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Food and Waterborne Disease Program

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Outbreak investigations are team efforts, guided by a designated leadinvestigatorInformationManagementLaboratoriesClinical<strong>Food</strong>/WaterSamplesRegionalEnvironmentalEpidemiologistImplicatedEstablishmentOr GroupNurseTeamMemberPartnerAgenciesStateFederalLeadInvestigatorEnvironmentalHealthTeamMemberCHDAdministrationDOHAdministrationPublicCommunicationsSpokespersonEpidemiologyTeamMember©4


Why report foodborne illnesses? To control outbreaks bypreventing further spread ofillness To prevent future occurrence ofsimilar outbreaks To promote timely treatment ofsusceptible populations5


Barriers to Surveillance for <strong>Food</strong>borne Illness• Many people not ill enough to visit physician(for diagnosis <strong>and</strong> reporting)• Cases may be scattered throughout acommunity even in outbreaks• Lack of victim cooperation• Outbreak denial by food preparer or facilityoperator• Lack of cooperation by institutions• Gastrointestinal illness from other sources iscommon• Fragmentation of public health responsibilitys • Multiple offices within the Department ofHealth6


Why do we investigate foodborneillness outbreaks?To identify cases associated with an incidentTo detect implicated foodsTo clarify information about causative agents <strong>and</strong>their sourcesTo determine the factors that t contribute t tocontamination, growth, <strong>and</strong> survival of etiologic agents7


Health Burden of <strong>Food</strong>borne <strong>Disease</strong>sin the United States• 48 million illnesses• 1 in 6 Americans gets a foodborne illness each year• 128,000 hospitalizations• 3,000 deaths• Most illness appears to be sporadic• 1,300 foodborne outbreaks reportedReference: <strong>Food</strong>borne Illness Acquired in the United States—Major Pathogens, ElaineScallan,1 Robert M. Hoekstra, Frederick J. Angulo, Robert V. Tauxe, Marc-Alain Widdowson,Sharon L. Roy, Jeffery L. Jones, <strong>and</strong> Patricia M. Griffin8


HEALTH-RELATED COSTS OFFOODBORNE ILLNESS – USU.S.• Medical Costs ($9,879 million)• Quality of Life Losses ($93,329 million)• Lost Life Expectancy ($49,160 million)• Total Cost ($152,369 million)• Cost per Case ($1,851)Reference:Dr. Robert L. Scharff. Health-Related Costs from <strong>Food</strong>borne Illness in the United States. 2010. Available From:http://www.producesafetyproject.org/media?id=0009producesafetyproject org/media?id=00099


HEALTH-RELATED COSTS OFFOODBORNE ILLNESS - Florida• Medical Costs ($227 million)• Quality of Life Losses ($5,996 million)• Lost Life Expectancy ($3,075 million)• Total Cost ($9,799 million)• Cost per Case ($1,984)Reference:Dr. Robert L. Scharff. Health-Related Costs from <strong>Food</strong>borne Illness in the United States. 2010. Available From:http://www.producesafetyproject.org/media?id=000910


From 1994-2010‣ Since 1994 3,640 foodborne disease outbreaksaffecting 29,198 people have been investigatedi by the Department of Health12


Reported <strong>Food</strong> <strong>and</strong> <strong>Waterborne</strong> <strong>Disease</strong>Outbreaks <strong>and</strong> Outbreak-related related Cases, Florida,1994-20103500# Outbreaks # Cases30002500# Outb breaks20001500100050001995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010Year13


Contributing Factors - 2010 # Outbreaks # CasesCONTAMINATION FACTORBare-h<strong>and</strong>ed contact by a food h<strong>and</strong>ler/worker/preparer who is suspected to beinfectious 12 167Contaminated raw product - food was intended to be consumed raw or undercooked /under-processed8 42PROLIFERATION FACTORImproper hot holding due to improper procedure or protocol 9 72No attempt was made to control temperature of implicated food or length of timefood was out of temperature 8 109SURVIVAL FACTORInsufficient i time <strong>and</strong>/or temperature t control during initial iti cooking/heat processing 3 79Insufficient time <strong>and</strong>/or temperature during reheating 2 39Other process failures that permit pathogen growth 4 37METHOD FACTORReady to eat food: Manual preparation, No cook step 23 205Cook <strong>and</strong> Serve <strong>Food</strong>s: Immediate service 10 93Cook <strong>and</strong> hot hold prior to service 10 9314


