REPORT ON THE OUTBREAK OF
E COLI O157 IN CHILDREN ATTENDING
MACDUFF PRIMARY SCHOOL,
ABERDEENSHIRE
JUNE 1999
Compiled by:
Dr Arun Mukerjee
Consultant in Public Health Medicine (CD&EH)
Grampian Health Board
Jayne Leith & Fiona Browning
Communicable Disease Nurses
Grampian Health Board
Colin Houston
Specialist Officer (Food)
Aberdeenshire Council
JULY 2000
TABLE OF CONTENTS
Chapter
Subject
Page No
1
Summary/Conclusions & Recommendations
3
2
Introduction
4
3
E coli O157
5
4
Epidemiology
6
5
Environmental Investigations and Results
8
6
Microbiological Investigations and results
9
7
Veterinary sampling and results
10
8
Control measures
11
9
Communication
12
References
13
Appendix 1– Outbreak Control Team Membership
Appendix 2 – Sample Enteric Form
Appendix 3 – Aberdeenshire Council’s Enteric Investigation Form
Appendix 4 – Letter to Parents 1 June 1999
Appendix 5 – Letter to Parents 2 June 1999
Appendix 6 – Grampian Health Board’s E Coli O157 patient
information leaflet
14
15
24
26
27
28
Appendices
2
Chapter 1
SUMMARY
Four confirmed cases of E coli O157 were notified to Grampian Health Board’s (GHB) Communicable
Disease Team and three further cases of enteric illness among children attending one class (3B) of
Macduff Primary School, Banff.
An outbreak was declared by the Consultant in Public Health
Medicine on 2nd June 1999 and an Outbreak Control Team was convened (See Appendix 1 for
Membership of Outbreak Control Team).
The potential risk factors identified by the Communicable Disease Team included a visit to Duff
House, Banff for a class outing and picnic on 19th May. They had also consumed home-made goats’
cheese in class on 26th May. The Communicable Disease Team arranged for the 30 class children
to be screened. 3 adults who had consumed the cheese were also tested. Environmental samples
from kitchen utensils and refrigerators where the cheese had been kept were submitted for
microbiological examination but no organisms where isolated. The cheese had all been consumed
therefore none could be submitted for testing. A sample of raw goats’ milk was tested and grew
coliforms suggesting environmental contamination. E coli O157 was not isolated from the goats milk.
Faecal samples from various animals on the smallholding where the cheese was produced, including
the goat, were positive for E coli O157. Both human and animal samples were phage type 21/28 and
indistinguishable from each other by pulsed-field gel electrophoresis. Between 27th May and 4th June,
24 children in the class and 3 adults who ate the cheese were confirmed positive for E coli O157
(96%). The high attack rate among the cheese tasters, the shape of the epidemic curve and illness in
an adult who did not visit Duff House but tasted the cheese strongly suggests that the cheese was
responsible for the illness.
The outbreak was controlled by taking joint action with the Aberdeenshire Council Environmental
Health & Consumer Protection Service, Aberdeenshire Council Education Service, veterinary section
of Scottish Agriculture College and local General Practitioners. Epidemiological information was
collected and recorded on the appropriate questionnaires (Appendices 2&3). GHB’s Communicable
Disease Team regularly updated families of positive cases, health professionals and the school.
Daily press updates after the outbreak control meetings were held. Secondary cases were prevented
by strictly adhering to exclusion criteria for positive cases, advising about potential transmission
routes of E coli O157 and emphasising the importance of hand hygiene. The outbreak was
successfully controlled within a fortnight.
CONCLUSIONS AND RECOMMENDATIONS.
1. Consumption of contaminated goat’s cheese was presumed to be the most likely cause of the
outbreak of E coli O157 although in the absence of microbiological evidence this could not be
confirmed.
2. The risks associated with preparation, storage and service of foods entering educational
establishments should be assessed.
3. More research should be focussed on immunity and susceptibility to E coli O157 infection.
3
Chapter 2
INTRODUCTION
Grampian Health Board’s Communicable Disease Team received notification from the Medical
Microbiology Department of Grampian University Hospitals Trust on Tuesday, 1st June 1999 that a
child from the Macduff area of Aberdeenshire had been admitted to Royal Aberdeen Children’s
Hospital (RACH) with confirmed Escherichia coli (E coli) O157. The hospital had also admitted
another child from the same area with gastro-enteritis on 31st May and a further three on 1st June.
