It has excellent sanitation: Winter’s coming so people stop going to the heated pool

I miss the hot tub we had in Kansas.

Yet in the U.S., thousands of public pools, hot tubs are closed each year due to serious violations.

caddyshack.pool.poop-1The U.S. Centers for Disease Control and Prevention reports that inspections of public pools and other aquatic venues enforce standards that can prevent illness, drowning, and pool-chemical–associated injuries such as poisoning or burns.

“No one should get sick or hurt when visiting a public pool, hot tub, or water playground,” said Beth Bell, M.D., M.P.H., director of CDC’s National Center for Emerging and Zoonotic Infectious Diseases. “That’s why public health and aquatics professionals work together to improve the operation and maintenance of these public places so people will be healthy and safe when they swim.”

Inspection data were collected in 2013 in the five states with the most public pools and hot tubs: Arizona, California, Florida, New York and Texas. Researchers reviewed data on 84,187 routine inspections of 48,632 public aquatic venues, including pools, hot tubs, water playgrounds and other places where people swim in treated water.

Among the key findings:

Most inspections of public aquatic venues (almost 80 percent) identified at least one violation.

1 in 8 inspections resulted in immediate closure because of serious health and safety violations.

1 in 5 kiddie/wading pools were closed—the highest proportion of closures among all inspected venues.

The most common violations reported were related to improper pH (15 percent), safety equipment (13 percent), and disinfectant concentration (12 percent).

“Environmental health practitioners, or public health inspectors, play a very important role in protecting public health. However, almost one third of local health departments do not regulate, inspect, or license public pools, hot tubs, and water playgrounds,” said Michele Hlavsa, R.N., M.P.H., chief of CDC’s Healthy Swimming Program. “We should all check for inspection results online or on site before using public pools, hot tubs, or water playgrounds and do our own inspection before getting into the water.”

When visiting public or private pools, swimmers and parents of young swimmers can complete their own inspection using a short and easy checklist that will identify some of the most common health and safety problems:

Use a test strip (available at most superstores or pool-supply stores) to determine if the pH and free chlorine or bromine concentration are correct. CDC recommends:

diaper.poolFree chlorine concentration of at least 1 ppm in pools and at least 3 ppm in hot tubs/spas.

Free bromine concentration of at least 3 ppm in pools and at least 4 ppm in hot tubs/spas.

pH of 7.2–7.8.

Make sure the drain at the bottom of the deep end is visible. Clear water allows lifeguards and other swimmers to see swimmers underwater who might need help.

Check that drain covers appear to be secured and in good repair. Swimmers can get trapped underwater by a loose or broken drain cover.

Confirm that a lifeguard is on duty at public venues. If not, check whether safety equipment like a rescue ring with rope or pole is available.

If you find problems, do not get into the water and tell the person in charge so the problems can be fixed. For more information and other healthy and safe swimming steps, visit www.cdc.gov/healthywater/swimming.

Before CDC-led development of the Model Aquatic Health Code, there were no national standards for the design, construction, operation, and maintenance practices to prevent illness and injury at public treated recreational water venues. Now, local and state authorities can voluntarily adopt these science- and best practices–based guidelines to make swimming and other activities at public pools and other aquatic venues healthier and safer. The second edition of the code will be released during the 2016 swim season. For more information about the Model Aquatic Health Code, visitwww.cdc.gov/mahc.


hot.tubProblem/Condition: Aquatic facility–associated illness and injury in the United States include disease outbreaks of infectious or chemical etiology, drowning, and pool chemical–associated health events (e.g., respiratory distress or burns). These conditions affect persons of all ages, particularly young children, and can lead to disability or even death. A total of 650 aquatic facility–associated outbreaks have been reported to CDC for 1978–2012. During 1999–2010, drownings resulted in approximately 4,000 deaths each year in the United States. Drowning is the leading cause of injury deaths in children aged 1–4 years, and approximately half of fatal drownings in this age group occur in swimming pools. During 2003–2012, pool chemical–associated health events resulted in an estimated 3,000–5,000 visits to U.S. emergency departments each year, and approximately half of the patients were aged <18 years. In August 2014, CDC released the Model Aquatic Health Code (MAHC), national guidance that can be adopted voluntarily by state and local jurisdictions to minimize the risk for illness and injury at public aquatic facilities.

