Foodborne Illness Outbreak IDMT Training

Objectives Training Objectives Define key aspects/steps of a Foodborne Illness (FBI) Outbreak. Understand Public Health responsibilities during a Foodborne Illness Outbreak. Instructor Guidance: Verbal Presentation: 2 hours (1 hour going over PPTs and 1 hour completing the forms and viewing websites on the Tool Kit slides. Training should consist of discussion with hands on participation for filling out the three forms presented.) AF Form 431, Food Poisoning Outbreak AF Form 432, Time Distribution of Persons Affected CDC 52.13, Investigation of a Foodborne Outbreak

Overview Define Foodborne Illness Outbreak Epidemiologic Steps of an Outbreak Investigation Public Health Roles and Responsibilities

Definition Foodborne Illness – disease carried or transmitted to people by food. Two main types of Foodborne Illness Infection Intoxication Outbreak – an epidemic limited to localized increase in the incidence of disease Infection - Infection occurs when the ingestion of Microbes in food causes illness. The microbes cause disease by invasion of the gut or body or toxin production in the gut/body (not toxin production in the food). Intoxication - Intoxication occurs when bacteria produce toxins in food which, if ingested, causes a foodborne illness. The microbes or bacteria themselves may be harmless, however, once the microbes produce toxins while growing in the food, the ingestion of the food toxin causes the illness. More than 250 pathogens and toxins are known to cause foodborne illness. Nearly all of them can cause an outbreak. Epidemic: the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time. Usually, the cases are presumed to have a common cause or to be related to one another in some way. Incidence: a measure of the frequency with which new cases of illness, injury, or other health condition occurs among a population during a specified period.

Epidemiologic Steps of an Outbreak Investigation Prepare for field work Establish the existence of an outbreak Verify the diagnosis Construct a working case definition Find cases systematically and record information Perform descriptive epidemiology Develop hypotheses Evaluate hypotheses epidemiologically

Epidemiologic Steps of an Outbreak Investigation As necessary, reconsider, refine, and re-evaluate hypotheses Compare and reconcile with laboratory and/or environmental studies Implement control and prevention measures Initiate or maintain surveillance Communicate findings

Prepare for Field Work Before a confirmation in increased cases or after the confirmation? Be prepared Required Forms *(AF Form 431, 432, and CDC 52.13) Tools to take samples (notify lab) Place to keep samples cold Gloves Camera Notebook/pen Plan of action Only occasionally does Public Health decide to conduct a field investigation before confirming an increase in cases and verifying the diagnosis. More commonly, they discover an increase in the number of cases of a particular disease and then decide that a field investigation is warranted. Regardless of when the decision to conduct a field investigation is made, you should be well prepared before leaving for the field. Notifying the lab will help to make sure you manage samples properly and then can help with equipment if needed. By notifying them you are also making them aware of the outbreak. Finally, before departing, you should have a plan of action. What are the objectives of this investigation, what are you trying to accomplish? What will you do first, second, or third? Making sure that everyone involved is on the same page. *Forms will be discussed later in this lesson.

Establish the Existence of an Outbreak More cases of disease than historically indicated Common cause or related to each other No changes in local procedures A change in local procedures can make reports look like an outbreak due to local reporting procedures, changes in case definition (a set of uniformly applied criteria for determining whether a person should be identified as having a particular disease, injury, or other health condition), increased interest because of local or national awareness, or improvements in diagnostic procedures. A new physician, infection control nurse, or medical facility may more consistently report cases, when in fact there has been no change in the actual occurrence of the disease.

Verify the Diagnosis Properly identify Rule out laboratory error Foodborne Illness testing Take a history Interview patient with AF Form 431 Document time distribution of those affected Verifying the diagnosis is important: to ensure that the disease has been properly identified since control measures are often disease-specific; and to rule out laboratory error as the basis for the increase in reported cases. A medical physician can not test for a foodborne illness without knowing what it is. For example: They can tell you that you have a foodborne illness but can only test for the specific type if they suspect that’s what it is. If they think due to the symptoms that it is E. coli then they can test for it. In some cases the cause and type of foodborne illness are never identified. That is why it is important to take a good food/medical history of the patient.

