commissioner Margaret A. Hamburg, M.D. “The FDA’s new ‘gluten-free’ definition will help people with this condition make food choices with confidence and allow them to better manage their health.”

This new federal definition standardizes the meaning of “gluten-free” claims across the food industry. It requires that, in order to use the term "gluten-free" on its label, a food must meet all of the requirements of the definition, including that the food must contain less than 20 parts per million of gluten. The rule also requires foods with the claims “no gluten,” “free of gluten,” and “without gluten” to meet the definition for “gluten-free.” 

The FDA recognizes that many foods currently labeled as “gluten-free” may be able to meet the new federal definition already. Food manufacturers will have a year after the rule is published to bring their labels into compliance with the new requirements.

“We encourage the food industry to come into compliance with the new definition as soon as possible and help us make it as easy as possible for people with celiac disease to identify foods that meet the federal definition of ‘gluten-free’” said Michael R. Taylor, the FDA’s deputy commissioner for foods and veterinary medicine.

The term "gluten" refers to proteins that occur naturally in wheat, rye, barley and cross-bred hybrids of these grains. In people with celiac disease, foods that contain gluten trigger production of antibodies that attack and damage the lining of the small intestine. Such damage limits the ability of celiac disease patients to absorb nutrients and puts them at risk of other very serious health problems, including nutritional deficiencies, osteoporosis, growth retardation, infertility, miscarriages, short stature, and intestinal cancers.

The FDA was directed to issue the new regulation by the Food Allergen Labeling and Consumer Protection Act (FALCPA), which directed FDA to set guidelines for the use of the term “gluten-free” to help people with celiac disease maintain a gluten-free diet.

The regulation was published today in the Federal Register2.

For more information:
FDA: Gluten-Free Labeling3
FDA: Gluten-Free Labeling Final Rule Q&A4
Consumer Update

The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.

Iams and Eukanuba dry pet food recalled due to the potential for Salmonella contamination

Proctor and Gamble is issuing a recall for Iams and Eukanuba dry dog food and dry cat food due to the potential to be contaminated with Salmonella. The issue was discovered during product testing. No illnesses have been reported.  

A wide variety of the products are being recalled, but is limited to a 10 day production window. Products were distributed across the US.

Salmonella in pet food can cause infection in pets as well as owners who do not wash their hands after handling contaminated product. Of course there are those people who either let the dog lick their face, or may try a kibble or two.

Dry pet food becomes contaminated with Salmonella through cross contamination in the post-process environment (after extrusion) when either the plant environment is contaminated or when one of the post-process additions (fat or flavoring) is contaminated. The way to prevent this is to prevent Salmonella in plant, specifically in the finished product areas. This is done through good sanitation, air control, as well as the movement of people and materials. Salmonella must also be eliminated from the post-process additions of fat and flavoring through proper processing and handling of those ingredients. Once either the post-process environment becomes contaminated with Salmonella, or one of the post-process addition becomes contaminated, then it can contaminate pet food. Salmonella can survive in the plant and on the dry pet food for months.

FDA Recall Notice

P&G Voluntarily Recalls Limited Quantity of Dry Pet Food Due to Possible Health Risk


Jason Taylor

FOR IMMEDIATE RELEASE - August 14, 2013 - The Procter & Gamble Company (P&G) has voluntarily recalled specific lots of dry pet food because they have the potential to be contaminated with Salmonella. These lots were distributed in the United States and represent roughly one-tenth of one percent (0.1%) of annual production. No Salmonella-related illnesses have been reported to date in association with these product lots.

Thursday, August 8, 2013

What is the Risk? - Household Germ Study

A newly released “study”, the 2013 NSF International Household Germ Study, has sparked some media attention.

The summary report discusses the analysis of 14 common kitchen items for the presence of E. coli, Salmonella, yeast and mold, and Listeria. In they identify:
The six “germiest” items contained the following microorganisms that can cause sickness:
1.) Refrigerator vegetable compartment: Salmonella, Listeria, yeast and mold
2.) Refrigerator meat compartment: Salmonella, E.coli, yeast and mold
3.) Blender gasket: Salmonella, E.coli, yeast and mold
4.) Can opener: Salmonella, E.coli, yeast and mold
5.) Rubber spatula: E. coli, yeast and mold
6.) Food storage container with rubber seal: Salmonella, yeast and mold
And share their analysis on organisms found.
E. coli – 36 percent of items contained E. coli. Items with E. coli included the refrigerator meat compartment, rubber spatula, blender gasket, can opener and pizza cutter.
• Salmonella – 36 percent of items had Salmonella including the refrigerator vegetable and meat compartments, can opener, blender gasket and the rubber seal on a food storage container.
• Yeast and mold – All 14 items (100 percent) tested positive for yeast and mold, and six items (43 percent) tested positive at concerning levels. The six items with concerning levels of yeast and mold were the refrigerator vegetable compartment, rubber spatula, blender gasket, refrigerator ice and water dispensers, and the rubber seal on a food storage container.
• Listeria – 14 percent of items tested positive for Listeria. The refrigerator vegetable compartment contained Listeria, as did the refrigerator door seal.

