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Capella University

Outbreak Investigation Introduction

Laura Hernandez's Office Outbreak Detection and Notification

Generating the Hypothesis

Testing the Hypothesis

Investigation Results

Control and Preventative Measures

Conclusion

Introduction For this assignment, you will explore an outbreak occurring at St. Anthony Medical

Center, an urban hospital that is part of the fictional Vila Health health care system

simulation. You will work through the various media components and throughout

the six parts of the case study, there will be stop points where you will need to

answer questions posed to you. Your responses will consist of the body of the Unit

7 assignment. You will label the questions and responses on a Word document

and submit all the questions answered for this assignment.

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After completing this case study, you should be able to:

Describe the appropriate response to a potential foodborne illness complaint.

List disease categories to include in the differential diagnosis of an acute

gastrointestinal illness, given clinical information.

Outline a hypothesis on the source of an outbreak

Interpret epidemiologic study findings.

Identify information to include in an outbreak investigation report.

Describe the epidemiology e.g., occurrence, transmission, and control of an

infectious disease

Outbreak Detection and Notification One Page

Voicemail from Keith Olson Hospital Infection Control

Hello, Laura. I wanted to reach out to you and let you know that yesterday our long

term care unit as well as our labor and delivery unit reported an unusually high

number of gastrointestinal symptoms. Nearly all of the 26 persons in both wards

(16 in long term and 10 in labor and delivery) reported they were suffering from

nausea, vomiting, and diarrhea. All reported they had become ill during the night. I

just wanted to make you aware of this situation as the epidemiologist for our local

health department.

Answer these questions based on your observations At this point, what types of questions are you, the epidemiologist, beginning to

think about asking the infection control nurse at the hospital? IN the first part of the

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assignment, please prepare an exhaustive list of questions you are looking to ask

to ascertain additional information to assist you in your investigation, if one is

needed at all. Should this complaint/concern be investigated further? Why or why

not?

Generating the Hypothesis One Page

Email from State Health Department.

From: Sarah Perkins, State Health Department

Sent: Tuesday, February 12, 2015 12:20

To: Laura Hernandez

Subject: Follow-Up

Staff from both the hospital and your epidemiological section were skeptical of the

infection control nurse's report but felt that a minimal amount of exploration was

necessary. You contacted the State Health Department to determine if their staff

was aware of a problem. State Health Department staff reviewed the foodborne

illness complaint log to see if others from the hospital had reported similar

illnesses or exposures. Although a few reports of vomiting and diarrhea had been

received, no other recent complaints mentioned the hospital or involved references

to patients at the hospital.

State Health Staff then made a few telephone calls. The hospital, where the sick

complaints came from, noted on this day the cafeteria had been closed until 11:00

A.M., outsourcing breakfast and snacks to patients from a licensed caterer. A

subsequent call to the emergency room learned they had been flooded with a

waiting room full (15 patients and counting!) of persons complaining of acute

gastroenteritis in the last 24 hours. You pull the emergency room surveillance log

for the past month and only four patients had been seen for similar symptoms,

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none associated with the hospital. Stool specimens from initial 26 patients in the

two hospital wards had been taken and submitted to the in-house hospital

laboratory for enteric analysis. Results were not available at this time.

Voicemail from Dr. Henry Johnson East Side Outpatient Clinic

Hello Laura, it's about 2:30 P.M. This is Dr. Henry Johnson from East Side

Outpatient Clinic- I just wanted to inform you that I have 7 patients in my waiting

room complaining of nausea, diarrhea, and vomiting. I find it bizarre because I've

only seen 1 case like this in the past month and every single patient I've seen has

stated they have been to the hospital to visit family or friends or were employees of

the hospital.

Answer these questions based on your observations At this point, do you think these cases of gastrointestinal illness represent an

outbreak at the hospital? Why or why not? Please discuss. What is the criterion for

definition of an outbreak? What are the critical components of this definition? As

the health department epidemiologist, please list your next priorities and discuss

them in relation to the steps of this outbreak investigation.

Generating the Hypothesis Three to Five Pages

Email from the Hospital Infection Control Nurse.

