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Shigella

Hubbard Splash Fountain

Outbreak: Hubbard Splash Fountain
Product: Splash Fountain in Hubbard, Oregon
Investigation Start Date: 7/25/2003
Location: Marion County, Oregon
Etiology: Shigella sonnei
Earliest known case onset date: 7/16/2003
Latest case onset date: 8/17/2003
Confirmed / Presumptive Case Counts: 19 / 37
Positive Samples: 0
Outbreak Summary:
Investigation of an outbreak of gastrointestinal illness erupted among children in a small community in Marion County, Oregon. Investigation by epidemiologists found that the illnesses were due to the fecal bacterium Shigella sonnei, and traced to an unusual common source: a splash fountain. This outbreak underscores the risk of large and prolonged outbreaks from these fountains and the need to develop and implement environmental health standards for their design and maintenance.

Documents


Media Coverage
Details:
Introduction
On July 25, 2003, a physician notified the Oregon Public Health Division about 5 unrelated children with diarrhea. Epidemiologists began investigating to ascertain the bacterial etiology and the means of transmission, so as to institute control measures.

Methods
Confirmed cases had S. sonnei infections with matching DNA patterns by pulsed-field gel electrophoresis (PFGE), with illness onset date during July–August 2003. Presumptive cases had dysentery or diarrhea with fever and were epidemiologically linked to a confirmed case. Primary cases were the first ill in a household or daycare group.

To identify the source of the outbreak, epidemiologists conducted a case-control study, using the first seven confirmed primary cases. Interviews were conducted in English or Spanish with cases or household proxies. Respondents were asked about activities in which they had participated and places at which they had eaten during the last two weeks of July. Fifteen control children, matched to cases by telephone prefix and loosely by age (e.g., being less than 15 years old), were identified by systematic calling.

To estimate an attack rate, epidemiologists conducted a telephone survey of 147 children drawn at random from the rosters of two local elementary (grades K–5) schools.

Water samples collected from the fountain’s sump tank and surge tank, and from a nearby drinking water fountain, were assayed for fecal coliforms, E. coli, pH, and free chlorine. They were also tested for Shigella by membrane filtration and plating on salmonella-shigella agar. Shigella isolates were then speciated and subtyped by PFGE.

Results
Initial interviews identified no obvious common foods, but revealed that many cases had attended a festival in the city park (now known as Rivenes Park) of Hubbard, Oregon. All 7 cases but only 1 of 15 controls had played in the park’s interactive fountain (matched OR undefined, P=0.001). Through case reporting and the subsequent survey, investigators identified 19 confirmed and 37 presumptive cases associated with the fountain. Primary cases were exposed during at least a 10-day period ending August 1, when the fountain was closed.

The fountain was a shallow basin about 8 meters in diameter with recessed spray nozzles that encouraged recreational interaction. The water drained to a central reservoir, which allowed standing water to accumulate and did not allow it to recirculate when the fountain was shut off at night. The surge tank was underground with a large device for straining out larger items like soda cans. Fresh water was supplied through a backflow device installed below ground level; the design did not provide adequate protection of the water supply from contamination.

The filtration system did not have influent and effluent gauges, nor was there a flow meter. Chlorine was added manually by tossing "tri-chlor" (trichloro-S-triazinetrione) tablets into the surge tank on an irregular basis. The ultraviolet light ozone generator was too small for the flow rate, and the bulb had never been changed.

Two water samples yielded fecal coliforms (940 and 370 per 100 mL, respectively) and E. coli (500 and 140 per 100 mL). Chlorine was not detectable.
Of the 147 local children surveyed, 51 (35%) had played in the fountain during the last two weeks of July. Of the 51, 20 (39%) subsequently developed diarrhea (compared with 3% of those who had not visited the fountain [P<0.001]). Investigators estimated that, including children from other schools, older persons, and those who may have contracted the illness from secondary person-to-person spread, >500 persons most likely contracted shigellosis in this outbreak.

Lessons learned/historical significance
This splash fountain outbreak provides two unique lessons. First, it is a reminder for epidemiologists to remain objective when investigating outbreaks and not to presume foodborne transmission when dealing with outbreaks of enteric disease. Mark Twain said, “To a man with a hammer, everything looks like a nail,” but epidemiologists need to maintain a broader perspective.

