Page 127 - Journal of Special Operations Medicine - Fall 2017

An Ongoing Series

An Outbreak Investigation Report
and Lessons Learned by Multinational Coalition Forces

October 2016, Baghdad, Iraq

Stanley A. Gorzelnik, BS, EIT *; Laura N. Kephart ; Wendy E. Miklos, MD, MPH 3
2
1

ABSTRACT
Background: Public health personnel from the 28th Combat possible because of technical constraints. A preponderance of
Support Hospital in Baghdad, Iraq, conducted an outbreak in- evidence implicated E. coli as the most probable etiological
vestigation in response to many local cases of gastrointestinal agent; salad ingredients served as the vehicle of transmission at
(GI) illness presenting to U.S. medical facilities. The investiga- the only communal dining source: the compound dining facil-
tion was conducted to identify the source of the illness, assess ity. All implicated salad ingredients originated from the same
the extent of cases, and make recommendations to prevent source of production.
similar outbreaks. Methods and Materials: For this retro-
spective cohort study, medical records and patient outbreak Mitigation strategies to reduce the probability of similar out-
questionnaires were reviewed. A patient case, relative to the breaks include purchasing food solely from vendors approved
outbreak, was defined as any person who had developed a GI by the Defense Logistics Agency (DLA), purchasing food from
illness and presented for medical evaluation to either sick call countries whose domestic food standards rival those of the
or an emergency service at a diplomatic or military medical fa- United States, or thoroughly cooking all foods, including fruits
cility in Baghdad from 30 September to 12 October 2016. Re- and vegetables.
sults: A total of 123 people met the case definition. The most
common presenting symptom was diarrhea (91% to 96% of Background
cases). Other symptoms included abdominal cramps, fatigue, This study presented several unique features in comparison
and headache. Most cases were military personnel (n =100). with a typical outbreak study. For example, eating at a single,
Salad was significantly associated with GI illness (70% of re- centralized dining facility for all meals is a characteristic of the
spondents). Five salad ingredients had significantly elevated deployed environment in contrast to the wide range and avail-
levels of Escherichia coli. Conclusion: Mitigation strategies to ability of food in the civilian setting. Also, military and U.S.
reduce the probability of similar outbreaks include purchasing Department of State (DoS) personnel had ready access to their
food solely from approved vendors or thoroughly cooking all respective healthcare facilities. This differs from many civilian
foods, including fruits and vegetables. healthcare structures that often comprise a variety of provid-
ers, clinics, and emergency services. Moreover, the relatively
Keywords: gastrointestinal illness; Escherichia coli; public small, closed, and geographically constrained population of
health interest enabled rapid reporting and quick recognition of the
illness. In contrast, civilian medical providers often use differ-
ent methods of health reporting, and public health centers that
Introduction receive the information may differ by geographical location
and in capabilities. Aside from similar deployed environments
An outbreak of GI illness associated with contaminated food or, perhaps, prison dining facilities, this case study provided a
occurred on a diplomatic compound in Baghdad, Iraq, from 30 unique setting.
September to 12 October 2016. All time, temperature, prepa-
ration, and hygienic procedures for food storage, preparation, Of additional importance, the dining facility implicated in our
and serving were followed. Hygienic practices and living con- study was located on a DoS compound. The DoS differs from
ditions of the camp were not exacerbating or contributing fac- the U.S. Department of Defense (DoD) in several important
tors. Phylogenetic analysis to compare clinical strains was not aspects pertinent to the outbreak and case study. DoD units

*Correspondence to stanley.a.gorzelnik.mil@mail.mil
1 CPT Gorzelnik is a preventive medicine officer and the senior engineer for health risk management in Public Health Command Europe. SSG
2
3
Kephart is a preventive medicine specialist with 10 years of experience in the U.S. Army. LTC Miklos is the chief of Preventive & Occupational
Medicine and the installation Public Health Emergency Officer at Ft Gordon, GA.
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