Reporting Period Covered: 2013.

Description of System: The Network for Aquatic Facility Inspection Surveillance (NAFIS) was established by CDC in 2013. NAFIS receives aquatic facility inspection data collected by environmental health practitioners when assessing the operation and maintenance of public aquatic facilities. This report presents inspection data that were reported by 16 public health agencies in five states (Arizona, California, Florida, New York, and Texas) and focuses on 15 MAHC elements deemed critical to minimizing the risk for illness and injury associated with aquatic facilities (e.g., disinfection to prevent transmission of infectious pathogens, safety equipment to rescue distressed bathers, and pool chemical safety). Although these data (the first and most recent that are available) are not nationally representative, 15.7% of the estimated 309,000 U.S. public aquatic venues are located in the 16 reporting jurisdictions.

Results: During 2013, environmental health practitioners in the 16 reporting NAFIS jurisdictions conducted 84,187 routine inspections of 48,632 public aquatic venues. Of the 84,187 routine inspection records for individual aquatic venues, 78.5% (66,098) included data on immediate closure; 12.3% (8,118) of routine inspections resulted in immediate closure because of at least one identified violation that represented a serious threat to public health. Disinfectant concentration violations were identified during 11.9% (7,662/64,580) of routine inspections, representing risk for aquatic facility–associated outbreaks of infectious etiology. Safety equipment violations were identified during 12.7% (7,845/61,648) of routine inspections, representing risk for drowning. Pool chemical safety violations were identified during 4.6% (471/10,264) of routine inspections, representing risk for pool chemical–associated health events.

Interpretation: Routine inspections frequently resulted in immediate closure and identified violations of inspection items corresponding to 15 MAHC elements critical to protecting public health, highlighting the need to improve operation and maintenance of U.S. public aquatic facilities. These findings also underscore the public health function that code enforcement, conducted by environmental health practitioners, has in preventing illness and injury at public aquatic facilities.

Public Health Action: Findings from the routine analyses of aquatic facility inspection data can inform program planning, implementation, and evaluation. At the state and local level, these inspection data can be used to identify aquatic facilities and venues in need of more frequent inspections and to select topics to cover in training for aquatic facility operators. At the national level, these data can be used to evaluate whether the adoption of MAHC elements minimizes the risk for aquatic facility–associated illness and injury. These findings also can be used to prioritize revisions or updates to the MAHC. To optimize the collection and analysis of aquatic facility inspection data and thus application of findings, environmental health practitioners and epidemiologists need to collaborate extensively to identify public aquatic facility code elements deemed critical to protecting public health and determine the best way to assess and document compliance during inspections.

Immediate Closures and Violations Identified During Routine Inspections of Public Aquatic Facilities — Network for Aquatic Facility Inspection Surveillance, Five States, 2013

Surveillance Summaries / May 20, 2016 / 65(5);1–26

Michele C. Hlavsa, MPH; Taryn R. Gerth, MPH; Sarah A. Collier, MPH; Elizabeth L. Dunbar, MPH; Gouthami Rao, MPH; Gregory Epperson; Becky Bramlett; David F. Ludwig, MPH; Diana Gomez, MPH; Monty M. Stansbury; Freeman Miller; Jeffrey Warren; Jim Nichol; Harry Bowman; Bao-An Huynh, MPH; Kara M. Loewe; Bob Vincent; Amanda L. Tarrier, MPH; Timothy Shay; Robert Wright; Allison C. Brown, PhD; Jasen M. Kunz, MPH; Kathleen E. Fullerton, MPH; James R. Cope, PhD; Michael J. Beach, PhD

http://www.cdc.gov/mmwr/volumes/65/ss/ss6505a1.htm?s_cid=ss6505a1_e

My back still aches when I hear that word, Tillsonburg: Oh, Thunder Bay

If you ate at a banquet or one of the restaurants at Thunder Bay’s Valhalla Inn this past weekend, the district’s health unit wants to hear from you.

