LARIMER COUNTY | HEALTH & ENVIRONMENT

1525 Blue Spruce Drive, Fort Collins, Colorado 80524, 970.498.6700, Larimer.org/health

January 17, 2019,

Dear Michelle Passater,

You have requested the following information for Samuel Allen:

1) Completed case investigation form 2) Completed reportable disease form 3) All enteric and molecular laboratory test results 4) Any document that identifies the source of our client’s infection 5) Any document that links our client’s illness to Salmonella

Please find the attached documentation in response to your Colorado Open Records Request.

Please let me know if you have any concerns.

Sincerely, Katie O’Donnell Public Information Officer Larimer County Department of Health and Environment

CEDRS Colorado Electronic Disease ReportingSystem Department ofPublic Health & Environment a r Event Number: 480683 Salmon el losis

bemographics

Last Name: -=--=------First Name: Middle Name: DOB: f•�!!!!!!___ Gender: Male----- Ethnicity: Not Hispanic or Latino Race: .;.W.;.ah.;.;.it;.;;e______

Event County: _L.... ar_ im�e�r _C�O______

Industry Type: Occupation: ______Employer:

Phone Type Phone Number Primary Residence Number (970)443 ....

kvent Information

Diagnosis Salmonellosis Onset Date 8"'"/'""'1=2/""2-'-0-'-18"------

Event Address QC Fort Collins, CO 80526 Living in institution at time of event? _N_o __ If yes, institution type ______Name Institution Phone biagnosis Details Age At Diagnosis _5 __ Outcome �A.... liv______e Acquired InState __ln_S .... tet ______a___ _

Report to Public Health Date 8/15/2018 CaseStatus .;;C;.;;o.;.;n.... r""m"" fie;;.;d;;.______Dr Details Core Data Approved Approved Reason Returned ------Core Data Ok'd By Susma Dahal Reporting Agency ...... a.o=ud=r P '-"e_ V.... "'" al-le..._y"'"H....o_s .._p_ita_l_____ Other Agency Person Reporting Phone ______Entered By Agency Susma Dahal

Entry Method ELR Entry Date 8/ 15/2018 base Investigation Primary Agency Assigned Larimer County Health Department Primary Assigned To Kim Meyer-Lee

Primary Assigned Date 8/16/2018 Secondary Agency Assigned Reg Epi Northeast Secondary Assigned To ______

Secondary Assigned Date 8/15/2018

Investigation Status ""C"""lo-s'""e""d______InvestigationStart Date 8/16/2018 Followup Type Followup Outcome Followup Date

Phone Interview Completed 08/16/2018 boPHE Reviews Reviewer ApprovalStatus Case Counted (WNV) _N_o______Date Counted Surveillance Forms Received No Surveillance FormsSent Date Environmental Investigation Reviewed No

Printed by: Kim Meyer-Lee Printed Date: 1/7/2019 9:36:00 AM CEDRS Colorado Electronic Disease Reporting System Departmentof Public Health & � nvironment

Salmonellosis

Reason/s Returned

?s •t •S:

PSW!1 tmploymom/Sci>oolrov1ders Has one of the providers or offices been notified that the Health Dept. may contact patient?

Provider Full Name Phone Number Practice Name Address Type VAUGHAN, KOLBY C (800) 298-8682 UCHEAL TH SERVICE AREA 1024 S LEMAY AVE

utbreak

Outbreak .... es___Y .... ___ CDC NORS Number 282732 CDPHE Outbreak ID/Name ""20""'18'-' '--35"" ""'-""0""15;.....______'11__ n _�__.;:. _-..__ . _.·___ _ Outbreak Type Unknown

bospitalization Hospitalized: ..;.Y.a.e.a;..s ______Hospital Admission Date Discharge Date Poudre Valley Hospital 08/14/2018 . 08/16/2018

Labs State Lab Specimen Collection Testing Lab Originating Lab Test ID# Date Count 1808200091 Stool 8/14/2018 Poudre Valley Hospital University Hospital 5 ll"est Result Result Value Result Date PCR at clinical lab Positive DETECTED- 8/14/2018 aiofire FilmArray Culture at state lab Positive Salmonella ser. Javiana­ 8/20/2018 Serotype (Salmonella) Javiana Salmonella ser. Javiana­ 8/20/2018 Sero!=Jroup (Salmonella) D Group D, I9,12:I,z28:1,5- 8/20/2018 =>fGE Result Result is Text 10-I State Lab Specimen Collection Testing Lab Originating Lab Test ID# Date Count Stool 8/14/2018 Poudre Valley Hospital Test Result Result Value Result Date Culture at clinical lab Positive SALMONELLA SPECIES- 8/14/2018

�otes

Printed by: Kim Meyer-Lee Printed Date: 1/7/2019 9:36:00 AM 1/7/2019 Labs CEDRS Colorado Electronic Disease Reporting System &Y Departmentof Public Health & Environment Home New Event Line Lists Messages Resources Administration Search Reports Log Out Q Event 10• -- --- C) r 8 Kim Meyer-Lee--:;:;' �- -- --'

� Birth Date 4/9/2013 Sex Male County Larimer Profile ID 1010694 EventID 480683 [ Diagnosis Salmonellosis

Profile Labs History

All Notes 0 Expand All

Events Add New Specimen Refresh

Labs Test Actions Specimen ID State Lab ID# I Specimen I Collection Date Testing Lab Originating Lab I 1 I I Count Surveillance Form I 498421 1808200091 Stool 8/14/2018 Poudre Valley Hospital University Hospital 5 Documents ·- Sharing Add New Test Refresh I Event Print Test ID I Test I Result I Result Value I Result Date I Actions 689006 PFGE Result Result is Text 10-1 I Edit

