GESTIÓN EN SALUD PÚBLICA: Outbreaks: Investigation, Response & Evaluation

Outbreaks: Investigation, Response & Evaluation

FDA Investigates Multistate Outbreak of Salmonella Infections Linked to Products Reported to Contain Kratom

March 15, 2018

The U.S. Food and Drug Administration along with the Centers for Disease Control and Prevention (CDC) and state and local officials are investigating a multistate outbreak of Salmonella infections linked to products reportedly containing kratom.

March 15, 2018 Update:

The investigation has expanded to include outbreak strains from three additional serotypes of Salmonella: Salmonella Javiana, Salmonella Okatie, and Salmonella Thompson, as well as the original strain, Salmonella I 4,[5],12:b:-.

Twenty-five product samples have tested positive for Salmonella. Three revealed isolates that are genetically related to an outbreak strain, while 22 have tested positive for a non-matching Salmonella, or tested positive for Salmonellaand further testing is pending.

On March 9, 2018, PDX Aromatics of Portland, Oregon, doing business under the names Kraken Kratom, Phytoextractum, and Soul Speciosa, recalled certain kratom-containing powder products after testing by the California Department of Public Health identified Salmonella in an open sample of kratom product originating from the business. Further FDA testing confirmed the presence of Salmonella in products purchased from this company.

As of March 14, 2018, CDC reports that 87 people infected with outbreak strains of Salmonella I 4,[5],12:b:- (50), Salmonella Javiana (5), Salmonella Okatie (16), or Salmonella Thompson (16) have been reported from 35 states. Twenty-seven people have been hospitalized. Interviews with ill people are continuing. So far, 40 of 55 ill people specifically asked about kratom reported consuming kratom before getting sick.

Fast Facts

The FDA is advising consumers to avoid kratom and kratom-containing products. These products have been linked to a multistate outbreak of salmonellosis from multiple strains of Salmonella. Mitragyna speciosa, commonly known as kratom, is a plant that grows naturally in Thailand, Malaysia, Indonesia, and Papua New Guinea.
As of March 14, 2018, the CDC reports that 87 people infected with outbreak strains of Salmonella I 4,[5],12:b:- (50), Salmonella Javiana (5), Salmonella Okatie (16), or Salmonella Thompson (16) have been reported from 35 states. Twenty-seven people have been hospitalized. Twenty-five products have been tested and reported positive for Salmonella. Three match one or more of the outbreak strains and an additional 22 have tested positive for Salmonella, and either do not match or are pending further characterization.
During interviews conducted by state and local health officials, ill people were asked about the foods they ate and other exposures before they became ill. As of March 14, 2018, 40 of 55 (73%) ill people specifically asked about kratom reported consuming kratom before getting sick.
State Health officials have collected various leftover and unopened kratom samples to test for Salmonella contamination. Testing by the North Dakota and Utah Departments of Health has identified the outbreak strain of Salmonella I 4,[5],12:b:- in opened, leftover kratom powder collected from ill people in their states. The ill person in North Dakota reported purchasing S.K. Herbalist brand kratom powder from the online retailer Soap Korner. The ill person in Utah reported purchasing kratom powder from the online retailer Kratoma.
Additionally, on March 9, 2018, PDX Aromatics of Portland, Oregon, doing business under the names Kraken Kratom, Phytoextractum, and Soul Speciosa, in full cooperation with FDA, recalled certain kratom-containing powder products after testing by the California Department of Public Health identified Salmonella in an open sample of kratom products originating from the business.
FDA has also conducted testing for Salmonella contamination on kratom-containing products. Three samples collected by internet purchases have tested positive for Salmonella, and further genetic testing on isolates is pending to determine if they are related to the outbreak strain(s).
Additional testing by states has revealed Salmonella in other brands of kratom, meaning it is likely that multiple kratom and kratom-containing brands and retailers are supplying contaminated product to the public. The FDA is continuing to work with state and local health officials and CDC to identify specific brand names and suppliers of products to learn more about the possible source and route of Salmonella contamination and will share more information as it becomes available.
In addition to the public health concerns raised by this outbreak, the FDA continues to warn consumers not to consume any kratom product. There is no FDA-approved use for kratom and the agency has received concerning reports about the safety of kratom, including deaths associated with its use.

What is the Problem and What is being Done About It?

The FDA, CDC, states and local health officials are investigating a multistate outbreak of salmonellosis from multiple serotypes of Salmonella: I 4,[5],12:b:-, Thompson, Okatie, and Javiana. CDC reports that epidemiologic evidence collected to date indicates that kratom or kratom containing products are a likely source of this outbreak. These products are marketed in many forms, including leaves, pills, capsules, powder and tea, and may not mention kratom on the labeling. Other names for kratom that have been identified by the U.S. Drug Enforcement Administration (DEA) are: Mitragyna speciosa, mitragynine extract, biak-biak, cratom, gratom, ithang, kakuam, katawn, kedemba, ketum, krathom, krton, mambog, madat, Maeng da leaf, nauclea, Nauclea speciosa, or thang.

