An outbreak of gastrointestinal illness following a christening

party

Epidemiology principles, BSN course

Developed by: Dr. Khalid Khadoura (13th November 2020)

(Outbreak Investigation)

Learning objectives

At the end of the case study, the participant will be able to:
1. Define an outbreak
2. List the steps of an outbreak investigation and its challenges
3. Draw an epidemic curve.
4. Calculate and compare food-specific attack rates to identify possible vehicles

Part 1

A cluster of gastro-intestinal illness following a christening party in the

suburbs of Warsaw

On 7 September 2011, a physician reported the occurrence of an outbreak of acute gastrointestinal

illness in the suburbs of Warsaw. There was no reference, at this stage, to hospitalized persons. As all
persons known to be ill had attended the same christening party held on 4 September 2011, Anna
Zielicka-Hardy, epidemiologist-in-training based at the National Institute in Warsaw, was assigned to
conduct an investigation.

The investigation was centered about the circumstances surrounding the party. Interviews regarding
the occurrence of symptoms, the date and hour of onset and the food taken at the party were
completed on 48 (87%) of 55 persons known to have attended. A total of 26 persons with
gastrointestinal illness were identified.

Question 1. A.
Would you call this an outbreak?

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Question 1. B.
Review the steps of an outbreak investigation.

Part 2

Clinical description
An outbreak is defined as the occurrence of health events that exceed what we would expect in a
given place and time. At this stage, the actual number of cases is unknown, but the initial alert is
compatible with an outbreak and further investigation is justified. The tasks in this outbreak
investigation should include (1) determining the existence of the outbreak, (2) confirming the
diagnosis, (3) defining a case, (4) searching for cases, (5) generate hypotheses using descriptive
epidemiology, (6) testing hypotheses using an analytical epidemiological study, (7) drawing
conclusions, (8) comparing the findings with established facts / conducting additional investigation, (9)
communicating the findings and (10) executing prevention measures.

The onset of all cases was acute, characterized chiefly by diarrhea (96% of cases). Abdominal pain
was present. More than 85% of ill persons had temperature >39C and 65% reported vomiting. A
small proportion reported feeling nauseous. Of the 26 ill individuals, 3 (12%) were seen at a hospital.

The investigation team obtained laboratory specimens for microbiological examination.

Question 2.A
List the broad categories of diseases that must be considered in the differential diagnosis of an
outbreak of gastrointestinal illnesses.

Question 2.B
If you were administering a questionnaire to the christening party participants, what information
would you collect?

Question 2.C
How would you summarize the collected information?

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Part 3

Description of the christening party

Usual agents of foodborne gastro-intestinal illnesses include bacteria (e.g., staphylococcus aureus,
bacillus, cholera, campylobacter, yersiniosis, salmonella and shigella), virus (e.g., norovirus and
rotavirus) and parasites (e.g., giardia and cryptosporidia). Heavy metals and toxic agent should also
be considered.

The party was held in a small village. The mother of the christened child and her sister prepared most
food items. The party began at 1:00 PM and continued until 6:00 PM. Food was spread out upon a
table and consumed over a period of several hours. The investigator defined illness as the occurrence
of any gastro-intestinal symptom among christening guests in the 72 hours following the party. Data
regarding onset of illness, food eaten or alcohol drunk by the 48 individuals interviewed are provided
in the attached table (Table 1). For most persons who had gastrointestinal illness, the approximate
time of eating at the party, was obtained.

Question 3.A1
Graph the cases by time of onset of illness. What does this graph tell you?

Question 3.B
Are there any cases for which the times of onset are inconsistent with the general experience? How
might they be explained?

Question 3.C
How could the data in the table be better presented?

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To save time, you may want to work by small groups of two and split the tasks to do according to a common work plan.

3
 Table 1: Line listing summarizing the information collected from the participants to the christening party Warsaw, 2011
Time Chicken Pork Cabbage Caramel Apples in
#. Age Sex eaten Ill Onset time soup Tripe chop Potatoes salad Bigos Chicken cake jelly Eclairs Cream cake Angel cake

1 50 m 3:00 PM y 06-09-11 N Y Y Y N N N N Y Y Y N

2 47 f 3:00 PM y 05-09-11 4:30 AM N N N N N N N N N N N Y

3 72 m 3:00 PM n . N Y Y Y N N N N N N N N

4 60 f 3:00 PM y 07-09-11 9:00 AM Y N Y Y N Y N N N Y N N

5 60 m 3:00 PM y 04-09-11 7:00 PM N Y Y Y N Y N N Y Y Y Y

6 28 f 3:00 PM y 05-09-11 12:00 PM Y N Y N N N N N N N N Y

7 28 m 3:00 PM y 06-09-11 2:00 AM N Y N N N Y N N N Y N N

8 10 f 3:00 PM n . . . . . . . . . . . . .

9 38 f 3:00 PM n . . . . . . . . . . . . .