688131 Serogroup (Salmonella) D Group D, I 9,12:l,z28:1,5- 8/20/2018 Javiana 688130 Serotype (Salmonella) - Salmonella ser. Javiana- 8/20/2018 � Positive 688129 Culture at state lab Salmonella ser. Javiana- 8/20/2018 � Positive 686441 PCR at clinical lab DETECTED- 8/14/2018 �

509551 Stool 8/14/2018 Poudre Valley Hospital 1 �

Add New Test Refresh Test ID l Test I Result I Result Value I Result Date I Actions 703874 Culture at clinical lab Positive SALMONELLA SPECIES- 8/14/2018 �

1 Page size: 20 2 items in 1 pages

1 C:1pfn()htr�: 21)19 I Ccbr.:,Co Depff,r:-:cm of PlJblic He.alth & £;y.,:1rr1nr:1ent I ,1\II R1�-:TT :::.t'.-:;:?rv,_.j ! r h,2St..:,te ct Colr-,r.:,do e"'pen::. th,:it this �•. 1:'brnc? ln�orrnation 1s ;1ccur.)t€'. thM Gnlini:� trar.�action: .:1r� SfCUre. ;,r:ci ::"'l.;is:- :;;ii rn,;:�('.;r,o::i- ::;s;-�·c:s c-, :;-,::-... ;:.:� ·-.m:tr:Jn prop-:-� .­ 1 Hov;e::v�1-, thr: St.:itr: m:ike-5 n-:•·,varr�nti:� \'h�t�t:,t>Vc�r m r(:l�,ticn le the ".lite .:i11d ,__.sers r1:ly upr-Jn it �t thl?ir ovm !'i:!::k. Th2 State spcc1fiCcll!v (J1-.;da1ms tl1e warr-t11''t1a:; ot rnf:>ri::f-:mt.:1bih�·and fltnes:. :Or;.1 p,1riicul�1r pi..1r?::sz https://efort.dphe .state .co. us/un iquesig936cf12d6a09153fb480d002e02621 fde823b9324d35936ddddede5536a9a98a/uniquesig 1/CED RS_I I I/Labs/Labs.aspx?WindowSession=1 ec0cfbe-b3a9-8378-216... 1/1 Salmonellosis Case Investigation Form

...._ Patient Name: JELL,�•�Ill!!·�.�,.�1.A..., !!ll;lll!l!ll! !:lllr_d�---- Event ID: Form completed by: ------� Interview date: -�LHeJW_L[)

KEY: Y = Yes I N = No I U = Unknown Demographics i�tt;- ate Js d : jlalla I Ag�: € _ -· _ ��!!'6'_I_Mo_s_J D�YS) circle o�ne__ ___ :sex: -dMale Ethnicity: □ Hispanic Race: □ Asian □ Black or African American □ Female □ Non Hispanic □ White □ American Indian or Alaska Native □ Male -. Female □ Unknown □ Unknown □ Native Hawaiian or Other Pacific Islander □ Female _,. Male □ Refused □ Other Race □ -- -- -Unknown- - ·- Contact Info

ddress: ome phone :c-.,l�A� � � ::: -=. :___ _j,....'4,Z�i,lll! MAimr;llll!l!Z�&ii�._.L ¥6Qitct _____---.- ______1 _____ / H . _ _ _: ______City/Zip: 11 j County: j Work phone: 1 ,r-.l::J,..Q..ih-_\_'rill ______--'-· ------1Email: / Mobile: ·--- ·--·-··------·--·-·-·----��-���-e��

Institution --- ·----·------··------·- --·!--- Was patient living in an institutional setting at time of event? Y�U ------If yes, what type? Institution Name: Phon_g.· '------·------. - -- � -- Case Investigation - - - - Contact attempts: Record date(s), contact method (phone, text, letter me-nere: �-� � Gn;erviewe�: ti □ □ □ I - -• -• �•� · �atie�t. Waren Spouse Refused/Unable to Contact Medical Record Other: I Preferred language: / ParenULe�al guardi;n: Outbreak y u I!· 1s �his patient par� of-a k�o�n/su�pected outbreak? N I CDPHE Outbreak ID/Name: j 1t yes, provide details: ·------

IP/ease confirm specimen information with patient. Specimen source: 21"stool □ Urine □ Blood □ Other: I Collectiondate: -oJ--'------1 + Lab or Hospital Name: \)IJ, ______� _ :culture: /as Neg Not tested j PCR: .,?6's Neg Not tested

Colorado Department of Public Health and Environment December 2017 Communicable Disease Branch I 4300 Cherry Creek Drive S, Denver, CO 80246 I Phone 303-692-2700 I Fax 303-782·0338 p. 1 V\ �ot 1-'S. 0..e,r f .-:::,\ t.,r�,,, .f),_o.l c-CN� .,. -�·l- 1,P" �,r. c/"- �. e e PatientNam : ------� Ev nt ID:

KEY: Y =Yes I N = No I U = Unknown Clinical Description

a a /N , f e e : Did p tient h ve symptoms? u --- - i y��' ons t dat : �oCno--e_l_v"Z-- i1 ______, Did patient have: Diarrhea U( N U Vomiting Y Lt< u Bloody Diarrhea vr N U Abdominal Cramps I.,)(' N u I' Fever (max temp: -�j=O�S'�_ � N U Other: ------....,. Y N u - a ess _ I How many d ys didill� l�rt? ______J_i� flil I _ �-- ______=-=--i-_-l.�t=· ·_-_-__· - � l t _ -�1-===· ===== ; . Did patient take any antibiotics for this illness? t.,,f N u