While the summary of the “study” highlights the need for cleaning in the kitchen, it is unknown to what degree this is actually a scientifically based study (statistically sound, peer reviewed, etc). The results are also questionable - the percent of samples found to be positive for Salmonella and E. coli is very high compared to previously published studies. (It is also important to note that this is generic E. coli, not necessarily pathogen E. coli). It would have been nice if they published the actual results so we could see the number of kitchens sampled (was it one kitchen?), percent positive for each item, etc.

Another item missed in this report is the impact of cross contamination during handling of raw foods and subsequent cleaning. This is when there is most likely to be transfer of pathogens to food contact surfaces, including appliance, as well as other foods. Along with this, there is the need for cleaning practices immediately after handling and processing (proper use of cleaning cloths and the use of cleaning/sanitizing agents). 

So yes, proper, routine cleaning of kitchen appliances and utensils is very important, and NSP does provide nice links for cleaning various kitchen appliances, but they miss what many consider a bigger risk for pathogen cross contamination in the kitchen – the potential for cross contamination during handling, processing, and subsequent cleaning. And there will be many who read this and overreact, thinking that their kitchen is full of Salmonella. Unfortunately, too others will carry this story not making any qualifying comments, but rather will probably further embellish upon the results.

Sunday, August 4, 2013

Cyclospora outbreak in salad linked to Mexican farm

The cyclospora outbreak has been linked to foodservice bagged salad served at Olive Garden and Red Lobster. The source of the salad was a Mexican farm. The farm, run as a subsidiary of the US produce company Taylor Farms, was said to be a state-of-the-art facility with an exception food safety record. It had been recently inspected by FDA in 2011 and they found no notable issues.

To date, over 400 individuals in 16 states have become ill from salad contaminated with cyclospora. Taylor Farms reports that none of the salad is still on the market.


FDA Links Bagged Salad Mix Stomach Bug In 2 States To Mexican Farm

WASHINGTON — The Food and Drug Administration says an outbreak of stomach illnesses in Iowa and Nebraska is linked to salad mix served at local Olive Garden and Red Lobster restaurants and supplied by a Mexican farm.

The outbreak of cyclospora infections has sickened more than 400 people in 16 states in all. The agency says it is still working to determine whether the salad mix is the source of illnesses in the other 14 states.

Friday, August 2, 2013

Local Farmers Worry About New Food Safety Guidelines

WPSU’s Emily Reddy talked with Dr. Luke LaBorde of Penn State and  Kim Tait, a small scale processor, on the FSMA bill and the impact on smaller farms and processors,   [Link to radio report]

Thursday, August 1, 2013

FDA proposes fee structure for re-inspections and recalls as part of FSMA

As part of the provisions in FSMA, FDA is setting a fee schedule for re-inspections of a facility when that facility had non-compliance/food safety issues during the initial inspection and for conducting a recall when the company fails to comply with a recall order.

For 2014 (which begins Oct 1, 2013), the fee rate is $237 an hour ($302 when foreign travel is required).

So for an all day visit (8 hours - arriving at 8 am and leaving at 4 am, no lunch), a facility is looking at a roughly a $1900 bill from Uncle Sam. Their goal will be to determine that corrective action was aken to resolve the noncompliance issue. Hopefully they can be convinced actions in 30 minutes the the corrective action was successful.

Industry Guidelines for Handling Foodborne Illness Investigation

CIFOR (The Council to Improve Foodborne Outbreak Response) released guidelines for industry to follow in the event of a foodborne illness outbreak investigation. This is very nice resource that warrants a review by every food company.  It provides a thorough review of the steps that occur when there is a foodborne illness that may be associated with an establishment.

The 78 page document lists procedures as well as forms that should be incorporated into a company’s crisis management plan. It details the roles of government and the food establishment in the event of a food emergency.

It was developed through a collaboration of food industry professionals and government authorities including FDA, USDA, and CDC.

Food industry owners or managers, need to print, review, and implement this document as part of the crisis management planning. Then keep it along with the required documentation as part of the company’s proactive action plan in the unfortunate event of the establishment may be involved in food illness outbreak. 

Print it today! 

HHS News Release 7/30/13
HHS, USDA and the food industry welcome new guidelines promoting industry

Guidelines provide tools for companies aiding government outbreak responders

Health and Human Services Secretary Kathleen Sebelius and Agriculture Secretary Tom Vilsack today commended the Council to Improve Foodborne Outbreak Response (CIFOR) for the new CIFOR Foodborne Illness Response Guidelines for Owners, Operators and Managers of Food Establishments.

155 ill from Hepatitis A in pomegranate used in frozen berry mix

The CDC reports that 155 people in 9 states have become ill from hepatitis A after eating frozen mixed berries with 67 people that had been hospitalized. The source of the Hepatitis A was the pomegranate seeds which were imported from Turkey. 

