On June 30, 2003, Lake County Health Department (LCHD) received a report from Lake Forest Hospital indicating that a patient was ill with a Salmonella infection. The LCHD immediately contacted the patient and interviewed him, using a questionnaire that is standard for the epidemiological investigation of foodborne illness outbreaks. One of the first things learned by the interviewer was that the patient had recently eaten at the Chili’s Grill & Bar in Vernon Hills, Illinois.
About an hour after receiving this first report, a second person contacted LCHD to report that a family member had become ill after eating at Chili’s in Vernon Hills. This prompted the LCHD to send investigators to the restaurant to inspect it. What they found was disturbing. The restaurant’s dishwashing machine was broken and corroded; the tube that fed chlorine into the machine was plugged, preventing proper sanitization of dishes. Employees told the investigators that the machine had not worked properly for at least a week. In fact, according to the LCHD Final Report, “[e]mployees had wrapped plastic bags around the line to stop the chlorine from spraying into the air.” Despite the obvious broken condition of the dishwasher, the restaurant management still had done nothing to get the machine repaired”that is, until caught by the health department.
During their inspection, the investigators also found food not stored at proper temperatures in the cooler. And following questioning of the on-duty manager, investigators learned that three employees, plus another manager, had called in sick that day with flu symptoms.
The next day, LCHD received two new reports of individuals with Salmonella infections who had eaten at Chili’s on June 26, while Chili’s management reported six more ill employees. With evidence of the outbreak-source growing increasingly clear, investigators returned to the restaurant to instruct employees on hand-washing procedures, require the use of nailbrushes, and to issue a glove-use order. This meant that no further bare-hand contact of food was to be allowed at the restaurant. The investigators also collected stool samples from the employees there in addition to interviewing each one of them regarding gastrointestinal symptoms. As a result of these interviews, investigators discovered thirteen employees who had been allowed to work despite suffering from diarrhea and other symptoms.
Because of the large number of infected employees identified, the LCHD ordered the restaurant to close. A statement issued by LCHD Executive Director Dale Gallassie announced that:
Due to the large number of ill employees, and the high potential for spread of this illness, Chili’s was required to cease all operation or face suspension or revocation of its food service permit, at which time Chili’s management made the decision to voluntarily close the establishment.
Despite the initially voluntary closure of the restaurant, Chili’s management pushed to re-open almost immediately, arguing that workers from other restaurants could safely run the operation. LCHD refused because the source of Salmonella was still not known, and it could have been in a food item still on the premises, or some other contamination at the restaurant itself.
Following closure, investigators collected an additional 38 stool samples from employees and interviewed them. Two symptomatic employees revealed that they worked at two other restaurants located in Lake County. These other two restaurants were then inspected, and the two employees were restricted from working there until it could be demonstrated that they were no longer infected with Salmonella. Finally, that afternoon, LCHD drafted and sent a letter by certified mail to the management of the Vernon Hills Chili’s restaurant detailing the reasons for the closure of the premises.
On July 2, investigators returned to Chili’s and collected 50 more employee stool samples, then issued a press release advising the public of the outbreak. People who had eaten at the restaurant between June 23 and July 1 were instructed to seek medical help if ill, and to report their illness to the health department. Just a few hours later, LCHD was flooded with telephone complaints of illness from people who had eaten at the restaurant. LCHD had to enlist the aid of two additional communicable disease nurses to help interview all of the people calling in about the outbreak.
The next day, on July 3, LCHD received a call from a customer that had dined at Chili’s on June 27. She informed LCHD that the establishment had no running water while she had been there for lunch. The customer estimated that Chili’s had no water for at least an hour or two. This was information that Chili’s management had not thought it necessary to share with investigators at the time of their initial interviews.
On July 7, LCHD received notice from the lab that the stool samples of seventeen employees had cultured positive for Salmonella. One of the employees had also worked at the Chili’s restaurant located in Gurnee, which was immediately inspected. This was the fourth restaurant potentially implicated in the Salmonella outbreak as a result of infected Chili’s employees working at more than one restaurant.
