Blaming consumers: Cruise ship edition

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Jim Walker of Cruise Law News writes the Centers for Disease Control (CDC) reports that there was a gastrointestinal outbreak on the Crown Princess during its recent cruise, from October 25th to November 8, 2017. The Princess cruise ship departed Quebec, Canada on October 25th for a two-week cruise to Canadian and U.S. ports. The cruise ship arrived in Fort Lauderdale, Florida on November 8th and will begin its Caribbean season.

According to the CDC report, 184 passengers and 12 crew members became ill with gastro-like symptoms which included diarrhea.  

During the period from 2010 to the current date, Princess Cruises experienced the most outbreaks on its cruise ships calling on U.S. ports, according to the CDC. Princess reported twenty-one (21) cases to the CDC during this time period.

The Crown Princess alone has suffered through six (6) norovirus outbreaks since 2010 to the present. Before the current GI outbreak, the last norovirus outbreak on the Crown Princess was from January 3 – 18, 2016 and, before that, from October 18 to November 16, 2014. Earlier, there was a norovirus and e-coli outbreak from February 5 to 12, 2014. It also experienced back-to-back norovirus outbreaks from January 29 to February 4, 2012 and February 4 to February 9, 2012.

The cruise line with the second most outbreaks is Holland America Line with 18 cases of GI sicknesses reported to the CDC since 2010. HAL suffered norovirus outbreaks on the Nieuw Amsterdam, and two outbreaks each on the Voendam and the Noordam this year.  

So why is Princess Cruises far more prone to norovirus outbreaks than Carnival cruise lines, for example?

The cruise industry always blames the passengers for bringing the virus aboard, rather than its food handlers, or contaminated food or water. So are Princess Cruises customers the sickest and the least hygienic cruisers around? Are guests of HAL the second most unhygienic cruisers? Do they wash their hands the least of any cruisers? This seems like absurd arguments to make.

Whoever is to blame, the crew members, of course, always pay the price, by having to wipe and scrub and spray everything in sight for long 16+ hour days to try to disinfect a ship longer than three football fields.

Irrespective of the blame-game, don’t call us if you get sick on a cruise. Proving where the virus came from, or that the cruise line was negligent, is virtually impossible to prove, especially since the CDC conducts no epidemiological analysis and sometimes can’t even figure out whether the outbreak is due to norovirus, e-coli or something as exotic as Shigella sonnei or Cyclospora cayetanensis.

For example, The New Zealand Herald reports, a passenger on a cruise ship plagued with a vomiting and diarrhoea bug says he only learnt previous guests had been struck down with the same thing once they set sail.

Sydney man Walter Gibian and his wife Elisabeth left Sydney on October 30 on a 12-day Celebrity Solstice cruise travelling from Sydney to Auckland via the South Island so they could see New Zealand. Gibian had worked in New Zealand in 1980s and loved it so booked the cruise to see the East Coast.

The ship had left Melbourne when the captain announced to guests that passengers on an earlier cruise had norovirus and asked guests to take extra precautions including washing their hands regularly and using hand sanitiser.

any notification before they left and by this time it was too late to do anything about it as they were well on their way to New Zealand.

“It think people should be told and given the option that if you don’t like being exposed to this virus you are allowed to get off. But we found out when we were sea.”

Halfway into the 12-day cruise passengers started falling ill and Elisabeth came down with the bug on Saturday night. She was then isolated to her cabin for 48 hours.

“They (passengers) are sick all right. But of course the ship won’t tell us how many are sick, but my wife got sick on Saturday night. They are taking all sorts of precautions but it is still happening. They keep telling me, they are doing their utmost and they are doing their best but the fact is it is not effective.”

It was the ice: 144 students sickened in Taiwan, 2015

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On 5 March 2015, Taiwan Centers for Disease Control was notified of more than 200 students with gastroenteritis at a senior high school during excursion to Kenting. We conducted an outbreak investigation to identify the causative agent and possible vehicle of the pathogen.