Banquet table, selective focus, canon 1Ds mark III

Banquet table, selective focus, canon 1Ds mark III

The Thunder Bay District Health Unit says nearly 50 people have reported becoming ill after eating at the hotel.

The health unit’s manager of environmental health says the symptoms most people had are consistent with a food-borne illness.

“The illness was characterized primarily by vomiting and diarrhea simultaneously,” Lee Sieswerda said. “It occurred about a day or two after the meal, and the symptoms lasted for about a day.”

Sieswerda said inspectors have looked at the kitchen at the Valhalla as part of their investigation and didn’t find any ongoing issues at the kitchen.

I don’t eat raw oysters: Gross and may have Vibrio

Following up a scientific report, Timothy B. Wheeler of the Bay Journal reports a 6-year-old outbreak of food poisoning linked to eating raw Chesapeake Bay oysters has left behind a lingering mystery. Scientists seeking to identify the water-borne pathogen that sickened a pair of Baltimore restaurant patrons have tracked the culprit to Asia.

Raw oystersHow a potent strain of Vibrio bacteria seemingly from so far away wound up in the Bay continues to puzzle Maryland health officials, who worked with researchers at the U.S. Food and Drug Administration to investigate the 2010 cases.

The microorganism could have gotten here in the ballast water of the many oceangoing ships that ply the Chesapeake every year, state and federal scientists suggested in a recently published journal article. Or, they added, perhaps it came via the introduction of non-native oysters or some exotic fish.

“It really is speculation,” acknowledged Dr. Clifford Mitchell, environmental health bureau director for the Maryland Department of Health and Mental Hygiene. “We didn’t sample ballast water. We didn’t take specimens that would lead us to know that we had fish coming over, or migration.”

But the case, published in the June issue of Applied and Environmental Microbiology, illustrates how disease-carrying organisms may travel around the world, researchers said. And while steps have been taken since 2010 to prevent the unintentional transport of pathogens, parasites and other potentially harmful organisms via ships’ ballast water, those safeguards still have significant gaps in them.

The bacterium involved in the 2010 food poisoning outbreak was Vibrio parahaemolyticus, strains of which are commonly found in coastal waters worldwide — including the Bay — though only some have been found to cause illness. When those are ingested, they can cause acute gastrointestinal distress, including diarrhea, stomach pain, nausea, fever and chills. It usually passes within a few days, but in rare cases can be more severe, especially in people with weakened immune systems.

There were 45 cases of Vibrio infections reported in Maryland in 2010, but it’s not that often, state health officials said, that they’re able to pinpoint the source of the bacteria that may have sickened a particular person. By the time laboratory tests identify Vibrio as the cause of someone’s GI distress and the information gets reported to the state, days or even weeks may have passed, and the food that person had eaten is long gone.

In this case, though, state health investigators got a lucky break. Two individuals who got sick said that shortly before they became ill that summer, they had eaten raw oysters at different Baltimore restaurants. They hadn’t traveled out of state or done anything else that likely could have exposed them.

When investigators visited the restaurants, they found the half-shells eaten by the two victims were from the Bay. And when they visited the Maryland aquaculture operation that supplied both eateries, investigators pulled some oysters from the water and discovered that they had Vibrio in them as well — 11 different potentially disease-causing strains, in fact. One of those appeared to match the Asian strain found in the two food poisoning victims.

Coos Bay Oyster Co.The investigation ended there, for the time being. Even though the Vibrio involved were similar, researchers couldn’t positively identify them as the same, using the analytic techniques they had at the time. “The chromosome patterns matched, but we weren’t sure how common that pattern was in the environment,” explained Robert Myers, director of the state health department’s laboratory administration. “We hadn’t seen it before.”

A few years later, though, “whole genome sequencing” technology became available, Myers said, giving researchers the ability to draw a more detailed map of an organism’s genetic makeup.

