1. 2009 National Western Stock Show E. Coli 0157 outbreak investigation

2. Background  The National Western Stock Show (NWSS) is a yearly event and provides fans with one of the largest assortments of a horse show, livestock, and rodeo in the world.  When: January 10-25, 2009  Where: Denver, CO  The National Western Stock Show (NWSS) is a yearly event and provides fans with one of the largest assortments of a horse show, livestock, and rodeo in the world.  When: January 10-25, 2009  Where: Denver, CO

3. Additional Background  Big event-650,000+ in attendance  Local, national, and international attendees  Covers over 100+ acres  Many exhibitors  Large number of venues,, including Children’s Activity Pavilion  Big event-650,000+ in attendance  Local, national, and international attendees  Covers over 100+ acres  Many exhibitors  Large number of venues,, including Children’s Activity Pavilion

4. COOPERATION, PARTNERSHIPS  Although this event occurred in Denver County, the following investigation involved health and environmental departments throughout Colorado, CDPHE, healthcare providers, media, and the Executive Board and staff from the National Western Stock Show.

5. Collaboration between many partners - Denver metro area  CDPHE-Communicable Disease and Consumer Protection Divisions  Denver Environmental Health  Denver Public Health  Tri-County Health Department  Jefferson County Health Department  Boulder County Health Department  Broomfield Health and Human Services  CDPHE-Communicable Disease and Consumer Protection Divisions  Denver Environmental Health  Denver Public Health  Tri-County Health Department  Jefferson County Health Department  Boulder County Health Department  Broomfield Health and Human Services

6. ETIOLOGY  Escherichia coli (E. coli) O157:H7 is one of over a hundred different serotypes belonging to gram negative bacteria group E. coli  Majority of the E.coli group do not cause human illness  E. coli O157:H7 and a few other serotypes produce potent cytotoxins, called Shiga toxins (STEC)  Escherichia coli (E. coli) O157:H7 is one of over a hundred different serotypes belonging to gram negative bacteria group E. coli  Majority of the E.coli group do not cause human illness  E. coli O157:H7 and a few other serotypes produce potent cytotoxins, called Shiga toxins (STEC)

7. CLINICAL DESCRIPTION  May be asymptomatic  Mild, non-bloody diarrhea  Bloody diarrhea  Abdominal cramps  Nausea and/or vomiting  Fever-is usually absent  Complications, especially in young children-HUS  May be asymptomatic  Mild, non-bloody diarrhea  Bloody diarrhea  Abdominal cramps  Nausea and/or vomiting  Fever-is usually absent  Complications, especially in young children-HUS

8. DISEASE REPORTING  Reports are received via:  Public  Providers-physicians, clinicians, infection control personnel, hospitals, clinics  Businesses  CDPHE  CDC  Reports are received via:  Public  Providers-physicians, clinicians, infection control personnel, hospitals, clinics  Businesses  CDPHE  CDC

9. Timeline of events  1/26/09 CDPHE noticed increase in lab confirmed cases of E. coli 0157  1/26-1/30/09-Individual case investigations; suspect common exposure was stock show  2/3/09 visit to NWSS complex  2/3/09 samples sent to CDPHE lab  2/9/09 visit for more samples  1/26/09 CDPHE noticed increase in lab confirmed cases of E. coli 0157  1/26-1/30/09-Individual case investigations; suspect common exposure was stock show  2/3/09 visit to NWSS complex  2/3/09 samples sent to CDPHE lab  2/9/09 visit for more samples

10. Case numbers:  29 confirmed cases  19 primary cases  10 secondary cases  1 probable case  9 cases hospitalized  2 cases of HUS  29 confirmed cases  19 primary cases  10 secondary cases  1 probable case  9 cases hospitalized  2 cases of HUS

11. Case Definition  Confirmed-  Lab confirmed  Onset since January 10  PFGE patterns 00-A/02-F or 00-A/09A  Probable-  Diarrhea in a person epi-linked to a confirmed case  Incubation period-2-10 days  Confirmed-  Lab confirmed  Onset since January 10  PFGE patterns 00-A/02-F or 00-A/09A  Probable-  Diarrhea in a person epi-linked to a confirmed case  Incubation period-2-10 days

12. CharacteristicCases Age in years -- range (median)1 - 66 (5) note: age missing on 1 probable case Gender -- n (%) -Male7 (23%) -Female23 (77%) County of residence -- n (%) -Adams1 (3%) -Arapahoe4 (13%) -Boulder1 (3%) -Broomfield1 (3%) -Denver12 (40%) -Douglas7 (23%) -Jefferson4 (13%)

13. VISIT FREQUENCIES

14. CASE COUNTS

15. CASE CONTROL STUDIES  Coordinated through CDPHE  Administered by staff from public health departments  Risk factors-touching certain animals located in specific areas, i.e. “Kids Zone” and visiting the Stockyards area  Protective factors-visiting the Coliseum area and eating/drinking there; and aware that animals can transmit disease  Coordinated through CDPHE  Administered by staff from public health departments  Risk factors-touching certain animals located in specific areas, i.e. “Kids Zone” and visiting the Stockyards area  Protective factors-visiting the Coliseum area and eating/drinking there; and aware that animals can transmit disease

16. Challenges for public health partners  Event was over  Sampling and testing methods  Entire event revolved around animals and animal feces  Media response  Children in daycare  Event was over  Sampling and testing methods  Entire event revolved around animals and animal feces  Media response  Children in daycare

