MEMORANDUM. Alfred DeMaria, Jr., MD State Epidemiologist Medical Director, Bureau of Infectious Disease

Transcription

1 MEMORANDUM TO: Kevin Cranston, MDiv Director, Bureau of Infectious Disease Alfred DeMaria, Jr., MD State Epidemiologist Medical Director, Bureau of Infectious Disease Suzanne K. Condon, MS Director, Bureau of Environmental Health Michael A. Pentella, PhD, D(ABMM) Director, Bureau of Laboratory Sciences William A. Hinton State Laboratory Institute FROM: Kerri Barton, MPH Epidemiologist, Division of Epidemiology & Immunization DATE: April 3, 2014 Emily Harvey Epidemiologist, Division of Epidemiology & Immunization Nora McElroy, MPH Epidemiologist, Division of Epidemiology & Immunization Rachel Burns, MPH Epidemiologist, Division of Epidemiology & Immunization Patricia Kludt, MPH Epidemiology Program Coordinator, Division of Epidemiology and Immunization Tara Harris Foodborne Illness Coordinator, Bureau of Environmental Health, Food Protection Program Brandi Stoffregen, MPH Local Health and Food Safety Coordinator, Bureau of Environmental Health, Food Protection Program Erika Buzby Molecular Diagnostics, Bureau of Laboratory Sciences RE: Reported clusters of Norovirus associated with oysters in Barnstable County from June 14 to June 17, 2013

2 WGFIC: MAVEN IDs: , I. Summary Gastrointestinal illness in multiple individuals was reported after three separate events which took place over the course of three days in June 2013 (June 14, June 15, and June 17) that included the consumption of raw oysters harvested from one shellfish bed by a single harvester. Norovirus G1.4 was identified in ill attendees of two of the events, foodhandlers from one of the events, the single harvester, and from oysters collected from the shellfish distributor. Samples collected from the distributor included oysters from harvest beds MA-SC:49 and SC:50. As a result of this investigation, the Division of Marine Fisheries (DMF) closed the implicated shellfish bed and the two adjacent beds on June 20, One bed (SC:49) reopened on October 15, 2013 and the other beds (SC:50 and SC:50.1) reopened on December 1, FPP ordered a recall of oysters from these harvest beds and conducted recall effectiveness investigations. II. Introduction 1- Cape Cod Wedding/ Wayside Inn On June 17, 2013, a Needham resident notified the Food Protection Program (FPP) at the Massachusetts Department of Public Health (MDPH) that several guests at his son s wedding became ill with gastrointestinal symptoms in the days following the event. The wedding was held on Saturday, June 15, 2013 at the Winslow Estate in Orleans, MA and was catered by Casual Gourmet in Barnstable; 128 adults and five children attended the wedding. Several of the ill guests reportedly also attended a rehearsal dinner on Friday, June 14, 2013 at the Wayside Inn in Chatham, MA (63 total guests were at the dinner). The Working Group on Foodborne Illness Control (WGFIC), in coordination with several local boards of health (LBOH) and DMF, initiated an investigation. 2- The Port Restaurant On June 20, 2013, the Harwich Board of Health (HBOH) notified the Division of Epidemiology and Immunization (EPI) of a complaint of gastrointestinal illness among attendees of a private birthday party held at the Port Restaurant in Harwich, MA. The party was held the evening of June 15, Thirty-five guests attended the party. WGFIC, in coordination with HBOH and DMF, initiated an investigation. 3- Mattakeese Wharf On June 20, 2013, the Barnstable Board of Health (BBOH) notified FPP of a third cluster of gastrointestinal illness occurring on Cape Cod. Two couples reported eating at Mattakeese Wharf in Barnstable, MA on June 17, 2013 and became ill with nausea, vomiting, and diarrhea within hours of the meal. The patrons reportedly ate raw oysters. 1

