Integrated Foodborne Illness Investigations: A Model of Epidemiology and Environmental Health Collaboration

State: GA Type: Promising Practice Year: 2019

The Gwinnett, Newton and Rockdale County Health Departments (GNR) comprise three counties in Georgia located in the metro Atlanta area. According to the Georgia Department of Public Health's Online Analytical Statistical Information System (Oasis, 2017) our District's Health Department serves over 1.1 million residents. Gwinnett, our largest and most urban county, is the second-most populous county in the state of Georgia, and in recent decades, one of the fastest growing counties in the nation (Gwinnett Community Health Assessment-Community Health Improvement Plan, 2013). GNR serves a demographically diverse population, with a community that encompasses urban, suburban and rural areas. Fourty-seven percent of the community identifies as White, 38% Black, and 12.5% Asian. Gwinnett County contains 19% of the state's Hispanic population (Oasis, 2017).

The CDC estimates that 48 million people are ill annually as a result of foodborne contaminants. Although most of these individuals recover, 128,000 are hospitalized and 3,000 die (CDC Food Safety, 2018). The trickledown effects of these morbidities are estimated to be quite significant. The U.S. spends $7 billion annually for food safety incidents (Hussain & Dawson, 2013). Additionally, productivity is affected when ill individuals stay home from work or school, or remain in these settings, exposing others (Newman, Leon, Rebolledo & Scallan, 2015). From 1998-2004, most foodborne disease outbreaks identified by the CDC were associated with restaurants (Angulo & Jones 2006).

GNR regulates 2,887 food service establishments. From January to November 2018, GNR received 127 food and waterborne illness (FBI) complaints. Year to date, this is a 39.4% increase of FBI complaints. During this time, GNR also identified 8 confirmed or probable foodborne illness outbreaks. When there is an FBI event at GNR, Epidemiology investigates the illness, advising Environmental Health (EH) on possible disease etiologies and potential routes of transmission. EH conducts facility inspections, educates, advises, and with their regulatory authority, enforces compliance to the requirements laid out in the Georgia Food Code. Without this cohesive approach, gaps during investigations exist. The goal is to conduct the most thorough foodborne illness investigations and to educate the communities we serve in order to minimize the spread and severity of foodborne illnesses in our district.

The objectives are: 1. To establish a systematic approach to addressing foodborne illness reports from community members that incorporates measureable outcomes 2. To increase collaboration between Environmental Health (EH) and Epidemiology staff 3. To identify and adequately address specific risk factors that may expose community members to illness or injury. Prior to implementation of our collaborative approach, the roles of both departments concerning food and waterborne illness investigations were often unclear. Epidemiology sometimes discussed regulatory issues with facilities, and EH interviewed individuals about their illness. In 2007, leadership saw the need to delineate these roles. An Environmental Epidemiology (Epi) internship was created to improve cohesion between the two departments, especially when investigating outbreaks and illnesses associated with regulated facilities. The internship proved successful and evolved into a full-time salaried position in 2009. This was the first Environmental Epi position in the state of Georgia. Based on the success of the program developed in GNR, a nearby district mirrored these efforts to enhance collaborative investigations. Part of this collaboration included the development of a Foodborne Illness Complaint Line, created in 2008. Individuals who become sick after eating at a regulated facility, swimming in a regulated pool or visiting a regulated tourist accommodation can call and report their illness to Epidemiology. Epidemiology attempts to interview complainants within 8 business hours, review illness information and refer to EH staff with recommendations.

GNR's EH program fulfillment of all 9 standards for the Food and Drug Administration's Voluntary National Retail Food Regulatory Program in 2018 was a recent milestone. This was a monumental accomplishment, as GNR is one of 5 local health departments in the nation who have achieved this standardization. All objectives in this practice were met. Epidemiology and EH report details of shared foodborne illness investigations into an online system called the Digital Health Department. The environmental Epi attends monthly Environmental Health meetings. Epidemiologists shadow inspectors during restaurant, pool and hotel inspections as part of their training. An annual educational symposium has been in place since 2011, where both departments are cross-trained.

