State of California Center For Disease Control and Prevention
Phan, Cruz, Cox 1
Date: Tuesday, May 7, 2013
To: State and Territorial Public Health Laboratory Directors State and Territorial Epidemiologists County Public Health Departments
Subject: POTENTIAL STUDY EXAMINING THE CAUSE FOR POSSIBLE FOOD RELATED ILLNESS
A tainted food product called cheeseburger-in-a-can is believed to be associated with a mystery airborne illness. The actual direct cause, transmission, and incubation period for this illness are being thoroughly investigated. The food product was found and consumed by 5 people on Delta Airlines flight 331 from Chicago OHare International Airport (ORD) to San Francisco International Airport (SFO). Three patients have been admitted to San Francisco Generals ED with symptoms of this mystery illness. Patient 1, who consumed the food product on flight 331, is in stage 3 of the illness, lacking a heart rate and neurological function. Patients 2 and 3 are believed to have come in contact with patient 1 on flight 331, and are currently in stage 2 of the illness, a comatose state. Approximately 435 people were aboard Delta Airlines flight 331 on Sunday, May 5, 2013. This flight had numerous connecting flights from SFO to major international airports around the country where similar cases of this illness have been reported (Figure 1), including: HartsfieldJackson Atlanta International Airport (ATL), Detroit Metropolitan Wayne County Airport (DTW), and San Antonio International Airport (SAT). Because this illness is believed to be transmitted through respiratory droplets and saliva, all passengers on these flights and all other airport patrons and employees present on May 5th have potentially been exposed through contact with passengers who consumed contaminated food product. Additionally, all citizens who come in contact with potentially exposed passengers after they have left the airports may State of California Center For Disease Control and Prevention Phan, Cruz, Cox 2
become exposed themselves. As a result, the number of infected persons may quickly reach the hundreds of thousands. Case-control and laboratory studies for all reported cases around the country are being employed to investigate the suspected cause of the infections and the resulting at-risk populations. Step 1: Initial Identification of Cases in San Francisco [COMPLETED] 1 patient in stage 3, 2 patients in stage 2 (all admitted in stage 1 with high-grade fever, muscle aches, and unusual tiredness) Step 2: Identifying Association between Flight and Illness [COMPLETED] Upon interviewing patient 1, it was discovered that he consumed an old canned food product during a 6-hour delay on the tarmac on flight 331. Upon interviewing patients 2 and 3, it was discovered that they did not consume the food product but were seated near patient 1 on flight 331. All patients interviewed while in stage 1. Hypothesis: Patient 1 became infected through consumption of canned food, while patients 2 and 3 were exposed to the illness via airborne transmission. Step 3: Confirming Hypothesis through Laboratory Studies [COMPLETED] Obtained mouth swabs and blood samples from the three patients in San Francisco and sent it to main CDC laboratory for confirmation. Obtained food can in question and sent it to CDC for comparison with patient samples. ! Lab results confirmed same pathogen present in patient samples and canned food. Step 4: Data Collection of Infected and Exposed Patients [ONGOING] Contacted destination cities of connecting flights and discovered incidences of cases with similar symptoms (Figure 1). State of California Center For Disease Control and Prevention Phan, Cruz, Cox 3
! 4 additional patients interviewed, confirmed to have consumed food item, and confirmed to have pathogen through laboratory testing. All are now in stage 3. CDC epidemiologists will interview all passengers on all flights resulting in confirmed cases. Cities with patients exhibiting these symptoms should continue reporting data and patient samples to the CDC. At the moment, the food attack rate from the common-vehicle exposure is 100%. The secondary attack rate will be determined upon further investigation of those exposed to the primary cases. If and when lab results from reported cases in other cities are confirmed as a match to the pathogen identified in the San Francisco cases, an odds ratio will be calculated for the overall case-control study to determine if the exposure is positively related to the disease. As a preventative measure, an official recall will be issued for the food product. Delta Airlines will be required to sterilize all planes in questions. Individual airports should notify all patrons who were present on Sunday, May 5, 2013 about possible exposure. Notification should encourage all persons exhibiting symptoms to seek medical assistance. Patients exhibiting symptoms of stage 1 should be immediately isolated and samples collected. To ensure efficiency of data collection and prevent hospital overcrowding with unexposed persons, a number of solutions to potential biases are given in Table 1. State and local public health departments, hospitals, and airport officials participating in the investigation of this outbreak should report any and all relevant information to the CDC. All relevant data collected in regards to this mystery illness outbreak will contribute to the case- control study to accurately measure the association between exposure and illness, as well as the containment and control of the spread of this fatal and acute disease. State of California Center For Disease Control and Prevention Phan, Cruz, Cox 4
Figure 1. Primary cases and connecting flights
Table 1. Potential Biases and Corrections for these Biases
Bias Corrections Misdiagnosis of illness Mandate confirmation through laboratory testing. Under/over reporting Encourage all susceptible persons to contact local officials. Proper training of CDC and local personnel to eliminate improbable exposures from reporting. Recall (over reporting) bias Proper training of CDC and local personnel to eliminate improbable exposures from reporting.