1. CIFOR Guidelines for Foodborne Disease Outbreak Response and the CIFOR Toolkit: Focus Area 8: Environmental Investigation
New York Integrated Center of Food Safety Center of Excellence – February 16, 2017
David Nicholas, MPH
Bureau of Community Environmental Health and Food Protection
New York State Department of Health

2. Background
This is the ninth webinar in a series of monthly webinars from the New York Integrated Food Safety Center of Excellence (CoE)
Session covers CIFOR Toolkit Focus Area 8: Environmental 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

3. 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)
Considering the keys to success on the previous page, describe your agency’s/jurisdiction’s current activities and procedures in this Focus Area. Refer to written protocols, if available, and materials related to ongoing efforts in capacity development or quality improvement (e.g., CIFOR target ranges for selected performance measures). As you list current activities and procedures related to this Focus Area, indicate those which could be changed to improve your agency’s/jurisdiction’s response to foodborne disease outbreaks

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

5. 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
PRIORITIZE CIFOR RECOMMENDATIONS TO ADDRESS NEEDED IMPROVEMENTS. Having identified activities and procedures in need of improvement, review the CIFOR recommendations related to this Focus Area (listed below).
Rate the priority for implementing each recommendation based on its likely impact on foodborne outbreak response at your agency/jurisdiction and available resources. Use a scale of 1 to 5 to rate each recommendation (1=Low priority for implementation and 5=High priority for implementation). If a recommendation is already in place in your agency/jurisdiction, check the appropriate box. If a recommendation is not relevant to your agency/jurisdiction, select N/A.
Refer to the blue underlined section number following each recommendation to view the recommendation as it appears in the CIFOR Guidelines.

6. What is Focus Area 8? Title: Environmental Investigation
Goals for the Environmental Investigation: During an Investigation, the agency/jurisdiction staff collect, analyze, and interpret information from the implicated facility or production site to determine the etiologic agent, mode of transmission and vehicle, source of contamination, contributing factors, environmental antecedents, and food supply chain.

7. Contributing Factors vs Environmental Antecedents
Factors that caused the outbreak
How the outbreak occurred
Environmental Antecedents
Factors that led to the contributing factors
Why the outbreak occurred
People
Equipment
Process
Food
Economic
Contamination
Proliferation
Survival

8. Keys to Success Staff skills and expertise Investigation Communication
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 8: Keys to Success
Staff skills and expertise
Investigation
Communication
Making changes
Determining whether an agency/jurisdiction has a particular key to success in place is somewhat subjective.
Metrics, such as measures of time (e.g., rapidly, timely, and quickly), have not been defined. Your workgroup should provide its own definitions for these terms, as is appropriate for your agency/jurisdiction, and use its best judgment in deciding whether a particular key to success is fully or partially in place.

9. Keys to Success: Staff Skills and Expertise
Staff have expertise in food production processes, HACCP, and environmental health assessments.
Staff have expertise in traceback and traceforward investigations (or have access to staff in other agencies with this expertise).
Staff have good interviewing skills to solicit information from facility managers and food workers.

10. Staff Skills and Expertise
Here we get to prioritizing the CIFOR recommendations to suggest/address improvements needed to ensure the staff have (and maintain) the skills and expertise to be competent and successful epidemiologic investigators.
Use a scale of 1 to 5 to rate each recommendation (1=Low priority for implementation and 5=High priority for implementation). If a recommendation is already in place in your agency/jurisdiction, check the appropriate box. If a recommendation is not relevant to your agency/jurisdiction, select N/A.
Qualifications to conduct an environmental health assessment to accurately relate the opportunities for contamination, survival, and growth of a disease
Consultation with a Laboratory investigator may be necessary.
Ongoing training is critical for all members of the outbreak investigation and control team to ensure they are proficient at performing the duties assigned to them.
Training also should be provided for additional tasks outside of a team member’s regular role that they might be required to perform.
See next slide for reference materials
Assemble a reference library (including online resources) with information about foodborne diseases, enteric illnesses, and control measures. Where possible include electronic resources that can be accessed by laptop computers during field investigations. Regularly review and update the contents of this reference library.

11. Staff Skills and Expertise
Assemble a list of resource persons who have expertise in specific disease agents and investigation methods and contact information for these persons.
Exercise teams together to ensure each team member understands and can perform his or her role according to agency-specific protocols and legal authorities and understands the roles and responsibilities of other team members. These exercises also can identify likely problem areas and gaps in resources.
Outbreaks themselves provide training opportunities. If an agency does not frequently have outbreaks, team members might be able to assist in responses to outbreaks in other jurisdictions. This can help promote learning and provide valuable insights an agency can use to refine its own protocols.
When possible, use standardized core questions and data elements used by other investigators to enhance data sharing and comparisons across jurisdictions. Experience can make one a better and more efficient interviewer. If investigations are infrequent, achieving and maintaining proficiency can be difficult; centralizing the interview process reduces these problems and makes questionnaires easier to modify on the fly.

