HomeMy WebLinkAboutCatawba Norovirus Outbreak Final Report
North Carolina Department of Health and Human Services
Division of Public Health Epidemiology Section
Communicable Disease Branch
1902 Mail Service Center Raleigh, North Carolina 27699-1902
Tel 919-733-3419 Fax 919-733-0490
Beverly Eaves Perdue, Governor Laura Gerald, MD, MPH
Lanier M. Cansler, Secretary State Health Director
Memorandum
Date: March 21, 2012
To:
Megan Davies, MD
State Epidemiologist,
North Carolina Division of Public Health
Douglas W. Urland
Health Director
Catawba County Public Health
From:
Stephanie Griese, MD MPH
Epidemic Intelligence Service (EIS) Officer
Centers for Disease Control and Prevention
North Carolina Division of Public Health
Aaron Fleischauer, PhD MSPH
Career Epidemiology Field Officer
Centers for Disease Control and Prevention
North Carolina Division of Public Health
Jennifer MacFarquhar, RN MPH CIC
Career Epidemiology Field Officer
Centers for Disease Control and Prevention
North Carolina Division of Public Health
Zack Moore, MD MPH
Medical Epidemiologist
North Carolina Division of Public Health
Subject: Restaurant Associated Norovirus Outbreak – Catawba County, 2012
We are submitting the attached memorandum as the final outbreak report to health department officials in
North Carolina.
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Summary
In January 2012, Catawba County Public Health received reports of gastrointestinal illness associated
with the Harbor Inn Seafood Restaurant in Hickory, North Carolina. One hundred sixty-six cases were
identified in total. Norovirus was identified as the etiologic agent based on laboratory testing and clinical
characteristics. A case control study was performed, which identified salad consumption as the primary
exposure associated with illness (OR 18.7, 95% CI: 7.0–50.4).A public health investigation revealed that
8 food handlers had worked while ill. Control measures were implemented in the restaurant based on
public health recommendations; no new illness onsets occurred after January 24.
Background
On January 17, 2012, Catawba County Public Health (CCPH) received an anonymous call from a
Catawba County resident reporting gastrointestinal illness after visiting the Harbor Inn Seafood
Restaurant located in Hickory, North Carolina. By January 19, ten cases of gastrointestinal illness
associated with the Harbor Inn Restaurant had been reported to the local health department and a public
health investigation was initiated.
Methods
Initial Public Health Response
CCPH conducted on-site inspections and developed a short questionnaire and line list to record case
information. Additional staff members were identified to respond to inquiries from the public. The North
Carolina Division of Public Health (NCDPH) was notified of the outbreak and dispatched a medical
epidemiologist from the Communicable Disease Branch and a Regional Communicable Disease Nurse
Consultant to provide onsite assistance. Information about norovirus and investigation updates were
published on the CCPH website. Talking points were developed for use with ongoing media interviews
and public inquiries. (Appendix A)
Case finding
Passive reporting of cases was enhanced by public notification of the outbreak through media reports.
State and local public health officials were notified through the NC Health Alert Network on January 23
and asked to contact CCPH if potential cases were identified.
Clinical Laboratory Investigation
Catawba County Public Health requested stool samples from case-patients. These stool specimens were
sent to the North Carolina State Laboratory of Public Health for norovirus PCR.
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Environmental Investigation
An Environmental Health officer from CCPH visited the Harbor Inn Restaurant on January 17 after
receiving the first reports of illness. Subsequent visits took place throughout the course of the
investigation. Environmental Health staff evaluated the temperatures of raw and cooked products,
methods of food preparation, and food storage facilities at the restaurant. CCPH staff also interviewed
restaurant managers to determine whether any food handlers had been ill during the likely exposure
periods. A site visit with environmental health and a medical epidemiologist occurred on January 31 to
identify possible vehicles of exposure and observe workflow patterns.
