College of Medicine

College of Medicine, Nursing & Health Science

EVH: 803- Food microbiology &
SAFETY
assignment 2: Fatal Foodborne Clostridium perfringens Illness at a State Psychiatric Hospital-Louisiana, 2010

Group: Sigatoka
Group Members: Shagufa Ali
Viliame Gonewai
Course Convenors: Mr Waisale Delai
Mr Inia Valemei
Mrs Railala Tavui

ABSTRACT
On the 7th of May 2010, there was a fatal foodborne Clostridium perfringens outbreak at a State Psychiatric Hospital in Louisiana. There were a total of 54 cases who had experienced the illness which included 42 residents and 22 staff members. There were 3 deaths of patients within 24 hours.
The cases had symptoms of vomiting, abdominal cramps with diarrhoea. An investigation was carried out by the Louisiana Office of Public Health (OPH) in conjunction with Centre for Disease Control to rule out the cause of the outbreak.
The investigation revealed that the illness was associated with cooking of chicken 24 hours before it was served and the chicken was not cooled in accordance to the hospital guidelines. Stool samples were taken from the ill residents and staff members whereby C. perfringens type A was found.

The investigation also identified the need for strict food preparation guidelines at the hospital. Public Health Authorities reviewed the food preparation policies at the hospital whereby recommendation was made for an additional food safety training for food service workers. Temperature logs were also implemented in the kitchen to monitor the cooling procedures in place.

TABLE OF CONTENTS
TOC o “1-3” h z u INTRODUCTION PAGEREF _Toc514410886 h 3METHODOLOGY PAGEREF _Toc514410887 h 5Case Definition…………….……………………………………………………………….5
Case Finding Methods…………………….……………………………………………………………….5
Laboratory Methods…………………………………………….……………………………………….5
Environmental Studies……………………………………………………………………………………….5
RESULTS PAGEREF _Toc514410888 h 6DISCUSSIONS PAGEREF _Toc514410889 h 7CONCLUSION PAGEREF _Toc514410890 h 9RECOMMENDATIONS PAGEREF _Toc514410891 h 10REFERENCES PAGEREF _Toc514410892 h 11
INTRODUCTIONClostridium perfringens is everywhere in nature, it forms heat resistant endospores, multiplies rapidly and produces a cytotoxic enterotoxin. The characteristics are being gram positive, rod shaped, anaerobic and spore forming pathogenic bacteria. This bacterium is found in many environmental sources as well as in the intestines of humans and animals. This type of bacteria prefers to grow in little or no oxygen, and under ideal conditions can multiply very rapidly. Some strains of C .perfringens produces a toxin in the intestine that causes illness. Outbreaks often occurs in institutions such as hospitals, school cafeterias, prisons, nursing homes or event at events with catered foods (Anon, 2018).
Common Food sources includes beef, poultry, gravies and dried or pre-cooked foods. One of the many ways these bacteria causes infection is when food is prepared in large quantities. The signs and symptoms includes an incubation period of 6-24 hours (typically 8 – 12 hours) with abdominal cramps and diarrhoea. The illness is not passes from one person to the other and with this infection usually, there will be no fever or vomiting.

Clostriduim perfringens is stated to be the third bacterial common causes of food borne illnesses in the United States estimated at causing the deaths of over 1 million people each year. In the United States, local, state and territorial health departments provide C. perfringens outbreaks to the U.S Centres for Disease Control and Prevention through the Foodborne Disease Outbreak Surveillance System.

Fatalities are rare occurring at less than 1%, however, death is usually caused by dehydration among the very young, the very old and persons weakened by illness.
A very intriguing case that was undertaken for studies was in Louisiana at Louisiana state psychiatric hospital on May 7, 2010, 42 residents and 12 staff members experienced vomiting, abdominal cramps, and diarrhoea claiming the lives of 3 people. The three fatalities occurred among patients aged 41–61 years who were receiving medications that had anti–intestinal motility side effects.

Investigation by the Louisiana Office of Public Health (OPH) and CDC found that eating chicken served at dinner on May 6 was associated with illness. The chicken was cooked approximately 24 hours before serving and not cooled in accordance with hospital guidelines. C. perfringens enterotoxin (CPE) was detected in 20 of 23 stool specimens from ill residents and staff members.

Genetic testing of C. perfringens toxins isolated from chicken and stool specimens was carried out to determine which of the two strains responsible for C. perfringens foodborne illness was present.

This outbreak accentuates the need for strict food preparation guidelines at psychiatric inpatient facilities and the potential risk for adverse outcomes among any patients with impaired intestinal motility caused by medications, disease, and extremes of age when exposed to C. perfringens enterotoxin.

