1. Foodborne diseases and outbreaks1 Foodborne Disease Outbreak Investigation Team Training: Module 1 – Foodborne Diseases and Outbreaks

2. Foodborne diseases and outbreaks2 Module Learning Objectives At the end of this module, you will be able to 1.Describe what is meant by “foodborne disease.” 2.List examples of common foodborne disease causative agents. 3.Define the terms “outbreak” and “cluster.” 4.List the goals of a foodborne disease outbreak investigation. 5.Describe the desirable knowledge and skills included on a foodborne outbreak investigation team.

3. Foodborne diseases and outbreaks3 BREAKING NEWS Students and teachers rushed to hospitalStudents and teachers rushed to hospital Nausea, vomiting, stomach pain, and dizziness after lunch at school cafeteriaNausea, vomiting, stomach pain, and dizziness after lunch at school cafeteria Health department team dispatched to school and hospital to investigateHealth department team dispatched to school and hospital to investigate Students and teachers rushed to hospitalStudents and teachers rushed to hospital Nausea, vomiting, stomach pain, and dizziness after lunch at school cafeteriaNausea, vomiting, stomach pain, and dizziness after lunch at school cafeteria Health department team dispatched to school and hospital to investigateHealth department team dispatched to school and hospital to investigate

4. Foodborne diseases and outbreaks4 Group Discussion Do you think the illnesses are foodborne? Do you think the illnesses represent an outbreak? If this is a foodborne outbreak, who would you involve in the investigation? Divide into groups by table. 1.Briefly introduce yourself to others at your table. 2.Re-read the news report at end of module and answer these questions. Time limit: 5 minutes Be prepared to share your thoughts with the class.

5. Foodborne diseases and outbreaks5 Illness caused by ingestion of contaminated food Symptoms often affecting stomach or intestinal tract including –Nausea and vomiting –Diarrhea –Abdominal pain Sometimes nonspecific symptoms and symptoms outside GI tract, depending on agent Young children, pregnant women, elderly, and immunocompromised persons at greatest risk for severe illness Foodborne Disease

6. Foodborne diseases and outbreaks6 An estimated 1 in 6 people suffers from foodborne illness each year in the United States leading to an estimated –48 million illnesses –128,000 hospitalizations –3,000 deaths More than 1,000 outbreaks detected annually $35 billion in medical costs, lost productivity, illness related mortality each year Foodborne Disease Source: Centers for Disease Control and Prevention http://www.cdc.gov/foodborneburden/index.htmlhttp://www.cdc.gov/foodborneburden/index.html

7. Foodborne diseases and outbreaks7 Bacteria Bacillus cereus Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Shiga toxin-producing E. coli Enterotoxin producing E. coli Enteroinvasive E. coli Enteropathogenic E. coli Listeria monocytogenes Salmonella, non-typhoid Salmonella Typhi Shigella Staphylococcus aureus Vibrio Yersinia enterocolitica Common Causative Agents Viruses Norovirus Astrovirus Hepatitis A virus Parasites Cryptosporidium Cyclospora cayetanensis Entamoeba histolytica Giardia intestinalis Trichinella Chemicals/other Heavy metals Pesticides Fungal toxins Fish toxins

8. Foodborne diseases and outbreaks8 Chemicals/other (5%) Parasites (<1%) Viruses (54%) Bacteria (40%) Source: Centers for Disease Control and Prevention based on data from 2008  Frequency of Causative Agents in Foodborne Outbreaks in the United States Norovirus Salmonella (18%) Clostridium perfringens (6%) STEC (5%) Campylobacter (4%)

9. Foodborne diseases and outbreaks9 Variety of foods associated with foodborne illnesses Almost any food can be a vehicle for disease but food and production/processing must –Allow opportunity for contamination by causative agent –Allow agent (or toxin) to survive (not be inactivated) and –(For some agents) support proliferation of agent and/or elaboration of preformed toxins Common food-causative agent pairings Food Vehicles

10. Foodborne diseases and outbreaks10 Pathogens associated with food can also be spread through other modes –Waterborne –Person-to-person –Animal-to-person Multiple modes of transmission possible in a single outbreak … Also Other Modes of Transmission

11. Foodborne diseases and outbreaks11 Definition of Outbreak Two or more cases of a similar illness among individuals who have had a common exposure Critical components of definition –Same diagnosis or symptoms and signs suggestive of same illness –Clear association between cases, with or without a recognized common source

12. Foodborne diseases and outbreaks12 Definition of Cluster More cases than expected for given geographic location and time No immediately obvious association between cases Suggestive of an outbreak but needs further exploration to make determination

13. Foodborne diseases and outbreaks13 Class Question Is this an outbreak? Development of nausea and vomiting in three friends within 30 minutes of eating at a restaurant. 

