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Published Date: 2019-05-29 12:14:28
Subject: PRO/AH/EDR> Yersiniosis - Denmark, Sweden: spinach, ex Italy
Archive Number: 20190529.6492672
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

Date: Tue 28 May 2019
Source: Food Safety News [edited]

An outbreak of yersiniosis in Denmark and Sweden with more than 50 cases has been linked to fresh spinach. Statens Serum Institut, a public health research institute in Denmark, reports 20 people have been infected in the country. One person needed hospital treatment. The Public Health Agency of Sweden has recorded 37 confirmed cases.

In March 2019, 20 cases of _Yersinia enterocolitica_ [infection] were found in Denmark. There were 11 women and 9 men aged 2 to 74 years old, with most cases aged 20 to 30. Patients were distributed throughout Denmark in Hovedstaden, Sjaelland, Syddanmark, Midtjylland, and Nordjylland.

The link to spinach was based on a case control study and the traceback investigation, which indicated spinach from Italy was responsible. In March 2019, most fresh spinach in Denmark comes from Spain or Italy. No specific batch of product was found to be the source of the outbreak and no product testing was conducted.

After interviews with patients, Statens Serum Institut did a study in which healthy people of the same gender and age, and who lived in the same municipality as those sick, were asked if they had eaten certain foods that many of the yersiniosis patients ate. The study showed patients had consumed fresh spinach to a far greater extent than the control people.

The investigation found spinach was bought in Netto and a supermarket chain in Sweden. Danish officials said the implicated product is no longer on the market because the country had not seen any cases since March 2019 and given duration of the outbreak it was likely only one batch that was contaminated.

The cause of the outbreak was _Yersinia enterocolitica_ serotype O3, biotype 4. Whole genome sequencing found all patients were infected with the same bacterial strain. "Although the outbreak is over, we can use this knowledge to prevent it from happening again. It is also a good reason to remind consumers that leafy greens always must be washed thoroughly before eating," said Luise Müller, an epidemiologist from Statens Serum Institut.

Denmark sees about 400 _Yersinia enterocolitica_ cases a year, with 366 having been reported in 2018.

In Sweden, the increase in _Yersinia_ infections started in March [2019] and the 37 cases were from across the country. 7 men and 20 women with an age range from 6 to 62 years fell ill. Swedish officials said they were not able to analyse food samples since no case had spinach left at home and their case-control study did not identify a specific food item. Infection with yersinia is relatively rare in Sweden, with between 200 to 300 cases reported annually. Previous outbreaks have been caused by raw or undercooked meat consumption and contaminated ready-to-eat vegetables. After an incubation period of 3 to 7 days, symptoms includes fever, diarrhea, and abdominal pain in the right lower part of the abdomen.

[byline: Joe Whitworth]

communicated by:
ProMED-mail from HealthMap Alerts

[It is not specifically stated whether the strains in Denmark and Sweden are genetically related.

The 2 species of _Yersinia_ associated with foodborne disease are _pseudotuberculosis_ and _enterocolitica_. The latter species can be associated with abdominal pain as a hallmark symptom. As a mesenteric lymphadenitis, yersiniosis can mimic appendicitis but may also cause infections of other sites, such as wounds, joints, and the urinary tract.

As noted in the FDA "Bad Bug Book" (https://wayback.archive-it.org/7993/20170406190140/https://www.fda.gov/Food/FoodborneIllnessContaminants/CausesOfIllnessBadBugBook/ucm070040.htm, "Strains of _Y. enterocolitica_ can be found in meats (pork, beef, lamb, etc.), oysters, fish, and raw milk. The exact cause of the food contamination is unknown. However, the prevalence of this organism in soil, water, and animals, such as beavers, pigs, and squirrels, offers ample opportunities for it to enter our food supply. Poor sanitation and improper sterilization techniques by food handlers, including improper storage, cannot be overlooked as contributing to contamination."

In addition, some strains of these organisms can be associated with blood transfusion-associated illnesses due to an ability to grow at refrigerator temperatures. - Mod.LL

HealthMap/ProMED-mail maps:
Denmark: http://healthmap.org/promed/p/111
Sweden: http://healthmap.org/promed/p/108]

See Also

Yersiniosis - Denmark 20190503.6454286
Yersiniosis - Sweden 20190425.6440548
Yersiniosis - Norway: undefined source 20180709.5895185
Yersiniosis - New Zealand (04) 20141016.2870345
Yersiniosis - New Zealand: packaged carrots/lettuce susp. 20141008.2838748
Yersiniosis, campylobacteriosis - Finland: (US) raw milk 20140426.2430474
Yersiniosis, pasteurized milk - USA (04): (PA) ice cream 20110828.2637
Yersiniosis, pasteurized milk - USA: (PA) 20110803.2345
Yersiniosis, lettuce - Norway (02): comment 20110411.1144
Yersiniosis, lettuce - Norway 20110409.1114
Yersiniosis - Russia: (Krasnoyarsk) 20080718.2184
Yersiniosis, cocktail sausages - New Zealand: (Canterbury) 20071128.3839
Yersiniosis - Russia (Yamalo-Nenetsky) 20071001.3240
Yersiniosis - Russia (Khabarovsk) 20070803.2511
Yersiniosis - Russia (Yugra) 20070501.1412
Yersiniosis, listeriosis - Canada (ON): unpasteurized milk/cheese 20070319.0968
Yersiniosis - Russia (Novosibirsk) 20060929.2792
Yersiniosis, kindergarten - Russia (Novgorod) 20051216.3617
Yersiniosis - Russia (Khakassia) 20051031.3178
Yersiniosis - Russia (Siberia) 20050427.1169
Yersiniosis - Russia (Far East) 20050202.0359

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