Second, this outbreak highlights the need for public health policy that addresses risks posed by the built environment. It underscores the risk of large and prolonged outbreaks from such fountains and the need to develop and to enforce standards for their design and maintenance. In 2003, the regulations and licensure regarding splash fountains were still being developed. After the outbreak, the state health department’s food, pool and lodging program visited and scrutinized the fountain and suggested that it be licensed and regulated as a public wading pool. The fountain was subsequently re-engineered and now has an automatic chlorinator.
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norovirus

Shopping Bag Norovirus

Outbreak: Reusable Shopping Bag
Product: Reusable Shopping Bag
Investigation Start Date: 10/13/2010
Location: Single County
Etiology: Norovirus
Earliest known case onset date: 10/10/2010
Latest case onset date: 10/12/2010
Confirmed / Presumptive Case Counts: 7 / 5
Positive Samples: 1
Outbreak Summary:
Health officials made a rare discovery with this outbreak by identifying a reusable shopping bag as the vehicle for norovirus investigation. The reusable shopping bag was stored in a bathroom used by the index case during her illness onset. The bag contained cookies, chips and other food items that were eaten by tournament attendees who subsequently became ill.

Documents
Details:
Introduction
On October 13, 2010, the Washington County (Oregon) Health Department was notified by epidemiologists from the Washington State Department of Health (WSDH) and Public Health—Seattle & King County (PHSKC) about an outbreak of gastroenteritis affecting members of an Oregon soccer team.
The soccer team had arrived in Redmond, Washington, on Friday, October 8; its members ate in restaurants around town and also consumed homemade items that they had brought with them.

Early the morning of Sunday, October 10, one girl became ill with vomiting and diarrhea and was driven home that day by one of the parent chaperones. A fellow team member, unaware of her teammate’s illness, went into the vacated room and found a reusable plastic grocery bag, containing lunch items, which was stored on the floor of the bathroom.

On Tuesday, October 12, other team members and chaperones became ill, and one of the parents notified PHSKC.

Methods
While epidemiologists of WSHD and PHSKC canvassed tournament organizers about any similar reports from other teams, Oregon epidemiologists obtained a team roster and chaperone list. Twenty-one interviews were conducted over the phone or in person at a team practice on Thursday, October 14. One healthy person refused the interview. One ill person was excluded from analysis due to direct exposure to the index case and her vomiting.

Cases were defined as group members who developed vomiting or diarrhea (≥3 loose stools within a 24-hour period) during October 9–13. The follow-up questionnaire specifically targeted meals and all reported food exposures on Friday, Saturday and Sunday, October 9–11. Stool specimens were solicited from persons who had been ill. A reusable grocery bag was tested for norovirus by swabbing small patches of the bag’s surface. Swabs of the surface of the reusable grocery bag were tested for norovirus by real-time, quantitative reverse-transcription polymerase chain reaction (RT-qPCR).

Results
Nine primary and five secondary cases were identified. The noroviral etiology and tight clustering of the Tuesday, October 12, case onsets suggested a common exposure on Sunday afternoon—most likely lunch or something at stopover on the drive home. In the initial cohort analysis, only eating cookies from an unopened package on Sunday at lunch was significantly associated with illness, with 3 of 7 cases consuming and none of 12 healthy cohort members exposed (risk difference [RD] 0.750; 95% CI 0.24–0.91; P = .01). After cases were re-interviewed with the focused questionnaire, investigators learned that the packaged cookies, packaged chips, and fresh grapes had been stored together in a reusable plastic shopping bag with an open top. Further, said shopping bag had been stored in the hotel bathroom where Case 1 had been vomiting throughout the night. Investigators then created a composite variable to include all three items in the bag. All 7 cases but only 4 of 12 healthy cohort members had consumed at least one of the 3 items in the bag (RD 0.636; 95% CI, 0.32–0.87; P < .01; see the published journal article for further analysis detail).

Norovirus genotype GII.2 sequence was detected by RT-qPCR in all 3 stool specimens collected from cases and in swabs of the reusable plastic shopping bag.

Lessons learned & historical significance
This outbreak highlights the risk of acquiring noroviral gastroenteritis from a fomes, the surface of which can be contaminated when left in an enclosed environment with someone who is vomiting. Any surface—not just a visibly soiled one—exposed to an ill person should be fully disinfected. Food and drink should not be stored in toileting areas; anything stored in areas where someone has vomited should never be consumed.
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norovirus

Diaper Changing Station Norovirus

Outbreak: Diaper Changing Station Norovirus
Product: Diaper Changing Station
Investigation Start Date: 5/16/2012
Location: Washington County, OR
Etiology: Norovirus
Earliest known case onset date: 5/15/2012
Latest case onset date: 5/15/2012
Confirmed / Presumptive Case Counts: 12 / 4
Positive Samples: 1
Hospitalizations: 0
Deaths: 0
Outbreak Summary:
This outbreak initially appeared to be a standard foodborne point-source outbreak from a restaurant with known previous critical violations. However, upon extensive interviewing, it transpired that a toddler with explosive diarrhea and the associated contaminated surfaces were the source of the outbreak.