Leadership's determination, support and excellent intradepartmental communication continue to lead to the practice's success. The Public Health impact of this practice is vast, but specifically this practice protects the health of the population served by reducing the spread of foodborne illness with quicker responses and clearer roles. Our website is

Our model practice of integrated response between Epidemiology and Environmental Health is not new to the field of public health, but it is a creative use of an existing practice. As the District's population grows, more regulated facilities are being built to accommodate the growth. Increased growth is associated with increased food and waterborne illnesses and the need to address the related circumstances. As both Environmental Health (EH) and Epidemiology play significant roles in food and waterborne disease investigations, understanding responsibilities, highlighting strengths and implementing collaborative investigation techniques are essential to limiting the spread of these illnesses and protecting our community's health. This model practice's target population includes anyone who lives in or visits our district and utilizes a regulated facility. The practice reaches anyone who uses products and services offered by our district's regulated facilities. It's difficult to say exactly what percentage has been reached. However, a 2016 Gallup poll analyzing how frequently Americans dine-out showed that 61% of Americans ate out at a restaurant at least once within the last week.  Assuming a similar trend within our district, approximately 671,000 people are affected by this practice, weekly. Studies have shown that foodborne illnesses are dramatically under reported by consumers in the United States (Arendt, et al., 2013). The CDC recognizes the challenges that exist for foodborne disease surveillance and outbreak detection as a result of this underreporting. Although there is no way to quantify the precise amount of residents or visitors who have gotten ill after eating at regulated facilities in our district, our practices are designed to more quickly identify existing issues.

In the past, food and waterborne illnesses were addressed separately by EH and Epidemiology. EH received the calls and interviewed complainants about their experience with the facility; this would include information about what they ate, when they ate and their subsequent illness. EH would then conduct an investigation of the facility involved. Epidemiology would usually only get involved when an outbreak or cluster of illness was identified. The current practice is an improvement on pre-existing programs because it allows for a more cohesive approach to investigating outbreaks and illnesses associated with regulated facilities. It streamlines the food and waterborne illness reporting process, so that all reports and investigation responsibilities are being filtered through one position. This approach is recommended by the Council to Improve Foodborne Outbreak Response (CIFOR) Guidelines for Foodborne Disease Outbreak Response, section 4.3. The approach limits gaps in food and waterborne illness investigations by increasing the probability of detecting patterns among complaints that could be linked to an outbreak. For example, in February of 2018, Epidemiology received several complaints of illness among individuals who ate at a restaurant while celebrating Chinese New Year. Some of the individuals affected reported illness independently of each other and over the span of a couple of days. Epidemiology was able to quickly identify the outbreak and provide EH with the information needed to initiate a facility inspection. EH inspections identified multiple foodborne illness risk factors. Stool samples identified Norovirus as the responsible pathogen for these illnesses.  Both Epidemiology and EH helped control further illness through investigation, education and regulation. If multiple individuals were responsible for the initial response to these reports, identifying this outbreak may have taken much longer causing delays in implementation of mitigation measures to reduce the spread of illness. This practice is also important for identifying much smaller outbreaks. In May of 2018, multiple individuals from two separate households reported illness to Epidemiology after eating a peanut butter and chocolate flavored frozen dessert from the same facility. These complaints were made just two days apart. This pattern may have been missed without a centralized reporting process. Having an Environmental Epidemiologist also limits opportunity for miscommunication and duplication of investigation efforts.

