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Homework answers / question archive / Gastroenteritis at a University in Minnesota PART I - OUTBREAK DETECTION  On the morning of March 11, the Minnesota Department of Health (MDH) in St

Gastroenteritis at a University in Minnesota PART I - OUTBREAK DETECTION  On the morning of March 11, the Minnesota Department of Health (MDH) in St


Gastroenteritis at a University in Minnesota


On the morning of March 11, the Minnesota Department of Health (MDH) in St. Paul received a telephone call from a student at a university in central Minnesota. The student reported that he and his roommate, a fraternity brother, were suffering from nausea, vomiting, and diarrhea. Both had become ill during the night. The roommate had taken an over-the-counter medication with some relief of his symptoms. Neither the student nor his roommate had seen a physician or gone to the emergency room.


The students believed their illness was due to food they had eaten at a local pizzeria the previous night. They asked if they should attend classes and take a biology midterm exam that was scheduled that afternoon.


Question 1: What questions (or types of questions) would you ask the student?



Question 2: What would you advise the student about attending classes that day?




The “Foodborne Illness Complaint Worksheet” (Appendix 1) was completed based on the call. The student refused to give his name or provide a telephone number or address at which he or his roommate could be reached.


Question 3: Do you think this complaint should be investigated further?




MDH staff were skeptical of the student’s report but felt that a minimal amount of exploration was necessary. They began by making a few telephone calls to establish the facts and determine if other persons were similarly affected. The pizzeria, where the student and his roommate had eaten, was closed until 11:00 A.M. There was no answer at the University Student Health Center, so a message was left on its answering machine.


A call to the emergency room at a local hospital (Hospital A) revealed that 23 university students had been seen for acute gastroenteritis in the last 24 hours. In contrast, only three patients had been seen at the emergency room for similar symptoms from March 5-9, none of whom were associated with the university.


At 10:30 A.M., the physician from the University Student Health Center returned the call from MDH and reported that 20 students with vomiting and diarrhea had been seen the previous day. He believed only 1-2 students typically would have been seen for these symptoms in a week.

The Health Center had not collected stool specimens from any of the ill student s.


Question 4: Do you think these cases of gastroenteritis represent an outbreak at the university? Why or why not?





By March 12, seventy-five persons with vomiting or diarrhea had been reported to MDH. All were students who lived on the university campus. No cases were identified among university faculty or staff or from the local community. Except for one case, the dates of illness onset were March 9-12. (Figure 1)   The median age of patients was 19 years (range: 18-22 years), 69% were freshman, and 62% were female.



Figure 1. Onset of gastroenteritis among students, University X, Minnesota, March 1998. (N=72) (Date of onset was not known for three ill students.)








MDH staff met with the Student Health Center physician and nurse, and several university administrators including the Provost. County health department staff participated in the meeting.


Question 5: What topics would you include in discussions with university officials?



MDH and County Health Department staff gathered the following information:


The university is located in a small Minnesota town with a population of 27,354. For the spring semester, the university had an enrollment of approximately 12,000 students; 2,386 students live on campus at one of the 36 residential halls scattered across the 200+ acres of the main campus. About 75% of the students are Minnesota residents.


The university uses municipal water and sewage services. There have been no breaks or work on water or sewage lines in the past year. There has been no recent road work or digging around campus.


The campus dining service includes two cafeterias managed by the same company and about half a dozen fast food establishments; about 2,000 students belong to the university meal plan which is limited to persons living on campus.  Most on-campus students dine at the main cafeteria which serves hot entrees, as well as items from the grill, deli bar, and a salad bar. A second smaller cafeteria on campus offers menu selections with a per item cost and is also accessible to meal plan members. In contrast to the main cafeteria, the smaller cafeteria tends to be used by students who live off campus and university staff. The smaller cafeteria also offers hot entrees, grilled foods, and a salad bar, but has no deli bar.


Spring break is to begin on March 13 at which time all dining services will cease until March 23. Although many students will leave town during the break, it is anticipated that about a quarter of those living on campus will remain.




Hypothesis generating interviews were undertaken with seven of the earliest cases reported by the emergency rooms and the Student Health Center; all of the cases had onset of illness on March 10. Four were male and three were female; all but one was a freshman. Two students were psychology majors; one each was majoring in English and animal husbandry. Three students were undecided about their major.


The students were from five different residential halls and all reported eating most of their meals at the university’s main cafeteria. During the past week, all but one student had eaten food from the deli bar; two had eaten food from the salad bar, and three from the grill. Seven-day food histories revealed no particular food item that was common to all or most of the students.


Except for the psychology majors, none of the other students shared any classes; only one student had a roommate with a similar illness. Five students belonged to a sorority or a fraternity. Three students had attended an all school mixer on March 6, the Friday before the outbreak began; two students went to an all night science fiction film festival at one of the dorms on March 7. Students reported attendance at no other special events; most had been studying for midterm exams for most of the weekend.


Question 6: Using information available to you at this point, state your leading hypothesis(es) on the pathogen, mode of transmission, source of the outbreak, and time-period of interest.


Question 7: What actions would you take?






On the evening of March 12, about 36 hours after the initial call to the health department, MDH staff conducted a matched case-control study among students at the university. Ill students (reported from emergency rooms and the Student Health Center) who could be reached at their dormitory rooms were enrolled as cases. Dormitory roommates who had not become ill were asked to serve as matched control subjects. Investigators inquired about meals the students might have eaten during March 5-10 and where the foods were eaten. All information was collected over the telephone.


Question 8: How would you define a case for this study? (e.g. who would count as being ill for this investigation)



Twenty-nine cases and controls were interviewed over the telephone. Investigators tabulated the most notable results in Table 1.


Table 1. Risk factors for illness, matched case-control study, main cafeteria, University X, Minnesota, March 1998.






Ill exposed/

Total ill* (%)


Well exposed/

Total well* (%)

Ate at deli bar - lunch on March 9



1/29 (3)

Ate at deli bar - dinner on March 9

7/27 (26)

2/29 (7)

Ate at deli bar - lunch on March 10

8/29 (28)

1/28 (4)

Ate at deli bar - dinner on March 10

2/29 (7)

2/28 (7)

Ate at deli bar - lunch or dinner

March 9 or lunch

March 10





*Denominator does not always total to 29 because several subjects could not remember where they ate the indicated meal.


Question 9: How do you interpret these data?







Eating at the main cafeteria, in general, was not associated with illness; however eating from the deli bar during lunch on March 9 or March 10 was significantly associated with illness. Because such a small number of controls ate at the deli bar, individual food items from the deli bar could not be examined.


Spring break at the university ended on March 23. The chief of the campus food service called MDH to find out what must be done to reopen the deli bar.


Question 9: Which of the following actions would you recommend? What are the pros and cons of each?


  1. throw away all leftover deli bar foods and ingredients
  2. clean and disinfect all equipment and surfaces in the deli bar
  3. require all foodhandlers to submit a stool specimen before allowing them to return to work
  4. educate foodhandlers on proper foodhandling procedures including handwashing and appropriate hot-holding and cold-holding temperatures
  5. develop a sick foodhandlers policy



Question 10: Who might you consult in developing actions/policies for the campus food service to prevent a recurrence of this problem in the future? Why?



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