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
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
Investigation Initiation Outbreak investigation initiated Monday, October 24, 2016 4 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
Louisburg Cider Mill Outside of Louisburg, KS 8 miles from Missouri border
Ciderfest photo: louisburgcidermill.com
Ciderfest photo: louisburgcidermill.com
Ciderfest
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
Cider Mill Inspection photo: louisburgcidermill.com
Cider Mill Inspection
Environmental Sampling
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
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
Symptoms and outcomes Symptom Number of ill persons Percent of ill persons Diarrhea 56 100% 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%
Study Population Characteristics Case-Patients, n=56 n (%) Control Subjects, n=55 n (%) Median age 22 29 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, 2016 32 (57%) 36 (65%) September 25, 2016 3 (5%) 2 (4%) October 1, 2016 5 (9%) 4 (7%) October 2, 2016 16 (29%) 12 (24%)
9/24/2016 9/25/2016 9/26/2016 9/27/2016 9/28/2016 9/29/2016 9/30/2016 10/1/2016 10/2/2016 10/3/2016 10/4/2016 10/5/2016 10/6/2016 10/7/2016 10/8/2016 10/9/2016 10/10/2016 10/11/2016 10/12/2016 10/13/2016 10/14/2016 10/15/2016 10/16/2016 10/17/2016 10/18/2016 10/19/2016 10/20/2016 10/21/2016 10/22/2016 10/23/2016 10/24/2016 Number of Cases Number of cases by onset date (n=56) 7 6 5 4 3 2 1 0 Ciderfest Date of Onset Attended Ciderfest September 24-25, 2016 Attended Ciderfest October 1-2, 2016
9/24/2016 9/25/2016 9/26/2016 9/27/2016 9/28/2016 9/29/2016 9/30/2016 10/1/2016 10/2/2016 10/3/2016 10/4/2016 10/5/2016 10/6/2016 10/7/2016 10/8/2016 10/9/2016 10/10/2016 10/11/2016 10/12/2016 10/13/2016 10/14/2016 10/15/2016 10/16/2016 10/17/2016 10/18/2016 10/19/2016 10/20/2016 10/21/2016 10/22/2016 10/23/2016 10/24/2016 Number of Cases Number of cases by onset date (n=56) 7 6 5 4 3 2 1 0 Date of Onset Attended Ciderfest September 24-25, 2016 Attended Ciderfest October 1-2, 2016
9/24/2016 9/25/2016 9/26/2016 9/27/2016 9/28/2016 9/29/2016 9/30/2016 10/1/2016 10/2/2016 10/3/2016 10/4/2016 10/5/2016 10/6/2016 10/7/2016 10/8/2016 10/9/2016 10/10/2016 10/11/2016 10/12/2016 10/13/2016 10/14/2016 10/15/2016 10/16/2016 10/17/2016 10/18/2016 10/19/2016 10/20/2016 10/21/2016 10/22/2016 10/23/2016 10/24/2016 Number of Cases Number of cases by onset date (n=56) 7 6 5 4 3 2 1 0 Date of Onset Attended Ciderfest September 24-25, 2016 Attended Ciderfest October 1-2, 2016
Associations between Illness and Exposures Exposure/Food Item Matched Odds Ratio 95% CI Any type of cold cider 6.6 1.2 - infinity cup of cold cider 2.1 0.4-11.6 cider slush 4.5 0.7 - infinity Hot cider 1.2 0.2-8.6 Pre-packaged bottle of cider 3.3 0.3-39.1 Cider doughnuts 10.3 1.1-94.8 Caramel apples 1.3 0.1-17.3 Pony ride 1.0 0-19 Contact with farm animals 4.7 0.5 - infinity Pumpkin patch 2.2 0.1-157 Mobile food vendors 0.3 0.3-2.4
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
Recommendations All tanks holding unpasteurized cider should be labeled Employees should be cross-trained about all processes on site
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
Questions? photo: louisburgcidermill.com
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