12. Keys to Success: Outbreak Investigation
Agency/jurisdiction has a written protocol outlining the steps in the environmental health investigation of a foodborne disease outbreak. Staff have easy access to the protocol and are trained in its implementation.
Staff undertake environmental health assessments at facilities or production sites implicated during a foodborne outbreak (not routine food establishment licensing inspections) and identify appropriate contributing factors and environmental antecedents.
Staff undertake traceback and traceforward investigations (or have access to staff in other agencies that undertake these investigations).
#2 – memory – no recall issues. Also, may allow for hypothesis generation and speed up control measures.
Remember that we always want to make every effort to have a system in which all lab-confirmed and outbreak associated cases as soon as possible when patient recall and motivation to cooperate is greatest.

13. Outbreak Investigation
Prepare a response protocol based on the CIFOR guidelines but also customized to the agency’s needs with specific information relevant to the agency.
Equipment: sterilization equipment for sample collection tools and temperature probes; temperature-checking probes and backups; equipment to determine food characteristics (e.g., pH, water activity, sugar content); capabilities and equipment for conference calls; multiple phone lines; computers, laptops, software (e.g., data entry, statistical), portable printers, paper, graph paper, pens, clipboards; camera.
Foodborne disease outbreak investigation kits should be maintained in ready-to-use condition, with sampling containers and implements kept sterile.
6.0 Rapid response is key, it is important for investigators to quickly assess available information to identify suspected food or facilities, and send environmental investigators into the field as soon as possible.
Sending at least two investigators to a food establishment implicated in an outbreak is best. One investigator can make certain that food about to be served is safe (e.g., no implicated leftovers are served, foods are at proper temperature, food was prepared without contact by bare hands, no ill food workers are preparing food). The second investigator conducts the investigation (e.g., obtains the menu to review everything served to cases, identifies persons who prepared suspected items, determines how the foods were prepared, determines what other groups were served the same foods).
The specific activities in an environmental health assessment differ by causative agent, suspected vehicle, and setting but usually include the following: describing the implicated food; observing procedures to make the implicated food; talking with food workers and managers; taking measurements (i.e. temperatures); developing of flow cart to capture detailed information about each step in the food-handling process; collecting food specimens (and occasionally clinical specimens); and collecting and reviewing documents on source of food.
Templates – event associated questionnaire, menu driven questionnaire (date, time eaten, plug in menu items, collect info about fellow diners, leftovers). Prepoulated with demographic and clinical information

14. Outbreak Investigation
Your state or agency may have laws or policies that dictate record management and sharing of confidential information.
Identify standardized forms, including illness complaint forms, disease-specific report forms, and trawling interview questionnaires, for recording information about possible cases (examples of such forms are available through the CIFOR Clearinghouse at www. cifor.us/clearinghouse/keywordsearch. cfm). These forms may need to be modified in response to the specifics of the current outbreak.
The use of standardized forms for collecting exposure histories ensures that pertinent information is collected from all cases. Consistently asking about high-risk exposures (e.g., sprouts, raw milk, ground beef, leafy greens) makes data easier to share among jurisdictions and commercial product outbreaks easier to resolve quickly. In addition, use of a standardized interview
Because good forms take time to develop and format, developing templates before a crisis is critical to their rapid deployment (see also Chapter 4, section 4.3.9). The CIFOR Clearinghouse (www. cifor.us/ clearinghouse/keywordsearch.cfm) provides examples of questionnaires used by various health departments to collect exposure information for different pathogens and might be useful in template development. The Environmental Health Specialists Network (EHS-Net) website ( EHSNet/) can be referenced for models of environmental assessment forms and consumer complaint forms.
Train staff in the use of standardized forms to ensure proper completion by all members of the investigation team.
Interviewers should be trained in the use of the standardized interview forms and techniques and have demonstrated proficiency in their use during previous investigations.
Determine how confidential information will be stored and whether and how it can be shared.
Determine when and how to share outbreak information with the person or organization in charge of the facility implicated in an outbreak.
All outbreak investigations involve collection of private information, such as names and symptoms that must be protected from public disclosure to the extent allowed by law. All members of the investigation team, including epidemiologists, laboratorians, environmental health specialists, and food-safety personnel, need to be familiar with and follow relevant state and federal laws and practices.