Returning to the Vernon Hills Chili’s restaurant, LCHD investigators interviewed restaurant managers again and confirmed that there had been no water during the lunch rush on June 27, and no hot water the entire day before. No one could explain why the decision was made to keep the restaurant open in violation of food-safety regulations requiring that hot water be available at all times during a restaurant’s operation.
Meanwhile, Chili’s corporate office discussed with LCHD officials the possibility of reopening the restaurant on July 10 or 11, believing that enough previously infected employees would test negative by then. A request was therefore made for a pre-opening inspection to occur on July 9 to clear the restaurant for reopening. LCHD tentatively agreed to do so pending confirmation of a sufficient number of negative Salmonella stool cultures from employees.
On the afternoon of July 8, LCHD issued a statement announcing that 31 cases of salmonellosis had by that time been confirmed, and well over 100 cases were suspected to be related to the Chili’s outbreak. Of the confirmed cases, 14 had eaten at the restaurant, and 17 others were employees.
Investigators inspected the restaurant on July 10, and then again on July 11 right before its reopening. LCHD staff provided a hand-washing demonstration for Chili’s employees, and then formally gave approval to operate. Chili’s reopened at 11:00 a.m. for lunch. The restaurant had been closed for over two weeks as a result of the outbreak.
At the time of the restaurant’s reopening, a total of 19 employees and 67 patrons had been confirmed positive for Salmonella, with an additional 128 cases suspected to be linked to the outbreak. Of the total cases so far, nine had been serious enough to require hospitalization.
On July 12, Chili’s management called LCHD to notify it that the restaurant again had no hot water. This time it ceased operation pending completion of additional repairs. Once it opened again, LCHD investigators continued to inspect the restaurant daily.
On July 16, the results of microbiological testing performed on food samples from the restaurant, and from leftovers provided by customers, came back from the lab. Only two food samples had tested positive for Salmonella, both from customer leftovers: one from the Vernon Hills restaurant, and one from the Gurnee restaurant.
By July 18, LCHD concluded its investigation and determined the outbreak was under control. No secondary cases had been reported, but over 300 individuals had been sickened as a result of consuming contaminated food at a Chili’s. Of those, 141 customers and 28 employees had tested positive for the Salmonella bacteria, while 105 other infected individuals met the LCHD’s definition of a probable case. LCHD issued a preliminary report that concluded the outbreak was caused by infected employees who contaminated food with Salmonella as a result of poor sanitary practices and improper food-handling. It was by this time also determined that the Salmonella associated with the outbreak was Salmonella serotype javiana, a relatively rare and virulent strain often associated with foodborne transmission.
Once the LCHD believed the outbreak was controlled, the department sent a letter by certified mail informing the restaurant’s management of a hearing scheduled for July 31 to discuss their failure to cease operations during periods where no hot water, or no water at all, was available, failure to adequately monitor their employees’ health, and the steps management had implemented to prevent future outbreaks.
Following the hearing, Executive Director Dale Galassie stated that Chili’s had violated local ordinances by remaining open and serving customers while without available water. Although LCHD decided not to pursue punitive measures against Chili’s and its management, the department sent a letter to Chili’s corporate parent requesting reimbursement of outbreak-related investigation costs, including testing and training of staff, in the total amount of $32,500. Mr. Galassie stated, “[t]hese were extraordinary circumstances. There were excessive costs in dealing with [the outbreak] and therefore we are requesting reimbursement. The good news is that it prevented a secondary outbreak as a result of cooperation of the Chili’s corporation, local media, and ourselves, but it doesn’t excuse poor local management decisions made that caused it.” After a relatively lengthy, silent delay, it was announced on December 2, 2003, that Chili’s agreed to reimburse the LCHD for the costs associated with the outbreak.