From: Susan Jones, Infection Control

Sent: Tuesday, February 12, 2015 12:20

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To: Laura Hernandez

Subject: Patient Interview Results

Per your recommendation and request, I interviewed the 26 patients from the two

wards here using the forms you gave me and I've done some preliminary analysis

of the symptomology presentation. I will share those with you now:

24 persons (91%) reported vomiting

22 persons (85%) reported diarrhea

18 persons (70%) reported abdominal cramping

15 persons (60%) reported headache

13 persons (50%) reported muscle aches

1 person (5%) reported bloody diarrhea

The range of temperatures recorded was from 98.8°F to 102.4°F. We only have

about half (12 persons) of the complete blood counts, but I thought it was

interesting to note that all 12 of those tested so far had an elevated white blood

cell count of 13.7 units or higher {normal: 4.8 – 10.8 units}.

The laboratory is still trying to type the organism but it has been able to rule out:

Salmonella

Shigella

Campylobacter

Vibrio

Listeria

Yersina

E. coli O0157:H7

Bacillus cereus

Staphylococcus aureus

Parasitology screens were also negative. A few of the stool specimens tested

demonstrate fecal leukocytes and occult blood.

I will keep you updated as I get more information. Do you have anything to share

with me?

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Answer these questions based on your observations At this point, how might you respond to the infection control nurse with the

information you have so far? How would you interpret these preliminary laboratory

results? Where would you be focusing your next round of laboratory analyses on

(bacteria, virus, parasite, toxin/chemical)? What agencies need to be notified at

this point? As the health department epidemiologist, please list your next priorities

and discuss them in relation to the steps of this outbreak investigation.

Feedback After some brief casework, you develop the epidemic curve for this outbreak at the

hospital and it looks like this in a graph format:

Based on the epidemic curve and likely causative agent, what is the likely mode of

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transmission and the period of interest for possible exposures related to this

outbreak? What was the likely incubation length and day? What type of outbreak is

this called?

Feedback The hospital uses municipal water and sewage services. There had been no work

on water or sewage lines in the past year nor recent roadwork or digging around

the hospital. The hospital dining service included two cafeterias. The main

cafeteria served as the primary arena for all food storage, preparation, cooking

and delivery to 100% of patients in the hospital. Visitors also ate at this main

cafeteria. The specific facilities within the main cafeteria served hot entrees, a grill,

deli bar, and salad bar. A second smaller cafeteria at the hospital offers menu

selections with a per item cost and predominantly is used by hospital staff.

Under the advisement of your State epidemiologist, you begin interviewing the sick

hospital patients to better understand the likely source of the outbreak. Among the

20 patients interviewed (6 had been discharged and were no longer at the

hospital), 25 had eaten food from the deli bar; 9 had eaten food from the salad bar,

and 3 from the grill. Seven-day food histories revealed no particular food item that

was common to all or most of the patients. It was also noted in the labor and

delivery ward that none of the newborns were exhibiting symptoms.

Given this information, what is your leading hypothesis on the mode of

transmission in this outbreak? What studies or other investigations would you

initiate to explore this hypothesis. Provide some descriptive epidemiology on the

nature of this outbreak and the likely culprit in terms of the epidemiological triangle.

As the health department epidemiologist, please list your next priorities and

discuss them in relation to the steps of this outbreak investigation.

Testing the Hypothesis Three to Five Pages

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Email from the Hospital Infection Control Nurse.

From:Brian Doyle, Director of Clinical Operations

Sent: Tuesday, February 12, 2015 12:20

To: Laura Hernandez

Subject: Thank You

Thank you, Laura, for continuing to investigate our unfortunate situation of

illnesses within our patient load here at the hospital. I want to let you know we are

willing to do whatever is necessary to assist your investigation to help determine

the agent and cause of this event. Per your recommendation, we are setting up

times and contacts with your staff to perform the three recommended lines of

investigation:

1. Laboratory studies to determine the causative agent,

2. Environmental health assessment of the hospital main cafeteria,

3. Epidemiologic study of patients still admitted at the hospital.

We have requested our clinicians to collect stool specimens from new cases of

vomiting and diarrhea; as well as bacterial cultures from patients seen in the

emergency rooms. Also, per your guidance, we have submitted stool samples of

those already sick from the initial phase of the outbreak and are shipping them to

the Centers for Disease Control and Prevention (CDC) for viral studies including

reverse transcription-polymerase chain reaction (RT-PCR). What else can we do

to assist you in this investigation?

