CIFOR Guidelines for Foodborne Disease Outbreak Response and the CIFOR Toolkit: Focus Area 6: Initial Steps of an Investigation

New York Integrated Center of Food Safety Center of Excellence – November 22, 2016

Paula Huth, MPHBureau of Communicable Disease ControlNew York State Department of Health

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Background• This is the seventh webinar in a series of monthly webinars from the New York

Integrated Food Safety Center of Excellence (CoE)– Session covers CIFOR Toolkit Focus Area 6: Initial Steps of an Investigation– Supplementary sessions will be devoted to assist states that wish to

complete internal evaluations using the metrics and target ranges developed for the 16 CIFOR performance measures.

– Additional topics will focus on emerging issues in food safety including culture‐independent diagnostic testing, antimicrobial resistance, and advanced molecular detection/whole genome sequencing.

– All webinars will be recorded and available through the CoE website athttp://nyfoodsafety.cals.cornell.edu/

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How to Use the CIFOR Toolkit

• Describe Your Current Activities and Procedures in relation to the Focus Area

• Complete the Worksheet as a Team (Workgroup)– Epidemiology, Laboratory and Environmental Health– Refer to written protocols/procedures– Describe your agency’s/jurisdiction’s current activities

and procedures based on the Focus Area

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How to Use the CIFOR Toolkit

• Prioritize CIFOR Recommendations to Address Needed Improvements– Review the CIFOR recommendations related to the

Focus Area of interest– Identify activities and procedures in need of improvement– Rate the priority for implementing each recommendation

based on its likely impact on foodborne outbreak response

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What is Focus Area 6?

• Title: Initial Steps (of an investigation of a cluster/outbreak)

• Goals: Agency/jurisdiction determines the likely occurrence of a foodborne outbreak based on case reports and characterizes the nature of the outbreak so that necessary resources can be mobilized and appropriate actions can be initiated

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Keys to Success• Activities, relationships, and resources that are critical to

achieving success in a Focus Area• Applying metrics and measures can help you identify the

success of your program or investigation process

Focus Area 6: Keys to Success• Initial steps• Requests for assistance• Communication• Making changes

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Initial Steps• Agency/jurisdiction has processes for the response to a

possible outbreak including who is to be notified and/or involved in the investigation and specific actions– Processes are written and easily accessible by staff

• Agency/jurisdiction has established criteria for determining the scale of the response to a possible foodborne outbreak based on the likely pathogen, number of cases, distribution of cases, hypothesized source, and agencies likely to be involved

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Initial Steps• Staff can prioritize the response to a possible outbreak

based on agency/jurisdiction criteria and know what outbreak circumstances require an immediate response, a more moderate response, or no response at all

• Staff have access to historical trends or other data to determine whether case counts exceed the expected number for a particular timeframe and population

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Initial Steps• Staff develop hypotheses about the source of an outbreak

early in the investigation to guide investigation steps– Review previously identified risk factors and exposures

for the disease– Examine the descriptive epidemiology of cases to identify

person, place, or time characteristics that might suggest a particular exposure

– Interview in detail the affected persons (or a sample of) to identify unusual exposures/commonalities among cases

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Characteristics of Outbreak Investigations• 3 Main Outbreak Types (for foodborne disease):

– Localized one-time event, such as a specific food-preparation error or ill food worker at a food-service establishment

– Widespread distribution of a perishable commodity, such as spinach or tomatoes

– Contamination of shelf-stable commodities, such as canned foods or peanut butter, or persistent environmental contamination at a farm, food-processing facility or a restaurant

• Outbreak Detection– Illness complaints attributed to a particular event/establishment– Clusters identified through pathogen specific surveillance

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Initial Steps

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Initial Steps

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Initial Outbreak Investigation Procedures: Priority

• On the basis of the outbreak setting and descriptive epidemiology, investigation team leaders should assess the priority of the investigation

• On the basis of the priority given the outbreak, investigation team leaders should ensure the presence of adequate staffing to interview cases (and solicit controls, as needed)– Within 24-48 hours for outbreaks that have a high public

health impact or appear to be ongoing

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Initial Steps

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Indicators suggestive of multijurisdictional outbreaks(excerpt, Ch. 7)

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GOALS OBJECTIVES

Obtain sufficient information to implement specific interventions to stop the outbreak

Identify the etiologic agent

Obtain sufficient information to prevent a similar outbreak in the future

Identify persons at risk, and size and scope of outbreak

Increase knowledge of the epidemiology and control of foodborne disease• Unanswered questions about the etiologic

agent, mode of transmission, or contributing factors should be identified and included in the investigation to add to the public health knowledge base

Identify mode of transmission and vehicle

Identify source of contamination

Identify contributing factors and environmental antecedents

Determine potential for ongoing transmission and need for abatement procedures

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Initial Steps

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Investigation Leadership• During an investigation, focus of activities may shift

among roles and/or levels of government in accordance with authority and capacity to carry out required tasks– Laboratory – Epidemiology– Environmental health– Regulatory agencies– Communication

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Investigation Activities for Outbreaks (excerpt, Ch. 5)

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Requests for Assistance(and Communication)

• Local agencies notify state agencies as soon as an outbreak is suspected

• Agency/jurisdiction asks for help as soon as the need is recognized

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Requests for Assistance

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Communication

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Making Changes

• Agency/jurisdiction conducts a debriefing among investigators following each outbreak response and refines outbreak response protocols based on lessons learned

• Agency/jurisdiction has performance indicators related to the initial steps of an outbreak investigation and routinely evaluates its performance in this Focus Area

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Helpful Tips for Using the Toolkit

• Don’t get distracted by the volume• Be clear on the process• Keep moving – don’t get caught up in too much detail• Focus on a few realistic changes• End with specific action plans with time frames and

responsible persons• Appoint a facilitator and a recorder for each discussion

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Why Should My State Use the Toolkit?

• Improve overall foodborne outbreak investigation and response

• Enhance partnerships with agencies/partners in foodborne outbreak investigations

• Identify areas needing improvement that may have gone unrecognized

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Where to Find the CIFOR Products

• Online at: www.cifor.us• Paper copies are also available from CSTE

– Contact Thuy Kim at tkiml@cste.org• Examples of CIFOR product use by other states:

http://www.coefoodsafetytools.org/

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Next Scheduled NY CoE CIFOR Webinars

• No webinar in December 2016; will resume in 2017

Next webinar: Thursday, January 19, 2017 at 2PM• Focus Area 7: Epidemiology Investigations

Course announcement and link to register is posted on the DOH Learning Management System (LMS): www.nylearnsph.com

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ResourcesComments or questions for NY CoE can be directed to:• Paula Huth or Andie Newman, NYSDOH • 518-473-4439

Integrated Food Safety CoE Websites:• NY CoE: http://nyfoodsafety.cals.cornell.edu/• CDC: http://www.cdc.gov/foodsafety/centers/

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Questions