|Outbreak: Hip-hop Measles|
|Product: N/A||Investigation Start Date: 5/27/2007|
|Location: Lane County, Oregon||Etiology: Measles|
|Earliest known case onset date: 5/20/2007||Latest case onset date: 6/5/2007|
|Confirmed / Presumptive Case Count: 2 / 1||Positive Environmental Samples: N/A|
|Hospitalizations: 2||Deaths: 0|
In 2007, two cases of measles detected in Oregon (both unvaccinated) led to an investigation of potential exposures within a hospital and the community at large. This investigation cost approximately $170,000 across local and state health departments, and the related medical system, highlighting the costs associated with measles contact investigation.
- • “Lessons Learned From A Measles Outbreak.” National Immunization Conference (NIC) Talk.
- • “Local Man Exposes Hospital To Measles.” The Register-Guard Newspaper, 2007.
- • “Eugene Man With Measles May Have Exposed Travelers.” The World Newspaper, 2007.
- • “Measles Victim Leaves House Despite Warning.” The Register-Guard Newspaper, 2007.
On May 27, 2007, Lane County Health and Human Services (LCHHS) received a report of a possible measles case admitted to a local hospital. The index case was in his twenties, unimmunized, and had been in Japan during his putative incubation period. A second case was identified later. The cases lived in a mid-sized urban community (pop. 200,000), and, as we were later to find out, had active social lives.
Hospital staff reviewed their employees’ immunization status and the airflow system. Measles cases and their exposed contacts were interviewed using Oregon’s standard measles case-report form. For those contacts lacking documentation of immunity, vaccine or immunoglobulin (IG) was offered. Instructions for voluntary quarantine were given to exposed non-immune contacts. The costs of containing the two measles cases was estimated for the hospital and local and state public health departments.
Public health recommendations included three tiers of contact investigation:
(1) Health-care workers (HCWs) in direct contact; patients in the waiting room and emergency department (ED); household contacts and close friends.
(2) HCWs in units potentially exposed via air flow.
(3) High-risk patients (pregnant moms, babies, immunocompromised) potentially exposed via air flow.
On May 31, 2007, Lane County officials confirmed the diagnosis of measles in the index case by polymerase chain reaction testing. His prodrome began on May 20. He flew on May 21 from Tokyo to San Francisco, and thence on May 22 to Eugene. His rash was first noted on May 25. He spent time at a local hospital ED and visited a health food store, naturopath and Japanese restaurant during his communicable period.
The patient was not given a mask while in the ED waiting for his initial evaluation; rather, he was placed in a regular airflow room and then wheeled through the hospital without a mask and ultimately put in a taxi for the ride home. Review of the hospital’s airflow system revealed that air from the ER (where case was housed but not isolated) was shared with the Coronary Care unit and Mother Baby Unit. The circulated air had a mixture of about 20% outside air and 80% recycled indoor air with 90%–95 % effective filtration and no HEPA filter.
During the investigation, the index patient refused to identify household contacts and did not respond to LCHHS phone calls, making contact investigation difficult. An unannounced home visit helped to clarify the situation and obtain new information.
Information regarding 4 persons exposed on airline flights was not received until two weeks after the likely exposure. A week later, health officials were informed of two additional persons considered exposed, having sat next to or in front of the case, but phone numbers were not provided, and they had common last names. It also transpired that the case provided an incorrect seat number, and the model of the one of the airplanes was different from that listed on the airline’s website, further confusing attempts to identify exposed persons.
A second, unimmunized case, who had socialized with the index patient the night he arrived home from Japan, developed a febrile prodrome on May 30 and a rash consistent with measles on June 1. Koplik spots were visible. He declined lab testing.
Although nurses advised case #2 to stay home to avoid spreading the disease, he went to public places. On May 29, the case caught a hip-hop show at a local concert hall, then to a downtown bar. The next night, he went out for sushi.
Three bands that played at the concert were on a national tour. During these shows, the attendees typically stand, dance and mingle, the band is on a stage just above the floor and the band members often venture into the audience. The band members were in Utah when they were notified about their possible exposure, and specimens to verify immunity were collected in Colorado. The testing was performed at CDC in Georgia, and after the tests proved negative they were vaccinated while performing in Iowa.