With that new, more powerful analytical tool, FDA researchers re-examined the Vibrio strains involved in the 2010 outbreak and those from the oysters that state health investigators had sampled. They identified them as belonging to a family of strains known as “sequence type 8.” 

When researchers consulted a worldwide Vibrio database, they found that the Maryland strains were unlike any seen to date in the United States. Instead, they were closely related to strains reported only in Asia, most recently in Hong Kong about four years before the outbreak.

Changes were made to shellfish safety protocols after a larger outbreak in 2013of Vibrio parahaemolyticus illnesses associated with eating raw oysters harvested along the Atlantic Coast. More than 100 people in 13 states, including Maryland and Virginia, became ill.  According to a spokesman for the Maryland Department of the Environment, which regulates shellfish harvest waters in the state, the Interstate Shellfish Sanitation Conference, a joint state-federal body, tightened its requirements for investigating such cases, closing implicated harvest areas and ordering a product recall when more than 10 cases are traced to a given area. 

But officials caution that the protocols are not foolproof, and cases like this are a reminder of the risk people run in consuming raw seafood, Mitchell said, especially if they have underlying health conditions.

The number of reported Vibrio infections in the state varies from year to year, but has been trending upward since 2005, according to state health data. Concentrations of the bacteria increase in warmer weather, and climate change could be a factor as Bay water temperatures tick upward. But Mitchell cautioned that the bacteria are present year-round.

“Given the number of people who eat oysters, certainly it’s a relatively small number of infections, but it can be a very significant one,” Mitchell said.

WGS, Vibrio and traceback in oysters

In the summer of 2010, Vibrio parahaemolyticus caused an outbreak in Maryland linked to the consumption of oysters. Strains isolated from both stool and oyster samples were indistinguishable by pulsed-field gel electrophoresis (PFGE). However, the oysters contained other potentially pathogenic V. parahaemolyticusstrains exhibiting different PFGE patterns.

Oyster-Vancouver, B.C.- 07/05/07- Joe Fortes Oyster Specialist Oyster Bob Skinner samples a Fanny Bay oyster at the restuarant. Vancouver Coastal Health now requires restaurants to inform their patrons of the dangers of eating raw shellfish.  (Richard Lam/Vancouver Sun)   [PNG Merlin Archive]

In order to assess the identity, genetic makeup, relatedness, and potential pathogenicity of the V. parahaemolyticusstrains, we sequenced 11 such strains (2 clinical strains and 9 oyster strains). We analyzed these genomes by in silico multilocus sequence typing (MLST) and determined their phylogeny using a whole-genome MLST (wgMLST) analysis. Ourin silico MLST analysis identified six different sequence types (STs) (ST8, ST676, ST810, ST811, ST34, and ST768), with both of the clinical and four of the oyster strains being identified as belonging to ST8.

Using wgMLST, we showed that the ST8 strains from clinical and oyster samples were nearly indistinguishable and belonged to the same outbreak, confirming that local oysters were the source of the infections. The remaining oyster strains were genetically diverse, differing in >3,000 loci from the Maryland ST8 strains. eBURST analysis comparing these strains with strains of other STs available at the V. parahaemolyticus MLST website showed that the Maryland ST8 strains belonged to a clonal complex endemic to Asia. This indicates that the ST8 isolates from clinical and oyster sources were likely not endemic to Maryland. Finally, this study demonstrates the utility of whole-genome sequencing (WGS) and associated analyses for source-tracking investigations.

A nonautochthonous U.S. strain of Vibrio parahaemolyticus isolated from Chesapeake Bay oysters caused the outbreak in Maryland in 2010

Appl. Environ. Microbiol. June 2016 vol. 82 no. 11 3208-3216

Julie Haendiges, Jessica Jones, Robert A. Myers, Clifford S. Mitchell, Erin Butler, Magaly Toro and Narjol Gonzalez-Escalona

http://aem.asm.org/content/82/11/3208.abstract?etoc

Dear Abby: how do I avoid botulism?

