Staphylococcal Food Poisoning from Turkey at a Country Club Buffet -- New Mexico

An outbreak of acute gastrointestinal illness followed a buffet served to approximately 855 people at a New Mexico country club on March 30, 1986. Of the 162 persons interviewed, 67 (35%) were ill with diarrhea, nausea, or vomiting. Twenty-four required emergency medical treatment or hospitalization. Of the 67 patients, 59 (88%) reported diarrhea; 52 (78%), nausea; 52 (78%), vomiting; 44 (66%), abdominal cramps; 30 (45%), headaches; 16 (34%), fever; and three (4%), bloody stool. Incubation periods ranged from 1.5 hours to 27.5 hours with a mean of 5.5 hours and a median of 4 hours. Duration of illness ranged from 1 to 88 hours with a mean of 26.3 hours and a median of 16 hours.

Three food items (turkey, poultry dressing, and gravy) were significantly associated with illness. For turkey, the odds ratio (OR) = 5.5 and the confidence limits (CL) = 2.3-13.1; for dressing, OR = 17.9 and CL = 6.1-56.4; and for gravy, OR = 2.9 and CL = 1.4-5.9. Bacteriologic cultures of the turkey and dressing yielded 4x10((7)) and 3x10((6)) Staphylococcus aureus organisms per gram respectively. Small concentrations of S. aureus were found in other foods that were not associated with illness, suggesting some degree of cross-contamination. Preformed staphylococcal enterotoxin type C was found in the turkey but not in the dressing.

S. aureus phage type 95 was isolated from the turkey and dressing, one food handler's nares (nasal passages) and stools, the nares of a second food handler, and the stools of a third. In addition, S. aureus that either could not be typed or was of another phage type was isolated from stools and nares of other food handlers and restaurant patrons. Two food handlers had open sores on their hands, but coagulase-positive staphylococci were not isolated from these sores. Although all of the food handlers had eaten at the buffet, none of them had gastrointestinal symptoms.

Review of food handling procedures indicated that the turkey had cooled for 3 hours at room temperature after cooking--a time and temperature sufficient for bacterial proliferation and toxin production. It was believed that the same utensils were used for both the turkey and other foods before and after cooking.

This same country club had experienced another foodborne outbreak in July 1984. The source of this outbreak was staphylococcal contamination of burritos and tacos. The ingredients had been cooked, assembled by hand, and then placed in a snack bar at room temperature. Phage typing was not performed. None of the food handlers with S. aureus isolated during investigation of the current outbreak were reported to have been working at the country club in July 1984.

After both outbreaks, food handlers were retrained by state environmental health personnel. Special emphasis was placed on increased hand washing, handling food only with gloves or implements, maintaining food below 45F (7.2C) or above 140F (60C), using smaller portions during cooling, maintaining better equipment and utensil sanitation, and exercising better management and supervision. Reported by R Munoz, MPH, E Ornelas Jr, LN Nickey, MD, S Balcorta, MSW, D Sublasky, I Rivas, El Paso City-County Health District, Texas; JT McLauchlin, RC Krehoff, PhD, GS Garcia, PE, District III, G Graves, MS, J Thompson, MPH, Community Services Bureau, Environmental Improvement Div, B Lara, P Jones, P Allman, District V, Health Svcs Div, PW Gray, J Miller, P Gutierrez, MS, J White, L Nims, MS, Scientific Laboratory Div, M Eidson, DVM, HF Hull, MD, State Epidemiologist, Office of Epidemiology, New Mexico Health and Environment Dept; Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Epidemiologic and bacteriologic data in this large outbreak strongly implicate turkey and dressing as the vehicle. Turkey has accounted for 10% to 21% of all bacterial foodborne outbreaks for which a vehicle has been determined (1). Such outbreaks are particularly frequent around the Thanksgiving and Christmas holidays. The large number of people who may eat the meat of a single bird may amplify errors in preparation and make turkey-associated outbreaks more likely to be detected. Cooking turkey calls for particular care because of the large volume of meat to be heated and cooled, the practice of preparing it the day before it is served, and the amount of handling needed to remove the meat from the carcass (2). The pathogens most frequently causing turkey-related outbreaks are Clostridium perfringens (36% of such outbreaks reported in 1982), Salmonella (36%), and Staphylococcus aureus (27%) (3).

This report illustrates several characteristics of staphylococcal foodborne outbreaks. Outbreaks most frequently involve foods high in protein. From 1977 to 1981, approximately 25 outbreaks of staphylococcal foodborne disease were reported to CDC annually. The most common vehicles were ham (27% of outbreaks with a known vehicle), potato or egg salad (15%), and poultry (11%) (4). An outbreak occurs when a contaminated food is held at inappropriate temperatures long enough to allow the organisms to elaborate toxin. The toxin is heat stable, and reheating foods will not prevent the illness. Human carriers are presumed to be the source of the enterotoxigenic S. aureus, but carriers often do not have visible lesions. Thus the absence of nasal or hand lesions is no guarantee of safety (4). As in this outbreak, the most frequently found problem is a critical error in food handling that facilitates bacterial contamination and growth (5). Proper education and supervision, along with thorough investigation of outbreaks, remain the cornerstones of prevention of foodborne illness.

References

1. Horwitz MA, Ganagarosa EJ. Foodborne disease outbreaks traced to poultry, United States, 1966-1974. J Milk Food Technol 1976;39:859-63.

2. Bryan FL, McKinley TW. Prevention of foodborne illness from turkeys by time-temperature control of thawing, cooking, chilling, and reheating turkeys in school lunch kitchens. J Milk Food Technol 1974;37:420-9.

3. CDC. Annual summary 1982. Foodborne disease outbreaks surveillance. Atlanta, Georgia: Public Health Service, 1985; DHHS publication no. (CDC)85-8185.

4. Holmberg SD, Blake PA. Staphylococcal food poisoning in the United States: new facts and old misconceptions. JAMA 1984;251:487-9.

5. Bryan FL. What the sanitarian should know about Staphylococci and Salmonellae in non-dairy products. I. Staphylococci. J Milk Food Technol 1968;31:110-6.

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