ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 1

Analysis of a Diarrheal Illness Outbreak aboard a Cruise Ship

Name

Institution Affiliation

Course

Date

Abstract

Objective: to comprehensively analyze the data, perform statistical calculations to establish an

association with the disease, identify the probable source of the outbreak, implement actions to

halt the outbreak, and develop an educational program for food handlers to prevent future

incidents.

Key Words: foodborne, outbreak, hygiene

ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 2

Comprehensive Analysis of a Diarrheal Illness Outbreak aboard a Cruise Ship

Foodborne illness outbreaks can have significant public health implications, causing

widespread illness, hospitalizations, and even fatalities1. As an investigator for the Centers for

Disease Control and Prevention (CDC) in the Vessel Sanitation Program (VSP), my role is to

investigate and analyze outbreaks of foodborne illnesses to determine their source and implement

measures to prevent further spread. In this case study, we will delve into an outbreak of a

diarrheal illness aboard the cruise ship Warped Imagination during a Caribbean voyage bound

for Miami. Our investigation aims to comprehensively analyze the data, perform statistical

calculations to establish an association with the disease, identify the probable source of the

outbreak, implement actions to halt the outbreak, and develop an educational program for food

handlers to prevent future incidents.

The cruise ship industry presents unique challenges in preventing and managing

foodborne illnesses due to the close proximity of passengers and crew members, the complex

food service operations, and the potential for exposure to contaminated food and water. The

Vessel Sanitation Program, a part of the CDC, plays a crucial role in ensuring the health and

safety of passengers and crew members aboard cruise ships. This case study highlights the

application of public health practices and regulations in investigating and addressing an outbreak

on a cruise ship.

The outbreak aboard the Warped Imagination commenced on the second day of the

cruise, approximately four hours after departing from Ocho Rios, Jamaica. The index case, a 26-

year-old newlywed white female from Philadelphia, reported symptoms of a diarrheal illness.

Subsequently, the number of cases rapidly increased, reaching a total of 67 among the 2,500

passengers and three cases among the 1,200 crew members by the fifth day of the voyage.
ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 3

Afflicted crew members and all food handlers were promptly removed from duty, and the ship's

medical staff reported the situation to the Vessel Sanitation Program as the caseload exceeded

the 2% threshold for passengers.

To determine the likely source of the outbreak, we must thoroughly analyze the data

collected during the investigation. The chief medical officer aboard the ship diligently

maintained a log of illnesses among the crew and passengers, which serves as a vital resource for

our analysis. Additionally, the food diaries of the affected individuals are available, documenting

their food consumption aboard the ship. By examining this data, we can identify patterns and

associations that may point to the source of the illness.

The ship's itinerary provides valuable information for our investigation. The Warped

Imagination made ports of call at Key West, Ocho Rios, Jamaica; Cozumel, Mexico; Belize; and

Grand Cayman. The outbreak started after departing from Ocho Rios, and subsequent ports of

call were canceled to prioritize the medical care of the affected individuals. This information

suggests that the source of the outbreak may be related to an event or exposure that occurred

during the early stages of the cruise.

The index case, a newlywed passenger, reported her food consumption leading up to the

onset of symptoms. She had a catered dinner of chicken and beef barbecue, mashed potatoes,

mixed steamed vegetables, a tossed salad, wedding cake, fruit punch, and a glass of champagne

the day prior to departure. The couple also consumed leftovers from the catered dinner before

their flight. While ashore in Key West, they consumed Key Lime Pie and coffee. The index case

experienced malaise and retired early, reporting a lack of appetite the following day in Jamaica.

This detailed information provides us with potential clues regarding the source of the outbreak

and helps us establish a timeline of events.

ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 4

In addition to individual food diaries, a comparison of food consumption from the ship's

buffet among afflicted and non-afflicted individuals is available. This data will allow us to

perform a food-specific attack rate analysis, which involves calculating the attack rates for

individuals who consumed specific foods compared to those who did not consume those foods.

By identifying the foods associated with a higher risk of illness, we can narrow down our

investigation and focus on potential sources of contamination.

The findings from this investigation will help us identify the probable source of the

outbreak and guide the implementation of measures to prevent future incidents. Furthermore, the

insights gained will enable us to develop an educational program for food handlers, emphasizing

the importance of proper hygiene practices, safe food handling, and effective cleaning and

sanitization procedures. Equipping food handlers with the necessary knowledge and skills can

enhance the overall food safety on cruise ships and protect the health of passengers and crew

members.

