The connections between the death of a 2-year-old boy and the violent illness suffered by three other children earlier this month weren’t at first apparent.
But on Friday, June 28, public health officials zeroed in on the common denominator: all four tested positive for E.coli bacteria and all four had visited animals at the San Diego County Fair.
The discovery prompted the closure of all animal exhibits Saturday, June 29, a safety measure that will remain in effect through the remainder of the fair’s 2019 run set to end July 4.
While the cluster of cases has not yet been definitively linked to fair animals, in part because testing is not yet complete, the decision to shut down the public livestock exhibits, including the popular petting zoo, seemed prudent.
The livestock auction, which took place in a different area and does not allow the public to have direct contact with animals, went forward as scheduled Saturday, June 29.
“We have taken this step to restrict access to animals at the fair in an abundance of caution,” Dr. Eric McDonald, a county public health official, said at a news conference Saturday, June 29. “We may find, as the investigation develops, as we develop genetic fingerprints of these organisms, that these cases are not related, that these just happened to be cases that occurred during the summer when it’s more common for these types of cases to occur.”
Jedidiah King Cabezuela, 2, visited the Del Mar Fairgrounds on June 15, became ill on June 19, and died on June 24.
McDonald said the boy suffered from a complication called hemolytic uremic syndrome which affects about one in 10 of those with E.Coli infections. The dangerous complication occurs when infection causes damage and inflammation in the kidneys, causing clots to form that can lead to organ failure. Though the syndrome can happen to anyone, it’s more common in young children.
The parents took their ill son to a hospital where he was treated and sent home on June 20, said Ed Sandford of Bonita, whose wife is related to Jedidiah’s mother. Later that day they took him to Rady Children’s Hospital.
“He was in a lot of pain and discomfort, crying,” Sandford said of the toddler. “He’s ‘upstairs’ now. I told the Lord ‘You’ve got your hands full now.’”
The boy’s unusual name is an expression of the couple’s Christian faith, Sandford said. King refers to Christ the King, Sandford said, and Jedidiah is an Old Testament name meaning “beloved of Jehovah.”
He said Rebecca Cabezuela has an older son, about 11 years old.
On Saturday afternoon, friends, family and supporters of the boy’s parents gathered at Rosie O’Gradys in Normal Heights to raise money with raffles and a dinner buffet. Family members of Jedidiah’s mother own the restaurant that operates inside the bar.
More than $17,000 has been raised on a GoFundMe page, where the boy called “Jedi” was remembered for his energy, smiles and silliness.
Sandford said the grieving couple were too distraught to appear at the fundraiser.
“All this happened overnight,” said Mark “Harpo” Delguidice, a local musician who acted as emcee to announce raffle numbers. “It’s overwhelming, all the donations coming in — gift certificates, an expensive bike, a DVD of my band. Every business on the street has donated, to express our caring and help this family through their grief.”
Authorities on Saturday, June 29, provided additional details about the other children who were sickened:
A 13-year-old girl who visited the fair on June 8 and had symptoms appear June 10;
An 11-year-old girl also present on June 8 with symptoms showing on June 12;
A 9-year-old boy who visited on June 13 and started showing symptoms on June 16.
The county’s recommendation to shut down the animal exhibits, including its sprawling livestock exhibits which fill row after row of barns, came Friday, June 28, nearly four days after the boy’s death. With symptoms showing up from June 10 through June 16, some have questioned why the action was not taken sooner.
McDonald explained that determining the sources of outbreaks don’t often happen quickly.
It takes time for symptoms to turn into doctor’s visits and for those visits to result in testing to indicate that E.Coli is or may be present. It’s only after the public health department is notified of possible infections that public health nurses can begin interviewing subjects and their families, gathering enough facts to determine whether people with similar conditions visited the same places, ate the same food or share some other critical commonality, said McDonald, medical director of the public health department’s Epidemiology and Immunization Services.
“It really did not come together as a picture until late yesterday (June 28),” McDonald said, adding that, in one case, it was only after a third interview that public health investigators learned that one of the four had indeed visited the animal areas of the fair.
Investigators have begun to rule out food poisoning.
McDonald and Dr. Wilma Wooten, the county’s public health officer, confirmed Saturday, June 29, that a full list of everything eaten by all four children was obtained and informed the basis of a food investigation by environmental health inspectors Friday, June 28.
“We had a detailed list of all of the foods that were consumed by all four of these patients, and our colleagues and environmental health looked at the food preparations for every single place where a food item was reported to us,” McDonald said. “There were no deficiencies found in any of those locations.”
Environmental health inspectors, he added, make daily rounds of fair food vendors to make sure that they’re following safety recommendations.
The E.Coli bacteria is best killed by hand washing with soap and water, and fair officials repeatedly advised attendees to wash their hands before indulging in the fair’s gauntlet of food booths.
Fairgrounds chief executive Tim Fennell, himself battling a cold, said that he has every confidence that fairgoers will be safe attending the remainder of the events. Fennell said his 18-month-old grandson would be attending Saturday, just as scheduled.
“I’m very confident that the fair is safe and secure, and we’re doing everything in our effort to cooperate with the health department,” Fennell said.
Two of the four cases in which E.Coli infection has been confirmed are of the O157 type responsible for causing a wide range of food-based outbreaks in recent years.
About 40 percent of the estimated 265,000 U.S. E.coli cases each year are of the O157 strain, which is known for its ability to cause severe kidney damage, especially in children.
Though fair-related E.coli deaths are rare, they’re not unheard of. In 2016, a two-year-old Indiana boy died of a similar infection after visiting the petting zoo at the Indiana State Fair, though investigators were unable to definitively link the outcome to animal exposure. In 2015, a 20-month-old boy died of an E.Coli infection after visiting a fair petting zoo in Maine. In 2013 the family of a 2-year-old boy sued a county fair after he died following a petting zoo visit in North Carolina.
Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said there is robust evidence that animal encounters in petting zoos and county fairs are a growing source of E.coli infection.
The big challenge, he noted, is that animals are the object of so much human affection. What may seem to be an innocuous hug around the neck of a young calf or goat can put people into direct contact with portions of an animal that have been reclining in areas where animal droppings are present.
“For sure, cases like the one in San Diego are tragic reminders of the importance of hand washing but also of the shared responsibility that petting zoos and parents share,” he said.
To prevent against infection at petting zoos, researchers recommend regular sanitation of animal cages and hand-washing stations nearby staffed with attendants to encourage visitors to comply. A fair official said such steps were in place on all of the dates when the four children visited.
Osterholm said that parents don’t necessarily need to run away from petting zoos, but caution is extremely important. That means making sure that kids and adults who are petting animals are not subsequently touching their faces or putting their hands in their mouths until their hands are washed.
“I don’t think they need to run away or avoid, but I do think they need to be vigilant when they’re in these situations,” Osterholm said.
Fairgoers were generally understanding of public health officials’ decision to close the animal barns and petting zoo.
Kathy Jugo, a dog trainer from Chula Vista who was outside the closed exhibit hall with her family early in the afternoon, said she looked forward to going next year.
“This doesn’t stop me from going in the future,” she said. “It just brings more attention and more awareness to the importance of washing your hands.”
Jugo said even if the parents of the deceased toddler made sure he washed his hands after exiting the petting zoo, the boy could have been infected by simply touching his face before he left the barn.
“Maybe that’s the education that needs to get out,” she said. “You need to use sanitizer every time you touch the animals”
All four local cases are expected of being a type of E.coli bacteria that produces shiga toxin, a substance that can cause more severe symptoms. These infections — known as STEC — cause severe abdominal cramps, watery or bloody diarrhea and vomiting with or without a fever.
When fever is present, it is usually in the 101-degree range. The incubation period for the bacteria is between one and 10 days with most cases declaring themselves in somewhere between two and four days.
Anyone who has experienced these symptoms since June 8 — especially those with diarrhea that lasts for more than three days, bloody stool, a fever higher than 102 or so much vomiting that they cannot keep liquids down — is urged to seek medical attention.
--Paul Sisson and Pauline Repard are reporters for The San Diego Union Tribune