Case Control Study
A case control study was initiated on January 30 to identify the source(s) of exposure. A case was
defined as onset of nausea, vomiting or diarrhea (3 or more loose stools in a 24 hour period) within 48
hours after eating at Harbor Inn Seafood Restaurant, with restaurant exposure occurring on or after
January 13. Cases were randomly selected from the CCPH line list and divided into two groups; those
thth
with exposures during January 13–15 (Group 1) and those with exposures during January 19–20
(Group 2). Controls were randomly selected from names identified through restaurant credit card receipts
and matched 1:1 with cases by date of restaurant exposure. (Figure 1)
Cases and controls were interviewed by phone using a detailed questionnaire including items from the
Harbor Inn Seafood Restaurant menu (Appendix B). Personal hygiene behaviors (including hand
washing practices, restroom hygiene and the sharing of cups and utensils) and known contact with other
ill persons were also assessed. All interviewers were trained in the use of the questionnaire before
conducting interviews.
strd
Interviews were initiated on February 1 and completed February 3. Data were entered into an Epi
Info™ 7 database (CDC, Atlanta, Georgia) and analyzed using SAS 9.2 (SAS Institute Inc. Cary, North
Carolina). Odds ratios and 95% confidence intervals were calculated using the Cochran–Mantel–
Haenszel method.
Results
Description of case patients
One hundred sixty-six cases were identified through passive reporting and through phone calls made
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during the case-control study. Exposure dates ranged from January 13 through January 29. Dates of
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exposure were clustered on the weekends of January 13–15 and January 19–20 (Figure 1); the tight
clustering of illness onset dates was most consistent with 2 point sources of the outbreak (Figure 2).
Fifty-five case-patients were enrolled in the case control study and completed standard interviews. Thirty-
four (62%) case-patients were female and 21 (38%) were male. The median age was 61 years with a
range of 9 to 79 years. Only one case-patient was less than eighteen years of age. The majority of cases
(66%) were 56 years old or older (Table 1). Forty-five (82%) case-patients resided in Catawba County.
The remaining case-patients were residents of Alexander, Burke, Caldwell, Lenoir and Lincoln counties.
The most common symptoms experienced by case-patients were nausea (92%), diarrhea (91%), and
vomiting (89%). Other symptoms included abdominal cramps (70%), fever (30%) and bloody diarrhea
(2%). Eighty-two percent of case-patients reported additional symptoms, including: dizziness, fatigue and
headache. The majority of case-patients did not seek medical care (85%); 6 (12%) visited their physician
and 2 (4%) went to the emergency room. No patients were hospitalized. Six (11%) case-patients noted
that members of their family had been sick prior to their symptoms and 21 (40%) noted that other family
members became sick after their own symptoms started.
Clinical laboratory results
Catawba County Public Health distributed stool collection kits to 9 case-patients. Eight (88%) stool
specimens were submitted to the North Carolina State Laboratory of Public Health for testing. Four (50%)
of these 8 specimens were positive for norovirus by PCR, 3 (38%) were negative and 1 (13%) was
indeterminate. One norovirus positive specimen was collected from a restaurant food handler; the
remaining positive specimens were from restaurant patrons.
Environmental Investigation results
Food Preparation
The majority of food preparation and cooking occurs by non-wait staff in the kitchen. However, the salad
plates, three salad dressings and beverages are prepared for each patron by the wait-staff. The raw
ingredients for the salad are prepared each morning and then placed in a salad bar. When a patron
orders a salad, a member of the wait staff uses tongs at the salad bar to prepare each individual plate.
During the site visit, the tongs were observed to be laying in the lettuce bin on the salad bar. The wait-
staff had to touch the lettuce bare-handed in order to lift the tongs up for use.
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Three salad dressings are prepared in house. These are made in batches by the wait-staff, stored in
pitchers, and then poured into containers on the salad bar when they get low. These are normally used
within 1–3 days.
The ice scoop for beverages was observed sitting directly on top of the ice maker. There was no
designated tray or bin for storage. The ice scoop did not have a sleeve or protective cuff to prevent hand
contact with the ice bin.
Employee illness
Eight staff members were identified who worked January 12–January 20 while experiencing
gastrointestinal symptoms.
