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Food poisoning in Makkah, Hajj 1415 H

Eight women from four different families decided to perform Hajj together. Six of the women live in Makkah, the other two live in Al Baha. The family from Al Baha stayed with one of the families in Makkah. The women decided that each family would prepare one food item to share among the group while performing Hajj.
On the morning of 9 Dhul Higga H (May 9 G) between 8:00 a.m. and 11:00 a.m., the three families from Makkah prepared food for the trip at their separate homes. The two women from Al Baha contributed by helping one of the Makkah families. One woman prepared koftah sandwiches for the group and for her two children. She gave the children koftah sandwiches for breakfast and for lunch before taking them to the baby-sitter. That afternoon all eight women and their driver left for Arafat in one car. The food for the trip was packed in plastic containers, but not packed in coolers or on ice.
In Arafat they shared some of the communal food. No individual food item was eaten by more than two women. They did not eat the koftah.
After 6:00 p.m., they all drove from Arafat to Muzdalifah. At 9:00 p.m. after they had arrived, they ate dinner All eight women ate koftah sandwiches. Two women also ate meat sandwiches and one also ate cheese sandwiches.
The next morning, 10 Dhul Higga H (May 10 G), between 8:00 a.m. and 3:00 p.m. all eight women developed diarrhea and abdominal cramps. All eight had nausea but nobody vomited.
Fever was reported by four patients but not documented. No organism was isolated from the stool.
The two children who had eaten the koftah sandwiches for breakfast and lunch before being taken to the baby-sitter remained well. All eight women had fully recovered in less than two days.

Editorial note:

As the attack rate (AR) for the koftah sandwiches was 100%, and no other food was eaten by more than two women, it appears that koftah was responsible for the outbreak. Since the children who ate freshly cooked koftah did not become sick, the responsible organism probably required a period of multiplication after cooking. Although no organism was isolated from the ill women, two organisms are likely causes. Clostridium perfringens if present in 103 organisms per gram of food will produce diarrhea and colic with onset from eight to 16 hours after eating.
C. perfringens poisoning symptomatology usually lasts for less than 24 hours, has no associated fever and only rare vomiting. Salmonellosis incubation can range from six hours to four days, produces colic, and diarrhea. It differs from C. perfringens food poisoning in that there is often fever, vomiting is more common, and the diarrhea lasts for several days. The lack of vomiting and the short duration of illness suggest C. perfringens. However, the fever history of four women suggests salmonellosis.
Both organisms typically produce food borne gastroenteritis if they multiply in the food before it is eaten. Critical time and temperature conditions for multiplication of both organisms in food are food temperatures between 10° and 55° C for five or more hours. C. perfringens also requires an anaerobic environment such as provided in a large tightly packed mass of food or in a closed container. The koftah was subjected to all these conditions from just after cooking until it was eaten.
C. perfringens contaminates food as heat resistant spores. The spores germinate when the food is cooked.
C. perfringens is part of the normal flora of the intestinal tract of mammals and the spores are widespread in the environment. Thus, accidental contamination of food can not be avoided. C. perfringens food poisoning is prevented only by avoiding time and temperature abuse of the food after cooking. Salmonellosis is a zoonosis and the organism may be found in a wide variety of animal derived foods including ground meat. It is killed by proper cooking. Thus, salmonella may contaminate the cooked koftah either by incomplete cooking or by cross contamination of the cooked koftah from utensils, containers, or food preparation surfaces used for raw foods.