The Bureau of Epidemiology, Salt Lake Valley Health Department (SLVHD) developed and implemented an innovative approach to detecting foodborne illness via a comprehensive automated foodborne surveillance system during 1998. This practice has been refined with the implementation of standards, guidelines and process reviews on a continual basis. This system was originally created to address an increase in Hepatitis A rates in Salt Lake County to alert staff to suspect point source exposures prior to laboratory confirmation. A system alert prompted a rapid response lead by Epidemiology Bureau staff with collaboration from the Bureaus of Food Protection and Infectious Disease.
Although, an automated data management system was in place for reportable diseases Epidemiology Bureau staff wanted to establish a reporting mechanism for persons with possible foodborne illness to identify establishments requiring an immediate inspection. This led to the establishment of a new surveillance method of tracking suspect foodborne illness based on reports generated through the Food Protection complaint line.
The goals of this automated system was to: 1) combine the foodborne illness complaints with the reportable disease database for trend analysis on food service establishments; 2) to rapidly detect and respond to clusters of illnesses from implicated food service establishments, group settings and implicated food items in a standardized approach in order to intervene in a timely manner; and 3) to encourage use of illness complaint line among the public. Data generated from this process are flagged only if specific criteria are met to increase the sensitivity of these reports. Protocols and guidelines were refined over the years and the surveillance and investigation response streamlined to reduce resources needed for outbreak investigations.
Epidemiology staff recognized that many foodborne illnesses, suspected food service establishment and food sources are underreported. The Centers for Disease Control and Prevention (CDC) estimate that only one to five percent of confirmed foodborne illnesses are reported to local health authorities. The majority of people who are affected by foodborne illnesses do not seek medical attention and those who do generally do not submit stool specimens. However, the public is willing to call the Health Department and report an illness. On average there are 479 reports of illnesses reported to the SLVHD each year. There is also a time delay of three to ten days when a stool specimen tests positive for an organism, reported results contact to the case for risk assessment including a food history.
According to the Utah Department of Health Epidemiology staff local health departments generally record the foodborne illness reports on a pad of paper and no method of tracking or surveillance has been in place. Prior to 1998 and the Hepatitis outbreak SLVHD was no exception. Traditionally foodborne illness complaints were logged by hand, placed in a note book for review by a supervisor and then assigned to a Licensed Environmental Health Scientist (LEHS) for an inspection. Automation of this data and implementing criteria for inspection has streamlined the process of outbreak investigations to an average of 79 outbreak responses for the last five years.
Agency Community RolesThis practice was designed to involve broad–based involvement within the Health Department and community partners. Internally, development and implementation of this system involved the Bureaus of Epidemiology as the lead, Food Protection, Water Quality and Infectious Disease. Administration and the Public Information Officer are also involved when an outbreak is detected. There are internal bi-monthly meetings for communication, training, reports and development or review of standards and guidelines.
In addition a process reviews are conducted when an outbreak investigation is implemented that is outside the scope of two unrelated households reporting an illness. Community agencies that participate in this program on an on-going basis are the Utah Department of Health Epidemiology and the Microbiology Laboratory, Department of Agriculture, Poison Control Center, other County agencies such as the 211 general information line and Aging Services, medical providers, and other local health departments.
Costs and ExpendituresThere was no cost to create or implement this automated surveillance program with non reportable diseases and response. Staffing and computer programs were in place and implementation are in the scope of job descriptions within the Health Department.
ImplementationTo accomplish program goals and objectives the following procedures were implemented; 1) Licensed Environmental Health Scientists (LEHS’s) are trained for screening foodborne illnesses and are designated as a duty officer for phone coverage on a rotating basis. The Duty Officers electronically logs complaints called in or e-mailed to the Health Department by the public. If a potential foodborne outbreak is detected a call tree has been established to immediately alert the appropriate personnel in Epidemiology for verification. In addition to regular business hours there is also an emergency number for the SLVHD that provides 24/7 coverage. The emergency response team is also trained to recognize foodborne illness outbreaks and there are guidelines in place to alert epidemiology staff after hours. The relevant information that is gathered on a standardized form is demographics, food history, illness status, signs and symptoms, incubation, duration and medical information if necessary. This information is then forwarded to the Epidemiology Bureau daily or immediately if an outbreak is suspected. This information then becomes part of the reportable disease data base; 2) Surveillance is conducted by epidemiology staff on a daily basis for trend analysis. The criteria that was developed for responding to a suspect foodborne illness outbreak is when an establishment is named by two unrelated households within fifty days or if there is compelling epidemiological evidence an outbreak is occurring. A report is then generated by Epidemiology staff to the Bureau of Food Protection requesting an investigation. A critical item inspection is conducted by an LEHS within 24 hours. In addition to the inspection there is a standardized questionnaire that is given to the Person in Charge (PIC) for completion. This questionnaire includes information such as food distributors, travel history of employees, second jobs of employees, sick policies of the establishment and unusual circumstances at the facility such as loss of water or power. Also, a food flow chart may be completed by the PIC if there are implicated food items. Food flow charts illustrate the Hazardous Analysis of Critical Control Points and kill steps during the food preparation process and to identify any potential contamination points; and 3) Increase the visibility of the Food Protection phone number beyond the Health Department Website and phone book. This was accomplished by collaborating with outside agencies such as the Poison Control Center, the 211 general information line provided by the county, Aging Services, Department of Agriculture, Utah Department of Health, other local health departments and by meeting with health care providers on a routine basis such as hospitals to distribute the food complaint line phone number and to encourage the reporting of non-reportable illnesses.
Goal: Development and implementation of an innovative approach to rapidly detect foodborne illness through a comprehensive automated surveillance system with a standardized response for foodborne outbreak investigations.
Objective: Development of criteria and guidelines to approach outbreaks in a standardized manner:
Performance measures: 1) epidemiology staff meets weekly as a group to discuss trends, review processes and provides training on a routine basis to the duty officer and infectious disease nurses; 2) development and implementation of criteria and guidelines for response.
Data collection: 1) implicated food sources, lab reports and data from outside agencies; 2) duty officers in Food Protection and epi staff from the reportable diseases database; and 3) data are collected on a standardized form, lab slips and response to outbreaks are also standardized.
Outcome (long-term): Approaching outbreak investigations using the developed criteria has decreased the number of investigations conducted by Food Protection staff, this approach has been more efficient.
Objective: Standardized data collection and surveillance for reportable and non-reportable diseases:
Performance measures: Orientation with every duty officer in Food Protection with Epidemiology staff and routine meetings that occur twice a month for reports, trainings and process reviews.
Data collection: 1) foodborne illness reports with identified food service establishments and demographic information; 2) duty officers in Food Protection; and 3) utilizing a standardized form to collect the data and electronically entered.
Outcome (long-term): The majority of foodborne outbreaks have been detected because of the comprehensive automated surveillance system.
Objective: Increased visibility of the Food Protection Complaint Line through community outreach:
Performance measures: Epidemiology staff meets with outside agencies at least once a month and participates in workgroups to increase visibility. A mailing is also sent out once a year to medical providers.
Data collection: 1) feedback of process is collected by Epi staff when meeting with external agencies on a routine basis; and 2) data is collected in person, anecdotally, phone surveys, electronic communication and paper surveys.
Outcome (long-term): Increasing visibility with outside agencies, the medical community has helped with the reporting of confirmed diseases.
This program is sustainable and been is a priority for the SLVHD. The funding for staff comes from general purpose revenue and food establishment licensing fees.