“As the Stomach Churns” –Food Illness PreventionStories from the Field

Harris County Food Safety Summit

June 1st, 2015

Diana Martínez, M.P.H., Ph.D.

Harris County & HCPHES• Harris County, TX:

3rd most populous in the nation with a population of 4.34 million

Spread over 1,778 square miles (size of Rhode Island)

Geographically, politically, and demographically diverse

• HCPHES: the county health department for Harris County with over 700 public health professionals

For many services including Epidemiology the jurisdiction of HCPHES extends to all Harris County excluding the City of Houston

Epidemiology

• What is it?• Epi---surrounding• Demos---people• Ology---the study of

• The study of the distribution and determinants of health related states or events in specific populations, and the application of this study to control of health problems

What is the role of Epidemiology?

• HCPHES Epidemiology Program is involved in the following activities:• Respond to infectious disease and other concerns of public’s health significance

related phone calls during normal business hours and after-hours• Provided education to school, universities, daycares and other public health

partners regarding infectious diseases and other related concerns• Monitor the health of the population by conducting disease surveillance, data

analysis and reporting• Guide healthcare providers for specific patients in evaluation process

Determination of a Notifiable Condition “Rule-in” and/or “Rule-out” cases of Notifiable Conditions

• Coordinate appropriate lab testing as part of evaluation for ill patients• Communicate with healthcare community on areas such as use of personal

protective equipment (PPE), isolation, coordination of care, etc.

What HCPHES Epidemiology Program Does When Illnesses are reported?

• Investigate cases and confirm illness• Confirm case meets surveillance definition

• Assist in implementing control measures• Exclusion criteria• Environmental assessment thru EPH• Education of staff & public• Initiate active surveillance (as appropriate)

Infectious Diseases in Harris County

• Over 1,900 notifiable infectious diseases occurred in one year alone (2013).

• This includes: 459 cases of salmonellosis 149 cases of campylobacteriosis 107 cases of entero hemorrhagic E. coli 20 cases of cyclosporiasis 1 case of typhoid fever (imported) 2 cases of brucellosis and listeriosis, each

Hepatitis A in a food handler -

many potentially exposed

Norovirus Outbreak in Restaurant Outbreak

associated with a potluck party

Stories from the Field in Harris County

Story from the Field #1Hepatitis A in a food handler -many potentially exposedFebruary, 2007

Epidemiology Investigation

• Investigation started February 14, 2007

• 1 employee at establishment was found positive for Hepatitis A.

• Initial onset of illness 1/31/2007

• Employee duties included:• Serving chip baskets• Garnish trays for drinks (bare hands contact)• Preparing soft drink: ice scoop provided and soda gun

Public Health Actions and Recommendations…• HCPHES recommended that anyone who dined at the restaurant on

certain dates (3 different dates) should receive Immune Globulin (IG) to prevent illness.

• Other 8 dates were identified as potential exposure dates but dinners on those dates were too late for prevention through IG and were recommended to watch for symptoms, contact their doctors and the health department if ill with Hepatitis A

• HCPHES provided IG on free clinics held on three different dates

• Our agency sent a press release and health alerts to healthcare providers

Results

• A four day hotline was set up for the public in obtaining additional information. During the four days, there were 1,948 calls that came in through the call center.

• In addition to the hotlines and clinic, HCPHES obtained all records of to-go parties and notified individuals of the situation.

• HCPHES set up a three day clinic for the public to receive Immunoglobulin (IG) depending on their level of exposure. There were 2,172 screenings and a total of 2,020 persons who received IG.

The Good News…

• Only one confirmed case of Hepatitis A. (initially reported case)

• No one who dined or worked in the restaurant during the time period acquired Hepatitis A.

Story from the Field #2

Norovirus Outbreak in a Restaurant, November 2008

Epidemiology Investigation

• Report received and investigation initiated on October 29th, 2008

• 1 employee (a cook) at establishment reported having had fever, body aches, and vomiting from October 18th thru October 20th. A household contact of this employee had fever and vomiting one day prior to her illness

• A group of 4 dinned on restaurant and developed fever and vomiting on October 24th. A household member of one of the 4 ate leftovers and also developed illness

• Five of six clinical specimens collected tested positive for Norovirus

• A restaurant inspection was conducted and recommendations were given regarding significant findings

• Employees were advise to seek medical care when ill with gastrointestinal illness and be excluded from work when symptoms are present and as recommended by physician

• The employees were recommended to follow proper hand hygiene and report gastrointestinal illnesses in their family members

• Other GI outbreaks have identified food handlers who cared for ill family members preceding outbreak

Public Health Actions and Recommendations…

The Good News…

• This was a small outbreak involving two ill food handlers, a family member of the food handler and 5 patrons

• All ill individuals recovered fully without needing medical care

Story from the Field #3

Foodborne Outbreak Associated with a Potluck-Party, July 2011

Background

• July 15th, 2011 at 8:35 am - report from an ER nurse that six persons had been transported to St. Luke’s Vintage Hospital ER with food poisoning.

