Gastroenteritis Outbreak within a College Football Team

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Gastroenteritis Outbreak within a College
Football Team

• David Millward, MD, MS

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Introduction

• Black Wednesday
• August 18th, 2004
• 1st day helping out with the football team

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Introduction

• An outbreak of gastroenteritis can spread quickly
  amongst an athletic program sidelining players,
  coaches and other team personnel from play
• Promptly identifying the source can interrupt the
  disease propagation and steps can be taken to
  prevent future outbreaks

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Objectives

• Identify the problem early on
• Discuss treatment and management strategies
• Discuss prevention

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Identifying the Problem

• How many is too many???
• Thursday, August 19, 2004 the local county health
  department was notified
• Additional 19 individuals associated with the
  team presented with nausea, vomiting and diarrhea
  during the following week

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Study Design

• Retrospective cohort study
• identify a common source for the disease outbreak
• interrupt the disease propagation
• Case definition a student athlete, athletic
  trainer, or coach with onset of illness beginning
  after August 16, 2004 and symptoms including
  vomiting and/or diarrhea lasting at least 12
  hours
• Environmental and illness questionnaire
• Team physicians report
• Personal phone calls
• Cases were instructed to seek medical attention

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Investigation

• Environmental Inspection
• A site inspection by the health department
• Athletic training room
• Fitness/weight training room
• Locker room
• Practice facility
• Kitchen and dining area
• Disease Control alerted the Consumer Health and
  Food Safety Division
• Interviews
• Assistant Director Food Services
• Executive Chef of the Student Union Dining
  Services

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Investigation

• Laboratory Investigation
• Five stool samples were obtained from five cases
• Two samples were sent in a stool culture
  collection vials
• Shigella
• Salmonella
• Campylobacter
• E. coli O157
• Three additional samples were sent in viral
  transport media tubes for viral cell culture

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Results

• Epidemiologic Investigation
• 23 questionnaires collected from suspected cases
• 22 of these fit the case definition
• No coaches reported the illness but five (5) of
  the cases were athletic trainers or student
  workers
• Campus Health records were provided for 32
  (7/22) of the case (same number seen)
• The average age of the cases was 21years
• Fifty percent (11/22) reported sharing water
  bottles
• The average length of illness for all of the ill
  persons was 48 hours

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Results

• Incubation period - difficult to determine
• Estimation based on two situations
• Aug.18th, 2 athletic trainers reported cleaning
  up vomit from 2 players around 2pm subsequently
  had symptoms 36 hours later
• 2 additional athletic trainers were in the
  medical facility with another player while he was
  vomiting subsequently became sick 48 hours
  later
• The average incubation period 41 hours

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Results Environmental Inspection

• General lack of sanitation
• Bathroom servicing the weight room and classrooms
• Bathroom located in the locker room
• Locker room placement of sinks relative to
  toilets (beverage dispenser)
• No barrier between the sink area and the many
  cups that sit upside-down on top of the beverage
  machine

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Results - Environmental Inspection

• The athletic training room was noted to be clean
  and tidy
• Appropriate surface antimicrobials
• Hot tubs were disinfected with bromine
• Missing log
• Ice machines within the training room
• Do not eat sign needed
• Water supplies
• Drink bottles and coolers were washed with soap
  and water, rinsed with clear water and sanitized
  with freshly mixed bleach and water solution at a
  110 dilution and allowed to air dry

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Results Food Inspection

• Football coaching staff suspected the fruit salad
• Many cases thought to have consumed the fruit
  salad
• 500 pounds distributed throughout the student
  union dining services
• Consumed at both the AM meal and evening meal on
  Aug. 18th
• No other illnesses were reported from other
  student dining

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Results Food Inspection

• Kitchen area at Student Union Dining Services was
  clean and well organized
• Food stored and transported using temperature
  controlled containers
• Food handling practices
• Stadium Club
• Fully equipped and licensed food service facility
• Appropriate serving containers
• Food handling practices
• Normal operations disrupted due to floor repairs
• Toilet areas again were not clean

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Results - Lab

• Stool Cultures
• One culture positive for E.Coli
• Remaining cultures were negative for common
  bacterial food and water pathogens (Salmonella,
  Shigella, and Campylobacter)
• 3 viral stool cultures were negative

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Discussion

• The epidemiological curve generated does not
  identify a clear incubation time
• Most likely not a food-borne illness, but an
  organism that is easily spread from person to
  person
• Food-borne illness - a sharp increase in the
  number of cases following the exposure rather
  than a prolonged propagation of the disease
• Detailed food history questionnaires were
  initially prepared and distributed but stopped

