Yersinia enterocolitica infections associated with improperly pasteurized milk products: southwest Pennsylvania, March–August, 2011

Thyme Essential Oil as a Potential Tool Against Common and Re-Emerging Foodborne Pathogens: Biocidal Effect on Bacterial Membrane Permeability

Over the past decade, foodborne diseases have become a significant public health concern, affecting millions of people globally. Major pathogens like Salmonella spp., Escherichia coli, Listeria monocytogenes, and Staphylococcus aureus contaminate food and cause several infections. This study investigates the potential of thyme essential oil (Thy-EO) as a natural antimicrobial agent against most common and re-emerging foodborne bacteria, including S. enterica, Yersinia enterocolitica, and L. monocytogenes. Preliminary tests provided qualitative evidence of Thy-EO's efficacy by evaluating its antibacterial activity through direct contact and vapor phase exposure. Then, the Minimum Inhibitory Concentration (MIC) and Minimum Bactericidal Concentration (MBC) were defined to quantitatively evaluate the bacteriostatic and bactericidal effects of Thy-EO, revealing a strong inhibitory effect against S. enterica, Y. enterocolitica and L. monocytogenes. Additionally, Thy-EO exerted rapid bactericidal kinetics characterized by the disruption of bacterial cell membrane integrity over time. Results highlight Thy-EO's potential as an alternative antimicrobial agent, demonstrating that treatment with Thy-EO significantly and irreversibly affects the growth of the tested foodborne pathogens.

A novel cgMLST for genomic surveillance of Yersinia enterocolitica infections in France allowed the detection and investigation of outbreaks in 2017-2021

Enteric yersiniosis, the third most common food-borne zoonosis in Europe, is mainly caused by the pathogen Yersinia enterocolitica. In France, the yersiniosis microbiological surveillance is conducted at the Yersinia National Reference Laboratory (YNRL). Since 2017, isolates have been characterized by whole genome sequencing (WGS) followed by a 500-gene Yersinia-cgMLST. We report here the data of the WGS-based surveillance on Y. enterocolitica isolates for the 2017-2021 period. The YNRL characterized 7,642 Y. enterocolitica strains distributed in 2,497 non-pathogenic isolates from lineages 1Aa and 1Ab, and 5,145 specimens belonging to 8 pathogenic lineages. Among pathogenic isolates, lineage 4 was the most common (87.2%) followed by lineages 2/3-9b (10.6%), 2/3-5a (1.2%), 2/3-9a (0.6%), 3-3b, 3-3c, 1B, and 3-3d (0.1% per each). Importantly, we developed a routine surveillance system based on a new typing method consisting of a 1,727-genes core genome Multilocus Sequence Typing (cgMLST) specific to the species Y. enterocolitica followed by isolate clustering. Thresholds of allelic distances (AD) were determined and fixed for the clustering of isolates: AD ≤ 5 for lineages 4, 2/3-5a, and 2/3-9a, and AD ≤ 3 for lineage 2/3-9b. Clustering programs were implemented in 2019 in routine surveillance to detect genomic clusters of pathogenic isolates. In total, 419 clusters with at least 2 isolates were identified, representing 2,504 of the 3,503 isolates characterized between 2019 and 2021. Most clusters (n = 325) comprised 2 to 5 isolates. The new typing method proved to be useful for the molecular investigation of unusual grouping of cases as well as for the detection of genomic clusters in routine surveillance.

IMPORTANCE

We describe here the new typing method used for molecular surveillance of Yersinia enterocolitica infections in France based on a novel core genome Multilocus Sequence Typing (cgMLST) specific to Y. enterocolitica species. This method can reliably identify the pathogenic Y. enterocolitica subspecies and compare the isolates with a high discriminatory power. Between 2017 and 2021, 5,145 pathogenic isolates belonging to 8 lineages were characterized and lineage 4 was by far the most common followed by lineage 2/3-9b. A clustering program was implemented, and detection thresholds were cross-validated by the molecular and epidemiological investigation of three unusual groups of Y. enterocolitica infections. The routine molecular surveillance system has been able to detect genomic clusters, leading to epidemiological investigations.

