title: A recurrent, multistate outbreak of salmonella serotype agona infections associated with dry, unsweetened cereal consumption, United States, 2008.
abstract: An outbreak of Salmonella enterica serotype Agona infections associated with nationwide distribution of cereal from Company X was identified in April 2008. This outbreak was detected using PulseNet, the national molecular subtyping network for foodborne disease surveillance,  which coincided with Company X's voluntary recall of unsweetened puffed rice and wheat cereals after routine product sampling yielded Salmonella Agona. A case patient was defined as being infected with the outbreak strain of Salmonella Agona, with illness onset from 1 January  through 1 July 2008. Case patients were interviewed using a standard questionnaire, and the proportion of ill persons who reported eating Company X puffed rice cereal was compared with Company X's market share data using binomial testing. The Minnesota Department of Agriculture inspected the  cereal production facility and collected both product and environmental swab samples. Routine surveillance identified 33 case patients in 17 states. Of 32 patients interviewed, 24 (83%) reported eating Company X puffed rice cereal. Company X puffed rice cereal represented 0.063% of the total  ready-to-eat dry cereal market share in the United States at the time of the investigation. Binomial testing suggested that the proportion of exposed case patients would not likely occur by chance (P < 0.0001). Of 17 cereal samples collected from case patient homes for laboratory  testing, 2 (12%) yielded Salmonella Agona indistinguishable from the outbreak strain. Twelve environmental swabs and nine product samples from the cereal plant yielded the outbreak strain of Salmonella Agona. Company X cereal was implicated in a similar outbreak of Salmonella  Agona infection in 1998 with the same outbreak strain linked to the same production facility. We hypothesize that a recent construction project at this facility created an open wall near the cereal production area allowing reintroduction of Salmonella Agona into the product, highlighting  the resilience of Salmonella in dry food production environments.
authors: Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail-stop C-09, Atlanta, GA 30333, USA. rxq1@cdc.gov
authors: Elizabeth T
authors: ET
authors: Russo
authors: Gwen
authors: G
authors: Biggerstaff
authors: R Michael
authors: RM
authors: Hoekstra
authors: Stephanie
authors: S
authors: Meyer
authors: Nehal
authors: N
authors: Patel
authors: Benjamin
authors: B
authors: Miller
authors: Rob
authors: R
authors: Quick
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D002523:Edible Grain / Q000382:microbiology*; D005260:Female; D005506:Food Contamination / Q000032:analysis*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D012275:Oryza / Q000382:microbiology; D012478:Salmonella Food Poisoning / Q000453:epidemiology*; D019779:Salmonella enterica / Q000302:isolation & purification*; D014908:Triticum / Q000382:microbiology; D014481:United States / Q000453:epidemiology; D055815:Young Adult