39 sickened: Cow shit carries bugs: Campy outbreak in drinking water, Nebraska 2017

Jim still has nightmares.

It’s the helicopters.

We live near the publicly-funded Princess Alexandria hospital in Brisbane.

A helicopter flies over our house a couple of times a day bringing some victim from the outback or the coast.

The state of Queensland is really, really big.

It reminds me of my friend, Jim, and what he went through in the aftermath of the E.coli O157 outbreak in drinking water that killed seven and sickened 2,500 in the town of Walkerton, population 5,000.

Jim knew that every helicopter was someone dead or dying being flown to the medical center in London, Ontario (that’s in Canada, like Walkerton).

I think of Jim and the victims every time a chopper goes past.

The U.S. Centers for Disease Control reports a center pivot irrigation system intended to pump livestock waste water onto adjacent farmland in Nebraska malfunctioned, allowing excessive run off to collect in a road ditch near two wells that fed a municipal water supply, sickening 39 persons who consumed untreated city water. The use of culture-independent diagnostic tests facilitated case identification allowing for rapid public health response.

Access to clean water sources continues to be an important public health issue, and public health professionals should consider exposure to untreated water sources as a potential cause for Campylobacter outbreaks.

In March 2017, the Nebraska Department of Health and Human Services (NDHHS) and the Southwest Nebraska Public Health Department were notified of an apparent cluster of Campylobacter jejuni infections in city A and initiated an investigation. Overall, 39 cases were investigated, including six confirmed and 33 probable. Untreated, unboiled city A tap water (i.e., well water) was the only exposure significantly associated with illness (odds ratio [OR] = 7.84; 95% confidence interval [CI] = 1.69–36.36). City A is served by four untreated wells and an interconnected distribution system. Onsite investigations identified that a center pivot irrigation system intended to pump livestock wastewater from a nearby concentrated animal feeding operation onto adjacent farmland had malfunctioned, allowing excessive runoff to collect in a road ditch near two wells that supplied water to the city. These wells were promptly removed from service, after which no subsequent cases occurred. This coordinated response rapidly identified an important risk to city A’s municipal water supply and provided the evidence needed to decommission the affected wells, with plans to build a new well to safely serve this community.

On March 10, 2017, NDHHS was notified of five reports of campylobacteriosis in the Southwest Nebraska Public Health Department jurisdiction. Two positive culture reports and three positive culture-independent diagnostic tests, specifically a gastrointestinal polymerase chain reaction (PCR) panel, were received from persons not living together. Campylobacteriosis is a reportable condition in Nebraska, and this number of cases was higher than expected; during 2006–2016, an average of one Campylobacter case was reported in a city A resident every 3 years. Initial questioning of ill persons did not include an assessment of exposure to untreated drinking water and suggested ground beef consumption as a possible shared exposure. The Nebraska Department of Agriculture Food Safety and Consumer Protection obtained distribution records for poultry and ground beef for two local restaurants and one local grocery store. The distribution of poultry and ground beef was evaluated by reviewing the routing records of these products to their source, and no evidence of a shared poultry source was identified. The ground beef was not ground in-house at the grocery store, and the distributors that supplied ground beef to the grocery store and each of the two local restaurants were not shared. Through interviews of city A residents and business owners, investigators were made aware of a report of standing water that “smelled of cattle manure” in a roadside ditch near two municipal water wells.

A collaborative on-site investigation revealed that during the pumping of a large volume of livestock wastewater from a concentrated animal feeding operation through a center pivot irrigation system, the system malfunctioned at an undetermined time. The wastewater was intended to be placed on adjacent farmland. This malfunction allowed excessive runoff to flood a road ditch approximately 15 feet (4.6 m) from two municipal water well houses (3 and 4) that had been operating 6 days before the onset of illness in the first patient. The presence of this standing water was confirmed by city A water operators, who reported seeing water in the ditch for 4 days (February 22–25) (Figure). Pump records indicated that during February 22–27, well 3 was in use, and during February 28–March 7, well 4 was in use (Table 1). During both periods, another well (well 2) was also operating. Wells are rotated in and out of service by city operators as part of regular operations. Water is distributed through the well system without any disinfection or filtration. Routine total coliform and Escherichia coli testing of water from the distribution system was performed on March 8; however, only wells 2 and 5 were operating on that date. As part of the investigation, additional coliform and E. coli testing was performed again on March 16 on direct samples from wells 2, 3, 4, and 5; bacterial culture specifically for Campylobacter was performed on March 20 (wells 4 and 5) and 27 (wells 2 and 3). All samples were negative for coliforms and Campylobacter. No additional pump or testing records were reviewed.

