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International Notes Campylobacter Enteritis -- New Zealand, 1990

In August-September 1990, an outbreak of Campylobacter enteritis occurred at a camp near Christchurch, New Zealand. This report provides a preliminary summary of the investigation of this outbreak by the New Zealand Communicable Disease Centre and the Canterbury Area Health Board.

The outbreak occurred at a modern camp and convention center (which hosts greater than 15,000 visitors each year) located approximately 19 km (12 miles) from Christ church. The facility caters to schools and church and youth groups and provides meals, housing, and indoor and outdoor recreation for visitors. Water at the camp, obtained from three springs on the premises, was neither chlorinated nor filtered before use. On September 4, the Canterbury Area Health Board received reports that two persons who lived at the camp had been hospitalized with Campylobacter enteritis and that a number of children who had visited the camp during the week of August 27-31 had become ill with vomiting and headaches.

All persons at the camp during August 27-31 (58 visiting children (age range: 9-12 years), 19 camp leaders, and 39 staff and their family members) were interviewed to identify cases of Campylobacter enteritis and risk factors for infection with Campylobacter. Because of concerns about the accuracy of information provided by children who had attended the camp, analysis of food and water consumption was limited to camp leaders and staff.

Based on completed interviews with 99 (85%) of the 116 persons, 44 (44%) had developed a gastrointestinal illness that met the case definition for Campylobacter enteritis,* with onset from August 9 through September 7 (Figure 1). Predominant manifestations included abdominal pain (80%), diarrhea (75%), headache (61%), nausea (60%), fever (59%), and vomiting (55%). The 44 case-patients ranged in age from 3 to 51 years (median: 11 years); 30 (68%) were male. Stool specimens from 11 of 14 symptomatic persons yielded C. jejuni. The pattern of clinical illness in persons with culture-confirmed Campylobacter enteritis was similar to that in persons whose illness was not culture-confirmed.

Investigation determined that case-patients drank more unboiled water than did persons who were not ill (median: 4 cups vs. 2 cups each day; p=0.03, Kruskal-Wallis test) and were more likely to drink water obtained from one particular spring (40/44 (90%) vs. 38/55 (69%); p less than 0.01, Fisher's exact test).** Coliform counts of water specimens from all three springs (collected at taps from staff houses and the camp kitchen) indicated fecal contamination. Water was not examined specifically for Campylobacter.

Private farmland adjacent to the camp is grazed by sheep and cattle. During the investigation, runoff from the surrounding pasture was noted to enter two springs through the basin covers. Torrential rains during the middle of August may have facilitated the seepage of surface contamination into the spring water.

Control efforts were initiated on September 11 and included 1) using rainwater and potable water supplied by tanker and boiling the water used in staff households until a water-treatment system was installed, 2) installing a water-treatment system, 3) conducting a complete water and sanitation survey, and 4) implementing an informal surveillance system to monitor illness among visitors and staff at the camp.

Since implementation of these control measures, no further cases of enteritis have been reported from the camp. Reported by: J Stehr-Green, MD, New Zealand Communicable Disease Centre, Porirua; P Mitchell, MB BS, C Nicholls, RGON, S McEwan, Dip Home Science, A Payne, BSc (Hons), Canterbury Area Health Board, Christchurch, New Zealand. Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: C. jejuni is the most common bacterial cause of gastroenteritis in the developed world (1). C. jejuni is frequently cultured from stool samples from patients with diarrhea in Africa, Australia, Europe, and North America and has been isolated from patients with diarrhea more frequently than Salmonella and Shigella combined (2). During 1989, in the United States, state health departments reported 7970 isolates of C. jejuni through CDC's Campylobacter Surveillance System; in New Zealand, Campylobacter infections accounted for 67% of reported gastrointestinal illnesses (3).

Most outbreaks of C. jejuni enteritis have been associated with consumption of raw milk or contaminated water (4). In the first known outbreak of waterborne campylobacteriosis, approximately 3000 persons in Bennington, Vermont, developed C. jejuni enteritis after the town's water system became contaminated with water from an unfiltered source (5). As in the New Zealand outbreak, boiling of water and other interim control measures were effective in stemming the outbreak. Waterborne outbreaks of C. jejuni infection reported to CDC from 1978 through 1986 were all associated with consumption of untreated surface water or inadequately chlorinated water. No reported outbreaks of Campylobacter enteritis have been associated with treated water.

Although other outbreaks such as that in Christchurch have been reported, most Campylobacter infections occur as sporadic cases (6). As with Salmonella, foods of animal origin are the most important sources of Campylobacter. In the United States, poultry is the most common source of sporadic infections (7,8). Epidemiologic investigations have also implicated raw milk (9), eggs, beef (6), contaminated water (5), and contact with infected animals, including cats and puppies (7,10).

References

  1. Blaser MJ, Hopkins JA, Vasil ML. Campylobacter enteritis. N Engl J

Med 1984;305:1444-52.

2. Blaser MJ, Wells JG, Feldman RA, Pollard RA, Allen JR, the Collaborative Diarrhea Disease Study Group. Campylobacter enteritis in the United States: a multicenter study. Ann Intern Med 1983;98:360-5.

3. New Zealand Communicable Disease Centre. Communicable Disease New Zealand: annual supplement. Porirua, New Zealand: New Zealand Communicable Disease Centre, 1989:16.

4. CDC. Campylobacter isolates in the United States, 1982-1986. MMWR 1988;37(no. SS-2):1-13.

5. Vogt RL, Sours HE, Barett T, et al. Campylobacter enteritis associated with contaminated water. Ann Intern Med 1982;96:292-6.

6. Finch MJ, Blake PA. Foodborne outbreaks of campylobacteriosis: the United States experience, 1980-1982. Am J Epidemiol 1985;122:262-8.

7. Deming MS, Tauxe RV, Blake PA, et al. Campylobacter enteritis at a university: transmission from eating chicken and from cats. Am J Epidemiol 1987;126:526-34.

8. Seattle-King County Department of Public Health. Surveillance of the flow of Salmonella and Campylobacter in a community. Seattle: Seattle-King County Department of Public Health, Communicable Disease Control Section, 1984.

9. Schmid GP, Schaefer RE, Pilkaytis BD, et al. A one-year study of endemic campylobacteriosis in a midwestern city: association with consumption of raw milk. J Infect Dis 1987;156: 218-22. 10. Blaser MJ, Cravens J, Powers BW, Wang WL. Campylobacter enteritis associated with canine infection. Lancet 1978;2:979-81.

  • The following in a person who had been at the camp: either a stool culture positive for C. jejuni, a history of diarrhea lasting greater than or equal to 2 days, or four of the following signs/symptoms--diarrhea for 1 day, nausea, vomiting, abdominal pain, fever, headache, myalgia, and malaise.

** Analysis based on total sample of 99 persons because spring source was known for all persons interviewed.

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