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12:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to rin and you grab the alarm clock and stick it under your pillow. The phone rings again and you grope for the receiver. The caller is your friend, Mustaf, who is the director of health for the city of El Guitar in the country of Beanictacya. El Guitar is a coastal city on the Fishn Sea. Mustaf tells you that there has been an outbreak of a mysterious illness among the people of El Guitar. He asks you to come and help solve the mystery. Your electronic plane ticket is available to you on your computer. It is a 15 hour flight to El Guitar. Mustaf says that 232 people were hospitalized with severe headache, vomiting, abdominal pain and liver failure. There is sudden onset and symptoms last four days. So far 27 of the 232 people have died. The illness has been more severe in men than women or children. All of the deaths have been men between the ages of 18 and 60. N infants have been affected. What are the key points of information? What information do you need? What are your hypotheses? What do you do next?
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1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Dec 17, 2015

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Theodore Joseph
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Page 1: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

12:20 AM November 14thThe phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it under your pillow. The phone rings again and you grope for the receiver. The caller is your friend, Mustaf, who is the director of health for the city of El Guitar in the country of Beanictacya. El Guitar is a coastal city on the Fishn Sea. Mustaf tells you that there has been an outbreak of a mysterious illness among the people of El Guitar. He asks you to come and help solve the mystery. Your electronic plane ticket is available to you on your computer. It is a 15 hour flight to El Guitar.

Mustaf says that 232 people were hospitalized with severe headache, vomiting, abdominal pain and liver failure. There is sudden onset and symptoms last four days. So far 27 of the 232 people have died. The illness has been more severe in men than women or children. All of the deaths have been men between the ages of 18 and 60. No infants have been affected.

What are the key points of information?What information do you need?What are your hypotheses? What do you do next?

Page 2: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Page 2. El Guitar

El Guitar is a city on the coast of the Fishn Sea. With a population of 80,000, fishing, tourism and the widget industry are the primary sources of employment. It has a mild climate with a rainy season that begins in March and ends in June.Al Guitar Widgets Company is the world’s leading maker of widgets for the manufacture of pin ball machines. The company employs 700 people. Widgets are shipped from the Port of El Guitar to all parts of the world.

During the summer people come to El Guitar to the resorts on the beaches. Hotels, cafes and shops employ much of the young adult population of El Guitar during the tourist season from June until October. Fishing goes on all year as fish are caught by small trawlers and transferred to large processing ships for sale in Asia.

Al Guitar farms produce pineapple, sugar cane and olives. Flour and rice come from the U.S. and Canada.

Ships dock at El Guitar for fresh water and widgets and unload the flour and rice.

Page 3: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Country of Beanictacya

Fishn Sea

El Guitar

Page 4: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Page 3

You arrive in El Guitar and meet with Mustaf. He reports that 305 people have now become ill and there have been 37 deaths now. All of the people who have become ill have the same symptoms.

You are given a map of El Guitar. There are two suburbs of El Guitar, Urbina and Raz. Urbina and Raz share a water treatment facility and a waste treatment facility. El Guitar has his own water and waste treatment facilities. A power plant in El Guitar furnishes power for the metropolitan area.

Page 5: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Port of El Guitar

Urbina

Raza

City of El Guitar

Water treatment plant

Water treatment plant

Waste treatment plant

Waste treatment plant

Power plant

Page 6: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

El Guitar Raz Urbina

Male 23 (25,000) 107 (7,000) 6 (4,500)

Female 7 (30,000) 62 (8,000) 0 (5,500)

<20 20-40 40-60 60>

Male 30 81 21 9

Female 11 34 12 7

Population by age and gender

Page 7: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

El Guitar Raz Urbina

Male 3 28 2

Female 0 4 0

Deaths reported by physicians

<20 20-40 40-60 60>

Male 4 19 7 3

Female 0 1 2 1

Deaths by age

What other information do you need?

Page 8: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Page 5

More residents of the suburb of Raz were affected. In El Guitar city, the neighborhoods of Bambazza and El Aida had the highest number of cases. A few cases occurred in the Al Jiwa neighborhood and there were no cases in Jimwa and Al Gone. A few cases occurred in Urbina.

Port of El Guitar

Urbina

Raz

City of El Guitar

Bambazza

El Aida

Al Jiwa

Al Gone

Jimwa

What are your hypotheses?What more information do you want?What would you do next?

Page 9: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Page 6

You conduct an air quality study of the power plant and find that it is compliance with all air pollution standards. The 80,000 citizens of El Guitar and the two suburbs are descendants of nomadic tribes from Egypt. Their traditional diet consists of fruits, goat and lamb stews, bread and popsicles. Cheeses from goat milk are also included in the diet. In addition, dates, olives and grapes are plentiful. There are numerous open-air cafes in El Guitar serving traditional and non-traditional meals, but are frequented mostly by tourists. Fast food has not come to this part of the world yet. Most families eat traditional meals together at mid-day. Open air markets provide fruits and vegetables. Small butcher shops sell meat and cheese. Neighborhood bakeries provide bread and pastry. Bread is served at every meal.

Building materials for homes and offices are scarce. The warm climate does not require substantial buildings so plywood and fiberboard are imported. Most families live in three room apartments and do their cooking on balconies or in open areas over charcoal. This causes air pollution at certain times of the day. No more cases of illness have occurred in Raz. However, two cases have been reported in Urbina and three cases have occurred in El Guitar.

