Course Overview - University of Colorado...

Applied Outbreak Investigation Training Instructor’s Guide

Applied Outbreak Investigation Training

Instructor’s GuideCourse Designed By:

Nicole Comstock, MSPH, Rachel Jervis, MPH, & Nereida Corral, MPH

Colorado Department of Public Health and Environment

Alice White, MSColorado School of Public Health

Acknowledgements: Elaine Scallan, PhD, Alicia Cronquist, RN, MPH,

Nisha Alden, MPH, Kate Lujan, RN, MPH, Marigny Klaber, MSc

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Table of ContentsCOURSE OVERVIEW............................................................................................................................................ 3

COURSE GOAL AND OUTCOMES.......................................................................................................................... 3

COURSE GOAL.............................................................................................................................................................3COURSE OBJECTIVES.....................................................................................................................................................3

INSTRUCTOR PREREQUISITES.............................................................................................................................. 3

HOW TO USE THIS GUIDE.................................................................................................................................... 4

COURSE COORDINATION..................................................................................................................................... 4

TARGET AUDIENCE.............................................................................................................................................. 4

CLASS SIZE.......................................................................................................................................................... 4

HOST AGENCY RESPONSIBILITIES......................................................................................................................... 5

TRAINING SUPPLIES CHECKLIST........................................................................................................................................5FINAL ARRANGEMENTS.................................................................................................................................................6

Two weeks before the course:............................................................................................................................6One week before the course:..............................................................................................................................6Immediately prior to the course:........................................................................................................................6

PRESENTER COURSE AGENDA.............................................................................................................................. 7

INSTRUCTOR: PRESENTATION REQUIREMENTS...................................................................................................7

BEFORE THE TRAINING EVENT PREPARATION LIST..............................................................................................................7DURING THE TRAINING EVENT........................................................................................................................................8AFTER THE TRAINING EVENT..........................................................................................................................................8

OUTBREAK SCENARIO FOR INSTRUCTORS............................................................................................................ 9

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Course OverviewThis in-person training is an intermediate level course for State and local public health agency staff who could potentially work on an outbreak investigation, including epidemiologists, public health nurses, environmental health specialists, emergency preparedness staff, etc. Ideally, attendees will have previously taken a “Basics of Communicable Disease” course or be familiar with communicable disease investigation in their jurisdiction.

The training is designed to be an intensive, interactive, full-day course to teach epidemiological skills during a foodborne outbreak investigation. It includes lectures, practical outbreak scenario exercises, and discussion. There is an option to integrate interactive polling clicker devices for quizzing participants during the lectures and outbreak scenario.

Course Goal and Outcomes

Course Goal

Provide practical training to participants so that they understand and practice the various steps involved in foodborne illness outbreak investigations.

Course Objectives

After completing this training, participants should be able to: • Define what constitutes an outbreak. • Identify when an outbreak investigation is necessary.• Understand and practice the basic steps of an outbreak investigation. • Understand the roles and responsibilities of epidemiology, environmental health,

and laboratory in an outbreak investigation.• Identify and know how and when to use outbreak resources and tools available

to assist local public health agencies during outbreaks.• Know how to document and report on outbreak findings. • Discuss communication strategies to employ during an outbreak.

Instructor PrerequisitesPrior to instructing this course, instructors should have completed the course and read through the instructor’s manual.

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How to Use This GuideThis Instructor’s Guide is designed to assist instructors in their organization and delivery of this training.

All the required materials (listed in bold italics in this document) for this course can be found at the Colorado Integrated Food Safety Center of Excellence website (www.COFoodSafety.org).

Preparation tips and instructions can be found throughout the guide to assist in efficiently and effectively coordinating and delivering the training

At the end of this guide there is an Outbreak Scenario guide that should be used to assist the instructor(s) as they go through the training. This scenario guide contains answers for each corresponding question that the participants are asked during the training regarding the outbreak scenario. As well as explanations of important information.

It is vital that instructors review this packet and contact CDPHE should they have any questions or concerns prior to the training.

Course CoordinationThe host agency should begin advertising once a training date has been chosen. Please see Applied Outbreak Investigation Flyer for an example template.

Once participants are confirmed (via selected RSVP method), the host agency should email the Agenda and directions to the meeting location.

