Chapter 3: Steps in Investigating

an Outbreak
Section One: The 10 Steps in Investigating an Outbreak

1) Prepare for an Outbreak Investigation and Field

Work
2) Confirm the Existence of an Epidemic or an Outbreak
3) Verify the Diagnosis
4) Define a Case and Identify and Count Cases
5) Describe the Data in Terms of Person, Place, and
Time
6) Develop Hypotheses
7) Evaluate Hypotheses (Analyze and Interpret the
Data)
8) Refine Hypotheses and Carry Out Additional Studies
9) Implement Control and Prevention Measures
10) Communicate Findings, Write a Report and Enter into
the National Outbreak Reporting System (NORS)

Section Two: Management of Multiple Outbreak

Investigations

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STEPS IN INVESTIGATING AN OUTBREAK

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50
CHAPTER 3

Overview of Steps in Investigating an

Outbreak

Introduction

An epidemiologic investigation is an important part of the complete foodborne or

waterborne illness investigation which also includes environmental and laboratory
investigations. Each part of the investigation compliments the others.
Teamwork and open communication are of utmost importance.

The purpose of the epidemiologic investigation is to identify the causes of a

public health problem by collecting data, and formulating and testing
hypotheses. It also involves implementing control measures to prevent additional
illness and evaluating the impact of those control measures to make sure that
the problem has been adequately addressed.

When an outbreak has been identified, the local health department (LHD) should
immediately notify the Infectious Disease Branch, Reportable Disease Section
at the Kentucky Department for Public Health (KDPH) and/or any other state
level office (e.g., Division of Public Health Protection and Safety, Division of
Laboratory Services, etc.) that might have expertise that could bear on the
investigation. The toll free number is 1-888-973-7678. These offices may assist
in coordinating the investigation, assist in the investigation itself if requested by
the LHD, and can be consulted on collection of food, clinical, and/or
environmental specimens.

Following, are 10 standard steps to an outbreak investigation. Though they are

listed in sequential order, their order of implementation is often non-sequential.
Knowing these steps prepares one to conduct an investigation properly, using
common sense and logic to determine when, how often, and to what extent the
different steps should be implemented in a real investigation.

51
 STEPS IN INVESTIGATING AN OUTBREAK

The following steps should be taken in all outbreak

investigations:

1. Prepare for an outbreak investigation and field work.

2. Confirm the existence of an epidemic or an outbreak.
3. Verify the diagnosis.
4. Define a case and identify and count cases.
5. Describe the data in terms of person, place, and time.
6. Develop hypotheses.
7. Evaluate hypotheses (analyze and interpret the data).
8. Refine hypotheses and carry out additional studies.
9. Implement control and prevention measures.
10. Communicate findings, write a report, and enter into the National Outbreak
Reporting System (NORS).

NOTE 1: It is important to note that while the above list of steps is in a

particular order, they do not necessarily have to be carried out in that order. In
fact, several steps may be put into action simultaneously. However, confirming
the existence of an outbreak and verifying the diagnosis always deserve early
attention.

NOTE 2: Depending on staffing, resources and time, all the steps may not be
covered thoroughly or even covered at all. As stated previously, KDPH is
available for guidance and assistance. (Telephone numbers for KDPH are
included in this chapter and in Appendix A.)

3.1.1 Step One: Prepare for Outbreak Investigation and

Field Work

Although the steps in investigating an outbreak are not always implemented

sequentially, preparing for an epidemiologic investigation may be considered as
the initial step in any outbreak because at least part of the planning can be done
before an outbreak occurs. The LHD can begin by training personnel in how to
compile line lists, develop questionnaires, conduct interviews, and use software
such as Epi Info for data entry and analysis. Physicians, hospitals, and nursing
homes should also be trained on the procedures for reporting infectious diseases.
It is important to establish rapport with community stakeholders and to provide
them with a copy of the Reportable Disease Desk Reference. The LHD should
have 6-8 stool culture kits on hand or readily available should an outbreak occur
because in most cases stool specimens must be collected within 72 hours of
onset of illness to isolate and identify certain pathogens (e.g., Clostridium
perfringens, Bacillus cereus, Staphylococcus aureus ). The LHD should also
maintain a supply of food collection kits and water collection kits so that prompt
collect of the suspect food items or water may be collected. Lists of contacts,
such as administrative contacts, additional personnel, sanitarians, regional

52
CHAPTER 3

contacts, physicians, clinical laboratories, or other persons who may become

involved in outbreak investigations should be assembled. Resource materials,
such as the Red Book or the Control of Communicable Diseases Manual (CCDM),
describing signs and symptoms, incubation times, vectors, probable routes of
exposure, and specifics regarding specimen collection (e.g. Appendices C, D, E
and F of this manual) and appropriate collection kits to be used should be
maintained and readily available to those responding to the initial calls. “Go kits”
for typical outbreaks can be assembled with all of these materials ready to roll
out the door at a moment’s notice.

These steps may help in fielding investigators faster and initiating an

investigation. It is also very important for the LHD to realize the limits of the
LHD’s resources; does the LHD have the means to properly conduct the
investigation or is there a need to seek outside assistance? If an outbreak
investigation requires additional resources, KDPH should immediately be notified.
Once the investigation is underway, the proper clinical specimens should be
collected as soon as possible before patients recover and become less likely to
submit specimens, or are treated, and before general interest in the investigation
wanes. Food and water specimens should also be collected as soon as possible.
Being prepared in advance increases the likelihood that this will happen. A
presumptive diagnosis may be misleading in the absence of a thorough
laboratory work up. A determination must be made regarding the feasibility of
conducting an investigation even if the time to collect proper clinical specimens
has passed. Each step of the investigation can be impacted by prior preparation.

