Foodborne Illness

1
Foodborne Illness

• Tabletop Exercise

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sustainable environments.
2
Exercise Orientation

• Rules of Play
• Dont fight the scenario.
• Actions must be documented.
• Use only resources you actually have.

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sustainable environments.
3
Exercise Orientation

• Assumptions
• Some actions have already been taken for you in
  order to facilitate the exercise.
• You dont know any of these folks in the video
• Data Collection
• Please appoint a scribe to take notes for your
  table. This will be essential to getting a good
  after action report.
• Please complete your Participant Evaluation Forms
  before departing.

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sustainable environments.
4
Exercise Objectives

• Objectives of the exercise include
•     Discuss the overall management of a
  large-scale foodborne illness outbreak involving
  vulnerable populations.
•        
•     Determine the capability and capacity of
  local entities to collect food and human clinical
  samples for testing during a large-scale
  foodborne outbreak.
•     Discuss the coordination needed among
  response agencies for a successful investigation
  including compliance with HIPAA requirements.
• Determine the ability of hospital response
  partners to respond to and coordinate a surge of
  patients suffering from a serious foodborne
  illness.

March 28, 2008. 800am
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5
Background

• Your community, along with others in the area,
  is undertaking an effort to go green. Several
  initiatives are underway at local schools as
  students study energy conservation and organic
  farming. One local school, Lightning Elementary,
  has numerous projects in progress and has
  registered themselves on the GoGreenInitiative.com
  website. Projects include replacment of
  existing lighting sources with longer lasting
  energy conserving bulbs, inclusion of at least
  one organic vegetarian option in the school lunch
  menu, creation of a compost bin for food scraps
  and yard waste, and recycling of materials such
  as newspapers, plastic bottles and aluminum cans.
  
• This year the elementary school principal, Mr.
  Kelvin, made a decision to obtain meat, milk and
  produce from a nearby organic farm. This
  business, Pauls Organics Only Products (POOP) is
  a new enterprise to the area but has been able to
  garner business with area hospitals, day cares,
  schools, and nursing homes. POOP has been
  providing food to Lightning Elementary since the
  beginning of the school year.

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sustainable environments.
6
Background

• The local hospital occasionally buys food from
  Pauls as well. Pauls is appropriately
  licensed and has passed all initial inspections
  although a recent complaint was substantiated
  about inappropriate storage of animal based
  products with vegetable products during
  transport. There have also been unsubstantiated
  reports of refrigeration issues with products
  during transport.

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March 28, 2008. 800am

• The hospital is at 80 occupancy with patients
  who have a respiratory illness. Mockingbird
  Manor, the local SNF, has had a small outbreak of
  seasonal influenza this year and you are dealing
  with those residents hospitalized with pneumonia
  and other complications. The local health
  department is following the patients at the Manor
  closely for signs of respiratory illness.
  Mockingbird Manor has 63 residents and 48 staff
  members.

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March 28, 2008. 1030am

• The kids are back in school after a wet and cold
  spring break. Principal Kelvin notes in this
  mornings records that a total of 8 students in
  the 1st and 2nd grades are out ill. While the
  absentee rate is usually a little higher the week
  after spring break, he finds this unusual and
  phones the school nurse. Lightning Elementary
  houses grades 1 through 5 and has approximately
  100 students.
• The ill students are
•  
• Benjamin Bond Grade 1
• Brandon Bond Grade 1
• Patsy Peterman Grade 1
• Mikey McNulty Grade 1
• Kyle Kelly Grade 1
• Mason Moore Grade 2
• Gretchen Gibbons Grade 2
• Corey Chase Grade 2

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Questions

• Did Principal Kelvin take the correct action?
•  
• What, if anything should the school nurse do in
  response to the call?
•  
• What triggers does your jurisdiction use for
  reporting unusual numbers of ill students? Is
  the reporting requirement illness dependent?
•  
• Are protocols in place that require absenteeism
  reporting for schools, businesses, others?

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March 28, 2008. 130pm

• The school nurse phones the parents of the
  students to gather more information. She also
  talks to the 1st grade teacher, Miss Current to
  see if any other students are ill today. After
  interviewing the parents she places a phone call
  to the local health department with the following
  information
•  
• We have 8 students ill today and I was able to
  talk to the parents of 6 of those students. I
  left a message for the other parents to call back
  but havent heard anything yet. All of the kids
  are in either the first or second grade and have
  a GI illness. Most have vomited once or twice
  and several have had diarrhea during the night.
  Mrs. Peterman says her little girl Patsy has a
  fever of 100.3 but none of the other mothers
  mentioned a fever when I talked to them.
  Principal Kelvin thinks maybe a virus is going
  around and we wanted to let you know. Miss
  Current the teacher says that the kids are having
  a hard time adjusting to school again after the
  break.

