No one wants the ‘Wedding Bell Blues.’ 
My son is getting married in mid-August, and the related preparations are starting to pick up a sense of greater urgency. I have been instructed not to interfere. Accordingly, I had a bit of time to follow up on the related morbid question that occurred to me; generally, what is the available CDC published data associating foodborne illness outbreaks with wedding celebrations?
The first relatively recent reference addressed an outbreak in Fayette County, Kentucky. In August 1990, 42 (65 percent) of 65 persons became ill with gastroenteritis following a restaurant brunch for a wedding party on August 11. Twenty-three ill persons sought medical care; four were hospitalized. The median incubation period was 28 hours. Stool cultures from seven patients yielded Salmonella Enteriditis (SE); all five SE isolates tested were phage type 8. Eating eggs benedict with hollandaise sauce was the only food exposure statistically associated with illness. Review of food handling practices at the restaurant indicated that eggs used in the hollandaise had been pooled, incompletely cooked, and served more than 1 hour after preparation. 
From July 21 through September 3, 1990, 90 (36 percent) of 250 persons who attended or ate food taken from a wedding in Des Moines, Iowa, on July 14 developed trichinosis. Most (approximately 95 percent) of the 250 persons had immigrated to the United States since 1975 from Southeast Asian countries. Of those who became ill, 52 (58 percent) were treated by physicians; one of the 52 was hospitalized. Case histories were obtained from 39 ill and 13 well persons who attended the wedding. Of the 39 ill persons, 34 (87 percent) ate uncooked pork sausage; no other foods were associated with illness. The sausage had been prepared from 120 pounds of commercially purchased pork and was served uncooked, as is customary for that food item in Southeast Asian culture. Interestingly, only four (4 percent) of 107 persons who attended the wedding and were interviewed knew about trichinosis or about the potential hazards of eating undercooked pork. 
On June 24, 1995, a total of 76 persons attended a catered wedding reception in Suffolk County, New York. Following the reception, attendees contacted the local health department to report onset of a gastrointestinal illness. Salmonella group D was isolated from stools of the 13 persons who submitted specimens; 11 of the 13 isolates further typed were identified as Salmonella Enteritidis. An investigation by the Suffolk County Health Department involved the 28 ill attendees and the 12 well attendees that were contacted. Twenty-six (93 percent) of 28 persons who had eaten Caesar salad became ill, compared with two (17 percent) of 12 persons who had not eaten the salad. The Caesar salad dressing was prepared with 18 raw shell eggs, olive oil, lemon juice, anchovies, Romano cheese, and Worcestershire sauce at 11:30 a.m. on June 24. The mixture was held unrefrigerated at the catering establishment for 2 hours, and was then placed in an unrefrigerated van until delivered and served at the reception at 6 p.m. 
On May 15, 1997, the Westchester County Health Department in New York was notified of two laboratory-confirmed cases of cyclosporiasis and other cases of diarrheal illness among persons who attended a wedding reception on April 20 at a private residence in the county. Of the 140 persons interviewed, 20 (14 percent) had illness that met the case definition; four cases were laboratory-confirmed. Eating raspberries was the exposure most strongly associated with risk for illness in univariate analysis and was the only exposure significantly associated with risk for illness in multivariate logistic regression analysis. The raspberries had not been washed. 
On June 10, 2000, a total of 83 persons attended a catered wedding reception in Pennsylvania. Approximately 8 days later, the bride notified the local health department that she, her husband, and many guests at the reception had a gastrointestinal illness. Stool specimens from attendees were positive for oocysts of the coccidian parasite Cyclospora cayetanensis, and an epidemiologic investigation was begun by the Philadelphia Department of Public Health and the Centers for Disease Control and Prevention (CDC). Fifty-four (68.4 percent) of the 79 interviewed guests and members of the wedding party met the case definition. The wedding cake, which had a cream filling that included raspberries, was the food item most strongly associated with illness (multivariate relative risk, 5.9; 95 percent confidence interval, 3.6 to 10.5). Leftover cake was positive for Cyclospora DNA by polymerase chain reaction analyses. Sequencing of the amplified fragments confirmed that the organism was Cyclospora cayetanensis. 
On July 18, 2001, the New York City Department of Health and Mental Hygiene received a complaint of illness from a person who ate at a wedding celebration on July 14; S. Uganda was isolated from the stool of another wedding attendee. By early August, a distinct strain of S. Uganda had been isolated from 11 New York City residents with illness onsets occurring June 24-August 4. All 11 case-patients were of Hispanic ethnicity, and 6 of 10 interviewed reported having eaten roast pork from a New York City restaurant in the 3 days before illness onset. Additionally, roast pork from that restaurant had been served at the wedding named in the initial consumer complaint. A sample of leftover roast pork from the wedding was positive for the same strain of S. Uganda as the one isolated from patients. At the time of a sanitary inspection initiated by the consumer complaint, raw pork was held at inadequate temperatures at the restaurant, and thermometers were inadequately used during cooking and hot-holding. Potential sources of cross-contamination, surfaces and wiping cloths, were not properly sanitized. The same S. Uganda strain found in patients was isolated from a cooked pork sample collected from the restaurant on July 18. 