Once an outbreak is identified, final preparation for field work must occur. What
will be needed in the field? Who should go? Will food, water, money, or hotel
reservations be needed? Who needs to be informed in the office and at the
investigation site? How will communications occur and are contact information
sheets and clear directions available? What will be the goal of the field work?
What is the timeline? Who are the interested parties or stakeholders? Answers
to these types of questions will be crucial to a successful investigation.

3.1.2 Step Two: Confirm the Existence of an Epidemic or an

Outbreak

Once the health department staff have been alerted to the possibility of some
unusual cases, or an unexpected increase in the number of cases of a particular
disease or group of symptoms, the first step is to make sure that the information
is correct and that there truly is an outbreak to investigate. What determines the
existence of an outbreak? The general rule is to compare the current rate of
occurrence of the disease to what “normally” occurs to determine if there is a
rise in cases beyond what is normally experienced. However, for diseases not

53
 STEPS IN INVESTIGATING AN OUTBREAK

often seen in a given area, two or more cases are usually the general rule for
declaring an outbreak.

Reporting of cases of illness can occur for any number of reasons that don’t
relate to a true outbreak. Misdiagnosis is a common occurrence and usually
happens in the absence of proper lab testing. Increases in reporting cases of a
disease may happen because a specialist starts practice in an area and identifies
and reports previously unrecognized cases. Media coverage may cause clinicians
to suspect a particular disease more often and report cases. The reportable
disease case definition (see Step 4) may change to include more people as
cases. Lab testing can bring about many false increases. For instance, a new lab
test may be created making testing possible, a more sensitive lab test might be
developed, more samples might be gathered and sent for testing because of
increased awareness among clinicians, or an increase in inappropriate testing of
people will naturally increase the false positive rate bringing about higher lab
reports of the disease. In all of these cases, the rate of occurrence of the
disease didn’t actually increase, but the number of reported cases appears to
indicate that it did.

Thus, one should always strive to establish the true existence of an outbreak by
comparing the incidence of the disease in a specified population during a
comparable previous time period. Often, individuals may exaggerate the
number or severity of cases related to a particular event or report “lots of people
have it” for a particular disease and once investigated this is not borne out by
the facts. It is often unclear when to conduct a full epidemiologic investigation.
There is usually no question when the team is notified about a large number of
people getting ill at approximately the same time after eating at the same
establishment or attending the same event. However, uncertainty arises when
sporadic complaints are reported. The response team will need to consider
whether the reports indicate that the affected cases are all suffering from the
same illness and whether there is any evidence of an association between them.
This underscores the need to follow-up (i.e., determine the validity of and initiate
further action if necessary) on every complaint received. It often occurs that
single complaints are actually related to an outbreak.

When a complaint implicates a food product, water source, retail food

establishment, the LHD environmentalist should be notified. The LHD
environmentalist should conduct an environmental assessment at the suspect
facility. This should include the collection of relevant environmental samples for
laboratory testing. If samples cannot be collected at the time of the
environmental assessment, the food items should be quarantined for later
collection.

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CHAPTER 3

To make the task of establishing an outbreak easier, investigators must be

familiar with the reportable disease system, know who to contact to find previous
and current rates of diseases, and know common disease trends in the
community. This can be done through diligent public health surveillance that
provides an accurate assessment of the status of the health of the community
and helps to determine any increases or decreases in communicable diseases in
the local population. Surveillance data should be reviewed by the LHD on a
regular basis to become familiar with the status of all communicable diseases in
the area of jurisdiction. Be aware of artificial causes of increases such as: (1)
changes in local reporting; (2) changes in case definitions of reportable diseases;
(3) increased local or national interest in particular diseases; (4) new physicians
in the area or those who might be specialists in certain diseases; (5) new
diagnostic procedures which might identify new or existing infectious agents; and
(6) increased populations or new arrivals into the area.

When notified of an incident in which illness has resolved and no new cases have
been identified, the decision to conduct an epidemiologic investigation should be
based on an assessment of what will be gained. As stated above, an
investigation always serves as a learning tool. But, if resources (time, personnel,
etc.) are limited, a full investigation may not be warranted. Rather, one should
ensure that appropriate control measures have been implemented to prevent
future outbreaks.

This is especially true of home-based foodborne outbreaks. In many instances,

the illness is confined to a finite number of people in a discrete time period. In
addition, the health department is often notified well after the fact when there is
little or no material left for testing and people have recovered. In this case, the
team should review food preparation techniques with the responsible parties and
use the opportunity to educate on proper food handling and preparation
methods.

Whenever an increase in cases is reported, this is the perfect opportunity to give

a “heads up” to each of the investigation partners in the health department. The
epidemiologists, communicable disease nurses, and environmentalists should all
be aware of the possibility of an investigation from this initial point. Each may
have insight into how to determine whether this is truly an outbreak based on
prior experience so the intake staff person should not waste an opportunity to
collaborate early.

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 STEPS IN INVESTIGATING AN OUTBREAK

NOTE: Investigation of an outbreak of foodborne or waterborne illness is a

team effort where each member has an essential role to perform. In some
instances the team may include a number of individuals at the local level (public
health nurse, sanitarian, regional epidemiologist) and the state level (state
epidemiologist, infectious disease branch, food safety branch, environmental
management branch). At times, there may be only one person involved at the
local level. Whatever the circumstances, it is important to remember
that KDPH is available for guidance and assistance throughout each
step of the investigation. Phone numbers are listed on the next page.

KDPH Contacts

Division of Public Health For policy and technical assistance with the
Protection and Safety, environmental investigation such as initiating
Food Safety Branch enforcement actions and collecting food samples. On-site
(502) 564-7181 investigation assistance is available to coordinate multi-
county or interstate outbreaks.
Division of Public Health For technical assistance with water sample collection.
Protection and Safety,
Environmental Management
Branch
(502) 564-4856
Division of Epidemiology For technical assistance with the epidemiologic
and Health Planning, investigation such as obtaining medical histories and
Reportable Disease developing questionnaires. On-site investigation
Section assistance is often available for larger outbreaks.