Documents
Details:
Introduction
On May 16, 2012, a local auto dealership called the Washington County (Oregon) Health Department to report a potential foodborne illness outbreak among employees who had attended a staff meeting on May 13. The meeting was held in an open space off the showroom floor. Submarine sandwiches, chips, and condiments from a nearby fast-food restaurant had been provided to attendees.

Environmental health staff conducted an onsite environmental inspection of the restaurant and its operations. Food handlers and restaurant managers reported no recent gastrointestinal illness (within previous 2 weeks) was reported by food handlers or restaurant managers. No other patrons had complained. The restaurant was cited for 2 violations defined by environmental health staff as critical: presence of potentially hazardous food not maintained at proper hot or cold holding temperatures and presence of open beverages on the food preparation table. During interviews with dealership employees, one recalled that a customer with a sick child had used the diaper-changing station in the women’s restroom before the lunch. When the woman and toddler left, the restroom was a mess. The employee cleaned it up as best she could with dry paper towels. She didn’t wear gloves or use bleach but did wash her hands. She left the restroom, opened the dealership’s front door for another employee carrying the food and was the first to take a sandwich from the platter.

Methods
Oregon epidemiologists conducted a retrospective cohort study among meeting attendees, using a standard questionnaire to ask about food, environmental exposures, and any history of illness. Cases were defined as meeting attendees who developed vomiting or diarrhea (defined as ≥3 loose stools within a 24-hour period) within 72 hours after the meeting. Environmental health staff evaluated the operations of the restaurant that provided the food, with particular attention to hand washing, food preparation practices, and recent employee illness. Stool specimens were solicited from ill persons and tested for norovirus. Epidemiologists collected environmental samples for norovirus testing from the diaper-changing station at the auto dealership and from a convenience sample of similar diaper-changing stations in public restrooms throughout Washington County.

Results
Stool specimens from 2 employees and the toddler—who was located through auto sales records—were positive for norovirus (genotype GII.6.C) with indistinguishable sequences. According to the mother, the child had been ill for 1 day before the visit to the auto dealership. Although the dealership diaper changing station had reportedly been routinely cleaned twice by a professional janitorial service, using quaternary ammonium disinfectants, we observed brown matter inside and underneath the changing station. Swabs of the brown matter on the changing station were positive for norovirus genotype GII, although the samples did not amplify in viral capsid coding regions C or D, rendering sequencing impossible.

To assess the prevalence of norovirus on diaper-changing stations in Washington County, epidemiologists tested a convenience sample of 14 stations in various restroom locations: 1 restaurant, 3 parks, 3 grocery stores, 1 gas station, 2 shopping malls, 1 aquatic center, 2 libraries, and 1 public health clinic. Eight (57%) of 14 stations had visible brown discoloration on the underside of the fold-down hinge or bed area. All 14 dispensers for disposable bed liners were empty. Norovirus was not detected in swabs of any of the diaper-changing stations other than that the auto dealership.

Lessons learned & historical significance
This outbreak initially appeared as a standard foodborne point-source outbreak from a restaurant with known previous critical violations. However, extensive interviewing revealed that a toddler with explosive diarrhea, and the associated contaminated surfaces, were the source of the outbreak. This outbreak confirms the ability of fomites to transmit norovirus, and the importance of reserving judgment regarding potential foodborne transmission and of considering environmental investigation as a key part of investigating outbreaks of enteric disease.
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Contest

Museum Exhibit Contest

Exhibit Submission Contest
OFFICIAL OUTBREAK EXHIBIT CONTEST RULES

Welcome, citizen, to the Museum's first outbreak submission contest!


Submit a significant or interesting outbreak investigation and you may win official International Outbreak Museum T-shirts! The winning outbreak investigation submission will also become an official online exhibit right here on the Museum website.


NO PURCHASE NECESSARY TO ENTER OR WIN.

   To download these rules as a PDF, Click Here
   To download these rules as a Microsoft Office Word Document, Click Here



Promotion Period:The International Outbreak Museum (IOM) Outbreak Submission T-shirt Contest begins March 1st, 2018 and ends March 31st, 2018. A winner will be chosen within 30 days of the promotion end date. We will contact the winner if additional online exhibit materials are needed.


Prize: The winner (or each member of the winning team) will receive a T-shirt in (choose one) small, medium, large, or extra large (subject to availability). In addition, your winning outbreak investigation will become an official IOM website online exhibit.



Special Requirements: Since the chosen winner’s exhibit will become an official online exhibit at www.outbreakmuseum.com, the aforementioned must be willing to work in a limited fashion with museum staff to finalize the online outbreak exhibit. This may include a request for additional information or materials (such as pictures, video, an epi curve, outbreak questionnaire, etc).