These five children reported that their symptoms started between Friday, 28 th May and Sunday, 31st
May. Therefore by June 1st the total number of hospitalised children from the Macduff area was 5.
The parents of the children were interviewed in hospital on 1 st June at which time Grampian Health
Board’s enteric surveillance forms were completed (Appendix 2). Various common risk factors were
identified including a class outing and picnic, to Duff House on 19th May and a class tasting of home
produced goats’ cheese on 26th May. Duff House, Banff, is a local historic house with grounds that
are open to the public. The visit to Duff House was excluded as a causative factor of the gastroenteritis because the first child did not become ill until twelve days after the visit. This is outside the
usual incubation period of E coli O157. It was further noted that the families concerned tended to
socialise together, and although a communal barbecue had been held on Sunday, 30th May, this was
discounted as a causative factor as some pupils’ symptoms pre-dated the barbecue. During the
course of the interviews the parents intimated that other children were also absent from class 3B at
Macduff Primary School.
On 1st June Macduff Primary School was advised that Grampian Health Board’s Communicable
Disease Team were treating this incident as a possible outbreak. The Scottish Office, Scottish Centre
for Infection and Environmental Health (SCIEH), Glasgow and Grampian Health Board’s Press Team
were briefed accordingly. By 2 nd June four of the five children hospitalised were confirmed positive
for E coli O157. At this time there were three further suspected cases in RACH. An outbreak was
officially declared on 2nd June 1999 and the first meeting of the Outbreak Control Team (OCT) was
convened at 2pm that afternoon at Summerfield House.
4
CHAPTER 3
E COLI O157
Escherichia coli (E coli) bacteria are found in the digestive tracts of most humans and animals.
There are hundreds of different strains of E coli and usually these bacteria cause no harm
(Pennington 1997).
The strains of E coli that are capable of producing toxins are described as Vero cytotoxin producing E
coli (VTEC). One VTEC strain that is able to cause serious illness in humans is E coli O157:H7 which
can be further sub-typed to assist with epidemiological investigation. The bacteria are capable of
invading the gut and can produce a toxin that may affect the kidneys leading to haemolytic uraemic
syndrome (HUS).
Over 15% of healthy cattle and 2% of sheep may carry E coli O157 in their gut. Animals are usually
unaffected by E coli O157. However a small number may become ill. Animal faeces contaminated
with E coli O157 may in turn contaminate water and soil. It is, at present, unknown how long E coli
O157 can survive in particular environments but research indicates that it can survive in soil for
several weeks (Maule 1999).
E coli O157 can be transmitted to humans in a variety of ways including eating under cooked meat
that is already infected, consuming unpasteurised milk or milk products or contaminated water.
Transmission can also occur through inadequate hygiene after contact with contaminated soil. Person
to person transmission can also occur by faecal-oral route. Inadequate hand hygiene following
contact with any of these vehicles can lead to the ingestion of the bacteria. E coli O157 needs very
few bacteria to cause infection in a susceptible individual.
The incubation period for E coli O157 varies between 1 and 14 days, usually 3-4 days. The symptoms
caused by E coli O157 can vary considerably depending on how the individual reacts to the organism.
The individual may be asymptomatic but is more likely to have stomach cramps and diarrhoea. This
may resolve but occasionally the disease progresses to the next stage where the diarrhoea becomes
bloody. A small number of individuals may develop more serious complications including kidney
failure (HUS). The disease tends to be more serious in young children and the elderly.
Diagnosis is made by culture of stool specimens and typing of the bacteria or by demonstration of
rising antibody titre in blood serum. Since the majority of Scottish E coli O157 isolates share the
same phage type (21/28), other typing techniques must be performed to distinguish potential outbreak
samples from the background of unrelated sporadic cases occurring at the same time. Pulsed- field
gel electrophoresis is a DNA fingerprinting technique that subdivides isolates within a particular phage
type, thus characterising them more accurately.
