Communicating Science with Integrity: A CDC Foodborne Outbreak Case Study Laura Burnworth, MPH Health Communication Specialist Outbreak Response and Prevention Branch Centers for Disease Control and Prevention 2017 International Crisis and Risk Communication Conference March 15, 2017

Objectives Understand CDC’s scenario-based framework for deciding to communicate about foodborne outbreaks Use the framework to highlight various investigation and communication decision points during a recent outbreak Demonstrate the success of following an established process to communicate clearly, despite challenges

Framework for Communication Decisions

Why CDC Communicates about Foodborne Outbreaks #1 REASON: Specific source identified & public can take action Other reasons CDC may communicate include: State health department(s) communicate High risk group involved Deaths, high hospitalization rate Intense media interest Misinformation being circulated

CDC’s Role in Foodborne Outbreak Communication CDC’s role in taking actions to stop a foodborne outbreak is usually limited to issuing public warnings Since 2006, CDC has posted over 100 multistate foodborne outbreak warnings on its website Postings include recommendations to the public, retailers, and other stakeholders As the nation’s public health agency, CDC serves as the unofficial “spokesperson” for the multistate epidemiologic outbreak investigation

Timing for Public Communication Communication to the public may be needed at any point, or it may never be needed In 2016, CDC investigated over 220 multistate clusters; 17 outbreaks were communicated about publicly Posting a notice on the CDC website involves balancing many priorities: Being “fast and right” Input from partners Science and plain language

5 Common Communication Scenarios The decision about “when” to communicate occurs quickly During an investigation, knowledge about what the food source is accumulates and changes, as does the need to communicate A working document was developed to assist federal agencies during multistate outbreak investigations Describes 5 common scenarios encountered during investigations Outlines reasons why or why not communication is needed Acts as a guide when discussing the need for public communication between federal agencies

5 Common Communication Scenarios Examples 20 people infected with one strain of E. coli Signal for ground beef Brand X ground beef is likely vehicle Outbreak of E. coli infections in Ohio Ground beef recalled for E. coli contamination Scenario 1 Cluster of illnesses with no specific source identified Scenario 2 Generic food type identified as likely vehicle Scenario 3 Specific food product, brand identified as likely vehicle Scenario 4 Local outbreak, locals and/or state release press Scenario 5 Pathogen identified in food independent of any human illness

Questions to Consider Is the outbreak ongoing? Is there a clear action step for people to take? Does the food item have a long shelf life? Is the food item widely distributed/available for purchase? Is a vulnerable group at higher risk? Is there sufficient evidence linking illness to the food item? Is the pathogen causing the outbreak causing severe illness?

Food with Integrity vs. Science with Integrity

Chipotle 101 Pronunciation: “Chi-pote-lay” Opened in 1993 Dramatic success and growth through the 2000s Customers looking for healthy fast-food alternative Many items used in multiple dishes: lettuce, cilantro, tomatoes, red onions, lime juice, beans, rice

Outbreak Overview In late October 2015, an outbreak of a rare strain of E. coli O26 infections was detected in Washington and Oregon; people reported eating at Chipotle restaurants By November 2015, cases in states outside of the Pacific Northwest had been identified; these people also reported eating at Chipotle restaurants When the outbreaks were declared over in February 2016, 60 ill people had been identified in 14 U.S. states; almost all reported eating at Chipotle Many communication decisions were made, but this presentation will focus on three decisions and their challenges: Announcing the multistate investigation Announcing a second, smaller outbreak linked to Chipotle Declaring the outbreaks over

Decision Point 1: The Multistate Investigation In mid-November, we began to see illnesses reported from states outside of the Pacific Northwest Same rare strain of E. coli O26 Questions to consider: Is this outbreak ongoing? Is the pathogen causing severe illness? Do we have sufficient evidence linking illness to Chipotle? Can we provide specific advice to people?

Challenges to CDC’s Scientific Integrity

Decision Point 2: Another Outbreak? In December, we identified a second outbreak of different, but still rare, E. coli O26 infections Five infections in 3 new states: Kansas (1), Oklahoma (3), and North Dakota (1) All five people ate at Chipotle All three OK cases at a single location ND case traveled to KS and ate at the same location as the KS case Questions to consider: Is this outbreak ongoing? Is the pathogen causing severe illness? Do we have sufficient evidence linking illness to Chipotle? Can we provide specific advice to people? AND: Is this linked to the larger outbreak?

More Challenges to CDC’s Scientific Integrity CDC received an “Information Quality Challenge” from Chipotle legal counsel Document questions the utility and accuracy of CDC’s public communication about the outbreaks, claiming: CDC did not adhere to guidelines on dissemination of information CDC inappropriately included cases in the case count CDC staff made unnecessary statements to the media

So, why did CDC communicate about the outbreaks? Infections with the rare strains of E. coli O26 continued to be reported to CDC and the outbreaks were causing severe illness Additionally, CDC sought to: Encourage sick people with exposure to Chipotle to seek medical attention and get information to prevent transmission of infection to close contacts Assist in identifying additional outbreak cases who might provide clues to solve the outbreak Give the public information to protect themselves by choosing to avoid certain food exposures associated with the outbreaks Government transparency and trust Applying the established framework, we decided to communicate

Decision Point 3: Declaring the Outbreaks Over CDC was cautious about declaring the outbreaks over for several reasons: Contaminated ingredient was never identified, so investigators weren’t sure if the food linked to illness was no longer available at restaurants Winter holidays likely increased the illness reporting delay

Challenges and Successes

Unique Communication Challenges Chipotle’s “Food with Integrity” tagline Publicly traded company = public financial losses Beloved brand among teens and young adults Massive social media following and internet presence

Communication Successes Increasing demands for government agencies to be transparent Transparency, trust, and credibility intrinsically linked Throughout the investigation, CDC applied its established framework for communications decision-making CDC could defend the decisions it made to communicate during the investigation Could demonstrate a consistent pattern of communicating Ultimately, Chipotle made substantial changes to their food safety program, hopefully leading to safer food for their customers

Contact: Laura Burnworth wmg5@cdc.gov 404-718-4574