case study about food poisoning in the philippines

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Staphylococcal poisoning during a village festival, Medina, Misamis Oriental, Philippines in 2014

John bobbie roca.

a Department of Health, Manila, Philippines.

Ruth Alma Ramos

Herdie hizon, vikki carr de los reyes, ma nemia l sucaldito, enrique tayag, introduction.

On 18 August 2014, cases of food poisoning in San Vicente Village were reported to the Event-Based Surveillance & Response Unit of the Philippine Department of Health. An investigation was conducted to identify the implicated source, describe the outbreak and evaluate the risk factors.

A case-control study was conducted. A suspected case was a previously well individual of Medina who attended the village festival and developed abdominal pain and vomiting with or without nausea, diarrhoea and fever from 18 to 19 August. A confirmed case was a suspected case with a rectal swab positive for bacterial culture. Rectal swabs, water and food samples were sent to the national reference laboratories. Food source and consumption interviews and environmental inspections were conducted.

Sixty-four cases and 123 unmatched controls were identified. The median incubation period was 1 hour 15 minutes. Five cases (8%) were positive for Staphylococcus aureus, one (2%) for Aeromonas hydrophilia and one (2%) for Shigella boydii. One (14%) water sample was positive for Aeromonas spp. Of the collected food samples, beef steak was positive for Staphylococcus aureus . Risk factors were consumption of Filipino-style beef stew (odds ratio [OR]: 6.62; 95% confidence interval [CI]: 2.90–15.12) and stir-fried noodles (OR: 3.15; 95% CI: 1.52–6.50). Prolonged serving time and improper food storage were noted.

In this foodborne outbreak, Staphylococcus aureus was the likely causative agent. Meals were contaminated due to improper food handling practices. We recommend that a policy be created to mandate that village-appointed food handlers undergo food safety training.

Staphylococcus aureus is a Gram-positive bacterium that is predominantly associated with food poisoning ( 1 ) and causes one of the most common foodborne illnesses worldwide. ( 2 ) About 25% of healthy people are carriers of Staphylococcus aureus . The bacterium is associated with skin, eye, nose or throat infections. ( 3 ) The most common way for food to be contaminated by the bacteria is through contact with infected food handlers. Other food contamination sources are the equipment or surfaces on which food is prepared ( 3 ) and infected house flies. ( 4 ) When food is contaminated, bacteria quickly multiply at room temperature and produce a fast acting enterotoxin ( 5 ) that can cause nausea, abdominal pain, vomiting and diarrhoea. ( 1 )

On 18 August 2014, the Event-Based Surveillance & Response Unit of the Philippine Department of Health received a report of food poisoning among villagers of San Vicente Village, a rural village in Medina, Misamis Oriental on the island of Mindanao. The village is subdivided into seven areas and has a total population of 978. ( 6 ) Every 18 August, the village celebrates its founding with a festival with free meals for all community members.

A team from the Philippines Field Epidemiology Training Program was deployed to conduct an epidemiologic investigation to identify the implicated source, describe the outbreak and evaluate the risk factors.

METHODOLOGY

Epidemiologic investigation.

A descriptive study was conducted by reviewing medical records of outpatients and inpatients at the local hospitals. A suspected case was defined as a previously well individual of Medina, Misamis Occidental who attended the village festival and developed abdominal pain and vomiting with or without nausea, diarrhoea and fever from 18 to 19 August 2014. A confirmed case was a suspected case with a positive rectal swab in bacterial culture.

An unmatched case-control study was conducted. Controls were individuals of Medina who attended the village festival and did not develop any symptoms and were negative on bacterial stool cultures. Subjective sampling from suspected and confirmed patient lists was used to identify cases for the study. Controls were identified from the same household and/or nearby households of the cases. Cases and controls were interviewed using a standard questionnaire that included demographics, symptoms (except for controls), history of food consumption within the past 24 hours, source of drinking-water, hygiene practices and other environmental factors.

Statistical analysis, including calculation of odds ratios (OR) and 95% confidence intervals (CI), was done using EpiInfo version 3.5.4 software. Significant bivariate analysis results were then tested by multivariable analysis.