15. Outbreak Investigation
Ideally get a copy of the laboratory report to verify confirmation and testing methods.
Interview - are signs and symptoms consistent with suspected/confirmed etiology?
Obtain clinical specimens from members of the ill group. If the presumed exposure involves food, collect and store—but do not test—food from the implicated event. All sampling must be conducted using legally defensible procedures (e.g., chain-of-custody) and using protocols as guided by the laboratory that will do the analysis.
Even though the etiology is not essential for primary linkage of cases, as it is for pathogen-specific surveillance, information about agents is important for understanding the outbreak and for implementing rational intervention and facilitates establishing links to other outbreaks or sporadic cases by PulseNet and the Foodborne Disease Outbreak Surveillance System.

16. Outbreak Investigation
Remember – these steps will be conducted concurrently with the lab and environmental health investigation.
Ideally you should aim to interview all attendees to find as many cases as possible. Interview ill and wells using the same, standardized form which includes all potential exposures.
Need to actively search for additional cases to
Determine true magnitude of outbreak
Characterize outbreak accurately
Increase ability of epidemiologic studies to link illness with true cause of outbreak
Store the food appropriately, but generally test the food only after epidemiologic implication or identification of specific food-safety problems through an environmental health assessment.
Food samples need to be collected as early in the outbreak investigation as possible. Whether to analyze these samples can be decided later when more information is available. Storage capacity for samples collected for later analysis should be considered before an outbreak.
The facility from which the samples are collected should be notified and afforded the opportunity to collect companion samples.
Certain microorganisms are associated with certain food items because the food derives from an animal reservoir of the microorganism or the food provides conditions necessary for the survival and growth of the organism. As a result, the food item suspected in an outbreak, if known, can occasionally provide insight into the etiologic agent. However, most foods can be associated with a variety of etiologic agents, and new vehicles for transmission emerge each year. Therefore, care must be taken in inferring the etiologic agent from the suspected food item.

17. Outbreak Investigation
Review interview data regularly to look for trends or commonalities. Compile interview data in a single database, and examine daily for exposure clustering.

18. Outbreak Investigation
Case definition - set of criteria used to classify ill people as being cases associated with a particular outbreak
Criteria include
Clinical findings (e.g., signs, symptoms, laboratory results)
Restrictions by time, place, and person
Different from a clinical diagnosis, used for epidemiologic purposes only
The definition can change over the course of the investigation (maybe there are two confirmed etiologies which may increase case counts; maybe it becomes more restrictive
objective and not open to interpretation (eg. Diarrhea vs greater or equal 3 or more loose stools in a 24 hour period).
Discriminating – Distinguish between individuals with illness associated with outbreak and those with illness not associated with the outbreak
Your linelist will help you do this, as well as summary statistics.
Epidemiologic information is necessary to initiate an environmental health assessment and guides the assessment as it progresses. Once an investigation begins, sources of information for an environmental health assessment include product information (e.g., chemical and physical characteristics and source); written policies or procedures; direct observations and measurements; interviews with employees and managers; and lab testing of suspected foods, ingredients, or environmental surfaces.

19. Outbreak Investigation
Have shoppers card release forms at the ready.
When investigating a food-production, food-processing or food-service establishment implicated in an outbreak, conduct an environmental health assessment. An environmental health assessment is a systematic, detailed, science-based evaluation of environmental factors that contributed to transmission of a particular disease in an outbreak.
When some or all of a number of conditions occur, an investigational traceback/ traceforward might be warranted:
• Linked cases occur in multiple locations or jurisdictions (particularly if they occur in multiple states);
• A vehicle cannot be clearly implicated with traditional epidemiologic, laboratory, and environmental assessment methods alone; and
• More information is needed to determine whether similar food items from different establishments, stores, or firms can be linked to a distributor or processor.
Although a primary goal of an environmental health assessment is to identify possible points of contamination, survival, or growth of the disease agent, to be most valuable, investigators also need to identify environmental antecedents that resulted in these conditions.

20. Outbreak Investigation
Other control groups we have used involved the comparison of case shopper card data to total sales of suspect products during a defined time period.

21. Outbreak Investigation
Can use an overestimate that may be an overestimate for comparison.
Gut feeling
Consider the vehicle and the setting, too. Perishable vs. long shelf life? No cases identified other than among attendees of a particular event suggest something specific to the event.

22. National Environmental Assessment Reporting System (NEARS)
Standardized Environmental Assessment form to help identify the underlying environmental causes of foodborne illness outbreaks
Allows you to:
Analyze standardized data to understand how and why outbreaks occur.
Share findings or recommend actions to better respond to outbreaks and prevent future ones.