There is the highly encouraged option to incorporate interactive polling clicker devices into this course. One version of the slides provided uses TurningPoint by TurningTechnologies. These can be used to test participants’ knowledge during the training. When the instructor gets to a particular slide, participants can select their answer on the clicker and results will be compiled. If interactive polling clicker devices will be used during this course, the host agency should secure these for the course. If using any clicker system other than TurningPoint you must link the slides. Alternatively, multiple-choice cards can be used for participant voting and have been provided on the CoE website.

Target AudienceThis course is designed for public health staff involved in outbreak investigation.

Class SizeThe suggested class size is ~20-40 people. The maximum class size should be close to 45-50 people. Smaller groups encourage discussion and interaction.

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http://www.COFoodSafety.org/


Host Agency Responsibilities

Training Supplies checklist

Visual aids for this course consist of PowerPoint slides and video clips. The following equipment is necessary for delivery of this course:

LCD projector compatible with a notebook computer and cables for proper connection

Spare projector bulb (optional) Electronic remote device to advance slides in PowerPoint presentation (if

available)

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Projection screen (at least 6’ x 6’) Laser pointer (optional) Interactive polling clickers networked to computer (optional, but highly

encouraged). Recommended: TurningPoint by TurningTechnologies as one slide set contains TurningPoint questions.

Power cord WiFi in room Speakers/audio in room Lab supplies: Local stool specimen testing lab form, pudding, Amies swabs,

specimen container labels, and gloves Participant Workbooks Flash drive with instructor materials Preloaded video and CoE website Preloaded Epi Info™ 7 Name Tents 2 sided Table Tents 2 sided Cowbell or other noise makers (optional) Norovirus section supplies (Slide notes for this section have instructions for use)

o Toy shopping carto Toy food

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o Bucket o Small broom or mopo Baseball capo Aprono Plastic Knifeo Plastic Plate

Food: Coffee, breakfast, snacks (granola bars, water bottles, fruit), and lunch (optional) If not providing lunch, allow for a longer lunch break

Final Arrangements

Two weeks before the course:

1. Print all the training materials:o Participant Workbooks (Different from presentation- there are no correct

answers, and no scenario slides) Materials should be printed and placed in individual binders in the

following order: Cover Page, Participant Agenda, Welcome and State Data, Steps in OB investigation handout, Establish existence of OB, E. Coli Fact sheet, Blank Calendar, Form a team, Blank page, Team members Handout, Etiology, Lab Form, Blank page, Identify cases, Describe and Orient Data, Blank page, Line List with Table 1, Graph Paper, Hypothesis, Blank page, Epi, Questionnaire, Exposure Data- Food Analysis, EH, Blank page, Control Measures, Blank page, Communication, Blank page, Closing and OB, NORS Form, Norovirus, Blank page

o Attendance Sign-in Sheeto Multiple Choice Cards (if not using interactive polling clickers)

These will be used in place of interactive polling clickers for participants to “vote” for answers.

See printing instructions on the first page of the document. One set for each participant. Laminate (optional).

o Certificate of Completion One for each participant

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Print on quality stock paper and sign

2. Reconfirm the training facilities, equipment and catering (if applicable).

3. Check to make sure a technician is available in case there are problems setting up the room or if something goes wrong during the course.

One week before the course:

1. Finalize presenter agenda.2. Send reminder email with the Agenda and driving directions (if necessary) to the

participants.

Immediately prior to the course:

1. Make sure all the materials are brought to class:o Participant Workbooks

Should include updated version of PowerPoint presentations received from instructor(s).

Additional resources for participants on www.cofoodsafety.org o Attendance Sign-in Sheeto Signed Certificates of Completiono Computer

Connected to projector Updated PowerPoint presentations received from the instructor

(see Instructor: Presentation Requirements for details) and Video, Epi Info™7, and CoE Website loaded onto computer

Interactive polling clicker receiver (optional) networked to computero Interactive polling clicker devices (optional)

2. Set-up the classroom (horse-shoe or small group tables if room allows)3. Set a Participant Workbook at each seat.4. Post directional signs.5. Test all equipment.

