Multistate Outbreak of Listeriosis Linked to Commercially Produced, Prepackaged Caramel Apples Made from Bidart Bros. Apples (Final Update)

Introduction

CDC collaborated with public health officials in several states and with the U.S. Food and Drug Administration (FDA) to investigate an outbreak of Listeria monocytogenes infections (listeriosis). Joint investigation efforts indicated that commercially produced, prepackaged caramel apples made from Bidart Bros. apples were the likely source of this outbreak. Listeria can cause a serious, life-threatening illness. People at higher risk for listeriosis include adults 65 years or older, people with weakened immune systems, and pregnant women.

Public health investigators used the PulseNet system to identify illnesses that were part of this outbreak. PulseNet is the national subtyping network of public health and food regulatory agency laboratories coordinated by CDC. DNA "fingerprinting" is performed on Listeria bacteria isolated from ill people using techniques called pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). WGS gives a more detailed DNA fingerprint than PFGE. PulseNet manages a national database of these DNA fingerprints to identify possible outbreaks of enteric illness. Two outbreak clusters were identified by the PFGE technique. When WGS was used, two Listeria isolates (one within each cluster) were found to be highly related but distinct between the two clusters. CDC investigated the two clusters together because one person was infected with both Listeria strains simultaneously and also because illnesses in the two clusters occurred during a similar time period and in similar regions of the country.

The 35 ill people included in this outbreak investigation were reported from 12 states: Arizona (5), California (3), Colorado (1), Minnesota (4), Missouri (5), Nevada (1), New Mexico (6), North Carolina (1), Texas (4), Utah (1), Washington (1), and Wisconsin (3). Illness onset dates ranged from October 17, 2014, to January 6, 2015. Eleven illnesses were associated with a pregnancy (occurred in a pregnant woman or her newborn infant). One fetal loss was reported. Among people whose illnesses were not associated with a pregnancy, ages ranged from 7 to 92 years, with a median age of 62 years, and 33% were female. Three invasive illnesses (meningitis) occurred among otherwise healthy children aged 5–15 years. Thirty-four people were hospitalized, and listeriosis contributed to at least three of the seven deaths reported.

The outbreak can be visually described with a chart showing the number of people who were diagnosed each day. This chart is called an epidemic curve or epi curve.

The Public Health Agency of Canada (PHAC) identified two cases of listeriosis in Canada with the same PFGE patterns as those seen in the U.S. outbreak. More detailed testing using WGS showed that the isolate from only one of the two cases was genetically related to the U.S. outbreak. That person reported eating a caramel apple.

Investigation of the Outbreak

In interviews, ill people answered questions about foods consumed and other exposures in the month before becoming ill. Twenty-eight (90%) of the 31 ill people interviewed reported eating commercially produced, prepackaged caramel apples before becoming ill. Caramel apple brands named in interviews included Happy Apples, Carnival, and Merb’s Candies. However, other brands may also have been consumed. The three ill people interviewed who did not report eating caramel apples did report eating whole or sliced green apples not covered in caramel. However, most (about 60%) of the general US population report eating apples [PDF – 29 pages] during a given week. The source of the reported whole or sliced green apples is unknown, and it is unknown whether these apples were linked to the patients’ illnesses.

On January 6, 2015, Bidart Bros. of Bakersfield, California, voluntarily recalled Granny Smith and Gala apples because environmental testing revealed contamination with Listeria monocytogenes at the firm’s apple-packing facility. The recall included all Granny Smith and Gala apples shipped from its Shafter, California, packing facility in 2014. On January 8, 2015, FDA laboratory analyses using PFGE showed that environmental Listeria isolates from the Bidart Bros. facility were indistinguishable from the outbreak strains. On January 18, 2015, WGS found that these isolates were highly related to the outbreak strains. In addition, WGS showed that Listeria isolates from whole apples produced by Bidart Bros., collected along the distribution chain, also were highly related to the outbreak strains. CDC recommends that consumers not eat any of the recalled Granny Smith and Gala apples produced by Bidart Bros. and retailers not sell or serve them.

