A foodborne outbreak after a circumcision feast meal in

Bahcekoy Village-Duzce Province, Turkey, June 2014Mine Yenice1, Dilek Cemil Goktas1, Berna Sezgin1,

Fehminaz Temel1, Bulent Gurbuzler2

1 Public Health Institution of Turkey, Early Warning and Response and Field Epidemiology Department, Ankara, Turkey2 Provincial Public Health Directorate, Communicable Diseases Department, Duzce, Turkey

Funded by the European Union

Funded by the European Union

Duzce

Bahçeköy6 km

Notification•Duzce Public Health Directorate reported to EWR Department of PHI of Turkey on 9 June 2014.•Common exposure: A circumcision feast meal served at 11:00 am. on 8 June.•37 sick people applied to the city hospital.•Nausea, vomiting, abdominal pain, diarrhoea•~ 300 people had eaten the meal.

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Background

BackgroundMenu •Boiled chicken•Pilav (rice)•Packaged ayran (a drink made of yogurt and water) •Tulumba dessert (a kind of pastry dessert)

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Background

…and an important information:

«Who had eaten the boiled chicken,all of them were sick!»

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Hypotesis

«At least one of the foods (chicken, rice, ayran

and dessert) served in the feast meal caused this outbreak»

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Objective

This outbreak investigation aims to determine •the cause/agent •mode of transmission •to implement control measures

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Methods• Retrospective cohort investigation

• Cohort: The residents who had eaten the lunch served at feast meal

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Funded by the European Union

Case definition• Probable case: Onset of nausea or vomiting or diarrhoea at

8 June 2014 among residents who had eaten the lunch served as feast meal

• Non-case: Asymptomatic people among residents who

had eaten the lunch served as feast meal

Field StudyFunded by the European Union

8 Ju

ne

9 Ju

ne

10 Ju

ne

11 Ju

ne

12 Ju

ne

13 Ju

ne

Feast meal

Cases-Notification QuestionnaireTrain of interviewersand preliminary interviews

Travel to Duzce and startthe investigation

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AGE Surveillance in Early Warning System Data Central District of Duzce, June 2014

ResultsAttack rate: 16.3% Women: 44% Mean age: 27.9 ± 20.6

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11.9

26.3

36.4

25.4

Age Distribution of Participants

Symptoms of Probable Cases

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Epidemic CurveFunded by the European Union

Meal Service

Incubation period Mean= 6.7+4.6 hrsCases Median= 6.0 (30 min-30.3 hrs) hrs

11:0

013

:00

15:0

017

:00

19:0

021

:00

23:0

001

:00

03:0

005

:00

07:0

0

Hours

09.06.201408.06.2014

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15

Bought from a local firm

1 day before the meal at 16:00 pm.

Boiled in 2 large potsCooled by breaking to pieces

Put in the refrigeratorat 18:30 pm.

Served at 11:00 am.on 8 June

Preparation of Chicken

Kept in outdoors for2,5 hours

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Bought on the same day

Rice: Boiled with tap water on the same day (8 June)

Other Foods

Tulumba Dessert

ResultsFunded by the European Union

Serving meal

Food

Attack Rates (%) RR (95% CI) ORadj (95% CI) Exposed Non-exposed

Chicken 44.5 0.0 4.1 (0.62-25.7) 12.3 (1.2-123.1)

Tulumba

36.2 62.5 0.57 (0.38-0.87) 0.19 (0.06-0.56)

Ayran 39.3 63.6 0.61 (0.37-1.02) Rice 41.4 50.0 0.82 (0.20-3.3)

Disease Risk by Foods (n=118)

Laboratory ResultsFunded by the European Union

Sample type n Test Test resultFood (chicken) 1 Cultural enumaretion

- Coagulase (+) Staphylococcus +- Salmonella spp. -- B. cereus -- E. coli O157 -- L. monocytogenes -

Tap water 1 Bacteriological analysis- Coliform bacteria 22 cfu/100ml- E.coli 18 cfu/100ml- C. perfringens 3 cfu/100 ml

Throat swabs 3* Throat culture -

Nasal swabs 3* Nasal culture Staph. aureus (1) +

*From 3 cooks

Limitations

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• Delay in notification• Limited number of samples

Conclusion

• This outbreak was likely due to chicken contaminated with Coagulase (+) Staphylococcus

• Mode of transmission?– Asymptomatic cook– Inappropriate storage and inadequate cooling

conditions

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Public Health Actions and Recommendations

• Trainings on food hygiene and safety for: - Public

- Family physicians

• Improvement on audits: - Increase number of periodic audits for food.

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EWR and Field Epidemiology Department: Dilek CEMIL GOKTAS, MD Berna SEZGIN, MD Fehminaz TEMEL, MD, PHS

Duzce Public Health Directorate: Bulent GURBUZLER, MD Duzce Public Health Center staff

Funded by the European Union

Acknowledgements

Back up Slides

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Su

Atak Hızı RR

(%95 GA) İçen İçmeyen

Şebeke suyu 40,2 59,8 0,7 0,4 - 1,3

Damacana suyu 54,5 45,5 1,3 0,6 - 2,6

Su tüketimine göre hastalanma durumu

Back up Slides

Funded by the European Union

Su tüketimine göre hastalanma durumu

Örnek Türü

Alındığı Tarih

Alındığı Yer Sonuç

Şebeke suyu

09.06.2014 Bahçeköy İÖOKoliform bakteri : 22 kob/100mlE.coli : 18 kob/100mlCl. Perfringens : 3 kob/100 ml

12.03.2014 Bahçeköy İÖOKoliform bakteri : 18 kob/100mlE.coli : 7 kob/100ml