Presenter Course AgendaExample Times Allotted Time Lesson Title8:30 - 9:00 AM 30 min Check-in / Breakfast

9:00 – 9:15 AM 15 min Welcome and introductions

9:15 – 9:20 AM 5 min Overview of State Outbreak Data

9:20 – 10:10 AM 50 min Outbreak Background, Establishing the Existence of an Outbreak, and Forming a Team

10:10 – 10:20 AM 10 min Break

10:20 – 11:05 AM 45 min Verifying the Diagnosis

11:05 - 11:45 AM 40 min Define and Identify Cases

11:45 AM - 12:15 PM 30 min Lunch

12:15 - 12:30 PM 15 min Recap of the morning, Describing and Orienting the Data

12:30 – 12:40 PM 10 min Developing a Hypothesis

12:40 – 1:40 PM 60 min Evaluate Hypothesis- Epidemiology

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http://www.cofoodsafety.org/


1:40 – 1:50 PM 10 min Break

1:50 - 2:20 PM 30 min Evaluating Hypothesis- Environmental Health

2:20 – 2:35 PM 15 min Implement Control and Prevention Measures

2:35 – 2:50 PM 15 min Communication During an Outbreak

2:50 – 3:00 PM 10 min Closing and Outbreak

3:00 – 3:45 PM 45 min Norovirus Outbreaks

3:45 – 4:00 PM 15 min Questions, Closure, and Evaluations

Instructor: Presentation Requirements

Before the Training Event Preparation List

Confirm the training dates, location, and number of participants. 1. Read, review, and modify (when necessary) the following materials:

Instructor’s Guide PowerPoint Presentation:

o Insert State information on slides: 2,9-13, 46 (state specific lab info), 49 (getting specimens to the lab)

o (Optional): Link slides to interactive polling clicker devices if using something other than TurningPoint.

Link slides: 18,19, 20, 26, 33, 57, 58, 59, 81, 82, 83, 102, 103, 104, 105, 106, 140, 147, 166, 170, 172, 175, 179, 183, 190-195

2. Email updated PowerPoint presentations to designated person so that he/she can upload them onto the computer to be used during the course and send them for print in the participant packets. Instructors should also save updated PowerPoint Presentations on a thumb drive as a backup.

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During the Training Event

1. Arrive early. Give yourself plenty of time to get organized.2. Circulate the Attendance Sign-in Sheet and be sure all participants sign-in.3. Start on time and stay on track. Keep exercises within their time limits.4. Be available during break and after class for questions.5. Mentor participants during the activities. Walk among groups during exercises,

answer questions and offer guidance as appropriate. Ensure participants are on track as they work. Give constructive feedback during the presentations and discussions.

6. Perform evaluation of the training at the end.a. Use either clicker questions or handout your own evaluation document

After the Training Event

1. Please email [email protected] with feedback, comments and/or evaluations regarding this course. This will facilitate improvements on future courses.

Outbreak Scenario for InstructorsQuestions for attendees are italicized.

STEP: Establish Existence of an Outbreak

You work at Mountain County Public Health.

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mailto:[email protected]


It is Friday, December 19, at 3:00 pm. You receive a Shiga Toxin-Producing E. coli (STEC) case in the Electronic Disease Reporting System which has been confirmed at the State lab as E. coli O157:H7.You promptly contact the case, a 25-year-old male; he reports that he ate the majority of his meals out in the week prior to his illness. He says his roommate has also had some diarrhea in the last week.

Shiga toxin-producing E. coli (STEC): pathogenic; different than E. coli found in our guts

Symptoms Diarrhea (often bloody), abdominal pain, sometimes vomiting and fever

Incubation Period 1 – 10 days (avg 3-4)

Duration Up to 12 days (can shed for longer)

Transmission Contaminated food/water (especially ground beef, produce); fecal-oral (animal-to-human, human-to-human)

Reservoir Gut of cattle, deer, elk, goats, other animals

Special Considerations

Low infectious dose; important cause of hemolytic uremic syndrome (HUS) in children; can persist in environment

Timeline review—Review the calendar of events that occur during the outbreak as you go through the scenario. An example calendar is provided on the last page of this guide.