This practice is innovative.  In 2007, when this idea was conceived, there were no other Environmental Epidemiologists (Epi) who operated locally or in this capacity in the state of Georgia.  Soon after this position was created, a nearby county in the metro Atlanta area modeled an Environmental Epi position after GNR's position. In 2012, GNR's Epidemiology and Environmental Health presented on the Collaborative Efforts to Control Foodborne Disease Transmission at a conference hosted by the National Environmental Health Association (NEHA). Environmental epidemiology, as it relates to possible links between environmental exposures and chronic disease, has existed for decades, often focusing on large populations and wide scale contamination of the environment. Environmental epidemiology as it relates to the inter-reliance between local environmental health and epidemiology during food and waterborne illness investigations is a relatively new concept not commonly addressed in the literature. The model practice was organized within the framework prescribed by CIFOR Guidelines for Foodborne Disease Outbreak Response, published in 2009 and edited in 2014. These guidelines were designed to help standardize how foodborne illness investigations were managed across the United States. CIFOR offers a useful toolkit, which provides a resource where users can become familiar with roles and responsibilities of each team member, facilitate communication, and engender team-building in the process” (CIFOR, 2009). CIFOR highlights four major tracks that collectively make up the most important parts of outbreak response activities. These areas are Planning and Preparation, Foodborne Disease Surveillance and Outbreak Detection, Investigation of Clusters and Outbreaks, and Control Measures. GNR used this outline as a guide to stipulate roles and departmental interactions during an investigation. GNR's aspiration to align with the Food and Drug Administration's Voluntary National Retail Food Regulatory Program Standards also played a role in developing this model practice. At the time, FDA's Standard 5 was used as a programmatic guide for what foodborne illness and food defense preparedness and response should look like. Developing the Foodborne Illness Complaint Line was an essential part of achieving this FDA standard. This practice utilizes two evidence-based references each citing model practices for regulatory retail food programs. CIFOR's Guidelines for Foodborne Disease Outbreak Response discusses model practices for notification and complaint systems. The guidelines encourage use of similar practices during outbreak investigations. Their recommendations are based on previous experiences resulting in successful investigations (CIFOR, 2014). Our model is also within the parameters of The FDA's Voluntary National Retail Food Regulatory Program Standard #5. These standards were developed by the FDA through ideas and input from federal, state and local experts in the field. 

The goal of this collaborative practice between Epidemiology and Environmental Health is to reduce the burden of food and waterborne disease on residents and visitors to our community.The objectives of our program include: establishing a systematic approach to addressing foodborne illness reports from community members that incorporates measureable outcomes such as improving response times to complaints; increasing collaboration between Environmental Health (EH) and Epidemiology staff; and identifying and adequately addressing specific risk factors that may expose community members to illness or injury. In 2007, GNR leadership took the first steps to stream line our process for responding to foodborne illness complaints by creating a three-tiered food service investigation algorithm. This algorithm outlined general risk, intermediate risk, and immediate risk categories with corresponding investigation response times ranging from three business days to within two hours. It was observed that Environmentalists interviewing complainants did not have the same level of disease knowledge as Epidemiology staff.To utilize the strengths and expertise of epidemiologists, it was established that all illness-related food or waterborne disease complaints would begin with Epidemiology, allowing a subject matter expert to provide guidance to Environmental Health before starting a field investigation. No additional staff or funding was required to implement this procedure, and with updates occurring as needed, this algorithm remains the backbone of our complaint response efforts. Between 2007 and 2008, department leadership took steps to build upon the response algorithm by establishing both an independent foodborne illness complaint phone line as well as a locally-funded Environmental Epidemiologist (Epi) position designed to be a liaison between both departments. Our local foodborne illness complaint line, or 770-339-4BUG, is the first and only one of its kind in the state of Georgia. All illness related calls are sent directly to this phone line by front office staff, and callers are encouraged to leave a detailed voice message with the name and location of the restaurant as well as their contact information. The number is also advertised through social media and on the District's website. The voicemail box is monitored throughout the day for new messages, and epidemiologists are required to respond to all callers within 8 business hours of receipt. Callers are asked a series of prepared questions with standardized forms for tourist accommodation, food service, or swimming pool exposures. In accordance with the Council to Improve Foodborne Outbreak Response or CIFOR's model practices, forms include a 5-day food history and are designed to capture data on a variety of community exposures including untreated water, pets or farm animals, contact with highly susceptible populations, and private events. All foodborne illness complaints are tracked separately from routine EH complaints, allowing Epidemiology to identify commonalities among multiple reports. Complaints of group illness (2 or more ill) are treated as an outbreak, and Epidemiology attempts to collect clinical specimens from ill individuals as well as arrange for food to be held for possible testing if warranted.In CIFOR's Guidelines for Foodborne Disease Outbreak Response 2014, their model practice for a complaint system includes making the reporting process as simple as possible for the public.” The foodborne illness complaint line established by our district is a budget-friendly approach to this model practice which required only the cost of an additional phone line and some initial staff training. Finally, the creation of the Environmental Epi position within the Epidemiology department was an innovative and novel solution to eliminate issues in the duplication of investigation efforts and to cover the substantial amount of work required to address the burden of foodborne and waterborne disease reported in our community. In 2017, our district received 377 reports of laboratory-diagnosed foodborne and waterborne diseases with the majority of those illnesses being Salmonella and Shigella. In accordance with Georgia Department of Public Health guidelines and the Georgia Food Code, Epidemiologists must facilitate follow up testing of food service workers and as well as daycare workers and attendees diagnosed with certain foodborne illnesses. This testing process may take weeks and requires a substantial amount of time, materials, and transportation. In addition, GNR receives approximately 100-150 human illness complaints annually and either coordinated or contributed to 29 foodborne or waterborne outbreak investigations in 2017.

