Outbreaks Involving Food & Lodging Establishments Partnerships Needed for a Successful Investigation

Outbreaks Involving Food & Lodging Establishments

Partnerships Needed for a Successful InvestigationCarl WilliamsMelissa HamNicole LeePresentation ContentWhy do we care about foodborne outbreaks?

What partners need to be involved and why?

How does this partnership work during an outbreak?

What are some common conflicts between partners?

Are there resources for partners?

Q & AWhy do we care about foodborne outbreaks?

3Why do we care about foodborne outbreaks?Potential illness reaching the masses

Intentional vs accidental contamination

Possible wide distribution of a contaminated item

Vulnerable populations

Loss of days worked, wages, business, trust

Community sickness, illness or death, criminal vs employee error cases, Widespread sickness, Highly susceptible populations more severe, damage creating chronic conditions in HSP, death, economic business, employees, and reduced/loss of trust in the community toward the business and/or health department, loss of trust business toward regulatory4Real Life Events: Salmonella

The outbreak of Salmonella last year from a hotel restaurant was not our largest outbreak but it definitely received the most press of any within foodborne that weve had since our group came on board.5Real Life Events: Salmonella

Total Ill100

Hospitalized8

Counties Represented11

Ages17yrs-81yrsMedian: 45 yrsThere were a large number of illnesses among people that crossed county and state lines. We ended up with cases from 11 different counties within NC and there were cases from 8 other states. 6Real Life Events: Salmonella

Another more recent NC example, mentioned here on the website of one of the popular foodborne litigation groups based in Seattle Washington, is that of a church barbeque in Cleveland county where the reports of illness were higher than the previously mentioned outbreak.7Real Life Events: Salmonella

Total Ill104

Hospitalized14

Counties Represented5

Ages3yrs 85yrsMedian: 55yrsThere were a total of 104 reported cases associated with the outbreak and 14 were hospitalized. Cases from 5 counties clustered around Cleveland were represented and the ages of those affected ranged from as young as 3 to as senior as 85. 8Real Life Events: Norovirus

Heres an example where food was the vehicle, but not the source of infection. This norovirus outbreak was due to food employees working while ill in Indiana.9Real Life Events: Hepatitis A

This attorney mentions the point of how foodborne illness can be prevented when ill food employees stay home while ill. He uses the incident of an outbreak of Hepatitis A (a virus transmitted by the fecal oral route) caused by an ill food employee who continued to work at a McDonalds in Illinois while ill.

These are just a few examples of why we care about and must respond to foodborne outbreaks.10What partners need to be involved and why?

What partners need to be involved?

When we think about what partners need to be involved, we think about the three-legged stool example. This stool cannot support any weight put on it without all three legs being present. In our case the weight we experience is that of an outbreak.12What partners need to be involved?

Laboratory13What partners need to be involved?

Environmental Health

LaboratoryWhat partners need to be involved?

Epidemiology

Environmental Health

LaboratoryAll three of these legs are needed to support the weight of an outbreak.15What partners need to be involved?

Epidemiology

Environmental Health

LaboratoryWe wouldnt be very confident in this stool if one of the legs were missing. In the same way, all three components are important for us to be confident in the outbreak investigation of food and lodging establishments.16What partners need to be involved?

Epidemiology

Environmental Health

LaboratoryWe wouldnt be very confident in this stool if one of the legs were missing. In the same way, all three components are important for us to be confident in the outbreak investigation of food and lodging establishments.17What partners need to be involved?

Epidemiology

Environmental Health

LaboratoryWe wouldnt be very confident in this stool if one of the legs were missing. In the same way, all three components are important for us to be confident in the outbreak investigation of food and lodging establishments.18What partners need to be involved?

Epidemiology

Environmental Health

LaboratoryThis is the set up thats most effective during an outbreak investigation at food and lodging establishments.19Purpose of partnersAgent specific

Verify diagnosis

Outbreak specific

Identify source

Implement control measuresLaboratoryEpidemiologyFacility specific

Identify exposure and transmission opportunities

Implement control measuresEnvironmental HealthHere is the reason why we need these three specific partners:

Laboratory partners identify what specific agent may be causing the outbreak. While someone may have general gastrointestinal illness, it is the result from the laboratory that can verify what agent is the likely cause of those symptoms.

