A number of issues were identified in the county health department's inspection report:
- Soaking the beans in a plastic-lined horse trough covered with plywood, with a water hose running water through the trough (the ADPH did not know if or how the trough, which was located at the church, had been used prior to the dinner)
- Handling food without gloves;
- Turning off the heat source for the beans and disconnecting gas lines for burners without monitoring the temperature of the food;
- Transferring the beans in outside cooking pots to a smaller iron pot on wheels to take large quantities of the beans inside the church;
- Using one sterno can per 6-inch-deep chaffing pan to maintain the holding temperature of the beans;
- Re-using chaffing pans and adding new beans to existing beans throughout the serving time. Illness sweeps
But looking at the sum of errors, one could see a laxness in the use of food safety procedures, indicating there may be a additional factors that may have contributed to this outbreak.
Health Dept.: Beans soaked in horse trough Dozens taken ill after annual event
By Jean Cole firstname.lastname@example.org
The News Courier Sun Feb 02, 2014, 02:00 AM CST
— The final report on the Bean Day salmonella outbreak that left a dozen people hospitalized and scores of people ill last October may make some Limestone County residents cringe.
A nine-page study issued by the Alabama Department of Public Health and obtained Friday by The News Courier reveals that uncooked beans for the annual fundraiser had been soaked in a plastic-lined horse trough covered with plywood before the event and that existing bean soup was topped off with new bean soup during the event.
Those are just some of the possible ways the beans became contaminated with salmonella senftenberg, according to the report. An estimated 250 to 300 people ate food prepared for the Oct. 4 dinner hosted by the Athens-Limestone Foundation for Aging and held at First Baptist Church Family Life Center in Athens. The menu included white beans with ham, onions, vinegar-based coleslaw, cornbread, soft drinks and a variety of homemade desserts.
About 50 people reported falling ill following the event, though some may never have reported their illness. Early on, public health officials determined that the beans were likely the source of the outbreak of salmonella senftenberg, but they did not know how the infection occurred.
While investigators could not determine definitively how, or at what point in preparation, the beans became contaminated, they did conclude in their final report that “opportunities for person-to-food, food-to-food and equipment-to-food cross-contamination or improper holding temperatures” could have been the cause.
Interviews with food preparers identified “several opportunities for cross-contamination and improper holding temperatures,” according to the report. Among them: 1.) Soaking the beans in a plastic-lined horse trough covered with plywood, with a water hose running water through the trough (the ADPH did not know if or how the trough, which was located at the church, had been used prior to the dinner) 2.) Handling food without gloves; 3.) Turning off the heat source for the beans and disconnecting gas lines for burners without monitoring the temperature of the food; 4.) Transferring the beans in outside cooking pots to a smaller iron pot on wheels to take large quantities of the beans inside the church; 5.) Using one sterno can per 6-inch-deep chaffing pan to maintain the holding temperature of the beans; 6.) Re-using chaffing pans and adding new beans to existing beans throughout the serving time. Illness sweeps
On Oct. 7, three days after the bean dinner, public health officials in the area were notified that several people had reported symptoms of gastrointestinal illness after eating food from the event. An infection preventionist for Athens-Limestone Hospital told public health officials that 47 people who said they had eaten food from the fundraiser had reported to the emergency room on Oct. 5 and 6. Public Health Department staff eventually identified 134 people who had been exposed to salmonellosis, and 73 of those were interviewed using outbreak-specific questionnaires. Of those interviewed, 50 reported illnesses, the report revealed. It did not seem to matter, statistically, whether those who fell ill ate at the church, picked up a to-go plate or had a plate delivered to them, according to the report.
Although the most common signs and symptoms reported were diarrhea, extreme tiredness/weakness and abdominal pain, other symptoms included muscle aches, nausea, headache, fever, vomiting and bloody stools, the report showed. Recovery time ranged from two hours to five days, with the median being three days, according to the report.
Some members of The News Courier staff said, however, that a month passed before they felt normal again. Error in report According to the report, investigators determined the food for the event had been prepared at “a foundation, a church and a local jail,” though the report did not specifically name the locations. But, this part of the report would appear to be in error. Beans were not prepared at a local jail. Rather, leftover beans were brought to the Limestone County Jail for the prisoners, according to Paul Cain with the Limestone County Sheriff’s Department. “As soon as (the leftovers) arrived, Sheriff Mike Blakely and the chief cook examined the beans and both remarked that they had soured in the pots … and an immediate decision was made not to use them for inmate meals,”
Cain said Friday. “The leftovers were refrigerated and, soon after, the sheriff was contacted to maintain what beans he had been offered for sampling.” Cain said it would have been easy for testing officials with the health department to misunderstand the situation and assume the beans had been prepared at the jail. “If I were a testing official and walked into the jail, observed the beans in jail pots being stored in the jail refrigerator, and being assisted by jail staff and not knowing the particulars of the fundraising event, I might have assumed the jail prepared the items,” Cain said.
“But in this instance, we were only the receivers.”
The final report said investigators studied 14 food samples (boxed plates left over from the event), 30 environmental samples (samples from the church and the jail and from a variety of areas where food could have been contaminated), and from 13 stool specimens from those who fell ill. Salmonella senftenberg was isolated “in two environmental samples obtained from the church, nine food samples and all stool specimens,” according to the report. “The two positive environmental samples were from environment swabs of a dirty strainer and the double sink floor drain at the church.”
The report says that while visiting the foundation, the church and the jail, health officials recommended ways to improve food safety and prevent salmonellosis infection and also distributed flyers.