CENTERS FOR DISEASE CONTROL 2 Autumn 1997 AN OUTBREAK OF ENTERITIS DURING A PILGRIMAGE TO MECCA Following this case study, the student should be able to: 1, Define an epidemic, an outbreak, and a cluster. 2. Create and understand the uses of a case definition 3. Draw an epidemic curve. 4, Calculate food-specific attack rates. 5. _ List the steps in investigating an acute outbreak. PARTI On the morning of November 1, 1979, during the pilgrimage to Mecca, the epidemiologist assigned to the Kuwaiti medical mission experienced acute onset of abdominal cramps and diarrhoea at the holy mosque before the walk around the Kaaba. He subsequently learned that other members of the mission had developed similar symptoms. When he returned that evening to Muna, he initiated an investigation. QUESTION 1; What information do you need to decide if this is an epidemic? ‘Severai ill members of the mission were interviewed by the epidemiologist to better characterize the iiness. On the basis of these interviews a questionnaire was quickly prepared and interviews were conducted with the 112 members of the Kuwaiti medical mission. A total of 66 cases of illness were identified; 2 had onset in Kuwait prior to the beginning of the pilgrimage and 64 had onset of symptoms beginning late in the afternoon on October 31 QUESTION 2: Is this an epidemic?CDC, 1991: Mecca D 0 of the Pilgrimage The Kuwaiti medical mission, consisting of 112 members, traveled, by automobile from Kuwait to Mecca. On October 30 all members of the mission slept in Muna. At sunrise on Octoter 31 they traveled to Arafat where at 8:00 a.m. they had tea with or without milk for breakfast. The milk was prepared immediately before consumption by mixing powdered milk with boiled water. The remainder of the day was devoted to religious services. At 2:00 p.m. a lunch was served tor all members of the mission who wished to partake. It was a typical Kuwaiti meal consisting of three dishes: rice, meat, and tomato sauce. Most individuals consumed all three dishes. The lunch had been prepared in Muna on October 30 and transported to Arafat by truck early on October 31. At sunset on October 31 the mission members returned to Muna. Clinical Description A total of 66 cases of gastroenteritis were identified. The onset of all cases was acute, characterized chie‘ly by diarrhoea and abdominal pain. Nausea, vomiting, and blood in the stool occurred infrequently. No case reported fever. All recovered within 12-24 hours. Approximately 20 percent of the ill individuals sought medical advice. No fecal specimens were obtained for bacteriologic examination. QUESTION Who should be considered at risk for illness in this outbreak? QUESTION 4: Develop a preliminary case definitionCDC, 1991: Mecca QUESTION 5: List the broad categories of diseases that must be considered in the differential diagnosis of an outbreak of gastrointestinal illness. QUESTION 6: What clinical and epidemiologic information might be helpful in determining the etiologic agent(s)? QUESTION 7: The Kuwaiti investigators distributed a questionnaire to all members of the mission. What information would you solicit on this questionnaire?CDC, 1991: Mecca AN OUTBREAK OF ENTERITIS DURING A PILGRIMAGE TO MECCA PART II Investigators determined that of the 64 cases with onset during the pilgrimage, all had eaten lunch in Arafat at 2:00 p.m. on October 31. Fifteen members of the mission did not eat lunch; none became ill QUESTION 8: Calculate the attack rate for those who ate lunch and those who did not. What do you conclude? QUESTION 9: At this point would you redefine your case definition? How? Table 1 (attached) presents some of the information collected by the investigators. The two members who developed illness prior to October 31 have been excluded. The 15 members of the mission who did not eat lunch are not included on Table 1. QUESTION 10: Using appropriate time periods, draw an epidemic curve. QUESTION 11: Are there any cases for which the times of onset seem inconsistent? How might they be explained? QUESTION 12: Modify the graph you have drawn (Question 10) to illustrate the distribution of incubation periods. Estimate the median incubation period and determine the range.CDC, 1991: Mecca 5 QUESTION 13a: QUESTION 13b: QUESTION 14a: QUESTION 14b: QUESTION 15: Among the cases, calculate the frequency of each clinical symptom. How does the information on the symptoms and incubation period help you to narrow the differential diagnosis? (You may refer to the attached "Abbreviated Compendium of Acute Foodborne Gastrointestinal