3 III. Background 1- Cape Cod Wedding/ Wayside Inn The wedding was held on Saturday, June 15, 2013 at the Winslow Estate in Orleans, MA. It included food items that were prepared and delivered by Casual Gourmet of Barnstable, MA. Food items included passed hors d oeuvres, a sit-down dinner that included a salad and a choice of fish or beef for the entrée, and wedding cake for dessert. The rehearsal dinner was held on Friday, June 14, 2013 at the Wayside Inn in Chatham, MA. The dinner included appetizers, a buffet, and a sundae bar. There were a variety of stationary appetizers, including a cheese display and raw oysters. The buffet included salad, rolls, steamers, watermelon, corn on the cob, baked potatoes, grilled chicken, BBQ ribs, and lobsters. 2- The Port Restaurant The Port is a restaurant located in Harwich, MA that features New England seafood. The birthday party on June 15, 2013 was held in a separate room from the main dining area. The menu for the party consisted of passed hors d oeuvres, including raw oysters. 3- Mattakeese Wharf Mattakeese Wharf is a waterfront restaurant in Barnstable, MA. Their menu includes a variety of seafood options, including oysters that are served raw during dinner. IV. Methods A. Epidemiologic 1- Cape Cod Wedding/ Wayside Inn EPI collected addresses from the bride for the wedding attendees and sent out a survey on June 20, The survey captured information about symptoms, whether they attended the rehearsal dinner, the wedding, or both, and food consumption [Attachment 1]. Cases were defined as any guest who reported any gastrointestinal symptom within 48 hours of the rehearsal dinner on June 14, 2013 or wedding on June 15, Data analysis of the results was conducted using SAS v9.3. Risk ratios were calculated using OpenEpi. 2- The Port Restaurant HBOH interviewed restaurant staff and three attendees of the birthday party and collected addresses from the party s organizer. EPI distributed an online survey to party attendees by and asked that the survey be forwarded to other attendees whose addresses were not obtained. The survey captured detailed information on food consumption and symptoms of party attendees. 2

4 Cases were defined as any guest who reported any gastrointestinal symptom within 48 hours of attending the party. [Attachment 2]. Data analysis of the results was conducted using Microsoft Excel Risk ratios were calculated using OpenEpi. 3- Mattakeese Wharf EPI attempted to contact the patrons who reported illness to the BBOH several times without success. A home telephone number given by the BBOH was valid and three messages were left by EPI. A survey of individual-level information could not be conducted and they were considered lost to follow-up for the remainder of the investigation. B. Environmental 1- Cape Cod Wedding/ Wayside Inn On June 17, 2013, an inspector from the Chatham Board of Health (CBOH) conducted an investigation at the Wayside Inn. 2- The Port Restaurant On June 18 and 19, 2013, an inspector from the CBOH conducted an investigation at the Port Restaurant. 3- Mattakeese Wharf An inspector from BBOH conducted an investigation at Mattakeese Wharf. C. Laboratory 1- Food A. Cape Cod Wedding/ Wayside Inn On June 18, 2013, an inspector from FPP collected five leftover food samples from the Wayside Inn. The food samples were walnuts, M&M candy, ice cream, chocolate chips and oysters that had been served at the rehearsal dinner. The tags for the oysters stated they were from harvest area MA-SC:61 and were harvested on June 6, 2013 [Attachments 3+4]. Eight leftover food samples from the wedding catered by the Casual Gourmet were collected on June 18, 2013 as well. The food samples were mint aioli, white balsamic dressing, cucumbers, red onions, red grape tomatoes, green lettuce, goat cheese and pears. B. The Port Restaurant No food items were collected for testing. C. Mattakeese Wharf 3

5 No food items were collected for testing. D. Additional testing Based on preliminary information that oysters served at all three events were harvested by a single harvester, oysters from harvest beds MA-SC:49 and MA-SC:50 were sent to the FDA Gulf Coast Seafood Laboratory in Alabama on June 26, Clinical A. Cape Cod Wedding/Wayside Inn Stool specimens were collected from four wedding attendees who experienced symptoms of gastrointestinal illness. They were tested at the Hinton State Laboratory Institute (HSLI) for bacterial and viral etiologic agents, including Salmonella sp., Shigella, Campylobacter, and norovirus. B. The Port Restaurant Stool specimens were collected from 11 employees at the Port and one party attendee who experienced symptoms of gastrointestinal illness. They were tested at HSLI for bacterial and viral etiologic agents, including Salmonella sp., Shigella, Campylobacter, and norovirus. C. Mattakeese Wharf No stool specimens were collected. D. Additional testing Stool specimens were collected from five harvesters at Chatham Shellfish Company, including one harvester who reported symptoms of gastrointestinal illness beginning June 16, They were tested at HSLI for norovirus. V. Results A. Epidemiologic 1- Cape Cod Wedding/ Wayside Inn Fifty-four out of 133 (41%) wedding attendees completed the survey distributed by EPI. Among these respondents, 25 (46%) individuals reported onset dates of gastrointestinal symptoms from June 15 June 21, Based on food and patron positive norovirus test results, it was determined that the exposures had to have occurred at the rehearsal dinner, as this is where the implicated oysters were served. Therefore, the four individuals who reported symptoms more than 48 hours after the rehearsal dinner were considered secondary cases. Please see Table 1 for 4