On March 16, Nebraska Department of Environmental Quality and the Department of Agriculture conducted an additional investigation of two concentrated animal feeding operation–certified waste lagoons (a manufactured basin that collects livestock waste and water in an oxygen-deprived setting to promote anaerobic conditions as a way to manage refuse)* and associated use of three pivot irrigation systems. The investigation team observed that water from the waste lagoons had been pumped through a pivot onto an adjacent field, which is a common farming practice for fertilizing farm ground or watering crops. City operators confirmed that on February 24 they had observed flow of livestock wastewater into the road ditch near well 4. They followed the wastewater up the road ditch and reported that it came out of the farmland upstream from the wells. Investigators also obtained details of total well depths, static water levels, and pumping water levels (measured during active pumping). Wells 4 and 3 were relatively shallow, with static water levels of 21 and 22 feet, pumping levels of 25 and 26 feet, and total well depths of 43 and 46 feet, respectively; both began service in the 1930s, similar to the other wells in the system, which were also older.

While details around this event were being clarified and environmental testing was pending, an Internet-based questionnaire was designed to aid case-finding and assess potential exposures. A probable case was defined as a diarrheal illness of ≥2 days’ duration with one or more additional signs or symptoms (nausea, vomiting, fever, chills, or headache) in a city A resident, with onset during February 28–March 23, 2017. A confirmed case was defined as a person meeting the probable case definition with either stool culture or PCR-positive results for Campylobacter, or a laboratory-confirmed probable illness in a nonresident who worked, dined, or shopped for groceries in city A. Among approximately 600 city A residents, 94 (16%) completed a questionnaire to report food consumption history, drinking water source, animal exposures, and symptoms. Among questionnaire respondents, 39 (41%) campylobacteriosis cases (six confirmed and 33 probable) were identified, with illness onset from February 28–March 21 (Figure); 25 (64%) cases occurred in females and 14 (36%) in males. The median age was 34.5 years (range = 1.5–85 years). Twelve (31%) patients sought medical care, and three (8%) were hospitalized; no deaths were reported.

Data analysis indicated a significant association between ill persons and consumption of untreated, unboiled municipal tap water (OR = 7.84; 95% CI = 1.69–36.36) (Table 2). Other exposures were assessed, including unpasteurized milk, animal contact, raw poultry, and ground beef, but none demonstrated a significant association with illness. Notably, no cases were reported among the approximately 28 residents of city A’s only nursing home, which used city water but treated it with a reverse osmosis system.

Public Health Response

Wells 3 and 4 were both permanently removed from service on March 16, and no additional illnesses were reported with onset after March 21. On April 25, NDHHS reclassified these wells to Emergency Status, meaning the well can only be pumped during a case of emergency (e.g., fire, drought, etc.) for nonpotable purposes. Furthermore, meetings were held with area stakeholders to present these findings as evidence to support the award of a planning grant to city A to explore options for a new, higher-volume well to be dug to an acceptable depth in a different location.

This investigation implicates Campylobacter jejuni as the cause of this outbreak, most likely from a municipal water system contaminated by wastewater runoff from an adjacent concentrated animal feeding operation (1). In addition to environmental and statistical findings, this conclusion is consistent with prior investigations that demonstrate Campylobacter outbreaks of similar size are historically associated with contaminated water (2–7). Although laboratory testing of the water in this investigation did not yield any positive results, samples were not taken until long after the contamination event, and test results might have been affected by switches among wells supplying the system over time. These findings also suggest that routine coliform testing might not be a good indicator of the presence of Campylobacter species (8). Further, it is possible that Campylobacter in particular might be viable but not necessarily detectable by culture in water systems (9,10). The use of both culture and culture-independent diagnostic tests (PCR) were needed to detect the initial cluster of cases and early recognition of this outbreak. If culture alone had been used, only two cases would have been reported, one of which did not occur in a city A resident. Of those two culture-confirmed cases, one patient refused the interview and the other had typical Campylobacter exposures, such as live poultry, which might not have prompted such a rapid response. This investigation demonstrates the importance of considering exposure to untreated water sources as a potential cause for Campylobacter outbreaks. Including this risk factor in initial questioning could help to expedite outbreak investigations. Ultimately, early recognition and a coordinated response by several state and local agencies greatly facilitated this successful public health intervention.