5
Chapter 4
EPIDEMIOLOGY
The Incident
The Head Teacher of Macduff Primary School confirmed that on the 24 th May one pupil brought a
cheese into the school for class 3B to taste. The cheese was made from goat’s milk. It was produced
on Sunday, 23rd May by the owner of the goat, stored in a refrigerator overnight and taken to school
on Monday, 24th May. The cheese was kept in the school refrigerator overnight and taken home by a
member of staff on Tuesday, 25th May to be kept in her domestic refrigerator. The cheese was then
brought back to school on Wednesday, 26th May, for consumption by class 3B. A small amount of
cheese was put onto a biscuit for each pupil. It was ascertained that not all the pupils had eaten the
cheese (Table 2)
School investigation
The Head Teacher confirmed that class 3B comprised of 31 children, one of whom was on holiday
throughout the incident (Table 1). She reported that 12 children (39%) were absent from Class 3B on
1st June out of a total of 31. She confirmed that this was unusually high and that no other class was
similarly affected. Class lists were faxed identifying children who were absent and who had eaten the
goats cheese (Table 2). It was reported that 3 children were on holiday and 2 children had tonsillitis.
This left 7 children off with “tummy upsets”. 30 children were present on 26 th May however only 25
tasted the cheese. Upon further inquiry it became obvious that the children started to fall ill from 27th
May.
Table 1 Composition of Class 3B (All born between March 91 - February 92)
Children in class
Male
13
Female
18
Total
31
Table 2 Relationship between cheese tasting and infection in children of class 3B ( N=30)
Cheese tasters
Total who Cases
ate cheese
positive
Attack rate
25
96%
24
Non cheese tasters
Total who Cases
refused
positive
cheese
5
0
Attack rate
Relative risk
0%

Table 3 Relationship between the children tasting the cheese and illness (N =25)
Cheese tasters
Symptomatic
19
Non cheese tasters
Total
25
Attack rate
76%
Symptomatic
0
Total
5
Attack rate
0%
Relative risk

Table 4 Relationship between cheese tasting and illness and infection in adults (N=3)
Adults who ate
cheese
Total
3
Symptomatic
3
Positive
3
6
Attack rate
100%
By 4th June a total of 19 children had become ill (Table 3). In addition 3 adults, who also consumed
the cheese, developed illness (Table 4). All symptomatic cases were confirmed as E coli O157
positive. One child developed haemolytic uraemic syndrome (HUS) four days after becoming ill which
is within the median range of the reported interval for the onset of HUS (EuroSurveillance 2000).
None among the cheesemakers household or contacts, including the pupil in class 3B, complained of
illness and all were microbiologically negative.
Incubation period.
Figure 1
Date of onset of symptoms
Macduff Outbreak
9
8
Cheese
tasted
Nos of cases
7
6
5
4
3
2
1
9
9
6/
9
/0
04
9
6/
9
/0
03
9
6/
9
/0
02
9
6/
9
/0
01
9
5/
9
/0
31
9
5/
9
/0
30
9
5/
9
/0
29
9
5/
9
/0
28
9
5/
9
/0
27
5.
9
/0
26
25
/0
5/
9
9
0
Date of Onset
Symptoms developed between 1-9 days after tasting the cheese in those who became ill. This is
within the extended incubation period of E coli O157. An incubation period of up to 14 days has been
reported in certain incidents (Marsh et al 1992, Kohli et al 1994). All but one child of class 3B visited
Duff House 12 days before the first reported illness which is also within the extended incubation
period of E coli O157. However, the shape of the epidemic curve (Fig I), the high attack rate among
the cheese tasters and illness in one adult who did not visit Duff House but tasted the cheese strongly
suggests that the cheese was responsible for the illness. This could not be confirmed by
microbiological tests because a sample of cheese was not available although the goat’s faeces were
positive for E coli O157.
7
Chapter 5
ENVIRONMENTAL INVESTIGATIONS AND RESULTS
The incident was reported to the Specialist Officer (Food) for Aberdeenshire Council on 1 st June 1999.
Information was gathered on which pupils consumed packed lunches or school meals. The school
kitchen was inspected and the food handlers questioned. The investigating officers were satisfied with
the conditions in the school kitchen and with the answers provided by the staff.
