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Red Book Online Outbreaks: Packaged Salads by Dole and Fresh Express – Listeria

January 26, 2022

CDC is currently investigating two Listeria outbreaks linked to packaged salads produced by two different manufacturers—Dole and Fresh Express. As of December 22, 2021:

  • The Listeria outbreak linked to packaged salads produced by Dole has caused 16 illnesses, 12 hospitalizations, and 2 deaths in 13 states.
  • The Listeria outbreak linked to packaged salads produced by Fresh Express has caused 10 illnesses, 10 hospitalizations, and 1 death in 8 states.  

Dole products:
Investigators found the outbreak strain of Listeria in two different packaged salads produced by Dole and are working to determine if additional products may be contaminated. Dole products are sold under multiple brands: Ahold, Dole, Kroger, Lidl, Little Salad Bar, Marketside, Naturally Better, Nature’s Promise, and Simply Nature. See Dole’s recall notice for the full list of recalled salads.

  • Products include mixed greens, garden salads, Caesar kits, and many other types of salads in bags or clamshells.
  • These products have “Best if used by” dates from 11/30/21 through 01/08/22.
  • Product lot codes begin with the letter “N” or “Y” in the upper right-hand corner of the package.

Fresh Express products:
On December 16, 2021, the Michigan Department of Agriculture identified the outbreak strain of Listeria in a bag of Fresh Express Sweet Hearts packaged salad. On December 20, 2021, Fresh Express recalled several brands of packaged salad products.

  • Brands include Fresh Express, Bowl & Basket, Giant Eagle, Little Salad Bar, Marketside, O Organics, Signature Farms, Simply Nature, Weis Fresh from the Field, and Wellsley Farms Organic.
  • These products have “use-by” dates with product codes Z324 through Z350.

Clinical Guidance

Presentation:

  • Patients should call their pediatrician right away if they exhibit any signs or symptoms of Listeria infection after eating packaged salads.
  • Listeria usually causes common food poisoning signs and symptoms, like fever and diarrhea. People who experience these symptoms usually recover without treatment. Symptoms of self-limited febrile gastroenteritis usually start within 24 hours of ingesting a contaminated food and last 2–3 days.
  • Less commonly, Listeria can cause severe illness (known as invasive listeriosis) when the bacteria spread beyond the gut to other parts of the body. Symptoms of invasive listeriosis usually start 1 to 4 weeks after eating contaminated food but may occasionally start even later.
    • Pregnant people with invasive listeriosis usually experience only fever, fatigue, muscle aches, and occasionally gastrointestinal tract infections.
    • Non-pregnant people with invasive listeriosis may experience headache, stiff neck, confusion, loss of balance, and convulsions, in addition to fever and muscle aches.

Who is at highest risk/complications?

  • Those at highest risk from Listeria infections include people who are 65 years or older, are pregnant, or are immunocompromised.
  • Listeria can cause pregnancy loss or premature birth.
  • Listeria can also cause serious illness or death in newborns.

Diagnosis:

  • L monocytogenes can be recovered readily on blood agar from cultures of blood, cerebrospinal fluid (CSF), meconium, placental or fetal tissue specimens, amniotic fluid, and other infected tissue specimens, including joint, pleural, or peritoneal fluid. 
  • A number of laboratory-derived polymerase chain reaction (PCR) assays have been described for detection of L monocytogenes in blood and CSF. 
  • Stool cultures are generally not useful for diagnosis of Listeria infection.

Precautions:

  • Do not eat any recalled packaged salads (discard or return product to store).
  • Ensure proper cleaning after exposure because Listeria can survive in the refrigerator and can easily spread to other foods and surfaces.

Risk Mitigation:

  • Antimicrobial therapy for infection diagnosed during pregnancy may prevent fetal or perinatal infection and its consequences.

Treatment:

  • Combination therapy using ampicillin and a second agent in doses appropriate for meningitis is recommended for severe infections. (see Treatment section in Red Book chapter)

Reporting:

  • Listeriosis is a nationally notifiable disease in the United States.
  • Cases should be reported promptly to the state or local health department to facilitate early recognition and control of common-source outbreaks.
  • Clinical isolates should be forwarded to a public health laboratory for genetic sequencing.

Resources

Pediatric Practice Tools and Information

Listeria (Listeriosis) | Listeria | CDC

 

Public Health Resources

Dole: Investigation Details | Where Sick People Lived | When People Got Sick

Fresh Express: Investigation Details | Where Sick People Lived  | When People Got Sick

 

Information for Patients and Caregivers

Listeriosis Infection – HealthyChildren.org

 

Infection Prevention and Control Resources

Project Firstline (aap.org)

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