EARLIER CHILI’S OUTBREAK
The Vernon Hills outbreak was not Chili’s first experience with the Salmonella bacteria. In June and July 2000, a Chili’s restaurant in Fort Smith, Arkansas caused an outbreak of Salmonella newport that sickened at least 96 people.
The Sebastian County Health Department (SCHD) first suspected the Fort Smith Chili’s when a woman reported that each member of her family had fallen ill with nausea, vomiting, and diarrhea two days after eating at the restaurant on June 24. Four days after this report, the SCHD received another report implicating Chili’s. This one came from a physician’s office that had hosted a Chili’s-catered luncheon on June 26. Several days after the luncheon, 16 to 20 people fell ill with similar symptoms.
After the SCHD received several more calls from people sickened at the luncheon, local sanitarians visited Chili’s to question employees about hygiene at the restaurant and to discover whether any employee was recently sick. On July 5, the SCHD received a report of an employee who was symptomatic. He had been seen by a physician on June 30 and submitted a culture. The employee had returned to work by July 4, but reported that he was no longer symptomatic.
By July 6, the SCHD had received over 50 reports of illness from people who had eaten Chili’s food in late June or early July. The focus was now squarely on the Fort Smith Chili’s. The SCHD obtained stool samples from all employees, and it prohibited symptomatic employees from returning to work. Also, a regional food safety specialist and a local sanitarian met with Chili’s management to discuss restrictions on ill or symptomatic employees returning to work.
On July 7, the SCHD received a report from another symptomatic person who had eaten at Chili’s on July 4. This report prompted a return visit by a sanitarian, who again conferred with management and collected various food samples for testing. It was soon learned, however, that restaurant management had allowed several Chili’s employees who had not been cultured to remain at work. The SCHD immediately restricted these employees and, on July 10, cultures taken from three of them returned positive for the Salmonella bacteria. Sanitarians again had to discuss with Chili’s management their concerns about work-place hygiene and restricting symptomatic employees.
All Chili’s employees were finally cultured by July 13, and several cultures had since returned positive for Salmonella. Meanwhile, the SCHD continued to receive reports of illness from people who had eaten at Chili’s in early to mid-July. Sanitarians continued their almost daily inspections until July 14 when, finally, Chili’s was closed down. The SCHD concluded that closure was necessary because the restaurant’s management had proved incapable of stopping the outbreak.
Sanitarians performed multiple intervention controls over the following several days. All kitchen utensils and equipment were cleaned and sanitized, cutting boards were replaced and color coded, food was thrown away, a produce cleaning system was installed, handwashing stations were upgraded, and the “shift table” system”i.e., where employees ate during breaks”was eliminated.
Chili’s remained closed until July 20. By this date, 12 employees had cultured positive for Salmonella newport, and 84 cases had been reported overall.
The Arkansas Department of Health issued its final report on March 14, 2002. The report noted two causes of the outbreak. The first “probable” cause was cross-contamination between raw poultry and fresh salsa, which was served as a side dish with most of the menu items. The second possible cause was food-handler contamination, which may have proliferated as a result of the “shift-table” system. In other words, contaminated salsa caused the initial wave of illnesses, and the outbreak was then propagated and made worse by person-to-person transmission from infected employees to restaurant customers.
Except for the elimination of the “shift table” at this particular Chili’s restaurant, it is not known what system-wide operational changes were made, if any, to prevent such an outbreak from occurring again. Assuming they were made, the changes were either not effective, or were not followed well enough at the Vernon Hills Chili’s restaurant. Either way, Chili’s is plainly in no position to claim that it was unaware of the risks that infected food-workers posed to its customers. And the fact that, in the restaurant industry, the risk of cross-contamination from an infected food-worker to food is a well-known and well-studied phenomenon, there is no room for Chili’s to argue that the policies in place at the time of the outbreak were consistent with those prevalent in the industry. And given that an unpaid consultant had inspected the Vernon Hills restaurant, and more than once told a manager there of numerous safety-risks and deficiencies, documenting the same, there is a wealth of evidence available to prove Chili’s knowledge of these problems.