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David Nicholas, MPHNew York State Department of Health
Bureau of Community Environmental Health and Food [email protected]
National Voluntary Environmental Assessment Information System
(NVEAIS)
National Center for Environmental Health
Environmental Health Services Branch
Original Presenters:Carol Selman, MPH
Team Lead, Food Safety Team, Environmental Health Services Branch, Division of Emergency and Environmental Health Services,
NCEH
Kristin Delea, MPH, REHSHealth Scientist/Epidemiologist
Overview Background
EHS-Net NVEAIS
Environmental Assessments: A systems approach to foodborne illness outbreak investigations Systems Theory Contributing Factors Environmental Antecedents
NVEAIS – Data Collection Information the data can provide How can we use the data
Training/ E-learning
BACKGROUND
Environmental Health Specialist Network
EHS-Net (pronounced S-Net) is a collaborative forum of environmental health specialists whose mission is to improve environmental health practice.
These specialists collaborate with epidemiologists and laboratorians to identify and prevent environmental factors contributing to foodborne and waterborne illness outbreaks.
EHS-Net Background
Environmental Health Specialists Network Collaboration between:
• US Centers for Disease Control and Preventiono National Center for Environmental Healtho Environmental Health Services Branch• US Food and Drug Administration
o Center for Food Safety and Applied Nutrition• US Department of Agriculture
• 8 siteso California, Cerro Gordo Iowa, Minnesota, New
York, New York City, Rhode Island, San Mateo California and Tennessee
EHS-Net Background
EHS-Net work is based on a system theory.EHS-Net assists state health departments in their efforts to improve the practice of environmental health service programs. EHS-Net conducts environmental assessments to determine why an agent was present in the environment in such a way that the host could be exposed. EHS-Net works to
Identify environmental antecedents (underlying factors) to illness and disease outbreaks.
Translate findings into improved prevention efforts using a systems-based approach.
Offer training opportunities to current and future environmental health specialists.
Strengthen collaboration among epidemiology, laboratory, and environmental health programs.
NVEAIS Background
EHS-Net Foodborne Outbreak Study Objective: To identify contributing factors to foodborne
illness outbreaks in food-service facilities and to describe the characteristics, policies and practices of those facilities.
What we learned No consensus on what a foodborne illness environmental
assessment was No standard methodology for conducting foodborne
outbreak environmental assessments Need for training on how to conduct a foodborne
outbreak environmental assessment using a systems approach
The Need to Improve Reporting of Environmental Factors to Foodborne
Illness Outbreaks
Environmental factor data are key to To improve hazard surveillance . To inform foodborne disease prevention policies Understanding how and why outbreaks occur. Preventing future outbreaks.
Limited environmental factor data are currently reported to CDC’s existing National Outbreak Reporting System (NORS).
Inspectors (environmental health specialists) need training on collecting environmental factor data during outbreak investigations.
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The Need to Improve Reporting of Environmental Factors to Foodborne
Illness Outbreaks
9
Contributing factors
• Factors that caused the outbreak
• How the outbreak occurred
Environmental
antecedents• Circumstances
that led to the contributing factors
• Why the outbreak occurred
Environmental factors
The Need to Improve Reporting of Environmental Factors to Foodborne
Illness Outbreaks
Environmental
antecedents• Worker in a
hurry
• Worker had not been trained on avoiding cross contamination
Contributing factor
• Cross contamination
• Worker used same utensils on raw ground beef and salads
Outbreaks
• E. Coli
• Outbreak caused by salads eaten at Restaurant A
NCEH/EEHS Activities to Improve Reporting of Environmental Factors to Foodborne Illness
Outbreaks Developed
National Voluntary Environmental Assessment Information System (NVEAIS)
e-Learning on Environmental Assessment of Foodborne Illness Outbreaks
Launched in April 2014 Purpose
NVEAIS: Discover environmental factors that cause foodborne outbreaks to prevent next one
e-Learning: Improve competency in collecting environmental factor data during foodborne outbreak investigations
http://www.cdc.gov/nceh/ehs/NVEAIS/index.htm; http://www.cdc.gov/nceh/ehs/elearn/ea_fio/
NVEAIS Purpose
Identify factors that can be routinely monitored by food control authorities to prevent or reduce the risk of foodborne outbreaks
Characterize food vehicles and monitor trends Identify and monitor contributing factors and
environmental antecedents Hypothesis generation Guide planning, implementation and evaluation of food
safety programs
NATIONAL VOLUNTARY ENVIRONMENTAL ASSESSMENT INFORMAITON SYSTEM
Improving Surviellance
Definition Environmental Assessment
The component of an outbreak investigation that fully describes how the environment contributed to the introduction and or transmission of agents that cause illness. Environment is everything external to the host, including air, food, water, animals, plants, climate, etc as well as people, social and built environments.