Answer these questions based on your observations At this point of the investigation, what instructions would you give to health care

providers for the collection of stool specimens from patients? Include instructions

on how specimens should be collected, stored, and transported. Given that

investigators suspect a virus as the causative agent, what contributing factors are

likely to have played a role in this outbreak? What activities would you undertake

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during the environmental health assessment? What key areas should be explored

during interviews with the cafeteria food workers? As the health department

epidemiologist, please list your next priorities and discuss them in relation to the

steps of this outbreak investigation.

Investingation Results Two Pages

Voicemail from Karen Walker Staff Epidemiologist and Environmental Health

Specialist

Investigators toured the facility and obtained a list of the foods served at the main

cafeteria during the implicated period. Cafeteria staff was questioned about their

responsibilities such as the foods they handled, which meals they served, and

where they usually worked (e.g., deli bar, grill). They also were asked about use of

gloves, hand washing practices, work schedule during the week before the

outbreak, and if they had been ill. None of the food workers reported being ill in the

last two weeks. The cafeteria did not have a sick food workers policy.

An inspection of the main cafeteria food preparation area, equipment, and serving

line was unremarkable. Walk-in refrigerators and freezers were organized to

prevent cross contamination and maintained at appropriate temperatures. Food

preparation surfaces were clean and appropriately situated with respect to flow of

kitchen traffic. Steam tables on the serving line heated to proper temperatures.

Other equipment (e.g., meat slicer) was clean and in good working order.

The deli bar had its own refrigerator and preparation area. During mealtimes,

sandwiches were made to order by a food worker. Each day, newly prepared deli

meats, cheeses, and condiments were added to partially depleted deli bar items

from the day before (i.e., without discarding leftover food items). While the deli bar

was open for service, sandwich ingredients were not kept refrigerated or on ice.

The deli bar containers were not routinely cleaned. The refrigerator cooled only to

47°F. Water and ice from the cafeteria were collected to test for fecal coliforms.

Samples of leftover food were collected from the deli bar for bacterial cultures and

special viral studies at CDC. Stool specimens were requested from all cafeteria

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staff. Sir/Ma'am, what do you recommend for action at this time?

Answer these questions based on your observations At this point in the outbreak investigation, do you recommend shutting down the

deli bar? What about the cafeteria? What type of epidemiological study design

would you employ to assist in narrowing down the list of likely agents that may be

the culprit for food-borne illness? What steps in the outbreak investigation are

utilized in this phase of the investigation? Please report on this development.

Feedback We have completed the surveys of all ill persons and matched them with control

(case-control) study to assist in determining the food source causing the illness.

This data is reflective of patients and persons consuming meals at the hospital

from Day 0-1, which falls in line with the incubation period. Sir/ma'am, please

instruct me what we (as a health department) need to do next?

Exposure Ill Exposed/ Total Ill(%)

Well Exposed/ Total Well(%)

Odds Ratio

95% Confidence Interval

p-value

Exposure American Cheese

Ill Exposed Total Ill(%) 13/28 (46)

Well Exposed Total Well(%) 4/20 (20)

Odds Ratio 3.4

95% Confidence Interval 0.80-17.5

p-value 0.06

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Exposure Swiss Cheese

Ill Exposed Total Ill(%) 8/28 (29)

Well Exposed Total Well(%) 8/20 (40)

Odds Ratio 0.61

95% Confidence Interval 0.15-2.4

p-value 0.30

Exposure Ham

Ill Exposed Total Ill(%) 11/28 (39)

Well Exposed Total Well(%) 6/20 (30)

Odds Ratio 1.5

95% Confidence Interval 0.38-6.3

p-value 0.36

Exposure Turkey

Ill Exposed Total Ill(%) 15/28 (54)

Well Exposed Total Well(%) 11/20 (55)

Odds Ratio 0.95

95% Confidence Interval 0.26-3.5

p-value 0.57

Exposure Shredded Lettuce

Ill Exposed Total Ill(%) 13/28 (46)

Well Exposed Total Well(%) 10/20 (50)

Odds Ratio 0.87

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95% Confidence Interval 0.24-3.2

p-value 0.52

Exposure Tomato

Ill Exposed Total Ill(%) 7/28 (25)

Well Exposed Total Well(%) 6/20 (30)

