About 60 people became sick after our annual awards banquet at the Bali Hai Wednesday night, July 29. When word of the outbreak began to spread two days later, our board contacted county health officials and the venue and started emailing attendees and members daily updates. They are listed below, in reverse chronological order. The latest update contains the county’s Sept. 28 report on the outbreak. The board is digesting it and welcomes any feedback at firstname.lastname@example.org. We’ll update this post as warranted.
Update 9, 10/2/15: The county issued a 15-page report in late September. Read it here.
Update 8, 9/4/15: The investigation will classify the outbreak as probable foodborne
The investigation is coming to conclusion. The epidemiological investigation will classify this outbreak as probable foodborne. Epidemiology was not able to make a definitive determination regarding the source of the recent norovirus outbreak. However, in analyzing the responses to the questionnaires from those who attended the banquet, the only item associated with a statistically increased risk of illness was ice. Norovirus is extremely common and while the ice was the only food correlated with an increased risk of illness, a definite source of the norovirus was not determined by the investigation. Other possible sources of Norovirus transmission could have occurred from an infected person, contaminated food or water, or by touching contaminated surfaces.
There is no official report that is produced in the process; however, HHSA does report the investigation classification of “probable foodborne illness” to the California Department of Public Health.
1. Was a source ever determined? As in, was it food or a person, or undeterminable?
The County of San Diego was unable to make a definitive determination regarding the source of the recent norovirus outbreak. In analyzing the responses to the questionnaires from those who attended the banquet, the only item associated with a statistically increased risk of illness was ice. Ice was not served separately, and water and other beverages were not found to be associated with illness.
2. How many filled out surveys, and was any pattern determined? Or did they yield any findings?
We received surveys from 84 of the 172 people that attended the banquet. Of those that said they were ill, 50 met our case definition for illness because they were ill within 72 hours of attending the banquet. There were an additional 8 that did not meet that criteria but who said they had become ill. We were able to confirm the illness was caused by norovirus type GI.1 from the 7 stool specimens we were able to collect. The most commonly consumed food was ice as stated in question 1 above, but we also understand that there were water glasses with ice on all of the tables.
3. The three additional diners and food service worker who were also ill but not directly associated with the event – was that related, or determined to be a separate issue/illness?
There were 3 other diners that were found to be ill with norovirus type GI.1, which is the same type associated with the banquet. We did not link any food service workers with the illness.
4. Last, did anything happen to Bali Hai?
The operators of the Bali Hai were very cooperative in assisting with our investigation. As part of our field visits, they also proactively cleaned and sanitized the facility according to guidelines we developed for norovirus outbreaks.“ http://www.sandiegocounty.gov/content/dam/sdc/deh/fhd/food/pdf/publications_norovirus.pdf”
In summary, there is no ongoing risk of illness at the facility. The investigation revealed that the cause of illness at the banquet was found to be norovirus type GI.1. Norovirus outbreaks are often found at events or places where a number of people congregate because it is ubiquitous and highly transmissible. Of the 36 norovirus outbreaks last fiscal year (2014-2015), 11 of them were classified as likely foodborne. The DEH and Public Health staff also appreciated the cooperation of the banquet attendees and conference participants in assisting with the investigation.
Then follow up questions
1. First, regarding this statement — “the most commonly consumed food was ice as stated in question 1 above, but we also understand that there were water glasses with ice on all of the tables.” — I actually don’t recall seeing water glasses on the tables. I remember distinctly going up to the bar where there was a jug of water and getting a glass from there. It contained no ice. I neither ate, drank, or sucked on any ice at the dinner, yet I got sick. I don’t know how people got ice, unless they ordered a cold drink from the bar that had ice added to it. Unless all the ice in the water jug had melted by the time I got there. How many of the surveys indicated that the sick people ate ice?
• Contact investigation is the process to determine common elements among those individuals who were ill. After interviewing individuals who became ill, “ice” was the only food item that had a significant risk associated with consumption.
• Surveys used for contact investigation are used to allow public health officials to generate hypotheses and make recommendations. Responses from those who meet a specific definition for illness (called “cases”) are compared to a group of those who did not become ill (called “controls”). Not all respondents answered all questions, so out of the 50 “cases,” only 42 answered the question about ice. Of those who were cases and answered specific questions about foods consumed, 26 out of 42 (62%) recalled consuming ice. Comparing the cases to controls, the risk of illness was 4 times higher for those who consumed ice. This was the only food or beverage item that demonstrated a statistically significant increased risk of illness. This does not mean that the ice caused illness, but it assists in providing preventive recommendations. Norovirus is extremely common and while the ice was the only food correlated with an increased risk of illness, a definite source of the norovirus was not determined by the investigation
2. And, sorry, I don’t understand this — “We received surveys from 84 of the 172 people that attended the banquet. Of those that said they were ill, 50 met our case definition for illness because they were ill within 72 hours of attending the banquet. There were an additional 8 that did not meet that criteria but who said they had become ill.” There were an additional 8 who became sick but did not get sick within 72 hours? Like, more than 72 hours later? Is that what that means? Is that the criteria?