• All aspects of the external environment can be listed as variables that, in relation to transmission, are neutral, conducive or protective.
• From this description contributing factors and environmental antecedents to an outbreak can be determined.
NOT an inspection
Foodborne Outbreak Environmental Assessment
Conducted as part of the foodborne illness outbreak team
A reconstruction of past events in the context of the outbreak investigation
Taking a systems approach
Inputs - Are the items which feed into the system
Process - Are the steps and methods to which the inputs are subjected
Internal System Variables - Are the factors that exert positive, negative and neutral influences on all other aspects of the system
Outputs - The immediate results of the system
Outcomes -What happens as a result of the outputs
External Feedback to System
Contributing Factor Definition The factors likely to be conducive to the
contamination and survival of the etiologic agent or suspected agent and/or to its growth or proliferation. Contamination Factors
• Toxic substance part of the tissue , Contaminated raw product, Cross-contamination of ingredients, Bare-hand contact by a food handler/worker/preparer who is suspected to be infectious
Proliferation Factors • Improper cold holding due to malfunctioning refrigeration
equipment, Improper hot holding due to improper procedure or protocol, Prolonged cold storage
Survival Factors• Insufficient time and/or temperature during cooking/heat
processing, Insufficient time and/or temperature during reheating
Contributing factors are NOT food code violations
Environmental Antecedents Definition
Root causes
Supporting factor(s) to the contamination, survival or increase of biological or chemical agents in food
They may be related to People Equipment Process Food Economics Behavior Other circumstances
Environmental Antecedents
Equipment
Economics
Processes
Food
Environmental Antecedents Related to Food System
Variables
People
• Location of hand wash sinks
• Availability of supplies for hand wash sinks
• Training• Supervision• Water available for hand
wash sinks• Availability of a supply of
gloves
People
Economics
Processes
Food
Equipment
• Design• Construction• Cleanability• Maintenance• Placement• Installation
Environmental Antecedents Related to Food System
Variables
People
Equipment
Economics Food
Processes • Handling after kill step• No kill step where kill
step is required• Multiple- step
processes
Environmental Antecedents Related to Food System
Variables
People
Equipment
Economics
Processes
Food
• Source• pH• Water activity (Aw)• Viscosity
Environmental Antecedents Related to Food System
Variables
Food
People
Equipment
Processes
Economics
• Shifting food trends• Profit margins• Operational costs such
as • Cost of food• Cost of equipment• Cost of facilities• Cost of staffing and
training
Environmental Antecedents Related to Food System
Variables
The Food Establishment System
Final Food Item
Ingredients
Organisms
Chemicals
Customer Health
Customer Satisfaction
Profit
External Feedback to System
Receive
Store
Prep
Cook
Cool
Reheat
Assemble
Hold
Serve
Processes
Internal System Variables
People
Food Economics
Equipment
Example Thorough
understanding of the problem On the ground
assessment by Environmental Health Specialist or Environmental Engineer
Identification of underlying causes of problems (not just symptoms) Contributing Factors Environmental
Antecedents
DATA COLLECTION
Data Collection
Data collection for FBIO environmental assessments Standardized data collection instrument to report
information FBIO environmental assessments Validated questions Identifying contributing factors Understanding how selected environmental antecedents
are related to contributing factors, vehicles, and agents
Is not a form or template for conducting a FBIO environmental assessment
Data Collection Tool
Part I General Characterization of Outbreak
Part II Establishment Description
Part III Manager Interview
Part IV Establishment – Observation
Part V Food Vehicle
Part VI Sampling
Part VII Contributing Factors (CF)
Part VIII National Outbreak Reporting System (NORS)
INFORMATION THE DATA CAN PROVIDE
Food Processing Characterization of the establishment (Part
II) 81.6 % Complex 15.6 % Cook / Serve 2.9 % Prep / Serve
Characterization of suspect food preparation (Part V) 25.3 % Complex 27.2 % Cook / Serve 47.5 % Prep / Serve
31.2% served raw or undercooked animal products (Part I) Of these, 61% did not have a customer advisory
Part – III Establishment Characteristics
Facilities
91% restaurants
• Independent 68%
Median meals/day 240
Busiest on weekends
In 50% food handler to kitchen manager ratio ≤ 4:1
Part III- Busiest Day
MONDAYTUESDAY
WEDNESDAY
THURSDAY
FRIDAYSATURDAY
SUNDAY
UNSURE / MISSING
Disposable Gloves
Yes No Missing
Glove Policy*
193 (79.1) 48 (19.7) 3 (1.2)
Glove Supply**
198 (81.1) 41 (16.8) 5 (0.4)
Glove Use** 159 (65.2) 72 (29.5) 13 (5.3)
*Part III**Part IV
Part V- Suspected Food Vehicles in Foodborne Disease Outbreaks
Ingredient n (%)
Produce 188 (50.8)
Poultry 42 (11.4)
Dairy 36 ( 9.7)
Beef 23 ( 6.2)
Pork 19 ( 5.1)
TRAINING
The Need for Training In 2001 Selman and Green surveyed local
and state Environmental Health Specialists (EHS) and found
EHS focus on pathogens during outbreaks instead of contributing factors and their environmental antecedents
A lack of communication between epidemiologist and EHS was found to be a barrier to EHS active engagement in foodborne illness outbreak environmental assessments
Local EHS staff require training because they are not involved in outbreaks often enough to attain competency in environmental assessments
EHS were in need of a basic training in how to conduct foodborne illness outbreak environmental assessments
Selman, CA and Green, LR (2001). Environmental health specialists’ self-reported foodborne illness outbreak investigation practices. Journal of Environmental Health, 20(6),16-21.