This investigation presented numerous challenges. Both measles patients came from families that did not believe in measles vaccination, and who “don’t think measles are a big deal.” Local public health officials’ recommendations for isolation and quarantine didn’t impede their pursuit of an active social life—which greatly increased the work of contact tracing. The following factors also complicated the response:
- 1. Exposures during multiple airplane flights
- 2. Delay in receipt of information about people exposed during travel
- 3. Exposures among a community of unimmunized peers
- 4. Delayed isolation of the case at the hospital
- 5. Shared ventilation between the case’s room and other hospital units
- 6. Lack of airborne precautions during transit through hospital at time of discharge
- 7. Withholding of information and non-compliance with voluntary home isolation
- 8. Limited documentation of measles immunity among healthcare workers
As a result, the investigation of these two measles cases and containment of the outbreak entailed substantial amounts of personnel time and money, as detailed below:
- • Hospital:
- – Incident Command System (ICS) activated
- – 1600 titers in a 2-week period
- – 97% of HCWs were immune
- – Cost of titers $40,000
- – 600 fit tested for N95 masks
- – 10 HCWs placed on furlough for several days
- – 3 HCWs furloughed for 21 days
- – 63 shots given
- – New policy requiring proof of measles immunity
- – Infection education module updated
- – Isolation & transferring process reviewed
- – $100,000 (estimated cost)
- • Local Health Department:
- – ICS activated
- – 2 cases
- – 168 contacts investigated
- – 90% were immune
- – 4 shots given
- – 4 people were placed in voluntary quarantine
- – $50,000 (estimated cost)
- • State Health Department:
- – ICS activated
- – $20,000 (estimated cost)
This outbreak was successfully controlled, despite the potential for spread. The limited extent of this outbreak, even in the setting of broad exposure, highlights the high level of population immunity achieved in Oregon and in other states.
This outbreak and its burden on clinical and public health resources could have been limited by adherence to recommendations of the Advisory Committee on Immunization Practices (ACIP) for vaccination of high-risk adults against measles.
- • Consider using quarantine orders and the quarantine process as outlined in statute to minimize the risk of spreading the virus
- • Consider taking legal action when cases are do not comply with public health investigation and control efforts
- • Develop educational materials with clear, relevant messages targeting vaccine-hesitant communities affected by the outbreak
- • Continue efforts to ensure networking with the alternative medical community
- • Expand use of digital communications for public information
- • Ensure airborne infection control precautions in healthcare settings
- • Promote measles vaccination and documented evidence of immunity among healthcare workers in Oregon
Welcome, citizen, to the Museum’s first outbreak submission contest!
Submit a significant or interesting outbreak investigation and you may win official International Outbreak Museum T-shirts! The winning outbreak investigation submission will also become an official online exhibit right here on the Museum website.
Promotion Period:The International Outbreak Museum (IOM) Outbreak Submission T-shirt Contest begins March 1st, 2018 and ends March 31st, 2018. A winner will be chosen within 30 days of the promotion end date. We will contact the winner if additional online exhibit materials are needed.
Prize: The winner (or each member of the winning team) will receive a T-shirt in (choose one) small, medium, large, or extra large (subject to availability). In addition, your winning outbreak investigation will become an official IOM website online exhibit.
Special Requirements: Since the chosen winner’s exhibit will become an official online exhibit at www.outbreakmuseum.com, the aforementioned must be willing to work in a limited fashion with museum staff to finalize the online outbreak exhibit. This may include a request for additional information or materials (such as pictures, video, an epi curve, outbreak questionnaire, etc).
Eligibility: Anyone can submit an outbreak investigation. There are no restrictions for eligibility based upon geographic location or whether or not you participated in the submitted outbreak investigation. T-shirts will be shipped to the winners within 2-8 weeks (to the best of our ability).
How To Enter: You may enter this contest as an individual or a small team. To enter the contest, a historically significant outbreak investigation report must be submitted to International Outbreak Museum staff.
To submit your exhibit, please fill out the online exhibit submission form (below) and submit it along with any supporting materials (images, captions for images, publications, presentations, epi curve, etc) to the following email address: email@example.com
NOTE: For examples of current online outbreak exhibits, please click “Outbreak Exhibits” at the top of this page or click here.
- 1) Investigation jurisdiction (local Health Department, state Health Department, Federal, Other)
- 2) Pathogen
- 3) Vehicle/venue
- 4) Case counts (confirmed/presumptive/suspect)
- 5) Geographic distribution of cases (single county/state-wide/multi-state/International)
- 6) First and last onset dates
- 7) Pictures! (please include captions for each photo submitted as part of exhibit)
- 8) Number of positive non-human specimens (water, environment, food, etc.)
