“Shigella at a Wedding” – Instead of “I do,” should be “Hell No.”

BACKGROUND

On August 14, 2018, the Oregon Health Authority (OHA) and Yamhill County Health and Human Services (YCHHS) independently received reports of persons with gastrointestinal illness days after attending a wedding and reception in Yamhill County on August 11. Over the next two days, additional wedding attendees reported gastrointestinal illness. OHA notified the Multnomah County Health Department (MCHD), and the agencies initiated an investigation to determine the cause of the outbreak and to prevent additional cases. YCHHS contacted the Oregon Department of Agriculture (ODA), which regulates some food-service establishments in Oregon.

By August 15, 10 cases had been reported to OHA. A Health Alert Network notice was sent to the ORCD1 group,1 advising them to ask patients with gastrointestinal illness whether they had attended a wedding in Yamhill County and, if they were willing, to submit a stool sample. Fecal samples from patients were cultured and isolates serotyped at the Oregon State Public Health Laboratory. On August 20, Shigella flexneri type 3a was first identified from a patient specimen. OHA consulted with subject matter experts at the Centers for Disease Control and Prevention (CDC) for information on this Shigella serotype.

METHODS

Methods YCHHS public health investigators obtained contact information for attendees and the caterer. The caterer is based in Multnomah County. MCHD officials contacted the caterer to obtain a menu of foods served at the wedding. Using this information, on August 16 OHA epidemiologists emailed to wedding attendees a link to an online survey asking them to identify foods they had eaten and to determine whether they had illnesses meeting the case definition.

Information from the first survey indicated that there was a cocktail hour between the wedding ceremony and the reception. Because S. flexneri infections have been associated with international travel,2 and there were additional food exposures, OHA invited wedding attendees to complete a second online survey on August 20. OHA asked respondents about their illness on this survey, too.

A confirmed case had S. flexneri cultured from a clinical specimen. A presumptive case was defined as self-reported diarrhea or vomiting in a person who attended the wedding reception.

An ODA environmental health specialist inspected the venue, collected water samples and leftover strawberries and cucumbers, and examined general biosecurity. Yamhill County environmental health specialists collected leftover potatoes. Well-water samples were tested using the Colilert test for total coliforms. Food samples were tested for Shigella species using polymerase chain reaction testing. Multnomah County environmental health specialists inspected the caterer. They observed hygiene practices and asked that people who prepared food for the reception submit stool samples for testing.

RESULTS

Among 263 wedding attendees and reception venue staff, 192 were represented on the first survey and 128 on the second survey; some people completed the survey for their children, spouses, or other relatives. In total, 200 people were represented by the two surveys combined.

One hundred seven cases were identified, of which 23 (21%) were confirmed. Eighty-two (77%) of the cases were Oregon residents; the remainder were residents of 11 other states. Oregon cases resided in 11 different counties.

Cases by time of illness onset are shown in Figure 1. Of the 93 cases with onset information, 89 (96%) were reported to have started on the two days between midnight on August 12th and midnight August 14th.

The median age of ill people was 30 years. Of 111 female attendees, 60 (54%) became ill. Of 88 male attendees, 47 (53%) became ill. Of 18 persons <18 years of age, 5 (28%) were ill.  Of 181 person >18 years of age, 102 (56%) were ill (Table 1). Persons < 18 years of age were significantly less likely to become ill (p = 0.03).

Of ill people, 74/105 (70%) missed school or work, 57/106 (54%) saw a clinician, 38/105 (36%) visited the emergency room, and 10/106 (9%) were hospitalized overnight.

Among the 48 cases whose illness had resolved when they completed the survey, illness duration ranged from 3 to 15 (median, 11) days. Forty-two cases were still ill when they completed their survey. No deaths were reported.

Persons (n = 55) who attended the rehearsal dinner were no more likely to become ill than those who did not attend it (RR 1.1, p= 0.54); therefore, the epidemiologic investigation focused on food exposures at the wedding reception. Food was served buffet-style. Five food items were each associated with a significantly increased risk of illness: asparagus, butter, bread, au gratin potatoes, and the aioli that was served with the asparagus. Asparagus was most strongly associated with illness: of those who ate asparagus, 64% became ill, compared to 12.5% of those who denied eating asparagus (RR 5.1, 95% CI 2.0–12.9). Asparagus consumption also accounted for a higher percentage of cases (96%) than any other exposure (Table 3). In a reanalysis of the other implicated foods, stratifying by asparagus consumption, only bread remained significantly associated with illness (RR 1.6, 95% CI 1.1–2.6).

There was a children’s buffet. Some persons under 10 ate food from the rest of the buffet, and some adults ate food from the children’s buffet. Persons under 10 were significantly more likely to have eaten from the kid’s buffet (p < 0.01) and significantly less likely to have eaten any adult food (p < 0.01).

