GIDSAS A Foodborne Outbreak of Gastroenteritis in a

GIDSAS A Foodborne Outbreak of Gastroenteritis in a Teaching Hospital Developing Family Medicine: Challenges for the Next Decade AKUH, February, 22, 2003 Rashid A. Chotani, MD, MPH 9/6/2021

Hospital n 940 bed hospital with 4 cafeterias. n Cafeteria A, located in the OPD, serves approximately 600 visitors and employees daily. GIDSAS 9/6/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU

Events n GIDSAS 9/6/2021 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 GIDSAS Any person who ate lunch prepared at cafeteria A on December 9, 1997 and developed sudden onset of l l l vomiting or diarrhea or abdominal cramps and Any of the following symptoms including nausea, fever, body aches, headache, chills or fatigue. 9/6/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU

Method: case finding GIDSAS 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: l l 9/6/2021 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 GIDSAS 9/6/2021 Standard questionnaires were used to obtain medical and food history from l Food service workers l Ill and non-ill employees Menu reviewed at Cafeteria A. Rashid A. Chotani, MD, MPH GIDSAS-JHU

Control Measures and Interventions: Cafeteria A Cafeteria: l l GIDSAS l l l 9/6/2021 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 n – Blood agar plate R/O Bacillus – CAN plate R/O Staphylococcus – Plates for enteric pathogens R/O Salmonella, Shigella, Aeromonas, Campylobacter, Yersinia GIDSAS n n 9/6/2021 Food was processed in standard fashion n Samples sent to city, state, FDA, and commercial laboratory Sequencing preformed Heavy metal testing Rashid A. Chotani, MD, MPH GIDSAS-JHU

Results n GIDSAS n n 9/6/2021 N = 75 (ill = 40; non-ill = 35) Mean age: 39 years (range 2556) Sex: 85% female Rashid A. Chotani, MD, MPH GIDSAS-JHU

Number of Cases Reported Incubation period: JHH employees (n=40) 12 Point source outbreak 10 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) 9/6/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU

Symptoms 18 fever body aches chills headache diarrhea fatigue 25 43 48 63 63 68 abdominal cramps vomiting nausea 78 0 20 40 60 80 93 100 Percent 9/6/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU

Results: outcomes n GIDSAS n n n 9/6/2021 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 GIDSAS 9/6/2021 Food item OR СI 95% p-value Green beans Tortellini Corn soup Veg soup 36. 4 5. 50 0. 23 6. 93, 341. 60 1. 03, 54. 50 0. 04, 1. 10 <0. 0001 0. 02 0. 03 Not associated: bread, breadsticks, chicken salad, broccoli salad, cheese salad, caesar salad, havarti cheese, swiss cheese, beef stew, Thai beef, cous, 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 GIDSAS 9/6/2021 Variable OR CI 95% p-value Green beans Tortellini Corn soup Veg soup 1. 84 1. 25 0. 89 0. 93 1. 49, 2. 27 <0. 005 0. 98, 1. 59 NS 0. 69, 1. 16 NS 0. 71, 1. 21 NS Rashid A. Chotani, MD, MPH GIDSAS-JHU

Results: laboratory n GIDSAS n n n 9/6/2021 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 n n GIDSAS n n n 9/6/2021 Frozen green beans steamed for 10 minu Seasoned with salt, pepper, olive oil a 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 n GIDSAS n n 9/6/2021 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 n GIDSAS n n 9/6/2021 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

GIDSAS 9/6/2021 n Thank you Rashid A. Chotani, MD, MPH GIDSAS-JHU