Running head: GASTROENTERITIS OUTBREAK Page |1

Investigation into an Outbreak of Gastroenteritis at a Canadian Cottage Retreat

Your Name

Subject and Section

Professor’s Name

March 22, 2019

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Introduction
Epidemics are one of the most dreaded occurrences in the history of mankind. Due to its scope
and effects, worldwide epidemics such as the bubonic plague have killed millions of people and resulted
great economic repercussions to countries that they have affected. This severity of its effects is one of the
reason why the field of medical science have devoted a specialized field only for the study, prevention,
and cure of such occurrences. Included in this field is the study of how certain viruses, pathogens, and
bacteria evolve against the current treatments that humans utilize against potential outbreaks In line with
this, this study would focus on understanding how epidemics spread within a contained population. In the
case presented, a gastroenteritis outbreak has spread among attendees of a business conference in a luxury
resort. Assuming the role of a medical practitioner, the author of this study would try to determine the
possible causes, vehicle, and effects of the said outbreak. All in all, the author believes that by looking
closely at the different pieces of evidences available, a plan of action can then be created to prevent the
further spread of such disease.

The Case
As stated earlier, the case at hand is about spread of a gastroenteritis among the attendees of a
business conference. The venue where the spread is believed to have started was an al-inclusive and
private resort that serves regular meals for the guests based on the time table of the activities.
Unfortunately, the spread of such disease has led to the hospitalization of about 30 individuals where one
has tragically died. Among the symptoms that the guests had experienced include severe stomach cramps,
diarrhea, and blood in the stool. Since there is similarity between their symptoms, despite the fact that the
attendees have come from different areas across Canada, then it could be presumed that the symptoms
have started since arrival. Lastly, it was said that the last patient that exhibited symptoms have been
admitted by August 9th, which was 10 days after their arrival. In order to make sure that a potential spread
could be recognized, the case definition for this study is that “Any individual that has cramps, diarrhea,
bloody stool or has been hospitalized since July 30th not obviously due to a previous condition”. Bearing
these facts into mind, an analysis of such spread can be done.

Case Analysis
Time
In the case, it could be seen that there was a 10-day period between the arrival of the guests and
the date where the last patient has been admitted. Most gastroenteritis viruses have an incubation period
of 24-48 hours, while that of norovirus is about 18-72 hours (VictoriaStateGovernment, n.d.). On the one
hand, since the first patients showed symptoms of the illness 2 days after their arrival (August 1), then
this suggests that the virus was contracted on the day of their arrival or the day prior the first appearance
of the symptoms. On the other hand, since the last showing of symptoms occurred 10 days after, then it is
possible that the last exposure was on the 7th to 9th day, following aforementioned incubation periods of
the viruses (Figure 1).

Epidemic Curve
Another way of understanding the spread of the epidemic would be through the epidemic curve.
An epidemic curve is simply the “visual display of the onset of illness among cases associated with an
outbreak” (Center for Disease Control and Prevention, n.d.). Based on the data provided on the number of
people afflicted with the disease, a table and an epi curve could be constructed as follows.
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Figure 2 – Epidemic Curve

The Epi curve shown above portrays the spread of the disease among attendees of the
conference. It could be noted that most of the symptoms (n = 6) have presented themselves during
August 3, from 12 NN to 12 MN. The spread has then subsided until August 5 12 NN to 12 MN. After
then, the spread continued sporadically, until August 9 where the last patient was admitted in the local
hospital. Considering that the number of reported patients have peaked during August 3 – PM, then the
possibilities for the meals and other exposures to be the source of the epidemic are as follows:

Possible Time of Possible Average Resulting Time for

Exposures Exposure microorganisms Incubation Exposure
and Agents (i.e., when it Date
is served)
Cucumber July 30; AM a. Campylobacte a. 2-5 days a. August 1 AM to
Sushi r b. 6-24 August 4 AM
b. Clostridium hours b. July 30 AM to
perfringens c. 3-4 days August 1 PM
c. E.coli d. 7 hours c. August 2 AM to
O157H7 August 3 AM
d. Salmonella d. July 30 PM
Sweet July 30; 6 a. E.coli a. 3-4 days a. August 2 PM to
potato tacos PM O157H7 August 3 PM
or burgers
Swimming July 31 a. E. coli a. 3-4 days a. August 3 AM to
race in the b. Shigellosis b. 1-3 days August 4 AM
lake c. norovirus c. 12 – 48 b. August 1 to August
hours 4
c. July 31 to August 2

Scavenger July 31 a. Borrelia a. 3- 30 days a. August 3 to August

hunt in the burgdorferi 31
woods
Chicken July 31; AM a. Campylobacter a. 2-5 a. August 2 AM to
Caesar b. Clostridium days August 5 AM
Salad perfringens b. 6-24 b. July 31 AM to
c. E.coli O157H7 hours August 1 AM
d. Salmonella c. 3-4 c. August 4 AM to
days August 5 AM
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e. Staphylococcus d. 7 d. July 31 PM
aureus hours e. July 31 PM
e. 1-6
hours
Cauliflower July 31; PM a. Clostridium a. 6- 24 a. August 1 AM to
curry perfringens hours August 1 PM
b. Bacillus cereus b. 30 b. July 31 PM to
toxicosis (emetic- minut August 1 AM
type) es to
6
hours
Pasta with July 31; PM E.coli O157 a. 3-4 a. August 3 PM to
Basil Pesto days August 4 PM