For assistance with the

epidemiological
investigation.
(502) 564-3261
1-888-9-REPORT or
1-888-973-7678
Division of Laboratory For technical assistance with the collection protocol for
Services food and clinical specimens.

j or technical assistance
with the collection protocol
for food and
(502) 564-
4446

I stool specimens.

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CHAPTER 3

3.1.3 Step Three: Verify the Diagnosis

Verifying the diagnosis is done by obtaining appropriate clinical histories and

proper specimens, patient and/or environmental, for laboratory study.

A diagnosis might already be established as is the case when someone notices

an increase in positive lab results for a certain disease. It could also happen
when area physicians report an increase in the number of patients they are
seeing with similar symptoms and at least one doctor tested appropriately and
thus already has a diagnosis for the outbreak (which of course must be further
confirmed with respect to the actual outbreak but gives the investigator a
definite starting point). However, if the diagnosis is not clearly established, then
the first step is to obtain clinical histories on the patients.

Obtaining Clinical History

Obtaining accurate clinical histories involves interviewing ill persons, family
members and/or physicians, either in person, on the phone, or through a formal
survey (discussed in Step 4) to record all relevant symptoms, possible exposures,
and other details that might reveal the disease in question. It is also a good
time to ask questions that might illuminate the cause of the outbreak or ways to
prevent further cases.

The important elements to cover when obtaining initial clinical histories include
anything that might lead to the determination of a specific disease entity that is
responsible for this outbreak. Primary among these are specific symptoms of the
illness, details that could help determine the incubation period, contacts with
other sick people who might already be diagnosed or offer a broader symptom
profile, and prominent exposures that may have led to infection or poisoning. All
of these categories of information could indicate what kind of disease is the
etiologic agent in this outbreak. Remember, the information gathered is
confidential and should be shared with only those individuals involved
in the investigation.

Laboratory Specimen Collection

Review the method of laboratory testing, (e.g., sputum swabs, blood tests, stool
culture, and select isolates). Be wary of verbal reports of any disease. Insist on
obtaining laboratory evidence of positive test results from established
laboratories and accepted tests. Other evidence to support the diagnosis (e.g., a
lab-confirmed case in a contact) can sometimes be used in lieu of laboratory
results. (Information on submitting clinical specimens is discussed in Step 4 of
this chapter). In some instances, there will be outbreaks of unknown etiology,
and there will be no laboratory results forthcoming to confirm the diagnosis.
This often happens because it is well after the outbreak when the investigation
begins or clinicians are likely to treat empirically rather than test so inadequate

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 STEPS IN INVESTIGATING AN OUTBREAK

or no testing has occurred. Cases or outbreaks of diseases of unknown etiology

are just as valid as those with known etiologies.

NOTE: Laboratory identification of a pathogen can validate the hypothesis and

perhaps allow easier implementation of control and preventive measures.
Therefore, time is of the essence when requesting and collecting
clinical, food and water specimens.
x Refer to Appendix D for information on submission of clinical specimens.
x Refer to Appendix E for more information on submission of food specimens.
x Refer to Appendix F for more information on submission of water samples.

It is important to notify the lab prior to the submission of food samples and other
specimens. Food pathogen testing is time consuming and involved and the lab
needs time to plan and prepare. Each food pathogen has a unique protocol of
media and incubation temperature. Media is made on demand because it is
expensive and has short expirations.

When submitting any specimens to the Division of Laboratory Services for

analysis, it is crucial to have an idea of what the disease or toxin is so that the
lab can test appropriately. Specimens should be packaged and shipped using
current transport regulations to arrive in the appropriate time frame (see
appendix D for packaging, shipping, and transport time frame). Refer to:
Appendix D: Collection and Submission of Clinical Samples; Appendix E:
Collection and Submission of Food Sample; and Appendix F: Collection and
Submission of Water Samples for specific guidance for collection packaging and
shipping. Flowcharts which describe the basic lab testing process are also
included in Appendix D, Appendix E, and Appendix F. Please keep in mind that
these flowcharts do not reflect the entire work process for testing of laboratory
specimens. Rather, they have been simplified to provide a basic description of
specimen flow through the lab and the testing process. These flow charts are
intended to provide a general idea of the steps and time required for testing.
It is very expensive to run tests on stool or food samples. A request to “test for
all gastrointestinal illnesses that could be in stool sample,” or “test for whatever
could make people sick in this food,” would also be too time consuming for the
Division of Laboratory Services. Use symptomatology, probable incubation
periods, and other characteristics of the outbreak (e.g., likelihood of waterborne,
foodborne or environmental contaminants vs. infectious etiologies), to assist in
making educated guesses about the agents to be tested for in order to request
specific tests to be performed. Appendix C contains this information and may
assist investigation team members in identifying agents to be tested for.

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3.1.4 Step Four: Define a Case and Identify and Count Cases

Develop the Case Definition

After establishing that an outbreak is occurring and attempting to verify the
correct diagnosis, a crucial step is to define what constitutes a case in this
investigation. This is called the Case Definition. The case definition is then
used to identify and count cases.

A case definition is a set of criteria for deciding whether an individual ill person
should be classified as a case. The case definition places boundaries on who will
be counted as a case, so the investigation does not include those with illnesses
unrelated to the outbreak. This step helps to get an idea of the magnitude of the
problem and records all cases for follow-up in the investigation.

The common elements of a case definition include information on symptoms,

laboratory results, and the essential elements of person, place, and time.

