E. coli O103 Outbreak Linked to Ground 

Beef

Outbreak Investigation After Action Review, Report 2019-07

Highlights

• This outbreak of 209 E. coli O103 illnesses was 

the largest outbreak of non-O157 Shiga toxinproducing E. coli ever involving an FSISregulated product in the United States.

• Complex traceback efforts identified 253 firms

throughout the supply chain, including point-ofpurchase locations, warehouses, distributors, 

federal establishments, and live animal 

suppliers. This includes facilities that grind beef 

sourced from numerous suppliers. Ground beef 

traceability throughout the supply chain is 

essential to investigate ground beef-associated 

outbreaks.

People infected with E. coli O103 by state of 

residence

Outbreak at a Glance

Illnesses 209

States included 10

Hospitalizations 29

Hemolytic uremic 

syndrome (HUS) cases 2

Deaths 0

Response at a Glance

Ill people with information 

to trace ground beef 21

Firms identified through 

traceback 253

In-plant assessments 5

Samples tested by FSIS 98

Recall or Public Health 

Alert Yes

Process improvements

 uring this outbreak, 

began using editor’s notes (like

in recall 047-2019) to highlight 

what is known about the 

relationship between recalls 

and ongoing investigations 

 sing feedback from state 

partners, updated 

 irective 10,000 1 to streamline 

the review process for the 

 gency to use results from non-

 laboratories to take a 

regulatory action 
What happened?

From March 29 to June 20, 2019, public health 

officials in multiple states, the Centers for 

Disease Control and Prevention (CDC), and 

the Food Safety and Inspection Service (FSIS) 

investigated an outbreak of 209 E. coli O103 

illnesses linked to ground beef. The outbreak 

strain of E. coli O103 was identified in a ground 

beef sample and the product was recalled. A 

second ground beef sample collected as 

part of the investigation also tested positive 

for E. coli O103, but genetic characterization 

showed this was a non-outbreak strain and 

there were no human illnesses linked to this product. 

Although investigators carried out an extensive traceback investigation, they did not 

identify a common source of ground beef consumed by ill people. Based on traceback 

evidence, FSIS identified five FSIS-regulated establishments of interest to conduct inplant assessments and collect beef trim samples. All samples collected from these 

establishments tested negative for E. coli and in-plant findings did not indicate that 

conditions in the establishments contributed to the outbreak.

What we learned from this outbreak

Traceback diagram used during the E. coli O103 

outbreak investigation. These diagrams allow 

investigators to visualize connections among 

suppliers of foods consumed by ill people.

Recordkeeping

 he traceback investigation during this outbreak was complicated, with 

ground beef incorporating source materials from several suppliers and 

passing through multiple federal establishments prior to being available 

for purchase by consumers dequate recordkeeping throughout the 

ground beef supply chain is imperative to identify commonalities during 

outbreak investigations and prevent additional illnesses 

Communication

 ditor’s notes, like those included in recall announcements during 

this outbreak, are an effective way to inform consumers about new 

developments since the recall was published ditor’s notes are 

updated as more information, such as genetic sequencing data, 

become available to provide consumers with updated information 
What can you do to prevent or solve the next 

outbreak?

Helpful Links

• Kentucky Health Alert, March 29, 2019 

• FSIS Recall 047-2019, April 23, 2019 

• FSIS Recall 048-2019*, April 24, 2019

• CDC Food Safety Alert, June 19, 2019

• Report a Problem with Food

• ore information about ’ response to foodborne outbreaks

• round Beef and ood afety

* ecall occurred during the outbreak investigation as a result of a product positive; however, the isolate 

did not match the outbreak strain and the recalled product was not linked to human illnesses

 lways handle ground 

beef safely and cook to an 

internal temperature of 

160 ° ocumentation 

(e g , receipts) showing 

what you purchased can 

provide useful information 

to help determine what is 

making people sick and 

help solve outbreaks 

 onsider how you 

purchase food and what 

types of information 

(shopper cards, delivery 

apps, receipts) could help 

public health partners 

investigate 

Consumers

 ederal establishments 

and retail stores that 

grind raw beef products 

are required to maintain 

complete and accurate 

records, including 

information on the source 

of raw beef (lot codes, 

establishment number, 

production date), date 

and time when ground 

beef is produced, and 

when grinding equipment 

is cleaned and sanitized 

 his information allows 

investigators to trace 

ground beef purchases

during outbreaks 

Industry

 ontinue to work closely 

with local, state, and 

federal partners to detect 

and investigate 

outbreaks mail 

 oodborne isease epor

ts@usda gov to notify 

 if -regulated 

products may be 

involved in an outbreak 

Public Health Partners

Collaboration

When reviewing and evaluating complex traceback information, 

found that working in small teams with representatives from the 

made collaboration more efficient and effective 

 lways handle ground 

beef safely and cook to an 

internal temperature of 

160 ocumentation 

(e g , receipts) showing 

what you purchased can 

provide useful information 

to help determine what is 

making people sick and 

help solve outbreaks 

 onsider how you 

purchase food and what 

types of information 

(shopper cards, delivery 

apps, receipts) could help 

public health partners 

investigate 

Consumers

 ederal establishments 

and retail stores that 

grind raw beef products 

are required to maintain 

complete and accurate 

records, including 

information on the source 

of raw beef (lot codes, 

establishment number, 

production dates), dates

and times when ground 

beef is produced, and 

when grinding equipment 

is cleaned and sanitized 

 his information allows 

investigators to trace 

ground beef purchases

during outbreaks 

Industry

 ontinue to work closely 

with local, state, and 

federal partners to detect 

and investigate 

outbreaks mail 

 oodborne isease epor

ts@usda gov to notify 

 if -regulated 

products may be 

involved in an outbreak 

Public Health Partners