Oklahoma E. coli O111 Outbreak: A Final Report

The Oklahoma State Department of Health has issued a final report on the E. coli O111 outbreak that struck the northeastern part of the state this past summer. 

The outbreak sickened 341 people, including 56 children (under 18 years old). The youngest victim was 3 months; the oldest was 88 years. Seventy-two (21%) of the victims were hospitalized, and one person died as a result of his infection.

The outbreak was traced to the Country Cottage restaurant in Locust Grove, OK, and included individuals who patronized the restaurant between August 15 and August 24th.

The outbreak investigation was unable to trace the source of the pathogen. Neither environmental sampling of working surfaces in the restaurant, nor water samples from the well on the property, nor samples of the restaurant's food supplies yielded E. coli O111. And exhaustive interviews of victims and healthy restaurant patrons failed to point to a specific food item. The conclusion?

"While no single food item was found to be the source of illness at the restaurant, the Oklahoma State Department of Health believes several different foods became contaminated with the E. coli 0111 bacteria, leading to exposure of restaurant customers Aug. 15-24."

The Country Cottage has been given permission to reopen, following a successful inspection on November 12th and after meeting a series of conditions that included, among others:

• disconnecting the on-site well from the restaurant's water supply;
  
• not permitting employees with diarrhea to work in the restaurant;
  
• installing additional hand-washing sinks;
  
• ensuring that all bathrooms are operational and monitoring employee hand-washing;
  
• requiring each employee to complete a food handler's class; and
  
• requiring the kitchen manager and owner to obtain a Food Service Manager's Certificate.
  

The tone and content of the list of requirements for reopening the restaurant, together with the DOH conclusion that "... several different foods became contaminated..." leads me to believe that an infected food handler was the source of the contamination. Inattention to appropriate food handling and sanitation practices, and poor temperature control – as detected in an earlier inspection – allowed the contamination to spread. Inadequate cleaning and sanitation of food contact surfaces and utensils enabled the pathogen to linger. 

This, of course, is pure speculation. I have no proof. But nothing else makes sense.

Oklahoma: Closing The Books On An Outbreak

The Oklahoma State Department of Health reported today that the E. coli O111 outbreak that killed one person, sickened at least 314, and caused a popular buffet restaurant to close, is officially over. At least 72 of the outbreak victims were hospitalized; 17 of them required dialysis treatment.

No one has fallen ill since September 6th, according to the state. And that means we are now outside the expected maximum incubation period.

In a herculean effort to determine the source of the outbreak, OSDH, aided by CDC and local health officials, interviewed 1,843 people. The results of those interviews are still being collated and analyzed. But the odds that these interviews will yield a conclusive answer are vanishingly slender.

Today's report made no mention of the outbreak cluster associated with the a Church event catered by the Country Cottage restaurant. Implicitly, however, OSDH did not exclude this cluster. The report states:

"All known cases had association with the Country Cottage restaurant in Locust Grove, OK. The spread of E. coli O111 in this outbreak was directly related to the restaurant."

"Association" can include direct association (worked at or ate at the restaurant), indirect association (ate a meal at a venue catered by the restaurant), or secondary infection (became ill as a result of contact with an infected individual).

 

There is no indication when – or if – the restaurant will reopen. Nor do we know when – or if – OSDH will reveal the final results of their outbreak investigation.

Oklahoma E. coli O111 Investigation: Last Unturned Stone

State and federal health officials who are investigating the E. coli O111 outbreak that has sickened at least 291 people have almost run out of leads. The Oklahoma State Department of Health and the CDC have explored all the usual avenues of investigation, without success.

• Well water: No E. coli O111.
  
• Restaurant food samples: No E. coli O111.
  
• Restaurant food preparation/service surface swabs: No E. coli O111.
  
• Interview of victims and healthy restaurant patrons: No clear-cut indication of contamination source.
  
• Interview and testing of employees: No E. coli O111 found, although several employees reported being ill.
  

