Food Safety and Inspection Service

U.S. DEPARTMENT OF AGRICULTURE

Multistate E. coli O157:H7 Outbreak

Possibly Associated with Beef 

After-Action Review Report 2022-05

Highlights

• The Food Safety and Inspection Service 

(FSIS), the Centers for Disease Control and 

Prevention (CDC), and public health partners in 

three states investigated beef as the possible 

source of illnesses in this outbreak. However,

the investigation did not identify a common 

source of beef for the illnesses. 

• This investigation highlights the need for 

continued outreach to food retail stores and 

preparers about best practices for beef that will

be ground. 

Outbreak at a Glance

Illnesses 8 

States included 3 

Hospitalizations 1 

Deaths 0

Process improvements

• FSIS continues to promote best 

practices for grinding beef and 

is working on developing and 

distributing targeted 

educational materials for

retailers and consumers. 

• FSIS will create a 

blogpost for consumers to 

address the risks of 

eating undercooked or 

raw ground beef.

• FSIS recommended that 

the Conference for Food 

Protection (CFP) revise

its Beef Grinding Log 

Guideline to provide 

additional information 

about grinding recordkeeping requirements and 

considering the intended 

use of beef prior to 

grinding the product. 

E. coli O157:H7 Illnesses by State of Residence

9-12 Illnesses

5-8 Illnesses

1-4 Illnesses

13+ Illnesses

5

2

1
What happened?

From May through June 2022, public health officials in California, Idaho, and New York, 

and the CDC and FSIS investigated an outbreak of eight E. coli O157:H7 illnesses. No 

follow-up information was available for two of the cases. Eighty-three percent (5 of 6) of

the ill people reported beef consumption, including raw beef and ground beef. Four ill

people reported eating traditional Middle Eastern foods. Detailed beef exposure 

information was available for three ill people. One ill person reported eating a raw beef 

dish at a restaurant. A second ill person reported eating ground beef kabobs at a

different restaurant. A third ill person reported possibly eating beef at a family event 

where ground beef kabobs and a raw beef dish were served. Detailed purchase 

information about the raw beef dish was not available. FSIS traced back the beef served 

at the two restaurants and the beef used to make kabobs at the family event, which was 

purchased cooked at a market. The traceback investigation did not identify a common 

beef supplier among the two restaurants and store. 

What we learned from this outbreak

Consumer Education

In this outbreak, at least one person reported eating raw beef in a 

traditional Middle Eastern dish. Outreach to groups who consume 

these dishes should emphasize the risks associated with consuming 

raw or not-fully-cooked ground beef. Consumers should be 

encouraged to consider alternative preparations of traditional dishes 

that involve fully cooked beef and reminded of safe cooking and 

handling practices. 

Communication

County public health officials notified FSIS when they identified

raw beef and ground beef as exposures of interest in the 

investigation. This early communication helped FSIS investigators 

coordinate visits to the restaurants and market which enabled 

investigators to complete their investigation more quickly.

Grinding Records

One market visited as part of the investigation did not maintain grinding 

records. Adequate recordkeeping throughout the beef supply chain

provides investigators information to trace ground beef during a 

foodborne outbreak investigation. Outreach concerning grinding best

practices continues to be important. 
What can you do to prevent or solve the next 

outbreak due to E. coli O157:H7?

Helpful Links

Helpful links

• Ground Beef and Food Safety

• Safe Minimum Internal Temperature Chart

• USDA Encourages the Use of Food Thermometers to be Food Safe this Summer

• FSIS Report a Problem with Food

• FSIS Retail Guidance

• Records to be Kept by Official Establishments and Retail Stores that Grind Raw 

Beef Products

• Resources for Public Health Partners

• Food Poisoning Symptoms

• Find more information about FSIS’ response to foodborne outbreaks on the FSIS 

Outbreak Page

For retail stores that grind 

raw beef products, FSIS 

requires the maintenance 

of the following records:

complete and accurate 

records, including the

source of raw beef (lot 

codes, establishment 

number, production dates), 

date and times when the 

ground beef is produced, 

and when the grinding

equipment and other 

related food-contact 

surfaces are cleaned and 

sanitized. These grinding 

records aid investigators to 

trace ground beef back to 

the producing 

establishment during an 

outbreak. 

Public health partners 

should encourage 

outreach to commercial 

food preparers about the 

importance of safe 

handling and cooking of 

raw beef.

They should also continue 

to work closely with local, 

state, and federal 

partners to detect and 

investigate outbreaks. 

Public health partners 

should email 

FoodborneDiseaseReport

s@usda.gov to notify 

FSIS if FSIS-regulated 

products may be involved 

in an outbreak.

Public Health Partners

Consumers should not

eat raw beef. They should 

handle ground beef safely 

and cook to an internal 

temperature of 160 °F. 

The best and only way to 

make sure that any 

bacteria have been killed 

and food is safe to eat is 

by cooking to the correct 

internal temperature as 

measured by a food 

thermometer. Please see 

Ground Beef and Food 

Safety for more 

information. 

Retailers Consumers
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actions consumers can take when specific products are linked to illness 

outbreaks.