E. coli food poisoning linked to McDonald’s Quarter Pounder hamburgers has sickened at least 49 people across 10 states, including one fatality and 10 hospitalizations, federal health officials announced on Tuesday.

The fatality occurred in an older adult from Colorado, and a child has been hospitalized with severe kidney complications, according to the U.S. Centers for Disease Control and Prevention (CDC).

The infections were reported between September 27 and October 11, affecting individuals in Colorado, Iowa, Kansas, Missouri, Montana, Nebraska, Oregon, Utah, Wisconsin, and Wyoming. Colorado has the highest number of cases with 27, followed by Nebraska with nine.

Those interviewed as part of the outbreak investigation all reported eating at McDonald’s prior to falling ill, with most mentioning Quarter Pounder hamburgers, according to the CDC. The U.S. Department of Agriculture (USDA), the Food and Drug Administration (FDA), and state health officials are also involved in the investigation.

Although no specific ingredient has been definitively identified as the cause, investigators are focusing on onions and beef. A preliminary investigation by the FDA suggests that slivered onions served on the burgers may be a likely source of contamination. Meanwhile, the USDA is investigating the hamburger patties.

This news adds to an already challenging year for McDonald’s, which is based in Chicago. The company saw its global same-store sales fall for the first time in nearly four years during the second quarter, as inflation-weary customers opted to dine out less or chose cheaper alternatives. In response, McDonald’s introduced a $5 meal deal at U.S. restaurants in late June, which has been extended through December. However, the deal does not include the Quarter Pounder.

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The bacteria implicated in this outbreak, E. coli O157 causes about 74,000 infections in the U.S. each year, resulting in more than 2,000 hospitalizations and 61 deaths. Infections are particularly dangerous for children under the age of 5, as they can lead to acute kidney failure.

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