• The criteria for defining an illness for the purposes of this investigation was at least one episode of vomiting and/or three or more episodes of diarrhea within 72 hours of exposure. Fifty people met this definition. There were eight people who reported some gastrointestinal symptoms, but did not meet this definition. This definition is helpful in analyzing for potential causes, and in no way indicates that they either did or did not have norovirus, nor does it mean that the symptoms they had were not significant for them. So to summarize:
• Of the 172 people that attended the banquet, 84 people responded to the survey.
• Of those 84 respondents, 58 (69%) individuals reported that they became ill, and the other 26 (31%) people did not report any illness.
• Of the 58 ill individuals:
• 50 individuals met the above case definition and were used as “cases.” They were compared to the 26 people who were not ill as “controls” to analyze for potential correlations between illness and the food and beverage items.
• 8 (13.8%) of the 58 individuals surveyed reported illness, but did not meet the case definition for this acute illness outbreak.
• Some “cases” and “controls” did not answer all the questions on the survey.
• Of the 50 “cases,” only 42 answered the question about ice.
• Of those who were cases and answered specific questions about foods consumed, 26 out of 42 (62%) recalled consuming ice.
• The only food or beverage item found to have a significant correlation with illness was ice (odds ratio = 4).
3. Finally, your Point #3 leaves open some questions: “There were 3 other diners that were found to be ill with norovirus type GI.1, which is the same type associated with the banquet. We did not link any food service workers with the illness.”
A. Since the restaurant publicly denied that it or its food or its servers were responsible and seemed to want to shift the blame onto just our banquet group for bringing in the virus, how does that fit with the fact that diners in the regular restaurant also got sick?
The epidemiological investigation will classify this outbreak as probable foodborne. Norovirus is extremely common and while the ice was the only food correlated with an increased risk of illness, a definite source of the norovirus was not determined by the investigation. Other possible sources of Norovirus transmission could have occurred from an infected person, contaminated food or water, or by touching contaminated surfaces.
B. Would that not indicate that there’s a connection and that the virus was present in the restaurant itself — either an employee, food, or some other form of contaminant?
Given that norovirus is extremely common and can be transmitted either person-to-person or via contaminated surfaces, food and beverages, the purpose of our investigation is to provide appropriate preventive advice to stop future cases. In this case, preventive measures were taken by the facility; beyond the three other diners who were ill with norovirus, no further cases were confirmed. A definite source of the norovirus was not determined by the investigation
C. The fact that only three diners in the regular restaurant that night came forward after reading about the outbreak in the paper several days later makes one wonder how many more were sick but didn’t hear the news and didn’t know to tie it back to two nights previous. No one I know who got sick knew to go back two nights prior, until we were contacted by the banquet organizers.
Several sets of diners reported illness between 7/29 and 8/1: 8 individuals out of 20 people in four different dinner groups reported gastrointestinal illness, as did 6 from a wedding party of 140. Of these 14 ill individuals, 3 people (all from the wedding party) were found to have norovirus GI.1, the others either did not submit specimens when requested (8), had no pathogens (2) or had another virus (1, norovirus GII.6C).
D. Did the restaurant or health dept. make any effort to contact people who ate there that night as regular restaurant guests?
No, the Epidemiology Program did not contact those who ate there that night as regular restaurant guests. We investigated only those who reported illness to us. As noted above, 14 individuals were reported to us as having illness after eating at the restaurant between 7/29 and 8/1, three of whom were confirmed to have norovirus GI.1. Looking for cases that are not reported is called “active case finding” and is not a standard procedure in this type of investigation.
4. Sorry, one more question — the paper reported that a food service worker did get sick. But you seem to say that is not the case so the report was in error?
• There was one food service worker who became ill after the banquet, but this individual was not serving food or beverages at the event and became ill when other banquet attendees became ill.
• The statement that no food worker was linked with the illness was intended to indicate that no ill food worker was identified who could have exposed those who attended the banquet or others at the restaurant.
• This individual was not ill during the event and did not work during their illness.
In summary, as described by the CDC:
• Each year, norovirus causes 19-21 million illnesses and contributes to 56,000-71,000 hospitalizations and 570-800 deaths.
• For most people norovirus illness is not serious and they get better in 1 to 3 days.
• Norovirus is also the most common cause of foodborne-disease outbreaks in the United States.
• You can get norovirus from an infected person, contaminated food or water, or by touching contaminated surfaces.
• Any of these conditions could have happened at the banquet.
• In most outbreaks the primary source of the infection is not determined.
