Salmonella Heidelberg – Outbreak to Recall

Eric Coffey, Environmental Health ManagerAmanda Taylor, MPH, Epidemiologist

Southeast Regional Office

Initial Outbreak Notification• On Friday, November 29th – TDH SER notified by local jail

administrators that 3 ill inmates were transported to ER with high fever, diarrhea and/or vomiting

• Debbie Walker (SER CEDS Director) worked with Dr. Allyson Cornell (Medical Director), jail staff and hospital ICN to gather information

• Newly symptomatic individuals were seen by jail medical staff and quarantined to one POD

• TDH PIO and jail PIO notified

December 2nd – 4th

• EH was notified of the outbreak and requested to collect samples of the Thanksgiving Meal. Two food trays sampled and 10 samples were overnighted to Lab.

• Hospital ICN informed SER that one stool sample tested positive for Salmonella.

• Kitchen supervisor contacted for menu information. • Questionnaire developed which included symptoms, activities,

cell location and foods eaten during the previous week. • Worked with jail nurse to solicit additional stool samples among

ill.

EPI

EH

LAB• Food samples arrived at the lab, analysis begins.

December 5th

• After the meeting, EH conducted the initial walk through assessment of the County Jail Food Facility.

• Case definition: an inmate or officer reporting diarrhea (≥3 loose stools in a 24 hour period) since November 27.

• Began interviewing ill cases (n=29)• Challenges

EPI

EH

LAB• Food sample testing continued

EPI/CEDS/EH/RO/MED Director met with BCSO administrators to discuss outbreak protocol, investigation direction, and expectations.

December 6th – 11th

• Environmental Health Manager was meeting with investigation team.

• Epi curve created• Moved to case-control study• Enrolled 20 controls

• Matched to cases by gender and POD location• Interviews continued among cases and controls• Database created in Epi Info 7 (EI7) • Began conducting data analysis using EI7 Dashboard.

• EP Nurse Consultants delivered stool collection kits to jail and provided education.

• Took a closer look at menu items served in the week prior to illness.

EPI

EH

LAB• No findings to note from food samples on Thanksgiving tray.• Additional stool samples received.

December 12th

• EH returned to the Facility with EPI to collect samples of the mechanically separated chicken (MSC). Three different lots and manufacture dates were identified. Two of the lots were from around the time of the thanksgiving meals. Two samples of the were collected from the chubs. Packaged and overnighted to the lab for analysis.

EPI

EH

LAB• Stool sample results positive for Salmonella Heidelberg

December 13th

EPI

EH

LAB• MSC samples received and testing began

• EH and EPI returned to the jail kitchen to conduct a food flow of MSC with the kitchen supervisor. Investigated distribution of meals (time and POD location), temp procedures/logs and potential areas for cross contamination.

December 20th – 30th

• Coordinated with USDA/FSIS to answer questions about food sample collection process

• Sent temp logs and inventory information to USDA/FSIS

• Continued data entry• Continued data analysis• Accompanied USDA representative during kitchen assessment

and shared information

EPI

EH

LAB

• Preliminary results of MSC chicken showed Salmonella Heidelberg

• Isolates from case-patients and MSC were subtyped using pulsed-field gel electrophoresis (PFGE) and antimicrobial susceptibility testing was performed

Descriptive Data

Table 1. Case Control Study Enrollment Demographics (n=40) Cases (n=20) Controls (n=20) Age (in years) 37 (22-59) 36 (23-59) # (%) White 19 (95) 19 (95) # (%) Black 0 (0) 1 (5) # (%) Other 1 (5) 0 (0) # (%) Inmates 20 (100) 20 (100)

Table 2. Symptom Profile of Cases (n=29)

Symptom # (%) of Cases

Diarrheaª 29 (100)

Abdominal cramps 27 (93)

Fatigue 27 (93)

Headache 27 (93)

Nausea 27 (93)

Muscle aches 25 (86)

Chills 24 (83)

Fever 21 (72)

Backache 18 (62)

Vomiting 17 (59)

Weight loss 13 (45)

Blood in stool 8 (28)

Fever > 103°F 3 (10)

Constipation 1 (3)

ª Median duration of diarrhea: 4.5 days (range: 1-8 days)

