1. Foodborne Illness Outbreak IDMT Training

2. 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

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

4. 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.

5. 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

6. 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

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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?

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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 , Food Safety Program
Once a completed foodborne outbreak investigation is accomplished make sure to report the information to MAJCOM/SGP and State Health Department.

24. 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.

25. 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 )

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

27. QUESTIONS?
QUESTIONS?

28. 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

29. Tool Kit Websites: Approved Source
CDC Food Safety Homepage
USAFSAM/PHR Website
Food Protection
View websites during training.

30. Tool Kit
Websites:
Armed Forces Reportable Medical Events Guidelines & Definitions
Air Force Disease Reporting System internet (AFDRSi)
Go to the following link:
This page will give you information and training on AFDRSi
(AFDRSi Website)
View websites during training.

31. USAFSAM Contact Information
USAFSAM Public Health Education Division
Mr. James Gage, Chief, Education and Training Branch
DSN:
Commercial: (937)