County of Sacramento's Report On Mulvaney's Outbreak 5-22-2013

Page 1 5/22/2013
Sacramento County, DHHS, Public Health Division

F I NAL REPORT: NOROVI RUS
OUTBRE A K ASSOCI AT ED WI T H A
REST AURANT
Cassius Lockett, Ph.D., Olivia Kasirye MD, Karen Collins,
PHN, Nikolay Yurashku, and June Nash, PHN
P D F a i d . C o m
# 1 P d f S o l u t i o n s
Page 2 5/22/2013
NOROVI RUS OUTBRE A K ASSOCI AT ED WI T H A REST AURANT
Cassius Lockett, Ph. D., Olivia Kasirye MD, Agnes Norman, PHN, Karen Collins, PHN and June Nash, PHN
I NTRODUCTI ON:
The following is a report of the outbreak investigation conducted by the Sacramento County
Disease Control and Epidemiology Unit (DCEU), Environmental Management Department (EMD)
and Public Health Laboratory following reports of acute gastroenteritis among patrons who ate dinner
at Mulvaney`s restaurant on Friday February 22, 2013, Saturday February 23, 2013, Monday February
25, 2013 or Tuesday February 26, 2013. Over the time span a total of 138 patrons and at least 6 food
service workers complained of either nausea, vomiting, fatigue, abdominal cramps or diarrhea. One of
the patrons tested positive for Norovirus strain GI on Monday March 4, 2013. Two food service
workers tested positive for Norovirus GI on March 5, 2013 and March 8, 2013.
Setting
On Thursday February 28
th
, EMD was contacted by the lawyer representing Mulvaney`s
restaurant stating that the restaurant had received a number of calls from patrons who had fallen ill
with gastrointestinal symptoms after eating at the restaurant. DCEU received a call from EMD to
contact an ill patron who consumed Iood at Mulvaney`s restaurant. The patron had subsequently
sought medical care at an Urgent Care Center. An outbreak investigation was launched by DCEU. A
foodborne illness line list was created with 22 patrons who had reported illness. The investigation
included patrons that had consumed food at a total of 6 events on 4 separate dates.
ME T HOD OF I NVESTI GATI ON
The investigation consisted of the following steps:
Interviews of patrons who attended the 6 events on 4 days.
Interviews oI ill Iood service workers at Mulvaney`s.
Site inspection of the restaurant and food handling training of food service workers by
EMD.
Laboratory analysis of clinical specimens.
Food analysis.
Laboratory Specimen Analysis:
One specimen was submitted to the public health laboratory (PH Lab) from an ill patron on
March 1, 2013. Subsequently, two additional specimens were submitted from ill food service workers
on March 4, 2013 and March 5, 2013. For all specimens submitted preliminary analysis of the data
indicate a viral source.
All specimens were tested at the PH Lab for bacterial agents, and for norovirus. Results for all
specimens were negative for bacterial agents (salmonella, shigella, campylobacter and E coli
O157:H7). Results were positive for Norovirus on March 4, 2013 (patron), March 5, 2013 (food
service worker) and March 8, 2013 (food service worker). Samples were sent to the State VRDL (Viral
& Rickettsial Disease Lab) for confirmation. Results revealed that all specimens were positive for
norovirus GI.
Page 3 5/22/2013
Epidemiology:

The epidemiology unit used a case-control study design to investigate the source of illness. The
information technology department of the restaurant provided menus and patron guest lists for each
event. A questionnaire, electronic data entry screen and database was generated using Epi-Info 6.04d
(DOS version).

Statistical analysis was performed using Epi-Info and subsequently analyzed in SAS to adjust
for zero in 2x2 cells using a correction factor by applying 0.5 to all cells
2
. Clinical characteristics and
food histories were ascertained. A total of 224 interviews were entered into the study.

Case Definition

Case Definition for Mulvaney`s (Case-Control Study)

True case:

In this investigation an true case is defined as a person who tested positive for Norovirus via
RT-PCR who: (1) was present and consumed Iood at Mulvaney`s restaurant between Friday February
22, 2013 and Tuesday February 26, 2013 (2) or was a food service worker that worked at Mulvaney`s
and (3) who had at least one or more of the following symptoms; nausea, vomiting, fatigue, diarrhea,
abdominal cramps, chills, or headache at the time period between consuming food at the restaurant and
the time of the interview.

Probable case:

In this investigation a probable case is defined as a person who : (1) was present and consumed
Iood at Mulvaney`s restaurant between Friday February 22, 2013 and Tuesday February 26, 2013 (2)
or was a food service worker that worked at Mulvaney`s and (3) who had at least one or more oI the
following symptoms; nausea, vomiting, fatigue, diarrhea, abdominal cramps, chills, or headache at the
time period between consuming food at the restaurant and the time of the interview.

Controls:
In this investigation a control is defined as a person who : (1) was present and consumed food at
Mulvaney`s restaurant between Friday February 22, 2013 and Tuesday February 26, 2013 (2) or was a
Iood service worker that worked at Mulvaney`s and (3) did not report any gastrointestinal symptoms or
fever.

