| Summary: | <p>Abstract</p> <p>Background</p> <p>This report describes a large international chocolate-associated Salmonella outbreak originating from Germany.</p> <p>Methods</p> <p>We conducted epidemiologic investigations including a case-control study, and food safety investigations. <it>Salmonella </it>(<it>S</it>.) Oranienburg isolates were subtyped by the use of pulsed-field gel electrophoresis (PFGE).</p> <p>Results</p> <p>From 1 October 2001 through 24 March 2002, an estimated excess of 439 <it>S</it>. Oranienburg notifications was registered in Germany. Simultaneously, an increase in <it>S</it>. Oranienburg infections was noted in other European countries in the Enter-net surveillance network. In a multistate matched case-control study in Germany, daily consumption of chocolate (matched odds ratio [MOR]: 4.8; 95% confidence interval [CI]: 1.3–26.5), having shopped at a large chain of discount grocery stores (MOR: 4.2; CI: 1.2–23.0), and consumption of chocolate purchased there (MOR: 5.0; CI: 1.1–47.0) were associated with illness. Subsequently, two brands from the same company, one exclusively produced for that chain, tested positive for <it>S</it>. Oranienburg. In two other European countries and in Canada chocolate from company A was ascertained that also contained <it>S</it>. Oranienburg. Isolates from humans and from chocolates had indistinguishable PFGE profiles. No source or point of contamination was identified. Epidemiological identification of chocolate as a vehicle of infections required two months, and was facilitated by proxy measures.</p> <p>Conclusions</p> <p>Despite the use of improved production technologies, the chocolate industry continues to carry a small risk of manufacturing <it>Salmonella</it>-containing products. Particularly in diffuse outbreak-settings, clear associations with surrogates of exposure should suffice to trigger public health action. Networks such as Enter-net have become invaluable for facilitating rapid and appropriate management of international outbreaks.</p>
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