Centers for Disease Control and Prevention

Epidemiology Program Office

Case Studies in Applied Epidemiology
No. 401-303

Oswego – An Outbreak
of Gastrointestinal Illness
Following a Church Supper
Student's Guide
Learning Objectives
After completing this case study, the participant should be able to:

G Define the terms “cluster,” “outbreak,” and “epidemic;”

G List the steps in the investigation of an outbreak;

G Draw, interpret, and describe the value of an epidemic curve;

G Calculate and compare food-specific attack rates to identify possible vehicles;

G List reasons for investigating an outbreak that has apparently ended.

This case study is based on an investigation conducted by the New York State Department of
Public Health Division. The case study was developed by Wendell Ames, MD, Stafford
Wheeler, MD, and Alexander Langmuir, MD in the early 1940s. It has been substantially
updated and edited since then by Philip Brachman, Michael Gregg, and Richard Dicker, with
input from the many instructors who have reviewed and taught "Oswego" as part of the EIS
Summer Course each year.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service
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PART I - Background
On April 19, 1940, the local health officer in the previous evening, April 18. Family members
village of Lycoming, Oswego County, New York, who did not attend the church supper did not
reported the occurrence of an outbreak of acute become ill. Accordingly, Dr. Rubin focused the
gastrointestinal illness to the District Health investigation on the supper. He completed
Officer in Syracuse. Dr. A. M. Rubin, Interviews with 75 of the 80 persons known to
epidemiologist-in-training, was assigned to have attended, collecting information about the
conduct an investigation. occurrence and time of onset of symptoms, and
foods consumed. Of the 75 persons
When Dr. Rubin arrived in the field, he learned interviewed, 46 persons reported
from the health officer that all persons known to gastrointestinal illness.
be ill had attended a church supper held on the

Question 1: Would you call this an epidemic? Would you call it an outbreak?

Question 2: Review the steps of an outbreak investigation.

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Clinical Description

The onset of illness in all cases was acute, temperature; all recovered within 24 to 30 hours.
characterized chiefly by nausea, vomiting, Approximately 20% of the ill persons visited
diarrhea, and abdominal pain. None of the ill physicians. No fecal specimens were obtained
persons reported having an elevated for bacteriologic examination.

Question 3: List the broad categories of diseases that must be considered in the differential
diagnosis of an outbreak of gastrointestinal illness.

The investigators suspected that this was a vehicle-borne outbreak, with food as the vehicle.

Question 4: In epidemiologic parlance, what is a vehicle? What is a vector? What are other modes
of transmission?
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Question 5: If you were to administer a questionnaire to the church supper participants, what
information would you collect? Group the information into categories.

Dr. Rubin put his data into a line listing.

Question 6: What is a line listing? What is the value of a line listing?

CDC-EIS, 2003: Oswego – GI Illness Following a Church Supper (401-303) - Student's Guide Page 5

PART II
Description of the Supper

The supper was held in the basement of the Data regarding onset of illness and food eaten
village church. Foods were contributed by or water drunk by each of the 75 persons
numerous members of the congregation. The interviewed are provided in the attached line
supper began at 6:00 p.m. and continued until listing. The approximate time of eating supper
11:00 p.m. Food was spread out on a table and was collected for only about half the persons
consumed over a period of several hours. who had gastrointestinal illness.

Question 7: What is the value of an epidemic curve?

Question 8: Using the graph paper provided, graph the cases by time of onset of illness (include
appropriate labels and title). What does this graph tell you?

Question 9: Are there any cases for which the times of onset are inconsistent with the general
experience? How might they be explained?

Question 10: How could the data in the line listing be better presented?
CDC-EIS, 2003: Oswego – GI Illness Following a Church Supper (401-303) - Student's Guide Page 6