Timeline of investigation:

The following is a summary of the major events in the investigation:

February 22
nd
Family style dinner (68 patrons, 43 ill)
February 22
nd
Company dinner (6 ill patrons)
February 23
th
February 25
th
Page 4 5/22/2013
February 25
th
Special Event dinner (27 patrons, 7 ill)
February 26
th
February 28
th
- EMD received complaints of illness from patrons
February 28
th
-Public Health Notified by EMD of complaints of illness
March 1
st
- Public Health staff conducted screening interviewed among patrons
March 1
st
-Specimen collected from ill patron submitted for testing
March 1
st
-Restaurant inspected by EMD
March 4
th
-Patron specimen positive for Norovirus GI
March 4
th
-Specimen collected from ill food service worker submitted for testing
March 5
th
- Food service worker specimen positive for Norovirus GI
March 5
th
-10 specimen kits delivered to Mulvaney`s Ior Iood service worker testing
March 8
th
-2
nd
Food service worker specimen positive for Norovirus GI
March 20Sacramento Bee reported outbreak. Link to article:
http://www.sacbee.com/2013/03/19/5276413/sacramento-county-probes-possible.html
March 20
th
Patrons notified Public Health of additional outbreaks that occurred on the following:
Friday February 22, 2013, 5 reports of illness
Wednesday February 27, 2013, 2 reports of illness
Monday February 25, 2013 (Special Event Dinner; previously no reported illness), 3
reports of illness
February 27, 2013, Company Luncheon (no patrons agreed to be interviewed resulting
in this cohort being eliminated from the analysis)
March 13
th
March 22
nd
256 patron interviews completed by Public Health staff.
March 22
nd
March 28
th
Database creation and data entry completed by epidemiology.
March 29
th
March 31
st
Data analysis and report writing initiated by epidemiology.
April 1
st
Draft report completed and submitted for review.
RESUL TS
Mulvaneys Interviews:
A total of 256 Mulvaneys patrons were interviewed. A total of 32 surveys were excluded due to
missing information. A total of 224 surveys were entered into the study. The age range for all events
was 18 to 80 years. The median age for cases and controls was 46.0 years; the median age for cases
was 44.0 years and the median age for controls was 48.0 years. Amongst all of the ill patrons who
dined at Mulvaney`s restaurant for all events 52.4% were female and 47.6% were male. Of the cases,
54.3% were female and 45.7% were male. Of the controls, 49.4% were female and 50.6% were male.
Of the 140 reported cases of illness, 2 were excluded because they did not meet the case
deIinition oI a probable case. The attack rate Ior all events held at Mulvaney`s amongst all patrons that
were interviewed was 61.6% (138 cases). Of the 138 cases, 126 (91.3%) complained of nausea, 114
(82.6%) complained of fatigue, and 105 (76.1%) complained of diarrhea (See Table 1). Sixty-seven
(51.2%) of the cases reported that their primary symptom was nausea.
Table 1: Overall Distribution of Symptoms
Symptoms Number % Of Cases
Nausea 126 91.3%
Page 5 5/22/2013

Onsets of illnesses for cases occurred over a period of 7 days from Friday, February 22, 2013 to
Thursday February 28, 2013. The first peak (81 cases; excludes 2 food service workers) occurred from
Saturday, February 23
rd
, to Monday, February 25
th
(See Figure 1). The second peak (35 cases)
occurred on Wednesday, February 27
th
. Duration of illness ranged from 1 to 201 hours, with a median
of 36.0 hours.
Figure 1: Epidemic Curve from Outbreak of Norovirus G1
Associated with Eating at Mulvaney's Restaurant, February 22,
2013 to February 27, 2013 (N=138 patrons, N=2 food service
workers)
0
3
6
9
12
15
18
21
24
27
30
33
36
39
2/21 2/22 2/23 2/24 2/25 2/26 2/27 2/28 3/1
Day of Onset
N
u
m
b
e
r

o
f

C
a
s
e
s

White-indicates probable cases that consumed food at Mulvanevs from Feb. 22 to Feb 26.
Yellow-indicates laboratory confirmed food service worker
Blue-indicates laboratory confirmed patron.

Food Analysis:

Attack rates for all events were calculated for each food item (See Table 2). Food-specific attack
rates were also calculated for each event separately. The table below shows pooled results from
multiple events. As a result not all patrons had equal exposure. This is a limitation of the table below
and therefore results should be interpreted with caution.
Of all the foods analyzed Turkish coffee pudding, pickled beet salad, grilled eggplant, ham, lamb
and Yukon potatoes were significantly statistically associated with the risk of developing illness
Fatigue 114 82.6%
Diarrhea 105 76.1%
Vomiting 102 74.0%
Abdominal Cramps 100 72.5%
Chills 96 69.6%
Muscle aches 83 60.1%
Headache 80 58.0%
Dizziness 62 44.9%
Fever 54 39.1%
Page 6 5/22/2013
(p=<0.05). Consumption of Turkish coffee pudding showed the greatest risk, followed by pickled beet
salad, ham and lamb (OR=3.7; OR=3.4; OR=3.1; OR=2.9).
Of all the foods analyzed rib eye and pasta and mushrooms were significantly statistically
associated with a decreased risk of developing illness (p=<0.05). Consumption of pasta and
mushrooms provided the most protection against developing illness, followed by rib-eye (OR=0.3;
OR=0.4).

