FOODBORNE ILLNESS OUTBREAK

Last updated: 11 April 2008

1. Reason for surveillance

• To identify the source of the outbreak and so control it and prevent further
• To monitor the epidemiology and so inform the development of better prevention strategies.

2. Case definition

Case definitions in an outbreak setting are usually determined by epidemiologists investigating the outbreak.

As a guide, a food borne disease outbreak may be defined as a situation where 2 or more people who are linked in time or place report acute onset of enteric or other symptoms caused by ingestion of infectious agents or toxins that may have been acquired by consuming contaminated food or drink.

3. Notification criteria and procedure

Foodborne illness in two or more related cases is to be notified to PHUs by telephone within 24 hours of diagnosis by:

• Hospital CEOs (or delegates) (ideal reporting by telephone)
• Medical practitioners (ideal reporting by telephone)

4. The disease

The agent
Many enteric pathogens such as viruses, bacteria and parasites, as well as toxins produced by bacteria (e.g. Staphylococcus aureus), can cause outbreaks of gastroenteritis. Foodborne illness may also be caused by other biological toxins, e.g., mushrooms, or other naturally occurring materials, e.g., heavy metal, etc.

Mode of transmission
Foodborne illness is transmitted by ingestion of contaminated food or drink (by definition). Secondary cases can occur through close contact with infected persons via the faecal oral route.

Timeline
Many different diseases with different symptoms can result from eating contaminated food or drink. Incubation periods and clinical features of some agents of foodborne illness are presented in the table below.

Depending on the aetiology, symptoms usually last between a few hours and many days, and some cases may be infectious while symptoms of diarrhoea or vomiting are present, and for at least 48 hours after symptoms cease.

Clinical manifestations
Symptoms vary depending on the aetiology, and may include nausea, vomiting, diarrhoea, abdominal pain, myalgia, headache, malaise and fever. Some marine toxins produce neurological symptoms.

5. Managing notifications

Response time
Investigation
On the day the notification of an outbreak is received, begin the follow-up investigation. Within one working day, notify the Communicable Diseases Branch (CDB) at enteric@doh.health.nsw.gov.au and the NSW Food Authority Foodborne Outbreak Coordinator of the nature of the outbreak. When an environmental investigation is required use the Environmental Investigation Request Form.

Data entry
Cases should not be entered onto NDD, except if they are diagnosed with a specific notifiable disease. Within one month of completion of the investigation, send the completed OzFoodNet Outbreak Summary Form to the OzFoodNet Epidemiologist, Communicable Diseases Branch.

The team members may include the following professionals as required:

• Director of the Public Health Unit
• Public health physician/s
• Public health nurse/s or surveillance officers
• Public health laboratory staff
• Epidemiologist/s
• Environmental health officer/s (EHO)
• Communications officer
• Administration support
• NSW Food Authority.

Roles and responsibilities
Liaison between NSW Health and the NSW Food Authority during foodborne events is outlined in the Investigation of Foodborne Illness Response Protocol-Operational Procedures Manual.
In investigating a foodborne illness outbreak, close collaboration among investigators is essential.
The responsibility for any epidemiological investigation rests with the Public Health Unit director.

This includes:

• Determining appropriate epidemiological methods for the investigation
• Interviewing cases (and non cases, if necessary)
• Advising cases on when to seek medical care
• Facilitating medical tests for cases, and obtaining the results of tests
• Advising cases on any exclusions from work
• Gathering information using aids such as menus and lists of patrons from caterers (sometimes it may be more practical for NSW Food Authority investigators to collect this information; the PHU should negotiate with NSW Food Authority if necessary)
• Identifying a potential link to food
• Where an investigation is referred to the PHU by NSW Food Authority, providing a progress report to the NSW Food Authority Foodborne Outbreak Coordinator, on the investigation within one working day of the referral using the Environmental Investigation Request Form
• Reporting the results of the epidemiological investigation to CDB and NSW Food Authority Foodborne Outbreak Coordinator on the day results are known (by telephone) and within 1 month of completion of the investigation (in writing using the OzFoodNet Outbreak Summary Form
• Alert the NSW Food Authority Foodborne Illness Investigation Unit by telephone (phone 1300 552 406) where an ongoing risk to the public has been identified and where the PHU Director believes further regulatory action is required.
• Reporting the de-identified result of an outbreak investigation to the public (when required) and determining the nature of that report after consultation with the NSW Food Authority Foodborne Outbreak Coordinator.

The responsibility for the environmental food investigation rests with the NSW Food Authority

This includes:

• Assessing the safety of food handling procedures (including food handlers' hygiene and reports of illness)
• Establishing the source of specific foods, where possible
• Testing foods suspected to be a source of illness, where available
• Obtaining the results of food tests
• Investigating any food retailer or manufacturer linked to an outbreak to ensure any ongoing public health risk is minimised
• Ensuring any risk identified by these investigations are rectified
• Reporting the preliminary results of environmental food investigations to the PHU on the day of the inspection (by telephone) and in writing within 5 working days.
• Initiate preventative action when the PHU director believes there is an ongoing risk to the public.

Investigation
The response to a notification of a foodborne illness will vary and may be influenced by the number of cases, the aetiology, severity, extent, location (eg., in a high-risk establishment) and further public health risk. Section 6 summarises the steps involved in an outbreak investigation.

There are three main scenarios to consider:
1. Investigation of an outbreak related to a single self-catered function with no evidence of ongoing risk to the general public
A formal investigation of these types of outbreak is generally of little value and is done at the discretion of the public health unit director.