OPTIONAL BONUS MATERIAL
- 9) Publication citation (optional)
- 10) Presentations (optional)
- 11) Investigation tools (e.g., questionnaire) (optional)
Please limit the 3 sections below to a total of ~1000 words
- 1) Abstract: Background, Methods, Results, Conclusions
- 2) Highlights: unique features or reasons why the outbreak is important
- 3) Lessons learned
|Outbreak: Raw Flour E. Coli|
|Product: Raw Flour||Investigation Start Date: 6/1/2016|
|Location: Multistate||Etiology: E. coli O121|
|Earliest known case onset date: 12/21/2015||Latest case onset date: 9/5/2016|
|Confirmed Case Count: 63||Positive Environmental Samples: 39|
|Hospitalizations: 17||Deaths: 0|
CDC worked with public health and regulatory officials in many states and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli (STEC) infections.
Public health investigators used the PulseNet system to identify illnesses that may be part of this outbreak. PulseNet, coordinated by CDC, is the national subtyping network of public health and food regulatory agency laboratories. PulseNet performs DNA fingerprinting on STEC bacteria isolated from ill people by using techniques called pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). CDC PulseNet manages a national database of these DNA fingerprints to identify possible outbreaks.
Sixty-three people infected with the outbreak strains of STEC O121 or STEC O26 were reported from 24 states. A list of the states and the number of cases in each can be found on the Case Count Map page. WGS showed that isolates from ill people were closely related genetically. This close genetic relationship means that people in this outbreak were more likely to share a common source of infection.
Illnesses started on dates ranging from December 21, 2015 to September 5, 2016. Ill people range in age from 1 year to 95, with a median age of 18. Seventy-six percent of ill people were female. Seventeen ill people were hospitalized. One person developed hemolytic uremic syndrome, a type of kidney failure, and no deaths were reported.
- • CDC Recall & Advice to Consumers and Retailers
- • CDC Signs and Symptoms
- • FDA Outbreak Investigation Info Page
- • General Mills Flour Recall Consumer Information
- • “General Mills announces flour recall” May 31, 2016
Flour is a raw, minimally processed product intended to be cooked before consumption. Although several previous Shiga-toxin-producing E. coli (STEC) outbreak investigations in the United States suspected contaminated flour as the source, none had been proven. In February 2016, PulseNet, the laboratory network for foodborne disease surveillance, detected a 12-state cluster of STEC O121 infections having the same rare genetic fingerprint. A multistate outbreak investigation was initiated. An additional STEC O26 strain was linked to the outbreak after testing of implicated flour.
A case was defined as infection with an outbreak strain of STEC O121 or O26 occurring between December 21, 2015, and September 5, 2016. Case-patients were interviewed about foods and other exposures in the week before illness onset. We performed univariable matched exact conditional logistic regression to identify exposures associated with illness, comparing them to exposures among people with reportable non-STEC enteric infections (primarily salmonellosis and campylobacteriosis), matched on age, gender, and state of residence. Four controls were sought for each case and interviewed by state and local health officials. Samples of suspected products were collected and cultured for STEC. A common point of contamination was sought through traceback. Whole genome sequencing (WGS) was performed on selected clinical and food isolates.
Fifty-six cases of STEC O121 and one case of STEC O26 infection were identified in 24 states; seventeen people were hospitalized; none died. Using General Mills flour (OR 21.0, 95% CI 4.7‒94.4) and tasting unbaked homemade dough or batter (OR 36.0, 95% CI 4.6‒280.2) were both significantly associated with illness. Traceback identified a common flour production facility. Three illnesses were in children exposed to raw dough for playing at several locations of a single restaurant chain. Leftover flour samples collected from cases’ homes and additional samples collected from the flour producer were tested, and five STEC strains were isolated (one STEC O26, three STEC O121, and one STEC O103). All isolates tested were closely related genetically.
This is the first investigation to link definitively an outbreak of STEC infections to raw flour. Nearly 250 products containing the implicated flour were recalled by the flour producer as well as by several companies that used recalled flour. Consumers should not eat products containing uncooked flour. Using uncooked dough for play should also be discouraged at restaurants and home. Flour producers should consider adding prominent packaging labels to warn consumer not to eat undercooked or raw flour. Foodborne illnesses associated with raw flour are likely preventable if appropriate control measures are taken from grain fields and production facilities to restaurants and consumers.
Publication citation: Crowe SJ., et al. Shiga toxin–producing E. coli infections associated with flour. New Engl J Med 2017; 377: 2036n43.
|Outbreak: Hubbard Splash Fountain|
|Product: Splash Fountain in Hubbard, OR||Investigation Start Date: 07/25/03|
|Location: Marion County, OR||Etiology: Shigella sonnei|
|Earliest known case onset date: 07/16/03||Latest case onset date: 08/17/03|
|Confirmed / Presumptive Case Count: 19 / 37||Positive Samples: 0|
Investigation of an outbreak of gastrointestinal illness erupted among children in a small community in Marion County, Oregon. Investigation by epidemiologists found that the illnesses were due to the fecal bacterium Shigella sonnei, and traced to an unusual common source: a splash fountain. This outbreak underscores the risk of large and prolonged outbreaks from these fountains and the need to develop and implement environmental health standards for their design and maintenance.
