Health officials in New Brunswick say they have some leads in their search for the source of an E. coli outbreak that they believe has left people ill in three communities.

However, a spokeswoman for the Health Department said Saturday there's, “still no clear evidence of the source of the outbreak.”

Jennifer Graham says in an email that 27 cases of bloody diarrhea suspected to be caused by E. coli have been reported since Tuesday.

The first person began showing symptoms on April 23 and as of Friday night 23 cases were reported in Miramichi, two in Saint John and two in Bathurst.

So far, 11 cases have tested positive as E. coli O157; 14 people have been hospitalized, eight of whom remain in hospital.

New Brunswick gets an average of 12 cases of E. coli per year. Dr. Eilish Cleary, the provinces's chief medical officer of health (left), issued a statement on Friday confirming the E. coli outbreak.

Dr. Denis Allard, the province's deputy chief medical officer for health, said there is no clear evidence yet that points to a source for the outbreak, but they do have some leads.

"Some of them are related — either family or friends — and some of them have eaten in common places," Allard said in an interview Friday.

"But it doesn't point to just a single restaurant or a single food at this stage."

There are now 37 people confirmed sick with Salmonella Paratyphi B linked to tempeh. Buncombe County Health Department in North Carolina has outlined three paths for infection: folks who have eaten tempeh (from Smiling Hara); others who have connections to someone ill with Salmonella Paratyphi b (person-to-person); and, a third group that is under further investigation to determine if there are other sources of contamination.
 
According to the update (and big props to the Buncombe Co health folks for releasing daily updates):
 
Confirmatory lab results are expected later this week that should confirm whether the tempeh is a match to the type of Salmonella associated with the current outbreak. At this time we cannot assure people that if they stay away from the tempeh that they won’t get sick. Health officials appreciate the precautionary measures taken by Smiling Hara, who recalled their tempeh product while awaiting confirmation that the tempeh is directly linked to this outbreak.
 
On the Smiling Hara Tempeh website, the product is marketed as a raw food and unpasteurized:
 
ONCE SMILING HARA TEMPEH IS THAWED YOU HAVE 5 DAYS TO COOK IT (for Listeria concerns? -ben).  For best taste and highest nutrtional value do not re-freeze. Our Tempeh is a raw food and is intended to be cooked.  In the heating process some of the probiotics and digestive enzymes will die, however, some will be retained and the mushroom qualities remain in full.  After eating our product regularly you will notice the cleansing effect it will have on your body, and how good you will feel after a “happy belly” meal including Smiling Hara Tempeh, vegetables, and grains.
 
It's unclear from the available information whether illnesses have been linked to consuming this product at restaurants or in the home (or both). And it’s really unclear what folks were doing with this product once in the kitchen: did they know it was raw? Did they know there was any potential risk? Was the product labeled and did anyone follow the label directions?
 
Cross-contamination also could be a factor here - it's likely that folks in the kitchen treat this stuff more like leeks and potatoes than raw chicken. Inadequately cleaned leeks and potatoes were thought to be responsible for an E. coli O157:H7 outbreak in the UK that sickened 250 people over months.
 

Sorenne’s school is doing the hatching-chicks-thing in anticipation of Easter (which is a surprisingly big deal in Australia) and I’ve been doing my best Dougie-Downer about handwashing, Salmonella, pestilence and death.

In the northern Hemisphere, this is apparently the start of the petting farm season (didn’t have that one penciled in), so the UK Health Protection Agency is reminding people, especially those with responsibility for young children, to enjoy their farm visits safely by ensuring good hand hygiene after touching farm animals or their surroundings.

Outbreaks of gastrointestinal illness associated with contact with farm animals peak in the spring and summer as this coincides with schools holidays when visits to petting farms tend to be more popular, although outbreaks can occur at other times.

The route of transmission in these illnesses, which include the infections E. coli O157 and Cryptosporidium, is direct contact with animals in petting and feeding areas as well as contact with the droppings of animals on contaminated surfaces around farms.

Dr Bob Adak, head of the gastrointestinal diseases department at the HPA, said, “… hand gels or wipes have their uses in areas that are generally clean, such as offices or hospitals, but they are not effective in completely removing from soiled hands bugs such as E. coli or Cryptosporidium that are commonly found in animal droppings and on contaminated surfaces around farms. This is why washing the hands thoroughly with soap and water is so important - it is the only way to effectively remove the bacteria and reduce the risk of becoming unwell.”

Figures from the HPA’s national surveillance system show that there were 61 outbreaks of gastrointestinal illness associated with farms visits between 1992 and 2011. Twenty two of these outbreaks (36 per cent) occurred in the last three years (2009-11).

Around half were caused by E. coli O157 and around half were caused by Cryptosporidium. A handful were caused by Salmonella. Overall 1,238 people were affected in these outbreaks – 1,003 people with Cryptosporidium and 235 with E. coli O157.

A table of petting farm-related outbreaks is available at http://bites.ksu.edu/petting-zoos-outbreaks.

We’ll have more to say about this once our research paper, led by Gonzalo, completes the peer review process and gets published.