Traceability, virulence and antimicrobial resistance of Yersinia enterocolitica in two industrial cheese-making plants

Between 2018 and 2019, 309 environmental and food samples were collected from two industrial cheese-making plants located in Sardinia, in order to investigate Y. enterocolitica presence and to characterize the isolates. Y. enterocolitica isolates were further compared with isolates detected during a previous investigation from sheep and goat raw milk samples. Y. enterocolitica was detected in 7.4 % of the samples and the prevalence was higher, even if not significantly (P > 0.05) higher in non-food contact surface samples (10.2 %) than in food contact surface samples (3.8 %). The highest prevalence was detected in floor samples (13.5 %), followed by drain samples (7.2 %), which might serve as main harborage sites for further contamination. Y. enterocolitica was also detected in food contact surfaces, namely shelves of the Ricotta cooling room and packaging room, one cheese cutting machine surface and one raw milk filter sample. The biotype 1A isolates identified in this study were classified into six different serotypes. Additionally, a bioserotype 2/O:5,27 isolate was identified in one goat milk sample. All 1A isolates possessed the virulence genes invA and ystB while the 2/O:5,27 isolate showed the presence of ail, ystA, invA and yadA genes, thus confirming a pathogenic potential. The isolates showed intrinsic resistance to amoxicillin-clavulanic acid, ticarcillin and cefoxitin due to the presence of the blaA gene. Whole genome sequencing allowed to identify seven different sequence types among the 1A isolates, thus showing a high genetic diversity. The same Y. enterocolitica sequence type (ST3) was detected from three different areas of the same cheese-making plant, indicating a possible transfer of the microorganism along the processing lines. Y. enterocolitica contamination in cheese-making plants can pose a risk to human health. Preventive measures include the hygienic design of the plant layout and equipment, in association with proper cleaning and disinfection programmes.

Retrospective study on the prevalence of Yersinia enterocolitica in food collected in Umbria region (central Italy)

Yersinia enterocolitica represents one of the main foodborne pathogens in Europe and the evaluation of possible sources of contamination and its prevalence in food is of considerable interest for risk analysis approach. The results of the search for Yersinia enterocolitica in food samples taken in Umbria region (central Italy) were evaluated during the years 2015-2018. Different types of foods were considered, both ready-to-eat (meat products, dairy products, and raw vegetables) and meat preparations to be eaten after cooking. Samples were assayed by molecular screening for the species indicator gene ompF. Screening positives were subjected to isolation and characterization by searching for specific virulence marker genes, including the ail gene responsible for invasiveness and the ystB gene for the production of enterotoxin. The total prevalence of positive samples for Yersinia enterocolitica was 16.86% with a higher percentage of positive samples in meat preparations (19.35%), followed by ready-to-eat vegetables (11.76%). Poultry meat samples had a higher prevalence than pork and beef samples. Neither positive samples were found in meat products and dairy, nor seasonality in positivity was observed. All isolated strains of Yersinia enterocolitica were biotype 1A, with absence of the ail virulence gene but presence of ystB gene. Since the strains isolated from human patients appear to be primarily biotypes that possess the ail marker, future investigations would be needed regarding the real role of biotype 1A in human disease. In this context, attention should certainly be paid to ready-to-eat vegetables and to careful cooking of meat preparations.

Virulence Determinants and Genetic Diversity of Yersinia Species Isolated from Retail Meat

Yersinia enterocolitica is an important foodborne pathogen, and the determination of its virulence factors and genetic diversity within the food chain could help understand the epidemiology of yersiniosis. The aim of the present study was to detect the prevalence, and characterize the virulence determinants and genetic diversity, of Yersinia species isolated from meat. A total of 330 samples of retailed beef (n = 150) and pork (n = 180) in Latvia were investigated with culture and molecular methods. Whole genome sequencing (WGS) was applied for the detection of virulence and genetic diversity. The antimicrobial resistance of pathogenic Y. enterocolitica isolates was detected in accordance with EUCAST. Yersinia species were isolated from 24% (79/330) of meats, and the prevalence of Y. enterocolitica in pork (24%, 44/180) was significantly higher (p < 0.05) than in beef (13%, 19/150). Y. enterocolitica pathogenic bioserovars 2/O:9 and 4/O:3 were isolated from pork samples (3%, 6/180). Only resistance to ampicillin was confirmed in Y. enterocolitica 4/O:3 and 2/O:9 isolates, but not in other antimicrobials. Major virulence determinants, including ail, inv, virF, ystA and myfA, were confirmed with WGS in Y. enterocolitica 2/O:9 and 4/O:3. MLST typing revealed 15 STs (sequence types) of Y. enterocolitica with ST12 and ST18, which were associated with pathogenic bioserovars. For Y. enterocolitica 1A, Y. kristensenii, Y. intermedia and Y. frederiksenii, novel STs were registered (ST680-688). The presence of virulence genes and genetic characteristics of certain Y. enterocolitica STs confirm the common knowledge that pork could be an important source of pathogenic Yersinia.

