Council to Improve Foodborne Outbreak Response (CIFOR) Update Lisa Hainstock, RS Michigan Department of Agriculture and Rural Development (Representing AFDO) October 26, 2016 1

Council to Improve Foodborne Outbreak Response (CIFOR) AFDO ASTHO USDA/ FSIS APHL NEHA NASPHV CDC The Council to Improve Foodborne Outbreak Response (or CIFOR) is a multi-disciplinary working group formed in 2006 that includes federal agencies and national professional organizations whose staff and members have an interest in and responsibility for controlling foodborne disease outbreaks in the United States. CIFOR member organizations are represented in the figure on this slide. CIFOR is co-chaired by CSTE and NACCHO. AFDO: Association of Food & Drug Officials ASTHO: Association of State & Territorial Health Officials APHL: Association of Public Health Laboratories CDC: Centers for Disease Control & Prevention CSTE: Council of State & Territorial Epidemiologists FDA: Food & Drug Administration NACCHO: National Association of County & City Health Officials NASDA: National Association of State Departments of Agriculture NASPHV: National Association of State Public Health Veterinarians NEHA: National Environmental Health Association USDA/FSIS: U.S. Department of Agriculture/Food Safety & Inspection Service NASDA CSTE* NACCHO* FDA

About CIFOR Vision: Local, state, and federal partners collaborating effectively to reduce the burden of foodborne illness in the U.S. Mission: To improve methods at the local, state, and federal levels to detect, investigate, control, and prevent foodborne disease outbreaks CIFOR was convened to increase collaboration across the country and across relevant areas of expertise in order to reduce the burden of foodborne illness in the United States. CIFOR identifies barriers to the rapid detection and response to foodborne disease outbreaks and then develops projects to address those barriers. The group was created to develop (and share) model programs, processes, and other products that facilitate investigation and control of foodborne disease outbreaks and improve performance and coordination in foodborne disease outbreaks across all levels of government. From the start, the development of comprehensive, consensus-based guidelines for foodborne disease outbreak response was a high priority for CIFOR.

A few CIFOR products… Guidelines for Foodborne Outbreak Response Guidelines Toolkit Legal Preparedness Resource Epi-Lab Integrated Reporting Software Outbreaks of Undetermined Etiology (OUE) Guidelines Target Ranges For Selected Performance Measures in the CIFOR Guidelines Metrics Entry Tool (C-MET) NEW

CIFOR Guidelines for Foodborne Disease Outbreak Response Developed by a workgroup with representatives from state, local, and federal level as well as all disciplines Recommendations are based on existing guidelines and practices Incorporated input from external reviewers and public review process 1st edition in 2009: 198 pages 2nd edition in 2014: 255 pages To improve the response to foodborne disease outbreaks nationwide, CIFOR developed comprehensive, consensus-based guidelines for foodborne disease outbreak response. The Guidelines for Foodborne Disease Outbreak Response were developed by a workgroup of experienced public health practitioners. The group represented epidemiology, environmental health, laboratory, and food regulation and included representatives from the local, state, and federal levels. The document is based on existing guidelines and practices and went through multiple revisions with input from external reviewers and a public review process. The CIFOR Guidelines were released in 2009 and have been distributed to state and local epidemiologists, environmental health specialists, public health laboratories, and many others, and have been used in trainings and workshops. In revised guidelines-- More recent evidence-based best practices, Recommendations from evaluation report, Revised Performance indicators/metrics-- Target ranges for some metrics Add significant changes in the foodborne disease outbreak investigation and response framework since 2009, especially Food Safety Modernization Act (FSMA) Add new information about model practices in outbreak investigation and response Update statistics, references, and examples Improve readability Adds linkage to 2nd Ed. of CIFOR Guidelines Toolkit Not intended to be a major re-write

Purpose of CIFOR Guidelines Help agencies improve foodborne outbreak detection and response Provide a comprehensive resource for food safety programs Harmonize foodborne disease investigation work across agencies and jurisdictions Available at www.cifor.us/CIFORGuidelinesProjectMore.cfm The Guidelines have three major purposes To help local and state agencies examine and improve their current foodborne disease outbreak response activities. To provide a comprehensive, foundational reference for anyone working in food safety or a food safety program, particularly new staff. To harmonize foodborne disease investigation work across all agencies, in order to have as much consistency as possible between jurisdictions. The CIFOR Guidelines describe the major functions that should occur before and during a foodborne disease outbreak. The Guidelines provide useful background information on these functions and the rationale for various activities. The Guidelines describe a range of practices to improve foodborne disease outbreak response. The Guidelines also have a chapter on performance indicators. These indicators are a means by which state and local health departments can evaluate the performance and determine the effectiveness of their food safety programs.