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Questions

• What questions would you have for the school
  nurse?
•  
• What next steps will need to be taken by the LHD?
  
•  
• What next steps will need to be taken by the
  school?
•  

12
March 28, 2008. 230 pm

• The local hospital receives a call that EMS is in
  route with a patient from Mockingbird Manor, the
  local skilled nursing facility. The patient,
  Aaron Adams is a 91 y/o male to be admitted with
  N/V x 2 days, diarrhea x 2 days and general
  malaise. They have physician orders to admit for
  assessment and rehydration.
•  
• Summary Patient is an 91 y/o white male patient
  named Aaron Adams with a c/c of N/V x 2 d and
  diarrhea x 2d. He has a history of prostate
  cancer, and hypertension. On a daily basis he
  takes digitalis, Lotrel, MOM, Clonapine, ASA,
  Tylenol (PRN) and Ativan (PRN). Mr. Adams is
  currently taking OTC Imodium. His temp is 100.5,
  resp 30, and p 112. In the ER, the MD orders
  CBC, Chem 6, blood cultures X 3, UA, and Urine
  culture. The patients physician is Dr. John
  Hick. On admission, Mr. Adams describes his
  pain level at 8 on a scale of 10. He voices the
  opinion that it was something he ate.

13
March 28, 2008 330 pm

• Principal Kelvin tells local health officials
  that the menus are abbreviated last week because
  its GoGreen week. The 4th and 5th grades went
  on a field trip to the nearby wind farm on Monday
  and werent back for lunch, and the 3rd grade had
  a pizza party on Monday with the money they
  earned from selling aluminum cans from their
  GoGreen project. The 1st and 2nd grades have a
  special sack lunch picnic at the library today.
  He says he can fax the lunch menus over if you
  want.

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Questions

• What important information is contained in the
  menus?

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March 31, 2008 830 am

• Principal Kelvin calls the local health agency to
  report that ½ of the first and second grade class
  is out ill. The parents who are calling in are
  saying that the kids are very sick and that they
  are really worried that there might be something
  contagious going around. He has received at
  least 7 calls from worried parents who are not
  planning to send their children to school until
  they know the cause of the illness and that their
  children are safe going to school.

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March 31, 2008 1115 am

The local health agency visits with Mrs. Gertrude
Gibbons, the mother of Gretchen Gibbons. The
Gibbons family has 4 children, Gretchen is 7,
Gregory is 5 and the twins are 2. The local
health agency representative learns that Gretchen
attends Lightning Elementary School and stays at
the Creative Learning Center after school with
her siblings. Gretchen started complaining of a
stomach ache this morning. She did vomit and
have diarrhea this morning. Mrs. Gibbons
indicates that she took her daughter to see her
physician this am. Gretchen didnt have a fever
and the doctor didnt take any stool cultures.
Gretchens mother indicates that she doesnt have
any pets or been around any other animals. She
eats at school everyday. Mrs. Gibbons tells the
local health department representative that
Gretchen hasnt been swimming lately and that she
takes only 2 medications. One for her ADHD and
she has an inhaler for her asthma.
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Questions

• What, if anything, concerned you about the
  interview? Risk factors for illness?
•  
• What additional questions would you have for Mrs.
  Gibbons?
•  
• What advise should Mrs. Gibbons be given
  regarding caring for her daughter?
•  

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March 31, 2008 320 pm

• The local health agency visits with Mr.
  Mitchell McNulty, the parent of Mikey McNulty.
  Mikey is an only child and he goes to Lightning
  Elementary school and stays at Miss Allens day
  care after school because both of his parents
  work. Mr. McNulty is a truck driver for Pauls
  Organics and his wife works at the local
  supermarket. The local health representative
  learns that Mikey started complaining of a
  stomach ache on Thursday night about 830pm.
  Mikeys father reports that he vomited twice that
  night and did have diarrhea. He is unsure how
  many stools his child had in a 24 hour period,
  but tells the health agency representative that
  it was more than 4. When questioned further
  about the diarrhea, Mr. McNulty indicates that
  there has been no bloody diarrhea, but it is very
  watery. Mikey doesnt have a temperature or
  any other complaints. No one else in the house
  is ill and Mikey hasnt yet been to see a
  physician. They dont have any sick pets but
  Mikey has been to his grandparents farm in the
  last week and they raise cattle. When questioned
  about medications, Mr. McNulty indicates that as
  far as he knows Mikey has had only Tylenol for
  his stomach ache. Mikey always eats lunch at
  school, but rarely eats out otherwise.

