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Four cases of a serious, sometimes fatal infection called melioidosis that have bedeviled public health investigators for months appear to have been linked to an aromatherapy room spray sold at Walmart, the Consumer Product Safety Commission and the Centers for Disease Control and Prevention announced on Friday.

The product, Better Homes and Gardens Lavender and Chamomile Essential Oil Infused Aromatherapy Room Spray with Gemstones, was sold at 55 Walmart locations and on the company’s website from February to Oct. 21. Walmart has issued a recall for roughly 3,900 bottles of the product that it sold. The recall includes five other scents of the Better Homes and Gardens Gem Room Spray: lemon and mandarin, lavender, peppermint, lime and eucalyptus, and sandalwood and vanilla.

The four cases that have been detected in the United States occurred over a five-month period, from March to late July. Two of the infected people died, including a child. The cases occurred in Kansas, Minnesota, Texas and Georgia, where a bottle of aromatherapy spray retrieved from the home of one of the fatal cases led to a break in the case.

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The bottle tested positive for contamination with Burkholderia pseudomallei, the bacterium that causes melioidosis. It is commonly found in soil and water in parts of South and Southeastern Asia, and northern Australia, but not in the continental United States, where it’s classified as a dangerous pathogen that could threaten public health. The strain found in the aromatherapy spray, manufactured in India, matches strains from South Asia.

The discovery involved a huge amount of detective work by local public health officers and the CDC.

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“We tested hundreds of specimens collected from the households of several of the patients, really looking for that needle in the haystack. And we didn’t know if we’d be able to find it,” Jennifer McQuiston, deputy director of the CDC’s Division of High Consequence Pathogens and Pathology, told STAT in an interview.

When a first batch of samples taken from the Georgia patient’s home failed to turn up a potential source, public health investigators went back to find other products in the household to test. “I don’t know that we immediately thought that an air freshener would be the likely source. I think we had a very wide net that we were casting,” McQuiston said.

Some testing remains to be completed. The positive reading from the aromatherapy bottle was done by polymerase chain reaction, or PCR, testing. CDC labs are trying to extract genetic sequence data from the PCR finding to compare to the bacteria from the Georgia patient, as well as the other three. McQuiston is confident it will prove the link. But even if it didn’t, the discovery of Burkholderia pseudomallei-contaminated room freshener being sold at one of the country’s largest big box chain required urgent action.

The euphoria of finding the source of the bacteria was quickly dampened by the realization that the product was something being sold at Walmart, McQuiston said.

“We were very concerned when we found this bacteria in this bottle and began to imagine what the distribution number might look like across the United States,” she said. But then came some good news: Walmart revealed that the product was new to the chain and being sold as a test in a limited number of stores. Furthermore, not much of the product — at least not in Walmart terms — had been sold.

McQuiston said the CDC has been working with Walmart and the product’s manufacturer to see, among other things, whether the manufacturer makes other products that might be contaminated. That work continues.

Because Burkholderia pseudomallei is classified in the U.S. as a Tier 1 select agent — a pathogen that has the potential to pose a severe threat to public health and safety — the CDC has brought the finding to federal law enforcement agents, McQuiston said.

“But in this case, at this point in time, we don’t have any suspicion that this is linked to some kind of intentional release activity,” she said. “A much more plausible explanation is that there was a contamination step in manufacturing process.”

The CDC is suggesting that people who have used the product in the past 21 days who have symptoms consistent with melioidosis should seek medical care and tell the attending doctor about the aromatherapy spray exposure. People who have no symptoms but have used the spray in the past seven days should also see a doctor, who may prescribe antibiotics to prevent infection, the CDC said.

People who have purchased the aromatherapy spray should stop using it immediately, the CDC statement said. People should not dispose of the product themselves — doing so could spread the bacteria further. Instead, they should double bag bottles in clear plastic bags, place them in a small box and return them Walmart.

Agency officials advised that any sheets or linens sprayed with the product should be washed and dried in a hot dryer, with bleach if desired. Surfaces the product might have been sprayed on should be cleaned with an undiluted disinfectant. People should wash their hands thoroughly after performing these tasks.

About a dozen cases of melioidosis are discovered in this country in any given year; they are almost always seen in people who have returned from traveling in Southeast Asia or northern Australia, where the bacteria are found in soil and water. People contract melioidosis by exposure to the bacteria via cuts in the skin or by consuming food or water contaminated with the bacteria.

Melioidosis has an estimated fatality rate of between 10% and 50%. People with some health conditions are at greater risk of severe if they contract the illness; those health conditions include diabetes, alcoholism, kidney disease, and chronic lung disease.

Symptoms of the disease can vary depending on the type and site of infection. There are four types of infection: localized, in the lungs, bloodstream infection, or disseminated infection, in which a localized infection spreads to another part of the body. Treatment depends on the type of infection, but consists of oral or intravenous antibiotics.

Melioidosis symptoms may include localized pain or swelling, fever or high fever, skin ulcers or abscesses, cough, chest pain, headache, anorexia, respiratory distress, abdominal discomfort, joint pain, disorientation, weight loss, stomach or chest pain, muscle or joint pain, and seizures, the CDC website states.

This story has been updated with additional information from the CDC. 

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