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Salmonella Enteritidis Illness Outbreak Associated with Raw, Breaded Chicken, 2018

After-Action Review Report 2018-10

March 19, 2020

Overview

During May–September 2018, public health officials in Wisconsin, Minnesota, and the Food Safety and Inspection Service (FSIS) investigated

an outbreak of 13 Salmonella Enteritidis illnesses linked to raw, breaded chicken products obtained primarily from multiple locations of Food

Pantry A; one ill person obtained the products from Grocery Store B. For both firms, the products were sourced from Establishment C. The

products were breaded and may have appeared to be cooked. After receipt, Food Pantry A and Grocery Store B repackaged the products in

packaging that did not include indications that the chicken was raw or cooking instructions. The absence of this information may have led to

inadequate cooking by consumers. On June 1, 2018, Wisconsin and Minnesota officials issued press releases about the outbreak

investigation. Three samples of raw, breaded chicken products obtained from ill people tested positive for the outbreak strain of Salmonella

Enteritidis. Public health officials educated Food Pantry A and Grocery Store B personnel regarding the importance of safe handling and

cooking instructions on the packaging of raw chicken products. FSIS is developing educational materials for food recovery operations,

including promotion of proper product labeling.

Epidemiology

On May 31, 2018, the Wisconsin Division of Public Health notified FSIS of a cluster of Salmonella Enteritidis infections (see Table 1 and

Figure 1 for epidemiologic details).

Molecular subtyping techniques were used to assess the relatedness of bacterial isolates and determine the outbreak strain.

All 13 ill people consumed breaded chicken products obtained from either Food Pantry A (12 person) or from Grocery Store B (1 person).

Of the 13 ill people, 11 (85%) had onset dates in May 2018 (Figure 1).

The ill person with the illness onset date of July 23, 2018 (Figure 1) reported obtaining the raw, breaded chicken products from

Grocery Store B.

The ill person with the illness onset date of September 27, 2018 (Figure 1) reported obtaining the raw, breaded chicken products

from Food Pantry A in July 2018 and storing them in the freezer.

Table 1. Characteristics of ill people—Salmonella Enteritidis illness outbreak associated with raw, breaded chicken, 2018.

Total number of ill people and states of residence 13 ill people from 2 states (6 from Wisconsin, 7 from Minnesota)

Estimated illness onset date range May 2—September 27, 2018

Age range (median) in years

1–80 (54)

Percent female

46

Number of reported hospitalizations

8

Number of reported deaths

0
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Figure 1. People infected with the outbreak strain of Salmonella Enteritidis associated with raw, breaded chicken, 2018, by week of illness

onset (n=13).

*Morbidity and Mortality Weekly Report week number

Environmental Assessment

State and FSIS officials assessed operations at Food Pantry A and determined:

The products in question were raw, breaded chicken products that had been donated to Food Pantry A.

The products were pre-browned and may have appeared from the outside to be cooked.

The original packaging of the products contained labeling with indications that the product was raw, cooking instructions

(including the instruction to not microwave), and ingredient information.

Food Pantry A repackaged the products into packages that did not include labeling with indications that it was raw, cooking

instructions, or ingredient information.

Food safety training for Food Pantry A workers was inadequate.

Minnesota officials visited Grocery Store B and determined that, similar to operations at Food Pantry A, Grocery Store B repackaged the

products into packages that did not include labeling with indications that it was raw, cooking instructions, or ingredient information.

Two ill people reported microwaving the repackaged, raw, breaded chicken products. Microwave ovens can cook products unevenly and

may leave products only partially cooked.

Traceback

State and FSIS officials separately visited Food Pantry A to conduct traceback investigations and determined that Establishment C in

Wisconsin donated the raw, breaded chicken products to Food Pantry A.

Though officials were able to determine the source of the donated products, insufficient recordkeeping at Food Pantry A

regarding the repackaged products made traceback challenging.

Minnesota officials visited Grocery Store B and determined that Establishment C was the source of the raw, breaded chicken products.

Product Sampling

Wisconsin officials collected two and Minnesota officials collected one non-intact (opened packaging) raw, breaded chicken samples

from the homes of ill people; these three samples tested positive for the outbreak strain of S. Enteritidis.

Per its Policy on Use of Results from Non-FSIS Laboratories (FSIS Directive 10,000.1), FSIS assessed and accepted these results from

Wisconsin and Minnesota.

Industry, Public Health, and Regulatory Actions
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Wisconsin and Minnesota officials issued news releases on June 1, 2018, warning consumers to cook raw, breaded chicken

products from Food Pantry A to a minimum internal temperature of 165°F.

Food Pantry A issued an announcement on June 1, 2018, informing customers that chicken from Food Pantry A needed to be

cooked thoroughly to 165°F.

FSIS and officials in Wisconsin and Minnesota conducted educational outreach at Food Pantry A regarding the importance of proper

handling and labeling of raw chicken products. FSIS officials informed Food Pantry A that uncooked products are required to be labeled

with safe handling instructions.

Minnesota officials informed Grocery Store B personnel that raw chicken products need to be appropriately labeled.

Lessons Learned and Related Policy Actions

Proper labeling of raw poultry that may appear fully cooked

The lack of safe handling and cooking instructions on the packaging of raw, breaded chicken product repackaged by Food Pantry A and

Grocery Store B may have led to inadequate cooking by consumers, resulting in illnesses. Lack of adequate worker training and lack of

recordkeeping at Food Pantry A may have been additional contributing factors. Meat and poultry products, including those distributed by

food recovery operations, must have proper labeling. Certain products, such as raw, breaded poultry products that may appear to be

fully cooked, should include cooking instructions. In response to previous outbreaks associated with raw poultry that may have

appeared to be fully cooked (e.g. stuffed chicken), FSIS has developed guidance regarding cooking instructions (see Draft FSIS

Compliance Guideline for Controlling Salmonella and Campylobacter in Raw Poultry [pages 92–95]). FSIS is developing educational

materials for food recovery operations, including promotion of proper product labeling.

Communication between partners

State and FSIS officials conducted separate traceback investigations during this outbreak investigation. Although this separate approach

was successful for determining the source of the implicated products, conducting investigations jointly is ideal. Collaborative outbreak

investigations can promote more effective response, facilitate more rapid sharing of investigative information, reduce duplication of effort,

make effective use of funding, and decrease the burden on industry.

Helpful Links

Wisconsin and Minnesota news releases, June 1, 2018

Food Pantry A announcement , June 1, 2018

FSIS Directive 10,000.1, Policy on Use of Results from Non-FSIS Laboratories

Outbreak review: Outbreaks of Salmonellosis in Minnesota (1998 through 2006) Associated with Frozen, Microwaveable, Breaded,

Stuffed Chicken Products (Journal of Food Protection, Vol. 71, No. 10, 2008, pages 2153–60).

FSIS After-Action Review Report 2015-11/2015-12: Salmonella Enteritidis Illness Outbreaks Associated with Raw, Frozen, Stuffed

Chicken Products, 2015

Draft FSIS Compliance Guideline for Controlling Salmonella and Campylobacter in Raw Poultry

Conference for Food Protection Comprehensive Resource for Food Recovery Programs

Last Modified May 20, 2020