Methods

We conducted a retrospective cohort study by using a structured questionnaire to interview all students for consumed food items during their stay at the resort. Students were defined as a gastroenteritis case while having vomiting or diarrhea after the breakfast on 4 March. We inspected the environment to identify possible contamination route. We collected stool or vomitus samples from ill students, food handlers and environmental specimens for bacterial culture for common enteropathogens, reverse transcription polymerase chain reaction (RT-PCR) for norovirus and enzyme-linked immunosorbent assay (ELISA) for rotavirus. Norovirus PCR-positive products were then sequenced and genotyped.

Results

Of 267 students enrolled, 144 (54%) met our case definition. Regression analysis revealed elevated risk associated with iced tea, which was made from tea powder mixed with hot water and self-made ice (risk ratio 1.54, 95% confidence interval 1.22–1.98). Ice used for beverages, water before and after water filter of the ice machine and 16 stool and vomitus samples from ill students were tested positive for norovirus; Multiple genotypes were identified including GI.2, GI.4 and GII.17. GII.17 was the predominant genotype and phylogenetic analyses showed that noroviruses identified in ice, water and human samples were clustered into the same genotypes. Environmental investigation revealed the ice was made by inadequate-filtered and un-boiled water.

Conclusions

We identified the ice made by norovirus-contaminated un-boiled water caused the outbreak and the predominant genotype was GII.17. Adequately filtered or boiled water should be strongly recommended for making ice to avoid possible contamination.

Ice-associated norovirus outbreak predominantly caused by GII.17 in Taiwan, 2015

BNC Public Health, 2017, 17:870, Hao-Yuan Cheng, Min-Nan Hung, Wan-Chin Chen, Yi-Chun Lo, Ying-Shih Su, Hsin-Yi Wei, Meng-Yu Chen, Yen-Chang Tuan, Hui-Chen Lin, Hsu-Yang Lin, Tsung-Yen Liu, Yu-Ying Wang, Fang-Tzy Wu https://doi.org/10.1186/s12889-017-4869-4

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4869-4

Raw is risky and a drain on public health

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A protracted outbreak of Escherichia coli O157:H7 infections was caused by consumption of unpasteurized (“raw”) milk sold at Oregon grocery stores. Although it never caused a noticeable increase in reported infections, the outbreak was recognized because of routine follow-up interviews.

Six of 16 Portland-area cases reported between December 1992 and April 1993 involved people who drank raw milk from dairy A. By pulsed-field gel electrophoresis (PFGE), E. coli O157:H7 isolates from these cases and from the dairy A herd were homologous (initially, 4 of 132 animals were E. coliO157:H7-positive).

Despite public warnings, new labeling requirements, and increased monitoring of dairy A, retail sales and dairy-associated infections continued until June 1994 (a total of 14 primary cases). Seven distinguishable PFGE patterns in 3 homology groups were identified among patient and dairy herd E. coli O157:H7 isolates. Without restrictions on distribution, E. coli O157:H7 outbreaks caused by raw milk consumption can continue indefinitely, with infections occurring intermittently and unpredictably.

A prolonged outbreak of Escherichia coli O157:H7 infections caused by commercially distributed raw milk

1.sep.2017

The Journal of Infectious Diseases

Keene et al.

https://academic.oup.com/jid/article/176/3/815/872141

Vaccines work: New York country club patrons exposed to hepatitis A linked to fancy place

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Christopher Eberhart of Lohud writes that patrons at the Sleepy Hollow Country Club may have been exposed to hepatitis A as an outbreak linked to bartaco in Port Chester continues to spread.  

A Sleepy Hollow Country Club employee was infected by one of the five people who were exposed to hepatitis A at bartaco, Westchester Health Department officials said today.  

Health officials don’t believe this outbreak will involve as many people as bartaco, which included treatments of more than 3,000 people, who were potentially exposed to Hepatitis A. 

“We’re not expecting to be treating thousands this time,” Amler said at a Friday afternoon press conference. 

While the greatest risk is to those who ate or drank at Sleepy Hollow’s Grill Room, in an abundance of caution the Health Department recommends preventive treatment for anyone who ate or drank at the club between Oct. 27 and Nov. 4.

