In August of 2000, the Kindercare facility located on Lexington Drive in Folsom, California, was traced as the source of an E. coli O157:H7 outbreak. Health department officials who investigated the outbreak determined that the probable “index case” – a child who unknowingly brought the bacteria into the facility – experienced “explosive diarrhea at the daycare on the afternoon of 8-3-00.” Shortly thereafter, four other children became infected with E. coli O157:H7 on successive days, the 6th, 7th, 8th and 9th of August, 2000. All of the children were in the same day care group. In addition to the illnesses of the children, the mother of one child, and another child’s sibling became ill and tested positive for E. coli. Another toddler also became ill.

According to the Facility Evaluation Report by the Department of Social Services dated November 7, 2000, “[t]he cause of the [E. coli O157:H7] outbreak [at the Lexington Drive Kindercare] was due to a sponge being used simultaneously for wiping down a changing table and wiping down a table used for serving meals.”

In June of 2002, the Disease Control Section of the Tarrant County Public Health Department (TCPHD) in Fort Worth, Texas, was notified that a 2-year old child had been hospitalized with hemolytic uremic syndrome, or HUS, a complication of E. coli O157:H7 infection. In the following days, TCPHD received several additional reports of E. coli O157:H7 illness, including five culture-positive cases. During its investigation into the outbreak, TCPHD learned that all of the victims were associated with the CCC Alternative Learning Program Daycare in Fort Worth, Texas; 12 children who attended the daycare, one daycare staff member, and one parent of a daycare attendee had all fallen ill with E. coli infections.  TCPDH’s inspection of the daycare revealed “several breaches in food preparation and procedures at the daycare facility.”  In its investigation report, TCPDH noted:

• The daycare had not obtained a city permit to prepare and serve food, but was providing food for the children attending the daycare.
• Appropriate sources of drinking water were not available in the building housing the smaller children; water jugs were filled using the bathroom sink.
• A swimming pool at the facility was in use with murky water prior to chlorination and the daycare had not obtained a city permit.

Perhaps the most important finding during TCPHD’s investigation was that staff, parents and children reported frequently eating portable lunches on the daycare grounds by a pond.  The pond collected run-off from a pasture that held grazing cattle.  TCPDH reported that several samples of pond water confirmed a heavy concentration of E. coli O157:H7.

On May 10, 2004, the Jasper County Health Department (JCHD) received a report from St. Johns Regional Medical Center that two 2-year-old children had been hospitalized with hemolytic uremic syndrome (HUS) at Children’s Mercy Hospital in Kansas City, Missouri.  The children, one boy and one girl, were residents of Carthage Missouri.  Five of the girl’s family members soon developed symptoms of E. coli infection, and one later tested positive for E. coli O157:H7. JCHD began investigating the apparent E. coli outbreak, and learned that the hospitalized girl and one of her siblings attended daycare at Kid’s Korner daycare in Joplin, Missouri. JCHD investigators visited the daycare facility on May 11.  They did not note any major hand washing or diapering violations, and discussed the importance of excluding children with diarrheal illness from the daycare with daycare operators and employees.

On May 24, JCHD was notified that a 4-year-old girl who attended daycare at Kid’s Korner had become ill with symptoms of E. coli infection on May 14 and was being transferred from a Joplin hospital to Children’s Mercy in Kansas City with HUS.  JCHD inspectors returned to Kid’s Korner on May 25, and instructed the daycare to distribute a letter explaining the incidence of E. coli at the daycare and the signs and symptoms of illness to parents.  During this inspection, JCHD investigators noted deficiencies conducive to the spread of disease and instructed Kid’s Korner employees on methods of hygiene and sanitation effective to prevent the further spread of E. coli.

By May 26, JCHD had received two additional reports of illness in children who attended Kid’s Korner.  One of the children had had bloody diarrhea on May 11; the child’s sibling fell ill on May 26 and was later hospitalized with HUS.  Despite their earlier assurances that no children at the daycare had been symptomatic during the month of May, Kid’s Korner then produced a list of nine children who had exhibited symptoms of E. coli infection to JCHD investigators.

On May 27, JCHD inspectors returned to the daycare center and noted handwashing lapses.  They also learned that Kid’s Korner had failed to distribute the May 25 letter regarding possible E. coli exposure and symptoms to 32 percent of the families with children in attendance at Kid’s Korner.