Page 131 - Journal of Special Operations Medicine - Fall 2017

Table 4 Polymerase Chain Reaction Results Identifying Microbiological Pathogens
Pathogen (n = 30 samples)
EAEC EPEC ETEC STEC EIEC Norovirus
No. 27 21 24 3 3 4
Percent of total 90 70 80 10 10 13
EAEC, enteroaggregative E. coli; EIEC, enteroinvasive E. coli; EPEC, enteropathogenic E. coli; ETEC, enterotoxigenic E. coli; STEC, Shiga
toxin–producing E. coli.
Table 5 Standard Polymerase Chain Reaction Panel Table 6 Summary of Food History a
Polymerase Chain Reactions Run Food Respondents Percent
Bacterial Salad 30 70
Campylobacter Eggs 29 67
Clostridium difficile A/B Chicken 26 60
Plesiomonas shigelloides Rice 13 30
Salmonella Oatmeal 11 26
Vibrio Vegetables 8 19
V. cholera Fruit 7 16
Yersinia enterocolitica a From 43 food histories completed.
Diarrheagenic Escherichia coli/Shigella
Enteroaggregative E. coli patients were treated with levofloxacin. Most patients were
Enteropathogenic E. coli not treated with antibiotics. Prochlorperazine and ondanse-
tron were prescribed as antiemetics for symptoms of nausea
Enteropathogenic E. coli lt/st or vomiting. Dicyclomine was given as an antispasmodic
Shiga-like toxin-producing E. coli stx1/stx2 (anticholinergic). An antacid (aluminum/magnesium/simethi-
E. coli O157 cone) was provided, as was the antidiarrheal medication
Shigella/enteroinvasive E. coli loperamide.
Parasites
Cryptosporidium Environmental Setting
Cyclospora cayetanensis The dining facility had been exceptionally clean and there had
Entamoeba histolytica been no open refuse or waste located nearby. A sewer system
Giardia lamblia drained the dining facility’s waste water and there had been
appropriate air gaps and backflow prevention devices to pre-
Viruses vent cross-contamination. There had been no noted pests or
Adenovirus F 40/41 stray animals near the facility. The facility had been in good
Astrovirus condition at all times, including during past surprise inspec-
Norovirus GI/GII tions. All employees were known to have washed their hands
Rotavirus A before starting their shifts, after using the toilet, and after each
Sapovirus break. Employees had not been allowed to eat, drink, spit,
lt, heat labile; st, heat stable; stx1, Shiga toxin 1; stx 2, Shiga toxin 2. chew gum, or use tobacco except in areas outside the din-
ing facility. All employees wore gloves, hair nets, and an ap-
The results from the investigation team are listed in Table 7 propriate uniform (including apron and hair net during food
and the units of measure are most probable number of coli- preparation and serving). In the past, minor infractions, such
form forming units per gram (MPN/g). All samples were taken as damaged weather stripping and malfunctioning air cur-
in accordance with ISO standards and analyzed against the tains, had led to an increase in houseflies. However, there had
Codex Alimentarius (Codex) standards. been no major contamination concerns previously as a result
1
of these observations. All time and temperature controls had
Coordination been followed. Vegetables and washes had all exceeded Tech-
2
The outbreak investigation was coordinated between the 28th nical Bulletin MED 530 (Tri-Service Food Code) standards.
Combat Support Hospital Preventive Medicine section, a sec- One example of exceeded standards was that vegetables had
tion from the 172nd Veterinarian Detachment, and the Com- been washed in a 200-ppm wash instead of the minimum re-
prehensive Health Services’ Public Health Section. Outlying quirement of a 100-ppm wash.
Role 1 clinics and the two hospitals provided staff for the out-
break questionnaires. The U.S. DoS contract manager for food Transportation vehicles for the dining facility food had been
services provided data for collection and analysis. checked for cleanliness and temperature with every shipment.
An internal, tamper-safe time–temperature monitor had accom-
Case Management panied food shipments from the warehouse to the compound
The patients with GI illness were generally handled at the until receipt. Upon receipt of shipment, food stuffs were imme-
Role 1 clinic level. Infrequently, the Role 1 provider directed diately downloaded into temperature-controlled storage.
patients to one of the hospitals (Role 3) for advanced case
management. However, no patients were admitted for inpa- All patrons had received training on personal hygiene and en-
tient care. The most symptomatic cases were managed with vironmental causes of foodborne diseases. The training was
orally dosed ciprofloxacin: either a 500mg twice daily course conducted before arrival on the compound as part of deploy-
for 3 days or a one-time dose regimen. A small subset of ment training or as stationing requirements to the area.

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