On Wednesday, the U.S. Centers for Disease Control and Prevention (CDC) again updated information regarding the multi-state Listeria monocytogenes outbreak linked to caramel apples. As of Dec. 30, there were 32 illnesses reported in 11 states, including 31 hospitalizations and six deaths. According to CDC, Listeriosis contributed to three of the deaths reported to date, but it is not clear whether it contributed to another two. The sixth death was unrelated to Listeriosis, CDC stated. The new cases were reported from CA (one more, for a total of two), NM (one more, for a total of six), and one in NV (which previously had not had any cases reported). The rest are in Arizona (4), Minnesota (4), Missouri (5), North Carolina (1), Texas (4), Utah (1), Washington (1), and Wisconsin (3). CDC reports that the dates when the Listeria strains were isolated range from Oct. 17, 2014, to Dec. 11, 2014. Ten illnesses have been associated with a pregnancy (the illness occurred in a pregnant woman or her newborn infant). One fetal loss has been reported. Among people whose illnesses were not associated with a pregnancy, ages ranged from 7 to 92 years, with a median age of 66 years, and 32 percent were female, CDC reported. Three invasive illnesses (meningitis) occurred among otherwise healthy children aged 5-15 years. Thirty-one ill people have been hospitalized, and six deaths have been reported. Listeriosis contributed to three of these deaths, and it is unclear whether it contributed to an additional two deaths. The sixth death was unrelated to listeriosis. Illnesses that started after Dec. 14, 2014, might not be reported yet due to the time it takes between when a person becomes ill and when the illness is reported. Outlets selling the apples included Cub Foods, Kwik Trip, and Mike’s Discount Foods in MN, which carried Carnival brand and Kitchen Cravings brand caramel apples, and Safeway, Walmart and Sam’s Club stores in a number of states. The Public Health Agency of Canada (PHAC) has identified 2 cases of Listeriosis in Canada with the same PFGE (pulsed-field gel electrophoresis) patterns as seen in the U.S. outbreak. PHAC is working with its provincial and territorial partners to determine the source of these illnesses. CDC and and the U.S. Food and Drug Administration (FDA) are working with Canadian health authorities to determine whether these illnesses are related to the U.S. outbreak. The information CDC reported continues to indicate that commercially produced, prepackaged caramel apples may be contaminated with Listeria. Listeria can cause a serious, life-threatening illness. In interviews, ill people answered questions about foods consumed and other exposures in the month before becoming ill. To date, 23 (88 percent) of the 26 ill people interviewed reported eating commercially produced, prepackaged caramel apples before becoming ill. Caramel apple brands named in interviews have included Happy Apple, Carnival, and Merb’s Candies. However, the investigation is ongoing, and other brands may be identified. At this time, no illnesses related to this outbreak have been linked to apples that are not caramel-coated and not prepackaged, or to caramel candy. So far, three firms that produce caramel apples have issued voluntary recalls after receiving notice from Bidart Brothers, a CA apple supplier, that there may be a connection between Bidart Brothers apples and this Listeriosis outbreak. On Dec. 24, 2014, Happy Apple Company of Washington, MO, voluntarily recalled Happy Apple brand caramel apples with a best use by date between Aug. 25 and Nov. 23, 2014. On Dec. 27, 2014, California Snack Foods voluntarily recalled Karm’l Dapple brand caramel apples with a best use by date between Aug. 15 and Nov. 28, 2014. On Dec. 29, 2014, Merb’s Candies of St. Louis, MO, issued a voluntary recall of Merb’s Candies Bionic Apples and Double Dipped Apples that would have been available between Sept. 8 and Nov. 25, 2014. In addition, Pacific Coast Fruit of Portland, OR, announced that it was recalling all Happy Apple brand apples it sold after Sept. 22, 2014, because they came from Bidart Brothers. The company noted in an online statement that it was contacting its customers as part of the recall. FDA noted in an investigation update posted Dec. 31 that investigators had traced the distribution of the caramel apples eaten by eight ill people involved in the outbreak. “Although the Happy Apple Company and Merb’s Candies receive apples from other growers, the FDA’s ongoing traceback investigation has confirmed that Bidart Bros. is the only apple grower that supplied apples to both companies,” according to FDA’s update, adding that the agency had briefed Bidart officials on the status of the FDA investigation on Dec. 22. “On December 22, 2014, Bidart Bros. issued a recall of Granny Smith apples it sold in 2014 to those customers known to produce caramel apples. Then, on December 24, 2014, Bidart Bros. notified all customers receiving Granny Smith apples in 2014 to recall those apples if they had been used to make caramel apples,” FDA stated. Meanwhile, CDC and other state and federal investigators are continuing to work to identify if any other brands or types of commercially produced, prepackaged caramel apples may be linked to illnesses and to identify the source of contamination. Although voluntary recalls have been issued for three brands of commercially produced, prepackaged caramel apples, CDC’s Advice to Consumers remains the same. CDC continues to recommend that U.S. consumers not eat any commercially produced, prepackaged caramel apples, including plain caramel apples as well as those containing nuts, sprinkles, chocolate, or other toppings, until more specific guidance can be provided. These products could have a shelf life of more than one month. CDC, the involved states, and FDA continue to work closely on this rapidly evolving investigation, and new information will be provided as it becomes available.