Eligibility: Anyone can submit an outbreak investigation. There are no restrictions for eligibility based upon geographic location or whether or not you participated in the submitted outbreak investigation. T-shirts will be shipped to the winners within 2-8 weeks (to the best of our ability).


How To Enter: You may enter this contest as an individual or a small team. To enter the contest, a historically significant outbreak investigation report must be submitted to International Outbreak Museum staff.


To submit your exhibit, please fill out the online exhibit submission form (below) and submit it along with any supporting materials (images, captions for images, publications, presentations, epi curve, etc) to the following email address: outbreak.museum@state.or.us

EXHIBIT SUBMISSION TEMPLATE


NOTE: For examples of current online outbreak exhibits, please click "Outbreak Exhibits" at the top of this page or click here.


   To download this form as a PDF, Click Here
   To download this form as a Microsoft Office Word Document, Click Here



SECTION 1

  • 1) Investigation jurisdiction (local Health Department, state Health Department, Federal, Other)

  • 2) Pathogen

  • 3) Vehicle/venue

  • 4) Case counts (confirmed/presumptive/suspect)

  • 5) Geographic distribution of cases (single county/state-wide/multi-state/International)

  • 6) First and last onset dates

  • 7) Pictures! (please include captions for each photo submitted as part of exhibit)

  • 8) Number of positive non-human specimens (water, environment, food, etc.)


OPTIONAL BONUS MATERIAL

  • 9) Publication citation (optional)

  • 10) Presentations (optional)

  • 11) Investigation tools (e.g., questionnaire) (optional)



SECTION 2


Please limit the 3 sections below to a total of ~1000 words

  1. 1) Abstract: Background, Methods, Results, Conclusions

  2. 2) Highlights: unique features or reasons why the outbreak is important

  3. 3) Lessons learned

    4. Please send this completed form to outbreak.museum@state.or.us
ecoli

Raw Flour E. coli

Outbreak: RAW FLOUR E. COLI
Product: Raw Flour
Investigation Start Date: 6/1/2016
Location: Multistate
Etiology: E. coli O121
Earliest known case onset date: 12/21/2015
Latest case onset date: 9/5/2016
Confirmed / Presumptive Case Counts: 63
Positive Samples: 39
Hospitalizations: 17
Deaths: 0
Outbreak Summary:
CDC worked with public health and regulatory officials in many states and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli (STEC) infections.

Public health investigators used the PulseNet system to identify illnesses that may be part of this outbreak. PulseNet, coordinated by CDC, is the national subtyping network of public health and food regulatory agency laboratories. PulseNet performs DNA fingerprinting on STEC bacteria isolated from ill people by using techniques called pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). CDC PulseNet manages a national database of these DNA fingerprints to identify possible outbreaks.

Sixty-three people infected with the outbreak strains of STEC O121 or STEC O26 were reported from 24 states. A list of the states and the number of cases in each can be found on the Case Count Map page. WGS showed that isolates from ill people were closely related genetically. This close genetic relationship means that people in this outbreak were more likely to share a common source of infection.

Illnesses started on dates ranging from December 21, 2015 to September 5, 2016. Ill people range in age from 1 year to 95, with a median age of 18. Seventy-six percent of ill people were female. Seventeen ill people were hospitalized. One person developed hemolytic uremic syndrome, a type of kidney failure, and no deaths were reported.
Details:
Background
Flour is a raw, minimally processed product intended to be cooked before consumption. Although several previous Shiga-toxin-producing E. coli (STEC) outbreak investigations in the United States suspected contaminated flour as the source, none had been proven. In February 2016, PulseNet, the laboratory network for foodborne disease surveillance, detected a 12-state cluster of STEC O121 infections having the same rare genetic fingerprint. A multistate outbreak investigation was initiated. An additional STEC O26 strain was linked to the outbreak after testing of implicated flour.

Methods
A case was defined as infection with an outbreak strain of STEC O121 or O26 occurring between December 21, 2015, and September 5, 2016. Case-patients were interviewed about foods and other exposures in the week before illness onset. We performed univariable matched exact conditional logistic regression to identify exposures associated with illness, comparing them to exposures among people with reportable non-STEC enteric infections (primarily salmonellosis and campylobacteriosis), matched on age, gender, and state of residence. Four controls were sought for each case and interviewed by state and local health officials. Samples of suspected products were collected and cultured for STEC. A common point of contamination was sought through traceback. Whole genome sequencing (WGS) was performed on selected clinical and food isolates.