Diseases”). Using the food consumption histories in Table 1, complete item 7 of the attached “Investigation of a Foodborne Outbreak" report form, Do these calculations help you to determine which food(s) served at the lunch may have been responsible for the outbreak? Outline further investigations which should be pursued. List one or more factors that could have led to the contamination of the implicated food.CDC, 1991: Mecca 6 Table 1 Selected Characteristics of Kuwaiti Medical Mission Members Who Ate Lunch at Arafat, Saudi Arabia, October 31, 1979 Onset of Iliness. Foods ‘Symptoms* Wd# Age Sex Date —_Hour Rice Mest IS* D C BS N V F 31 36M Oct.31 5 p.m. aaa kee Xe DCH eS| 77 28 M_ Oct.31 5 p.m. m3 = 53 Doc Si 93) Me (OceS eal O]pim a Xen Xt eX) Dee 7 CES 15 38M — Oct.31 10 p.m. x D BS ON 17. 48 M = Oct31 10pm. xX =X dD oc 18 35 M Oct31 10pm. =X xX XxX D Cc 35 30 M Oct-31 11 p.m. ee Xe ic (1 Ceo be fb 4 76 29 M Oct31 11pm xX XxX xX DBD C Bs 71 80 M_ — Oct.31 12 MN x xX xX D 1 39 F Nov. 1 Tam. xX xX x dD C v 527 36 M = Nov.1 1am. x xX xX Dd Cc N 28 0 44 ~M_— Nov.1 1am. x xX xX Dd Cc 529° 48 M = Nov.1 1am. x xX xX D Cc BS 30 35 M Nov. 2am, x x x Dd C 50 29 M = Nov.1 2am. x x xX Dd C 5951 M_~ Nov.1 2am. x xX xX dD C 67 40 M_ Nov.1 2am. x x D 72 58 M Nov.1 2am. xX xX x dD ¢ 73 28 M Nov. 3am, Det Xe Oe 60 31 M_ Nov.1 3am, xX xX xX Dd Cc 61° 38 M Nov.1 3am, x xX xX oD BS 51 32 M_ Nov.1 3am. x xX xX Dd ¢ v 52 37 M_ Nov.1 3am. x Xx D 58 30 M Nov.1 3am, x xX x DC 22 35 M = Nov.1 3am, Oe eX) eee Dac) 25 30 M = Nov.1 3am. x x oc 32. 50 M Nov.1 3am. Dex xe OG) 38 26 M = Nov.1 3am. ext eet) 79 29 M = Nov.1 3am. ee ac 80 28 M Nov.? 3am. ig ee aOR) 37 30 M Nov.1 4am. x XxX xX D 65 34M Nov.1 4am. x x D Bs 66 45 M = Nov.1 4am. ks Doc 87 41M Nov.1 4am. x xX x Dd C¢ 89 43 ~M = Nov.1 4am. x xX x dD ¢ 90 43 M = Nov.1 4am. x xX xk oD ¢ 91 38 M = Nov.1 4am. x xX xX Dd C¢ 92 37 M_ Nov.1 4am. xX xX xX Dd C 70 31 M = Nov.1 Sam. x xX xX dD C 2 34 F Nov.1 Sam. xX x xX dD ¢ 21. 38 M Nov.1 Sam. x xX x Dd ¢ 40. 38 M = Nov.1 Sam. ee eX eX a0) 78 27: M Nov.1 5am. eee Ke xe) 82 39 ~M_—Nov.1 Sam. eee ec) 83 40 M = Nov.1 Sam. eee Xe Xa eC) + TS = Tomato sauc D = diarrhoea, C = cramps, BS = blood in stool, N = nausea, V = vomiting, F = feverCDC, 1991: Mecca Table 1 (continued) Onset of iliness, ___ Foods Wd# AgeSex Date Hour Rice Meat 84 34 M_ Nov.1. 5 am. x x 14 52 M Nov. 6am. x Xx 16 40 M = Nov.1 6am. x Xx 93 30 M Nev? 6am. i 3 94 39 M = Nov.1 6am. x x 33° 55M Nov.1 7am. x x 34-28 M_ Nov.1 7am. x x 85 38 M Nov.1 7am. xX xX 43° 38 M = Nov.1 Sam. x x 69 30 M_ Nov.1 9am. x x 4 30 F No.1 10am Xx 5 45 F Nov.1 10am. x 3 29 F Nov.1 1pm. oe 12. 22 F Nov.1 2pm. x x 74 44 M Nov.1 2pm. x Xx 73 45 M Nov.1 5 p.m. x Xx 95 40 M Nov.1 tipm. X xX 6 38 F WELL x x 7 52 F WELL x x 8 35 F WELL x 9 27 F WELL x x 10 40 F WELL ee x 14 40 F WELL x x 13° 50 M WELL i 19 38 M WELL x x 20 38 M WELL x x 23°29 «MM WELL x x 240-27 M WELL x x 26 47 M WELL x x 36 60 M WELL x 39°27: M WELL xeex 41 30 M WELL xox 420 38 M WELL ax 44 50 M wet max 450027 M WELL me 46 31 M WELL ie 47 46 M WELL x 48 38 M WELL poe 49° 36 M WELL x 5336 M — WELL Be bs 5427 M WELL x x 55 40 M WELL x x 56 30 M WELL x x 57 25 M WELL x Xx 62 50 M WELL x 6300 44 Ms WELL x 64 47 M WELL x 68 31 M (WELL pa ‘Tomato sauce; diarrhoea, C = cramps, BS = blood in stool, N = Symptoms* iD sge Cog na eevee vies D c D D Bs D c D c D c D c Doc D c x D c D c c D c x c x D x oD Bs x D c x x x x x x x x x x x x x x x x x x x x x x 3 x x x nausea, V = vomiting, F = feverDc USE ONLY FORM APPROVED ‘pwte 0. 0820-0004, INVESTIGATION OF A FOODBORNE OUTBREAK 1 Where cid he outbreak occur 7 2 Date of outbreak: (Dave of onset 1st cae) ste (8-6) City or Town county WOTORTYA ot ‘T indicate acwola) or estimated (e) numbers: | 4, Hngory of Exported Persons Incubation period (hour No, nstories obtained Shortest, Longer. Perone expo aan Tan aaa No. penon with symptoms 62639] apgron tor saert tan Peroni aan —— Nouses______ aon) Oiartbes _caean)[ 6 Duration of lines our? 251) Fever. Vomiting Shortt, Longest, Hospitalized —_—_____ 23.271 a saat, (Cramps (96-59) Other, specify Approx, for majority (101 404) Food Wert Served ‘Number of persons who ATE ‘Number who aid NOT ext soectied ood soeciied food my Not | rorat | Percent it ‘Not uw ] Total apes a tases [eames ee ‘nme tng Ceca fam as, to Net Yet eves IO nan) teen ceee ED A | Rent scecees El 4 I) Elen ieee ces ese es Fe) cn eee) DatteeweeseseseeE] 2 Coie, ee OO tu a chs Coomdvacwm eons OE) 0) a EP Rss Sterne oa oe 5 to vendon Maine. 