The annual Rock ‘n’ Roll Las Vegas Marathon and ½ Marathon was attended by about 44,000 runners on Sunday Dec. 4, 2011. By Tuesday, complaints of illness were trickling in to the Southern Nevada Health District. By Thursday, traditional media reported on increasing complaints of barfing on the event’s Facebook page. An investigation was launched.

Within a week, health-types were able to say it wasn’t the water distributed during the race that made runners sick, quelling a rumor that had already taken on a life of its own.

Below are excerpts from the final report, issued last week, identifying the first outbreak of sapovirus in Nevada and the emerging role of social media in epidemiological investigations.

Links to an epidemiology online survey were shared on the marathon’s Facebook page (with 25,732 followers) by members of the running community on four consecutive days starting on the day of release of the survey, and a total of 42 times within one week as part of a number of discussions among ill runners. Twenty-two people shared the survey link on Twitter, potentially reaching 17,982 followers. A total of 362 responses had been submitted within 12 hours of the release of the survey. After the survey had been posted for 4 days, a total of 1,146 surveys had been submitted. Of the 1,082 completed surveys, 578 (53.4%) were from persons who reported developing diarrhea or vomiting. Of these, 528 (91.3%) met the case definition.

Seventeen ill local runners were requested to provide stool specimens; specimens were provided by nine marathon runners and two symptomatic children of a symptomatic marathon runner. Specimens were collected between December 9, 2011 and December 11, 2011 (5-7 days after symptom onset), and all specimens submitted were formed stools. Two were positive by rRT-PCR for sapovirus and negative for all other tested pathogens at CDC and the SNPHL

The findings of this investigation point to the source of the sapovirus outbreak among marathon runners as a common exposure on the morning before the race, most likely at the health and fitness expo. It was not possible to determine which common exposure was responsible for the outbreak. The timing of the exposure and the incubation period of sapovirus resulted in the majority of cases becoming ill during the race or in the hours shortly after; however, exposure during the race was not the cause of the outbreak.

Sapoviruses (genus Sapovirus, family Caliciviridae) are a group of viruses that cause acute gastroenteritis in humans. Sapovirus is not as well-characterized as norovirus, but is thought to be similar to norovirus in that it has a short incubation period (1-2 days), low infectious dose, causes a self-limiting illness that is rarely serious with a significant percentage of asymptomatic infections, and is easily spread from person to person through fecal-oral transmission. Both infections cause diarrhea, although a lesser percentage of sapovirus patients develop vomiting as compared to norovirus patients.

Outbreaks of sapovirus have been reported in the literature, but reports of foodborne outbreaks and outbreaks among adults outside long-term care are rare and the majority of cases occur in children under 5 years of age. This outbreak represents the first outbreak of sapovirus in Southern Nevada and the first time the virus has been identified in the local population. However, sapovirus testing is not available locally and has not been previously ordered during an outbreak. Rather than representing a newly-introduced disease, the identification of the virus likely indicates that sapovirus circulates at low levels in the population but goes unidentified.

This investigation was also the health district’s foray into using social media as an investigative tool, rather than just as a method of disseminating information to the public. Using the active community of runners on Facebook and Twitter allowed for the rapid dissemination of the survey directly to the exposed population without a delay in requesting participant information from the race organizers. Comments posted to social media sites provided ongoing, real-time insight into the needs and concerns of the ill population, and provided a feel for the efficacy of health district investigation efforts. Comments about SNHD were overwhelmingly positive, and indicated a level of trust and willingness to cooperate from the community.

Ill and non-ill runners quickly responded to the survey, which allowed SNHD staff to rapidly identify ill persons for laboratory testing. It also allowed for a preliminary data analysis to be quickly completed, which allowed the water provided by race organizers, an early focus of complaints by runners, to be ruled out as a source of the outbreak. The water provided in the race was the same potable water that is distributed throughout Southern Nevada, and it was important to quickly determine if the general population was at risk of disease.

The ill persons identified by SNHD staff complied very quickly with the request to submit specimens for laboratory testing. The submission of stool samples for testing is often a difficult task due to the type of sample requested and the handling requirements. The ill persons were highly motivated to provide samples that could be used to identify the causative agent of the outbreak.

In the future, several steps should be implemented to improve the investigative process and to prevent disease at similar events. First, although the survey was developed quickly, a standard template should be developed to allow the rapid deployment of standardized surveys for illness. In addition, corresponding standard analytic tools should be developed to allow for the rapid analysis of survey data.

Next, SNHD should consider using social media more frequently to administer surveys given the appropriate audience; in this case, the use of Facebook was effective because there was an active community of marathon frequently posting and reading the marathon’s page. During a large event, it might be appropriate to set up a social media site for the event response. This would provide an additional avenue for SNHD to share information from the public, and following discussions would allow for real-time feedback on the needs and concerns of the public. However, the decision to launch a social media site should be thoroughly discussed prior to launch, as it would place SNHD in the role of moderating the discussion on the topic (for example, removing libelous comments or threats against employees). It would also necessitate the development of policies on the participation in such discussion by staff members on work time or personal time.

The complete report is available at: http://www.southernnevadahealthdistrict.org/download/stats-reports/rocknroll-marathon-sapovirus-outbreak-final-report.pdf.