Food Poisoning Outbreak During a Wedding Banquet in San Juan, Metro Manila*

Douglas L. Ting, M.D., Benjamin D. Dacula, M.D., Grace B. Abad-Viola, M.D. and Ma. Concepcion R. Roces, M.D., MSc.
(*Field Epidemiology Training Program, Department of Health, Manila, Philippines) ABSTRACT We investigated a food poisoning outbreak during a wedding banquet at a Chinese restaurant. Food handlers were interviewed and the kitchen facilities at the restaurant were inspected. Rectal swabs were obtained from some of the guests. A case-control study was conducted. Cases were defined as previously well persons who attended the banquet and developed diarrhea, and/or from whom enteropathogens were isolated on rectal swab. Controls were defined as well persons who attended the same banquet, with a negative rectal swab culture. Fifty three guests (42 cases and 11 controls) were interviewed. Cases were more likely than controls to have eaten seaweeds (OR 10.32, 95% CI, 1.93-55.10) and shrimp salad (OR 6.67, 95% CI, 1.25-35.48). Vibrio parahaemolyticus was isolated from the rectal swabs of 10 cases and one food handler. On inspection the kitchen was dirty and several violations of the sanitation code were noted. This outbreak was caused by unsanitary food handling practices. To prevent similar outbreaks in the future, we recommended stricter implementation of the sanitation code by the local government unit and compliance of the restaurant staff with safe food handling practices. (Phil J Microbiol Infect Dis 1997; 26(4):173-176) Keywords: Vibrio parahaemolyticus, food poisoning, case-control study, sanitation code

INTRODUCTION Since 1987, the Field Epidemiology Training Program (FETP) of the Department of Health has been conducting outbreak investigations in response to requests from local government units, media, or private citizens. The main objectives of such endeavors are to determine the factors that caused the outbreak and to recommend control and preventive measures to stop or check future outbreaks. On the afternoon of March 17, 1996, a wedding banquet was held at a Chinese restaurant in San Juan, Metro Manila. The next day, one of the guests informed FETP that several guests got sick after attending the wedding banquet. On the same day, an FETP team was sent to conduct an epidemiologic investigation. MATERIALS AND METHODS We visited the Chinese restaurant and obtained permission to inspect the place, particularly the kitchen and dining hall. We interviewed the management and staff (cooks and helpers) and obtained a list of food items served during the wedding banquet. We attempted to get a guest list from the bride and groom but none was available. A partial list was then made from information obtained from guests. Those we were able to contact, whether sick or well, were then interviewed using a standard questionnaire. Included were questions on demographic data, foods or drinks consumed during the banquet, the time these were eaten, the quantity of foods or drinks taken, and for those who got sick, we inquired about signs and symptoms of illness, onset of illness and outcome. To minimize recall bias, the maximum time frame for data collection was set at six days from the time of the wedding banquet. Interviews were done in person at the hospital, home, office or by phone. An unmatched case-control study was done. A case was defined as a previously well person who attended the banquet and developed diarrhea and/or from whom enteropathogens

were isolated on rectal swab. A control was defined as a well person who attended the same banquet with a negative rectal swab culture. Since no leftover foods were available, raw ingredients (dried jellyfish, dried scallop, mayonnaise, and fruit cocktail) used to prepare some of the dishes served in the banquet were submitted to the Bureau of Food and Drug (BFAD) for laboratory analysis. Rectal swabs from all food handlers and some of the guests were also taken. These were submitted to the Bureau of Research and Laboratories (BRL) for bacteriologic analysis. Data were analyzed using Chi Square and Kruskal-Wallis tests; 95% confidence intervals (CI) around the odds ratios (OR) were calculated by means of Cornfield's method using Epi Info software version 6.02.1 Unconditional logistic regression was also done using MULTLR software.2 RESULTS There were 110 attendees in the wedding banquet. Fifty three (48%) guests were interviewed. Their ages ranged from 1 to 72 years (median 34). There were 31 (59%) females and 22 (41%) males. Forty-two (79%) got sick. Ages of cases ranged from 4 to 68 years (median 35), while ages of controls ranged from 1 to 72 years (median 25). There were no significant differences between cases and controls with regards to age and gender. Diarrhea and abdominal cramps were the most prominent sign and symptom noted among the cases (Figure 1). Incubation periods ranged from 4.5 to 21 hours with a median of 1255 (Figure 2).
Figure 1. Signs and symptoms of cases (N=42)*

Percent of cases *one case asymptomatic Figure 2. Incubation periods of cases (N=42)*

*one case with unknown incubation period

The banquet was a lauriat with 11 dishes (excluding drinks) served one after the other. On univariate analysis, assorted cold cuts, particularly seaweeds, asado pork and century egg, fish/scallop soup, crabstick roll, taro duck and shrimp salad were implicated (Table 1). On multiple logistic regression, cases were 10 times more likely to have eaten seaweeds and seven times more likely to have eaten shrimp salad than controls (Table 2). Foods were prepared and cooked from 10:00 to 11:00 am and served between 1:30 to 3:30 p.m. The time interval from food preparation to consumption was as short as 2.5 hours to as long as 4 hours. Although the restaurant had a sanitary permit, there were no health certificates for the cooks and helpers. Inspection of the kitchen revealed raw food items in containers without covers scattered on and under the tables. Food handlers were seen handling foods without any protective gloves or clothing. Cockroaches were also seen. The kitchen floor was greasy and dirty. There were 10 stoves in one row set against a wall with 6 to 8 small exhaust fans (some non-functional) at the top of the wall and two big windows without screens at both ends of the kitchen. The ventilation was poor and the room temperature was very warm. Only 24 cases agreed to have their rectal swabs taken. Ten (42%) were positive for Vibrio parahaemolyticus. One food handler was also positive for Vibrio parahaemolyticus. No enteropathogens were isolated from the ingredients submitted to BFAD.
Table 1. Odds Ratios of Food Items Served in a Wedding Banquet San Juan, Metro Manila, March 17, 1996 Food Items Assorted cold cuts Seaweeds Asado pork Century egg Fish/scallop soup Crabstick roll Taro duck Shrimp salad *on univariate analysis Odds Ratios 23.43 12.95 875 8.53 11.43 7.43 6.67 8.53 95% Confidence Intervals 1.88 - 656.97 2.22 - 85.78 1.63 - 51.32 1.57 - 52.14 1.36 - 117.37 1.05 - 57.61 1.26 - 39.55 1.57 - 52.14