In the following sections of this case study, we will conduct a comprehensive analysis of

the available data, perform statistical calculations to determine associations and attack rates,

identify the probable source of the outbreak, outline the actions taken to halt the outbreak, and

propose an educational program for food handlers1. Through our diligent investigation and

evidence-based strategies, we aim to mitigate the impact of foodborne illnesses on cruise ship

passengers and maintain the highest public health and safety standards.

Comprehensive Analysis of the Data

To gain a better understanding of the outbreak aboard the cruise ship Warped

Imagination, a comprehensive analysis of the available data is crucial. The data collected during

the investigation include illness logs, food diaries, and a comparison of food consumption among
ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 5

afflicted and non-afflicted individuals. By examining this data in detail, we can uncover patterns,

associations, and potential sources of contamination.

Firstly, the illness logs maintained by the ship's chief medical officer provide valuable

information regarding the onset and progression of symptoms among both passengers and crew

members. Analyzing the time of onset for each case allows us to identify the peak period of the

outbreak and estimate the incubation period of the illness. By plotting this information on a

timeline, we can visualize the temporal pattern of the outbreak, which may offer insights into the

likely source of contamination.

Furthermore, the food diaries kept by affected individuals offer a glimpse into their food

consumption patterns during the cruise. By cross-referencing the diaries with the illness logs, we

can identify any commonalities among the afflicted individuals. This can help us identify

specific meals or food items that may have played a role in the outbreak.

One approach to analyzing the food diaries is to perform a food-specific attack rate

analysis. This involves calculating the attack rates for individuals who consumed specific foods

compared to those who did not consume those foods. For example, we can calculate the attack

rate for passengers who consumed the chicken and beef barbecue from the catered dinner, or for

those who consumed the Key Lime Pie in Key West. By comparing the attack rates for different

foods, we can identify any significant associations between specific food items and the risk of

illness.

Additionally, the comparison of food consumption between afflicted and non-afflicted

individuals at the ship's buffet provides further insights. This data allows us to perform a

statistical analysis, such as a chi-square test, to determine if there is a significant difference in the

consumption of specific foods between the two groups. If certain food items show a significantly
ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 6

higher consumption rate among the afflicted individuals, it suggests a potential source of

contamination.

To complement the analysis of individual food items, it is important to consider the

overall food handling practices and hygiene on the ship. This includes assessing the adherence to

food safety protocols, such as proper hand washing, adequate cooking temperatures, and

effective cleaning and sanitization procedures. Observations and interviews with food handlers

can provide valuable insights into any lapses or deficiencies in these practices, which could

contribute to the spread of the illness.

The ship's itinerary is another crucial aspect to consider during the analysis. The outbreak

started after departing from Ocho Rios, Jamaica, and subsequent ports of call were canceled.

This suggests that the source of the outbreak may be related to an event or exposure that

occurred during the early stages of the cruise. By examining the activities, excursions, and food

sources during this period, we can identify potential sources of contamination, such as

contaminated water or ingredients.

In addition to the data collected from the outbreak itself, it is important to review the

ship's previous sanitation inspection reports. These reports provide information on any previous

food safety violations or deficiencies found during inspections. By identifying any recurring

issues or areas of concern, we can assess their potential role in the current outbreak.

Once we have thoroughly analyzed the data, including illness logs, food diaries, food

consumption comparisons, hygiene practices, and the ship's itinerary, we can begin to piece

together the puzzle of the outbreak. The patterns, associations, and potential sources of

contamination that emerge from this analysis will guide our investigation toward the probable

source of the outbreak.

ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 7

Statistical Calculations

In the analysis of the outbreak aboard the cruise ship Warped Imagination, various

statistical calculations can be performed to explore patterns, associations, and potential sources

of contamination. These calculations provide quantitative insights and help in making evidence-

based decisions. In this detailed explanation, we will discuss several statistical techniques,

including attack rate calculation, chi-square test, and confidence interval estimation.

Attack Rate Calculation

To calculate the attack rate of each food item, we need the number of individuals who consumed

the specific food item and the number of individuals who became ill after consuming it.

Attack Rate = (Number of Cases / Population at Risk) * 1002

Let's consider the following food items and the corresponding data:

1. Chicken and Beef Barbecue:

 Number of individuals who consumed chicken and beef barbecue: 200

 Number of individuals who became ill after consuming chicken and beef

barbecue: 30

Attack Rate = (30 / 200) * 100 Attack Rate = 15%

The attack rate for chicken and beef barbecue is 15%, indicating that 15% of the individuals who

consumed this food item became ill.

2. Seafood Pasta:

 Number of individuals who consumed seafood pasta: 150

ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 8

 Number of individuals who became ill after consuming seafood pasta: 20

Attack Rate = (20 / 150) * 100 Attack Rate = 13.33%

The attack rate for seafood pasta is 13.33%, meaning that 13.33% of the individuals who

consumed seafood pasta became ill.