Symptoms: People with the same illness do not always have the same
symptoms, but they will experience similar ones. It is important to
remember that the symptoms of some foodborne and waterborne
illnesses can mimic other foodborne and waterborne diseases. For
assistance in determining the incubation period and possible etiologic
agent, please refer to the Kentucky Field Guide for Foodborne and
Waterborne Diseases in Appendix C as well as the Control of
Communicable Diseases Manual.

b) Laboratory results: When a laboratory confirmation is made, the

task of defining a case is much easier. Hospitals or local clinicians in the
affected jurisdiction may be notified that an outbreak exists and asked to
notify the LHD of additional cases of the illness under investigation. Note:
during an outbreak of foodborne illness, efforts should be made
to send specimens and/or isolates to the Kentucky Division of
Laboratory Services (DLS) for further identification, confirmation
and to assure coordination of the investigation. Please contact
the Infectious Disease Branch before sending specimens. (See
Appendices D, E, and F for more information on what testing is done at
DLS.)

c) Person: The outbreak may or may not take place within a particular
group of people. Therefore, characteristics such as age, sex, occupation,
ethnic group, social affiliations or function attendance greatly assist in
qualifying the case definition.

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 STEPS IN INVESTIGATING AN OUTBREAK

d) Place: When there is a common meal involved, the place is already

established. But sometimes the only information available may be that
cases are occurring in several different locations over the same time
period. It is only after more information becomes available that the case
definition will become more specific as to the location of the outbreak.

e) Time: If there appears to be a common meal involved, then the time

between consumption of that meal and the onset of symptoms provides
an indication of the incubation period. The incubation period and
symptoms are helpful in determining which illnesses should be considered
as possible causes of the outbreak and thus may facilitate decision-making
regarding what types of laboratory tests should be run. As with
symptoms, incubation periods can vary among individuals; therefore, one
should consider a range of time of exposure for the case definition. For
example, in the case of a salmonella outbreak, cases may be defined to
include those persons who experienced symptoms consistent with the
case definition anywhere from 6 – 72 hours after the meal in question.

The initial case definition is usually general so that potential cases are not left
out. Once more information is obtained about the outbreak and the team is
more certain of the characteristics of true cases, the case definition may be
refined to “weed out” extraneous cases. This allows analysis to be more sensitive
to true risk factors because ill persons who are probably not related to the
current outbreak are excluded.

Case definitions are often broken into sub-categories based on the strength of
evidence that this is a true case of the disease or is truly related to the particular
outbreak being investigated. These designations are usually, “suspect,”
“probable,” and “confirmed.” A suspect case is usually one that has some
symptoms similar to known cases, but may be missing a crucial symptom or may
not link clearly to known cases and is not lab-confirmed. A probable case usually
has all the crucial characteristics but is missing a final component of
confirmation, such as a required final lab test, or an epidemiologic link to a
known case. A confirmed case meets all the characteristics established in the
case definition for a true case. CDC has established guidelines for the suspect,
probable and confirmed case definitions for many diseases. Investigators may
want to modify these for a particular outbreak investigation to fit the current
investigation needs.

Finding Cases
With the case definition in place, the next half of the equation is to decide how
to find additional cases, (i.e., routine methods versus more intensive methods).
Is it reasonable to rely on telephone reporting from physicians? Should case
reports be actively solicited from area physicians, laboratories, or hospitals?

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CHAPTER 3

Should the help of the local media be enlisted? These are all “judgment calls”
which must be made while taking into account the severity of the disease, how
widespread it is, the urgency of intervention, and the manpower available to find
and interview case patients.

Develop a Line Listing

During this step (or even in Step 2 or 3), is a great time to start a line listing. A
line listing is a simple list of case patients used to keep track of pertinent basic
data for cases and potential cases as they are identified. Case names and
numbers are listed down the left hand column, and the heading row at the top of
the table should contain pertinent information such as the case’s age, sex, onset
time, and symptoms. This type of organization permits a simple means for
comparison of many characteristics at one time, giving a quick way to look for
possible patterns, similarities, or associations. Later in the investigation, the team
may need to conduct a survey (discussed below) which would be facilitated by
having all the case patients listed in one succinct table. As the investigation
progresses, one may refine the line list to only include cases that meet a more
specific case definition (see Develop a Case Definition section above) but initially
it may be very inclusive of all potential cases in order to facilitate a broader look
at verifying the outbreak and the diagnosis.

Example of a Line Listing Table

# Name Age Sex Onset Date Onset Time Symptoms
1 Mary 32 F 6/4/99 1:00 PM Diarrhea, abd. cramps
2 Bob 25 M 6/4/99 1:30 PM Diarrhea
3 Carol 26 F 6/4/99 10:15 AM Diarrhea, nausea
4 Mark 18 M 6/3/99 11:30 PM Diarrhea, abd. cramps

Develop the Questionnaire/Survey

A common method of finding cases and simultaneously gathering, organizing and
analyzing initial risk factor data is to conduct a questionnaire or survey among
the population believed to be at risk. This is particularly effective when the
exposure event is already known (e.g., attendees of a wedding). A questionnaire
that targets specific questions about foods eaten and symptoms experienced is a
valuable epidemiologic tool. A questionnaire is solicited from those ill and well
who are associated with the incident and assists in developing better hypotheses
about the etiologic agent’s identity, the source of the infection, and the mode
and time of transmission.

Key questions to consider when developing a questionnaire:

x What are the demographic characteristics of the individual? (name, age, sex,
occupation, home and work addresses, phone numbers)
x Was the individual exposed to potential sources of infection and when?

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 STEPS IN INVESTIGATING AN OUTBREAK

x What are the symptoms, date of onset, their order of occurrence and
duration?
x What medical treatment has been sought and received?
x Did anyone affected get a diagnosis or do they have laboratory results?
x Who else has been exposed to a case during his or her infectious period?
(secondary contacts)
x What foods were consumed in the last 72 hours, or other appropriate time
frame, before the time of onset? It is also important to interview and obtain
food histories from those who ate the same suspect food and did not get sick.