a __ f yes antibiotic n mes f-v ;�1l __ _ _,______(_se_e_c_ED_ _Rs_1 is_0_: ____--<: ;,t1.1..1.J£!"11'.4•l�l-( t �-a.-�--,nJ _ : During the 30 days before illness, did patient tak e any antibiotics? Y ef U :; If yes, a ntibiotic names (see CEDRS list): 11 : ! During the 30 days before illn ess, did patient have any form of antacid (medications to block acid, such as those tak en for heartburn, i indigestion or acid reflex)? Y 4'("' U I ______------ii \If yes, a ntaci�na�es (see_CE�� /�st): _ ------·--·--·---�- _____ --~-- ___ /1 During the 30 days before illness, did the patient take a probiotic (probiotics can take the form of pills, powders, yogurt s, and other fermented dairy products, a s well as anything labeled as cont3.ini�g_ "liv=._and ac�ve cultures" ��-��robiotics .")? U 'j .!..___ --�-- - i During the 6 months before illness, was patient diagnosed or treated for cancer (including leukemia/lymphoma)? Y N U 1 f I: s e a a e a s ;,1 During the 6 month before illness, was pati nt di gnosed or tre t d for di bete ? Y N U :: During th e 6 months before illness, did patient have abdominal surgery y u 1j (e.g., removal of appendix or gallbladder, or any surgery of the stomach or large intestine)? N ! Outcome / Hospitalization

,;outcome: ��d Died Unknown e [ l (Record patient outcome on 7th day afterspecimen collection date.) l If died, dat of death: 1: :,, j Did patient visit the Emergency Room? Y N u ,. Was patient hospitalized? X N U (ER visits only are not considered "hospitalized.") ------·�----•··--·- -·--·· ------�� ·-�·-· I HospitalName: Date of admission:

If not otherwise specified, please ask about exposures 6 hours-7 days beforesymptom onset.

Salmonellosis Colorado Department of Public Health and Environment December 2017 Communicable Disease Branch I 4300 Cherry Creek Drive S, Denver, CO 80246 I Phone 303-691-2700 I Fax 303-782-0338 p. 2 Patient Name: Event ID:

School / Work KEY: Y = Yes I N = No I U = Unlmown

�--�-�------��-�--.-·--·------,------/ Event Employment (for disease control purposes) ------Employer/School Name Occupation Category Occupation Dates

___ j

Primary occupation during seven days before illness: I Industry during seven days before------illness: -·------·---·- ----

Describe main occupational duties during seven days before illness: I !------·-··•------

I Does patient:-- - -- ···------·------l y u ► Attend, work or volunteer at a child care center/preschool? N y CA< u '► Have a child(ren) in a childcare center? If yes, name & location of facility: y u Are other children/staff ill? N y u j ► Attend, work or volunteer at a residential facility? (e.g., nursing home) N '' If yes, name & location of facility: y u I Are other staff/residents ill? N y u ► Provide direct patient care as a health care worker? N I If yes, name & location of facility: y u 1/ ;1 ► Work as a food handler? ------N I If yes, name ft location of facility: I y N u :i ► Since becoming ill, did patient prepare food for any public or private gatherings?

If yes, provide------details:------·-·-----� -- -·--- Contact Management ------·- .

lDid patien e contact with any individual who had a diarrheal illness (before case's onset)? Y N U I �_ �y . ____ I I Completeonset the table below for all household membersdisease and other close contacts. If any of these persons has been ill with similar symptoms, please indicate the ' date of and symptoms. [Note: This table is for control purposes and is not currently in CEDRS.]

Occupation/ Onset ��Relationship- - A ge I Simil illne -- Comments- -- - ....,.____,._--=--== ..... _ • ....__ __ - l --- =-..--- Child care (mm/dd/yy)=-----� ----·---- I ex �� � {ll'(b,I -· __S;_ n(. J . N u /I ;-· ---- Man1 i ( I L�I ··---, -- Ma�ci.&lv✓ tS· S4�ve-1fi IX' N U Dlvf- I f �------y I I u �---- N y u I I 1C:twq N $i.�(bY�). y u I I N ' y u I I I N

'If case or household contact is high risk (e.g., food handler, health care worker, ·child care), refer to CD manual for restrictions/follow up. Obtain details of site j_C>b des ription, dates worked/attended during communicable period, supervisor name, etc. ! �_ __ _ � Salmonellosis 2017 December Colorado Department of Public4300 Health and Environment CO 80246 303-692-2700 Fax 303-782-0338 Communicable Disease Branch I Cherry Creek Drive S, Denver, I Phone I p. 3 Patient Name: Event ID:

KEY: Y = Yes I N = No I U = Unknown Travel Information 1 During the 7 days before onset of illness, did patient travel outside the US? Y. � (If yes, pr ovide details below .) Country I Date left US Date returned to US i

I == D Check box if case was adop ted or immigrated to US (no "date left US") ______=___ ------1 : If patient stayed in----������-J a resort, please note resort name and location: ==------�---�=��=�::::��=�=--==-·�=--=-=l If case traveled outside the country within 7 days before illness onset, complete travel section and conclude interview. It's not necessary to collect other food or exposure information.

j Did patient travel within the US in the 7 days prior to the onset of illness? y u i------·------N --· ·------If yes, when and where?

During the 6 months before onset of illness, did patient travel outside the US? y N u If yes, country:

: During the 6 months before onset of illness, did any member(s) of your household I travel outside the US? y N u ; If yes, country: iij______Water y u I During the 7 days before illness, did patient drink any water from a- private-- ---well? -----✓------··------l If yes, location and type of well:

I Did patient live in a home with a septic system? y ef u

Did patient drink� untreated water from a pond, stream, spring, lake or river? y N u

I Did the patient swim or wade in any of the following types of recreational_ water? ( lf ye_s,_p_r _ov_i de lo_c_at_io_n_a_nd d_a _tes be_lo_w_._) ______I Lake, pond, river or stream: u ___ y___ _r ______-;r'------"'�..,.-=' -=------y r >---Ocean:--· Hot tub/spa, whirlpool, Jacuzzi: y r u

