Foodborne Disease Outbreak Investigation Team Training:

1. Foodborne Disease Outbreak Investigation Team Training: Module 1 – Foodborne Diseases and Outbreaks

2. Module Learning Objectives At the end of this module, you will be able to • Describe what is meant by “foodborne disease.” • List examples of common foodborne disease causative agents. • Define the terms “outbreak” and “cluster.” • List the goals of a foodborne disease outbreak investigation. • Describe the desirable knowledge and skills included on a foodborne outbreak investigation team.

3. BREAKING NEWS • Students and teachers rushed to hospital • Nausea, vomiting, stomach pain, and dizziness after lunch at school cafeteria • Health department team dispatched to school and hospital to investigate

4. Group Discussion • Divide into groups by table. • Briefly introduce yourself to others at your table. • Re-read the news report at end of module and answer these questions. • Do you think the illnesses are foodborne? • Do you think the illnesses represent an outbreak? • If this is a foodborne outbreak, who would you involve in the investigation? Be prepared to share your thoughts with the class. Time limit: 5 minutes

5. Foodborne Disease • Illness caused by ingestion of contaminated food • Symptoms often affecting stomach or intestinal tract including • Nausea and vomiting • Diarrhea • Abdominal pain • Sometimes nonspecific symptoms and symptoms outside GI tract, depending on agent • Young children, pregnant women, elderly, and immunocompromised persons at greatest risk for severe illness

6. Foodborne Disease • An estimated 1 in 6 people suffers from foodborne illness each year in the United States leading to an estimated • 48 million illnesses • 128,000 hospitalizations • 3,000 deaths • More than 1,000 outbreaks detected annually • $35 billion in medical costs, lost productivity, illness related mortality each year Source: Centers for Disease Control and Prevention http://www.cdc.gov/foodborneburden/index.html

7. Common Causative Agents Viruses Norovirus Astrovirus Hepatitis A virus Parasites Cryptosporidium Cyclospora cayetanensis Entamoeba histolytica Giardia intestinalis Trichinella Chemicals/other Heavy metals Pesticides Fungal toxins Fish toxins Bacteria Bacillus cereus Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Shiga toxin-producing E. coli Enterotoxin producing E. coli Enteroinvasive E. coli Enteropathogenic E. coli Listeria monocytogenes Salmonella, non-typhoid Salmonella Typhi Shigella Staphylococcus aureus Vibrio Yersinia enterocolitica

8.  Frequency of Causative Agents in Foodborne Outbreaks in the United States Bacteria (40%) Salmonella (18%) Clostridium perfringens (6%) STEC (5%) Campylobacter (4%) Viruses (54%) Norovirus Chemicals/other (5%) Source: Centers for Disease Control and Prevention based on data from 2008 Parasites (<1%)

9. Food Vehicles • Variety of foods associated with foodborne illnesses • Almost any food can be a vehicle for disease but food and production/processing must • Allow opportunity for contamination by causative agent • Allow agent (or toxin) to survive (not be inactivated) and • (For some agents) support proliferation of agent and/or elaboration of preformed toxins • Common food-causative agent pairings

10. … Also Other Modes of Transmission • Pathogens associated with food can also be spread through other modes • Waterborne • Person-to-person • Animal-to-person • Multiple modes of transmission possible in a single outbreak

11. Definition of Outbreak • Two or more cases of a similar illness among individuals who have had a common exposure • Critical components of definition • Same diagnosis or symptoms and signs suggestive of same illness • Clear association between cases, with or without a recognized common source

12. Definition of Cluster • More cases than expected for given geographic location and time • No immediately obvious association between cases • Suggestive of an outbreak but needs further exploration to make determination

13.  Class Question Is this an outbreak? Development of nausea and vomiting in three friends within 30 minutes of eating at a restaurant. Meets definition of outbreak.

14.  Class Question Is this an outbreak? Diarrhea and abdominal pain due to Salmonella Agona (an unusual serotype only seen once before) in 24 persons in one state. Does not meet definition of an outbreak because no obvious association between cases. The number of cases is higher than expected and deserves further exploration.