National Perspective


<strong>Food</strong>borne <strong>Disease</strong> Outbreaks, 1973–200916001400120010001998: improvedsurveillance~1,200 1200outbreaks/yearOutbreaks800600~500 outbreaks/year40020001973 1978 1983 1988 1993 1998 2003 2008All data from <strong>Food</strong>borne <strong>Disease</strong> Outbreak Surveillance System.Color of bars indicates improvements in data reporting systems.Preliminary data16


Multistate foodborne disease outbreaks,1990-2009Preliminary data18


Multi-disciplinary, multi-agency OutbreakDetection & InvestigationEpidemiologyCDC, State, CountyTracebackTrace forwardFDA & Industry<strong>Food</strong>:CDCFDAStateMicrobiologyMedical: CDC, StateEnvironmentalinvestigationsFDA, State, CountyIndustry21


Where do food <strong>and</strong> waterborneillnesses get reported?• Health departments• Restaurant/grocery store• Inspecting agency y( (DBPR, DACS, DOH, OTHERS)• State Health Offices• World Wide Web• Electronic Communications• Syndromic Surveillance Systems22


Where do food <strong>and</strong> waterborneillnesses get reported?• Poison control centers• Event organizer (wedding, conference, etc.)• Media-Print, Audio, Visual• Health care practitioners:• Physicians• Nurses• Emergency room23


What is a foodborne illnessoutbreak?An outbreak is an incident in which two ormore persons have the same disease, have similarsymptoms, or excrete the same pathogens; <strong>and</strong> thereis a time, place, <strong>and</strong>/or person association betweenthese persons. A foodborne disease outbreak is onein which a common food has been ingested by suchpersons.24


What is a foodborne illness outbreak?Nevertheless, a single case of suspected botulism, mushroompoisoning, ciguatera or paralytic shellfish poisoning, otherrare disease, or a case of a disease that can be definitelyi related to ingestion of a food, can be considered as anincident of foodborne illness <strong>and</strong> warrants furtherinvestigation.i i25


<strong>Waterborne</strong> <strong>Disease</strong> OutbreakDefinitionAn outbreak is an incident in which two or morepersons have the same disease, have similar clinicalfeatures, or have the same pathogen, <strong>and</strong> there is atime, place, or person association among these persons.A waterborne outbreak is traceable to ingestion ofcontaminated water or to contact with water.26


<strong>Waterborne</strong> <strong>Disease</strong> OutbreakDefinitionA single case of either chemical poisoningor a disease that can be definitely related toingestion of drinking water or contact withwater can also be considered an incident ofwaterborne illness <strong>and</strong> warrants furtherinvestigation27


Recreational <strong>Waterborne</strong><strong>Disease</strong>Recreational waterborne diseases as defined by CDCinclude: swimming pools, whirlpools, hot tubs, spas, waterparks, <strong>and</strong> df fresh <strong>and</strong> marine surface waters. CDC alsoincludes whirlpool <strong>and</strong> hot tub-associated outbreaks ofdermatitis caused by Pseudomonas aeruginosa, but notwound infections resulting from waterborne organisms.<strong>Waterborne</strong> disease outbreaks = 2 or more persons mustbe epidemiologically linked by location of exposure towater, time <strong>and</strong> illness.2828


Essential Steps for Successful Investigation of<strong>Food</strong>borne <strong>Disease</strong> Outbreaks :29


Roles in Outbreak Investigations Regulatory Agency:Perform inspectionDiscuss findings with establishmentDiscuss findings with DOH DOH Role:Perform outbreak investigationKeep partner agencies informed of investigation developmentsCommunicate findings to partner agencies <strong>and</strong> to the establishment30


Roles in Outbreak InvestigationsLaboratory• Public Health• Regulatory Agencies• Private Industry• Processes• Traceback Affected populationsp• Accessibility• Cooperation• Other entities• Media• Lawyers• Public Information• Administration31