Swimming or wading pool: y r1 u 1 -·· I Recreational waterpark or any type of fountain: y r u ,1 y ir I Drainage ditch/irrigation canal: u -----�-- I I Other (pleasespecify):

Salmonellosis

Colorado Department of Public Health and Environment December 2017 Communicable Disease Branch I 4300 Cherry Creek Drives, Denver, co 80246 I Phone 303-692-2700 I Fax 303-782-0338 p. 4 Patient Name: � t.AY. -lk=-- \o r-J I� \V/ruV' D1v\-- ✓ 1 o KEY: Y = Yes I N = No I U = Unknown Pet or animal exposure - l 'Did the patient: · '. ► Visit, work, or live on a farm within 7 days prior------to illness? y ur u ! 1> Visit any animal exhibits (petting zoo, county fair, etc.)? y u (If yes to either, provide details below.) ------u< Did the case have exposure to manure? y N u ------· ------·---- / ___ I Did the case participate in calving or birthing any animals? y N u ;

Did the case participate in branding? y N u

I► Have contact with a pet or any other animal at home, school, work, etc.? Y � U (If yes, provide details below.) I o·og1�y�- o --=-=-=-. v �-N u ____ J_� ':"_��---~ -�-- v �- u _____-__ -_J Cat/kitten --�-=- Y N U Chicken/duck/turkey Y N U '

Y N U Sheep Y N U ' Reptile (e.g., snake, iguana, turtle) Y N U Goat Y N U :------! Y U Y U I Rodent (e.g., mouse, hamster, guinea pig) ------1------N Pig ------N 1 Ferret, hedgehog or similar small animal Y N U Horse Y N U ,

Pet bird or wild bird (e.g., parakeet, bird feeder bird) Y N U Other: Y U Did any of these animals recently have diarrhea? -----N------Which one(s)? Were any of them recently acquired? Y N U Details: jProvide details about the type and location of contact with any animals noted above. (e.g., was this contact at home, in a store, a farm, etc.?) I ·!Note dates and locations here, if relevant. I i --·1I ! Did case handle any pet food or pet treats? y N u ,, ----i ; If yes, provide details of type of pet food/treat:

, ___ ---· ------. Restaurant history / Group activities ---1 --- . --·-·----- I Any group gatherings, picnics, sporting events, etc., during the 7 days before illness? y � u ____ l Did others accompanying the case become ill with diarrhea, fever, or abdominal pain? y N u I (If others became ill after a common exposure, this may be an outbreak. Call the regional epidemiologist or CDPHE for assistance.) ! -----1 I Did the patient eat out at any restaurants or other commercial places (i.e., not at a friend's house)? y N u '-----·-� -·------Name of business Address Date of exposure Foods eaten

Salmonellosis December 2017 Colorado Department of Public Health and Environment Communicable Disease Branch 1 4300 Cherry Creek Drives, Denver, co 80246 I Phone 303-692-2700 I Fax 303-782-0338 p. 5 Patient Name: Event ID:

KEY: Y = Yes I N = No I U = Unknown i Grocery / food store history List food store(s) or grocery store(s) for foods consumed during 7 days prior to illness: ·-1 Shopper card number Name Location I I (if applicable ______Ji� ...,_ r .�J?r-i1��"----.-----:'- J£-,L-, -£L�---=- =-----=----_· --·_--q1---� j�� ______t---' 1 �Vii=.z1k-u- 14l� I (} 52,<:" 1/v9 �()'-j' • Did the patient purchase or consume any food from a farmer's market? y 1..-1<( u I. 1, �'If yes,-- what/where?------__ I Did the patient purchase or consume any food from a CSA (community-supported agriculture project)--- or- a------y (A( u 1 food coop, or a home delivery service (such as a service that delivers fresh produce to your doorstep)? ). i'f yes, what/where? 1 1 Did the patient purchase- -or consume any food from- a specialty store (such as a carniceria or ethnic market?) ,,...,� I ·1f yes, what/where? ------y I � --U---1, __ __ -··------______I , Food History ; : If patient is unsure, ask patient if it is likely that slhe ate a particular food item. If the patient is still unsure of a specific food item, please : enter "Unknown." If the patient was not asked about a specific food item, please leave blank.

: OUT refers to foods cooked at a commercial establishment, such as by a restaurant, deli, fast food, take out, farmer's market, or caterer. This ' ! does not include at another person's house, a potluck, etc. i------·------�------� �-•------··------�------1 ',Do you follow any special or restricted diet (such as vegetarian, vegan, gluten free, kosher, etc.)? Y ;:...w/ U .. j ! ;1f yes, describe (include any foods that are typically avoided): I' I' -,·

During the 7 days prior to onset of illness, did the case eat: (Provide details including where food was obtained, when consumed, etc., below) I· i Dairy :A,y d�i;;; ; prodoct? � ;:Pasteurized cow's goat'smi, - t[o l--/l(A "S c..< N U _ � � ! Nonpasteurized (raw) milk? �-___.,..,______-�-- Y l.),1---N--U U ------1I ------; :,Other products made from raw milk (e.g., kefir, ice cream, yogurt, etc.)? Y N U I -�'---- i 1· 1�l!1Any --- soft chee;-�uch------as Queso-- fresco,--- Brie-- or goat---- cheese?------Y \,))J---" U :'------· Was the cheese made with raw milk? ------Y N U i,Any eggs? � N U

i•' �------Any eggs OUT? v -�u y u ! ------Raw or lightly- .. cooked eggs-· ·-(runny- - --- yolks)------· or - -foods--- made with raw- eggs------(e.g.,-�----- sauces,------�------cookie dough,•----· etc.)? 'Meat 1.--M" ------·--··-----·------"• -----·--·-·-----· ------u ------,! IIAny chicl

Salmonellosis Colorado Department of Public Health and Environment December 2017 Communicable Disease Branch I 4300 Cherry Creek Drives, Denver, co 80246 I Phone 303-692-2700 I Fax 303-782-0338 p. 6 en en Pati t Name: ------Ev t ID:

