Mid-America Regional Public Health Leadership Institute Year 8 Fellows
Maxine Barth, RN, MSN, Administrator, Bond County Health Department, Illinois
Beverly J. English, MS, MCH Nurse Consultant Supervisor, Illinois Department Human Services
Marcia H. Levin, MPH, Immunization Program Coordinator, Cook Co. Dept. of Public Health, Illinois
Sharon Frederking, MSN, Administrator, Washington County Health Department, Illinois
Steven D. Kelley, BS, Regional Health Officer, Illinois Department of Public Health
Helen Baker, EdD, Mentor, President, Kendall County Board of Health, Illinois
Adapted from Leadership in Public Health 2002;6(1):3-12
An outbreak investigation of an E. coli illness includes the examination of an epidemiologic study, an environmental investigation and an analysis of laboratory samples. In any outbreak, it is critical that assessment data be accumulated and analyzed as soon as possible. Early investigation by public health officials is critical in reducing the impact of an outbreak. To assure a timely assessment for early detection and intervention of emerging disease and outcomes, health care facilities and private practitioners should report all reportable communicable disease and unusual illness trends to the local health department.
On July 15, 1999, approximately 1,200 people from 23 Illini counties and six other states, attended an annual party. The party (Pasture Party '99) was held in a cow pasture in Bovine County. More than 300 people became ill and 22 were hospitalized after feasting on beef, pork and ostrich meat. The outbreak was the largest one in state history involving E. coli 0157:H7.Health officials traced the source of E. coli to contaminated meat served at the party by specific E.coli bacteria in stool samples taken from the infected persons.State and local health department staff interviewed more than 657 persons who attended the party.While no particular group claimed responsibility, results indicated that this particular strain of E. coli was possibly linked to bio-terrorism.
Bovine County is located in the central part of the Midwest, 20 miles northwest of the state capital, Springpatch. The county population is about 17,000, and the county seat of Guernsey is a bedroom and agricultural town of 10,000.The entire area is included in the Springpatch metropolitan service area of just more than 100,000 people. There is no hospital in Guernsey, but it is served by an outpatient clinic operated by St. Ralph's Hospital, the largest of the three hospitals in Springpatch.
Cowpile Farms is a large livestock and grain operation located just outside the town of Guernsey. It is run by Harry Hapless, the owner of Cowpile Farms, who is a wealthy politically-connected farmer and local bank owner. He has been sponsoring a large party on his farm every year for the past seven years. He invites many important people from all over the state of Illini and the Midwest. His guests are primarily involved in government, banking and agriculture.
Harry Hapless, a wealthy farmer and bank owner from Bovine County, had scheduled his annual "Pasture Party '99" for Saturday, July 15, 1999, and as usual, had invited the most influential people in state government, banking and agricultural circles. This year, as an added bonus, he invited Governor Homer George, who would be returning from a trip to the Despot Republic, an island in the Caribbean under a trade embargo that had lasted for forty years. George, who was very interested in improving the overseas markets for Illini agribusiness, was attempting to force the federal government into reconsidering the embargo, hopefully creating a prime market for Illini farm products.
In addition to the federal government, opponents to the Governor's trip included a large, vocal group of exiles from the Despot Republic, who call themselves The Despot Republic Organization (DRO). The exiles now reside in south Sunnyland, the winter playground of our country, located only 90 miles from their homeland. They had made public threats against the Governor, should he not heed their protests and indeed go ahead with his trip. The DRO was fearful that the Governor's trip would result in an economic benefit to the Despot Republic, thereby, weakening the effect of the embargo.
Just hours before his scheduled appearance at "Pasture Party '99," the Governor was admitted to a Springpatch hospital due to a gall bladder attack. At the last moment, Harry Hapless was notified. This was unknown to anyone at the party until it had begun.
The party was a huge success, with more than 1,200 attending. They were served from tables set up in a pasture at Cowpile Farms. The beef served was from cattle raised at the farm and it was butchered at a local custom slaughterhouse. The sweet corn was also grown at Compile Farm. The chicken was purchased from a poultry wholesaler from nearby Poultryville and the pork was from hogs donated by another area farmer. The hogs were butchered at the same slaughterhouse as the cattle. All the food was cooked at the Cowpile Farm immediately prior to the event.