Laboratory examinations

Rectal swabs were collected for culture and sensitivity testing from cases and controls including food handlers. Water samples from the water reservoir and communal faucets were collected for bacteriologic analysis. Both were sent to the national reference laboratories. Food samples were sent to the Food and Drug Administration Satellite Laboratory for Mindanao for bacteriologic analysis.

Environmental investigation

We visited the food handling and preparation area and water sources. We interviewed food handlers on the food production chain, food consumption history and presence of signs and symptoms.

Ethical approval

Ethics clearance was not required according to local regulations as this investigation was part of an emergency response to an outbreak. However, a signed consent was obtained before interviews and specimen collection.

Case-control study

All 64 cases (57 suspected and seven confirmed) and 123 controls were included in the study. All cases and 121 controls ate food served at the festival. Six out nine food handlers were included in the case-control study. One food handler did not meet the definition of case or control, and two others could not be located for the study. All of the interviewed food handlers fit the control definition. All of the individuals approached agreed to be involved in the study.

The first case manifested signs and symptoms in less than 15 minutes after ingestion of food. The number of subsequent cases peaked by 14:00. The median incubation period was 1 hour 15 minutes (range: 10 minutes to 16.98 hours). No deaths were reported ( Fig. 1 ). All cases had abdominal pain and vomiting. Other symptoms reported were nausea (88%), diarrhoea (52%) and fever (16%). There were 40 (63%) female cases; ages ranged from 1 to 75 years (median: 22 years, interquartile range: 7 to 38 years). The most affected age group was 21–35 years (25%).

Distribution of foodborne illness cases by onset of illness ( n  = 64), San Vicente Village, Medina, Misamis Oriental, Philippines, 18–19 August 2014

Bivariate analysis revealed that consumption of Filipino-style beef stew (OR: 8.16, 95% CI: 3.77–17.66) and stir-fried noodles (OR: 2.38; 95% CI: 1.28–4.40) were risk factors for food poisoning ( Table 1 ). After adjusting for demographics and exposure variables, consumption of Filipino-style beef stew (OR: 6.62; 95% CI: 2.90–15.12) and stir-fried noodles (OR: 3.15; 95% CI: 1.52–6.50) remained statistically significant risk factors for food poisoning. On the contrary, consumption of pork humba (OR: 0.42; 95% CI: 0.20–0.89) and Filipino-style pork stew (OR: 0.22; 95% CI: 0.06–0.83) were inversely associated with being a case.

OR, odds ratio; CI, confidence interval.

* May have had more than one response.

A rectal swab was collected from each of the 64 cases and 123 controls. Of the samples from cases, five (8%) were positive for Staphylococcus aureus, one for (2%) for Aeromonas hydrophilia and one (2%) for Shigella boydii. However, 45 (70%) of the cases were given antibiotics before specimen collection. All controls showed no growth in the bacterial culture test. One out of the seven (14%) rectal swab cultures from food handlers was positive for Aeromonas sobria.

One out of the eight (13%) water samples collected was found to be positive for Aeromonas species.

Beef steak and rice were the only leftover food samples collected. Bacterial culture revealed that the beef steak was positive for Staphylococcus aureus; the culture from the rice yielded no bacterial growth.

Seven out of the nine village-appointed food handlers were interviewed. All were asymptomatic. Food source investigation revealed that a cow and a pig were bought from a local farm, while the vegetables and commercially prepared seasonings came from a nearby market. Animals were slaughtered in an open space at the town hall by 08:00 on 17 August 2014 (the day before consumption). Meat and entrails were butchered to desired cuts. Cooking of dishes started by 14:00 with beef dishes prepared first followed by the pork dishes. The cooking process ended by 22:30. Water from communal faucets was used to wash raw ingredients and for cooking. Cooked dishes were cooled in a separate room and covered with banana leaves.

Meals were packed between 22:45 on 17 August 2014 and 06:00 the following day. Two varieties of dishes were packed in a “chorizo-like” manner where one plastic bag was used ( Fig. 2 ). Packed meals were stored in either a plastic tray, carton box or empty rice sack at room temperature.

Packed meal

By 11:30, packed meals were distributed among villagers.

No food handlers wore aprons or hair nets during food preparation. They did not have formal food safety training, and proper hand hygiene was not observed. Flies were also claimed to be present during food preparation.