The outbreak was first reported at the end of May, with cases beginning in April and extending into July. The reason is that symptoms do not occur for 2 to 6 weeks after exposure, and then those symptoms can last 2 to 6 months. Symptoms include fever, fatigue, nausea, vomiting, dark urine, and of course, jaundice . Although most people recover, it can cause liver failure in more susceptible individuals (elderly, people with liver disease) .

The organic frozen berry mix was sold by an Oregon company, Townsend Farms, and distributed through Costco. The blend is produced using fresh fruit and then is bought and used fresh by customers to make smoothies and other fruit drinks. So if Hepatitis A is present on the incoming ingredients, it will not be eliminated by processing (viruses will easily survive freezing), and then end up in product the consumer eats. With the long delay in seeing symptoms, it is easy to see why so many may have become infected.

The strain of Hepatitis A is found primarily in North Africa and the Middle East, and one of the ingredients, pomegranate seeds, is said to come from Turkey.

Food safety is important for ingredients used in products that will be used in RTE (ready-to-eat) applications, This is especially difficult when those ingredients are purchased in international markets. If this company lives up to the promise posted on their website, they should have no problems working back to the source of the issue. Unfortunately, this is not the first time berries have been involved in outbreaks. Earlier this year, there was an outbreak in Europe (71) and another in Canada (8). The Canadian product contained pomegranate. So at this point, if a company is using pomegranate, it may be good to stop using it until the safety can be verified. As a consumer, I would forgo my pomegranate-containing smoothie.

Multistate outbreak of hepatitis A virus infections linked to pomegranate seeds from Turkey
Posted July 30, 2013 9:15 AM ET

CDC is collaborating with public health officials in several states and the US Food and Drug Administration (FDA) to investigate a multistate outbreak of hepatitis A virus infections. Results from the ongoing investigation are highlighted below.

Epidemiologic Investigation:

· As of July 29, 2013, 155 people have been confirmed to have become ill from hepatitis A after eating ‘Townsend Farms Organic Antioxidant Blend’ in 9 states: Arizona (23), California (76), Colorado (27), Hawaii (8), New Hampshire (1), New Mexico (9), Nevada (6), Utah (3), and Wisconsin (2). [Note: The cases reported from Wisconsin resulted from exposure to the product in California, and the cases reported from New Hampshire reported fruit exposure during travel to Nevada.]

o 86 (55%) ill people are women
o Ages range from 1 – 84 years;
  -  87 (56%) of those ill were between 40 – 64 years of age.
  -  11 children age 18 or under were also ill. None were previously vaccinated.
o Illness onset dates range from 3/31/2013 – 7/14/2013
o 67 (43%) ill people (all over 18 years of age) have been hospitalized, and no deaths have been reported
o All ill people who reported eating this product purchased it from Costco markets; however, the product was also sold at Harris Teeter stores. No ill people have been identified that bought the product at Harris Teeter at this time.
 o CDC continues to track hepatitis A cases in all states and test specimens in order to determine if any other cases are related to this outbreak.

Cyclospora outbreak linked to bagged salad

The cyclospora outbreak centered in Iowa has been linked to bagged spinach. The brand has not yet been identified. At this point, there is a reported 378 cases in 15 states.

 Cyclospora is a parasite, most often seen in tropical and subtropical regions, results in watery diarrhea, stomach pain, etc ( ). If one had to guess, cyclospora oocysts would have contaminated the produce in the field probably from contaminated irrigation water and then it would be unlikely that washing would be sufficient to destroy the oocysts, perhaps even spreading it to more more product and thus more bags in the washing system. Although it could also be that the wash water used was contaminated. Hopefully the investigation will provide that information.

CDC has a listing of organisms and their inactivation by chlorine. (Bottom of this and ) As can be seen, parasites are much more resistant, especially cyclospora (listed in the footnote on the CDC table).

At this point, they have not yet released the information surrounding the brand name. This is interesting in that they know the product is no longer on the shelf. As a consumer, I would be interested in knowing that information so that I could avoid that brand, and then would also have more confidence in buying other brands. Therefore, I think delaying the release of this information, it has the potential to negatively impact sales of other brands of bagged salad.

Salad Mix Behind Food Poisoning Outbreak, Health Officials Say 

 LINCOLN, Neb. — Health officials in Iowa and Nebraska on Tuesday identified prepackaged salad mix as the source of a severe stomach bug that sickened hundreds of people in both states, but federal authorities said it's not clear whether cyclospora outbreaks elsewhere in the U.S. are also linked to that produce.

Cyclospora is a rare parasite that causes a lengthy gastrointestinal illness, and outbreaks of the illness have been reported in 15 states. The U.S. Centers for Disease Control and Prevention said Tuesday that it's not clear whether all of the illnesses are linked to a single source. The outbreak has sickened at least 145 residents in Iowa and 78 in Nebraska.