There was no evidence that the goat had been ill and the owner stated that the teats had been
cleaned with anti-bacterial wipes prior to milking. The owner stated that the goat's milk was boiled for
one minute before adding the rennet to make the cheese. The milk obtained from the goat to make
this cheese was all used in its production. The rennet was only used to make this specific batch of
cheese. During a later interview with the producer of the cheese it was confirmed that the milk was
not boiled but warmed up.
Samples of milk from the goat and the rennet used in the cheese were submitted for examination and
reported as negative for E coli O157. The sample of milk did not comply with the Dairy Products
(Hygiene) Regulations 1995. The milk contained a total viable count /gm at 30 degrees of 1.3 X 107
and a coliform count /gm at 30 degrees of 1.6 X 102.
The cheese was a domestic product, and was not commercially produced for wider consumption.
General household implements were used to make the cheese. Accordingly these were swabbed
and submitted for examination. Swabs from the washed bowl that contained the cheese were
submitted for examination. Swabs from the producer’s refrigerator, the pupil’s refrigerator, the staff
member’s refrigerator and the school refrigerator were submitted for examination. The producer’s
premises were on a private water supply and water sample was also submitted for testing. Results of
all these swabs and samples were reported as negative.
8
Chapter 6
MICROBIOLOGICAL INVESTIGATIONS AND RESULTS
Environmental Health Officers from Aberdeenshire Council contacted the head teacher of Macduff
Primary School and interviewed the pupils of the class in the presence of their parents using the
outbreak investigation form of Aberdeenshire Council (Appendix 3). Faecal sample pots were given
to all pupils and teachers of class 3B including those who were absent. A GHB letter and information
leaflet about E coli O157 (Appendices 4&6) accompanied the faecal sample pots. Faecal sampling
was extended to include three people who were identified as people who regularly drunk the goat’s
raw milk.
Thirty-one children were registered in the class. One child was on holiday throughout. 30 children in
class 3B submitted faecal samples. The adults who consumed the cheese also submitted faecal
samples. Table 5 shows that 27/28 (96%) of the samples were positive for E coli O157 but only 22/28
(79%) individuals were symptomatic. Asymptomatic infection with E coli O157 has been reported in
investigation of outbreaks (Heuvelink et al 1999) The cheese brought into the class room was small
and children only received a small quantity (about a teaspoonful each). Five children were
microbiologically positive but did not exhibit any symptoms. At this time little is known about
differences in susceptibility and immunity.
Table 5 showing the microbiological results
Male
Female
Total
Ate
cheese
12
16
28
Negative
Positive
Symptomatic
Asymptomatic
Propn. +ve
0
1
1
12
15
27
10
12
22
2
3
5
100%
94%
96%
One child, not in class 3B, who regularly consumed raw milk from the same goat, was asymptomatic
but tested positive for E coli O157. All household contacts of positive cases were tested as per local
policy revealing secondary infection in four adults and four children. The E coli O157 Reference
Laboratory, Aberdeen reported that all the human samples were phage type 21/28, verotoxin 1
negative, verotoxin 2 positive and they were indistinguishable by pulse field gel electrophoresis.
Some cases agreed to take part in a research project running in Grampian at the time of the outbreak.
As part of this project, individuals were asked to submit a faecal sample daily for 10 days. Those
who did not take part in the research or those who were still positive at the end of 10 days were
sampled weekly. The final negative faecal sample was received twelve weeks after consuming the
cheese.
9
Chapter 7
VETERINARY SAMPLING AND RESULTS
Scottish Agricultural College (SAC) Craibstone was contacted on 2 nd June to arrange faecal sampling
of the goat and other animals at the cheesemakers smallholding (Table 6). However the owner had
already approached her own vet to do this who liased with SAC.
Table 6 Results of microbiological tests on farm animals.
Sample type
Goat faeces
Ewe faeces
Lamb faeces
Goose / Duck faeces
Hen faeces
Total no of
animals
No of samples
taken
1
6
5
4 geese / 5
ducks
13
9
9
7
7
No of samples
positive for E coli
O157
7
8
6
2
3
0
All the positive veterinary samples were E coli O157 phage type 21/28 verotoxin 1 negative, verotoxin
2 positive. The E coli O157 Reference Laboratory reported that the animal samples were
indistinguishable in type from each other and from the human isolates by pulsed-field electrophoresis.