Thinking Differently –<strong>Food</strong>borne Illness Investigation• We are trying to determine whether or not the outbreak is associated with theimplicated establishment <strong>and</strong> what may have contributed to the illnesses.• We are performing an investigation not an inspection.• Utilize the information you have regarding implicated food items, symptoms,incubation period, <strong>and</strong> duration of illness to focus your investigation.• Utilize knowledge on the contributing i factors associated with foodborneillness when performing the investigation.• Utilize knowledge regarding common foodborne diseases when performingthe investigation.32


Scenarios


Dissemination of <strong>Food</strong> <strong>and</strong> <strong>Waterborne</strong> Outbreak <strong>and</strong>Prevention Information• Annual <strong>Food</strong> <strong>and</strong> <strong>Waterborne</strong> Outbreak Report – posted onwebsite• <strong>Food</strong> <strong>and</strong> <strong>Waterborne</strong> <strong>Disease</strong> Website – reports, links, riskinformation, investigation tools, online food <strong>and</strong> waterborne illnesscomplaint form• Publications – EpiUpdate, MMWR, FEHA journal, NEHA journal,NEJM, JID, JAMA34


Dissemination of <strong>Food</strong> <strong>and</strong> <strong>Waterborne</strong> Outbreak <strong>and</strong>Prevention Information• Posters – for display at CHDs, professional meetings, health fairs• Educational materials – information i cards, magnets, cutting boards• Presentations – to DOH groups, professional associations,interested community groupsFOODANDWATERDISEASE.COM35


Outbreak Summary36


Norovirusov October, 2008• October 8 Orange County notified ofapproximately 47 gastrointestinal illnessin a group of 155 conference attendeesat a local resort on October 1-5• Joint inspection of banquet facilities• Epidemiologic investigation commenced37


NorovirusOctober, 2008• Questionnaire developed <strong>and</strong> self administered to conferenceattendees• Stools samples from two conference attendees collected• Three employees reported to be ill during conference but didnot work per company policy• Banquet food workers interviewed with questionnaire• Ill workers from Restaurant a t A identifieded• Restaurant A workers interviewed also• Stool samples collected from six ill food workers38


• 22/62 respondents illNorovirusOctober, 2008• Classic Norovirus symptoms• Diarrhea, fatigue, weakness, nausea, vomiting• Illness onsets from October 3-6• Age 33-71 years with median 53• Duration 6-155 hours with median 67• Stools samples positive Norovirus GII.4 Minerva• Two attendees• One food worker39


NorovirusOctober, 2008• October 3 Lunch -RR=2.62 (CI 1.10-6.22,p=0.0148)• Four locations available for lunch including roomservice• Three of the four locations are Restaurant A• Restaurant A October 3 Lunch-RR=4.18 (CI1.76-9.93, p=0.0001)40


NorovirusOctober, 2008• Salad SldO October 3L Lunch hR Restaurant A• RR=2.10, CI 1.21-3.64; p=0.0284• Cold s<strong>and</strong>wiches October 3 Lunch RestaurantA• RR=2.00, CI 1.29-3.10; p=0.02826• Three other significant exposures• None account for majority of illnesses41


NorovirusOctober, 2008• 13/130 food workers interviewed met casedefinition• Onsets September 26-October 11• Restaurant A-10• Banquet-3• Six of the ill food workers reported workingwhile ill or infectious42


NorovirusOctober, 2008• Duties- included cold food preparationincluding the preparation <strong>and</strong> serving of cold<strong>and</strong> hot foods in Restaurant on October 3 <strong>and</strong>October 4.• <strong>Food</strong> workers who worked while ill did notreport illness to supervisor thus were notexcluded per policy• Even with paid time off policy43


NorovirusOctober, 2008• Ill food workers not reporting gastrointestinali illness• Contamination of ready to eat products (salads<strong>and</strong> s<strong>and</strong>wiches) likely occurred on October 3 rd• Larger outbreak may have been averted byinfection control procedures implementedparticularly the exclusion of ill food workers46


… the prevention of disease transmission!47


The End49

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