1. A Foodborne outbreak of Salmonella enteritidis following a birthday party in Podgorica, Montenegro, 2014 Laušević Dragan, Djuravčaj A, Nikolić A, Galić I, Čampar A, Vuković J, Vujović J, Đor đ ević Z, Rakocevic B, Medenica S Center for Disease Control and Prevention Public Health Institute of Montenegro Funded by the European Union

2. Background Tuesday, 17 June 2014, 18:30-22:30 Birthday party in family X, Podgorica, Montenegro 46 attendee (plus one person on 18 June in the morning) Different food items prepared by – party host – illegal bakery (two cakes) and – relative of revelers (domestic fruit cake) Funded by the European Union

3. Time line of events and outbreak investigation Funded by the European Union

4. Methodology June, 19-16: Paper-based, standardized questionnaire among party invitees demographic symptoms consumtion with remarks of quantity/doses food preparation (including domestic fruit cake) gastrointestinal ilness in previous weeks Laboratory analysis Stool samples (cases & staff of illegal bakery) Food samples (party host & illegal bakery) Recomendation for proper food preparation, storage, transport and serving Legal action of sanitary inspection Descriptive analysis Retrospective cohort study June 19: Interviews with owner and staff of illegal bakery Procurement of food Cake preparation Storage of cakes Gastrointestinal illness in previous weeks Consumption of cake that bakery produce Funded by the European Union

5. Case definition Attendees of birthday party on 17 june 2014 who had  2 episodes of diarrhea per day and/or vomiting and/or fever and/or abdominal cramps with or without nausea or malaise Funded by the European Union

6. Results Funded by the European Union

7. Descriptive analysis Attack rate = 54% (25/46 )

8. - Descriptive analysis - Distribution of cases by age and sex, Birthday party Podgorica, Montenegro, June 2014 Funded by the European Union Age groupMaleFemaleTotal 0--- 1-6123 7-14224 15-19112 20-29134 30 +5712 Total101525

9. Funded by the European Union Clinical symptoms/signs among cases in gastroeneteritis outbreak after Birthday party Podgorica, Montenegro, June 2014 (total 25) Clinical symptoms/signsNo% Diarrhea2184 Vomiting1560 Fever1664 Others (abdominal cramps and/or nausea and/or malaise) 312 8 cases have been hospitalized - Descriptive analysis -

10. Funded by the European Union Ate the food Did not eat FoodIll Total % Ill Total % RR* 95% CI Jaffa cake23 24 95.8 2 22 9.1 10.5 (2.8 - 39.6) Greece cake15 16 93.7 10 30 33.3 2.8 (1.7 – 4.7) Domestic fruit cake13 17 76.5 12 29 41.4 1.8 (1.1 – 3.0) Icecream18 31 58.0 7 15 46.7 Salad 0 4 0.0 25 42 59.5 Corn bread 4 9 44.4 21 37 56.7 Barbecue sausages 5 10 50.0 20 36 55.5 Fish 3 5 60.0 22 41 53.6 Smoked ham 2 8 25.0 23 38 60.5 Cheese (Edamer) 0 4 0.0 25 42 59.5 Soft drinks12 25 48.0 13 21 61.9 Tap water12 16 75.0 13 40 32.5 Bottled water 0 3 0.0 25 43 58.1 * RR – Risk ratio (Relative risk) CI – Confidence interval Food Specific Attack Rates, Outbreak of Salmonellosis, Birthday party of family X, Podgorica, Montenegro, June 2014

11. Laboratory results Participant of the birthday party (17) 10 samples positive for Salmonella enteritidis * Illegal bakery Cream for Jaffa cake positive for Salmonella enteritidis * Staff of illegal bakery (2) no patogen bacteria Home of party host Residuals of Jaffa cake positive for Salmonella enteritidis * Residuals of Domestic fruit cake positive for Salmonella enteritidis * Stool samplesFood samples * Antibiogram for all Salmonella isolates was the same Funded by the European Union