Asparagus consumption differed by age: it was consumed by 150/172 (87%) of persons >10 but by none of 10 children <10 years old (p < 0.001) Bread consumption did not differ significantly by age.

When visiting the caterer, Multnomah County inspectors did not observe any food-handling violations. Stool samples were submitted by some of the food-handling staff; none were positive for Shigella. Food preparers were primarily responsible for specific dishes. When analyzing attendees’ exposures by who was responsible for the foods they consumed, illness rates did not differ significantly by food preparer. Catering records revealed that the caterer served some of the same foods, including the grilled asparagus dish, at multiple events that same weekend. The asparagus was sourced domestically. No illnesses related to those other events were reported to OHA.

The ODA inspector concluded that biosecurity on the venue’s water supply was sufficient to protect against intentional contamination. The water tested negative for bacterial contamination. The leftover strawberries, cucumbers and potatoes tested negative on bacterial culture; no asparagus had been left over for testing.

CONCLUSIONS

An outbreak of Shigella flexneri type 3a infections was most likely caused by contaminated asparagus consumed by people who attended a wedding reception in Yamhill County on August 11, 2018. Bread was also associated with illness, but it is less likely to be the cause of the outbreak. Asparagus accounts for a higher proportion of cases, and the age breakdown of illness is better explained by asparagus consumption patterns.

This is the second-largest foodborne outbreak of S. flexneri infections reported in the U.S. since 1988. The source of the contamination was not definitively identified. Because humans are the natural reservoir for Shigella species, and there were no concurrent outbreaks to suggest upstream contamination, poor food-handler hygiene is the most likely cause.

Outbreak 2018-4979 Shigellosis at a Wedding

See also, www.about-shigella.com.

The Department of Public Health and Social Services (DPHSS) is monitoring an outbreak of Shigellosis on Guam.  In 2018, a total of 29 cases of Shigellosis were reported (with 23 cases or 79% confirmed) and so far in 2019, a total of 10 cases have been reported (with 90 percent confirmed).

Shigellosis is an infectious disease caused by a group of bacteria called Shigella (shih-GEHL-uh). Most who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria. Shigellosis usually resolves in 5 to 7 days. Some people who are infected may have no symptoms at all, but may still pass the Shigella bacteria to others. The spread of Shigella can be stopped by frequent and careful handwashing with soap and taking other hygiene measures.

People usually get sick from Shigella bacteria after putting something in their mouth or swallowing something that has come into contact with the stool (poop) of someone else who is sick from Shigella bacteria.

The Vermont Department of Health is investigating an outbreak of an antibiotic-resistant bug that sickened 70 people at a retirement community.

Investigators have confirmed 22 cases of Shigellosis and 48 others have shown symptoms consistent with the bacteria at the Wake Robin retirement community in Shelburne.

The Shigella bacteria can cause diarrhea and fever.

The investigation into the outbreak began a month ago, and units were quarantined for a time. Officials say there have been no new cases in several weeks

Health Commissioner Mark Levine said the federal Centers for Disease Control and Prevention are assisting because the bacterial strain is resistant to antibiotics. He said most affected people needed five to seven days to recover.

The Vermont Health Department is investigating an outbreak of gastrointestinal illness at Wake Robin, a retirement community in Shelburne. Specimens from seven individuals have tested positive forShigella sonnei. More than 50 individuals associated with the facility, or with someone who lives or works at the facility, have reported symptoms consistent with shigellosis.

Consider Shigellosis When Evaluating Clinically Compatible Illnesses

Clinical manifestations of shigellosis range from watery or loose stools with minimal symptoms to more severe illness including high fever, abdominal cramps or tenderness, tenesmus, and mucoid stools with or without blood. Symptoms usually resolve in five to seven days but sometimes last for four or more weeks. Asymptomatic infection is possible.

Shigella bacteria are present in the stools of infected people while they have diarrhea, and for up to four weeks after symptoms resolve. The primary mode of transmission is fecal-oral, although transmission can also occur via contact with a contaminated fomite, ingesting contaminated food or water, or sexual contact. The incubation period is one to seven days, but is usually less than four days.

Report all suspected and confirmed cases to the Health Department’s Infectious Disease – Epidemiology program at 802-863-7240.

Test for Shigella

Clinicians who see patients with symptoms of shigellosis are encouraged to collect a stool specimen and have it tested for Shigella. Antibiotic resistance is relatively common, so susceptibility testing of clinical isolates is indicated to guide appropriate therapy. To date, testing of isolates associated with this outbreak has indicated susceptibility to Ciprofloxacin and resistance to Ampicillin and Trimethoprim-Sulfa. Hospital or reference laboratories in Vermont should forward Shigella isolates or original specimens to the Health Department Laboratory for further testing such as molecular subtyping (performed at no charge).