KEY: Y = Yes I N = No U = Unknown

--- - - . , 1Meat (cont.) -�------e e e Ulr" - - I Any t�rk_y _ or_ _f_ood- -s �ith turk y-in -th m? y u ______- ______! Any turkey OUT? ·---- y u N - ______] n e______- ___ Any grou d turk y? ------y --N u - e - j \J>I"" - .,Rare or und rcooked poultry? Y U j n e vv/ �------. -- . - - - 1 Anyone in household ha dl raw poultry? N U � 1 n ee e de ------d -e ---- � A y b f or food with b ef in them (inclu s grou·n b ef)? N U ___,______! _ n ee nd y f beef OU _ N U 1 _! �__ ��-��� _ _ _ ��-- ---__------.:---- ___ Uc:An�:�\:l�-=------: d ee - \.,I" Any groun b f? N U ___ __,I I e e h.� 1 Ground be f prepared at hom ? � N U ---(0--(..P � e --- round b f prepar d elsewh - Where? . '._�_ _ _ _ e_�_ -______���--- --�-� � I _ �-�-- ___·.,. ______t n ee y X u _ Any pi k or raw ground b f? I I ______n e en e e - _ _ u<' 1 'A y ground b ef in home, ev if cas did_not at it?_ .,, Y U i: < n e e e n e __ _--_□ -· : _-n_- - -�--_ -_-_-_-__ -' · ow do as usu lly eat gr?u_ _�_ b_'.: f? -· _� �-�_:.-__k__ - --□--�-�--! �-�--th-_ ----�--1 /-�-�-�-t_h___ _- _-9_Ne_ v= ==r --_-_ u kno - j 'H _��-=�_ :::.: _ _� n e e ee - � , : ;A yon in household handl raw b f? Y N U •I ------n - n e ;::?' - - I: A y fish or foods with fish i th m Y ··u - n __ __ _ i: Was a y of this fish raw or partially cooke-d?_ ___ y ____N _ _ _ _ n e e - - - U______I' ; :A y s afood, such as crab, shrimp, oyst -r-s, etc. ? -- - -y L,l'( U n e ----y- - - !. Was a y of this s afood raw or partially cooked? --N- -U ----- I, 1 - -l"' ______J 1 ;:Any veal? Y 1,,1(° U J'1 e u< - 1:Any liv r pate? y ---u ------n e e ------/, 11'Any raw or u d rcook d liver? ------Y L-1(' U ------:• 1 ed e j !Any dri m ats (e.g., salami, jerky, etc.)? Y u _ __L)(______I e u< ___,J !Any bison or buffalo m at? Y U --r------{I i e - :·--,:Any wild------gam (venison, elk,- other--- game)?- --·------·- Y CJ)Y u .. -·· ·-· ___, ! Produce ------· u· ��? -·· e e !;Any-food f-;:-om a s�lad Y � J Wh r ?· I: ------!i: ;sprouts (e.g., bean, alfalfa, clover, etc.)? Y ✓u I. e e i/ e IG,ru1'-cl I 'uncook d, fresh tomato s? /I N u Typ (s): --- 1 e -- -- - _ i.¥______------'---- _ __ :...... :. __ -7'. Lettuc ? y u Packaged (incl. bagged or boxed)? y N U n � e I! i,'' Fresh spi ach? . Y u j Packag d (incl. bagged or boxed)?_ -y N U ee n ..I(' ··Uncooked gr n onw s? Y u I U(" ,. uncooked cilantro? �"'-----u ------�1- ,,L _ _ e_ _ _ e_ _ _ _ e______v___ _ _ 1.'· !Ot, h r fr sh h rbs (e.g., parsley, basil, ------etc.)? Y ·------·-u

Salmonellosis

n n n 2017 Colorado Departme t of Public Health a d Environme t December 4300 S, CO 80246 303-692-2700 Fax 303-782-0338 Communicable Disease Branch I Cherry Creek Drive Denver, f Phone I p. 7 Patient Name: Event ID:

KEY: Y = Yes N = No = I U Unknown

Produce (cont.) - -- u-] �11 I �he� ra;-v;g;t�bles? ------Y N Lis :-- --���-k(.,LLl'..f--:,(I'-&_l- �;_- -�,-�h t 1�� -� I � - Any juice or cider that was NOT pasteurized? Y � U ------·------· ·---- -l --- ·-·------Cantaloupe? Y 4lur U /Watermelon? ------Y U v .JY-:-:--� u - Honeydew? u ------··------·------j ���;-;; - • Fr;sh-stra- �;b s? � N --u ------1 . i.x7 '7 Any other fresh berries? N U ,..., ______�-✓ btuJd) , I , Mangoes? Y IA"!, _. U I ______�� I '!Grapes_? ______---- Y (.])I/ U _ ---- ��:::_-_-cc-----_-_-_-_----:::______,,,__ ! Other !:uits? U - r -h ______� -----�� _ [ �-t:_(t{) \�j--�CAc-rt!;Ls,[-u :J.v� )__ 1 UJd/'ld-� . · other food items y u I Foods brought from other countries? N Fresh -1 ) sals_c1__!_Pico d=-��o?_ _ _ _ N u __ u Health food products or supplements? h\a-v s01,1,v�1 N 1 Infant food or formula? NA-Y N u

I! Raw nuts (e.g., almonds, walnuts, etc.)? ----·--·--·------y i-H-- u

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SalmonellosisDecember 2017 Colorado Department of Public Health and Environment 4300 Cherry Creek Drives, Denver, 80246 Phone 303-692-2700 Fax 303-782-0338 p. 8 Communicable Disease Branch I co I I

Salmonella Javiana Outbreak Mexican Style Restaurant Fort Collins, Colorado

August 2018

Summary An outbreak of Salmonella Javiana occurred in August of 2018 among patrons of a Fort Collins Mexican Style Restaurant. There were 31 laboratory cases confirmed in the outbreak including 6 of the employees of the restaurant. The large data collection/investigation effort gathered restaurant and case information. Analysis of data did not determine a food-specific cause for the outbreak. The restaurant voluntarily closed and later was approved by the Larimer County Department of Health and Environment to reopen after meeting set conditions for reopening.

