VAN BUREN/CASS DISTRICT HEALTH DEPARTMENT

CONDUCTING AND COMMUNICATING

FOODBORNE ILLNESS AND OUTBREAK INVESTIGATIONS

OPERATING PROCEDURE

OBJECTIVE

To protect the health or lives of persons in the community against the adverse effects of a foodborne disease.

DESCRIPTION

Conducting foodborne illness and outbreak investigations is one of the core competencies of a local health department. This operating procedure addresses several of the key issues involved with conducting and communicating a foodbome illness or outbreak investigation.

LEGAL BASIS

Food Law of 2000 (Act 92), Michigan Local Public Health Accreditation Program Cycle 5 (2012), Local Public Health Operations Section II; Food Service Minimum Program Requirements 15, 19 & 20.

POLICY Foodbome illness and outbreak investigations will be conducted in accordance with the document "Procedures to Investigate a Foodbome Illness" by the International Association of Milk, Food, and Environmental Sanitarians (IAMFES). The Director of Environmental Health will make copies of this available to other team members when the investigation team is activated. The most recent version of this document that is available will be used. An investigation will be initiated within 24 hours of communication of each complaint involving suspected food borne illness or injury. When epidemiological analysis supports the decision, and it is documented in the investigation report, the complaint investigation may be closed after an interview with the complainant, but without inspection of the establishment. The results of that investigation and how it was handled will be documented and maintained on file. All suspected foodbome diseases or poisonings associated with a food service establishment within the jurisdiction of the Van Buren/Cass District Health Department will be reported promptly to the Michigan Department of Agriculture. An investigation report for each food borne outbreak will be submitted to the Michigan Department of Agriculture. Foodbome outbreak means an incident where 2 or more persons, not of the same household, have ingested a common food and have a similar disease, similar symptoms, or excrete the same pathogens, and there is a time, place, or person association between these persons; where there is a single case of suspected botulism, mushroom poisoning, paralytic shellfish poisoning, or other rare disease; or where there is a case of a disease or poisoning that can be definitely related to ingestion of a food. TEAM MEMBERSHIP The foodborne outbreak investigation team consists of: •

Director of Environmental Health

• • • • •

Director of Nursing Medical Director Health Officer Communicable Disease Nurse Sanitarian

If the Medical Director is unavailable, the Deputy Medical Director will serve in his place. If the Director of Nursing is unavailable, the Health Officer or Medical Director will designate one of the public health nurses to serve in his/her place. If the Director of Environmental Health is unavailable, the Health Officer or Medical Director will designate one of the sanitarians to serve in his/her place. Additional communicable disease nurses, sanitarians and support staff will be assigned to the team as needed based on work demands. When work volume necessitates it, team members may assume the duties typically assigned to another team member, such as a nurse helping with the duties of a sanitarian or vice versa. ROLES AND RESPONSIBILITIES

The health officer will stay abreast of the investigation and assure the availability of resources necessary for the prompt and effective conduct of the investigation and the communication of results. He will assist in communications within and outside of the department, as necessary. The medical director will assist with the clinical evaluation of patients, decisions regarding prophylactic and therapeutic treatment, obtaining background medical information relevant to the investigation, assist with hypothesis generation and the subsequent hypothesis evaluation, selection of necessary clinical testing and the subsequent evaluation of results, and communication of results to the public and within the department. The communicable disease nurse will assist with the evaluation of patients and potentially exposed individuals, their treatment, obtaining clinical specimens, evaluation of the cause of the outbreak, and communication of results. The sanitarian will assist with the inspection of food service facilities and processes, evaluation of possible causes for the illness outbreak, obtaining relevant specimens for testing, determination of appropriate interventions, and monitoring of the results of those interventions. The Directors of Nursing and Environmental Health will guide and assist their workers in the conduct of their duties, collaborate with other team members for the coordinated conduct of the investigation, and communicate the results and progress of the investigation with both those within and outside of the department. Certain functions are accomplished by two sub-teams namely the communicable disease nursing team and the environmental health team. The roles of these teams are described later in this document. COMMUNICATIONS

During a food borne outbreak investigation, the investigation team will meet frequently, either formally or informally, to keep one another abreast of the progress of the investigation. The Director of Nursing will keep the nursing staff updated regarding the progress of the investigation. The Director of Environmental Health will keep the environmental health staff

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updated regarding the progress of the investigation. The investigation team will designate one of its own members to keep the other members of the district health department updated regarding the progress of the investigation. If the investigation indicates a source of a food-borne disease or poisoning was from a food processing, food storage, or similar type of food establishment over which the department of agriculture has legal jurisdiction or responsibility, the Health Officer will immediately notify the Director of the Michigan Department of Agriculture while the food borne illness outbreak investigation team is completing the investigation. The Medical Director will contact appropriate representatives from the Michigan Department of Community Health regarding the progress of the investigation. Other team members such as the Health Officer, Director of Nursing, and Director of Environmental Health will assist with this communication as needed. The Medical Director will communicate with interested members of the community and the press regarding the progress of the investigation. Other team members such as the Health Officer, Director of Nursing, and Director of Environmental Health will assist with this communication as needed.

