Download 2009 National Western Stockshow

2009 National Western Stock
Show
E. Coli 0157 outbreak investigation
Background
 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 Background
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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, 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.
Collaboration 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
ETIOLOGY
 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 DESCRIPTION
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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 REPORTING
 Reports are received via:
 Public
 Providers-physicians, clinicians, infection control
personnel, hospitals, clinics
 Businesses
 CDPHE
 CDC
Timeline 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
Case numbers:
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29 confirmed cases
19 primary cases
10 secondary cases
1 probable case
 9 cases hospitalized
 2 cases of HUS
Case 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
Characteristic
Age in years -- range (median)
Cases
1 - 66 (5)
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%)
note: age missing on 1
probable case
01
/1
0
01 /200
/1
1/ 9
01 20
/1 09
2
01 /200
/1
3/ 9
01 20
/1 09
4
01 /20
/1 09
5
01 /200
/1
6/ 9
01 20
/1 09
7
01 /200
/1
8/ 9
01 20
/1 09
9
01 /200
/2
0/ 9
01 20
/2 09
1
01 /20
/2 09
2
01 /200
/2
3/ 9
01 20
/2 09
4
01 /200
/2
5/ 9
20
09
Primary cases visits
VISIT FREQUENCIES
Stock Show visit frequencies
(Stock Show ran from Jan 10 - 25)
8
7
6
5
4
3
2
1
0
Visit date
01
/1
9
01 /2 0
/2 09
0
01 /2 0
/2 09
1
01 /2 0
/2 09
2
01 /2 0
/2 09
3
01 /2 0
/2 09
4
01 /2 0
/2 09
5
01 /2 0
/2 09
6
01 /2 0
/2 09
7
01 /2 0
/2 09
8
01 /2 0
/2 09
9
01 /2 0
/3 09
0
01 /2 0
/3 09
1
02 /2 0
/0 09
1
02 /2 0
/0 09
2
02 /2 0
/0 09
3
02 /2 0
/0 09
4
02 /2 0
/0 09
5
02 /2 0
/0 09
6
02 /2 0
/0 09
7
02 /2 0
/0 09
8
02 /2 0
/0 09
9
02 /2 0
/1 09
0
02 /2 0
/1 09
1
02 /2 0
/1 09
2
02 /2 0
/1 09
3/
20
09
# of cases
CASE COUNTS
Epi Curve 1: Confirmed "primary" cases (n=19)
5
4
3
2
1
0
Illness onset date
CASE 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
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
Environmental Investigation
 Site visits
 Walk through of area
 Sampling of area (3rd floor “Feed the Animals”
exhibit)
 Answering questions for staff
 Cleanup
Sampling
 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.
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Communication and Situation
Reports
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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 media
 Dr. Chris Urbina from Denver Public
Health was the lead
 PIOs coordinated talking points
 Stock Show CEO conducted interviews with
media
Educational opportunities
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Attendees
Childcare facilities
NWSS staff
Investigative team
Biggest Lesson Learned….
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
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
Acknowledgements
 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
Questions????
Contact Info
 Carol McDonald
DPH Epidemiology and Surveillance
303-602-3626
[email protected]
 Abby Bronken
DEH Public Health Inspection
720-865-5377
[email protected]