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Bureau of Epidemiology and Public Health Informatics
Shiga Toxin-Producing Escherichia coli O157:H7 Infections After
Attendance at a Cider Festival—Kansas, 2016
Daniel Neises, MPH
Senior Epidemiologist
Cluster Notification
Friday, October 21, 2016 at 4:56 pm KDHE
received a call
6 persons with Shiga toxin-producing Escherichia
coli (STEC) O157:H7 with indistinguishable pulsed-
field gel electrophoresis (PFGE)
10/21
Cluster Notification
Investigation Initiation
Outbreak investigation initiated Monday, October
24, 2016
4 PFGE matches and 1 other STEC case attended
Ciderfest at Louisburg Cider Mill in Louisburg, KS
on September 24, 2016
10/21
Cluster Notification
10/24
Investigation Initiated
9/24 9/25 10/1 10/2
Ciderfest
Louisburg Cider Mill
Outside of Louisburg, KS
8 miles from Missouri border
Ciderfest
photo: louisburgcidermill.com
Ciderfest
photo: louisburgcidermill.com
Ciderfest
Cider Mill Inspection
10/219/24 9/25 10/1 10/2 10/24 10/27
Ciderfest
Cider Mill Inspection
Investigation Initiated
Cluster Notification
Cider Mill Inspection
photo: louisburgcidermill.com
Cider Mill Inspection
Environmental Sampling
Case finding
10/219/24 9/25 10/1 10/2 10/24 11/2
CiderfestInvestigation
InitiatedPress
Release
Cluster Notification
10/27
Cider Mill Inspection
Methods
Case definition: diarrhea in a person beginning ≥1
day after attending Ciderfest and lasting ≥2 days
Matched case-control study
Friend-and-family group controls
Interviewed with outbreak-specific questionnaire
Calculated matched odds ratios and 95%
confidence intervals
Conditional logistic regression with exact estimates
Symptoms and outcomesSymptom Number of ill persons Percent of ill persons
Diarrhea 56 100%
Blood in stool 14 25%
Abdominal pain 43 77%
Nausea 32 57%
Fever 23 41%
Headache 20 36%
Myalgia 18 32%
Vomiting 16 29%
Other symptoms 16 29%
Outcome Number of ill persons Percent of ill persons
Visited healthcare provider 17 30%
Emergency room 11 20%
Hospitalized 10 18%
Hemolytic uremic syndrome (HUS) 2 4%
Case-Patients, n=56
n (%)
Control Subjects, n=55
n (%)
Median age 22 29
Sex
Male 18 (32%) 26 (47%)
Female 38 (68%) 29 (53%)
State of residence
Kansas 37 (66%) 37 (67%)
Missouri 19 (34%) 18 (34%)
Date of attendance
September 24, 2016 32 (57%) 36 (65%)
September 25, 2016 3 (5%) 2 (4%)
October 1, 2016 5 (9%) 4 (7%)
October 2, 2016 16 (29%) 12 (24%)
Study Population Characteristics
0
1
2
3
4
5
6
7
9/2
4/2
016
9/2
5/2
016
9/2
6/2
016
9/2
7/2
016
9/2
8/2
016
9/2
9/2
016
9/3
0/2
016
10/
1/2
016
10/
2/2
016
10/
3/2
016
10/
4/2
016
10/
5/2
016
10/
6/2
016
10/
7/2
016
10/
8/2
016
10/
9/2
016
10
/10
/20
16
10
/11
/20
16
10
/12
/20
16
10
/13
/20
16
10
/14
/20
16
10
/15
/20
16
10
/16
/20
16
10
/17
/20
16
10
/18
/20
16
10
/19
/20
16
10
/20
/20
16
10
/21
/20
16
10
/22
/20
16
10
/23
/20
16
10
/24
/20
16
Nu
mb
er o
f C
ases
Date of Onset
Attended Ciderfest September 24-25, 2016 Attended Ciderfest October 1-2, 2016
Number of cases by onset date (n=56)
