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A Large Community Outbreak of Salmonellosis Caused by Intentional Contamination of Restaurant Salad Bars

Thomas J. Török, MD; Robert V. Tauxe, MD, MPH; Robert P. Wise, MD, MPH; John R. Livengood, MD; Robert Sokolow; Steven Mauvais; Kristin A. Birkness; Michael R. Skeels, PhD, MPH; John M. Horan, MD, MPH; Laurence R. Foster, MD, MPH
JAMA. 1997;278(5):389-395. doi:10.1001/jama.1997.03550050051033.
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Context.  —This large outbreak of foodborne disease highlights the challenge of investigating outbreaks caused by intentional contamination and demonstrates the vulnerability of self-service foods to intentional contamination.

Objective.  —To investigate a large community outbreak of Salmonella Typhimurium infections.

Design.  —Epidemiologic investigation of patients with Salmonella gastroenteritis and possible exposures in The Dalles, Oregon. Cohort and case-control investigations were conducted among groups of restaurant patrons and employees to identify exposures associated with illness.

Setting.  —A community in Oregon. Outbreak period was September and October 1984.

Patients.  —A total of 751 persons with Salmonella gastroenteritis associated with eating or working at area restaurants. Most patients were identified through passive surveillance; active surveillance was conducted for selected groups. A case was defined either by clinical criteria or by a stool culture yielding S Typhimurium.

Results.  —The outbreak occurred in 2 waves, September 9 through 18 and September 19 through October 10. Most cases were associated with 10 restaurants, and epidemiologic studies of customers at 4 restaurants and of employees at all 10 restaurants implicated eating from salad bars as the major risk factor for infection. Eight (80%) of 10 affected restaurants compared with only 3 (11%) of the 28 other restaurants in The Dalles operated salad bars (relative risk, 7.5; 95% confidence interval, 2.4-22.7; P<.001). The implicated food items on the salad bars differed from one restaurant to another. The investigation did not identify any water supply, food item, supplier, or distributor common to all affected restaurants, nor were employees exposed to any single common source. In some instances, infected employees may have contributed to the spread of illness by inadvertently contaminating foods. However, no evidence was found linking ill employees to initiation of the outbreak. Errors in food rotation and inadequate refrigeration on icechilled salad bars may have facilitated growth of the S Typhimurium but could not have caused the outbreak. A subsequent criminal investigation revealed that members of a religious commune had deliberately contaminated the salad bars. An S Typhimurium strain found in a laboratory at the commune was indistinguishable from the outbreak strain.

Conclusions.  —This outbreak of salmonellosis was caused by intentional contamination of restaurant salad bars by members of a religious commune.


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