A pseudo-outbreak of foodborne illness in a hospital cafeteria caused by consumption of sorbitol

Foodborne illness causes significant morbidity and mortality in the United States. An estimated 128,000 people are hospitalized and 3,000 people die from foodborne illness in the United States each year.1Centers for Disease Control and Prevention Estimates of foodborne illness in the United States.http://www.cdc.gov/foodborneburden/#Date: 2014Google Scholar Food service establishments, including those within hospitals, must meet stringent food safety regulations to prevent foodborne illness. However, numerous outbreaks of foodborne illness linked to eating at hospital cafeterias have occurred.2Gellert G.A. Tormey M. Rodriguez G. Brougher G. Dassey D. Pate C. Food-borne disease in hospitals: prevention in a changing food service environment.Am J Infect Control. 1989; 17: 136-140Abstract Full Text PDF PubMed Scopus (2) Google Scholar, 3Pollock A.M. Whitty P.M. Crisis in our hospital kitchens: ancillary staffing levels during an outbreak of food poisoning in a long stay hospital.BMJ. 1990; 300: 383-385Crossref PubMed Scopus (9) Google Scholar, 4Jacks A. Pihlajasaari A. Vahe M. Myntti A. Kaukoranta S.S. Elomaa N. et al.Outbreak of hospital-acquired gastroenteritis and invasive infection caused by Listeria monocytogenes, Finland, 2012.Epidemiol Infect. 2015; : 1-11Crossref Scopus (16) Google Scholar Because hospital cafeterias serve patients who may have compromised immune systems, hospital infection control programs must be vigilant about any potential foodborne illness outbreaks related to food service establishments at their facilities. However, the gastrointestinal (GI) symptoms of foodborne illness (eg, nausea, vomiting, diarrhea) are not specific. We describe multiple cases of GI symptoms caused by consumption of a sugar substitute that were initially mistaken for an outbreak of foodborne illness at our institution. In September 2014, a physician notified the infection control program at our hospital that multiple residents and medical students on his team had fallen ill with GI symptoms after eating at our hospital food court over the prior several months. In response to his concerns, we undertook an outbreak investigation. We defined a case as any individual who suffered from nausea, vomiting, or diarrhea (3 loose stills within a 24-hour period) after eating at the food court from July 1, 2014-September 30, 2014. Individuals identified by the reporting physician were interviewed. Confirmed cases are described in Table 1. All other residents who had called in sick during the defined time period were contacted and questioned regarding food consumption and GI symptoms. One additional student and 2 residents were identified as potential cases by medical student A, but we were unable to successfully contact them. We reviewed all complaints received by food services during the time period but did not identify any additional possible cases among visitors or other employees. A food safety inspection was undertaken of all vendors in the food court; no serious violations were noted.Table 1Confirmed casesCaseFood consumedDate consumedSymptom onsetSymptomsSymptom durationMedical student AFrozen sorbetAugust 26, 201430 min after consumptionNausea, vomiting, inability to tolerate oral intake24 hMedical student BFrozen sorbetAugust 25, 201420-30 min after consumptionLoose stools, bloating6 hSurgical residentFrozen sorbetSeptember 11, 20142 h after consumptionAbdominal pain, cramping, diarrhea12 h Open table in a new tab A careful evaluation of the confirmed cases revealed they had all consumed frozen yogurt containing sorbitol from the same vendor. Sorbitol is a sugar substitute that is not absorbed in the GI tract. It can cause GI symptoms including nausea, bloating, and diarrhea.5Jain N.K. Rosenberg D.B. Ulahannan M.J. Glasser M.J. Pitchumoni C.S. Sorbitol intolerance in adults.Am J Gastroenterol. 1985; 80: 678-681PubMed Google Scholar, 6Jain N.K. Patel V.P. Pitchumoni C.S. Sorbitol intolerance in adults. Prevalence and pathogenesis on two continents.J Clin Gastroenterol. 1987; 9: 317-319Crossref Scopus (32) Google Scholar We determined that sorbitol consumption, rather than an infectious foodborne pathogen, was the cause of the cases' symptoms. Others have similarly reported individual cases of GI symptoms as a result of sorbitol consumption.7Breitenbach R.A. “Halloween diarrhea”. An unexpected trick of sorbitol-containing candy.Postgrad Med. 1992; 92: 63-66Crossref Scopus (7) Google Scholar, 8Goldberg L.D. Ditchek N.T. Chewing gum diarrhea.Am J Dig Dis. 1978; 23: 568Crossref PubMed Scopus (32) Google Scholar, 9Bauditz J. Norman K. Biering H. Lochs H. Pirlich M. Severe weight loss caused by chewing gum.BMJ. 2008; 336: 96-97Crossref PubMed Scopus (31) Google Scholar, 10Ravry M.J. Dietetic food diarrhea.JAMA. 1980; 244: 270Crossref PubMed Scopus (38) Google Scholar Prior reports have documented diarrhea and weight loss as a result of heavy use of chewing gum or consumption of candy and other sorbitol-containing foods.7Breitenbach R.A. “Halloween diarrhea”. An unexpected trick of sorbitol-containing candy.Postgrad Med. 1992; 92: 63-66Crossref Scopus (7) Google Scholar, 8Goldberg L.D. Ditchek N.T. Chewing gum diarrhea.Am J Dig Dis. 1978; 23: 568Crossref PubMed Scopus (32) Google Scholar, 9Bauditz J. Norman K. Biering H. Lochs H. Pirlich M. Severe weight loss caused by chewing gum.BMJ. 2008; 336: 96-97Crossref PubMed Scopus (31) Google Scholar, 10Ravry M.J. Dietetic food diarrhea.JAMA. 1980; 244: 270Crossref PubMed Scopus (38) Google Scholar However, to our knowledge, this is the first report of a pseudo-outbreak of GI illness caused by sorbitol in a cluster of individuals. Although foodborne illness is a frequent cause of GI symptoms, it is important to recognize alternative etiologies that can be mistaken for an infectious foodborne outbreak.