23. National Environmental Assessment Reporting System (NEARS)
Information Can be Found at:
Free e-Learning on Environmental Assessment of Foodborne Illness Outbreaks can be found at:

24. Keys to Success: Communication
Staff communicate in a timely fashion and coordinate activities with epidemiology and laboratory staff
This also includes other individuals in your chain of command including your press office/public information officer

25. Communication
Coordinate activities and set up good lines of communication between individuals and agencies involved in the investigation. To avoid mixed messages and incomplete information or misinformation, each investigation should have a consistent point of contact. Guidelines for coordinating multijurisdictional investigations are summarized in Chapter 7. Investigations are rarely linear. Although most procedures for investigating outbreaks follow a logical process—from determining whether an outbreak is occurring to identifying and controlling the source—most actual investigations feature multiple concurrent steps. In addition, the focus of the investigation may need to shift as the situation warrants. Maintaining close communication and coordination among members of the outbreak investigation team is the best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten.
With PIO, we often give what information can be released publicly and what information can be
Establish routine communication among the outbreak investigation and control team members before an outbreak. Define a formal communication process for agencies of the outbreak investigation and control team for use during outbreaks. Options include daily phone calls and routine alerts. Developing a consistent approach to internal communications during an outbreak helps everyone on the team know what to expect.
Guide staff on how to respond to and communicate with angry food-service workers, managers, and members of the public.
Determine when and how to share outbreak information with the person or organization in charge of the facility implicated in an outbreak.
Ensure everyone who may be involved in outbreak response knows the other team members.
Identify the persons who will be responsible for communication on behalf of their organizational unit (epidemiology, environmental health, laboratory) and for the outbreak investigation and control team.
Coordinate activities and set up good lines of communication between individuals and agencies involved in the investigation. To avoid mixed messages and incomplete information or misinformation, each investigation should have a consistent point of contact.
Whether the outbreak is restricted to one jurisdiction or involves multiple jurisdictions, notification and updates should be provided to other interested agencies following the Guidelines for Multijurisdictional Investigations
Communicate actions taken and outbreak status information to all persons involved in an outbreak investigation, including those in different agencies or different departments within the agency.

26. 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 environmental health investigation and routinely evaluates its performance in this Focus Area. .

27. Making Changes
This, too, is a critical opportunity for the team to learn from each other. It should involve the whole team.
6.7. A formal after-action meeting should:
• Identify the contributing factors and environmental antecedents of the outbreak and measures (preventive controls) to prevent additional outbreaks at this and other food establishments;
• Identify the long-term and structural control measures, and develop a plan for their implementation;
• Assess the effectiveness of outbreak control measures and difficulties in implementing them;
• Assess whether further scientific studies should be conducted;
• Clarify resource needs, structural changes, or training needs to optimize future outbreak response;
• Identify factors that compromised the investigations, and seek solutions;
• Identify necessary changes to current investigation and control guidelines and development of new guidelines or protocols as required; and
• Discuss any legal issues that might have arisen and the need for new laws to strengthen response (see Chapter 9).
Conduct a debriefing after each outbreak to identify lessons learned and refine the agency’s response protocols.
Encourage a post-outbreak meeting among investigators to assess lessons learned and compare notes on ultimate findings. Debriefing should include a review of coordination and communication during the investigations, where breakdowns may have occurred, and how prior experience and training facilitated or hindered investigation efforts.
Establish a process for creating after-action reports following investigations, with lessons learned and action items for follow-up and quality improvement.
At a minimum, document every outbreak investigation by using a standardized form to facilitate inclusion in state and national outbreak databases (e.g., CDC’s form or its equivalent).
6.8. Prepare reports for all outbreaks.
Summary data should be reported nationally to CDC’s National Outbreak Reporting System (NORS) database. The usefulness of the reports depends on the quality and quantity of information submitted. Make every effort to complete both Part 1: Basic Information, and Part 2: Additional Information, and submit the information as soon as possible.

28. 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

29. 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

30. Where to Find the CIFOR Products
Online at:
Paper copies are also available from CSTE
Contact Thuy Kim at
Examples of CIFOR product use by other states:

31. Upcoming NYS CoE CIFOR Webinars
Next webinar: Wednesday, March 22, 2017 at 2PM
Focus Area 9: Laboratory Investigation
Course announcement and link to register is posted on the DOH Learning Management System (LMS):

32. Resources Comments or questions for NY CoE can be directed to:
Paula Huth or Andie Newman, NYSDOH
Integrated Food Safety CoE Websites:
NY CoE:
CDC: