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Table 1. Food Items Served at Catered Buffet and Relative Risk of Acute Gastrointestinal Illness Among Hospital Staff Exposure
Illness in Those Who Ate Brisket
Pulled pork Pork sausage Chicken Hot dogs Chips
Cookies Yogurt parfait
Specified Food, No./Total No. (%) 36/55 (65) 32/45 (71) 21/27 (78) 14/25 (56) 5/7 (71)
13/18 (72) 1/2 (50)
10/12 (83)
14/25 (56) 17/35 (49) 28/53 (53) 35/55 (64) 44/73 (60) 36/62 (58) 48/78 (62) 39/68 (57)
Lucila Marquez et al
Illness in Those Who Did Not Eat Specified Food, No./Total No. (%)
Relative Risk (95% CI)
1.17 (0.79–1.74) 1.46 (0.99–2.16) 1.47 (1.06–2.04) 0.88 (0.59–1.31) 1.19 (0.72–1.96) 1.24 (0.87–1.76) 0.81 (0.20–3.28) 1.45 (1.05–2.01)
chicken were submitted to a certified food safety reference laboratory for testing. Ill hospital staff were excluded from work until resolution of
symptoms for 24 hours. Hand hygiene practice was emphasized, and nursing staff were instructed to report any patients with new onset vomiting or diarrhea to infection control staff. Medical records of inpatients were reviewed daily for these symptoms and/ or orders for stool studies.
Results
All 191 staff who were working at the hospital when the meal was served were contacted, and 92 (48%) reported eating some of the catered meal. Of these 92 consumers, 50 (54 %) reported acute onset of gastrointestinal symptoms within 14 hours of the meal being served and were defined as cases. All ill hospital staff recovered within 24 hours. Those who were well when they were initially contacted remained symptom free. No hospitalized patients developed new gastrointestinal symptoms. Of the 50 cases, 49 (98%) fully completed the questionnaire,
compared to 31 of 42 (74%) asymptomatic hospital staff. The relative risk of illness from eating pork sausage and yogurt was 1.47 (95% confidence interval [CI], 1.06–2.04) and 1.45 (95% CI, 1.05–2.01), respectively (Table 1). Exposure to flood water or flooded homes was not associated with acute gastrointestinal symptoms, and no staff were staying in shelters. Food items were tested for foodborne pathogens with a short incubation period: S. aureus, shigatoxin-producing E. coli, and Bacillus cereus. Staphylococcus aureus were isolated from portions of pulled pork and pork sausage. Testing for S. aureus enter- otoxins was not available. Brisket and chicken were negative for these pathogens. No yogurt was available for testing. Stool sam- ples from ill staff were not available for testing.
Discussion
Staphylococcus aureus is 1 of 31 known causes of foodborne ill- ness and outbreaks. Foods implicated in S. aureus foodborne illness include meats, salads, pastries, and dairy products.1,2,5–8 In the United States from 1998 to 2008, 458 foodborne disease outbreaks that occurred due to S. aureus were reported to the
CDC.2 The source of S. aureus contamination is usually colonized or infected food handlers, and if the strain of S. aureus produces 1 of several heat-stable enterotoxins, illness may occur even if food is kept at the recommended temperature.5–7 This outbreak was associated with a catered meal served to hospital staff following a natural disaster. Foodborne outbreaks reported in hospitals have been linked to ill food handlers and/or contaminated foods pre- pared in the hospital food service department and have impacted both hospital staff and patients.9 Fortunately, no patients were affected by this outbreak. In the setting of natural disasters, most foodborne illness is
associated with water contamination or transmission of highly contagious agents in crowded living conditions.4,10 Emergency preparedness for institutions such as hospitals involves securing stockpiles of water and nonperishable food. However, after such disasters, volunteers often donate supplies, water, and catered meals, especially for first responders and hospitals. Institutions should be cautious when accepting donations of catered meals and should consider whether safe food handling practices have been followed because foodborne outbreaks can impact the delivery of needed services after natural disasters. Although the outbreak was reported to the health department, the catering business was not immediately investigated given the tremendous disruption of many public health services for weeks following the hurricane. Limitations include bias introduced by the higher response
rate in symptomatic staff. Additionally, we were unable to test yogurt, which had a significantly elevated risk for illness. Testing for Staphylococcus enterotoxins and of stool from case patients was not available.
Acknowledgments. The authors thank the staff, physicians and administra- tion for their assistance in this investigation.
Financial support. No financial support was provided relevant to this article.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References
1. Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne illness acquired in the United States—major pathogens. Emerging Infect Dis 2011;17:7.
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