Doug introduced me to John Prine about 15 years ago. I’ve got a bunch of Prine albums in my iTunes and Dear Abby, from Sweet Revenge is a great kitchen sing-along song.

Food safety questions pop up in the Dear Abby-type advice columns, this weeks version from Telegram.com.

Q: How do I avoid botulism poisoning in my potato salad and deviled eggs during the summer picnic season? I am very concerned about this.220px-Pauline_Phillips_1961

— Chris Snashall, Grove City, Ohio

A: Let’s first distinguish between botulism and other forms of foodborne illnesses.
Botulism is a severe illness in which a nerve toxin produced by the bacterium Clostridium botulinum causes paralysis — and in severe cases, death.

Botulism is most often caused by food that isn’t properly home-canned. Typically it results when low-acid foods (such as potatoes or green beans) are not pressure-canned; the high temperature of that process is required to make them safe.

Because the botulinum toxin is destroyed by high temperatures, people who eat home-canned foods should, to ensure safety, consider boiling the food for 10 minutes before eating it. (or follow evaluated, science-based recipes/processing times -ben)

Other common causes of botulism are home-made herb or garlic oils that aren’t refrigerated, and potatoes that have been wrapped in foil to bake and either not kept hot enough or refrigerated in the foil. In both cases, the bacteria are left at a temperature at which they can multiply rapidly. (first they go from spore form to vegetative cell and then secrete the toxin while multiplying -ben).

Unless you are making your potato salad and deviled eggs with home-canned foods, botulism should not be a concern.

In 2015, home canned potatoes used in potato salad caused one of the largest bot outbreaks in the U.S. with over 20 illnesses and two deaths.

How do you like them tamales: Variations in storage and reheating procedures

Once made, quickly refrigerate tamales to limit spore growth, and frying may not be the best reheating option. Microwaves are lousy for cooking but great for reheating.

tamalesThis study analyzed the behavior of Clostridium perfringens in individual ingredients and tamales containing different pathogen concentrations upon exposure to different temperatures and methods of cooking, storage, and reheating.

In ground pork, C. perfringens cells were inactivated when exposed to 95°C for 30 min. Three lots of picadillo inoculated with 0, 3, and 5 log CFU/g C. perfringens cells, respectively, were exposed to different storage temperatures. At 20°C, cell counts increased 1 log in all lots, whereas at 8°C, counts decreased by 2 log. Four lots of tamales prepared with picadillo inoculated with 0, 2, 3, and 7 log CFU/g prior to the final cooking step exhibited no surviving cells (91°C for 90, 45, or 35 min). Four lots of tamales were inoculated after cooking with concentrations of 0, 0.6, 4, and 6 log CFU/g of the pathogen and then stored at different temperatures. In these preparations, after 24 h at 20°C, the count increased by 1.4, 1.7, and 1.8 log in the tamales inoculated with 0.6, 4, and 6 log inoculum, respectively. When they were stored at 8°C for 24 h, enumerations decreased to <1, 2.5, and 1.9 log in the tamales inoculated with 0.6, 4, and 6 log of C. perfringens cells, respectively. However, when the lots were exposed to 20°C and then 8°C, 0.8, 1.8, and 2.4 log changes were observed for the tamales inoculated with 0.6, 4, and 6 log, respectively.

how.tamalesMicrowaving, steaming, and frying to reheat tamales inoculated with 6 log CFU/g C. perfringens cells showed that the pathogen was inactivated after 2 min of exposure in the microwave and after 5 min of exposure to steam. In contrast, no inactivation was observed after 5 min of frying. The tamales inoculated with spores (7 log most probable number [MPN]/g) showed a decrease of 2 log after steaming or frying, and no survival was observed after microwaving. Tamales inoculated with spores (7 log MPN/g) after cooking were susceptible to microwaves, but 2.4 and 255 MPN/g remained after frying and steaming, respectively.

