USDA 

--

Food Safety and Inspection Service 

U.S. DEPARTMENT OF AGRICULTURE 

FSIS Foodborne Illness 

Outbreak Investigations, 

Fiscal Year 2022 

Introduction 

The U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS), Office of 

Public Health Science, Applied Epidemiology Staff, coordinates the FSIS response to 

foodborne illness outbreaks that may involve FSIS-regulated products. This includes outbreaks 

that involve four foodborne pathogens that most frequently affect FSIS-regulated products: 

Salmonella, Shiga toxin-producing Escherichia coli (STEC), Listeria monocytogenes (Lm), and 

Campylobacter. FSIS may investigate illnesses associated with other less common foodborne 

pathogens (e.g., Clostridium botulinum) if they are potentially associated with FSIS-regulated 

products. 

FSIS collects and evaluates epidemiologic, laboratory, and traceback information to determine 

if there is an association between an FSIS-regulated product and human illnesses. 

Epidemiologic information can include details like which foods ill people ate, where they 

purchased these foods, and where they live. Laboratory information can include comparing 

bacteria from FSIS samples and ill people to see if they are genetically similar or have similar 

characteristics. Traceback activities may include determining the location where the product 

was sold (e.g., grocery store, deli counter, or restaurant) or the source of a product (e.g., the 

federally inspected slaughter or processing facility). Depending on the evidence collected 

during an investigation, FSIS may have enough detailed exposure and product information to 

take one or more actions to prevent additional illnesses. These actions may include 

requesting that a company remove product from commerce and FSIS issuing a press release 

announcing that a firm is recalling meat, poultry, or egg products linked to human illnesses or 

FSIS notifying the public of potential food safety concerns through the issuance of a Public 

Health Alert (PHA). 

This report summarizes outbreaks that FSIS investigated from October 1, 2021, to September 

30, 2022, Fiscal Year 2022 (FY 2022). This report also highlights key lessons learned from 

outbreak investigations in FY 2022. 
 

 

 

 

 

 

 

 

 

 

 

 

 

- - - - T 

Fiscal Year 2022 in Review 

During FY 2022, FSIS investigated seven outbreaks in coordination with local, state, and 

federal public health partners. These outbreaks involved approximately 120 illnesses and 30 

hospitalizations. The Centers for Disease Control and Prevention (CDC) notified FSIS of six 

(86%) of these outbreaks. FSIS became aware of the seventh outbreak by notification from a 

state public health agency. Five (71.4%) outbreaks involved illnesses in more than one state. 

Of the seven outbreaks investigated by FSIS in FY 2022, Salmonella and STEC each caused 

three outbreaks. The seventh investigation involved a botulism illness where FSIS investigated 

commercially canned soup as a potential source (Figure 1). Given botulism’s potential to 

cause outbreaks and the severity of illness, FSIS investigates reports of one or more botulism 

illnesses that may be associated with FSIS-regulated products and includes those 

investigations in the Agency’s annual outbreak report. Of the non-botulism pathogens causing 

investigations, the three Salmonella outbreaks investigated involved serotypes Enteritidis, 

Muenchen, and I 4,[5], 12: i-. The three STEC outbreaks were all caused by the serogroup 

O157:H7. Beef was the most common food product of interest (Figure 2). 

Figure 1. FY 2022 Outbreaks by Figure 2. FY 2022 Outbreaks by Product of 

5 Pathogen (N = 7) 

5 

Interest (N = 7) 

0 

1 

2 

3 

4

Number of Outbreaks 

0 

1 

2 

3 

4

Number of Outbreaks 

Salmonella STEC Clostridium 

botulinum* 

Beef Chicken Pork Multi-ingredient+ 

Pathogen Commodity 

+ Product investigated was canned soup that * FSIS investigated a case of botulism and a 

contained multiple ingredients, including chicken, rice, commercially canned soup was a suspected 

and vegetables source 

FSIS may ask an establishment to voluntarily recall product from commerce to protect public 

health when the product is found to be associated with an outbreak. A recall is a firm’s 

removal of distributed meat, poultry, or egg products from commerce when there is a reason 

to believe that such products are adulterated or misbranded under the provisions of the 

Federal Meat Inspection Act, the Poultry Products Inspection Act, or Egg Products Inspection 

Act. FSIS may issue a PHA when the Agency determines that a meat, poultry, or egg product 

may be associated with human illness and no adulterated product remains in commerce. FSIS 
 

 

 

 

 

 

 

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may also issue a PHA when the Agency is unable to determine what specific regulated product 

is implicated by the illnesses and thus adulterated. In FY 2022, outbreak investigations led to 

one recall of FSIS-regulated products and two PHAs. 