Odds Ratio 0.78

95% Confidence Interval 0.18-3.5

p-value 0.50

Exposure Pickles

Ill Exposed Total Ill(%) 7/28 (25)

Well Exposed Total Well(%) 7/20 (35)

Odds Ratio 0.63

95% Confidence Interval 0.15-2.6

p-value 0.63

Exposure Mayonnaise

Ill Exposed Total Ill(%) 20/28 (71)

Well Exposed Total Well(%) 9/20 (45)

Odds Ratio 3.1

95% Confidence Interval 0.78-12.4

p-value 0.06

Exposure Mustard

Ill Exposed Total Ill(%) 10/28 (36)

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Well Exposed Total Well(%) 9/20 (45)

Odds Ratio 0.68

95% Confidence Interval 0.18-2.6

p-value 0.52

Interpret the table. Please provide a brief discussion on implicated foods vs. non-

implicated foods, the benefits of this study design and what the confidence interval

and p-value mean in relation to this data. What steps in the outbreak investigation

are utilized in this phase of the investigation? Please report on this development.

Control and Preventative Measures One Page

Voicemail from Kristin Malecha Hospital Food and Beverage Director

Good afternoon. It's been 3 days since our cafeterias have been closed and I am

getting pressure from the higher-ups at the hospital system to reopen the

cafeterias. Can you give me a sign-off please, or let me know what I can do to get

our cafeterias back open again? I look forward to hearing from you.

Voicemail from Keith Olson Hospital Infection Control Nurse

Hello! I know you were hoping to never hear from us again but I have some very

interesting news to share with you. Did you know of all the hospital cafeteria staff

you stool sampled, 28 of the 29 (97%) came back negative for any norovirus

presence. But I couldn't figure out the reason why there wasn't 100%. So, I did

some digging and found out Ms. Mary Mallon was the morning shift deli prep cook

who did not submit a stool sample due to her religious beliefs. She has not been

sick but did take off 2 days before Day 0 to care for her ill daughter (who ironically

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had a diarrheal illness). Ms. Mallon again vehemently denied she has been sick

and further states she wore gloves while doing all the slicing of the cheese, meat,

etc, but didn't wash her hands because she had gloves on. What is your take on

this? Do you think she is the source of transmission?

Answer these questions based on your observations Given your conversation with the infection control nurse and the food and

beverage direction, what actions and next steps do you require/recommend? Once

the cafeterias are reopened, what is the epidemiologist's next step in the outbreak

investigation?

Conclusion In this scenario, you investigated several aspects of an outbreak at St. Anthony Medical Center, a hospital in the Vila Health health care system. You answered questions along the way that allowed you to build a hypothesis on the origin of the outbreak, interpret epidemiologic study findings, and determine and describe the appropriate response to the complaint.

Your assignment is to answer the questions posed during this scenario, and:

Describe the appropriate response to a potential foodborne illness complaint.

List disease categories to include in the differential diagnosis of an acute

gastrointestinal illness, given clinical information.

Outline a hypothesis on the source of an outbreak BACK TO TOP

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Interpret epidemiologic study findings.

Identify information to include in an outbreak investigation report.

Describe the epidemiology e.g., occurrence, transmission, and control of an Licensed under a Creative Commons Attribution 3.0 License

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HEART DISEASE

& STROKE

GOALS

BENEFITS TO

POPULATION

Decrease # of patients with heart

problems

Decrease body weight

Decrease blood

pressure

Increase exercise tolerance

Lower risk of

disease in older population

Boost moodControl over weight

Control blood

pressure

Stakeholders: play an important role in

conducting research and applying this to real life for the

improvement of healthcare. Building diverse partnerships is vital to

make a systematic and coherent approach for this

policy to work

Improve sleep

Stress control

Control over other associated

diseases

Patients

Physicians Employers

Pharmaceutical

Insurance Companies

Government

Their products are used to treat

and cure diseases

Key role in providing adequate health care

and controling the cost of health care

Have the responsibilty of taking care of themselves and in doing so controlling prices by lowering health

care costs

Health care is a human right and

commodity

Provides healthcare

without population

bias

Healthier employees cost

the company less and take less sick time

Profit driven

InterestBenefits to stakeholders

Ratio of benefits to cost

Aggregate impact on socirty as a whole

Maintain incentives

Seeing impact of their products

on patients' health

Provide diversity training

Health and safety

Profits

Social Impact