In the state of Georgia, each health district receives state funding for one local epidemiologist position tasked with investigating over 70 notifiable disease conditions. Establishing the Environmental Epi position has an added benefit of freeing the District Epidemiology team to focus on other morbidity investigations such as Rabies, Meningitis, or Pertussis. Utilizing funds generated from EH fees, Environmental Health is able to support this position at a salary comparable to a mid-level EH specialist position. The Environmental Epi attends monthly EH staff meetings, participates in EH trainings and events, pursues EH certifications such as the REHS, and connects EH staff to state resources including laboratory support for food specimen testing. Former employees who have trained and worked in this position have continued their work in the field of Public Health, serving communities in the metropolitan area as well as statewide. GNR has had great success with hiring Environmental Epidemiologists who have a Masters in Public Health, excellent communication and customer service skills, and a positive, resilient attitude. In Health Departments where the level of foodborne disease is not as substantial, it may be possible to create a hybrid position where the Environmental Epi is also standardized to conduct facility inspections. The time frame for implementation of these model practices is dependent on internal Health Department objectives and procedures, but it is important to begin with stakeholder support from leadership, Environmental Health, Epidemiology, Communications, as well as the Board of Health or governing entity.

Communications is an essential stakeholder. Communications staff are able to share messaging with community members about reporting foodborne illness, to disseminate food safety information during outbreaks, and to provide clear instructions on what to do or where to go during bioterrorism events involving contaminated food or water. Communicators are experts at leveraging social media, an increasingly common method of reporting illness. In 2018, epidemiology received 35 reports of illness online compared to 8 in 2017. (For now, our foodborne illness complaint line remains the most common way we receive illness complaints.)

The following section describes the quantitative and qualitative measures used to evaluate the success of our integrated Epidemiology and Environmental Health practice.

Objective 1: Establish a systematic approach to addressing foodborne illness reports from community members that incorporates measureable outcomes.

Between 2008 and 2009, Environmental Health (EH) began routine auditing of program data with an emphasis on quality assurance. This process would eventually lead to the EH quality assurance team, a group of experienced inspectors responsible for training new staff members and ensuring current staff complete and maintain their standardization.With the establishment of the three-tiered food service investigation algorithm, response times to complaints were also monitored. By 2011, the Health Department began the five-year process of becoming nationally accredited through the Public Health Accreditation Board. The efforts surrounding accreditation, successfully completed in 2016, lead to formalized tracking of complaint response times within the Epidemiology department and highlighted the data already being collected by EH. For the last five years, Epidemiology has responded to over 95% of foodborne illness complaints within 8 business hours of receipt. Putting this in historical perspective, in 2006 the average time between complaint receipt and the first attempt to contact the complainant was 2.3 days. In 2017, the average response time was less than 1 day, often within hours of receipt. Through a series of annual data reviews conducted by the Environmental Epidemiologist (Epi), it was observed that complaints that were called more than 8 hours after receipt were being received through the contact form on our website. To address this issue, department leadership created redundancies in the number of people receiving these online messages as well as redundancies in who receives notifications of illness reports in their email inbox. In addition, the variable report type” was added to Epidemiology's data collection spreadsheet to facilitate tracking of trends in reporting source.