Three firms that produce caramel apples issued voluntary recalls after receiving notice from Bidart Bros. that there may be a connection between Bidart Bros. apples and this listeriosis outbreak. On December 24, 2014, Happy Apple Company of Washington, Missouri, voluntarily recalled Happy Apples brand caramel apples with a best use by date between August 25 and November 23, 2014. On December 31, 2014, Happy Apple Company expanded the recall to include Kroger brand caramel apples produced by Happy Apple Company with a best use by date between September 15 and November 18, 2014. On December 27, 2014, California Snack Foods voluntarily recalled Karm'l Dapple brand caramel apples with a best use by date between August 15 and November 28, 2014. On December 29, 2014, Merb’s Candies of St. Louis, Missouri issued a voluntary recall of Merb's Candies Bionic Apples and Double Dipped Apples that would have been available from September 8 through November 25, 2014.

This outbreak appears to be over. However, recalled products may still be in people’s homes. Consumers unaware of the recalls could continue to eat the products and get sick.

Investigation Update

The information CDC has at this time continues to indicate that commercially produced, prepackaged caramel apples may be contaminated with Listeria. Listeria can cause a serious, life-threatening illness. In interviews, ill people answered questions about foods consumed and other exposures in the month before becoming ill. To date, 23 (88%) of the 26 ill people interviewed reported eating commercially produced, prepackaged caramel apples before becoming ill. Caramel apple brands named in interviews have included Happy Apples, Carnival, and Merb’s Candies.  However, the investigation is ongoing and other brands may be identified. The three ill people interviewed who did not report eating caramel apples did report eating whole or sliced green apples not covered in caramel. The source of these apples is unknown, and it is unknown whether these apples are linked to the patients’ illnesses.

On January 6, 2015, Bidart Bros. of Bakersfield, California voluntarily recalled  Granny Smith and Gala apples because environmental testing revealed contamination with Listeria monocytogenes at the firm’s apple-packing facility. The recall includes all Granny Smith and Gala apples shipped from its Shafter, California packing facility in 2014. CDC recommends that consumers not eat any of the recalled Granny Smith and Gala apples produced by Bidart Bros. and that retailers not sell or serve them.

To date, three firms that produce caramel apples have issued voluntary recalls after receiving notice from Bidart Bros. that there may be a connection between Bidart Bros. apples and this listeriosis outbreak. On December 24, 2014, Happy Apple Company of Washington, Missouri, voluntarily recalled Happy Apples brand caramel apples with a best use by date between August 25 and November 23, 2014. On December 31, 2014, Happy Apple Company expanded the recall to include Kroger brand caramel apples produced by Happy Apple Company with a best use by date between September 15 and November 18, 2014. On December 27, 2014, California Snack Foods voluntarily recalled Karm'l Dapple brand caramel apples with a best use by date between August 15 and November 28, 2014. On December 29, 2014, Merb’s Candies of St. Louis, Missouri issued a voluntary recall of Merb's Candies Bionic Apples and Double Dipped Apples that would have been available from September 8 through November 25, 2014.  Investigators are continuing to work to determine if any other brands or types of commercially produced, prepackaged caramel apples are linked to illnesses and to determine the source of contamination.

CDC’s Advice to Consumers continues to recommend that U.S. consumers not eat any commercially produced, prepackaged caramel apples, including plain caramel apples as well as those containing nuts, sprinkles, chocolate, or other toppings, until more specific guidance can be provided. These products could have a shelf life of more than one month. CDC, the involved states, and FDA continue to work closely on this rapidly evolving investigation, and new information will be provided as it becomes available.

Case Count Update

As of December 30, 2014, a total of 32 people infected with the outbreak strains of Listeria monocytogenes have been reported from 11 states: Arizona (4), California (2), Minnesota (4), Missouri (5), Nevada (1), New Mexico (6), North Carolina (1), Texas (4), Utah (1), Washington (1), and Wisconsin (3). Dates when the Listeria strains were isolated range from October 17, 2014, to December 11, 2014. Ten illnesses have been associated with a pregnancy (occurred in a pregnant woman or her newborn infant). One fetal loss has been reported. Among people whose illnesses were not associated with a pregnancy, ages ranged from 7 to 92 years, with a median age of 66 years, and 32% were female. Three invasive illnesses (meningitis) occurred among otherwise healthy children aged 5–15 years. Thirty-one ill people have been hospitalized and six deaths have been reported. Listeriosis contributed to three of these deaths, and it is unclear whether it contributed to an additional two deaths. The sixth death was unrelated to listeriosis.

