The E. coli outbreak linked to romaine lettuce has sickened a total of 43 people on 12 states, the US Food and Drug Administration reported on Monday. The FDA states the ongoing outbreak is linked to the “end of season” harvest throughout some parts of California.

People began to  fall ill in California, Connecticut, Illinois, Massachusetts, Maryland, Michigan, New Hampshire, New Jersey, New York, Ohio and Wisconsin, after the consumption of romaine lettuce contaminated with E. coli. In addition, 22 people in Canada also became ill – resulting in the FDA coordinating their investigation with the Canadian health and food safety authorities, according to the agency.

CNN notes that when the outbreak was initially announced last week, the FDA and the Centers for Disease Control and Prevention warned consumers to avoid all romaine lettuce, regardless of where it was purchased or how it was packaged. However, the FDA said the investigation was primarily focused on California and Mexico.

“Over the Thanksgiving holiday, the FDA continued to investigate the outbreak,” according to a statement from FDA Commissioner Dr. Scott Gottlieb. “Our investigation at this point suggests that romaine lettuce associated with the outbreak comes from areas of California that grow romaine lettuce over the summer months, and that the outbreak appears to be related to ‘end of season’ romaine lettuce harvested from these areas. The involved areas include the Central Coast growing regions of central and northern California.”

Lettuce is grown and harvested during the winter months in California, Arizona’s desert regions, Florida and Mexico. The FDA investigation does not currently implicate lettuce from any of these areas.

While the romaine supply regularly undergoes a “clean break” to ensure all the contaminated lettuce is effectively gone from the market, the FDA requested that producers and distributors provide clear labeling with the lettuce’s date and origin in the future. In addition to the request, a task force within the lettuce industry was established to determine better solutions for labeling long-term in order to assist in tracing.

“Based on discussions with major producers and distributors, romaine lettuce entering the market will now be labeled with a harvest location and a harvest date,” Gottlieb said. “Romaine lettuce entering the market can also be labeled as being hydroponically or greenhouse grown. If it does not have this information, you should not eat or use it.

“If consumers, retailers and food service facilities are unable to identify that romaine lettuce products are not affected — which means determining that the products were grown outside the California regions that appear to be implicated in the current outbreak investigation — we urge that these products not be purchased, or if purchased, be discarded or returned to the place of purchase.”

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