Table 2: Overall Food Specific Attack Rates. Mulvaney`s.
Food Item
Exposed Non-exposed
Odds
Ratio
Lower
95% C.I.
Upper
95% C.I.
P Value
N % Ill N % Ill
Turkish Coffee
Pudding
42 83.3 179 57.5 3.7
1.6 8.8
0.00
Pickled Beet
Salad
33 82.5 181 58.0 3.4
1.4 8.1
0.00
Ham 33 81.8 188 59.0 3.1 1.1 8.8 0.01
Lamb 49 80.0 100 58.1 2.9 1.3 6.1 0.5
Yukon Potatoes 41 78.0 180 58.5 2.5 1.2 5.5 0.02
Rib-eye 52 44.2 169 68.0 0.4 0.2 0.7 0.00
Pasta and
Mushrooms
28 39.2 193 65.8 0.3
0.2 0.8
0.00

Family Style Dinner on February 22, 2013

A total of 68 patron interviews qualified for analysis. The age range for this group was 22 to
80 years. The median age for cases and controls was 40.0 years; the median age for cases was 36.5
years and the median age for controls was 53.0 years. Among this group, 47.1% were female and
52.3% were male. Of the cases, 51.2% were female and 48.8% were male. Of the controls, 40.0%
were female, and 60.0% were male.

The attack rate among the attendees that were interviewed was 63.2% (43 cases). Of the cases,
40 (97.6%) complained of nausea, 16 (80.0%) complained of headache, and 15 (75.0%) complained of
abdominal cramps (See Table 3). Thirteen cases (65.0%) reported that their primary symptom was
nausea.

Table 3: Distribution of Symptoms. February 22, 2013 Dinner
Nausea 40 97.6%
Vomiting 38 92.7%
Diarrhea 33 80.5%
Chills 32 78.1%
Fatigue 32 78.1%
Muscle Aches 30 73.2%
Page 7 5/22/2013

Onset of illnesses occurred over a period of 3 days from Friday February 22
nd
to Sunday
February 24
th
. The peak (41 cases) occurred on Saturday, February 23
rd
until Sunday February 24
th

(See Figure 2). Duration of illness ranged from 1 to 72 hours, with a median of 24 hours.

Figure 2: Epidemic Curve from Outbreak of Norovirus G1 Associated
with Eating at Mulvaney's Restaurant, February 22, 2013 (N=43)
0
3
6
9
12
15
18
21
24
2/21 2/22 2/23 2/24 2/25
Day of Onset
N
u
m
b
e
r

o
f

C
a
s
e
s

Attack rates for all events were calculated for each food item (See Table 4). Of all the foods
analyzed, Turkish coffee pudding, chocolate cake, wine and salmon were significantly statistically
associated with the risk of developing illness (p=<0.05). Turkish coffee pudding and chocolate cake
showed the greatest risk, followed by wine (OR=11.1; OR=11.1; OR=4.1).
Of all the foods analyzed Southside aquaponics salad was not associated with a risk of developing
illness (OR=0.08; p=<0.00). .

Table 4: February 22, 2013 Dinner. Food Specific Attack Rates

Dizziness 24 58.6%
Fever 21 51.2%
Headache 18 43.9%
Page 8 5/22/2013
Food Item
Exposed Non-exposed
Odds
Ratio
Lower
95% C.I.
Upper
95% C.I.
P Value
N % Ill N % Ill
Turkish Coffee
Pudding
14 92.9 52 53.8 11.1
1.4 91.5
0.00
Chocolate Cake 14 92.9 52 53.8 11.1 1.4 91.5 0.00
Wine 35 77.1 31 45.1 4.1 1.4 11.8 0.00
Salmon 23 78.3 43 53.5 3.1 1.0 9.9 0.05
Southside
Aquaponics Salad
7 14.3 59 67.8 0.08
0.01 0.7
0.00
Company Dinner on February 22, 2013
A total of 6 patron interviews qualified for analysis. The age range for this group was 29 to 64
years. The median age for cases and controls was 42.0 years; the median age for cases was 42.0 years
and the median age for controls was 42.0 years. Among this group, 57.1% were female and 42.9%
were male. Of the cases, 57.1% were female and 42.9% were male. Of the controls, 57.1% were
female, and 42.9% were male.
The attack rate among the attendees that were interviewed was 100% (6 cases). Of the cases, 6
(100.0%) complained of nausea, 6 (100.0%) complained of fatigue and 5 (83.3%) complained of
diarrhea (See Table 5). All six cases reported nausea as their primary symptom.
Onset of illnesses occurred over a period of 2 days from Saturday, February 23
rd
to Sunday,
February 24
th
(See Figure 3). Duration of illness ranged from 24 to 48 hours, with a median of 30
hours.
Nausea 6 100.0%
Fatigue 6 100.0%
Diarrhea 5 83.3%
Chills 5 83.3%
Vomiting 4 66.7%
Dizziness 4 66.7%
Fever 4 66.7%
Headache 3 50.0%
Page 9 5/22/2013
with Eating at Mulvaney's Restaurant.
Company Dinner, February 22, 2013 (N=6)
0
3
6
2/22 2/23 2/24 2/25
Day of Onset
N
u
m
b
e
r

o
f

C
a
s
e
s

Since there were no controls for this event, no attack rates for food items were calculated.