These questions are intended as a guide. They will require modification to fit the
particular circumstances surrounding the investigation. Questionnaires can be
designed for personal or telephone interviews by the investigator
(epidemiologist, nurse, sanitarian, health agent, etc.). Once again, it is
important to administer the questionnaire to all associated with the exposure
event, both ill and well.

The KDPH Enteric Disease Investigation Form should be completed for all
confirmed or suspect Campylobacter, Cryptosporidium, Salmonella, Shiga toxin-
producing E. coli (STEC), and Shigella cases. This form may also be used for
suspected foodborne or waterborne outbreaks when the specific source or
pathogen is not known. See Appendix I for the KDPH Enteric Disease
Investigation Form.

NOTE: The KDPH Enteric Disease Investigation Form can be found in Appendix
I.

There is a computer software program called Epi InfoTM which can be used to
develop questionnaires and analyze data. (The software is free. A copy can be
obtained via the internet at www.cdc.gov/epiinfo ). For more information about
when to use a questionnaire, contact the Division of Epidemiology and Health
Planning, Reportable Disease Section at (502) 564-3261.

3.1.5 Step Five: Describe the Data in Terms of PERSON,

PLACE and TIME

The purpose of data orientation or epidemiological characterizations is to arrange

all incoming data so that patterns or anomalies will be illuminated, both of which
might be the key to determining the cause or source of the outbreak. The
investigator searches for common associations to strengthen or amend current
hypotheses and unusual occurrences to give additional clues. A common method

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of data orientation is plotting on a graph the cases by time of symptom onset to

get an epidemic curve.

NOTE: An epidemic curve is a graph that depicts the association of the time
of illness onset of all cases that are associated with the outbreak. It helps to
determine whether the outbreak originated from a common source or is spread
person-to-person. Time is plotted on the horizontal axis and the number of cases
is plotted on the vertical axis.

A description of how to prepare an epidemic curve in Excel can be found at the

following link provided in the FOCUS on Field Epidemiology newsletter, a product
of the University of North Carolina Center for Public Health Preparedness.

http://cphp.sph.unc.edu/focus/vol1/issue5/1-5EpiCurves_flash.pdf

From the line listing and/or survey described above (Steps 3 and 4), information
will have been collected on the characteristics of the ill persons (age, sex,
occupation, exposures to specific foods or other items). Very often, simply by
knowing these descriptive aspects and the diagnosis, and then plotting an
epidemic curve, the source, mode of transmission, and who is at risk can be
determined. Once the population at risk has been determined, appropriate
control measures can be targeted.

The shape of the epidemic curve may suggest what kind of outbreak is
occurring. A common-source or point-source outbreak looks different than a
propagated-source, a person-to-person outbreak or a continual source outbreak.
Definitions of these kinds of outbreaks, and an example of each epidemic curve
are found below. Epidemic curves are not only useful in pursuit of the
investigation but are also helpful when communicating to lay persons
(consumers, restaurant operators, etc.) the nature and magnitude of the
outbreak spread.

NOTE: The following pages contain definitions and examples of the different
kinds of outbreaks:
x Common-Source or Point-Source Outbreak
x Propagated-Source Outbreak or Person-to-Person Outbreak
x Continual-Source Outbreak
x Intermittent-Source Outbreak

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 STEPS IN INVESTIGATING AN OUTBREAK

Common-Source or Point-Source Outbreak: An outbreak of illness in which

susceptible individuals are exposed simultaneously to one source of infection. For
example: guests at a company retirement party potluck. The epidemic curve for
this type of outbreak is characterized by a sharp rise to a peak followed by a
decline usually less abrupt than the rise. See Example 3.1 below. The slower
decline is related to the manifestation of varying incubation periods in different
individuals. Most people will get sick in a short time frame but others may have
delayed onset based on several characteristics, such as the dose of infectious or
toxic material they received, their body’s defenses, when they ate the meal, and
other factors specific to the person.

Example 3.1
Point Source Outbreak Epidemic Curve

S. aureus Outbreak Associated with a Kentucky Restaurant,

Easter Sunday 2008
Number of Cases

Date and Time of Illness Onset

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Propagated-Source Outbreak or Person-to-Person Outbreak: An

outbreak of disease or illness that is spread from one person to another rather
than from a single source. For example: a community-wide outbreak of
shigellosis or pertussis. The epidemic curve for this type of outbreak is
characterized by a relatively slow, progressive rise. The curve will continue for
the duration of several incubation periods of the disease. Propagated outbreaks
may exhibit periodic peaks that correspond to incubation cycles of the disease,
particularly if the disease is highly infectious. This typically occurs earlier in the
outbreak rather than later when infection is more widespread. See Example 3.2
below.

Example 3.2
Propagated-Source Outbreak Epidemic Curve

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 STEPS IN INVESTIGATING AN OUTBREAK

Continual-Source Outbreak: An extended outbreak of disease or illness

caused by a source that continues to be contaminated. For example: an outbreak
where food is continuously contaminated by an infected food handler. The
epidemic curve for this type of outbreak is characterized by ongoing peaks over
time (e.g., weeks, months). The peaks may not be as dramatic as a common-
source epidemic curve, and the outbreak may not be as obvious (i.e., lower
incidence). See Example 3.3 below.

Example 3.3
Continual-Source Outbreak Epidemic Curve

Onset of Illness by Day

Restaurant B, Town X - August 2004
Cases

Date of Onset (August 2004)

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Intermittent-Source Outbreak: An extended outbreak of disease or illness

caused by a source in which exposure is not consistent but intermittent in
nature. This type of outbreak is characterized by an epidemic curve with
irregular peaks and valleys and the incubation period is often unclear. Examples
include chemical exposures at a worksite related to specific work processes that
occur at different times, irregular emissions from a factory, or a sick food worker
who serves on different days at restaurant while infectious over a period of time.

