11 sick: E. coli O157 outbreak linked to Minnesota state fair

The Minnesota State Fair has been connected to an outbreak of an E. coli strain, according to the Minnesota Department of Health (MDH).

To date, disease doctors have identified 11 cases of E. coli 0157 among Minnesotans who were at the State Fair between Aug. 25 and Sept. 2. All of them fell ill between Aug. 29 and Sept. 6.

Ages of those sickened range from 2 to 43 years old. Six of the cases required the patient to be hospitalized, including one person developing hemolytic uremic syndrome, which the MDH says is a potentially fatal complication.

One person is still in a hospital being treated.

Investigators are working to determine the source of the outbreak, with evidence so far indicating that it most likely began with contact with livestock.

Most of the 11 patients visited the Miracle of Birth exhibit and made physical contact with calves, goats, sheep or piglets, but others suffering from the E. coli strain did not make direct contact with animals, leading the MDH to consider the possibility that those people made contact with contaminated surfaces.

“This serves as a strong reminder to always wash your hands after being around livestock and their enclosures,” the MDH says.

Fortunately, there is “little chance” of ongoing exposure to the strain since the fair has ended.

Erdozain GKukanich KChapman BPowell D. 2012. Observation of public health risk behaviours, risk communication and hand hygiene at Kansas and Missouri petting zoos – 2010-2011. Zoonoses Public Health. 2012 Jul 30. doi: 10.1111/j.1863-2378.2012.01531.x.

Observation of public health risk behaviors, risk communication and hand hygiene at Kansas and Missouri petting zoos – 2010-2011Outbreaks of human illness have been linked to visiting settings with animal contact throughout developed countries. This paper details an observational study of hand hygiene tool availability and recommendations; frequency of risky behavior; and, handwashing attempts by visitors in Kansas (9) and Missouri (4), U.S., petting zoos.

Handwashing signs and hand hygiene stations were available at the exit of animal-contact areas in 10/13 and 8/13 petting zoos respectively. Risky behaviors were observed being performed at all petting zoos by at least one visitor. Frequently observed behaviors were: children (10/13 petting zoos) and adults (9/13 petting zoos) touching hands to face within animal-contact areas; animals licking children’s and adults’ hands (7/13 and 4/13 petting zoos, respectively); and children and adults drinking within animal-contact areas (5/13 petting zoos each). Of 574 visitors observed for hand hygiene when exiting animal-contact areas, 37% (n=214) of individuals attempted some type of hand hygiene, with male adults, female adults, and children attempting at similar rates (32%, 40%, and 37% respectively). Visitors were 4.8x more likely to wash their hands when a staff member was present within or at the exit to the animal-contact area (136/231, 59%) than when no staff member was present (78/343, 23%; p<0.001, OR=4.863, 95% C.I.=3.380-6.998). Visitors at zoos with a fence as a partial barrier to human-animal contact were 2.3x more likely to wash their hands (188/460, 40.9%) than visitors allowed to enter the animals’ yard for contact (26/114, 22.8%; p<0.001, OR= 2.339, 95% CI= 1.454-3.763).

Inconsistencies existed in tool availability, signage, and supervision of animal-contact. Risk communication was poor, with few petting zoos outlining risks associated with animal-contact, or providing recommendations for precautions to be taken to reduce these risks.

 

Missed phone calls, changing stories: How E. coli spread at the San Diego County Fair

More than 1.1 million people had already passed through the gates of the San Diego County Fair this summer by the time an E. coli outbreak forced the closure of all animal exhibits and rides.

News that a 2-year-old boy had died after picking up the particularly nasty infection, which was also contracted by three other children with animal contact at the fair, stirred alarm within the community. Many had already roamed the midway, stuffed themselves full of fair food and passed through the venue’s cavernous livestock barns en route to pig races, pony rides and the petting zoo.

Paul Sisson of The San Diego Union Tribune reports hundreds of emails and other documents obtained through Public Records Act requests show that, while the public health team was able to move quickly, more frequent county case reviews, a more modern medical records system and more prompt and accurate responses from families with infected children might have gotten the investigation started days earlier.