Investigation The Larimer County Department of Health & Environment (LCDHE) received a complaint on Thursday, August 16, 2018 from an individual that reported dining at a restaurant in “Old Town” in Fort Collins, Colorado on Friday, August 10, 2018. The complainant indicated that she/he dined with two employees from that restaurant. The complainant reported becoming ill with vomiting, diarrhea, cramps, chills, headache and muscle aches approximately 15 hours after eating. The complainant also reported the employees she/he had dined with at the restaurant also become ill.

On Friday, August 17, 2018, LCDHE staff conducted an on-site investigation/inspection at the restaurant. During the investigation the restaurant’s management reported four employees, two bartenders and two servers, being ill with the “stomach flu” on Thursday, August 9, 2018. They reported these employees were still out sick and had not returned to work as of the time of the inspection. Management of the restaurant was asked to provide the names of the ill employees and their contact information. This information was provided to LCDHE on Monday morning August 20, 2018.

Also, on August 17, 2018, routine follow-up on a reported Salmonella case from the Colorado Department of Public Health and Environment’s (CDPHE) communicable disease reporting system identified a Salmonella case that had also eaten at the restaurant on August 9, 2018.

On Monday, August 20, 2018, LCDHE staff made a second on-site visit to the restaurant to apprise the restaurant operators of the situation, evaluate the correction of violations identified during the August 17, 2018 on-site inspection and to continue to investigate the possible source of the illnesses. The operator was notified that all the establishment’s employees would need to be interviewed to determine scope of duties at the restaurant and to provide information on recent health status; employees were instructed to submit rectal swabs for testing for Salmonella. Employees were required to have a negative test result for Salmonella before they would be allowed to work. If an employee tested positive, they would need two negative stool tests taken 24 hours apart before they would be allowed to return to work.

On Tuesday, August 21, 2018, a conference call was held with CDPHE’s Disease Control and Environmental Epidemiology Division (Epi Division) and Division of Environmental Health and Sustainability. At the time of this meeting, five laboratory confirmed Salmonella cases had been identified, and all reported eating at the restaurant between Thursday, August 9, 2018 and Sunday, August 12, 2018. All five cases had been hospitalized. Consensus from the meeting was to seek voluntary closure of the establishment and to continue collection of rectal swabs to test for Salmonella from all employees who could potentially transmit the infection. LCDHE staff conducted a third site visit that afternoon to verify violations found at the time of the initial August 17, 2018 inspection were corrected. The operator of the establishment was requested to voluntarily close and discontinue all food preparation and sale of food. The establishment closed late that afternoon.

On August 21, 2108 a Health Alert message was sent to health care providers with recommendations and guidance for providers on surveillance, testing, and reporting. An illness reporting website was also created at that time for the public to report illness and exposure history.

A letter outlining the conditions for the establishment to reopen and a Public Health order for employees outlining when they can resume working as food handlers were issued on August 22, 2018.

An Illness questionnaire was developed by CDPHE Epi Division. The questionnaire was administered to contacts obtained from LCDHE’s reporting website, individuals who placed on-line orders for food from the establishment, and Salmonella positive cases and their dining companions. The questionnaire was administered from August 23, 2018 through September 01, 2018. Eighty-five individuals completed the questionnaire. All individuals who completed the survey reported eating food from the restaurant and sixty-one of these reported symptoms of gastrointestinal illness.

For ill individuals responding to the survey, symptoms of illness included diarrhea (61, 100%), abdominal cramps (53, 87%), fever (51, 84%), body aches (49, 80%), headaches (48, 79%), bloody stool (19, 31%), and vomiting (18, 30%). Of these 61 individuals, 30 (49%) were female and 31 (51%) were males. Ages ranged from 4 years to 72 years of age with the median age of 36 years. Onset of illness ranged from 2 hours to 243.5 hours with an average of 59.6 hours (mean 45 hours). Duration of symptoms ranged from 1 day to 17 days with median of 6 days (mean of 6 days). A statistical analysis of the questionnaire data was conducted to determine if there were any specific foods associated with the outbreak. No specific foods were shown to be significant in association with the outbreak.

Thirty-one individuals were laboratory confirmed positive for Salmonella, serotype Javiana. Including six of 20 of the restaurant’s employees. Cases were confirmed through culture and/or PCR; all cases had matching PFGE patterns. Three laboratory confirmed cases were identified as food service workers employed at three other food establishments in Fort Collins. Five cases reported being hospitalized and no deaths were associated with this outbreak. While most cases were Larimer County residents, there were also laboratory confirmed cases from Weld (1), Jefferson (1), Boulder (2), Montrose (1), and Denver (1) Counties. These non-county resident cases required significant coordination with the other local public health agencies doing those case interviews.

On September 4, 2018, LCDHE approved the establishment to receive food and conduct food preparation. On September 6, 2018, LCDHE approved the establishment to reopen to the public. The establishment reopened to public September 11, 2018

Management Investigation into this outbreak used resources available throughout the Health Department. LCDHE’s Public Information Office (PIO) staff developed a web-based information portal where the public could obtain information about the status of the outbreak and to complete an illness questionnaire. The PIO staff managed media requests and press releases. LCDHE’s Communicable Disease staff assisted with interviews and rectal swab sample collection with some of the restaurant’s staff. Clerical staff provided Spanish speaking interpreters to help with restaurant employee interviews and rectal swab sample collection for Spanish speaking individuals.

