Investigation of a Salmonella Outbreak at Western University
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2 Investigation of a Salmonella Outbreak at Western University IPAC Southwestern Ontario Friday June 13, 2014 Joanne Dow, Public Health Nurse ext. 2240; joanne.dow@mlhu.on.ca Alison Locker, Epidemiologist ext. 2463; alison.locker@mlhu.on.ca Cheryl Tung, Public Health Inspector ext. 2304; cheryl.tung@mlhu.on.ca
3 Outline Background Reportable diseases Chronology of the outbreak Overview of investigation components Understanding the kitchen Food samples Food handler testing Analysis of meal plan data and case control studies Recommendations and Conclusions Acknowledgements
4 Reportable Diseases
5 Health Protection and Promotion Act ~ 75 reportable diseases or conditions Must be reported by: physicians and other health care providers laboratories school principals hospitals directors of institutions
6
7 Reason for Reportable Diseases Prevent spread of the communicable disease to others by: counseling and treatment of person contact tracing vaccination of contacts antibiotics for contacts Surveillance data to establish baselines and identify outbreaks Identify trends and risk factors in order to design prevention programs
8 Disease Follow-up Contact the physician Contact client Determine that they understand the disease and treatment (if available) Discuss methods of preventing transmission Determine the source of infection Discuss contact tracing (if applicable)
9 Detecting a Reportable Disease Outbreak E. coli O157:H7 at the petting zoo 3 cases in three days normal 3 per month Meningococcal cases 6 cases in three months normal 6 cases per year Salmonella 6 cases in an hour normal 6 cases per month
10 Salmonella at the University
11 Symptoms: Salmonella Diarrhea, sometime bloody Fever Headache Nausea, sometimes vomiting Duration 4-7 days Carriage can be prolonged: At 12 weeks, 5% still carry At 1 year, 1% still carry
12 Complications: Salmonella Dehydration Septicemia Extra-intestinal infections Incubation hours (usual 12-36) Communicable - while organism in stool Infectious dose - varies by serotype
13 Average number of reported cases ( ) Average Salmonella by Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ML Cases Month
14 How Did We Know There Was Salmonella an Outbreak? Normally six cases per month in November On Thursday November 8, 2007, MLHU was notified of six cases in an hour
15
16 Chronology of the Outbreak By end of day: 4 lab-confirmed cases reached All Western students 3 ate at pita outlet at Western Centre Spot (UCC) 4 non-lab confirmed case reached 2 Western students 1 ate at pita outlet
17 Chronology of the Outbreak Pita outlet closed for night Not allowed to open until inspected in morning Processes reviewed Individuals interviewed No food on site from previous week Allowed to re-open November 9
18 Understanding the Kitchen
19 UCC Centre Spot at Western Western: 30,000 students; 3,500 faculty Food court in the University Community Centre (UCC) - Centre Spot Seven fast food outlets Common preparation area at the back At night, do baking and prepare foods for Lifestyle fridges across campus Production Centre
20 Pita Outlet Between wall and Chinese food outlet Mostly pitas and some salads; many toppings and sauces 2 counters 3-4 staff per counters
21
22 Understanding the Kitchen Sources of food for pita outlet all distributed widely Chicken at pita outlet precooked, frozen, thawed, chopped, reheated and held food Raw frozen chicken at food outlet next door Potential for cross-contamination
23 Understanding the Kitchen Pita preparation Slide pitas down from one person to the other adding ingredients Wrapped at the end Production centre and lifestyle refrigerators Space and lay out Shipping and receiving
24 Chronology of Outbreak By early Saturday, November 10, laboratory confirmed cases 6 reached 5 ate at pita outlet 2 non-lab confirmed ate at pita outlet Based on information available, a press release was issued
25 Salmonella Cases Linked to Food Outlet FOR IMMEDIATE RELEASE November 10, 2007 LONDON, ON - The Middlesex-London Health Unit has received seven laboratory reports of salmonella between November 8 th and 9 th, The Health Unit is advising students and staff at The University of Western Ontario who currently have symptoms compatible with salmonella to contact a health care provider. Students and staff who have been ill with diarrhea since November 2 nd, 2007 are also advised to contact the Middlesex-London Health Unit...
