CERTIFIED PUBLIC HEALTH MANAGER (CPHM)

1. Leadership Program CERTIFIED PUBLIC HEALTH MANAGER (CPHM)

2. Outbreak Investigations • There are three main activities to a U.S.P.H. outbreak investigation. • Laboratory Assessment - identifies the agent or the causative agent of the outbreak itself, the environment of the ship, what might have contributed to the outbreak, or at least its spread. • Targeted Environmental Health Assessment- a fact finding evaluation of the same areas that are covered during an operational ship inspection, except deficiencies noted are specific to those related to the cause of the outbreak or results in the outbreak's spread. • Epidemiological Investigation - searches for common exposures among cases for possible sources of illness.

3. Outbreak Investigations: cont’d • While some bacterial pathogens that cause illness such as Staphylococcus aureus, Clostridium perfringens and Salmonella are almost always associated with foodborne transmission, other bacterial pathogens such as Shigella are more frequently transmitted person-to-person. Parasitic outbreaks are usually associated with waterborne or person-to-person transmission. • In outbreaks, viruses are most often reported as being transmitted person-to-person. Direct and indirect transmission of pathogens has been responsible for outbreaks comes into contact with a contaminated food supply. To identify the responsible agent(s), a method commonly used is to identify 1) a passenger attack rate and 2) a crew attack rate. Each calculation would be: • Attack Total Number of ill people • Rate = Total number of people in population X 100 • (%)

4. Outbreak Management Protocol The source of illness is not always determined at a specific stage of an investigation. The following protocol is based on the U.S.P.H. Vessel Sanitation Program for illness investigations. It is intended as a guide only, as the investigation procedures will vary - parallel or sequentially - according to the nature and size of the outbreak. The goal of an investigation is to identify the source of the illness, so that potential control measures can be implemented.

5. Outbreak Management: 10-Step Investigation Protocol • Act on Notification of Illness • Enter into Gastrointestinal Log and submit information for each complaint. • Confirm Diagnosis - Medical • Case history (e.g.: medical records and management/standards questionnaire), clinical specimens (e.g.: 10 bacterial and 10 viral specimen containers), environmental samples (e.g.: food/water) • Prepare & Submit Written Reports to Public Health/Regulatory Officials • Use as a basis for development of prevention measures and crew training (2% = Notification level. 3% = Outbreak level. Daily updates = new and old cases.) Follow case reporting requirements. • Develop a Case Definition • Use symptom profile to help characterize what the likely causative agent is. Compare characteristics with unaffected individuals related to the outbreak.

6. Outbreak Management: 10-Step Investigation Protocol • Make Epidemiologic Associations – who, what, when (descriptive) • Make time (e.g.: on the ship/after boarding, etc.), place (restaurant/boat drill, etc.), person associations (e.g.: across age spectrum: elderly/young, etc.) • Cooperate with Regulatory Investigation • Plan and Conduct Onsite Investigation • Conduct hazard analysis (Targeted Environmental Health Assessment): calibrations, measure temperatures, investigate potential sources of illness, obtain samples, conduct interviews. • Analyze Data from Outbreak Investigation • Plot epidemic curve to help determine outbreak origination. • Test Hypothesis Based on Results – why and how (analytical) • Recommend and Implement Control Measures - Recommendations for follow-up for immediate control and future prevention (PAX, ship, system, etc.).

8. Surveillance • Ongoing surveillance to support early identification of illness is an important public health function and may include: • monitoring the environment (ship/itinerary) for illness events • recognizing, treating and reporting cases of gastrointestinal illness • documenting an increase of positive results indicating possible enteric/foodborne/waterborne agents • integrating information from investigations based on interviews and standardized questionnaires • investigating complaints of food and water quality • identifying food and water handling deviations during auditing activities • detecting unacceptable levels of contaminants through routine sampling in food, potable water and recreational water • reporting of a food safety problem from external sources (e.g.: health officials)

9. Surveillancecont’d. DETECTION: There are many routes through which an illness outbreak can be detected by surveillance activities. On cruise ships, there is reliance on passive disease surveillance, which involves self-reporting of illness and receipt of communication reports of infections/disease to/from regulatory agencies, laboratories and other health professionals. In some situations, the ships utilize active disease surveillance, which involves contacting passengers to “actively” search for cases. REPORTING: The nature of the illness defines the areas of responsibility for the various crew disciplines involved. Investigations require a coordinated team effort involving senior management, medical staff, housekeeping, and culinary staff. Prompt notification is essential for reportable diseases, and required under the U.S.P.H. The U.S.P.H. assumes the lead role for assessment, management and decision-making during an outbreak investigation within U.S. jurisdiction.

10. External Communications Develop and maintain regular lines of communication with the affected passengers and, when applicable, any establishment presumed to be the source of an outbreak. External communications should be undertaken in collaboration with public health authorities. Communications should remain objective and not a need to “point the finger”. The goal should be to rectify the source of the problem as soon as possible, ensure that steps are taken to prevent a future recurrence and reassure the affected passengers and public that the problem has been resolved.

11. Internal Communications Develop and maintain regular lines of communication between key investigation team members including public health authorities. Regular and daily communications may be indicated in more serious and complex outbreaks.