Environmental Health-menu review, invoices, anything different than normal, who was working the day in question, sick employees, employees with exposure opportunities, laboratory results can narrow down where to start the assessment sick employee vs contamination, source, temperature abuse

Epidemiology partners use the information gathered from laboratory results, environmental health results, and epidemiology information to try to identify a likely source.20One exampleWhen has this worked?Now lets look at an example of when these partnerships worked together on an outbreak.21Real Life Event: Salmonella

Well use the example shown at the beginning of the presentation.22Monday, May 13, 2013Day 1Fifteen ill with N/V/D (some bloody)10 / 15 hotel staff (3/10 food handlers)1 hospitalizedTwo of three samples (+ Salmonella)May 8th was the first onset

4pm - Conference callLocal Health Dept: Epi, Env HlthState: Epi, Env Hlth, Lab, Public Affairs

10:00am Call from CD NurseDay 1 Summary of Actions/DecisionsConfirm the storyImplement control measures with hotel/rest.Interview illCoordinate hotel assessment with Env HlthCoordinate stool specimen collection, shipment, and testing with state labDevelop communication toolsSend statewide & national alerts to identify additional casesRequest receipts from hotel (case-control study)Develop survey from hotel menuSend state staff to Cumberland to assist with summarizing data and data entry

Now is not the time to conduct a routine inspection, this is the time to get as much information as possible without the undercurrent of a sanitation grade. Folks tend to start performing when inspected and you are not getting the true scenarios. What are you going to do with the sanitation grade if you do the inspection? Grade goes up what does that mean to the program? Grade goes down, how far down? The knowledge going in even if presumptive tells a lot about where we need to focus. Fecal oral transmission-staff, NBHC of RTE food, employee health, handwashing etc. Other organisms may take us to a different location say Salmonella Heidelberg would point us toward contamination. It is imperative to have laboratory information at the onset of conducting the assessment.253 Partners with 1 Goal

Stop the OutbreakActivities of partnersTest stoolGrow isolateBiochem testsSubtypingPFGEEnvironmental testing (partner labs)

Coordinate activitiesCharacterize illnessAnalyze data from all partnersLaboratoryEpidemiologyFacility AssessmentProcessesEmployeesEnvironmental HealthWe could elaborate and explain that testing stool is broad it included receiving a specimen and trying to grow an isolate, then doing biochemical tests, subtyping, PFGE. This may help people to see why it takes time b/c each step takes hours to days. Without an isolate we cant do PFGE and without PFGE we cant really link from a laboratory perspective.27ResultsLaboratoryEnvironmental HealthEpidemiologyLaboratory Results54 specimens tested

2 (4%) unsatisfactory

27 (50%) negative

25 (46%) positive25 (100%) Salmonella typhimurium25 (100%) had the same matching PFGE pattern

A total of 54 specimens were tested. You may notice and wonder why about half were negative. There could be multiple reasons for this, including someone no longer shedding organism at the time the stool was collected. For outbreak purposes, we still include people who were symptomatic and exposed even if the specimen ends up being negative.

For those who were positive all of these specimens ended up with the same DNA fingerprint, which is an uncommon, but recurring pattern in NC. The fact that no other state labs in the US identified this same pattern during the outbreak is an indication that the source was only a local one.

29Environmental Health ResultsEnvironmental AssessmentsRisk FactorsPersonal HygieneApproved SourceContaminationHoldingCookingInterviewsTrainingsEnvironmental Health ActionsRequired reportable BIG 5ToolsThree legged stoolEmployee HealthHand washingNo Bare Hand Contact of Ready to Eat foodRisk Control PlansEnforcement

The identified organism/isolate tells us first where to go in the assessment. The BIG 5 Norovirus, Salmonella Typhi, Shigella, Hepatitis A, or EHEC/STEC required reportable per the code for employee health. Importance of the three legged stool. Handwashing isnt enough, NBHC isnt enough, keeping sickness out of the establishment is good but not enough due to folks can be shedding without symptoms. Risk Control plans were developed for NBHC and handwashing. The management was approached about developing procedures to remediate weaknesses identified in the assessment such as barriers between hands and foods and handwashing. Health department were vigilant making daily visits and holding trainings for several consecutive days. The management agreed to a whistle type procedure for handwashing so supervisors in the kitchen areas could actually hear a whistle blow when an employee started washing their hands. The employees would respond with Great Job or you rock response upon hearing the whistle. Enforcement-was not required during this outbreak; having detailed specific citations in regard to communicable disease enforecment action can be taken without additional steps by the REHS or health director. Not a need for a declaration of an imminent health hazard from the health director. Failure for an establishment to adhere to employee health, make corrections or a priority or a priority foundation violation can result in permitting action.Priority items are directly related to elimination, prevent or reduction of hazards associated with FBI or injury. Priority foundation supports, facilities or enables priority items. (example: the process PF which led to a temperature violation P.

They wanted to go above and beyond and get out in front of this risk control plan.

Enforcement no use of communicable disease statute anymore using the food code instead now. No need to call the health director anymore.31

Using information from patient interviews, we graph the date that each individual began feeling sick. This is called an epi curve and it can show you when your outbreak starts and ends, the magnitude of people involved, and the pattern of illness (i.e. quick peak with one likely exposure, vs multiple peaks with secondary transmission, vs no peaks showing continued ongoing illness).

