CAT 1

DISEASE SURVEILLANCE
1

a. What features in such a table would incriminate a particular food as being responsible for the
epidemic?

According to the table calculating attack rates for those persons who did not get ill (those persons who
were unexposed). Comparison is fundamental to epidemiology and the same rules apply here. Using the
food-specific attack rate table, we would calculate food-specific attack rates for both groups—ill
(exposed) and ill (unexposed)—and compare differences between the attack rates to identify the most
likely food product responsible for the outbreak.

As shown in the Table, the greatest difference in attack rates between the exposed and unexposed
people is highest (64.9%). That is subtracting the ILL percentage of persons who ate the turkey to the
percentage of Ill who did not eat the turkey.

Turkey has the highest difference when subtracting the percentages of those who got ill having eaten to
those who did not eat.

People who ate turkey 72.9 percent of them got ill which is 97 people making it the highest number of
people who got unwell compared to the other food consumed.

In the same way its only 2 people who got ill from not consuming turkey making it a very low chance
that turkey is not the cause of the illness. As the 23 other who took other meals did not get ill at all.

Turkey also has the highest number of people who ate that food and still recorded the most number of
people getting ill.

Similarly turkey had the least number of people who did not get sick who did not eat that meal
compared to all the other food.

Therefore I would incriminate turkey as being the most suspicious or responsible for the epidemic. In
general, a higher attack rate among a food-specific item indicates that a food or beverage item is
strongly suspicious for being the contaminated product.

b. Does the table suggest that one food must be responsible? More than one food? If the latter,
what further information may be helpful in incriminating a specific food?

According to the table there is a high chance that there is more than one food causing. Like for
example the turkey and gravy in the table. Gravy is closely following turkey as high suspect of
 bringing the illness there are enough food-intake histories, so one can do a more detailed, stratified
analysis by cross tabulation in order to come up with the conclusion.

In my calculations I have divided people two groups: those who ate turkey and those that did not;
each group is then subdivided into groups of people who ate gravy and those who did not. You will
find out that turkey was the principal determinant, with quite similar illness rates for those who ate
turkey, whether or not they also ate gravy.

This could be achieved by identifying the greatest difference in attack rates between the exposed
and unexposed people are highest. Making gravy second close, in terms of percentage difference.

A point to note is Not all outbreaks of food borne disease occur in connection with common meals.

The food preference approach can also be used with illnesses such as hepatitis A that have such
long incubation periods that most of the victims may not be able to remember exactly what they ate
at a given meal more than a month earlier.

In investigating a food borne outbreak caused by participation in a common, contaminated meal,

one is in fact doing a “retrospective cohort study.” The attempt is to identify as many exposed and
unexposed people as possible and see what the exposure did to them. That’s why gravy has almost
similar affects characteristics nearing to turkey in the table. Even though it may be at a lower chance
but it has a hand in the responsibility of the illness.

2. If laboratory facilities are available, appropriate food and environmental samples should be taken
as early as possible since the amount of physical evidence will diminish with time. Explain the
procedures of food and environmental sampling.

In order to be able to carry out the appropriate microbiological examinations on a sample and provide a
meaningful interpretation of test results, it is essential that samples are collected in a suitable manner
using the correct equipment. General procedures for the sampling should be described For more
unusual sampling requirements, advice on procedures and sampling equipment should be sought from a
specialist food, water and environmental microbiology laboratory with appropriate accreditation.

