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State of California Center For Disease Control and Prevention

Phan, Cruz, Cox 1

Date: Tuesday, May 7, 2013

To: State and Territorial Public Health Laboratory Directors
State and Territorial Epidemiologists
County Public Health Departments


A tainted food product called cheeseburger-in-a-can is believed to be associated with a
mystery airborne illness. The actual direct cause, transmission, and incubation period for this
illness are being thoroughly investigated. The food product was found and consumed by 5 people
on Delta Airlines flight 331 from Chicago OHare International Airport (ORD) to San Francisco
International Airport (SFO). Three patients have been admitted to San Francisco Generals ED
with symptoms of this mystery illness. Patient 1, who consumed the food product on flight 331,
is in stage 3 of the illness, lacking a heart rate and neurological function. Patients 2 and 3 are
believed to have come in contact with patient 1 on flight 331, and are currently in stage 2 of the
illness, a comatose state.
Approximately 435 people were aboard Delta Airlines flight 331 on Sunday, May 5,
2013. This flight had numerous connecting flights from SFO to major international airports
around the country where similar cases of this illness have been reported (Figure 1), including:
HartsfieldJackson Atlanta International Airport (ATL), Detroit Metropolitan Wayne County
Airport (DTW), and San Antonio International Airport (SAT). Because this illness is believed to
be transmitted through respiratory droplets and saliva, all passengers on these flights and all
other airport patrons and employees present on May 5th have potentially been exposed through
contact with passengers who consumed contaminated food product. Additionally, all citizens
who come in contact with potentially exposed passengers after they have left the airports may
State of California Center For Disease Control and Prevention
Phan, Cruz, Cox 2

become exposed themselves. As a result, the number of infected persons may quickly reach the
hundreds of thousands.
Case-control and laboratory studies for all reported cases around the country are being
employed to investigate the suspected cause of the infections and the resulting at-risk
Step 1: Initial Identification of Cases in San Francisco [COMPLETED]
1 patient in stage 3, 2 patients in stage 2 (all admitted in stage 1 with high-grade fever,
muscle aches, and unusual tiredness)
Step 2: Identifying Association between Flight and Illness [COMPLETED]
Upon interviewing patient 1, it was discovered that he consumed an old canned food
product during a 6-hour delay on the tarmac on flight 331. Upon interviewing patients 2
and 3, it was discovered that they did not consume the food product but were seated near
patient 1 on flight 331. All patients interviewed while in stage 1.
Hypothesis: Patient 1 became infected through consumption of canned food, while
patients 2 and 3 were exposed to the illness via airborne transmission.
Step 3: Confirming Hypothesis through Laboratory Studies [COMPLETED]
Obtained mouth swabs and blood samples from the three patients in San Francisco and
sent it to main CDC laboratory for confirmation. Obtained food can in question and sent
it to CDC for comparison with patient samples.
! Lab results confirmed same pathogen present in patient samples and canned food.
Step 4: Data Collection of Infected and Exposed Patients [ONGOING]
Contacted destination cities of connecting flights and discovered incidences of cases with
similar symptoms (Figure 1).
State of California Center For Disease Control and Prevention
Phan, Cruz, Cox 3

! 4 additional patients interviewed, confirmed to have consumed food item, and
confirmed to have pathogen through laboratory testing. All are now in stage 3.
CDC epidemiologists will interview all passengers on all flights resulting in confirmed
Cities with patients exhibiting these symptoms should continue reporting data and patient
samples to the CDC.
At the moment, the food attack rate from the common-vehicle exposure is 100%. The
secondary attack rate will be determined upon further investigation of those exposed to the
primary cases. If and when lab results from reported cases in other cities are confirmed as a
match to the pathogen identified in the San Francisco cases, an odds ratio will be calculated for
the overall case-control study to determine if the exposure is positively related to the disease.
As a preventative measure, an official recall will be issued for the food product. Delta
Airlines will be required to sterilize all planes in questions. Individual airports should notify all
patrons who were present on Sunday, May 5, 2013 about possible exposure. Notification should
encourage all persons exhibiting symptoms to seek medical assistance. Patients exhibiting
symptoms of stage 1 should be immediately isolated and samples collected. To ensure efficiency
of data collection and prevent hospital overcrowding with unexposed persons, a number of
solutions to potential biases are given in Table 1.
State and local public health departments, hospitals, and airport officials participating in
the investigation of this outbreak should report any and all relevant information to the CDC. All
relevant data collected in regards to this mystery illness outbreak will contribute to the case-
control study to accurately measure the association between exposure and illness, as well as the
containment and control of the spread of this fatal and acute disease.
State of California Center For Disease Control and Prevention
Phan, Cruz, Cox 4

Figure 1. Primary cases and connecting flights

Table 1. Potential Biases and Corrections for these Biases

Bias Corrections
Misdiagnosis of illness Mandate confirmation through laboratory testing.
Under/over reporting
Encourage all susceptible persons to contact local officials.
Proper training of CDC and local personnel to eliminate
improbable exposures from reporting.
Recall (over reporting) bias
Proper training of CDC and local personnel to eliminate
improbable exposures from reporting.