Objective 2: Increase collaboration between Environmental Health (EH) and Epidemiology staff.

In 2017, our EH department became one of only five programs in the country to complete all nine FDA Voluntary National Retail Food Regulatory Program Standards. The Retail Program Standards define what constitutes a highly effective and responsive program for the regulation of foodservice and retail food establishments. The completion of these standards is the best indicator that we have met our objective. Having developed a culture of collaboration between EH and Epidemiology and through using evidence-based models, the documentation required to complete Standard 5 focused on Foodborne Illness and Food Defense Preparedness and Response, was easily accessible and required only minimal alterations and updating before submitting for review. As an example of this collaboration in action, in 2016, the Environmental Epi received a report of an outbreak of gastroenteritis among residents of a memory care and assisted living facility. During the initial investigation, it was revealed that a large family dinner had been hosted the day prior to the first reports of illness and that symptoms, onset, and duration of illness were consistent with norovirus. The Epidemiologist immediately reported this suspect norovirus outbreak to the county EH manager who arranged for an Environmentalist to complete a full inspection of the permitted kitchen within 7 business hours of notification. Epidemiology requested that the Environmentalist investigate a list of potential risk factors most commonly associated with norovirus transmission based on the International Association for Food Protection's Procedures Keys. During the on-site inspection, the Environmentalist observed and ultimately corrected violations related to barehand contact with ready to eat foods, improper storage of employee food items, inaccessible hand sinks, and inadequate levels of chemical sanitizer in the dishwashing unit.In addition, Epidemiology and the EH manager co-lead a disease control training and walkthrough of the facility. Epidemiology was able to collect specimens from ill residents resulting in norovirus as the confirmed etiology, and the facility was successful in halting the spread of the virus within their community.Though outbreaks of norovirus in institutional facilities are extremely common, the level of response to them by our Epidemiology and Environmental Health team is unique. In 2017, the Georgia Public Health Association, in recognition of GNR's outstanding outbreak response efforts, presented the epidemiology team with the Sellers-McCroan award for excellence in Epidemiology functionality. Seeing the success of our collaborative program and realizing the potential of the Environmental epi, a sister health district in our metropolitan area created a similar position, which they have maintained since 2012. This district has also met Standard 5 of the FDA Retail Program Standards, further emphasizing the value of this unique role.

Objective 3: Identify and adequately address specific risk factors that may expose community members to illness or injury.