During interviews conducted by health officials, ill people were asked about the foods they ate and other exposures before they became ill. As of March 12, 40 of 55 ill people specifically asked about kratom reported consuming kratom before getting sick. Most people report having used Maeng da red vein kratom.

On March 9, 2018, PDX Aromatics of Portland, Oregon, doing business under the names Kraken Kratom, Phytoextractum, and Soul Speciosa, in full cooperation with FDA, recalled certain kratom-containing powder products after testing by the California Department of Public Health identified Salmonella in samples of kratom products collected from the business. Additional testing by FDA has identified Salmonella in products with the Kraken Kratom brand name.

As of March 13, 2018, 22 state-tested product samples have tested positive for Salmonella. There are three positive samples that are genetically related to one or more of the Salmonella outbreak strains. One of these samples was opened and collected from a case-patient who reported purchasing the product from Soap Korner. The product is labeled, “S.K. Herbalist Red Tea MD Kratom.” Another of the samples with isolates matching two of the outbreak strains was also opened and collected from a case-patient who reported purchasing from https://buy-kratom.us/. This product was labeled RMD-1. The third sample matching one of the outbreak strains was a sample of “Green Malaysian” collected from an open bin at a retail location, Torched Illusions in Oregon. Nineteen other state samples have revealed Salmonella and either are not genetically related to the outbreak strains or are pending further analysis.

FDA has also conducted testing for Salmonella contamination on kratom-containing products. Three samples collected by internet purchases have identified Salmonella with further genetic testing on isolates pending to determine if they are related to the outbreak strain(s). Two of these samples were Kraken Kratom brand products and one was purchased from the online retailer Kratoma.

Although most of these samples do not match the strains of the Salmonella outbreak, any positive result for Salmonella poses a threat to consumers. The FDA continues to warn consumers not to consume any kratom product. There is no FDA-approved use for kratom and the agency has received concerning reports about the safety of kratom, including deaths associated with its use.

The FDA is continuing to work with state and local health officials and CDC to identify specific brand names or suppliers of products to learn more about the possible source and route of Salmonella contamination and will share more information as it becomes available.

As of March 15, 2018, the CDC reports that 87 people in 35 states are infected with outbreak strains of Salmonella I 4,[5],12:b:-, Salmonella Javiana, Salmonella Okatie, or Salmonella Thompson. The states include: AK (1), AL (1), AZ (4), CA (4), CO (2), DE (1), FL (3), GA (2), IL(1), IN(1), KS (1), KY (3), LA (1), MA (2), MD(1), MI (3), MN (2), MO (2), MS(1), NC (4), ND (1), NV(1), NY (2), OH (4), OK (3), OR (4) PA (2), SC (1), TN (1), TX(1), UT (3), VA (4), WA (10), WI (6) and WV(1). Twenty-seven of these people have been hospitalized and no deaths have been reported. Ill people range in age from 6 to 67 years. Illnesses started on dates ranging from January 21, 2017 to February 24, 2018.

All of the cases have been confirmed to have an outbreak strain of Salmonella I 4,[5],12:b:- (50), Salmonella Javiana (5), Salmonella Okatie (16), or Salmonella Thompson (16). Analysis using whole genome sequencing performed to date on isolates from ill people shows most isolates within the Salmonella I 4,[5],12:b:- serotype are closely relatedly genetically. This means that people in this outbreak are more likely to share a common source of infection.

This investigation is ongoing. The FDA is currently conducting traceback efforts in order to determine the source(s) of the outbreak. Based on the information presented above, it is likely that multiple brands and retailers are supplying contaminated product to the public. The positive results also indicate possible concerns with the manufacturing practices used in production and/or handling of these products.

Timeline

On February 12, 2018, the FDA learned of a multistate outbreak of salmonellosis from a rare strain of Salmonella I 4,[5],12:b:-.

On February 20, 2018, CDC announced that, as of February 16, 28 people in 20 states were infected, and that 11 people had been hospitalized. Eight of 11 people interviewed reported consuming kratom as pills, powder, or tea.

On February 28, 2018, the CDC reported 40 people in 27 states are infected with Salmonella I 4,[5],12:b:-. Fourteen people have been hospitalized. Seventeen of 24 of ill people interviewed reported consuming kratom before getting sick.

On February 28, 2018, the North Dakota and Utah Departments of Health collected leftover kratom powder from ill people in their states. The outbreak strain of Salmonella I 4,[5],12:b:- was identified in both samples. The ill person in North Dakota reported purchasing S.K. Herbalist brand kratom powder from the website soapkorner.com. The ill person in Utah reported purchasing kratom powder from the website kratoma.com.