Results
Fifty-six cases of STEC O121 and one case of STEC O26 infection were identified in 24 states; seventeen people were hospitalized; none died. Using General Mills flour (OR 21.0, 95% CI 4.7‒94.4) and tasting unbaked homemade dough or batter (OR 36.0, 95% CI 4.6‒280.2) were both significantly associated with illness. Traceback identified a common flour production facility. Three illnesses were in children exposed to raw dough for playing at several locations of a single restaurant chain. Leftover flour samples collected from cases’ homes and additional samples collected from the flour producer were tested, and five STEC strains were isolated (one STEC O26, three STEC O121, and one STEC O103). All isolates tested were closely related genetically.

Conclusion
This is the first investigation to link definitively an outbreak of STEC infections to raw flour. Nearly 250 products containing the implicated flour were recalled by the flour producer as well as by several companies that used recalled flour. Consumers should not eat products containing uncooked flour. Using uncooked dough for play should also be discouraged at restaurants and home. Flour producers should consider adding prominent packaging labels to warn consumer not to eat undercooked or raw flour. Foodborne illnesses associated with raw flour are likely preventable if appropriate control measures are taken from grain fields and production facilities to restaurants and consumers.

Publication citation: Crowe SJ., et al. Shiga toxin–producing E. coli infections associated with flour. New Engl J Med 2017; 377: 2036n43.
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Measles

Hip-hop Measles

Outbreak: HIP-HOP MEASLES
Product: N/A
Investigation Start Date: 5/27/2007
Location: Lane County, Oregon
Etiology: Measles
Earliest known case onset date: 5/20/2007
Latest case onset date: 6/5/2007
Confirmed / Presumptive Case Counts: 2 / 1
Positive Samples: N/A
Hospitalizations: 2
Deaths: 0
Outbreak Summary:
In 2007, two cases of measles detected in Oregon (both unvaccinated) led to an investigation of potential exposures within a hospital and the community at large. This investigation cost approximately $170,000 across local and state health departments, and the related medical system, highlighting the costs associated with measles contact investigation.
Details:
Background
On May 27, 2007, Lane County Health and Human Services (LCHHS) received a report of a possible measles case admitted to a local hospital. The index case was in his twenties, unimmunized, and had been in Japan during his putative incubation period. A second case was identified later. The cases lived in a mid-sized urban community (pop. 200,000), and, as we were later to find out, had active social lives.

Methods
Hospital staff reviewed their employees’ immunization status and the airflow system. Measles cases and their exposed contacts were interviewed using Oregon’s standard measles case-report form. For those contacts lacking documentation of immunity, vaccine or immunoglobulin (IG) was offered. Instructions for voluntary quarantine were given to exposed non-immune contacts. The costs of containing the two measles cases was estimated for the hospital and local and state public health departments.

Public health recommendations included three tiers of contact investigation:
(1) Health-care workers (HCWs) in direct contact; patients in the waiting room and emergency department (ED); household contacts and close friends.
(2) HCWs in units potentially exposed via air flow.
(3) High-risk patients (pregnant moms, babies, immunocompromised) potentially exposed via air flow.

Results
On May 31, 2007, Lane County officials confirmed the diagnosis of measles in the index case by polymerase chain reaction testing. His prodrome began on May 20. He flew on May 21 from Tokyo to San Francisco, and thence on May 22 to Eugene. His rash was first noted on May 25. He spent time at a local hospital ED and visited a health food store, naturopath and Japanese restaurant during his communicable period.

The patient was not given a mask while in the ED waiting for his initial evaluation; rather, he was placed in a regular airflow room and then wheeled through the hospital without a mask and ultimately put in a taxi for the ride home. Review of the hospital’s airflow system revealed that air from the ER (where case was housed but not isolated) was shared with the Coronary Care unit and Mother Baby Unit. The circulated air had a mixture of about 20% outside air and 80% recycled indoor air with 90%–95 % effective filtration and no HEPA filter.

During the investigation, the index patient refused to identify household contacts and did not respond to LCHHS phone calls, making contact investigation difficult. An unannounced home visit helped to clarify the situation and obtain new information.

Information regarding 4 persons exposed on airline flights was not received until two weeks after the likely exposure. A week later, health officials were informed of two additional persons considered exposed, having sat next to or in front of the case, but phone numbers were not provided, and they had common last names. It also transpired that the case provided an incorrect seat number, and the model of the one of the airplanes was different from that listed on the airline’s website, further confusing attempts to identify exposed persons.

A second, unimmunized case, who had socialized with the index patient the night he arrived home from Japan, developed a febrile prodrome on May 30 and a rash consistent with measles on June 1. Koplik spots were visible. He declined lab testing.