The CDC National Outbreak Reporting System or NORS is a nationwide database of foodborne and waterborne outbreaks and their contributing factors.In 2016, NORS recorded 41 outbreaks for the entire state of Georgia with 1,431 related illnesses. Unfortunately, this database does not publish county-level data, which is crucial for local community assessments and for internal program evaluations.Thus, our district has prioritized management of our primary data sources, especially inspection, food safety complaint, and foodborne illness report data. At an annual team-building event held for Epidemiology and Environmental Health, the Environmental Epi conducts a data review that covers laboratory-confirmed diseases reported by healthcare providers, outbreak investigations, and foodborne illness complaints. Between 2016 and 2018, some of the most common violations recorded by Environmentalists during a foodborne illness complaint inspection included improper cold holding, hot holding, cooling, storing food in a way that risks contamination, and failing to separate and protect raw meats and seafood. Each of these unsafe practices can contribute to the proliferation and transmission of harmful foodborne pathogens, and though only 30-40% of foodborne illness investigations result in the identification of food code violations, it is clear that our Environmentalists are finding and addressing high risk food safety issues during complaint investigations. Besides foodborne illness complaints, Epidemiology and EH can also identify and eliminate hazards in the community through routine notifiable disease investigations and outbreaks. In this section, we describe three recent examples of integrated food and waterborne disease investigations.In 2017, Epidemiology discovered through routine interviews that two residents with Legionella infection had reported attending the same fitness facility in the two weeks prior to their illness. As Legionella cases are somewhat rare and common exposures between cases even rarer, Epidemiology and EH took immediate action by meeting with the facility the same afternoon the outbreak was identified. Epidemiology and EH met with facility leadership and requested that the facility voluntarily close all recreational water areas as well as all showers. The facility complied and hired a consultant experienced in Legionella remediation. This was the first documented Legionella outbreak in GNR history. EH and Epidemiology conducted extensive research into Legionella remediation, reviewing guidance from CDC, OSHA, ASHRAE, and even recommendations used in the European Union to improve their knowledge base. Using this research and state guidance, Epidemiology created written recommendations for the facility focused on remediation and environmental testing. Facility leadership, the consulting company, and representatives from EH and Epidemiology met to discuss the remediation plans and completed a walkthrough of the building. A thorough environmental assessment of the building was conducted during that time using a CDC tool. The presence of experienced EH staff and their expertise in maintaining swimming pools and spas was essential to this investigation as it was later revealed that both the facility's men's and women's hot tubs were positive for Legionella contamination. The facility continued to comply with all health department recommendations and even commended the health department staff on their customer service during the outbreak. No additional Legionella cases were reported associated with this outbreak. This investigation, and the model of collaboration between Epidemiolony and EH was presented in a nationwide NACCHO webinar in May, 2018. In 2018, Epidemiology received a report of a resident diagnosed with Listeria infection at a local hospital. During a routine interview, the resident revealed she consumed head cheese, goat sausage, and stew made with goat's meat and blood from a vendor selling butchered meat products from his home. In the state of Georgia, butchers are regulated by the Georgia Department of Agriculture (GDA).As local Epidemiology does not work closely with GDA, Environmental Health stepped in to make the appropriate introductions with local GDA investigators specializing in illegal meat sales. Epidemiology shared their findings with the investigators who responded immediately. GDA was able to observe and document the illegal sale of food products at the vendor's home. They seized 253 pounds of product, issued a Stop Sale notice, and tested the suspect food items for Listeria and Salmonella (all negative). Finally, the partnership between our programs has improved our ability to address ever larger, more complex outbreak investigations involving multiple retail food facilities and requiring ongoing communication with the general public. Also In 2018, Epidemiology received a report of gastrointestinal illness following a private event with over 200 attendees. A local deli and catering company, as well as a local restaurant and a bakery, served food and beverages at the event. Epidemiology worked very closely with EH through the investigation to re-create menus, identify suspect food items, conduct analyses, and provide daily updates on the ongoing reports of illness. Environmental Health conducted outbreak-specific inspections of the permitted facilities and reported their findings to Epidemiology almost daily. Through their partnership with GDA, EH was able to discuss the food process flow with the bakery owner and verify the eggs they used were not part of a recent Salmonella recall. Environmental Health noticed several risk factors within the local deli that can be associated with the proliferation and spread of Salmonella. These included improper storage of equipment used to cook raw chicken, inadequate access to hand sinks, and the storage of raw meats including chicken in proximity to fresh, unwashed produce. All these violations were addressed on site by the Environmentalist and the facility owner, but Epidemiology continued to receive reports of Salmonella associated with the restaurant, some independent from the original private event. Environmental Health and Epidemiology requested the restaurant close for an intensive deep cleaning as well as staff education, and the restaurant complied. This outbreak received a substantial amount of media attention, and both departments advised the GNR communications team on press releases updating the general public about the investigation. Following this closure, no additional cases of Salmonella were reported in this outbreak and the restaurant continues to be monitored by EH. In total, 95 illnesses were reported with the majority attending the original private event. Utilizing the information gathered by EH in the field along with information gathered through standardized questionnaires, Epidemiology determined that chicken was a statistically significant food exposure in this outbreak though all food specimens tested negative for Salmonella. The success of these investigations, whether due to a single case or a hundred, highlight the capability of our EH and Epidemiology teams to identify, respond to, and prevent foodborne disease risk factors in our community.