Campylobacteriosis outbreak associated with contaminated municipal water supply-Nebraska, 2017



Caitlin Pedati, Samir Koirala, et al


Nebraska basketball team hit with food poisoning


I used to play basketball when I was younger and was MVP in high school. Now I would be lucky if I could dribble the ball properly.

I guess it would be hard to practice when you’re on the verge of barfing.

10/11 Now reports

The Nebraska Wesleyan men’s basketball team had to battle food poisoning Monday, as only nine players practiced with several sick, including Head Coach Dale Wellman.

Wellman said he was forced to sleep in his office while he tried to prepare for the national semifinals.

The Prairie Wolves think it was actually the meal before their Elite 8 win that caused over half the team to get sick.

Nebraska Wesleyan advanced to the Final Four over the weekend and will play on Friday in Salem, Virginia.

That will be the program’s fifth Final Four appearance.

E. coli O165:H25 in Nebraska cattle

Russ Rice a DVM from Broken Bow, Nebraska, writes in Bovine Veterinarian that a recent experience in a Nebraska feedlot, supported by extensive diagnostic work from veterinarians at the University of Nebraska-Lincoln, indicates Escherichia coli O165:H25, an enterohemorrhagic strain, can cause disease in cattle and potentially poses a food-safety hazard for humans.

Russ RiceNebraska veterinarians whose work on this case proved critical in establishing a diagnosis and analyzing the implications included Bruce Brodersen, DVM, PhD, Dee Griffin, DVM, MS, John D. Loy, DVM, PhD and Rodney A. Moxley, DVM, PhD.

The case report was published in JMM Case Reports in November 2015, in an article titled “Haemorrhagic colitis associated with enterohaemorrhagic Escherichia coli O165:H25 infection in a yearling feedlot heifer.” Authors, in addition to Brodersen, Loy and Moxley, included Zachary R. Stromberg and Gentry L. Lewis from the University of Nebraska School of Veterinary Medicine and Biomedical Sciences, and Isha R. Patel and Jayanthi Gangiredla from the FDA’s Center for Food Safety and Applied Nutrition.

This case began in early January, 2014, with a pen of 170 Iowa-origin heifers, averaging 160 pounds, in a Nebraska feedlot. The 54 mega-calorie ration included dry and high moisture corn, 32% wet distillers’ grains, syrup, roughage, standard supplements and Bovatec.

In February, the feedlot crew began pulling some heifers from the pen for respiratory disease treatment. Crews noted that some bloody stools were present in the pen, and we treated the cattle with amprolium based on a presumptive diagnosis of coccidiosis. Bloody stools persisted though, and one animal died and another showed neurological signs and bloody diarrhea on February 18th. We euthanized that heifer using methods approved by the University of Nebraska Institutional Animal Care and Use Committee, and conducted a necropsy immediately. The gross lesion appeared to be acute inflammation of the cecum and colon. Our differential diagnosis included coccidiosis, salmonellosis, BVD, bovine coronavirus and clostridial enteritis.

We prepared fresh and fixed specimens and sent them to the UNL diagnostic laboratory for analysis. Dr. Loy’s laboratory isolated a strain of E. coli from the colonic mucosal tissue, and Dr. Brodersen noted histopathologic lesions in the colon that were suggestive of infection with a strain of attaching-and-effacing E. coli. He consulted with Dr. Moxley, an E. coli researcher, who requested the gross and fixed tissues for further study. Upon close examination, Dr. Moxley found small erosions in the colonic mucosa which he photographed.  He then had his laboratory conduct other cultures, and had the original E. coli isolate serotyped.  The isolate was determined to be an O165:H25 serotype.  At this point, Dr. Moxley obtained specific antiserum to O165, and had the histology laboratory of the diagnostic lab conduct immunohistochemistry using this antiserum. Dr. Moxley found O165-positive bacteria in lesion sites corresponding to the gross erosions, and it was then that the cause of the lesions was confirmed. He had the isolate tested further by microarray analysis through collaborators at the FDA. It was found to contain virulence genes corresponding to type III secretion system (T3SS) structure and regulation. Microarray analysis of another E. coli strain (serotype O145:H28) isolated from the same tissue by the Moxley laboratory ruled the latter organism out as a pathogen in the case because that strain was found to have a number of mutations that inactivated virulence genes, such as those of the T3SS. Details of the molecular typing are included in the paper published in JMM Case Reports. …

The O165:H25 serotype is similar to E. coli O157:H7, and could be an emerging food-borne pathogen in cattle and beef. The pathogen has been isolated from the feces and beef carcasses of cattle, but has not previously been associated with disease in cattle. UNL scientists note that the serotype has been involved in uncommon, but potentially severe disease in humans. Based on findings in this case, we suggest veterinarians include enterohemorrhagic E. coli in their list of differential diagnoses when they see enteric disease, particularly bloody diarrhea, in feedlot cattle. If EHEC is suspected, veterinarians should work with their diagnostic laboratory to ensure proper collection, handling and submission of appropriate samples for diagnosis.

