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Epi-Ready Team Training: Foodborne Illness Response Strategies

About Epi-Ready

Epi-Ready is a two-day in-person workshop developed by the National Environmental Health Association (NEHA) and the Centers for Disease Control and Prevention (CDC) for environmental and public health professionals responsible for investigating foodborne illness outbreaks. Through a team-based approach, participants learn how to efficiently and effectively respond to foodborne illness outbreaks.

Epi-Ready is built around the inherent need for collaboration among environmental health specialists/sanitarians, epidemiologists, and laboratory staff during a foodborne outbreak investigation. Additionally, collaboration during these investigations must include all others who may be directly or indirectly involved in outbreak investigations (e.g., public health nurses, health educators, industry, risk communication/public information officers).

The goal of this training is to help members of the foodborne outbreak investigation team prepare for and rapidly detect foodborne disease outbreaks; quickly launch a coordinated investigation involving epidemiology, environmental health, and the laboratory; and implement control measures in a timely fashion to reduce the incidence of foodborne illness.

The workshop will help participants to:

  • Improve performance as members of the foodborne disease outbreak investigation team

  • Develop insights into the work of other team members

  • Enhance communications with other team members

  • Increase familiarity with other local, state, and federal partners

For more information about Indiana’s 2015 Epi-Ready Team Training, please contact Tess Gorden, tgorden@isdh.in.gov.

Registration

The Indiana State Department of Health (ISDH) conducted six Epi-Ready trainings across Indiana in 2015. This training will likely not be held again until 2020.

Continuing Education Hours

Epi-Ready has been approved for 14 hours of Continuing Education through NEHA. The training has also been approved by CDC for Continuing Medical Education (CME), Continuing Nursing Education (CNE), and International Association for Continuing Education and Training (IACET) credits. Please visit http://www.neha.org/epi_ready/#CE for continuing education credit requirements.

ISDH Articles about Epi-Ready

The ISDH will be releasing an eight part series to overview the main concepts addressed during the Epi-Ready trainings. Articles will be released once per month March through October, so be sure to check back here for new information!

An article regarding Epi-Ready was also included in the Winter 2015 issue of the ISDH FoodBytes newsletter, found at http://www.in.gov/isdh/21061.htm.


Epi-Ready Series Part 1: Foodborne Diseases & Outbreaks

Foodborne diseases infect approximately 1 in 6 Americans every year. They are caused by ingested a food contaminated with a bacteria (e.g., Salmonella), a virus (e.g., norovirus), a parasite (e.g., Cryptosporidium), or other agents (e.g., fish toxins). Most foodborne outbreaks are the result of a virus (54% in 2008) or bacteria (40% in 2008). Symptoms often affect the stomach or intestinal tract (e.g., nausea, vomiting, and diarrhea).

An outbreak of a foodborne illness is defined as two or more cases of a similar illness among individuals who have had a common exposure. Similar to an outbreak, is a “cluster”. A cluster of foodborne illness is defined as more cases than expected for a given geographic location and time. There is no immediately obvious association between cases and clusters are only suggestive of an outbreak; they require further exploration to make this determination.

The primary goal of an outbreak investigation is to stop the current outbreak as soon as possible by implementing effective control measures and to prevent similar outbreaks in the future. In order to accomplish this goal, an outbreak investigation team is needed. This team should consist of members with knowledge and skills in environmental health, epidemiology, laboratory, public health education, communication, and leadership. Epi-Ready is a two-day workshop designed to help outbreak investigation team members work together more efficiently and effectively.

Epi-Ready Series Part 2: Surveillance and Outbreak Detection

Foodborne diseases and outbreaks are detected through many different types of surveillance; however, the two most common methods are foodborne illness complaint systems and pathogen-specific surveillance. Both methods have different strengths and weaknesses; therefore it is most effective to utilize multiple methods of foodborne illness surveillance in order to identify foodborne illnesses and outbreaks.

Foodborne complaints are reports of any illness among individual groups within the community. Complaints are often characterized by common exposures used to link cases together. Occasionally, the reports are made by a third party who recognizes a pattern of illness in the community (e.g., a physician who has seen multiple ill patients with a common exposure). While foodborne complaints have the advantages of localized outbreaks or illness with a short incubation period, they are more prone to bias (e.g., last meal bias).

Pathogen-specific surveillance identifies individual cases of disease through laboratory and/or medical staff reporting (also known as notifiable/reportable diseases or laboratory-based reporting). Isolates of certain pathogens are forwarded onto the state laboratory for further characterization to identify potentially linked cases. While pathogen-specific surveillance is effective in detecting wide-spread outbreaks due to a low-level food contamination or disease with a long incubation period, the reporting process takes much longer and only a fraction of the total estimated number of cases will be reported.

Epi-Ready Series Part 3: Preliminary Outbreak Investigations

While the intricacies of each outbreak investigation will vary depending on the specific investigation, most preliminary outbreak investigations follow the same key steps. Step one is verifying the diagnosis to ensure all cases are suffering for the same illness and eliminate the possibility for laboratory reporting error. Second is the search for additional cases, because passive surveillance techniques do not detect all outbreak associated cases. Searching for additional cases provides a more complete picture of the outbreak and increases the ability to identify the true source of exposure.

