Foodborne Disease Outbreak Investigation Team Training:

1
Foodborne Disease Outbreak Investigation Team
Training

• Module 1 Foodborne Diseases and Outbreaks

2
Module Learning Objectives

• At the end of this module, you will be able to
• Describe what is meant by foodborne disease.
• List examples of common foodborne disease
  causative agents.
• Define the terms outbreak and cluster.
• List the goals of a foodborne disease outbreak
  investigation.
• Describe the desirable knowledge and skills
  included on a foodborne outbreak investigation
  team.

3
BREAKING NEWS

• Students and teachers rushed to hospital
• Nausea, vomiting, stomach pain, and dizziness
  after lunch at school cafeteria
• Health department team dispatched to school and
  hospital to investigate

4
Group Discussion

• Divide into groups by table.
• Briefly introduce yourself to others at your
  table.
• Re-read the news report at end of module and
  answer these questions.

• Do you think the illnesses are foodborne?
• Do you think the illnesses represent an outbreak?
  
• If this is a foodborne outbreak, who would you
  involve in the investigation?

Be prepared to share your
thoughts with the class.
Time limit 5 minutes
5
Foodborne Disease

• Illness caused by ingestion of contaminated food
• Symptoms often affecting stomach or intestinal
  tract including
• Nausea and vomiting
• Diarrhea
• Abdominal pain
• Sometimes nonspecific symptoms and symptoms
  outside GI tract, depending on agent
• Young children, pregnant women, elderly, and
  immunocompromised persons at greatest risk for
  severe illness

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Foodborne Disease

• An estimated 1 in 6 people suffers from
  foodborne illness each year in the United States
  leading to an estimated
• 48 million illnesses
• 128,000 hospitalizations
• 3,000 deaths
• More than 1,000 outbreaks detected annually
• 35 billion in medical costs, lost productivity,
  illness related mortality each year

Source Centers for Disease Control and
Prevention http//www.cdc.gov/foodborneburden/i
ndex.html
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Common Causative Agents

• Bacteria
• Bacillus cereus
• Campylobacter
• Clostridium botulinum
• Clostridium perfringens
• Escherichia coli
• Shiga toxin-producing E. coli
• Enterotoxin producing E. coli
• Enteroinvasive E. coli
• Enteropathogenic E. coli
• Listeria monocytogenes
• Salmonella, non-typhoid
• Salmonella Typhi
• Shigella
• Staphylococcus aureus
• Vibrio
• Yersinia enterocolitica

Viruses Norovirus Astrovirus Hepatitis A
virus Parasites Cryptosporidium Cyclospora
cayetanensis Entamoeba histolytica Giardia
intestinalis Trichinella Chemicals/other Heavy
metals Pesticides Fungal toxins Fish toxins

8
Frequency of Causative Agents in Foodborne
Outbreaks in the United States
?
Bacteria (40)
Salmonella (18) Clostridium perfringens
(6) STEC (5) Campylobacter (4)
Viruses (54)
Norovirus
Chemicals/other (5)
Source Centers for Disease Control and
Prevention based on data from 2008
Parasites (lt1)
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Food Vehicles

• Variety of foods associated with foodborne
  illnesses
• Almost any food can be a vehicle for disease but
  food and production/processing must
• Allow opportunity for contamination by causative
  agent
• Allow agent (or toxin) to survive (not be
  inactivated) and
• (For some agents) support proliferation of agent
  and/or elaboration of preformed toxins
• Common food-causative agent pairings

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Also Other Modes of Transmission

• Pathogens associated with food can also be spread
  through other modes
• Waterborne
• Person-to-person
• Animal-to-person
• Multiple modes of
• transmission possible
• in a single
• outbreak

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Definition of Outbreak

• Two or more cases of a similar illness among
  individuals who have had a common exposure

• Critical components of definition
• Same diagnosis or symptoms and signs suggestive
  of same illness

• Clear association between cases, with or without
  a recognized common source

12
Definition of Cluster

• More cases than expected for given geographic
  location and time
• No immediately obvious association between cases
• Suggestive of an outbreak but needs further
  exploration to make determination

13
Class Question
?

• Is this an outbreak?
• Development of nausea and vomiting in three
  friends within 30 minutes of eating at a
  restaurant.

Meets definition of outbreak.
14
Class Question
?

• Is this an outbreak?
• Diarrhea and abdominal pain due to Salmonella
  Agona (an unusual serotype only seen once before)
  in 24 persons in one state.

