FSIS Foodborne Illness Outbreak 

Investigations, Fiscal Year 2019 

Introduction 

The United States Department of Agriculture’s Food Safety and Inspection Service, 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 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 

includes details like the foods ill people ate, where they purchased these foods, and where they live. 

Laboratory information includes comparing bacteria in FSIS samples and ill people to see if they are 

genetically similar or have similar characteristics. Traceback activities may include determining the 

location (e.g., grocery store, deli counter, or restaurant) where the product was sold 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 issuing a press release announcing that a federal 

establishment is voluntarily recalling product(s) linked to human illnesses or notifying the public of 

potential food safety concerns through the issuance of a public health alert. 

This report summarizes outbreaks that FSIS investigated during October 1, 2018 through September 30, 

2019, Fiscal Year 2019 (FY 2019). 

Fiscal Year 2019 in Review 

During FY 2019, FSIS investigated 16 outbreaks in coordination with local, state, and federal public health 

partners that involved approximately 1,000 illnesses and more than 175 hospitalizations. The Centers for 

Disease Control and Prevention notified FSIS about the majority (11, 68.8%) of these outbreaks, and 

fifteen (93.8%) outbreaks involved illnesses in more than one state. 

Of the 16 outbreaks investigated by FSIS in FY 2019, Salmonella (7, 43.8%) was the most common 

pathogen, followed by STEC (6, 37.5%), and Lm (3, 18.8 %) (Figure 1). Beef (6, 37.5%) and chicken (4, 

25.0%) were the most common food products of interest (Figure 2). Serotypes involved in the FY 2019 

Salmonella outbreaks included Blockley, Enteritidis, Newport, Rissen, and Schwarzengrund. STEC 

outbreaks were caused by one or more of the following serogroups: O157:H7, O26, O103, and O121. 

Three (18.8 %) outbreaks led to a product recall. FSIS requests that establishments recall product 

associated with an outbreak. 

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Table 1 depicts characteristics about these outbreaks, including information on the serotype/serogroup, 

product of interest, if FSIS samples were determined to be related to human illnesses, and if the available 

outbreak information resulted in a recall of FSIS-regulated products from commerce to prevent additional 

illnesses. 

Figure 1. FY 2019 Outbreaks by Pathogen, Figure 2. FY 2019 Outbreaks by Product of 

N = 16 (%) Interest, N = 16 (%) 

Non-FSIS regulated 

product (2, 12.5%) Lm (3, 18.8%) 

Multi Beef (6, -ingredient 37.5%) Product* (2, 12.5%) 

Turkey Salmonella (7, (1, 6.3%) 43.8%) 

Pork (1, 6.3%) STEC (6, 37.5%) 

Chicken (4, 25.0%) 

* Product investigated included multiple ingredients 

Table 1. FY 2019 Outbreak Characteristics 

Pathogen Serotype/Serogroup ProductA FSIS isolatesC Non FSIS 

IsolatesD RecallE 

STEC 

O157:H7 Beef Yes No No 

O157:H7 Beef Yes No NoF 

O157:H7 Multi-ingredient B No No No 

O103 Beef No Yes Yes 

O121 and O103 Non-FSIS Regulated 

Product (Bison) No 

No 

No 

O26 Non-FSIS Regulated 

Product (Flour) Yes Yes No 

Lm 

Chicken Yes No NoG 

Multi-ingredientB Yes Yes No 

Pork Yes No Yes 

Salmonella 

Rissen Beef No No No 

Newport Beef Yes Yes No 

Newport Beef Yes No No 

Blockley Chicken Yes Yes No 

Enteritidis Chicken Yes Yes No 

Enteritidis Chicken Yes Yes No 

Schwarzengrund Turkey Yes Yes Yes 

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

B) Product(s) investigated included multiple ingredients 

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C) Isolates recovered from FSIS product (or cecal) or environmental testing found to be related (either by whole 

genome sequencing or pulsed-field gel electrophoresis) to clinical isolates and are included in the outbreak cluster 

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

whole genome sequencing or pulsed-field gel electrophoresis) to clinical isolates and are included in the outbreak 

cluster) 

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

company voluntarily recalled product from commerce 

F) Recall of FSIS-regulated product occurred prior to identification of human illness 

G) Recall of FSIS-regulated product occurred during the outbreak investigation as a result of a product positive result; 

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

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 routinely conducts after-action reviews (AARs) 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 for several FY 2019 outbreak investigations. For example, FSIS conducted an AAR in 

collaboration with public health partners for a Salmonella Schwarzengrund outbreak associated with 

ground turkey. Similar to other outbreaks, this AAR identified the need to improve communication 

between partners. The AAR also identified a best practice when public health partners notified FSIS about 

the outbreak early using the FSIS outbreak notification email address 

(FoodborneDiseaseReports@usda.gov). This outbreak highlighted the importance for FSIS to communicate 

with industry early and inform a firm when it is determined that a potential association exists between 

illness and the firm’s product. FSIS continues to improve processes and procedures related to industry 

notification. The AAR report for this outbreak investigation is posted on the FSIS website. 

To see additional posted FSIS AAR reports and examples of how FSIS has applied outbreak lessons learned 

toward illness prevention, visit Foodborne Outbreak Investigation Outcomes - Response and Prevention. 

Contact and Questions 

For more information, contact askFSIS. 

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