The number of E. coli cases among people who attended the Cleveland County Fair has nearly doubled, from 21 to 38, state officials said Monday.

A Gaston County boy died Friday from complications of the infection.

According to the N.C. Department of Health and Human Services, 22 children and 16 adults were known to have been affected by the outbreak. Eight individuals were or are hospitalized, the state said.

The specific cause is not yet known.

Officials in Cleveland, Gaston, Lincoln and other counties continue to interview families of those who are sick along with those who didn’t get ill. E. coli bacteria are found in the wastes of animals; people who come in contact with contaminated materials can transfer the bacteria to their mouths or other people.

Information from local interviews is being passed along to the state for analysis.

“We’re trying to pinpoint the source as precisely as possible,” said state epidemiologist Megan Davis. “The local health departments are working hard and diligently and we’re working in the background with them.”

The list of victims includes the 13-year-old son of Cleveland County Sheriff Alan Norman, according to WCNC-TV, the Observer’s news partner.

Originally, the outbreak seemed confined to Cleveland, Gaston and Lincoln counties, plus one case in York County, S.C.

But the area has now widened. As of Monday, the county case counts were: Cleveland County, 18 cases; Gaston County, 7; Lincoln County, 9; Catawba County, 1; Union County, 1; York County, S.C. 1; Cherokee County, S.C., 1. The Gaston figure includes the death related to the outbreak.

All the victims had attended the Cleveland County Fair, which ran Sept. 27-Oct. 7 in Shelby.

Gage Lefevers, 2, died Friday from complications of the E. coli infection. A funeral service will be held at 4 p.m. Wednesday in Gastonia.

The number of people sickened in the outbreak may continue to grow because symptoms can take up to 10 days to develop.

Symptoms can include vomiting, diarrhea and stomach cramps. Most victims recover in five to seven days, but the illness can be life-threatening for others.

No ‘red flags’ so far

Cleveland County Health Director Dorothea Wyant said that officials have interviewed some fairgoers who had gotten sick, but had no contact with animals. Despite rumors that corndogs and funnel cake were sources of the outbreak, no particular food has yet been identified as the suspect source, she said.

Fairgoers interviewed so far ate from “the whole food list,” Wyant said.

She described the outbreak as “…devastating, confusing and frustrating.”

“We can’t pinpoint anything that could be the cause,” Wyant said. “Nothing sent up red flags to us. So far, it’s a puzzle.”

According to Wyant, state officials said on Monday that “so far food hasn’t shown up as a risk factor.”

The N.C. State Fair opened on Thursday in Raleigh, and state officials stressed the need for fairgoers to follow safety precautions. Officials have said people and livestock will be separated as much as possible. Food vendors at the State Fair have been relocated and hand-washing stations have nighttime lighting and more signs.

Cleveland County Fair Director Calvin Hastings said the fair tried to prevent E. coli problems, including working with the fair’s 50 food vendors. The fair had nine hand-washing stations, instead of the five required by the state, and signs were posted around the grounds reminding people to wash their hands.

“We did everything we knew to do,” Hastings said Monday. “We thought we were very prepared.”

Hastings said he’s lost sleep over the outbreak, especially after learning of the toddler’s death. His two grandchildren went to the fair, and one visited a petting zoo three times.

“This could have affected me, easily,” he said. “It just tears your heart up. We’re hoping and praying for the people who are still sick.”

Founded in 1924 as a project of the Shelby Kiwanis Club, the Cleveland County Fair grew to become the state’s largest county fair. The first manager, Dr. J.S. Dorton, became one of the best-known fair managers in the state and nation. He went on to manage the N.C. State Fair, where Dorton Arena is named in his honor.

Rain fell for six days of this year’s Cleveland County Fair, but the event still attracted 165,000 people.

“It’s a place designed to have a good time,” Hastings said. “A place to bring your family and kids. Something like this just breaks your heart.”

Norman, the Cleveland County sheriff, said his son became ill last Wednesday.

“This came on extremely fast,” he told WCNC. “All the symptoms, it seemed, attacked at one time.”

Norman said he visited the fair almost daily and ate dinner there 10 times. He never got sick, he said.

Trusting food handlers

As the state analyzes data provided by local health officials they’ll face a special challenge with food.

Ben Chapman, food safety specialist with the N.C. Cooperative Extension, said these investigations are complex because of many different variables.

“It’s not just food,” he said. “It’s looking at vendors – the persons who handled the food. I think about that anytime I eat anything. It comes down to trust of the person who handled the food – trusting someone did everything right.”

Gaston County Health Director Chris Dobbins called the outbreak “tragic … absolutely heartbreaking.”

“We’re working 24/7 trying to figure this out,” he said. “There are so many possibilities. It’s not unreasonable to think there are possibilities we haven’t considered.”

But it’s important that “we make sure we pinpoint the source,” he said. “And that we learn from this and prevent it from happening again.”

WCNC-TV contributed