Foodborne Disease Outbreak

1
Foodborne Disease Outbreak Investigation Team
Training
Module 7 Multijurisdictional Outbreaks
2
Module Learning Objectives

• At the end of this module, you will be able to
• Discuss recent shifts in the nature of foodborne
  disease outbreaks.
• List indicators that suggest an outbreak is
  likely to involve cases from multiple
  jurisdictions.
• Describe federal public health agencies likely to
  participate in multijurisdictional
  investigations.
• List clues that an outbreak might be due to
  intentional contamination.
• State whether the local incident command system
  is activated during an outbreak response in your
  jurisdiction.

gt Learning objectives
3
Traditional Outbreak Scenario

• Focal outbreak
• Caused by local food handling error (endpoint
  contamination event)
• Large number of cases in one jurisdiction
• Detected by affected group
• Local investigation
• Local solution

4
Traditional Outbreak Scenario (contd)
Farm
Production
Processing
Distribution
Final preparation and cooking
Problematic food safety practices
Localized cases
5
New Outbreak Scenario

• Dispersed outbreak
• Caused by industrial contamination event (during
  production, processing, or distribution) with a
  widely distributed food
• Small numbers of cases in many jurisdictions
• Detected by pathogen-specific surveillance with
  subtyping
• Multijurisdictional
  investigation
• Solution that has broad
  implications

6
Diffuse Outbreak Scenario (contd)
Farm
Production
Problematic food safety practices
Processing
Distribution
Final preparation and cooking
Dispersed cases
7
E. coli O157H7 and Cookie Dough

• Cluster of E. coli O157H7 detected by PulseNet
  with cases from 13 states
• No commonalities through initial case interviews
  open-ended interviews in WA revealed 5 of 5 cases
  ate raw cookie dough
• Multistate case-control study linked illness to
  Brand X cookie dough
• Non-outbreak STEC
  isolated from cookie
  dough and flour
  supplier
• 77 cases in 30 states
  

8
Significance of Multijurisdictional Outbreaks
?

• Small proportion (2) of reported foodborne
  outbreaks are multistate

9
Significance of Multijurisdictional Outbreaks
(contd)
Multistate foodborne outbreaks, 1989-2008
Number of outbreaks
Year of Report
Source CDC, National Foodborne Disease Outbreak
Surveillance System
10
Reasons for Increase

• Centralized production and wide distribution of
  food products
• Globalization of food supply
• Increased detection of outbreaks through
• Improved surveillance efforts
• Subtyping of causative agents
• Information sharing

11
Local Significance of Multijurisdictional
Outbreaks

• Local outbreak may herald a national or
  international event.

12
Listeriosis and Cantaloupe

• Seven cases of listeriosis reported from CO
• All had eaten cantaloupe in month before illness
• Cases in other states detected through PulseNet
  comparisons of outbreak-related and non-outbreak
  related listeriosis cases confirm cantaloupe link
• Traceback converges on
  CO producer that
  shipped cantaloupe
  to
  24 states
• 146 cases from
  28 states

13
Multijurisdictional Outbreak Indicators

• Implicated food contaminated before point of
  service and is
• Commercially distributed, processed, or
  ready-to-eat item
• Fresh produce item
• Ground beef in E. coli O157H7 outbreak
• Illnesses linked to multiple food-service
  establishments
• Molecular subtype of causative agent matches
  agent associated with outbreaks in other
  locations
• Exposed persons have subsequently dispersed

14
Class Question
?
Which of the following outbreaks are likely to
involve cases residing in multiple jurisdictions?
Multiple jurisdictions
No

• Illness linked to food safety problem at
  elementary school cafeteria

Yes
Outbreak associated with national brand food no
local contributing factors identified
Yes
Cases linked to food purchased from several
different restaurants in one city
Yes
Outbreak linked to food served on airline flight
15
Local Significance of Multijurisdictional
Outbreaks

• Local outbreak may herald a national or
  international event.
• Local jurisdictions will need to coordinate
  investigation efforts with other local, state,
  and federal partners.

16
Federal Public Health Agencies

• Centers for Disease Control and Prevention (CDC)
  - Non-regulatory agency that focuses on disease
  surveillance, outbreak detection, and
  investigation
• U.S. Department of Agriculture/Food Safety and
  Inspection Service (USDA/FSIS) - Regulatory
  agency that oversees safety of meat, poultry, and
  pasteurized egg products
• U.S. Food and Drug Administration (FDA) -
  Regulatory agency that oversees safety of most
  foods except meat, poultry, and pasteurized egg
  products

gt Federal public health agencies
17
Federal Agency Contributions to Outbreak
Investigation

• Leadership and coordination
• Expertise and experience
• Laboratory testing
• Other resources (e.g., manpower, educational
  materials)
• Public health regulatory authority over certain
  control measures (e.g., recalls)

gt Federal public health agencies
18
When to Involve Federal Agencies

• Outbreaks associated with
• Cases from multiple states (or countries)
• Commercially distributed food contaminated before
  point of service
• Highly pathogenic or unusual causative agent
• Large numbers of cases that require additional
  resources to investigate
• Intentional contamination suspected
• Request for assistance through state
  epidemiologist

gt Federal public health agencies
19
Local Significance of Multijurisdictional
Outbreaks

• Local outbreak may herald a national or
  international event.
• Local jurisdictions will need to coordinate
  investigation efforts with other local, state,
  and federal partners.
• Local jurisdictions may be asked to urgently
  investigate one or a few cases that are part of a
  larger outbreak despite their apparently small
  local impact.

20
Anatomy of a Multijurisdictional Outbreak (1)

• March 1 NY State notifies CDC of 4 persons
  infected with Salmonella Bareilly with unusual
  PFGE pattern.

Vigilant state health department quickly brings
attention to problem.
21
Anatomy of a Multijurisdictional Outbreak (1)

• March 1 NY State notifies CDC of 4 persons
  infected with Salmonella Bareilly with unusual
  PFGE pattern.
• March 2 PulseNet shows 11 persons in 7 states
  with the same pattern. CDC initiates multistate
  investigation and holds first conference call.

Rapid communication ensues between local, state,
and federal public health partners states share
case information during conference call and are
asked to use same hypothesis-generating
questionnaire.
22
Anatomy of a Multijurisdictional Outbreak (1)

• March 1 NY State notifies CDC of 4 persons
  infected with Salmonella Bareilly with unusual
  PFGE pattern.
• March 2 PulseNet shows 11 persons in 7 states
  with the same pattern. CDC initiates multistate
  investigation and holds first conference call.

• March 8 Interviews of 8 ill persons reveal 7
  ate seafood and 5 ate sushi before illness.

Since most states have only 1-2 cases, comparison
of case information across states is critical for
hypothesis generation.
23
Anatomy of a Multijurisdictional Outbreak (2)

• March 8-13 TX and WI each
  report cluster of unrelated cases
  who ate a same
  Japanese
  restaurant. Focused hypothesis
  generating questionnaire deployed.

New hypothesis-generating questionnaire to be
used by all investigators focuses on sushi
restaurant clusters allow initiation of traceback
studies.
24
Anatomy of a Multijurisdictional Outbreak (2)

• March 8-13 TX and WI each
  report cluster of unrelated cases
  who ate a same
  Japanese
  restaurant. Focused hypothesis
  generating questionnaire deployed.
• March 15 FDA begins receiving supplier and
  invoice data.

Local and state staff collect invoices, receipts,
and bills of lading from food establishments
associated with clusters.
25
Anatomy of a Multijurisdictional Outbreak (2)

• March 8-13 TX and WI each
  report cluster of unrelated cases
  who ate a same
  Japanese
  restaurant. Focused hypothesis
  generating questionnaire deployed.
• March 15 FDA begins receiving supplier and
  invoice data.
• March 16-27 WI, CT, and MD report clusters that
  ate sushi from same store/restaurant based on 20
  case interviews, gt90 ate sushi, primarily spicy
  tuna.