CIFOR Guidelines Toolkit A process and supporting materials to help agencies and jurisdictions: Become more familiar with the recommendations in the CIFOR Guidelines Systematically evaluate their current foodborne disease detection and outbreak response activities Identify appropriate Guidelines recommendations to improve performance Make plans to implement those recommendations Given these challenges, implementation of the Guidelines isn’t always easy, and that’s where the CIFOR Toolkit comes in. The CIFOR Toolkit is a process and set of supporting materials designed to help agencies and jurisdictions. The Toolkit helps agencies and jurisdictions: Better understand their current foodborne disease outbreak response activities, Become more familiar with the CIFOR Guidelines and recommended practices, Identify specific CIFOR recommendations appropriate to the agency/jurisdiction to improve performance, and Make plans to implement those activities.

CIFOR Guidelines Toolkit “Repackaging” of recommendations from the CIFOR Guidelines Stepwise process, guided by easy-to-use worksheets Helps agency/jurisdiction zero in on most appropriate recommendations First edition was released in 2011 Second edition released in 2015 http://www.cifor.us/toolkit.cfm To help agencies and jurisdictions identify the most appropriate recommendations from the CIFOR Guidelines for their agency/jurisdiction, a companion “Toolkit” was developed. The Toolkit largely repackages the recommendations included in the Guidelines and promotes a simple stepwise process guided by a series of worksheets. Like the CIFOR Guidelines, the Toolkit was developed by a CIFOR Workgroup with practical experience and expertise in foodborne disease outbreak response. The workgroup reflected a wide variety of perspectives including epidemiology, environmental health, laboratory sciences, and food regulation and included representatives from the local, state, and federal level. The first version of the Toolkit was released in 2011. The companion to the revised CIFOR Guidelines will be released in early 2015.

Toolkit Focus Areas Planning and Preparation Relationships with relevant agencies & organizations Necessary resources Communication Surveillance and Outbreak Detection Control Measures Control of source and secondary spread Food recall Complaint systems Pathogen-specific surveillance Investigation of Outbreaks and Clusters Focus Areas are used in the CIFOR Toolkit as a way of organizing the recommendations in the CIFOR Guidelines. Focus Areas are critical aspects of outbreak response broken into “bite-sized” chunks that allow users to systematically examine the myriad of foodborne disease-related activities being undertaken in an agency and focus on those most critical to their agency. In the revised CIFOR Toolkit, there are 11 Focus Areas (as seen in this slide). They are grouped under four different tracks (planning and preparation, surveillance and outbreak detection, investigation of outbreaks and clusters, and control measures). Each recommendation in the CIFOR Guidelines has been categorized according to these 11 Focus Areas. Focus Area-specific worksheets allow users to review the recommendations associated with any particular Focus Area and select a priority level for implementation of the recommendation at the agency/jurisdiction (1=low priority, 5=high priority). The end result is that once an agency or jurisdiction identifies the Focus Areas in greatest need, they can more easily zero in on CIFOR Guidelines recommendations to address that particular Focus Area. Initial steps Epidemiology investigation Environmental health investigation Laboratory investigation

CIFOR Legal Preparedness Resources Tools for public health agencies to improve legal preparedness to conduct surveillance for foodborne diseases & respond to outbreaks Documents: Analysis of State Legal Authorities Practitioners’ Handbook on Legal Authorities Menu of Legal Options Released Spring 2013 Available at http://www.cifor.us/projlaw.cfm Analysis of State Legal Authorities Describes and analyzes the types of state legal authorities generally available to conduct FBD investigation and response activities Based on 12 states’ laws; findings may not apply in all states Report used as the basis for the foregoing information Practitioner’s Handbook on Legal Authorities A practical guide for public health professionals who perform key roles in FBD events A primer on the array of potential legal authorities that may be used Provides a series of checklists for identifying relevant agency actors and laws within a jurisdiction Menu of Legal Provisions A menu of legal provisions for state public health officials and policy makers A resource for states to use in filling gaps and clarifying or enhancing their legal authorities NOT a model law or otherwise suggesting “ideal” language