The county is offering free preventative treatment today from 4-7 p.m. and Saturday from 10 a.m. to 4 p.m. at the county clinic at 134 Court St. in White Plains. Dr. Sherlita Amler, commissioner of health, said more clinics are expected to be scheduled for next week, but the details haven’t been sorted out yet. 

Our church: 4 years of Sunday practice (and games) will get most improved

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After four years as an atom minor hockey player — there aren’t enough kids in Australia playing hockey to have different divisions between 5-and-9-year olds, although it used to be 5-11-year-olds, which was dangerous, so we’re growing — Sorenne was selected as most improved player for her team.

I love how Mason, the player-voted MVP, is always smiling and supportive of his teammates (he’s grinning in the background).

On to atom majors next year, if she wants.

India:1 farmer dead, 67 ill in food poisoning at seed promo

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A farmer died and 67 others were hospitalised due to alleged food poisoning after they participated in a lunch given by a seed manufacturing company in Dindori, India on Wednesday. The police have arrested the caterer who distributed the food and the cook who prepared it.

Police sources said a seed manufacturing company had arranged a seminar on hybrid tomato US 1143 at Umrale village in Dindori tehsil of Nashik district on Wednesday. Around 300 farmers attended the seminar. Later lunch was served which, according to the farmers included mattha. Mattha, a digestive drink, is curd diluted with water with addition of coriander and spices.

After the lunch, the farmers began feeling uneasy. Farmer Atul Pandurang Kedar (41) of Umrale Bu village began feeling dizzy and collapsed. He was treated at a private hospital in Umrale and then rushed Magnum Heart Hospital in Nashik. From here he was shifted to Nashik Civil Hospital, where he succumbed to the alleged food poisoning on Wednesday evening while 67 others have been admitted to various hospitals.

Senior police inspector Rajesh Shirsath told The Asian Age on Thursday that they had sealed the food, which included rice, jelabi and mattha. “Our forensic team checked everything and will submit its report to our seniors,” he said.

Water water everywhere, but is it safe?

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Potable water and the U.S. Centers for Disease Control: two things we take for granted.

CDC reports that during 2013–2014, a total of 42 drinking water–associated outbreaks were reported, resulting in at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was responsible for 57% of outbreaks and 13% of illnesses, and chemicals/toxins and parasites together accounted for 29% of outbreaks and 79% of illnesses. Eight outbreaks caused by parasites resulted in 289 (29%) cases, among which 279 (97%) were caused by Cryptosporidium and 10 (3%) were caused by Giardia duodenalis. Chemicals or toxins were implicated in four outbreaks involving 499 cases, with 13 hospitalizations, including the first outbreaks associated with algal toxins.

To provide information about drinking water–associated waterborne disease outbreaks in the United States in which the first illness occurred in 2013 or 2014 (https://www.cdc.gov/healthywater/surveillance/drinking-surveillance-reports.html), CDC analyzed outbreaks reported to the CDC Waterborne Disease and Outbreak Surveillance System through NORS (https://www.cdc.gov/nors/about.html) as of December 31, 2015. For an event to be defined as a waterborne disease outbreak, two or more cases must be linked epidemiologically by time, location of water exposure, and illness characteristics; and the epidemiologic evidence must implicate water exposure as the probable source of illness. Data requested for each outbreak include 1) the number of cases, hospitalizations, and deaths; 2) the etiologic agent (confirmed or suspected); 3) the implicated water system; 4) the setting of exposure; and 5) relevant epidemiologic and environmental data needed to understand the outbreak occurrences and for determining the deficiency classification.§ One previously unreported outbreak with onset date of first illness in 2012 is presented but is not included in the analysis of outbreaks that occurred during 2013–2014.

Public health officials from 19 states reported 42 outbreaks associated with drinking water during the surveillance period (Table 1) (https://www.cdc.gov/healthywater/surveillance/drinking-water-tables-figures.html).

One outbreak reported during 2013–2014 in an individual system led to 100 estimated illnesses associated with a wedding. The public health challenges highlighted here underscore the need for rapid detection, identification of the cause, and response when drinking water is contaminated by infectious pathogens, chemicals, or toxins to prevent and control waterborne illness and outbreaks.