Submit specimens through the existing hospital courier service for receipt at Health Department Laboratory within 48 hours. Stool specimens should be collected and preserved in Cary-Blair medium. VDHL Kit #1 (which may be obtained at no charge by contacting theLaboratory’s Customer Service at 802-338-4724), or an appropriate culture specimen container (available from hospital laboratories) should be used for the collection and transport.

Treatment

Shigellosis is usually self-limited and treatment with antibiotics is not generally recommended in otherwise healthy adults with mild illness. However, antibiotics may be prescribed when warranted by the severity of the illness, underlying health conditions, or patient’s occupation. Anti-diarrheal medication that inhibits peristalsis, such as loperamide (e.g. Imodium) or diphenoxylate with atropine (e.g. Lomotil) are contraindicated and may prolong illness and increase the rate of complications.

Prevent New Cases

Strict attention to hand hygiene is essential to limit spread. Symptomatic children who attendday care should stay home until the Health Department says it’s safe to return. People with confirmed shigellosis who work as health care providers, child care workers or food handlers should be excluded from work until two consecutive negative stool cultures (collected 24 hours apart and at least 48 hours after discontinuation of antibiotics) have been documented.

Symptomatic people should not prepare food or share food with others. They should not swim and should not have sex (vaginal, anal, and oral) for one week after diarrhea has resolved.

Shigellosis Information for Clinicians

Resources for clinicians are available on the Health Department’s website:

http://www.healthvermont.gov/immunizations-infectious-disease/food-waterborne- diseases/shigellosis.

If you have questions, contact the Vermont Department of Health, Infectious Disease – Epidemiology program at 802-863-7240.

The San Diego County Health and Human Services Agency is advising gay and bisexual men, homeless individuals, and people with compromised immune systems that they could be at an increased risk for the intestinal disease shigellosis.

According to the Centers for Disease Control and Prevention, young children and travelers to developing countries are also at risk for shigellosis.

Last year, the County saw the highest number of cases in 20 years, including a disproportional increase in the gay and bisexual community and among the homeless population.

The number of cases typically increases in the late summer and fall and there have already been 98 cases of shigellosis reported in the county so far in 2018. In 2017, a total of 334 cases were reported, representing a 37 percent increase compared to 2016 when there were 232 cases.

A larger proportion of 2017 cases (63 percent) were among men, many of whom self-identified as gay or bisexual, compared to previous years. Additionally, the percentage of homelessness cases also experienced an increase from 7 percent of total cases to 12 percent from 2016 to 2017.

So far in 2018, 25 percent of the reported cases involve gay or bisexual men and 7 percent involve homeless people.

The Shigella infection or Shigellosis causes a diarrheal illness lasting for 5 to 7 days. Shigella is very contagious. Infection can occur through person-to-person contact, eating food contaminated by someone who has shigellosis, or swallowing water from pools and ponds or drinking water that was contaminated with the bacteria.

“Shigellosis is a very contagious disease, but there are many steps people can take to reduce their chances of getting it,” said Wilma Wooten, M.D., M.P.H., County public health officer. “The infection can be prevented by conducting frequent and thorough hand washing; disinfecting any areas that may be contaminated, such as restrooms or diaper changing areas; avoiding swallowing water from untreated pools and ponds, and not preparing or serving food to others when having diarrhea.”

HHSA is recommending that those at risk, including gay and bisexual men and homeless people:

  • Practice good hand hygiene at all times washing your hands with soap and water, especially before eating or preparing food for others or changing diapers
  • Avoid swallowing water from ponds, lakes or untreated swimming pools
  • Be aware of your HIV status
  • Be aware of the local increase in shigellosis, which can be a severe illness, particularly in those with reduced immunity.
  • Seek care for diarrheal illness, especially with fever or bloody diarrhea, and be sure that their healthcare provider tests to see if symptoms are caused by Shigella.
  • Discuss antibiotic treatment for shigellosis with their doctors to shorten the duration of illness and reduce the risk of infecting others.
  • Abstain from sex, for several days after you stop having diarrhea, to prevent spreading the illness to others.

Several persons associated with a Lexington County pre-K may have been infected with a contagious bacteria, according to a letter issued by the state’s health department.

Parents of the Lexington 4 Early Childhood Center in Swansea were sent a letter with a Friday date warning of shigella, an “easily spread” bacteria that can lead to an infection of the lining of the stomach, according to a letter sent by the S.C. Department of Health and Environmental Control.

Fever, stomach cramps and diarrhea are among the common symptoms associated with the infection, the DHEC letter stated. They typically last five to seven days.