6 a complete list of symptoms. Duration of symptoms of both the primary and secondary cases ranged from 12 to 72 hours with a mean of 39 hours. Analysis of food items consumed at the rehearsal dinner revealed that consumption of raw oysters was the only significant potential source of infection [Table 3]. Of those that reported consumption of raw oysters at the rehearsal dinner (n=22), 18 (82%) were primary cases. Those that consumed oysters at the rehearsal dinner were 9.82 times (95% confidence interval: ) more likely to become ill than those who did not consume oysters. 2- The Port Restaurant Fourteen of 35 birthday party attendees (40%) completed the survey distributed by EPI. Among these respondents, six (43%) had gastrointestinal illness within 48 hours of the birthday party, meeting the case definition. Please see Table 2 for a complete list of symptoms. Symptom onsets occurred on June 16 and June 17, The duration of symptoms was from 12 to 48 hours, with a mean of 24 hours. HBOH reported that four of 11 food handlers also experienced gastrointestinal illness. Symptom onsets occurred from June 16 to June 19, Analysis of food items consumed at the party revealed that raw shellfish consumption was a significant potential source of infection (Table 4). Those who reported consumption of raw littleneck clams (n=3), were 3.33 times (95% confidence interval: ) more likely to become ill than those who did not consume raw littleneck clams. These cases also all reported eating raw oysters. Of all the attendees who reported consumption of raw oysters (n=6), five became ill (RR= 5.83, CI= ). Oyster consumption had the highest relative risk of all food products. 3- Mattakeese Wharf No person-level epidemiologic information could be obtained for the four individuals who reported eating at Mattakeese Wharf in Barnstable, MA on June 17, The aggregate report from the BBOH listed that all four became ill with nausea, vomiting, and diarrhea within 24 to36 hours of the meal. B. Environmental Results 1- Cape Cod Wedding/ Wayside Inn The investigation conducted by CBOH on June 17, 2013 identified no violations related to foodborne illness risk factors. There were no food handlers reported to be ill. A HACCP risk assessment of the raw oysters revealed the following: Raw oysters are washed in a 2-bay sink, shucked, placed in a perforated pan on ice. 5