Case Control Study
We enrolled 55 case-patients and 56 control subjects; 45 cases and 45 control subjects in Group 1
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(January 13–15 exposure) and 10 cases and 11 controls in Group 2 (January 19–20 exposure). Control
subjects did not differ significantly from cases on sex, age, county of residence, or type of meal (dinner
vs. lunch or dine-in vs. take-out) (Table 1). None of the personal hygiene behaviors assessed were
significantly associated with illness.
Fifty-six food and beverage items were assessed. Salad was the only exposure significantly associated
with illness, with an odds ratio of 18.7 (95% CI: 7.0–50.4.) When stratified by date grouping, the
association was strongest for Group 1 with an odds ratio of 27.3 (95% CI: 8.5–87.7). Although exposure
to salads was also more common among case-patients than control subjects in Group 2 (50% vs. 18%),
this association was not statistically significant with an odds ratio of 4.5 (95% CI: 0.6–32.3). (Table 2)
Conclusions
One hundred and sixty six individuals reported becoming ill with gastrointestinal symptoms after
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eating at the Harbor Inn Seafood Restaurant in Hickory, North Carolina between January 13
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and January 29, 2012.
Laboratory testing and clinical characteristics of illness were consistent with norovirus infection.
Salad was significantly associated with illness among patrons who ate at the restaurant during
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January 13–15. Cases were 27 times more likely to eat salad than controls.
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Food handlers working while ill and bare-hand contact with uncooked foods during salad
preparation might have facilitated contamination of salads.
No single exposure was significantly associated with illness among patrons who ate at the
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restaurant during January 19–20, suggesting that norovirus contamination may have been
widespread at that point or that there was insufficient power to detect a difference.
Limitations
It is likely that not all cases associated with this outbreak were reported to public health, so the case
count presented here may underrepresent the true magnitude of the outbreak. Conversely, some cases
attributed to this outbreak may have been the result of other community exposures since norovirus was
widely circulating in North Carolina during the outbreak period.
Laboratory evidence of norovirus was only found in 4/8 stool samples. It is possible that another pathogen
played a role in this outbreak. However, the incubation period, symptoms, and communicability apparent
during this outbreak are most consistent with norovirus. (1)
No trace back of food items used in salad preparation was performed. Although contamination by ill food
handlers is more likely, it is possible that contamination of the salad ingredients occurred prior to their
arrival in the restaurant.
Recommendations
The following recommendations were made to restaurant management during the investigation:
1. All ill staff should be excluded from work until 48 hours after the resolution of symptoms.
2. Restaurant staff and management should be educated on good hygiene practices, including
proper hand washing, glove use, and staying home while ill.
3. Disinfection of all surfaces should be conducted nightly, using 250-500ppb bleach solution.
4. All items that cannot be disinfected properly should be discarded.
5. Bare hand contact should not occur with ready to eat foods.
6. Utensils and tongs should be stored in designated containers separate from food.
(Appendix C)
CCPH took the following actions to further protect the Catawba County community:
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1. Norovirus guidelines were distributed to local schools, daycares and long term care facilities. The
guidelines provided an overview of norovirus symptoms, suggestions for reducing transmission,
and reinforced the importance of exclusionary policies and cohorting.
2. Area restaurants were given information about norovirus, as well as a reminder to follow best
practice guidelines to protect food products from contamination.
Discussion
CCPH and NCDPH worked collaboratively on this outbreak. Excellent communication between public
health and restaurant management facilitated the rapid identification of a source, and allowed CCPH to
implement protective health measures immediately. This outbreak serves as a model for local and state
cooperation, stakeholder communication, and high quality, efficient investigative technique.
North Carolina currently follows a food code derived from past FDA Food Codes and adapted to account
for North Carolina’s own initiatives. This year, North Carolina will adopt the 2009 FDA Food Code,
customized to reflect the North Carolina grading and enforcement system. (2) This will be the first time
since 1976 that a full FDA food code has been adopted in North Carolina. One notable change related to
food safety is increased vigilance when handling ready to eat foods. Bare hand contact is prohibited and
utensils are to be stored in a clean location with the handles away from food. (2)
The restaurant associated norovirus outbreak in Catawba County was associated with consumption of
salads that were likely contaminated by one or more ill food handlers. This scenario illustrates the
importance of adopting the 2009 FDA Food Code, which prohibits bare hand contact with ready-to-eat
foods and storage of utensils in food products. The purpose of this increased regulation is to help prevent
food contamination and subsequent illness.