July 13, 1999
An Ostrich was donated by a citizen. The animal had
been butchered three weeks before the event and the carcass had been cut into pieces and
frozen.
July 14, 1999
The ostrich meat was thawed in an ice chest
July 14, 1999
Cooking of the beef and pork began at about 7:00 p.m. (At 5:30 p.m. the steer carcass arrived via pick-up truck to the site and it was
stored in a machine shed where cutting and cooking occurred).
July 15, 1999
The "Pasture Party" event in Guernsey, IL:
July 18, 1999
The Sangamo County Health
Department notified the Illini Department of Public Health (IDPH) regarding a patient that
presented at a St. Ralph's Hospital and subsequently was admitted with bloody diarrhea,
presumptive of E. coli. Four others had been treated for bloody diarrhea
stools in the past 24 hours. Stool specimen results were pending. All five
patients had attended the "Pasture Party" at the same place in Guernsey, Illini
in Bovine County. Sangamo County Health Department notified Bovine County
Health Department.
July 19,1999
July l9, 1999
Press Release: E.coli
outbreak linked to private party; 336 sick.
July 21, 1999
Press Release: More
hospitalized with outbreak. An environmental investigation began. Personnel from
IDPH (Foods, Drug & Dairies, Infectious Disease and Environmental Health) and the
local health department participated.
The following was done:
July 22, 1999
Press Release: E. coli
outbreak linked to private party. Drinking water ruled out as possible cause. 336
report symptoms, 22 require hospitalization, 48 culture positive for E coli. Lab
tests and environmental sampling are ongoing. Health departments respond with
inquiries from residents regarding illness. "Panic" feared.
July 23, 1999
Press Release: IDPH went
on-line with a news update: 600 of the estimated 1200 have been contacted. The number ill
increased to 336, 22 hospitalized, 58 culture positive for E.coli. Two different
strains of E. coli identified. Three cases of E. coli infection were
reported by people who did not attend, but who lived with someone who had
attended. IDPH alerted people to "good hand washing" to avoid
secondary infection. Illinois Bureau of Investigations (IBI) intervenes: No
further press releases.
July 25, 1999
A news story was leaked to the
press that bio-terrorism is being suspected as the cause
of serious illness among party-goers. The assumption is made because of FBI/IBI
investigation of the threats made against the Governor and his trip to the Despot
Republic.
July 28, 1999
Traced one strain of E. coli to cattle from property of Harry Hapless; source of second
strain causing illness among party-goers is unidentified.
August 1, 1999
Eleven soil samples were collected from the event site. Information of food handling at the event was
obtained.
August 3, 1999
News Article: First the Bacteria, Then the Bills.
August 4, 1999
News Article: Fund raiser held to help those stuck with E. coli related costs.
August 11, 1999
Lab analysis compares outbreak strain with others. This outbreak strain of E. Coli 0157:H7 causing
illness among party-goers to "Pasture Party '99" genetically differs from the
environmental strains found at the party site. The investigation, which continues, will
examine possible sources of this particular strain. Although bio-terrorism has been
suspected, not enough evidence is currently available to be definitive.
The event took place on July 15, 1999 at a rural farm site about 20 miles northwest of the state capital of Springpatch in Bovine County.
The party was held in a cow pasture. The pasture's owner indicated it had been cleaned of manure before the party, although some traces undoubtedly remained behind. It was determined that the traces were an unlikely source of contamination, since E. coli will not survive long outside a host animal. The owner said he took care to keep the field free of manure, allowing cattle to graze there only two to three times a year to keep the grass short. The last time any cows had been in the field was one month before the party. Bacteria can, however, live outside cattle for several months. The steer that was eaten had not been in the field for one year. There were two ponds nearby, the smaller surrounded by an orchard.
Food was prepared in a large air-conditioned barn consisting of a large room and an open-sided attached shed. The large room was where the food was served and the shed was where the meat cutting and cooking occurred. Organizers controlled how many people were in the serving line at a time. The steer provided by Harry Hapless had been slaughtered and prepared off-site beforehand. Other farmers had donated a hog and an ostrich. The meat was sliced into 20 lb-cuts and cooked over a spit for approximately 13 hours. If bacteria were already present on any meat's surface, it could have seeped through to the center of the meat during cooking.
