Assist Prof.

Maria Pavlova, NCIPD, Sofia

Steps in a Foodborne Outbreak Investigation
*investigations are dynamic and several steps may happen at the same time

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 Regional Health Inspectorations, formal
reports of illnesses, and informal reports of illnesses.
 How are outbreaks found?

One way health officials find outbreaks is through public health

surveillance. By routinely gathering reports of illnesses, they know
how many illnesses to expect in a given time period in a given area.
If a larger number of people than expected appear to have the same
illness in a given time period and area, it’s called a cluster.
When an investigation shows that ill people in a cluster have something
in common to explain why they all got the same illness, the group of
illnesses is called an outbreak.
• Informal reports of outbreaks - Informal reports occur
when members of a community call the local health
department to report suspected food-related illnesses.
For example, this might happen if several people got sick
after eating at a group dinner.

• Formal reports of outbreaks - Doctors and

microbiologists in each state must formally report
infections that are on a list of notifiable diseases when
they diagnose them in patients. This list includes many
foodborne illnesses. 
 Suspect a person has a foodborne illness

• The patient may be asked to submit a stool sample (or some other type of
sample) to help figure out what germ is making them ill.
• The patient’s sample is sent to a clinical laboratory.
• The clinical laboratory tests and may identify the germ (for example a bacteria or
virus) that is making them ill.
• The clinical laboratory tells the doctor’s office the results of their testing so the
doctor can treat the illness.
• The germ may then be sent to the state public health laboratory for confirmation-
NRL for Enteric Infections, NCIPD.
Steps in a Foodborne Outbreak Investigation
*investigations are dynamic and several steps may happen at the same time

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?
• Case definitions are developed by health officials to spell out who
will be included as part of the outbreak. Case definitions may
include details about:
• Features of the illness
• DNA fingerprint
• The pathogen or toxin (if known)
• Certain symptoms typical for that pathogen or toxin
• Time range for when the illnesses occurred
• Geographic range, such as residency in a state or region

There might be several case definitions for an outbreak investigation, each with a different purpose. For example, one
case definition might be for confirmed illnesses and another for probable illnesses. The number of illnesses that meet
the case definition is called the case count.
How are cases of illness found? How are cases tracked?

• Reviewing laboratory reports to PulseNet • Who becomes ill ?

• Reviewing regular surveillance reports • When they become ill?
• Asking local clinical and laboratory • Where they live?
professionals to report cases of the particular A graph called an epidemic curve or epi curve to track the number of
illness more quickly, as soon as they suspect illnesses over time. 

the diagnosis
• Reviewing emergency room records for similar
illnesses
• Surveying groups that may have been exposed
• Asking health officials in surrounding areas to
look for illnesses that might be related
 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?
Three types of data to generate hypotheses about the likely source of the
outbreak: epidemiologic, traceback, and food and environmental testing.
Investigators begin by trying to pinpoint how the pathogen spread. 

 The specific pathogen causing illness

 Where sick people live
 Where did sick people travel
 How old they are, their sex, and race/ethnicity
 Did they have contact with a sick person
 Where the ill person ate and stores where they bought food
 Steps in a Foodborne Outbreak Investigation
*investigations are dynamic and several steps may happen at the same time

Step 4: Test Hypotheses

A hypothesis is tested to determine if
the outbreak source has been
correctly identified.
Investigators use many methods to
test their hypotheses.
Two main methods are analytic
epidemiologic studies and food
testing.
 Epidemiologic Studies
• Investigators collect information from sick people (cases) and non-sick people
(controls) to see if sick people were more likely to have eaten a certain food or to
report a particular exposure. Case-control studies try to include controls who have
had the same opportunities to be exposed to an unsafe food item as a case has. 
• Statistical Testing - If eating a particular food is reported more often by sick people
than by well people, it may be causing illness. 
• Factors Considered When Interpreting Study Results:
 Frequencies of exposure to a specific food item
 Strength of the statistical association
 The food’s production, distribution, preparation, and service
Step 5: Solve Point of Contamination and
Source of the Food
Health officials use three types of data to link
illnesses to contaminated foods and solve
outbreaks: epidemiologic, traceback, and
food and environmental testing.
Health officials assess all of these types of
data together to try to find the likely source
of the outbreak.
A contamination can happen anywhere along
the chain of food production, processing,
transportation, handling, and preparation.
What epidemiologic data is used to help find the likely source of the
outbreak?