At the diagnostic laboratory, Drs. Moxley, Brodersen, and Loy indicate that these lesions might not have been seen in samples taken as early as ten minutes of death. Fortunately in this case, in which we euthanized the heifer and were able to collect samples immediately, we were able to verify this unexpected diagnosis. Most of the time, post-mortem changes will occur before we get the opportunity to collect samples.

Several veterinarians have commented to me they may have missed cases of EHEC in the past. I probably have missed these as well. Going forward, I plan to take extra care in collecting samples and communicating this to our clients. This case serves as a good reminder of the public-health risk we face on a daily basis. We all need to emphasize this to our clients and staff.

Another audit, more failings with restaurant inspection, Nebraska-style

From the state with the creepiest football mascots, Nebraska’s Douglas County’s switch from paper to digital food safety records is taking much longer than expected, leaving restaurant patrons in the dark.

nebraska.cornhuskersEighteen months have elapsed since the Douglas County Health Department signed a contract for a digital record-keeping system to track inspections of food and drink establishments. But persistent delays with the software vendor have pushed back the start date into next year.

The lack of progress was highlighted this week when State Auditor Charlie Janssen released an audit showing that food safety inspections in Nebraska are routinely late.

Douglas County health officials disputed the audit’s findings, but it took some time for them to assemble the numbers to back up their claims.

That’s because in Nebraska’s largest county, those records still exist only on paper.

Douglas County Health Director Adi Pour acknowledged that restaurant inspections sometimes lag in the spring, when food and drink inspectors are busy helping other divisions. But the backlog is always cleared, she said.

ghostbuster.marsmellow“At the end of every year, we are caught up,” she said.

As The World-Herald reported last year, inspection records for food and drink establishments can be difficult to obtain in Douglas County and elsewhere in Nebraska.

Unlike many other cities and states in the region, Douglas County does not have an electronic system to manage those public records. Instead, every month, the department posts a snapshot of inspection scores online.

Hundreds of Nebraska food safety inspections running late

Nebraska food safety officials are late inspecting hundreds of restaurants, meat markets and other food establishments, according to a new state audit.

nebraska.restThe problem affects nearly one of every three food facilities inspected by the State Department of Agriculture. Food safety checks are more than four years overdue in some cases, the audit said.

Douglas, Lancaster and Hall Counties are inspected by local health departments working under contract with the state. The audit raises questions about whether those inspections are being done on time, but state and local officials said that conclusion is based on faulty state records.

In addition, the audit found that state agriculture inspectors are overdue in checking the accuracy of 14 percent of weighing and measuring devices, ranging from the scales used at supermarket checkout counters to fuel pumps to railroad weight scales. The oldest cases were 11 to 23 years late. The audit does not provide details such as the names or locations of the establishments involved.

The late inspections of food establishments and of weighing and measuring devices were the top concerns raised by an Agriculture Department audit recently released by State Auditor Charlie Janssen’s office.

Bobbie Kriz-Wickham, an Agriculture Department spokeswoman, did not dispute the audit findings.

She said Wednesday that eliminating the backlog of inspections is a “huge priority” for the department and has been a focus of efforts since the current food program manager started in February.

“The audit report confirmed what we were already working on,” Kriz-Wickham said. “We definitely need to get to all of them (overdue inspections) that are on the list.”

She said department officials aim to catch up by January on inspections of facilities deemed at high risk because they prepare or serve food that could potentially cause illness. The goal for catching up with other inspections is June 1.

The Agriculture Department’s food program is responsible for inspecting 6,135 food facilities across 90 of the state’s 93 counties. The department contracts with local health departments to do food safety checks in Douglas, Lancaster and Hall Counties.

Under Agriculture Department policy, inspections are to be done every six months at the highest risk places, such as full-service restaurants, school cafeterias, nursing home kitchens and food processing plants.

