Steps in a Foodborne Outbreak Investigation

To be able to properly investigate an outbreak of a foodborne illness, a multidisciplinary approach is

required. A response team framework is in place in many health districts to enable a timely and effective
reaction when and if foodborne illness outbreaks develop in their area. Generally speaking, this
response team structure for the health department consists of:

Each multistate foodborne epidemic is extensively investigated by the CDC utilizing a 7-step procedure.

The general steps of an inquiry into a foodborne illness epidemic are listed below. The public can give
crucial information that can be used to solve an outbreak through phone calls, disease reports, or
follow-up investigations.

Step 1: Detect a Possible Outbreak

Detecting an outbreak is the first step in investigating a multistate foodborne
outbreak. An outbreak with multiple sick people can be missed if they are
spread out over a wide area. Outbreaks are detected by using public health
surveillance methods, including PulseNet, formal reports of illnesses, and
informal reports of illnesses.

• How are outbreaks found?

Public health surveillance is one method used by health professionals to identify epidemics. They are
able to predict the number of diseases that will occur in a specific location and time period by
consistently accumulating reports of sickness. A cluster is defined as an unanticipated increase in the
number of cases of a certain illness in a particular location and time frame. The collection of diseases is
known as an outbreak when an inquiry reveals that sick persons in a cluster have a common factor that
might explain why they all contracted the same sickness.

1. Informal reports of outbreaks - Informal reports are made when members of the community
contact the neighborhood health office to report illnesses they believe may be caused by food.
This may occur, for instance, if numerous diners at a group supper became ill after eating.
2. Formal reports of outbreaks – Each state has a list of notifiable illnesses that doctors and
microbiologists must legally notify when they identify infections in patients that are on the list.
There are several foodborne diseases in this list. When public health professionals review
sickness statistics, they can find that a certain ailment is more common than anticipated. Formal
reports can also be made when a medical professional contacts the health department directly
after realizing that there are more cases of a disease than would be predicted.
 • What happens when a doctor suspects a person has a foodborne
illness?
1. To identify the germ causing the patient's illness, the doctor may ask for a stool sample (or any
other kind of sample).
2. The patient's sample is delivered to a medical lab.
3. The clinical laboratory performs tests and may locate the pathogen (such as a virus or bacteria)
causing the patient's illness.
4. In order for the doctor to treat the sickness, the clinical laboratory informs the doctor's office of
the findings of their tests.
5. The state public health laboratory may then receive the germ for DNA fingerprinting.

For some pathogens, such as the bacterium E. coli and Salmonella. Public health laboratories that deal
with E. coli O157 submit their DNA fingerprinting findings to the PulseNet database.

• What is the PulseNet database?

1. A national laboratory network called PulseNet connects cases of foodborne illness to identify
outbreaks. For the purpose of identifying thousands of regional and multistate outbreaks,
PulseNet employs DNA fingerprinting, or patterns of germs that cause illness. From the time a
person becomes ill until the day the results of fingerprinting the bacteria are added to the
PulseNet database, it may take several weeks.
2. By early outbreak detection, PulseNet has enhanced our food safety systems since the network's
founding in 1996. This enables investigators to track down the cause, notify the public earlier,
and spot weaknesses in our procedures for ensuring the safety of our food that might otherwise
go undetected.

Step 2: Define and Find Cases

Finding sick people is important to help public health officials understand the
size, timing, severity, and possible sources of an outbreak. A case definition is
developed to define who will be included as part of an outbreak.
Investigators use the case definition to search for illnesses related to the
outbreak. Illnesses are plotted on an epidemic curve (epi curve) so that
public health officials can track when illnesses occur over time.

• What is a case definition?

Health authorities create case definitions to specify who will be included in the epidemic. Case
definitions may provide information on:
 1. Symptoms of the disease
2. DNA fingerprint (if the pathogen is tracked by PulseNet)
3. The pathogen or toxin (if known)
4. a few signs that the virus or toxin causes
5. the onset of the ailments happened between
6. variety of locations, such as residing in a state or area

A case definition for an epidemic investigation might have multiple distinct purposes. A case definition
for verified diseases could differ from one for suspected illnesses, for instance. The term "case count"
refers to the total number of diseases that satisfy the case criteria.

