19 sickened: Temperatures matter; C. perfringens outbreak at a catered lunch Connecticut, 2016

The U.S. Centers for Disease Control reports in September 2016, the Connecticut Department of Public Health was notified of a cluster of gastrointestinal illnesses among persons who shared a catered lunch.

The Connecticut Department of Public Health worked with the local health department to investigate the outbreak and recommend control measures. Information about symptoms and foods eaten was gathered using an online survey. A case was defined as the onset of abdominal pain or diarrhea in a lunch attendee <24 hours after the lunch. Risk ratios (RRs), 95% confidence intervals (CIs), and Fisher’s exact p-values were calculated for all food and beverages consumed. Associations of food exposures with illness were considered statistically significant at p<0.05. Among approximately 50 attendees, 30 (60%) completed the survey; 19 (63%) respondents met the case definition. The majority of commonly reported symptoms included diarrhea (17 of 18), abdominal pain (15 of 16), and headache (7 of 15).

The median interval from lunch to illness onset was 5.3 hours (range = 0.4–15.5 hours) for any symptom and 7 hours (range = 2.5–13 hours) for diarrhea. Analysis of food exposures reported by 16 ill and 10 well respondents (four respondents did not provide food exposure information) found illness to be associated with the beef dish (RR = undefined; CI = 1.06–∞; p = 0.046) (Table). All 16 ill respondents reported eating the beef. Coffee was also associated with illness; however, all 13 coffee drinkers who became ill also ate the beef. Eating cake approached significance (p = 0.051); all 10 cake eaters who became ill also ate the beef.The caterer had begun preparing all dishes the day before the lunch. Meats were partially cooked and then marinated in the refrigerator overnight. In the morning, they were sautéed 2 hours before lunch. Inspection of the facility found the limited refrigerator space to be full of stacked containers that were completely filled with cooked food, disposable gloves that appeared to have been washed for reuse, and a porous wooden chopping block.

The caterer’s four food workers reported no recent illness. Stool specimens from the food workers and from four ill attendees all tested negative for norovirus, Campylobacter, Escherichia coli O157, Salmonella, and Shigella at the Connecticut State Public Health Laboratory. All eight specimens were sent to the Minnesota Department of Health Public Health Laboratory, where additional testing was available. Two specimens from food workers were positive for enterotoxigenic Escherichia coli by polymerase chain reaction, but no enterotoxigenic E. coli colonies were isolated. Seven specimens (four from food workers and three from attendees) were culture-positive for Clostridium perfringens, and specimens from all attendees contained C. perfringens enterotoxin. Pulsed-field gel electrophoresis of 29 C. perfringens isolates from the culture-positive specimens found no matches among attendee isolates, but demonstrated a single matching pattern between two food worker specimens. No leftover food items were available for testing.

C. perfringens, a gram-positive, rod-shaped bacterium, forms spores allowing survival at normal cooking temperatures and germination during slow cooling or storage at ambient temperature (1). Diarrhea and other gastrointestinal symptoms are caused by C. perfringens enterotoxin production in the intestines. Vomiting is rare and illness is usually self-limited, although type C strains can cause necrotizing enteritis (1).

Symptoms reported were consistent with C. perfringens infection, with a predominance of diarrhea, and median diarrhea onset time was at the lower end of the typical C. perfringens incubation period (6–24 hours) (1). C. perfringens enterotoxin detection in the stool of two or more ill persons confirms C. perfringens as the outbreak etiology (2). Both C. perfringens and enterotoxigenic E. coli can colonize asymptomatic persons (3,4), which might explain the presence of these pathogens in the stools of asymptomatic food workers. Pulsed-field gel electrophoresis did not identify the C. perfringens strain responsible for the outbreak, but findings add to the evidence for a wide variety of C. perfringens strains, not all producing C. perfringens enterotoxin (5).

C. perfringens outbreaks are typically associated with improper cooling or inadequate reheating of contaminated meats (1), which might have occurred with the beef dish. The restaurant was advised about the need for adequate refrigeration and best practices for cooling foods, including using stainless steel rather than plastic containers, avoiding filling containers to depths exceeding two inches, avoiding stacking containers, and ventilating hot food. Upon follow-up inspection, staff members discarded disposable gloves after one use, used only food-grade cutting boards, and maintained proper food temperatures for hot holding, cold holding, cooling, and reheating, as outlined in the Food and Drug Administration Food Code.

An estimated 1 million illnesses in the United States each year are attributable to C. perfringens, but fewer than 1,200 illnesses are reported annually with C. perfringens outbreaks (6). C. perfringens testing is not routine for foodborne outbreaks; even if testing is unavailable, C. perfringens should be considered when improper cooling, inadequate reheating, and improper temperature maintenance of meat are identified.

15 sick with E. coli linked to goats at Conn. farm

The Connecticut Department of Public Health (DPH) today issued the following update on the E.coli outbreak linked to the Oak Leaf Farm in Lebanon, CT

aok.leaf.dairyAs of 1:00 p.m. today, DPH is investigating 15 confirmed cases of E. coli O157 infection.  The number of cases could increase in the near future as DPH is actively identifying individuals who were not initially reported. 