Although nurses advised case #2 to stay home to avoid spreading the disease, he went to public places. On May 29, the case caught a hip-hop show at a local concert hall, then to a downtown bar. The next night, he went out for sushi.

Three bands that played at the concert were on a national tour. During these shows, the attendees typically stand, dance and mingle, the band is on a stage just above the floor and the band members often venture into the audience. The band members were in Utah when they were notified about their possible exposure, and specimens to verify immunity were collected in Colorado. The testing was performed at CDC in Georgia, and after the tests proved negative they were vaccinated while performing in Iowa.

Discussion
This investigation presented numerous challenges. Both measles patients came from families that did not believe in measles vaccination, and who “don’t think measles are a big deal.” Local public health officials’ recommendations for isolation and quarantine didn’t impede their pursuit of an active social life—which greatly increased the work of contact tracing. The following factors also complicated the response:

1. Exposures during multiple airplane flights
2. Delay in receipt of information about people exposed during travel
3. Exposures among a community of unimmunized peers
4. Delayed isolation of the case at the hospital
5. Shared ventilation between the case’s room and other hospital units
6. Lack of airborne precautions during transit through hospital at time of discharge
7. Withholding of information and non-compliance with voluntary home isolation
8. Limited documentation of measles immunity among healthcare workers

The Impact of Two Measles Cases
As a result, the investigation of these two measles cases and containment of the outbreak entailed substantial amounts of personnel time and money, as detailed below:

• Hospital:
– Incident Command System (ICS) activated
– 1600 titers in a 2-week period
– 97% of HCWs were immune
– Cost of titers $40,000
– 600 fit tested for N95 masks
– 10 HCWs placed on furlough for several days
– 3 HCWs furloughed for 21 days
– 63 shots given
– New policy requiring proof of measles immunity
– Infection education module updated
– Isolation & transferring process reviewed
– $100,000 (estimated cost)

• Local Health Department:
– ICS activated
– 2 cases
– 168 contacts investigated
– 90% were immune
– 4 shots given
– 4 people were placed in voluntary quarantine
– $50,000 (estimated cost)

• State Health Department:
– ICS activated
– $20,000 (estimated cost)

Conclusion and Highlights
This outbreak was successfully controlled, despite the potential for spread. The limited extent of this outbreak, even in the setting of broad exposure, highlights the high level of population immunity achieved in Oregon and in other states.
This outbreak and its burden on clinical and public health resources could have been limited by adherence to recommendations of the Advisory Committee on Immunization Practices (ACIP) for vaccination of high-risk adults against measles.

Recommendations
• Consider using quarantine orders and the quarantine process as outlined in statute to minimize the risk of spreading the virus
• Consider taking legal action when cases are do not comply with public health investigation and control efforts
• Develop educational materials with clear, relevant messages targeting vaccine-hesitant communities affected by the outbreak
• Continue efforts to ensure networking with the alternative medical community
• Expand use of digital communications for public information
• Ensure airborne infection control precautions in healthcare settings
• Promote measles vaccination and documented evidence of immunity among healthcare workers in Oregon
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Campylobacter

Pennsylvania Raw Milk

Outbreak: PENNSYLVANIA RAW MILK CAMPYLOBACTER
Product: Raw Milk
Investigation Start Date: 01/24/2012
Location: Multi-state
Etiology: Campylobacter jejuni
Earliest known case onset date: 01/14/2012
Latest case onset date: 02/01/2012
Confirmed / Presumptive Case Counts: 81 / 67
Positive Samples: 2
Hospitalizations: 10
Deaths: 0
Outbreak Summary:
While it is legal to sell unpasteurized raw milk in Pennsylvania and illegal to sell in neighboring Maryland, New Jersey and West Virginia, this outbreak included cases in residents from all of these states.

While additional regulations by state officials could be considered, such as monthly pathogen testing, that could reduce the risks associated with consumption of raw milk, the only way to prevent unpasteurized milk–associated disease outbreaks is for consumers to refrain from consuming unpasteurized milk.
Details:
The following is the abstract from the published article found here. The full, free text can be found here.

This multistate outbreak of campylobacteriosis was among the largest (148 confirmed and probable cases) nationally in recent years associated with consumption of unpasteurized raw milk and was epidemiologically and molecularly linked to consumption of certified unpasteurized milk from a Pennsylvania dairy.

15 unpasteurized milk samples obtained directly from the dairy during the investigation (but after most of the onsets of the cases) were negative for Campylobacter. However, 2 unopened retail samples collected from Maryland consumers tested at Maryland’s state public health lab, yielded C. jejuni with an indistinguishable PFGE pattern to all clinical isolates.