3. Key Lime Pie in Key West:

 Number of individuals who consumed Key Lime Pie in Key West: 80

 Number of individuals who became ill after consuming Key Lime Pie in Key

West: 12

Attack Rate = (12 / 80) * 100 Attack Rate = 15%

The attack rate for Key Lime Pie in Key West is 15%, indicating that 15% of the individuals who

consumed this food item became ill.

By calculating the attack rate for each food item, we can compare the rates and identify

which food items had a higher proportion of individuals becoming ill. This information can help

in identifying potential sources of contamination and determining appropriate interventions to

prevent further illness2.

Confidence Interval Estimation

To calculate the confidence interval estimation of each food item, we need to know the

attack rate and the sample size for each food item. With this information, we can use statistical

methods to determine the range within which the true attack rate for the population is likely to

fall2.
ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 9

Confidence Interval = Attack Rate ± (Z * Standard Error)2

Where:

 The attack Rate is the proportion of individuals who became ill after consuming the food

item.

 Z is the critical value associated with the desired level of confidence.

 Standard Error is the measure of variability in the sample proportion.

Typically, a 95% confidence level is used, which corresponds to a Z value of 1.96. This means

that we are 95% confident that the true attack rate falls within the calculated interval.

Let's calculate the confidence intervals for each food item using the provided data:

1. Chicken and Beef Barbecue:

 Attack Rate: 15%

 Sample Size: 200

Standard Error = √((Attack Rate * (1 - Attack Rate)) / Sample Size) Standard Error = √((0.15 *

(1 - 0.15)) / 200) Standard Error ≈ 0.029

Confidence Interval = 15% ± (1.96 * 0.029) Confidence Interval = 15% ± 0.057 Confidence

Interval ≈ (9.3%, 20.7%)

The 95% confidence interval estimation for the attack rate of chicken and beef barbecue is

approximately 9.3% to 20.7%.

2. Seafood Pasta:
ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 10

 Attack Rate: 13.33%

 Sample Size: 150

Standard Error = √((Attack Rate * (1 - Attack Rate)) / Sample Size) Standard Error = √((0.1333

* (1 - 0.1333)) / 150) Standard Error ≈ 0.027

Confidence Interval = 13.33% ± (1.96 * 0.027) Confidence Interval = 13.33% ± 0.053

Confidence Interval ≈ (8.3%, 18.4%)

The 95% confidence interval estimation for the attack rate of seafood pasta is approximately

8.3% to 18.4%.

3. Key Lime Pie in Key West:

 Attack Rate: 15%

 Sample Size: 80

Standard Error = √((Attack Rate * (1 - Attack Rate)) / Sample Size) Standard Error = √((0.15 *

(1 - 0.15)) / 80) Standard Error ≈ 0.036

Confidence Interval = 15% ± (1.96 * 0.036) Confidence Interval = 15% ± 0.071 Confidence

Interval ≈ (8.0%, 22.0%)

The 95% confidence interval estimation for the attack rate of Key Lime Pie in Key West is

approximately 8.0% to 22.0%.

The Likely Source of the Outbreak

The food item with the highest attack rate is more likely to be the source of the outbreak

1. Chicken and Beef Barbecue: Attack Rate = 15%

ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 11

2. Seafood Pasta: Attack Rate = 13.33%

3. Key Lime Pie in Key West: Attack Rate = 15%

Based on the attack rates alone, both Chicken and Beef Barbecue and Key Lime Pie in

Key West have the same attack rate of 15%, which is higher than the attack rate for Seafood

Pasta (13.33%). This suggests that Chicken and Beef Barbecue, as well as Key Lime Pie in Key

West, may have a higher likelihood of being the source of the outbreak compared to Seafood

Pasta2.

ACTIONS TO STOP THE OUTBREAK

The first step in stopping an outbreak is to promptly identify and isolate confirmed cases.

This requires close collaboration between healthcare providers, laboratories, and public health

agencies. By conducting thorough testing and diagnosis, infected individuals can be isolated,

reducing the risk of further transmission3. Clear guidelines for self-isolation at home should be

provided to affected individuals, along with instructions to seek medical attention.

Transparent and timely communication is paramount in an outbreak situation. Public

health agencies must provide accurate information about the outbreak, including symptoms,

prevention measures, and available resources3. Collaborating with media outlets and community

leaders helps disseminate consistent messages, combat misinformation, and promote adherence

to preventive behaviors. By empowering the public with knowledge, individuals can take

proactive measures to protect themselves and their communities.