Verifying the Diagnosis AF Form 431, Food Poisoning Outbreak – Individual Case History (72 hours) To help better understand the foodborne illness and help diagnose, interview patients using the AF Form 431, Food Poisoning Outbreak-Individual Case History. Once aware that it is a foodborne disease and considered an outbreak you will need to use this form to try and identify where the contamination occurred.

Verify the Diagnosis AF Form 432, Time Distribution of Persons Affected (Onset data) To get a better idea of the incubation period of the disease and to help diagnosis, record the onset times of illness of those sick.

Construct a Working Case Definition Clinical Criteria* Fever Abdominal cramps Diarrhea A case definition is a standard set of criteria for deciding whether an individual should be classified as having the health condition of interest. A case definition includes clinical criteria and, particularly in the setting of an outbreak investigation, restrictions by time, place, and person. The clinical criteria should be based on simple and objective measures. Whatever the criteria, they must be applied consistently to all persons under investigation. * A person infected with the Salmonella bacterium usually has fever, abdominal cramps, and diarrhea beginning 12 to 72 hours after consuming a contaminated food or beverage.

Find Cases Systematically and Record Information Healthcare practitioners Medical facilities Alerting the public* Public Health must look for additional cases using the case definition to determine the true geographic extent of the problem and the populations affected by it. *If alerting the public is warranted either to find or warn people it must be done carefully as to not cause panic.

Perform Descriptive Epidemiology Summarizing data Time (epidemic curve) Descriptive epidemiology is the process in which the outbreak is characterized by time, place, and person. Time: Traditionally, a special type of graph called an epidemic curve is used to provide a simple visual display of the outbreak’s magnitude and time trend.

Perform Descriptive Epidemiology Summarizing data Place Person Susceptibility Age Race Sex Medical status Opportunities for exposure Occupation Leisure activities Medications, tobacco, drugs Descriptive epidemiology is the process in which the outbreak is characterized by time, place, and person. Place: Knowing the place where food was consumed can help determine if it is the food, food service workers, or the facility that caused the contamination of the food. Inspecting the place where it is thought that the contamination occurred will help determine the cause. Person: Characterization of the outbreak by person provides a description of susceptibility to disease and opportunities for exposure.

Develop Hypotheses The hypotheses should address: Source of the agent Mode of transmission Exposures that caused the disease What is the actual foodborne illness? How did it infect the patients? Where did the patients consume the contaminated food?

Evaluate Hypotheses Epidemiologically Plausibility Laboratory testing of patient for foodborne illness Laboratory testing of suspect food After a hypotheses that might explain how an outbreak developed, the next step is to evaluate the plausibility of that hypotheses.

As Necessary, Reconsider, Refine, & Re-Evaluate Hypotheses Necessity Reconsider Refine Re-evaluate Throughout the outbreak investigation you might find yourself doing some of the steps out of order, or over again as you gain more knowledge of the outbreak. These steps are guidelines to use to help identify what caused the foodborne illness outbreak in the first place. Necessity – if your diagnosis was wrong it is necessary to figure out a new one. Reconsider – if it doesn’t seem possible to be the potato salad, what else could it be. Refine – if later on you have someone with bloody stools, you might need to refine your case definition. Re-evaluate – if you don’t seem to be getting the answers that are needed, re-evaluate the outbreak. All of these are needed to create a hypotheses, as they change so will your hypotheses.

Compare & Reconcile with Lab and/or Environmental Studies Provide the proof Laboratory results (human & food) Inspection findings Using your resources, provide the proof of what your hypotheses was.

Implement Control and Prevention Measures Control & Prevention Educate the population/food facility Treat the ill Dispose of contaminated food Learn from the outbreak investigation Educate the population/food facility – this can be done with training one on one, in a group setting, and sometimes you might have to write an article for the base paper or advertise through computer announcements. Learn from the outbreak investigation – you can turn what you learned from the investigation into training, discuss what you could have done differently.

