module 2: otb dk t i itoutbreak determination and

Module 2:Module 2:O tb k D t i tiO tb k D t i tiOutbreak DeterminationOutbreak Determination

and Investigationand Investigationgg

Epidemiology DivisionSurveillance Branch

Epidemiology DivisionBureau of Clinical Laboratories

Bureau of Environmental Services



Module Learning ObjectivesModule Learning ObjectivesModule Learning ObjectivesModule Learning Objectives

List steps needed to prepare for anList steps needed to prepare for an investigationDefine foodborne outbreak (FBO)Define foodborne outbreak (FBO)Gather information to determine the sourcesourceIdentify means for searching for ddi i ladditional cases


Bureau of Environmental Services2

M d l L i g Obj ti ( t )M d l L i g Obj ti ( t )Module Learning Objectives (cont.)Module Learning Objectives (cont.)List three phases of interviewingList three phases of interviewingDescribe methods to ensure consistency of interview dataconsistency of interview dataList steps for obtaining a case historyhistoryDescribe methods for overcoming b i i i ibarriers to interviewingPerform group exercise



Outbreak Determination Outbreak Determination Flow DiagramFlow DiagramFlow DiagramFlow Diagram

Collect Food

Generatetermination

reportCollect FoodSamples

Environmental Health

Make

report

NO

PrepareInvestigation

Take steps toverify

diagnosis

Get Case History

Surveillance Staff

Develop initialcase definition

Make epidemiologic(time, place,

person)associations

Determineif an outbreak

occurred

Obtain ClinicalSpecimens

Surveillance & Med Providers Outbreak

YES

OutbreakInvestigation

Remember the Three-Legged Stool: Epidemiology, Environmental Health, & Laboratory



Steps to Prepare for InvestigationSteps to Prepare for InvestigationSteps to Prepare for InvestigationSteps to Prepare for Investigation

Follow Foodborne Outbreak (FBO)Follow Foodborne Outbreak (FBO) Protocol (see Intro Module)Complete Preliminary OutbreakComplete Preliminary Outbreak Investigation Report Notify DETECT TeamNotify DETECT Team

Minimally Field Surveillance Staff (FSS) and 2 Environmentalists (Env)and 2 Environmentalists (Env)



Additional Investigation PreparationAdditional Investigation PreparationAdditional Investigation PreparationAdditional Investigation Preparation

Grab your DETECT KitsHuman & environmental sample collection kit

Plan and Train:Team members understand their role according to protocolCannot address every situationReduces confusion during the crisis



I it f db tb k?I it f db tb k?Is it a foodborne outbreak?Is it a foodborne outbreak?



Foodborne Illness Foodborne Illness Outbreak DefinitionOutbreak Definition

CDC and IAFP Definition

An outbreak is an incident in which two or more persons have the psame disease, have similar clinical features, or have the same pathogen – thus meeting the case definition - and there is a time, place or person association among these personsplace or person association among these persons.

A foodborne outbreak is one that is traceable to ingestion of acontaminated food.



Foodborne Illness Foodborne Illness Outbreak Definition (cont.)Outbreak Definition (cont.)

CDC and IAFP DefinitionA single case of suspected botulism, mushroom poisoning, g p , p g,ciguatera or paralytic shellfish poisoning or other rare disease, or a case of a disease that can be definitely related to ingestion of a food can be considered an incident ofto ingestion of a food, can be considered an incident of foodborne illness and warrants further investigation.



Foodborne Outbreak DefinitionFoodborne Outbreak Definition

Alabama DefinitionAlabama Definition

An incident in which two or more persons from different households experience a similar illnessdifferent households experience a similar illness resulting from the ingestion of a common food.

E ti b t li d h i l i iExceptions: botulism and chemical poisoning (1 case = outbreak).