The bulk of the investigation was managed by LCDHE’s Communicable Disease and Consumer Protection staff. These two groups communicated frequently on the status of the outbreak investigation. Communicable Disease conducted case interviews of Salmonella positive individuals reported through CDPHE’s communicable disease reporting system, this included most of the 31 laboratory confirmed Salmonella cases associated with the outbreak. They developed and sent a Health Alert message to health care providers. They also worked extensively with CDPHE, coordinated conference calls with CDPHE’s Epi Division and laboratory staff. Communicable Disease coordinated and managed the collection, submission and result reporting for rectal swab samples submitted to the CDPHE laboratory. They also managed dissemination of the sample results to Consumer Protection staff.

Consumer Protection focused upon interaction with the restaurant that was identified as the source of the outbreak. Efforts included the preliminary illness complaint investigation, closure of the restaurant, outlining conditions for reopening, issuing the Public Health order to employees outlining when they can resume working as food handlers, conducting follow-up inspections, consultation with the restaurant’s management and staff to address questions, conducting restaurant employee interviews, collection of rectal swab samples from the restaurant’s staff and assessment of the restaurant’s condition for reopening to the public. In addition, Consumer Protection conducted seven Environmental Health inspections related to the outbreak at other retail food establishments that had exposure to this outbreak as an identified case, close personal contact of a case or a possible source of the outbreak.

CDPHE’s Epi Division developed and administered a food specific illness questionnaire based upon the outbreak restaurant’s menus and conducted a statistical analysis of the data collected. They also researched other cases and outbreaks associated with Salmonella, Javiana in Colorado as well as in the rest of the Country to evaluate an association with this outbreak.

LCDHE visits to restaurant • August 17, 2018, complete inspection, initial Foodborne Illness investigation • August 20, 2018, site visit, collection of rectal swabs, continue investigation • August 21, 2018, closure, follow-up inspection, collection of rectal swabs • August 22, 2018, issue PH order to restaurant employees and condition for reopening, collect rectal swabs • August 29, 2018, inspection to check cleaning • August 31, 2018, inspection to check cleaning • September 4, 2018, approval to receive food and conduct food preparation • September 6, 2018, approval to reopen to the public

Establishment Reopened to public September 11, 2018.

Summary Statistics CDPHE Questionnaire Total number of individuals interviewed: 85 Total number reporting symptoms: 61 (72%) Sex: 31(51%) Male 30(49%) Female Age of Cases: Minimum: 4 years Maximum: 72 years Median: 36

Table 1. Summary of Symptoms Symptom Number Percent Diarrhea (n=61) 61 100% Cramps (n=56) 53 94.6 Fever (n=57) 51 89.5 Body Aches (n=56) 49 87.5 Headache (n=56) 48 85.7 Bloody Stool (n=55) 19 34.5% Vomiting (n=52) 18 34.6%

CDPHE Survey Group* Reported Illnesses by Date of Exposure and Date of Onset 10 9 8 7 6 5 4 3 2 1 Number Reporting Illness Reporting Number 0

Date

Onset of Symptoms Date of Exposure

*Group does not include laboratory confirmed cases

Lab Confirmed Cases without Employee Cases by Date of Exposure and Date of Onset 8

7

6

5

4

3

2 Number of Lab Confirmed Cases 1

0

Date

Onset of Symptoms Date of Exposure

Onset of Symptoms-Employees 4

3

2

1 Number Reporting Illness Reporting Number

0 8-Aug 9-Aug 10-Aug 11-Aug 12-Aug 13-Aug 14-Aug 15-Aug 16-Aug Onset of Symptoms

Food Specific Attack Rate (from CDPHE survey) Food/Drink Exposures (n=79) Exposure Control (%) Case (%) p-value OR Confidence Interval

Breakfast burrito exp 5 38% 8 62% 0.51 0.62 0.18 2.20

Bacon burrito 1 14% 6 86% 0.67 2.64 0.30 23.25

Chorizo burrito 0 0

Veggie burrito 1 100% 0

Steak burrito 2 100% 0

Salsa breakfast burrito 2 22% 7 78% 0.22 0.10 0.01 1.50

Chip salsa 11 25% 33 75% 0.30 1.76 0.63 4.98

Queso app 0 0

Chips guac 5 29% 12 71% 1.00 1.04 0.31 3.43

Grill avo 3 75% 1 25% 0.08 0.13 0.01 1.34

Steak tacos 1 50% 1 50% 0.51 0.42 0.02 6.99

Chicken tacos 0 2 100%

Veggie tacos 1 100% 0

Carnitas tacos 0 2 100%

Steak nachos 0 0

Chicken nachos 0 0

Carnitas nachos 0 0

Bean nachos 0 1 100%

G-fish street tacos 6 35% 11 65% 0.76 0.76 0.24 2.44

Camaron street tacos 1 17% 5 83% 0.66 2.44 0.27 22.29

Alpastor street tacos 2 18% 9 82% 0.48 2.25 0.44 11.46

Tinga street tacos 0 4 100%

Carne street tacos 3 33% 6 67% 1.00 0.88 0.20 3.91

Lengua street tacos 0 2 100% Primavera street tacos 2 40% 3 60% 0.64 0.65 0.10 4.20