Using Environmental Assessments to Investigate
Illness Outbreaks Environmental Health Specialists are
accustomed to look for violation of regulations not contributing factors and their environmental
antecedents Performing an environmental assessment (EA) requires a
different mindset than other environmental food safety activities
No two outbreaks are alike No single ‘checklist’ applies to all environmental
assessments Conducting an EA requires a complex set of
knowledge and skills including the ability to apply ‘critical thinking’
Training must promote development of competency in the field and not just the acquisition of knowledge
Goal of this Training Effort Use cutting-edge e-learning technologies to
develop competency with Foodborne Illness Outbreak Environmental Assessments and deliver training free of charge over the Internet to enhance global food safety
Incorporation of ‘Gaming’ Each virtual learning experience scenarios
is framed as a forensic investigation mystery of an outbreak
Participants decide
Who to interview What topics to interview about Which actions to take What observations to perform and samples to collect
At end, learners must identify contributing factors and environmental antecedents
Actions and conclusions are tracked and evaluated
Learners receive individual feedback on results
Accompany the Worker
The Cognitive Domain
Involves knowledge and the development of intellectual skills
Includes 6 categories of behavior Knowledge (recall data or information)
Comprehension (understanding the meaning)
Application (use a concept in a new situation)
Analysis (separate materials into component parts)
Synthesis (build a pattern from diverse elements)
Evaluation (make judgments)
Analysis of Learner Performance
Learner receives individualized feedback on: Interview effectiveness
• Did the learner choose the correct questions?
Interview efficiency• Did the learner choose the questions in the correct order?
Observational skills• Did the learner find all the important embedded clues in
the environment?
Critical thinking• Did the learner correctly identify contributing factors and
environmental antecedents
VIRTUAL WORLD TRAINING
E-Learning on Environmental Assessments of Foodborne Illness Outbreaks
Promotional Video
https://www.youtube.com/watch?v=77w9aVeROiA&index=1&list=PLvrp9iOILTQaRWTguYiBvPlVB7R-88Wbq
PARTICIPATING IN THE TRAINING
Information
www.cdc.gov/nceh/ehs Provides information about e-Learning on
Environmental Assessments of Foodborne Illness Outbreaks and NVEAIS
Registration information Complete the registration Take the pre-test
Important Websites
• More information on CDC EHS-Net:– http://www.cdc.gov/nceh/ehs/EHSNet/
• Information on National Voluntary Environmental Assessment Information System (NVEAIS):
– http://www.cdc.gov/nceh/ehs/NVEAIS/index.htm
• Additional information on e-Learning:– http://www.cdc.gov/nceh/ehs/eLearn/EA_FIO/index.htm
• Register for the e-Learning course at:– https://ehseleafio.cdc.gov/
• National Outbreak Reporting System (NORS) Guidance:– http://www.cdc.gov/nors/pdf/NORS_Guidance_20130219_508c.pdf
• National Outbreak Reporting System (NORS) Form:– http://www.cdc.gov/nors/pdf/NORS_CDC_5213.pdf
Acknowledgements• Centers for Disease Control and Prevention
– Carol Selman– Kristin Delea– Erik Coleman– Laura Brown
• EHS-Net Site Partners
• Local Health Departments
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention (CDC).
Thank You! Questions
David C. Nicholas, MPHNYSDOH BCEHFPPh:518-402-7600Email: [email protected]