States search for cases related to outbreak and
complete interviews link to sushi strengthens.
26
Anatomy of a Multijurisdictional Outbreak (3)

• March 29-April 9 Comparison of meal receipts at
  4 restaurants shows 84 of case meals and 37 of
  meals of other customers contained spicy tuna.

Local and state staff undertake study at
restaurants linked to outbreak.
27
Anatomy of a Multijurisdictional Outbreak (3)

• March 29-April 9 Comparison of meal receipts at
  4 restaurants shows 84 of case meals and 37 of
  meals of other customers contained spicy tuna.
• April 10 WI reports 5 Salmonella Nchanga
  infections in same states as S. Bareilly cases.
  One ate at same restaurant as S. Bareilly case
  one was chef at restaurant where S. Bareilly case
  ate.

Continued sharing of information brings new twist
28
Anatomy of a Multijurisdictional Outbreak (3)

• March 29-April 9 Comparison of meal receipts at
  4 restaurants shows 84 of case meals and 37 of
  meals of other customers contained spicy tuna.
• April 10 WI reports 5 Salmonella Nchanga
  infections in same states as S. Bareilly cases.
  One ate at same restaurant as S. Bareilly case
  one was chef at restaurant where S. Bareilly case
  ate.
• April 13-14 Producer is identified,
  recalls yellowfin tuna
  from
  processing facility in India CDC
  and FDA warn public.

Recall based on data collected by states and
analyzed by FDA.
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Anatomy of a Multijurisdictional Outbreak (4)

• April 19-24 FDA conducts inspection at
  processing facility noting several seafood HACCP
  deficiencies and sanitation concerns.

30
Anatomy of a Multijurisdictional Outbreak (4)

• April 19-24 FDA conducts inspection at
  processing facility noting several seafood HACCP
  deficiencies and sanitation concerns.
• April 24-26 S. Bareilly is isolated from
  recalled tuna and spicy tuna roll made with
  recalled tuna outbreak strains of S. Bareilly
  and Nchanga found in unopened packages of
  
  yellowfin tuna product
  from producer.

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Anatomy of a Multijurisdictional Outbreak (4)

• April 19-24 FDA conducts inspection at
  processing facility noting several seafood HACCP
  deficiencies and sanitation concerns.
• April 24-26 S. Bareilly is isolated from
  recalled tuna and spicy tuna roll made with
  recalled tuna outbreak strains of S. Bareilly
  and Nchanga found in unopened packages of
  
  yellowfin tuna product
  from producer.
• Total 425 cases from
  28 states
  and D.C.

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Role of State and Local Jurisdictions in
Multijurisdictional Outbreaks
?

• Notify others of local outbreaks.
• Be aware of outbreaks in other jurisdictions.
• Search for local cases/clusters associated with
  multijurisdictional outbreak.
• Participate in hypothesis generation.
• Perform tasks (e.g., interview cases, undertake
  studies) as agreed upon.
• Collect paperwork to support traceback
  investigations by federal agencies.

33
Intentional Contamination
34
Intentional Contamination of Food

• Few documented incidents
• Food vulnerable target
• Vigilance and heightened awareness regarding
  tampering with food supply are essential

gt Intentional contamination
35
Nicotine Poisoning and Ground Beef

• Supermarket customers in MI complain of burning
  of the mouth, nausea, vomiting, and dizziness
  following consumption of ground beef purchased on
  certain dates
• Supermarket recalls 1,700 lbs. beef from
  out-of-state processor that was ground at the
  store
• Samples of ground beef found positive for
  nicotine
• Local health department
  identifies over 90 cases
  
• Employee indicted by grand
  jury

gt Intentional contamination
36
Public Health Clues
?

