Shiga Toxin-Producing Escherichia coli O157:H7 Infections After Attendance at a Cider Festival Kansas, 2016
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1 Shiga Toxin-Producing Escherichia coli O157:H7 Infections After Attendance at a Cider Festival Kansas, 2016 Daniel Neises, MPH Senior Epidemiologist Bureau of Epidemiology and Public Health Informatics
2 Cluster Notification Friday, October 21, 2016 at 4:56 pm KDHE received a call 6 persons with Shiga toxin-producing Escherichia coli (STEC) O157:H7 with indistinguishable pulsedfield gel electrophoresis (PFGE) 10/21 Cluster Notification
3 Investigation Initiation Outbreak investigation initiated Monday, October 24, PFGE matches and 1 other STEC case attended Ciderfest at Louisburg Cider Mill in Louisburg, KS on September 24, 2016 Cluster Notification 9/24 9/25 10/1 10/2 10/21 10/24 Ciderfest Investigation Initiated
4 Louisburg Cider Mill Outside of Louisburg, KS 8 miles from Missouri border
5 Ciderfest photo: louisburgcidermill.com
6 Ciderfest photo: louisburgcidermill.com
7 Ciderfest
8 Cider Mill Inspection Cluster Notification Cider Mill Inspection 9/24 9/25 10/1 10/2 10/21 10/24 10/27 Ciderfest Investigation Initiated
9 Cider Mill Inspection photo: louisburgcidermill.com
10 Cider Mill Inspection
11 Environmental Sampling
12 Case finding Cluster Notification Cider Mill Inspection 9/24 9/25 10/1 10/2 10/21 10/24 10/27 11/2 Ciderfest Investigation Initiated Press Release
13 Methods Case definition: diarrhea in a person beginning 1 day after attending Ciderfest and lasting 2 days Matched case-control study Friend-and-family group controls Interviewed with outbreak-specific questionnaire Calculated matched odds ratios and 95% confidence intervals Conditional logistic regression with exact estimates
14 Symptoms and outcomes Symptom Number of ill persons Percent of ill persons Diarrhea % Blood in stool 14 25% Abdominal pain 43 77% Nausea 32 57% Fever 23 41% Headache 20 36% Myalgia 18 32% Vomiting 16 29% Other symptoms 16 29% Outcome Number of ill persons Percent of ill persons Visited healthcare provider 17 30% Emergency room 11 20% Hospitalized 10 18% Hemolytic uremic syndrome (HUS) 2 4%
15 Study Population Characteristics Case-Patients, n=56 n (%) Control Subjects, n=55 n (%) Median age Sex Male 18 (32%) 26 (47%) Female 38 (68%) 29 (53%) State of residence Kansas 37 (66%) 37 (67%) Missouri 19 (34%) 18 (34%) Date of attendance September 24, (57%) 36 (65%) September 25, (5%) 2 (4%) October 1, (9%) 4 (7%) October 2, (29%) 12 (24%)
16 9/24/2016 9/25/2016 9/26/2016 9/27/2016 9/28/2016 9/29/2016 9/30/ /1/ /2/ /3/ /4/ /5/ /6/ /7/ /8/ /9/ /10/ /11/ /12/ /13/ /14/ /15/ /16/ /17/ /18/ /19/ /20/ /21/ /22/ /23/ /24/2016 Number of Cases Number of cases by onset date (n=56) Ciderfest Date of Onset Attended Ciderfest September 24-25, 2016 Attended Ciderfest October 1-2, 2016
17 9/24/2016 9/25/2016 9/26/2016 9/27/2016 9/28/2016 9/29/2016 9/30/ /1/ /2/ /3/ /4/ /5/ /6/ /7/ /8/ /9/ /10/ /11/ /12/ /13/ /14/ /15/ /16/ /17/ /18/ /19/ /20/ /21/ /22/ /23/ /24/2016 Number of Cases Number of cases by onset date (n=56) Date of Onset Attended Ciderfest September 24-25, 2016 Attended Ciderfest October 1-2, 2016
18 9/24/2016 9/25/2016 9/26/2016 9/27/2016 9/28/2016 9/29/2016 9/30/ /1/ /2/ /3/ /4/ /5/ /6/ /7/ /8/ /9/ /10/ /11/ /12/ /13/ /14/ /15/ /16/ /17/ /18/ /19/ /20/ /21/ /22/ /23/ /24/2016 Number of Cases Number of cases by onset date (n=56) Date of Onset Attended Ciderfest September 24-25, 2016 Attended Ciderfest October 1-2, 2016
19 Associations between Illness and Exposures Exposure/Food Item Matched Odds Ratio 95% CI Any type of cold cider infinity cup of cold cider cider slush infinity Hot cider Pre-packaged bottle of cider Cider doughnuts Caramel apples Pony ride Contact with farm animals infinity Pumpkin patch Mobile food vendors
20 Conclusions 56 persons with STEC O157 after Ciderfest Cold cider and cider doughnuts were associated with illness Onsite inspection was essential for identifying un-pasteurized cider was served during the cider festival
21 Recommendations All tanks holding unpasteurized cider should be labeled Employees should be cross-trained about all processes on site
22 Acknowledgments Kansas Department of Health and Environment Charlie Hunt Ingrid Trevino-Garrison Daniel Neises* IDER Staff Kansas Department of Agriculture Amber Barham* Adam Inman* Autumn Schuck Steve Moris Centers for Disease Control and Prevention Jessica Nadeau Tomov** Andrea Winquist Rashida Hassan Missouri Department of Health and Senior Services Elizabeth Anderson CJon Hinkle Mark Buxton United States Food and Drug Administration Sam Gibbons Jeffrey Moody Erin Dugan **Lead Author **Co-Author
23 Questions? photo: louisburgcidermill.com
24 Jurisdictions and Cluster Identification 4 PFGE matches in KS All were tested in MO KS case interviews conducted by county that opted-out of centralized interviewing Case 1 and 2 reported attending cider festival Could have identified common event when 2 nd interview was completed on 10/13 Case 3 interviewed by KDHE Reported to KDHE about same time as case 1, 2 No isolate for PFGE Reported attending cider festival KDHE interviewed 10/7, didn t find link to other cases
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35 36 37 38 39 4 41 42 43 44 45 46 47 48 49 5 51 52 **53 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 26 27 28 29 3 31 32 33 34 Percent of Total Visits ESSENCE ILI Surveillance Week
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