County Fair Chocolate Scare Case Study - Colorado Integrated Food Safety Center for Excellence

County Fair Chocolate Scare
Case Study
Colorado Integrated Food Safety
Center for Excellence - 2017
County Fair Chocolate Scare Case
Denver, Colorado
Summary: 
the case study is based on a
foodborne illness outbreak caused by the
unintentional ingestion of marijuana-infused
foods (edibles) at a county fair in Colorado.
Case study designed to facilitate a discussion
among disease investigators, epidemiologists,
medical staff and other public health
professionals about how to respond to an
outbreak involving a marijuana-infused food.
Objectives
After completing this case study, participants
should be able to:
Give an example of an unintentional marijuana
exposure
Name agencies that may be involved in an
unintentional marijuana exposure investigation
List available resources that address marijuana
exposure
Formulate interview questions for an
unintentional marijuana exposure investigation.
Objectives (cont.)
Establish a case definition for marijuana
exposure.
List special considerations that should be
made during an environmental assessment of
a marijuana facility.
Recommend control measures to prevent
unintentional marijuana exposure in the
future.
Denver County Fair
Dates:
 Weekend of: August 1 – August 3
Attendees: ~ 20,000 people
Featured:
Themed vendor pavilions highlighting selected businesses
The Pot Pavilion
For 21 years and older
Housed 44 vendors
Vendors were ONLY allowed to talk
Vendors could NOT display, sell or consume any marijuana or
infused products.
Products were defined as: marijuana flower (bud, grass),
concentrates (hash oil, shatter), and infused foods and drinks.
Initial Complaint
Call came in on Tuesday August 5
th
 to Public Health
Male attended fair on Sunday August 3
Symptoms:
anxious and “weird”
Tightness of chest, heavy head & body, dry mouth and
intense nausea
Symptoms began one hour after consumption of
chocolate bar (LoveALL booth @ Pot Pavilion)
Consumed only ¼ of bar due to an “off taste”
Wife did not consume bar and felt fine
Recovered by next day
Also Complained to the Vendor
The man called the vendor to assure him that
the chocolate bar did not contain marijuana
Wanted to document the official complaint
since started new job the next week
New job required drug test
Question #1
Question 1
: What other agencies might you
involve or consult after receiving this initial
complaint?
PLEASE WRITE DOWN RESOURCE IDEA(S)
ON POST-IT NOTE
Complaint #2
On Monday, August 4
th 
Denver Public Health contacted the Marijuana
Enforcement Division (MED) Colorado Department of
Revenue
MED received a similar complaint from a man
reporting nausea, loss of coordination, and dizziness
after consuming samples from a vendor at the Pot
Pavilion
The man reported using marijuana in the past and
stated the chocolate bars got him “high”
previously had NOT experienced nausea or disorientation
from marijuana use.
More Complaints…
MED contacted the Denver County Fair coordinator,
Four individuals reporting symptoms after attending the
Pot Pavilion.
The coordinator provided contact information for the
additional persons.
The MED, with the Denver Police Department, had
already launched a criminal investigation.
PH was left to determine whether to initiate a PH
investigation
PH contact Environmental Health (who inspect
marijuana facilities) to discuss the situation.
Question #2
Question 2
: Would you investigate this incident
further as a foodborne outbreak?
The Investigation Begins
After consulting with the State Health
Department and the Centers for Disease
Control and Prevention (CDC)
considers unintentional ingestion of a marijuana-
infused food a reportable foodborne illness,
Denver PH and EH decided to initiate an
outbreak investigation to determine the
source of contamination
Question #3
Question 3
: What resources would you use to
find additional information on marijuana-
infused foods?
PLEASE WRITE DOWN RESOURCE IDEA(S)
ON POST-IT NOTE
Question #3
Question 3
: What resources would you use to find
additional information on marijuana-infused foods?
California Bureau of Cannabis Control
http://bcc.ca.gov/
California Poison Control System (UCSF/SFGH)
https://calpoison.org
CDPH – Center for Environmental Health
Division of Food, Drug and Cannabis Safety
https://www.cdph.ca.gov/Programs/CEH/DFDCS/Pages/DF
DCS.aspx
CDPH
Division of Food, Drug & Cannabis Safety
Marijuana / THC 101
Tetrahydrocannabinol (THC) is the primary
active ingredient in marijuana-infused foods
(edibles).
In Colorado,
the maximum serving size for retail, marijuana-
infused foods is 10mg of active THC
single serving sizes must be clearly marked.
A retail product cannot contain more than 100mg
THC total.
Common Effects of Marijuana
Include:
a happy, relaxed, or
“high” feeling
slower reactions and
hand/eye coordination
distorted perceptions
of time and distance
difficulty thinking,
learning, and
remembering
anxiety, panic, or
paranoia
increased heart rate
increased blood
pressure
decreased interest in
normal activities
increased appetite
dry mouth
red eyes
Symptoms of Overconsumption
Include:
extreme confusion, anxiety, panic, or paranoia
hallucinations or delusions
increased blood pressure
severe nausea and vomiting
psychosis
suicidal ideations
Marijuana Consumption
