2009 National Western Stock Show

2009 National Western Stock Show

E. Coli 0157 outbreak investigation

E. Coli 0157 outbreak investigation

BackgroundBackground

The National Western Stock Show (NWSS) is a yearly event and provides fans with one of the largest assortments of a horse show, livestock, and rodeo in the world.

When: January 10-25, 2009 Where: Denver, CO

The National Western Stock Show (NWSS) is a yearly event and provides fans with one of the largest assortments of a horse show, livestock, and rodeo in the world.

When: January 10-25, 2009 Where: Denver, CO

Additional BackgroundAdditional Background

Big event-650,000+ in attendance Local, national, and international attendees Covers over 100+ acres Many exhibitors Large number of venues, , including

Children’s Activity Pavilion

Big event-650,000+ in attendance Local, national, and international attendees Covers over 100+ acres Many exhibitors Large number of venues, , including

Children’s Activity Pavilion

COOPERATION, PARTNERSHIPSCOOPERATION, PARTNERSHIPS

Although this event occurred in Denver County, the following investigation involved health and environmental departments throughout Colorado, CDPHE, healthcare providers, media, and the Executive Board and staff from the National Western Stock Show.

Although this event occurred in Denver County, the following investigation involved health and environmental departments throughout Colorado, CDPHE, healthcare providers, media, and the Executive Board and staff from the National Western Stock Show.

Collaboration between many partners - Denver metro areaCollaboration between many partners - Denver metro area

CDPHE-Communicable Disease and Consumer Protection Divisions

Denver Environmental Health Denver Public Health Tri-County Health Department Jefferson County Health Department Boulder County Health Department Broomfield Health and Human Services

CDPHE-Communicable Disease and Consumer Protection Divisions

Denver Environmental Health Denver Public Health Tri-County Health Department Jefferson County Health Department Boulder County Health Department Broomfield Health and Human Services

ETIOLOGYETIOLOGY

Escherichia coli (E. coli) O157:H7 is one of over a hundred different serotypes belonging to gram negative bacteria group E. coli

Majority of the E.coli group do not cause human illness

E. coli O157:H7 and a few other serotypes produce potent cytotoxins, called Shiga toxins (STEC)

Escherichia coli (E. coli) O157:H7 is one of over a hundred different serotypes belonging to gram negative bacteria group E. coli

Majority of the E.coli group do not cause human illness

E. coli O157:H7 and a few other serotypes produce potent cytotoxins, called Shiga toxins (STEC)

CLINICAL DESCRIPTIONCLINICAL DESCRIPTION

May be asymptomatic Mild, non-bloody diarrhea Bloody diarrhea Abdominal cramps Nausea and/or vomiting Fever-is usually absent Complications, especially in young children-HUS

May be asymptomatic Mild, non-bloody diarrhea Bloody diarrhea Abdominal cramps Nausea and/or vomiting Fever-is usually absent Complications, especially in young children-HUS

DISEASE REPORTINGDISEASE REPORTING

Reports are received via: Public Providers-physicians, clinicians, infection control

personnel, hospitals, clinics Businesses CDPHE CDC

Reports are received via: Public Providers-physicians, clinicians, infection control

personnel, hospitals, clinics Businesses CDPHE CDC

Timeline of eventsTimeline of events

1/26/09 CDPHE noticed increase in lab confirmed cases of E. coli 0157

1/26-1/30/09-Individual case investigations; suspect common exposure was stock show

2/3/09 visit to NWSS complex 2/3/09 samples sent to CDPHE lab 2/9/09 visit for more samples

1/26/09 CDPHE noticed increase in lab confirmed cases of E. coli 0157

1/26-1/30/09-Individual case investigations; suspect common exposure was stock show

2/3/09 visit to NWSS complex 2/3/09 samples sent to CDPHE lab 2/9/09 visit for more samples

Case numbers:Case numbers:

29 confirmed cases 19 primary cases 10 secondary cases 1 probable case

9 cases hospitalized 2 cases of HUS

29 confirmed cases 19 primary cases 10 secondary cases 1 probable case

9 cases hospitalized 2 cases of HUS

Case DefinitionCase Definition Confirmed- Lab confirmed Onset since January 10 PFGE patterns 00-A/02-F or