On March 8, 2018, Oregon Health Agency issued a press release warning that kratom products could be contaminated with the Salmonella bacteria after two people in Oregon who consumed the herbal supplement fell ill.

On March 9, 2018, PDX Aromatics voluntarily recalled the Red Dragon Kratom Powder, Red Vein Borneo Kratom Powder, Red Vein Sumatra Kratom Powder, Red Vein Thai Kratom Powder and Super Indo Kratom Powder sold through Kraken Kratom, Phytoextractum, and Soul Speciosa.

As of March 14, 2018, the FDA and state partners have tested multiple kratom products and 25 of these products are positive for Salmonella. Three match this outbreak strain, while 22 have tested positive for a different Salmonella or tested positive for Salmonella and further testing is pending.

As of March 14, 2018, the CDC reports that 87 people in 35 states have been reported infected with outbreak strains from four serotypes of Salmonella I 4,[5],12:b:-, Salmonella Javiana, Salmonella Okatie, and Salmonella Thompson. Twenty-seven people have been hospitalized.

Products and associated companies that tested positive for Salmonella:

Product	Retailer	Known or Labeled Distributor
Red Maeng Da (RMD 1-kg)	Kratoma (buy-kratom.us)	Kratoma
S.K. Herbalist Red Tea MD	Soap Korner (soapkorner.com)	Soap Korner
Red Vein Borneo	Phytoextractum (phytoextraxtum.com)	PDX Aromatics
Red Borneo	Kraken Kratom (krakenkratom.com)	PDX Aromatics
Red Dragon (Red Vein)	Kraken Kratom (krakenkratom.com)	PDX Aromatics
White Maeng Da	Kraken Kratom (krakenkratom.com)	PDX Aromatics
NXT GEN Botanicals Maeng Da	Smoke Station, Salt Lake City, UT	NGB Corp, West Jordan, UT
Eclipse Premium Maeng Da	Smoke Station, Salt Lake City, UT	Tamarack, Cheyenne, WY
Dragon Bali	Fastrac, Salt Lake City, UT	Not stated
Green Bali bulk powder	Torched Illusions, Tigard, OR	Unlabeled
Green Sumatra bulk powder	Torched Illusions, Tigard, OR	Unlabeled
Green Malaysian bulk powder	Torched Illusions, Tigard, OR	Unlabeled
White Maeng Da bulk powder	Torched Illusions, Tigard, OR	Unlabeled
White Borneo bulk powder	Torched Illusions, Tigard, OR	Unlabeled
White Sumatra bulk powder	Torched Illusions, Tigard, OR	Unlabeled

Note: some products had duplicate samples

What are the Symptoms of Salmonella Infection?

Salmonella bacteria cause the foodborne illness salmonellosis. Most people infected with Salmonella develop diarrhea, fever, and abdominal cramps. The illness usually lasts 4 to 7 days, and most people recover without treatment. However, in the current outbreak, an unusually high rate of cases has been hospitalized for their illness.

How Soon After Exposure do Symptoms Appear?

Most people infected with Salmonella develop diarrhea, fever, and abdominal cramps 12 to 72 hours after infection.

What are the Complications of Salmonella Infections?

In some people, the diarrhea may be so severe that they need to be hospitalized. In these patients, the Salmonella infection may spread from the intestines to the blood stream and then to other body sites and can cause death unless the person is treated promptly with antibiotics.

Who is at Risk?

Children are the most likely to get salmonellosis, although other groups are also at risk. Children younger than five, the elderly, and those people with weakened immune systems are more likely to have severe infections. It is estimated that approximately 400 persons in the United States with acute salmonellosis die each year.

What Do Consumers Need To Do?

Consumers who have symptoms of salmonellosis should contact their health care provider. If you are diagnosed with salmonellosis, be sure to tell your health care provider about all products you may be using, including products reported to contain kratom. Consumers should be aware that some products may not list kratom on the labeling.

If consumers have one or more of these products in their homes, they should throw them away. As a precaution, kratom no longer stored in its original packaging should be discarded, and the containers used to store it should be thoroughly washed and sanitized. In order to prevent cross-contamination, wash hands, work surfaces, and utensils thoroughly after contact with these products, and do not prepare food in the area at the same time.

The FDA advises consumers to avoid kratom in any form. In addition to the public health concerns raised by this outbreak, there is strong evidence that kratom affects the same opioid brain receptors as morphine and appears to have properties that expose people who consume kratom to the risks of addiction, abuse, and dependence.

There are no FDA-approved uses for kratom, and the agency has received concerning reports about the safety of kratom, including deaths associated with its use. FDA is actively evaluating available scientific information on this issue and continues to warn consumers not to consume any products containing the botanical substance kratom or its psychoactive compounds, mitragynine and 7-hydroxymitragynine. FDA encourages more research to better understand kratom’s safety profile, including the use of kratom combined with other substances.