4 OUTBREAK OF AN ENTERIC ILLNESS

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1 4 OUTBREAK OF AN ENTERIC ILLNESS 4.1 Definition An outbreak of an enteric illness is defined as the occurrence of case(s) in a particular area and period of time, which is in excess of the expected number of cases. Alert ALS Laboratory (or other accredited laboratory) if appropriate. Post initial outbreak report on alth/surveillance/forms.html 4.2 Outbreak Response The primary goal of investigation is the containment of an enteric outbreak. The complexity of outbreaks will require a coordinated team effort. A team approach is a prerequisite for the development of a case definition and the search for a common source. The unique nature of each outbreak will define the areas of responsibility for the various disciplines involved. The Medical Officer of Health will assume the lead role for assessment, management, and decisionmaking during an outbreak investigation. Refer to Table Two for the roles and responsibilities of each team member. 4.3 Outbreak Response Summary Public Health Notification (Laboratory Report or Complaint/Referral) Action Complete summary of case histories (Appendix 9.8) Make epidemiological associations Formulate hypothesis: common factors such as time, person, place, food and water consumed Develop case definition, including common signs and symptoms, incubation period, establishment. Obtain outbreak code from CPL. Alert CPL of the outbreak and the approximate numbers of specimens to expect. Investigation Identification of potential source Collection of clinical specimens Collection of food and/or water samples Site inspection Case visit / interview Confirmation Identification of pathogen, and likely mode of transmission and source Notification of Results Follow-up with cases and premise(s) Summary / Evaluation Completion of outbreak summary report to Manitoba alth/surveillance/forms.html Prevention / Risk Management Recommendation for practice changes Preventive action Education and training Outbreak of an Enteric Illness 1 Feb. 2013

2 TABLE 2. Outbreak of Enteric Illness - Roles and Responsibilities Public Health Nurse (PHN) Telephone Complaint: Telephone Complaint: 1. Member of outbreak response team 1. Complete summary of case histories/epi 2. Complete a health history (Appendix 9.7 FBI) 2. table (Appendix 9.8) Notify CD 3. Orient case histories according to person, place and time Coordinator and PHI Manager (if 4. Refer symptomatic individuals to physician(s) permitted premise or private function 5. Obtain name of event organizer or guest/staff list 3. involved) Document on 6. Ensure that clinical (stool) specimens are obtained to verify diagnosis appropriate Enteric illness forms 7. Participate in problem solving, management/control Confirmed Enteric Illness Investigation: 1. Member of outbreak response team 2. Inform physician of positive lab results 3. Interview client and provide education 4. Obtain case history of current illness 5. Discuss etiology (cause) and epidemiology of pathogen (source, transmission, incubation period and period of communicability), and treatment as required 6. Discuss preventive measures, including safe food handling and hygiene practices 7. Determine list of contacts and obtain clinical specimens as required (Appendix 9.3) 8. Determine occupation and assess risk factors for transmission 9. Obtain follow-up (stool) specimens as required Reference appendices re stool collection, CPL etc 10. Refer client/contacts to physician as required 11. Complete follow-up teaching, referral for counseling as required 12. Participate in additional epidemiological investigation (e.g., case control study) If tests identify reportable organism documentation will take place in iphis. Confirmed Reportable Communicable Disease Investigation: 1. Collaborate with CD Coordinator to determine if high-risk categories require exclusion and to rule out outbreak 2. Notify PHI if public premise is involved such as home child care, licensed child care, licensed residential care facilities, restaurant *(Appendix 9.4 referral/notification form & Questionnaire if applicable ) 3. Complete all documentation in iphis and refer completed investigation to CD Coordinator via iphis * Food service establishments include restaurants; deli or food counters in grocery stores, mobile food trucks or carts etc. Outbreak of Enteric Illness 2

3 Public Health Inspector (PHI) Complaint or Referral: 1. Member of outbreak response team 2. Interview ill person(s) for a thorough case history 3. Obtain information regarding: Communicable Disease Coordinator (CD Coordinator) Location of event/place Event organizer Guest list/staff list Menu (including beverages) Food sources/suppliers, other suspect items 4. Refer to reference material for possible causative agent(s) 5. Collection of and transport of stool specimens and original food/water/environmental samples to appropriate laboratories as quickly as possible (if not collecting stool specimen, may refer to a physician for specimen submission see Appendix 9.3) 6. Conduct site inspection of implicated food service establishment and all known food suppliers 7. Institute immediate and risk prevention actions to prevent further illness 8. Participate in problem solving, management/control of the outbreak 1. Member of outbreak response team 2. Coordinate public health nursing aspects of outbreak response, including assignment of PHN case managers; resource for PHN re case management 3. Liaison outbreak response team and other stakeholders 4. Obtain outbreak code from Cadham Provincial Laboratory in consultation with the Medical Officer of Health 5. Identify and arrange for additional staff and material resources (as required) 6. Participate in problem solving, management/control of the outbreak 7. Participate in the development and implementation of preventive measures 8. Outbreak debriefing, staff development and training 9. Participate in outbreak report writing 1. Complete food borne illness complaint form (Appendix 9.7) 2. Consult with PHI Manager 3. Consult with MOH/CD Coordinator 4. Notify CD Coordinator (if stool specimens requested and sent to CPL) 5. Notify and consult with CFIA and / or MAFRI. 6. Notify CPL and ALS regarding submission of clinical and environmental specimens; complete corresponding requisitions; (refer to Section 5; Appendix 9.10 & 9.3 ) 1. Notify MOH, Team Manager and PHI Manager and consult with Outbreak Response Team 2. Notify Community Area Team Manager 3. Complete and submit Manitoba Health Outbreak Report Form (initial assessment and final report; Section 7) 4. Ensure that all aspects of case/contact management are entered into iphis 5. Maintain updated line-list 6. Contribute to outbreak investigation summary report (public health nurse management and response) Outbreak of Enteric Illness 3