Yersinia enterocolitica Outbreak Associated with Pasteurized Milk

In July 2019, we investigated a cluster of Yersinia enterocolitica cases affecting a youth summer camp and nearby community in northeastern Pennsylvania. After initial telephone interviews with camp owners and community members, we identified pasteurized milk from a small dairy conducting on-site pasteurization, Dairy A, as a shared exposure. We conducted site visits at the camp and Dairy A where we collected milk and other samples. Samples were cultured for Y. enterocolitica. Clinical and nonclinical isolates were compared using molecular subtyping. We performed case finding, conducted telephone interviews for community cases, and conducted a cohort study among adult camp staff by administering an online questionnaire. In total, we identified 109 Y. enterocolitica cases. Consumption of Dairy A milk was known for 37 (34%); of these, Dairy A milk was consumed by 31 (84%). Dairy A had shipped 214 gallons of pasteurized milk in 5 weekly shipments to the camp by mid-July. Dairy A milk was the only shared exposure identified between the camp and community. Y. enterocolitica was isolated from Dairy A unpasteurized milk samples. Five clinical isolates from camp members, two clinical isolates from community members, and nine isolates from unpasteurized milk were indistinguishable by whole-genome sequencing. The risk for yersinosis among camp staff who drank Dairy A milk was 5.3 times the risk for those who did not (95% confidence interval: 1.6-17.3). Because Dairy A only sold pasteurized milk, pasteurized milk was considered the outbreak source. We recommend governmental agencies and small dairies conducting on-site pasteurization collaborate to develop outbreak prevention strategies.

Sepsis due to Yersinia enterocolitica in an aborted equine fetus: case report

ABSTRACT Yersinia enterocolitica is a bacterium with zoonotic potential and there are no previous records of this bacteria being isolated from aborted foals. This report aims to describe a case of sepsis due to Y. enterocolitica in a seven month old aborted equine. The fequinoetus was submitted to necropsy and samples of all the organs were collected for the histological exam. Samples of liver, lung, placenta, and stomach contents were collected for bacterial culture. Macroscopically, the liver was enlarged with yellowish heterogeneous color, heart with pale myocardial areas; lungs not collapsed, heavy and shiny, thickened umbilical cord covered with fibrin and pus. Histopathologically, there was moderate multifocal necrosuppurative myocarditis and thrombosis, moderate diffuse suppurative bronchopneumonia, mild multifocal fibrinonecrotic hepatitis, and moderate diffuse necrosuppurative omphalitis with intralesional bacterial myriads and thrombosis. Mild multifocal suppurative placentitis, nephritis, myositis, cystitis, and dermatitis were also observed, in addition to mild diffuse lymphoid rarefaction. The microbiological evaluation identified Y. enterocolitica in the liver, lung, and stomach fluid. This is the first report of sepsis due to Y. enterocolitica causing an abortion in a horse. This bacterium has zoonotic importance; therefore, it should be investigated in abortion in this species, serving as a differential diagnosis in reproductive disorders.

Yersinia enterocolitica biotype 1B case report: an unusual pathogen in an osteoarticular infection on device

Background

Yersinia enterocolitica is an aero-anaerobic Gram-negative coccobacilli of the Enterobacteriaceae family, rarely reported in osteoarticular infection.

Case presentation

This report case described a rare septic osteoarticular infection on device due to Yersinia enterocolitica biotype 1B. A purulent fistula appeared after osteosynthesis with plate performed abroad 27 days prior to the presentation for a distal femoral fracture. The treatment consisted of surgical irrigation and washing of the femoral plate and a bitherapy by levoflaxacine and ceftriaxone during 3 months.

Conclusion

Y. enterocolitica biotype 1B is extremely rare in France. Moreover, the strain implicated in this european case is extremely close from the USA reference strain (with only 2 SNP difference) described in a septicemia in Ohio. The extreme proximity of the strains underlines the need for a sustained surveillance of the spread of this pathogen in France.

