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original article

2008 Outbreak of Salmonella Saintpaul Infections Associated with Raw Produce
Casey Barton Behravesh, D.V.M., Dr.P.H., Rajal K. Mody, M.D., M.P.H., Jessica Jungk, M.P.H., Linda Gaul, Ph.D., M.P.H., John T. Redd, M.D., M.P.H., Sanny Chen, Ph.D., M.H.S., Shaun Cosgrove, B.A., Erin Hedican, M.P.H., David Sweat,M.P.H., Lina Chávez-Hauser, M.A., Sandra L. Snow, M.D., Heather Hanson, M.P.H., Thai-An Nguyen, M.P.H., Samir V. Sodha, M.D., M.P.H., Amy L. Boore, Ph.D., M.P.H., Elizabeth Russo, M.D., Matthew Mikoleit, M.A.S.C.P., Lisa Theobald, B.S., Peter Gerner-Smidt, M.D., D.M.S., Robert M. Hoekstra, Ph.D., Frederick J. Angulo, D.V.M., Ph.D., David L. Swerdlow, M.D., Robert V. Tauxe, M.D., M.P.H., Patricia M.Griffin, M.D., and Ian T. Williams, Ph.D., for the Salmonella Saintpaul Outbreak Investigation Team*

A bs t r ac t
From the National Center for Emerging and Zoonotic Infectious Diseases (C.B.B., R.K.M., T.-A.N., S.V.S., A.L.B., E.R., M.M., L.T., P.G.-S., R.M.H., F.J.A., D.L.S., R.V.T., P.M.G., I.T.W.) and the Scientific Education and Professional Development Program Office (R.K.M., S. Chen,A.L.B., E.R.), Centers for Disease Control and Prevention, Atlanta; the New Mexico Department of Health, Santa Fe (J.J.); Texas Department of State Health Services, Austin (L.G.); Indian Health Service, Albuquerque, NM (J.T.R.); Arizona Department of Health Services, Phoenix (S. Chen); Colorado Department of Public Health and Environment, Denver (S. Cosgrove); Minnesota Department of Health, St. Paul(E.H.); North Carolina Division of Public Health, Raleigh (D.S.); Missouri Department of Health and Senior Services, Jefferson City (L.C.-H.); Arkansas Department of Health, Little Rock (S.L.S.); and New York City Department of Health and Mental Hygiene, New York (H.H.). Address reprint requests to Dr. Barton Behravesh at the Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, MSA-38, Atlanta, GA 30333, or at cbartonbehravesh@cdc.gov. * Additional members of the Salmonella Saintpaul Outbreak Investigation Team are listed in the Supplementary Appendix, available at NEJM.org. This article (10.1056/NEJMoa1005741) was published on February 23, 2011, at NEJM.org. N Engl J Med 2011;364:918-27.
Copyright © 2011 Massachusetts Medical Society.

Background

Raw produce is anincreasingly recognized vehicle for salmonellosis. We investigated a nationwide outbreak that occurred in the United States in 2008.
Methods

We defined a case as diarrhea in a person with laboratory-confirmed infection with the outbreak strain of Salmonella enterica serotype Saintpaul. Epidemiologic, traceback, and environmental studies were conducted.
Results

Among the 1500 case subjects, 21%were hospitalized, and 2 died. In three case– control studies of cases not linked to restaurant clusters, illness was significantly associated with eating raw tomatoes (matched odds ratio, 5.6; 95% confidence interval [CI], 1.6 to 30.3); eating at a Mexican-style restaurant (matched odds ratio, 4.6; 95% CI, 2.1 to ∞) and eating pico de gallo salsa (matched odds ratio, 4.0; 95% CI, 1.5 to 17.8),corn tortillas (matched odds ratio, 2.3; 95% CI, 1.2 to 5.0), or salsa (matched odds ratio, 2.1; 95% CI, 1.1 to 3.9); and having a raw jalapeño pepper in the household (matched odds ratio, 2.9; 95% CI, 1.2 to 7.6). In nine analyses of clusters associated with restaurants or events, jalapeño peppers were implicated in all three clusters with implicated ingredients, and jalapeño or serrano pepperswere an ingredient in an implicated item in the other three clusters. Raw tomatoes were an ingredient in an implicated item in three clusters. The outbreak strain was identified in jalapeño peppers collected in Texas and in agricultural water and serrano peppers on a Mexican farm. Tomato tracebacks did not converge on a source.
Conclusions

Although an epidemiologic association with raw tomatoes...