The ongoing E. coli outbreak associated with romaine lettuce has reached North Dakota, bringing the total of states with confirmed sick people to 26.

The other 25 states have a total of 121 people confirmed with the outbreak strain of E. coli O157:H7. One person in California has died. At least 14 of the sick people have developed kidney failure. 

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Of the 102 victims for whom complete information is available, 52 have been admitted to hospitals, according to the Centers for Disease Control and Prevention’s most recent update on May 2. 

North Dakota’sDepartment of Health did not provide any details about the age or gender of the person confirmed as being an outbreak case. State health officials are investigating another potential case. 

The onset dates for the illnesses in North Dakota were not provided by the state health department in its May 4 notice.

During foodborne illness outbreaks, public health officials stress that there is a lag time of two to four weeks from the time a person becomes ill and they are included in the CDC’s case count. Laboratory tests and confirmation tests must be conducted before doctors can report cases to local public health officials. Local departments then report to state health officials who in turn notify federal officials.

As of Saturday, a specific source of the pre-chopped romaine lettuce that is associated with all but eight of the infected people remained unknown, according to federal officials. Eight people, all inmates at a prison in Alaska, ate romaine from whole heads before becoming sick. Prison officials helped the Food and Drug Administration trace the whole-head romaine to Harrison Farms in Yuma, AZ.

Other traceback efforts have not been as successful.

Based on information from the fresh produce industry, the FDA and CDC have been warning consumers, restaurants and retailers to avoid eating and selling romaine only from the Yuma area since April 13 when the leafy green was linked to the sick people. 

The annual romaine harvest in the Southwest begins in November in Yuma and transitions with the weather to growing regions in southern California between mid-March and early April.

“The FDA has stated they cannot be certain that romaine lettuce from the Yuma region is no longer in the supply chain due to the 21-day shelf life,” said Laura Cronquist, epidemiologist with the North Dakota health department.

Product industry groups have been saying since the FDA’s announcement on April 13 that Yuma-area romaine was likely no longer being shipped.

Anyone who has eaten romaine lettuce and developed symptoms of E. coli infection should immediately seek medical attention and tell their doctors about their possible exposure pathogen. Specific tests are required to diagnose E. coli infections, which generally should not be treated with antibiotics.

The most common symptoms of E. coli include diarrhea, bloody diarrhea, abdominal pain, nausea and vomiting. Symptoms typically begin three to four days after exposure to the bacteria, but can take as long as 10 days.

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