Outbreaks of shiga toxin–producing Escherichia coli linked to sprouted seeds, salad, and leafy greens: A systematic review

Erica Kintz, Lisa Byrne, Claire Jenkins, Noel McCarthy, Roberto Vivancos, Paul Hunter

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37 Citations (Scopus)
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Shiga toxin-producing E. coli (STEC) outbreaks involving ready-to-eat salad products have been described in the scientific literature since 1995. These products typically do not undergo a definitive control step such as cooking to eliminate pathogens. To reduce the number of STEC infections from salad products, efforts will need to focus on preventing and reducing contamination throughout the food chain. We performed a systematic review of STEC outbreaks involving sprouted seeds, salad, or leafy green products to determine if there were recurrent features, such as availability of microbiological evidence or identification of the contamination event, which may inform future investigations and prevention and control strategies. Thirty-five STEC outbreaks linked to contaminated leafy greens were identified for inclusion. The outbreaks occurred from 1995-2018 and ranged in size from 8 cases to over 8,500. Detection of STEC in the food product was rare (4/35). For the remaining outbreaks, the determination of leafy greens as the source of the outbreak mainly relied on analytical epidemiology (20/35) or descriptive evidence (11/35). The trace back investigation in 21/32 outbreaks was not able to identify possible routes of where the STEC bacteria came from or how the leaves were contaminated. Investigations in eight outbreaks found poor practice during processing that may have contributed to the outbreak, such as insufficient post-harvest disinfection of the product. Six outbreak investigations were able to identify the outbreak strain in animal feces near the growing fields; two of these were also able to find it in irrigation water on the farms, providing a likely route of contamination. These results highlight the limitations of relying on microbiological confirmation as a basis to initiate investigations of upstream production to understand the source of contamination. This review also demonstrates the importance of, and difficulties associated with, food-chain trace back studies to inform control measures and future prevention.
Original languageEnglish
Pages (from-to)1950-1958
Number of pages9
JournalJournal of Food Protection
Issue number11
Early online date22 Oct 2019
Publication statusPublished - Nov 2019

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