The Centers for Disease Control has issued a warning about consuming raw oysters, citing an ongoing salmonella outbreak.

In total, 64 people have reported getting sick with 20 hospitalizations across 22 states, the CDC said.

Pennsylvania and New York both have the most cases with 17 total.

“The true number of sick people in this outbreak is likely much higher than the number reported, and the outbreak may not be limited to the states with known illnesses. This is because many people recover without medical care and are not tested for salmonella. In addition, recent illnesses may not yet be reported as it usually takes three to four weeks to determine if a sick person is part of an outbreak,” the CDC said in a statement.

Most people infected with salmonella experience diarrhea, fever and stomach cramps. Symptoms usually start six hours to six days after swallowing the bacteria. Most people recover without treatment after four to seven days, according to the CDC.

Some people — especially children younger than 5 years old, adults 65 and older and people with weakened immune systems — may experience more severe illnesses that require medical treatment or hospitalization.

Other common symptoms of salmonella poisoning include diarrhea and a fever higher than 102 degrees, excessive vomiting, signs of dehydration, loss of appetite, dry mouth and throat and feeling dizzy when standing up. Experts say it is important to seek treatment if you suspect you have a severe case of salmonella.

Health experts warn the only way to ensure safety is to cook oysters thoroughly before eating. The CDC recommends different ways of cooking oysters including boiling oysters for at least three minutes, frying in oil for at least three minutes at 375 degrees, broil oysters three inches from heat for three minutes or bake at 450 degrees for 10 minutes. The CDC recommends cooking all seafood until the inside reaches a temperature of 145 degrees for at least 15 seconds.

The CDC said it is working with the U.S. Food and Drug Administration to investigate the outbreak and see if it is linked to one type of oyster or location.

“CDC, public health and regulatory officials in several states, and the U.S. Food and Drug Administration are collecting different types of data to identify the food source of a multi-state outbreak of Salmonella Telelkebir infections,” CDC officials said in a statement. “The CDC and FDA are working to determine the source of these oysters.”

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