• What’s important is prevention and sanitation efforts.
Again, Norovirus is extremely common and while the ice was the only food correlated with an increased risk of illness, a definite source of the norovirus was not determined by the investigation.
We hope the above information helps to explain and understand how these situations occur and are managed by the health department.
Update 7, 9/4/15: Email request from SPJ San Diego to county DEH
The SPJ San Diego board has some questions for the county we’re hoping it can answer. Thanks in advance.
Did the County Health Dept. conclude its investigation?
Did it issue a report?
How many people tested positive for norovirus? How many people exhibited symptoms?
Based on the strain of norovirus, is it more likely to have come from food/water/drinks or a patron?
Did anyone outside the patio area become ill? Any Bali Hai employees? Any patrons not with our party?
Did any family members or significant others of people at our banquet get sick? If so, how many and how badly?
Update 6, 8/14/15: County responds to an email query with this reply
As of August 13, 2015, we collected information from 84 out of 172 attendees, five of which tested positive for Norovirus gastrointestinal illness in our local public health lab. The samples we analyzed also were confirmed by the California Department of Public Health as positive for norovirus. The investigation is nearing completion at this point. There are no other public health actions that need to be taken and norovirus GI.1 was determined to be the cause of illness. With respect to the restaurant, the DEH investigation is complete with the facility implementing all recommended precautions to ensure there is not an ongoing source of illness.
Update 5, 8/4/15: Norovirus led to post-SPJ banquet health issues
Friends: The county of San Diego has confirmed that the outbreak was caused by norovirus G1.
Three tested specimens confirmed it. The county is currently running tests on two other people and will test a sixth, all perhaps by day’s end, but health officials are confident in saying norovirus is now the cause. Next steps? Today, county officials will conduct more interviews, focusing on people who did not get sick and asking them what they ate or touched at the banquet at the Bali Hai Wednesday night. The county’s goal is to make sure no one else will get sick at the restaurant, not necessarily to find patient zero, the person who caused the outbreak, unless it can show that person is working at the restaurant and compromising public health.
So far, only banquet attendees (about 60) have reported sick. No one else at the restaurant (patron or staff) has reported an illness.
After the county does more interviews today, it will begin to crunch and cross-reference data to see what can be ruled in or out. Possible explanations include food, touching infected objects such as silverware or chairs and attendees coming in contact with other attendees. No one can say for sure right now. If there are no reports of illness by other people in the restaurant and sick cases are limited to the banquet, the analysis may wrap up this week.
Thanks for your patience as the health experts get to the bottom of this.
President, SPJ San Diego Pro Chapter
Western region director, SPJ
Update 4, 8/3/15: Update on Food Poisoning Post-SPJ Banquet
Friends: I hope you’re all feeling better this week. The total of people reporting symptoms after Wednesday night’s banquet stands at more than 60 now.
The county investigation continues, but a spokesman says it suspects a norovirus outbreak. The Bali Hai’s manager is quoted in The San Diego Union-Tribune and Times of San Diego, as is county spokesman Michael Workman. Stories in both outlets raise the possibility that the virus may have started with a diner. Both also point out it could have originated with a food preparer. County officials told me today that some lab tests of theirs could be ready this week. If norovirus is not the cause, analysis may take longer. More information as we know it.
San Diego SPJ president
From the U-T story:
Larry Baumann, the restaurant’s manager, said Monday that news of the outbreak has been distressing.
“We feel terrible that anybody got ill,” Baumann said. “We’re working very closely with the health department and following their guidelines and procedures.”
Recent inspection reports show that the restaurant, popular for its Polynesian cuisine and sweeping views of San Diego Bay, did receive some recent scrutiny from the environmental health department.
A routine inspection on July 22 gave Bali Hai an “A” grade for food safety, but subtracted seven points out of 100 for having several types of food kept at above-recommended temperatures. The restaurant was required to discard one pound of cooked shrimp, one pound of chicken, two pounds of quinoa salad and two pounds of pork belly.
Inspectors also observed that a dishwashing machine was being used with water that had a lower-than-recommended concentration of sanitizing solution.
When inspectors returned on July 31, a new report found no problem with food temperatures but again noted that dishwasher sanitizer concentration was at 10 parts per million, below the 50 ppm guideline.
None of the findings resulted in a fine, and Workman said that all were considered minor.
It remains to be seen whether the Wednesday infection started with workers or diners.
According to the U.S. Centers for Disease Control and Prevention, norovirus comes from fecal contamination, often due to a lack of hand-washing.
An infected food service worker could have transferred the virus to prepared food, or it could have been passed from diner to diner through close contact such as handshakes or touching a contaminated surface. Contamination can also occur in farm fields.
From the Times of San Diego story:
In the next day or two, he said, the county will have a better fix on the cause of the illness — which might have come from a banquet guest or someone who prepared the food before it even got to Bali Hai.