7 At the time of the inspection, the walk-in refrigeration unit was maintaining 37.6ºF and shellfish were being properly stored. The menu for the rehearsal dinner on June 14, 2013 showed 175 oysters were ordered for the event. The oysters were served raw. An invoice dated June 14, 2013 indicated that the oysters were purchased from Chatham Fish & Lobster., a wholesale seafood distributor located in Chatham, MA, which is licensed by FPP. The shellfish tags that accompanied the raw oysters served at the event indicated Chatham Fish & Lobster as the wholesale distributor, a harvest date of June 11, 2013 and harvest area of MA-SC: The Port Restaurant The investigation conducted by CBOH on June 19, 2013 identified one violation related to foodborne illness risk factors, inadequate sanitizing of food contact surfaces. Specifically, the chemical sanitizer was not being added to the sanitizing cycle of the dishwasher. A HACCP risk assessment of the raw oysters revealed the following: Raw oysters are delivered by Chatham Shellfish Co. in a refrigerated truck and received by the person-in-charge. The raw oysters are stored in the walk-in cooler at 38ºF. Whole, raw oysters are washed in the prep-sink, placed in stainless steel pans, labeled and stored in the walk-in cooler located in the basement. A portion of these oysters is transferred to the raw bar and placed on ice. Once an order is placed, the raw oysters are shucked and served. It was determined that 250 raw oysters were served at the party event. The shellfish tags that accompanied the raw oysters served at the birthday event indicated Chatham Shellfish Co, a wholesale seafood distributor, located in Chatham as the distributor, a harvest date of June 13, 2013 and harvest area of MA-SC: Mattakeese Wharf The investigation conducted by BBOH revealed that the shellfish tag that accompanied the raw oysters served on June 17, 2013 (i.e., the night the two couples consumed raw oysters) indicated Chatham Fish and Lobster, a harvest date of June 13, 2013 and harvest area of MA-SC: Additional Results On June 20, 2013, DMF prohibited the harvesting or collection of shellfish in harvest areas MA- SC:49, SC:50 and SC:51. Traceback records collected by FPP indicated that 52,480 oysters were harvested from MA-SC:49 between June 11 and June 20, of which 26,240 were sold. Of these oysters, 14,594 were consumed, 3,500 were sold to out of state vendors, and 11,646 were returned or destroyed. On July 11, 2013 FPP notified the director of the Interstate Shellfish Sanitation Conference of the oysters shipped to out-of-state establishments. EPI had contacted the out of state health departments that had establishments listed as having received oysters to alert them of the outbreak and for them to notify MDPH of any illnesses associated with 6

8 consumption. No additional complaints of illness associated with these oysters has been received. Recall effectiveness investigations were conducted on June 24 and 27, 2013, by FPP at Chatham Fish and Lobster, Chatham Shellfish Co. and Island Creek Oyster Inc. to verify the effectiveness of the recall. Shellfish bed MA-SC:49 reopened on October 15, MA-SC:50 and 50.1 reopened December 1, C. Laboratory 1- Food A. Cape Cod Wedding/ Wayside Inn Oysters collected from the rehearsal dinner were positive for norovirus G1.4 and matched the strain obtained from the four positive wedding attendees. Note: The oysters submitted for testing were not, as the tag initially seemed to indicate, from MA-SC:61. They were actually from MA- SC:49. Further investigation by CBOH revealed that the Wayside Inn had received three shellfish tags from area MA-SC:49 and one tag from MA-SC:61 for oysters served at the rehearsal dinner. The tag from area MA-SC:61 was in the walk-in refrigerator, in the bus pan of leftover oysters from the rehearsal dinner. The kitchen s preparatory process included washing all oysters in a prep sink prior to opening and icing them. When staff finish prepping one bag of oysters, they begin the prep process with the next bag of oysters even though there may still be oysters from the first bag in the bottom of the prep sink. Co-mingling oysters from the MA- SC:49 and MA-SC:61 areas is therefore highly probable. After the rehearsal dinner, the leftover oysters were most likely a mix of oysters from area MA-SC:61 and area SC:49; the tag for area SC:61 was left with them. The chef also confirmed this process. The eight leftover food samples collected from the Casual Gourmet were not analyzed. N/A N/A B. The Port Restaurant C. Mattakeese Wharf D. Additional testing Oysters from MA-SC:49 tested positive for norovirus G1.4 at the FDA Gulf Coast Seafood Laboratory in Alabama. 2- Clinical A. Cape Cod Wedding/Wayside Inn 7