This highlights the importance of testing food and environmental samples linked to actual exposure dates whenever available.

This outbreak occurred despite a state program implemented to reduce the risk associated with raw milk consumption. Although the dairy had tested for Escherichia coli O157:H7 more frequently than required by state regulations, those regulations for testing for other pathogens, such as Campylobacter, was only performed biannually.
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acuterespiratoryillness

Wilson’s Leather Spray

Outbreak: LEATHER SPRAY & RESPIRATORY ILLNESS
Product: Wilson's Leather Spray
Investigation Start Date: 12/27/1992
Location: OR, WA
Etiology: Acute Respiratory Illness
Earliest known case onset date: 12/21/1992
Latest case onset date: 12/31/1992
Presumptive Case Count: 84
Positive Samples: 0
Hospitalizations: 6
Deaths: 0
Outbreak Summary:

On December 27th, 1992, reports filtered in over the course of several days that people were becoming ill following the use of an aerosol leather conditioner. Symptoms reported included prolonged cough, shortness of breath, pleuritic chest pain, headaches, malaise, chills, and fever. In total, reports increased to 400 persons, involving approximately 550 persons. The product, Wilson’s Leather Protector, was recalled by mid-day on December 27th. Six people were hospitalized.


• "Acute Respiratory Illness Linked to Use of Aerosol Leather Conditioner"
(CDC outbreak page)
• "Acute lung injury induced by a commercial leather conditioner"
(Peer-reviewed publication)
From the Annals of the IOM

Episode 7: Wilsons Leather Spray. Click the play button to view our informational video on this outbreak!

Wilsons Leather Spray can.
Oregonian piece partway through the outbreak.
Symptoms included prolonged cough, shortness of breath, and pleuritic chest pain. Many persons also reported headaches, malaise, chills, and fever as high as 104 degrees Fahrenheit!
Following the public recall, as of December 31st, the number of preliminary reports to the Oregon Health Division and Oregon Poison Center of illness associated with use of this spray, increased to 400 and involved approximatey 550 persons in at least 17 states.
The technology was different back then, but it got the job done!
e-coli-o157nm

Sally Jackson Cheese

Outbreak: Sally Jackson Cheese
Product: Raw milk goat, sheep, & cow cheeses
Investigation Start Date: 12/06/2010
Location: Multi-state
Etiology: E. coli O157:NM
Earliest known case onset date: 09/09/2010
Latest case onset date: 11/26/2010
Confirmed Count: 8
Positive Samples (Food / Environmental): 0 / 0
Hospitalizations: 2
Deaths: 0
Outbreak Summary:
Oddly, none of the cases in this outbreak ever recalled the cheese by the brand name, even after investigators deduced the brand of cheese and questioned the cases about it specifically. It was fortunate that investigators could make a compelling case with largely circumstantial evidence that was later bolstered by laboratory and environmental evidence. Following a recall, the Sally Jackson facility closed permanently.
Details:
E. coli O0157:NM Outbreak Associated with Artisan Cheese from Sally Jackson Cheese

Background
On December 6, 2010, routine follow-up interviews, conducted by the Oregon Public Health Division, on 2 patients diagnosed with E. coli O157 infection with indistinguishable PFGE patterns, positive for both Shiga toxins stx-1 and stx-2, revealed that they had both patronized ClarkLewis a local farm to table-style restaurant in Portland, Oregon.

Methods
Menus were reviewed, and the only item in common to both cases was an unspecified selection of artisanal cheeses. As the chef was not able to identify which cheeses were served on cases’ meal days, Oregon Public Health Division staff reviewed their invoices from the past 2 weeks to determine which cheeses could have been served. Staff also queried the national laboratory network, PulseNet, to identify possible additional cases. Cases were defined as patients with PFGE-matching E. coli O157 isolates since July 2010. Investigators reviewed interview records; menus; sales records; and shipping invoices from restaurants, retailers, and food distributors; patients were reinterviewed as necessary. Food samples were assayed.

Results
Eight cases were identified from Oregon (1); Washington (4); Vermont (1) and Minnesota (2). Median age was 39 (range, 22–69) years, and 5 were female. All patients had diarrhea with onset during September–November 2010. Two patients were hospitalized; none had HUS; none died.