12. No puls gel electroforesis to make differentiation betwen Salmonellas isolated from jaffa and domestic cake as well as between Salmonellas isolated from stool samples of cases. No enviromental investigation of hens farm Limitation

13. Conclusions Salmonella enteritidis was the microbial cause of outbreak Jaffa cake and possibly domestic fruit cake were the vehicle. Consumption of jaffa and domestic cake can explane 92% and 52% of cases respectively and together 100% of cases Possible source could be eggs but it was not possible to confirm that hypothesis Food (cake) contamination probably due to primary contamination of ingredients, inproper food preparation and handling practices Funded by the European Union

14. Recommendation Recomendation for proper food preparation, storage, transport and serving to both illegal bakery and party host and relative who made domestic fruit cake Illegal bakery was temporarily closed Cases and outbreaks of gastrointestinal ilness should be reported to public health authority as soon as possible in order to put control measures in time as well as to increase chance for identifcation of causative agent Funded by the European Union

15. Thank you for your attention !!! Funded by the European Union

16. Acknowledgements: - Staff of CDC&P and staff of centers for environmental medicine and medical microbiology of IPH - Members of Sanitary inspection Funded by the European Union

17. Back-up slides Funded by the European Union

18. Ate the food Did not eat FoodIll Total % Ill Total % RR* 95% CI Jaffa cake23 24 95.8 2 22 9.1 10.5 (2.8 - 39.6) Greece cake15 16 93.7 10 30 33.3 2.8 (1.7 – 4.7) Domestic fruit cake13 17 76.5 12 29 41.4 1.8 (1.1 – 3.0) Icecream18 31 58.0 7 15 46.7 Salad 0 4 0.0 25 42 59.5 Corn bread 4 9 44.4 21 37 56.7 Barbecue sausages 5 10 50.0 20 36 55.5 Fish 3 5 60.0 22 41 53.6 Smoked ham 2 8 25.0 23 38 60.5 Cheese (Edamer) 0 4 0.0 25 42 59.5 Soft drinks12 25 48.0 13 21 61.9 Tap water12 16 75.0 13 40 32.5 Bottled water 0 3 0.0 25 43 58.1 * RR – Risk ratio (Relative risk) CI – Confidence interval Food Specific Attack Rates, Outbreak of Salmonellosis, Birthday party of family X, Podgorica, Montenegro, June 2014

19. STRATIFICATION JAFFA CAKE + JAFFA CAKE – ILL NOT ILL TOTAL ILL NOT ILL TOTAL Greek YES 15 0 15 0 1 1 cake NO 8 1 9 2 19 21 RR = 1.13 (0.89-1.42) RR = 0.00 (??? - ???) aRR = 1.1 (0.86-1.42) cRR = 2.8 (1.67-4.74) aRR  cRR Funded by the European Union

20. STRATIFICATION Attack rate in % Risk ratio Jaffa cake +, Greece cake + 100.0%10.5 Jaffa cake +, Greece cake - 88.9% 9.3 Jaffa cake -, Greece cake + 0.0% 0.0 Jaffa cake -, Greece cake - 9.5% Ref. Funded by the European Union

21. STRATIFICATION JAFFA CAKE + JAFFA CAKE – ILL NOT ILL TOTAL ILL NOT ILL TOTAL Domestic YES 11 0 11 2 4 6 cake NO 12 1 13 0 16 16 RR = 1.08 (0.93-1.27) RR =  (??? - ???) Funded by the European Union

22. STRATIFICATION JAFFA CAKE + JAFFA CAKE – ILL NOT ILL TOTAL ILL NOT ILL TOTAL Domestic YES 11 0 11 2 4 6 cake NO 12 1 13 1 15 16 RR = 1.1 (0.9-1.23) RR = 5.3 (0.6-48.0) Funded by the European Union

23. STRATIFICATION Attack rate in % Risk ratio Jaffa cake +, Domestic cake +100.0% 14.9 Jaffa cake +, Domestic cake - 92.3% 13.8 Jaffa cake -, Domestic cake + 33.3% 5.0 Jaffa cake -, Domestic cake - 6.7% Ref. Funded by the European Union