Initiate or Maintain Surveillance Continue to monitor the situation Is it getting better or worse? Are the control methods even working? If you are still getting new cases, you might have to go back to the drawing board, maybe you missed something.

Communicate Findings Briefing for the local authorities/base/medical group/public health Written report/documentation for historic value/training Report of foodborne illness outbreak Good documentation will help when the next foodborne illness outbreak occurs.

Communicate Findings CDC 52.13, Investigation of a Foodborne Outbreak Send to MAJCOM/SGP In the 50 states also send to the state health department Per AFI 48-116, Food Safety Program Once a completed foodborne outbreak investigation is accomplished make sure to report the information to MAJCOM/SGP and State Health Department.

Public Health Roles and Responsibilities Conduct annual in-service training on foodborne illness Investigate and report all foodborne illness outbreaks to MAJCOM/SGP and the state health department Report each confirmed case in accordance with current AF reportable event guidelines. Training must include the following: Roles and responsibilities, procedures for identifying an outbreak, taking a history with emphasis on foods consumed, case definitions, collecting appropriate laboratory samples, verifying diagnoses, statistical data analysis. The current AF reportable event guidelines are: Armed Forces Reportable Medical Events Guidelines & Case Definitions (March 2012). A link to this PDF is located on the Tool Kit slides. Also, we are to report using the following the computer system: Air Force Disease Reporting System internet (AFDRSi). A link to this website and information including training on it is also located on the Tool Kit slides.

Public Health Roles and Responsibilities Ultimate goal Preventing them from happening in the first place. The ultimate goal for public health and food safety officials is not just stopping foodborne illness outbreaks once they occur, but preventing them from happening in the first place. Public Health uses the following tools to prevent foodborne illness outbreaks: - Training for/with food facilities, managers/supervisors (annually) and or employees of food facilities, training within Public Health and the Medical Group. - Food Facility Inspections - Trend analysis - Food Vulnerability Assessment - Investigations - Surveillance - ALFOODACT messages (you can view these at https://gumbo2.wpafb.af.mil/epi-consult/foodprotection/foodsafety/ALFOODACTS/ )

Summary Define Foodborne Illness Outbreak Epidemiologic Steps of an Outbreak Investigation Public Health Roles and Responsibilities

QUESTIONS? QUESTIONS?

Tool Kit References: AFI 48-116, Food Safety Program Principles of Epidemiology in Public Health Practice, Third Edition, Updated May 2012 from the Centers for Disease Control and Prevention (CDC) US Department of Health and Human Services, Food and Drug Administration (FDA) Food Code

Tool Kit Websites: Approved Source http://phc.amedd.army.mil/topics/foodwater/ca/Pages/DoDApprovedFoodSources.aspx CDC Food Safety Homepage http://www.cdc.gov/foodsafety/investigations.html USAFSAM/PHR Website https://gumbo2.wpafb.af.mil/epi-consult/index.cfm Food Protection https://gumbo2.wpafb.af.mil/epi-consult/foodprotection/ View websites during training.

Tool Kit Websites: Armed Forces Reportable Medical Events Guidelines & Definitions https://gumbo2.wpafb.af.mil/epi-consult/reportableevents/documents/Tri-Service%20Reportable%20Events,%20Guidelines%20and%20Case%20Definitions%20(2012).pdf Air Force Disease Reporting System internet (AFDRSi) Go to the following link: https://gumbo2.wpafb.af.mil/epi-consult/reportableevents/ This page will give you information and training on AFDRSi https://data.nmcphc.med.navy.mil/afdrsi/Login.aspx (AFDRSi Website) View websites during training.

USAFSAM Contact Information USAFSAM Public Health Education Division Mr. James Gage, Chief, Education and Training Branch DSN: 798-4130 Commercial: (937) 938-4130 Email: james.gage.2@us.af.mil