26 Case Investigations Obtained all available meal items from pita outlet - including toppings and sauces Detailed questionnaire for all lab-confirmed and non-lab confirmed cases (3 stools in 24 hours) Symptoms Health care Meals eaten on campus Details of meal eaten at pita outlet
27
28 Number of cases Salmonella Outbreak - November 9 - December 11, 2007 Approximate Number of Cases Reported Per Day All pita outlet but two case Date
29 Number of cases Salmonella Outbreak - November 9 - December 11, 2007 Approximate Number of Cases Reported Per Day One lab confirmed and one non-lab confirmed Lifestyles fridges Centre Spot closed and cleaned despite Fall Preview Intensify inspection of kitchen at Centre Spot 10 lab-confirmed cases not pita outlet but other Centre Spot prepared food Date
30 Number of cases Onset Dates of Laboratory Confirmed Salmonella Typhimurium 90 Cases Other UCC Pita Pit Nov 4-Nov 5-Nov 6-Nov 7-Nov 8-Nov 9-Nov 10-Nov 12-Nov 11-Nov 13-Nov 15-Nov 14-Nov 16-Nov 18-Nov 17-Nov 19-Nov 21-Nov 20-Nov
31 Number of cases Exposure dates laboratory-confirmed cases 76 cases Note: The following cases are excluded: - Multiple exposure dates (6) - No obvious on campus exposure (5) - Secondary transmission (3) Pita outlet UCC others UCC Lifestyles 10 non-pita outlet cases received 15 First six laboratory reports received Additional kitchen investigation begins Centre Spot kitchen clean-up Oct 02-Nov 01-Nov 03-Nov 05-Nov 04-Nov 07-Nov 06-Nov 09-Nov 08-Nov 10-Nov 12-Nov 11-Nov 14-Nov 13-Nov 16-Nov 15-Nov 17-Nov 19-Nov 18-Nov 20-Nov
32 Hypotheses: Hypotheses Food brought in contaminated Contaminated through infected foodhandler Contaminated through cross contamination Likely never be sure
33 Testing the Hypothesis Analysis of meal plan data Analysis compared to cash register sales Case control study of people who ate at pita outlet web based Case control study of people to assess usual eating patterns related to UCC web based
34 Chicken Problems Not everyone ate chicken November 2, lab confirmed only 12 / 26 (46%) did not eat chicken Chicken for pita location arrived cooked and frozen; then thawed, chopped, reheated, hot held Other explanations: Tong bath with chicken-serving tongs Chicken server Place on cutting board where chicken pitas prepared
35 Collection of Food and Environmental Samples
36 Collection of Food and Environmental Samples November 9, food samples pita outlet Bacillus Cereus in chicken and some evidence of bacteria on tomatoes and lettuce November 13, food samples pita outlet negative 14 environment samples - negative November 18, 2007 Two drippy chickens Salmonella Heidelberg on one
37 Testing of Food Handlers
38 Testing of Stool from Pita Outlet Food Handlers 27 staff identified for testing related to pita outlet 24 tested 2 positive but onset after outbreak started
39 Where Did We Land? Raw chicken contaminated pita outlet around November 2 Contaminated product Hands of a food handler Contaminated cutting board Subsequently spread from either pita outlet or original contamination to other surfaces in Centre Spot kitchen
40 Kitchen Recommendations
41 Prevent Cross-Contamination No raw chicken Pita on wrapping paper No utensils in sink with raw produce Change cutting board and sanitize Sanitize utensils Allow dishes to air dry Sanitize all bins for transporting food Install handwashing sinks and dispensers Review steps where hands should be washed
42 Temperature Recommendations Calibration of thermometers Record temperatures and respond appropriately Maintenance of refrigerators Ensure dishwashers reach appropriate temperatures
43 Simplification of Processes Moved Production Centre Close Centre Spot 15 minutes each day to reset Enhanced food handler training and use of checklists Audits by outside consultants Modify dishwashing area, food storage, locker rooms Install dispenser for disinfectants and waterless handwash
44 Descriptive Epidemiology 90 laboratory confirmed cases Pita outlet 41 (45.6%) Pita outlet exclusively 26 Pita outlet plus other UCC exposures 15 Food prepared at UCC, not pita outlet 35 (38.9%) Lifestyle fridges 15 Other food Centre Spot food 20 Other 14 (15.6%) Cannot decide 6 Nothing on campus 5 Person-to-person 3
45 Descriptive Epidemiology Mean age: 22 years Age range: years Female 57.8%; Male 42.2% 15 food handlers - victims not source 2 of these were pita outlet employees
46 Descriptive Epidemiology 7 hospitalizations 60% had bloody diarrhea Diarrhea severe mean 17 and median 15 times on worst day For 37 people where duration known Mean 8 and median 7 days duration Range 3-21 days
47 Descriptive Epidemiology All laboratory confirmed cases were: Salmonella Typhimurium PT 108, STXAI.0312 Same type as causing large provincial outbreak in 2007 with 198 cases?? Linked to chicken
48 What Did We Learn? Many issues identified and improved in kitchen Recall of foods are not as good as electronic records Web based technology for conducting studies is great
49 Want to Read More? Report available at:
50 Acknowledgements
51 Authors Dr. Bryna Warshawsky, (former) Associate Medical Officer of Health Alison Locker, OHCDSH Epidemiologist Dr. Sue Pollock, Field Epidemiologist, PHAC Wally Adams, Director, Environmental Health and Chronic Disease Cathie Walker, (former) Manager, Infectious Disease Control Team Jim Reffle, (former) Director, Environmental Health and Chronic Disease Dan Flaherty, Communication Manager Dr. Graham Pollett, (former) Medical Officer of Health
52 Acknowledgements Infectious Disease Control Team Jessie Britstone Ellen de Freitas Gil Desjardins Joanne Dow Cassandra Elliott Melanie Elms Chris Felker Sheila Montague Eleanor Paget Jody Paget Amy Pavletic Wesmond Rosca Sara Trudel Cheryl Tung Laurie Young Environmental Health Team Richard Barrette Michelle Martin David Pavletic Zak Viljevac Chris Walsh
53 Acknowledgements Western University Hospitality Services Student Health Services Information Technology Services Department of Epidemiology and Biostatistics Dedicated to Dr. Tom MacFarlane, Director of Health Services
54 Acknowledgements Medical students Philip Hui Eric Morgan Ontario Ministry of Health and Long Term Care Public Health Agency of Canada London Public Health Laboratory Infection Control Practitioners from London hospitals London Laboratories Central Public Health Laboratories National Microbiology Laboratory
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