1. WHO guidelines for investigation and control of Foodborne Diseases outbreak Dr. Christina Rundi Ministry of Health, Malaysia

2. Why is there a need for this guideline? The investigation and control of foodborne disease outbreaks are multi-disciplinary tasks. Skills required in the areas of clinical medicine, epidemiology, laboratory medicine, food microbiology and chemistry, food safety and food control, and risk communication and management. Many outbreaks of foodborne disease are poorly investigated; Reasons: these skills are unavailable or because field investigators are not adequately trained.

3. Target groups Public health practitioners, Food and health inspectors, District and national medical officers, Laboratory personnel and others who may undertake or participate in the investigation and control of foodborne disease outbreaks.

4. Focus Focuses on practical aspects of outbreak investigation and control. Field level: –Guide initial epidemiological, environmental and laboratory investigations, –Implementation of appropriate control measures, and –Alert investigators on the need to seek assistance for more complex situations. At national and regional levels - Assist decision-makers in identifying and coordinating resources and in creating an environment appropriate for the successful management of foodborne disease outbreaks. Divided into six main sections.

5. Section 1: Practical guide  Summarizes the steps in outbreak investigation (can be used as checklist) Preliminary assessment of the situation Communication Descriptive epidemiology Food and environmental investigations Analysis and interpretation Control measures Further studies

6. Section 2: Planning and preparation 2.1 General 2.2 Outbreak control team(OCT) - when to form a OCT - role of OCT - composition of team 2.3 Record keeping - what records should be kept 2.4 Communication - share information with who, what to share and why share

7. Section 3: Surveillance to detect foodborne disease outbreaks 3.1 Introduction 3.2 Definitions - surveillance, foodborne disease, foodborne disease outbreak, sporadic cases, cluster/outbreak/epidemic 3.3 Data sources - source of data for detecting foodborne disease outbreak 3.4 Interpreting data sources - how to interpret data from sources

8. Section 4: Investigation of foodborne disease outbreaks 4.1 General 4.2 Epidemiological investigations - preliminary assessment of the situation - preliminary hypotheses and plan further action - Descriptive epidemiological investigations – establish case definition, identify case, interview case, collate data, analyse data (include how to draw epidemic curve), calculate incubation period, determine people at risk, develop explanatory hypotheses, analytical epidemiological (retrospective cohort and case control)

9. Section 4: Investigation of foodborne disease outbreaks 4.3 Environmental and food investigations - Investigation of food establishments - Investigation of a suspect food (interview food handlers, draw flowchart of the operation, conduct outbreak hazard analysis), food and environmental sampling 4.4 Laboratory investigations - Microbiological analyses - Chemical investigations

10. Section 5: Control measures 5.1 General 5.2 Control of source - Closing food premises - Removing implicated foods from the market (include communication with the public - Modifying a food production/preparation process 5.3 Control of transmission - Public advice - Exclusion of infected persons from work and school, personal hygiene, infection control, protecting risk groups 5.4 End of outbreak - Review of outbreak, outbreak report, further studies

11. Section 6: Features of important foodborne diseases 6.1 Foodborne pathogens, toxins and chemicals of public health importance 6.2 Major foodborne pathogens: predominant clinical features 6.3 Major foodborne diseases: epidemiology and methods of control and prevention

12. Annexes 1.Glossary 2. Outbreak control meeting: draft agenda  minutes of last meeting, outbreak update, management of outbreak 3. Examples of outbreak investigation forms;  Initial response form for disease outbreaks,  Initial case report form  Line listing 4. Questionnaire design 5. Sample questionnaires

13. Annexes 6. Investigation report forms;  Outline of outbreak investigation report 7. Statistics;  calculating rates, median, statistical significance testing 8. Situations likely to contribute to foodborne disease outbreaks 9. Procedures and equipment for specimen collection;  feces, vomitus, serum, food and environmental specimens 10. The WHO Five Keys to Safer Food

14. 8. Situations likely to contribute to foodborne disease outbreaks

15. 10. The WHO Five Keys to Safer Food