Foodborne Illness and the Public Health Nurse

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Foodborne Illness and the Public Health Nurse

• Bureau of Epidemiology
• Sally A. Bidol, MPH
• Mark A. Schmidt, MPH
• Office of Public Health Preparedness
• Susan L. Shiflett

Michigan Department of Community Health
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Day 1Monday06/07
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Laboratory Report To Local Health
DepartmentFrom HighTECH Labs, Inc

• Patient Doe, Thomas
• DOB 12/03/93
• Address 300 Any Street, Anytown,
  Michigan
• Result Presumptive E. coli O157H7

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What would you do?What information will you
need to collect?
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Information Collected

• Onset Sunday, 5/30
• Bloody diarrhea, fever
• No travel history
• Municipal water
• Not aware of any ill contacts
• Mother shops at Grocery Store A
• Boy Scout trip to petting zoo

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Pet
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Day 1
Dinner
Breakfast
Snack
Lunch
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Day 2
Breakfast
Lunch
Dinner
Snack
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Day 3
Lunch
Breakfast
Snack
Dinner
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What are the most likely causes of infection?

• Food history
• Pet
• Other exposures

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What is the major limitation of the data
collected?

• Incubation of E. coli O157H7
• Median 2 to 4 days
• Up to 8 days

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Day 2Tuesday06/08
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Laboratory Report To Local Health Department
From HighTECH Labs, Inc

• Presumptive Positive E. coli O157H7
• 2 Children
• 9 y/o attends same school as Thomas Doe
• 5 y/o attends day care
• 1 Teenager
• Works as a food handler at The Healthy Deli
• 1 Adult

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School Nurse Reports

• June 1 4, 30 children absent
• Typically 5 absent
• Most gave reason as Stomach Flu

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Group Questions

• Is it time to activate your outbreak team?
• If no, what additional information needs to be
  collected before you activate the team
• How would you go about
• Verifying the diagnosis
• Searching for additional cases
• Determining if cases are associated
• What is your initial hypothesis?

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Answers

• Is it time to activate your outbreak team?
• Yes
• Verify the diagnosis
• Contact students, ask about symptoms and clinical
  samples

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Answers

• Search for additional cases
• Ask cases for others experiencing symptoms
• Contact medical facilities
• Contact EH to check for unconfirmed illness
  reports
• Contact suspect facilities (EH) to ask about
  complaints
• Determine if cases are associated
• Person, Place, and Time

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More Patient Information

• Confirmatory reports from MDCH indicated that 4
  patients are positive for E. coli O157H7 and
  produce STX I and STX II. PFGE is performed and
  all isolates are identical.
• 2 children on basketball team
• Teenager is youth coach of team
• Adult is parent of basketball player

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More Patient Information

• One patient is positive for E. coli O26NM
• 1 child
• Not associated with basketball team

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Interpreting Laboratory Reports
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E. coli Serotyping

• O Somatic antigen in cell wall
• H Flagellar antigens in the flagellar structure
• NM non-motile, has lost the flagella
• Common serotypes include O157H7

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E. coli Toxin Testing

• Shiga-like toxin I and II (STX I, STX II)
• More important than serotyping
• Presence of STX causes illness
• Cytotoxic effect, inflammation of intestinal wall
  leading to death of cells
• Results in
• Hemorrhagic colitis
• Hemolytic Uremic Syndrome (HUS)
• Thrombotic Thrombocytopenic Purpura (TTP)

Website of Dr. Brett Finlay Dept. of Microbiology
and Immunology Dept. of Biochemistry and Mol.
Biology University of British Columbia
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E. coli O157H7 DNA Fingerprinting

• Pulsed-field gel electrophoresis (PFGE)
• PulseNET

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MDCH Laboratory Report
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MDCH Laboratory Report
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What does this mean?

Website of Dr. Brett Finlay Dept. of Microbiology
and Immunology Dept. of Biochemistry and Mol.
Biology University of British Columbia
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Lab Testing Results

• Does this change the direction of your
  investigation?

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• E. coli O157H7
• May - June 2003 (N28)

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Summary of Outbreak

• Implicated meal--Steak House Buffet 5/27
• All confirmed E. coli O157H7 cases consumed
  fruit from the salad bar
• Basketball team ate from the salad bar

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Loosely Based on Milwaukee Sizzler Restaurant
Outbreak of 2000

• 736 cases, 63 culture confirmed
• 18 hospitalizations, 5 cases HUS, 1 fatality
• Sirloin tri-tips
• Meat ground within 1 foot of fruit and vegetable
  preparation table.

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Management of Food Handlers

• Michigan Food Law of 2000
• Regulates all food establishments in Michigan
• Provides essential powers, duties, penalties
• Adoption of FDA Food Code (model)

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Exclusions and Restrictions - Definitions

• Big 4
• Salmonella Typhi
• Shigella spp.
• E. coli O157H7
• Hepatitis A virus (HAV)
• High infectivity
• Severe medical consequences
• High risk conditions
• Caused, or exposed to, a confirmed Big 4 outbreak
  since person-
• consumed implicated food, or
• consumed food prepared by infected person, or
• consumed food prepared by suspected shedder
• Lives with someone diagnosed with Big 4
• Lives with someone who attended/worked at a
  confirmed Big 4 outbreak

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Exclusions and Restrictions ILL Employee Serving
General Population
Diagnosed with Big 4
Persistent sneezing, coughing or runny nose
Asymptomatic positive stool
GI symptoms
Jaundice gt 7 days
Exposed lesion, boil or wound
Jaundice within 7 days
Exclude
Restrict
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Child Care CenterAttendance

• E. coli O157 illness
• spread is a major concern
• Infected child or care giver should be excluded
  until
• Diarrhea resolves
• 2 negative stool cultures
• Early involvement of local health authorities can
  prevent further disease

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Points to Ponder Conducting an Investigation

• Remember normal background activity
• Teamwork between nursing and EH essential
• What information is pertinent in an
  investigation?
• How do you interpret the laboratory results?
• Dont forget your epi tools

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RUsick2 FORUM
Got Food Poisoning?

Welcome to the Foodborne
Outbreak Early Detection System (FOEDS)
Forum   Web users share and compare info
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WWW.RUSick2.msu.edu

• Forum for people with suspected foodborne disease
  to share and compare their pre-illness food
  history and other factors. Objective Did they
  eat the same food items? Identify common source
  outbreaks.
• Being pilot tested in Greater Lansing Area.
• Delivers foodborne disease reports to the LHD

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Holly Wethington165 Food Safety Toxicology
BldgMichigan State UniversityEast Lansing, MI
48824P 517.432.7181 (128)F
517.432.2310Email ffmod_at_cvm.msu.edu
RUsick2 Contact Information (www.RUsick2.msu.edu)

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Questions?