This outbreak also highlights the importance of good hand hygiene among food handlers, exclusionary
work policies for ill workers, and compliance with routine disinfection procedures.
Works Cited
1. CDC, Updated Norovirus Outbreak Management and Disease Prevention Guidelines. MMWR
2011;60(RR03);1-15.
2. FDA, FDA 2009 Food Code.
http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/default.htm
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Acknowledgements
We would like to acknowledge the following groups for their assistance during this investigation:
Catawba County Public Health, North Carolina State Laboratory of Public Health and the North Carolina
Division of Public Health.
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Tables and Figures
Figure 1. Control Selection Process
Names Obtained
from Credit Card
Receipts
Internet search
engines used to
find contact
information
212 Possible Control
Subjects Identified
41 excluded
87 excluded
Incorrect or
No answer
disconnected
after 3 attempts
phone number
84
Contacted
Successfully
28 excluded
Did not eat at restaurant (9)
Refused interview (1)
Wrong exposure date (4)
Experienced symptoms (11)
Extra controls (3)
56
Enrolled and
Interviewed
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Figure 2. Number of Cases by Date of Restaurant Visit.
Date Patrons Ate at the Restaurant
80
70
60
50
Cases (#)
40
30
20
10
0
1/10/20121/11/20121/12/20121/13/20121/14/20121/15/20121/16/20121/17/20121/18/20121/19/20121/20/20121/21/20121/22/20121/23/20121/24/20121/25/2012
Exposure Date
Figure 3. Number of Cases by Date of Symptom Onset
Epi Curve
60
50
40
Cases (#)
30
20
10
0
1/10/20121/11/20121/12/20121/13/20121/14/20121/15/20121/16/20121/17/20121/18/20121/19/20121/20/20121/21/20121/22/20121/23/20121/24/20121/25/20121/26/20121/27/2012
Onset Date
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Table 1. Demographics of Case-Patients and Control Subjects, Stratified by Date Grouping
Group 1 Group 2 Total
Cases Controls Cases Controls Cases Controls
(n=45) (n=45) (n=10) (n=11) (n=55) (n=56)
n(%)n(%)n(%)n(%)n(%)n(%)
1
Female sex
29 (64%) 16 (36%) 5 (50%) 4 (36%) 34 (62%) 20 (36%)
Median age
2
(range)
62 (31–79) 62 (8–85) 56 (9–75) 59 (56–71) 61 (9–79) 61 (8–85)
1,2
Sex missing for 1 case-patient; age missing for 3 control-subjects
Table 2. Select Food and Beverage Results
(The five exposures that accounted for the highest percentage of cases were chosen for each group.)
Cases Controls
Food n % n % OR 95% CI
Total
Hushpuppies 53 95 54 96 0.7 0.1 - 4.1
Ice in drink 44 79 40 71 1.5 0.6 - 3.4
Salads 41 73 7 13 18.7 7.0 - 50.4
Baked potatoes 37 67 32 57 1.3 0.6 - 2.8
Water 31 55 26 46 1.3 0.6 - 2.8
Group 1
Hushpuppies 42 93 43 96 0.7 0.1 - 4.1
Ice in drink 37 82 31 69 2.1 0.8 - 5.6
Salads 35 78 5 11 27.3 8.5 - 87.7
Baked potatoes 32 71 25 58 1.8 0.7 - 4.3
Water 24 53 20 47 1.3 0.6 - 3.0
Group 2
Hushpuppies 10 100 11 100 -- --
Ice in drink 6 60 9 82 0.3 0.0 - 2.4
Salads 5 50 2 18 4.5 0.6 - 32.3
Baked potatoes 5 50 7 70 0.4 0.1 - 2.7
Water 7 70 6 55 1.9 0.3 - 11.8
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Appendix A: Catawba County Talking Points
Catawba County Public Health
Norovirus Outbreak Associated with Harbor Inn Seafood
Talking Points
What do we know already about this outbreak?