Investigators are in the process of turning over the last stone. A separate cluster of illnesses recently came to light, involving attendees at a Ladies' Tea held August 16th at the Bethany Free Will Baptist Church in Broken Arrow. The event was catered by the Country Cottage restaurant. At least 30 of the 250 participants complained of gastroenteritis. 

OSDH and CDC investigators are interviewing attendees of the Ladies' Tea in the hopes that this will help to reveal the source of the Country Cottage outbreak. Apparently, the range of food items served at the Tea was more limited that what was available at the restaurant during the August 15-17 weekend – the time frame when most of the outbreak victims ate at the Country Cottage.

It's not surprising that investigators are coming up with empty hands. Water, swab, and food samples were only taken several days after the weekend when the contamination is thought to have occurred. Persons who have suffered an infection with a gastrointestinal pathogen often will not continue to excrete the pathogen in their stools. And the nature of the restaurant's format – a large buffet – makes it very difficult for patrons to recall exactly what they did, or didn't eat.

Unless the Ladies' Tea produces a miracle, this outbreak will likely be added to the "cold case" list of unsolved epidemiological mysteries.

Oklahoma E. coli Investigation Running Out Of Gas

Oklahoma's State Department of Health reported today that none of the food samples submitted for lab analysis yielded E. coli O111. 

While waiting for the lab results, investigators continued with their interviews yesterday, and now have spoken with more than 1,500 restaurant patrons. OSDH continues to beat the bushes in an effort to uncover additional people to interview, but the state is probably coming face-to-face with the law of diminishing returns.

The extensive series of interviews has turned up additional cases of E. coli O111 gastroenteritis. OSDH now says that at least 248 people fell victim to the outbreak – 202 adults and 46 children. Sixty-four people were hospitalized, and 16 of them required dialysis. Nine of the dialysis patients were children.

In an interview yesterday, the State Epidemiologist, Dr. Kristy Bradley, spoke for the first time of the possibility that a restaurant employee might have been a carrier of the outbreak strain. According to Dr. Bradley, the Country Cottage employed 58 food handlers. 

We suggested several days ago that a human carrier might be the source of the outbreak. OSDH has been very forthcoming in discussing the number of interviews it is conducting, and releasing the negative lab results obtained from environmental and equipment swabs, food samples and well water. But Dr. Bradley has said nothing at all about the Department's investigation – if any – of restaurant employees.

Have we missed something?

Oklahoma E. coli O111: Interviews Uncover Additional Victims

Even when a food poisoning outbreak has been well publicized, some outbreak victims fall between the cracks. Oklahoma's intensive search for answers has uncovered 25 more cases of E. coli O111 gastroenteritis.

As of today, the Oklahoma State Department of Health reports that at least 231 people have been infected with E. coli O111 – including 185 adults and 43 children. At least 61 of the victims were hospitalized as a result of the severity of their symptoms; 16 required dialysis treatment. One person has died.

As part of their investigation into the source of the outbreak, the state submitted samples of well water, restaurant food, and environmental swabs of food preparation and serving surfaces for lab analysis. The water and swab samples did not uncover any traces of E. coli O111. Lab results on the food samples are not yet available.

Oklahoma investigators continue to ask everyone who ate at the Country Cottage restaurant during the period of August 15-17, and who has not yet been interviewed, to contact OSDH at 1-800-990-2769. 

Oklahoma Still Searching for Source of E. coli O111

The Oklahoma State Department of Health has received the results of its environmental swab samples. The state found no trace of E. coli O111 on any of the food preparation and serving surfaces at the Country Cottage restaurant.

Under normal circumstances, this would be good news. But in the context of the state's outbreak investigation, thought not unexpected, it is a disappointment. 

Investigators had hoped that their swab samples might yield a clue to the source of the pathogen that has sickened 206 residents of the northeastern part of Oklahoma and has killed one man. 

