A package of romaine lettuce is stamped with a harvest date and location.

A note at the top right corner of a bag of romaine at a Billings grocery store Friday told consumers a key bit of information.

“Romaine grown in Yuma, AZ. Harvested after 11/26/18,” the black lettering read.

That’s important to know in the midst of the multistate Shiga toxin-producing E. coli outbreak linked to romaine lettuce. Since the Centers for Disease Control and Prevention first announced the outbreak, 52 cases from 15 states, not counting Montana, have been reported.

That includes nine more people reported ill since the CDC's last update on Nov. 26. Of the total number, 19 people have been hospitalized, including two who developed hemolytic uremic syndrome, a type of kidney failure.

Investigators connected the lettuce’s DNA fingerprint to the central coastal growing regions of northern and central California, although no common grower, supplier, distributor or brand has been identified. Because of that, no recall has been issued.

Areas not linked to the outbreak include the desert growing region near Yuma, the California desert growing region near Imperial County and Riverside County, as well as Florida and Mexico.

The CDC continues to recommend that shoppers who have purchased romaine lettuce that doesn't include the growing region throw it out. That includes whole heads, hearts of romaine and bags and boxes of pre-cut lettuce.

In a briefing on Tuesday with members of the Association of Health Care Journalists at CDC headquarters in Atlanta, epidemiologist Matt Wise said the leaf industry has just started putting labels on bags to specifically identify where the lettuce is grown.

“I think that’s a huge step to have a bag say this is the place or places where it came from,” Wise said.

Stores face a challenge when it comes to something like romaine lettuce, Wise said. They may sell up to 200 products that contain it.

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With a label on the outside identifying its place of origin, that allows the CDC to offer consumers advice they can quickly follow.

“The right message at the right time can save lives,” he said.

Wise, who works in the Outbreak Response and Prevention Branch of the CDC, said there’s been a shift over the past several decades in the production of food. It has slowly consolidated and travels greater distances to get to consumers.

In regard to foodborne illnesses, the most common situation involves a church dinner or other social event where several people eat the same dish and fall ill. The local health department investigates the incident.

Only 3 percent of all U.S. foodborne outbreaks are multi-state, Wise said. Even so, they cause 11 percent of the illness, 34 percent of hospitalizations and 56 percent of deaths, due to the more serious pathogens they carry.

The Shiga toxin-producing E. coli found in romaine lettuce takes an average of three to four days after a person ingests the germ to make its presence known. Symptoms may include severe stomach cramps, diarrhea and vomiting.

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General Assignment and Health Care Reporter

General assignment and healthcare reporter at The Billings Gazette.