The CDC has compiled more related recent data, available at its Foodborne Outbreak Online Database. The Database is designed to allow the public direct access to information on foodborne outbreaks reported to the Centers for Disease Control and Prevention (CDC). Most outbreaks are reported to the National Outbreak Reporting System (NORS) by the state, local, territorial, or tribal health department that conducted the outbreak investigation. Outbreak reporting is voluntary. Multi-state outbreaks are generally reported to NORS by CDC. Clearly, there are far more outbreaks that simply have not been reported to the CDC, as outbreak reporting is in fact voluntary.
The Database identifies outbreaks from 1999 through 2007 in part by location, including a “wedding” location category. The wedding reception database indicates the CDC was notified of approximately 65 outbreaks associated with weddings during that time frame, with 2301 persons becoming ill, and 52 being hospitalized. The vast majority of these outbreaks associated with weddings unsurprisingly occurred during the spring and summer months. Thirty-seven outbreaks, over 50 percent, involved confirmed or suspected norovirus cases; eight outbreaks were attributed to a number of Salmonella strains. The implicated vehicles were quite varied, and included strawberries, chicken dishes, antipasti, roast beef, salads, cakes, and ice water. 
Foodborne illness outbreaks are obviously not associated with weddings only in the United States. A review of recent related articles identified an outbreak in March, 2010, in Vadodara, India, where as many as 150 persons suffered from food poisoning after eating a wedding feast including dal, rice, laddu and various vegetables. In May, 2010, wedding food also hospitalized at least one hundred people in Northern India. Apparently, for ast
rological reasons, a lot of weddings in India take place during May and June, the hottest months. Food spoils very quickly, and it is common for many wedding guests to become ill. In July, 2010, approximately four hundred people attending a wedding feast in the Kabylie region of Algeria became violently ill, with sixty wedding guests being hospitalized. Again, the summer heat increases the number of illnesses due to improperly stored or outdated food. Additionally, during the summer season and Ramadan, meals are often prepared and served outdoors, increasing the risk of foodborne illnesses.
Going with professional and experienced caterers may be the wise choice. Even there, however, there is the risk of a foodborne illness outbreak. A recent story on msnbc.com reported new CDC figures showing that illnesses from reported outbreaks of food poisoning linked to catering outpace those from restaurants or home cooking. Dana Cole, a CDC researcher quoted in the story, provided data indicating that between 1998 and 2008 there were 833 outbreaks of foodborne illness traced to caterers, causing 29,738 illnesses, 345 hospitalizations, and 4 deaths. Proportionately, the outbreaks from catering are higher than the 22,600 illnesses from 1,546 reported home cooking outbreaks and the 101,907 illnesses from 7,921 outbreaks in restaurants and delis. In fact, according to Cole, there are 36 illnesses for every outbreak caused by catering compared with 13 illnesses per outbreak from restaurants or home-prepared meals. 
A recent paper presented the microbiological and epidemiologic results of a large Clostridium perfringens outbreak in England, in July 2009, occurring simultaneously at two weddings that used the same caterer. The outbreak involved several London locations and required coordination across multiple agencies. A case-control study was carried out to analyze possible associations between the food consumed and becoming ill. Food, environmental, and stool samples were tested for common causative agents, including enterotoxigenic C. perfringens. The clinical presentation and the epidemiologic findings were compatible with C. perfringens food poisoning and C. perfringens enterotoxin was detected in stool samples from two cases. The case-control study found statistically significant associations between becoming ill and eating either a specific chicken or lamb dish prepared by the same food handler of the implicated catering company. 
I am pretty confident no one associated with my son’s wedding will read this article before the wedding. I will inevitably be thinking about it, though, when I grab another canape` from a passing tray.
 “Wedding Bell Blues” is a song written and recorded by Laura Nyro in 1966. It became a number one hit for The 5th Dimension in 1969, spending three weeks as number one on the U.S. pop singles chart in November, 1969, and subsequently becoming a popular phrase in American culture.
 “Epidemiologic Notes and Reports Update: Salmonella enteritidis Infections and Shell Eggs — United States, 1990”, MMWR, December 21, 1990 / 39(50); 909-912.
 “Epidemiologic Notes and Reports Trichinella spiralis Infection — United States, 1990”, MMWR, February 01, 1991 / 40; 57-60.
 “Outbreaks of Salmonella Serotype Enteritidis Infection Associated with Consumption of Raw Shell Eggs — United States, 1994-1995”, MMWR, August 30, 1996 / 45(34); 737-742.
 “Update: Outbreaks of Cyclosporiasis — United States, 1997”, MMWR, May 30, 1997 / 46(21); 461-462.
 Ho AY, Lopez AS, Eberhart MG, Levenson R, Finkel BS, da Silva AJ, et al. “Outbreak of cyclosporiasis associated with imported raspberries, Philadelphia, Pennsylvania, 2000”, Emerg Infect Dis, Vol. 8, No. 8, August 2002.
 Jones RC, Reddy V, Kornstein L, Fernandez JR, Stavinsky F, Agasan A, et al. “Salmonella enterica serotype Uganda infection in New York City and Chicago”, Emerg Infect Dis, Vol. 10, No. 9, September 2004.
 OutbreakNet Foodborne Outbreak Online Database, Centers for Disease Control and Prevention, at http://wwwn.cdc.gov/foodborneoutbreaks/.
 “Caterers dish up more cases of food poisoning”, JoNel Aleccia, msnbc.com, 7/30/2010.
 Eriksen J, Zenner D, Anderson SR, Grant K, Kumar D. “Clostridium perfringens in London, July 2009: two weddings and an outbreak”. Euro Surveill. 2010;15(25):pii=19598.
Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19598