17. Environmental Investigation  Site visits  Walk through of area  Sampling of area ( 3rd floor “Feed the Animals” exhibit)  Answering questions for staff  Cleanup  Site visits  Walk through of area  Sampling of area ( 3rd floor “Feed the Animals” exhibit)  Answering questions for staff  Cleanup

18. Sampling  50 initial swabs of area. All swabs tested negative for E. coli 0157  4 specimens from floor sweepings and the mats on which animals stood in the “Feed the Animals” area on the third floor. All four tested positive for the identical strain of E. coli O157 found in the ill persons.  50 initial swabs of area. All swabs tested negative for E. coli 0157  4 specimens from floor sweepings and the mats on which animals stood in the “Feed the Animals” area on the third floor. All four tested positive for the identical strain of E. coli O157 found in the ill persons.

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20. Communication and Situation Reports  Meetings with NWSS management  Daily conference calls between all parties  Individual phone calls, emails, and CEDRS  Coordination with PIO’s  Meetings with NWSS management  Daily conference calls between all parties  Individual phone calls, emails, and CEDRS  Coordination with PIO’s

21. E. coli outbreak linked to Denver cattle show Posted on February 5, 2009 by Doug PowellDoug Powell Health officials are investigating an outbreakHealth officials are investigating an outbreak linked to Colorado's largest stock show after 20 people, including 17 kids, came down with E. coli O157. Chris Urbina with Denver Public Health said a lab has confirmed 20 E. coli cases but the number is expected to grow. The Colorado Department of Public Health and Environment said in a news release, "While the investigation is ongoing, we suspect that these infections are linked to attending the National Western Stock Show, which was held in Denver from Jan. 10 to Jan. 25.” Although health officials haven't pinpointed the exact cause of the E. coli, the common denominator in all the cases is the stock show, Urbina said. Many schools and child care centers organized trips to the stock show, and many children attended with their families, so there is the potential that the number of cases could jump, health officials said. On Wednesday, the CDPHE sent a letter to daycare centers alerting them to the outbreak and asking the staff to take special precautions. For disease reporting or other questions please contact the CDPHE Communicable Disease program at 303-692-2700.

22. Working with the media  Dr. Chris Urbina from Denver Public Health was the lead  PIOs coordinated talking points  Stock Show CEO conducted interviews with media  Dr. Chris Urbina from Denver Public Health was the lead  PIOs coordinated talking points  Stock Show CEO conducted interviews with media

23. Educational opportunities  Attendees  Childcare facilities  NWSS staff  Investigative team  Attendees  Childcare facilities  NWSS staff  Investigative team

24. Biggest Lesson Learned….

25. Prevention and future planning for NWSS  Focus efforts on exhibits that are geared towards children  Provide signage about risks of animal-associated illness and encouraging hand hygiene, especially at the entrances to areas where animals are housed and areas where food is served/consumed.  Discourage use of sippy cups, pacifiers, bottles, food/beverage in animal contact areas  Provide hand washing facilities with running water and soap  Transition areas prohibiting strollers from entering  Move food vendors away from feed the animals area  Focus efforts on exhibits that are geared towards children  Provide signage about risks of animal-associated illness and encouraging hand hygiene, especially at the entrances to areas where animals are housed and areas where food is served/consumed.  Discourage use of sippy cups, pacifiers, bottles, food/beverage in animal contact areas  Provide hand washing facilities with running water and soap  Transition areas prohibiting strollers from entering  Move food vendors away from feed the animals area

26. Why the recommendations?  Since 1996, 100+ human infectious disease outbreaks involving animals in public settings reported to CDC  Risk factors-Direct animal contact and inadequate hand washing  In 2000, two E. coli outbreaks of 0157-H7 in Pa. and Wash. prompted CDC to establish recommendations  Since 1996, 100+ human infectious disease outbreaks involving animals in public settings reported to CDC  Risk factors-Direct animal contact and inadequate hand washing  In 2000, two E. coli outbreaks of 0157-H7 in Pa. and Wash. prompted CDC to establish recommendations

27. Acknowledgements  CDPHE: Alicia Cronquist, Nicole Comstock, Jennifer Sadlowski, Ken Gershman, and Nicole Grisham  DPH/DH: Dee Martinez, Tony Encinias, Dr. Chris Urbina, Dr. David Cohn, Dr. Judith Shlay, Carol McDonald, Stephanie Stark, Lori Kennedy, and Charles Smedly  CDPHE: Alicia Cronquist, Nicole Comstock, Jennifer Sadlowski, Ken Gershman, and Nicole Grisham  DPH/DH: Dee Martinez, Tony Encinias, Dr. Chris Urbina, Dr. David Cohn, Dr. Judith Shlay, Carol McDonald, Stephanie Stark, Lori Kennedy, and Charles Smedly  DEH: Bob McDonald and Abby Bronken

28. Questions????

29. Contact Info  Carol McDonald DPH Epidemiology and Surveillance 303-602-3626 Carol.mcdonald@dhha.org  Abby Bronken DEH Public Health Inspection 720-865-5377 Abby.bronken@denvergov.org  Carol McDonald DPH Epidemiology and Surveillance 303-602-3626 Carol.mcdonald@dhha.org  Abby Bronken DEH Public Health Inspection 720-865-5377 Abby.bronken@denvergov.org