Illnesses that started after December 14, 2014, might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

The Public Health Agency of Canada (PHAC) has identified 2 cases of listeriosis in Canada with the same PFGE patterns as seen in the U.S. outbreak. PHAC is working with its provincial and territorial partners to determine the source of these illnesses. CDC and FDA are working with Canadian health authorities to determine whether these illnesses are related to the U.S. outbreak.

Investigation of the Outbreak

The information CDC has at this time continues to indicate that commercially produced, prepackaged caramel apples may be contaminated with Listeria. Listeria can cause a serious, life-threatening illness. In interviews, ill people answered questions about foods consumed and other exposures in the month before becoming ill. To date, 23 (88%) of the 26 ill people interviewed reported eating commercially produced, prepackaged caramel apples before becoming ill. Caramel apple brands named in interviews have included Happy Apple, Carnival, and Merb’s Candies.  However, the investigation is ongoing and other brands may be identified. At this time, no illnesses related to this outbreak have been linked to apples that are not caramel-coated and not prepackaged or to caramel candy.

To date, three firms that produce caramel apples have issued voluntary recalls after receiving notice from Bidart Brothers, an apple supplier, that there may be a connection between Bidart Brothers apples and this listeriosis outbreak. On December 24, 2014, Happy Apple Company of Washington, Missouri, voluntarily recalled Happy Apple brand caramel apples with a best use by date between August 25 and November 23, 2014. On December 27, 2014, California Snack Foods voluntarily recalled Karm'l Dapple brand caramel apples with a best use by date between August 15 and November 28, 2014. On December 29, 2014, Merb’s Candies of St. Louis, Missouri issued a voluntary recall of Merb's Candies Bionic Apples and Double Dipped Apples that would have been available between September 8 and November 25, 2014. Investigators are continuing to work to identify if any other brands or types of commercially produced, prepackaged caramel apples may be linked to illnesses and to identify the source of contamination.

Although voluntary recalls have been issued for three brands of commercially produced, prepackaged caramel apples, CDC’s Advice to Consumers remains the same. CDC continues to recommend that U.S. consumers not eat any commercially produced, prepackaged caramel apples, including plain caramel apples as well as those containing nuts, sprinkles, chocolate, or other toppings, until more specific guidance can be provided. These products could have a shelf life of more than one month. CDC, the involved states, and FDA continue to work closely on this rapidly evolving investigation, and new information will be provided as it becomes available.

Case Count Update

As of December 22, 2014, a total of 29 people infected with the outbreak strains of Listeria monocytogenes have been reported from 10 states: Arizona (4), California (1), Minnesota (4), Missouri (5), New Mexico (5), North Carolina (1), Texas (4), Utah (1), Washington (1), and Wisconsin (3). Illness onset dates range from October 17, 2014, to November 27, 2014. Nine illnesses have been associated with a pregnancy (occurred in a pregnant woman or her newborn infant). No miscarriages or fetal losses have been reported. Among people whose illnesses were not associated with a pregnancy, ages ranged from 7 to 92 years, with a median age of 66 years, and 41% were female. Three invasive illnesses (meningitis) occurred among otherwise healthy children aged 5–15 years. All 29 ill people have been hospitalized and, five deaths have been reported. Listeriosis contributed to three of these deaths and it is unclear whether it contributed to a fourth. The fifth death was unrelated to listeriosis.

The outbreak can be visually described with a chart showing the number of people who were diagnosed each day. This chart is called an epidemic curve or epi curve. Illnesses that started after December 7, 2014, might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Investigation of the Outbreak

The information CDC has at this time indicates that commercially produced, prepackaged caramel apples may be contaminated with Listeria. Listeria can cause a serious, life-threatening illness. In interviews, ill people answered questions about foods consumed and other exposures in the month before becoming ill. To date, 20 (87%) of the 23 ill people interviewed reported eating commercially produced, prepackaged caramel apples before becoming ill. At this time, no illnesses related to this outbreak have been linked to apples that are not caramel-coated and not prepackaged or to caramel candy. Although limited information is currently available about the specific brand(s) of commercially produced, prepackaged caramel apples consumed, the finding that most of the ill people reported consuming these apples suggests that these Listeria infections are likely related to commercially produced, prepackaged caramel apples. Investigators are rapidly working to determine specific brands or types of commercially produced, prepackaged caramel apples that may be linked to illnesses and to identify the source of contamination.

