Clostridiumperfringens outbreak at a juvenile detention facility linked to a Thanksgiving holiday .... Elkin Parks (PA): Franklin, 1985,. 6:117-143. 2. ... sive outbreaks of Clostridium perfringens at a state correctional institution. Am J. Public Health ...
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Alerts, Notices, and Case Reports Clostridium perfringens Outbreak at a Juvenile Detention Facility Linked to a Thanksgiving Holiday Meal ARTI 1. PARIKH, MPH MICHELE T. JAY, DVM, MPVM DIAMOND KASSAM, MD TERRY KOCIEMBA, REHS* BOBBE DWORKIS, REHS* PAMELA D. BRADLEY, PHN KENNETH TAKATA
Sacramento, California
Clostridium perfringens is one of the most common etiologic agents of food-borne illness in the United States, representing an estimated 10% to 20% of all reported food-borne illness outbreaks.' Many of the documented outbreaks have occurred in institutional settings and at holiday meals where, because of the large quantities of food prepared, the potential for food mishandling and many people being exposed is particularly high." Improper storage and holding temperatures of large pieces of meat and poultry products, such as chicken, beef, and turkey, are most commonly associated with C perfringens outbreaks.',- We describe a classic outbreak of C perfringens illnesses in a northern California juvenile detention facility, probably linked to the mishandling of food served at a holiday meal.
Background and Methods Background On November 19, 1995, the county medical officer on call became aware of a suspected food-borne outbreak of illness at the juvenile hall. Of 250 residents and staff members, about 100 (40%) had reported symptoms of diarrhea and vomiting during the preceding eight hours. Anecdotal evidence incriminated the lunch meal served on Thanksgiving Day, November 18. Specifically, residents from one of the ten living units did not become ill; these children were at a special event on November 18 *Registered Environmental Health Specialist.
(Parikh Al, Jay MT, Kassam D, Kociemba T, Dworkis B, Bradley PD, et al. Clostridium perfringens outbreak at a juvenile detention facility linked to a Thanksgiving holiday meal. West J Med 1997 June;
166:417-419) From the Sacramento County Departments of Health and Human Services (Mss Parikh and Bradley, Dr Jay, and Mr Takata) and Medical Systems (Dr Kassam) and the Sacramento County Environmental Management Department (Mss Kociemba and Dworkis), Sacramento, Califomia. Reprint requests to Arti I. Parikh, MPH, Sacramento County Dept of Health and Human Services, Epidemiology and Disease Control, 3701 Branch Center Rd, Sacramento, CA 95827.
and ate a barbeque lunch instead of the cafeteria lunch eaten by the other children and staff. Epidemiologic Investigation A case of gastroenteritis was defined as a person who reported having diarrhea (defined as the occurrence of loose or watery stools), along with one or more of the following symptoms: abdominal cramps, nausea, or vomiting-all occurring after 5 PM on November 18, 1995. The members of each of ten units eat, reside, and sleep in the same area, with no opportunity for mixing with members of the other units. Residents and staff both eat meals at the facility cafeteria. We obtained from staff the menu of meals served on November 18, along with a roster of residents of juvenile hall. A standardized questionnaire was developed to determine a food history, a symptoms inventory, and demographic data. A randomnumbers table was used to select a sample of persons to complete the questionnaire. Interviews of residents were conducted face-to-face, and staff surveys were self-administered. Data from the questionnaires were analyzed using Epi Info 6.0;6 univariate statistics were generated.
Environmental and Bacteriologic Investigation The food preparation facility was inspected on November 19. Remaining food specimens were collected for analysis, and staff members were interviewed regarding food-handling and preparation methods. The food specimens were tested for Salmonella and Shigella species, Escherichia coli 0157:H7, Staphylococcus aureus, Campylobacter species, and Clostridium perfringens. In addition, stool specimens were taken from nine persons who reported gastrointestinal symptoms. These specimens were tested for Salmonella, Shigella, and Campylobacter species and C perfringens.
Results Epidemiologic Investigation About 33% (n = 82) of residents and staff at the juvenile hall were interviewed; all ten units-including the unit that had the barbeque lunch in lieu of the cafeteria lunch-were represented in the sample. Of the people interviewed, 42 (51%) were residents of juvenile hall and 40 (49%) were staff. The mean ages of the residents and staff were 16 years and 31 years, respectively. Of the 82 persons interviewed, 53 (65%) reported symptoms of gastrointestinal illness, with the remaining 29 (35%) reporting no such symptoms. Symptoms included diarrhea (100%), abdominal cramps (90%), nausea (63%), and vomiting (30%). Additional symptoms reported included muscle aches and chills. The mean incubation time was 13 hours (range, 5 to 19) (Figure 1). The duration of illness was 8 to 72 hours (median, 24). Most people were asymptomatic after 24 to 48 hours. Only one youth had protracted symptoms and needed intravenous hydration.
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WJM, June 1997-Vol 166, No. 6 166,
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Onset of symptoms (hours) Figure 1.-The graph shows the epidemic curve for gastrointestinal illness associated with meals at juvenile hall on November 18, 1995.
An analysis of food histories revealed that food items served at lunch were associated with illness. Although no single item was implicated as the source of illness, the turkey and gravy served at lunch time had the highest relative risks and lowest P values (Table 1). Attack rates for the people who did not eat turkey and gravy were 22% and 28%, respectively. In addition to the attack rates for turkey and gravy (P < .001), those for bread, mashed potatoes, melon, and milk from the lunch meal were significant.
Environmental Investigation The suspect cafeteria lunch meal consisted of sliced roasted turkey, bread, mashed potatoes, gravy, mixed vegetables, garden salad with Italian dressing, honeydew melon, and milk. The handling and preparation of the turkey was a cause for concern On November 17, frozen turkey breasts were thawed and cooked until they were .
TABLE No. /Il
Bacteriologic Investigation Laboratory results revealed that of the nine stool specimens cultured for C perfringens, five contained median counts of more than 1 X 106 organisms per gram of feces,
1,-Attack Rates for Food Items Consumed ot Lunch at Juvenile Holl on November 18, 1995 Ate
Food
visually observed to be done. The cooked turkeys were then piled on top of each other in a large stock pot, covered with foil, and placed in a walk-in refrigerator. On November 18, the cooked turkey was sliced, reheated, and served. The juice from the turkeys was used to make gravy, which was also cooled in large pots in the walk-in refrigerator on November 17. The turkey and gravy were reheated and served at noon on November 18; temperatures were not measured before removal from the oven or before serving. Interviews with the food handlers revealed that some of the turkey was still warm when removed from the walk-in refrigerator.
Total
Did Not Eot Attock Rate, %
No. 1I11
Total
77 73 73 75 76 70 74 85 79 81
4 15 6 5 27 23 23 30 19 33
18 31
Attack Rate, %
Attributable RR
P Vlue
Risk, %
3.45 1.52
