CIFOR Guidelines for Foodborne Disease Outbreak Response and the CIFOR Toolkit: Focus Area 7: Epidemiology Investigation New York Integrated Center of Food Safety Center of Excellence – January 19, 2017 Andie Newman, DVM, MPH Bureau of Communicable Disease Control New York State Department of Health

Background This is the eighth webinar in a series of monthly webinars from the New York Integrated Food Safety Center of Excellence (CoE) Session covers CIFOR Toolkit Focus Area 7: Epidemiology Investigation Supplementary sessions will be devoted to assist states that wish to complete internal evaluations using the metrics and target ranges developed for the 16 CIFOR performance measures. Additional topics will focus on emerging issues in food safety including culture‐independent diagnostic testing, antimicrobial resistance, and advanced molecular detection/whole genome sequencing. All webinars will be recorded and available through the CoE website at http://nyfoodsafety.cals.cornell.edu/

How to Use the CIFOR Toolkit For each Focus area, consider the “Keys to Success” listed Describe your agency’s/jurisdiction’s current activities and procedures in relation to the Focus Area Work as as a team: epidemiology, laboratory and environmental health Refer to written protocols/procedures and other performance measures (e.g., CIFOR target ranges for selected performance measures)

The Toolkit includes a worksheet so you can list your current activities or procedures and prioritize some areas for improvement.

How to Use the CIFOR Toolkit Indicate those activities or procedures which could be changed to improve your agency’s/jurisdiction’s response to foodborne disease outbreaks Review the CIFOR recommendations related to the Focus Area of interest Rate the priority for implementing each CIFOR recommendation based on its likely impact on outbreak response at your agency/jurisdiction and available resources

What is Focus Area 7? Title: Epidemiology Investigation Goals for the Epidemiology Investigation: During an outbreak, agency/jurisdiction staff collect, analyze, and interpret exposure (and other) information from cases (and comparison groups, where appropriate) to determine the etiologic agent, persons at risk, mode of transmission, and the vehicle of the outbreak

Keys to Success Staff skills and expertise Outbreak Investigation Activities, relationships, and resources that are critical to achieving success in a Focus Area Applying metrics and measures can help you identify the success of your program or investigation process Focus Area 7: Keys to Success Staff skills and expertise Outbreak Investigation Communication Making changes

Keys to Success: Staff Skills and Expertise Staff have good interviewing skills and can collect complete and accurate exposure information from cases and controls, where appropriate* Staff have expertise in epidemiologic study design* * Or the outbreak investigation team has access to staff in other agencies with expertise in interviewing and epidemiologic study design

Staff Skills and Expertise

Staff Skills and Expertise

Keys to Success: Outbreak Investigation Agency/jurisdiction has a written protocol outline the steps in the epidemiologic investigation of a foodborne disease outbreak. Staff have easy access to this protocol and have been trained in its implementation. Staff interview cases about exposures as soon as possible after the case is reported. Staff have access to standard epidemiologic questionnaires used by other investigators in similar outbreaks.

Outbreak Investigation

Outbreak Investigation

Outbreak Investigation

Outbreak Investigation

Outbreak Investigation

Outbreak Investigation

Outbreak Investigation

Outbreak Investigation

In this model, cases are interviewed with a detailed exposure history questionnaire. Specific exposures shared by multiple cases might surface that are suspicious because they involve commodities not commonly eaten or involve specific brands of a commonly eaten food item. Because the original questionnaire might not have captured these exposures, specific questions should be added to the questionnaire for future use and to systematically re-interview cases to assess the suspicious sources discovered during the investigation process. “Novel exposure” refers to exposure that was not specifically listed on the original detailed exposure history questionnaire

Outbreak Investigation

Outbreak Investigation

Keys to Success: Communication Staff communicate in a timely fashion and coordinate activities with environmental health and laboratory staff

Communication

Keys to Success: Making Changes Agency/jurisdiction conducts a debriefing among investigators following each outbreak response and refines outbreak response protocols based on lessons learned. Agency/jurisdiction has performance indicators related to the epidemiologic investigation and routinely evaluates its performance in this Focus Area. .

Making Changes

Make Plans to Implement Selected CIFOR Recommendations For selected recommendations identified in the prioritization process, identify Lead person responsible implementation of the recommendation Time from for implementation Consider necessary antecedents to implementation or other factors that might impact success or time frame

Helpful Tips for Using the Toolkit Don’t get distracted by the volume Be clear on the process Keep moving – don’t get caught up in too much detail Focus on a few realistic changes End with specific action plans with time frames and responsible persons Appoint a facilitator and a recorder for each discussion

Where to Find the CIFOR Products Online at: www.cifor.us Paper copies are also available from CSTE Contact Thuy Kim at tkiml@cste.org Examples of CIFOR product use by other states: http://www.coefoodsafetytools.org/

Upcoming NYS CoE CIFOR Webinars Next webinar: Thursday, February 16, 2017 at 2PM Focus Area 8: Environmental Health Investigation Wednesday, March 22, 2016 at 2PM Focus Area 9: Laboratory Investigation Course announcement and link to register is posted on the DOH Learning Management System (LMS): www.nylearnsph.com

Resources Comments or questions for NY CoE can be directed to: Paula Huth or Andie Newman, NYSDOH 518-473-4439 Integrated Food Safety CoE Websites: NY CoE: http://nyfoodsafety.cals.cornell.edu/ CDC: http://www.cdc.gov/foodsafety/centers/