19
Questions

• What, if anything, concerned you about the
  interview? Risk factors for illness?
•  
• What additional questions would you have for Mr.
  McNulty?

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PHIX REPORT 3/31/08 930p

• To County Health, KDHE-BEDP, and Food Coalition
  PHIX UsersThe Kansas Department of Health and
  Environment (KDHE) and associated health
  departments throughout Kansas are investigating
  at least 6 possible foodborne disease outbreaks
  related to undercooked meat products and
  associated cross-contaminated foodstuffs. All
  outbreaks are confined to institutional
  populations including long term care facilities,
  prisons, day care centers, and hospitals.
  Approximately 100 persons from multiple Kansas
  counties have been affected. Patients
  initially report nausea, vomiting and diarrhea
  followed within 48 hours by fever and bloody
  diarrhea. At least 38 persons have been
  hospitalized. The causal agent has not yet been
  confirmed, but E.coli 0157H7 is suspected based
  on symptomology. Stool specimens are being
  collected. Bacterial and PCR testing will be
  performed at the KDHE laboratory.

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April 1, 2008 1000am

• The local food service inspector visits with
  Becca Bradford, the school cook prior to
  conducting an inspection of the kitchen. The
  inspector learns that the school regularly
  monitors the temperature of the coolers, but
  isnt as good at monitoring the temperatures of
  the hot food they serve. Most of the food at the
  school comes from 2 suppliers. SYSORG supplies
  all the dry goods and canned food and Pauls
  Organics now provides the fresh vegetables, meat
  and milk. The inspector learns that the school
  cook isnt very happy with Pauls Organics. She
  indicates that they frequently make substitutions
  and dont always have all the food they order.
  The inspector has been given the menus for the
  last week and asks about the hamburgers served
  last week. The cook says that they arrived the
  day they were served at approximately 1100 am
  and were frozen solid. When the inspector asks
  about the process for lunch, shes told that the
  first graders come first at 1130 am followed 10
  minutes later by the second graders and so on.
  
•  
• The cook says that leftovers are placed
  immediately in the refrigerator. She indicates
  that she and her staff eat after the children are
  through. They reheat the food after the
  dishwashers are started. The cook indicates that
  no staff members are ill.

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Questions

• What, if anything, concerned you about the
  interview? Risk factors for illness?
•  
• What items should the inspector review in her
  inspection of the kitchen?
•  
• What follow-up steps should be taken regarding
  Pauls Organics Only Plant?

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April 1, 2008 1030 am

• Mrs. Jacobs, the DON from Mockingbird Manor
  places a call to the local health department
  requesting assistance with a small outbreak of
  diarrhea among the residents. She reports that
  at least 10 residents on the west wing of the
  facility have had 4 or more loose stools in the
  last 24 hours. Four of the eight have a low
  grade fever and the staff isnt able to keep up
  with rehydration protocols. Mrs. Jacobs also
  reports that 3 staff members are out ill with the
  stomach flu. The ill staff members include
  Sandy Morgan, dietary aide from the evening
  shift Cora Johnson, housekeeping from the
  evening shift, and Pauline Morris, an LPN who
  works PRN. Mrs. Jacobs says shell fax over the
  names of the residents who are ill and she wants
  to know what she should do now? She says she
  can also send over the menus from last week if
  you think it will help.

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Questions

• What actions will the local health agency take to
  conduct the investigation?
•  
• What partners will be involved in the
  investigation?
•  
• One person from the local health agency should
  place a call to the control cell at 785-296-8605
  to conduct an interview of an ill resident, Mrs.
  Violet Van Veen.
•  

25
April 1, 2008 930 pm

• Mockingbird Manors evening shift RN calls the
  hospital to report that the local physician
  assistant, Patti Pierson has been over to visit
  the residents who have the stomach flu and she
  has decided to admit 6 of the 8 for rehydration
  and follow-up. The RN says shell call EMS for
  transport, but the Manors van will be bringing
  over some of the residents as well.
•  
• The arriving patients are
•  
• Summary Arthur Andrews Patient is an 83 y/o
  white male with a cc of N/V and diarrhea x 2d
  with subsequent dehydration. He has a history of
  chronic active hepatitis, alcoholism, and BPH.
  He had a CABG in 2000. On a daily basis he takes
  coumadin, antabuse, Senacot, Zoloft, ASA, and
  Tylenol (PRN). His temp is 101.2, resp 20, p 96,
  and B/P 128/90. In the ER, the MD orders CBC,
  Chem 20, UA, PT, and PTT
•  