No chlorine residue was noted inside the water reservoir, and breakage in water distribution pipelines was seen.

The epidemiological evidence suggests that the most likely source of this foodborne outbreak was the consumption of contaminated packed meals served during the village festival. The short incubation period (median 1 hour 15 minutes) and the symptoms manifested by cases suggest a Staphylococcus aureus enterotoxin poisoning. Staphylococcus aureus was seen in the human specimens and food samples (beef steak); both consumption of Filipino-style beef stew and stir-fried noodles were statistically most likely to be associated with the illness.

The issue of food safety practices by the food handlers played a part in this outbreak. The observed improper food handling practices such as poor hand washing technique, prolonged serving time ( 2 , 7 ) and improper temperature for food storage ( 1 , 2 , 5 , 7 ) have been linked to staphylococcal foodborne outbreaks.

The isolation of Aeromonas hydrophilia and Shigella boydii in one of the cases could have been incidental to this outbreak. The typical incubation period of 12 to 72 hours ( 1 ) after ingestion of food contaminated by both bacteria does not coincide with the incubation period of the cases.

The Sanitation Code of the Philippines requires all food caterers, regardless of type and enterprise size, to secure sanitary permits and health certificates for all their employees before operation. ( 8 , 9 ) This policy only covers licensed food establishments. However, most foodborne outbreaks in the Philippines occur in home settings and at events where the food handlers are not trained on food safety. ( 10 )

This study has some limitations. First, we were not able to locate and test all the food handlers. Second, most the cases were already treated with antibiotics before stool collection. This may have contributed to low positivity rates in clinical specimens. Third, dose–response was not investigated. Fourth, there is the possibility of recall bias on the specific food exposure due to the retrospective nature of data finding. In spite of these limitations, we were able to identify the source of this outbreak from both the clinical and epidemiological results.

As a response to the outbreak, we recommended the reinforcement of the Sanitation Code of the Philippines by municipal governments through the release of an ordinance mandating that village-appointed food handlers secure updated health certificates and attend formal food safety training before engaging in mass feeding activities to prevent further outbreaks.

Acknowledgements

We are grateful for the cooperation and support of the Center for Health and Development – Northern Mindanao, the local government of Medina and village leaders and residents of San Vicente Village during the field investigation. We also thank the laboratory staff of the Research Instituted for Tropical Medicine and Food and Drug Administration Satellite Laboratory for Mindanao for testing the samples.

This foodborne outbreak investigation was funded by the Department of Health, Philippines.

Conflicts of interest

None declared.

Foodborne Disease Outbreaks in the Philippines (2005-2018) - Philippine Journal ...

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Staphylococcal poisoning during a village festival, Medina, Misamis Oriental, Philippines in 2014

• John Bobbie Roca Department of Health, Manila, Philippines
• Ruth Alma Ramos Department of Health, Manila, Philippines
• Herdie Hizon Department of Health, Manila, Philippines
• Vikki Carr de los Reyes Department of Health, Manila, Philippines
• Ma Nemia Sucaldito Department of Health, Manila, Philippines
• Enrique Tayag Department of Health, Manila, Philippines

Introduction: On 18 August 2014, cases of food poisoning in San Vicente Village were reported to the Event-Based Surveillance & Response Unit of the Philippine Department of Health. An investigation was conducted to identify the implicated source, describe the outbreak and evaluate the risk factors.

Methods: A case-control study was conducted. A suspected case was a previously well individual of Medina who attended the village festival and developed abdominal pain and vomiting with or without nausea, diarrhoea and fever from 18 to 19 August. A confirmed case was a suspected case with a rectal swab positive for bacterial culture. Rectal swabs, water and food samples were sent to the national reference laboratories. Food source and consumption interviews and environmental inspections were conducted.

Results: Sixty-four cases and 123 unmatched controls were identified. The median incubation period was 1 hour 15 minutes. Five cases (8%) were positive for Staphylococcus aureus, one (2%) for Aeromonas hydrophilia and one (2%) for Shigella boydii. One (14%) water sample was positive for Aeromonas spp. Of the collected food samples, beef steak was positive for Staphylococcus aureus . Risk factors were consumption of Filipino-style beef stew (odds ratio [OR]: 6.62; 95% confidence interval [CI]: 2.90–15.12) and stir-fried noodles (OR: 3.15; 95% CI: 1.52–6.50). Prolonged serving time and improper food storage were noted.