Line listing from investigation of outbreak of gastroenteritis,

Oswego, New York, 1940

Mashed potatoes

Choc ice cream

Cabbage salad

Van ice cream

Brown bread
Baked ham

Fruit salad
Spinach

Coffee

Cakes
Water
TIME DATE OF TIME OF

Rolls
Jello

Milk
ID AGE SEX OF MEAL ILL ONSET ONSET
1 11 M unk N N N N N N N N N N N N N Y N
2 52 F 8:00 PM Y 4/19 12:30 AM Y Y Y N N Y N N Y N N Y N N
3 65 M 6:30 PM Y 4/19 12:30 AM Y Y Y Y N N N N Y N N Y Y N
4 59 F 6:30 PM Y 4/19 12:30 AM Y Y N N N N N N Y N Y Y Y N
5 13 F unk N N N N N N N N N N N N N Y N
6 63 F 7:30 PM Y 4/18 10:30 PM Y Y N Y Y N N N N Y N Y N N
7 70 M 7:30 PM Y 4/18 10:30 PM Y Y Y N Y Y Y N Y Y N Y N N
8 40 F 7:30 PM Y 4/19 2:00 AM N N N N N N N N N N N Y Y N
9 15 F 10:00 PM Y 4/19 1:00 AM N N N N N N N N N N Y N Y N
10 33 F 7:00 PM Y 4/18 11:00 PM Y Y Y N N Y Y N N Y N Y Y N

11 65 M unk N Y Y Y N Y Y N N N N N Y N N
12 38 F unk N Y Y Y N N Y N N Y N N Y Y Y
13 62 F unk N Y Y N Y Y Y Y N N Y N N N N
14 10 M 7:30 PM Y 4/19 2:00 AM N N N N N N N N N N N Y Y N
15 25 M unk N Y Y Y Y Y Y Y Y Y Y Y Y N N
16 32 F unk Y 4/19 10:30 AM Y Y N N N Y N N Y N Y Y Y N
17 62 F unk Y 4/19 12:30 AM N N N N N N N N N N N Y N N
18 36 M unk Y 4/18 10:15 PM Y Y N Y N Y Y N N N N Y N N
19 11 M unk N Y Y ? Y N Y N N N Y N N Y N
20 33 F unk Y 4/18 10:00 PM Y Y Y Y Y Y N N Y Y Y Y Y N

21 13 F 10:00 PM Y 4/19 1:00 AM N N N N N N N N N N Y Y N N

22 7 M unk Y 4/18 11:00 PM Y Y Y Y Y Y Y N N Y Y Y Y N
23 64 M unk N N N N N N N N N N N N Y N N
24 3 M unk Y 4/18 9:45 PM N Y Y N N Y N N N Y Y Y N N
25 65 F unk N Y Y Y Y Y N Y N Y N Y Y Y N
26 59 F unk Y 4/18 9:45 PM N Y Y Y N Y Y N N Y Y Y N N
27 15 F 10:00 PM Y 4/19 1:00 AM N N N N N N N N N N Y Y Y N
28 62 M unk N Y Y N Y N Y Y N Y Y Y N Y N
29 37 F unk Y 4/18 11:00 PM Y Y Y N Y Y Y N Y N Y Y N N
30 17 M 10:00 PM N N N N N N N N N N N Y Y Y N

31 35 M unk Y 4/18 9:00 PM Y Y Y N Y Y Y N Y N Y Y N Y

32 15 M 10:00 PM Y 4/19 1:00 AM N N N N N N N N N N Y Y N N
33 50 F 10:00 PM Y 4/19 1:00 AM N N N N N N N N N N N Y N N
34 40 M unk N Y Y N N N Y Y N Y Y Y N Y Y
35 35 F unk N Y Y Y N N Y Y N Y Y N N Y N
36 35 F unk Y 4/18 9:15 PM Y Y Y Y N Y Y N Y N N Y N N
37 36 M unk N Y N Y Y N Y Y N Y N N N Y N
38 57 F unk Y 4/18 11:30 PM Y Y N Y Y Y Y N Y N Y Y Y N
39 16 F 10:00 PM Y 4/19 1:00 AM N N N N N N N N N N Y N Y N
40 68 M unk Y 4/18 9:30 PM Y N Y Y N N Y N Y N N Y N N
CDC-EIS, 2003: Oswego – GI Illness Following a Church Supper (401-303) - Student's Guide Page 7