Epi Curve of Ill

Results Summary

• No single food item or activity was found to have a statistically significant association with illness• Due to the nature of Salmonella, mechanically separated

chicken served on 11/27 in breakfast gravy and spaghetti was identified as possible exposure• Stool specimens collected from 13 inmates• 9 (69%) positive for Salmonella Heidelberg with

indistinguishable PFGE patterns• Testing of unopened MSC chub received at jail on

November 22 yielded Salmonella Heidelberg indistinguishable from the outbreak strain • Kitchen assessment identified the possibility of cross-

contamination through improper hand washing, poor personnel hygiene, and inadequate sanitation of utensils

Recall Assessment Summary

• FSIS/USDA contacted for assistance with traceback investigation of MSC• Epi, environmental and lab data provided

• Several detailed questions were asked• Microbiology assessment of sample collection and lab procedures

were conducted to rule out cross-contamination• Representative sent to jail to inspect kitchen• Manufacturer’s legal counsel notified of findings

• Wednesday, January 10 - MSC manufacturer initiated a voluntary recall of approximately 33,840 lbs of product

Further Action• CDC notified of findings• Data and media talking points discussed• SharePoint site updated• Human and food isolates tested for antimicrobial resistance (NARMS)

• Relayed information to TDH PIO and jail PIO for media inquiries

Table 4. Antimicrobial Resistance Results ª for Two Human Samples Antimicrobial Class Antimicrobial Agent Human Isolate 1 Human Isolate 2 Aminoglycosides Gentamicin Susceptible Susceptible

Kanamycin Susceptible Susceptible Streptomycin Susceptible Susceptible

β-Lactam/ β-Lactamase inhibitor Combinations

Amoxicillin-Calvulanic Acid Resistant Resistant

Cephems Cefoxitin Resistant Resistant Ceftiofur Resistant Resistant Ceftriaxone Resistant Resistant

Folate Pathway Inhibitors

Sulfisoxazole Susceptible Resistant Trimethoprim/Sulfamethoxazole Susceptible Resistant

Macrolides Azithromycin Susceptible Susceptible Penicillins Ampicilin Resistant Resistant Phenicois Chloramphenicol Susceptible Susceptible Quinolones Ciprofloxacin Susceptible Susceptible

Nalidixic acid Susceptible Susceptible Tetracyclines Tetracycline Susceptible Resistant ª NARMS INTERPRETIVE CRITERIA – The criteria used to categorize minimum inhibitory concentration results as susceptible, intermediate, or resistant are based on current guidelines provided by the Clinical and Laboratory Standards Institute (CLSI). Interpretive criteria published in the most recent National Antimicrobial Resistance Monitoring System (NARMS) annual report (www.cdc.gov/narms) are applied for drugs that lack CLSI interpretive criteria.

Conclusion• Contaminated MSC and poor food handling practices

contributed to a substantial Salmonella Heidelberg outbreak • Presumptive multidrug-resistant Salmonella may have

contributed to more severe illness• Foodhandlers in institutional settings should receive food

safety training to minimize the risk of illness associated with high-risk foods such as MSC

• USDA News Release:• http://

www.fsis.usda.gov/wps/portal/fsis/topics/recalls-and-public-health-alerts/recall-case-archive/archive/2014/recall-001-2014-release

• CDC Web Announcement:• http://www.cdc.gov/salmonella/heidelberg-01-14/index.html

SERO StaffDr. Allyson Cornell, Debbie Walker, Deb Solomon, Amanda Taylor, Eric Coffey, Marsha Rogers, Robin Moore, Melanie Grant, Christina Arriaga, Robert Goff, Beth Delaney, Glenn Czarnecki

TDH StaffDr. John Dunn, Katie Garman, Amanda Ingram, Dr. Tim Jones, Dr. Rendi Murphree, Dr. Amy Woron, Sheri Roberts, Parvin Arjmandi, Ellyn Marder, Marie Bottomley, Shelley Walker, Latoya Simmons

Acknowledgments

OthersDr. Stephanie Defibaugh-Chávez, FSIS/USDA Staff, CDC Staff, Sheila Spencer, Dr. Alice Green, Dana Maxwell, Latoya Simmons, Jail Administrators, Jail Medical Staff