A foodborne disease outbreak investigation experience in a College in Lusaka , Zambia , 2017

Introduction: On 19 March 2017, an outbreak of unknown etiology was reported among students at a college in Lusaka, Zambia. We investigated to confirm the outbreak, identify exposures, determine the aetiological agent, and implement preventive measures. Methods: We conducted an unmatched case-control study. Cases and controls were selected conveniently. A suspected case was diarrhea or abdominal pains in any student at College A and Controls were asymptomatic students at College A during 18-23 March. We interviewed cases and controls about exposures to suspected food and water and collected saved food samples and swabs from food-handlers' hands and kitchen surfaces for culture. We analyzed data using Epi-info v 7.2 (Atlanta, Georgia). Results: We identified 59 suspected case-patients. Predominant symptoms were diarrhea (n = 51.83%) and abdominal pains (n = 44.75%). The outbreak started on 18 March, peaked on 19, and concluded on 20 March. We interviewed 30 case-patients and 71 controls. Exposures associated with increased odds of illness included eating food served at dinner on Saturday (18 March) in school cafeteria (OR = 5.8, 95% CI = 2.0-16.7); specifically, eating beans at Saturday dinner (OR = 21.6, 95% CI = 4.5104) and drinking water supplied at school (OR = 8.8, 95% CI = 1.45-53.6). Samples from all food-handlers (n = 13) yielded Staphylococcus aureus and all food samples (n = 3) yielded Escherichia coli, Staphylococcus aureus and fecal coliforms. Conclusion: The results suggest a foodborne outbreak caused by consumption of contaminated food served at dinner on 18 March at College A. We educated the food handlers and school management about the importance of disinfection of preparation surfaces, supervision of food handling and handwashing practices. Pan African Medical Journal. 2018;29:100. doi:10.11604/pamj.2018.29.100.14737 This article is available online at: http://www.panafrican-med-journal.com/content/article/29/100/full/ © Fred Kapaya et al. The Pan African Medical Journal ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Pan African Medical Journal – ISSN: 19378688 (www.panafrican-med-journal.com) Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net) Research Open Access


Introduction
Foodborne diseases are of major public health concern globally and are caused by the consumption of food or water contaminated with infectious microorganisms and/or toxic chemicals [1].Contamination can occur during storage, transportation, and preparation of food for consumption [2].The most common clinical manifestations are acute diarrhea and abdominal cramps [3,4].Most foodborne illnesses are mild and self-limiting but severe cases may occur, especially in children, the elderly and immunocompromised persons [5][6][7].The global burden of foodborne diseases was estimated to be 600 million cases and 420,000 deaths in 2010 [3].Children under five years of age bear 40% of this burden [3].In Zambia, diarrheal diseases rank in the top five causes of morbidity and mortality in all ages; according to the Zambia Demographic and Health Survey 2013-2014, the annual incidence of diarrheal diseases among the under five children was 16% [8].On

Methods
Case identification: We conducted the outbreak investigation during the 20 to 24 March, 2017.We identified cases by reviewing medical records at Mwanawasa General Hospital.It was assumed that all ill students would have presented to Levy Mwanawasa General Hospital, as it was the closest to the college, and any students transported in the college van were taken there.A suspected case was any student from College A complaining of or presenting with diarrhea or abdominal pains during 18 to 23 March.

Data collection:
We visited Levy Mwanawasa General Hospital to abstract clinical data from presenting case-patients, and we visited College A to conduct hypothesis-generating interviews with students and school management.College A is a residential college, with most students living in dormitories on campus.The on-campus dining options consist of the main school cafeteria and a smaller snack shop.We then conducted an unmatched 1:2 case-control study.Interviews were conducted on a single day, three days following the start of cases, in order to limit recall bias.Controls were students at College A without a history of diarrhea or abdominal pains during the same time period.We selected suspected cases and controls conveniently; fliers were hung up on the day of the interviews inviting any student who had been sick and who was available and willing to be interviewed to come to the location of the interviews.In addition, students who passed by the interview room during the day of the interviews were asked if they wanted to participate, which generated the majority of the controls.This method of selection was performed in order to cause minimal disruption to scheduled classes.We designed a structured questionnaire to collect data on residence, food consumed during the two days preceding the outbreak (17 and 18 March), source of drinking water, and sanitation practices.

