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Salmonella Schwarzengrund Illness Outbreak Associated with Ground Turkey, 2019

After-Action Review Report 2019-06

January 3, 2020

Overview

During February –May 2019, public health officials in Wisconsin, Minnesota, North Carolina, the Centers for Disease Control and Prevention (CDC), and

the Food Safety and Inspection Service (FSIS) investigated an outbreak of seven Salmonella Schwarzengrund illnesses linked to ground turkey produced

by an FSIS-regulated establishment (Establishment A). A Minnesota food bank (Food Bank B) supplied the ground turkey to a Wisconsin residential

facility (Residential Facility C) and a Minnesota food pantry (Food Pantry D). Three ground turkey samples from Residential Facility C were positive for the

outbreak strain of Salmonella Schwarzengrund. On March 13, 2019, Establishment A voluntarily recalled the ground turkey products. The FSIS outbreak

notification email address (FoodborneDiseaseReports@usda.gov) was used to quickly and effectively notify FSIS of this outbreak. Early and consistent

communication between government partners and industry during outbreak investigations can facilitate collaborative response.

Epidemiology

On February 14, 2019, the Wisconsin Department of Agriculture, Trade, and Consumer Protection (WDATCP) notified FSIS through the FSIS

outbreak notification email address (FoodborneDiseaseReports@usda.gov) that Wisconsin officials were investigating a cluster of Salmonella

Schwarzengrund illnesses (see Table 1 for epidemiologic details).

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

Five (71%) of the seven case-patients either lived in Residential Facility C where ground turkey was served (four case-patients) or reported eating

ground turkey at home purchased from Food Pantry D (one case-patient).

Table. Case-patient characteristics—Salmonella Schwarzengrund outbreak associated with ground turkey, 2019.

Total number of case-patients and states of residence

7 case-patients from 3 states (see CDC map of reported cases )

Illness onset date range December 19, 2018—March 16, 2019 (see

CDC timeline of reported cases )

Age range (median) in years

<1–71 (46)

Percent female

86

Number of reported hospitalizations

1

Number of reported deaths

0

Traceback Investigation

FSIS investigators and officials in Wisconsin and Minnesota obtained information from Food Bank B, Residential Facility C, and Food Pantry D to

determine the source of the ground turkey.

Ground turkey produced by Establishment A in North Carolina was supplied by Food Bank B to Residential Facility C and Food Pantry D.

Environmental Assessment

FSIS investigators and officials in Wisconsin visited Residential Facility C to review menus and food thermometer use; findings suggested the

product may have been inadequately cooked prior to consumption.

Product Sampling

Routine Sampling

The following samples of ground turkey produced by Establishment A were positive for Salmonella Schwarzengrund; these isolates were similar to

the outbreak strain by molecular subtyping:

Two samples collected by FSIS from Establishment A (one in 2016, one in 2018).

Three samples collected at retail in Pennsylvania (two in 2017, one in 2019) as part of the

National Antimicrobial Resistance Monitoring System.

Investigative Sampling
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Minnesota officials visited Food Pantry D and collected two intact (unopened packaging) samples of ground turkey produced by Establishment A;

these samples were negative for Salmonella.

Wisconsin officials visited Residential Facility C and collected five intact ground turkey samples produced by Establishment A.

Two samples were negative for Salmonella.

Three samples were positive for the outbreak strain of Salmonella Schwarzengrund.

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

Industry, Public Health, and Regulatory Actions

Establishment A voluntarily recalled approximately 78,164 pounds of raw, ground turkey products (produced on July 7, 2018) on March 13, 2019.

The Wisconsin Department of Health Services and WDATCP issued a joint News Release on March 14, 2019.

CDC published a Food Safety Alert on March 14, 2019 (final update May 7, 2019 ).

Lessons Learned and Related Policy

Communication between partners

Early collaboration between state partners expedited this investigation.

WDATCP used the FSIS outbreak notification email address (FoodborneDiseaseReports@usda.gov) to quickly and effectively notify FSIS of this

outbreak; public health partners are encouraged to continue using this method to notify FSIS of outbreaks that may be associated with FSISregulated products and to request illness-related information from FSIS.

It is important to keep lines of communication between investigating partner agencies open during traceback and throughout the investigation; early

collaboration between federal and state partners will help facilitate coordinated investigations and could reduce duplication of effort.

Communication with industry

To facilitate collaborative outbreak response, FSIS will communicate with involved industry and public health partners in accordance with the

procedures outlined in FSIS Directive 8080.3, Foodborne Illness Investigations, including:

Inform a firm when it is determined that a potential association exists between illness and the firm’s product;

Notify a firm when the firm’s product has been collected for testing as part of the investigation; and

Develop a plan for sharing information with a firm in a consistent manner throughout the investigation.

Helpful Links

FSIS Recall 030-2019, March 13, 2019

Wisconsin Department of Health Services and Wisconsin Department of Agriculture, Trade, and Consumer Protection Joint News Release, March

14, 2019

CDC Food Safety Alert, May 7, 2019 (final update)

National Antimicrobial Resistance Monitoring System informational webpages: FSIS; Food and Drug Administration ; CDC

Last Modified May 20, 2020