Application of data science in risk assessment and early warning

The food supply chain has been recognised by the EU as a critical infrastructure, and its complexity is the main cause of vulnerability. Depending on the food matrix, natural and/or deliberate contamination, food-borne diseases or even food fraud incidents may occur worldwide. Consequently, robust predictive models and/or software tools are needed to support decision-making and mitigating risks in an efficient and timely manner. In this frame, the fellow participated in data collection and analysis tasks, so as to provide additional predictive models. The working programme, covered a wide range of aspects related to risk assessment including identification of emerging risks (quantitative), microbiological risk assessment, authenticity assessment, spatio-temporal epidemiological modelling and database formation for hosting predictive microbial models. The training and close integration, in the open-source, in-house (German Federal Institute for Risk Assessment (BfR)) developed software tools under the framework of FoodRisk-Labs (https://foodrisklabs.bfr.bund.de.) for data analysis, predictive microbiology, quantitative microbiological risk assessment and automatic data retrieval purposes allowed for the independent use. Moreover, the fellow actively contributed to the update of the upcoming Yersinia enterocolitica risk assessment, and also in authenticity assessment of edible oils. Over the course of the year, the fellow was closely involved in international and national research projects with experts in the above-mentioned disciplines. Lastly, he consolidated his acquired knowledge by presenting his scientific work to conferences, and BfR-internal meetings.

QUEIJO ARTESANAL PRODUZIDO NO SUL DO RIO GRANDE DO SUL: AVALIAÇÃO FÍSICO-QUÍMICA, MICROBIOLÓGICA E SUSCETIBILIDADE A ANTIMICROBIANOS DE ISOLADOS DE STAPHYLOCOCCUS COAGULASE POSITIVA

Resumo Objetivando o conhecimento do queijo colonial artesanal produzido na região Sul do Rio Grande do Sul, foram analisadas 30 amostras adquiridas no comércio local e feiras quanto às características físico-químicas, além das análises microbiológicas exigidas pela Agência Nacional de Vigilância Sanitária (ANVISA), isolamento de Yersinia enterocolitica e resistência aos antimicrobianos de isolados de Staphylococcus coagulase positiva, obtidos a partir destas amostras. Os valores medianos resultantes das análises físico-químicas foram: pH 5,81, acidez titulável de 0,44 g de ácido lático/100g, umidade de 48,55%, atividade de água de 0,973, proteína de 19,36%, gordura de 14,54%, teor de cinzas de 2,88% e teor de cloretos 0,51 gNaCl/100g. Quanto às análises exigidas pela ANVISA, 86,66% das amostras estavam fora dos padrões exigidos e nenhuma foi positiva para Salmonella e Listeria monocytogenes. Houve também isolamento de Yersinia enterocolitica em 3,33% das amostras. A maior taxa de resistência dos isolados de Staphylococcus coagulase positiva ocorreu frente à Penicilina G com 100% dos isolados resistentes e a menor contra Ciprofloxacina com nenhum isolado resistente. 65,00% dos isolados foram resistentes a, pelo menos, seis antimicrobianos e 86,95% demostraram resistência à Cefoxitina, resultados preocupantes, especialmente quanto aos isolados Meticilina Resistentes. Além disso, o queijo produzido e comercializado informalmente no Sul do Rio Grande do Sul apresenta grande variação nas características físico-químicas e, em geral, alta contaminação microbiana, podendo representar risco à saúde do consumidor.

Foodborne pathogens in unpasteurized milk in Sweden

Raw milk may be a risk for public health if it is contaminated with zoonotic pathogens. To study the prevalence in unpasteurized milk from Swedish farms, bovine and small ruminant dairy farms were sampled. Since the sampling method and transport conditions may influence the outcome of analyses, efforts were made to optimize the methodology. Culturing of bacteria was done from in-line milk filters collected from the milk pipe at the point where it enters the milk bulk tank at the farms and this way of sampling was compared to sampling bulk tank milk (BTM) directly. Analysing milk filters were found to be superior to analysing BTM directly. Conditions for transport of milk filter samples were further improved by the addition of Cary Blair transport medium, which significantly increased the number of positive samples for pathogenic bacteria. The isolation of several foodborne pathogens from milk filters was demonstrated. The prevalence of samples with Staphylococcus aureus was 71% and 64%, and Listeria spp. 21% and 29% from dairy cow and goat/sheep farms, respectively. Campylobacter jejuni, Yersinia enterocolitica and verotoxigenic Escherichia coli (VTEC) O157 were detected in 9%, 2% and 2% of samples from bovine milk, respectively. We conclude that the choice of sampling method and sample handling influence the results of bacterial culturing. From the results of this study, we strongly recommend to sample in-line milk filters instead of BTM directly and to use Cary Blair medium during transport, especially if the samples are to be analysed for Campylobacter spp. and/or Listeria spp. The findings also show that unpasteurized milk from Swedish farms occasionally contain bacteria with zoonotic potential.