What more information do you need?What are your hypotheses?

Page 10: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

3 Day Dietary Recall for 232 Individuals Who Became Ill Fruits Lamb Goat Water Milk Cheese Popscl Bread Rice Beans Other

RazM 8

240 24 107 44 23 76 125 92 34 104

RazF 6021 16 82 39 33 51 58 14 22 62

El M 2218 17 27 15 14 23 27 16 23 30

El F 7 1 2 7 5 4 7 7 5 3 7

U M 6 6 5 6 3 6 6 6 6 4 6

3 Day Dietary Recall, New Cases

El M 2 3 1 3 1 2 3 3 1 2 3

U M 2 2 2 2 0 1 1 2 1 1 2

The health department has contacted the individuals who became ill. They did a 3 day dietary recall of

all foods they could remember eating prior to their illness.

Page 11: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

3 Day Dietary Recall for 50 Individuals Who Did Not Become Ill

Fruits Lamb Goat Water Milk Cheese Popscl Bread Rice Beans Other

RazM 12 11 10 17 7 10 7 7 10 8 18

RazF 11 8 6 16 7 10 7 5 11 4 15

El M 7 6 7 9 7 7 5 5 4 2 3

El F 5 2 2 6 3 2 4 3 3 0 3

U M 3 4 2 2 3 2 4 3 0 0 2

Page 12: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Only 11 of the patients ate at cafes. All others had their meals at home or had meals prepared at home and eaten while working.

What are your hypotheses?What would you do next?

Water quality tests have come back and all standards have been met. During the outbreak there was no record of contamination. The focus of the investigation moved to the possibility of food poisoning or food contamination. Almost everyone recalled drinking water. The area has three different sources of water. Some areas of the city were illness-free so water was eliminated as possible cause. The investigation turned to the sources of food. Meat and cheese came from at least 32 sources including open markets, butcher shops, and meat purchased from farmers. Bread was a common food among those who were ill and those who were not, but a higher percentage of those who became ill ate bread. Raz has three bakeries, Asiri, Al Pan and Razpan. The El Aida neighborhood has two bakeries, Ynez and Twookra. The Bambazza neighborhood has one bakery, Bobaks.

Page 13: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Further investigation showed that most of the people who became ill bought bread from Asiri, Al Pan and Ynez bakeries. Interviews with the bakeries revealed that five brands of flour were used.

Bakery Luna Jiffy Golden Jack’s Whole Nut

Asirix x

Al Pan x x

Razpan x x

Ynez x x x

Twookra x x

Bobaks x x

Page 14: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Five sources of eggs were found.

Bakery Morning Star Cackle Golan Red Hen Jones Farm

Asiri

x x

Al Pan x

Razpan x x

Ynez x x

Twookra x x x

Bobaks x x

Page 15: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Three sources of milk were found

Bakery Parkside Energywise Olden Days

Asiri

x x

Al Pan x

Razpan x

Ynez x x x

Twookra x

Bobaks x x

Page 16: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

The common factor seemed to be flour used in three of the bakeries. The Luna brand flour from Canada appeared to be the common link. Eggs and milk did not appear to be common to the three bakeries.

Samples of Luna flour were taken from the three bakeries. The samples were negative for contaminants.

Luna flour is unloaded from freighters in the Port of El Guitar and stored in a warehouse with other products brought in by ship such as corn, rice and beans. Some 80 sacks of Luna flour were found in the warehouse stacked on pallets in sanitary conditions. A sample was taken from sacks selected at random. All were negative except for one which showed high amounts of Roachend, an insecticide. However, Roachend is not used in this part of the world.

Page 17: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

Delivery Service Asiri Bakery Al Pan Razpan

Zippy Deliveries x

Rumdum Fast Track x

Slo Mo Shun x

An interview with the warehouse foreman provided information about the origin of the shipment and the storage process. The 100 sacks of Luna flour had arrived in October on the Canadian Star, a freighter from British Columbia. Bakeries using Luna flour contract with a delivery service to pick up flour and transport it to the bakery.

What would you do next?

Page 18: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

The Canadian Star is still in the Port of El Guitar taking on a cargo of widgets. You inspect the cargo hold of the ship and find traces of Roachend. After lengthy questioning, the captain of the ship admits that bags of flour had been contaminated when the Canadian Star encountered a storm en route to El Guitar.

A barrel of some kind of liquid had tipped over and spilled its contents. Some of the liquid had leaked into the cargo area below where the Luna flour was stored. About 15 bags of flour were wet with the liquid. To avoid losing money by destroying the contaminated bags of flour, the captain stacked uncontaminated bags on top of the soiled bags so inspectors certifying cargo arriving in El Guitar would not find the bags of flour.

Some bags of flour were delivered to the three bakeries and two remained in the warehouse.

Page 19: 1 2:20 AM November 14th The phone rings and you reach over to shut off the alarm. The phone continues to ring and you grab the alarm clock and stick it.

The captain was arrested and tried for manslaughter. Today, he sits in the El Guitar prison.

Several questions remained:

Why did more males become ill than females?

Why did deaths occur predominantly among males?

Why did illness occur in Urbina since this area is far from the center of the outbreak?

Case author: Michael HosokawaAssociate Dean for CurriculumProfessor, Family Medicine

University of Missouri School of MedicineThis case is based on an actual incident. All names, locations and products are figments of the author’s imagination. Permission is granted by the author to use the case for educational purposes.