One well was in use at the site. Although the well failed to meet code (not to be located less than minimum 25 ft. away from any pond), the water cultured was negative for E. coli. A watering hose that had been used to provide water for hand washing was also cultured and found negative for the E. coli bacteria. Each pond was tested and the results were negative.
The following samples were secured and tested:
There was no refrigeration available at the site of the event. The uncooked meat was cut into 25 lb. chunks, wrapped in chicken wire and put on a spit. A propane cooker was used to cook the pork and beef. The cooker had an air temperature gauge and four burners (as a size reference, 52 chickens per bay could be cooked at a time).
Food served at the event included 1500 ears of sweet corn, onions, tomatoes and barbecue sauce.
Attendees were questioned as to where they sat, whether they washed their hands, whether they washed in a nearby creek or pond, what they ate and drank and who attended with them. All answers were fed into an Epi-Info 6.0 program to look for patterns. Nothing had been noted to suggest negligence by the owner.
After St. Ralph's Hospital in Springpatch, Illini reported several suspected cases of E. coli, an epidemiological investigation began. A list of "Pasture Party" attendees was secured and a questionnaire was developed by IDPH personnel. Attendees were asked questions as noted above in the Environmental Setting Evaluation. An Epi-Info 6.0 data base was established.
A case was defined as someone who either experienced diarrhea or had culture confirmation of E. coli after having attended this party. A well person, for the purposes of the epidemiologic analysis, was defined as someone who experienced no gastrointestinal symptoms (abdominal pain, diarrhea or vomiting) following the event. The epidemic curve used the date of onset of diarrhea for the x-axis. Some individuals attended but did not eat any food at the event and were excluded from the epidemiologic analysis of food items, but were included in the epidemiologic analysis of other risk factors (sitting on the ground, wading, etc.).
Pulse Field Gel Electrophoresis (PFGE, or DNA fingerprinting) testing is a new technique that has been recently found to be a useful tool in distinguishing epidemiologically related isolates (e.g., isolates from same household or outbreak), while showing diversity within larger geographic areas. In an effort to identify not only the pathogen associated with this outbreak, but to determine its link to any environmental source of contamination, PFGE was used to identify the particular isolate or isolates that caused illness among the guests.
Isolates of E. coli were characterized with regard to productions of shiga-like toxins. Antibiotic resistance patterns were determined by standard methods. A sample of party-associated isolates were compared with isolates obtained from the grounds of the "Pasture Party" by pulse field gel electrophoresis (PFGE). All party-associated isolates of E. coli had identical patterns of antibiotic resistance and produced shiga-like toxins 1 and 2. All stool specimens collected from party-goers were identical to one another. These isolates were, however, distinct from all isolates found in two of the eighteen cow pies and from any food preparation area within the machine shed. In fact, meat that was held in reserve in the machine shed after cooking was found to be uncontaminated with any E. coli.
On July 18, Sangamo County Health Department officials were notified by a local hospital that they had seen and treated five individuals that day who presented for treatment with persistent bloody diarrhea. Stools samples had been collected from two patients and results were pending. All five persons had attended the July 15 "Pasture Party" event. On July 18, 1999, Bovine County Health Department also reported to IDPH that almost 35 persons were being evaluated for some type of food borne illness, possibly Salmonella or E. coli. Each of these persons had reported to various clinics and hospitals around the county seeking medical attention for protracted diarrheal episodes, sometimes bloody, accompanied by cramps, some nausea and vomiting. Other reports were still being investigated on numbers of persons residing outside the county reporting similar illness. The commonality appeared to be that each of these stricken individuals had attended the July 15 event known as "Pasture Party '99". Walter Curem, the administrator of the Bovine County Health Department, had received an anonymous phone call on July 18 suggesting that the illnesses being experienced by county residents may be more serious than perceived. He made the decision to contact Thomas Justfax, Director of the Illini Bureau of Investigation (IBI) with the information now being unfolded:
On July 19, 1999, an alert was sent to local health departments and area physicians informing them of the outbreak and to report any cases. Hospital emergency rooms were also notified. On July 20, the results of the first five stool cultures reported culture positive specimens of E. coli. A decision was made by Dr. James R. Munchkin, Director of IDPH, to transmit a broadcast fax to all the health departments throughout the State seeking their cooperation in locating any participant of the event through hospitals and/or clinics who might be reporting stool culture results. It was, however, decided by Tom Justfax that all persons attending this event be identified and contacted. This task was not easy because the "guest register" displayed illegible handwriting and many incomplete addresses and phone numbers.