Behavior and inactivation of enterotoxin-positive Clostridium perfringens in pork picadillo and tamales filled with pork picadillo under different cooking, storage, and reheating conditions

Journal of Food Protection®, Number 5, May 2016, pp. 696-889, pp. 741-747(7)

Villarruel-López, A.; Ruíz-Quezada, S. L.; Castro-Rosas, J.; Gomez-Aldapa, C. A.; Olea-Rodríguez, M. A.; Nuño, K.; Navarro-Hidalgo, V.; Torres-Vitela, M. R.

http://www.ingentaconnect.com/contentone/iafp/jfp/2016/00000079/00000005/art00007

Parasites at retail: Not so much (cause testing don’t tell ya much)

Cyclospora and Cryptosporidium are protozoan parasites which infect humans, primarily through contaminated food and water. Cyclospora is endemic in a number of subtropical and tropical countries. Cryptosporidium infection can be found in people worldwide. Cyclospora and Cryptosporidium infections can cause mild to severe gastrointestinal (GI) symptoms including, but not limited to, diarrhea, weight loss, cramping, flatulence, nausea, fatigue and low grade fever.

basil.salmonellaCyclospora and Cryptosporidium were ranked 13th and 5th, respectively, out of 24 parasites in overall global ranking for their public health importance by a Food and Agriculture Organization of the United Nations/World Health Organization (FAO/WHO) expert committee (September 3 to 7, 2012). Produce such as fresh herbs and berries have been identified in the past as sources of Cyclospora and Cryptosporidium contamination in Canada. This survey focused on fresh herbs, berries, green onions and mushrooms.

The objective of this survey was to determine the occurrence and distribution of Cyclospora and Cryptosporidium contamination in fresh produce such as herbs, berries, mushrooms and green onions. A total of 1,590 samples were analyzed for the presence of Cyclospora and 1,788 samples were analyzed for Cryptosporidium. Samples were collected at retail from various regions across Canada between May 2011 and March 2013.

raspberryOf the samples analyzed for Cyclospora, none were positive for the parasite. Of the samples analyzed for Cryptosporidium, six samples of green onions, one sample of parsley, and one sample of mushroom were positive, however, the analytical method used to detect the parasites in the samples cannot determine if the parasite is viable and potentially infectious. It is important to note that there were no reported illnesses associated with the consumption of the products found to be positive for Cryptosporidium. Positive results are followed up by the Canadian Food Inspection Agency (CFIA). In this case, because of the perishable nature of the products and the time elapsed between sample pick up and the completion of analysis, the fresh product was no longer available on the market when the parasite was detected. As such, no direct follow up was possible. This information was used to inform CFIA’s programs and inspection activities.

The Canadian Food Inspection Agency regulates and provides oversight to the industry, works with provinces and territories, and promotes safe handling of foods throughout the food production chain. However, it is important to note that the food industry and retail sectors in Canada are ultimately responsible for the food they produce and sell, while individual consumers are responsible for the safe handling of the food they have in their possession. Moreover, general advice for the consumer on the safe handling of foods is widely available. The CFIA will continue its surveillance activities and inform stakeholders of its findings.

Try harder: UK petting farm ‘doing all it can’ after E. coli outbreak

The owners of a petting farm at the centre of a parasitic disease outbreak that has left dozens ill said they are working with the local authority to investigate its cause.

swithern.farmIan and Angela Broadhead, who run Swithens Farm, in Rothwell, Leeds, have reassured visitors that their “health, safety and welfare” is of “utmost importance” to them as they continue to work with public health experts.

The petting farm has been linked to 29 cases of cryptosporidiosis, and two cases of E.coli O157.

The Broadhead family said: “As a small family-run business the health, safety and welfare of our visitors is of utmost importance to us all.

handwash.UK_.petting.zoo_.09Between January and May 2015 around 130 people were affected by outbreaks of cryptosporidiosis linked to petting farms in England.

PHE has advised all visitors to wash their hands after touching animals.

Handwashing, however, is never enough.