10
Chapter 8
CONTROL MEASURES
Removal of risk at source
During the course of the investigation it became apparent that the most likely source of infection was
the homemade goats cheese. After investigation Environmental Health advised that the cheese
making operation was not commercial and that the cheese maker only had one goat from which one
small cheese was made specifically for the school. All the cheese was taken to school and consumed
therefore no sample could be obtained. No other cheese had been made therefore there was no
ongoing risk.
Case definition
A ‘case’ was defined as any individual who tasted the cheese and either developed symptoms of
diarrhoea or became positive for E coli O157 by stool examination.
Ascertainment of cases
All class members including the teacher were asked to submit a faecal sample for testing.
Arrangements were made to sample the household members of positive cases in accordance with
local policy.
Exclusion of cases
On 1st June it was agreed that anyone who had diarrhoea or “upset tummies” should be excluded
from school until their faecal test results were available. It was agreed at the outbreak control
meeting on 4th June to close class 3B. When sufficient children screened negative the class would
reconvene.
Asymptomatic children from class 3B who tested negative would be re-tested during the week
beginning 7th June, with a view to returning to school on 14th June, if the result of the second test was
negative.
Symptomatic contacts of positive cases were asked to remain at home until the results of their faecal
sample tests were available.
All positive individuals were excluded from school/work until they had submitted two consecutive
negative faecal specimens twenty-four hours apart. The last individual became negative 84 days
after consumption of the cheese.
Macduff School
The OCT recommended that hand hygiene was promoted throughout the school and that sufficient
soap and hand-drying facilities were available and that the school toilets be cleaned four times a day.
The class was closed on 4th June, as most of the pupils proved positive. It reopened on 14th June.
Counselling of contacts
The Communicable Disease Team prepared information to be sent home with the pupils of class 3B
including routes of transmission of E coli O157 and preventative measures. All parents of positive
cases were contacted by the Communicable Disease Team and advised on the precautions to be
taken to prevent secondary spread.
11
Chapter 9
COMMUNICATION
General Practitioners
Local General Practitioners (GPs) and Grampian Doctors On-call Service (GDOCS) were advised of
the outbreak by fax. A GP from the locality was invited to become a member of the OCT.
Parents
A Grampian Health Board letter and information leaflet about E coli O157 accompanied the faecal
sample pots that were given to all children of class 3B on 1st June 1999 (Appendix 4 & 6).
A second letter addressed to all parents of children at Macduff School was issued on 2 nd June
explaining the situation and precautions to be taken to prevent secondary spread (Appendix 5).
The parents telephoned the Communicable Disease Team for the results.
results were given advice on how to prevent secondary spread.
All those with positive
School
Regular contact was maintained with the school during the outbreak. Advice was freely sought and
given. Advice centred on the routes of transmission of E coli O157 and how to prevent secondary
spread. Sickness absence in school was monitored. When the class reopened the school were
updated daily on who were still excluded.
Helpline
It became apparent from the number of telephone calls received by the Communicable Disease Team
that a dedicated telephone helpline was needed. This was started on 7th June and was manned by
trained Health Board Staff. Thirty-seven calls were answered by the helpline although more were
received and dealt with by the Communicable Disease Team.
Press
Parents and Environmental Health Officers in Macduff reported that the press were waiting in the
streets and asking residents and parents for comments. It was reported that this was hindering the
Environmental Health Officers and causing the parents further distress. The Public Relations Officer
from Grampian Health Board reported that the press were anxious for information and telephoned
regularly. A press conference was held daily after the Outbreak Control Meetings.
The OCT agreed that the Chairperson would be the only spokesperson for the team.
12
References
EuroSurveillance,
2000, Surveillance of haemolytic uraemic syndrome in children under 15
years of age in France in 1998.vol 5, June
Heuvelink et al
1999, Verocytotoxin producing Escherichia Coli O157 infection in household
members with haemolytic uraemic syndrome in the Netherlands. Paed Inf Dis
J, 18:709-14
Kohli et al.
1994. A severe outbreak of Escherichia Coli O157 in two psycogeriatric
wards. Journal of Public Health Medicine,1994; 16:11-15.
Marsh et al.
