Foodborne disease outbreaks requiring public health emergency responses occur regularly across the nation. The U.S. Centers for Disease Control and Prevention (CDC) estimated in 2011 that foodborne illnesses are responsible for an average of 47.8 million illnesses of various types, more than 125,000 hospitalizations, and over 3,000 deaths per year in the United States. Unlike other disaster-response scenarios, training for this type of response is continuous – and usually acquired on the job. To provide a better and more structured framework for training and evaluation, several improved guidelines were developed by the Council to Improve Foodborne Outbreak Response (CIFOR) – which is co-chaired by the National Association of County and City Health Officials (NACCHO) and the Council of State and Territorial Epidemiologists (CSTE), and is supported by both the CDC and the U.S. Food and Drug Administration (FDA).
A grant from the CDC also is being used to support the University of Minnesota’s U-SEEE (Simulations, Exercises, and Effectiveness in Education) program to carry out a “Retrospective Cohort Study of Responders Training and System Performance.” U-SEEE investigators are using the CIFOR guidelines as the metrics needed to evaluate training, communications, and the foodborne outbreak response system in Minnesota itself. This approach addresses the top-priority research areas for public health preparedness asentified in the National Academy Institute of Medicine’s 22 January 2008 report on Research Priorities in Emergency Preparedness and Response for Public Health Systems.
These research areas focus primarily on, but are not necessarily limited to, the following: (a) enhancing the usefulness of training; (b) improving the availability and use of timely emergency communications; (c) creating and maintaining sustainable response systems; and (d) generating effectiveness criteria and metrics.
Suggested Models & Flexible Guidelines – But Uncertain Compliance The CIFOR guidelinesentify the following suggested models for conducting investigations of foodborne outbreaks:
- Local- and state-level public health department activities focused on outbreak detection and response – from disease surveillance carried out by public health laboratories and/or healthcare professionals, as well as from complaint-based surveillance information received from the general population;
- The preparation and planning used for outbreak investigations, including defining the roles of specific agencies, standardizing processes, and the training of investigative teams;
- Suggested procedures for investigating clusters and outbreaks – while also maintaining flexibility; and
- The reduction of further exposure to the public, and – after a source for the initial outbreak has been established – the prevention of additional future outbreaks.
These models are not meant to be followed rigidly, but can be adapted, for the use of each individual agency and municipality participating, in ways that are considered to be the most useful and expedient to the needs of a particular area and/or outbreak investigation.
Although the CIFOR guidelines were intended to be flexible, the level of compliance to these model practices at local- and state-level public health departments in Minnesota was somewhat uncertain. To learn more about the overall implementation of these model practices, the U-SEEE research team surveyed a number of public health departments throughout the state. The survey results compared the use of model practices in state- and local-level foodborne outbreak investigations. In the model practices described, there appeared to be, at both state and local levels, a bimodal pattern of usage. Model practices appeared to be either commonly used (75 percent of the time or more) or infrequently used (25 percent of the time or less); a few fell somewhere between these upper and lower extremes. The same pattern was observed regardless of whether the investigation was initiated as a result of a public complaint or as follow-on to lab reporting.
The Framework Needed for “New and Better Methods” Future research will enable the comparison of model practice use patterns in multiple states, with different systems for organizing outbreak responses. Currently, a second survey is underway investigating the practices used in the CDC’s FoodCORE (Foodborne Diseases Centers for Outbreak Response Enhancement) sites, which, as described by CDC itself, “work together to develop new and better methods to detect, investigate, respond to, and control multistate outbreaks of foodborne diseases.” The principal goal of this second survey is to establish a framework to relate the use of the model practices, training, staffing, resources, and agency roles to the ability of the system to detect and respond to foodborne outbreaks.
For states with limited resources, it may be necessary to prioritize which practices to implement and in what situations. These decisions should be based on successes that the health department can maintain toentify how investigations could be improved. Determining where there are shortcomings in the process – in surveillance, preparation and planning, defining agency roles, standardizing processes, training, staffing, or resources – can lead to more precisely targeted improvements.
Those improvements, it is hoped, will be obvious not only in Minnesota, but throughout the entire country. By using standard practices and including measures focused on thorough data collection and timely responses, all of the nation’s health departments will be better able to predict the outcomes of outbreak investigations, in a more timely, more complete, and more effective way.
For additional information on: CIFOR Guidelines, visit http://www.cifor.us/documents/CIFORGuidelinesforFoodborneDiseaseOutbreakResponse.pdf
________________________ Kimberley Wetherille, MPH, (pictured) is a PhD candidate in Environmental Health Sciences at the University of Minnesota’s School of Public Health. Her research examines the relationship between disaster responses and training for emergencies in the state of Minnesota during situations ranging from flooding and foodborne outbreaks to structural collapses.
Evan Henke, MPH, is a PhD candidate in Environmental Health Sciences at the University of Minnesota’s School of Public Health. His research is focused on the evaluation and continuous improvement, for rapid outbreak detection and investigation, of foodborne disease surveillance systems.