Data analysis:
We used Epi Info version 7.2 (Atlanta, Georgia) for data entry and analysis.We conducted univariable logistic regression to identify exposures associated with case-patient status.
We then conducted backwards logistic regression to develop a multivariable logistic regression model, starting with all exposures that were statistically significant (p<0.05)during univariable analyses.We present adjusted odds ratios (OR) and 95% confidence intervals (CI) for all exposures that remained statistically significant in the final multivariable logistic regression model.

Laboratory investigations:
We collected swabs from the hands of the food handlers found working at the time of the visit (20 March) and swabbed kitchen preparation surfaces.We collected available food samples from remaining leftover foods served on Saturday 18 March (cabbage, fried meat balls, and fried beef).The

Laboratory investigations
The swab results (Table 4) revealed that all the food handlers and the kitchen preparation surfaces had Staphylococcus aureus.
Additionally, seven (54%) food handlers and five (83%) of kitchen preparation surfaces had fecal coliforms.Cultures from all three food samples from the school kitchen yielded E.coli and Staphylococcus aureus.Coliform testing identified fecal coliforms in all three food samples tested (Table 5).

Discussion
Foodborne disease outbreaks in institutional settings where large quantities of food are prepared several hours before serving is common [9][10][11][12].Several micro-organisms have been implicated but the common ones include Bacillus cereus, Clostridium perfringens, Escherichia coli, Staphylococcus aureus, Salmonella species or even Campylobacter jejuni [13,14].In our study one of these microorganisms or a mixture of organisms could be responsible for this outbreak.Our findings suggest that this was likely a foodborne disease outbreak.There was an association between case-patient status and eating food served at dinner on Saturday, 18 March at the school cafeteria (Figure 1).The epidemic curve suggests a point source exposure and the short incubation period suggests a toxinproducing pathogen contamination such as Staphylococcus aureus, Bacillus cereus or Clostridium perfringens [15,16] [5,[19][20][21][22].In this outbreak, E.coli and Staphylococcus aureus were isolated from the leftover food samples tested.
However, the symptoms and course of the illness exhibited by casepatients were not typical of E.coli infection.In addition, the incubation period of 2-34 hours observed among the cases in this outbreak contrasts with 3-4 days incubation period of E.coli.
Therefore, it is unlikely that the responsible organism for this outbreak would be E.coli [23].
No biologic samples were collected from case-patients for laboratory testing, so we cannot pinpoint the single agent responsible for the outbreak.One possibility is Staphylococcus aureus infection, which is compatible with the clinical characteristics and which was isolated from the food handlers' hands and the kitchen surfaces.
However, Staphylococcus aureus is in the normal flora of nasal passages, so it would not be unusual to detect this in a healthy person.Additionally, the surface contamination could have occurred the day the swabs were collected.We also did not detect staphylococcal enterotoxins in food samples, which is required for conclusive diagnosis [24].These findings are similar to a study in

Zimbabwe on Staphylococcus aureus food poisoning among
Bulawayo City Council employees, in which they found that Staphylococcus aureus was isolated from the hands of food handlers although no leftover food could be sent for microbial analysis [13,25].Another possibility is C. perfringens.The beansepidemiologically implicated in this outbreak-are prepared by soaking them in water for a period, cooking them, and then storing them often at room temperature for several hours before consumption.This could make it ideal for germination and multiplication of C. perfringens spores.A third possibility is B.cereus, which is compatible with the clinical characteristics exhibited by case-patients.This is similar to a study in Ghana on "outbreak of foodborne gastroenteritis in a high school in South-eastern Ghana".
They found that it was difficult to pinpoint to a single etiological agent for the outbreak [12].However, in our study, it is clear that there was a foodborne disease outbreak linked to the contamination of food served at dinner on Saturday, 18 March 2017 at the College A cafeteria.