1992. A restaurant associated outbreak of Escherichia Coli O157 infection.
Journal of Public Health Medicine. 114:78-83,
Maule A.
1999. Environmental aspects of Escherichia Coli O157. International Food
Hygiene .9:21-3
Pennington Group
1997, Report on the circumstances leading to the 1996 outbreak of infection
with E coli O157 in Central Scotland, the implications for food safety and
lessons to be learned.
13
Appendix 1
Outbreak Control Team membership
Dr John Curnow, Chairman, Consultant in Public Health Medicine (CD&EH), Grampian Health Board
Dr Jon Cresswell, Consultant in Public Health Medicine, Grampian Health Board
Dr Stuart Watson, Registrar in Public Health Medicine, Department of Public Health, Aberdeen
University
Dr Helen Howie, Senior Registrar in Public Health Medicine, Grampian Health Board
Ms Izzy Swanston, Public Relations Team, Grampian Health Board
Mrs Shaunagh Kirby, Public Relations Manager, Grampian Health Board
Mrs Fiona Browning, CD Nurse, Grampian Health Board
Mrs Jayne Leith, CD Nurse, Grampian Health Board
Ms L Robertson, Aberdeenshire Council Public Relations Team
Mr K McGowan, Aberdeenshire Council Education Department
Dr R Hobson, Registrar, Medical Microbiology Department, GUHT
Dr I Auchterlonie, Consultant Paediatrician, Royal Aberdeen Children’s Hospital
Dr Diana Webster, Consultant Public Health Medicine, Grampian Health Board
Mr Colin Houston, Principal Environmental Health Officer, Aberdeenshire Council
Dr Fiona Thomson-Carter, Consultant Microbiologist, GUHT
Dr A Barbour, Macduff Practice
Secretariat
Mrs Alison Jones, Grampian Health Board
Mrs Diane McGregor, Grampian Health Board
14
APPENDIX 2
GRAMPIAN HEALTH BOARD
ENTERIC DISEASE SURVEILLANCE FORM
Communicable Disease Team
Summerfield House, 2 Eday Road
DISEASE
TYPE
DATE OF NOTIFICATION
NOTIFIED
BY:
DATE OF INTERVIEW
LABORATORY CONFIRMATION
A
PERSONAL DETAILS
CHI NO_________________(For office use only)
SURNAME
FORENAME(S)
ADDRESS_________________________________________________________________________
_________________________________________________________________________________
POSTCODE_____________________________TELEPHONE__________________________________
DATE OF BIRTH_______________________
AGE_____
SEX______
OCCUPATION______________________________________________________________________
_________________________________________________________________________________
PLACE OF WORK/SCHOOL___________________________________________________________
_________________________POSTCODE____________________TELEPHONE______________
IF UNDER 5, ATTENDANCE AT PRE-SCHOOL GROUP________YES/NO
ADDRESS________________________________________________________________________
POSTCODE____________________TELEPHONE ________________________________________
GP
_________________________________________________________________________
ADDRESS________________________________________________________________________
____________________________________________________________________________
POSTCODE_______________TELEPHONE_____________
ADMITTED TO HOSPITAL
DISCHARGED
15
DATE OF ONSET OF SYMPTOMS
TIME_______________
SYMPTOMS (Please tick)
SYMPTOM
YES
DATE & TIME
1 DIARRHOEA
2 NAUSEA
3 VOMITING
4 FEVER
5 STOMACH PAIN
6 LOSS OF APPETITE
7 JAUNDICE
8 BLOODY STOOLS
9 HUS*
10 DIC*
11 OTHER
* For Office Use Only
DURATION OF ILLNESS __________ DAYS
PRESENTLY SYMPTOMATIC ___________ YES/NO
