Title: Foodborne Disease Outbreak
1Foodborne Disease Outbreak Investigation Team
Training
Module 7 Multijurisdictional Outbreaks
2Module 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
3Traditional 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
4Traditional Outbreak Scenario (contd)
Farm
Production
Processing
Distribution
Final preparation and cooking
Problematic food safety practices
Localized cases
5New 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
6Diffuse Outbreak Scenario (contd)
Farm
Production
Problematic food safety practices
Processing
Distribution
Final preparation and cooking
Dispersed cases
7E. 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
8Significance of Multijurisdictional Outbreaks
?
- Small proportion (2) of reported foodborne
outbreaks are multistate
9Significance of Multijurisdictional Outbreaks
(contd)
Multistate foodborne outbreaks, 1989-2008
Number of outbreaks
Year of Report
Source CDC, National Foodborne Disease Outbreak
Surveillance System
10Reasons 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
11Local Significance of Multijurisdictional
Outbreaks
- Local outbreak may herald a national or
international event.
12Listeriosis 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
13Multijurisdictional 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
14Class 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
15Local 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.
16Federal 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
17Federal 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
18When 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
19Local 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.
20Anatomy 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.
21Anatomy 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.
22Anatomy 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.
23Anatomy 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.
24Anatomy 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.
25Anatomy 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.
26Anatomy 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.
27Anatomy 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
28Anatomy 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.
29Anatomy of a Multijurisdictional Outbreak (4)
- April 19-24 FDA conducts inspection at
processing facility noting several seafood HACCP
deficiencies and sanitation concerns.
30Anatomy 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.
31Anatomy 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.
32Role 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.
33Intentional Contamination
34Intentional Contamination of Food
- Few documented incidents
- Food vulnerable target
- Vigilance and heightened awareness regarding
tampering with food supply are essential
gt Intentional contamination
35Nicotine 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
36Public 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
37Nicotine 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
38Investigation 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
39Incident Command System
40Incident 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
41Salmonella 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
42Activation 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
43Class Question
- Is the Incident Command System (ICS) activated in
your jurisdiction when a foodborne outbreak is
detected? - If so, under what circumstances is it activated?
gt Incident Command System
44Quick Quiz
45Quick 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
46Quick 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.
47Quick 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
48Quick Quiz
- Only uncommon microbial agents are associated
with intentional outbreaks. - True
- False
49Quick 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.