Surveillance and Detection – Implications for Response Epi-Ready Surveillance and Detection – Implications for Response Module 4

Module Objectives By the end of this module, participants will be able to describe the various methods used to detect foodborne illness and determine if a response action is necessary. Identify the various surveillance systems available to detect foodborne illness. Compare and contrast pathogen-specific surveillance and complaint- based surveillance to detect foodborne illness. Identify initial outbreak response activities.

Surveillance Public health surveillance is a system that acquires, organizes, and interprets data for action to prevent and control disease the population.

Characteristics of Effective Surveillance There is a willingness to participate in the surveillance activity. Very few barriers to use – accessible. Acceptable This is the value of the system to identify illness when it is actually present. Positive Predictive Value This is a measure of the surveillance system’s ability to detect disease as it is intended. Sensitive This is a measure of the system’s ease of use. Simple The ability of the system to acquire data rapidly enough to take action to prevent additional disease. Timely

Methods of Surveillance Active Passive

Pathogen-specific (Laboratory) Types of Surveillance Pathogen-specific (Laboratory) Complaint-based Sentinel Syndromic

Burden of Illness Pyramid Reported to Health Department/CDC 2% 100% Adapted from a CDC Source

Syndromic Surveillance Surveillance of health-related data prior to diagnosis Clinical or non-clinical Used continuously or for special events National Syndromic Surveillance Program

Sentinel Surveillance Selected group of “reporters” that provide high quality information Active Surveillance FoodNet FoodNet Sites

Laboratory Surveillance Systems Pathogen-specific in nature High quality data very sensitive and has a positive predictive value Not always procedurally simple or timely

Timeframe of Laboratory Analysis - Salmonella Consumption of Food Person Becomes Ill Stool Sample Collected Salmonella Identified Isolate received by Public Health Case confirmed as Part of an Cluster 1 – 3 days 1 – 5 days 0 – 7 days 2 -10 days 5 to 28 days to identify an illness as part of a cluster through PulseNet Adapted from a CDC source

Laboratory Surveillance Systems PulseNet CaliciNet CryptoNet NARMS CDC

PulseNet Main laboratory cluster detection method Considered molecular epidemiology DNA Analysis Important system to detect multistate outbreaks

CaliciNet Norovirus surveillance network Started in 2009 Outbreak surveillance of norovirus at genetic level Monitors circulating norovirus strains 50% more norovirus illness in years when there is a new strain of the virus circulating Source: CDC

CryptoNet Established in 2010 One species now is 30, many with multiple subtypes Culture-independent identification Oocysts of Cryptosporidium Source: CDC

NARMS Established in 1996, nationwide in 2003 Collaboration of state and local public health with: CDC (humans) FDA (retail meats) USDA (food animals) Covers 18 antimicrobial agents in: Salmonella Shigella E. coli Campylobacter Certain Vibrio species

Epidemiologic Surveillance Systems Case-based, passive systems Laboratory Reporting/Provider Notifications Generally regulatory in nature System is sensitive and has positive predictive value

National Notifiable Disease Surveillance System Important component of all public health system Reporting of infectious, noninfectious and outbreak conditions Major foodborne illness pathogens are listed as well foodborne disease outbreaks States may add conditions States require timely reporting Provider- Local/State PH Local PH – State PH Source: CDC

Foodborne Illness Complaint Surveillance Based on complaints of illness Coordination and follow- up enhances the system Need for uniform practice of investigation across jurisdictions

Electronic and Social Media

The Interview Process Primary tool to gather information from complainants and case-patients regarding possible exposure. Standardized approach Quite place to interview Assure confidentiality Probe for additional information Make associations Don’t give advice Translation services Remind them of their importance

Activity This table group exercise will demonstrate how to conduct an interview using a food history form. Choose a person to be interviewed and an interviewer. The remaining members of the table group will be evaluators. This activity should take 15 minutes. Instructors will be available to assist as necessary.

Thoughts on the Exercise Was this exercise easy or difficult? Did you obtain a full five-day history? What approaches were helpful?

Place/date of meal consumed Type of Complaint Date of Illness onset Number ill in party Symptoms Suspected Source Place/date of meal consumed Comments 2/13/18 Illness 2/11/18 1 nausea vomiting Ham Sandwich starting to feel better illness 2/12/18 8 nausea vomiting diarrhea wedding buffet Buffet on 6th 2/10/18 Most of the party is sick now Unsanitary conditions   Joe's Beer Barn Bathrooms need cleaned 2/14/18 double vision does not eat away from home home canned corn on 2/12 2 bloody diarrhea chicken That BBQ Place South of Town 2/9/18 spouse not sick 3 all you can eat night Buffet on 6th 2/11/18 2/15/18 vomiting no recall 4 diarrhea fever chills oysters House of Seafood 2/12/18 2/16/18 cobb salad 2/17/18 facial flushing mouth burns sushi House of Seafood 2/15/18 called in by Dr. J. at ED unsanitary conditions no glove use 2/18/18 diarrhea hamburger Joe's Beer Barn 2/17/18 Activity Work in table groups to determine how you would approach this list of complaints received at the Health Department. Use the space in the participant’s manual to record your thoughts. 15 minute activity. 10 minutes working in groups and 5 minutes for class discussion.

Moving to Response–Cluster Detection What do you know? What information is missing? How will you find the information that is missing?

Laboratory-Identified Clusters Pathogen identified by DNA analysis indicate clusters of disease Long lag periods from exposure to identification as part of a cluster may be unavoidable Recall becomes a challenge Provides specificity to the epidemiologic investigator CIDT identified illness, by itself, will not identify a cluster

Complaint-based Cluster Identification Good record keeping and prompt response necessary Good for the identification of: Illness with short incubation periods Illness isolated to a single jurisdiction – usually a single event Recall bias – last meal bias Focus on food histories and geographic information Provider notification without laboratory identification handled as a complaint

Summary Identified the various surveillance systems available to detect foodborne illness Compared and contrasted pathogen-specific surveillance and complaint-based surveillance to detect foodborne illness Identified initial outbreak response activities

Laboratory Investigation Coming Up Next Laboratory Investigation