One Washington State resident was lost to follow-up. The Oregon resident and one Washington resident reported cheese exposures at ClarkLewis on November 12 and November 13, 2010; 8 different artisanal cheeses were potentially served those days. One Washington resident reported consumption of cheeses at a wedding in northeastern Washington on September 5, 2010, where locally bought goat, sheep and cow cheeses where served; the Sally Jackson facility was located a few miles from the northeastern Washington wedding location. Another Washington resident tasted various artisanal cheeses at Calf & Kids cheese shop in Seattle on November 21. The Vermont resident had visited a relative in Washington State and partook of a cheese plate at Palace Kitchen restaurant in Seattle on October 23, 2010. The 2 Minnesota residents had onset dates of September 26 and October 8, 2010; one was a member of a cheese club, and the second recalled having eaten artisanal cheeses. Altogether, 7 cases reported consumption of artisanal cheeses, but none recalled specific varieties or brands. Invoices from ClarkLewis suggested 8 cheeses that could have been served, including Sally Jackson raw goat cheese.

Review of invoices from the distributor indicated that Sally Jackson cheeses were also sold at Calf & Kids in Seattle and at Palace Kitchen. Invoices from Palace Kitchen indicated that they could have carried Sally Jackson’s raw sheep cheese when the Vermont resident ate there. The Sally Jackson distributor also supplied ClarkLewis, and invoices indicated that the cheeses were sold to ClarkLewis on November 10 (and potentially served on November 12 and 13). Those cheeses had been received by the distributor on September 28, indicating that a single contaminated batch released for consumption in September could have accounted for all cases. Three additional restaurants (2 in Washington, 1 in Oregon) that received the same September batch were identified, and leftovers were collected for testing.

Based on this information, investigators decided to visit the cheese production site to assess whether any violations were occurring that might contribute to the contamination of the cheese. Officials of the Washington Department of Agriculture (WDA) and the U.S. Food and Drug Administration (FDA) visited the Sally Jackson facility on December 10, 2010. Sally Jackson was producing raw milk cheeses from its own goats, sheep and cows. Goat cheeses were wrapped in grape leaves, while sheep and cow cheeses were wrapped in chestnut leaves. Both types of leaves were from the trees surrounding the facility. Multiple hygiene violations were identified, including improper handwashing after contact with livestock (before making cheese); kitchen well-water source for food and food surfaces that was not in microbiological compliance; unsanitary non-food areas (e.g., manure on the floor, black mold deposits on the ceiling); suitable outer garments not worn (owner wore manure-soiled clothing during cheese production). Cheeses were unlabeled, and no lot or code numbers had been assigned. The owner was unable to identify the production dates of the cheeses but was able to identify those aged more than 60 days and those less. Employee food handling and hygiene practices were reviewed, potential source of contamination were assessed, and multiple cheese samples were collected for testing.

Despite the fact that no cases could name a specific cheese product and before any laboratory results were available, suspicion was sufficient to take public health actions. Sally Jackson had a limited but multi-state distribution and voluntarily recalled products nationwide on December 20, 2010; FDA released the information to the news media. PFGE-matching E. coli O157 was subsequently cultured on December 20 from raw cheeses collected at the Sally Jackson facility and restaurants.

The bride’s family confirmed that the cheeses served at the wedding had been bought from Sally Jackson, and invoices from the distributor in Minnesota indicated that the 2 Minnesota cases could have been exposed to Sally Jackson products.

Conclusion
Sally Jackson cheeses were the source of this outbreak of E. coli O157:NM.
Though the raw milk could have been contaminated at the timing of milking, direct raw milk contamination also could have occurred as multiple obvious hygiene violations were identified (i.e., improper handwashing, manure-soiled clothing). Additionally, the cheeses could also have been contaminated from the leaves in which they were wrapped. Following the recall, the Sally Jackson facility closed permanently.

Back to Outbreak Exhibits
Salmonella

Salmonella and backyard poultry

Outbreak: Salmonella and backyard poultry
Product: Chicks, chickens, ducks, ducklings
Investigation Start Date: 06/26/15
Location: Multi-state
Etiology: Salmonella Enteritidis, Salmonella Hadar, Salmonella Indiana, Salmonella Muenchen, and Salmonella Muenster
Earliest known case onset date: 01/03/2015
Latest case onset date: 09/07/2015
Confirmed Case Count: 252
Positive Samples: 0
Hospitalizations: 63
Deaths: 0
Outbreak Summary:

In January 2015, a coast to coast outbreak infected 252 people with five different strains of Salmonella infections: Salmonella Enteritidis, Salmonella Hadar, Salmonella Indiana, Salmonella Muenchen, and Salmonella Muenster.

By the end of the outbreak on September 6th, 2015, all but 7 U.S. states had at least one person ill. 63 people were hospitalized but thankfully no one died.

Click the following link to view the CDC outbreak page.
From the Annals of the IOM

Episode 4: Salmonella and Backyard Poultry. Click the play button to view our informational video on this outbreak!

CDC outbreak map.
Epi curve for the outbreak.
The International Outbreak Museum exhibit, next to Bill Keene action figure.