CIFOR Epi-Lab Integrated Reporting Software Free, open-source cluster detection software database and platform independent More quickly identify potential clusters within their jurisdictions Built in reports provide “30-day” and historical analyses Mapping feature provides additional geographical analysis of cases Piloted in 4 states: more clusters detected faster IT resources needed will vary from state to state User guide, software files available on CIFOR website http://www.cifor.us/projelr.cfm The CIFOR Application is intended to provide a bridge(s) among the various informatics systems and provide the user with combined and ultimately automated daily reports (modeled on Minnesota’s daily report) paired with a historic companion report that can provide pattern frequencies over a specified period of time, etc. The ultimate goal of these reports is assist the user in more quickly identifying clusters or situations of interest. The Work Group initially worked with contractors in Minnesota to develop a domestic, open source application that is designed to be database and platform independent. An application such as this could potentially be built into the PulseNet web portal, but in the meantime, this is a way to bridge lab & epi systems that are not well integrated or in some cases, not integrated at all.

Outbreaks of Undetermined Etiology (OUE) Guidelines (2014-15) Purpose: to provide adequate specimens for second-tier testing and pathogen discovery should the etiology prove elusive Scope: the guidelines include both infectious and non-infectious agents Target Audience: primarily intended for state health departments Organized by syndromes and outbreak profiles Specimen collection/testing/storage/shipping http://www.cifor.us/productOUE.cfm The Outbreaks of Undetermined Etiology (OUE) work group has been drafting guidelines to help guide investigators on the preferred specimens to be collected for foodborne/diarrheal disease outbreaks and how to appropriately ship and retain those specimens should first-tier testing all be negative. Investigators generally collect and handle foodborne outbreak specimens with a specific agent in mind. But by the time investigators establish/ conclude the etiology is undetermined, the initial specimens may no longer be available or usable. Attaining an additional specimen may prove unproductive or impossible, if the patient has recovered or died. The guidelines are designed to provide adequate specimens for second-tier testing and pathogen discovery should the etiology prove elusive. The OUE Guidelines are comprised of three documents- an introduction providing background on the project and the purpose of the guidelines, the main guidelines which provide guidance on universal specimen collection for all foodborne outbreaks along with additional specimen collection, testing, shipping and storage guidance based on syndromes and outbreak profiles. The agent list provides more detailed information on each agent listed in the guidelines. More information will be provided on each of the document in a moment. In an attempt to address all foodborne outbreak scenarios, the guidelines include both infectious and non-infectious agents. The primary, intended audience for these guidelines are state health departments though they may also be appropriate for some local health departments. We decided to limit the scope to infectious agents.

CIFOR Industry Guidelines: “Foodborne Illness Response Guidelines for Owners, Operators & Managers of Food Establishments” (2013) Provide guidance & tools to encourage industry to take an educated role in outbreak investigation & response Targeted to owners, operators, and managers of food establishments Developed by workgroup of CIFOR Council representatives and industry representatives

Development of Target Ranges For Selected Performance Measures in the CIFOR Guidelines Target ranges were developed for 16 performance indicators in the CIFOR Guidelines Measures cover key areas at state and local levels Surveillance system Follow up on complaints, cases and isolates Investigations of clusters Outbreak summaries and reporting to NORS Include epi, lab, and EH functions Abridged and full versions available at http://www.cifor.us/projmetrics.cfm Released in spring 2014

Metrics Entry Tool (C-MET) Based on CIFOR Performance Measures Agencies can anonymously enter their jurisdiction’s metrics data annually, and assess progress for each of the 16 metrics across multiple years. Determine where their performance falls when compared to de-identified aggregate national data. http://metrics.cifor.us/ Prior to C-MET, there was no efficient way to collect de-identified, aggregate data across multiple jurisdictions to identify nationwide gaps regarding food safety activities. Collecting and analyzing this new data set will allow CIFOR, Food Safety CoEs, and other partners to develop more effective training, resources, and tools to better assist public health agencies in their food safety efforts. C-MET data can support efforts by officials in leveraging additional resources for food safety activities.

To Access these tools or for more Information About CIFOR: Visit the CIFOR website: www.cifor.us Contact the CSTE National Office: Dhara Patel, MPH Senior Research Analyst dpatel@cste.org 17