title: Molecular and epidemiologic analysis of a county-wide outbreak caused by Salmonella enterica subsp. enterica serovar Enteritidis traced to a bakery.
abstract: BACKGROUND
  An increase in the number of attendees due to acute gastroenteritis and fever was noted at one hospital emergency room in Taiwan over a seven-day period from July to August, 2001. Molecular and epidemiological surveys were performed to trace the possible source of infection.
  
  
  METHODS
  An epidemiological investigation was undertaken to determine the cause of the outbreak. Stool and blood samples were collected according to standard protocols per Center for Disease Control, Taiwan. Typing of the Salmonella isolates from stool, blood, and food samples was performed with serotyping, antibiotypes, and pulsed field gel electrophoresis (PFGE) following XbaI restriction enzyme digestion.
  
  
  RESULTS
  Comparison of the number of patients with and without acute gastroenteritis (506 and 4467, respectively) during the six weeks before the outbreak week revealed a significant increase in the number of patients during the outbreak week (162 and 942, respectively) (relative risk (RR): 1.44, 95% confidence interval (CI): 1.22-1.70, P value < 0.001). During the week of the outbreak, 34 of 162 patients with gastroenteritis were positive for Salmonella, and 28 of these 34 cases reported eating the same kind of bread. In total, 28 of 34 patients who ate this bread were positive for salmonella compared to only 6 of 128 people who did not eat this bread (RR: 17.6, 95%CI 7.9-39.0, P < 0.001). These breads were produced by the same bakery and were distributed to six different traditional Chinese markets., Salmonella enterica subsp. enterica serovar Enteritidis (S. Enteritidis) was isolated from the stool samples of 28 of 32 individuals and from a recalled bread sample. All S. Enteritidis isolates were of the same antibiogram. PFGE typing revealed that all except two of the clinical isolates and the bread isolates were of the same DNA macrorestriction pattern.
  
  
  CONCLUSIONS
  The egg-covered bread contaminated with S. Enteritidis was confirmed as the vehicle of infection. Alertness in the emergency room, surveillance by the microbiology laboratory, prompt and thorough investigation to trace the source of outbreaks, and institution of appropriate control measures provide effective control of community outbreaks.
authors.affiliation: Department of Internal Medicine, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd., Kaohsiung, Taiwan. d830166@cc.kmu.edu.tw <d830166@cc.kmu.edu.tw>
authors.forename: Po-Liang
authors.initials: PL
authors.lastname: Lu
authors.forename: In-Jane
authors.initials: IJ
authors.lastname: Hwang
authors.forename: Ya-Lina
authors.initials: YL
authors.lastname: Tung
authors.forename: Shang-Jyh
authors.initials: SJ
authors.lastname: Hwang
authors.forename: Chun-Lu
authors.initials: CL
authors.lastname: Lin
authors.forename: L K
authors.initials: LK
authors.lastname: Siu
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016470:Bacteremia / Q000382:microbiology; D001939:Bread / Q000382:microbiology*; D002648:Child; D002675:Child, Preschool; D016172:DNA Fingerprinting; D004196:Disease Outbreaks; D016521:Electrophoresis, Gel, Pulsed-Field; D004636:Emergency Service, Hospital; D005243:Feces / Q000382:microbiology; D005260:Female; D005334:Fever; D005759:Gastroenteritis / Q000453:epidemiology* / Q000382:microbiology; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D012478:Salmonella Food Poisoning / Q000453:epidemiology* / Q000382:microbiology; D012477:Salmonella enteritidis / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D012703:Serotyping; D013624:Taiwan / Q000453:epidemiology