31 (81.6%) complained of nausea, 31 (81.6%) complained of fatigue and 29 (76.3%) complained of
diarrhea (See Table 3). Nine cases (26.5%) reported that their primary symptom was vomiting.


Nausea 31 81.6%
Fatigue 31 81.6%
Diarrhea 29 76.3%
Headache 24 63.2%
Chills 23 60.5%
Dizziness 14 36.8%
Fever 12 31.6%
Page 10 5/22/2013
Onset of illnesses occurred over a period of 3 days from Sunday February 24
th
to Tuesday
February 27
th
. The peak (22 cases) occurred on Monday, February 25
th
(See Figure 5). Duration of
illness ranged from 6 to 120 hours, with a median of 36 hours.
with Eating at Mulvaney's Restaurant, Family Style Dinner on
February 23, 2013 (N=38)
0
3
6
9
12
15
18
21
24
2/23 2/24 2/25 2/26 2/27
Day of Onset
N
u
m
b
e
r

o
f

C
a
s
e
s

Attack rates were calculated for each food item (See Table 7). Of all the foods analyzed salmon,
and bread showed the greatest risk (OR=5.5) and were statistically significantly associated with the
risk of developing illness (p=<0.05). Potato and garlic soup was not associated with a risk of
developing illness (OR=0.04; p=<0.00).
Food Item
Exposed Non-exposed
Odds
Ratio
Lower
95% C.I.
Upper
95% C.I.
P Value
N % Ill N % Ill
Salmon 21 90.4 30 63.3 5.5 1.1 28.2 0.03
Bread* 21 90.4 30 63.3 5.5 1.1 28.2 0.03
Potato and Garlic
Soup
9 22.2 42 85.7 0.04
0.01 0.28
0.00
*Item associated with Smoked Salmon selection
Page 11 5/22/2013
30 (90.9%) complained of nausea, 28 (84.9%) complained of fatigue, 24 (72.7%) complained of chills
and 23 (69.7%) complained of vomiting (See Table 8). Eighteen cases (56.3%) reported that their
primary symptom was nausea.
Onset of illnesses occurred over a period of 4 days from Tuesday February 26
th
to Friday
March 1
st
. The peak (24 cases) occurred on Wednesday, February 27
th
Nausea 30 90.9%
Fatigue 28 84.9%
Chills 24 72.7%
Vomiting 23 69.7%
Diarrhea 23 69.7%
Headache 23 69.7%
Dizziness 14 42.4%
Fever 9 27.3%
Page 12 5/22/2013
0
3
6
9
12
15
18
21
24
27
2/25 2/26 2/27 2/28 3/1 3/2
Day of Onset
N
u
m
b
e
r

o
f

C
a
s
e
s

Attack rates for each food item were calculated (See Table 9). Of all the foods analyzed
consumption of pickled beet salad, walnuts (salad ingredient), Yukon potatoes (associated with roasted
Dixon lamb) and grilled eggplant (associated with eggplant gratin) were statistically significantly
associated with the risk of developing illness (p=<0.05). Pickled beet salad and walnuts showed the
greatest risk, followed by Yukon potatoes (OR=18.3; OR=8.9; OR= 8.3).
Food Item
Exposed Non-exposed
Odds
Ratio
Lower
95% C.I.
Upper
95% C.I.
P Value
N % Ill N % Ill
Pickled Beet
Salad
39 82.1 5 20.0 18.3
1.8 189.6
0.00
Walnuts* 38 81.6 6 33.3 8.9 1.3 58.3 0.01
Yukon Potatoes 36 83.3 8 37.5 8.3 1.6 44.6 0.00
Eggplant 30 86.7 14 50.0 6.5 1.5 28.7 0.01
*Ingredients in the Pickled Beet Salad
Special Event Dinner on February 25, 2013
Page 13 5/22/2013
The attack rate among the attendees that were interviewed was 26.0% (7 cases). Of the cases, 6
(85.7%) complained of nausea and abdominal cramps, 5 (71.4%) complained of diarrhea and fatigue,
and 3 (42.9%) complained of vomiting (See Table 10). Three cases (42.9%) reported that their
primary symptom was abdominal cramps.
Table 10: Distribution of Symptoms. Special Event Dinner February 25, 2013
Onset of illnesses occurred over a period of 4 days from Tuesday February 26
th
to Friday
March 1
st
. The peak (6 cases) occurred on Tuesday, February 26
th
and Wednesday, February 27
th
(See
Figure 6). Duration of illness ranged from 4 to 96 hours, with a median of 72 hours.
with Eating at Mulvaney's Restaurant, Special Event Dinner,
February 25, 2013 (N=7)
0
3
6
2/24 2/25 2/26 2/27 2/28 3/1 3/2 3/3
Day of Onset
N
u
m
b
e
r