Next StepsNext StepsNext StepsNext Steps

G th i f ti t d t iGather information to determine sourceSearch for additional casesBegin Interviewsg



Information to Information to Determine SourceDetermine Source

Preliminary Outbreak InvestigationPreliminary Outbreak Investigation ReportO tb k ifi Q ti iOutbreak-specific QuestionnairesEnvironmental Inspection ReportClinical and food specimen test resultsHealthcare provider medical records



S h f Additi l CS h f Additi l CSearch for Additional CasesSearch for Additional Cases

C i t ith C itCommunicate with CommunityHealth Care FacilitiesSchoolsPrivate ProvidersExposure Location



Interviewing ObjectivesInterviewing ObjectivesInterviewing ObjectivesInterviewing Objectives

To determine source of illness and means of transmission

Minimize repeat interviewsMinimize repeat interviews



B gi I t iB gi I t iBegin InterviewsBegin InterviewsCentral Office Epi ProvidesCentral Office Epi Provides

Outbreak-specific QuestionnaireCase DefinitionCase DefinitionWho to InterviewOutbreak NameOutbreak NameType of SpecimenAdditi l C lt tiAdditional Consultation



T W t Obt i I f tiT W t Obt i I f tiTwo Ways to Obtain InformationTwo Ways to Obtain Information

I t i L dInterviewer LedIn-personTelephone

Self AdministeredWeb-basedForms distributed



SelfSelf--Administered QuestionnairesAdministered QuestionnairesSelfSelf Administered QuestionnairesAdministered QuestionnairesAlternative to in-person or telephone interviewsLimitations

Poor response ratesRespondent can misinterpret or fail to p punderstand questions

AdvantageReduce resources devoted to gathering information, esp. with large outbreaks



Th Ph f I t i i gTh Ph f I t i i gThree Phases of InterviewingThree Phases of Interviewing

1. Before

2. During

3. After



B f I t i i gB f I t i i gBefore InterviewingBefore Interviewing

Review working case definitionReview working case definitionObtain outbreak-specific

ti i f E iquestionnaire from EpiAssess workload Id tif d t i i t iIdentify and train interviewers



Develop the Working Develop the Working Case DefinitionCase Definition

Person, Place and TimeLaboratory DataLaboratory DataEnvironmental Data



Outbreak Questionnaire FormatOutbreak Questionnaire FormatOutbreak Questionnaire FormatOutbreak Questionnaire Format

Demographic informationDemographic information Age, gender, address, other identifying dataidentifying data

Exposure history F d tiFood consumption

Disease informationSymptoms/signs



OO E d d Q tiE d d Q tiOpenOpen--Ended QuestionsEnded QuestionsRarely usedRarely usedData gatheringHypothesis generatingHypothesis generatingDrawback - difficult to analyze statisticallyTime consuming



C t i d FC t i d FCustomized FormsCustomized Forms

G th ifi i f ftGather specific info after have basic initial informationRead all questions in the order as they appear on y ppquestionnaire



Cl dCl d E d d Q tiE d d Q tiClosedClosed--Ended QuestionsEnded Questions

P f dPreferredGather specific informationCan be restrictive and leadingCan target specific topicsCan target specific topics

Yes No UnknownYes______ No_______ Unknown______



B f I t i i g R bB f I t i i g R bBefore Interviewing…RememberBefore Interviewing…Remember

B i t t i i t iBe consistent in interviews

B f ili ith ti iBecome familiar with questionnaire before conducting interviews

Practice with someone on team before interviews begin



A G d I t i i M tA G d I t i i M tA Good Interview is a MustA Good Interview is a Must

Accurate and complete data required

Obtain answers for all questions, even if “unknown”if unknown

Interview 3 “not ill” for every 1 “ill”



A i g W kl dA i g W kl dAssessing WorkloadAssessing Workload

Identify and prepare interviewersAssign interviewers; training for all Arrange work schedules (24/7 work)

Assess workloadAssess workloadNumber of interviews neededTypes of individuals to interviewTypes of individuals to interview



Outbreak InvestigationOutbreak InvestigationInterviewing SkillsInterviewing Skills




1. Before

2. During

3. After



During InterviewsDuring Interviews

Establish rapportIdentif self and organi ationIdentify self and organizationReason for investigation

Need to indentify source and prevent others from getting sickExpress empathyExpress empathyMay be contacted multiple times

Start with easy questionsStart with easy questions“Your name/ address/ occupation?”



