Salmonella Heidelberg –
Outbreak to Recall
Eric Coffey, Environmental Health Manager
Amanda Taylor, MPH, Epidemiologist
Southeast Regional Office
Initial Outbreak Notification
• On Friday, November 29th – TDH SER notified by local jail
administrators that 3 ill inmates were transported to ER with
high fever, diarrhea and/or vomiting
• Debbie Walker (SER CEDS Director) worked with Dr. Allyson
Cornell (Medical Director), jail staff and hospital ICN to gather
information
• Newly symptomatic individuals were seen by jail medical staff
and quarantined to one POD
• TDH PIO and jail PIO notified
December 2nd – 4th
EPI
• Hospital ICN informed SER that one stool sample tested positive
for Salmonella.
• Kitchen supervisor contacted for menu information.
• Questionnaire developed which included symptoms, activities,
cell location and foods eaten during the previous week.
• Worked with jail nurse to solicit additional stool samples among
ill.
EH
• EH was notified of the outbreak and
requested to collect samples of the
Thanksgiving Meal. Two food trays sampled
and 10 samples were overnighted to Lab.
• Food samples arrived at the lab, analysis begins.
LAB
December 5th
EPI/CEDS/EH/RO/MED Director met with BCSO administrators to discuss
outbreak protocol, investigation direction, and expectations.
EPI
EH
LAB
• Case definition: an inmate or officer reporting diarrhea (≥3
loose stools in a 24 hour period) since November 27.
• Began interviewing ill cases (n=29)
• Challenges
• After the meeting, EH conducted the initial walk through
assessment of the County Jail Food Facility.
• Food sample testing continued
December 6th – 11th
• Epi curve created
• Moved to case-control study
• Enrolled 20 controls
• Matched to cases by gender and POD location
EPI
• Interviews continued among cases and controls
• Database created in Epi Info 7 (EI7)
• Began conducting data analysis using EI7 Dashboard.
• EP Nurse Consultants delivered stool collection kits to jail and
provided education.
• Took a closer look at menu items served in the week prior to
illness.
EH
• Environmental Health Manager was meeting with investigation
team.
LAB
• No findings to note from food samples on Thanksgiving tray.
• Additional stool samples received.
December 12th
EPI
• EH returned to the Facility with EPI to collect samples of the
mechanically separated chicken (MSC). Three different lots and
manufacture dates were identified. Two of the lots were from
around the time of the thanksgiving meals. Two samples of the
were collected from the chubs. Packaged and overnighted to
the lab for analysis.
EH
• Stool sample results positive for Salmonella Heidelberg
LAB
December 13th
• EH and EPI returned to the jail kitchen to conduct a food flow of
MSC with the kitchen supervisor. Investigated distribution of
meals (time and POD location), temp procedures/logs and
potential areas for cross contamination.
EPI
EH
LAB
• MSC samples received and testing began
December 20th – 30th
EPI
• Continued data entry
• Continued data analysis
• Accompanied USDA representative during kitchen assessment
and shared information
EH
• Coordinated with USDA/FSIS to answer questions about food
sample collection process
• Sent temp logs and inventory information to USDA/FSIS
LAB
• Preliminary results of MSC chicken showed Salmonella
Heidelberg
• Isolates from case-patients and MSC were subtyped using
pulsed-field gel electrophoresis (PFGE) and antimicrobial
susceptibility testing was performed
Descriptive Data
Table 1. Case Control Study Enrollment Demographics (n=40)
Cases (n=20)
37 (22-59)
Age (in years)
19 (95)
# (%) White
0 (0)
# (%) Black
1 (5)
# (%) Other
20 (100)
# (%) Inmates
Controls (n=20)
36 (23-59)
19 (95)
1 (5)
0 (0)
20 (100)
Table 2. Symptom Profile of Cases (n=29)
Symptom
# (%) of Cases
29 (100)
Diarrheaª
Abdominal cramps
Fatigue
Headache
Nausea
27 (93)
27 (93)
27 (93)
27 (93)
Muscle aches
Chills
25 (86)
24 (83)
Fever
Backache
Vomiting
Weight loss
21 (72)
18 (62)
17 (59)
13 (45)
8 (28)
Blood in stool
3 (10)
Fever > 103°F