11) te Ream Yorowne CTCL 30y| See o O68 fetnror DG am} owe o Bs i OO asl cme ‘Oe eoteat OO ass} omer, specity ....-O Oe 1s somos pie nate Mand rene dt soma aaeaso agen DEPARTMENT OF HEALTH AND HUMAN SERVICES. PUBLIC HEALTH SERVICE CENTERS FOR DISEASE CONTROL ATLANTA, GEORGIA 30333 —_—_—CDC, 1991: Mecca 9 ‘AN OUTBREAK OF ENTERITIS DURING A PILGRIMAGE TO MECCA PART ill The lunch which was served in Arafat at 2:00 p.m. on October 31 was prepared at 10:00 p.m. the night before while in Muna. It consisted of boiled rice, chunks of lamb fried in oii, and tomato ‘sauce prepared from fresh tomatoes which were sectioned and stewed. The cooked rice was placed in two large pots and the lamb was divided evenly on top. The tomato Sauce was kept in a third pot. ‘These pots were covered with metal tops and placed in an open spot among some rocks near the hen and allowed to stand overnight. They were presumably not touched by anyone during this period. Early in the morning on October 31, the pots were transported by truck from Muna to Arafat where they stood in the truck until 2:00 p.m. ‘The temperature in Arafat at noon that day was 35°C. The food was not refrigerated from the time of preparation to the time of consumption. Cooks and all other individuals who helped in preparing the meal were intensively interviewed regarding any illness present before or at the time of preparation, All individuals interviewed denied having any iliness and knew of no illness among any other members of the group responsible for ‘meal preparation. No specimens were obtained from any of the cooks for laboratory examination. The following is quoted verbatim from the report prepared by the epidemiology who investigated the outbreak: "This clinical picture probably suggests an infection by Clostridium perfringens. This organism could be detected in the food elements consumed as well as in the patients stool. However, no laboratory diagnostic procedures were possible in the outbreak site, All the investigations conducted were based entirely en epidemiologic grounds.” "The incubation period as well as other data extrapolated from epidemiological analysis suggests that Clostridium perfringens is the causative agent. This organism is widely distributed in nature especially in soil and dust. So there is ample opportunity for contamination of the food. If cooked meat is allowed to cool slowly under suitable anaerobic conditions, spores which might have survived cooking or have subsequently come from dust may germinate and within a few hours produce large numbers of vegetative bacilli. In fact, the pilgrimage camp in Muna lacks sanitary cooking facilities. The food is usually prepared in 2 dusty place open to the blowing winds creating an ideal situation for Clostridium perfringens contamination.” "The type of the organism, the type of food dish it usually contaminates, its mode of spread and the differences in the attack rates for those who consumed meat 2nd those who did not points to the meat as the probable source of infection in this outbreak.”CDC, 1991: Mecca 10 “Conclusion: The acute itiness of enteritis in Arafat affected many persons in an epidemic form. it was a common-source outbreak, the source being the meat consumed at the Arafat lunch. The incubation period was about 13 hours. The illness was charactesized by colicky abdominal pain and diarrhoea with no elevation of temperature. The responsible agent for this outbreak is most probably Clostridium perfringens. “The lunch at Arafat should have been prepared in the same day of consumption, or kept ‘etrigerated if it had to be prepared the day before. although kitchens could not be fully equipped to fulfill the essential safety measures in a place like Muna, they should be supplied by essential measures to protect food from contamination. The remaining food in Arafat should have been condemned after the investigation, but none remained at that time. “The epidemiological investigations carried oUt in this epidemic could explore the nature of this epidemic and answer most of the questions raised, The laboratory investigation, although helpful to detect the causative organisms, should not replace the mare efficient epidemiological methods in the exploration of such epidemics. The lack of the necessary laboratory facilities to detect the causative organisms in foodborne outbreaks should not discourage the investigative epidemiologist and make him doubtful and lose confidence in his epidemiological tools.” QUESTION 16: In the context of this outbreak, what control measures would you recommend? 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