o
f

C
a
s
e
s

Attack rates were calculated for each food item (See Table 11). A smaller menu was offered at the
special event dinner. The main dishes included smoked salmon, pasta and mushrooms, filet mignon,
carrot spaetzel and grilled eggplant. Of all the foods analyzed eggplant was the only food item
statistically associated with the risk of developing illness (OR= 17.7; p=<0.05). The confidence
Nausea 6 85.7%
Diarrhea 5 71.4%
Fatigue 5 71.4%
Vomiting 3 42.9%
Headache 3 42.9%
Chills 3 42.9%
Dizziness 2 28.6%
Fever 2 28.6%
Page 14 5/22/2013
interval for eggplant however includes 1.0. This means that this data should be interpreted with
caution (See Table 11.)
Table 11: Special Event Dinner February 25, 2013. Food Specific Attack Rates
Food Item
Exposed Non-exposed
Odds
Ratio
Lower
95% C.I.
Upper
95% C.I.
P Value
N % Ill N % Ill
Eggplant 2 100.0 24 20.8 17.7 0.7 426.5 0.02
13 (100.0%) complained of nausea, 12 (92.3%) complained of vomiting and fatigue, 10 (76.9%)
complained of diarrhea and abdominal cramps and 9 (69.2%) complained of headache and chills (See
Table 12). Five cases (45.5%) reported that their primary symptom was vomiting.
Onset of illnesses occurred over a period of 2 days from Wednesday February 27
th
to Thursday
February 28
th
. The peak (8 cases) occurred on Wednesday, February 27
th
Nausea 13 100.0%
Vomiting 12 92.3%
Fatigue 12 92.3%
Diarrhea 10 76.9%
Headache 9 69.2%
Chills 9 69.2%
Fever 6 46.2%
Dizziness 4 30.8%
Page 15 5/22/2013
0
3
6
9
2/26 2/27 2/28 3/1
Day of Onset
N
u
m
b
e
r