9 All four wedding attendees who submitted stool specimens to HSLI had stool positive for norovirus G1 and all matched by genotype analysis (G1.4). All stool specimens were negative for other enteric pathogens. B. The Port Restaurant Of the 11 employees who submitted stool specimens to HSLI, four had stool positive for norovirus G1 and matched by genotype analysis (G1.4). Positive foodhandlers included oyster shuckers and one employee who ate the oysters. Two of these employees had previously reported symptoms of gastrointestinal illness. The party attendee who submitted a stool specimen (and who also consumed raw oysters) was positive for norovirus G1.4. All stool specimens were negative for other enteric pathogens. N/A C. Mattakeese Wharf D. Additional testing Out of the five oyster harvesters tested, one had reported symptoms of gastrointestinal illness and tested positive for norovirus G1. This specimen was matched by genotype analysis (G1.4) to the wedding guests, the Port employees, and the party attendee. The other four oyster harvesters were negative for norovirus. All stool specimens were negative for enteric bacterial pathogens. VI. Discussion Noroviruses (genus Norovirus, family Caliciviridae) are a group of related, single-stranded RNA, nonenveloped viruses that cause acute gastroenteritis in humans, previously referred to as Norwalk-like viruses (NLV). This group of viruses has also been referred to as caliciviruses (because of their virus family name) and as small round structured viruses, or SRSVs (because of their morphologic features). Norovirus is the most common cause of acute gastroenteritis in the United States. Each year, it causes about 21 million illnesses and contributes to about 70,000 hospitalizations and 800 deaths. 1 Norovirus is a leading cause of illness from contaminated food in the United States. The virus can easily contaminate food because it is resistant to inactivation and infective. It only takes a very small number of virus particles (fewer than 100) to make someone sick. Food can get contaminated with norovirus when infected people who have stool or vomit contaminating their hands touch the food, or when food is placed on counters or surfaces that have been contaminated, or when tiny drops of vomit from an infected person spray through the air and 8

10 land on the food. Foods can also be contaminated at their source. For example, oysters that are harvested from contaminated water, or fruit and vegetables that are contaminated in the field. Oysters harvested from harvest bed MA-SC:49 were tested and found to be positive for norovirus G1.4. It is clear that these contaminated oysters led to the illnesses of the oyster harvester, the guests at the Wayside Inn, and the guests and food handlers at the Port Restaurant. All oysters served at the Wayside Inn and the Port were traced back to this harvest bed and all specimens collected were matched by genotype analysis to the contaminated oysters. Although no stool or food samples were available for testing from the Mattakeese Wharf, shellfish tags clearly link the contaminated oysters from MA-SC:49 to the dinner served to the ill patrons. Environmental contamination of bed MA-SC:49 could have been the result of boats dumping human waste into the water or via sewage leaks from nearby homes. VII. Recommendations It is well known that consumption of raw shellfish may be a risk for a variety of infectious diseases, so it is always recommended to not consume raw food items. Oyster beds should be frequently monitored and sampled for fecal contamination. Foodhandling employees, including oyster harvesters, should be made aware of their duty to report symptoms of foodborne illness. Foodhandlers should wash their hands thoroughly with soap and warm water before eating or preparing food, and after using the toilet. Foodhandlers should use physical barriers such as gloves during preparation of readyto-eat foods. Employees involved in foodhandling should be trained in the appropriate use of gloves. VIII. Acknowledgments MDPH thanks the Chatham, Harwich, and Barnstable Boards of Health, the Division of Marine Fisheries, and the staff at the Wayside Inn, Casual Gourmet, the Port Restaurant, and Mattakeese Wharf for their assistance in the investigation. IX. References 1. American Academy of Pediatrics. Section3: Summaries of Infectious Diseases. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee of Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009: Kaplan JE, Feldman r, Campbell DS, Lookabaugh C, Gary GW. Frequency of a Norwalk-like pattern of illness in outbreaks of acute gastroenteritis. Am J Pub Health 1982; 72: Dalton CD, Mintz ED, Wells JG, Bopp CA, Tauxe RV. Outbreaks of enterotoxigenic Escherichia coli infection in American Adults: A Clinical and Epidemiologic Profile. Epidemiol. Infect. 123:9-16,

11 4. Turcios RM, Widdowson MA, Sulka AC, Mead PS, Glass RI. Reevaluation of epidemiological criteria for identifying outbreaks of acute gastroenteritis due to norovirus: United States, Clin. Infect. Dis. 42(7): Westrell T, Dusch V, Ethelberg S, Harris J, Hjertqvist M, Jourdan-da Silva N, Koller A, Lenglet A, Lisby M, Vold L. Norovirus outbreaks linked to oyster consumption in the United Kingdom, Norway, France, Sweden and Denmark, Euro Surveill. 2010:15(12):pii= Available online: Attachment 1 Survey for Cape Cod Wedding/Wayside Inn Attachment 2 Survey for the Port Restaurant Attachment 3 Inspection Report Attachment 4 Laboratory report for oysters Table 1: Cape Cod Wedding/Wayside Inn Reported Symptoms among Primary and Secondary Cases (N=25) Symptom Number Nausea 24 Vomiting 21 Diarrhea 18 Abdominal pain 16 Fever 7 Table 2: The Port Restaurant Symptoms (N=6) Symptom Number Diarrhea 6 Fatigue 5 Chills 5 Vomiting 5 Fever 4 Nausea 4 Abdominal pain 4 Headache 1 10