 So far, investigators have been able to link 14 of these cases to Oak Leaf Farm.  The patients range in age from 1-44 years old, with a median age of six.  In total, five patients have been hospitalized with three still in the hospital.  Two of the hospitalized patients have been diagnosed with hemolytic uremic syndrome (HUS), as first reported last week.

 Yesterday, the Centers for Disease Control and Prevention (CDC) dispatched a team to Connecticut to assist in the investigation of this outbreak.  Today, officials from DPH, the Connecticut Department of Agriculture, the Uncas Health District, and the CDC team are at the Oak Leaf Farm conducting an onsite investigation.  The Farm remains voluntarily closed to the public, and the owners are cooperating with the investigation.

 The outbreak was first identified on Thursday, March 24th when six of seven individuals sickened with E. coli were confirmed by DPH to have recently visited Oak Leaf Farm and come into contact with goats on the farm. 

From the we’ve-never-made-anyone-sick-before files: Conn. E. coli on goat farm edition

The goat farm in Lebanon that may be linked to an E. coli outbreak has been given two stipulations by the health department, the owner told NBC Connecticut.

oak-leaf-dairy-goat-farm-march-6th-1024x684Oak Leaf Dairy Farm is no longer allowed to have the public visit its goats and may not distribute unpasteurized products, Mark Reynolds, the farm’s owner, said.

Reynolds said the outbreak has already started affecting his wholesale business. He said he had never had E. coli linked to his farm before.

The Department of Health and other agencies began to investigate Oak Leaf Dairy Farm after seven people contracted E. coli.

Six of those people were children who visited the farm and petted the goats.

Connecticut Children’s Medical Center said two patients have been diagnosed with hemolytic uremic syndrome (HUS).

What makes people sick in Connecticut

Foodborne pathogens cause >9 million illnesses annually. Food safety efforts address the entire food chain, but an essential strategy for preventing foodborne disease is educating consumers and food preparers.

connecticut.foodTo better understand the epidemiology of foodborne disease and to direct prevention efforts, we examined incidence of Salmonella infection, Shiga toxin–producing Escherichia coli infection, and hemolytic uremic syndrome by census tract–level socioeconomic status (SES) in the Connecticut Foodborne Diseases Active Surveillance Network site for 2000–2011.

Addresses of case-patients were geocoded to census tracts and linked to census tract–level SES data. Higher census tract–level SES was associated with Shiga toxin–producing Escherichia coli, regardless of serotype; hemolytic uremic syndrome; salmonellosis in persons ≥5 years of age; and some Salmonella serotypes. A reverse association was found for salmonellosis in children <5 years of age and for 1 Salmonella serotype. These findings will inform education and prevention efforts as well as further research.

Socioeconomic status and foodborne pathogens in Connecticut, USA, 2000–20111

Emerging Infectious Diseases, Volume 21, Number 9—September 2015

Bridget M. Whitney, Christina Mainero, Elizabeth Humes, Sharon Hurd, Linda Niccolai, and James L. Hadler

http://wwwnc.cdc.gov/eid/article/21/9/15-0277_article

7 confirmed sick, 2 HUS; E. coli outbreak in Connecticut

The North Central District Health Department said seven cases were confirmed.
All of them required the patients to be hospitalized, according to the department.

Health officials said five of them were mild cases, but two were a severe form of the bacterial infection known as Hemolytic Uremic Syndrome, or HUS.

They said the people with the mild cases have already been released, but one of the two with HUS remains in the hospital.

The source of the E. coli has not been found.

Connecticut school cafeterias lack local health inspections

Nathan Hale School in New Haven had an inspection in March that found chicken was being served to children at a temperature that can carry bacteria. Inspectors did not go back to the school to re-inspect until December, when they found the same problem.

In October 2010, local health inspectors in Meriden found rodent droppings in the cafeteria of Maloney High School, as well as dirty cabinets and other health violations. Inspectors didn’t go back last year to check to see if the problems were remedied.

In Stamford last year, nine of 32 schools did not have their cafeterias inspected, with the remaining schools inspected fewer than the three times a year required under state regulations.

Those are the findings of a team of journalists and interns reporting for the New Haven Independent.

Paul Kowalski, New Haven’s environmental health director, said, “There is no way we are meeting the state mandate on inspections. I have three sanitarians and over 1,100 food establishments to inspect.”

A review of more than 1,700 inspection reports from 103 cities and towns in 2010 found that many local health agencies, responsible for ensuring that school cafeterias are safely preparing and serving food to children, are not meeting the state Public Health Code on mandated annual inspections. Of the 38 health agencies overseeing those towns, at least half were not meeting the state requirement, the review shows.

In addition to failing to meet the required number of inspections, the review found that timely re-inspections of cafeterias cited for violations were rare.