Main Groups of Microorganisms of Relevance for Food Safety and Stability

Microbiology is important to food safety, production, processing, preservation, and storage. Microbes such as bacteria, molds, and yeasts are employed for the foods production and food ingredients such as production of wine, beer, bakery, and dairy products. On the other hand, the growth and contamination of spoilage and pathogenic microorganisms is considered as one of the main causes to loss of foodstuff nowadays. Although technology, hygienic strategies, and traceability are important factors to prevent and delay microbial growth and contamination, food remains susceptible to spoilage and activity of pathogen microorganisms. Food loss by either spoilage or contaminated food affects food industry and consumers leading to economic losses and increased hospitalization costs. This chapter focuses on general aspects, characteristics, and importance of main microorganisms (bacteria, yeasts, molds, virus, and parasites) involved in food spoilage or contamination: known and recently discovered species; defects and alterations in foodstuff; most common food associated with each foodborne disease; resistance to thermal processing; occurrence in different countries; outbreaks; and associated symptoms.

Foodborne pathogens

Foodborne pathogens are causing a great number of diseases with significant effects on human health and economy. The characteristics of the most common pathogenic bacteria (Bacillus cereus, Campylobacter jejuni, Clostridium botulinum, Clostridium perfringens, Cronobacter sakazakii, Esherichia coli, Listeria monocytogenes, Salmonella spp., Shigella spp., Staphylococccus aureus, Vibrio spp. and Yersinia enterocolitica), viruses (Hepatitis A and Noroviruses) and parasites (Cyclospora cayetanensis, Toxoplasma gondii and Trichinella spiralis), together with some important outbreaks, are reviewed. Food safety management systems based on to classical hazard-based approach has been proved to be inefficient, and risk-based food safety approach is now suggested from leading researchers and organizations. In this context, a food safety management system should be designed in a way to estimate the risks to human health from food consumption and to identify, select and implement mitigation strategies in order to control and reduce these risks. In addition, the application of suitable food safety education programs for all involved people in the production and consumption of foods is suggested.

Development of a novel multiplexed qPCR and Pyrosequencing method for the detection of human pathogenic yersiniae

The purpose of this study was to develop a novel and robust molecular assay for the detection of human pathogenic yersiniae (i.e. Yersinia enterocolitica, Y. pseudotuberculosis and Y. pestis) in complex food samples. The assay combines multiplexed real-time PCR (qPCR) and Pyrosequencing for detecting and differentiating human pathogenic yersiniae with high confidence through sequence based confirmation. The assay demonstrated 100% specificity and inclusivity when tested against a panel of 14 Y. enterocolitica, 22 Y. pestis, 24 Y. pseudotuberculosis and a diverse selection of 17 other non-Yersinia bacteria. Pyrosequencing reads ranged from 28 to 40bp in length and had 94-100% sequence identity to the correct species in the GenBank nr database. Microbial enrichments of 48 ready-to-eat foods collected in the Greater Toronto Area from March 2014 to May 2014, including 46 fresh sprout and 2 salad products, were then tested using the assay. All samples were negative for Y. pestis and Y. pseudotuberculosis. Both salads (n=2) and 35% of sprout products (n=46) including 7.1% of alfalfa sprouts (n=14), 81% of bean sprouts (n=16), 12% of mixed sprouts (n=8) tested positive for Y. enterocolitica which was not detected in broccoli sprouts (n=5), onion sprouts (n=1), and pea sprouts (n=2). Cycle thresholds (Ct) of positive samples for Y. enterocolitica were between 23.0 and 37.9 suggesting post enrichment concentrations of approximately 1×10² to 1×10⁶Y. enterocolitica per 1mL of enriched broth. An internal amplification control which was coamplified with targets revealed PCR inhibition in five samples which was resolved following a one in ten dilution. Pyrosequencing of qPCR amplicons suggests monoclonality and revealed a single nucleotide polymorphism that is present in Y. enterocolitica biotype 1A suggesting low pathogenicity of the detected strains. This study is the first to combine Pyrosequencing and qPCR for the detection of human pathogenic yersiniae and is applicable to a broad range of complex samples including ready-to-eat food samples.