00-A/09A

Probable- Diarrhea in a person epi-linked to a

confirmed case

Incubation period-2-10 days

Confirmed- Lab confirmed Onset since January 10 PFGE patterns 00-A/02-F or

00-A/09A

Probable- Diarrhea in a person epi-linked to a

confirmed case

Incubation period-2-10 days

Characteristic Cases

Age in years -- range (median) 1 - 66 (5)note: age missing on 1

probable case

Gender -- n (%)  

-Male 7 (23%)

-Female 23 (77%)

County of residence -- n (%)  

-Adams 1 (3%)

-Arapahoe 4 (13%)

-Boulder 1 (3%)

-Broomfield 1 (3%)

-Denver 12 (40%)

-Douglas 7 (23%)

-Jefferson 4 (13%)

VISIT FREQUENCIESVISIT FREQUENCIES

Stock Show visit frequencies(Stock Show ran from Jan 10 - 25)

0

1

2

3

4

5

6

7

8

Visit date

Pri

mar

y ca

ses

visi

ts

CASE COUNTSCASE COUNTS

Epi Curve 1: Confirmed "primary" cases (n=19)

0

1

2

3

4

5

01/19

/200

9

01/20

/200

9

01/21

/200

9

01/22

/200

9

01/23

/200

9

01/24

/200

9

01/25

/200

9

01/26

/200

9

01/27

/200

9

01/28

/200

9

01/29

/200

9

01/30

/200

9

01/31

/200

9

02/01

/200

9

02/02

/200

9

02/03

/200

9

02/04

/200

9

02/05

/200

9

02/06

/200

9

02/07

/200

9

02/08

/200

9

02/09

/200

9

02/10

/200

9

02/11

/200

9

02/12

/200

9

02/13

/200

9

Illness onset date

# o

f ca

ses

CASE CONTROL STUDIESCASE CONTROL STUDIES

Coordinated through CDPHE Administered by staff from public health

departments Risk factors-touching certain animals located in

specific areas, i.e. “Kids Zone” and visiting the Stockyards area

Protective factors-visiting the Coliseum area and eating/drinking there; and aware that animals can transmit disease

Coordinated through CDPHE Administered by staff from public health

departments Risk factors-touching certain animals located in

specific areas, i.e. “Kids Zone” and visiting the Stockyards area

Protective factors-visiting the Coliseum area and eating/drinking there; and aware that animals can transmit disease

Challenges for public health partners

Challenges for public health partners

Event was over Sampling and testing methods Entire event revolved around animals and

animal feces Media response Children in daycare

Event was over Sampling and testing methods Entire event revolved around animals and

animal feces Media response Children in daycare

Environmental Investigation

Environmental Investigation

Site visits Walk through of area Sampling of area (3rd floor “Feed the

Animals” exhibit) Answering questions for staff Cleanup

Site visits Walk through of area Sampling of area (3rd floor “Feed the

Animals” exhibit) Answering questions for staff Cleanup

SamplingSampling

50 initial swabs of area. All swabs tested negative for E. coli 0157

4 specimens from floor sweepings and the mats on which animals stood in the “Feed the Animals” area on the third floor. All four tested positive for the identical strain of E. coli O157 found in the ill persons.

50 initial swabs of area. All swabs tested negative for E. coli 0157

4 specimens from floor sweepings and the mats on which animals stood in the “Feed the Animals” area on the third floor. All four tested positive for the identical strain of E. coli O157 found in the ill persons.

Communication and Situation Reports

Communication and Situation Reports

Meetings with NWSS management Daily conference calls between all

parties Individual phone calls, emails, and

CEDRS Coordination with PIO’s

Meetings with NWSS management Daily conference calls between all

parties Individual phone calls, emails, and

CEDRS Coordination with PIO’s

E. coli outbreak linked to Denver cattle show Posted on February 5, 2009 by Doug Powell Health officials are investigating an outbreak linked to Colorado's largest stock show after 20 people, including 17 kids, came down with E. coli O157.