A table of petting zoo outbreaks is available at http://barfblog.com/wp-content/uploads/2016/05/Petting-Zoo-Outbreaks-Table-5-5-16.xlsx

Best practices for planning events encouraging human-animal interations

Zoonoses and Public Health 62:90-99

Erdozain , K. KuKanich , B. Chapman and  D. Powell, 2015

http://onlinelibrary.wiley.com/doi/10.1111/zph.12117/abstract?deniedAccess

Educational events encouraging human–animal interaction include the risk of zoonotic disease transmission. ‘It is estimated that 14% of all disease in the USA caused by Campylobacter spp., Cryptosporidium spp., Shiga toxin-producing Escherichia coli (STEC) O157, non-O157 STECs, Listeria monocytogenes, nontyphoidal Salmonella enterica and Yersinia enterocolitica were attributable to animal contact. This article reviews best practices for organizing events where human–animal interactions are encouraged, with the objective of lowering the risk of zoonotic disease transmission.

petting1-791x1024

petting2-791x1024 

Restaurant was never named but should be: 33 sickened by Campylobacter in Cardiff, 2015

Knowing when to go public in an outbreak situation is challenging. But it’s better than silence.The most important conclusions from this Public Health Wales report are:

Buffet_CounterOn the 27th May 2015 the Shared Regulatory Services Communicable Disease Team (Cardiff)  identified two cases of Campylobacter (one in Cardiff and the other in the Vale of Glamorgan) that were linked to the same premises (Premises A) in Cardiff.

This triggered an immediate investigation and an Outbreak Control Team was subsequently convened, declaring a formal outbreak on 4th June 2015.

In total there were 33 cases meeting the case definition of which 11 were microbiologically confirmed as Campylobacter jejuni. No cases were hospitalised. 24 cases ate at Premises A on 17th May. Of the remaining cases, seven ate on 16th May and one on 18th May. The final case ate on 7th June.

Repeated environmental visits were undertaken and issues that could potentially lead to cross contamination were identified. Premises A voluntarily closed on 4th June to address these issues and reopened on 6th June.

Of the 33 cases, 31 participated in a case control study.  These all ate between the 16th and 18th May.  The study revealed that 100% (31) of included cases had eaten from the salad bar compared to 84.9% (45/53) controls (p=0.024). In addition, 30 of 31 cases (96.8%) had eaten pasta salad from the salad bar, compared with 22/50 controls  (44%) (odds ratio 38; 95% CI 5.3–1611). Adjustment for other exposures using logistic regression did not materially change the association with eating pasta salad. A similar but independent association with eating noodles from the salad bar was also identified but few of the cases (6/31) had consumed noodles.

Environmental investigation found areas of non compliance with statutory food hygiene regulations and confirmed that several poor food hygiene practices had been identified that potentially could result in pasta salad cross-contamination within the kitchen area.

It was therefore concluded that eating pasta salad from the salad bar between 16th and 18th May 2015 was significantly associated with acquiring Campylobacter infection in this outbreak, and that for the small number of individuals who ate noodles this may have been independently associated with acquiring Campylobacter infection. The identification of non-meat items (often salad) in Campylobacter outbreaks is a reoccurring theme.

IMG_7739Ensuring good food hygiene is always the sole responsibility of the Food Business Operator. Nevertheless, it is important to note that this outbreak identified several issues which have implications more widely.

These included:

  • Issues with the interpretation and implementation by the food business of the Food Standards Agency E. coli O157 Control of Cross Contamination Guidance (revised December 2014).
  • Issues relating to the Primary Authority’s response in outbreak situations (relevant to Food Business Operators with multiple outlets).

The specific points of concern are explained in the discussion section of this report. 

Related to these issues, investigations highlighted three matters which may have implications for other high throughput food businesses.  These were:

  • Not using physical separation as the primary control measure to prevent cross-contamination.
  • An over reliance on two-stage cleaning as a control measure which may fail during busy periods.
  • The need to design out (as much as possible) any potential for human error resulting in cross-contamination.

Following this outbreak, improvements with respect to these three matters have been implemented in Premises A and all other similar premises nationally that are under the same ownership.