This epi curve shows that people began feeling ill on May 1st and the last day someone began feeling ill was May 17th which means that people were ill over the course of 17 days. The most people began feeling ill on May 9th.

We also added the information we received from the lab to this graph. The plus signs represent those individuals who tested positive for the outbreak strain of Salmonella. This outbreak strain was not seen anywhere else in the US database of PFGE results.32

We also added information obtained during the environmental health assessment to this graph. In the background you can see multiple activities that were occurring at this facility during the course of the outbreak.33

From our investigation we were able to exclude these events as causes for the outbreak.34Epidemiology ResultsTotal Ill100

Hospitalized8

Counties Represented11

Ages17yrs-81yrsMedian: 45 yrsExposureRelative RiskFOODEmployee Potluck0.62Caf Breakfast Buffet0.89Caf Lunch Buffet1.09All American Grill3.6WORK TASKAll American Grill Supervisor4.3RESULTS

Those who ate/drank at the All American Grill were 3.6 times more likely to become ill when compared to those who did not eat/drink at the All American GrillFrom our investigation where we administered surveys to compare the activities of ill and well staff, we found that those who ate/drank at the All American Grill were 3.6 times more likely to become ill when compared to those who did not eat/drink at the All American Grill. Due to small numbers we could not pinpoint a specific food item from the All American Grill that was associated with illness.

BUT, the environmental health assessment revealed multiple opportunities for the ongoing transmission of Salmonella. In addition, we can see on our epi curve that the results from the work of our lab colleagues show cases positive for the outbreak strain over multiple incubation periods suggesting that the source of the outbreak was not one point in time but a continuous exposure over multiple days otherwise the number of cases would only occur over one incubation period.

35Process ResultsAfter outbreaks are over the following questions are asked of those involved:

What worked well during this outbreak?

What did not work well during this outbreak?

What recommendations do you have to improve the handling of future outbreaks?What are some common conflicts between partners?

37Potential conflicts with partnersNot aware of numerous incoming specimensSpecimens may be un-satisfactory

Interest in accompanying EH during facility assessmentsTiming of lab results can feel delayedLaboratoryEpidemiologyExpanded workload Additional team members on siteEnvironmental HealthCommunication is very important because the lab may not aware of numerous incoming specimens

The actual cases are partners as well and an unsatisfactory lab result can be frustrating for them too they may have to be out of work/daycare longer until a specimen/result is satisfactory.

Interest in accompanying EH during facility assessments because we want to be able to understand your processes and concerns, and be able to present them accurately.

Having epi go to regional meetings about what we all do.

38Potential conflicts with partnersFeels like state is taking over instead of assistingNursing staff pulled from clinic to address outbreak needs

Ensure the county is happy with how the outbreak is leadEnsuring the same message is communicated to the publicLocal Health DeptState Health DeptNursing staff pulled from clinic to address outbreak needs which has an affect on clinic flow you may have to reschedule appointments

Working with the Local Health Dept to ensure the same message is communicated to the public

We recognize the inherint challenges with where you are and what youre dealing with.

39Conflict resolutionEstablish relationships with partners before or outside of an outbreak situationWho is your point of contact and what can they do for you

Understand the role of each partnerWhat do they do and whyDo they have the resources the response requires

CommunicationHow often is everyone updated and through what method

Take the opportunity to both learn from others and share your knowledgeAre there resources for partners?

41Partnership ResourcesSLPH website

CDC resources

MOA with other states for surge capacity

NC Online Communicable Disease Manual

APHL Control of Communicable Disease ManualLaboratoryEpidemiologyNC Food Code

Online EH training for Assessments during Outbreaks http://www.cdc.gov/nceh/ehs/eLearn/EA_FIO/ Environmental HealthPartnership ResourcesLaboratoryEpidemiologyEnvironmental Health

We eliminate redundancy when we know each others materiali.e. public health was asked to draft an isolation order, but that didnt need to be done because the food code, which is already established, already has the exclusion requirement.43Partnership ResourcesLaboratoryEpidemiologyNC Food Code Cheat SheetEnvironmental Health

This would be a quick reference resource for local CD nurses. Weve made copies and have them in the back if youre interested in bringing them back to your local health departments.

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This would be a quick reference resource for local CD nurses. Weve made copies and have them in the back if youre interested in bringing them back to your local health departments.

A sequestered population is also included as a highly suseptible population

46Q & A?

47Carl Williams, Public Health Veterinarian carl.williams@dhhs.nc.gov, 919-733-0391

Melissa Ham, Regional Environmental Health Specialist melissa.ham@dhhs.nc.gov, 910-303-9247

Nicole Lee, Foodborne Epidemiologist nicole.lee@dhhs.nc.gov, 919-715-1162

Thank You

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