• Likely to mimic unintentional foodborne outbreak

Envt Health Epidemiologic Laboratory

Unusual food Contamination without clear
natural pathway Contamination at unexpected
step in production Evidence of
tampering Multiple exposure sites or foods
with no apparent link
Large number of cases in short time Multiple
labs or states in short time Setting of large
exposure numbers Unusual illness, treatment
response, high hospitalization and death
rate Unseasonal pattern
High concentration of causative agent in
implicated food Unusual agent Unexpected agent
for food Combination of agents Isolates from
unrelated foods
gt Intentional contamination
37
Nicotine Poisoning and Ground Beef (contd)

• Hints of intentional contamination
• Nicotine as a contaminant of ground beef
• 300 mg/kg of nicotine in implicated ground beef
• Contamination limited to single store
• Nicotine-containing pesticides not used at store
• Source of nicotine thought to be Black Leaf 40,
  an insecticide formulation discontinued in 1992

gt Intentional contamination
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Investigation of Intentional Contamination

• Follows same approach as for all outbreaks until
  intentional contamination suspected
• Then everything changes!!!
• Different partners with different objectives
• Added steps (e.g., parallel investigation by law
  enforcement)
• Special issues (e.g., safety of team members,
  proper handling of specimens, capacity of
  laboratory to test for unusual agents)
• Importance of developing working relationship
  with possible partners BEFORE incident occurs

gt Intentional contamination
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Incident Command System
40
Incident Command System (ICS)

• Management system that helps multiple agencies
  work together
• Supports and coordinates necessary activities and
  communications
• Has operating rules and processes

gt Incident Command System
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Salmonella and Public Water System

• Salmonella outbreak in Alamosa, Colorado
• 442 illnesses and one death
• Source determined to be public water system
• Colorado Safe Drinking Water program focused on
  correcting problems with public water system
• ICS helped to manage others aspects of response
  including
• Bulk water delivery
• Public notification of
  advisories and updates
• Interagency coordination

gt Incident Command System
42
Activation of ICS in Outbreak Response?

• Determined by agency/jurisdiction
• Some jurisdictions use ICS extensively
• Others do not
• Triggers for involvement should be decided in
  advance
• Necessary integration of ICS into response
  planning and team training, if decision is made
  to activate system under certain circumstances

gt Incident Command System
43
Class Question

1. Is the Incident Command System (ICS) activated in
   your jurisdiction when a foodborne outbreak is
   detected?
2. If so, under what circumstances is it activated?

gt Incident Command System
44
Quick Quiz
45
Quick Quiz

• Which of the following is a likely reason for the
  increase in multijurisdictional outbreaks in
  recent years?
• Food produced in the United States is less safe
  than it used to be
• Improved ability to link cases of foodborne
  illness due to subtyping efforts
• Antibiotic use in livestock
• Increased interest in locally produced foods sold
  through farmers markets

46
Quick Quiz

• All of the following characteristics suggest that
  cases associated with a local outbreak might
  reside in multiple jurisdictions EXCEPT
• Implicated food was widely distributed.
• Contributing factors were found at the implicated
  restaurant during the environmental health
  assessment.
• Illness among cases was linked to multiple
  restaurants.
• Outbreak was linked to an event that drew
  participants from many states.

47
Quick Quiz

• Which of the following is a likely contribution
  of federal public health agencies to a
  multi-jurisdictional foodborne outbreak
  investigation.
• Expertise and experience
• Resources such as laboratory testing
• Leadership and coordination
• All of the above

48
Quick Quiz

• Only uncommon microbial agents are associated
  with intentional outbreaks.
• True
• False

49
Quick Quiz

• Which of the following statements about the
  incident command system (ICS) is correct?
• The health department should not activate the ICS
  until the situation reaches a crisis.
• ICS operating rules and processes can help
  multiple agencies work together efficiently and
  effectively.
• It is recommended that the local ICS be activated
  in all foodborne outbreaks.
• Involved agencies will be familiar with public
  health and foodborne diseases.