Health and safety considerations

Collection of food and environmental samples in hospitals may occur in a variety of locations including
wards, operating theatres, equipment decontamination and preparation areas, plant rooms and cooling
towers. Each location and reason for sampling will be associated with its own risks. It is important to
make an assessment of these risks and put appropriate control measures in place before any sampling is
carried out. Examples of hazards include:

• Wet floors that present a slip hazard when sampling from swimming and hydrotherapy pools or from
kitchen areas
• working at height when ladders/steps are required to reach sampling points

• manual handling when carrying large amounts of sampling equipment to and from the site of sampling
• working in confined spaces when sampling from difficult-to-reach parts of water systems

General equipment requirements

Some of the Equipment’s that may be needed for sampling includes:

• Sterile food-grade plastic bags/twist-seal bags/honey jars

• tamper evident tags or evidence bags

• labels

• Permanent waterproof marker pens and biros

• Laboratory sample submittal forms for food, water and environmental samples (usually provided by
the laboratory)

• alcohol wipes

 Procedure for food sampling

The sampling procedure may vary depending on the type of food and the reason for sampling. If food-
handling practices within a catering unit are being investigated, it may be appropriate to sample the
food using the utensils that would normally be used for handling or serving the food. However, if a sub-
sample of food is to be examined as supplied by the producer to the hospital catering department, the
sample should be collected using sterile utensils.

i. At least 100 grams of food is usually required, unless an alternative quantity has previously
been agreed with laboratory staff.
ii. Where intact foods are to be examined, the whole sample in its original wrapping is placed
inside a food-grade bag.
iii. For aseptic sampling of open packs, take a portion of the food using appropriate sterile
utensils. This will normally be a representative portion of all components but may be a
specific portion such as a core sample, surface sample, filling etc. Place the food sample
Examining food, water and environmental samples from healthcare environments 9 into a
sterile food-grade bag or plastic honey jar, taking care not to allow the sample to touch the
outside or top edge of the container. Label the container with the location and sample
details, sender’s unique reference/identification code, sampling officer and date and time of
sampling. When a secure chain of evidence is required, place the container into another
sterile bag and seal with a tamper evident tag.
iv. Record the sender’s reference code and any relevant information such as the place of
sampling, temperature of storage, type of packaging and type of sample on the laboratory
sample submittal form.
 v. Store samples in a cool box, preferably between 1 and 8oC (taking care to keep raw foods in
a separate box from ready-to-eat foods, and hot food separate from cold), and return to the
laboratory as soon as possible, preferably on the same day (unless there is a particular
reason for a delay such as sampling late in the evening) but always within 24 hours of
collection.

If necessary, samples can be left in a cool-box overnight, provided that it is properly packed with an
adequate number of cold packs (10% of the total cool box volume; see Appendix 2 for further guidance)
or transferred to a secure fridge or cold-room, and submitted to the laboratory as early as possible on
the following day. A calibrated datalogger should be used to monitor the temperature throughout the
storage period.

 In sampling the environment

Random, undirected sampling differs from the current practice of targeted sampling for defined
purposes. Previous recommendations against routine sampling were not intended to discourage the use
of sampling in which sample collection, culture, and interpretation are conducted in accordance with
defined protocols.

Targeted microbiologic sampling connotes a monitoring process includes,

a. written, defined, multidisciplinary protocol for sample collection and culturing

b. analysis and interpretation of results using scientifically determined or anticipatory baseline
values for comparison; and
c. Expected actions based on the results obtained.

Infection control, in conjunction with laboratorians, should assess the health-care facility's capability to
conduct sampling and determine when expert consultation and or services are needed.

3 It may be useful to think of the simplicity of a surveillance system from two perspectives: the design
of the system and the size of the system. An example of a system that is simple in design is one whose
case definition is easy to apply and in which the person identifying the case will also be the one
analyzing and using the information. Outline and discuss a more complex system but still maintaining
simplicity and flexibility.

The following can be a complex system that still maintains simplicity and flexibility;

(i) Special laboratory tests to confirm the case

Laboratory diagnosis is an essential element of communicable disease surveillance, both for routine
confirmation of infections and for the rapid identification of the cause of outbreaks and epidemics.

