Stopping at a café during a trip to Asheville, North Carolina with family this past March, Mary Ann Hurtado decided to order a veggie sandwich while everyone else chose something with meat. It was a choice she regularly made — she’s not a vegetarian by any means, but she does love vegetables. But less than a week after eating this particular dish, Hurtado found herself lying on a hospital bed back home in Jacksonville, Florida. She had been so sick she couldn’t walk across the room. Her physician decided to connect her to a potassium I.V. drip — the most painful I.V. she’d felt in her life. A registered nurse, Hurtado spent two nights in the hospital — the same one where she works — before being released with 10 days’ worth of antibiotics. It wasn’t until a week after she was discharged that she finally learned why she got sick: She had contracted a Salmonella infection, but at the time it was impossible to say where it came from. As it turned out, Hurtado’s sandwich contained unpasteurized tempeh — a soy-based food — from an Asheville-based producer called Smiling Hara. More than a month after she ate her sandwich, Smiling Hara tempeh was identified as the source of a Salmonella Paratyphi B outbreak that had sickened at least 89 people in 5 states. The company had already issued a voluntary recall days earlier, following suspicion its tempeh might have been the source. “The chills were just so bad – just miserable,” Hurtado said, speaking of her illness a day prior to her emergency room visit. “I was shaking so hard in the bed that I had to move to the couch so I wouldn’t wake up my husband.” But while Hurtado became so ill that she required hospitalization and I.V. treatment, she is not included among the 89 victim case count and likely never will be. That’s because of technicalities surrounding the identification of her infection. The bacterial isolate that confirmed her Salmonella infection was never serotyped, meaning that the specific strain was never identified and Hurtado’s infection will never be genetically linked to the strain found in samples of Smiling Hara’s tempeh. In short, she’s in a sort of classification limbo, neither officially confirmed as part of the outbreak nor confirmed to be excluded from it — and she’s likely not alone. 29 out of 30 Considering the U.S. Centers for Disease Control and Prevention estimates that 29 out of 30 Salmonella infections go unreported, Hurtado is potentially one of thousands of people sickened by the tempeh outbreak who will never be counted, either because of epidemiological technicalities or — more often — they just didn’t seek medical attention. In Hurtado’s case, she fell through the cracks of the outbreak investigation because of where she was hospitalized. While many state health departments — including North Carolina’s — try to identify all cases of foodborne pathogen infections, some states’ do not. Florida is one that does not typically serotype. Tests that identify bacterial strains cost additional money, which some states choose not to spend. A spokesman for the Florida Department of Health told Food Safety News that the state typically only serotypes isolates “on identified need for enhanced surveillance or suspected outbreak investigation.” If Hurtado had been hospitalized in North Carolina, she’d likely have a confirmed serotype and been included in the official case count, according to Hurtado’s attorney Bill Marler. Marler’s law firm, Marler Clark, specializes in foodborne illness litigation and underwrites Food Safety News. Hurtado recently filed the first lawsuit against Smiling Hara and Tempeh Online, the retailer that sold Smiling Hara the Salmonella-contaminated spore culture used to make their tempeh. Currently, the only states considered to have cases in this outbreak are North Carolina, South Carolina, Georgia, Tennessee and Michigan. New York was originally thought to have a case, but that individual was placed under the banner of North Carolina because they attend college in Asheville. When Hurtado’s county health department learned of her Salmonella infection, they uploaded her information to a statewide infection database. From there, the Florida Department of Health likely included Hurtado’s basic information in a generalized weekly report to the CDC. The CDC often coordinates information between states involved in multistate outbreaks, including the Smiling Hara outbreak. But without any serotype information, Hurtado’s infection would not stand out as having any connection to an outbreak. In effect, it looked exactly like the numerous other isolated infections the CDC sees on a weekly basis. “At this point, it’s not likely [Hurtado] will be considered anything other than another Florida Salmonella case,” said Dr. William Keene, senior epidemiologist for Oregon Public Health. Keene was not involved in the Smiling Hara outbreak investigation, but is considered one of the eminent epidemiologists in public health. “She’s got the exposure. She was in the right place when the outbreak happened, but without her isolate being compared to the outbreak strain, you can’t really know [she was infected in the outbreak] for sure,” Keene added. As Keene explained, the vast majority of consumers who eat a recalled product never actually become infected from it, but many still attribute any gastroenteritis-like symptoms to it. The predicament causes public health professionals to rely even more on serotype evidence, he said. “It’s possible she’s part of the outbreak — maybe even likely, depending on all the evidence — but it doesn’t matter without knowing the serotype,” Keene said. Marler said that Hurtado had a strong case regardless of her missing serotype information, considering all the other evidence. She ate tempeh at an establishment listed as a vendor on Smiling Hara’s website, and then fell ill with a Salmonella infection within the outbreak window and within the expected incubation period. Left in the dark Not only did Hurtado not know what tempeh was when it turned up in the sandwich she ordered at the Asheville café, she had no indication that the product was unpasteurized. It was advertised as grilled or sauteed, she said, so she didn’t expect it to carry anything dangerous. “It looked good, it smelled good, and I ate it all,” she said. Along with losing seven pounds, she still hasn’t fully recovered from her infection, she said. Three months later, she still needs to be near a bathroom at all times. “That’s not something I’ve ever experienced before,” she said. “Now, If I have to go, I have to go, and it’s at least once a day. It’s not a pleasant situation to be in. You’re trying to work or trying to play or anything, and you’re always wondering about where the bathroom is.” The only reason she learned about the Smiling Hara outbreak at all, Hurtado said, is because her brother lives in Asheville and saw in the local news that an outbreak was going on. When he told her, she looked online and found that the café bought their tempeh from Smiling Hara. One of the most unpleasant parts of her infection, she said, was that she had to produce two negative stool samples at least 24 hours apart before she could once again have contact with patients at work. Now, Hurtado said she’s grown more wary of eating out, an activity she and her family especially enjoy w hen traveling. “It just makes you realize that when you eat out you don’t really know what’s going on behind the scenes,” she said. “I haven’t been right since.”