2. Investigation of other point source outbreaks
These investigations require joint involvement from public health unit and NSW Food Authority staff. The extent of the investigation will depend on the likelihood of ongoing risk to the public. Further expertise may be required from epidemiologists, microbiologists, virologists, food industry, and the CDB.

• Where a commercial food establishment is linked to an outbreak, the PHU should telephone the NSW Food Authority Foodborne Outbreak Coordinator without delay for an investigation of that establishment. The PHU should provide details of the symptoms, onset dates, times that any suspected foods were eaten, and name and address of the establishment, and evidence of the link
• Where it can be established that the only event that links most cases is a common meal, then the exposure investigation can usually be limited to foods and other exposures that occurred associated with that meal
• For outbreaks of viral gastroenteritis, if it can be established that a person who handled or otherwise contaminated other cases' food had symptoms of viral gastroenteritis at the time of a common meal, then it may not be necessary to continue with a formal epidemiological investigation to identify the food vehicles.

3. Investigation of community-wide outbreaks
Community-wide outbreaks are often the most difficult to investigate. In multi-jurisdictional outbreaks central coordination is useful and regular communication vital. Cooperation is required from food, communicable diseases and laboratory experts. Frequent evaluation of the progress of the investigation through teleconference is usually required.

Education
The case or relevant caregiver should be informed about the nature of the infection and the mode of transmission. Emphasise the importance of hand washing, particularly after going to the toilet, changing nappies, before eating and preparing food.

The NSW Food Authority should provide education regarding food safety and hygiene standards in commercial food settings, including institutions.

Isolation and restriction
The PHU should instruct cases who are health care workers, food handlers or who care for children or the elderly not to attend work until at least 48 hours after symptoms cease.

Cases who reside in an institution should be cohorted (separated from non-infected residents) if possible. This should include separate hand washing, toilet and bathroom facilities.

Infants and children attending childcare or school should be excluded from attending whilst they have symptoms of diarrhoea or vomiting.

Environmental evaluation
Where a food manufacturer or retailer is a possible source of foodborne illness, contact the NSW Food Authority Foodborne Outbreak Coordinator to:

• Assess food handling procedures
• Sample foods that have been epidemiologically linked to illness.

Where contaminated water sources are suspected, PHU environmental health officers will need to investigate and control possible risks, in liaison with the Water Unit, NSW Health.

Contact management
Identification of contacts
Secondary cases may occur in persons exposed to the faeces or vomitus of cases.

Treatment
No specific treatment is usually recommended to contacts, except for hepatitis A (see protocol).

Education
Provide information to others at risk of illness about the condition, and actions they should take if symptoms develop.

Isolation and restriction
None.

6. Epidemiological investigation

The following are ten steps that provide a systematic approach to investigations. Note that many of these steps will be done concurrently.

1 Determine the existence of an outbreak
Determine whether the number of cases is higher than expected. Information on the background rate of illness in the group can be sought from a range of sources, e.g., surveillance data, hospital records, in patient statistics.

2 Verify the diagnosis
Try to determine likely aetiological agent based on the epidemiological features. Foodborne illness will usually require laboratory investigation to help determine the diagnosis. Alert the laboratory of the outbreak and its suspected aetiology to guide testing procedures. Ask about any specific requirements for the collection of certain specimens and the estimated time frame for results. Stool samples from as many patients as possible should be collected as early as possible after onset of illness.

Each sample should undergo standard bacterial testing and testing for viral pathogens depending on the symptom profile and epidemiology. If a toxin is suspected, vomitus is also required for testing. If needed, further testing (e.g., for toxins) should be determined by the investigation coordinator in consultation with microbiological experts.

3 Define and identify cases
A case definition should be developed specifying time, person and place. Cases may be sought from a range of sources, e.g., facility organizers, laboratories or hospitals.

4 Perform descriptive epidemiology
Cases (and possibly people who were not ill) will need to be interviewed about risk factors for illness. Development of the questionnaire is often a painstaking process that involves:

• A search of the literature for risk factors for the illness
• Hypothesis generating interviews with several cases, including questions about all their exposures, including food and water, and other environmental contacts (such as animals, and other ill people) in the likely incubation period
• A review of questionnaires used in similar outbreak investigations.

• Case identifiers
• Age, sex, place of residence
• Other relevant demographic factors
• Whether ill, date of onset
• Symptoms
• Foods eaten, other relevant exposures.

• Draw an epicurve (number of cases by day of onset)
• Plot cases on a map (using relevant parameters, e.g., place of residence, place of work)
• Construct a table of demographic characteristics and common exposures.

6 Develop hypothesis
Consider the source of the illness and the usual mode of transmission based on analysis of the data gathered on the place, time and person characteristics of the cases, and exposure histories.

7 Evaluate hypothesis
Perform an analytical study, usually a cohort or a case-control study. In a case-control study, controls must be representative of the population from which the cases arose.

8 Perform additional studies
This will include an assessment of the environmental circumstances that could contribute to the outbreak (e.g., food source, storage and handling procedures), further laboratory testing of human, environmental or food isolates, or special epidemiological studies to further determine the risk, e.g., dose response relationships.

9 Implement control measures
This may include recall of product, public warnings, clean up orders, education and training.

10 Communicate findings
Documentation of findings is important to convey science-based recommendations about the immediate control of the outbreak to key personnel, and to provide evidence for policies designed to prevent future outbreaks.