1. OUTBREAKS INVOLVING FOOD & LODGING ESTABLISHMENTS PARTNERSHIPS NEEDED FOR A SUCCESSFUL INVESTIGATION Carl Williams Melissa Ham Nicole Lee

2. Presentation Content  Why do we care about foodborne outbreaks?  What partners need to be involved and why?  How does this partnership work during an outbreak?  What are some common conflicts between partners?  Are there resources for partners?  Q & A

3. Why do we care about foodborne outbreaks?

4.  Potential illness reaching the masses  Intentional vs accidental contamination  Possible wide distribution of a contaminated item  Vulnerable populations  Loss of days worked, wages, business, trust

5. Real Life Events: Salmonella

6. Total Ill 100 Hospitalized 8 Counties Represented 11 Ages 17yrs-81yrs Median: 45 yrs

7. Real Life Events: Salmonella

8. Total Ill 104 Hospitalized 14 Counties Represented 5 Ages 3yrs – 85yrs Median: 55yrs

9. Real Life Events: Norovirus

10. Real Life Events: Hepatitis A

11. What partners need to be involved and why?

12. What partners need to be involved?

13.  Laboratory

14. What partners need to be involved?  Environmental Health  Laboratory

15. What partners need to be involved?  Epidemiology  Environmental Health  Laboratory

16. What partners need to be involved?  Epidemiology  Environmental Health  Laboratory

17. What partners need to be involved?  Epidemiology  Environmental Health  Laboratory

18. What partners need to be involved?  Epidemiology  Environmental Health  Laboratory

19. What partners need to be involved?  Epidemiology  Environmental Health  Laboratory

20. Purpose of partners  Agent specific  Verify diagnosis  Outbreak specific  Identify source  Implement control measures LaboratoryEpidemiology  Facility specific  Identify exposure and transmission opportunities  Implement control measures Environmental Health

21. One example… When has this worked?

22. Real Life Event: Salmonella

23. Monday, May 13, 2013 Day 1

24.  Fifteen ill with N/V/D (some bloody)  10 / 15 hotel staff (3/10 food handlers)  1 hospitalized  Two of three samples (+ Salmonella)  May 8 th was the first onset 4pm - Conference call Local Health Dept: Epi, Env Hlth State: Epi, Env Hlth, Lab, Public Affairs 10:00am – Call from CD Nurse

25. Day 1 Summary of Actions/Decisions  Confirm the story  Implement control measures with hotel/rest.  Interview ill  Coordinate hotel assessment with Env Hlth  Coordinate stool specimen collection, shipment, and testing with state lab  Develop communication tools  Send statewide & national alerts to identify additional cases  Request receipts from hotel (case-control study)  Develop survey from hotel menu  Send state staff to Cumberland to assist with summarizing data and data entry

26. 3 Partners with 1 Goal Food & Lodging Outbreak Laboratory Test stool samples Environmental Health Assess facilities Epidemiology Coordinate activities Interview patients Characterize ill Stop the Outbreak

27. Activities of partners  Test stool  Grow isolate  Biochem tests  Subtyping  PFGE  Environmental testing (partner labs)  Coordinate activities  Characterize illness  Analyze data from all partners LaboratoryEpidemiology  Facility Assessment  Processes  Employees Environmental Health

28. Results Laboratory Environmental Health Epidemiology

29. Laboratory Results  54 specimens tested  2 (4%) unsatisfactory  27 (50%) negative  25 (46%) positive 25 (100%) Salmonella typhimurium 25 (100%) had the same matching PFGE pattern

30. Environmental Health Results  Environmental Assessments  Risk Factors  Personal Hygiene  Approved Source  Contamination  Holding  Cooking  Interviews  Trainings

31. Environmental Health Actions  Required reportable BIG 5  Tools  Three legged stool Employee Health Hand washing No Bare Hand Contact of Ready to Eat food  Risk Control Plans  Enforcement

35. Epidemiology Results Total Ill 100 Hospitalized 8 Counties Represented 11 Ages 17yrs-81yrs Median: 45 yrs Exposure Relative Risk FOOD Employee Potluck0.62 Café Breakfast Buffet0.89 Café Lunch Buffet1.09 All American Grill 3.6 WORK TASK All American Grill Supervisor 4.3 RESULTS Those who ate/drank at the All American Grill were 3.6 times more likely to become ill when compared to those who did not eat/drink at the All American Grill

36. Process Results  After outbreaks are over the following questions are asked of those involved:  What worked well during this outbreak?  What did not work well during this outbreak?  What recommendations do you have to improve the handling of future outbreaks?

37. What are some common conflicts between partners?

38. Potential conflicts with partners  Not aware of numerous incoming specimens  Specimens may be un- satisfactory  Interest in accompanying EH during facility assessments  Timing of lab results can feel delayed LaboratoryEpidemiology  Expanded workload  Additional team members on site Environmental Health

39. Potential conflicts with partners  Feels like state is taking over instead of assisting  Nursing staff pulled from clinic to address outbreak needs  Ensure the county is happy with how the outbreak is lead  Ensuring the same message is communicated to the public Local Health DeptState Health Dept

40. Conflict resolution  Establish relationships with partners before or outside of an outbreak situation  Who is your point of contact and what can they do for you  Understand the role of each partner  What do they do and why  Do they have the resources the response requires  Communication  How often is everyone updated and through what method  Take the opportunity to both learn from others and share your knowledge

41. Are there resources for partners?

42. Partnership Resources  SLPH website  CDC resources  MOA with other states for surge capacity  NC Online Communicable Disease Manual  APHL Control of Communicable Disease Manual LaboratoryEpidemiology  NC Food Code  Online EH training for Assessments during Outbreaks http://www.cdc. gov/nceh/ehs/e Learn/EA_FIO/ http://www.cdc. gov/nceh/ehs/e Learn/EA_FIO/ Environmental Health

43. Partnership Resources LaboratoryEpidemiology Environmental Health

44. Partnership Resources LaboratoryEpidemiology NC Food Code Cheat Sheet Environmental Health

47. Q & A?

48. Carl Williams, Public Health Veterinarian carl.williams@dhhs.nc.gov, 919-733-0391 carl.williams@dhhs.nc.gov Melissa Ham, Regional Environmental Health Specialist melissa.ham@dhhs.nc.gov, 910-303-9247 melissa.ham@dhhs.nc.gov Nicole Lee, Foodborne Epidemiologist nicole.lee@dhhs.nc.gov, 919-715-1162 nicole.lee@dhhs.nc.gov Thank You