1. A foodborne outbreak after a circumcision feast meal in Bahcekoy Village-Duzce Province, Turkey, June 2014 Mine Yenice 1, Dilek Cemil Goktas 1, Berna Sezgin 1, Fehminaz Temel 1, Bulent Gurbuzler 2 1 Public Health Institution of Turkey, Early Warning and Response and Field Epidemiology Department, Ankara, Turkey 2 Provincial Public Health Directorate, Communicable Diseases Department, Duzce, Turkey Funded by the European Union

2. Duzce Bahçeköy 6 km

3. Notification Duzce Public Health Directorate reported to EWR Department of PHI of Turkey on 9 June 2014. Common exposure: A circumcision feast meal served at 11:00 am. on 8 June. 37 sick people applied to the city hospital. Nausea, vomiting, abdominal pain, diarrhoea ~ 300 people had eaten the meal. Funded by the European Union Background

4. Menu Boiled chicken Pilav (rice) Packaged ayran (a drink made of yogurt and water) Tulumba dessert (a kind of pastry dessert) Funded by the European Union

5. Background …and an important information: «Who had eaten the boiled chicken, all of them were sick!» Funded by the European Union

6. Hypotesis «At least one of the foods (chicken, rice, ayran and dessert) served in the feast meal caused this outbreak» Funded by the European Union

7. Objective This outbreak investigation aims to determine the cause/agent mode of transmission to implement control measures Funded by the European Union

8. Methods Retrospective cohort investigation Cohort: The residents who had eaten the lunch served at feast meal Funded by the European Union

9. Case definition Probable case: Onset of nausea or vomiting or diarrhoea at 8 June 2014 among residents who had eaten the lunch served as feast meal Non-case: Asymptomatic people among residents who had eaten the lunch served as feast meal

10. Field Study Funded by the European Union 8 June9 June 10 June 11 June 12 June 13 June Feast meal Cases-Notification Questionnaire Train of interviewers and preliminary interviews Travel to Duzce and start the investigation

11. Funded by the European Union AGE Surveillance in Early Warning System Data Central District of Duzce, June 2014

12. Results Attack rate: 16.3% Women: 44% Mean age: 27.9 ± 20.6 Funded by the European Union 11.9 26.3 36.4 25.4 Age Distribution of Participants

13. Symptoms of Probable Cases Funded by the European Union

14. Epidemic Curve Funded by the European Union Meal Service

15. Funded by the European Union 15 Bought from a local firm 1 day before the meal at 16:00 pm. Boiled in 2 large pots Cooled by breaking to pieces Put in the refrigerator at 18:30 pm. Served at 11:00 am. on 8 June Preparation of Chicken Kept in outdoors for 2,5 hours

16. Funded by the European Union Bought on the same day Rice: Boiled with tap water on the same day (8 June) Other Foods Tulumba Dessert

17. Results Funded by the European Union Serving meal Food Attack Rates (%)RR (95% CI) OR adj (95% CI) ExposedNon-exposed Chicken44.5 0.04.1 (0.62-25.7)12.3 (1.2-123.1) Tulumba36.262.50.57 (0.38-0.87)0.19 (0.06-0.56) Ayran39.363.60.61 (0.37-1.02) Rice41.450.00.82 (0.20-3.3) Disease Risk by Foods (n=118)

18. Laboratory Results Funded by the European Union Sample typenTestTest result Food (chicken)1Cultural enumaretion - Coagulase (+) Staphylococcus+ - Salmonella spp.- - B. cereus- - E. coli O157- - L. monocytogenes- Tap water1Bacteriological analysis - Coliform bacteria22 cfu/100ml - E.coli18 cfu/100ml - C. perfringens 3 cfu/100 ml Throat swabs3*Throat culture- Nasal swabs3*Nasal cultureStaph. aureus (1) + *From 3 cooks

19. Limitations Funded by the European Union Delay in notification Limited number of samples

20. Conclusion This outbreak was likely due to chicken contaminated with Coagulase (+) Staphylococcus Mode of transmission? – Asymptomatic cook – Inappropriate storage and inadequate cooling conditions Funded by the European Union

21. Public Health Actions and Recommendations Trainings on food hygiene and safety for: - Public - Family physicians Improvement on audits: - Increase number of periodic audits for food. Funded by the European Union

22. EWR and Field Epidemiology Department: Dilek CEMIL GOKTAS, MD Berna SEZGIN, MD Fehminaz TEMEL, MD, PHS Duzce Public Health Directorate: Bulent GURBUZLER, MD Duzce Public Health Center staff Funded by the European Union Acknowledgements

23. Back up Slides Funded by the European Union Su Atak Hızı RR (%95 GA) İçenİçmeyen Şebeke suyu40,2 59,80,70,4 - 1,3 Damacana suyu54,545,51,30,6 - 2,6 Su tüketimine göre hastalanma durumu

24. Back up Slides Funded by the European Union Su tüketimine göre hastalanma durumu Örnek Türü Alındığı Tarih Alındığı Yer Sonuç Şebeke suyu 09.06.2014 Bahçeköy İÖO Koliform bakteri : 22 kob/100ml E.coli : 18 kob/100ml Cl. Perfringens : 3 kob/100 ml 12.03.2014 Bahçeköy İÖO Koliform bakteri : 18 kob/100ml E.coli : 7 kob/100ml