Ciderfest
0
1
2
3
4
5
6
7
9/2
4/2
016
9/2
5/2
016
9/2
6/2
016
9/2
7/2
016
9/2
8/2
016
9/2
9/2
016
9/3
0/2
016
10/
1/2
016
10/
2/2
016
10/
3/2
016
10/
4/2
016
10/
5/2
016
10/
6/2
016
10/
7/2
016
10/
8/2
016
10/
9/2
016
10
/10
/20
16
10
/11
/20
16
10
/12
/20
16
10
/13
/20
16
10
/14
/20
16
10
/15
/20
16
10
/16
/20
16
10
/17
/20
16
10
/18
/20
16
10
/19
/20
16
10
/20
/20
16
10
/21
/20
16
10
/22
/20
16
10
/23
/20
16
10
/24
/20
16
Nu
mb
er o
f C
ases
Date of Onset
Attended Ciderfest September 24-25, 2016 Attended Ciderfest October 1-2, 2016
Number of cases by onset date (n=56)
0
1
2
3
4
5
6
7
9/2
4/2
016
9/2
5/2
016
9/2
6/2
016
9/2
7/2
016
9/2
8/2
016
9/2
9/2
016
9/3
0/2
016
10/
1/2
016
10/
2/2
016
10/
3/2
016
10/
4/2
016
10/
5/2
016
10/
6/2
016
10/
7/2
016
10/
8/2
016
10/
9/2
016
10
/10
/20
16
10
/11
/20
16
10
/12
/20
16
10
/13
/20
16
10
/14
/20
16
10
/15
/20
16
10
/16
/20
16
10
/17
/20
16
10
/18
/20
16
10
/19
/20
16
10
/20
/20
16
10
/21
/20
16
10
/22
/20
16
10
/23
/20
16
10
/24
/20
16
Nu
mb
er o
f C
ases
Date of Onset
Attended Ciderfest September 24-25, 2016 Attended Ciderfest October 1-2, 2016
Number of cases by onset date (n=56)
Associations between Illness and ExposuresExposure/Food Item Matched Odds Ratio 95% CI
Any type of cold cider 6.6 1.2 - infinity
cup of cold cider 2.1 0.4 - 11.6
cider slush 4.5 0.7 - infinity
Hot cider 1.2 0.2 - 8.6
Pre-packaged bottle of cider 3.3 0.3 - 39.1
Cider doughnuts 10.3 1.1 - 94.8
Caramel apples 1.3 0.1 - 17.3
Pony ride 1.0 0 - 19
Contact with farm animals 4.7 0.5 - infinity
Pumpkin patch 2.2 0.1 - 157
Mobile food vendors 0.3 0.3 - 2.4
Conclusions
56 persons with STEC O157
after Ciderfest
Cold cider and cider doughnuts
were associated with illness
Onsite inspection was essential
for identifying un-pasteurized
cider was served during the cider
festival
Recommendations
All tanks holding
unpasteurized cider
should be labeled
Employees should be
cross-trained about all
processes on site
Acknowledgments Kansas Department of Health and
Environment
Charlie Hunt
Ingrid Trevino-Garrison
Daniel Neises*
IDER Staff
Kansas Department of Agriculture
Amber Barham*
Adam Inman*
Autumn Schuck
Steve Moris
Centers for Disease Control and Prevention
Jessica Nadeau Tomov**
Andrea Winquist
Rashida Hassan
Missouri Department of Health and Senior Services
Elizabeth Anderson
CJon Hinkle
Mark Buxton
United States Food and Drug Administration
Sam Gibbons
Jeffrey Moody
Erin Dugan
**Lead Author
**Co-Author
Questions?
photo: louisburgcidermill.com
Jurisdictions and Cluster Identification
4 PFGE matches in KS All were tested in MO
KS case interviews conducted by county that opted-out of centralized interviewing Case 1 and 2 reported attending cider festival
Could have identified common event when 2nd interview was completed on 10/13
Case 3 interviewed by KDHE Reported to KDHE about same time as case 1, 2
No isolate for PFGE
Reported attending cider festival
KDHE interviewed 10/7, didn’t find link to other cases