Example 3.4
Intermittent Source Outbreak Epidemic Curve

Onset of Illness by Day

Restaurant A, Town Y - July 2008
Cases

Day of Onset (July

3.1.6 Step Six: Develop Hypotheses

Using the information gathered so far, the next step is to consider which specific
exposure(s) may have caused the disease and develop a hypothesis (or several
hypotheses). A useful hypothesis is testable, sensible, and fits the full picture of
what has been learned as much as is possible. One example of a simple
hypothesis is: The cases became ill after eating at a local restaurant. A more
specific example, arrived at after further investigation, might be: The illness was
caused by eating the potato salad at the Restaurant X’s salad bar on Tuesday,
June 5th.

As stated in Step 5 above, very often simply by knowing the descriptive aspects,
the diagnosis, and then plotting an epidemic curve, the source, mode of

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 STEPS IN INVESTIGATING AN OUTBREAK

transmission and who is at risk can be determined. To test or prove the

hypothesis, analytical techniques such as statistical testing need to be applied
using the data collected. The epidemiologist is usually the team member who
specializes in statistical analysis and should be in charge of this part or consulted
about analytic techniques. This may also be carried out by an epidemiologist at
the state level or done in collaboration with the state staff.

One very important point in hypothesis development is that it is the job of the
team to find the actual cause of the outbreak and not to prove or disprove any
particular theory. Many times, a cause may seem obvious at first review but as
the investigation progresses facts seem to conflict with this theory. It can be a
strong temptation, especially when a scenario fits into the category of “what
usually happens” in a certain type of outbreak, to bend the facts to fit the theory
rather than bending the theory to fit the facts. The latter course is what should
happen and needs to be protected against over-exuberant team members who
have a pet hypothesis to prove.

NOTE: Although implementing control and prevention measures is not noted as

a step on the outbreak investigation until Step 9, it should be noted that if at any
time throughout the entire investigation, an ongoing, potentially hazardous
source of illness is discovered, recommendations for control measures should be
implemented immediately. Regulatory actions may also need to be taken.

3.1.7 Step Seven: Evaluate Hypotheses (Analyze & Interpret

the Data)

In order to evaluate a hypothesis, one must compare the hypothesis with

established facts. There are many ways to do this, including lab testing and
environmental investigation, which may confirm or deny the plausibility of a
given hypothesis. The primary tools that epidemiologists use in foodborne and
waterborne outbreaks are specific study designs. These study designs are
particular ways of collecting and analyzing data that allow easy comparisons of
hypotheses to facts (the data collected). The basic epidemiologic study designs
are the “Case/Control” and “Cohort” studies.

Cohort Study
Cohort studies are used when a whole group of people who might have been
exposed can be surveyed to test hypotheses about what caused the illness. This
is the typical study done in foodborne outbreaks when one can identify all who
ate at a restaurant, for example. All people had an equal chance of being
exposed but only some got sick. This type of study can be done retrospectively,

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and commonly is in foodborne outbreak investigations. All people who ate at the
restaurant during a given period of time are asked what specific food items they
ate and if they became ill. We then compare food exposures to illness status to
determine what food items might have caused the outbreak.

To do this in a foodborne illness outbreak, food-specific Attack Rates (AR) are

calculated. Attack rates are used to determine if one or more food items were
responsible for causing the illness. The food that caused the problem shows a
higher attack rate in persons who ate the food than in those who did not. The
AR is usually expressed as a percent. It represents the proportion of ill persons
observed due to a specific exposure or event.

Attack Rate (AR)

The Attack Rate is simply the percentage of people who become ill out of all who
were exposed. Example: If 228 people attended the catered wedding banquet
and 46 got sick, the Attack Rate would be 46 / 228 x 100 or 20.2%.

When doing analysis in a cohort study design, the common measure of exposure
is the Relative Risk (RR). When several sources of exposure are implicated
(a fairly common situation), the epidemiologist can run a model on the computer
that compares all the food items at once and arrives at relative risks for each
item compared to all the others so that the one with the greatest likelihood of
being the culprit can be identified.

Risk
Risk is the percentage of people who become ill divided by all who were at risk
and in an acute outbreak setting is represented by the Attack Rate.
And
Relative Risk (RR)
A Relative Risk is a proportion. It is the risk among those exposed to some risk
factor divided by the risk among those who are not exposed. For example, in a
restaurant outbreak, if 28 of 90 people who ate asparagus got ill (31.11%) while
only 3 of 98 who didn’t eat it got sick (3.06%), the RR is 31.11 / 3.06 = 10.2. In
other words, people who ate asparagus were 10.2 times more likely to become ill
than those who did not eat asparagus.

Case/Control Study
Case/control studies are used primarily when the illness is rare or when it is
easier to select participants for the study based on illness status. This is
different from a cohort study because participants are selected not on where
they ate, or swam, or lived, but on whether they got sick or not. This can be
used in the typical restaurant outbreak when there are so many patrons that
surveying them all would not be possible. In this case, all or a random selection

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of sick patrons can be enrolled in the study and then controls, or well people
who also ate at the restaurant, can be selected randomly from restaurant
patrons or groups of patrons. The primary measure of association that is used
with case/control studies is the Odds Ratio (OR). This compares the “odds of
exposure” to particular sources of infection between cases and controls,
indicating the most likely sources.

Odds
An “Odds” of something happening is the probability of it happening divided by
the probability of it not happening. In the case of outbreak investigation, it is
applied to the probability of having a risk factor among those who are ill or not
ill. For example, if we have 31 sick people in a particular outbreak and 28 of
them ate the asparagus, then the odds of exposure to asparagus among the sick
is (28/31) / {1 – (28/31)} = 9.33.
and
Odds Ratio (OR)
The Odds Ratio is a ratio of the odds of having exposure to a particular risk
factor among the sick divided by the odds of having the risk factor among those
who are not ill. To continue the example above, if we find additionally that 26
ate asparagus among 62 people who did not get sick then the odds of exposure
to asparagus among these controls is (26/62) / {1 – (26/62)} or 0.72. Thus, the
Odds Ratio for the odds of exposure to asparagus between the ill (cases) and not
ill (controls) is 9.33 / 0.72 or 12.96. Interpreting this, ill people were nearly 13
times as likely as not ill people to have eaten asparagus.