The graph above would show different answers to the questions at hand. First, the characteristic
of the curve as well as the number of people afflicted would suggest that this is indeed an epidemic.
Aside from this, but looking at the peaks and the troughs of the epi curve itself, one could see that this is
a kind of ‘point-source outbreak’. Generally speaking, in a point source outbreak, “persons are exposed
over a brief time to the same source, such as a single meal or an event” (Center for Disease Control and
Prevention, n.d.). This results to a graph with one single peak, and smooth curve on both sides showing
onset of the diseases on one side and the gradual tapering of the cases on the other. Accordingly, this
shows that there is no propagation (person-to-person) contamination that is happening between the
patients. As compared to point-source outbreaks, propagation would show a “curve shape of
progressively taller peaks”, which is not the case in the graph provided above.

Person
In assessing the spread of an epidemic, another factor that must be taken into consideration is the
demographic data of those who are afflicted with the disease. This includes age and gender, among other
factors. However, considering that our sample population is only limited to adults, due to the nature of the
said conference, the demographic factors that would be considered are only gender and age (25 – 60 years
old). The following sections would determine if there’s correlation between the said factors and the
spread of the disease through the use of tabular representations and odd ratios.

Gender
In analyzing demographic factors, it is important to determine whether there is a specific
correlation between gender and illness. Doing so would help rule out as to whether the disease is sex-
related or not. Aside from this, looking at these facts would also help the practitioner to determine the
manner of transmission by isolating possible mediums (or vehicles) of exposure (i.e., water in the
women’s comfort room). To determine whether there is a relationship between these two variables, a
table below is provided (Table 2 and 3). At first glance, data in table 2 would show that the number of
females who were afflicted of the disease is lower as compared to the males. However, due to the greater
total number of former attendees, it is important to view the differences in terms of percentages.
Accordingly, Table 3 provides the differences in percentages between males and females who contracted
the diseases relative to their groups. It shows that there are no significant differences between the two
gender groups, which can help us remove it from the possible mediums of transmission for the disease at
hand.
ILL Column Labels
Row Labels N Y Total
F 11 16 27
M 9 14 23
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Total 20 30 50
Row Labels Y Percentage Odds Ratio:
F 16 59% OR = (11/9) / (16/14)
M 14 61% = (1.22) / (1.14)
Grand Total 30 OR = 1.07
Based on the odd ratio calculated above (1.07 or 107%), it could be seen that the likeliness of one
gender to contract the disease is 7% higher than the other. However, this is not significant enough to rule
out that gender is a strong force in the determination of the spread of the disease.

Age
Table 2 below would show that relative percentages of the people who contracted the disease
based on age. The author has initially enumerated the ages of the attendees to serve as the categories.
After this, the number of those afflicted (n=30) were then counted and recorded to the corresponding
category where they belong. As could be seen from the resulting table, about 10% of the total people who
were afflicted with the illness was 53 years of age. Aside from that, no other patterns were apparent from
the sample population.
Age Y Percentage Age Y Percentage Age Y Percentage
25 1 3.3% 39 2 6.7% 51 0.0%
27 1 3.3% 40 1 3.3% 52 1 3.3%
28 1 3.3% 41 1 3.3% 53 3 10.0%
29 0.0% 42 2 6.7% 54 1 3.3%
30 2 6.7% 43 0.0% 55 1 3.3%
32 1 3.3% 44 1 3.3% 56 0.0%
33 2 6.7% 45 1 3.3% 57 1 3.3%
35 0.0% 46 0.0% 59 1 3.3%
36 1 3.3% 47 1 3.3% 60 1 3.3%
37 1 3.3% 48 0.0% Total 30 33.3%
38 0.0% 50 2 6.7%

Cryptosporidium
Aside from the possibility of contracting the disease from food, it is also possible that the virus
(or bacteria) that caused the epidemic could have used the water in the lake as a medium. This is because
most of the attendees have went swimming during the duration of their conference. However, upon
looking at the table below (Table 4), the number of attendees who did not swim yet contracted the disease
(n = 17) exceeds those who swim (n =13).
Count of ILL Column Labels
Swim N Y Total Odds Ratio:
OR = (11/9) / (17/13)
N 11 17 28
= (1.22) / (1.31)
Y 9 13 22 OR = 0.93
Total 20 30 50

The computation for the odds ratio between swimming and contracting the disease showed a
result of 0.93. Accordingly, this shows that one odd (swimming or not) has a 7% lower chance of leading
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to the disease as compared to the other. Similarly, this odd is not sufficient enough to rule out that
swimming is the cause of the outbreak.

