12:20 AM November 14th
The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the
alarm clock and stick it under your pillow. The phone rings again and you grope for the receiver.
The caller is your friend, Mustaf, who is the director of health for the city of El Guitar in the country of
Beanictacya. El Guitar is a coastal city on the Fishn Sea. Mustaf tells you that
there has been an
outbreak of a mysterious illness among the people of El Guitar. He asks you to come and help solve the
mystery. Your electronic plane ticket is available to you on your computer. It is a 15 hour flight to El Guitar.
Mustaf says that 232 people were hospitalized with severe headache, vomiting, abdominal pain and liver
failure. There is sudden onset and symptoms last four days. So far 27 of the 232 people have died. The
illness has been more severe in men than women or children. All of the deaths have been men between the
ages of 18 and 60. No infants have been affected.
What are the key points of information?
What information do you need?
What are your hypotheses?
What do you do next?
Page 2. El Guitar
El Guitar is a city on the coast of the Fishn Sea. With a population of 80,000, fishing, tourism and the
widget industry are the primary sources of employment. It has a mild climate with a rainy season that
begins in March and ends in June.
Al Guitar Widgets Company is the world’s leading maker of widgets for the manufacture of pin ball
machines. The company employs 700 people. Widgets are shipped from the Port of El Guitar to all parts
of the world.
During the summer people come to El Guitar to the resorts on the beaches. Hotels, cafes and shops
employ much of the young adult population of El Guitar during the tourist season from June until
October. Fishing goes on all year as fish are caught by small trawlers and transferred to large processing
ships for sale in Asia.
Al Guitar farms produce pineapple, sugar cane and olives. Flour and rice come from the U.S. and Canada.
Ships dock at El Guitar for fresh water and widgets and unload the flour and rice.
Country of Beanictacya
El Guitar
Fishn Sea
Page 3
You arrive in El Guitar and meet with Mustaf. He reports that 305 people have now become
ill and there have been 37 deaths now. All of the people who have become ill have the same
symptoms.
You are given a map of El Guitar. There are two suburbs of El Guitar, Urbina and Raz.
Urbina and Raz share a water treatment facility and a waste treatment facility. El Guitar has
his own water and waste treatment facilities. A power plant in El Guitar furnishes power for
the metropolitan area.
Waste treatment plant
Urbina
Water treatment plant
City of El Guitar
Power plant
Water treatment plant
Waste treatment plant
Port of El Guitar
Raza
ale
emale
El Guitar
Raz
Urbina
23 (25,000)
107 (7,000)
6 (4,500)
7 (30,000)
62 (8,000)
0 (5,500)
opulation by age and gender
Male
emale
<20
20-40
40-60
60>
30
81
21
9
11
34
12
7
Deaths reported by physicians
El Guitar
Raz
Urbina
Male
3
28
2
Female
0
4
0
Deaths by age
<20
20-40
40-60
60>
Male
4
19
7
3
Female
0
1
2
1
What other information do you need?
age 5
More residents of the suburb of Raz were affected. In El Guitar city, the neighborhoods of Bambazza and El
ida had the highest number of cases. A few cases occurred in the Al Jiwa neighborhood and there were no
ases in Jimwa and Al Gone. A few cases occurred in Urbina.
Jimwa
Urbina
Al Jiwa
City of El Guitar
Bambazza
Al Gone
El Aida
Port of El Guitar
Raz
What are your hypotheses?
What more information do you want?
What would you do next?
You conduct an air quality study of the power plant and find that it is compliance with all air pollution
standards.
The 80,000 citizens of El Guitar and the two suburbs are descendants of nomadic tribes from Egypt. Their
traditional diet consists of fruits, goat and lamb stews, bread and popsicles. Cheeses from goat milk are
also included in the diet. In addition, dates, olives and grapes are plentiful.
There are numerous open-air cafes in El Guitar serving traditional and non-traditional meals, but are
frequented mostly by tourists. Fast food has not come to this part of the world yet. Most families eat
traditional meals together at mid-day. Open air markets provide fruits and vegetables. Small butcher
shops sell meat and cheese. Neighborhood bakeries provide bread and pastry. Bread is served at every
meal.
Building materials for homes and offices are scarce. The warm climate does not require substantial
buildings so plywood and fiberboard are imported. Most families live in three room apartments and do
their cooking on balconies or in open areas over charcoal. This causes air pollution at certain times of
the day.
No more cases of illness have occurred in Raz. However, two cases have been reported in Urbina and
three cases have occurred in El Guitar.
The health department has contacted the individuals who became ill. They did a 3 day dietary recall of
all foods they could remember eating prior to their illness.