The decision to shut down the animal exhibits on June 29, records show, came after four days of a behind-the-scenes scramble by the county’s public health department. With one death already on the books, they decided to notify the public even though testing had not yet confirmed that all four of those first four cases had E. coli infections.

It quickly became clear those initial instincts were accurate. In the following weeks, an additional seven people, plus two more whose infections weren’t confirmed, came forward, including another young boy who nearly died after suffering severe complications that attacked his kidneys.

Records show that zeroing in on the fairgrounds was no simple task. Epidemiologists had to eliminate a broad range of possible locations, from restaurants to a busy daycare center, before they were able to zero in on the fairgrounds.

And there was plenty of other work that had to be done simultaneously. County records show that the department investigated 435 disease cases in June alone. Of those, there were 43 cases of shiga toxin-producing E. coli reported that month, forcing disease detectives to sift out the 11 eventually confirmed to be part of the outbreak.

Determining whether there are connections between cases requires interviews with each subject or their legal guardians. Depending on the type of pathogen involved, it’s a process that often relies on frail human memory to recall the finest possible details of possible exposure routes from foreign travel and foods consumed to places visited and close contact with others.

The investigative process doesn’t get started until the health department is notified, usually after a test result administered in a doctor’s office or hospital comes back positive.

Subjects often aren’t interviewed until weeks after they got infected because many infections have incubation periods measured in days or weeks and it usually takes time before individuals decide to seek medical attention and additional time for medical providers to make a diagnosis.

Often, those charged with reading these particularly fragile tea leaves learn to trust their instincts, and that was certainly the case with the fairgrounds outbreak.

Emails show that the county’s epidemiology team first began to suspect that it might have an outbreak on its hands on June 24, the day that 2-year-old Jedidiah King Cabezuela (right) was admitted to the intensive care unit at Rady Children’s Hospital with severe kidney problems.

While discussing his condition, an epidemiologist noted that the boy had visited the fair before he got sick. And, she said, the county had been notified just before Cabezuela’s death of another boy, this one 9 years old, who tested positive for the type of toxin produced by the E. coli strain causing so much difficulty for Cabezuela.

Though the 2-year-old and 9-year-old hadn’t eaten the same foods at the fair, and the older boy’s parents said he didn’t visit animal areas, the fact that both visited the same location was enough for the epidemiologist to suggest that the department “should at least keep an eye on” the 9-year-old, even though he never got sick enough to need hospitalization.

By Tuesday, June 25, the public health department received the news that Cabezuela died overnight, and that information pushed the team to begin a relentless search for similar shiga toxin-producing E. coli infections.

They quickly found a report of a 13-year-old girl who had a positive toxin test after visiting the fair on June 8. Her parents had told interviewers that she had contact with animals and had eaten fair food afterward without first washing her hands.

Another girl, this one age 11, had also had a positive test but her parents had not returned repeated calls for an interview. It would not become clear that she, too, had visited the fair and had contact with animals until her parents were finally reached on June 28, the same day that the county announced it would close all public animal exhibits.

Then there was the 9-year-old boy mentioned in that prescient June 24 email. His parents initially said that he had no animal contact at the fair, but in subsequent interviews those parents remembered that, yes, their son did visit the livestock barn when the family visited on June 13.

With three, then four cases all reporting food consumption and animal contact at the fairgrounds, food inspectors descended on five different food vendors who sold items that the kids reported eating and found no traces of E. coli contamination.

Food poisoning ruled out, officials concluded that the E. coli exposure was most likely down to animals and, with the cooperation of the fair board, shut down all public access to animal exhibits and rides on June 29. Testing never did pinpoint the exact source of contamination, though the fair’s petting zoo and pony rides were ruled out.

Once public health nurses do their phone interviews and build up as clear a picture as they can of the circumstances surrounding each individual case, epidemiologists can begin looking for patterns, keeping an eye out for clusters of patients in specific geographic areas or with other commonalities such as foreign travel or consumption of tainted food.