Marijuana is eaten, effects typically take longer to
start (up to 4 hours) and last longer (4-10 hours)
than smoked or inhaled marijuana.
Marijuana-infused foods are absorbed by:
 gastrointestinal uptake (digested through the
stomach),
oral uptake (digested through saliva), or
a hybrid of gastrointestinal and oral uptake.
Time to onset and duration of effects depend on
method of absorption, dose, and individual
factors, such as prior marijuana use.
Absorption of Marijuana-Infused
Foods
Time to onset and duration of effects depend
on method of absorption, dose, and individual
factors, such as prior marijuana use.
Question #4
Question 4
: What questions would you ask
during these initial case interviews?
PLEASE WRITE DOWN QUESTION(S)
ON POST-IT NOTE
Public Health Line List
On August 3
rd
, all four cases reporting
consuming samples at the LoveAll booth in
the Pot Pavilion
How to Create a Case Definition
Question #5
Person
Place
Time
Clinical Features
How to Create a Case Definition
Question #5
Person
 (age, sex, race, occupation, etc.)
Place
 (specific geographic location or facility)
Time
 (period of time associated with illness
onset for cases under investigation)
Clinical Features 
(signs, symptoms and
laboratory tests)
How to Create a Case Definition
Question 5
: Based on the information provided
so far, establish a case definition for this
outbreak…
Case Definition (Working)
Anyone who attended the Pot Pavilion at the
Denver County Fair on August 3
rd
;
AND
Subsequently had two or more of the following
symptoms: nausea, vomiting, disorientation,
dizziness, anxiety, hallucinations, stomach ache,
dry mouth, numbness/tingling in extremities,
confusion, dyspnea, sweating, fainting, chest
tightness, loss of coordination, panic, paranoia,
difficulty in speaking, or memory loss.
Question #6
Question 6: 
How would you find additional
cases?
Any ideas for enhanced reporting and
surveillance
PLEASE WRITE DOWN IDEA(S)
ON POST-IT NOTE
Question #6
Question 6: 
How would you find additional cases?
Ask cases know other individuals who attended the
event and became ill
Contact local hospitals, ER, and urgent cares
Contact other local jurisdictions for similar complaints
Ask vendors if they received any complaints
Ask vendors if they collected contact information on
patrons
Ask fair coordinator for list of patrons
Media
Situation Status Update
On August 12th, a health department in a
nearby county notified Denver Public Health
of 5 additional cases
three adults
two children
Denver Police Department reported one
additional case to Denver Public Health on
August 14
th
NEW total case count: 10 cases.
Epidemiologic Studies
Question # 7
Common Epidemiology Study –
Foodborne Illness Outbreaks
Common Epidemiology Study –
Foodborne Illness Outbreaks
Question #7
Question 7: 
What type of epidemiologic study
would you conduct to investigate this outbreak?
Question #7
Question 7: 
What type of epidemiologic study would you
conduct to investigate this outbreak?
Both Study Designs Work Here
BUT
Case-Control would be the BEST
Compare
fairgoers with illness (cases)
to
Sample of fairgoers without the illness (controls)
Measure of Association
Assess the strength of an association between
an exposure and the outcome of interest
Indicate how more or less likely one is to
develop disease as compared to another
Two widely used measures:
Relative Risk 
(RR, or risk ratio)
Odds Ratio 
(OR)
Measure of Association
Relative Risk
 (Cohort Study)
The risk of disease in the exposed group divide by
the risk of disease in the non-exposed group
Odds Ratio 
(Case-Control Study)
The risk of disease cannot be directly calculated
because the population at risk is not known
Interpretation of Measures
Both the RR and the OR are interpreted as
follows:
=1 - indicates no association
>1 - indicates a positive association
<1 - indicates a negative association
Interpretation of Measures
If the RR = 5
People who were exposed are 
5X
 more likely to have
the outcome then compared with persons who were
not exposed
If the RR = 0.5
People who were exposed are 
half
 as likely to have
the outcome then compared with persons who were
not exposed
If the RR = 1
People who were exposed are 
no more or less 
likely
to have the outcome then compared with persons
who were not exposed
Tests of Significance
Indication of reliability of the association that
was observed
Answers the question:
How likely is it that the observed association may
be due to chance?
Two main tests:
95% Confidence Intervals (CI)
p-values
95% Confidence Interval (CI)
The 95% CI is the range of values of the
measure of association (RR or OR) that has a
95% chance of containing the true RR or OR
One is 95% 
“confident” 
that the true measure
of association falls within this interval
Interpreting
95% Confidence Interval (CI)
To have a significant association between
exposure and outcome, the 95% CI 
should not
include 1.0
A 95% CI range below 1 suggest less risk of the
outcome in the exposed population
A 95% CI range above 1 suggests a higher risk of
the outcome in the exposed population
Case-Control Study Results
Case-Control Study Results (cont.)
Environmental Assessment
Environmental assessment is to conduct a
systematic, detailed, science-based evaluation
of environmental factors that contributed to
the transmission of illness in an outbreak. 
 
Question #8
Question 8: 
What special considerations should
be made during an environmental assessment of
a marijuana facility?
PLEASE WRITE DOWN CONSIDERATION (S)
ON POST-IT NOTE
Environmental Assessment 101
An assessment should include:
interviewing workers and managers,
sampling,
making observations,
reviewing records,
identifying contributing factors and
environmental antecedents, and
implementing control measures 
 
Joint Facility Investigation
EH was joined by MED as a criminal
investigation was ongoing during the
assessment
Employees could not be interviewed by EH staff
because of ongoing criminal investigation.
Outbreak Conclusion
MED and Police Department reviewed video
of surveillance of the facility from July 29 to
August 3
rd
No post-production tampering or comingling of
THC and non-THC chocolates
Police Department did not share findings with PH
Question #9
Question 9: 
Discuss control measures and
future recommendations to prevent
unintentional ingestion of marijuana-infused
foods.
PLEASE WRITE DOWN CONTROL
MEASURE (S)
ON POST-IT NOTE
Discussion
IMPORTANT NOTE:
People assume that a product infused with
marijuana would give off an odor or flavor
similar to marijuana.
However, as demonstrated by this investigation,
this was not the case
The initial complaint case only stated the
product has an off-taste and no cases
reported an odor
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Based in Denver, Colorado, this case study discusses a foodborne illness outbreak at a county fair due to unintentional marijuana-infused food consumption. The study aims to prompt discussions among health professionals on responding to such outbreaks, outlining objectives like identifying unintentional marijuana exposure and formulating investigation questions. The scenario involves an attendee experiencing symptoms after consuming a chocolate bar at the fair's Pot Pavilion, leading to an investigation into the incident. Recommendations for preventing future incidents are also highlighted.


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  1. County Fair Chocolate Scare Case Study Colorado Integrated Food Safety Center for Excellence - 2017

  2. County Fair Chocolate Scare Case Denver, Colorado Summary: the case study is based on a foodborne illness outbreak caused by the unintentional ingestion of marijuana-infused foods (edibles) at a county fair in Colorado. Case study designed to facilitate a discussion among disease investigators, epidemiologists, medical staff and other public health professionals about how to respond to an outbreak involving a marijuana-infused food.

  3. Objectives After completing this case study, participants should be able to: Give an example of an unintentional marijuana exposure Name agencies that may be involved in an unintentional marijuana exposure investigation List available resources that address marijuana exposure Formulate interview questions for an unintentional marijuana exposure investigation.

  4. Objectives (cont.) Establish a case definition for marijuana exposure. List special considerations that should be made during an environmental assessment of a marijuana facility. Recommend control measures to prevent unintentional marijuana exposure in the future.

  5. Denver County Fair Dates: Weekend of: August 1 August 3 Attendees: ~ 20,000 people Featured: Themed vendor pavilions highlighting selected businesses The Pot Pavilion For 21 years and older Housed 44 vendors Vendors were ONLY allowed to talk Vendors could NOT display, sell or consume any marijuana or infused products. Products were defined as: marijuana flower (bud, grass), concentrates (hash oil, shatter), and infused foods and drinks.

  6. Initial Complaint Call came in on Tuesday August 5thto Public Health Male attended fair on Sunday August 3 Symptoms: anxious and weird Tightness of chest, heavy head & body, dry mouth and intense nausea Symptoms began one hour after consumption of chocolate bar (LoveALL booth @ Pot Pavilion) Consumed only of bar due to an off taste Wife did not consume bar and felt fine Recovered by next day

  7. Also Complained to the Vendor The man called the vendor to assure him that the chocolate bar did not contain marijuana Wanted to document the official complaint since started new job the next week New job required drug test

  8. Question #1 Question 1: What other agencies might you involve or consult after receiving this initial complaint? PLEASE WRITE DOWN RESOURCE IDEA(S) ON POST-IT NOTE

  9. Complaint #2 On Monday, August 4th Denver Public Health contacted the Marijuana Enforcement Division (MED) Colorado Department of Revenue MED received a similar complaint from a man reporting nausea, loss of coordination, and dizziness after consuming samples from a vendor at the Pot Pavilion The man reported using marijuana in the past and stated the chocolate bars got him high previously had NOT experienced nausea or disorientation from marijuana use.

  10. More Complaints MED contacted the Denver County Fair coordinator, Four individuals reporting symptoms after attending the Pot Pavilion. The coordinator provided contact information for the additional persons. The MED, with the Denver Police Department, had already launched a criminal investigation. PH was left to determine whether to initiate a PH investigation PH contact Environmental Health (who inspect marijuana facilities) to discuss the situation.

  11. Question #2 Question 2: Would you investigate this incident further as a foodborne outbreak?

  12. The Investigation Begins After consulting with the State Health Department and the Centers for Disease Control and Prevention (CDC) considers unintentional ingestion of a marijuana- infused food a reportable foodborne illness, Denver PH and EH decided to initiate an outbreak investigation to determine the source of contamination

  13. Question #3 Question 3: What resources would you use to find additional information on marijuana- infused foods? PLEASE WRITE DOWN RESOURCE IDEA(S) ON POST-IT NOTE

  14. Question #3 Question 3: What resources would you use to find additional information on marijuana-infused foods? California Bureau of Cannabis Control http://bcc.ca.gov/ California Poison Control System (UCSF/SFGH) https://calpoison.org CDPH Center for Environmental Health Division of Food, Drug and Cannabis Safety https://www.cdph.ca.gov/Programs/CEH/DFDCS/Pages/DF DCS.aspx

  15. CDPH Division of Food, Drug & Cannabis Safety

  16. Marijuana / THC 101 Tetrahydrocannabinol (THC) is the primary active ingredient in marijuana-infused foods (edibles). In Colorado, the maximum serving size for retail, marijuana- infused foods is 10mg of active THC single serving sizes must be clearly marked. A retail product cannot contain more than 100mg THC total.