Many individuals became ill with vomiting and diarrhea after eating at the Harbor Inn Seafood
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restaurant in Catawba County. Most ill individuals visited the restaurant between January 13
st
and January 21. Laboratory tests have identified norovirus as the cause of the illness.
What are we doing about this outbreak?
Catawba County Public Health has already been working closely with the Harbor Inn restaurant
to help prevent and control the further spread of the virus. The Harbor Inn has been using
disinfectants known to kill norovirus. The next step is to perform a study to try and identify the
source of the illness.
Why are we conducting a case control study for this outbreak?
Catawba County Public Health has identified 131 individuals who became ill after eating at
Harbor Inn Seafood. When this many individuals become ill, it is the responsibility of public
health to conduct a thorough investigation and attempt to identify the vehicle responsible.
Were any wait staff sick?
Yes, but over hundred more individuals were also sick, which is why we are further looking into
the cause in this norovirus case.
What type of study is the Health Department doing?
Catawba County Public Health is performing a case control study, which compares people who
became ill (“cases”) and people who did not become ill (“controls.”) We interview both groups
with the same set of questions, and then look for differences to see if there is a particular food
item that ill individuals ate more often than healthy individuals. This can help us identify the
source.
Will the case control study identify a particular staff member as the source?
No, the purpose of the case control study is not to identify a specific person – staff or patron –
who contributed to the outbreak. The purpose is to identify a food item or activity that may
have been contaminated with norovirus. By identifying a specific food item, we can better
prevent norovirus outbreaks in the future.
If norovirus is such a common cause of outbreaks, why are you doing this study at the Harbor
Inn? North Carolina has already had many norovirus outbreaks this winter. Most of these
outbreaks have been in assisted living facilities, nursing homes, or daycares. We know how
norovirus is spread in these environments and how to control and prevent it. This outbreak is
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associated with a restaurant and caused more than one hundred illnesses; this makes us
concerned that a particular food product could have contributed to the outbreak. If we can
identify that food product, then we can use that information to help prevent future outbreaks.
How soon will we know what caused the outbreak?
A case control study can take several weeks, as we identify people to interview, conduct the
interviews, gather our data, and then analyze the data. We will keep the media and public
informed of our progress. It is also important to keep in mind that we may not be able to
identify a specific source.
What is norovirus?
Norovirus is a common cause of gastrointestinal illness. It causes vomiting, watery diarrhea and
abdominal cramps. Norovirus is found in the vomit and stool of infected people. It is highly
contagious and is transmitted either by direct person-to-person spread or by touching, eating
or drinking something that has been contaminated with the virus.
Individuals usually become ill within 12 to 48 hours of coming in contact with the virus.
Symptoms usually last 1-3 days. Some individuals may require intravenous fluids to prevent
dehydration during their illness. Most individuals make a complete recovery with no long-term
health effects. Washing your hands carefully with soap and water is the best way to avoid
getting sick. Alcohol-based hand sanitizers are not as effective against norovirus.
Key Messages:
1. Catawba County Public Health and the North Carolina Division of Public Health are working
with the Harbor Inn Seafood restaurant to prevent and control the spread of norovirus.
2. Catawba County Public Health and the North Carolina Division of Public Health are working
with the Harbor Inn Seafood restaurant to find the cause of the outbreak by conducting a case
control study.
3. Our case control study may not be able to identify a food source.
4. The results may not be available for several weeks.
5. If you become ill after eating at the Harbor Inn Seafood restaurant between January 13 and
21, please contact the Catawba County Public Health and seek care with your medical provider.
Further Resources and Information about Norovirus:
CDC Norovirus Homepage:
http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus.htm
North Carolina Division of Public Health Norovirus Homepage:
http://epi.publichealth.nc.gov/cd/diseases/norovirus.html
North Carolina Division of Public Health Norovirus Outbreaks:
http://epi.publichealth.nc.gov/cd/norovirus/outbreaks.html
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Appendix B: Questionnaire
Catawba County Public Health
Foodborne Illness Investigation Packet
Instructions:
This questionnaire is to be administered to patrons of the Harbor Inn Seafood Restaurant as part
of a case-control study. It is intended to identify and interview both case-patients and controls.