A C i ti St lA C i ti St lAssess Communication StylesAssess Communication StylesIdentify communication style ofIdentify communication style of interviewee and adjust your style to matchmatch

Action - bottom line / “Just the facts”Feeling empatheticFeeling – empatheticCreative - need to see the big pictureThinking want all the detailsThinking - want all the details



C id H D iC id H D iConsider Human DynamicsConsider Human DynamicsAnticipate communicationAnticipate communication barriers

Demographic or cultural factorsDemographic or cultural factorsDefensiveness

Identify appropriate sites andIdentify appropriate sites and times for interviews

PrivacyPrivacyFree from distractions



Strategies for Food RecallStrategies for Food RecallStrategies for Food RecallStrategies for Food Recall

Ask about food preferencesAsk about food preferencesRule in/out some foods Show calendar to identify key daysShow calendar to identify key days and jog memoryR i i d/ h kb kReview receipts and/or checkbookIf buffet, clearly describe each foodShow the menu if available



RestaurantsRestaurantsRestaurantsRestaurants

Be as specific as ppossibleHow many “combination chicken platters”

th b ?can there be?



Challenges During InterviewChallenges During Interviewg gg g

Information often missedIdentify facility locations, extent of exposure, timeline and specific signs and symptomsCheck for food or clinical samplespConsider non-foodborne transmission

Commercial food productsCommercial food productsObtain specific dates, locations, lot number and product descriptions



Read Labels Read Labels Be SpecificBe Specific

HamburgerGround chuck

LettuceShredded

Ground sirloin

23% fat content

ChoppedType- iceberg v romaine23% fat content

30% fat content

romaine



I f ti Oft Mi dI f ti Oft Mi dInformation Often MissedInformation Often MissedLocation of facility (be specific)Location of facility (be specific)

Chain X store in Anytown, ALChain X store on corner of Main andChain X store on corner of Main and Fourth in Anytown, ALChain X store located at 245 MainChain X store located at 245 Main Street in Anytown, AL

urth

Main Fou

245 Main StXAnytown



I f ti Oft Mi d ( t )I f ti Oft Mi d ( t )Information Often Missed (cont.)Information Often Missed (cont.)Extent of exposureExtent of exposure

Who else ate the foodNames and contact information of other persons at eventHow much did they eat?

Timeline informationPurchase date/timeConsumption date/timeSymptom onset date/time



I f ti Oft Mi d ( t )I f ti Oft Mi d ( t )Information Often Missed (cont.)Information Often Missed (cont.)Specific signs and symptomsSpecific signs and symptoms

Especially important if no laboratory confirmation

Check if food or clinical samples stillCheck if food or clinical samples still availableInformation needed to assess potentialInformation needed to assess potential for non-foodborne routes of transmissiontransmission



Communication Barriers (cont )Communication Barriers (cont )Communication Barriers (cont.)Communication Barriers (cont.)

Last meal biasLast meal biasTake multi-day food history

Irate consumerIrate consumerBe sensitive, adjust communication style

Cultural DiversityCultural DiversityDifferent cultures have different styles of communicating (age, gender, cultural, g ( g , g , ,ethnic)



The Last Meal BiasThe Last Meal Bias



NonNon--FoodborneFoodborne Routes Routes of Disease Transmissionof Disease Transmission

Petting ZoosDay Care CentersDay Care CentersDrinking WaterS i i P lSwimming Pools



Before Ending InterviewBefore Ending InterviewBefore Ending InterviewBefore Ending InterviewAsk about “Other Food”A k ti ittAsk questions as writtenReview for completeness and accuracyAsk if individuals have

Unanswered questionsAdditional information

Thank them




1. Before

2. During

3. After



After the InterviewAfter the InterviewAfter the InterviewAfter the InterviewKeep track of interviewees and interviewersFax questionnaires to Communicable Di (CD) 334 206 3734Disease (CD), 334-206-3734Confirm all information was receivedWhen notified and by whomWhen notified and by whomNumber of possible attendees/patronsCoordinate reports from othersCoordinate reports from others involved (Area/Local staff)



“I can give you a six-wordI can give you a six word formula for success. “Think things thro gh then follothings through – then follow through”g

-Sir Walter Scott



Module Learning ObjectivesModule Learning ObjectivesModule Learning ObjectivesModule Learning Objectives

List steps needed to prepare for anList steps needed to prepare for an investigationDefine foodborne outbreak (FBO)Define foodborne outbreak (FBO)Gather information to determine the sourcesourceIdentify means for searching for ddi i ladditional cases



Group ExerciseGroup ExerciseFraternity/Sorority Student Interview

Group ExerciseGroup Exercise





module 2: otb dk t i itoutbreak determination and

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