A Foodborne Outbreak of Gastroenteritis in a Teaching Hospital

1. Developing Family Medicine: Challenges for the Next Decade AKUH, February, 22, 2003 A Foodborne Outbreak ofGastroenteritis in a TeachingHospital Rashid A. Chotani, MD, MPH

2. Hospital • 940 bed hospital with 4 cafeterias. • Cafeteria A, located in the OPD, serves approximately 600 visitors and employees daily. Rashid A. Chotani, MD, MPH GIDSAS-JHU

3. Events • On 12/9/97 individuals who ate at Cafeteria A reported nausea and projectile vomiting after eating a noon meal. Rashid A. Chotani, MD, MPH GIDSAS-JHU

4. Method: case definition Any person who ate lunch prepared at cafeteria A on December 9, 1997 and developed sudden onset of • vomiting or • diarrhea or • abdominal cramps and Any of the following symptoms including nausea, fever, body aches, headache, chills or fatigue. Rashid A. Chotani, MD, MPH GIDSAS-JHU

5. Method: case finding We identified all cases who identified individuals who ate with them. All non-Ill persons were used as controls. • Additional cases were found when we contacted: • Nurse managers • Hospital managers • Directors of nursing, functional unit directors, JHH vice-presidents • Several employee groups were notified via e-mail and asked to identify cases. Rashid A. Chotani, MD, MPH GIDSAS-JHU

6. Methods: questionnaires Standard questionnaires were used to obtain medical and food history from • Food service workers • Ill and non-ill employees • Menu reviewed at Cafeteria A. Rashid A. Chotani, MD, MPH GIDSAS-JHU

7. Control Measures and Interventions: Cafeteria A Cafeteria: • Kitchen was inspected • Leftover foods recovered and cultured • Food preparation, kitchen cleaning procedures reviewed • Certain food items quarantined • Employees were interviewed, inspected for sores, boils, cuts, IV tract marks and sent to occupational health services • We obtained nares swabs • 3 cafeteria staff members submitted stool samples or rectal swabs • All staff (n=17) were questioned daily for symptoms Rashid A. Chotani, MD, MPH GIDSAS-JHU

8. Laboratory • Food was processed in standard fashion • Blood agar plate R/O Bacillus • CAN plate R/O Staphylococcus • Plates for enteric pathogens R/O Salmonella, Shigella, Aeromonas, Campylobacter, Yersinia • Samples sent to city, state, FDA, and commercial laboratory • Sequencing preformed • Heavy metal testing Rashid A. Chotani, MD, MPH GIDSAS-JHU

9. Results • N = 75 (ill = 40; non-ill = 35) • Mean age: 39 years (range 25-56) • Sex: 85% female Rashid A. Chotani, MD, MPH GIDSAS-JHU

10. Incubation period: JHH employees (n=40) 12 Point source outbreak 10 Number of Cases Reported 8 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Incubation Period (Hours)

11. Symptoms 18 fever 25 body aches 43 chills 48 headache 63 diarrhea fatigue 63 68 abdominal cramps vomiting 78 93 nausea 0 20 40 60 80 100 Percent

12. Results: outcomes • Duration of illness: mean--24 hr. (range <24 - 72 hr.) • Bedridden 62.5% • Sought medical care 27.5% • Hospitalized 2.5% Rashid A. Chotani, MD, MPH GIDSAS-JHU

13. Results: univariate analysis Food item OR СI 95%p-value Green beans 36.4 6.93,341.60 <0.0001 Tortellini 5.50 1.03, 54.50 0.02 Corn soup 0.23 0.04, 1.10 0.03 Veg soup 0.23 0.04, 1.10 0.03 Not associated: bread, breadsticks, chicken salad, broccoli salad, cheese salad, caesar salad, havarti cheese, swiss cheese, beef stew, Thai beef, couscous, honey turkey, chicken fingers, cheese pizza, sausage pizza, chow mein noodles, marinated tomatoes, onions, mixed greens, cucumbers, dressing tomato-bacon/peppercorn, creamy, sunflower seeds, crackers, chips, cookies, yogurt, and fresh fruits Rashid A. Chotani, MD, MPH GIDSAS-JHU

14. Results: multivariate analysis VariableORCI 95%p-value Green beans 1.84 1.49,2.27 <0.005 Tortellini 1.25 0.98,1.59 NS Corn soup 0.89 0.69,1.16 NS Veg soup 0.93 0.71,1.21 NS Rashid A. Chotani, MD, MPH GIDSAS-JHU

15. Results: laboratory • Bacillus sp. recovered from garlic mix (opened/unopened jars), Moroccan beef stew and vegetable soup. • Bacillus subtilis was identified based on the library profiles. • Heavy metals negative. • Patient/employees culture negative. Rashid A. Chotani, MD, MPH GIDSAS-JHU

16. Food preparation • Frozen green beans steamed for 10 minutes. • Seasoned with salt, pepper, olive oil and garlic mix. • Baked in oven for 15 minutes at 375 OF. • Stored in warmer at 180 degrees. • Placed in pan and sent to serving line (140 degrees); maximum time 4 hours. Rashid A. Chotani, MD, MPH GIDSAS-JHU

17. Summary • 40 persons became ill after eating green beans. • We under-estimated magnitude of problem because case ascertainment difficult. • The symptoms pointed to a toxin mediated illness. • The process of preparing green beans with garlic (in soy oil base) most likely led to the illness. • Bacillus was isolated from opened/unopened jars. Rashid A. Chotani, MD, MPH GIDSAS-JHU

18. Conclusions • FDA • Inspected the manufacturing facility • Inspected food supplier • Ordered recall of all garlic jars produced by company A • Mandated new control protocols • Aggressive control measures should be taken to prevent the spread of any outbreak particularly in a hospitals in order to protect not just the patients but the staff. • Rarely bacillus subtilis has been associated in food poisoning. Rashid A. Chotani, MD, MPH GIDSAS-JHU

19. Thank you Rashid A. Chotani, MD, MPH GIDSAS-JHU