TREATMENT (DRUGS) ______YES/NO TYPE __________________
REGULAR DRUGS (OTHER)
ANTIBIOTICS 3 WEEKS PRIOR TO ILLNESS __________________
OTHER ILLNESS_________________________________________
NOTES:
16
NO
NOT
SURE
LABORATORY RESULTS
17
C
HOUSEHOLD AND OTHER CONTACTS
DETAILS OF HOUSEHOLD MEMBERS (NOT CASE) IN THE PRECEDING 3 WEEKS
BEFORE CASE ILLNESS
NAME
S
E
X
D
O
B
RELATION
SHIP
OCCUPATION
OR SCHOOL/
NURSERY
SYMPTOMS
D=DIARR
V-VOMIT
J=JAUND
N=NONE
DATE
OF
ONSET
OTHER PERSONS WITH SIMILAR ILLNESS
NAME
D
S
E
X
D
O
B
RELATION
SHIP
OCCUPATION
OR SCHOOL/
NURSERY
SYMPTOMS
D=DIARR
V=VOMIT
J=JAUND
DATE
OF
ONSET
ANIMAL CONTACTS
DOMESTIC
YES/NO
TYPE
___________________________
FARM
YES/NO
TYPE
___________________________
SICK ANIMALS
YES/NO
TYPE
___________________________
DETAILS - KNOWN CASES OF SIMILAR ILLNESS AMONGST CONTACTS OF
ANIMALS
NAME
S
E
X
D
O
B
RELATION
SHIP
18
OCCUPATION
OR SCHOOL/
NURSERY
SYMPTOMS
D=DIARR
V=VOMIT
DATE
OF
ONSET
E
RECENT TRIPS TO THE COUNTRY
YES
WHEN
F
NO
WHERE
FOOD/DRINK CONSUMED
HOLIDAYS/BUSINESS TRAVEL
HOLIDAYS (LAST 3 MONTHS) - PLEASE TICK
YES
NO
ABROAD
WHERE __________________________________________
WHEN __________________________________________
FLIGHT OR FERRY NUMBER__________________________
HOTEL_________________________ TOUR OPERATOR_________________________
G
DATE
FOOD HISTORY FOR FOOD NOT PREPARED IN HOUSEHOLD
WHERE
FOOD EATEN
19
OTHERS ILL IN
PARTY?
ANY HIGH RISK FOOD (REFER TO SURVEY FORM)
DATE
H
WHERE
WHAT
EATEN BY
OTHERS?
HISTORY OF BAR-B-QUES OR PICNICS
YES
DATE
I
WERE THEY
ILL?
WHERE
NO
WHAT EATEN
HOW COOKED
OTHERS ILL?
WATER SUPPLY (ALL SOURCES)
PUBLIC MAINS
PRIVATE
IF PRIVATE, SOURCE
__________________________________WATER SUPPLY ZONE
(Office use only)
RECENT PROBLEMS
_________________________________________________________________________________
CONSUMPTION OF BOTTLED WATER
BRAND __________________________________
_______YES/NO
SPRING/RIVER WATER CONSUMED IN LAST 3 WEEKS
_______YES/NO
WHERE__________________________________________________________________________
20
J
HOBBIES/ACTIVITIES & OUTDOOR SPORTS
Y/N
WHERE
DATES
OTHERS ILL?
SWIMMING
BOATING
FISHING
CAMPING
OTHER
K
BLOOD DONOR
YES
REGISTRATION NO
NO
BLOOD GROUP
_________________________________________________________
DATE OF LAST DONATION_________________________________________________________
PLACE
L
_________________________________________________________
SPECIFIC RISK FACTORS
YES
NO
DETAILS
Bird pecking of milk bottle tops
Farm visits
Nail biting/thumb sucking or the
like
Children playing with raw
vegetables
Animals on kitchen surfaces
Smoking
COMPLETED BY____________________________________ DATE_______________________
LOCAL AUTHORITY________________________________
Revised April 1994
21
FOOD SURVEY FORM
FOOD
REGULAR
SUPPLIER
OCCASIONAL
SUPPLIER
SOURCE IN WEEK
PRIOR TO ILLNESS
RED MEAT
POULTRY:FRESH
FROZEN
MINCE &
SAUSAGES
BURGERS
DELICATESSEN
FOODS
COOKED MEAT
(COLD)
MEAT PIES
FISH/SEA FOOD
EGGS:HEN
OTHERS
MILK:PASTEURISED
UNPASTEURISED
SALAD
VEGETABLES
FRUIT
ICE CREAM
OTHER
FRIDGE
STORAGE
DEEP FREEZE
22
TEMPERATURE
FOOD HISTORY ONE WEEK PRIOR TO ILLNESS
NAME__________
FOOD TYPE
DATE OF ONSET_______________
CONSUMED
PREPARED
MEAT
POULTRY
MINCE
BURGERS
SAUSAGES
DELICATESSEN
FOODS
COOKED
MEATS
(COLD)
MEAT PIES
SANDWICHES
FISH/
SEA FOOD
EGGS:CHICKEN
OTHERS
MILK:PASTEURISED
OTHER
SALAD
VEGETABLES
FRUIT
ICE CREAM
MAYONNAISE
23
NORMALLY
STORED
WHERE?
