A listeriosis outbreak involving 28 illnesses in 10 states, with 5 deaths, prompted federal health officials today to warn consumers against eating any commercially produced caramel apples until more is known about the situation.
In issuing the warning, the Centers for Disease Control and Prevention (CDC) did not name any specific caramel apple brands. But the Minnesota Department of Health (MDH) said yesterday that patients in the state had bought Carnival brand and Kitchen Cravings brand caramel apples. Minnesota has had four cases, two of which were fatal.
High hospitalization rate
The CDC said 26 patients in the outbreak—all of those for whom the information was available—were hospitalized, and 5 of them died. Listeriosis contributed to at least 4 of the deaths. Three cases in the outbreak involved meningitis in children between the ages of 5 and 15, the agency said.
Investigative efforts by the CDC, the Food and Drug Administration, and several state health departments have pointed to commercially produced caramel apples as the source of Listeria monocytogenes in the outbreak, the CDC reported. Fifteen of 18 people interviewed reported eating the products before they got sick.
The agency is recommending avoidance of all commercial caramel apples, including those with toppings such as nuts, sprinkles, or chocolate, "until more specific guidance can be provided." It said that though caramel apples are usually a fall seasonal product, some may still be in stores or consumers' homes.
States that have reported cases, the CDC said, are Arizona, 4; California, 1; Minnesota, 4; Missouri, 5; New Mexico, 5; North Carolina, 1; Texas, 4; Utah, 1; Washington, 1; and Wisconsin, 2.
Illness-onset dates ranged from Oct 17 to Nov 27, the CDC reported. Nine illnesses have occurred in pregnant women or newborn babies, but no miscarriages have been reported.
Using molecular techniques—pulsed-field gel electrophoresis and whole-genome sequencing—investigators have identified two case clusters in the outbreak, the CDC said. Listeria isolates were found to be closely related within each cluster but distinct between the clusters.
"CDC is investigating the two clusters together because one person was infected with both Listeria strains simultaneously and also because illnesses in the two clusters have occurred during a similar time period and in similar regions of the country," the agency said.
Stores listed in Minnesota
In Minnesota, patients bought caramel apples from Cub Foods, Kwik Trip, and Mike's Discount Foods, which carried the Carnival and Kitchen Cravings brands, the MDH said. Those two brands are no longer available in stores, but the MDH is concerned that people may still have them at home. The department said other brands and locations may be affected as the investigation continues.
The MDH noted that listeriosis mainly affects older adults, pregnant women, newborns, and people with weakened immune systems, causing symptoms such as fever, muscle aches, headache, stiff neck, confusion, loss of balance, and convulsions. In pregnant women, the infection can lead to miscarriage, stillbirth, or premature delivery. Symptoms may begin anytime from 3 to 70 days after infection.
The CDC said none of the cases have been tied to any apples other than commercially produced caramel apples.
Caramel apples are an unusual vehicle for L monocytogenes, which is more typically associated with raw meats and vegetables, unpasteurized milk and cheese, soft cheeses, processed meats, and smoked seafood. However, a listeriosis outbreak linked to Colorado cantaloupes caused at least 147 cases and 33 deaths in 2011 and 2012.
Dec 19 CDC notice
Dec 18 MDH statement
CDC information on Listeria
Aug 28, 2012, CIDRAP News item on cantaloupe-linked outbreak