1. Kristin C. Delea MPH, REHS Health Scientist/Epidemiologist Environmentl Health Services Branch National Center for Environmental Health Environmental Assessments: Improving Foodborne Illness Outbreak Investigations

2. Definitions  Environmental Assessment  The component of an outbreak investigation that fully describes how the environment contributed to the introduction and or transmission of agents that cause illness. Environment is everything external to the host, including air, food, water, animals, plants, climate, etc as well as people, social and built environments. All aspects of the external environment can be listed as variables that, in relation to transmission, are neutral, conducive or protective. From this description contributing factors and environmental antecedents to an outbreak can be determined.  NOT an inspection

3. Contributing Factor Definition  The factors likely to be conducive to the contamination and survival of the etiologic agent or suspected agent and/or to its growth or proliferation.  Contamination Factors Toxic substance part of the tissue, Contaminated raw product, Cross- contamination of ingredients, Bare-hand contact by a food handler/worker/preparer who is suspected to be infectious  Proliferation Factors Improper cold holding due to malfunctioning refrigeration equipment, Improper hot holding due to improper procedure or protocol, Prolonged cold storage  Survival Factors Insufficient time and/or temperature during cooking/heat processing, Insufficient time and/or temperature during reheating  Contributing factors are NOT food code violations

4. Definition Environmental Antecedents Definition  Root causes  Supporting factor(s) to the contamination, survival or increase of biological or chemical agents in food  They may be related to  People  Equipment  Process  Food  Economics  Behavior  Other circumstances

5. Example: Understanding environmental causes of foodborne illness  An E. coli outbreak associated with salads eaten at a restaurant is caused when a restaurant worker uses the same equipment to first handle raw ground beef and then ready-to-eat salads without cleaning the equipment in between.  Contributing factor: Cross contamination from ground beef to ready-to-eat food through contaminated equipment  Environmental antecedents: Food worker was in an hurry and had not been trained on the importance of preventing cross contamination

6. Environmental Antecedents Medium (food, water, Wastewater, Air, etc.) Environmental Assessment Equipment People Process Economics Protective System prevention unsuccessful No illness prevention succe s sful Adverse Health Outcomes Increasing Severity of illness Outbreak Exposure Using Environmental Assessments to Investigate Disease Outbreaks Contributing Factors Epidemiology Lab (Identify and/or confirm Agent)

7. Foodborne Illness Outbreak Environmental Assessments  Describes how the environment contributes to the introduction and or transmission of agents that cause illness  Objectives of the assessment Identify contributing factors Identify environmental antecedents Generate recommendations for informed interventions Science-based policy and practice

8. NATIONAL VOLUNTARY ENVIRONMENTAL ASSESSMENT INFORMAITON SYSTEM Improving Surviellance

9. Data Collection  Data collection for FBIO environmental assessments  Standardized data collection instrument to report information FBIO environmental assessments  Validated questions  Identifying contributing factors  Understanding how selected environmental antecedents are related to contributing factors, vehicles, and agents  Is not a form or template for conducting a FBIO environmental assessment

10. Using Environmental Assessments to Investigate Disease Outbreaks  Environmental Health Specialists are accustomed to look for violation of regulations (not contributing factors and their environmental antecedents)  Performing an environmental assessment (EA) requires a different mindset than other environmental food safety activities  No two outbreaks are alike  No single ‘checklist’ applies to all environmental assessments  Conducting an EA requires a complex set of knowledge and skills including the ability to apply ‘critical thinking’  Training must promote development of competency in the field and not just the acquisition of knowledge

11. VIRTUAL WORLD TRAINING E-Learning on Environmental Assessments of Foodborne Illness Outbreaks

12. Goal of this Training Effort  Use cutting-edge e-learning technologies to develop competency with Foodborne Illness Outbreak Environmental Assessments and deliver training free of charge over the Internet to enhance global food safety

13. The Cognitive Domain  Involves knowledge and the development of intellectual skills  Includes 6 categories of behavior  Knowledge (recall data or information)  Comprehension (understanding the meaning)  Application (use a concept in a new situation)  Analysis (separate materials into component parts)  Synthesis (build a pattern from diverse elements)  Evaluation (make judgments)

14. Incorporation of ‘Gaming’  Each virtual learning experience scenarios is framed as a forensic investigation mystery of an outbreak  Participants decide  Who to interview  What topics to interview about  Which actions to take  What observations to perform and samples to collect  At end, learners must identify contributing factors and environmental antecedents  Actions and conclusions are tracked and evaluated  Learners receive individual feedback on results

15. Analysis of Learner Performance  Learner receives individualized feedback on:  Interview effectiveness Did the learner choose the correct questions?  Interview efficiency Did the learner choose the questions in the correct order?  Observational skills Did the learner find all the important embedded clues in the environment?  Critical thinking Did the learner correctly identify contributing factors and environmental antecedents

16. Purpose of Module 1  To provide participants with the skills and knowledge to participate effectively in an environmental assessment of a foodborne illness outbreak at a Retail Point of Service

17. M1, L2: Overview of Foodborne Illness Outbreak Environmental Assessments M1, L3: Interviewing M1, L4: Observation M1, L5: Sampling M1, L6: Organizing Assessment information M1, L1: Your Assignment M1, L7: Critical Thinking M1, L8: Concluding actions

18. TRAINING DEMO

19. HOW TO BECOME INVOLVED

20. How and where to receive more information  www.cdc.gov/nceh/ehs  Provides information about e-Learning on Environmental Assessments of Foodborne Illness Outbreaks and NVEAIS  Registration information  Registering to use the e-Learning on Environmental Assessments of Foodborne Illness Outbreaks and NVEAIS  Send and email to NVEAIS@cdc.gov First and Last Name E-mail address Organization you work for

21. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Thank you Kristin C. Delea kdelea@cdc.gov http://www.cdc.gov/nceh/ehs/EHSNet/index.htm National Center for Environmental Health Environmental Health Services Branch