Thanks to Cara Lynn Shultz at People for going back to this one. She picked the right date. September 9 is not the day people got sick at the Washington County Fair — that had already happened. It is the day the laboratory proved why.
A week in August
The Washington County Fair ran from August 23 to 29, 1999, in Greenwich, New York, northeast of Albany. About 108,000 people came through the gates that week.
On September 3, the New York State Department of Health got reports of at least ten children hospitalized with bloody diarrhea or E. coli O157:H7 infection in counties near Albany. Every one of them had been to the fair. An environmental investigation of the fairgrounds went out the same day. Most of the fair was supplied with chlorinated water. But in at least one area, a shallow well — Well No. 6 — supplied unchlorinated water to several food vendors, who used it to make beverages and ice. The first cultures from that well came back with high levels of coliforms and E. coli. Officials believed a rainstorm on August 26 had washed cow manure into it.
September 9
On September 9, the New York State Public Health Laboratory — the Wadsworth Center — ran five different polymerase chain reaction assays and demonstrated E. coli O157:H7 DNA in water from the well. Wadsworth then isolated the organism itself, from the well and from the water distribution system. Pulsed-field gel electrophoresis showed that the DNA fingerprints from the well, from the distribution system, and from most of the patients were the same.
The epidemiology matched the lab. In a case-control study of 32 case-patients and 84 controls, 26 of 32 cases had consumed water from the suspect well during the last four days of the fair, against 9 of 57 controls — a matched odds ratio of 23.3, with a 95 percent confidence interval of 6.3 to 86.9. When water consumption was controlled for, eating food at the fair and contact with manure were not significantly associated with illness. It was the water. See the CDC’s Public Health Dispatch of September 17, 1999.
What the numbers actually are
The MMWR figures were preliminary and are still the ones most often quoted. As of September 15, 1999: 921 people reported diarrhea after attending the fair; stool cultures yielded O157:H7 from 116, thirteen of them co-infected with Campylobacter jejuni; 32 more yielded Campylobacter alone; 65 people were hospitalized; 11 children developed hemolytic uremic syndrome; and two people died — a three-year-old girl and a 79-year-old man, she of HUS, he of HUS with thrombotic thrombocytopenic purpura. Illness was reported from 14 New York counties and four states.
The count that has held up is 781. CDC’s review of 350 O157 outbreaks from 1982 through 2002 put the Washington County Fair at 781 ill persons, 9 percent hospitalized, HUS in 2 percent, two dead — still the largest waterborne E. coli O157:H7 outbreak reported in the United States. Wadsworth’s own 2003 paper in the Journal of Clinical Microbiology reported O157:H7 isolated from 128 of 775 patients with suspected infection, and C. jejuni from 44.
Larger numbers circulate — 2,800 turns up in a county planning document — but those are estimates of how many people were probably exposed and probably sickened, not counted cases. Use 781 and say what it is.
What the state did next
On September 13, four days after the lab confirmation, the state health commissioner issued an order requiring county fairgrounds to use disinfected water when hosting public events and began reviewing the laws and regulations that applied to fairs. Letters went to schools and day care centers about excluding symptomatic children and handwashing, and to nursing homes and hospitals about employees and residents with diarrhea. That is what a competent public health response looks like. It came two weeks after the fair closed.
And then the fairs kept going
Well No. 6 was capped and the water rule changed. What did not change is that fairs put small children and ruminant animals in the same square acre, and the pathogen does not care whether it arrives by ice cube or by hand. A partial list from the years right after: Medina County, Ohio in 2000; the Wyandot County Fair in Ohio in 2001, with 92 cases; the Lane County Fair in Eugene, Oregon in 2002, at least 82 ill and 22 hospitalized, the largest E. coli outbreak in Oregon history at the time; the Fort Bend County Fair in Texas in 2003, where the rodeo and animal exhibition areas were saturated with O157:H7; the North Carolina State Fair in 2004, with 108 cases; the Cleveland County Fair in North Carolina in 2012, 106 reported ill; and the San Diego County Fair in 2019, where two-year-old Jedidiah King Cabezuela died of HUS after visiting the animal areas. There are dozens more at fair-safety.com.
None of this is a surprise to anyone who has looked. A 2003 study of livestock at 29 county fairs and three large state fairs isolated E. coli O157:H7 from 13.8 percent of beef cattle, 5.9 percent of dairy cattle, 3.6 percent of pigs, 5.2 percent of sheep and 2.8 percent of goats. The prize animals carry it too.
What should be true at every fairgrounds in America
All water used for drinking, ice, beverages and food preparation comes from a disinfected, tested, monitored supply. No shallow, unregulated well serving vendors, ever.
Handwashing stations with soap and running water at the exits of every animal contact area — not hand sanitizer alone, which does not do the job on soiled hands.
No food, drinks, bottles, pacifiers, sippy cups or strollers in animal contact areas.
Signs people can actually read, at the entrance and the exit, and staff whose job it is to enforce them.
A written agreement between the fair board and every animal exhibitor that says, in plain terms, who is responsible for each of the above. When no one has written it down, everyone points at everyone else afterward.
Twenty-seven years. The three-year-old girl who died would be in her thirties now. The eleven children who went into kidney failure are in their thirties and forties, and some of them are still seeing a nephrologist. That is what these anniversaries are actually about.