Foodborne Illness and the Public Health Nurse

Bureau of EpidemiologySally A. Bidol, MPH

Mark A. Schmidt, MPHOffice of Public Health Preparedness

Susan L. Shiflett

Michigan Department of Community Health

Day 1Monday06/07

Laboratory Report To: Local Health DepartmentFrom: HighTECH Labs, Inc

• Patient: Doe, Thomas• DOB: 12/03/93• Address: 300 Any Street, Anytown,

Michigan• Result: Presumptive E. coli O157:H7

What would you do?

What information will you need to collect?

Information Collected• Onset: Sunday, 5/30• Bloody diarrhea, fever• No travel history• Municipal water• Not aware of any ill contacts• Mother shops at Grocery Store A• Boy Scout trip to petting zoo

Pet

Day 1

Breakfast

Lunch

Dinner

Snack

Day 2

Lunch

Breakfast

Dinner

Snack

Day 3

Breakfast

Lunch

Snack Dinner

What are the most likely causes of infection?

• Food history• Pet• Other exposures

What is the major limitation of the data collected?

• Incubation of E. coli O157:H7:– Median 2 to 4 days– Up to 8 days

Day 2Tuesday

06/08

Laboratory Report To: Local Health Department From: HighTECH Labs, Inc

• Presumptive Positive E. coli O157:H7 – 2 Children

• 9 y/o attends same school as Thomas Doe• 5 y/o attends day care

– 1 Teenager• Works as a food handler at The Healthy Deli

– 1 Adult

School Nurse Reports

• June 1 – 4, 30 children absent• Typically 5 absent• Most gave reason as “Stomach Flu”

Group Questions • Is it time to activate your outbreak

team?– If no, what additional information needs to be

collected before you activate the team• How would you go about:

– Verifying the diagnosis– Searching for additional cases– Determining if cases are associated

• What is your initial hypothesis?

Answers

• Is it time to activate your outbreak team?– Yes

• Verify the diagnosis– Contact students, ask about symptoms and

clinical samples

Answers• Search for additional cases

– Ask cases for others experiencing symptoms

– Contact medical facilities– Contact EH to check for unconfirmed

illness reports– Contact suspect facilities (EH) to ask about

complaints• Determine if cases are associated

– Person, Place, and Time

More Patient Information• Confirmatory reports from MDCH

indicated that 4 patients are positive for E. coli O157:H7 and produce STX I and STX II. PFGE is performed and all isolates are identical.– 2 children on basketball team– Teenager is youth coach of team– Adult is parent of basketball player

• One patient is positive for E. coli O26:NM– 1 child– Not associated with basketball team

More Patient Information

Interpreting Laboratory Reports

E. coli Serotyping

• O = Somatic antigen in cell wall

• H= Flagellar antigens in the flagellar structure

• NM = non-motile, has lost the flagella

• Common serotypes include O157:H7

E. coli Toxin Testing• Shiga-like toxin I and II (STX I, STX II)• More important than serotyping• Presence of STX causes illness

• Cytotoxic effect, inflammation of intestinal wall leading to death of cells

• Results in: –Hemorrhagic colitis–Hemolytic Uremic Syndrome (HUS)–Thrombotic Thrombocytopenic

Purpura (TTP)Website of Dr. Brett Finlay

Dept. of Microbiology and Immunology

Dept. of Biochemistry and Mol. Biology

University of British Columbia

E. coli O157:H7 DNA Fingerprinting

• Pulsed-field gel electrophoresis (PFGE)

• PulseNET

MDCH Laboratory Report

MDCH Laboratory Report

Website of Dr. Brett Finlay

Dept. of Microbiology and Immunology

Dept. of Biochemistry and Mol. Biology

University of British Columbia

What does this mean?

Lab Testing Results

Does this change the direction of your investigation?

0123456789

May26

May27

May28

May29

May30

May31

Jun 1

Jun 2

Jun 3

Jun 4

Jun 5

Jun 6

Illness Onset Date

# of

Cas

es E. coli O157:H7 May - June 2003 (N=28)

Summary of Outbreak

• Implicated meal--Steak House Buffet 5/27• All confirmed E. coli O157:H7 cases

consumed fruit from the salad bar • Basketball team ate from the salad bar

Loosely Based on Milwaukee Sizzler Restaurant Outbreak of 2000

• 736 cases, 63 culture confirmed• 18 hospitalizations, 5 cases HUS, 1

fatality• Sirloin tri-tips• Meat ground within 1 foot of fruit and

vegetable preparation table.

Management of Food Handlers

• Michigan Food Law of 2000 – Regulates all food establishments in

Michigan– Provides essential powers, duties,

penalties– Adoption of FDA Food Code (model)

Exclusions and Restrictions - Definitions

Big 4Salmonella TyphiShigella spp.E. coli O157:H7Hepatitis A virus (HAV)

• High infectivity• Severe medical consequences

High risk conditionsCaused, or exposed to, a confirmed Big 4 outbreak since person-

consumed implicated food, orconsumed food prepared by infected person, orconsumed food prepared by suspected shedder

Lives with someone diagnosed with Big 4Lives with someone who attended/worked at a confirmed Big 4 outbreak

Exclusions and Restrictions ILL Employee Serving General

Population

Diagnosedwith Big 4

Jaundice >7 days

Exposed lesion,boil or wound

Persistent sneezing,coughing or runny nose

Asymptomatic& positive stool

Exclude

GI symptoms

Jaundice within 7 days

Restrict

Child Care CenterAttendance

• E. coli O157 illness– spread is a major concern

• Infected child or care giver should be excluded until:– Diarrhea resolves– 2 negative stool cultures

• Early involvement of local health authorities can prevent further disease

Points to Ponder: Conducting an Investigation

• Remember normal background activity • Teamwork between nursing and EH

essential • What information is pertinent in an

investigation?• How do you interpret the laboratory

results?• Don’t forget your epi tools

Got Food

Poisoning?

Welcome to the

Foodborne Outbreak

Early Detection System (FOEDS) Forum

 

Web users share and

compare info

RUsick2 FORUM

WWW.RUSick2.msu.edu

– Forum for people with suspected foodborne disease to share and compare their pre-illness food history and other factors. Objective: Did they eat the same food items? Identify common source outbreaks.

– Being pilot tested in Greater Lansing Area.

– “Delivers” foodborne disease reports to the LHD

Holly Wethington165 Food Safety & Toxicology BldgMichigan State UniversityEast Lansing, MI 48824P: 517.432.7181 (#128)F: 517.432.2310Email: ffmod@cvm.msu.edu

RUsick2 Contact Information (www.RUsick2.msu.edu) :

Questions?