Outbreaks Involving Food & Lodging Establishments Partnerships Needed for a Successful Investigation

1. Outbreaks Involving Food & Lodging EstablishmentsPartnerships Needed for a Successful Investigation Carl Williams Melissa Ham Nicole Lee

2. Presentation Content • Why do we care about foodborne outbreaks? • What partners need to be involved and why? • How does this partnership work during an outbreak? • What are some common conflicts between partners? • Are there resources for partners? • Q & A

3. Why do we care about foodborne outbreaks?

4. Why do we care about foodborne outbreaks? • Potential illness reaching the masses • Intentional vs accidental contamination • Possible wide distribution of a contaminated item • Vulnerable populations • Loss of days worked, wages, business, trust

5. Real Life Events: Salmonella

6. Real Life Events: Salmonella Total Ill 100 Hospitalized 8 Counties Represented 11 Ages 17yrs-81yrs Median: 45 yrs

7. Real Life Events: Salmonella

8. Real Life Events: Salmonella Total Ill 104 Hospitalized 14 Counties Represented 5 Ages 3yrs – 85yrs Median: 55yrs

9. Real Life Events: Norovirus

10. Real Life Events: Hepatitis A

11. What partners need to be involved and why?

12. What partners need to be involved?

13. What partners need to be involved? • Laboratory

14. What partners need to be involved? • Laboratory • Environmental Health

15. What partners need to be involved? • Laboratory • Environmental Health • Epidemiology

16. What partners need to be involved? • Laboratory • Environmental Health • Epidemiology

17. What partners need to be involved? • Laboratory • Environmental Health • Epidemiology

18. What partners need to be involved? • Laboratory • Environmental Health • Epidemiology

19. What partners need to be involved? • Laboratory • Environmental Health • Epidemiology

20. Purpose of partners Laboratory Epidemiology Environmental Health • Agent specific • Verify diagnosis • Outbreak specific • Identify source • Implement control measures • Facility specific • Identify exposure and transmission opportunities • Implement control measures

21. When has this worked? One example…

22. Real Life Event: Salmonella

23. Monday, May 13, 2013 Day 1

24. 10:00am – Call from CD Nurse • Fifteen ill with N/V/D (some bloody) • 10 / 15 hotel staff (3/10 food handlers) • 1 hospitalized • Two of three samples (+ Salmonella) • May 8th was the first onset 4pm - Conference call • Local Health Dept: Epi, EnvHlth • State: Epi, EnvHlth, Lab, Public Affairs

25. Day 1 Summary of Actions/Decisions • Confirm the story • Implement control measures with hotel/rest. • Interview ill • Coordinate hotel assessment with EnvHlth • Coordinate stool specimen collection, shipment, and testing with state lab • Develop communication tools • Send statewide & national alerts to identify additional cases • Request receipts from hotel (case-control study) • Develop survey from hotel menu • Send state staff to Cumberland to assist with summarizing data and data entry

26. 3 Partners with 1 Goal • Stop the Outbreak

27. Activities of partners Laboratory Epidemiology Environmental Health • Test stool • Grow isolate • Biochem tests • Subtyping • PFGE • Environmental testing (partner labs) • Coordinate activities • Characterize illness • Analyze data from all partners • Facility Assessment • Processes • Employees

28. Results Laboratory Environmental Health Epidemiology

29. Laboratory Results • 54 specimens tested • 2 (4%) unsatisfactory • 27 (50%) negative • 25 (46%) positive • 25 (100%) Salmonella typhimurium • 25 (100%) had the same matching PFGE pattern

30. Environmental Health Results • Environmental Assessments • Risk Factors • Personal Hygiene • Approved Source • Contamination • Holding • Cooking • Interviews • Trainings

31. Environmental Health Actions • Required reportable BIG 5 • Tools • Three legged stool • Employee Health • Hand washing • No Bare Hand Contact of Ready to Eat food • Risk Control Plans • Enforcement

35. Epidemiology Results RESULTS Those who ate/drank at the All American Grill were 3.6 times more likely to become ill when compared to those who did not eat/drink at the All American Grill Total Ill 100 Hospitalized 8 Counties Represented 11 Ages 17yrs-81yrs Median: 45 yrs

36. Process Results • After outbreaks are over the following questions are asked of those involved: • What worked well during this outbreak? • What did not work well during this outbreak? • What recommendations do you have to improve the handling of future outbreaks?

37. What are some common conflicts between partners?

38. Potential conflicts with partners Laboratory Epidemiology Environmental Health • Not aware of numerous incoming specimens • Specimens may be un-satisfactory • Interest in accompanying EH during facility assessments • Timing of lab results can feel delayed • Expanded workload • Additional team members on site

39. Potential conflicts with partners Local Health Dept State Health Dept • Feels like state is taking over instead of assisting • Nursing staff pulled from clinic to address outbreak needs • Ensure the county is happy with how the outbreak is lead • Ensuring the same message is communicated to the public

40. Conflict resolution • Establish relationships with partners before or outside of an outbreak situation • Who is your point of contact and what can they do for you • Understand the role of each partner • What do they do and why • Do they have the resources the response requires • Communication • How often is everyone updated and through what method • Take the opportunity to both learn from others and share your knowledge

41. Are there resources for partners?

42. Partnership Resources Laboratory Epidemiology Environmental Health • SLPH website • CDC resources • MOA with other states for surge capacity • NC Online Communicable Disease Manual • APHL Control of Communicable Disease Manual • NC Food Code • Online EH training for Assessments during Outbreaks http://www.cdc.gov/nceh/ehs/eLearn/EA_FIO/

43. Partnership Resources Laboratory Epidemiology Environmental Health

44. Partnership Resources Laboratory Epidemiology Environmental Health NC Food Code Cheat Sheet

47. Q & A?

48. Thank You Carl Williams, Public Health Veterinarian carl.williams@dhhs.nc.gov, 919-733-0391 Melissa Ham, Regional Environmental Health Specialist melissa.ham@dhhs.nc.gov, 910-303-9247 Nicole Lee, Foodborne Epidemiologist nicole.lee@dhhs.nc.gov, 919-715-1162