Discussion: In this foodborne outbreak, Staphylococcus aureus was the likely causative agent. Meals were contaminated due to improper food handling practices. We recommend that a policy be created to mandate that village-appointed food handlers undergo food safety training.

Author Biography

John bobbie roca, department of health, manila, philippines.

Fellow - Field Epidemiology Training Program Epidemiology Bureau Department of Health Manila, Philippines

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Food poisoning kills 27 in Philippines, sickens 100 children who ate cassava

Wailing parents carried the bodies of their children from hospitals after a snack of cassava — a root that's poisonous if not prepared...

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MANILA, Philippines — Wailing parents carried the bodies of their children from hospitals after a snack of cassava — a root that’s poisonous if not prepared correctly — bought from an outside vendor killed 27 and sickened 100 others yesterday at an elementary school in the south-central Philippines.

With the nearest hospital 20 miles away from San Jose school, in Bohol island’s Mabini town, some victims died while being carried in a variety of vehicles, including three-wheel motorcycle taxis.

Francisca Doliente said her niece Arve Tamor, 9, was given some of the deep-fried caramelized cassava by a classmate who bought it from the vendor.

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“Her friend is gone. She died,” Doliente said. Her niece was being treated, she said.

The roots of the cassava plant, a major crop in Southeast Asia and other parts of the world, are rich in protein, minerals and the vitamins A, B and C. However, if eaten raw or prepared incorrectly, one of its chemical constituents will be attacked by digestive enzymes and give off the deadly poison cyanide.

“Some said they took only two bites because it tasted bitter and the effects were felt 5-10 minutes later,” said Dr. Harold Gallego of Garcia Memorial Provincial Hospital in the nearby town of Talibon, where 47 patients were taken.

producing sugar derivative is usually removed by grating, pressing and heating the tubers. The poison (hydrocyanic acid) has been used for darts and arrows.

Source: Encyclopedia Britannica online

The victims suffered severe stomach pain, vomiting and diarrhea. They were taken to at least four hospitals from the school in Mabini, about 380 miles southeast of the capital, Manila.

Sobbing parents left hospitals carrying the bodies of their children wrapped in blankets.

Some victims were still vomiting nearly 12 hours after eating the morning snack, said Dr. Nenita Po of the government-run Gov. Celestino Gallares Memorial Hospital. However, those who were alive when they reached the hospital had a good chance of surviving, Po said. He said some worried parents brought in their children even if they did not show any symptoms of poisoning.

Po said 15 patients were brought there, including the 68-year-old woman who prepared the cassava along with another woman. Officials wanted to talk with the ailing woman but said she was complaining of pain. A specimen of the cassava was taken for inspection at the local Crime Laboratory Group.

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A retrospective cohort study on cassava food poisoning, Santa Cruz, Davao del Sur, Philippines, October 2015

Affiliation.

• 1 Department of Health, Philippines.
• PMID: 30766741
• PMCID: PMC6356042
• DOI: 10.5365/wpsar.2017.8.1.010

Objective: On 2 October 2015, the Event-Based Surveillance and Response Unit of the Department of Health (DOH), Philippines received a report of foodborne illness cases in Santa Cruz, Davao del Sur. A team from DOH was sent to conduct an investigation to identify the implicated source and determine risk factors.

Methods: A retrospective cohort study was done. A suspect case was defined as a previously well individual in Compound A, Santa Cruz who developed abdominal pain, headache, dizziness, diarrhoea or vomiting on either 1 or 2 October 2015. A confirmed case was a suspect case positive for cyanide in urine. Family members who prepared the food were interviewed. Urine specimens were collected to test for thiocyanate, and cassava tuber and soil samples were tested for cyanide and other chemicals.

Result: Fourteen cases with two deaths were identified (case fatality ratio: 14%). All cases consumed cassava on 1 October 2015 except for one child who spat it out. Urine samples were all negative (36, 100%) for thiocyanate so there were no confirmed cases. The cassava sample had a cyanide level of 68.94 ug/g and was identified as bitter cassava, also known as a potentially dangerous kind. Insufficient food preparation was noted. In the retrospective cohort study, intake of cassava (RR = 208, 95% CI: 19.94-2169.32) was associated with the illness.

