Tag Archives: international outbreak museum iom

Protected: Spiritual Retreat Shigella

March 4, 2015 admin

Outbreak: Lighthouse Retreat Shigella
Product: Never pinpointed
Investigation Start Date: 7/28/2005
Location: Douglas County, OR
Etiology: Shigella
Earliest known case onset date: 07/19/2005
Latest case onset date: 08/06/2005
Confirmed / Presumptive Case Counts: 18 / 262
Positive Samples (Food / Environmental): 0 / 0

Large parking lot and camping area of the spiritual retreat.
Group meals were self-served 3 times each day in a converted barn.
Group meals were self-served 3 times each day in a converted barn.
This large collection of portable toilets and sinks were available to the 750+ campers.
Signage reminder attendees (and presumably food handlers) to wash their hands with soap.
Group meeting during the retreat.
Control measures included keeping sick attendees together in separate rooms while they got well.
Map of the countries involved in this outbreak.

Outbreak Summary:
This outbreak of shigellosis is one the largest Oregon has ever seen with at least 280 cases identified (18 of which were lab-confirmed). • Full outbreak questionnaire (PDF) • Supplemental follow-up questionnaire (PDF) • Epi Curve (JPG)

Details:
A local organic farm and meditation retreat center hosted its annual 16-day retreat in 2005; the ill were among 1,400 people from 38 states and 21 foreign countries who converged on the center between July 22 and August 7. Daily attendance was ~750 people but this fluctuated with people coming and going. Most visitors had been staying for 1 to 4 weeks. The even was organized and executed by volunteers and 20 permanent staff members. Though this is a farm, no animals were kept on site. The group meals (only vegetarian) were prepared in one of two kitchens and consumed in a barn converted into a mess hall. Group meetings and meditation, as well as volunteer work, happened multiple times each day. Attendees camp or bunk on site and there were 55 portable toilets and sinks brought in for the event. We identified 280 persons who met the case definition for shigellosis; 250 saw a clinician and 9 were hospitalized. Many had come from around the world and made closing the camping areas seem like a poor option. Water samples were collected and did not yield positive results; food samples were not available for testing. The source of the outbreak was not found; it is likely that a human carrier working in the food prep or serving area contaminated some food items, which led to point source spikes in the epi curve (“simultaneous” infection, following one or two meals). Once Shigella seeded into this temporary community, it spread through a person-to-person route; difficult hygiene conditions at the center made this a plausible scenario. Putting disease control measures rapidly into place was critical for stopping the outbreak at this mass gathering event.

Details:

A local organic farm and meditation retreat center hosted its annual 16-day retreat in 2005; the ill were among 1,400 people from 38 states and 21 foreign countries who converged on the center between July 22 and August 7. Daily attendance was ~750 people but this fluctuated with people coming and going. Most visitors had been staying for 1 to 4 weeks.

The even was organized and executed by volunteers and 20 permanent staff members. Though this is a farm, no animals were kept on site. The group meals (only vegetarian) were prepared in one of two kitchens and consumed in a barn converted into a mess hall. Group meetings and meditation, as well as volunteer work, happened multiple times each day. Attendees camp or bunk on site and there were 55 portable toilets and sinks brought in for the event.

We identified 280 persons who met the case definition for shigellosis; 250 saw a clinician and 9 were hospitalized. Many had come from around the world and made closing the camping areas seem like a poor option.

Water samples were collected and did not yield positive results; food samples were not available for testing. The source of the outbreak was not found; it is likely that a human carrier working in the food prep or serving area contaminated some food items, which led to point source spikes in the epi curve (“simultaneous” infection, following one or two meals). Once Shigella seeded into this temporary community, it spread through a person-to-person route; difficult hygiene conditions at the center made this a plausible scenario. Putting disease control measures rapidly into place was critical for stopping the outbreak at this mass gathering event.

