341 sick, 1 dead; no source found food worker suspected; epidemiology of 2008 E. coli O111:NM outbreak at Oklahoma restaurant

In Aug. 2008, 26-year-old Chad Ingle had a meal at the Country Cottage in Locust Grove, Oklahoma, a popular family-owned buffet-style restaurant.

Nine days later, Chad was dead from E. coli O111.

By the end of the outbreak, 341 people had been sickened with E. coli O111, all from eating at the country diner in a town of 1,423 people.

Early in the outbreak investigation, health types said it was unlikely that any well water contamination was the source of the outbreak.

A paper describing the investigation was published last week in
Epidemiology and Infection
and concluded from epidemiological evidence the outbreak resulted from cross-contamination of restaurant food from food preparation equipment or surfaces, or from an unidentified infected food handler.

From the paper:

The establishment was out of compliance with five regulations associated with hot and cold holding of foods, food storage, labeling and storage of toxic items, and cleanliness of food contact surfaces. The restaurant did not have written protocols or schedules for cleaning the kitchen, buffet, dining, or bathroom areas. A diluted bleach solution was used to clean surfaces and food spills, but there was no established method for monitoring the concentration.

The restaurant owners disclosed that their private well had been accessed briefly on 10 August to supply water to the restaurant when a sudden interruption of the municipal water system occurred during a lunch period of high volume patronage. The private well was the sole water source for a few hours on this date, but was not accessed again once the municipal water service was restored. The well was physically located
on the restaurant property, which is positioned on a major road on the outskirts of a small rural community.

Pasture land with livestock adjoins the property on the rear aspect of the restaurant. Well water samples collected on 27 and 29 August were positive for total and fecal coliforms. Numerous types of bacteria, including Proteus , Klebsiella , Serratia,
Enterobacter, Pseudomonas , and Pantoea species were cultured from the well-water samples. E. coli isolates were also identified, but none were Stx-producing or serogrouped as O111. PCR testing by the CDC Waterborne Diseases Laboratory also failed to detect the presence of E . coli O111.

To our knowledge this is the largest community outbreak of E. coli O111 on record. Several potential vehicles of introduction and contributing factors for spread within the restaurant were explored, including a primary contaminated food item, an infected food handler, contaminated well water, and cross-contamination from restaurant surfaces or equipment harboring the organism. Multiple specimens representing these potential vehicles were obtained for laboratory testing, but E. coli O111 was not isolated by culture or identified by molecular methods in any of them. The epidemiological findings suggest that foodborne transmission of E. coli O111 through
various food items – either contaminated directly by an infected food handler’s hands or by cross-contamination from food preparation equipment, counter surfaces, or storage areas – occurred at the restaurant.

While bacterial culture and Shiga toxin testing of submitted stool specimens did not identify an infected food handler, epidemiological findings are most consistent with foodborne transmission by an ill employee who continued to work, or by an asymptomatic food handler. Two employees, one with hostess duties and the other a food handler, reported working with diarrheal illness during 15–17 August.

The U.S. Centers for Disease Control says there had been 10 previous outbreaks of E. coli O111, of which four were linked to food. Before the Oklahoma outbreak the biggest O111 outbreak happened in New York in 2004. Unpasteurized apple cider was blamed for 212 illnesses.

In 1995, E. coli O111 sickened 173 people and killed a four-year-old girl in Australia, after eating contaminated mettwurst, an uncooked, semi-dry fermented sausage.

A table of non-O157 shiga-toxin producing outbreaks is available at http://bites.ksu.edu/nonO157outbreaks.

Abstract below.
Epidemiology of a large restaurant-associated outbreak of Shiga toxin-producing Escherichia coli O111:NM***
Epidemiology and Infection, pp 1-11
K.K. Bradley, J.M. Williams, L.J. Burnsed, M.B. Lytle, M.D. McDermott, R.K. Mody, A. Bhattarai, S. Mallonee, E.W. Piercefield, C.K. McDonald-Hamm and L.K. Smithee
In August 2008, a large outbreak of Shiga toxin-producing Escherichia coli (STEC) O111:NM infections associated with a buffet-style restaurant in rural Oklahoma was identified. A case-control study of restaurant patrons and a retrospective cohort study of catered event attendees were conducted coupled with an environmental investigation to determine the outbreak’s source and mode of transmission. Of 1823 persons interviewed, 341 (18·7%) met the outbreak case definition; 70 (20·5%) were hospitalized, 25 (7·3%) developed haemolytic uraemic syndrome, and one died. Multiple food items were significantly associated with illness by both bivariate and multivariate analyses, but none stood out as a predominant transmission vehicle. All water, food, and restaurant surface swabs, and stool cultures from nine ill employees were negative for the presence of Shiga toxin and E. coli O111:NM although epidemiological evidence suggested the outbreak resulted from cross-contamination of restaurant food from food preparation equipment or surfaces, or from an unidentified infected food handler.