12 Table 3. Attack rates associated with food items consumed at the Wayside Inn rehearsal dinner on June 14, 2013 Attack Ratio 95% Food # Who Ate # Ill # Well Exposed Unexposed Relative Risk p-value Confidence Interval Oysters % 8% 9.82 < , Cheese plate % 55% , 1.98 Garden salad % 58% , 1.74 Caesar salad % 56% , 1.84 Rolls % 53% , 2.06 Cranberry bread % 52% , 2.49 Butter % 50% , 2.27 Steamers % 56% , 2.12 Watermelon % 57% , 2.07 Corn on the cob % 61% , 1.62 Baked potato % 63% , 1.40 Grilled chicken % 61% , 1.51 BBQ ribs % 50% , 2.23 Steamed lobster % 33% , 5.87 Ice cream % 50% , 2.36 Coffee with milk % 52% , 2.71 Coffee without milk % 62% ,

13 Table 4. Food item attack rates consumed at The Port birthday party on June 15, 2013 Attack Ratio 95% Food # Who Ate # Ill # Well Exposed Unexposed Relative Risk p-value Confidence Interval Birthday Cake n/a 54% n/a Bruschetta % 25% , Chicken Fajitas % 56% , 2.71 Chicken Quesadillas % 75% , 1.31 Chicken Skewers % n/a n/a Crab Cakes % 0% n/a Red Chili Sauce for Crab Cakes % 45% , 5.08 Sour Cream Sauce for Crab Cakes % 38% , 5.03 Kobe Burger % 50% n/a Littleneck Clams, raw % 30% , 8.59 Lobster Fritters % 0% n/a Mayo, Caper, and Cilantro Sauce for Fritters % 25% , Mussel Scampi % 71% , 1.48 Oysters, raw % 14% , Cocktail Sauce for Oysters % 22% , Lemon Juice for Oysters % 36% , 6.01 Raspberry Vinaigrette for Oysters % 40% ,

14 Norovirus Clusters - Contaminated Oysters, Barnstable County, MA Symptom Onset Dates for Cases Number of Cases /14/2013 6/15/2013 6/16/2013 6/17/2013 6/18/2013 6/19/2013 6/20/2013 6/21/2013 *Cases include ill guests and symptomatic foodhandlers who tested positive. Birthday Party* Rehearsal Dinner Shellfish Harvester 13

15 Cape Cod wedding * Required 1. What are the first and last initials of your name? 2. Did you attend both the rehearsal dinner in Chatham, MA on Friday June 14th and the wedding in Orleans, MA on Saturday June 15th? * Mark only one oval. Yes, I attended both Skip to question 12. No, I attended only the wedding Skip to question 7. No, I attended only the rehearsal dinner Skip to question 3. I did not attend either event Stop filling out this form. Rehearsal dinner 3. Rehearsal dinner: Appetizers and Cocktail hour Please check off all of the items you consumed at the rehearsal dinner on Friday June 14th. Check all that apply. Beer Wine Cocktail Oysters Cheese plate Other:

16 4. Rehearsal dinner: Main Meal Please check off all of the dinner items you consumed at the rehearsal dinner on Friday June 14th. Check all that apply. Garden Salad Caesar Salad Rolls Cranberry Bread Butter (rosettes for bread) Steamers Watermelon Corn on the Cob Baked Potato Grilled Chicken BBQ Ribs Steamed Lobster Other: 5. Rehearsal dinner: Dessert Please check off all of the dessert items you consumed at the rehearsal dinner on Friday June 14th. Check all that apply. Ice Cream Watermelon Coffee with milk/cream Coffee without milk/cream Other: 6. Did you experience any symptoms of illness anytime from Saturday June 15th through today? * Mark only one oval. Yes Skip to question 20. No Stop filling out this form. The Wedding

