Comprehensive Foodborne Illness Investigation

State: WI Type: Model Practice Year: 2004

The Madison Department of Public Health’s Comprehensive Foodborne Illness Investigation procedures address how the Madison Department of Public Health (MDPH) follows up with foodborne illness complaints related to food establishments and events within its jurisdiction. These procedures were developed by a cross-departmental team in order to make foodborne illness complaint follow-up more efficient and consistent, to identify foodborne outbreaks and their underlying causes, to prevent further disease transmission, and to provide education for community members and food service workers. The main element needed to replicate this practice is a team representing all areas of foodborne illness complaint follow-up. Team members may all be from one agency, or from more than one, such as a local health department public health nurse and a state sanitarian. This team is essential in writing and formalizing procedures appropriate for a particular jurisdiction and for modifying these procedures as improvements are identified. Another necessary element is having a dedicated Intake Nurse or other staff to take foodborne illness complaints. This individual should be trained in using a standard form to interview callers and indicators of potential outbreaks. Another element is the commitment of staff at all levels to the importance of following foodborne illness complaints with goal of identifying and preventing further illnesses.
This practice addresses how the MDPH follows up with foodborne illness complaints related to food establishments and events within its jurisdiction. During 2000-2003, MDPH received at least 75 complaints each year of illness suspected to be related to licensed establishments. These calls may represent legitimate complaints, may serve to identify outbreaks of foodborne illness, or the illness may be unlikely to be related to the suspected establishment. These policies and procedures specify how each complaint should be reviewed and followed in order to prevent and detect other cases of illness, to use staff time efficiently, and to ensure uniformity of follow-up among establishments. MDPH has recently revised and updated its foodborne illness follow-up policies and procedures. A foodborne illness team, consisting of the Communicable Disease Epidemiologist (CDE), Environmental Health Services Supervisor (EHSS), Public Health Nurse (PHN), and Foodborne Illness Specialist Sanitarian (FISS) was created in order to review and improve procedures. This team meets on a regular basis to evaluate the policies and procedures related to foodborne illness follow-up and to continually make improvements in the process. A foodborne illness specialty was assigned to the FISS in order to provide resources and support to the district sanitarians, and to offer input into the procedures from a field worker’s point of view. The old version of the written policy and procedures was inefficient and confusing. Its design has been improved upon so that anyone would be able to pick up a copy of the procedures and know exactly what is supposed to be done. According to state officials, most local health departments review foodborne illness complaints with a goal of detecting an outbreak. Many do not collect a food history besides the suspect meal unless there are two or more unrelated people with the same complaint. Most do not contact the establishment listed in the complaint unless it is considered a “problem establishment,” or if there is strong evidence to indicate an outbreak. A lack of time, resources, and local sanitarians are common reasons that there is not more follow-up on these complaints. The MDPH foodborne illness investigation procedures are much more thorough, but also as efficient as possible. All local health departments are facing cutbacks and budget issues, and the MDPH procedures were designed to gather enough information in order to spot potential outbreaks, but without adding a lot of paperwork or staff time.
Agency Community RolesThe MDPH is the sole developer and user of this practice. It is designed to be used as an internal system for investigating foodborne illness complaints and outbreaks. There is collaboration between all divisions within MDPH. The Foodborne Illness Team consists of members from the Division of Community Health and the Division of Environmental Health and Laboratories. Also, during an investigation of a complaint, the Office of Administration is involved. During a complaint investigation or outbreak, there is also collaboration between the State Division of Public Health staff, including epidemiologists and food safety staff, and the MDPH staff, especially the CDE. MDPH receives guidance and assistance, if necessary, in order to complete the investigation. Stool samples collected from ill patrons or employees are sent to the State Laboratory of Hygiene for processing, and food samples may be tested at the Department of Agriculture, Trade and Consumer Protection (DATCP) laboratory. If necessary, federal agencies may also be contacted. There is a partnership with neighboring local health departments such as the Dane County Division of Health (DCDH) and UW Health Services, if multiple food establishments are involved. Also, MDPH sometimes collects information for other agencies before referring it to the appropriate jurisdiction, and vice versa. During an outbreak or complaint investigation, there is cooperation within the community and its members. Costs and ExpendituresA small amount is spent on photocopying forms and phone calls. The Wisconsin State Lab of Hygiene performs any lab testing at no cost to the department. The main costs for this practice for the department are in staff time. The time for each complaint that does not lead to an outbreak investigation varies. In the case of an outbreak investigation, times have varied greatly, and are difficult to estimate. The Foodborne Illness Team consisting of the FISS, EHSS, CDE, and a PHN meets one time per month for approximately one and a half hours. Each team member spends approximately one hour per month on team-related work outside these meetings. Preventing foodborne illness and responding to foodborne illness complaints is a high priority for the department. The duties regarding foodborne illness complaint investigations are part of each relevant employee’s job description and are budgeted for appropriately. The funding for this staff time comes from food establishment licensing fees and general purpose revenue.  
ImplementationThese steps all occur as quickly as possible, to accomplishment program objectives, but the timeline varies by situation. Objective 1: Investigation of suspect foodborne illnesses to identify foodborne outbreaks. Each individual who calls MDPH to complain of an illness related to a food establishment or event is interviewed by an Intake Nurse to gather information about his/her symptoms and meals before the onset of illness. Each complaint is then reviewed by the CDE within 24 hours of the initial call in order to determine how likely it is the illness is related to the establishment in question and to identify other possible sources. The complaint is then forwarded to the EHSS, who assigns a sanitarian to follow-up on the complaint as recommended by the CDE and EHSS. The recommended follow-up may range from simply reviewing the complaint to a full inspection of the establishment. The sanitarian should perform this follow-up within three days of the initial complaint. Objective 2: Investigation of foodborne outbreaks to identify the underlying cause of each. A sanitarian contacts the establishment in question the same day a suspected foodborne outbreak is identified and makes arrangements for an onsite visit as soon as possible but within 24 hours. Public Health Nurses (PHN) conduct these interviews during the next few days, using a translator if necessary. The PHN also attempts to collect stool samples from each ill patron and employee. The CDE analyzes the data after all interviews are complete and identifies possible sources of the outbreak. Objective 3: Prevent additional transmission of the disease following an outbreak. MDPH takes several steps to prevent further transmission. Any ill employees are restricted or excluded from food handling and/or the establishment until either their symptoms resolve or they have negative stool samples, depending on the agent. Ill patrons are educated about how to prevent transmission of their illness to others. Sanitarians educate establishments on proper food handling practices and write orders as appropriate. Any remaining food is tested and discarded if contaminated. If the contamination is identified to be external to the establishment, the proper agencies are notified. Objective 4: Ongoing education of community members and food service workers regarding safe food handling practices. Employees of an affected establishment are educated and trained during the visits that occur in follow-up to a potential or actual outbreak.