Ladies Tea outbreak linked to Country Cottage

An E. coli O111 outbreak linked to Country Cottage, a Locust Grove, OK buffet restaurant, has expanded to a church gathering in Broken Arrow, OK (not to be confused with Neil Young’s home, the Broken Arrow Ranch in Northern California). 

According to KFSM, Tests show at least one person at the tea, which was catered by Country Cottage, has E. coli O111. There are four additional probable cases and 10 suspected cases.

The Country Cottage outbreak was the inspiration for the latest iFSN infosheet, which you can download here.

E. coli O111 toll in Oklahoma: 1 dead, 206 sick

On Feb. 1, 1995, the first report of a food poisoning outbreak in Australia involving the death of a child from hemolytic uremic syndrome (HUS) after eating contaminated mettwurst, an uncooked, semi-dry fermented sausage, reached the national press. The next day, the causative organism was identified in news stories as E. coli O111, a verotoxigenic E. coli (VTEC) which was previously thought to be destroyed by the acidity in fermented sausage products like mettwurst. By Feb. 3, 1995, the child was identified as a four-year-old girl and the number sickened in the outbreak was estimated at 21.

By Feb. 6, 1995, the manufacturers, Garibaldi Smallgoods, declared bankruptcy. Sales of smallgoods like mettwurst plummetted anywhere from 50 to 100 per cent according to the National Smallgoods Council.

The outbreak of E. coli O111 and the reverberations fundamentally changed the public discussion of foodborne illness in Australia, much as similar outbreaks of VTEC in Japan, the U.K. and the U.S. subsequently altered public perception, regulatory efforts and industry pronouncements in those countries.

In all, 173 people were stricken by foodborne illness linked to consumption of mettwurst manufactured by Garibaldi smallgoods. Twenty-three people, mainly children, developed HUS, and one died. Although sporadic cases of HUS had been previously reported, this was the first outbreak of this condition recognized in Australia.

The citizens of Locust Grove, Oklahoma, a community of 1,500 about 50 miles east of Tulsa, now know about E. coli O111. What no one knows is how it got into food associated with the Country Cottage restaurant

Health officials, who first reported the outbreak Aug. 25, said Tuesday that 206 people have become sick, including 53 children. Those sickened range in age from 2 months to 88 years.

The outbreak has been blamed for the death of 26-year-old Chad Ingle of Pryor, who died Aug. 24, a week after eating at the restaurant.

Search for E. coli O111 source continues in Oklahoma; 1 dead, 175 sick

The Oklahoma State Department of Health (OSDH) reported Saturday Aug. 30/08 that at least 176 persons have become ill as a result of the E. coli O111 outbreak in northeastern Oklahoma. Cases include 128 adults and 48 children. Federal and state health officials say E. coli O111 is a rare type not normally associated with an outbreak this large.

OSDH disease investigators, along with staff from Tulsa Health Department and area local county health departments, have interviewed more than 450 persons in an effort to identify the source of the outbreak. Interviews continue this weekend.

While the source has not yet been identified, health officials continue to focus on the Country Cottage restaurant in Locust Grove, OK, after interviews with cases indicated most had eaten there during the time period Aug. 15 through Aug. 23.

The restaurant is closed while the investigation continues. Not all persons who ate at the restaurant have become ill. No other restaurant or food service outlet in the area has been linked to the outbreak.

OSDH laboratory analysis of water samples taken from a private well on the restaurant property is continuing, however, health officials believe it is unlikely that any well water contamination is the source of the outbreak.

One person has died in the outbreak.

Suspected E. coli claims Oklahoma newlywed; dozens sickened

The Tulsa World reports that Chad Ingle married the love of his life June 21.

He died just nine weeks later, on Sunday, of what is suspected to be E. coli poisoning. He was 26.

His sister, Laura Claypool, said Ingle ate a meal Sunday Aug. 17 at the Country Cottage in Locust Grove, a popular family-owned buffet-style restaurant.

Ingle fell ill Wednesday night with severe stomach pain and diarrhea and went to Integris Mayes County Medical Center. On Thursday, he began to pass blood.

An ambulance took him to St. Francis Hospital in Tulsa on Friday. He underwent a colonoscopy, and doctors concluded that he had acute colitis, Claypool said.

Ingle felt better Friday evening and urged his parents to return home. But his condition grew worse, and his mother-in-law called Ingle’s parents Saturday morning to return to St. Francis.

"By the time Mom and Dad got there, they had called a code blue," Claypool said. Ingle was placed on kidney dialysis, but he died Sunday, she said.

The Oklahoma State Department of Health said it is investigating an outbreak of severe diarrheal illness among residents of several northeastern Oklahoma communities. At least 17 cases have been hospitalized and 40 or more potential cases are under investigation. One person has died.