Study limitations
The study had a few limitations.Stool samples were not collected from case-patients, which prevented us from confirming the aetiology of illness.In addition, although beans were most strongly associated with illness, leftover beans from the implicated dinner were not collected because they had been discarded by the time we arrived at College A. There is also a possibility of recall bias, as case-patients might have recalled differently from the controls.
Finally, diarrhea being common, it is possible that some non-cases may have been included as suspect cases, as well as we may have missed some of the less severe cases.

Conclusion
This was a foodborne disease outbreak among students at College A. The epidemic curve suggested a point source.We concluded that the food served at dinner on 18 March in the school cafeteria was likely responsible for the outbreak.The incubation period profile fit that of toxin-producing bacteria such as Staphylococcus aureus, which was isolated from swabs from food handlers, surfaces, and from food cultures.However, other organisms like C.
perfringens and B. cereus can also fit this picture.What is clear is that there was a food borne disease outbreak at college A in Lusaka.The general response to this outbreak was prompt and effective.First, we conducted health education to reminded food handlers on the importance of hand washing before food preparation.Second, we reminded food handlers on the recommended disinfecting procedures for kitchen preparation surfaces.Third, we advised the food handlers and school

Tables and figures
19 March 2017, Levy Mwanawasa General Hospital notified the Lusaka District Health Office of an outbreak of unknown etiology among students at College A. This was after the hospital received 72 students from College A experiencing sudden onset of abdominal pains and diarrhea.Because the etiology was uncertain and additional cases were feared, the Lusaka District Health Office then alerted the Ministry of Health headquarters and requested for the Zambia Field Epidemiology Training Program to investigate.The objectives were to confirm the outbreak, identify the exposures, determine the etiological agent, and institute control and preventive measures.

FoodFunding:
fecal coliforms.We conducted unstructured interviews with food preparers and kitchen management to learn the general process of food preparation and storage; however, due to limited time and resources, no formal environmental investigation was performed and no water samples were tested.Ethical considerations:We used unique identifiers to protect participant confidentiality and we obtained oral consent before the 3 interviews.Permission to conduct the investigations was granted by the Lusaka District Health Management Team.The investigation was regarded as a response to a public health emergency by the Zambia National Health Research Authority (ZNHRA) and thus did not receive a formal review by the ethics committees but rather ZNHRA ethics body provided an expedited review of the protocol.The ZNHRA also granted consent to publish the findings of the investigations.The report of the investigations has been communicated to the Ministry of Health, the Lusaka District Health Management Team and the college management.The investigation was funded by the U.S President's Emergency Plan for AIDS Relief (PEPFAR).The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official views of the U.S. Centers for Disease Control and Prevention.

Table 1 :
Clinical characteristics of case-patients at College A (N =

Table 2 :
Univariable analysis showing associations between exposures of interest and illness status at College A-Lusaka, Zambia, 2017

Table 3 :
Multivariable analysis showing association betweenexposures of interest and case-patient status at College A-Lusaka,

Table 4 :
Laboratory swab results for suspected foodborne outbreak

Table 5 :
Laboratory food sample results for suspected food

Table 1 :
Clinical characteristics of case-patients at

Table 2 :
Univariable analysis showing associations between exposures of interest and illness status at College A-Lusaka, Zambia, ** Nshima is a staple food in Zambia made from maize flour (corn meal--mealie meal) and water

Table 3 :
Multivariable analysis showing association between exposures of interest and casepatient status at College A-Lusaka, Zambia, 2017

Table 4 :
Laboratory swab results for suspected foodborne outbreak at College A-

Table 5 :
Laboratory food sample results for suspected food poisoning at College A-Lusaka, Zambia, 2017 Epidemic curve of suspected foodborne disease outbreak at College A-Lusaka, Zambia, 2017 ** Fecal coliforms 10= number of colonies/ml of water (acceptable level of fecal coliform is 0) Figure 1: