SANFORD -- Fistfuls of food pellets made Matthew Baldwin popular among the baby goats and sheep in the petting zoo at the N.C. State Fair.
As the critters nudged and licked his hands, the 3-year-old Lee County boy squealed for more pellets. He'd have been happy to spend the whole day feeding the animals, forgoing the rides and fried goodies and midway games: "He loves animals," said his mother, Kellie.
But a 45-minute visit to the petting zoo on an October Sunday may have been all the exposure Matthew needed to pick up the E. coli bacterium, turning the Baldwins' happy afternoon celebrating the state's agricultural heritage into a monthlong medical horror.
A few days after the fair excursion, Matthew doubled over with stomach cramps and bloody diarrhea. He was the first of more than 100 people who apparently got sick from E. coli last month in the days after the State Fair, giving rise to a mystery that has yet to be solved.
Health investigators are still working to pinpoint the source of the bacteria among exhibitors or food vendors who set up on the fairgrounds in Raleigh for the 10-day event.
One of the two petting zoos has emerged as a prime suspect; the bacterium is common in farm animals and spreads to people through exposure to manure.
That makes sense to Kellie Baldwin. "The stroller was covered in poop," she said, noting that the animals milled about freely in the pen with children and their parents.
A genetic strain of the bacterium that infected at least 20 people has been found in soil samples near one of the petting zoos, but health officials said that such evidence is incomplete and may turn out to be misleading. For that reason, they are waiting to finish their investigation before pronouncing a source of the outbreak.
"We are zeroing in on the petting zoo," said Dr. Jeff Engel, state epidemiologist, but he said the investigation hinges on other clues, specifically the actions of thousands of others who went to the fair and came home healthy.
"We want to see if people went to the petting zoo and didn't get [E. coli], or if they had behaviors that protected them," Engel said.
Finding those people to interview is laborious. Between 15 and 20 state health workers, college students and federal officials are calling fairgoers to find three healthy people who match the age of each E. coli victim and ask them where they went during their visit, what they ate, and whether they washed their hands, among other things.
That process may conclude this coming week, Engel said, with a final report naming the source of the outbreak prepared by Christmas, he said.
The petting zoo
Tim and Kellie Baldwin thought they had done everything right on Oct. 17, when they drove up from their home in Sanford to treat Matthew and little Timothy, 19 months, to the fair. Tim Baldwin, a helicopter pilot with the N.C. Highway Patrol, loved taking the boys to the patrol's exhibit of the chopper.
"We went to our exhibit first, but then we went straight to the animals," Tim Baldwin said. "Matthew is infatuated with animals, so we went to every animal exhibit we could find."
At the petting zoo, Timothy stayed in the stroller, but Matthew got out and walked around. The Baldwins loaded up on food pellets three or four times, and some of the goats would beg for food by rearing up and planting their forelegs on people.
"I had that stuff all over the front of my pants," Kellie Baldwin said, referring to the dirt and manure that clung to her from the animals.
As the Baldwins left, they washed their hands using liberal amounts of an anti-bacterial gel available in dispensers near the petting zoo. Kellie Baldwin said the family was fastidious with the gel, and Tim Baldwin even washed the car seats and strollers with bleach when they got home, and steam-cleaned the carpet in the car.
"Everything was just filthy," he said.
Kellie Baldwin said she and the boys returned to the fair that Monday with her mother. The mission that day was to hit the rides, but Matthew also milked a cow, and got manure on himself again.
Everyone rated their annual trip to the fair as top-notch.
Then Tuesday evening, Matthew started complaining of stomach cramps, and by Wednesday, he was throwing up and having diarrhea. Kellie Baldwin picked him up immediately from the baby sitter's and tried to nurse him as best she could with fluids, but he was crying in pain.
"There were some bad boys in my tummy," Matthew said, pointing to the offending area.
The Baldwins figured Matthew had gotten a stomach bug, but as the symptoms lingered, they grew more alarmed. That Saturday, they took him to his pediatrician, who noted that the problems seemed severe. But he suggested the family weather the weekend and said if Matthew didn't get better, they'd perform some tests the next week.
On Monday night, Oct. 25, Matthew became so sick the Baldwins were on the phone numerous times in panicked calls to the doctor. His diarrhea was bloody, he was throwing up blood and he had also developed croup, a respiratory virus that obstructed his breathing.
"He'd be screaming, and then he couldn't breathe to scream," said Tim Baldwin. "I'd take him outside so he could catch his breath."
They checked him into the hospital in Sanford first thing Tuesday morning. The little boy was hooked up to intravenous lines delivering fluids to his dehydrated body, and doctors sent tests off for diagnosis. In the meantime, they decided not to give him antibiotics, which can sometimes backfire in intestinal cases, causing worse illness.
By Wednesday, Matthew seemed a little better, and the family was able to take him home that night. But he stayed frighteningly sick.
Thursday, the lab results explained everything: Matthew was fighting an E. coli infection.
106 cases break out
Across the state, people with similar symptoms and similar experiences were getting the same diagnosis. By Halloween, three cases in Wake County were suspected. Many people, like Matthew, had battled the intestinal symptoms for more than a week, but only got a definitive diagnosis after lab tests came back.
The number of victims grew each day, and almost immediately a petting zoo at the State Fair seemed to be a common thread.
As medical sleuths with the state Division of Public Health intensified their probe, they whittled the disease definition to people who were hit with severe diarrhea between Oct. 15 and Nov. 9. Using that time frame, they ruled out some cases originally suspected of being part of the outbreak. Other cases are still being added. Some cases have been excluded or included on the basis of DNA tests of the bacteria's genetic properties.
So far, 106 cases are believed to be involved in the outbreak, with 50 confirmed as E.coli. More than three-fourths of the victims are children from at least 14 counties, with most victims from Wake. It's the largest outbreak in North Carolina since 2001, when more than 200 people became ill from food exposure in Robeson County.
Armed with the DNA analysis of the bacteria that sickened many of the fair victims, the investigators collected 100 soil samples from every section of the fairgrounds. The strain that infected the largest cluster of people was found in soil near a petting zoo; the area has since been sprayed with disinfectant and is not believed to pose any further risk.
But without corroborating evidence, Engel said, such strong molecular clues do not prove the petting zoo was the ultimate source of the outbreak. People's experiences might lead to another conclusion, he said, which is why the interviews with other fairgoers are taking place.
If the source is found to be the petting zoo, it would fit a pattern.
William D. Marler, a personal injury lawyer in Seattle who specializes in contamination cases, said petting zoos are increasingly being identified as sources of E. coli outbreaks. He said the Centers for Disease Control and Prevention has published suggestions to cut exposure, such as providing hand-washing stations with running water and soap -- an amenity that wasn't offered at the State Fair's petting zoos.
Exhibits that fail to take such measures, Marler said, may carry some legal liability, and four North Carolina families have contacted him.
"I don't think we, as the public and people in positions of authority, have taken this seriously," Marler said. "Maybe five years ago nobody really knew about this, and it was novel. But it's far more than novel at this point. There are dozens of outbreaks that have occurred in petting zoos and fairs.
"We have to get past the thought that we're not going to do anything because fairs are part of Americana. If these were Ferris wheel accidents year in and year out, the public would go crazy."
Thirteen of the North Carolina victims developed a serious complication of E. coli infection called hemolytic-uremic syndrome, in which toxins destroy red blood cells and the kidneys shut down. Four patients remain on dialysis, state health officials said.
After Matthew was diagnosed, the Baldwins were told to watch for any signs that the youngster's kidney function was impaired.
"They told us he could fully recover or he could die, and it would all happen within the next two weeks," Tim Baldwin said -- "and there was nothing they could do for it except monitor it. It was devastating."
On Nov. 1, Matthew had a blood test that showed he was still healthy. He turned 4 the next day, with a family celebration that carried extra emotion. A subsequent kidney test showed continued health, but Matthew still suffers from stomach cramps at least three or four times a day.
The Baldwins are among those who have been in contact with Marler, although Tim Baldwin said he's not sure the family wants to pursue a lawsuit. Marler said he is awaiting the final report from state health investigators to determine if a lawsuit is warranted. The N.C. Attorney General's Office said it has not assessed whether the state has any liability, because no claims have been filed.
For the Baldwins, one thing is certain: They'll never attend the State Fair again.
"It's ruined our experience of the fair," Tim Baldwin said, "for our whole lives."
E. COLI BACTERIA
Harmful E. coli strains attack the body through the intestines. Unless it is treated, toxins can pass into the bloodstream and spread throughout the body. If they collect in the kidneys, they can lead to kidney failure and possible death.
- The bacteria are most often transmitted in undercooked meat, but they can also be transmitted through feces of contaminated livestock - most often cattle - or humans. Infected animals might not display signs of illness.
- About 73,000 cases are reported in the United States each year; about 61 cases prove fatal. North Carolina reported 38 cases in 2003.
- Human symptoms include nausea and bloody diarrhea. Victim might not run a fever.
- Symptoms show up from two to 10 days after exposure; most people fall ill within three to five days.
- The illness is usually resolved withing five to 10 days.
- Best prevention is thorough hand-washing, particularly after using the restroom, changing diapers or before preparing or eating food.
UNIVERSITY OF KENTUCKY CHANDLER MEDICAL CENTER, KNIGHT RIDDER TRIBUNE
E. COLI AT FAIRS
E. coli outbreaks at agricultural fairs have become a growing concern across the nation.
Four years ago, two separate episodes in Pennsylvania and Washington sickened 56 people and put 19 in the hospital. Other outbreaks have occurred in Ohio and Texas. The federal Centers for Disease Control and Prevention has published a paper suggesting ways of curbing the risks.
Among the recommendations:
- Inform the public with signs and posters at petting zoos that E. coli is often carried by farm animals, including cattle, sheep and goats.
- Separate animals from people, and allow petting in a distinct area.
- Prepare, serve and eat foods well away from animal exhibits.
- Keep babies from using pacifiers around animal areas, and adults should avoid smoking.
- Provide hand-washing stations that include running water, soap and disposable towels.
- Where running water is not available," the CDC report states, "hand sanitizers may be better than nothing. However, the CDC makes no recommendation about the use of hand sanitizers because of a lack of independently verified studies of efficacy in this setting."
CENTERS FOR DISEASE CONTROL AND PREVENTION