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Staphylococcal Food Poisoning on a Cruise Ship

In February 1983, an outbreak of staphylococcal food poisoning occurred on a Caribbean cruise ship sailing from the United States. The probable source was cream pastries served during two separate meals.

The overall attack rate of acute gastroenteritis on board, estimated from the 56 passengers who responded to a 10% systematic survey of the 715 passengers, was 32%. Ninety-four percent of patients filling out questionnaires complained of nausea and/or vomiting, 82% reported diarrhea, and 60% reported abdominal cramps. Symptoms usually subsided within 12 hours, although 36% of patients indicated illness lasted at least 2 days. The incubation period ranged from 1 to 8 hours (median 5 hours).

When plotted by time of onset, the number of cases peaked twice, corresponding to meals served 2 days apart. Forty-six (95.8%) of 48 patients and 20 (58.8%) of 34 well passengers ate the cream pastry served for dessert on the evening of February 22 (p 0.001). Seven (70%) of 10 patients and four (13.3%) of 30 controls ate a similar pastry item for lunch on February 24 (p 0.001).

Staphylococcus aureus, phage type 85/+, was isolated from the stools of five (38.4%) of 13 patients cultured and from none of nine controls. The same staphylococcal phage type was grown from a perirectal swab, an anterior nares culture, and a swab of a forearm lesion from three of the seven crew members who made pastry. Pastries from the implicated meals were not available for culture because the pastry kitchen routinely disposed of leftovers. Cultures of the mixture used to prepare the cream filling were positive.

Investigation of the ship's pastry kitchen did not reveal any improper food handling in the preparation of the pastry items. Refrigeration temperatures were adequate, and the foodhandlers were free of pustular skin lesions. However, because the pastry was prepared in large quantities in several steps by a number of foodhandlers, opportunities could have existed for the introduction of staphylococci into the pastry, with adequate time for incubation of the enterotoxin. Reported by Div of Quarantine, Center for Prevention Svcs, Dengue Br, Div of Vector-Borne Viral Diseases, Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Although Staphylococcus remains the second most common etiologic agent (after Salmonella) in foodborne outbreaks in the United States, this is the first well-documented outbreak of staphylococcal food poisoning on a cruise ship sailing from the United States. This outbreak emphasizes the importance of extreme care in adequately refrigerating perishable food items prepared in large kitchens. The elaboration of staphylococcal enterotoxin requires incubation at temperatures above 6.7 C (44 F). The investigation also shows the value of phage typing to support epidemiologic evidence on the probable source of an outbreak, despite the inability to culture the implicated food item.

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