10 40 m 3:00 PM y 05-09-11 Y Y Y Y Y Y Y Y Y Y Y Y

11 31 m 3:00 PM n . N Y Y Y N N N N N N N N

12 32 f 3:00 PM n . N Y N N N N N N Y N N N
13 57 f 3:00 PM y 07-09-11 12:00 PM N Y Y N N N N N N Y N Y

14 88 f 3:00 PM n . Y N N Y N N N N N N N N

15 35 m 3:00 PM y 05-09-11 7:00 AM Y Y Y Y N Y N Y Y Y Y Y

16 5 m 3:00 PM y 05-09-11 7:00 PM N Y N N N N N N N N N Y

17 13 f 3:00 PM y 05-09-11 12:00 PM N Y N Y N N N N N N N Y

18 44 m 3:00 PM y 05-09-11 5:00 AM N N N N N N N N N N N Y

19 68 f 3:00 PM n . N Y N Y Y N N N N Y N N

20 41 f 3:00 PM n . N Y Y Y Y Y N N N N N N

21 35 m 3:00 PM n . N N N Y N N N N N N N N

22 50 f 3:00 PM n . N Y Y Y Y N N N N Y N N
23 86 m 3:00 PM n . N Y N Y Y N N N N Y N N

24 12 f 3:00 PM y 05-09-11 00:00 AM Y N N N N N N N N Y N Y

25 51 f 3:00 PM n . N Y Y N N N N N N N N Y

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 Time Chicken Pork Cabbage Caramel Apples in
# Age Sex eaten Ill Onset time soup Tripe chop Potatoes salad Bigos Chicken cake jelly Eclairs Cream cake Angel cake
26 37 f 3:00 PM y 05-09-11 11:00 PM N Y N N Y N N N N Y N Y

27 4 f 3:00 PM y 06-09-11 7:00 AM Y N N N N N N N N Y N N

28 77 f 3:00 PM y 06-09-11 10:00 AM N Y N N N N N N N N N Y

29 4 m 3:00 PM y 06-09-11 1:00 AM N N N N N N N N N Y N N

30 56 m 3:00 PM y 05-09-11 3:00 PM N Y Y N N N N N N N N Y

31 24 m 3:00 PM n . N Y Y N N N N N N Y N N

32 6 m 3:00 PM n . Y N N N N N N N N N N N

33 10 m 3:00 PM n . Y Y N N N N N N Y N N N

34 31 f 3:00 PM n . N Y N Y Y N N N N Y N Y
35 6 m 3:00 PM n . N Y N N N N N N N Y N N

36 9 m 3:00 PM y 05-09-11 3:00 PM Y N N N N N N N N N N Y

37 7 m 3:00 PM y 04-09-11 6:30 PM N Y N N N N N N N Y N N

38 33 m 3:00 PM n . N Y N Y Y N N N N Y N N

39 33 f 3:00 PM y 05-09-11 3:00 AM Y Y Y N Y N N N N Y N Y

40 13 f 3:00 PM y 05-09-11 6:00 AM Y N N N Y N N N N Y N Y

41 9 m 3:00 PM n . Y N N N N N N N N Y N N
42 32 m 3:00 PM y 05-09-11 7:00 AM N Y N Y N N N N Y N N Y

43 56 f 3:00 PM y 05-09-11 5:00 PM N Y N N N N N N N N N Y

44 66 m 3:00 PM y 05-09-11 8:00 AM N N N N N N Y N N N N N

45 32 m 3:00 PM n . Y Y N Y N N N N N N N N

46 57 f 3:00 PM n . N Y N Y Y N N N N Y N N

47 57 m 3:00 PM n . N Y N Y N N N N N N N N

48 29 f 3:00 PM y 05-09-11 2:00 AM N Y N Y N N N N N N N Y

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 Part 4

Looking at the incubation period

The description of the curve indicates that cases first occurred from 6:30PM on 4 September, peaked
between midnight and noon on 5 September and decreased after. No cases were reported after noon on 7
September (Figure 1). The interpretation suggests a point-source outbreak. There were two cases on the 7th
September that were inconsistent with the general experience. Such cases (called outliers) would have been
important to consider as they could have helped generating hypotheses regarding the source of infection.

10
9
Number of people il

8
7
6
5
4
3
2
1
0
0:00- 12:00- 0:00- 12:00- 0:00- 12:00- 0:00- 12:00-
11:59 23:59 11:59 23:59 11:59 23:59 11:59 23:59

4th 5th 6th 7th

Date and hours of onset, 4-7 September, 2011

Figure 1: Cases of gastro-intestinal illness (N= 24) by time of onset, 4-7 September 2011,
Warsaw, Poland

To better understand the situation, the epidemiologist-in-training decided to sort the line listing by illness
status and onset (ill/well, Table 2).

Question 4.A
Where possible, calculate incubation periods and illustrate their distribution with an appropriate graph.

Question 4.B
Estimate the median incubation period and determine the range.

Question 4.C
How does the information on incubation period, combined with the data on clinical symptoms, help in the
differential diagnosis of the illness?
 Table 2 (Revised): Line listing summarizing the information collected from the participants to the christening party Warsaw, 2011
(Sorted by illness status and onset time)

Chicken Pork Cabbage Carame Apples in Cream

Nbr. Age Gender Time eaten Ill Onset time soup Tripe chop Potatoes salad Bigos Chicken l cake jelly Eclairs cake Angel cake

3 72 M 3:00 PM N . N Y Y Y N N N N N N N N

8 10 F 3:00 PM N . . . . . . . . . . . . .

