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Developing Family Medicine: Challenges for the Next Decade AKUH, February, 22, 2003. A Foodborne Outbreak of Gastroenteritis in a Teaching Hospital. Rashid A. Chotani, MD, MPH. Hospital. 940 bed hospital with 4 cafeterias.

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A foodborne outbreak of gastroenteritis in a teaching hospital l.jpg

Developing Family Medicine:

Challenges for the Next Decade

AKUH, February, 22, 2003

A Foodborne Outbreak ofGastroenteritis in a TeachingHospital

Rashid A. Chotani, MD, MPH


Hospital l.jpg
Hospital

  • 940 bed hospital with 4 cafeterias.

  • Cafeteria A, located in the OPD, serves approximately 600 visitors and employees daily.

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Events l.jpg
Events

  • On 12/9/97 individuals who ate at Cafeteria A reported nausea and projectile vomiting after eating a noon meal.

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Method case definition l.jpg
Method: case definition

Any person who ate lunch prepared at cafeteria A on December 9, 1997 and developed sudden onset of

  • vomiting or

  • diarrhea or

  • abdominal cramps

    and

    Any of the following symptoms including nausea, fever, body aches, headache, chills or fatigue.

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Method case finding l.jpg
Method: case finding

We identified all cases who identified

individuals who ate with them.

All non-Ill persons were used as

controls.

  • Additional cases were found when we contacted:

    • Nurse managers

    • Hospital managers

    • Directors of nursing, functional unit directors, JHH vice-presidents

    • Several employee groups were notified via e-mail and asked to identify cases.

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Methods questionnaires l.jpg
Methods: questionnaires

Standard questionnaires were

used to obtain medical and food

history from

  • Food service workers

  • Ill and non-ill employees

  • Menu reviewed at Cafeteria A.

  • Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Control measures and interventions cafeteria a l.jpg
    Control Measures and Interventions: Cafeteria A

    Cafeteria:

    • Kitchen was inspected

    • Leftover foods recovered and cultured

    • Food preparation, kitchen cleaning procedures reviewed

    • Certain food items quarantined

    • Employees were interviewed, inspected for sores, boils, cuts, IV tract marks and sent to occupational health services

    • We obtained nares swabs

    • 3 cafeteria staff members submitted stool samples or rectal swabs

    • All staff (n=17) were questioned daily for symptoms

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Laboratory l.jpg
    Laboratory

    • Food was processed in standard fashion

      • Blood agar plate R/O Bacillus

      • CAN plate R/O Staphylococcus

      • Plates for enteric pathogens

        R/O

        Salmonella, Shigella, Aeromonas, Campylobacter, Yersinia

    • Samples sent to city, state, FDA, and commercial laboratory

    • Sequencing preformed

    • Heavy metal testing

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Results l.jpg
    Results

    • N = 75 (ill = 40; non-ill = 35)

    • Mean age: 39 years (range 25-56)

    • Sex: 85% female

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Incubation period jhh employees n 40 l.jpg
    Incubation period: JHH employees (n=40)

    12

    Point source outbreak

    10

    Number of Cases Reported

    8

    6

    4

    2

    0

    0

    1

    2

    3

    4

    5

    6

    7

    8

    9

    10

    11

    12

    13

    14

    15

    16

    17

    18

    19

    20

    Incubation Period (Hours)


    Symptoms l.jpg
    Symptoms

    18

    fever

    25

    body aches

    43

    chills

    48

    headache

    63

    diarrhea

    fatigue

    63

    68

    abdominal cramps

    vomiting

    78

    93

    nausea

    0

    20

    40

    60

    80

    100

    Percent


    Results outcomes l.jpg
    Results: outcomes

    • Duration of illness: mean--24 hr. (range <24 - 72 hr.)

    • Bedridden 62.5%

    • Sought medical care 27.5%

    • Hospitalized 2.5%

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Results univariate analysis l.jpg
    Results: univariate analysis

    Food item OR СI 95%p-value

    Green beans 36.4 6.93,341.60 <0.0001

    Tortellini 5.50 1.03, 54.50 0.02

    Corn soup 0.23 0.04, 1.10 0.03

    Veg soup 0.23 0.04, 1.10 0.03

    Not associated: bread, breadsticks, chicken salad, broccoli salad, cheese salad, caesar salad, havarti cheese, swiss cheese, beef stew, Thai beef, couscous, honey turkey, chicken fingers, cheese pizza, sausage pizza, chow mein noodles, marinated tomatoes, onions, mixed greens, cucumbers, dressing tomato-bacon/peppercorn, creamy, sunflower seeds, crackers, chips, cookies, yogurt, and fresh fruits

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Results multivariate analysis l.jpg
    Results: multivariate analysis

    VariableORCI 95%p-value

    Green beans 1.84 1.49,2.27 <0.005

    Tortellini 1.25 0.98,1.59 NS

    Corn soup 0.89 0.69,1.16 NS

    Veg soup 0.93 0.71,1.21 NS

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Results laboratory l.jpg
    Results: laboratory

    • Bacillus sp. recovered from garlic mix (opened/unopened jars), Moroccan beef stew and vegetable soup.

    • Bacillus subtilis was identified based on the library profiles.

    • Heavy metals negative.

    • Patient/employees culture negative.

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Food preparation l.jpg
    Food preparation

    • Frozen green beans steamed for 10 minutes.

    • Seasoned with salt, pepper, olive oil and garlic mix.

    • Baked in oven for 15 minutes at 375 OF.

    • Stored in warmer at 180 degrees.

    • Placed in pan and sent to serving line (140 degrees); maximum time 4 hours.

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Summary l.jpg
    Summary

    • 40 persons became ill after eating green beans.

    • We under-estimated magnitude of problem because case ascertainment difficult.

    • The symptoms pointed to a toxin mediated illness.

    • The process of preparing green beans with garlic (in soy oil base) most likely led to the illness.

    • Bacillus was isolated from opened/unopened jars.

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Conclusions l.jpg
    Conclusions

    • FDA

      • Inspected the manufacturing facility

      • Inspected food supplier

      • Ordered recall of all garlic jars produced by company A

      • Mandated new control protocols

    • Aggressive control measures should be taken to prevent the spread of any outbreak particularly in a hospitals in order to protect not just the patients but the staff.

    • Rarely bacillus subtilis has been associated in food poisoning.

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Slide19 l.jpg

    Thank you

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


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