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Discussion

• Offending organism was not identified in this
  outbreak investigation
• In 1080 outbreaks reported to the CDC during 2003
  from food-borne illnesses alone, 664 (61) did
  not confirm an etiology4
• Number has averaged 65 during the time period
  1990-2002 with a range of 55-736

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Discussion

• Reasons for unconfirmed etiologies
• Limited collection or testing of specimens
• Bacterial, parasitic and virus cultures should be
  collected in an outbreak investigation using
  standardized methods
• Lack of access and reliable laboratory testing
• Limited health care-seeking behavior of ill
  persons
• Delayed reporting
• Limited resources and competing priorities in
  health departments10

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Discussion

• Viral culture
• Enterovirus is usually the only virus identified
  by this method11
• Rotavirus, coronavirus, noroviruses, small round
  particles, and the adenovirus, do not grow in
  routine tissue culture11
• Electron microscopy (EM)
• Immunofluorescence and PCR can be used where
  available

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Discussion

• Evidence gathered is consistent with a Norovirus
• 96 of non-bacterial causes acute gastroenteritis
  in the United States8
• Sudden onset of illness
• Average illness length of 24-60 hours
• Incubation period of 24-48 hours
• Stool and vomit can be infectious up until two
  weeks after the onset of symptoms7
• Mode of transmission
• Consuming contaminated food/drink
• Touching contaminated surfaces
• Direct contact with an infected person
• Aerosolized?

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Discussion

• Norovirus spread through direct contact in a
  football game in 19983
• University in North Carolina and a University in
  Florida
• Infective agent was traced to a box lunch,
  players from the North Carolina school
  transmitted the virus through direct contact to
  members of the Florida team during a game

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Discussion

• In order to prevent future outbreaks the
  following recommendations were made
• Education and implementation of proper
  hand-washing techniques and bathroom hygiene
• Increasing the frequency of bathroom sanitization
• Contaminated restrooms have been at the center of
  previous outbreaks9 and could have propagated the
  spread of disease amongst this football program
• Relocation of the beverage station in the locker
  room

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Discussion

• Discontinuing the practice of sharing water
  bottles
• A large outbreak of gastroenteritis has
  previously been reported and traced back to
  contaminated ice consumed at an athletic event1
• Removal of players from play until symptoms have
  cleared
• Implementation of appropriate methods for
  cleaning up potentially infectious vomit

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References

• 1. Outbreak of viral gastroenteritis--Pennsylvania
  and Delaware. MMWR Morb Mortal Wkly Rep 36(43)
  709-711,1987
• 2. Barker J, Vipond IB, Bloomfield SF Effects of
  cleaning and disinfection in reducing the spread
  of Norovirus contamination via environmental
  surfaces. J Hosp Infect 58(1) 42-49,2004
• 3. Becker KM, Moe CL, Southwick KL, et al
  Transmission of Norwalk virus during football
  game. N Engl J Med 343(17) 1223-1227,2000
• 4. Centers for Disease Control and Prevention
  The Total Number of Foodborne Disease Outbreaks
  by Etiology, 2003 Summary Statistics. 2004(11/24)
  2004
• 5. Centers for Disease Control and Prevention
  Guidelines for Specimen Collection. 2005(1/15)
  1, 2003
• 6. Centers for Disease Control and Prevention
  U.S. Foodborne Disease Outbreaks, Summary
  Statistics 1990-2003. 2004(11/24) 2003

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References

• 7. Centers for Disease Control and Prevention
  "Norwalk-Like Viruses" Public Health
  Consequences and Outbreak Management. MMWR Vol.
  50(No. RR-9)2001
• 8. Fankhauser RL, Monroe SS, Noel JS, et al
  Epidemiologic and molecular trends of
  "Norwalk-like viruses" associated with outbreaks
  of gastroenteritis in the United States. J Infect
  Dis 186(1) 1-7,2002
• 9. Ho MS, Glass RI, Monroe SS, et al Viral
  gastroenteritis aboard a cruise ship. Lancet
  2(8669) 961-965,1989
• 10. Jones TF, Bulens SN, Gettner S, et al Use of
  stool collection kits delivered to patients can
  improve confirmation of etiology in foodborne
  disease outbreaks. Clin Infect Dis 39(10)
  1454-1459,2004
• 11. Murray PR, Baron EJ in Murray PR and Baron
  EJ (eds) Manual of Clinical Microbiology.
  Washington, D.C., ASM Press, 2003

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Acknowledgements

• Lori Strazda, MPH
• Randy Cohen PT, ATC
• Dr. Steve Paul, MD
• Dr. Don Porter, MD