Enterotoxigenic e. coli (ETEC) Outbreak Investigation of a Catered Luncheon May 4, 2016
Overview Background information Who we are Outbreak investigation process Case management Caterer investigation Laboratory Findings Epidemiology Outbreak Summary Communications Lessons learned
Who we are Brant County Health Unit Population of 136,000 Mix of urban and rural ID team 2 PHIs, 3 PHNs Manager and Director
Outbreak Investigation Friday, September 11, 2015 report received Phone call from concerned employee of Brant FACS 26-30 ill employees 150 staff attended an agency wide meeting on Thursday, September 10, 2015 Menu obtained Email from Human Resources OUTBREAK DECLARED!
Case Management Case questionnaire self administered Contact tracing Stool specimen collection and testing Health teaching
Catered Luncheon Mayo transported in large margarine container Mayo on table in margarine containers, no spoons Saran wraps on trays was falling off in transport into facility Trays were stacked on top of each other Food not in cooler bags, but on ice Cookies were transported in a bucket with no lid
Catered Luncheon Salads were transported in white buckets Pop and food trays were warm Not enough food Disorganized and unprofessional Lost in transit to facility HEAT ALERT DAY!!!!!!
Catering Investigation Inspection of catering operation Approved kitchen Insufficient refrigeration and food preparation space Transported food on ice in bus pans Caterer interviews Obtain food samples Obtain stool sample Section 13 order issued on Sept. 16, 2015
Early Outbreak Findings Food safety concerns Negative stool sample results reported Water results were acceptable Epi curve Signs and Symptoms
Epi Curve
Signs and Symptoms Signs or Symptoms n % Diarrhea 105 95.5 Stomach cramps 98 89.1 Nausea 65 59.1 Headache 65 59.1 Chills 59 53.6 Muscles aches 47 42.7 Fever 24 21.8 vomiting 14 12.7
Information Gathering - Sept 16, 2015
Laboratory Findings Plesimonas shigelloides 2 positives reported 1 st - Presumptive positive Sept. 19, 2015 Confirmed - Sept. 25, 2015 2 nd Presumptive positive Sept. 23, 2015 Confirmed - Sept. 28, 2015 Found in freshwater, estuarine and marine environments Associated with travelers' diarrhea Most strains associated with disease are from patients living in tropical or subtropical areas
Or did we
Enterotoxigenic e. coli Enterotoxigenic e. coli First report received on Oct. 1, 2015 Non-reportable disease Travelers' diarrhea Generally mild illness, can resemble cholera Sudden onset of diarrhea, rarely fever or vomiting Incubation period 8-48 hours, usually 26 hours High infectious dose
Laboratory Findings 9 (36%) confirmed cases for enterotoxigenic E. coli (ETEC) 25 stool specimens were submitted for testing 8 food samples submitted for testing 1 food sample, egg salad, tested above acceptable limits for total gram negative bacteria
Epidemiology 84% response rate for questionnaire (n=134) 78% attack rate (i.e., met case definition), 105 individuals
Food Attack Rate Table Symptomatic cases Non-symptomatic cases Food items consumed n Attack rate % n Attack rate % Relative risk Potato salad* 97 92.4 9 31.0 3.0 Cookies 78 74.3 18 62.1 1.2 Couscous 60 57.1 20 69.0 0.8 Ham wrap 59 56.2 14 48.3 1.2 Egg salad wrap* 68 64.8 7 24.1 2.7 Greek salad* 64 61.0 8 27.6 2.2 Turkey wrap 45 42.9 12 41.4 1.0 Veggie wrap 14 13.3 5 17.2 0.8
Outbreak Summary Point source outbreak Confirm the cause of the outbreak was ETEC Confirm the source was the food Confirm the Caterer did not comply with food safety requirements Confirm that the food supplied by the catering company was the source of the outbreak Charges have been laid
Communications Requests from Brant FACS for information to staff Fact sheets, website links Town hall meetings Media Social media
Communications 20 Facebook posts, with 7 separate conversations 17 Twitter tweets, with 54 separate conversations 5 media releases 14 News articles Brantford, Woodstock, Simcoe and London Barf blog Medical advisory
Lessons Learned Incident Management System is helpful Provide input into the Community Outbreak Management Plan Consult with Public Health Ontario and Public Health Laboratory Catering is a complex business Laboratory specimen collection P&P Watch for Red Herrings
Many thanks to.. Brant FACS Haldimand Norfolk Health Unit Public Health Ontario and PHO Laboratory BCHU programs Environmental Health Sexual Health Communications Program Evaluation
Thank You! Sandi Amorim-Daly sandi.amorim-daly@bchu.org www.bchu.org 519-753-4937 @BrantHealthUnit Brant Health Unit