Foodborne Illness Outbreak Investigation Case Study: Escherichia coli O157:H7 Seven physicians from bordering counties in the

states of Washington and Oregon report to their respective State Departments of Health a total of 20 individuals with severe gastroenteritis and stool samples positive for E. coli O15 !H " #he Departments of Health from both states notify the $nited States %enters for Disease %ontrol and &revention '%D%(" #he %D% launches an investigation into the cluster of illnesses" )s an epidemiologist with the %D%* it is your +ob to determine how widespread the outbrea, has become* the source of infection* and means to halt the outbrea," #his involves interviewing food borne illness victims* determining common e-posures* determining what potential vehicles 'food* individuals* environmental samples* other( should be tested* interpreting laboratory results* helping to determine necessary actions to stop the outbrea,* and helping to determine actions necessary to prevent future outbrea,s" .ou interview the patients to determine a possible common source of infection" /rom these interviews* you are able to identify one commonality! all patients had visited 0ainy %ounty /arm during elementary school field trips within 1 to 5 days prior to the onset of symptoms" Were their illnesses the result of consumption of one type of contaminated food or beverage* several different contaminated foods or beverages* environmental e-posure* and1or e-posure to an infected individual2 Or is the farm a purely coincidental commonality and not the point of infection2 3leven patients are showing signs of recovery4 however* 5 individuals are in reportedly in poor medical condition and another has since died due to ,idney failure" )dditional cases of severe gastroenteritis have been reported in the region" 6ore people may become sic, if you cannot identify the source 7uic,ly and recommend actions necessary to stop the outbrea," #he public is counting on you to solve this case" 1" )side from tal,ing with farm patrons who contracted E. coli O15 !H infection* who else should you interview to help determine what could have been the source of the illness versus what did not cause illness2 2" .ou have been provided with names of interviewees" 8ased on the information you already have '#able 1(* prepare a list of interview 7uestions to gather more of the same type of information from the new interviewees" 9" $sing the sets of 7uestions you developed* conduct interviews with the latest cases" %ompile interview responses in #able 1" :" ;raphs are helpful to 7uic,ly visuali<e patterns in large data sets" $sing data from #able 1* prepare the following! a" ) bar graph of the number of patients who developed symptoms for the dates of symptom onset"

b" On the same graph as plotted for part a* plot the number of patients who developed symptoms for the dates they visited the farm" c" #able 2 completed with data on the foods consumed by all individuals and whether the foods were positively or negatively associated with illness" 5" ) review of farm employee health and absentee records and interviews with select individuals were conducted" %ould the ill farm employee listed in #able 1 have been the original source of contamination in this outbrea,2 Why or why not2 =" One of the individuals whose stool sample tested positive for E. coli O15 !H is a food handler in a restaurant" What additional measures should be ta,en to protect the public2 " >ews of the outbrea, and the association to the farm has hit news sources including newspapers* radio* television* and the internet" )s a result* numerous individuals other than those sought during the interviews have contacted their doctors* public health professionals* and1or attorneys with concerns they may also be victims in this foodborne illness outbrea," 0eview the symptoms and circumstances of the cases presented in #able 9* and determine which individuals may be additional victims of foodborne illness due to this particular outbrea, versus which individuals are not li,ely to be cases associated with this outbrea," &rovide an e-planation for your assessment on each individual" 5" /rom the data compiled in #able 2* calculate the odds ratio to determine what foods1events are positively associated with illness2 ?" What do you want to have tested for E. coli O15 !H contamination2 10" ;ive a reason why would you not necessarily want to have all foods tested" 11" @n any outbrea,* when there are multiple foods associated with illness* what could be the reasons for several foods being implicated2 12" Aaboratory data for various foods consumed at 0ainy %ounty /arm and stool samples from affected individuals are presented in /igure 1" Do the laboratory results support your hypothesis on which food's( were associated with illness2 3-plain your response" 19" #he $nited States Department of )griculture '$SD)( 3conomic 0esearch Service '30S( has an interactive website to calculate the cost of foodborne illness outbrea,s attributed to shigaBto-in producing E. coli O15 !H . 3nter the calculator at http!11www"ers"usda"gov1Data1/oodborne@llness1" @n the cost component feature 'left column of the table(* clic, on Cchange number of casesD" 3nter the number of ,nown cases from this case according to how they meet the descriptions of severity of illness" What is the estimated total cost associated with this outbrea, using the 30S assumptions2 1:" @f it is concluded that a product grown and processed 'elsewhere* by two different organi<ations( but distributed at the farm is the vehicle for E. coli O15 !H in this outbrea,* provide an opinion statement on who is responsible for contamination" &rovide

