title: A large outbreak of Brainerd diarrhea associated with a restaurant in the Red River Valley, Texas.
abstract: BACKGROUND
  In June 1996, an outbreak of chronic diarrhea was reported to the Texas Department of Health (Austin).
  
  
  METHODS
  We initiated active case finding, performed 2 case-control studies, and conducted an extensive laboratory and environmental investigation.
  
  
  RESULTS
  We identified 114 persons with diarrhea that lasted > or = 4 weeks. Symptoms among 102 patients who were studied included urgency (87%), fatigue (86%), fecal incontinence (74%), and weight loss (73%); the median maximum 24-h stool frequency was 15 stools. Diarrhea persisted for > 6 months in 87% and for > 1 year in 70% of patients who were observed. Fifty-one (89%) of 57 ill persons had eaten at a particular restaurant within 4 weeks before onset, compared with 8 (14%) of 59 matched control subjects (matched odds ratio [OR], undefined; 95% confidence interval [CI], 11.2-infinity). At the restaurant, patients were more likely than their unaffected dining companions to have drunk tap water (OR, 2.8; 95% CI, 1.0-9.9) and to have eaten several specific food items, and they were less likely to have drunk iced tea made from boiled water and store-bought ice (OR, 0.3; 95% CI, 0.05-1.0). A multivariable model that included consumption of tap water and salad bar tomatoes best fit the data. The restaurant had multiple sanitary and plumbing deficiencies. Extensive laboratory and environmental testing for bacterial, parasitic, mycotic, and viral agents did not identify an etiologic agent.
  
  
  CONCLUSIONS
  The clinical, laboratory, and epidemiologic findings are consistent with those of previous outbreaks of Brainerd diarrhea. To our knowledge, this is the largest reported outbreak of Brainerd diarrhea associated with a restaurant.
authors.affiliation: Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Akiko C
authors.initials: AC
authors.lastname: Kimura
authors.forename: Paul
authors.initials: P
authors.lastname: Mead
authors.forename: Brad
authors.initials: B
authors.lastname: Walsh
authors.forename: Edie
authors.initials: E
authors.lastname: Alfano
authors.forename: Shellie Kolavic
authors.initials: SK
authors.lastname: Gray
authors.forename: Lisa
authors.initials: L
authors.lastname: Durso
authors.forename: Charles
authors.initials: C
authors.lastname: Humphrey
authors.forename: Stephan S
authors.initials: SS
authors.lastname: Monroe
authors.forename: Govinda
authors.initials: G
authors.lastname: Visvesvera
authors.forename: Nancy
authors.initials: N
authors.lastname: Puhr
authors.forename: Wun-Ju
authors.initials: WJ
authors.lastname: Shieh
authors.forename: Mark
authors.initials: M
authors.lastname: Eberhard
authors.forename: Robert M
authors.initials: RM
authors.lastname: Hoekstra
authors.forename: Eric D
authors.initials: ED
authors.lastname: Mintz
mesh_terms: D016022:Case-Control Studies; D002908:Chronic Disease; D003967:Diarrhea / Q000453:epidemiology* / Q000209:etiology*; D004196:Disease Outbreaks; D004784:Environmental Monitoring; D062665:Epidemiological Monitoring; D005516:Food Microbiology; D006801:Humans; D012147:Restaurants; D013781:Texas / Q000453:epidemiology; D014871:Water Microbiology