On July 20, the first of several press releases was issued by Don Rather, Director of Communications of IDPH. This news release, although superficially non-threatening, did suggest the potential for concern among party-goers who were experiencing symptoms and those who were not. Immediately the IBI intervened and asked that no further news releases be issued until they had time to interview the host of the party, conduct a site inspection and evaluate for the potential of bio-terrorist activity at the party. Thomas Justfax, Director of the IBI, contacted A.S. McGarrett, Director of the FBI, and a gag order was issued.
The second series of stool cultures was received on July 22, which identified E. coli as the source of the illness among another eight party-goers. Several health departments began to respond to the inquiry for information from those who attended. Unfortunately, with the "gag order" in effect from the Bureau, the Regional Health Officer, Fred Sockless, was unable to respond to any inquiries from local health authorities, which caused additional confusion and anger. A local news reporter who had first heard of the report through a relationship with a local public information officer in a neighboring county health department, began to investigate what seemed to him to be simple ineptness on the part of the state health department. He contacted A. S. McGarrett, Director of the FBI's Springpatch Office, who gave him incomplete but highly suggestive news about the Bureau's official entry into the investigation. The next day, on the cover of the local downstate newspaper, the headlines read, "Possible Bio-Terrorist Attack Investigated at Pasture Party." The story went on to report that serious illnesses had occurred among those attending and the source of this illness has not yet been confirmed.
Many frightened and concerned attendees from the July 15 party began to swamp the switchboard with phone calls.
One of the first major financial concerns according to Anita Shotem, Communicable Disease. Specialist from the IDPH, are the costs of an epidemiologic study, an environmental investigation and analyses of lab samples. Resources from the Illini Department of Public Health and Bovine County Health Department were utilized. Through these efforts, 1,200 persons were identified as having attended the event or eaten food from the event and were interviewed. The personnel cost of interviewing this number of people must be considered as one of the important factors in the financial impact of such an outbreak. Most of the State's county health departments, as well as health departments in other states which had residents attending the party, had personnel costs associated with trying to locate victims. Illness was also reported as one of the important factors in the financial impact of such an outbreak. Illness was reported by 336 of the 1,200 individuals. The laboratory costs of testing stool samples is another significant cost to be considered. The number of laboratory confirmed cases was 48. Hospitalization costs and medical bills of those who became seriously ill were other key and unexpected costs to the party participants. Twenty-two people were hospitalized. One person did require intensive care during the hospitalization.
Additional costs relating to the epidemiologic investigation were the sampling of other possible sources of contamination. Water samples were taken from nearby ponds and well water. Eighteen samples of cow and other farm animal feces were collected and analyzed. Other samples taken were from items involved in food preparation, including: knife handles, the wood table, stainless steel table and water from a hose used in the cooking process. Eleven soil samples were also collected at the site of the event. The meat was sent to the IDPH, as well as the US Department of Agriculture laboratories, for testing for E. coli.
Untold days of lost work and child care accounted for a significant cost related to this event. According to Nancy Homblower, Public Information Office of the Bovine County Health Department, in some cases, whole families were too ill to care for each other. Relatives and others took time off from work to care for these ill people.
One of the final aspects of the E. coli outbreak was expressed in an article: First the Bacteria, Then the Bills. Some of the guests at the party also had the unexpected surprise of medical bills, in addition to their illness. However, the local community showed their support with two fund raisers. The first was a fish fry and blues jam. The second event was an all-day concert. A committee, with physician representation, was established to determine who would be eligible for financial assistance. Information was published in local newspapers regarding how to donate to the events and also how to apply for assistance.
E. coli is an emerging cause of food borne illness. While most strains of E. coli are harmless and live in the intestines of healthy humans and animals, this particular strain produces a powerful toxin that can cause severe illness. It was first identified as a cause of illness in 1982 during an outbreak of severe bloody diarrhea traced to contaminated hamburgers. Data from one laboratory that routinely tests for E. coli suggest that an estimated 20,000 cases may occur in the United States annually. In 1994, it became a required reportable disease in Illini.