o
f

C
a
s
e
s

Attack rates for each food item were calculated (See Table 13). Of all the foods analyzed
consumption oI pickled beet Carpaccio salad and it`s ingredients including but not limited to cilantro,
spicy pecans and Bartlett pears were statistically significantly associated with the risk of developing
illness (p=<0.05). A smaller number of respondents remembered consuming the ingredient of the
pickled beet Carpaccio salad. This may explain why the odds are higher than those who responded to
consuming the salad. Regardless, the ingredients showed the greatest risk, followed by the salad
(OR=16.3; OR=16.3; OR= 16.3; OR=9.0).
Food Item
Exposed Non-exposed
Odds
Ratio
Lower
95% C.I.
Upper
95% C.I.
P Value
N % Ill N % Ill
Pickled Beet
Carpaccio Salad
12 75.0 16 25.0 9.0
1.6 50.7
0.01
Cilantro* 8 87.5 20 30.0 16.3 1.6 163.4 0.01
Spicy Pecans* 8 87.5 20 30.0 16.3 1.6 163.4 0.01
Bartlett Pears* 8 87.5 20 30.0 16.3 1.6 163.4 0.01
*Ingredients in the Pickled Beet Carpaccio Salad
Page 16 5/22/2013
DISCUSSI ON:
A variety of foods contributed to patron illness. Of the foods served at multiple events, salad
with beets, Turkish coffee pudding, Salmon, eggplant, and Yukon potatoes had the highest probability
of association with illness as demonstrated by the significantly high odds ratios.
The epidemic curves for each event and the isolation of GI Norovirus (rare strain) in at least one patron
and two restaurant employees strongly suggests a single source contamination. The data strongly
suggest that ill food handlers who prepared, served or plated the food at the different events may have
contaminated the food. At least six food-service workers at Mulvaney`s restaurant reported illness
during the week of February 17, 2013 to February 24, 2013. Ill food service workers may have also
contaminated the restaurant bathrooms possibly increasing environmental contamination and
transmission of the Norovirus. No index case was identified in the investigation.
It is interesting to note that some dishes including rib-eye, mushrooms & pasta, Southside Aquaponics
salad and potato and garlic soup were not associated with a risk of illness. A possible explanation is
that these dishes were prepared, plated or served by non-ill food service workers.
Noroviruses are the leading cause of gastroenteritis outbreaks in the United States
3
.
Noroviruses belong to a family of viruses called Caliciviridae and can be grouped into five genogroups
which are GI through GV
4
. Norvirus has a single-stranded RNA genome -7.5 kb long
5
. Noroviruses
are highly infectious and only a few viral particles (3-10) can cause acute gastroenteritis
3
. Laboratory
characterization and classification of noroviruses are based upon reverse transcriptase polymerase
chain reaction (RT)-PCR and genomic sequencing
5
. Of the five genogroups, GI and GII infect
humans and GII4 has recently been the most widely circulating strain in the world over the past 10
years, responsible for at least 70% of all outbreaks
4
.
Norovirus can be transmitted person-to-person by the fecal-oral route and spread through contaminated
airborne droplets, food, water, environmental surfaces, and fomites. It has been estimated that 50% of
all norovirus outbreaks are linked to ill food-service workers
6
.
RE COMMENDATI ONS:
The following recommendations were made to the restaurant owner:
1. Review of food handling techniques and sanitary measures such as diligent hand washing.
Diligent hand washing with antibacterial soap and hot water is most effective against
Norovirus.
2. Review of policies for ill food service workers returning to work and food handling. Ill
employees are to be excluded from work until they have been symptom free for at least 48
hours.
3. Education regarding cross contamination of food should also be reviewed.
4. Review protocols for Iood temperature and proper engineer`s controls to minimize
environmental contaminants.
Page 17 5/22/2013
RE F ERENCES:
1. Bad Bug Book. U.S. Food & Drug Administration. Center for Food Safety & Applied Nutrition
Foodborne Pathogenic Microorganisms and Natural Toxins Handbook.
http://www.cfsan.fda.gov/~mow/intro.html.
2. Cochrane collaboration: Statistical methods programmed in metaview: Review manager help
version 4.1, 2000. 'Where zero cells cause problems with computation of effects or standard
errors, 0.5 is added to all cells (ai, bi, ci, di) for that study, except when ai=ci=0 or bi=di=0,
when the relative effect measures Ori and Rri are undeIined.
3. Teunis, P. F.M., Moe, C. L., Liu, P., E. Miller, S., Lindesmith, L., Baric, R. S., Le Pendu, J. and
Calderon, R. L. (2008), Norwalk virus: How infectious is it?. J. Med. Virol., 80: 14681476.
doi: 10.1002/jmv.21237
4. Notes from the Field: Emergence of New Norovirus Strain GII.4 Sydney-United States, 2012.
Morbidity and Mortality Weekly Report (MMWR), January 25, 2013;62(03);55-55.
5. Papaventsis DC, Dove W, Cunliffe NA, Nakagomi O, Combe P, Grosjean P, et al. Norovirus
infection in children with acute gastroenteritis, Madagascar, 20042005. Emerg Infect Dis
[serial on the Internet]. 2007 Jun [date cited]. Available from
http://wwwnc.cdc.gov/eid/article/13/6/07-0215.htm
6. Widdowson M-A, Sulka A, Bulens S, et al. Norovirus and foodborne disease, United States,
1991--2000. Emerg Infect Dis 2005;11:95--102.
GL OSSARY OF T ERMS
Case-Control study: An analytical study which compares individuals who have a specific disease
("cases") with a group of individuals without the disease ("controls"). The proportion of each group
having a history of a particular exposure or characteristic of interest is then compared. An association