By implementing this collaborative practice, it has reduced the duplication of efforts and defined roles of Environmental Health (EH) and Epidemiology by bringing in skill sets from both disciplines.  Working as a team instead of operating independently, foodborne illness investigations are now captured and investigated in a timely manner.  Each department utilizes the other's guidance to ensure all aspects of the investigation are maintained and followed through until abatement.  We quickly realized the value of bringing the two disciplines together. Without Epidemiology's guidance, EH did not have a clear picture of what areas to focus on during their on-site investigations.  Without EH's guidance, Epidemiology did not have a clear picture of what issues in food service facilities posed the greatest threat to restaurant customers.  By both EH and Epidemiology depending on one another, a clearer picture emerges.  This is a huge benefit to our community.  As a team, we are able to quickly respond to an incident, help provide guidance to all parties involved, ensure the root cause of the issue has been reduced and/or eliminated, and provide our community a sense of protection. Some additional keys to the success of our program included allowing the Environmental Epidemiologist (Epi) access to create and record foodborne illness complaints within the online EH inspection management system. Having a one-stop repository for all notes related to a complaint made it simple for both Epidemiology and EH to complete their assigned tasks within the investigation. It also gave both parties a better understanding and appreciation for the work of the other discipline. Having regular face to face communication at monthly EH meetings has also significantly improved the relationship between both departments. The Environmental Epi has time allotted each month to share program updates and answer EH questions. EH is also able to share upcoming trainings, new projects or grants, new processes, and discuss their challenges and success stores while in the field. GNR's decision to develop a collaborative effort between EH and Epidemiology not only increased our availability to customers, but also allowed for enhanced targeted disease investigation without a significant financial impact.  Standard Environmental Health annual fees were adjusted and budgeted to cover the cost of the Environmental Epi position.  To receive buy-in from our stakeholders, District leadership approached the Board of Health members and explained to them that the newly proposed fee schedule did take into account the cost for this position.  The cost of the increase was an average of $20 per permit and is sustainable because our permits are renewed annually.  This action secured our funding to cover the new position indefinitely.

The Environmental Epi position has been extremely well-received by Board members and the District leadership continues to support this practice. The fees charged for our services are funded through our regulatory mandates and not through outside funding sources.  They are included in the cost of doing business.  With this being the case, our stakeholders are more than willing to keep the new Environmental Epi position intact. Our sustainability plan is fairly simple. The processes and procedures put in place for foodborne illness complaints require no additional funding and will continue to be evaluated annually for areas of improvement. Measures involving complaint response have been included in the district-wide strategic plan, further formalizing the quality improvement process originally established by EH ten years ago.  To sustain the Environmental Epidemiologist position, EH made sure that the funding source for this position was included in the annual fees required to renew a food service permit.  Finally, the program will continue to evolve in response to new and emerging community threats such as Legionella outbreaks or the rise of tickborne disease in the United States.  Collaboration to enhance education to empower owners of regulated facilities and customers is a future goal of both departments. To maintain their standardization, Environmental Health must continue to make updates and improvements to their program as the FDA Retail Food Program standards also change.  We are looking forward to the future evolution of this collaborative practice and believe other health departments can benefit greatly from implementing one or more aspects of this approach.

Sources Cited:

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Newman, K. L., Leon, J. S., Rebolledo, P. A., & Scallan, E. (2015). The impact of socioeconomic status on foodborne illness in high income countries: A systematic review. Epidemiology Infectious Disease, 143(12): 2473–2485; doi:10.1017/S0950268814003847

Angulo, F. J. & Jones, T. F. (2006). Eating in Restaurants: A Risk Factor for Foodborne Disease? Clinical Infectious Diseases, 43(10): 1324–1328;

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Arednt, S., Rajagopal, L., Strohbehn, C., Stokes, N., Meyer, J. & Mandernach, S. (2013). Reporting of Foodborne Illness by U.S. Consumers and Healthcare Professionals. International Journal of Environmental Research and Public Health, 10(8): 3684–3714; doi: 10.3390/ijerph10083684

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NACCHO Website