17 7. Butlered Hors d'oeuvres Please indicate all of the appetizers you consumed at the wedding on Saturday June 15th. Check all that apply. Crab Arancini with Fondue (deviled crab balls) Tuscan Mushrooms Garlic rubbed lamb chop lollipops Wontons with raspberry and brie Gazpacho shots with chili shrimp skewers Spicy Thai summer rolls with mango sauce Other: 8. Sit-down dinner Please indicate all of the dinner items you consumed at the wedding on Saturday June 15th. Check all that apply. Salad: baby butter lettuce topped with pears, red and yellow tomatoes, goat cheese, and balsamic vinaigrette Beef tenderloin Panko and almond crusted haddock Potato Asparagus Other: 9. Dessert Please indicate all of the dessert items you consumed at the wedding on Saturday June 15th. Check all that apply. Cake Coffee with cream/milk Coffee without cream/milk Other: 10. Children's Meals Please indicate any other items that you consumed from the children's menu. Check all that apply. Chicken fingers French fries Steamed carrots Other:

18 11. Did you experience any symptoms of illness anytime from Saturday June 15th through today? * Mark only one oval. Yes Skip to question 20. No Stop filling out this form. Rehearsal dinner and Wedding Skip to question Rehearsal dinner: Appetizers and Cocktail hour Please check off all of the items you consumed at the rehearsal dinner on Friday June 14th. Check all that apply. Beer Wine Cocktail Oysters Cheese plate Other: 13. Rehearsal dinner: Main Meal Please check off all of the dinner items you consumed at the rehearsal dinner on Friday June 14th. Check all that apply. Garden Salad Caesar Salad Rolls Cranberry Bread Butter (rosettes for bread) Steamers Watermelon Corn on the Cob Baked Potato Grilled Chicken BBQ Ribs Steamed Lobster Other:

19 14. Rehearsal dinner: Dessert Please check off all of the dessert items you consumed at the rehearsal dinner on Friday June 14th. Check all that apply. Ice Cream Watermelon Coffee with milk/cream Coffee without milk/cream Other: 15. Wedding: Butlered Hors d'oeuvres Please indicate all of the appetizers you consumed at the wedding on Saturday June 15h. Check all that apply. Crab Arancini with Fondue (deviled crab balls) Tuscan Mushrooms Garlic rubbed lamb chop lollipops Wontons with raspberry and brie Gazpacho shots with chili shrimp skewers Spicy Thai summer rolls with mango sauce Other: 16. Wedding: Sit-down dinner Please indicate all of the dinner items you consumed at the wedding on Saturday June 15th. Check all that apply. Salad: baby butter lettuce topped with pears, red and yellow tomatoes, goat cheese, and balsamic vinaigrette Beef tenderloin Panko and almond crusted haddock Potato Asparagus Other: 17. Wedding: Dessert Please indicate all of the dessert items you consumed at the wedding on Saturday June 15th. Check all that apply. Cake Coffee with cream/milk Coffee without cream/milk Other:

20 18. Wedding: Children's Meals Please indicate any other items that you consumed from the children's menu. Check all that apply. Chicken fingers French fries Steamed carrots Other: 19. Did you experience any symptoms of illness from Saturday June 15th through today? * Mark only one oval. Yes Skip to question 20. No Stop filling out this form. Symptoms Skip to question Which of the following symptoms did you experience anytime from Saturday, June 15th through today? Check all that apply. Nausea Vomiting Diarrhea Abdominal pain Bloody stool Fever I did not experience any of the above symptoms. Other: 21. Did you experience any of those symptoms in the days prior to Saturday June 15th? Mark only one oval. Yes No Unknown 22. When did your symptoms initially start? Example: December 15, :03 AM

21 23. How long did your symptoms last? If your symptoms are ongoing please indicate how long you have been experiencing symptoms. Mark only one oval. Less than 12 hours hours hours Longer than 48 hours 24. Have you sought medical attention for your illness? Mark only one oval. Yes No 25. Are you going to submit a stool specimen (either through your doctor, a clinic, a hospital, or the health department) or have you already? Mark only one oval. Yes No I don't know Powered by

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