A table of petting zoo outbreaks is available at https://www.barfblog.com/wp-content/uploads/2017/08/Petting-Zoo-Outbreaks-Table-7-26-17.xlsx

A timeline of the E. coli outbreak at the San Diego County Fair

May 31– San Diego County Fair opens

June 8 –11-year-old and 13-year-old girls visit fair

June 10 –13-year-old becomes ill

June 12 –11-year-old becomes ill after a second fair visit

June 13 – 9-year-old boy visits fair

June 15 – 2-year-old Jedidiah Cabezuela visits fair

June 16 – 9-year-old becomes ill

June 18 – Investigator call parents of 11-year-old, get no reply

June 19 – 13-year-old reports visiting animal areas at fair; Jedidiah becomes ill; county holds weekly analysis meeting

June 20 – Jedidiah admitted to Rady Children’s Hospital

June 21 – 4-year-old and 38-year-old who later test positive for E. coli infections visit fair

June 22 – Jedidiah diagnosed with severe E. coli infection; 6-year-old Ryan

Sadrabadi, 2-year-old Cristiano Lopez and his mother, Nicole Lopez, and another 2-year-old girl, visit the fair

June 23 – Family confirms Jedidiah visited fair’s animal exhibits; one-year-old girl later confirmed to have E. coli infection visits the fair

June 24 – Jedidiah dies from kidney failure; 9-year-old’s fair attendance confirmed, animal contact denied; County epidemiologist raises red flag about possible case cluster at fair; Nicole Lopez becomes ill, treated at Kaiser La Mesa

June 25 – County learns of Jedidiah’s death, begins exploring fair connections in depth

June 26 –Ryan, 2-year-old girl and 1-year-old become ill

June 28 – Family of 9-year-old revises statement, confirms visiting livestock barn; Family of 11-year-old confirms she visited sheep exhibit at fair; County announces E. coli cluster at Del Mar Fairgrounds; County inspects five food booths visited by first four cases, no E. coli found; Cristiano becomes ill

June 29 – County inspects all 160 food booths at fair, finds no E. coli contamination; All animal areas at the fair are closed; four-year-old becomes ill

June 30 – Ryan becomes ill diagnosed with E. coli infection

July 1 – 6-year-old’s case reported to county

July 2 – Cristiano admitted to Kaiser Permanente San Diego Medical Center with worsening symptoms, diagnosed with E. Coli infection

July 3 – 2-year-old girl and 4-year-old’s cases reported to county

July 4 – Fair closes with an attendance that exceeds 1.5 million; Cristiano’s infection reported to county; Cristiano transferred to Rady Children’s Hospital, undergoes dialysis for hemolytic uremic syndrome that attacks his kidneys

July 6 – 38-year-old becomes ill

July 9 – 38-year-old’s infection reported to county

July 10 – 30-year-old’s and 1-year-old’s infections reported to county

July 29 – Three families file claims against fair board, alleging they weren’t properly warned of E. coli risk

July 31 – Environmental and animal testing fail to reveal a clear source of outbreak, but exposure in fair’s livestock barn deemed “likely”

Best practices for planning events encouraging human-animal interactions

Zoonoses and Public Health

G. Erdozain , K. KuKanich , B. Chapman  and D. Powell

http://onlinelibrary.wiley.com/doi/10.1111/zph.12117/abstract?deniedAccess

Educational events encouraging human–animal interaction include the risk of zoonotic disease transmission. It is estimated that 14% of all disease in the US caused by Campylobacter spp., Cryptosporidium spp., Shiga toxin-producing Escherichia coli (STEC) O157, non-O157 STECs, Listeria monocytogenes, nontyphoidal Salmonella enterica and Yersinia enterocolitica were attributable to animal contact. This article reviews best practices for organizing events where human–animal interactions are encouraged, with the objective of lowering the risk of zoonotic disease transmission.

Petting zoo illnesses make me sad because the food and ag community has failed

I’m a fan of agritourism, whether that’s touring a bunch of backyard chicken coops or learning about animals, I see value in this stuff. It’s not without risk though – and managing that risk is imperative. A while ago someone asked me about the types of food businesses I like to frequent, from a food safety perspective, and I thought about it a while and came up with this: I like to eat food from places where the people involved in making decisions are constantly worried about making people sick. Like it’s their nightmare. Not places that tell me not to worry about stuff.