The outbreak was declared over on 25th August 2015.

Conclusions

  1. There were 33 cases of Campylobacter associated with this outbreak. Eleven were microbiologically confirmed.
  2. This had the features of a point source outbreak. All but one case ate at Premises A on the weekend 16-18th May. The final confirmed case ate at the premises on 7th June.
  3. Epidemiological and environmental investigation identified cross-contamination of the pasta salad as the most likely source of the outbreak for the cases on 16-18th May. No source was identified for the case on 7th June.
  4. Environmental investigation found areas of non compliance with statutory Food Hygiene Regulations and confirmed that several poor food hygiene practices had been identified that potentially could result in pasta salad cross-contamination within the kitchen area.
  5. The interpretation and application of the December 2014 revised version of the Food Standards Agency E. coli O157 Control of Cross Contamination Guidance by the Food Business Operator of Premises A resulted in the business not using physical separation as the primary control measure to prevent cross-contamination. This and over reliance on two-stage cleaning as a control measure was potentially not effective in preventing cross-contamination. This guidance was then used by the Food Business Operator to defend such arrangements and structural layouts as being in line with the recommendation of this guidance.
  6. Implementation of some control measures in this outbreak were delayed by involvement of the Primary Authority.
  7. Being unable to interview food handlers involved in this outbreak at an early stage in a structured format away from Premises A hampered outbreak investigation and control.
  8. Issuing a proactive press release without naming the premises resulted in this decision becoming the media focus rather than the outbreak.

Recommendations

  1. The Food Standards Agency E. coli O157 Control of Cross Contamination Guidance (revised December 2014) should be reviewed in light of the issues identified in this outbreak.
  2. The Food Standards Agency should work with the Better Regulation Delivery Office to develop advice for Primary Authorities on providing timely and effective responses to outbreak investigations.
  3. Proactive follow-up for example via telephone of all confirmed Campylobacter cases in Wales should be routine practice by all Local Authorities. This supports early detection of outbreaks, the application of control measures to be timely and prompt hygiene advice to be given to cases.
  4. Local Authorities should ensure that they retain sufficient Environmental Health staff with Food Safety and Communicable Disease skills to be able to proactively follow up communicable disease cases and investigate suspected outbreaks.
  5. Although direct poultry contact or consumption is known to be the most common source for Campylobacter infection in humans, the Food Standards Agency Campylobacter Reduction Strategy should note for consideration that outbreaks in Wales have also been linked to non meat products such as salads. This could of course in some cases represent cross contamination but they may wish to consider looking at the body of evidence from such outbreaks across the United Kingdom to inform the Strategy going forward.
  6. The use of ‘Requests for Co-operation’ under health protection legislation should be considered early in outbreak investigations in order to effectively interview food handlers.
  7. In future outbreaks proactive media engagement without naming the premises should be avoided.

 

Vibrio, from raw oysters, and cirrhosis aren’t a good combination

Vibrio is one of the nastier foodborne pathogens, one of the reasons why I don’t go near raw oysters (the other being that I just don’t like them).

It’s particularly a problem with folks with existing liver problems.

Nazir and colleagues provide an example in the British Medical Journal.

Oyster-Vancouver, B.C.- 07/05/07- Joe Fortes Oyster Specialist Oyster Bob Skinner samples a Fanny Bay oyster at the restuarant. Vancouver Coastal Health now requires restaurants to inform their patrons of the dangers of eating raw shellfish. (Richard Lam/Vancouver Sun) [PNG Merlin Archive]

We present a case of a 40-year-old man with decompensated alcoholic liver cirrhosis presenting with atraumatic cellulitis of one extremity and severe sepsis that rapidly progressed to compartment syndrome despite broad-spectrum antibiotics. Local cultures following debridement revealed Vibrio vulnificus, and subsequent history revealed consumption of raw oysters 48 h before presentation. Our case points out the unique susceptibility of those with cirrhosis and elevated iron saturation to Vibrio septicaemia, as well as the rapidity and severity of the disease progression.