between the hypothesized exposure and the disease being studied will be reflected in a greater
proportion of the cases being exposed. It is advantageous for the controls to come from the same
population from which the cases were derived, to reduce the chance that some other difference
between the groups is accounting for the difference in the exposure that is under investigation. A case-
control study generally depends on the collection of retrospective data, thus introducing the possibility
of recall bias. Recall bias is the tendency of subjects to report events in a manner that is different
between the two groups studied. People who have a disease may be more likely to remember
exposures more readily than those without the disease.
Odds Ratio: A measure of association between an exposure and an outcome. It represents the odds
that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring
in the absence of that exposure. Odds ratios are most commonly used in case-control studies, however
they can also be used in cross-sectional and cohort study designs as well (with some modifications
and/or assumptions).
Page 18 5/22/2013
Attack rate: A special incidence rate used in investigations of disease outbreaks. New cases are
counted in the numerator and the denominator is the population at risk at the beginning of the outbreak.
Epidemic curve: A graph in which the number of new cases of a disease is plotted against an interval
of time to describe a specific epidemic or outbreak
Fomites: An inanimate object (as a dish, toy, book, doorknob, or clothing) that may be contaminated
with infectious organisms and serve in their transmission.
I ndex Case: The earliest/ primary/ initial documented case of a disease included in an epidemiologic
study.
L M D
M 8 L I I S
Timelineofthemajoreventsintheinvestigation:
February28,2013:Twoseparatefoodborneillnesscomplaintsreceived.
March1,2013:OnsiteinvestigationoffoodborneillnesscomplaintsconductedbyKariWagner,ESIII.
March12,2013:AnonsiteconsultationwasconductedbyKariWagner,ESIIIandColleenMaitoza,
SupervisingEStodiscusssanitizationofthefacility.
Summaryofthemajoreventsintheinvestigation:
February28,2013
CO0045859
Complaint:
Complainantsstatetheybecameillwithnausea,vomiting,abdominalcramps,diarrheaandheadaches
aftereatingarugulasaladswithbeetsandgoatcheese,figcakewithcream,asparaguscheesepasta,
braisedlambwithpotatoes,eggplantparmesanandicewater.Complainantsateatfacilityon2/25/13
between79pmandbecameillthemorningof2/27/13.
March1,2013
Onsiteinvestigation:
ExecutiveChef(Chef)wasonsiteandstatedhewasawareofthecomplaint.Hestatedthatafterthey
receivedthecomplaint,theyreviewedallfooditems,talkedwithstaff,andreviewedallofthefood
handlingprocesses.PerChef,noemployeeshavecalledinsickinthelastweek.Hestatedthatone
employeewasoutsickaround2/16/13,wenttothedoctor,anddidnotcomebackuntilclearedbythe
doctor.Thissameemployeefeltsickonedaylater,wentbacktothedoctoranddidnotcomebackuntil
theywereagainclearedbythedoctor.ThisemployeeisnotresponsibleforfoodhandlingperChef.Chef
statedthattherehavebeennodisruptionsinhotwater,refrigerationhasbeenfunctioning,theytake
temperaturelogsforthewalkin,theyhavenotexperiencedanysewagebackups,andthedishmachine
istesteddaily.Thefoodconsumedonthisdaywasapartoftheirfamilystyledinnerheldinthebanquet
room.Foodismadeinkitchen,placedinchafingdishes,andbroughttobanquetroom.
EnvironmentalManagementDepartment(EMD)wasunawareoftheunpermittedbanquetroom.Hand
washstationsarenotavailableinthebanquetroom,fiverestroomswithhandwashingareavailable,
andobservedtwobarareaswithnohandsinks.KariWagner,ESIIIobtainedphotographic
documentationofthebanquetareaduringtheinspection.Mulvaneyswasorderedtonotconductfood
preparation(includingbeveragesatthebar)intheBanquetarea.Foodmaybeplatedinsidethe
permittedfacilityandbroughttothebanquetareaandimmediatelyserved.
Arugulasalad:containsarugula,beets,goatcheese,andcitrusvinaigrette.Allitemsdeliveredfrom
ProduceExpressdaily.Perchef,arugulaisprewashed>washedagain>placedinthewalkin.The
beetsarewashed>roastedw/orangezest,staranise,fennelandwater>cooled>peeled>sliced>
pickledinabrineandplacedintherefrigeratoruntilused.Thedressingismadewithfreshlemonjuice,
oliveoil,shallots,salt/pepperandismadedaily.
Page 19
3/22/2013
Figcakewithcream:containsdriedfigsthatarereconstituted,butter,eggs,heavycream,flour,sugar,
bakingsodaandpowder,salt.Theitemsaremixedandbaked.Thenacreammadefromcreamand
sugarisplacedinabowlontheside.MostingredientsarefromTony'sfinefoodsandItalfoods.The
vanillaisfromPacificRimGourmet.
BraisedLambw/potatoes:containslambandroastedpotatoes.Awholelambisdeliveredfreshfrom
PreferredMeatsonlywhenorderedspecifically.Temperaturesofdeliveriesarenottakenperchef.The
lambisplacedinthewalkin,butchered,grilledwithsaltandpepper,allowedtorest,carvedandplaced
inchaffingdishes.
Theyukonpotatoesaredeliveredfromproduceexpress,theyarenotwashed,andareroastedwithsalt,
pepperandoliveoil.
EggplantGratin:containseggplant,marinarasaucethatarebothalternatedthenitistoppedwitha
bechamelsauceandcheeseandcooked.Themarinarasaucecontainscannedstewedtomatoes,
shallots,freshherbs,andgarlic.AllfoodforthisdishisdeliveredbyProduceExpress.Thebechamel
saucecontainscream,butter,nutmeg,flour,saltandpepper.AlldairyisdeliveredfromCrystalDairy.
ThecheesespecorinoandgranaaredrycheesesthataredeliveredbyItalfoods.
AsparagusCheesePasta:containsasparagus,housemadepasta,anddrycheese.Theasparagusis
purchasedfromProduceExpress.Asparagusissauteedinbutter,garlic,shallots,saltandpepper,then
addedtobutteredpastaandcheeseissprinkledontop.Thepastaismadefromflour,butter,oiland