4 PHI Manager 1. Member of outbreak response team 1. Notify MOH/CD Coordinator and consult with 2. Coordinate environmental investigations/inspections associated with Outbreak Response Team outbreak response, including assembly of environmental health case managers and team leader 2. Notify and consult with Manitoba Health director of Food Protection. 3. Liaison outbreak response team and other stakeholders 3. Consult / notify PHI of updates 4. Identify and allocate additional staff and material resources (as required) 4. Contribute to outbreak investigation summary report (environmental investigation/inspection, 5. Participate in problem solving, management/control of the outbreak results and response) 6. Participate in the development and implementation of preventive measures 7. Outbreak debriefing, staff development and training 8. Participate in outbreak report writing Medical Officer of Health (MOH) 1. Outbreak response team lead role (decision-making authority): confirm existence of an outbreak, establish case definition, ensure surveillance, epidemiologic and environmental investigations, risk assessments; implement response, management, and control actions, communicate internally and externally and provide program and or policy recommendations. 2. Enforcement of regulations under The Public Health Act. 1. Chair and consult with Outbreak Response Team 2. Notify and consult with WRHA Senior Management and Director, Media Relations 3. Notify and consult with Manitoba Health (Food Protection) and/or CFIA and / or MAFRI 4. Notify and consult with Manitoba Health and Public Health Agency of Canada (as required) 5. Coordinate completion of outbreak investigation summary report Public Health Epidemiologist 1. Member of outbreak response team 2. Maintain a line-list of cases 3. Assist with the establishment of case definitions 4. Conduct epidemiologic investigation and analysis of data 5. Provide summaries to the outbreak response team, as needed 6. Participates and coordinates outbreak report writing Communicable Disease Clerk 1. Member of outbreak response team 2. Receives and refers positive lab results and clinical case reports to case managers 3. Receives and disseminates outbreak documentation to team members 4. Assists with data entry (as required) 1. Notify MOH/CD Coordinator and consult with Outbreak Response Team 1. Notify CD Coordinator/PHN of positive lab results or clinical case reports via iphis 2. Notify PHI Supervisor of positive and negative lab results 3. Maintains central documentation file Outbreak of Enteric Illness 4

5 Additional Outbreak Team Members Depending upon the extent and severity of the outbreak, the MOH may request that additional persons working within jurisdictions other than the Winnipeg Regional Health Authority, or Manitoba Health participate as team members, or alternatively, provide consultation and/or guidance during the course of the outbreak investigation. Manitoba Health The Public Health Division and Office of the Chief Provincial Health Officer are the usual first point of contacts for issues related to actual or potential enteric illness outbreaks and collectively is responsible for supporting and facilitating outbreak investigation and management (e.g., public health and epidemiological consultation, purchase and storage of vaccine and medications, communication and liaison with national health officials such as the Canadian Food Inspection Agency, MAFRI and Public Health Agency of Canada. Manitoba Agriculture Food and Rural Initiatives (MAFRI) The Chief Veterinary Office(CVO)/Food Safety Knowledge Centre of Manitoba Agriculture Food and Rural Initiatives (MAFRI) is responsible for the inspection and enforcement of food safety standards in food premises from the farm up to the back door of retail. Under this mandate MAFRI inspects dairy farms, provincially licensed abattoirs (currently contracted to CFIA), food processors and distribution warehouses. Canadian Food Inspection Agency (CFIA) The CFIA delivers all federal inspection and enforcement services related to food and administers and enforces federal acts that address all stages of the food continuum. The CFIA inspects not only foods, but also the seed, livestock feed, fertilizers, plants and animals on which a safe food supply depends. The CFIA contributes to the investigation and control of foodborne illness outbreaks through its food safety investigation and recall activities, as well as its regulatory compliance and enforcement activities. Public Health Agency of Canada (PHAC) The Centre for Infectious Disease Prevention and Control is the first point of contact for provinces on issues related to actual or potential enteric illness outbreaks and is responsible for public health surveillance and applied epidemiological studies. Outbreak of Enteric Illness 5