On May 8, a state psychiatric hospital contacted OPH to report three resident deaths that occurred following an outbreak of gastrointestinal illness in patients and staff members that began late in the evening of May 6.
The only common exposure was food from the hospital’s kitchen. CDC joined the investigation on May 13 to help identify the outbreak cause. A case was defined as onset of any loose stools or vomiting from the evening of May 6 through the morning of May 8 in residents or staff members. Hospital infection control staff members identified 42 cases from among the 136 residents (attack rate = 31%). Illness onset ranged from 9:00 p.m. on May 6 through 3:00 p.m. on May 7th. Because of the tight clustering of symptom onset, food served at the evening meal on May 6 was considered to be the most likely cause of illness. The mean incubation time from eating the suspect meal was 13 hours (range: 5–21 hours). The most common symptoms were diarrhoea (94%), abdominal cramps (51%), nausea (39%), and vomiting (27%).

In response to this outbreak, regional public health sanitarians conducted food safety presentations for all food service workers at the hospital. After reviewing its food preparation policies, the hospital additionally required all of its food service workers to attend a six-part food safety training course and temperature logs were developed to monitor cooling procedures (Cdc.gov, 2018).
METHODOLOGY(a)- Case definition
The case was defined as onset of any loose stools or vomiting from the evening of May 6th through the morning of May 8th in both the residents and staff members
(b) Case Finding Methods
The source and mode of gathering data was through carrying out personal interview with the kitchen staff members, nursing notes and emergency department records.

(c) Laboratory Methods
Stool specimens were taken from ill residents and staff members.

Genetic Testing of C. perfringens toxins were isolated from the chicken and stool specimens was carried out to determine which of the two strains caused the foodborne illness.

(d) Environmental Studies
CDC conducted the inspection with Public Health Inspectors whereby kitchen staff were interviewed.

Recommendation was made to review the food preparation policies at the hospital.

Temperature logs were also implemented in the kitchen to monitor the cooling procedures in place.

RESULTS
FIGURE 1: Indicates the date and time of the symptoms onset during the outbreak of Clostridium perfringens food poisoning at a state psychiatric hospital in Louisiana, 2010

 The graph above shows the date and time of onset symptoms during the outbreak of Clostridium perfringens food poisoning at a state psychiatric hospital in Louisiana, during 2010. On the 8th of May, a state psychiatric hospital contacted OPH to report three resident deaths that occurred after an outbreak of gastrointestinal illness in patients and staff members that began late in the evening of May 6th. The only common exposure was food from the hospital’s kitchen. CDC joined the investigation on May 13th to identify the outbreak cause. A case was defined as onset of any loose stools or vomiting from the evening of May 6th through the morning of May 8th in residents or staff members. Hospital infection control staff members identified 42 cases from the 136 residents with an attack rate of 31%. Illness onset ranged from 9:00 pm of May 6th through 3:00 p.m. on May 7th.

DISCUSSIONSOn May 7th, 2010, 42 residents and 12 staff members at a Louisiana state psychiatric hospital experienced vomiting, abdominal cramps, and diarrhoea. Within 24 hours, three patients had died. The three mortalities occurred among patients aged 41–61 years who received medications that had anti–intestinal motility side effects.
Investigation carried out by the Louisiana Office of Public Health (OPH) and CDC found that eating chicken served at dinner on May 6th was associated with the foodborne illness. The chicken was cooked approximately 24 hours before serving and not cooled in accordance to the hospital guidelines.  The C. perfringens enterotoxin (CPE) was detected in 20 of the 23 stool specimens from both the ill residents and staff members.

Through Laboratory analysis of genetic testing of C. perfringens toxins which was isolated from chicken and stool specimens determined which of the two strains accountable for C. perfringens foodborne illness was present. This outbreak highlighted the need for strict food preparation guidelines at psychiatric inpatient facilities and the potential risk for adverse outcomes among any patients with impaired intestinal motility caused by medications, disease, and extremes of age when exposed to C. perfringens enterotoxin.

On May 8th, 2010 a state psychiatric hospital contacted the Office of Public Health to report the death of the three residents that occurred immediately after an outbreak of gastrointestinal illness in patients and staff members that began late in the evening of the 6th of May. The only common exposure was food from the hospital’s kitchen. Centres for Disease Control combined the investigation on the 13th of May to identify the cause of the outbreak.

A case was defined as onset of any loose stools or vomiting from the evening of May 6th through the morning of May 8th in residents or staff members. Hospital infection control staff members identified 42 cases from among the 136 residents with an attack rate of 31%.

The Illness onset ranged from 9:00 p.m. on May 6th through 3:00 p.m. on May 7th as showed in the above Figure 1. Due to the of the tight clustering of onset symptoms, food that was served at the evening meal on May 6th was considered to be the most likely cause of illness.
The mean incubation time from eating the suspected meal was 13 hours with a range of 5–21 hours. The most common symptoms were diarrhoea (94%), abdominal cramps (51%), nausea (39%), and vomiting (27%).