• The reporter stated that the ill persons worked at Company A, and had attended a party held at the company.

• Company potluck-style party – 7/15/2011, 2:30 a.m. (company’s thirds shift)

• 50 - 70 attendees

Methods of Investigation

The Investigation

• Site visit – July 15th 11:00 pm• Three epidemiologists• Two food inspectors

• Interviews on site• Epidemiologists interviewed 26 attendees• Food inspectors interviewed 4 individuals who had provided food for

the event

• Specimens for testing• Secured stool specimens collected by local hospital• Obtain left over food samples

Table 1. Demographic Information of Company A employees who participated in party and were interviewed

ParticipantsN=57

IllN=30

Age, Median Age RangeMissing Age, count

3519 - 62

5

3119 – 62

1Gender, count/%MalesFemales

40/7017/30

23/777/23

Unit Name, count/%Run in (pre test)Assembly (builder, repair) Other building

32/5624/42

1/2

17/5713/43

0

Features of Illness

Toxin-mediated etiology• Short incubation period• Short duration• Abrupt onset

No secondary transmission

Table 2. Symptom profile of cases and other clinical characteristicsAttack rate 53%Incubation PeriodMedian timeRange

3 hours10 minutes – 6.5 hours

Duration of IllnessMedian time*Range

5 hours1 – 73 hours

Symptoms, count/%Diarrhea Abdominal painNausea VomitingHead ache/body acheFever

30/10025/8321/7019/6313/439/30

*This duration excludes five individuals that were unable to state a specific time whentheir symptoms ended. Three individuals indicated an approximate time; including those,the median increased to almost 6 hours duration. The range didn’t change.

0

1

2

3

4

5

6

3:10 3:40 4:00 4:30 5:00 5:25 5:30 6:00 6:20 6:30 6:40 6:45 7:00 7:30 8:00 9:00

Num

ber o

f Cas

es

July 15, 2011

Cases of Gastrointestinal Illnesses associated with company outbreak by time of Onset of Illness

Harris County, TX

End of Shift

Median Incubation Period

Clinical Specimens

• Three stool specimens provided for testing were positive for

Staphylococcus aureus

• These specimens were negative for Bacillus cereus, Salmonella,

Shigella, Yersinia, Vibrio, Campylobacter and E. coli.

• Staphylococcus enterotoxin test results were positive.

• Two were positive for Norovirus.

Food Specimens

• The food samples were unrefrigerated at measured at an internal temperature of 77⁰F at time of pick-up.

• The sample of fried rice was positive for Staphylococcal enterotoxin (SET)

• The sample of pork chops tested negative for the SET

• Food testing was conducted by the Houston Department of Health and Human Services, Bureau of Laboratory Services.

Food Inspector’s Findings

• Identified areas of concern regarding the food preparation methods described were:

• the lack of temperature control of ready-to-eat foods for up to 10.5 hours

• the use of bare hand to tear the pork chops into small pieces after cooking.

Conclusions

• Considering all results including the outcome of the food specimens testing, the clinical specimens testing and the data analysis it is concluded that a toxin mediated foodborne illness occurred as a result of the potluck party on July 15th 2011 at Company A.

• One or more poor food handling practices were identified that could be possible contributors to this foodborne illness outbreak.

• The symptoms presented by the individuals ill, as well as the incubation period and the duration of illness are all representative of staph intoxication.

• The sample of fried rice tested positive for Staph toxin and while toxin test results are still pending on the clinical specimens, Staphylococcus aureus was isolated from three clinical specimens.

Best way to prevent disease transmission

•Hand washing!

•Hand washing!

•Hand washing!

QUESTIONS???

Diana Martínez, M.P.H., Ph.D.Program Manager, Epidemiology

Harris County Public Health & Environmental Services• dmartinez@hcphes.org• 713-439-6164

www.hcphes.org