In October 2012 North Carolina state health officials investigated an outbreak of E. coli O157 infections among persons who attended the Cleveland County Fair. The fair ran from September 26 to October 7. In total 106 people were reported ill; 25 were confirmed cases and 81 were probable cases. One confirmed case acquired illness via secondary transmission while providing care for another confirmed case. Patients resided in the following North Carolina counties: Cleveland, Gaston, Lincoln, Catawba, Mecklenburg, Rutherford, and Union. Residents of York and Cherokee Counties in South Carolina were also ill. There was one death in a Gaston County child. Eleven cases were hospitalized. Seven children developed HUS. One child died. Investigators concluded that two methods of disease transmission occurred in this outbreak: point source (petting zoo and associated physical environment) and person-to-person.