Clostridium perfringens is a common infectious cause of outbreaks of foodborne illness in the United States, especially outbreaks in which cooked beef is the implicated source (1,2). This report describes two outbreaks of C. perfringens gastroenteritis following St. Patrick's Day meals in Ohio and Virginia during 1993. Ohio

On March 18, 1993, the Cleveland City Health Department (CCHD) received telephone calls from 15 persons who became ill after eating corned beef purchased from one delicatessen. After a local newspaper article publicized this problem, 156 persons contacted CCHD to report onset of diarrheal illness within 48 hours of eating food from the delicatessen on March 16 or March 17. Symptoms included abdominal cramps (88%) and vomiting (13%); no persons were hospitalized. The median incubation period was 12 hours (range: 2- 48 hours). Of the 156 persons reporting illness, 144 (92%) reported having eaten corned beef; 20 (13%), pickles; 12 (8%), potato salad; and 11 (7%), roast beef.

In anticipation of a large demand for corned beef on St. Patrick's Day (March 17), the delicatessen had purchased 1400 pounds of raw, salt-cured product. Beginning March 12, portions of the corned beef were boiled for 3 hours at the delicatessen, allowed to cool at room temperature, and refrigerated. On March 16 and 17, the portions were removed from the refrigerator, held in a warmer at 120 F (48.8 C), and sliced and served. Corned beef sandwiches also were made for catering to several groups on March 17; these sandwiches were held at room temperature from 11 a.m. until they were eaten throughout the afternoon.

Cultures of two of three samples of leftover corned beef obtained from the delicatessen yielded greater than or equal to 105 colonies of C. perfringens per gram.

Following the outbreak, CCHD recommended to the delicatessen that meat not served immediately after cooking be divided into small pieces, placed in shallow pans, and chilled rapidly on ice before refrigerating and that cooked meat be reheated immediately before serving to an internal temperature of greater than or equal to 165 F ( greater than or equal to 74 C). Virginia

On March 28, 1993, 115 persons attended a traditional St. Patrick's Day dinner of corned beef and cabbage, potatoes, vegetables, and ice cream. Following the dinner, 86 (76%) of 113 persons interviewed reported onset of illness characterized by diarrhea (98%), abdominal cramps (71%), and vomiting (5%). The median incubation period was 9.5 hours (range: 2-18.5 hours). Duration of illness ranged from 1 hour to 4.5 days; one person was hospitalized.

Corned beef was the only food item associated with illness; cases occurred in 85 (78%) of 109 persons who ate corned beef compared with one of four who did not (relative risk=3.1; 95% confidence interval=0.6-17.1). Cultures of stool specimens from eight symptomatic persons all yielded greater than or equal to 106 colonies of C. perfringens per gram. A refrigerated sample of leftover corned beef yielded greater than or equal to 105 colonies of C. perfringens per gram.

The corned beef was a frozen, commercially prepared, brined product. Thirteen pieces, weighing approximately 10 pounds each, had been cooked in an oven in four batches during March 27-28. Cooked meat from the first three batches was stored in a home refrigerator; the last batch was taken directly to the event. Approximately 90 minutes before serving began, the meat was sliced and placed under heat lamps.

Following the outbreak, Virginia health officials issued a general recommendation that meat not served immediately after cooking be divided into small quantities and rapidly chilled to less than or equal to 40 F (less than or equal to 4.4 C), and that precooked foods be reheated immediately before serving to an internal temperature of greater than or equal to 165 F (greater than or equal to 74 C). Follow-Up Investigation

The results of the epidemiologic and laboratory investigations suggest that the two outbreaks in this report were not related. Traceback of the corned beef in both of these outbreaks indicated that the meat had been produced by different companies and sold through different distributors. Serotyping was performed on C. perfringens isolates recovered from the stool samples in Virginia and on an isolate from a food sample obtained in Ohio. Six of the seven Virginia stool isolates were serotype PS86; however, the food isolate from Ohio could not be serotyped using available antisera.