• How are cases of illness found?

Investigators look for further diseases connected to the epidemic based on the case definition. They
achieve this by:

1. reviewing lab report submissions to PulseNet

2. going through routine surveillance report
3. requesting that local medical staff report cases of the specific sickness more rapidly, as soon as
they detect a diagnosis
4. to search emergency room data for conditions that are comparable
5. surveying potential exposure groups
6. requesting local health authorities to search for possible connected diseases

• How are cases tracked?

Tracking helps investigators follow the spread of an outbreak.

1. Who becomes ill

2. When they become ill
3. Where they live

To monitor the progression of sickness rates over time, researchers use a graph known as an epidemic
curve, or epi curve. The epi curve's pattern aids investigators in determining whether sick persons were
exposed to the same sickness over a short period of time or over a prolonged period of time. Maps are
used by investigators to indicate the locations of ill persons so they can quickly determine whether and
how the outbreak is spreading.
Step 3: Generate Hypotheses about Likely
Sources
Hypothesis generation is an ongoing process. Possible explanations of an
outbreak are continually changed or disproved as more information is
gathered. Interviews, questionnaires, and home visits are helpful in
narrowing down how and where people in the outbreak got sick.

• How are hypotheses generated?

To create theories regarding the most likely cause of the epidemic, health authorities analyze three
different sorts of data: epidemiologic, traceback, and food and environmental testing. The first step
taken by the investigators is to determine how the infection spread. They examine information like:

1. The specific pathogen causing illness

2. Where sick people live
3. How old they are, their sex, and race/ethnicity
4. Did they have contact with a sick person

• Why are interviews conducted?

1. When a contaminated food is considered to be the source of a disease, investigators must take
into account a wide range of potential foods.
2. Interviews assist in compiling a list of the items that individuals consumed before to being
unwell and gather data on additional exposures, such as eating establishments and grocery
shops visited by the sick person.

Investigators utilize this list to identify the foods or substances the ill persons have in common.

• What are hypothesis-generating interviews?

In addition to direct contact with a sick person, contaminated water, and direct or indirect contact with
an infected animal, pathogens that cause foodborne disease can also spread through these routes.
Health officials question people to learn what the sick person ate and where they traveled in the days or
weeks before to being unwell. Interviews that generate hypotheses are known as such. Interview topics
may be narrowed down to certain dishes depending on what is already known. Interviews could center
on the food made, served, or sold at a restaurant, hotel, or event, for instance, if numerous instances
are related to those establishments. The length of time that researchers inquire about is determined by
the pathogen's incubation period, which differs for various infections.
 • What is a shotgun questionnaire?
Investigators may employ a standardized questionnaire known as a shotgun questionnaire if there isn't a
clear source of the illness (such as everyone eating at the same restaurant). Questions on: are included
in shotgun questionnaires.

1. A standard list of food items

2. Each meal a person ate before becoming ill
3. Food shopping habits
4. Travel
5. Restaurant dining
6. Attendance at events where food was served

Only the hypotheses that are listed on the questionnaire can be suggested by a shotgun interview. This
strategy might not produce a precise and verifiable hypothesis. Open-ended, in-depth interviews can be
useful in this circumstance.

• What do investigators do with information collected from interviews?

1. Make a list of the common meals and beverages that unwell patients consume.
2. Examine additional data, such as prior exposure to the suspected pathogen and the age or
ethnicity of the ill.
3. Make a prediction on the outbreak's most likely cause.

• Challenges of Hypothesis Generation

1. Interviews depend on recall. From the moment someone gets sick until it is determined they are
a part of an outbreak, it might take several weeks. It's possible that someone won't be able to
recall their meal in full.
2. Because people frequently forget or are unaware of the specific ingredients of the foods they
ate, the task is made even more difficult when the contaminated food is an ingredient (such as
eggs, spices, or herbs).
3. Several interviews could be required as fresh suggestions for potential sources emerge.

These difficulties might delay the emergence of a hypothesis. Examining the items in a sick person's
pantry and refrigerator during home visits might be beneficial. It may also be beneficial, with their
consent, to go at the data from their shopper cards.