an opinion statement on who should be held financially accountable 'grower* processor* retail '0ainy %ounty /arm(* other( for e-penses associated with the outbrea, including! a" @ndividualsE medical e-penses* lost wages b" %osts associated with determining source of outbrea, 'epidemiologist wages* lab tests* etc"( c" 3-penses associated with recall and destruction of food 15" )fter this outbrea,* various groups with sta,e in this issue met to discuss appropriate actions for consumer protection with this type of product" #wo alternatives were discussed" Which of these do you favor2 State the reason's( for your opinion" a" Aabel product with a warning that it might contain microorganisms that can cause illness" b" 0e7uire treatment to ,ill pathogenic bacteria prior to distribution to the consumer" 1=" @f a vaccine could be developed to minimi<e or even prevent the shed of E. coli O15 !H by cattle* do you thin, administration should be re7uired2 Do you thin, such a strategy would be sufficient to decrease the ris, of E. coli O15 !H in human foods and beverages2 &lease state the reason's( for your opinion" 1 " &repare a =0Bsecond television news piece that informs the public of the critical information related to the case" 15" &repare a 15Bminute presentation for the class giving an overview of case study"

#his case study was prepared by the $niversity of Delaware" #his material is based upon wor, supported by the %ooperative State 0esearch* 3ducation* and 3-tension Service* $" S" Department of )griculture* under )ward >o" 200?B95:1:B1?=?5" )ny opinions* findings* conclusions* or recommendations e-pressed in this publication are those of the author's( and do not necessarily reflect the view of the $"S" Department of )griculture"

Table 1. Data fro Individual 1 2 9 : 5 = 5 ? 10 11 12 19 1: 15 1= 1 15 1? 20 21J 22J 29J 2:J 25J 2=J 2 J #ender /emale /emale 6ale /emale 6ale 6ale 6ale 6ale /emale /emale 6ale /emale 6ale 6ale 6ale /emale /emale /emale /emale 6ale 2? 95 = 5 5 $ge %yrs& Sy 'to s 8D* H$S* )* F/ 8D* H$S 8D* H$S 8D 8D 8D 8D 8D 8D 8D* H$S 8D 8D 8D 8D 8D* / 8D* H$S 8D 8D* I 8D 8D Date Sy 'to Onset Oct 2 Oct 2 Oct 2 Oct 9 Oct 9 Oct 2 Oct 2 Oct : Oct 9 Oct 9 Oct : Oct : Oct 5 Oct 5 Oct 5 Oct Oct 5 Oct 5 Oct 10 Oct 11

Intervie!s !it" Individuals ( 'loyee) *atron) Close Conta+t &atron &atron &atron &atron &atron &atron &atron &atron &atron &atron &atron &atron &atron &atron &atron &atron &atron &atron 3mployee 3mployee Consu ed H* G* @ H* G* @ H* G* @ H* G* @ H* G* @ G* @ G* A* @ H* G* W* A S* G* @ G* @ H* G* @ S* G H* G* @ H* G H* G* A G* A* @ H* G* W H*G S* G H* A* @ *arti+i'ated O O O* &H O* &H &H &H &H O* &H &H >) O* &H >) >) O* &H &H >) O O* &H >) &H S'e+ial Healt" Con+erns >F >F >F >F >F >F >F >F >F >F >F >F >F >F >F >F >F >F >F >F Current Healt" Status Deceased &oor* Hospitali<ed &oor* Hospitali<ed 0ecovering 0ecovering 0ecovering 0ecovering* Hospitali<ed 0ecovering 0ecovering &oor* Hospitali<ed 0ecovering 0ecovering &oor &oor 0ecovering &oor* hospitali<ed &oor 0ecovering 0ecovering &oor

Date visited Far Oct 1 Oct 1 Oct 1 Oct 1 Oct 1 Oct 1 Oct 1 Oct 1 Oct 2 Oct 2 Oct 2 Oct 2 Oct : Oct : Oct : Oct = Oct = Oct = Oct = Oct =