1 (3)
Constipation
ª Median duration of diarrhea: 4.5 days (range: 1-8
days)
Epi Curve of Ill
Results Summary
• No single food item or activity was found to have a
statistically significant association with illness
• Due to the nature of Salmonella, mechanically separated
chicken served on 11/27 in breakfast gravy and spaghetti
was identified as possible exposure
• Stool specimens collected from 13 inmates
• 9 (69%) positive for Salmonella Heidelberg with
indistinguishable PFGE patterns
• Testing of unopened MSC chub received at jail on
November 22 yielded Salmonella Heidelberg
indistinguishable from the outbreak strain
• Kitchen assessment identified the possibility of crosscontamination through improper hand washing, poor
personnel hygiene, and inadequate sanitation of utensils
Recall Assessment Summary
• FSIS/USDA contacted for assistance with traceback
investigation of MSC
• Epi, environmental and lab data provided
• Several detailed questions were asked
• Microbiology assessment of sample collection and lab procedures
were conducted to rule out cross-contamination
• Representative sent to jail to inspect kitchen
• Manufacturer’s legal counsel notified of findings
• Wednesday, January 10 - MSC manufacturer initiated a
voluntary recall of approximately 33,840 lbs of product
Further Action
• CDC notified of findings
• Data and media talking points discussed
• SharePoint site updated
• Human and food isolates tested for antimicrobial resistance (NARMS)
Table 4. Antimicrobial Resistance Results ª for Two Human Samples
Antimicrobial Class
Antimicrobial Agent
Human Isolate 1
Human Isolate 2
Aminoglycosides
Gentamicin
Susceptible
Susceptible
Kanamycin
Susceptible
Susceptible
Streptomycin
Susceptible
Susceptible
β-Lactam/ β-Lactamase Amoxicillin-Calvulanic Acid
Resistant
Resistant
inhibitor Combinations
Cephems
Cefoxitin
Resistant
Resistant
Ceftiofur
Resistant
Resistant
Ceftriaxone
Resistant
Resistant
Folate Pathway
Sulfisoxazole
Susceptible
Resistant
Inhibitors
Trimethoprim/Sulfamethoxazole Susceptible
Resistant
Macrolides
Azithromycin
Susceptible
Susceptible
Penicillins
Ampicilin
Resistant
Resistant
Phenicois
Chloramphenicol
Susceptible
Susceptible
Quinolones
Ciprofloxacin
Susceptible
Susceptible
Nalidixic acid
Susceptible
Susceptible
Tetracyclines
Tetracycline
Susceptible
Resistant
ª NARMS INTERPRETIVE CRITERIA – The criteria used to categorize minimum inhibitory
concentration results as susceptible, intermediate, or resistant are based on current guidelines provided by
the Clinical and Laboratory Standards Institute (CLSI). Interpretive criteria published in the most recent
National Antimicrobial Resistance Monitoring System (NARMS) annual report (www.cdc.gov/narms) are
applied for drugs that lack CLSI interpretive criteria.
• Relayed information to TDH PIO and jail PIO for media inquiries
Conclusion
• Contaminated MSC and poor food handling practices
contributed to a substantial Salmonella Heidelberg outbreak
• Presumptive multidrug-resistant Salmonella may have
contributed to more severe illness
• Foodhandlers in institutional settings should receive food
safety training to minimize the risk of illness associated with
high-risk foods such as MSC
• USDA News Release:
• http://www.fsis.usda.gov/wps/portal/fsis/topics/recalls-andpublic-health-alerts/recall-case-archive/archive/2014/recall-0012014-release
• CDC Web Announcement:
• http://www.cdc.gov/salmonella/heidelberg-01-14/index.html
Acknowledgments
SERO Staff
Dr. Allyson Cornell, Debbie Walker, Deb Solomon, Amanda Taylor, Eric Coffey, Marsha Rogers, Robin Moore,
Melanie Grant, Christina Arriaga, Robert Goff, Beth Delaney, Glenn Czarnecki
TDH Staff
Dr. John Dunn, Katie Garman, Amanda Ingram, Dr. Tim Jones, Dr. Rendi Murphree, Dr. Amy Woron, Sheri
Roberts, Parvin Arjmandi, Ellyn Marder, Marie Bottomley, Shelley Walker, Latoya Simmons
Others
Dr. Stephanie Defibaugh-Chávez, FSIS/USDA Staff, CDC Staff, Sheila Spencer, Dr. Alice Green, Dana Maxwell,
Latoya Simmons, Jail Administrators, Jail Medical Staff