Question for group: Is this an outbreak? (Yes / No / I don’t know)Correct Answer: I don’t know, need more information to determine if it is an outbreak

On Monday morning, December 22, you receive a phone call from Rita, a resident of Valley County (a county adjacent to you). Rita and members of her frisbee golf team have experienced “stomach flu” over the past week. Over a week ago, during the weekend of December 6-7, they participated in a frisbee golf tournament in Mountain County.

Question for group: What questions would you ask?Answers: How many people are on the Frisbee team?

Where do team members live? How many have been sick with GI symptoms since the tournament? What are the ill members’ symptoms? Have any been hospitalized?

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Where did the team eat during the tournament? What other exposures did they have? Animals? Recreational Water?

From your interview with Rita, you learn: There are 18 adult players on the team. Team members live in Mountain, Valley, and Plateau Counties. Rita knows that at least 4 have been sick with some sort of GI symptoms since the

tournament, but does not know their exact symptoms. Rita has been ill as well. One ill person is currently hospitalized in Plateau County. While in Mountain County, the team dined at Burger Central and Deli Queen on

December 7.

After talking to Rita, you logged the complaint into Mountain County’s foodborne illness complaint system.

Question for group: Here’s a copy of the abbreviated complaint log. What are you concerned about?

Answer: Burger central has other complaint, sick while eating and ill household memberYou notice that the STEC case you interviewed on Friday, December 19, also ate at DeliQueen on December 5, two days prior to the Frisbee Golf team.

Timeline Review

Question for group: Is this an outbreak? (Yes / No / I don’t know)Answer: Yes

You report the outbreak to the state health department and begin your investigation.

STEP: Form a Team

You form your investigation team.*Back at your office, you can use the “Outbreak Team Members” resource on the flash drive to create your office’s outbreak team.

STEP: Attempt to Identify an Etiology

When talking to Rita on Monday, December 22, she agreed to provide a stool specimen to public health for testing. Using her bulk stool sample, prepare a bacterial culture swab and package for transport.

Group practice: Please complete the specimen and testing sections of the lab form. Consider the symptom profile when deciding which tests to select. (Definitely request bacterial culture for E. Coli and consider norovirus. Have participants practice doing a bacterial swab from pudding and labeling/sealing swab).

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Question for group: How would you get the specimen to the state public health lab from YOUR public health agency?

Answers: Ask about courier services, Drive it there, FedEx, UPS

STEP: Define and Identify Cases

On Tuesday, December 23, the local hospital calls to say that they have another case of STEC in a 7-year-old girl.Upon interviewing her mother, she dined at Deli Queen on Monday, December 8.On Friday, December 26 you receive results from Rita’s stool specimen that was tested at the CDPHE Laboratory – it is positive for STEC O157.

Review Timeline

Group practice: Create a case definition – Remember to include: person, place, time, clinical information.

Answer: “An individual with lab-confirmed STEC and/or clinically compatible symptoms (3 or more episodes of diarrhea in a 24-hour period, bloody diarrhea, abdominal cramps) with illness onset in December 2014 who ate at Deli Queen prior to becoming ill”

How do we identify additional cases? Team roster Online ordering logs from deli queen Catering orders from deli queen Reach out to health care providers Health Alert Notice Contact other teams in tournament Press release Contact nearby local public health agencies Contact local hospitals

STEP: Describe and Orient the Data

Let’s review the outbreak You are investigating an enteric disease outbreak There are 5 ill people who meet confirmed and probable case definitions

o 2 identified through public health surveillanceo 3 are members of the frisbee golf team; illness was discovered through a

complaint callo All cases report eating at Deli Queen between December 5th and 8th

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You have some information on 6 ill people that you put into a line list:o Ritao 3 other team memberso Initial reported case - 25-year-old STEC caseo Second reported case - 7-year-old hospitalized STEC case

Using the data in the line list, calculate: Number male/female Median age (range) Symptom description numbers

From this line list, apply your case definition and construct an epi curve

Timeline review

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STEP: Develop a Hypothesis

Question for group: Using the data you have, what is your leading hypothesis?Hypothesis: Foodborne outbreak of STEC associated with deli queen

This is different from the case definition because it includes mode of transmission and vehicle. Make sure it includes: Includes likely causative agent, people at risk, mode of transmission, vehicle, and period of interest.