Limitations such as histories of food eaten were not obtained from patients because of their difficulties in recalling events, and food consumption was not recorded in nursing notes. There were 32 employees being interviewed whereby13 reported eating some portion of the kitchen-prepared suspect meal. Among these 13, nine had illness that met the case definition (attack rate = 69%). None of the staff members who did not eat the suspect dinner were ill (relative risk = infinity, 95% confidence interval = 3.7–infinity).

Interviews of the kitchen staff members indicated that the chicken served as the suspect meal had been delivered frozen to the kitchen on the 4th of May and was cooked on the 5th of May, the day before serving.
The cooling procedure differed the hospital guidelines as the chicken was placed in a 6-inch deep pan after cooking and covered with aluminium foil this slowed cooling of the meat and the first temperature check was not until 16 hours later.

The interview revealed that during the 24 hours between cooking and serving, the chicken was removed from cooling three times for preparation steps before being served as cold chicken sandwiches or chicken salad. Inspection of the hospital kitchen by Office of Public Health inspectors found no critical desecrations of Louisiana sanitary code.

The state public health laboratory detected C. perfringens enterotoxin by reversed passive latex agglutination (RPLA) in 20 of 23 stool specimens from both ill residents and staff members. CDC’s Enteric Diseases Laboratory Branch detected C. perfringens enterotoxin by RPLA and polymerase chain reaction (PCR) assays for species-specific C. perfringens and CPE genes in 15 of 20 stool specimens available for testing. CDC’s laboratory also isolated enterotoxin-producing C. perfringens and detected the CPE gene in all four of the samples of chicken served at the suspect meal. The stool specimens and bacterial isolates tested negative for the beta toxin gene, confirming that C. perfringens type C was not the etiologic agent and implicating C. perfringens type A.

In response to this outbreak, regional public health inspectors conducted food safety presentations to all food service workers at the hospital. After reviewing its food preparation policies, the hospital was recommended for all of its food service workers to attend a six-part food safety training course. The temperature logs were also developed to monitor cooling procedures.

CONCLUSIONThe results in this report are subjected to at least two limitations. Firstly, the patient information was obtained from secondary sources such as hospital staff members, nursing notes and emergency department records. These contained estimated measures of onset time which reduced the reliability of incubation time calculation.

Secondly, no records were kept of the quantity of food each patient ate which prevented a determination of correlation with disease severity.

The providers of psychiatric care should be informed that impaired intestinal motility places their patients at risk for adverse outcomes which includes death, when exposed to enterotoxin-producing C. perfringens.

Psychiatric hospital residents exposed to C. perfringens have a high risk for developing necrotizing colitis because of impaired gastrointestinal motility from chronic use of anticholinergic medications.

RECOMMENDATIONSThe following recommendations are made after analysis of the case investigation report:
Food should not be cooked long before it is served as in this case it was cooked 24 hours and cooled before serving that triggered the outbreak.

All meat, poultry and dried and pre- cooked food to be cooked at the optimum temperature and kept at 600c in a warmer to avoid spores developing and leftover food to be kept in the refrigerator at 4.40c or colder as soon as possible within 2 hours’ preparation and again left overs should be heated to at least 740c before serving.

If there is in doubt, discard the food and any food that has been left too long is a risk to eat even if it looks alright due to the fear of this Clostriduim perfringens bacteria.

REFERENCESAnon, (2018). online Available at: http://www.cdc.gov/foodsafety/diseases/clostrodium perfringen.html Accessed 15 May 2018.

Anon, (2018). Clostridium perfringens Sporulation and Sporulation-Associated Toxin Production.

Cdc.gov. (2018). Clostridium perfringens Infection Among Inmates at a County Jail — Wisconsin, August 2008. online Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5806a2.htm Accessed 15 May 2018.

Cdc.gov. (2018). Fatal Foodborne Clostridium perfringens Illness at a State Psychiatric Hospital — Louisiana, 2010. online Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6132a1.htm Accessed 16 May 2018.

Keita-Perse, O., Pradier, C., Tempesta, S., Oran, N., Girard-Pipau, F., Popoff, M., Vautor, E., Vezolles, M. and Dellamonica, P. (2018). Outbreak of diarrhea related to Clostridium perfringens in a correctional facility: an epidemiologic investigation.

Lund, B. and O'Brien, S. (2018). The Occurrence and Prevention of Foodborne Disease in Vulnerable People. online Academia.edu. Available at: http://www.academia.edu/27815468/The_Occurrence_and_Prevention_of_Foodborne_Disease_in_Vulnerable_People Accessed 18 May 2018.

Microbewiki.kenyon.edu. (2018). Clostridium perfringens toxins – microbewiki. online Available at: https://microbewiki.kenyon.edu/index.php/Clostridium_perfringens_toxins Accessed 15 May 2018.

Scallan, E., Hoekstra, R., Angulo, F., Tauxe, R., Widdowson, M., Roy, S., Jones, J. and Griffin, P. (2018). Foodborne Illness Acquired in the United States—Major Pathogens.