Tempura street tacos 4 57% 3 43% 0.19 0.29 0.06 1.43

Steak

Quesadillas 0 0

Fish quesadillas 0 0

Carn quesadillas 0 1 100%

Shrimp quesadilla 0 0

Chix quesadilla 1 25% 3 75% 1.00 1.40 0.14 14.26

Spin-bean quesadilla 0 1 100%

Bean quesadilla 0 3 100%

Carn tostadas 0 0

Tinga tostadas 0 0

Primavera tostadas 0 0

Gourmet burrito 2 100% 0

Gourmet type 1 100% 0

Fajita burrito 1 20% 4 80% 1.00 1.82 0.19 17.32

Fajita type 0 0

Potato burrito 4 80% 1 20% 0.03 0.09 0.01 0.89

Potato type 1 100% 0

Atomic burrito 0 0

Atomic delmar burrito 0 1 100%

Pesto burrito 0 0

Garden burrito 0 0

Entrée plate 0 2 100%

Plate type 0 0

Chili rellenos 2 100% 0

Enchiladas 2 100% 0 Enchilada type 2 100% 0

Fajita plate 0 0

Fajita plate type 0 0

Fish salad 0 0

Shrimp salad 0 0

Steak salad 0 0

Carnitas salad 0 0

Chicken salad 0 0

House salad 0 1 100%

Churros 0 1 100%

Sopapilla 0 0

Kids taco 0 0

Kid taco type 0 0

Kids burrito 0 0

Kids burrito type 0 0

Kids quesadilla 0 2 100%

Type quesadilla 0 1 100%

Kids chips cheese 1 100% 0

Soda 1 17% 5 83% 0.66 2.38 0.26 21.75

Lemonade 0 0

Lemon slices 0 0

Straw-cucumber lemonade 1 50% 1 50% 0.53 0.43 0.03 7.30

Cucumber slices 1 50% 1 50% 0.53 0.43 0.03 7.30

Latini lemonade 0 1 100%

Minty arnie 1 100% 0 v8 0 0

Iced tea 1 50% 1 50% 0.52 0.42 0.03 7.11 Horchata 0 0

Any beverage 10 26% 28 74% 0.43 1.62 0.58 4.57

Ice 10 25% 30 75% 0.29 1.94 0.68 5.51

Any salsa 15 27% 41 73% 0.10 3.19 0.92 11.02

Appendix Contents 1. August 17, 2018, Complete Inspection/Complaint/Condemn-Embargo 2. August 21, 2018, Follow-up Inspection 3. August 21, 2018, Other-Closure 4. August 22, 2018, Letter-Conditions for Reopening 5. August 22, 2018 Public Health Order-Restaurant Employees 6. August 29, 2018, Other-Inspection to Check Status 7. August 31, 2018, Other-Inspection to Check Status 8. September 4, 2018, Other-Inspection to Check Status 9. September 6, 2018, Follow-up Inspection-Re-Opening 10. Health Alert Network Notice

DEPARTMENT OF HEALTH AND ENVIRONMENT

1525 Blue Spruce Drive Fort Collins, Colorado 80524-2004 General Health (970) 498-6700 Environmental Health (970) 498-6775 Fax (970) 498-6772

Health Alert Network Broadcast HEALTH ADVISORY | Salmonella infections associated with La Luz Mexican Grill in Fort Collins | August 21, 2018 Health care providers: Please distribute widely in your office This information is for the public health and health care community. Do not post this document on a public web or social media site.

Key points • The Larimer County Department of Health and Environment (LCDHE) is investigating multiple confirmed Salmonella cases in people who report eating at La Luz Mexican Grill in the Old Town area of Fort Collins since August 1, 2018. • Health care providers are encouraged to collect stool specimens from patients presenting with symptoms consistent with Salmonella who report eating at the Old Town Fort Collins location of La Luz Mexican Grill since August 1, 2018.

Background information As of August 21, 2018, LCDHE has identified five Recommendations / guidance laboratory-confirmed cases of Salmonella, with more • Clinicians should consider collecting stool specimens cases pending, among people who report eating at the from patients presenting with symptoms of Old Town Fort Collins location of La Luz Mexican Grill Salmonella who report eating at the Old Town Fort in August 2018; many of the confirmed cases have been Collins location of La Luz Mexican Grill in August hospitalized. LCDHE is working closely with the 2018. restaurant to identify a possible source of the • Promptly report suspect cases to LCDHE at 970-468- outbreak. 6775. • Salmonella testing is typically part of the enteric PCR Information about Salmonella: panels that many clinical laboratories are using, or ● Organism: Salmonella is a bacteria that causes stool cultures can be ordered. Clinical laboratories gastrointestinal symptoms. Salmonella is a public are required to submit isolates or clinical material to health reportable condition in Colorado. the Colorado Department of Public Health and ● Symptoms: Diarrhea (sometimes bloody), stomach Environment (CDPHE) laboratory if Salmonella is cramps, fever, nausea, and sometimes vomiting. identified by culture or PCR. ● Incubation period: Generally six to 72 hours, but can • Persons with diarrhea should avoid handling and be as long as seven days. preparing food for others until their diarrhea has ● Duration of illness: Usually lasts four to seven days. been resolved for at least 24 hours. Children with ● Treatment: Antibiotics are not usually indicated for diarrhea should not attend school or child care until uncomplicated salmonellosis cases. Antibiotics do not their diarrhea has been resolved for at least 24 hours. shorten the duration of disease and may prolong • Cases of Salmonella who work in healthcare, food shedding of the bacteria in the stool. Antibiotics are service, or childcare should consult with public recommended only for patients who have a serious health before returning to work. illness (such as severe diarrhea, high fever, bloodstream infection, or condition requiring hospitalization) or patients considered at high risk for For more information serious disease or complications (such as infants, adults • Additional information about Salmonella can be over 65 years old, and people with weakened immune found at the Centers for Disease Control and systems). Prevention (CDC) website: ● Transmission: Salmonella bacteria are transmitted https://www.cdc.gov/salmonella/index.html via the fecal-oral route. The most common mode of • Larimer County Department of Health and transmission is ingestion of food or water that has been Environment 970-498-6775; after hours, contaminated with human or animal feces, or through through Sheriff’s Dispatch at 970-416-1985. contact with environments contaminated with animal • CDPHE Disease Reporting Line: 303-692-2700 feces. or 303-370-9395 (after hours).