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salmonella-typhimurium

Cold Stone

March 4, 2015 admin

Outbreak: Cold Stone Cake Batter Ice Cream
Product: Cake Batter Ice Cream
Investigation Start Date: 06/29/2005
Location: Multi-state
Etiology: Salmonella Typhimurium
Earliest known case onset date: 05/21/2005
Latest case onset date: 07/04/2005
Confirmed / Presumptive Case Counts: 25 / 0
Positive Samples (Food): 2

Cold Stone Creamery in Seattle, Washington
Cold Stone Creamery in Seattle, Washington
Bill Keene and Chris Van Beneden outside a Cold Stone Creamery in Seattle, WA
At a store, mix-in ingredients are combined with ice cream to create various customized sundaes and treats.
Melissa Plantega holding a box of cake mix at a Cold Stone Creamery store in Tigard, OR.
Illness onset dates of cases by state of residence.
Traceback results for cake mix used in cake batter ice cream.
Selected Cold Stone Creamery ice cream flavors and ingredients.
Cold Stone Creamery – Tigard, OR: A Cold Stone Creamery store posted this sign on their walk-in cooler.
Gold Medal SuperMoist Yellow Cake Mix.
Cake batter mix ingredients.

Outbreak Summary:
The vehicle for this outbreak was ice cream made with a contaminated cake mix ingredient. Four patients reported eating cake batter flavor ice cream from two separate outlets of Cold Stone Creamery. • Final outbreak questionnaire (PDF) • PubMed.gov publication (Center for Food Safety, University of Georgia)

Details:
Salmonella Typhimurium Outbreak Associated with Cake Batter Ice Cream from Cold Stone Creamery Background On June 29, 2005, the Minnesota Department of Health identified four Salmonella Typhimurium isolates with a pulsed-field gel electrophoresis (PFGE) subtype that was new to the PulseNet national database. Four patients reported eating cake batter flavor ice cream from two separate outlets of Cold Stone Creamery. Methods The PulseNet national database was queried to identify potential cases in other states. A case was defined as infection with an S. Typhimurium isolate that matched the outbreak PFGE pattern, and illness onset since May 2005. All cases were interviewed with a standard questionnaire. State and federal officials conducted a traceback of ice cream ingredients. Results We identified 25 cases in nine states (MN, 5; OR, 5; WA, 5; VA, 3; OH, 2; CA, IL, MA, MI, PA, 1 each); 24 reported eating cake batter ice cream from Chain A. The median age of cases was 13years (range, 2–32 years). The median incubation was 4 days (range, 1–7 days). Illness onset dates ranged from May 21 to July 4; four cases were hospitalized. Cold Stone Creamery voluntarily recalled cake batter ice cream on July 1. This flavor’s ingredients included a pasteurized liquid sweet cream base and Gold Medal Super Moist yellow cake mix. The sweet cream base was used in numerous other ice cream flavors, but the cake mix was used only in cake batter ice cream. The cake mix comprised spray-dried egg whites, flour, and several low-risk components. Tracebacks in Minnesota, Oregon, and Virginia implicated a single lot of cake mix produced on April 14, 2005. No manufacturing anomalies were identified for this lot; but two cake mix samples yielded the outbreak strain of S. Typhimurium. The Food and Drug Administration warned food retailers that cake mixes and flour are not considered “ready to eat” and should be heat processed before consumption. Conclusion The vehicle for this outbreak was ice cream made with a contaminated cake mix ingredient. While the ultimate source of contamination was not confirmed, we recommend a review of the efficacy of spray-drying egg whites as a kill step for Salmonella. Routine and rapid subtyping of bacterial isolates, coupled with a vigorous epidemiological response, is critical to identifying and abating multi-state outbreaks.

Details:

Salmonella Typhimurium Outbreak Associated with Cake Batter Ice Cream from Cold Stone Creamery

Background
On June 29, 2005, the Minnesota Department of Health identified four Salmonella Typhimurium isolates with a pulsed-field gel electrophoresis (PFGE) subtype that was new to the PulseNet national database. Four patients reported eating cake batter flavor ice cream from two separate outlets of Cold Stone Creamery.

Methods
The PulseNet national database was queried to identify potential cases in other states. A case was defined as infection with an S. Typhimurium isolate that matched the outbreak PFGE pattern, and illness onset since May 2005. All cases were interviewed with a standard questionnaire. State and federal officials conducted a traceback of ice cream ingredients.