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• Summary BethAnne Brady Patient is a 96 y/o
  white female, with a c/c of dehydration. She has
  a history of depression, hypertension, and lung
  cancer. On a daily basis she takes verapamil,
  digitialis, potassium, Lasix, Detrol, Paxil, MOM,
  and Tylenol (PRN). Her temp is98.4, resp 26, p
  100, and B/P 140/ 100 . In the ER, the MD orders
  CBC, Chem 6
•  
• The other patients all have similar complaints of
  nausea, vomiting, diarrhea and subsequent severe
  dehydration. They are Eileen Ellis (94 y/o),
  Fred Farkle (87y/o), Kathleen Kincaid (83 y/o),
  and Violet VanVeen (77 y/o).

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Questions

• What issues are you anticipating in admission of
  these patients?
•  
• What actions will the hospital take with regard
  to this many admissions from one LTC facility?
•  

28
April 2, 2008 945 am

• The local newspaper has contacted the hospital
  public information office and the local health
  department asking for an interview related to the
  ill children and the tainted meat.
•  
• Local Health Agency Inquiry The reporter
  indicates that she needs the local health officer
  to set the record straight about whether
  Principal Kelvin is liable for the poisoning of
  the children. She also demands to know how many
  additional cases are expected. She is interested
  in publishing a list of all the tainted foods in
  the local paper so the public will know their
  risk.
•  
• Hospital Inquiry The reporter indicates that
  she has been told that the hospital isnt able to
  perform the tests that are needed to diagnose the
  patients and that some have been sent to other
  hospitals and she wants to know if the public
  should be advised to seek medical care elsewhere.
  The reporter also shares a citizen hotline tip
  that patients who are better insured are
  receiving preferential treatment over those
  without insurance. She is specifically
  interested in talking with staff members and in
  following a patient case, perhaps a child,
  through the hospitalization process.

29
Questions

• Who at the LHD and hospital is responsible for
  answering these requests?
•  
• Please prepare a public information statement or
  statements regarding the outbreak.

30
April 2, 2008 200pm

• Calls from local physician offices regarding new
  admissions are piling up. Most of the patients
  have had bloody diarrhea for at least two days
  and the physicians are requesting admission for
  rehydration. At least 3 additional admissions
  are lightning elementary students who have begun
  to develop signs of Hemolytic Uremic Syndrome
  (HUS).

31
PHIX Notice 4/4/08 830am

• To County Health, KDHE-BEDP, and Food Coalition
  PHIX UsersThe Kansas Department of Health and
  Environment (KDHE) is advising consumers and food
  service workers that ground beef has been
  identified as the suspected pathogen in a series
  of E. coli 0157H7 illnesses, including the deaths
  of 8 children throughout the state. The ground
  beef, produced by Pauls Organics Only Plant for
  institutional settings with production dates from
  1/20/2008 through and including 3/1/2008 has been
  recalled. All outbreaks are confined to
  institutional populations including long term
  care facilities, prisons, day care centers, and
  hospitals. Any foods that contain the recalled
  products should be disposed of carefully.

32
April 4, 2008 100pm

• Pauls Organics Only Products has a state of the
  art computer system for delivery of products. It
  informs the local health officials that the
  recalled product was delivered to these locations
  within the jurisdiction
•  
• Local Hospital Cafeteria
• Elks Club
• Mockingbird Manor LTC
• Crystal Village LTC
• First Christian Church
• Boy Scouts of America Troop 303
• Marthas Dairy Bar
• Frenchs Bistro
• Lightning Elementary
• Washington Memorial Middle School

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Questions

• Who will be responsible for assuring the recalled
  products are removed from circulation?
•  
• What process will each entity have for
  determining if potentially contaminated food was
  served?
•  
• What additional steps need to be taken to
  complete the investigation?

34
Hot Wash

• What went well?
• What could be improved?
• What additional training / plans / exercises are
  needed?

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sustainable environments.
35

• Thank You for attending the exercise.
• Please complete your participant evaluation.

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sustainable environments.
36
www.kdheks.gov
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sustainable environments.