The Iowa Department of Public Health (IDPH) has completed a final report on last May’s Shiga-toxin E. coli outbreak in a Jackson County childcare facility.  Pursuant to Iowa Open Records law, IDPH has shared its findings with Food Safety News

The onset of the E. coli illnesses occurred from May 6 to May 22.  IDPH and Jackson County Public Health learned, through the reportable disease system, of a Jackson County child suffering from Shiga-toxin E. coli.

“Local public health spoke to the healthcare provider and the case’s family to get information for IDPH’s Shiga-toxin investigation form,” according to the final report. “JCPH learned the child attended local childcare and placed the child under an exclusion order to exclude the child from childcare until resolution of diarrhea and two consecutive tested negative for Shiga-toxin E. coli.”

JCPH told the childcare provider that the child could not attend the facility until released by the public health department.

Next, the family told the state and county public health officials that their child was hospitalized with the sometimes fatal kidney disease known as  hemolytic uremic syndrome or HUS.

“HUS is an illness in which the red blood cells are destroyed and the kidneys fail. HUS is a condition that can follow diarrhea caused by certain kinds of bacteria, including E. coli O157:H7 and other E. coli strains. It can be serious, especially to elderly and pediatric patients,” the report said.

HUS is also a reportable condition in Iowa, but there is no specific test for this condition. HUS is almost always identified when local public health contacts a provider to complete an investigation another reportable disease follow-up. Also, HUS can be identified if a healthcare provider calls IDPH or local public health to verbally report.

In a few days, JCPH received a reportable disease alert for a second child with Shiga-toxin E. coli who was also hospitalized with HUS. Upon investigation, the second child attended the same childcare as the first child. However,  both children only attended the childcare for one day in common and it was prior to either child having symptoms.

The second child was given exclusion orders to remain out of childcare until the resolution of diarrhea and two consecutive stool samples tested negative for Shiga-toxin E. coli.

JCPH and their childcare nurse consultant interviewed the childcare provider to see if the provider, any other staff, or any other attendees had symptoms consistent with Shiga-toxin E. coli illness. The provider denied any other ill staff or attendees had symptoms. The childcare provider was educated about ways to prevent the spread of illness and reporting requirements if staff or attendees did report consistent illness.

The childcare provider was questioned about what foods were prepared and served to the attendees on the day both children were in attendance. Both ill children ate similar things, but so did other attendees and staff who did not become ill.  The child care provider reported there was a city water main near the childcare that had broken. The city had the street and some of the property around the childcare under construction.

A food diary questionnaire did not identify any commonalities, IDPH decided to interview each case with CDC’s National Hypothesis Generating Questionnaire (NHGQ). The National Hypothesis Generating Questionnaire is a set of questions used by public health officials to interview ill people in the early stages of a multistate foodborne, The NHGQ questions were entered into an online survey and the survey link was sent to each case’s family to complete. Both families completed the survey. Results from the NHGQ survey revealed neither child was on a restrictive diet.

One child routinely took a probiotic prior to their illness. Diarrhea lasted 17 – 21 days. In their respective homes, both children ate a dish that contained ground beef. However, the source of the ground beef was different. Both children drank pasteurized milk, but different brands of milk. Two children consumed yogurt, but the brands were different.

Both children ate grapes and strawberries. Both children had contact with dogs in their homes.

The State Hygienic Laboratory at the University of Iowa (SHL) completed whole-genome sequencing (WGS) on two clinical specimens.. When the WGS results were compared to other isolates in Iowa and the United States, no other statewide or national clusters were identified.

Public health did not identify a common source for the two cases. Both children are currently recovering.

The children, one boy, and one girl were both 1 to 4 years old.  No food, water, animal, person-to-person or environmental cause  was identified  as a source of transmission

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