Once the diagnosis is verified and additional cases identified, develop a case definition – a standard set of criteria used to classify ill people as being cases associated with a particular outbreak. A good case definition will include clinical findings; establish restrictions by time, place, and person; and is not open to interpretation. Lastly, a hypothesis regarding the source of exposure needs to be developed. Consider basic information about the causative agent, available information on the implicated facility (if applicable), and descriptive epidemiology (e.g., epidemic curve or spot map) to develop a meaningful hypothesis.

After completing these steps, the outbreak can be prioritized for further investigation according to available resources, public health impact, and ability to control ongoing transmission.

Epi-Ready Series Part 4: Laboratory Investigation

Laboratory testing is critical to confirming etiology for any foodborne illness outbreak. Before clinical and food specimens are collected and sent to the testing laboratory, it is important to use the clinical findings and/or suspected food to determine what type of specimens to collect, how to handle the specimens, and what tests the laboratory will need to run.

In order to ensure the specimens are not compromised in-route to the laboratory, proper collection and handling procedures for both clinical and food samples need to occur. Collect clinical specimens for bacterial and/or viral testing in 7A containers and parasites in 4A containers, if specimen is to be sent to the ISDH laboratory for outbreak testing. Remember, these containers expire after one year; send expired containers back to the ISDH Laboratory to be recycled and replaced. Following the chain-of-custody for the specimen collection and transport is critical, particularly for food samples.

Once initial test results are back, additional subtyping may be done on the sample to help differentiate between strains of the causative agent and identify isolates with a common origin. Serotyping and pulsed field gel electrophoresis (PFGE) are two common methods of subtyping conducted at the ISDH Laboratory. PFGE results are uploaded to a national database (PulseNet) to compare Indiana specific isolates with patterns seen across the country and used to identify potential outbreaks.

Epi-Ready Series Part 5: Environmental Health Investigation

Most food establishments are complex systems influenced by many interrelated and changing factors. Since many interrelated components affect the final product produced by a food establishment, environmental health investigators need to understand the underlying interactions of all the forces that impact the system and address the deeper factors to improve the outcome.

During a foodborne illness outbreak investigation, environmental health investigators will be looking to identify contributing factors that increase the risk of foodborne illness and repeatedly contribute to outbreaks. Once the contributing factors have been identified, the investigator will try to determine the environmental antecedents, or the circumstances behind the contributing factors that allowed the contributing factors to occur.

An environmental health assessment is used with epidemiology and laboratory data to determine possible contributing factors and environmental antecedents. Unlike a HACCP risk assessment review, facility plan review, or food establishment regulator inspection, the environmental health assessment is a systematic, detailed, science-based evaluation focusing on specific factors which may have contributed to the outbreak.

Epi-Ready Series Part 6: Epidemiologic Investigation

Once case history and exposure data has been collected for cases in an outbreak, an epidemiologic study (e.g., case series, cohort, or case-control) may be undertaken to identify a common source of exposure among cases. While a case series examines only the ill individuals associated with an outbreak, both cohort and case-control studies use a comparison group of well individuals to put finding in perspective. The ill and well cases are compared by the appropriate measure of association for the study (i.e., relative risk for a cohort study and odds ratio for a case-control study).

Both the relative risk and odds ratio are just estimates; therefore, epidemiology studies also need to account for the possibility of the observation occurring due to chance. The p-value and confidence interval (CI) are calculated to explore this possibility. A p-value is the probability of findings occurring due to chance alone and a CI is the range of values for the measure of association that are consistent with study findings. These calculations are evaluated to determine statistical significance (i.e., it is unlikely the findings were due to chance for the observed association).

Epi-Ready Series Part 7: Multijurisdictional Outbreaks

Traditionally, outbreaks have been considered "focal" events caused by a local food handling error and affecting a large number of individuals within one jurisdiction. However, for many years now, we have been seeing a new outbreak scenario – the multijurisdictional outbreak – where cases are geographically widespread and illness caused by an industrial contamination event with a widely distributed food. This shift in outbreak scenarios is due to a more centralized production and wide distribution of food products, the globalization of food supply, and increasing our ability to detect outbreaks through surveillance and laboratory testing. While we still see more of the tradition outbreak scenario, the multijurisdictional outbreaks disproportionately impact public health in terms of outbreak-associated hospitalizations and deaths.

Local investigation of multijurisdictional outbreaks is critical to the success of the outbreak investigation. For instance, an outbreak that may appear local could have national or international implications. Additionally, coordination among all outbreak partners at the local, state, and federal levels is necessary to understand the complete picture of the event. Finally, urgent investigation action (e.g., follow-up case investigations or environmental assessments) may be required at the local level.

Epi-Ready Series Part 8: Team Communications

Successful outbreak investigations rely on good communication between all team members. Information needs to be shared in a way that supports timely, coordinated, and effective outbreak response. Organizations can work on improving their communication skills before, during, and after an outbreak.

Before an Outbreak: be sure team members and their likely roles have been designated, ensure team members know each other and the roles of other members, and conduct trainings/exercises together as a team.

During an Outbreak: notify the team upon first outbreak suspicion; assemble and brief team immediately following confirmation of an outbreak; hold regular meetings to share information, interpret findings, and collaborate on next activities; and document actions, findings, and decisions. A specific spokesperson(s) should be designated to talk with the implicated business and/or media to ensure consistent and appropriate messaging.

After an Outbreak: schedule a debriefing as soon as possible, assign the responsibility to compete the final report, and delegate national reporting of the outbreak.

Page last updated: August 1, 2016

Page last reviewed: August 1, 2016