Results
We identified 25 cases in nine states (MN, 5; OR, 5; WA, 5; VA, 3; OH, 2; CA, IL, MA, MI, PA, 1 each); 24 reported eating cake batter ice cream from Chain A. The median age of cases was 13years (range, 2–32 years). The median incubation was 4 days (range, 1–7 days). Illness onset dates ranged from May 21 to July 4; four cases were hospitalized. Cold Stone Creamery voluntarily recalled cake batter ice cream on July 1. This flavor’s ingredients included a pasteurized liquid sweet cream base and Gold Medal Super Moist yellow cake mix. The sweet cream base was used in numerous other ice cream flavors, but the cake mix was used only in cake batter ice cream. The cake mix comprised spray-dried egg whites, flour, and several low-risk components. Tracebacks in Minnesota, Oregon, and Virginia implicated a single lot of cake mix produced on April 14, 2005. No manufacturing anomalies were identified for this lot; but two cake mix samples yielded the outbreak strain of S. Typhimurium. The Food and Drug Administration warned food retailers that cake mixes and flour are not considered “ready to eat” and should be heat processed before consumption.

Conclusion
The vehicle for this outbreak was ice cream made with a contaminated cake mix ingredient. While the ultimate source of contamination was not confirmed, we recommend a review of the efficacy of spray-drying egg whites as a kill step for Salmonella. Routine and rapid subtyping of bacterial isolates, coupled with a vigorous epidemiological response, is critical to identifying and abating multi-state outbreaks.

Back to Outbreak Exhibits

e-coli-o157

Jack In The Box

March 3, 2015 admin

Outbreak: Jack In The Box Hamburgers
Product: Hamburgers
Investigation Start Date: 01/12/1993
Location: Multi-State Outbreak
Etiology: E. coli O157
Earliest known case onset date: 11/18/1992
Latest case onset date: 02/21/1993
Confirmed / Presumptive Case Counts: 503 / 229
Positive Samples (Food / Environmental): 0 / 0
Hospitalizations: 151
Deaths: 3

Jack In The Box frozen hamburger patties.
Grill with frozen hamburger patties adjacent.
"Do not use" on box of hamburger patties.
Under-cooked Jack In The Box hamburger.

Outbreak Summary:
This was the largest outbreak of E. coli O157 infections ever documented in the United States, and it injected this pathogen—and threats to food safety in general—into popular consciousness. • Associated Bloody Diarrhea and Hemolytic Uremic Syndrome From Hamburgers: The Washington Experience • Hamburger-associated E. coli O157:H7 infection in Las Vegas: hidden epidemic • A cluster of Escherichia coli O157:H7 infections with the hemolytic-uremic syndrome and death in California • Lessons from a large outbreak of Escherichia coli O157:H7 infections

Outbreak Summary:

This was the largest outbreak of E. coli O157 infections ever documented in the United States, and it injected this pathogen—and threats to food safety in general—into popular consciousness.

• Associated Bloody Diarrhea and Hemolytic Uremic Syndrome From Hamburgers: The Washington Experience

• Hamburger-associated E. coli O157:H7 infection in Las Vegas: hidden epidemic

• A cluster of Escherichia coli O157:H7 infections with the hemolytic-uremic syndrome and death in California