My petting zoos/animal interaction wants are the same.

A few years ago my friend (and Carolina Hurricane superfan), Dr. Megan Jacob and I took a couple of visits to animal education/interaction sites to get some ideas about what people do (visitors and organizers). From those visits we saw a lot of stuff that made us think we need to take a different approach. Lots of signs saying to wash hands. Don’t bring food around the animals, don’t bring strollers.

And not a lot of people following the messages. I don’t blame the visitors. I blame us (or at least the collective us) for not doing a better job at saying why it’s important, not having enough people there with reminders and actively helping visitors reduce their risks.

A couple of years ago Gonzalo Erdozian esteemed member of the barfblog team, looked at what was available at a bunch of small petting zoo sites/events in Kansas and Missouri – and came up with some great suggestions after finding lots of risky practices (abstract is below). Reducing risks at fairs and petting zoos isn’t a simple thing – it’s a mix of having the tools, people to point patrons to them, and explaining the risks (without being jerks).

Gonzo found that the reminders really worked.

After those visits, Megan and I, with the help from some others put together a workshop for NC folks who run these events and sites. We learned a whole bunch more from the participants – one of the biggest takeaways for me was that organizers were reluctant to engage in these discussions because although they knew that there was a risk, they didn’t want to alert people who were there that it was risky because maybe they wouldn’t come. I’m not sure what the correct word for that is, but it seems paternalistic or something. One philosophy we’ve followed at barfblog is that people can handle risk discussions and we’re kinda responsible to have them. And let the participants choose.

I home almost daily past the Kelley Building, ground zero for an E. coli O157:H7 outbreak in 2011 linked to 25 illnesses at  the NC State Fair. The building wasn’t considered to be an animal contact area – a petting zoo – but was a spot that was a popular cut-through from an entrance gate to the midway area. Organizers of the fair led a commission to look at what happened, and made changes – having more handwashing stations, passive reminders and actively having actual people reminding; further limiting access to non-petting zoo animal buildings; and, increasing cleaning and sanitation.

People brought food, strollers, and their hands touched a lot of likely contaminated handles and rails.

Over the weekend news broke of another tragic cluster of illness linked to fair/animal interactions. 

A 2-year-old boy died and three others were sickened upon contracting the E. coli virus after coming into contact with farm animals at the San Diego County Fair, according to authorities.

The child was hospitalized after visiting the county fair two weeks ago, and died Monday after complications stemming from the virus, the San Diego County Health and Human Services Agency confirmed on Friday. The other three children did not need medical attention.

A 2-year-old boy died and three others were sickened upon contracting the E. coli virus after coming into contact with farm animals at the San Diego County Fair, according to authorities.

The child was hospitalized after visiting the county fair two weeks ago, and died Monday after complications stemming from the virus, the San Diego County Health and Human Services Agency confirmed on Friday. The other three children did not need medical attention.

The frustrating nexus of these (and all the other illnesses) is that it’s good for folks to learn about agriculture and farming and food by seeing and interacting – and that very situation is risky.

What doesn’t help is when the agricultural community scoffs at these illnesses (I haven’t heard it on this one, but have in the past) essentially saying that handwashing is common sense, so these illnesses happen because people are ignorant. Except that all falls apart because we (the folks in the know) haven’t done our job telling folks how they can manage some of the risk of getting sick, and how organizers are also trying to reduce the risk to patrons. By missing that, we’re not doing everything we can to ensure that the safe behaviors take place. And that makes me sad.