Now they must pin their hopes for an answer to the mystery on lab results from food samples, and on the statistical analysis of information obtained during interviews with restaurant patrons. Those interviews are continuing, with the assistance of CDC staff members who have joined the investigation team.

The state has been conscientious about issuing daily reports on the status of its investigation into this outbreak. Those reports, however, have been strangely silent about any interviews conducted with restaurant employees, or any lab tests of employee stool samples. Why?

OSDH continues to ask anyone who ate at the Country Cottage restaurant between August 15 and August 23 – and especially during the period of August 15-17 – and who has not yet been interviewed, to please contact the Department of Health, toll-free at 1-800-990-2769.

Oklahoma E. coli Outbreak: A Weekend of Activity

Oklahoma's State Department of Health (OSDH) investigators are still scratching their heads over the source of the E. coli O111 strain that has sickened 206 people and killed one. They may not have the answer yet, but one must give them an "E" for Effort.

According to the update posted late this afternoon on the OSDH website, state investigators – and three staff members from the CDC – spent their weekend interviewing 310 additional patrons of the Country Cottage, the restaurant that is at the epicenter of this outbreak. So far, 1,300 people have been interviewed in an attempt to differentiate between the menu or buffet items eaten by outbreak victims, and food eaten by those who did not become sick.

OSDH has not mentioned the total number of cases since the September 3rd update. We can probably assume this means that the number of new cases has dried up and that the final tally will remain at 206 victims, including one death.

The weekend's interviews generated the names of another 300 or so restaurant patrons. These individuals will be contacted and interviewed. CDC staff members are assisting both in the interviews and in the epidemiological analysis of the information obtained from restaurant patrons. The state also is waiting for lab results to arrive for environmental swabs and food samples taken at the restaurant.

There has been no official indication whether any employees of the Country Cottage restaurant became ill, or whether the employees were asked to submit a stool specimen for lab testing. It would be usual, in this type of investigation, to make such a request of all restaurant staff. But cooperation with this sort of request is voluntary.

If luck is on the side of the investigation team, the lab results and interviews will provide some answers. Otherwise, the source of this outbreak will remain a mystery forever.

Oklahoma Digs Deeper For Clues To Outbreak

The Oklahoma Department of Health announced today that it has invited representatives from the CDC's Foodborne and Diarrheal Diseases Branch to take part in its investigation of the Locust Grove E. coli O111 outbreak.

Investigators with the ODH also have decided to expand their epidemiological investigation by interviewing as many as 320 additional people who ate at the Country Cottage restaurant between August 15 and August 17, and who did not become ill. 

The state has taken this step because the information it has obtained so far is insufficient to finger a probable source for the E. coli O111. By comparing what was eaten by the 206 victims of the outbreak against what was eaten by those who remained unaffected, investigators hope to identify the item (or items) that made people ill.

If the additional interviews don't produce a clear-cut outcome, that could point to the possibility of a human carrier as the source of the outbreak. Obtaining stool samples from all employees for testing is routine in this type of investigation. But we've heard from two separate – though unconfirmed – sources that some of the employees may be reticent to provide samples, possibly due to immigration-related issues. 

The good news for citizens of Locust Grove is that no new cases have been added in the last two days to the total of 206 outbreak victims reported on September 3rd. If this trend continues, the ODH soon will be able to declare the outbreak over, even as the investigation into its source continues.

This declaration can't come soon enough for area residents, restaurants and other businesses. The town has suffered loss of business and even outright ostracism – a high school football team from the neighboring town of Wagoner backed out of a scheduled game out of concern that their players might become infected. 

In the absence of any unexpected developments, there will be no daily bulletins posted by the ODH over the weekend, even though the investigation will continue without interruption. Let's hope that Monday brings good news.

Oklahoma Still Investigating E. coli Outbreak

The state's Department of Health has conducted nearly 600 interviews so far – with 200 more still to come – in its investigation into the E. coli O111 outbreak that has been linked to the Country Cottage restaurant in Locust Grove. The town is situated in the northeastern part of Oklahoma, about 50 miles from Tulsa.