In early September 2017, an over-30-year-old male who resides in northern Taiwan traveled to Bali, Indonesia with 18 tour group members. On the following day the case returned, he sought medical attention after developing symptoms, including fever, diarrhea and nausea, and was diagnosed with shigellosis. After a further investigation conducted by the health authority, a female group member who is over 20 years old had also experienced symptoms, including vomiting and diarrhea and was also diagnosed with shigellosis. According to the cases, they consumed mostly cooked food while in Bali. However, they had seafood at a restaurant with poor hygiene. Hence, it was determined that these two cases constitute a cluster. As of now, none of the contacts residing in the same household with the 2 cases has developed suspected symptoms. Moreover, the local health authority has collected specimens from the other 13 tour group members who experienced symptoms for laboratory testing.

Ventura County Public Health was notified on Thursday, June 22nd, of an unusually high number of Shigella cases in the county. Shigellosis is an infectious disease caused by a group of bacteria called Shigella (shih-GEHL-uh), which most often causes diarrhea and fever. It is highly contagious.

Through a series of interviews with those affected, it has been determined that a number of the cases reported to have eaten at the Souplantation in Camarillo. Of the diners interviewed, there are a total of eight individuals with laboratory evidence of Shigella infection.

Ventura County Public Health’s laboratory sent the culture confirmed samples to the State laboratory for typing.

“We’re tracking these cases closely,” said Public Health Officer Dr. Robert Levin, “and are working closely with Ventura County Environmental Health, which has completed two inspections of the restaurant in the past two days.” Dr. Levin credits Souplantation corporate office for making the decision to close the restaurant, starting Thursday through the weekend, to make certain that all steps have been taken to prevent further cases.

The Souplantation Chief Operating Officer has arrived at the Camarillo location and has been joined by a vice- president and the quality assurance manager. All employees are being put through a sanitary training refresher course, the restaurant is being thoroughly cleaned and all food on the premises is being thrown out.

“Souplantation’s actions have been exemplary. This is the kind of swift and decisive action, which leads to a collaboration with Public Health that results in a rapid resolution of the problem,” added Dr. Levin.
It is not currently clear what the source of the infection is. No one food item has been indicated. All employees are being tested and will need to be cleared before returning to work. There are approximately 40 employees at the restaurant.

Most people who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria. Shigellosis usually resolves in 5 to 7 days. Some people who are infected may have no symptoms at all, but may still pass the Shigella bacteria to others. The spread of Shigella can be stopped by frequent and careful hand-washing. Antibiotic treatment is known to decrease the length of illness and to end shedding of the organism within a day or two of starting therapy. People most at risk of serious illness are those with underlying immunosuppressive conditions. Those who may have been exposed who are feeling ill should consult their physician.

Florida health officials in Seminole County are warning about a shigella outbreak at a daycare. A shigella outbreak was reported to Florida Health Department officials on Tuesday at the Kids City USA daycare in Altamonte Springs. According to the Centers for Disease Control and Prevention, symptoms appear one to two day after exposure, with diarrhea, fever and abdominal pain. CDC said symptoms last five to seven days; however, people with mild cases may only need fluids and plenty of rest. In severe cases, antibiotics may be used. However, shigella is antibiotic-resistant. The bacteria is highly contagious, CDC officials said. A tiny amount of exposure to contaminated stool can cause infection. Health officials said the daycare is still open. CDC recommends that if an outbreak occurs at a daycare, to have a child who is infected with diarrhea to stay home and children who have recently recovered to be placed in one classroom to minimize the risk of exposure. Also, staff should be assigned to change diapers and prepare the food, the CDC said. Young children and travelers are among the most at-risk groups of being affected.

102557636-Shigella.1910x1000The Arkansas Department of Health (ADH) is continuing to see cases in Northeast Arkansas of Shigellosis, an infectious disease that commonly causes diarrhea, fever and stomach cramps. Shigellosis is caused by the Shigella bacteria and is very contagious. The ADH urges residents to wash their hands and take other protective measures to keep Shigella from spreading.

In Louisiana, Dr. Anatole Karpovs, pediatrician with The Children’s Clinic of Southwest Louisiana, has been treating young patients with shigellosis, caused by a group of bacteria called shigella.

“It causes specifically diarrhea and high fevers,” said Dr. Karpovs  “It sometimes causes bloody diarrhea or pus or mucus in the diarrhea.”

Dr. Karpovs says most people infected with shigella start experiencing these symptoms within a day or two of exposure to the bacteria.  It spreads easily through fecal-oral routes.

“If a child has diarrhea and that spreads or gets on a surface and somebody touches it unknowingly, then they can spread it to themselves or other people,” he said.

Anyone can be infected, but some people might not even know it.

Those most at risk are people with weakened immune systems, the elderly, and the young.