Patterns in the geographic distribution of illnesses,

the time periods when people got sick, and past
outbreaks involving the same germ.
Foods or other exposures occurring more often in
sick people than expected
Clusters of unrelated sick people who ate at the
same restaurant, shopped at the same grocery
store, or attended the same event.
Step 6: Control an Outbreak
Once the food source of an outbreak is determined, control measures must be
taken.
If contaminated food stays on store shelves, in restaurant kitchens, or in home
pantries, more people may get sick.
There are several different outbreak control measures that can be taken.
Public health officials choose measures based on the information available to
them.
Measures can change as the investigation goes on.
How are control measures chosen?

• control measures based on strong epidemiological evidence of the disease’s

origin, spread, and development, no need for proof of contamination from the
laboratory

How are outbreaks communicated?

• warning consumers quickly about a contaminated food to take to protect
themselves
Step 7: Decide an Outbreak is Over
An outbreak is over when the number of new illnesses drops back to what
investigators normally expect.
With continued public health surveillance, if the number of illnesses rises again,
the investigation continues or restarts.
 When is an outbreak over?
An outbreak ends when the number of new reported
illnesses drops back to the number normally expected. The
epidemic curve helps investigators see that illnesses are
declining. Even when illnesses from the outbreak appear to
have stopped, public health officials continue surveillance for
a few weeks to be sure cases don’t start to increase again.

What if the number of new illnesses increases?

• It could be that the source was not completely controlled
• A second contamination involving another food or location is linked to the first
outbreak
• The investigation continues or restarts
 Report a Foodborne Illness / outbreaks
Suspected cases of foodborne infection with Salmonella especially typhoid and paratyphoid fever, Shigella especially Shiga-toxin producing Escherichia
coli (STEC, including O157 and other serogroups), Listeria, Campylobacter, Cholera, Yersinia enterocolitica and hepatitis A virus, as well as Botulism, should
be reported directly to the Regional Health Inspectorates (RHI) and NCIPD for FWD-outbreaks.
Suspected botulism cases should be reported immediately.
Standardized forms should be used to report additional information about certain health conditions to RHI.
NOT A FOODBORNE
OUTBREAK
Most cases of illness, even those caused by
common foodborne germs, are not linked to
a foodborne outbreak

most illnesses are not part of an outbreak

germs that cause foodborne illness can also be spread in other ways, such as by
water or directly from one person to another.
if an illness is diagnosed by a culture-independent diagnostic test, that case may not
be linked to an outbreak because these tests do not provide the information needed
to link it to an outbreak.
many people do not seek medical care for foodborne illnesses, so their illnesses
cannot be diagnosed or reported to public health officials
Food poisoning
Bacteria Typical start of symptoms after exposure
Campylobacter 2 –5 days
E. coli 3–4 days
Listeria 1–4 weeks
Pregnant women usually have a fever and other flu-like symptoms, such as fatigue and muscle
aches. Infections during pregnancy can lead to serious illness or even death in newborns.
Other people (most often older adults): headache, stiff neck, confusion, loss of balance, and convulsions in
addition to fever and muscle aches.
Salmonella 6 hours–6 days
Shigella 8 hours-3 days
Vibrio 2 to 48 hours
Staphylococcus aureus  30 minutes to 8 hours
Clostridium perfringens 6 to 24 hours
Clostridium botulinum (Botulism) 18 to 36 hours
Double or blurred vision, drooping eyelids, slurred speech. Difficulty swallowing and breathing,
dry mouth. Muscle weakness and paralysis. Symptoms start in the head and move down as the illness gets
worse.
Thank you for your attention!