15.  Class Question Is this an outbreak? A single case of botulism. Does not meet definition of an outbreak used in this course because there is only one case. However, single cases of certain rare and serious conditions, such as botulism, toxin poisoning, or chemical contamination, are considered public health emergencies and elicit an outbreak-like response.

16.  Primary Goals of Outbreak Investigations • Stop current outbreak as soon as possible by implementing effective control measures and • Prevent similar outbreaks in future. • To achieve these goals, you must rapidly identify the cause of the outbreak including: • People at risk (and characteristics) • Causative agent • Mode of transmission and vehicle • Source of contamination • Contributing factors • Environmental antecedents

17.  To do all these things …. you need an Outbreak Investigation Team. > The team

18. Outbreak Investigation Team • Composition varies but almost always needs knowledge and skills in • Environmental health • Epidemiology • Laboratory • Public health education • Communications • Leadership • Usually includes environmental health investigator, epidemiology investigator and/or public health nurse, and laboratory investigator > The team

19. The Team: Env’t Health Investigator The env’t health investigator focuses on the contaminated food: • Receives and interprets foodborne illness complaints • Investigates suspected food and/or food establishment • Interviews food workers and managers • Examines food storage, handling, preparation • Identifies factors that resulted in food contamination • Collects environmental and food samples • Collects paperwork • Implements control measures > The team

20. The Team: Epidemiologic Investigator The epidemiologic investigator focuses on cases: • Analyzes data from pathogen- specific surveillance and identifies clusters • Characterizes cases by time, place, and person • Plans epidemiologic studies • Interviews cases and healthy controls • Analyzes and interprets results of epidemiologic studies > The team

21. The Team: Public Health Nurse The public health nurse focuses on patients: • Interviews patients • Collects clinical specimens from patients • Administers questionnaires for epidemiologic studies • Advises patients on how to prevent spread of illness • Provides public health education > The team

22. The Team: Laboratory Investigator The laboratory investigator focuses on specimens: • Analyzes clinical, food, and environmental specimens • Interprets test results • Advises team about tests and collection, handling, storage, and transport of specimens • Coordinates additional testing by partner labs > The team

23. The Team: Other Skill Sets Other persons often included on outbreak investigation team: • Public health officer • Public health educator • Clerical staff • Public information officer • Regulatory investigators • Interpreters • Veterinarians • Health care providers • Industry members > The team

24. The Team: Together • Work together and support each other • Team responsibilities • Develop hypotheses about outbreak source • Prioritize and assign activities • Interpret investigation findings • Determine how far to take an investigation • Develop public messages • Decide on control measures > The team

25. Group Exercise Working alone or with others who are from the same jurisdiction, complete the outbreak investigation team matrix at the end of the module. • Examine the roles and responsibilities listed under each outbreak investigation team member. • Insert your name and the names of your team members in the appropriate cells. • Which responsibilities are not covered? How might these gaps be filled? • Are there others included on your team? What do they do? Time limit: 10 minutes

26. Quick Quiz

27. Quick Quiz • Which of the following causative agents is the most common cause of foodborne disease outbreaks in the United States? • Viruses • Bacteria • Parasites • Chemicals

28. Quick Quiz • Some foodborne pathogens can also be spread by water, from person-to-person, and from animal-to-person. • True • False

29. Quick Quiz • An outbreak is an increase in the number of cases of a particular disease greater than is expected for a given time and geographic location. • True • False

30. Quick Quiz • Which of the following is a primary goal for undertaking foodborne disease outbreak investigations? • To study the natural history of the causative agent • To train staff • To stop the current outbreak by implementing effective control measures • To respond to public concerns

31. Quick Quiz • Knowledge and skills from all of the following disciplines should be represented on every foodborne outbreak investigation team EXCEPT • Environmental health • Epidemiology • Laboratory • Industry members