- • Outbreak Investigation Questionnaire
- • CD Summary article: Shigellosis at the Fountain of Youth 7/13/04
- • Shigellosis from an Interactive Fountain: Implications for Regulation (Journal of Environmental Health)
- Media Coverage
- • Statesmen Journal: Outbreak closes fountain
On July 25, 2003, a physician notified the Oregon Public Health Division about 5 unrelated children with diarrhea. Epidemiologists began investigating to ascertain the bacterial etiology and the means of transmission, so as to institute control measures.
Confirmed cases had S. sonnei infections with matching DNA patterns by pulsed-field gel electrophoresis (PFGE), with illness onset date during July–August 2003. Presumptive cases had dysentery or diarrhea with fever and were epidemiologically linked to a confirmed case. Primary cases were the first ill in a household or daycare group.
To identify the source of the outbreak, epidemiologists conducted a case-control study, using the first seven confirmed primary cases. Interviews were conducted in English or Spanish with cases or household proxies. Respondents were asked about activities in which they had participated and places at which they had eaten during the last two weeks of July. Fifteen control children, matched to cases by telephone prefix and loosely by age (e.g., being less than 15 years old), were identified by systematic calling.
To estimate an attack rate, epidemiologists conducted a telephone survey of 147 children drawn at random from the rosters of two local elementary (grades K–5) schools.
Water samples collected from the fountain’s sump tank and surge tank, and from a nearby drinking water fountain, were assayed for fecal coliforms, E. coli, pH, and free chlorine. They were also tested for Shigella by membrane filtration and plating on salmonella-shigella agar. Shigella isolates were then speciated and subtyped by PFGE.
Initial interviews identified no obvious common foods, but revealed that many cases had attended a festival in the city park (now known as Rivenes Park) of Hubbard, Oregon. All 7 cases but only 1 of 15 controls had played in the park’s interactive fountain (matched OR undefined, P=0.001). Through case reporting and the subsequent survey, investigators identified 19 confirmed and 37 presumptive cases associated with the fountain. Primary cases were exposed during at least a 10-day period ending August 1, when the fountain was closed.
The fountain was a shallow basin about 8 meters in diameter with recessed spray nozzles that encouraged recreational interaction. The water drained to a central reservoir, which allowed standing water to accumulate and did not allow it to recirculate when the fountain was shut off at night. The surge tank was underground with a large device for straining out larger items like soda cans. Fresh water was supplied through a backflow device installed below ground level; the design did not provide adequate protection of the water supply from contamination.
The filtration system did not have influent and effluent gauges, nor was there a flow meter. Chlorine was added manually by tossing “tri-chlor” (trichloro-S-triazinetrione) tablets into the surge tank on an irregular basis. The ultraviolet light ozone generator was too small for the flow rate, and the bulb had never been changed.
Two water samples yielded fecal coliforms (940 and 370 per 100 mL, respectively) and E. coli (500 and 140 per 100 mL). Chlorine was not detectable.
Of the 147 local children surveyed, 51 (35%) had played in the fountain during the last two weeks of July. Of the 51, 20 (39%) subsequently developed diarrhea (compared with 3% of those who had not visited the fountain [P<0.001]). Investigators estimated that, including children from other schools, older persons, and those who may have contracted the illness from secondary person-to-person spread, >500 persons most likely contracted shigellosis in this outbreak.
This splash fountain outbreak provides two unique lessons. First, it is a reminder for epidemiologists to remain objective when investigating outbreaks and not to presume foodborne transmission when dealing with outbreaks of enteric disease. Mark Twain said, “To a man with a hammer, everything looks like a nail,” but epidemiologists need to maintain a broader perspective.
Second, this outbreak highlights the need for public health policy that addresses risks posed by the built environment. It underscores the risk of large and prolonged outbreaks from such fountains and the need to develop and to enforce standards for their design and maintenance. In 2003, the regulations and licensure regarding splash fountains were still being developed. After the outbreak, the state health department’s food, pool and lodging program visited and scrutinized the fountain and suggested that it be licensed and regulated as a public wading pool. The fountain was subsequently re-engineered and now has an automatic chlorinator.