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3.1.8 Step Eight: Refine Hypotheses and Carry Out

Additional Studies

Analytic studies often reveal results that require modifications of, or fail to
confirm, the hypotheses that were originally generated. Additional sources of
infection may be identified through the investigation. The existing hypotheses
may need to be modified or new hypotheses generated. In either case, the
hypotheses will need to be tested requiring further studies be conducted.

For example, based on evidence gathered, the team generates a hypothesis that
the salad was the vehicle of transmission in a salmonella outbreak. The next
logical questions are, “How did the salad become contaminated with salmonella
and could this be verified with the results of the environmental investigation?” In
other words, are the epidemiologic results plausible and consistent with other
investigational findings? For instance, salad is not usually a food that harbors
salmonella. However, it can become contaminated when ill or infected food
handlers prepare the salad without adequate hand washing or use of gloves.
Compare hypotheses to the results of the environmental investigation. Did the
inspector note how the salad was made and served? Was it possible for this
scenario to have happened? Was any of the salad available for lab testing? Can
laboratory results confirm that salmonella found on the salad matches that found
in a patient’s stool specimen? Some of the questions that need to be addressed
to make sure that the hypothesis is not only statistically sound, but makes sense
in the real world are:

x Could the hypothesized events actually have happened?

x Is the hypothesis consistent with environmental aspects of the investigation?
x Is it likely the vehicle of transmission identified became contaminated with
the organism that has been isolated?

NOTE: Not all outbreaks have a resolution. In fact, it is rare when everything
comes together and a cause can be definitively determined. Investigators should
not become discouraged. Careful development of epidemiologic inferences
coupled with persuasive clinical and environmental evidence will almost always
provide convincing evidence of the source and mode of the spread of a disease.
In most cases, there will be enough evidence to present a plausible hypothesis.

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3.1.9 Step Nine: Implement Control and Prevention

Measures

Control Measures
Once an outbreak is identified, control measures are important for interrupting
disease transmission and/or limiting exposure to the source of infection. If a
pathogen or other suspected source of the outbreak is identified, control
measures should target specific agents, sources, or reservoirs of infection.
The objectives of foodborne and waterborne outbreak control measures are:
x Control of Source
x Control of Secondary Transmission
x Prevention Future Outbreaks

NOTE: Be advised that control measures can sometimes be

implemented very early in an outbreak investigation.

Control measures should be implemented at the first available point in the

investigation and should occur concurrently with other investigation steps. Often,
non-specific control measures can be put into place regardless of the type of
disease or source. Decisions should be made based on available evidence and
control measures should be prioritized in consultation with Epidemiologists,
Environmentalists, and Laboratory personnel, if available.

Control of Source

Known Pathogen, Unknown Source

If a source of infection has not been implicated but the pathogen is known,
control measures will include non-specific recommendations in order to prevent
secondary spread among known cases.
Non-specific control measures may include:
x Communication with healthcare providers
o Advice about specific treatment and follow up
o Ways to avoid spread
o Infection control precautions for hospitalized or institutionalized
patients
o Reporting newly identified cases to the local health department
x Communication with the public
o Practical measures to decrease risk
o Basic food/water safety recommendations
o Instructions on what to do if illness is suspected
o Contact information for public health officials

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o Outbreak communications with the public must balance the

potential for legal or economic consequences for implicated sources
and the health consequences of no communication (harm to
industry vs. harm to consumers)

Known Pathogen, Suspected Source

Once an association between an exposure and illness has been identified, control
measures should be implemented based upon the known exposure and the
suspected pathogen. Information such as suspected source of infection (i.e. food
item/water exposure), incubation period, symptom profile, and duration of illness
can assist the investigator in narrowing down the list of suspected pathogens
(Appendix C contains information to support this process). If a facility has been
implicated as a common exposure but no specific food or water item has been
identified some steps to implement regardless of the disease include:
x Review the history of the implicated establishment to identify previous
outbreaks or issues.
x Environmental Assessment by Environmental Health Personnel from the
Local Health Department
o Including an inspection of the implicated facility
ƒ Educate employees about the implicated disease and about
general infection control precautions
ƒ Observe food preparation processes
ƒ Assess food holding temperatures
ƒ Observe food service processes
ƒ Review appropriate logs for quality control
ƒ Interview facility manager and food service workers
ƒ Determine if any employees are ill
ƒ Determine if there have been any issues with systems and
processes at the facility (e.g. pool filters, water treatment
systems, coolers, etc.)
ƒ Obtain menus of food served for 1 week prior to earliest
case illness onset
o Quarantine or collect any suspect food item(s) for testing (if
applicable)
o Collect water samples for testing (if applicable)
o Recommendations for control measures should be made, based
upon inspection findings, including, but not limited to:
ƒ Properly holding the leftovers for further laboratory analysis
if warranted
ƒ Stopping bare-hand contact