9 38 F 3:00 PM N . . . . . . . . . . . . .

11 31 M 3:00 PM N . N Y Y Y N N N N N N N N

12 32 F 3:00 PM N . N Y N N N N N N Y N N N
14 88 F 3:00 PM N . Y N N Y N N N N N N N N

19 68 F 3:00 PM N . N Y N Y Y N N N N Y N N

20 41 F 3:00 PM N . N Y Y Y Y Y N N N N N N

21 35 M 3:00 PM N . N N N Y N N N N N N N N

22 50 F 3:00 PM N . N Y Y Y Y N N N N Y N N

23 86 M 3:00 PM N . N Y N Y Y N N N N Y N N

25 51 F 3:00 PM N . N Y Y N N N N N N N N Y
31 24 M 3:00 PM N . N Y Y N N N N N N Y N N

32 6 M 3:00 PM N . Y N N N N N N N N N N N

33 10 M 3:00 PM N . Y Y N N N N N N Y N N N
34 31 F 3:00 PM N . N Y N Y Y N N N N Y N Y

35 6 M 3:00 PM N . N Y N N N N N N N Y N N

38 33 M 3:00 PM N . N Y N Y Y N N N N Y N N

41 9 M 3:00 PM N . Y N N N N N N N N Y N N

45 32 M 3:00 PM N . Y Y N Y N N N N N N N N

46 57 F 3:00 PM N . N Y N Y Y N N N N Y N N
47 57 M 3:00 PM N . N Y N Y N N N N N N N N
 Chicken Pork Cabbage Carame Apples in Cream
Nbr. Age Gender Time eaten Ill Onset time soup Tripe chop Potatoes salad Bigos Chicken l cake jelly Eclairs cake Angel cake

37 7 M 3:00 PM Y 04-09-11 6:30 PM N Y N N N N N N N Y N N

5 60 M 3:00 PM Y 04-09-11 7:00 PM N Y Y Y N Y N N Y Y Y Y

10 40 M 3:00 PM Y 05-09-11 Y Y Y Y Y Y Y Y Y Y Y Y

24 12 F 3:00 PM Y 05-09-11 00:00 AM Y N N N N N N N N Y N Y

48 29 F 3:00 PM Y 05-09-11 2:00 AM N Y N Y N N N N N N N Y

39 33 F 3:00 PM Y 05-09-11 3:00 AM Y Y Y N Y N N N N Y N Y

2 47 F 3:00 PM Y 05-09-11 4:30 AM N N N N N N N N N N N Y

18 44 M 3:00 PM Y 05-09-11 5:00 AM N N N N N N N N N N N Y

40 13 F 3:00 PM Y 05-09-11 6:00 AM Y N N N Y N N N N Y N Y

15 35 m 3:00 PM Y 05-09-11 7:00 AM Y Y Y Y N Y N Y Y Y Y Y

42 32 m 3:00 PM Y 05-09-11 7:00 AM N Y N Y N N N N Y N N Y

44 66 m 3:00 PM Y 05-09-11 8:00 AM N N N N N N Y N N N N N

6 28 f 3:00 PM Y 05-09-11 12:00 PM Y N Y N N N N N N N N Y

17 13 f 3:00 PM Y 05-09-11 12:00 PM N Y N Y N N N N N N N Y

30 56 m 3:00 PM Y 05-09-11 3:00 PM N Y Y N N N N N N N N Y

36 9 m 3:00 PM Y 05-09-11 3:00 PM Y N N N N N N N N N N Y

43 56 f 3:00 PM Y 05-09-11 5:00 PM N Y N N N N N N N N N Y

16 5 m 3:00 PM Y 05-09-11 7:00 PM N Y N N N N N N N N N Y

26 37 f 3:00 PM Y 05-09-11 11:00 PM N Y N N Y N N N N Y N Y

1 50 m 3:00 PM Y 06-09-11 N Y Y Y N N N N Y Y Y N

29 4 m 3:00 PM Y 06-09-11 1:00 AM N N N N N N N N N Y N N

7 28 m 3:00 PM Y 06-09-11 2:00 AM N Y N N N Y N N N Y N N

27 4 f 3:00 PM Y 06-09-11 7:00 AM Y N N N N N N N N Y N N

28 77 f 3:00 PM Y 06-09-11 10:00 AM N Y N N N N N N N N N Y

4 60 f 3:00 PM Y 07-09-11 9:00 AM Y N Y Y N Y N N N Y N N

13 57 f 3:00 PM Y 07-09-11 12:00 PM N Y Y N N N N N N Y N Y

Part 5

Question 5.A
By appropriate tabulation for specific items of food, identify, if possible, any common vehicle(s) of infection
Question 5.B
Outline further investigations that should be pursued.

Question 5.C
What control measures would you suggest at this point of the investigation?

Question 5.D
How would you communicate the results?