At this point in the investigation, CDC’s Advice to Consumers remains the same. Out of an abundance of caution, CDC recommends that U.S. consumers not eat any commercially produced, prepackaged caramel apples, including plain caramel apples as well as those containing nuts, sprinkles, chocolate, or other toppings, until more specific guidance can be provided. These products could have a shelf life of more than one month. CDC, the involved states, and FDA continue to work closely on this rapidly evolving investigation, and new information will be provided as it becomes available.

December 19, 2014

Introduction

CDC is collaborating with public health officials in several states and with the U.S. Food and Drug Administration (FDA) to investigate an outbreak of Listeria monocytogenes infections (listeriosis). Joint investigation efforts indicate that commercially produced, prepackaged caramel apples are the likely source.

Public health investigators are using the PulseNet system to identify cases that may be part of this outbreak. PulseNet is the national subtyping network of public health and food regulatory agency laboratories coordinated by CDC that identifies possible outbreaks. DNA "fingerprinting" is performed on Listeria bacteria isolated from ill persons using techniques called pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). WGS gives a more detailed DNA fingerprint than PFGE. Two outbreak clusters were identified by the PFGE technique, and Listeria isolates within each cluster were found to be highly related by the WGS technique but distinct between the two clusters. CDC is investigating the two clusters together because one person was infected with both Listeria strains simultaneously and also because illnesses in the two clusters have occurred during a similar time period and in similar regions of the country.

The 28 ill people included in this outbreak investigation have been reported from 10 states: Arizona (4), California (1), Minnesota (4), Missouri (5), New Mexico (5), North Carolina (1), Texas (4), Utah (1), Washington (1), and Wisconsin (2). Illness onset dates range from October 17, 2014, to November 27, 2014. Nine illnesses have been associated with a pregnancy (occurred in a pregnant woman or her newborn infant). No miscarriages or fetal losses have been reported. Among people whose illnesses were not associated with a pregnancy, ages ranged from 7 to 92 years, with a median age of 64 years, and 32% were female. Three invasive illnesses (meningitis) occurred among otherwise healthy children aged 5–15 years. Of the 26 ill persons for whom information is available, all have been hospitalized, and five deaths have been reported. Listeriosis contributed to at least four of these deaths.

The outbreak can be visually described with a chart showing the number of persons who were diagnosed each day. This chart is called an epidemic curve or epi curve. Illnesses that started after December 3, 2014, might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Investigation of the Outbreak

The information CDC has at this time indicates that commercially produced, prepackaged caramel apples may be contaminated with Listeria. Listeria can cause a serious, life-threatening illness. In interviews, ill persons answered questions about foods consumed and other exposures in the month before becoming ill. To date, 15 (83%) of the 18 ill people interviewed reported eating commercially produced, prepackaged caramel apples before becoming ill. At this time, no illnesses related to this outbreak have been linked to apples that are not caramel-coated and not prepackaged or to caramel candy. Although limited information is currently available about the specific brand(s) of commercially produced, prepackaged caramel apples consumed, the finding that most of the ill people reported consuming these apples suggests that these Listeria infections are likely related to commercially produced, prepackaged caramel apples. Investigators are rapidly working to determine specific brands or types of commercially produced, prepackaged caramel apples that may be linked to illnesses and to identify the source of contamination.

Out of an abundance of caution, CDC recommends that U.S. consumers not eat any commercially produced, prepackaged caramel apples, including plain caramel apples as well as those containing nuts, sprinkles, chocolate, or other toppings, until more specific guidance can be provided. These products could have a shelf life of more than one month. CDC, the involved states, and FDA continue to work closely on this rapidly evolving investigation, and new information will be provided as it becomes available.