Line listing from investigation of outbreak of gastroenteritis,

Oswego, New York, 1940

Mashed potatoes

Choc ice cream

Cabbage salad

Van ice cream

Brown bread
Baked ham

Fruit salad
Spinach

Coffee

Cakes
Water
TIME DATE OF TIME OF

Rolls
Jello

Milk
ID AGE SEX OF MEAL ILL ONSET ONSET
41 54 F unk N Y Y Y N N Y N N Y N Y N Y N
42 77 M unk Y 4/19 2:30 AM N N N N N N N N N N N Y N Y
43 72 F unk Y 4/19 2:00 AM Y Y N Y Y N Y N Y N Y Y Y N
44 58 M unk Y 4/18 9:30 PM Y Y Y N N N Y Y Y N N Y ? Y
45 20 M 10:00 PM N N N N N N N N N N N Y Y Y N
46 17 M unk N Y Y Y N N Y N N N Y N Y Y N
47 62 F unk Y 4/19 12:30 AM Y Y N N N Y N N N Y N Y N N
48 20 F 7:00 PM Y 4/19 1:00 AM N N N N N N N N N N N Y N N
49 52 F unk Y 4/18 10:30 PM Y Y Y Y N Y N N Y N N Y Y N
50 9 F unk N N N N N N N N N N N Y N Y N

51 50 M unk N Y Y Y Y Y Y Y Y Y Y Y N Y N
52 8 M 11:00 AM Y 4/18 3:00 PM N N N N N N N N N N N Y Y N
53 35 F unk N N N N N N N N N N N N Y Y N
54 48 F unk Y 4/19 12:00 AM* Y Y Y Y Y Y Y Y Y N Y Y Y N
55 25 M unk Y 4/18 11:00 PM Y N Y N N Y Y N N Y Y Y Y N
56 11 F unk N N N N N N N N N N N N N Y N
57 74 M unk Y 4/18 10:30 PM Y Y Y Y Y Y Y N Y N Y Y N N
58 12 F 10:00 PM Y 4/19 1:00 AM N N N N N N N N N N Y Y Y N
59 44 F 7:30 PM Y 4/19 2:30 AM Y Y Y N N Y N N N Y Y N Y N
60 53 F 7:30 PM Y 4/18 11:30 PM Y Y Y Y Y N Y N Y Y Y Y Y N

61 37 M unk N N N N N N N N N N N N N Y N
62 24 F unk N Y Y Y N N Y N N Y N N N N N
63 69 F unk N N Y Y N Y N Y N N Y Y N Y N
64 7 M unk N Y Y Y Y Y Y N N N Y Y N Y N
65 17 F 10:00 PM Y 4/19 1:00 AM N N N N N N N N N N Y Y Y N
66 8 F unk Y 4/19 12:30 AM Y N Y Y Y N N N N N Y Y Y N
67 11 F 7:30 PM N Y Y Y Y N Y N N Y Y N N Y N
68 17 M 7:30 PM N Y Y Y Y N Y N N Y N Y Y N N
69 36 F unk N N N N N N N N N N N N N Y N
70 21 F unk Y 4/19 12:30 AM Y N N Y Y N N N N N N Y Y N

71 60 M 7:30 PM Y 4/19 1:00 AM N N N N N N N N N N Y Y N N

72 18 F 7:30 PM Y 4/19 12:00 AM* Y Y Y Y Y N N N N Y Y Y Y N
73 14 F 10:00 PM N N N N N N N N N N N Y Y N N
74 52 M unk Y 4/19 2:15 AM Y N Y N Y Y Y N Y Y Y Y Y N
75 45 F unk Y 4/18 11:00 PM Y Y Y Y Y Y Y N Y N Y Y N Y

* Midnight between 4/18 and 4/19

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PART III
Attached is the line listing sorted by illness status (ill or well), and by time of onset.

Question 11: Where possible, using the new line listing, calculate incubation periods and illustrate
their distribution with an appropriate graph.

Question 12: Determine the range and median of the incubation period.

Question 13: How does the information on incubation period, combined with the data on clinical
symptoms, help in the differential diagnosis of the illness? (If necessary, refer to
attached Compendium of Acute Foodborne Gastrointestinal Disease).
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Question 14: Using the data in the attached line listing, complete the table below. Which food is the
most likely vehicle of infection?

Food Items Served Number of persons who ATE Number of persons did NOT eat
specified food specified food

Percent Ill Percent Ill Attack Rate

Ill Not Ill Total (Attack rate) Ill Not Ill Total (Attack rate) Ratio

Baked ham

Spinach

Mashed potato

Cabbage salad

Jello

Rolls

Brown bread

Milk

Coffee

Water

Cakes

Ice cream, vanilla

Ice cream, chocolate

Fruit salad
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Question 15: Outline further investigations that should be pursued.

Question 16: What control measures would you suggest?

Question 17: Why was it important to work up this outbreak?