EQUIPMENT A.

Initial Referral Slip from a patient, friend, M.D., food service establishment, hospital, or school.

B.

Forms 1. 2. 3. 4. 5. 6.

C.

Lab slips MDCH Microbiology Test Requisition - The state will accept food and stool specimens for viral, paraSites, and fungus.

(lAMFES)* Food Related Alert/Complaint form - Form A Case History: Clinical Data - Forms C1 & C2 Summary of Case Histories - Forms D1 & D2 Food Preparation Review - Form H Attack Rate and Exposure Tables - Forms K1 & K2 Investigation of a Foodborne outbreak - CDC Form 52:13 * Or equivalent - provided by regional epidemiologist

Kalamazoo County Human Services Lab: Miscellaneous examination slip is used for food and stool specimens for an outbreak of Salmonella, Shigella, E. coli 0157:H7 and Campylobacter. D.

Clinical Specimen Containers (kits units 45, 45A, 46A) 1.

2. 3.

E.

46A food outbreak kit sent to Kalamazoo Regional Lab has 5 stool specimen containers, plastic bags, lab request forms, box, refrigerant, 5 sterile plastiC containers, 5 para-pak C & S fecal bacteria cultures, and 5 50ml sterile tubes for fecal-viral detection. Use lab slips and specimen container (kits units appropriate for the type of specimen. Botulism tests from blood, stools, food or any other clinical specimen requires prior approval 1-517-331-8067.

Food Outbreak Log (Complaint Log).

F.

Kalamazoo County HSD Regional Lab Contact Person and Numbers

PROCEDURE A.

Initial Investigation 1.

The referral may be received verbally or in writing from nearly anyone including a call from a patient, friend, M.D., food service establishment, hospital or school. The individual making the referral will be put in contact with a food service sanitarian, or in their absence, a communicable disease nurse. This person will document the referral using Form A. This form will be placed in the Food Outbreak Log (Complaint Log) which is a file kept in the Environmental Health Food Service Cabinet. The entry pages in that file are kept in chronological order. From time to time the food service sanitarian adds each entry into a computerized file which tabulates the complaints. If Form A is completed by someone other than the food service sanitarian, that person will also leave a message for the food service sanitarian so that they know to follow through with the next step.

2.

The food service sanitarian will make inquiry after each complaint to determine whether there appears to be any substance to the issue. They will determine whether to trigger a foodborne illness outbreak investigation. They will do so if: (a) there is a single case of suspected botulism, mushroom poisoning, paralytic shellfish poisoning, or a case of a disease which can be definitely related to ingestion of a food, or a very rare disease with strong suspicion of being related to food ingestion, or (b) 2 or more persons, not of the same household, have ingested a common food and have a similar disease, similar symptoms, or excrete the same pathogens, and there is a time, place, or person association between these persons. In the absence of a food service sanitarian, another sanitarian, a communicable disease nurse, or any other member of the team can decide whether to trigger an investigation.

3.

If an outbreak doesn't appear to have manifested based upon the investigation and information provided, the complaint will be considered isolated and closed. However, a case history shall be completed in the event the information becomes relevant of future complaints.

4.

When the decision is made to trigger a foodborne outbreak investigation, the initiating team member will advise the Directors of Environmental Health and Nursing of the referral. The Director of Nursing will assign one or more communicable disease nurses to the investigation. The Director of Environmental Health will assign one or more sanitarians to the investigation. One of the above directors will notify the Medical Director and Health Officer. The Health Officer, the Medical Director, and the Directors of Nursing and Environmental Health will collaborate throughout the investigation, and determine when formal and informal meetings of the investigation team are necessary.

B.

ENVIRONMENTAL HEALTH TEAM: 1.

The Lead Sanitarian will: a. Call initial suspects and complete Forms C1 & C2. b.

Obtain itemized list of persons and phone numbers exposed to the suspect meal; ill and well contacts alike. This may include an attendance list. credit card receipts, or roster of normal clientele. These individuals, also, will be contacted and interviewed in order to complete case histories.

c.

Obtain a complete menu, including side dishes, desserts and beverages of the suspect meal to assist in more accurate interviewing of persons exposed. The sanitarian will complete the Food Preparation Review Form (Form H) including a review of each step of the preparation process, e.g .. thawing, backing. pre-chilling, re-heating. cross­ contamination of foods, etc.

d.