We will be taking a sample of case-patients from two date ranges to interview with our
questionnaire.
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40 case-patients from January 13 – January 15
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10 case-patients from January 19 – 20
We will attempt to enroll one control for each case-patient, and will match them by restaurant
visit date.
Each packet has the name and phone number of one patron identified from credit card receipts,
health department reports, or well meal companions. At least three attempts should be made to
interview each patron. If the patrons cannot be contacted, please contact Stephanie Griese for
additional names and phone numbers. The names of other persons who ate at the Harbor Inn
Seafood Restaurant with the cardholder on the same date should be recorded on the last page.
These persons should be interviewed during the same call if available; if they are willing to be
interviewed but not available, a specific callback time should be determined.
Each case-patient and control will have his or her own ID number. Please circle “Case” or
“Control” on the top of each page, and write in the case ID number. Thank you for your
participation! Please contact me with any questions.
Sincerely,
Stephanie Griese, MD, MPH
Epidemic Intelligence Service Officer
North Carolina Division of Public Health
XXX-XXX-XXXX (mobile)
XXX-XXX-XXXX (office)
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Case Definitions
Case
A patron or staff member reporting acute onset of nausea, vomiting, and/or diarrhea (3 or more
loose stools within a 24 hour period) within 48 hours after visiting the Harbor Inn Seafood
Restaurant during the time period 1/13/2012 through 1/21/2012.
Control
A person who ate at the Harbor Inn Seafood Restaurant between 1/13/2012 and 1/21/2012 and
did not experience any symptoms of gastrointestinal illness during the 2-10 days afterwards.
Interview Key:
Y = Yes
N = No
DK = Don’t Know
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Catawba County Norovirus Outbreak: Call Log
Case patient ID:_________
If control, matched case-patient ID: _________
Meal date: ___ / ___ / _____
Patron name: ___________________________
Phone Number: _________________________
st
1 Attempt:
Date/Time: ______________________
Result: □ Interview completed
□ Refused
□ No answer
□ Call back (date/time): _________________________________________
nd
2 Attempt:
Date/Time: ______________________
Result: □ Interview completed
□ Refused
□ No answer
□ Call back (date/time): _________________________________________
rd
3 Attempt:
Date/Time: ______________________
Result: □ Interview completed
□ Refused
□ No answer
□ Call back (date/time): _________________________________________
DISPOSITION:
□ Interview completed
□ Wrong number
□ Refused
□ No answer
□ Did not visit restaurant
□ Controls only: Became ill within 48 hours of visiting the restaurant
□ Controls only: Became ill more than 48 hours after visiting the restaurant
□ Other: __________________________________________________________________
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Catawba County Public Health
Foodborne Illness Investigation Form
Hello, my name is _______ and I am calling on behalf of (Catawba County Public Health or
North Carolina Division of Public Health). I’m contacting you because we’re investigating
recent illnesses in people who have eaten at Harbor Inn Seafood. In order to determine what may
have made people sick, we need to gather information from individuals who were sick and
individuals who were not sick. All information will be kept confidential and will only be used to
help with this investigation. Is this a good time and would you be willing to help us by
responding to questions about illness and food consumption? It takes about 15 minutes to go
over these questions.
If yes, continue to Section I.
If no, thank them for their time and end the call.
I. General Information
Date of Interview_______________ Interviewer __________________________
Did you visit or eat food from Harbor Inn Seafood between January 13 – 21, 2012? Yes
No
If yes, what date: ____________
If no, thank them for their time and end the call.
Did you eat (circle one): Lunch Dinner Other: _______
What time did you eat? _____________ AM/ PM (circle)
Did you dine in or take out (circle one)? In Restaurant Take Out
Name___________________________________
County of Residence:______________________
Best contact number___________________________
Date of birth_______________ Sex (circle): Male Female
II. Case Ascertainment Questions
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Have you been sick any time since Friday, January 13? Y N
1.