14. Foodborne diseases and outbreaks14 Class Question Is this an outbreak? Diarrhea and abdominal pain due to Salmonella Agona (an unusual serotype only seen once before) in 24 persons in one state. 

15. Foodborne diseases and outbreaks15 Class Question Is this an outbreak? A single case of botulism. 

16. Foodborne diseases and outbreaks16 Primary Goals of Outbreak Investigations Stop current outbreak as soon as possible by implementing effective control measures and Prevent similar outbreaks in future.  To achieve these goals, you must rapidly identify the cause of the outbreak including: –People at risk (and characteristics) –Causative agent –Mode of transmission and vehicle –Source of contamination –Contributing factors –Environmental antecedents

17. Foodborne diseases and outbreaks17 you need an Outbreak Investigation Team. > The team To do all these things …. 

18. Foodborne diseases and outbreaks18 Outbreak Investigation Team Composition varies but almost always needs knowledge and skills in –Environmental health –Epidemiology –Laboratory –Public health education –Communications –Leadership Usually includes environmental health investigator, epidemiology investigator and/or public health nurse, and laboratory investigator > The team

19. Foodborne diseases and outbreaks19 The env’t health investigator focuses on the contaminated food: Receives and interprets foodborne illness complaints Investigates suspected food and/or food establishment −Interviews food workers and managers −Examines food storage, handling, preparation −Identifies factors that resulted in food contamination −Collects environmental and food samples −Collects paperwork Implements control measures The Team: Env’t Health Investigator > The team

20. Foodborne diseases and outbreaks20 The Team: Epidemiologic Investigator Analyzes data from pathogen- specific surveillance and identifies clusters Characterizes cases by time, place, and person Plans epidemiologic studies Interviews cases and healthy controls Analyzes and interprets results of epidemiologic studies The epidemiologic investigator focuses on cases: > The team

21. Foodborne diseases and outbreaks21 The Team: Public Health Nurse Interviews patients Collects clinical specimens from patients Administers questionnaires for epidemiologic studies Advises patients on how to prevent spread of illness Provides public health education The public health nurse focuses on patients: > The team

22. Foodborne diseases and outbreaks22 The Team: Laboratory Investigator The laboratory investigator focuses on specimens: Analyzes clinical, food, and environmental specimens Interprets test results Advises team about tests and collection, handling, storage, and transport of specimens Coordinates additional testing by partner labs > The team

23. Foodborne diseases and outbreaks23 The Team: Other Skill Sets Other persons often included on outbreak investigation team: Public health officer Public health educator Clerical staff Public information officer Regulatory investigators Interpreters Veterinarians Health care providers Industry members > The team

24. Foodborne diseases and outbreaks24 The Team: Together Work together and support each other Team responsibilities −Develop hypotheses about outbreak source −Prioritize and assign activities −Interpret investigation findings −Determine how far to take an investigation −Develop public messages −Decide on control measures > The team

25. Foodborne diseases and outbreaks25 1.Examine the roles and responsibilities listed under each outbreak investigation team member. 2.Insert your name and the names of your team members in the appropriate cells. 3.Which responsibilities are not covered? How might these gaps be filled? 4.Are there others included on your team? What do they do? Group Exercise Working alone or with others who are from the same jurisdiction, complete the outbreak investigation team matrix at the end of the module. Time limit: 10 minutes

26. Foodborne diseases and outbreaks26 Quick Quiz

27. Foodborne diseases and outbreaks27 Quick Quiz 1.Which of the following causative agents is the most common cause of foodborne disease outbreaks in the United States? A.Viruses B.Bacteria C.Parasites D.Chemicals

28. Foodborne diseases and outbreaks28 Quick Quiz 2.Some foodborne pathogens can also be spread by water, from person-to-person, and from animal-to-person. A.True B.False

29. Foodborne diseases and outbreaks29 Quick Quiz 3.An outbreak is an increase in the number of cases of a particular disease greater than is expected for a given time and geographic location. A.True B.False

30. Foodborne diseases and outbreaks30 Quick Quiz 4.Which of the following is a primary goal for undertaking foodborne disease outbreak investigations? A.To study the natural history of the causative agent B.To train staff C.To stop the current outbreak by implementing effective control measures D.To respond to public concerns

31. Foodborne diseases and outbreaks31 Quick Quiz 5.Knowledge and skills from all of the following disciplines should be represented on every foodborne outbreak investigation team EXCEPT A.Environmental health B.Epidemiology C.Laboratory D.Industry members