The popular Peppa's Korean BBQ on South King Street was shut down yesterday by the state Department of Health after seven people were diagnosed with E. coli poisoning last month, four of them requiring hospitalization.

Health officials said the department confirmed that at least four of the seven actually ate at the Ke'eaumoku-area fast-food establishment between March 2 and March 23, when the bacterial infections occurred.

Peppa's Korean BBQ locations on Wilder Avenue in Makiki and at Manoa Marketplace were not affected and remain open.

The outbreak of the bacterial strain known as E. coli 0157:H7 is believed to be the most severe of its kind in Hawai'i in recent years.

The only other time a local restaurant was shut down due to E. coli infections occurred in 2008 when Sekiya's Restaurant and Delicatessen in Kaimukī was closed for several weeks when seven people came down with severe diarrhea after eating there.

"We don't often get clusters of cases like this," said Health Department spokeswoman Janice Okubo.

Three of those hospitalized by last month's outbreak have since been released but one is in serious condition, according to Okubo. That person is elderly and, therefore, more susceptible to serious complications, she said.

VIOLATIONS NOTED

After it was confirmed that some of those sickened by E. coli 0157:H7 had eaten at Peppa's, state Sanitation Branch inspectors were dispatched to the restaurant, where they observed food-handling violations, Okubo said.

Those violations, coupled with confirmation of the Peppa's connection, caused inspectors to issue a "notice of permit suspension" and a cease-and-desist order against the restaurant at about 10 a.m. yesterday, Okubo said.

The owner, identified as Chong Hon Kim, agreed voluntarily to shut down, she said.

Phone calls to Peppa's yesterday were not returned. People working inside the 1240 South King St. establishment yesterday afternoon would not comment.

Like other typical Korean takeout restaurants in Hawai'i, Peppa's allows customers purchasing a plate lunch to pick from an assortment of pickled vegetables and other side dishes placed in cafeteria-style serving trays behind a glass counter. Those dishes are usually cooked.

Okubo said the department last gave the restaurant a routine inspection in January.

The restaurant won't reopen until it undergoes an intensive mitigation plan to correct permit violations, according to the Health Department. In addition, restaurant managers must attend a Sanitation Branch food safety certification workshop to learn about property food-handling practices.

"We do have evidence that there might be some cause to link Peppa's, but we haven't really identified the definite source of the illness," Okubo said. "So we can't say that that restaurant was the exact cause of all these illnesses. It may be that, for example, they might have a product that they purchased that maybe they're using, and that might be the cause. We're still trying to pin that down.

"And in these investigations, unfortunately, sometimes we're never able to pin down an exact source. But we just have to go by our findings and ... try to figure out a way to stop any other illness from occurring."

In the case of Sekiya's, the restaurant reopened only after it had dumped all its food stock, disinfected the premises and had employees undergo training for proper food preparation.

PROBE ONGOING

Okubo said the investigation into the Peppa's Korean BBQ outbreak is ongoing. On Tuesday, O'ahu physicians were sent a medical alert asking them to watch for additional cases and to order E. coli O157:H7 laboratory testing for patients with severe or bloody diarrhea.

The number of E. coli cases in Hawai'i can vary widely from year to year, but averaged 19 annually during the 10-year period from 1999 to 2008. Data for 2009 and 2010 were not immediately available.

Most strains of E. coli bacteria are harmless, but some, including E. coli 0157:H7 can sicken people by making a toxin called Shiga toxin.

According to the U.S. Centers for Disease Control and Prevention, infections start when people get tiny — usually invisible — amounts of human or animal feces in their mouth from contaminated food or eating food prepared by people who did not wash their hands well after using the toilet.

The incubation period is usually three to four days after exposure, with symptoms often beginning slowly with mild belly pain or non-bloody diarrhea that worsens over several days.

Other symptoms include severe stomach cramps, diarrhea (often bloody) and vomiting. The CDC said most people get better within five to seven days, but 5 percent to 10 percent of those diagnosed with E. coli 0157:H7 infection develop a potentially life-threatening complication known as hemolytic uremic syndrome, which is signaled by decreased frequency of urination, fatigue, and losing pink color in cheeks and inside the lower eyelids.