Lyme Disease
Since the attendees have also gone on a scavenger hunt in tall grass, it is also possible that the
disease that they have contracted is Lyme Disease. Lyme disease is “caused by the bacterium Borrelia
burgdorferiand is transmitted to humans through the bite of infected blacklegged ticks” (Center for
Disease Control and Prevention, 2018). The possibility for such is strengthened considering that among
those who joined the scavenger hunt (n=33), 20 has contracted the disease while 13 did not. However, it
must also be noted that Lyme disease is not contagious between persons. Thus, this raises the question as
to why 10 attendees have contracted the disease despite them not joining the said activity.
ILL Column Labels
Odds Ratio:
Hunt N Y Total OR = (7/13) / (10/20)
N 7 10 17 = (0.54) / (0.5)
Y 13 20 33 OR = 1.08
Total 20 30 50

Just like the previous exposures and elements that have been discussed above, the odds ratio for
Lyme disease and the symptoms are low (1.08). Particularly, the resulting odd ratio suggest that the other
factor only has 8% higher probability as compared to the other.

Symptoms
Symptom Profile
Frequency Percentage
Disease Frequency (Y) Percentage (n=30) Disease (Y) (n=30)
Diarrhea 26 87% Blood 17 57%
Cramps 28 93% Dead 2 7%
Hospital 11 37%

Table 8, would show the particular symptom profile of the patients who had afflicted the disease.
Although, there are differences between the symptoms diarrhea, cramps, and bloody stool, these three are
the most common among all the patients who contracted the disease.

Median Incubation Period

The epi curve would show the sudden increase and gradual decrease of the outbreak at hand.
From this, the median incubation period of the virus or pathogen could be deduced. Accordingly, the
results show that Period between the hypothesized exposure and the outbreak of the disease coincides
with each other.

Conclusion
Based on the table provided above, two different possible causes for the disease was isolated.
These are (1) Campylobacter and (2) shigellosis. On the one hand, this is because the start of their
incubation period coincides with the minimum time needed, relative to the first case presented. On the
other hand, these two also satisfies the maximum time needed to reach their “maximum incubation
period”, which could be seen at the end of the curve.
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References

Center for Disease Control and Prevention. (2018, December 21). Lyme Disease. Retrieved from

CDC.gov: https://www.cdc.gov/lyme/index.html

Center for Disease Control and Prevention. (n.d.). Epi Curve. Retrieved from CDC.gov:

https://www.cdc.gov/training/QuickLearns/createepi/1.html

Center for Disease Control and Prevention. (n.d.). Using an Epi Curve to Determine Mode of

Spread. Retrieved from CDC.gov: https://www.cdc.gov/training/QuickLearns/epimode/

VictoriaStateGovernment. (n.d.). Viral gastroenteritis (not rotavirus). Retrieved from

VictoriaStateGovernment.Gov: https://www2.health.vic.gov.au/public-health/infectious-

diseases/disease-information-advice/viral-gastroenteritis-not-rotavirus
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Appendix

Possible Possible Reasons for elimination

Exposures microorganisms
and Agents
Cucumber a. Campylobacter a. Campylobacter is a possible agent
Sushi b. Clostridium b. Possibility of Clostridium Perfringens as the
perfringens virus causing the disease is eliminated because
c. E.coli O157H7 the ‘resulting outbreak expected’ (July 30 AM
d. Salmonella to August 1 PM) does not match the outbreak in
the epi curve
c. Possibility of the outbreak being caused by E
coli on the sushi is eliminated because its
incubation period is only supposed to be
between Aug 2 to Aug 3, whereas the outbreak
happened from Aug 1 PM to Aug 5 PM
d. Possibility of Salmonella being the main cause
is also eliminated as the ‘resulting outbreak
expected’ is July 30
Sweet a. E.coli O157H7 a. Eliminated since the resulting outbreak
potato tacos expected is both later and earlier than the
or burgers outbreak period.
Swimming a. E. coli a. Any possibilities of the disease being contracted
race in the b. Shigellosis from swimming in the lake is eliminated due to
lake c. norovirus the low ‘odds ratio’ (0.93) provided in the
previous section
b. Admitted
c. Eliminated due to incubation periods.
Scavenger a. Borrelia a. Any possibilities of the disease being contracted
hunt in the burgdorferi from scavenger hunt is eliminated due to the
woods low ‘odds ratio’ (1.08) provided in the previous
section
Chicken a. Campylobacter a. Eliminated because expected outbreak does not
Caesar b. Clostridium coincide with the real time period
Salad perfringens b. Expected outbreak is a lot earlier than what
c. E.coli O157H7 appeared, thereby eliminating it
d. Salmonella c. Eliminated since expected outbreak should be
e. Staphylococcus much latter than what happned
aureus d. Eliminated since expected incubation period is
July 31
e. Eliminated since expected incubation period is
July 31
Cauliflower a. Clostridium c. Eliminated because expected incubation period
curry perfringens is much earlier
b. Bacillus cereus d. Eliminated because expected incubation period
toxicosis (emetic- is much earlier
type)
Pasta with a. E.coli O157 b. Eliminated since incubation period does not
Basil Pesto coincide
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