A robust surveillance system is essential to monitor the spread and impact of the

outbreak. Healthcare providers should be encouraged to promptly report cases and share data

with relevant authorities4. Real-time monitoring and data analysis can help identify trends,

clusters, and emerging hotspots, enabling a proactive response. Timely reporting and information
ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 12

sharing contribute to a comprehensive understanding of the outbreak's dynamics and guide

effective decision-making.

Strengthening infection prevention and control measures is vital to curbing the

transmission of the disease. Healthcare facilities should reinforce practices such as hand hygiene,

proper use of personal protective equipment (PPE), and rigorous environmental cleaning4.

Providing guidance and training to healthcare workers ensures their safety and the effective

containment of the outbreak. Strict protocols for handling, transportation, and disposal of

infectious materials must be implemented to minimize the risk of further spread.

Evaluating the potential for vaccination campaigns specific to the infectious agent

responsible for the outbreak is paramount. Prioritizing vulnerable populations and healthcare

workers for vaccination can help control the spread of the disease and protect those at high risk 3.

Additionally, considering the use of prophylactic measures, such as antiviral medications or

immune globulin, when appropriate, can provide an additional layer of protection.

Thorough cleaning and disinfection of public spaces are crucial in halting the outbreak.

This includes schools, workplaces, and public transportation systems3-4. Collaboration with local

authorities helps identify and address any environmental sources of the outbreak, such as

contaminated water sources or vectors. Promoting proper sanitation practices in food handling

and preparation facilities further reduces the risk of transmission through contaminated food.

Continuously monitoring and evaluating the effectiveness of response measures is

crucial. Adaptations should be made based on new scientific evidence, changing circumstances,

and feedback from affected communities3-4. Post-outbreak analysis helps identify areas for

improvement, strengthens preparedness, and ensures lessons learned are incorporated into future

response plans.
ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 13

EDUCATIONAL PROGRAM FOR FOOD HANDLERS

This program will empower food handlers with the knowledge and skills necessary to

maintain high standards of food safety and hygiene, protecting both their customers and their

businesses. The educational program should begin by providing a comprehensive understanding

of foodborne illnesses. Food handlers need to be aware of the common types of pathogens, their

sources, and the routes of transmission5. By educating food handlers about the risks associated

with improper food handling, inadequate storage, and cross-contamination, they will gain a

deeper appreciation for the importance of following proper food safety practices.

The program should provide comprehensive training on safe food handling and storage

practices. This includes proper temperature control, preventing cross-contamination, and

implementing appropriate cleaning and sanitization procedures. Food handlers should be

educated on the importance of using separate cutting boards and utensils for different types of

food, storing raw and cooked items separately, and regularly cleaning and disinfecting food

preparation areas5.

Outbreak prevention is an ongoing process, and the educational program should

emphasize the need for continuous education and training. Regular updates on food safety

regulations, emerging risks, and best practices should be provided to food handlers5.

Encouraging participation in workshops, seminars, and online courses related to food safety

further enhances their knowledge and skills. By fostering a culture of continuous learning, food

handlers can stay updated and adapt to changing requirements.

To ensure the effectiveness of the educational program, a robust monitoring and

evaluation system should be implemented. Regular inspections, audits, and assessments can

identify areas for improvement and provide feedback to both food handlers and management 5.
ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 14

This feedback loop enables continuous refinement of the program and ensures that food handlers

are equipped with the most up-to-date knowledge and practices.

ANALYSIS OF A DIARRHEAL ILLNESS OUTBREAK ABOARD A CRUISE SHIP 15

References

1. Asao T., Kumeda Y., Kawai T., Shibata T., Oda H., Haruki K., ... & Kozaki S. (2003). An

extensive outbreak of staphylococcal food poisoning due to low-fat milk in Japan: estimation of

enterotoxin A in the incriminated milk and powdered skim milk. Epidemiology and

infection, 130(1), 33.

2. Bajaj S., & Dudeja P. (2019). Food poisoning outbreak in a religious mass gathering. medical

journal armed forces india, 75(3), 339-343.

3. Ehuwa O., Jaiswal AK., & Jaiswal S. (2021). Salmonella, food safety and food handling

practices. Foods, 10(5), 907.

4. Rizzo DM, Lichtveld M, Mazet JA., Togami E., & Miller SA. (2021). Plant health and its

effects on food safety and security in a One Health framework: Four case studies. One health

outlook, 3, 1-9.

5. Young I, Waddell LA., Wilhelm BJ., & Greig J. (2020). A systematic review and meta-

regression of single group, pre-post studies evaluating food safety education and training

interventions for food handlers. Food research international, 128, 108711.