When this outbreak is suspected and an alert is triggered, collect stool samples from symptomatic
individuals and send them to the reference laboratory for microbiological confirmation by culture
and/or PCR and antimicrobial susceptibility testing. Verifying the diagnosis, is closely linked to verifying
the existence of an outbreak. In fact, often these two steps are addressed at the same time. Verifying
the diagnosis is important:

(a) To ensure that the disease has been properly identified, since control measures are often disease-
specific;

(b) To rule out laboratory error as the basis for the increase in reported cases.

There will be review of the clinical findings and laboratory results. summarize the clinical features using
frequency distributions. Are the clinical features consistent with the diagnosis? Frequency distributions
of the clinical features are useful in characterizing the spectrum of illness, verifying the diagnosis, and
developing case definitions.

The role of the laboratory is to:

a. Monitor causal bacteria

b. Identify trends of causative disease pathogens
c. Ensure effective monitoring of programmes (elimination/eradication programmes)
d. Detect new or re-emerging pathogens
e. Monitor bacterial resistance to antimicrobials

Some of the Advantages of this include the highly controlled setting of lab experiments, the
standardized procedures and causal conclusions that can be drawn.

Disadvantages include the low ecological validity of lab experiments and demand characteristics
participants may present.

(ii) Telephone contact or a home visit by a public health nurse to collect detailed information

During an infectious disease outbreak, outbreak control measures may include a reduction in the
number of people entering and leaving a care home to reduce the spread of infection, subject to an
individual risk assessment. Visiting should only be restricted in exceptional circumstances, where
facilitating a visit would pose a significant risk to the health or wellbeing of someone in the care home
premises, which cannot be mitigated through other precautions. When the specific circumstances of an
outbreak require this, any advice on reducing visiting should always be time limited, proportionate to
each specific outbreak and risk based.

Telephone contact or a home visit by a public health nurse helps and allows the health worker to assess
the home and family situation in order to provide the necessary nursing care and health-related
activities. The purpose of the home visit here is to have face-to-face contact at an individual’s home,
with a healthcare professional.

The home visit allows an assessment of the home environment and family situation to provide for
healthcare-related activities. It is done to reduce the defaulter rate and to enhance compliance with
treatment. Home visits provide opportunities for professional development, as well as improve the life
orientation skills of healthcare.

In this case a clinical health worker can organize for telephone or home visit to establish some additional
historical background and family background in order to understand how to deal with the
gastrointestinal outbreak

Advantages include

a. The nurse obtains the full picture of the home environment the individuals reside in.
b. Identification of the influence of the environment on the individual’s health.
c. It allows the CHW to view the individuals’ relationship with family members and the community.
d. It is an opportunity for a CHW to view the individual’s performance of activities of daily living.
e. It gives the CHW a perspective to plan and evaluate interventions in a natural setting.
f. It allows a CHW to recognize unidentified health and social needs.
g. It provides an assessment window into the household characteristics.

Some Precautions include

I) Visitors should be warned of the outbreak and any symptomatic residents so that they are
aware of the risks and can decide whether to go ahead with the visit or postpone if they
wish to do so.
II) It is also important that visitors follow the IPC processes put in place by the care home, such
as practising hand hygiene and following the same PPE recommendations as staff.
III) Health, social care and other professionals may need to visit residents within care homes to
provide services. Visiting professionals should follow the same PPE recommendations as
other visitors.

Disadvantages include:

a. A stigma attached to the family’s self-perspective of incompetence.

b. It is not cost-effective for a health worker to travel to one individual and see them at home
unlike seeing them at the clinic and achieving the goal of consulting twenty individuals in a day

(iii) Multiple levels of reporting

For example with the Notifiable Diseases Reporting System, case reports may start with the
doctor who makes the diagnosis and pass through county and state health departments before
going to the Centers for Disease Control) Simplicity is closely related to timeliness and will affect
the amount of resources that are required to operate the system.