Table 1 depicts characteristics about these outbreaks investigated in FY 2022, including 

information on the serotype/serogroup, product of interest, whether FSIS or non-FSIS 

samples were genetically related to human illnesses, and if the available outbreak information 

resulted in a recall of FSIS-regulated products from commerce or a PHA to prevent additional 

illnesses. 

Table 1. FY 2022 Outbreak Characteristics 

Pathogen 

STEC 

Salmonella 

Clostridium 

botulinum++ 

Serotype/ 

Serogroup 

O157:H7 

O157:H7 

O157:H7 

Enteritidis 

Muenchen 

I 4,[5],12:iCommodityA 

Beef 

Beef 

Beef 

Chicken 

Beef 

Pork 

Multiingredient 

product+++ 

FSIS 

IsolatesB 

No 

No 

No 

Yes 

Yes 

Yes 

No 

Non FSIS 

IsolatesC 

No 

No 

No 

Yes 

Yes 

No 

Yes++ 

RecallD 

No 

No 

No 

No 

No+ 

Yes 

No 

PHAE 

Yes 

No 

No 

No 

No 

Yes 

No 

A) Product investigated by FSIS as possible, likely, or confirmed cause of illnesses during investigation. 

B) Isolates recovered from FSIS testing (product, cecal, or environmental) found to be related by whole genome 

sequencing or another testing method to clinical isolates and are included in the outbreak. 

C) Isolates recovered from non-FSIS testing (product, live animal, or environmental) found to be related by 

whole genome sequencing to clinical isolates and are included in the outbreak. 

D) Based on available evidence, FSIS-regulated product was determined to be the cause of human illnesses and 

an FSIS-regulated establishment recalled product from commerce. 

E) Based on available evidence, FSIS-regulated product poses a public health risk; however, the product is no 

longer available for sale in commerce or FSIS is unable to determine which specific product is adulterated 

or misbranded and FSIS issued a PHA to notify the public. 

+) Recall of a non-FSIS regulated pet food product occurred during the outbreak investigation as a result of a 

sample that tested positive, however the isolate did not match the outbreak strain and the recalled product 

was not linked to human illness. 

++) Investigation of a case of botulism; botulinum toxin was detected in the patient’s blood and an empty soup 

can recovered from the kitchen trash can. 

+++) The product investigated was canned soup that contained multiple ingredients, including chicken, rice, and 

vegetables. 

Learning from Outbreaks 

Assessment of outbreaks associated with FSIS-regulated products is crucial to FSIS’ mission 

to prevent foodborne illness and to protect public health. FSIS conducts after action reviews 

(AAR) at the conclusion of foodborne outbreak investigations to identify lessons learned 

that can help improve response and prevent future illnesses. Applying and sharing outbreak 
 

 

 

 

 

 

 

 

 

 

 

 

lessons learned may lead to improved food safety policies and can strengthen collaborative 

investigations with public health partners. FSIS conducted AARs and published AAR Reports 

for several FY 2022 outbreak investigations to identify best practices and areas for 

improvement. Below are highlights from some of the AARs conducted during FY 2022. 

FSIS investigated a Salmonella outbreak linked to Italian-style meats. The AAR report 

summarizes findings and lessons learned from two outbreaks linked to ready-to-eat, Italianstyle meat products that were produced using multiple interventions (e.g., fermentation and 

drying) to control Salmonella and other bacteria that can make people sick. FSIS conducted 

assessments at the establishments where the products associated with these outbreaks were 

produced and identified factors that may have contributed to the outbreaks, including the use 

of a reduced salt formulation and lack of validated scientific support to achieve a 5-log 

reduction in Salmonella. A 5-log reduction in Salmonella means that the process will result in a 

99.999% reduction of Salmonella that may be present in the raw meat, spices, and other 

ingredients used to make salami. FSIS has determined this level of reduction in shelf-stable 

products like salami will result in a safe product at the end of the process. FSIS is working with 

research partners to fill data gaps and better identify support for the safety of these products. 

FSIS investigated a Clostridium botulinum illness potentially associated with commercially 

canned soup. Botulinum toxin type A was identified in both the patient and an empty soup can 

collected from the kitchen trash can in the patient’s home. FSIS’ investigation of the 

establishment where the soup was produced, including laboratory results of similar cans tested, 

did not confirm that the soup was the source of the illness. This appears to have been an 

isolated incident and underscores the importance of public awareness regarding hazards 

associated with eating food from damaged or dented cans. This investigation highlights the 

importance of a quick response and good collaboration between state and federal public health 

partners involving an uncommon bacterium (C. botulinum). Continuing to foster relationships 

with public health partners will enable FSIS to continue to quickly respond to potential 

outbreaks in the future. 

To learn more about outbreaks and to see examples of how FSIS has applied outbreak lessons 

learned toward illness prevention, visit the FSIS Outbreaks webpage.