()
If No, skip to section III for food item information
Which of the following symptoms did you have:
2. (circle all that apply) (diarrhea is 3 or
more episodes of loose stools in a 24-hour period)
Nausea Y N DK
Vomiting Y N DK
Diarrhea Y N DK
Bloody diarrhea Y N DK
Abdominal cramps Y N DK
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Fever Y N DK
Other: Y N DK_______
_________________
What symptom did you experience first? (Choose one.) Vomiting Diarrhea Neither
Illness onset date_____________ Illness onset time ___________AM/PM (provide approximate
time)
Are you still experiencing vomiting or diarrhea?
3. Y N (circle) Vomiting Diarrhea
Both
Last date of vomiting________________ Last time of vomiting_________________AM/PM
Last date of diarrhea ________________ Last time of diarrhea__________________AM/PM
Did you see a doctor for this illness?
4. (Circle all that apply)
No medical care Physician visit Emergency Room Hospital
Other______________
Were you admitted to the hospital for more than 24 hours? Y N
Doctor/Hospital/Clinic
Name_______________________________________________________
Did you get any stool or blood testing during your illness?
5. Y N (If yes, circle) Stool
Blood
Do you know you results (if yes, please
explain)___________________________________________
Do you have any existing medical problems, such as diabetes, cancer, or respiratory
6.
disease
?
Y N DK
(If yes, please
describe)_________________________________________________________________
Do you know anyone else who was sick with similar symptoms during the week before
7.
your illness?
Y N DK
(Please explain and identify these persons, get contact information and date of onset of
symptoms)
______________________________________________________________________________
_________
Do you know anyone else who was sick with similar symptoms during the week after
8.
your illness?
Y N DK
(Please explain and identify these persons, get contact information and date of onset of
symptoms)
______________________________________________________________________________
_________
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III. Food and Beverages
In order for us to determine what may have made people sick, and how we can help prevent
future outbreaks like this in the future, I would like to ask you some questions about what you
ate and drank. I will ask you a series of items from the menu at the restaurant, and I’d like you to
tell me whether you ate or tasted each item, either from your plate or someone else’s plate at
your table.
Did you eat any appetizers?
1. Y N DK
If yes, please go through the following and place a check in the appropriate box:
Appetizers Yes No Don’t Know
Clam Chowder
Oyster Stew
Onion Rings
Shrimp Cocktail
Oyster Cocktail
Cheese Sticks
Fried Mushrooms
Crab Legs
Did you eat any salads?
2. Y N DK
If yes, please go through the following and place a check in the appropriate box:
Salads Yes No Don’t Know
House Salad
Tuna Salad Cold Plate
Shrimp Salad Cold Plate
Cottage Cheese and Fruit
Please circle the dressing you used on your salad:
Thousand Island Blue Cheese Ranch Other:_____________
Now I’m going to ask you about the seafood, steak and chicken that you may have eaten.
3.
(Go through each item on the list for all patrons and check the appropriate box.)
Seafood Yes No Don’t Know
Flounder
Shrimp
Catfish
Perch
Oysters
Location: 225 N. McDowell Street Raleigh, N.C. 27603
An Equal Opportunity Employer
20
Whiting
Perch
Crab
Alaskan White Fish
Clams
Scallops
Cod
Tilapia
Salmon
Tuna
Red Snapper
Swordfish
Steak Yes No Don’t Know
Ribeye
New York Strip Steak
Sirloin
Ground Sirloin
Hamburger
Sliced Steak
Chicken Yes No Don’t Know
Grilled Chicken
Baked Chicken
Chicken Fingers
Condiments Yes No Don’t
Know
Ketchup
Cocktail Sauce
Tartar Sauce
Hot Sauce
Lettuce (on a sandwich or with your meal)
Tomato (on a sandwich or with your meal)
Other: ____________________
Did you eat any of the following side items?
4.
Please go through the following and place a check in the appropriate box:
Side Items Yes No Don’t Know
Coleslaw
Hush Puppies
Baked Potato
French Fries
Location: 225 N. McDowell Street Raleigh, N.C. 27603
An Equal Opportunity Employer
21
Cottage Cheese
Bread
2. Please indicate which beverages you drank during your visit to Harbor Inn Seafood:
(Go through each item on the list for all patrons and check the appropriate box.)