Transferring data from moi referral hospital will be the first step after getting all the necessary
information and findings through a disease reporting system. Doctors report either from the lab
tests or diagnosis in the hospital is very efficient and essential in this first step. Data correctly
 analyzed after proven through various test findings to offer the best reliable source to be
propelled to the next level

After the system has acquired data from Moi teaching and referral hospital it may be propelled
to the county or state health departments for further analysis and directions and guidelines on
the same in order to come up with a specific framework of ideas and recommendations that
may lead to offer a satisfactory solution on the same. The county departments establish a full
report that will be presented to the centers for disease control for the next if not the least
process.

When the system pushes the report to reach the centers of disease control , this body then
serves as the national focus for developing and applying disease prevention and control,
environmental health, and health promotion and health education activities designed to
improve the health of the people. CDC identifies and defines preventable health problems and
maintains active surveillance of diseases through epidemiologic and laboratory investigations
and data collection, analysis, and distribution

This process helps attain global aid in cases that are extreme and allows the matter be address
in a global perspective from a local diagnosis. The multiple levels of reporting is a simple yet still
complex way to achieve the objectives appropriately it is efficient and essential process that
could be applied here in case it grows to be pandemic

4.During foodborne disease outbreak advice on personal hygiene is critical should be issued to all
individuals with gastrointestinal disease. Discuss the precaution required at this time of the
foodborne outbreak both for the patients and the public.

During the outbreak there are a number of precautions required at this time of the foodborne outbreak
both for the patients and the public.

 Hand hygiene and general cleanliness in handling food

1. Wash hands with warm, soapy water for 20 seconds:

 before and after handling food

 after using the bathroom

 after changing a diaper

 after handling pets

 after tending to a sick person

 after blowing your nose, coughing or sneezing

  after handling uncooked eggs, raw meat, poultry or fish and their juices

2. If your hands have any kind of skin abrasion or infection, always use clean disposable gloves.
Wash hands (gloved or not) with warm, soapy water.
3. Thoroughly wash with hot, soapy water all surfaces that come in contact with raw meat, poultry,
fish, and eggs before moving on to the next step in food preparation. Consider using paper
towels to clean kitchen surfaces. If you use dishcloths, wash them often in the hot cycle of your
washing machine. Clean other surfaces, such as faucets and countertops, with hot, soapy water.
4. To keep cutting boards clean, wash them in hot, soapy water after each use; then rinse and air
or pat dry with clean paper towels. Cutting boards can be sanitized with a solution of 1
tablespoon of unscented, liquid chlorine bleach per gallon of water. Flood the surface with the
bleach solution and allow it to stand for several minutes; then rinse and air or pat dry with clean
paper towels.
5. Don't use the same platter and utensils that held the raw product to serve the cooked product.
Any bacteria present in the raw meat or juices can contaminate the safely cooked product.
Serve cooked products on clean plates, using clean utensils and clean hands.
6. When using a food thermometer, it is important to wash the probe after each use with hot,
soapy water before reinserting it into food.
7. Keep pets, household cleaners, and other chemicals away from food and surfaces used for food.
8. When picnicking or cooking outdoors, take plenty of clean utensils. Pack clean, dry, wet and
soapy cloths for cleaning surfaces and hands.

 Routine Practices

Routine practices are the IPC practices for use in the routine care of all patients at all times in all
healthcare settings and are determined by the circumstances of the patient, the environment and the
task to be performed

Routine practices such as hand hygiene, and cleaning and disinfection must always be followed when
there is a potential risk of exposure to body fluids. care centers must ensure that personal protective
equipment is worn during activities in which staff may be exposed to infection. For example, staff must
wear appropriate PPE when they are required to handle soiled items, such as diapers; when they clean
and disinfect surfaces or objects that have been contaminated by body fluids, such as vomit; or when
they provide care to a child experiencing symptoms of illness.

 Exclusion and Cohorting of Ill patients and Staff

Risk-based assessments should be undertaken to determine the appropriate location for patient care.
Where the safest option is not available or appropriate, a risk-based decision should be made by the
senior admitting staff in consultation with service leaders and local infection prevention and control
(IPC) teams if available.
Patients who are ill should be isolated from other patients. During the outbreak, patient and staff
should be assigned to dedicated rooms (e.g., cohorting). As much as possible, this helps to limit the
movement of staff from room-to-room. Patients and staff who are experiencing gastroenteritis will be
sent home and should not return to the care center until they are no longer infectious to others which
means symptom-free for at least 48 hours.

