Thirteen people across nine states have confirmed E. coli O26:H11 infections linked to Sierra Nevada Graziers grass-fed raw milk cheese, and eight of them required hospitalization, according to the Centers for Disease Control and Prevention.

Three patients have developed hemolytic uremic syndrome, a form of kidney failure that can also cause brain damage and death. More than half of the confirmed patients are younger than 5 years old. Illness onset dates run from July 7 through Aug. 26.

The cases span coast to coast: California, Colorado, Georgia, Kentucky, Michigan, Nevada, Oregon, Tennessee and Utah. Investigators interviewed nine patients about foods eaten before they became sick. All nine reported eating Sierra Nevada Graziers grass-fed raw milk cheese.

The CDC estimates that for every confirmed patient in an E. coli outbreak, 26 infections go undetected, because some people do not seek medical care and others are not specifically tested for the bacteria. The current case count almost certainly understates the outbreak's reach.

On Sept. 24, the Food and Drug Administration contacted Sierra Nevada Cheese Company LLC, notified the company of the outbreak and recommended a recall. The company agreed the same day and initiated a recall of all Graziers raw milk cheeses, working with the FDA.

What operators need to check

The recalled cheeses were distributed nationwide. They include medium cheddar, sharp cheddar, jalapeño jack and Monterey jack varieties sold in 8-ounce and 16-ounce packages, plus 5-pound loaves sold to foodservice customers and wholesalers.

That wholesale format puts restaurants and foodservice distributors squarely in the recall's scope. The FDA's guidance for operators:

• Do not eat, serve or sell any recalled Sierra Nevada Graziers raw milk cheese. Consumers who purchased the product may return it to the place of purchase for a refund.
• The cheese has a long shelf life. Check refrigerators and freezers and discard the product. If cheese was stored without original packaging and cannot be identified, throw it away.
• Restaurants, retailers and foodservice customers who purchased or received the product, including wholesale loaves, should clean and sanitize any surfaces or containers the cheese touched.
• Retailers that received recalled product and repackaged it for individual sale should pull it from the market immediately.

The sanitation instruction carries weight for operators: E. coli contamination spreads through contact with contaminated surfaces and equipment, so cutting boards, slicers and storage containers that held the cheese need thorough cleaning before reuse.

The illness picture

Contaminated food does not look, smell or taste off, which limits what kitchen staff can detect through inspection. Anyone who ate the recalled cheese and developed symptoms should seek medical attention and report the possible exposure to a doctor. Specific tests are required to diagnose E. coli infections, which can mimic other illnesses.

Symptoms vary by patient but often include severe stomach cramps and diarrhea, frequently bloody, and sometimes fever. Most patients recover within five to seven days. Others develop severe or life-threatening complications.

About 5 to 10 percent of those diagnosed with E. coli infections develop hemolytic uremic syndrome. HUS symptoms include fever, abdominal pain, fatigue, decreased urination, small unexplained bruises or bleeding, and pallor. The condition can strike at any age but is most common in children under 5 because of immature immune systems, older adults with weakening immune systems, and immunocompromised people such as cancer patients.

Many HUS patients recover within a few weeks, but some suffer permanent injury or death. The condition often requires hospitalization because it can cause hypertension, chronic kidney disease, brain damage and neurologic problems. People experiencing HUS symptoms should seek emergency care immediately.

The outbreak adds to the food safety record of raw milk cheeses, which skip the pasteurization step that kills pathogenic bacteria. With the recall still unfolding and the CDC's case count expected to grow, foodservice operators holding Graziers product face the immediate tasks of verification, disposal and sanitation before the investigation concludes.