At this stage of the investigation, nearly two weeks after the last victim ate at the Country Cottage, the state is fairly certain of the following:

• The E. coli that has sickened more than 200 people did not come from the well located on the restaurant property;
  
• No other restaurants or food sources appear to have been involved in the outbreak; and
  
• Most of the victims ate at the Country Cottage restaurant between August 15th and August 23rd.   
  

The most probable sources of this rare (for the United States) strain of E. coli are either a food that was prepared and served exclusively at the restaurant or a human carrier – perhaps someone who had traveled recently outside the United States. Since the Country Cottage offers a buffet, the carrier could have been either a restaurant worker or a customer. The one-week window would suggest a worker, unless management was very lax in its sanitation routine.

Country Cottage was inspected under Oklahoma's food service establishment inspection program on August 23rd. The restaurant was cited for several violations, including two critical holding temperature violations, either of which could have contributed to this outbreak. These were described in the inspection report, available on-line, as:

• Cold Hold (41/45 F)
  
• Hot Hold (140 F)/Time Control
  

Attention to correct holding and display temperatures is fundamental. Neglecting to do so is unpardonable. Holding food for any length of time at temperatures between 45ºF and 140ºF is a recipe for an outbreak. 

At nearly two weeks after the last theoretical exposure date, we are nearing the outer limits of the incubation period for this type of E. coli infection. The outbreak is unlikely to grow much larger. And that's good news for Locust Grove. The town will survive.

Whether, and in what form, the Country Cottage restaurant will survive is another story.

Oklahoma Update

There's very little new to report on the northeast Oklahoma E. coli O111 outbreak. According to today's Situation Update (issued by the Oklahoma Department of Health), there has been no change in the total number of confirmed victims; the tally stands at 206. 

Approximately 50 of the victims required hospitalization, and 27 remain in hospital as of today. One person has died. The Country Cottage restaurant remains closed, and the investigation – consisting of lab tests, restaurant inspection and patron interviews – is continuing. 

The state believes that this outbreak is restaurant-associated, and that the relatively small number of patients who did not eat at the Country Cottage were the victims of a secondary infection carried by a restaurant patron. 

The Department of Health is reminding everyone to pay special attention to personal hygiene – especially careful and thorough hand-washing – during and after this outbreak. Anyone who is experiencing symptoms of E. coli O111 infection, such as diarrhea, should not be preparing food, washing dishes, or cleaning up in the kitchen. 

Oklahoma Food Poisoning Outbreak - E. coli Suspected

The Oklahoma State Department of Health announced yesterday that it is looking into an outbreak of bloody diarrhea in the northeastern part of the state. One person has died so far, at least 14 people have been hospitalized, and more than 20 possible cases are under investigation. 

The victims are from Tulsa and several other communities in that part of the state, including Bixby, Pryor, Sand Springs, Locust Grove, Broken Arrow, Peggs and McAlester. Many of them ate at the Country Cottage restaurant in Locust Grove, OK.

Health authorities suspect E. coli, based on the range and severity of the symptoms – diarrhea, bloody diarrhea, vomiting, severe abdominal cramps, with little or no fever. There is not yet any confirmation of this hypothesis; lab tests are still in progress.

There is no firm evidence that the outbreak originated with the restaurant; an investigation is still in progress. The Country Cottage is reportedly "in compliance" with health standards, according to a report in the Tulsa World, and was given permission by health inspectors on Saturday to remain open. Nevertheless, the restaurant was planning to close today (Tuesday) in order to cooperate in the outbreak investigation.

Anyone who lives in or has recently visited the northeastern part of Oklahoma – including Tulsa – and who is experiencing any of the symptoms described above, should seek medical attention immediately. Whether this proves to be an outbreak of E. coli O157:H7 or some other gastrointestinal pathogen, it is a very dangerous microbe.