Contact Precautions plus measures to ensure safe handling and disposal of faecal material. Infected
patients should not be managed in open wards except as part of a cohort.

Though Isolation alone is not enough to prevent transmission of infectious agents - it must be applied as
part of a rigorous programme of infection control measures. This should include appropriate barrier
precautions, controlled use of antibiotics, eradication of bacterial carriage when appropriate,
environmental cleaning, disinfection of equipment and education. Active surveillance cultures are also
important to allow early detection and isolation of colonized patients.

The goal of cohorting patients and the staff that attend to them is to minimize opportunities for
infection transmission. Cohorting minimises interactions between those who are infectious and those
who are not. Staff caring for patients with suspected or confirmed infections, where possible, should be
cohorted. Each cohort should be assigned to work with either suspected or confirmed patients to
minimize the risk of transmission.

 Enhanced Cleaning and Disinfection

During an outbreak, additional cleaning and disinfection measures are needed. For example: Frequently-
touched surfaces, objects and toys should be cleaned and disinfected more frequently, at a minimum of
twice daily and as needed. The disinfectant used during an outbreak must be effective. In some cases, a
higher concentration of disinfectant is needed during an outbreak (e.g, “Outbreak Situation” level).
Always follow the manufacturer’s instructions. If using chlorine (bleach) as a disinfectant, in cleaning,n
once the ill person has left the setting or area Identify all areas accessed by the symptomatic person.
Ensure all necessary equipment and products are readily available and appropriate for use

Other ways in cleaning can be initially cleaning visibly contaminated areas with detergent and hot water,
using a disposable cloth. For areas where gross contamination has already been removed, ensure that
an area 2 meters surrounding the contaminated area is also cleaned and disinfected.

Avoid creating splashes and spray when cleaning. For items that cannot be laundered or cleaned with
chemical products, steam cleaning should be carried out. Dispose of all materials/items within the
contaminated area that cannot be sufficiently cleaned and disinfected. Undertake cleaning activities in a
methodical manner so pre-cleaned surfaces do not become re-contaminated.

 Group Activities
Mass gatherings, like sporting events or religious pilgrimages, are highly visible events attended by tens
of thousands of people. They can pose public health risks and strain the public health resources of the
hosting community, city or country.

During an outbreak, group activities should be stopped temporarily until the outbreak is declared over.
Any sensory materials that were prepared and in use or prior to an outbreak; being declared should be
discarded. Group activities may increase the rates of infections if not properly managed. In organised
mass gathering events as a good opportunity to arrange health promotion activities. Prepare risk
communication, community engagement and infodemic management activities ahead of mass
gatherings. Participants should ideally receive information before, during and after such events

 Ensure Ventilation and Air Quality

Ventilation moves fresh air from outside to replace stale air inside and clears odors, germs, and other
harmful particles from the air. Good ventilation can reduce the number of virus particles in the air. Along
with other preventive actions, ventilation can reduce the likelihood of spreading disease.

Safely opening windows and doors, including on buses and transportation vehicles, and using portable
air cleaners with HEPA filters, are examples of strategies to improve ventilation. Contaminated air by the
disease causing organism may increase the rate of infection rather than prevention and protection.

References
Disease Surveillance". The Task Force for Global Health. Retrieved

WHO (2002). Introduction to basic epidemiology and principles of statistics for tropical diseases control.

Borgdorff MW, Motarjemi Y (1997). Surveillance of foodborne diseases

Bryan FL, Guzewich JJ, Todd ECD (1997). Surveillance of foodborne disease.

Department of Health (1994). Management of outbreaks of foodborne illness. London, HMSO