Erdozain G, Kukanich K, Chapman B, Powell D. 2012. Observation of public health risk behaviours, risk communication and hand hygiene at Kansas and Missouri petting zoos – 2010-2011. Zoonoses Public Health. 2012 Jul 30. doi: 10.1111/j.1863-2378.2012.01531.x. [Epub ahead of print]

Outbreaks of human illness have been linked to visiting settings with animal contact throughout developed countries. This paper details an observational study of hand hygiene tool availability and recommendations; frequency of risky behavior; and, handwashing attempts by visitors in Kansas (9) and Missouri (4), U.S., petting zoos. Handwashing signs and hand hygiene stations were available at the exit of animal-contact areas in 10/13 and 8/13 petting zoos respectively. Risky behaviors were observed being performed at all petting zoos by at least one visitor. Frequently observed behaviors were: children (10/13 petting zoos) and adults (9/13 petting zoos) touching hands to face within animal-contact areas; animals licking children’s and adults’ hands (7/13 and 4/13 petting zoos, respectively); and children and adults drinking within animal-contact areas (5/13 petting zoos each). Of 574 visitors observed for hand hygiene when exiting animal-contact areas, 37% (n=214) of individuals attempted some type of hand hygiene, with male adults, female adults, and children attempting at similar rates (32%, 40%, and 37% respectively). Visitors were 4.8x more likely to wash their hands when a staff member was present within or at the exit to the animal-contact area (136/231, 59%) than when no staff member was present (78/343, 23%; p<0.001, OR=4.863, 95% C.I.=3.380-6.998). Visitors at zoos with a fence as a partial barrier to human-animal contact were 2.3x more likely to wash their hands (188/460, 40.9%) than visitors allowed to enter the animals’ yard for contact (26/114, 22.8%; p<0.001, OR= 2.339, 95% CI= 1.454-3.763). Inconsistencies existed in tool availability, signage, and supervision of animal-contact. Risk communication was poor, with few petting zoos outlining risks associated with animal-contact, or providing recommendations for precautions to be taken to reduce these risks.

 

 

Food safety at fairs and festivals

Tanya Banuelos of the Argus Observer writes:

As the last few weeks of summer vacation dwindle down and families are taking advantage of outdoor food at barbecues, picnics and the county fair, it’s time to talk about warm weather and food safety.
With 100-degree weather expected this week, it’s important to remember how much sooner food can become perishable when it’s out in the heat.
When it comes to food safety, food handlers at the Malheur County Fair must adhere to health guidelines, and an inspector is on site throughout the week. And as with every year at the fair, for those who sell consumable goods, food safety is a priority for vendors, such as Awesome Blossom and Fiesta Guadalajara.
Rely on equipment
One of the key details to remember is the importance of temperature.
Modesto Vega, co-owner of Fiesta Guadalajara, said he is able to keep foods at the appropriate temperature during the fair with commercial equipment.

I have inspected my fair share of temporary events including festivals and fairs and not all vendors are equipped with commercial fridges, freezers, etc. If you got them, all the power to you. I would typically see a lot of residential equipment, some good and some bad. As long as cold/hot holding temperatures are maintained, I’m good.

There have been a myriad of outbreaks associated with outdoor events nationally and internationally. The ethnic nature and diversity of foods prepared coupled with extreme temperatures pose unique problems for public health types. Public health inspections of said facilities rarely assess behavioral practices; rather, they are focused on meeting Regulatory standards. Time commitment and lack of public health staff have a lot to do with this, I have experienced this personally.

Effective food safety training during these events is critical. A number of operators at fairs and festivals are typically required to take a mandatory 8- hour food safe course or variation thereof prior to the event. I would rather see on-site hands-on training during vendor set-up focusing specifically on their menu items to ensure food safety, a mini HACCP if you will. If a vendor intends on serving hamburgers, well let’s go over what you need to do to ensure that no one barfs from your hamburgers.

Therman Collins, who has been a food vendor at the fair for eight years, said the key to keeping food safe for consumption is to make it fresh and send it right on out, adding that when it comes to food safety, “we know it all.”
Time, temperature equally important
When food is already cooked, especially with warm temperatures, how long people keep their food outside is a cause for concern, according to the Oregon Health Authority.
Most picnic foods will only be safe on the table for two hours; however, if the air temperature is higher than 90 degrees Fahrenheit, then the food is only safe for an hour.
Most importantly, food should be kept out of the danger zone, where cold foods are recommended to be kept below 40 degrees Fahrenheit, and hot foods above 140 degrees Fahrenheit, according to the United States Department of Agriculture.