5 5 5 5 25 29

J Data gathered by students through mock interviews

Sy 'to s ,ey! 8D* bloody diarrhea4 I* vomiting4 /* fever4 H$S* hemolytic uremic syndrome4 F/* ,idney failure4 )* anemia )ll sic, individuals visited their physicians" Food ,ey! S* salad4 H* hamburger4 G* freshBpressed apple +uice4 A* fresh lemonade4 W* water4 @* ice cream* (vent ,ey! &H* petting <oo4 O* orchard pic,ing Ot"er! >)* >ot applicable4 >F* >one ,nown

Table -. $+tivity.Consu 'tion at Far

Food or $+tivity 2n'asteuri3ed $''le 4ui+e 5ottled 6ater 7e onade Ha burger Salad I+e Crea *etting 8oo Or+"ard *i+king / Consu ed or 'arti+i'ate d and Si+k

and $sso+iation !it" Illness

/ 0ot Consu ed or 'arti+i'ate d and Si+k / 0ot Consu ed or 'arti+i'ate d and 0ot Si+k Odds 1atio

/ Consu ed or 'arti+i'ate d 0ot Si+k

Odds 0atio K

L'M %onsumed and Sic,( 'M>ot %onsumed and Sic,(N L'M %onsumed >ot Sic,( 'M>ot %onsumed and >ot Sic,(N

Table 9. 0e! Cases : 1elated to Outbreak; Individual 1 2 9 : Sy 'to s >ausea* headache Severe diarrhea* abdominal pain 6ild diarrhea )bdominal pain* diarrhea 8loody diarrhea* abdominal pain Sy 'to Onset Guly 90 October = October 5 October Sy 'to Duration 1 day >early gone 2 hours Ongoing Date <isited Far Guly 90 October : October 5 >)* mother of child who visited farm on Oct 2 >)* no ,nown contact with sic, patron* employee Current Healt" Status ;ood 0ecovering ;ood &oor

October 5

Ongoing

&oor

Figure 1. 7aboratory Data fro Food *rodu+ts) (nviron ental S!abs) and *atient Stool S'e+i en fro 1ainy County Far :$sso+iated Illness Outbreak &ulsed field gel electrophoresis results" 8acterial isolates from growth media are treated with en<ymes to cut the genetic material at specific se7uences" &ieces of D>) of different si<es react with a dye and are visuali<ed on a gel" @solates from different sources are compared to determine relatedness based on banding patterns"
Aane 1 2 9 : 5 = Aane 1 2 9 : 5 = @solate Si<e reference &atient M1 stool specimen $npasteuri<ed cider @ce cream &etting <oo environmental swab Orchard environmental swab Hamburger

Image Source: Delaware Public Health Laboratory

$''endi= $ $+tor 1es'onses for Intervie!ees / -1: -7 to Co 'lete Table 1. 0ote: Only 'rovide ans!ers if >uestions asked. Do not offer unsoli+ited infor ation. $+tor 1! 6ale* age 99 years" >ot sic,* health currently good" >o ,nown health problems" &atron of farm on October 9" %onsumed salad* hamburger* lemonade* and ice cream" &articipated in orchard pic,ing and petting <oo" $+tor -: /emale* age 92 years" >ot sic,* health currently good" >o ,nown health problems" &atron of farm on October =" %onsumed salad* hamburger* and lemonade" &articipated in orchard pic,ing and petting <oo" $+tor 9: /emale* age 1?" >ot sic,* health currently good" >o ,nown health problems" &atron of farm on October =" %onsumed salad* hamburger* and water" &articipated in orchard pic,ing and petting <oo" $+tor ?: 6ale* age 1? years" >ot sic,* health currently good" >o ,nown health problems" 3mployee of farm" Wor,ed on October 5" %onsumed hamburger and ice cream" &articipated in petting <oo" $+tor 5: /emale* age 1 years" >ot sic,* health currently good" >o ,nown health problems" 3mployee of farm" Wor,ed October :" %onsumed hamburger* +uice* water* and lemonade" Did not partipate in orchard pic,ing or petting <oo" $+tor @: /emale* age 90 years" >ot sic,* health currently good" >o ,nown health problems" &atron of farm on October :" %onsumed salad* hamburger* and water" &articpated in orchard pic,ing" $+tor 7: 6ale* age 95 years" >ot sic,* health currently good" >o ,nown health problems" &atron of farm on October 9" %onsumed salad* lemonade* and ice cream" &articipated in orchard pic,ing and petting <oo"