Table 2. Odds Ratios of Food Items Served in a Wedding Banquet San Juan, Metro Manila, March 17, 1996 Food Items Odds Ratios 95% Confidence Intervals Food Items Seaweeds Shrimp salad *using multiple logistic regression Odds Ratios 10.32 6.67 95% Confidence Intervals 1.93 -55.10 1.25 - 35.48

DISCUSSION There was a food poisoning outbreak at the wedding banquet held in a Chinese Restaurant on March 17,1996 as shown by the epidemic curve. The etiologic agent was Vibrio parahaemolyticus as suggested by the prominent sign and symptoms of diarrhea and abdominal cramps, the short incubation period, and confirmed by isolation of the organism from cases. Seaweeds and shrimp salad were the most likely vehicles for transmission as evidenced by the significant statistical association between getting sick and eating these food items. Vibrio parahaemolyticus is an aerobic, gram-negative bacillus found in coastal waters throughout the world, particularly in the temperate zone. It has commonly been associated with acute diarrhea illness in Japan, presumably because of the frequency of ingestion of raw seafood.3 It has also been implicated in several outbreaks of acute diarrheal disease in the coastal United States, always as a common source outbreak related to ingestion of inadequately cooked seafood.4

In 1995, FETP investigated an outbreak associated with canned salmon served to employees of an establishment in Manila.5 Dishes such as assorted cold cuts and shrimp salad entail considerable food handling during preparation. Contamination of the food items probably occurred during food handling. The unsanitary condition of the kitchen, poor food handling practices and the number of dishes that had to be prepared that day allowed for contamination and cross contamination to occur. It was possible that on the day of the wedding banquet, cooked foods were placed alongside uncooked ingredients creating an opportunity for cross-contamination. Conditions that facilitated the proliferation of Vibrio parahaemolyticus in the food items were the warm environment of the kitchen and the long time interval from food preparation to consumption. A study by Dr. Sanyal6 of Tokyo showed that Vibrio parahaemolyticus multiplies rapidly and at an optimum temperature of 30-37C, doubles in number within 12 to 18 minutes. When foods are contaminated by even a small amount of organisms, the number can reach pathogenic levels in a very short period of time. The dried seaweeds were cut and boiled for a few minutes and drained for a few hours at room temperature, then packed in a covered plastic box and refrigerated for three days. On March 17 at 10:00 am, the seaweeds were retrieved from the refrigerator and prepared with seasoning. From preparation to consumption, there was ample time for the organism to multiply to pathogenic levels. Actions were taken to control the outbreak and prevent further cases. Untreated cases were advised medical consultation. The food handler found positive with Vibrio parahaemolyticus was treated with tetracycline and was advised not to handle food until the three consecutive rectal swab cultures were negative. The restaurant management was informed of the food poisoning outbreak. Staff was advised on proper food sanitation.7 This included reducing food handling time, refrigerating perishable foods and ensuring that cooked seafood reach adequate temperatures to kill any organism by heating for 15 minutes at 70C. They also needed to maintain proper ventilation and cleanliness of the kitchen and perimeter. We recommended that their food handlers attend a class on safe food handling and secure health certificates. We also recommended that the Local Health Unit conduct seminars for food handlers before proper health certificates are issued. Regular inspection of food establishments should also be done to ensure compliance with the sanitation code.8
ACKNOWLEDGMENTS We thank the staff of BFAD and BRL for their laboratory support during this investigation. REFERENCES 1. Dean AG, Dean JA, Burton AH, et al. Epi Info, Version 6: a Word Processing, Database and Statistics Program for Public Health, Epidemiology Program Office, Centers for Disease Control. Atlanta, GA, April 1994. 2. Campos-Filho N, Franco EL. MULTLR: A microcomputer program for multiple logistic regression by unconditional and conditional maximum likelihood methods. Am J Epidemiol 1989; 129(2):439-444. 3. Kujino T, Okuno Y, et al. On the bacteriologic examination of Shirasu food poisoning. Med J Osaka Univ 1953; 4:299-307. 4. Baker et al. Vibrio parahaemolyticus outbreak in Covington, Louisianna in August, 1972. Am J Epidemiol 1974; 100:316. 5. Dayrit MM, Roces MCR, Magboo FP, Catintdig NT, Roque VG, Adorio-Arce LP. Final report on the food poisoning outbreak in Casino Filipino, Manila Pavilion. Philippine Department of Health memorandum, October 31,1995. 6. Chao DY, Wu PF, Hsu SY, Pan TM, Chen KT. Investigation of a food poisoning outbreak in four schools in Tainan City and Tainan County. Republic of China Epidemiology Bulletin 1995; 11 (11):167-176. 7. Jacob, M. Safe Food Handling: A Training Guide for Managers of Food Service Establishments. Geneva: WHO, 1989. 8. The Code of Sanitation of the Philippines: Presidential Decree No. 856. Manila: Department of Health, 1976.