Report their findings, from time to time, as the investigation progresses to the Director of Nursing, Director of Environmental Health, and the Medical Director.

2.

Information will be summarized, either by hand (e.g. using Forms 01 & 02) or by computer, from the Case History/Clinical Data Sheets for both ill and well individuals to facilitate comparisons.

3.

All foods from the suspect meal(s) will be entered into the Food Specific Attack Rate Table (Form K1) and data compiled for each food regarding the number of ill and well people who ate the food and the numbers of ill and well people who did not (Form K2). Using these tables, calculations will be made to indicate the food specific attack rates and exposures.

4.

From above, #2 and #3, the hypotheses for a possible pathogen and an implicated food will be formed.

5.

A sanitarian will conduct a thorough inspection of establishment and interview all food service personnel regarding food sources, food preparation techniques, storage, display. and transportation procedures utilized at the time of the suspect meal.

6.

Environmental Health makes a decision of what collected food samples will be forwarded to a laboratory for testing. a. b. c. d. e.

Use the correct kit for specimen collection and delivery. Food samples will only be analyzed when submitted with corresponding stool specimens. CALL FIRST! See attached list of telephone and pager numbers, Kalamazoo Lab and MDCH. Directions for travel to the Kalamazoo laboratory. What to do when you arrive: Specimens must be handed to an authorized laboratory representative.

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. f.

C.

Reporting of results: Telephone, FAX, Mail - give contact name and number for results.

7.

Environmental Health conducts supportive tests for outbreak, i.e., Chi-square and Fishers Exact Tests and handles computer print­ outs, attack rates and symptom summaries of ill and well.

8.

The Environmental Health Team is responsible for creating a final report of the foodborne illness outbreak investigation for submission to the Michigan Department of Agriculture. They will complete CDC Form 52.13 to summarize the foodborne outbreak investigation results. In addition, they will compile a cover letter describing any components of the investigation which were not adequately summarized in CDC Form 52.13. This cover letter along with CDC Form 52.13 will be submitted to the Michigan Department of Agriculture as a final report of the investigation.

COMMUNICABLE DISEASE NURSING TEAM: 1.

The Communicable Disease Nurse(s) will: a.

Contact hospitals, clinics, local physicians, etc. to notify the medical community of a possible disease outbreak and to request assistance in obtaining fecal, vomitus, blood and other related samples prior to administration of antibiotics.

b.

Obtain appropriate clinical specimens from food handlers and preparers (whether ill or not), and individuals exposed to the suspect food(s). These specimens will be submitted ASAP to the appropriate laboratory, typically the Kalamazoo Regional Lab or MDCH, depending on the specific pathogen being tested. 1.

2. 3.

4.

5.

Send the clinical specimens to the lab along with food specimens, using kit 46A for food poisoning from MDCH. Vomitus specimens should be placed in sterile containers as viral samples. Fecal specimens for presumptive testing of Salmonella, Shigella, E. coli 0157:H7, and Campylobacter are sent to Kalamazoo Regional Lab. Fecal specimens for presumptive testing of Norwalk virus, ova and parasites, and Hepatitis A are sent to MDCH. When Norwalk-like virus is suspected, blood samples should be obtained from persons submitting fecal specimens (ill and controls i.e. well), and a second blood sample should be obtained from these same individuals about 3 weeks later - 21 days (use kit 45 & 45A for this). - see MDCH Lab Manual (Viral serology Kit #41). All specimens, fecal, blood, food, etc., should be kept in a designated refrigerator until delivered to the laboratory, but none should be frozen.

6.

c.

2.

Check with Environmental Health as fecal and food specimens need to be sent together to the lab for analyzing.

Members of the Communicable Disease Nursing Team will assist members of the Environmental Health Team with completing their duties when work demands make it more reasonable to re­ allocate responsibilities. This could include, for example, contacting contacts and completing Forms C1 & C2 for each one, or compiling data and assisting in its' interpretation.

Control Measures for the Communicable Disease Nurse a.

The Communicable Disease Nurse needs to educate all the clients about the disease process emphasizing hygiene, particularly hand washing with soap.

b.

The client needs to know proper handling and storage of food as well as proper preparation methods.

REFERENCES International Association of Milk, Food, and Environmental Sanitarians (IAMFES), th Procedures to Investigate Foodborne Illness, 5 ed., 1999. Food Law of 2000 (Act 92). Michigan Local Public Health Accreditation Program Tool 2012, MPR Indicator Guide; Food Service Section II; MPR 15, 19 & 20.

-/z Date

Rev. 8/22/2012