Reported by: J Zimomra, MPA, T Wenderoth, A Snyder, R Russ, Div of Environmental Health, Cleveland City Health Dept; ED Peterson, R French, MPA, TJ Halpin, MD, State Epidemiologist, Div of Preventive Medicine, Ohio Dept of Health. JE Florance, MD, A Adkins, J Andrew, M Burkgren, K Crisler, T Fagen, L Fass, JM Galloway, S Haines, RH Hinton, C Jackson, NS Rivera, EL Testor, C Williams, Prince William Health District; AA DiAllo, PhD, DR Patel, Virginia Div of Consolidated Laboratory Svcs, Dept of General Svcs; CW Armstrong, MD, D Woolard, MPH, GB Miller, MD, State Epidemiologist, Virginia Dept of Health. Div of Field Epidemiology, Epidemiology Program Office; Foodborne and Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: C. perfringens is a ubiquitous, anaerobic, gram-positive, spore-forming bacillus and a frequent contaminant of meat and poultry (3). C. perfringens food poisoning is characterized by onset of abdominal cramps and diarrhea 8-16 hours after eating contaminated meat or poultry (4). By sporulating, this organism can survive high temperatures during initial cooking; the spores germinate during cooling of the food, and vegetative forms of the organism multiply if the food is subsequently held at temperatures of 60 F-125 F (16 C-52 C) (3). If served without adequate reheating, live vegetative forms of C. perfringens may be ingested. The bacteria then elaborate the enterotoxin that causes the characteristic symptoms of diarrhea and abdominal cramping (4).

Laboratory confirmation of C. perfringens foodborne outbreaks requires quantitative cultures of implicated food or stool from ill persons. Both outbreaks described in this report were confirmed by the recovery of greater than or equal to 105 organisms per gram of epidemiologically implicated food (5). Cultures of stool samples from persons affected in Virginia also met the alternate criterion of a median of greater than or equal to 106 colonies per gram (6). Serotyping is not useful for confirming C. perfringens outbreaks and, in general, is not available (7).

Corned beef is a popular ethnic dish that is commonly served to celebrate St. Patrick's Day. The errors in preparation of the corned beef in these outbreaks were typical of those associated with previously reported foodborne outbreaks of C. perfringens (8). Improper holding temperatures were a contributing factor in most (97%) C. perfringens outbreaks reported to CDC from 1973 through 1987 (2). To avoid illness caused by this organism, food should be eaten while still hot or reheated to an internal temperature of greater than or equal to 165 F (greater than or equal to 74 C) before serving (9).

References

1. Shandera WX, Tacket CO, Blake PA. Food poisoning due to Clostridium perfringens in the United States. J Infect Dis 1983;147:167-70.

2. Bean NH, Griffin PM. Foodborne disease outbreaks in the United States, 1973-1987: pathogens, vehicles, and trends. Journal of Food Protection 1990;53:804-17.

3. Hall HE, Angelotti R. Clostridium perfringens in meat and meat products. Appl Microbiol 1965;13:352-7.

4. Hughes JM, Tauxe RV. Food-borne disease. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone Inc, 1990;893-

6. Hauschild WAH. Criteria and procedures for implicating Clostridium perfringens in food-borne outbreaks. Can J Public Health 1975;66:388-92.

7. Hauschild WAH, Desmarchelier P, Gilbert RJ, Harmon SM, Vahlefeld R. ICMSF methods studies: XII. Comparative study for the enumeration of Clostridium perfringens in feces. Can J Microbiol 1979;25:953-63.

8. Hatheway CL, Whaley DN, Dowell VR Jr. Epidemiological aspects of Clostridium perfringens foodborne illness. Food Technology 1980;34:77-9.

9. Loewenstein MS. Epidemiology of Clostridium perfringens food poisoning. N Engl J Med 1972;286:1026-8.

10. Bryan FL. What the sanitarian should know about Clostridium perfringens foodborne illness. Journal of Milk and Food Technology 1969;32:381-9.

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