  17. Common Effects of Marijuana anxiety, panic, or paranoia increased heart rate increased blood pressure decreased interest in normal activities increased appetite dry mouth red eyes Include: a happy, relaxed, or high feeling slower reactions and hand/eye coordination distorted perceptions of time and distance difficulty thinking, learning, and remembering

  18. Symptoms of Overconsumption Include: extreme confusion, anxiety, panic, or paranoia hallucinations or delusions increased blood pressure severe nausea and vomiting psychosis suicidal ideations

  19. Marijuana Consumption Marijuana is eaten, effects typically take longer to start (up to 4 hours) and last longer (4-10 hours) than smoked or inhaled marijuana. Marijuana-infused foods are absorbed by: gastrointestinal uptake (digested through the stomach), oral uptake (digested through saliva), or a hybrid of gastrointestinal and oral uptake. Time to onset and duration of effects depend on method of absorption, dose, and individual factors, such as prior marijuana use.

  20. Absorption of Marijuana-Infused Foods Time to onset and duration of effects depend on method of absorption, dose, and individual factors, such as prior marijuana use.

  21. Question #4 Question 4: What questions would you ask during these initial case interviews? PLEASE WRITE DOWN QUESTION(S) ON POST-IT NOTE

  22. Public Health Line List On August 3rd, all four cases reporting consuming samples at the LoveAll booth in the Pot Pavilion

  23. How to Create a Case Definition Question #5 Person Place Time Clinical Features

  24. How to Create a Case Definition Question #5 Person (age, sex, race, occupation, etc.) Place (specific geographic location or facility) Time (period of time associated with illness onset for cases under investigation) Clinical Features (signs, symptoms and laboratory tests)

  25. How to Create a Case Definition Question 5: Based on the information provided so far, establish a case definition for this outbreak

  26. Case Definition (Working) Anyone who attended the Pot Pavilion at the Denver County Fair on August 3rd; AND Subsequently had two or more of the following symptoms: nausea, vomiting, disorientation, dizziness, anxiety, hallucinations, stomach ache, dry mouth, numbness/tingling in extremities, confusion, dyspnea, sweating, fainting, chest tightness, loss of coordination, panic, paranoia, difficulty in speaking, or memory loss.

  27. Question #6 Question 6: How would you find additional cases? Any ideas for enhanced reporting and surveillance PLEASE WRITE DOWN IDEA(S) ON POST-IT NOTE

  28. Question #6 Question 6: How would you find additional cases? Ask cases know other individuals who attended the event and became ill Contact local hospitals, ER, and urgent cares Contact other local jurisdictions for similar complaints Ask vendors if they received any complaints Ask vendors if they collected contact information on patrons Ask fair coordinator for list of patrons Media

  29. Situation Status Update On August 12th, a health department in a nearby county notified Denver Public Health of 5 additional cases three adults two children Denver Police Department reported one additional case to Denver Public Health on August 14th NEW total case count: 10 cases.