EATEN OUT
WHERE?
REMARKS
APPENDIX 3
ABERDEENSHIRE COUNCIL
ENVIRONMENTAL HEALTH & CONSUMER PROTECTION SERVICE
OUTBREAK INVESTIGATION FORM
Investigating Officer(s)
Ref. No.
Date
Case
Name ……………………………………………….
GP…………………………….
Address……………………………………………….
Telephone No……………………………………………….
Postcode………………………
Age …………………..Date of Birth …………………
M/F
Occupation………………………………………………………………………………………………………….
Address …………………………………………………………………………………………………………….
Date and time of onset of illness
Date
……………………….
Symptoms
Diarrhoea
Time……………………………..
Fever
Vomit
Nausea (Circle)
Severity and duration of illness …………………………………………………………………………………….
Contacts with similar illness and family contacts
Name
Address
Telephone No
1.
2.
3.
4.
5.
6.
Overseas Travel YIN
If Yes, details:
Places and Times of food and drink consumed
Name
Address
1.
2.
3.
24
Time
Food Consumed
Type of Food
Location
Specimen data
Report compiled by: Officer………………………………………
Witness……………………………………..
Address of Office …………………………..
………………………………………………
………………………………………………
Tel: ……………………………
Fax: …………………………...
E-mail:……………………………………..
25
Date/Time
Appendix 4
Letters to the Parents
1 June 1999
TO ALL PARENTS OF CHILDREN IN PRIMARY 3 OF
MACDUFF PRIMARY SCHOOL
Dear Parent
We have become aware of 2 children from Primary 3 who have been admitted to hospital with
severe diarrhoea. Tests have shown that the illness has been caused by E coli O157. Our
experience in the past has shown that the illness is very variable in how it presents and may
cause little or no symptoms or just a minor stomach upset. Very occasionally however it can
produce severe or bloody diarrhoea and in this case it is important to visit your general
practitioner. Because of the variability of symptoms we would like to sample the whole of
Primary 3 and we are including with this letter a sample kit for your child. Instructions of how to
use the kit are contained in the pack. We would emphasise that the two cases are confined to
one class only. The cause is being urgently investigated by the Communicable Disease Team.
Symptoms of E coli O157 include diarrhoea, vomiting, stomach cramps and in more severe
cases, bloody motions. The organism if often spread from person to person in family groups and
it is very important to ensure that children wash their hands after going to the toilet or before
handling or eating food. It is also necessary to ensure that individuals suffering gut symptoms
should not go to school or work until 48 hours free from symptoms. Experience has shown that
only a small proportion of individuals exposed to the bacteria actually become ill.
We will endeavour to keep you informed about developments with this incident. If you have any
concerns or questions, please contact your GP, but in the meantime we enclose an information
leaflet which might be helpful.
Yours sincerely,
DR JOHN CURNOW
Consultant in Public Health Medicine (Cd&EH)
26
Appendix 5
Letter to Parents
2nd June 1999
TO ALL PARENTS OF CHILDREN AT
MACDUFF PRIMARY SCHOOL
Dear Parent
As you are now doubt aware, there have been some cases of E coli O157 at Macduff Primary
School. At present, it appears that pupils in only one class are at risk.
However, as a precaution against secondary spread of this illness, which usually occurs person
to person within households, we advise the following measures:
Everyone should practice thorough handwashing and drying after visiting the toilet and before
handling food or eating.
If anyone develops any symptoms such as stomach cramps, diarrhoea or vomiting they should
remain at home and consult their GP.
As always, with any diarrhoeal illness we advise that the person affected should stay off work or
school until they have been free of symptoms for 48 hours.
Many thanks for your assistance.
Yours sincerely,
DR JON CRESSWELL
Consultant in Public Health Medicine
27