Editor’s Note:  This is the third installment in a ten-part series on meaningful foodborne illness outbreaks. After many outbreaks of E. coli O157:H7, usually associated with a recall of contaminated beef, Oklahoma woke up one morning to learn that another strain could also injure and kill.   The largest outbreak of E coli O111 saw limited attention out of the Sooner State, but there it was a scary mystery story.  It happened this way: country-cottage-Ecoli-O111.jpgOn Friday, August 22, 2008, the Director of the Tulsa EMSA/Metropolitan Medical Response system notified the Oklahoma State Department of Health (OSDH) and Tulsa Department of Health (TDH) of an unusual increase in patients being admitted to St. Francis Hospital in Tulsa with severe hemorrhagic diarrhea.  Patient interviews indicated that all had recently eaten at the Country Cottage restaurant, a buffet-style eatery, in Locust Grove, Mayes County, Oklahoma, and laboratory testing indicated all were suffering from E. coli O111: NM infection. The Mayes County Health Department sanitarian conducted an unannounced inspection of Country Cottage on August 23, and within 48 hours of the first reported illness associated with Country Cottage, the restaurant was closed.  Meanwhile, illnesses continued to be reported and at one point at least 70 people had been hospitalized; 17 were on dialysis due to kidney failure attributable to hemolytic uremic syndrome (HUS) secondary to E. coli infection. Epidemiologic and environmental investigations were conducted, and several potential vehicles of introduction and spread within Country Cottage were explored by investigators; however, according to the OSDH final report:

E. coli O111 was not isolated by bacterial culture methods or identified by molecular methods in any of them. In the absence of finding the outbreak organism in any food handler or environmental specimen, how E. coli O111 entered the restaurant and was spread over numerous consecutive days is unclear.  Apart from whatever mode the bacteria was introduced into the restaurant, the epidemiologic findings suggest that food borne transmission of E. coli O111 through various food items–either contaminated with the bacteria by food handlers or by cross-contamination from food preparation equipment, counter surfaces, or storage areas – occurred at Country Cottage from August 15 – 24.

The findings of epidemiologic investigators were:

  • A point-source outbreak originated from the Country Cottage restaurant in Locust Grove, Oklahoma
  • It could not be conclusively determined how E. coli O111: NM was introduced into the restaurant because E. coli was not isolated from any environmental specimen
  • Although an exact mode of transmission for E. coli O111: NM was not identified, epidemiologic analysis suggested there was ongoing food borne transmission of E. coli to Country Cottage customers between August 15 and August 24, 2008.

In its final report OSDH concluded that at least 341 people had become ill with E. coli O111: NM during the outbreak traced to Country Cottage Restaurant.  Seventy people were hospitalized, 17 with hemolytic uremic syndrome, and one person died as a result of E. coli infection in what is believed to be the largest community outbreak of diarrheal illness and HUS attributable to E. coli O111: NM ever reported. As postscript to the story, it should be noted that Oklahoma’s State Attorney General ordered tests of private wells in the area, and some were contaminated with E. coli strains, but not O111.