Rodney Moran - Department of Health

Outbreaks - who are you going to call?
Rodney Moran
Communicable Disease Prevention and Control Unit
Health Protection Branch

Who is CDPCU?
• Unit within the Dept of Health, Health Protection Branch
• Centralised surveillance and control unit
– monitoring incidence of disease
– outbreak detection and response
– case management
– research and evaluation
– policy development and implementation
– public health advice and education
• General responsibilities of the CDPCU include
– formulating policy and program standards for the prevention and control eg.
gastrointestinal illness
– maintaining a surveillance system for notifiable infectious diseases in Victoria
– developing and coordinating appropriate education and prevention strategies
– providing expert advice on infectious diseases issues
– providing public health emergency response to infectious disease outbreaks
– coordinating and delegating the investigation of single incidents, clusters and
outbreaks of gastroenteritis
– notifying the Victorian State Coroner of any deaths associated with an outbreak

Make up of CDPCU
• Six programmes within CDPCU
– Investigation & Response Section
– Epidemiology Section
– Policy, Planning & Information Section
– TB control Section
– Immunisation Section
– Office of the Assistant Director
• Multidisciplinary team
– Environmental health officers, epidemiologists, public
health clinicians, policy officers, public health nurses and
trainees to name a few

What is an outbreak and who do you call?
• For gastro
– 2 or more cases of vomiting/and or diarrhoea amongst
residents/patients and/or staff (that cannot be explained by
medication or other medical conditions) within 72 hours in a setting
that makes epidemiological sense
• For respiratory illness
– 3 new cases of respiratory disease within 72 hours
• Call the Department of Communicable Disease Prevention & Control Unit
– Ph: 1300 651 160
(Number above voice message provides contact details for our on call public health
officer)
• Recommended you also advise Cwlth Dept of Health and Ageing

Notification and law
• The Public Health and Wellbeing Act 2008 requires medical practitioners
and pathology services to notify a number of conditions to the Department
(prescribed conditions in regulations)
• The list includes “two or more related cases of food or waterborne illness”
(to be notified on suspicion). Information about notification requirements is
available at http://www.health.vic.gov.au/ideas/notifying/howto
• Although outbreaks of viral gastroenteritis is not required to be reported by
law, this is strongly encouraged on a voluntary basis as it is often difficult
to distinguish whether the illness is being spread person to person, or from
contaminated food or water

Why is it important to notify?
• A viral gastro outbreak in 2002
closed the emergency department
of a major hospital for several
weeks and affected >15 wards
• One nursing home outbreak had
22 cases in residents. Illness was
found to be due to food served at
the facility. Coronial enquiries due
to deaths
• A campylobacter outbreak in a
nursing home resulted in 3 staff
being hospitalised and a
workcover case being mounted
against the facility
• A salmonella outbreak in a hospital
affected 15 young children and
was believed to have been spread
person-to-person by health care
staff

Basic roles and responsibility
• DH (CDPCU and Region)
– Coordinate response
– May assist onsite
– Review findings
• Council
– Onsite attendance to review cleaning, hygiene, food
preparation, & collect samples/specimens
– Provide advice
– Respond to identified issues

DH roles and responsibilities
• The role of CDPCU during outbreak investigations includes
– circulating an incident report within 24 hours of the outbreak being notified
– managing and coordinating the investigation of gastroenteritis outbreaks and the
investigation teams
– liaising with OzFoodNet, Communicable Diseases Network Australia, the Department
of Health and Ageing and other public health authorities
– liaising with public health laboratories
– liaising with the FSRAU with regard to foodborne outbreaks, and EHU for waterborne
outbreaks
– requesting information and action from REHOs and local government EHOs relating to
the outbreak (for example, infection control measures, audit reports, FSP compliance,
premises inspection, process information, written reports, food and faecal samples,
interviews)
• For successful and effective investigation of gastrointestinal illness and outbreaks, it is
necessary that all involved parties work together as a team
• Responsibilities for the investigation and management of the public health aspects of cases
and outbreaks of gastrointestinal illness are shared by the department and local government