water.TheoilisfromItalfoods,theeggsarefromCrystalandtheflourisfromPacificGourmet.The
fiscalinicheeseispurchasedfromItalfoods.
Observations:
Walkin:rawporkandrawchicken43Fwithwalkinobservedtobeveryfull.Ambientairtemperaturein
middleofwalkinat39F.
2doorstandup:creamintwodifferentcontainers43F/44Fandshelleggsat46F.Ambientair
temperatureinunitat39F.
Allhandsinksstockedandaccessible.
Hotwaterat3compsink:146F.
Dishmachine:washcycle119Fand50ppm.
Sanitizerbucketinfrontprepareaat200ppmQA.
PerChef,allofthebeetsalad(alsocalledBeetcarpacciosalad)wasconsumedonthisdateandanynew
saladsweremadeonthenextdaybyadifferentemployee.
February28,2013
CO0045862
Complaint:
Complainantstatesthatsixpeoplebecameillwithnausea,vomiting,anddiarrheaaftereatingarugula
saladswithbeetsandgoatcheese.Complainantsateatfacilityon2/26/13betweenaround6:30pm.
March1,2013
OnsiteInvestigation:
Exec.Chefwasonsiteandstatedhewasawareofthecomplaint.Hestatedthataftertheyreceivedthe
complaint,theyreviewedallfooditems,talkedwithstaff,andreviewedallofthefoodhandling
Page 20
3/22/2013
processes.PerChef,noemployeeshavecalledinsickinthelastweek.Hestatedthatoneemployee
wasoutsickaround2/16/13,wenttothedoctor,anddidnotcomebackuntilclearedbythedoctor.
Thissameemployeefeltsickonedaylater,wentbacktothedoctoranddidnotcomebackuntilthey
wereagainclearedbythedoctor.ThisemployeeisnotresponsibleforfoodhandlingperChef.Chef
statedthattherehavebeennodisruptionsinhotwater,refrigerationhasbeenfunctioning,theytake
temperaturelogsforthewalkin,theyhavenotexperiencedanysewagebackups,andthedishmachine
istesteddaily.Thefoodconsumedonthisdaywasapartoftheirfamilystyledinnerheldinthebanquet
room.Foodismadeinkitchen,placedinchafingdishes,andbroughttobanquetroom.
EnvironmentalManagementDepartment(EMD)wasunawareoftheunpermittedbanquetroom.Hand
washstationsarenotavailableinthebanquetroom,fiverestroomswithhandwashingareavailable,
andobservedtwobarareaswithnohandsinks.KariWagner,ESIIIobtainedphotographic
documentationofthebanquetareaduringtheinspection.Mulvaneyscannotconductfoodpreparation
(includingbeveragesatthebar)intheBanquetarea.Foodmaybeplatedinsidethepermittedfacility
andbroughttothebanquetareaandimmediatelyserved.
Arugulasalad:containsarugula,beets,goatcheeseandacitrusvinaigrette.Allitemsdeliveredfrom
ProduceExpressdaily.Perchef,arugulaisprewashed>washedagain>placedinthewalkin.The
beetsarewashed>roastedw/orangezest,staranise,fennelandwater>cooled>peeled>sliced>
pickledinabrineandplacedintherefrigeratoruntilused.Thedressingismadewithfreshlemonjuice,
oliveoil,shallots,salt/pepperandismadedaily.
Observations:
Walkin:rawporkandrawchicken43Fwithwalkinobservedtobeveryfull.Ambientairtemperaturein
middleofwalkinat39F.
2doorstandup:creamintwodifferentcontainers43F/44Fandshelleggsat46F.Ambientair
temperatureinunitat39F.
Allhandsinksstockedandaccessible.
Hotwaterat3compsink:146F.
Dishmachine:washcycle119Fand50ppm.
Sanitizerbucketinfrontprepareaat200ppmQA.
Perchef,allofthebeetsalad(alsocalledBeetcarpacciosalad)wasconsumedonthisdateandanynew
saladsweremadeonthenextdaybyadifferentemployee.
March1,2013
NotestofilewrittenbyKariWagner,ESIII
Duringacomplaintinvestigationattheabovefacility,itwasobservedthatasecondfoodareawasused
forbanquetsthathasnotbeenapprovedorpermittedbyEMD.
ThebanquetroomcontainsasmallprepareathathasanAltoSham,noncommercialchestfreezer,2
doorstandupfreezer,twopreptables,twobars,and5restrooms.Therearenohandsinks,prepsinks,
waresinks,ormopsinksobservedinthisarea.Graffitipaintedrestroomonlyhasacoldwaterfaucetand
nowarmwaterisavailable.MopsinkinMulvaney'sislocatedinkitchennexttofoodprepandisnotin
theideallocationfordumpingunsanitaryliquids.PerChef,theareaisusedforbanquetsonly.Thearea
isnotapprovedforanyfoodprep(includemakingorpouringdrinks)orserviceandmaynotbeusedin
Page 21
3/22/2013
thismanneruntilapprovedtodosobyEMD.Areamaybeusedforseatingbutallfoodmustbe
preparedandplatedinsideapprovedfacility.
PlansmustbesubmittedtoEMDplanreviewifownerswouldliketousethisfacilityformorethanjust
seating.Areahasadifferentaddressthanthecurrentlypermittedfacility.Plansmustbesubmittedand
approvedpriortoanyconstruction.Handsinks,amopsink,aprepsink,anda3compartmentsinkmay
berequireddependingontheuseofthisarea.Otherstructuralrequirementsmayapply.Thisareawill
alsorequireitsownpermit.
March12,2013
NotestofilewrittenbyKariWagner,ESIII
ColleenMaitoza,SupervisingESandKariWagner,ESIIIstoppedbytheabovefacilitytodiscusscleanup
proceduresforthefacilityafterthepositiveNorovirusresultsfromonestaffmemberandonepatient.
WespokewiththeOwner,andtheExecutiveChef.TheOwnerstatedthatonTuesday,March5th,they
metwiththeirstaffandinstructedthemtodoacleaningofthefacilitywithableachsolutionofallfood
preparationareas.Thefollowingday,staffalsocleanedthefacilitywithableachsolutioninotherareas
includingdoors,doorhandles,chairs,tablesandalllinenswereremovedandwashed.Allstaffhadbeen
instructedonhandwashingandgoodhygieneduringtheabovemeeting.Wealsodidawalkthroughof
theunpermittedbuildinganddiscussedPlanReviewrequirementsandsuggestionsforcompliance.
Page 22
3/22/2013
Page 5/22/2013
Sacramento County
Board of Supervisors
Phil Serna, District 1
Jimmie R. Yee, District 2
Susan Peters, District 3
Roberta MacGlashan, District 4
Don Nottoli, District 5
County Executive
Bradley J. Hudson
www.saccounty.net
Environmental Management
Department
Director
Val Siebal
http://www.emd.saccounty.net
Department of
Health & Human Services
Director
Sherri =Heller, Ed.D
County Health Officer
Olivia Kasirye, M.D.
Epidemiology Program Manager
Cassius Lockett, Ph.D., MS
www.scph.com

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