Question for group: What are some other possible hypotheses?Don’t rule out other possibilities, such as person-to-person, water, etc

STEP: Evaluate Hypothesis – Epi

Question for group: What type of study would you conduct for this outbreak?Could do a case/control with all persons who ate at the restaurant; hard to identify and enroll controls. Could do a cohort for just the frisbee team (this would be an easier option – n=18)

You decided to do a cohort study with the frisbee golf Team. You would then develop a questionnaire based on the Deli Queen menu.

Here is the questionnaire used for this outbreak. (handout in participant workbook)

Question for group: Which measure of association should we calculate? Answer: Relative Risk

Here’s the new line list that includes some exposure data (handout in participant workbook)

Question for group: Who do we include in cohort analysis?Answer: Frisbee golf team

Create 2 x 2 tables for each food item on the line list.

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Use Epi Info STAT CALC to calculate risk ratios.

Looking at relative risks, which are elevated above one? Answer: Veggie sandwich, tomato, sprouts. The relative risk for tomatoes is only 1.3, so that isn't enough over 1 to be concerning. The relative risk for sprouts is 9.6; that is a high enough magnitude to be very concerned.

The relative risk for veggie sandwiches is slightly elevated with 1.7. Why might this be? Answer: there are likely sprouts on the veggie sandwich.

For advanced students:For the relative risk to be statistically significant, the confidence interval should not cross 1. Which foods have a statistically significant relative risk?Answer: sprouts.

If a relative risk isn't statistically significant, we still consider the relative risk.

Question for group: What are some reasons you might not achieve statistical significance?Answer: small sample size, confounding factors

STEP: Evaluate Hypothesis – EH

Question for group: Would you collect food and/or environmental samples for testing in this outbreak?

Answer: Probably test food samples, check with the lab first. Discuss with group state practices on food testing

Question for group: If so, what food item(s)?Answer: Sprouts

Question for group: Would you start traceback activities? Yes, we have epi evidence

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ATE FOOD DID NOT EAT FOODFOOD Ill Well Total Who

Ate FoodAttack

Rate (%)Ill Well Total Who Did Not

Eat FoodAttack

Rate (%)Relative

RiskConfidence

IntervalVeggie

Sandwich

3 5 8 38% 2 7 9 22% 1.7 (0.4, 7.7)

Turkey Sandwic

h

2 7 9 22% 3 5 8 38% 0.6 (0.1, 2.3)

Tomato 3 6 9 33% 2 6 8 25% 1.3 (0.3, 6.1)Lettuce 3 7 10 30% 2 5 7 29% 1.1 (0.2, 4.7)Sprouts 4 1 5 80% 1 11 12 8% 9.6 (1.3, 65.9)


Question for group: Which EH actions would be most crucial at this point? Pick two.Answers: No Right answer. All are important EXCEPT looking at how all foods are

made. During and Environmental Assessment your focus on suspected foods in an outbreak.

An environmental assessment was conducted at Deli Queen on Wednesday, December 24. During the environmental assessment, you determine that at least one food handler was ill with diarrhea in the beginning of December.

EH collected produce items (lettuce, sprouts, tomatoes, onions, cucumbers) along with other items that were statistically associated with illness to submit to the CDPHE Laboratory for STEC testing; these items are not likely from the same lots served to the ill persons due to product turnover.

o The lab only tested the sproutso They were negative for STEC

STEP: Implement Control and Prevention Measures

Question for group: Which control measures are most important? Choose your top 2 in order.Answer: No right answer, all are good except quarantine. Discuss closing restaurants as this varies by jurisdiction.

STEP: Communication during and after outbreak

STEP: Closing the Outbreak

A case in the outbreak calls you to let you know that he wants to sue the Deli Queen. How would you handle this?

Answer: Ex: Tell the client that public health cannot make recommendations around legal action and he will need to make his own decision. If he does chose legal action, you can tell him what forms he/his lawyer will need to use to request outbreak documentation. You cannot recommend a specific lawyer, but can tell the case that some lawyers specialize in this and he could search on the internet.

Write an outbreak report and complete NORS Form (handout in participant workbook)

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Complete Outbreak Timeline

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