Inspections are to be done every 12 months for medium-risk places with limited food preparation, such as fast-food restaurants and cook-to-order kitchens. Low-risk places, which handle only prepackaged or bulk foods, are to be inspected every 18 to 24 months.

Based on department records, the audit found that inspections were overdue for 1,882 facilities, including 1,232 high-risk facilities.

In addition, as of June 8, there were 94 newly licensed food establishments that had never been inspected.

Is that all there is? Norovirus suspected by Nebraska health department

The Lincoln-Lancaster County Health Department is investigating an incidence of what it suspects is norovirus.

Details of who may have the highly contagious disease, where and how it was reported were not available from the department. 

“We have an ongoing investigation, so we can’t discuss specifics,” said Tim Timmons, communicable disease program supervisor. “At this point we suspect norovirus, but we’re still investigating. There is no risk to the public at this time.” 

Is that all there is?

We’ve done it this way for years no one sick: Iowa edition

Hamburg and Farragut schools are taking precautions against salmonella and waiting for information from state health authorities regarding four students reportedly treated for the bacterial disease.

Hamburg School Superintendent Jay Lutt said it’s unknown whether the cases in his district are linked to the salmonella outbreak in 20 states belushi.cafeteriaconnected to Foster Farms. However, he says an investigation determined the illnesses are not linked to the district’s food provider.

“Even before I knew about that outbreak,” said Lutt, “I called the provider of our foods, which provides to all schools in southwest Iowa. In their 31 years of business, they have not had a case of salmonella. One thing we’re pretty certain is that it didn’t come from any of the food we bring in from their main supplier.”

Restaurant inspections to become available on Lincoln, Nebraska website

Lincoln, Nebraska, home to many food safety types at the University of Nebraska, has finally joined hundreds of other communities by providing food inspection reports online.

The JournalStar reports that Mayor Chris Beutler also announced that the Lincoln-Lancaster County Health Department has received a $350,000, five-year federal grant to reduce foodborne illnesses originating from retail food businesses.

The city will hire a food safety consultant to work with problem businesses and with a newly established task force that will identify barriers that hinder staff from using safe food practices, Beutler said.

The health department will report on its findings, on what works well, to the U.S. Food and Drug Administration.

The link to the restaurant inspection site is available by typing “food inspection” in the search line on the city’s home page, www.lincoln.ne.gov.

19 sick; Salmonella outbreak in Nebraska care facility

South Heartland District Health Department along with the Nebraska Department of Health and Human Services is investigating an outbreak of salmonellosis associated with the Blue Hill Care Center in Webster County. To date there have been 17 confirmed cases and 2 probable or suspected cases reported in residents, staff or visitors. Four residents were temporarily hospitalized after showing symptoms. A visitor is still hospitalized. Blue Hill Care Center is cooperating fully with the investigation to help identify the source and eradicate the issue.

Anyone experiencing symptoms consistent with Salmonella should contact their doctor for recommendations on testing and treatment. For further information or to report suspected cases, contact South Heartland District Health Department toll free at 1-877-238-7595.


Blame the consumer – Nebraska-style

Campylobacter is on the rise, so the Douglas County Health Department has decided to remind consumers they are the critical control point when it comes to food safety.

With 40 confirmed cases of campylobacter this year — 35 per cent of cases treated in an emergency department and 12 per cent requiring hospitalization – the health department reports 85 per cent of those who became ill had eaten poultry products and 32 per cent had handled raw meat. All of the cases have involved meals prepared in the home.

With 40 people, this percentage talk is fairly meaningless. The press release also does not state whether these campylobacter cases involved frozen chicken thingies. And yes, it’s important for consumers to handle any raw food like it’s toxic waste, but why isn’t the public health dude asking, why so much campylobacter in food?

Douglas County Health Director Dr. Adi Pour said,

“This illness can be prevented with just a little extra precaution. The cases range in age from less than one year to over 80 years of age.”

The release also states that,

“cooked food appears to have been contaminated when it was reintroduced to plates that previously held the meat which had dripped juice on the plate.”

If there are 40 cases of campylobacter in Nebraska that can be traced to cross-contamination via plates, this is a significant research finding and should be published immediately in a peer-reviewed journal. We have found in our own research that cross-contamination is much higher than anyone expects. But then the release goes into standard talk of “Clean, Separate, Cook, Chill,” so maybe this is speculation rather than a scientific assessment.

Don’t know, can’t tell. Maybe the people who write press releases should provide more information and be less patronizing.