Raw is risky: Over 100 oyster festival attendees ill in Maryland

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Health officials say they are investigating a stomach flu outbreak, after over 100 people are apparently ill after attending an oyster festival, in Worcester County.

The Maryland Department of Health says on Friday, that their Division of Outbreak Investigation is working with the Worcester County Health Department to investigate a gastroenteritis outbreak that happened at a Beer and Oyster Festival, in Ocean City. The festival was apparently held at Fager’s Island Restaurant, on November 4.

According to state health officials, to date, there have been 145 cases of illness reported in Maryland, Delaware, Pennsylvania, and New Jersey that could be connected to the outbreak. There have been no reports of hospitalizations and deaths.

Two stricken with Giardia in Norway

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Many thanks to our Norwegian correspondent who reports that two people admitted to Haukeland Hospital have been diagnosed with Giardia infection.

“We have two confirmed cases, but it is possibly a third too. It is too early to say anything about the source of infection,” says Surveillance Authority in Bergen municipality Kari Stidal Øystese.

Bergen is sensitive to Giardia outbreaks because in autumn 2004, the drinking water was infected by the Giardia parasite and approximately 5,000 people from Bergen became sick, and many have suffered after-effects for years.

In 2006, a SINTEF report commissioned drainage systems related to the buildings at Knatten, Starefossen and Tarlebøveien, triggered the epidemic. Local authority Torgeir Landvik would blame the dog owners for the fact that thousands of mountain people were infected by Giardia in the fall of 2004. But in 2015, an expert group picked up the dog-kit theory. “Based on available knowledge, Giardia infection from humans is still the most likely cause of the outbreak of disease and long-term strokes,” said the group’s conclusion.

A large community outbreak of waterborne giardiasis- delayed detection in a non-endemic urban area

BMC Public Health, 2006, 6:141,   Karin Nygård, Barbara Schimmer, Øystein Søbstad, Anna Walde, Ingvar Tveit, Nina Langeland, Trygve Hausken and Preben Aavitsland, https://doi.org/10.1186/1471-2458-6-141

https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-6-141

Background

Giardia is not endemic in Norway, and more than 90% of reported cases acquire the infection abroad. In late October 2004, an increase in laboratory confirmed cases of giardiasis was reported in the city of Bergen. An investigation was started to determine the source and extent of the outbreak in order to implement control measures.

Methods

Cases were identified through the laboratory conducting giardia diagnostics in the area. All laboratory-confirmed cases were mapped based on address of residence, and attack rates and relative risks were calculated for each water supply zone. A case control study was conducted among people living in the central area of Bergen using age- and sex matched controls randomly selected from the population register.

Results

The outbreak investigation showed that the outbreak started in late August and peaked in early October. A total of 1300 laboratory-confirmed cases were reported. Data from the Norwegian Prescription Database gave an estimate of 2500 cases treated for giardiasis probably linked to the outbreak. There was a predominance of women aged 20–29 years, with few children or elderly. The risk of infection for persons receiving water from the water supply serving Bergen city centre was significantly higher than for those receiving water from other supplies. Leaking sewage pipes combined with insufficient water treatment was the likely cause of the outbreak.

Conclusion

Late detection contributed to the large public health impact of this outbreak. Passive surveillance of laboratory-confirmed cases is not sufficient for timely detection of outbreaks with non-endemic infections.

85 sick with shiga-toxin E. coli at Marines base

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About 85 U.S. Marines-in-training remained ill last week after an apparent shiga-toxin producing E. coli outbreak at Marine Corps Recruit Depot San Diego and Camp Pendleton amid a week-old outbreak of diarrheal illnesses at the military installations, authorities reported.

Among the medical cases were 19 new ones diagnosed since Oct. 31, 2017, according to MCRD public affairs. In all, 16 recruits were receiving treatment at an off-base hospital, with the remainder being cared for at military medical facilities.

Base officials initially announced a total of about 300 cases of intestinal ailments at the 2 San Diego-area installations on Oct. 30, 2017.

 That tally was down to roughly 215 a day later. The cause or causes of the debilitating bacterial exposure remain under investigation.