Question 18: Refer to the steps of an outbreak investigation you listed in Question 2. How does this
investigation fit that outline?
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PART IV - CONCLUSION

The following is quoted verbatim from the report follows: 'Staphylococcus aureus and hemolytic
prepared by Dr. Rubin: streptococci were isolated from nose culture and
Staphylococcus albus from throat culture of
"The ice cream was prepared by the Petrie Grace Petrie. Staphylococcus albus was
sisters as follows: isolated from the nose culture of Marian Petrie.
The hemolytic streptococci were not of the type
"On the afternoon of April 17 raw milk from the usually associated with infections in man.'
Petrie farm at Lycoming was brought to boil over
a water bath, sugar and eggs were then added "Discussion as to Source: The source of
and a little flour to add body to the mix. The bacterial contamination of the vanilla ice cream
chocolate and vanilla ice cream were prepared is not clear. Whatever the method of the
separately. Hershey's chocolate was necessarily introduction of the staphylococci, it appears
added to the chocolate mix. At 6 p.m. the two reasonable to assume it must have occurred
mixes were taken in covered containers to the between the evening of April 17 and the morning
church basement and allowed to stand overnight. of April 18. No reason for contamination
They were presumably not touched by anyone peculiar to the vanilla ice cream is known.
during this period.
"In dispensing the ice creams, the same scooper
"On the morning of April 18, Mr. Coe added five was used. It is therefore not unlikely to assume
ounces of vanilla and two cans of condensed milk that some contamination to the chocolate ice
to the vanilla mix, and three ounces of vanilla and cream occurred in this way. This would appear
one can of condensed milk to the chocolate mix. to be the most plausible explanation for the
Then the vanilla ice cream was transferred to a illness in the three individuals who did not eat
freezing can and placed in an electrical freezer the vanilla ice cream.
for 20 minutes, after which the vanilla ice cream
was removed from the freezer can and packed "Control Measures: On May 19, all remaining
into another can which had been previously ice cream was condemned. All other food at the
washed with boiling water. Then the chocolate church supper had been consumed.
mix was put into the freezer can which had been
rinsed out with tap water and allowed to freeze "Conclusions: An attack of gastroenteritis
for 20 minutes. At the conclusion of this both occurred following a church supper at Lycoming.
cans were covered and placed in large wooden The cause of the outbreak was contaminated
receptacles which were packed with ice. As vanilla ice cream. The method of contamination
noted, the chocolate ice cream remained in the of ice cream is not clearly understood. Whether
one freezer can. the positive Staphylococcus nose and throat
cultures occurring in the Petrie family had
"All handlers of the ice cream were examined. anything to do with the contamination is a matter
No external lesions or upper respiratory of conjecture."
infections were noted. Nose and throat cultures
were taken from two individuals who prepared Note: Patient #52 was a child who while
the ice cream. watching the freezing procedure was given a
dish of vanilla ice cream at 11:00 a.m. on April
"Bacteriological examinations were made by the 18.
Division of Laboratories and Research, Albany,
on both ice creams. Their report is as follows: Addendum:
'Large numbers of Staphylococcus aureus and Certain laboratory techniques not available at
albus were found in the specimen of vanilla ice the time of this investigation might prove very
cream. Only a few staphylococci were useful in the analysis of a similar epidemic
demonstrated in the chocolate ice cream.' today. These are phage typing, which can be
done at CDC, and identification of
"Report of the nose and throat cultures of the staphylococcal enterotoxin in food by
Petries who prepared the ice cream read as immuno-diffusion or by enzyme-linked
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immunosorbent assay (ELISA), which is available as cultures of others who might have been in
through the Food and Drug Administration (FDA). contact with the ice cream in preparation or
consideration of the possibility that
One would expect the phage types of contamination occurred from using a cow with
staphylococci isolated from Grace Petrie's nose mastitis and that the only milk boiled was that
and the vanilla ice cream and vomitus or stool used to prepare chocolate ice cream. If the
samples from ill persons associated with the contaminated food had been heated sufficiently
church supper to be identical had she been the to destroy staphylococcal organisms but not
source of contamination. Distinctly different toxin, analysis for toxin (with the addition of
phage types would mitigate against her as the urea) would still permit detection of the cause of
source (although differences might be observed the epidemic. A Gram stain might also detect
as a chance phenomenon of sampling error) and the presence of nonviable staphylococci in
suggest the need for further investigation, such contaminated food.

Reference
Gross MB. Oswego County revisited. Public Health Reports 1976;91:160-70.