  30. Epidemiologic Studies Question # 7

  31. Common Epidemiology Study Foodborne Illness Outbreaks COHORT Well-defined group of individuals - Members are easily identifiable - Members are easily accessible Exposure is rare There may be multiple diseases involved CASE-CONTROL Disease or outcome of interest is rare, or The group is not well-defined - Identifying entire cohort would be too costly or time consuming - Accessing entire cohort would be too costly or time consuming Preferred Study Design When Measure of Association Study compares the incidence of disease in exposed persons and unexposed persons Relative Risk (RR) Study compare the odds of exposure between the ill (cases) and the not ill (contacts) Odds Ratio (OR)

  32. Common Epidemiology Study Foodborne Illness Outbreaks COHORT CASE-CONTROL Study population is grouped by exposure status Study population grouped by outcome Study Group Exposed persons Persons with illness (cases) Comparison Group Unexposed persons Persons without illness (controls) Examples Determine if the coleslaw was the cause of a foodborne outbreak Determine an association between salmonella infection and eating at a fast food restaurant

  33. Question #7 Question 7: What type of epidemiologic study would you conduct to investigate this outbreak?

  34. Question #7 Question 7: What type of epidemiologic study would you conduct to investigate this outbreak? Both Study Designs Work Here BUT Case-Control would be the BEST Compare fairgoers with illness (cases) to Sample of fairgoers without the illness (controls)

  35. Measure of Association Assess the strength of an association between an exposure and the outcome of interest Indicate how more or less likely one is to develop disease as compared to another Two widely used measures: Relative Risk (RR, or risk ratio) Odds Ratio (OR)

  36. Measure of Association Relative Risk (Cohort Study) The risk of disease in the exposed group divide by the risk of disease in the non-exposed group Odds Ratio (Case-Control Study) The risk of disease cannot be directly calculated because the population at risk is not known

  37. Interpretation of Measures Both the RR and the OR are interpreted as follows: =1 - indicates no association >1 - indicates a positive association <1 - indicates a negative association

  38. Interpretation of Measures If the RR = 5 People who were exposed are 5X more likely to have the outcome then compared with persons who were not exposed If the RR = 0.5 People who were exposed are half as likely to have the outcome then compared with persons who were not exposed If the RR = 1 People who were exposed are no more or less likely to have the outcome then compared with persons who were not exposed

  39. Tests of Significance Indication of reliability of the association that was observed Answers the question: How likely is it that the observed association may be due to chance? Two main tests: 95% Confidence Intervals (CI) p-values

  40. 95% Confidence Interval (CI) The 95% CI is the range of values of the measure of association (RR or OR) that has a 95% chance of containing the true RR or OR One is 95% confident that the true measure of association falls within this interval

  41. Interpreting 95% Confidence Interval (CI) To have a significant association between exposure and outcome, the 95% CI should not include 1.0 A 95% CI range below 1 suggest less risk of the outcome in the exposed population A 95% CI range above 1 suggests a higher risk of the outcome in the exposed population

  42. Case-Control Study Results

  43. Case-Control Study Results (cont.)

  44. Environmental Assessment Environmental assessment is to conduct a systematic, detailed, science-based evaluation of environmental factors that contributed to the transmission of illness in an outbreak.

  45. Question #8 Question 8: What special considerations should be made during an environmental assessment of a marijuana facility? PLEASE WRITE DOWN CONSIDERATION (S) ON POST-IT NOTE

  46. Environmental Assessment 101 An assessment should include: interviewing workers and managers, sampling, making observations, reviewing records, identifying contributing factors and environmental antecedents, and implementing control measures

  47. Joint Facility Investigation EH was joined by MED as a criminal investigation was ongoing during the assessment Employees could not be interviewed by EH staff because of ongoing criminal investigation.

  48. Outbreak Conclusion MED and Police Department reviewed video of surveillance of the facility from July 29 to August 3rd No post-production tampering or comingling of THC and non-THC chocolates Police Department did not share findings with PH

  49. Question #9 Question 9: Discuss control measures and future recommendations to prevent unintentional ingestion of marijuana-infused foods. PLEASE WRITE DOWN CONTROL MEASURE (S) ON POST-IT NOTE

  50. Discussion IMPORTANT NOTE: People assume that a product infused with marijuana would give off an odor or flavor similar to marijuana. However, as demonstrated by this investigation, this was not the case The initial complaint case only stated the product has an off-taste and no cases reported an odor

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