Discussion: This study identified insufficiently processed cassava root crop as the source of the foodborne illness. The cassava consumed was the bitter variety that contains greater than 50 ug/g of hydrogen cyanide and requires thorough preparation before consumption. Community education was provided on identifying and preparing cassava appropriately.

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Number of cases by date and time of illness onset, cassava poisoning, Compound…

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126 students suffer from ‘food poisoning’ in Makati

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MANILA, Philippines (4th UPDATE) – More than 100 students from the Pio del Pilar Elementary School in Makati City were rushed to medical facilities after suffering from “food poisoning,” city officials said on Thursday, January 14.

Acting Makati Mayor Romulo “Kid” Peña Jr said in a statement he had ordered the Makati Health Department and the Makati City Police to conduct a thorough investigation of the incident.

“We deeply regret the food poisoning incident earlier today in Pio del Pilar Elementary School that has caused at least 100 students to fall ill after reportedly ingesting snack foods sold by the school canteen,” Peña said.

The students, aged between 9 to 13 years old, complained of dizziness and stomach pains.

Dominico Idanan, acting schools division superindendent in Makati for the Department of Education, told Rappler that 126 pupils were affected.

Sixty-four were sent to the Palanan Health Center while the rest were sent to the Ospital ng Makati (OsMak).

As of 9 pm on Thursday, all the students have been discharged except for 11-year-old Arabel Ablang, who is only consuming the IV fluids that were given to her in the hospital. She will be discharged thereafer. Another student also still under observation at a private hopsital due to mild dehydration.

Peña said he has personally visited the students to check on their condition on Thursday morning.

“I am assuring their parents that the city government will shoulder the costs of their treatment and management until they have fully recovered….The public may rest assured that the city government will do its best to prevent a repeat of the unfortunate incident,” he said. – Rappler.com

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MHD extends sympathies to victims of food poisoning in Tondo

The City of Manila, through the Manila Health Department (MHD), extended on Thursday, July 21, its sympathies to the victims of food poisoning in Gagalangin, Tondo.

One woman died while 15 others were hospitalized after eating “chicken mami” in Gagalangin in Tondo, Manila on Wednesday, July 20.

“To the life that was lost because of this unfortunate event, we're deeply sorry for the sudden grief it has cost your family,” MHD said in a statement.

“On July 20, 2022 at around 2:30pm, Manila received a report of 11 alleged food poisoning cases from the DOH regional office. They sought consultation at Tondo Medical Center for treatment and management,” it said.

According to patients, they ate chicken mami in a makeshift table along the sidewalk located at 392 Gapan St., Earnshaw Gagalangin, Tondo on Wednesday at around 10 a.m.

The victims said they experienced dizziness, headache, vomiting, cyanosis, and changes in sensorium (brain function) three hours after.

MHD said human and food samples were already sent for laboratory analysis.

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33 students in Occidental Mindoro in hospital for ‘food poisoning’

CITY OF CALAPAN, Oriental Mindoro, Philippines – Thirty-three students who were apparently suffering from food poisoning were taken to a hospital in Sablayan town, Occidental Mindoro province on Monday (Oct. 10) evening, according to the Municipal Disaster Risk Reduction and Management Office (MDRRMO).

They are students at the San Francisco Elementary School, according to Hyacinth Arah Dacayanan, MDRRMO communications officer.

“Police said the food — fried spring rolls — that reportedly caused the poisoning came from outside and was brought inside the school,” Dacayanan told the Inquirer.

MDRRMO head Arcris Canillo said they received a call from Barangay San Francisco around noon after students complained of stomach aches. They were taken to San Sebastian District Hospital.

Dr. Simon Salazar, hospital chief, said a total of 97 patients were affected by the food poisoning incident. Out of these, 86 are students, six are teachers, and five are outsiders.

Sixty-four were mild cases and were sent home with instructions, and the rest — the 33 students — were admitted to the hospital.

Canillo said authorities were still investigating the incident, adding that the local government unit was assisting the students.

The Department of Education has not issued a statement.

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