Beverage Yes No Don’t Know
Did you have ice in your beverage?
Iced Tea
Soft Drink
Coffee
Milk
Water
Was there a food or beverage that you ate or drank that I did not ask you about?
Y
N DK
If yes, please
describe_________________________________________________________________
Was there anything unusual about any of the foods or beverages?
Y
N DK
If yes, please
describe_________________________________________________________________
______________________________________________________________________________
_____
______________________________________________________________________________
_____
IV. Personal Hygiene and Infection Control
Did you wash your hands before eating?
1. Y N DK
If yes, how did you wash your hands? (Circle) Soap and water Hand
sanitizer
Did you share your cup or utensils with anyone else?
2. Y N DK
Did you visit the restroom while dining at the Harbor Inn?
3. Y N DK
If yes, did you wash your hands after using the restroom? Y N DK
If yes, how did you wash your hands? (Circle) Soap and water Hand
sanitizer
V. Other Information
Is there anything else you would like to tell me about your meal?
1. Y N
DK
Location: 225 N. McDowell Street Raleigh, N.C. 27603
An Equal Opportunity Employer
22
If yes, please
describe:______________________________________________________________________
______________________________________________________________________________
__________
______________________________________________________________________________
__________
______________________________________________________________________________
__________
VI . Closing
“That’s the end of the questionnaire. Were there other members of your household or
other people who ate at Harbor Inn Seafood restaurant with you on that day?”
Yes / No
If “Yes”, record names on the last page and interview if available
If “No”, continue
“Do you have any concerns or information you think could be helpful for this
investigation?”
If so, please record below. If not:
“Thank you very much for your time. If you think of other questions about this outbreak
or questionnaire, please call the Catawba County Public Health at828-695-5800”.
Additional questions / comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Location: 225 N. McDowell Street Raleigh, N.C. 27603
An Equal Opportunity Employer
23
Other Meal Companions
List others who ate with patron at Harbor Inn Seafood restaurant on the same date:
Name Phone <18 years old? Sick after meal? Best time to call
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________
Thank you for your time! This information will be very helpful for us in our investigation.
Location: 225 N. McDowell Street Raleigh, N.C. 27603
An Equal Opportunity Employer
24
Appendix C: Catawba County Public Health Recommendations
Catawba County Public Health Recommendations
Harbor Inn Seafood Restaurant
Provided Verbally: January 19—26, 2012
1)Install two extra hand sinks - one by the salad prep table and one in the waitress area.
2)All employees should wear gloves, including cooks and wait staff. Encourage the wait staff to
wash hands in between food preparation for each customer. Consider wearing gloves when
busing tables.
3)Use mixed bleach solution at the end of each night on all surfaces. The chlorine bleach/water
solution should remain on the surface for ten minutes and then rinsed with clean water.
a.For stainless steel, food/mouth contact items: 1 tablespoon of bleach in 1 gallon of
water (1:256 or 200 ppm)
b.For non-porous surfaces such as tile floors, counter-tops, sinks, etc.: a third (1/3) cup of
bleach in 1 gallon of water (1:50 or 1000 ppm).
c.For porous surfaces such as wooden floors: one and two-thirds (1 2/3) cups of bleach in
1 gallon of water (1:10 or 5000 ppm)
4)Put tongs in containers at the salad prep station so that they will not slide down into the lettuce
and salad fixings or be placed directly in it where the hand contact end would touch those items.
5)Have wait staff wear gloves when cutting lemons and place them in a container. Remove
lemons with tongs.
6)Limit bare hand contact "on ready to eat foods."
7)Consider changing the fountain drink machine levers to push buttons, to limit possibility of
contamination if cups are refilled. Recommend using a new cup with each refill.
8)Create a chart where employees record ill symptoms in themselves or their family prior to the
start of the work shift.
9)Have wait staff wear gloves when they wrap silverware.
10)As always WASH HANDS.
Location: 225 N. McDowell Street Raleigh, N.C. 27603
An Equal Opportunity Employer