3 Day Dietary Recall for 232 Individuals Who Became Ill
Fruits
Lamb
Goat
Water
Milk
Cheese
Popscl
Bread
Rice
Beans
Other
8
40
2
24
107
44
23
76
125
92
34
104
RazF
6
21
0
16
82
39
33
51
58
14
22
62
El M
2
18
2
17
27
15
14
23
27
16
23
30
El F
7
1
2
7
5
4
7
7
5
3
7
UM
6
6
5
6
3
6
6
6
6
4
6
RazM
3 Day Dietary Recall, New Cases
El M
2
3
1
3
1
2
3
3
1
2
3
UM
2
2
2
2
0
1
1
2
1
1
2
3 Day Dietary Recall for 50 Individuals Who Did Not Become Ill
Fruits
Lamb
Goat
Water
Milk
Cheese
Popscl
Bread
Rice
Beans
Other
12
11
10
17
7
10
7
7
10
8
18
RazF
11
8
6
16
7
10
7
5
11
4
15
El M
7
6
7
9
7
7
5
5
4
2
3
El F
5
2
2
6
3
2
4
3
3
0
3
UM
3
4
2
2
3
2
4
3
0
0
2
RazM
Only 11 of the patients ate at cafes. All others had their meals at home or had meals prepared at home
and eaten while working.
What are your hypotheses?
What would you do next?
Water quality tests have come back and all standards have been met. During the outbreak there was no
record of contamination.
The focus of the investigation moved to the possibility of food poisoning or food contamination. Almost
everyone recalled drinking water. The area has three different sources of water. Some areas of the city
were illness-free so water was eliminated as possible cause.
The investigation turned to the sources of food. Meat and cheese came from at least 32 sources including
open markets, butcher shops, and meat purchased from farmers. Bread was a common food among those
who were ill and those who were not, but a higher percentage of those who became ill ate bread. Raz has
three bakeries, Asiri, Al Pan and Razpan. The El Aida neighborhood has two bakeries, Ynez and Twookra.
The Bambazza neighborhood has one bakery, Bobaks.
Further investigation showed that most of the people who became ill bought bread from Asiri, Al
Pan and Ynez bakeries. Interviews with the bakeries revealed that five brands of flour were used.
Bakery
Luna
Jiffy
Golden
x
Jack’s
Whole Nut
x
Asiri
Al Pan
x
x
Razpan
Ynez
x
x
x
Twookra
Bobaks
x
x
x
x
x
x
Bakery
Morning Star
Cackle
Golan
x
Red Hen
Jones Farm
x
Asiri
x
Al Pan
Razpan
x
Ynez
Twookra
Bobaks
x
x
x
x
x
x
x
x
Bakery
Parkside
Energywise
x
Olden Days
x
Asiri
x
Al Pan
x
Razpan
Ynez
x
Twookra
x
Bobaks
x
x
x
x
The common factor seemed to be flour used in three of the bakeries. The Luna brand
flour from Canada appeared to be the common link. Eggs and milk did not appear to be
common to the three bakeries.
Samples of Luna flour were taken from the three bakeries. The samples were negative
for contaminants.
Luna flour is unloaded from freighters in the Port of El Guitar and stored in a warehouse
with other products brought in by ship such as corn, rice and beans. Some 80 sacks of
Luna flour were found in the warehouse stacked on pallets in sanitary conditions. A
sample was taken from sacks selected at random. All were negative except for one
which showed high amounts of Roachend, an insecticide. However, Roachend is not
used in this part of the world.
An interview with the warehouse foreman provided information about the origin of the shipment and the
storage process. The 100 sacks of Luna flour had arrived in October on the Canadian Star, a freighter
from British Columbia. Bakeries using Luna flour contract with a delivery service to pick up flour and
transport it to the bakery.
Delivery Service
Asiri Bakery
Zippy Deliveries
x
Rumdum Fast Track
Slo Mo Shun
What would you do next?
Al Pan
Razpan
x
x
inspect the cargo hold of the ship and find traces of Roachend. After lengthy
questioning, the captain of the ship admits that bags of flour had been contaminated
when the Canadian Star encountered a storm en route to El Guitar.
A barrel of some kind of liquid had tipped over and spilled its contents. Some of the
liquid had leaked into the cargo area below where the Luna flour was stored. About 15
bags of flour were wet with the liquid. To avoid losing money by destroying the
contaminated bags of flour, the captain stacked uncontaminated bags on top of the
soiled bags so inspectors certifying cargo arriving in El Guitar would not find the bags of
flour.
Some bags of flour were delivered to the three bakeries and two remained in the
warehouse.
The captain was arrested and tried for manslaughter. Today, he sits in the El Guitar prison.
Several questions remained:
Why did more males become ill than females?
Why did deaths occur predominantly among males?
Why did illness occur in Urbina since this area is far from the center of the outbreak?
Case author:
Michael Hosokawa
Associate Dean for Curriculum
Professor, Family Medicine
University of Missouri School of Medicine
This case is based on an actual incident. All names, locations and products are figments of the author’s
imagination. Permission is granted by the author to use the case for educational purposes.