Chris Urbina with Denver Public Health said a lab has confirmed 20 E. coli cases but the number is expected to grow.

                                                 The Colorado Department of Public Health and Environment said in a news release,

"While the investigation is ongoing, we suspect that these infections are linked to attending the National Western Stock Show, which was held in Denver from Jan. 10 to Jan. 25.”

Although health officials haven't pinpointed the exact cause of the E. coli, the common denominator in all the cases is the stock show, Urbina said.

Many schools and child care centers organized trips to the stock show, and many children attended with their families, so there is the potential that the number of cases could jump, health officials said.

On Wednesday, the CDPHE sent a letter to daycare centers alerting them to the outbreak and asking the staff to take special precautions.

For disease reporting or other questions please contact the CDPHE Communicable Disease program at 303-692-2700.                                               

Working with the mediaWorking with the media

Dr. Chris Urbina from Denver Public Health was the lead

PIOs coordinated talking points Stock Show CEO conducted

interviews with media

Dr. Chris Urbina from Denver Public Health was the lead

PIOs coordinated talking points Stock Show CEO conducted

interviews with media

Educational opportunitiesEducational opportunities

Attendees Childcare facilities NWSS staff Investigative team

Attendees Childcare facilities NWSS staff Investigative team

Biggest Lesson Learned….Biggest Lesson Learned….

Prevention and future planning for NWSS

Prevention and future planning for NWSS

Focus efforts on exhibits that are geared towards children Provide signage about risks of animal-associated illness

and encouraging hand hygiene, especially at the entrances to areas where animals are housed and areas where food is served/consumed.

Discourage use of sippy cups, pacifiers, bottles, food/beverage in animal contact areas

Provide hand washing facilities with running water and soap

Transition areas prohibiting strollers from entering Move food vendors away from feed the animals area

Focus efforts on exhibits that are geared towards children Provide signage about risks of animal-associated illness

and encouraging hand hygiene, especially at the entrances to areas where animals are housed and areas where food is served/consumed.

Discourage use of sippy cups, pacifiers, bottles, food/beverage in animal contact areas

Provide hand washing facilities with running water and soap

Transition areas prohibiting strollers from entering Move food vendors away from feed the animals area

Why the recommendations?

Why the recommendations?

Since 1996, 100+ human infectious disease outbreaks involving animals in public settings reported to CDC

Risk factors-Direct animal contact and inadequate hand washing

In 2000, two E. coli outbreaks of 0157-H7 in Pa. and Wash. prompted CDC to establish recommendations

Since 1996, 100+ human infectious disease outbreaks involving animals in public settings reported to CDC

Risk factors-Direct animal contact and inadequate hand washing

In 2000, two E. coli outbreaks of 0157-H7 in Pa. and Wash. prompted CDC to establish recommendations

AcknowledgementsAcknowledgements

CDPHE: Alicia Cronquist, Nicole Comstock, Jennifer Sadlowski, Ken Gershman, and Nicole Grisham

DPH/DH: Dee Martinez, Tony Encinias, Dr. Chris Urbina, Dr. David Cohn, Dr. Judith Shlay, Carol McDonald, Stephanie Stark, Lori Kennedy, and Charles Smedly

CDPHE: Alicia Cronquist, Nicole Comstock, Jennifer Sadlowski, Ken Gershman, and Nicole Grisham

DPH/DH: Dee Martinez, Tony Encinias, Dr. Chris Urbina, Dr. David Cohn, Dr. Judith Shlay, Carol McDonald, Stephanie Stark, Lori Kennedy, and Charles Smedly

DEH: Bob McDonald and Abby Bronken

DEH: Bob McDonald and Abby Bronken

Questions????Questions????

Contact InfoContact Info

Carol McDonaldDPH Epidemiology and Surveillance303-602-3626Carol.mcdonald@dhha.org

Abby Bronken DEH Public Health Inspection 720-865-5377 Abby.bronken@denvergov.org

Carol McDonaldDPH Epidemiology and Surveillance303-602-3626Carol.mcdonald@dhha.org

Abby Bronken DEH Public Health Inspection 720-865-5377 Abby.bronken@denvergov.org