Outside the patio banquet area, no other Bali Hai customers got sick, Workman said.
Workman said the restaurant was asked to raise the sanitizer level, which was done Friday.
Bali Hai has an A grade (and 93 score) from county health officials — but three times in the past five months it was found to have “major” violations during inspections. Twice the county found a problem with holding temperatures. Once it didn’t have shellfish tags in the right place.
Update 3, 8/2/15: Food-poisoning symptoms from SPJ banquet
Here is an update on the foodborne illness investigation at the Bali Hai.
As many of you know, there have been more than 55 reported cases of food poisoning out of 170 attendees at our annual banquet Wednesday night. The county Department of Environmental Health is investigating and interviewing those of us who fell ill as well as others who did not in an attempt to isolate the problem. It intended to inspect the Bali Hai on Friday. You’ll find the county’s two-page questionnaire attached; if you attended the banquet and haven’t filled it out or haven’t already been interviewed by the county, please consider sharing your information with them. The completed questionnaires may be returned to the attention of Azarnoush Maroufi via fax at [redacted] or e-mail: [redacted]. To be interviewed by phone, call her at [redacted] during normal business hours next week.
Here’s what’s new this morning:
1) KGTV had a report on the Bali Hai last night toward the top of its broadcast. No one went on camera. They quoted “organizers” (me, I’m assuming) as saying more than 50 people had food poisoning symptoms at an SPJ banquet. They said the restaurant said people shouldn’t be worried about eating there. They didn’t specify a cause.
2) No word yet from the health department on what pathogen may have caused this. Worth noting: One person who got sick (and whose spouse did not) ate only salmon and caesar salad and guesses the salad may be the culprit. Obviously, we don’t know whether that’s the case until and unless the county tells us. For now, this information from the FDA on foodborne illnesses is worth a look: http://www.fda.gov/food/resourcesforyou/consumers/ucm103263.htm
3) The people hardest hit by this seem to be on the mend. I’ve been told that several people who were treated at the hospital are feeling better, although one person became ill late yesterday and had to be transported by paramedics.
As always, any questions or concerns, contact me directly at email@example.com. We hope everyone is or starts feeling better, so we can shift all our focus from the health concerns to the investigation.
San Diego SPJ president
Update 2: 8/1/2015, Foodborne Illness Questionnaire — Bali Hai, Shelter Island
A quick update and a brief request. We are now at about 55 reported cases of food poisoning symptoms, out of 170 banquet attendees.
Attached you’ll find a questionnaire from the county’s Department of Health. If you attended the banquet, whether you fell ill or not, could you please take the time to fill out the questionnaire and send it along to Azarnoush Maroufi at the county? Her email address and full message/directions are [redacted]. Alternatively, you can call her next week at the office, number [redacted].
[Attachment: Foodborne Illness Questionnaire – Bali Hai, Shelter Island]
I did an interview with her by phone last night and it took about 5-10 minutes. It’s basically questions about what I ate (salmon, pork, salad, mashed potatoes, bread) and what symptoms I have. (I’ll spare you those details.) Again, they are hoping to hear from people who are sick and others who are not reporting symptoms, so they can isolate the issue and get to the bottom of this. I still expect to hear from them next week (again, I’m not sure specifically when) about what might have caused this. I hope everyone who is sick is starting to feel better, and I hope you all enjoy your weekend.
If you or anyone you know is having symptoms but hasn’t notified us, please email me at firstname.lastname@example.org with names and phone numbers, and I will forward that information to the health department. Any questions, you can ping me on email, too.
San Diego SPJ president
Update 1, 7/31/15: Food-poisoning symptoms from SPJ banquet at Bali Hai
Friends: I regret to inform you that at least 30-35 of the 170 people who attended the SPJ banquet at the Bali Hai Wednesday night have reported food-poisoning symptoms to us that include vomiting and diarhhea; some stayed or went home sick today.
If you are sick as well, please email your name and phone number to email@example.com, and I will pass the information along to the Health Department. Today officials there told me they planned to begin a food-borne illness investigation by visiting the venue and calling those of us who are sick. They requested a copy of the menu and have created a questionnaire to help determine what happened. The department expects to resolve its investigation next week, and as soon as they tell us more, we will let everyone know what happened. They don’t have a more specific timeline, and I don’t know much if anything else at this point.
We are also in touch with the Bali Hai, which is trying to get to the bottom of this.
My apologies to everyone who is sick and to everyone else whose news report was disrupted today. If there are questions, email me and I will attempt to respond in a timely way, but I am one of the people who went home early myself.
Please also pass this on to anyone else you know of who was at the banquet, in case we missed anyone with this email.
Matthew T. Hall
President, SPJ San Diego Pro Chapter
Western region director, national SPJ