Metro-Nashville and Tennessee NEARS Metro-Nashville Public Health Department Nashville, TN Danny Ripley Metro-Nashville Public Health Department Food & Public Facilities Protection

Tennessee Demographics 95 Counties 7 Regions 5 Contract Counties 169 EHS Centralized food regulations Tennessee Department of Health Based on the 2009 FDA Food Code 63 Million population 28 Thousand Food Establishments Metro-Nashville Public Health Department Food & Public Facilities Protection

Outbreak Investigation Procedures Outbreak Investigation Team Environmental Health Epidemiology Laboratory Factors that influence an investigation Data Communication Individual abilities EHS OB training opportunities Metro-Nashville Public Health Department Food & Public Facilities Protection

EHS Outbreak Investigation Challenges Very few outbreaks identified per county Limits outbreak investigation experience Necessitates outbreak training Designation of outbreak investigators Metro-Nashville Public Health Department Food & Public Facilities Protection

Addressing the Challenges 1/4 1/1 1/4/1 1/2/2 1/2 1/2 1/1 1/2 1/1/1 1/2/2 1/1 1 1/1 13 Regions Primary Contacts: 13 Secondary Contacts: 23 Field EHS: 6 "Primary Contact"/"Secondary Contact"/"Field EHS" Metro-Nashville Public Health Department Food & Public Facilities Protection

Regional Outbreak Investigators Senior EHS staff Participated in Epi-Ready and NEARS training Completed E-Learning web-based training Continued Central Office EHS-Net support All outbreaks NEARS data collection and entry Metro-Nashville Public Health Department Food & Public Facilities Protection

Metro Nashville Public Health Department Local Government Food regulations contracted with TDH and TDA 20 Environmental Health Specialists 4900 Food establishments Restaurants, schools, mobile units, daycare facilities Markets, groceries & convenience stores Metro-Nashville Public Health Department Food & Public Facilities Protection

NEARS Assisting an Outbreak Investigation January 2017 Overview: Three clinically confirmed cases identified through pathogen surveillance One food establishment in common Several reported foods in common Lab: Known etiology (Campylobacter) No food for additional testing Epidemiology: Very limited data for studies Environmental: Significant time gap between incident and notification Several implicated foods Metro-Nashville Public Health Department Food & Public Facilities Protection

Environmental Assessment and NEARS Data Collection Subtle cross contamination Hand contact Inappropriate use of wiping towels Mild temperature abuse No glaring contributing factors observed NEARS Manager Interview Policy questions prompted further investigation Prep table policies Foods used Cleaning policies Significant CF identified Occasionally, one table used raw chicken and RTE food Policy did not address proper sanitization Employees were not trained in proper sanitization between raw and RTE production Metro-Nashville Public Health Department Food & Public Facilities Protection

Why do we participate in NEARS? Improves outbreak investigations Improved Team Communication Epi and Environmental (contributing factor reporting) Environmental and operators Improved consistency of environmental assessments Training Outbreak support Use of NEARS data Evaluate outbreaks across the entire state Better understand contributing factors and antecedents Routine inspection Training provided Provides documentation of the work we do Contributes to nationwide research Metro-Nashville Public Health Department Food & Public Facilities Protection

Thank You Metro-Nashville Public Health Department Food & Public Facilities Protection