Fontes de contaminação de Yersinia enterocolitica durante a produção de leite

RESUMO Objetivou-se determinar as possíveis fontes de contaminação de Yersinia enterocolitica em diferentes pontos do processo de ordenha de vacas leiteiras em oito propriedades da região de Pelotas, RS, ao longo de um ano. Foram analisadas amostras de leite cru de conjunto logo após a ordenha, água de estábulo leiteiro, mão de ordenhador, balde de recolhimento do leite e insuflador de teteiras. As amostras de leite cru e água foram coletadas em frascos estéreis, e as amostras de mão, balde e teteiras com zaragatoas estéreis. As amostras de leite cru foram submetidas a um pré-enriquecimento em água peptonada, sendo posteriormente incubadas em caldo PSTA, adicionado de ampicilina. As amostras de água foram filtradas em membrana de éster de celulose e incubadas em caldo TSB. As amostras de leite após incubação em PSTA, as membranas utilizadas na filtragem da água incubadas em TSB, bem como o material de mãos, balde e teteiras coletadas nas zaragatoas, foram semeados em ágar MacConkey e incubados para a obtenção de colônias. Colônias características foram analisadas por meio de duplex PCR para confirmação da espécie. Os perfis moleculares dos isolados de Y. enterocolitica foram comparados utilizando-se a técnica de rep-PCR. Y. enterocolitica foi isolada de 9,37% das amostras de leite, 6,25% das amostras de água e 12,5% das amostras de mão. Não houve similaridade no perfil de bandas dos isolados encontrados, entretanto foi identificada a presença de cepas diferentes na mesma amostra, demonstrando uma variedade grande de cepas distribuídas no ambiente. A presença de Y. enterocolitica em leite cru no Brasil é preocupante, já que uma quantidade considerável do produto ainda é comercializada de forma clandestina, expondo o consumidor ao risco de infecção pela bactéria, ao consumi-lo sem tratamento térmico adequado.

The descriptive epidemiology of yersiniosis: a multistate study, 2005-2011

OBJECTIVES

Yersiniosis, a foodborne infection of zoonotic origin caused by the bacteria Yersinia enterocolitica and Yersinia pseudotuberculosis, is a reportable disease in 38 states. Both sporadic and foodborne outbreaks of yersiniosis have been reported in the U.S., with annual occurrence of an estimated 98,000 episodes of illness, 533 hospitalizations, and 29 deaths. We analyzed surveillance data from nine non-FoodNet-participating U.S. states during the period 2005-2011 to describe the epidemiology of this disease.

METHODS

As part of a passive surveillance system, laboratory-confirmed cases of yersiniosis were reported to state health departments in Arizona, Illinois, Michigan, Missouri, Nebraska, North Carolina, South Carolina, Washington, and Wisconsin. We calculated overall, age-, and race-specific annual incidence rates per 100,000 population using 2010 Census data as the denominator. We used Poisson regression to examine seasonal variation and annual incidence trends by race, age group, and overall.

RESULTS

The average annual incidence of yersiniosis was 0.16 cases per 100,000 population during 2005-2011. We observed a statistically significant decreasing annual trend of yersiniosis incidence among African Americans <5 years of age (p<0.01), whereas white people aged 19-64 years (p=0.08) and Hispanic people (p=0.05) had an overall increasing annual incidence of yersiniosis. We observed higher incidence during October-December (p<0.01) and January-March (p=0.03) quarters among African Americans, whereas white people had a higher incidence during April-June (p=0.05).

CONCLUSION

This multistate analysis revealed differences in the epidemiology of yersiniosis by race/ethnicity that may be useful for future research and prevention efforts. While this study was consistent with the FoodNet report in recognizing the high and declining incidence among African American children and winter seasonality among African Americans, our study also identified April-June seasonality among the white population.