Does not meet definition of an outbreak because
no obvious association between cases. The number
of cases is higher than expected and deserves
further exploration.
15
Class Question
?

• Is this an outbreak?
• A single case of botulism.

Does not meet definition of an outbreak used in
this course because there is only one case.
However, single cases of certain rare and serious
conditions, such as botulism, toxin poisoning, or
chemical contamination, are considered public
health emergencies and elicit an outbreak-like
response.
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Primary Goals of Outbreak Investigations
?

• Stop current outbreak as soon as possible by
  implementing effective control measures and
• Prevent similar outbreaks in future.

• To achieve these goals, you must rapidly identify
  the cause of the outbreak including
• People at risk (and characteristics)
• Causative agent
• Mode of transmission and vehicle
• Source of contamination
• Contributing factors
• Environmental antecedents

17
?
To do all these things .
you need an Outbreak Investigation Team.
gt The team
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Outbreak Investigation Team

• Composition varies but almost always needs
  knowledge and skills in
• Environmental health
• Epidemiology
• Laboratory
• Public health education
• Communications
• Leadership
• Usually includes environmental health
  investigator, epidemiology investigator and/or
  public health nurse, and laboratory investigator

gt The team
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The Team Envt Health Investigator
The envt health investigator focuses on the
contaminated food

• Receives and interprets foodborne
  illness complaints
• Investigates suspected food and/or
  food establishment
• Interviews food workers and managers
• Examines food storage, handling, preparation
• Identifies factors that resulted in food
  contamination
• Collects environmental and food samples
• Collects paperwork
• Implements control measures

gt The team
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The Team Epidemiologic Investigator

• Analyzes data from pathogen-
  specific surveillance and
  identifies clusters
• Characterizes cases by time, place, and person
• Plans epidemiologic studies
• Interviews cases and healthy controls
• Analyzes and interprets results of epidemiologic
  studies

The epidemiologic investigator focuses on cases
gt The team
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The Team Public Health Nurse
The public health nurse focuses on patients

• Interviews patients
• Collects clinical specimens from
  patients
• Administers questionnaires for
  epidemiologic studies
• Advises patients on how to prevent spread of
  illness
• Provides public health education

gt The team
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The Team Laboratory Investigator
The laboratory investigator focuses on specimens

• Analyzes clinical, food, and
  environmental
  specimens
• Interprets test results
• Advises team about tests and collection,
  handling, storage, and transport of specimens
• Coordinates additional testing by partner labs

gt The team
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The Team Other Skill Sets

• Other persons often included on outbreak
  investigation team
• Public health officer
• Public health educator
• Clerical staff
• Public information
  officer
• Regulatory investigators

• Interpreters
• Veterinarians
• Health care providers
• Industry members

gt The team
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The Team Together

• Work together and support each other
• Team responsibilities
• Develop hypotheses about outbreak source
• Prioritize and assign activities
• Interpret investigation findings
• Determine how far to take an investigation
• Develop public messages
• Decide on control measures

gt The team
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Group Exercise
Working alone or with others who are from the
same jurisdiction, complete the outbreak
investigation team matrix at the end of the
module.

1. Examine the roles and responsibilities listed
   under each outbreak investigation team member.
2. Insert your name and the names of your team
   members in the appropriate cells.
3. Which responsibilities are not covered? How
   might these gaps be filled?
4. Are there others included on
   your team? What do they do?

Time limit 10 minutes
26
Quick Quiz
27
Quick Quiz

• Which of the following causative agents is the
  most common cause of foodborne disease outbreaks
  in the United States?
• Viruses
• Bacteria
• Parasites
• Chemicals

28
Quick Quiz

• Some foodborne pathogens can also be spread by
  water, from person-to-person, and from
  animal-to-person.
• True
• False

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Quick Quiz

• An outbreak is an increase in the number of cases
  of a particular disease greater than is expected
  for a given time and geographic location.
• True
• False

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Quick Quiz

• Which of the following is a primary goal for
  undertaking foodborne disease outbreak
  investigations?
• To study the natural history of the causative
  agent
• To train staff
• To stop the current outbreak by implementing
  effective control measures
• To respond to public concerns

31
Quick Quiz

• Knowledge and skills from all of the following
  disciplines should be represented on every
  foodborne outbreak investigation team EXCEPT
• Environmental health
• Epidemiology
• Laboratory
• Industry members