Many persons infected with the bacterium develop severe diarrhea and painful abdominal cramps, although some people show few or no symptoms. The diarrhea can be very bloody.
Because there is usually little or no fever, a person may think some other condition is causing the bowel to bleed and thus the infection may go unrecognized. The illness usually resolves itself in 5 to 10 days. In some persons, particularly children younger than five years of age and the elderly, the infection can lead to destruction of red blood cells and acute kidney failure. This complication, hemolytic uremia syndrome, can lead to stroke, seizures and death. Approximately two to seven percent of infections lead to hemolytic uremia syndrome E.coli can be very difficult to diagnose because there are many causes of bloody diarrhea and abdominal cramps. Specific laboratory tests can identify E. coli 0I57:H7 in the stool of an infected person. However, these tests often are not performed unless the laboratory is instructed to do them. Most persons recover without antibiotics or other specific treatment in five to ten days. Anti-diarrheal agents, such as Imodium, should be avoided. However, the hemolytic uremia syndrome is a life-threatening condition that is usually treated in an intensive care unit and often requires blood transfusions and kidney dialysis. The fatality rate for this complication is three to five percent.
Persons with diarrhea alone usually recover completely, although it may be several months before bowel habits are entirely normal. Among those who develop the hemolytic uremia syndrome, about 15 percent have a poor outcome, such as chronic kidney failure, high blood pressure, stroke, paralysis, blindness or seizures.
From the first realization that the illness being experienced was not just another pesky bout of intestinal virus, but possibly something more serious, people began reacting. The reactions varied, but were characterized by some degree of fear, pain, discomfort, worry and anger in any combination.
Most "victims" expressed concern/worry over what they were experiencing. These worries were intensified exponentially by the sensational bio-terrorist news story describing the threats and innuendo that had preceded the event. Public Health Officials feared that, if this was the result of bio-terrorist activity, more catastrophic events were looming on the horizon.
Many victims were suffering physically because of their illnesses. Protracted diarrheal episodes, weight loss, moderate to severe abdominal cramps, headaches, weakness and general malaise were described by most individuals interviewed. Most had lost days of work and had experienced an inability to care for home and family. Those hospitalized were more seriously afflicted with profound toxigenic food poisoning caused by the E. coli. Some had chronic illnesses, such as diabetes, which was seriously compromised by the diarrheal illness.
Many of the party-goers were frightened that other illnesses too horrible to conceive were about to befall them as a result of bio-terrorism. Even those without diarrheal symptoms of E. coli were afraid that they would become victims of a horrible illness. Many experienced hysteria-induced symptoms of unfounded illness. Some people complained of hair loss, some of joint and body aches, bleeding gums, extreme fatigue, blurred vision, severe headaches, muscle spasms and other symptoms not related to poisoning from E. coli.
Some of the party-goers were angry. They felt that they had become unwitting victims of some terrorist attack. Others, unsuspecting of the terrorist angle, felt that they had been poisoned by their host's stupidity.
The epidemiological investigation of E. coli demonstrates the importance of public health assessment. Assessment, when properly performed, can ensure early identification of disease and its causal agent.
In the present case study, the assessment led by BCHD and IDPH led to a rapid discovery of the cause of the outbreak. State and local officials spent a great deal of time, effort and resources to investigate the E. coli outbreak.
On July 19, 1999, the investigation began when five people were admitted to area hospitals exhibiting symptoms of the illness. Since the presence of bacteria had been confirmed by lab tests, the investigation had found a common thread. All of the people who were infected had attended the same party on July 15, 1999.
The hospitals and private physicians notified Bovine County Health Department and state officials appropriately. Local, state and federal officials worked together expeditiously to control the situation. BCHD appeared to have carried on an effective assessment. Because of bio-terrorism implications, the case is not closed at this time. Although the Governor has indicated that this event will not sway his efforts to create more foreign markets for Illini farmers, tighter security surrounding all events involving the Governor will be instituted.
SuspectedBT Case Study last revised April 21, 2004 (epowell)