4/12/2021

Unit III – Investigation of

Foodborne Disease
Outbreaks

Foodborne Disease
• 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

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Common Causative Agents

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

Food Vehicles
• 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

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… Also Other Modes of Transmission

• 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

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

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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

To do all these things ….

you need an Outbreak
Investigation Team.

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Outbreak Investigation Team

• Composition varies but almost always needs
knowledge and skills in
– Public/Environmental health
– Epidemiology
– Laboratory
– Public health education
– Communications
– Leadership
• Usually includes public/environmental health
investigator, epidemiology investigator and/or
public health nurse, and laboratory investigator

Before an Outbreak Occurs

Be Prepared!

 Be educated on clinical features of specific

foodborne illness and the specific factors
that contribute to these illnesses – stay
current!
 Establish a system for intake and review of
complaints and illness reports
 Know your baseline- How many of these do
we “normally” get?

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The Team: Env’t Health Investigator

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

When You Get the Initial Call…

 Record information
 Signs and symptoms
 Date and time of onset
 Obtain 72 hour food history
 Any other people who are ill
 How many people at the activity
 Any medical treatment or testing
 If random complaint
 check complaint log for similar reports
 If reporting on an event (i.e. banquet, wedding)
 Obtain information on event organizer
 Contact information for attendees

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Collect information

• Contact others on list to identify other

potential cases
• Systematically look at information to
determine plausibility of an outbreak
– Are reported symptoms consistent
– Any common exposures

USE A LINELIST TO DO THIS!

Start a Linelist
• Keeps all information in one place
• Allows for systematic evaluation of cases
• Used to make an epicurve

• See separate Linelist sample form

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The Team: Epidemiologic Investigator

The epidemiologic investigator

focuses on cases:

• 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

What does this epi-curve tell you

about the outbreak?
Gastroenteritis in Nursing Home
Person-to-Person
18
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Number of cases

12
10
8
Staff
6
Residents
4
2
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12 PM

6: PM

9: PM

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6: PM
9: PM

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12 A

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12 P

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Onset Time

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What does this epi-curve tell you

about the outbreak?
Point-source

Once you have determined you have an

outbreak
 Develop a case definition
 a case is a person in the population or study group
identified as having the particular disease, health
disorder, or condition under investigation.
 A case definition includes criteria for person, place,
time, and clinical features specific to the outbreak
under investigation
 Conduct hypothesis generating interviews
 In depth and detail oriented
 About 8 to 10 cases
 Develop questionnaire
 Broad range of exposures

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The Team: Public Health Nurse

The public health nurse focuses
on patients:
• 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

Conduct Interviews

• Can be used for :

 Verifying outbreak
 Searching for additional cases
 Determining if cases are associated
 Collecting data to determine possible
sources
A good interview is a MUST!

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Interviewing Goals
• Be consistent in interviews
• Do your homework to minimize repeat
contacts
• Target questions to greatest degree possible

Before the Interview Begins…

• Be prepared-conduct training if needed
• Select form to be used

During the Interview

• Establish rapport
• Identify self, organization, and reason for
investigation
• Start with easy questions
– Demographics, etc.
• Let them know you may be need to re-contact
them

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Interview Tips
• When they cannot remember meals:
– Ask about food preferences
– Can rule in/out some foods
– Identify key days and dates to jog memory (use
a calendar)
– Review receipts or checkbook
• Buffets-need to clearly describe each food item
• Recall is better for items from a menu

Interview Tips
• Last Meal Bias
– Take multi day food history
– Explain that pathogens may take days to cause
illness
• Ask if leftovers are available for testing
• Don’t forget the details
– Exact restaurant locations

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Interview Tips
• Ask questions as written on form
• Review form before ending interview
• Ask if individuals have
– Unanswered questions
– Additional information
• Thank them for their time!!

Summarize Initial Steps

• Collect Information on Line listing
• Determine transmission mode
• Develop case definition
• Hypothesis Generating Interviews

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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: Other Skill Sets

Other persons often included on outbreak
investigation team:
• Public health officer • Interpreters
• Public health educator • Veterinarians
• Clerical staff • Health care providers
• Public information • Industry members
officer
• Regulatory investigators

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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 and implement prevention and control
measures
− Communicate investigation findings

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