Salmonella Typhimurium Associated with Unpasteurized Homemade Queso Fresco March-April, 2013
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1 Salmonella Typhimurium Associated with Unpasteurized Homemade Queso Fresco March-April, 2013 C. Medus 1, B. Crosby 1, H. Fox 1, G. Dobbins 1, H. Kassenborg 2, D. Huff 3, K. Smith 1 1 Minnesota Department of Health 2 Minnesota Department of Agriculture 3 Minneapolis Health Department
2 April 18, 2013 Background The Minnesota Department of Health (MDH) pulsed-field gel electrophoresis (PFGE) laboratory identified 2 Salmonella Typhimurium isolates indistinguishable PFGE PulseNet PFGE pattern JPXX Both cases were Hispanic
3 S. Typhimurium Cluster Cases by Date of PFGE Result Number of Cases :17 PM: Notified of new matching isolates; all cases Hispanic. Six more Salmonella cases in Hispanic persons reported Case 1 interviewed Case 2 interviewed April Date of PFGE Result Note: FRIDAY AFTERNOON
4 Minnesota Approach to Investigation of PFGE Clusters All reported Salmonella cases are interviewed even before a cluster is identified Collect details on specific exposures Point of sale or service Food brands, variety names Used in generating hypotheses for commercially distributed food outbreaks
5 Minnesota Approach to Investigation of PFGE Clusters: Dynamic Cluster Investigation Model Case #1 Case #2 Case #3 Case #4
6 Methods Case interviews were conducted by phone in Spanish or English by MDH staff Dynamic interviewing approach
7 Case definition: Methods Confirmed case: a person with confirmed infection with S. Typhimurium PFGE pattern JPXX Probable case: a person with diarrhea ( 3 loose stools in 24 hours) and fever from the same household as a confirmed case or identified from a list of customers of the implicated vendor
8 Methods City of Minneapolis Environmental Health led a joint investigation to identify the suspected vendor MDH, Minnesota Department of Agriculture (MDA), and Minneapolis police participated Confiscated products were tested by MDA MDA conducted a farm investigation, including collection and testing of milk and environmental samples
9 S. Typhimurium Cluster Cases by Date of PFGE Result Number of Cases :17 PM: Notified of new matching isolates; all cases Hispanic. Six more Salmonella cases in Hispanic persons reported 6:30 PM: Unpasteurized queso fresco purchased from a private cheesemaker mentioned by 2 of case-households Case 1 interviewed 3 rd case household reported unpasteurized queso fresco; expecting home delivery Case 2 interviewed April Date of PFGE Result
10 S. Typhimurium Outbreak Investigation April 23 Initial Results 6 of 11 (%) cases reported eating unpasteurized homemade queso fresco delivered to their home or purchased at a street corner 4.% of Hispanics in Minnesota report consumption of any unpasteurized cheese (FoodNet population survey, 2007) P value <0.001
11 S. Typhimurium Cases by Date of PFGE Result 3 rd case household reported unpasteurized queso fresco; expecting home delivery Surveillance operation Number of Cases :17 PM: Notified of new matching isolates; all cases Hispanic. Six more Salmonella cases in Hispanic persons reported 6:30 PM: Unpasteurized queso fresco purchased from a private cheesemaker mentioned by 2 of case-households Case 1 interviewed Case 2 interviewed April Date of PFGE Result
12 Area Under Surveillance Street corner where cheese was sold Area where cheesemaker was expected to make a home delivery
13 Street Corner Under Surveillance
14 Minneapolis Street Under Surveillance
15 S. Typhimurium Cases by Date of PFGE Result 3 rd case household reported unpasteurized queso fresco; expecting home delivery Surveillance operation Number of Cases :17 PM: Notified of new matching isolates; all cases Hispanic. Six more Salmonella cases in Hispanic persons reported 6:30 PM: Unpasteurized queso fresco purchased from a private cheesemaker mentioned by 2 of case-households Case 1 interviewed Case 2 interviewed April Date of PFGE Result
16 S. Typhimurium Cases by Date of PFGE Result 3 rd case household reported unpasteurized queso fresco; expecting home delivery 2:17 PM: Notified of new matching isolates; all cases Hispanic. Six more Salmonella cases in Hispanic persons reported Cheesemaker identified, cheese confiscated Number of Cases :30 PM: Unpasteurized queso fresco purchased from a private cheesemaker mentioned by 2 of case-households Case 1 interviewed Case 2 interviewed April Date of PFGE Result
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19 S. Typhimurium Cases by Date of PFGE Result 3 rd case household reported unpasteurized queso fresco; expecting home delivery 2:17 PM: Notified of new matching isolates; all cases Hispanic. Six more Salmonella cases in Hispanic persons reported Cheesemaker identified, cheese confiscated Press release Number of Cases :30 PM: Unpasteurized queso fresco purchased from a private cheesemaker mentioned by 2 of case-households Case 1 interviewed Case 2 interviewed April Date of PFGE Result
20 Cheese-making Operation Unpasteurized milk purchased by cheesemaker directly from a farm gallons at a time Milk collected from the line, not the bulk tank - still warm, not chilled Cheese made in cheesemaker s rented apartment in Bloomington, MN Delivered to his customers homes and sold on a street corner in South Minneapolis Delivered every 7 to 8 days
21 S. Typhimurium Cases by Date of PFGE Result 3 rd case household reported unpasteurized queso fresco expecting home delivery Cheesemaker identified, cheese confiscated 2:17 PM: Notified of new matching isolates; all cases Hispanic. Six more Salmonella cases in Hispanic persons reported Press release Number of Cases :30 PM: Unpasteurized queso fresco purchased from a private cheesemaker mentioned by 2 of case-households Case 1 interviewed Case 2 interviewed Farm identified Presumptive positive Salmonella from cheese April Date of PFGE Result
22 Food Testing Results Final results for the cheese samples were available on April 30 8 of 8 samples tested positive for S. Typhimurium of the outbreak PFGE pattern
23 Food and Environmental Testing Results Raw milk samples collected from the bulk tank at the farm on April 30 3 of 3 tested positive for S. Typhimurium of the outbreak PFGE pattern Cow manure samples of tested negative for Salmonella
24 Case Summary 26 cases in 14 households 19 confirmed 7 probable 6 were household members of confirmed cases, had onset on the same day as confirmed case 1 from cheesemaker customer list Additional illnesses reported 1 (8%) hospitalized No deaths
25 S. Typhimurium Outbreak Cases by Date of Illness Onset (N=26) Confirmed case Probable case Cheesemaker identified, cheese confiscated Unpasteurized queso fresco first suspected Number of Cases Case 1 interviewed Case 2 interviewed Press release March April
26 Unpasteurized Queso Fresco Consumption at Initial Interview Ate unpasteurized queso fresco? Yes (n=13) Number of Cases No (n=12) Maybe/Unknown (n=1) March April
27 Unpasteurized Queso Fresco Consumption at Re-interview Ate unpasteurized queso fresco? Yes (n=1) Number of Cases No (n=7) Maybe/Unknown (n=4) March April
28 Crime and Punishment The City of Minneapolis waived a $600 fine in exchange for the cheesemaker s cooperation during the investigation MDA issued A notice of warning $4,000 assessment for investigation costs City of Bloomington inspected the home No additional cheese or cheese-making equipment found on the premises Was not fined for housing and zoning violations
29 Conclusions Outbreak of salmonellosis associated with unpasteurized homemade queso fresco purchased directly from a cheesemaker Early mention of specific food detail by one case-household led to asking all subsequent cases about this exposure Risky exposures warrant suspicion even when a small proportion of cases mention it
30 Conclusions Dynamic interviewing approach was essential in rapidly confirming the vehicle Simultaneous investigation steps rather than the more traditional sequential steps Environmental health/regulatory agencies involvement with early signals Press release and interventions before food testing results
31 Conclusions Despite asking specifically about this food, many cases initially denied eating it Concerned that the cheesemaker would get in trouble Aggressive efforts to identify the cheesemaker led to rapid removal of the cheese from the market
32 Minneapolis Health Department Ryan Krick Investigation team City of Minneapolis Police Department City of Bloomington, Environmental Health Division Lynn Moore Jeff Luedeman Doug Dyer Acknowledgments Hennepin County Medical Center Minnesota Department of Health Team Diarrhea Epidemiology and laboratory investigation team Minnesota Department of Agriculture Valerie Gamble Kathy Jorgensen Todd Whalen Investigation team
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