• Lessons from a large outbreak of Escherichia coli O157:H7 infections

Details:
On January 12, 1993, a pediatric gastroenterologist notified the Washington State Department of Health (WSDOH) of an increase in emergency department visits for bloody diarrhea and the hospitalization of three children with hemolytic uremic syndrome. Hypothesis-generating interviews suggested exposure at Jack In The Box restaurants, and in a swiftly conducted matched case-control study WSDOH confirmed association of illness with Jack-in-the-Box hamburgers. After news of the Seattle outbreak broke, clusters of bloody diarrhea and lab-confirmed E. coli O157 infections were soon recognized as associated with Jack In The Box hamburgers in California, Nevada and Idaho — an association confirmed by molecular testing by the newly developed Pulsed-Field Gel Electrophoresis (PFGE)method. Observation of cooking methods revealed that hamburgers did not consistently reach internal temperatures lethal for E. coli. Product trace-backs implicated selected lots of hamburgers (picture); culture of uncooked hamburger patties corroborated the epidemiologic findings. (1) Several pivotal public-health initiatives were undertaken in this outbreak's wake: 1. At the time of the outbreak, E. coli O157 infection was reportable in only 12 states. By the end of 1994, 33 states had made it reportable, and by the end of 1996, it was reportable in all but 6 states. 2. The outbreak "broke" the weekend of Bill Clinton's first Presidential inauguration, and it was one of the first exigencies that faced the new administration. Agriculture Secretary Mike Espy proposed sweeping changes to existing regulations regarding beef production, which had required only visual inspection of beef-processing operations. Under the new rules, USDA began testing samples of raw ground beef in 1994 for E. coli O157, which was declared an "adulterant," indicating a zero-tolerance policy for its presence even in uncooked beef; and in 1996 required the risk-reduction system known as "Hazard Analysis & Critical Control Points" (HACCP) in meat-processing establishments. 3. A renewed emphasis on foodborne illness was undertaken at CDC. In 1995, "FoodNet" was initiated to capture detailed data regarding foodborne illnesses systematically and to conduct special studies into their sources. Today, food safety has public health prominence as one of CDC's "Winnable Battles." 4. The Jack In The Box outbreak was the first major use of PFGE -- a new DNA typing technique that could explore relatedness of bacterial isolates. CDC trained and funded state health departments to test bacterial isolates routinely using this method and to report to a centralized system, where widespread but low-level outbreaks could be detected. Today, this "PulseNet" system can be credited with detecting a substantial fraction of recognized foodborne outbreaks. References: 1. Tuttle et al. "Lessons from a large outbreak of Escherichia coli O157:H7 infections: insights into the infectious dose and method of widespread contamination of hamburger patties."

Details:

On January 12, 1993, a pediatric gastroenterologist notified the Washington State Department of Health (WSDOH) of an increase in emergency department visits for bloody diarrhea and the hospitalization of three children with hemolytic uremic syndrome.

Hypothesis-generating interviews suggested exposure at Jack In The Box restaurants, and in a swiftly conducted matched case-control study WSDOH confirmed association of illness with Jack-in-the-Box hamburgers.

After news of the Seattle outbreak broke, clusters of bloody diarrhea and lab-confirmed E. coli O157 infections were soon recognized as associated with Jack In The Box hamburgers in California, Nevada and Idaho — an association confirmed by molecular testing by the newly developed Pulsed-Field Gel Electrophoresis (PFGE)method.

Observation of cooking methods revealed that hamburgers did not consistently reach internal temperatures lethal for E. coli. Product trace-backs implicated selected lots of hamburgers (picture); culture of uncooked hamburger patties corroborated the epidemiologic findings. (1)

Several pivotal public-health initiatives were undertaken in this outbreak's wake:

1. At the time of the outbreak, E. coli O157 infection was reportable in only 12 states. By the end of 1994, 33 states had made it reportable, and by the end of 1996, it was reportable in all but 6 states.

2. The outbreak "broke" the weekend of Bill Clinton's first Presidential inauguration, and it was one of the first exigencies that faced the new administration. Agriculture Secretary Mike Espy proposed sweeping changes to existing regulations regarding beef production, which had required only visual inspection of beef-processing operations. Under the new rules, USDA began testing samples of raw ground beef in 1994 for E. coli O157, which was declared an "adulterant," indicating a zero-tolerance policy for its presence even in uncooked beef; and in 1996 required the risk-reduction system known as "Hazard Analysis & Critical Control Points" (HACCP) in meat-processing establishments.

3. A renewed emphasis on foodborne illness was undertaken at CDC. In 1995, "FoodNet" was initiated to capture detailed data regarding foodborne illnesses systematically and to conduct special studies into their sources. Today, food safety has public health prominence as one of CDC's "Winnable Battles."

4. The Jack In The Box outbreak was the first major use of PFGE -- a new DNA typing technique that could explore relatedness of bacterial isolates. CDC trained and funded state health departments to test bacterial isolates routinely using this method and to report to a centralized system, where widespread but low-level outbreaks could be detected. Today, this "PulseNet" system can be credited with detecting a substantial fraction of recognized foodborne outbreaks.

References: 1. Tuttle et al. "Lessons from a large outbreak of Escherichia coli O157:H7 infections: insights into the infectious dose and method of widespread contamination of hamburger patties."

Back to Outbreak Exhibits