Gastro Guidelines
• This publication provides a comprehensive
guide for those involved in the
investigation of a number of infectious
diseases causing gastroenteritis
• It guides investigators from the time the
incident is detected, through the
investigational requirements, to the
implementation of control measures

Why do we investigate?
• Prevent further transmission of illness
• Provide information which can be used to control outbreak
• Prevent similar occurrences in the future
• Help identify populations at risk for a disease
• Learn more about the disease including the impact of control
measures

General management summary

What do we know?
• Viral outbreaks are most common
• Person-to-person transmission
most common type of transmission
in institutions
• Food-borne outbreaks can be
easily overlooked
• Nursing staff usually adequately
briefed – other staff not always
• Staff exclusion and hand washing
is often where outbreak control
falls down
• Identification of the source of an
outbreak of illness is not always
straight forward
• Almost every outbreak will be
unique in some way, requiring a
degree of flexibility when
recognising and investigating
outbreaks

Outbreaks by mode of transmission.
Victoria 2010 (n=557)
Foodborne (35)
Unknown (70)
Person to person (452)

Viral and suspected viral outbreaks by setting
2010 (n=459)
Residential facility (26)
Hospitals (108)
Child care (48)
Other (12)
Aged Care (265)

Foodborne outbreaks by setting.
Victoria 2010 (n=35)
Restaurants (6)
Private residences (6)
Community (2)
Aged Care (18)

Outbreaks in Aged care settings by aetiology
Victoria 2010 (n=319)
Clostridium perfringens (3)
Rotavirus (2)
suspected viral (86)
unknown (44)
Campylobacter (2)
Salmonella (3)
Norovirus (177)

Outbreaks of Norovirus/suspected viral aetiology by quarter
Victoria – 2005 - 2010
Number of outbreaks
250
200
150
100
50
0
1st Q 2005
2nd Q 2005
Norovirus suspected viral
3rd Q 2005
4th Q 2005
1st Q 2006
2nd Q 2006
3rd Q 2006
4th Q 2006
1st Q 2007
2nd Q 2007
3rd Q 2007
4th Q 2007
1st Q 2008
2nd Q 2008
Notification quarter
3rd Q 2008
4th Q 2008
1st Q 2009
2nd Q 2009
3rd Q 2009
4th Q 2009
1st Q 2010
2nd Q 2010
3rd Q 2010
4th Q 2010

Number of outbreaks
Foodborne outbreaks by aetiology (n=35)
14
12
10
8
6
4
2
0
Salmonella Campylobacter Clostridium
perfringens
Listeria
monocytogenes
Aetiology
Bacillus cereus Histamine poisoning Unknown

Food borne outbreaks
• Food borne outbreaks in nursing homes / institutions
increased over last couple of years
• Can be difficult to recognise food-borne outbreaks in
institutions
• Predominantly associated with Salmonella or Clostridium
perfringens
– Preparing food ahead of service
– Inadequate cooling and reheating
– Inadequate hot holding/cold storage of meals
– Use of gravies and soups / vitamised meals
– Holding over of leftover meals
– Inadequate equipment cleaning

Influenza
• Key interventions for influenza outbreak control
– Annual influenza vaccination of residents and staff
• Keep line list of vaccinated residents and staff
– Pneumococcal vaccination of residents
– Outbreak recognition and management – report >=3 new cases of
respiratory disease within 72 hours
– Institute appropriate infection control practices
– Antiviral medication recommended for treatment and for prophylaxis
of staff and residents
– Have procedures in place for timely collection of appropriate
specimens
– Have procedures in place, endorsed by visiting GPs, for antiviral use

Contacting Us
Communicable Diseases Prevention & Control Unit
Telephone:1300 651 160
(24 hours, 7 days a week)
Website: www.health.vic.gov.au/ideas
Email: infectious.diseases@health.vic.gov.au