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

1. 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, MPH Bureau of Communicable Disease Control New York State Department of Health

2. 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 at http://nyfoodsafety.cals.cornell.edu/

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Initial Steps

12. Initial Steps

13. 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

14. Initial Steps

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

17. Initial Steps

18. 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

19. Investigation Activities for Outbreaks (excerpt, Ch. 5)

20. 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

21. Requests for Assistance

22. Communication

23. 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

24. 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

25. 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

26. 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/

27. 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

28. Resources Comments or questions for NY CoE can be directed to: • Paula Huthor 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/

29. Questions