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ƒ Emphasizing hand washing

ƒ Monitoring time and temperature control of food
ƒ Excluding employees ill with gastrointestinal symptoms
(vomiting and diarrhea)
ƒ Prohibiting serving of uncooked foods if any possibility of
norovirus exists
ƒ Cleaning/sanitizing of equipment and other high-touch areas
ƒ Corrective actions for treatment or chemical balance of
recreational water (if applicable)
ƒ Closing of specific parts of a facility (e.g. kiddie pool, a
specific food service area, etc.)
o Closing the facility:
ƒ If site inspections reveal a situation that poses a continuing
health risk to consumers, it may be advisable to close the
premises until the problem has been solved. Ideally, this will
be done with:
x the agreement of the business or
x enforced by law through a closing order
ƒ Once closed, they should be monitored by the appropriate
authorities and remain closed until reopening is approved.
ƒ Potential consequences (economic or legal) for closing a
facility should be weighed against the likelihood of additional
cases occurring if the facility is not closed.
o Removing implicated foods from the market:
ƒ The objective of food recall and food seizure is to remove
implicated foods as efficiently, rapidly and completely as
possible from the market.
ƒ A food recall is undertaken by any business responsible for
the manufacture, wholesale, distribution, or retailing of the
suspect food and may be initiated by the business itself or
undertaken at the request of an appropriate health
authority.
ƒ Food seizure is the process by which an appropriate
authority removes a food product from the market if the
business does not comply with the request to recall.
ƒ The longer the time that passes between a food appearing
on the market and it being identified as a potential source,
the less likely is the recovery of that food. This should be
coordinated with appropriate food safety agencies.

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* Remember: Those participating in facility improvement

recommendations (corrective actions), facility closures,
food seizures, or food recalls must balance potential
consequences (economic/legal) against the likelihood
that any action taken will prevent further cases of
disease.

o Modifying a facility’s process:

ƒ Once the investigation identifies the specific issues in a
facility’s process that may have contributed to the outbreak,
corrective action should be taken immediately to avoid
recurrences. Examples of corrective action are: modification
of water treatment procedures, modification of recipe or
process, reorganization of working practices, change in
storage temperatures, or modification of instructions to
consumers.
o Menu modification to remove a suspected food from the menu until
control measures are in place
o Excluding ill food workers

x Public Health Agency communication with the public regarding suspected

source

Although the business may have already issued a press release, the Public
Health agency may decide to notify the public. Ideally, this should be
coordinated with the business and done on the same day as the decision
to close a facility or recall a food product. Information given to the public
should include:
o Actions the consumers should take to prevent further exposure and
illness
o Name and brand of the food product (including labeling) being
recalled
o Name and location of the implicated facility (e.g. swimming pool
name, city, state)
o The nature of the problem, the reason for the facility closure or
recall of the product, and information about how the problem was
discovered
o Names and locations of the food producing establishment and point
of contact
o Locations where the product is likely to be found

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o Product numbers, amounts, and distribution

o A description of common symptoms of the illness associated with
the contamination
o Appropriate food-handling information for consumers
o Appropriate water safety information for consumers
o Actions that consumers should take if illness occurs

Control of Secondary Transmission

Communication with Healthcare Providers

x Encourage reporting newly identified cases to the local health department
or the Kentucky Department for Public Health
x Provide specific treatment guidelines
x Provide infection control guidance
x Encourage appropriate specimen collection

Public Advice
If contamination of the water or food product cannot be controlled at the source,
or a facility cannot be temporarily closed, steps need to be taken to eliminate or
minimize the opportunities for further transmission of the pathogen. Depending
on the situation, appropriate public advice may be issued during a period of
hazard. For example:
x Cleaning/disinfecting high-touch or high-risk areas, such as, areas in the
bathroom
x Boiling microbiologically contaminated water or avoidance of chemically
contaminated water
x Advice on proper preparation of foods
o Avoid cross-contamination
o Thoroughly wash fruits and vegetables prior to cutting
x Advice on proper disposal of implicated foods
x Emphasizing personal hygiene measures (e.g. washing hands after
defecation and urination and before preparing or consuming food)
x Avoid eating food that has not been handled properly (e.g. hot food that
has not been kept hot, cold food that has not been kept cold)
x If an individual has diarrhea, do not prepare food for others, until
symptoms have stopped
x If an individual has diarrhea, do not swim in pools or hot tubs, until
symptoms have stopped
x Public notices to avoid swimming/bathing in suspected bodies of water

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Exclusion of Infected Person from Work and School

The risk of infection being spread person to person depends on their clinical
state and their personal hygiene. People with diarrhea are more likely to spread
infection than asymptomatic individuals with subclinical illnesses. For certain
illnesses, individuals in high-risk settings may be required to have two negative
stool cultures collected 24 hours apart and 48 hours after completion of antibiotic
treatment, before being cleared to return to work/school. Disease specific
criteria may be found in the American Academy of Pediatrics Red Book or the
Control of Communicable Diseases Manual (CCDM). In general, the following
groups with diarrhea or vomiting should be excluded from work or school until
they are no longer infectious:
x Food-handlers
x People who have direct contact with highly susceptible patients or persons
in whom gastrointestinal infection would have particularly serious
consequences (i.e. health care workers, daycare workers)
x Children under age 5
x Older children and adults with doubtful personal hygiene or with
unsatisfactory toilet, hand-washing or hand drying facilities at home,
work, or school.

If these individuals cannot be excluded from work, consider restricting them to

specific areas and tasks that provide minimal risk for transmitting the disease.

*When making decisions to exclude individuals, the legal and economic impact of
exclusion of individuals from work or school should be considered.

Food or Water Potentially Contaminated by an Infected Individual

Identify potentially contaminated food items or water sources that may be
contaminated by an infected individual.
x Embargo or dispose of potentially contaminated food items
x Treat or take other measures necessary to control the spread of disease
through water sources potentially contaminated by an infected individual
(e.g. shock treatment of pools, draining and cleaning of hot tubs, etc.)

Facility Control Measures

The facility should create a risk-control plan or have an infection control plan in
place, including:
x Employee training
x Adequate oversight to ensure procedures are being followed
x Staff education
o Implicated disease
ƒ Symptoms

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 STEPS IN INVESTIGATING AN OUTBREAK

ƒ Mode of transmission
ƒ Prevention of spread
o Infection control precautions
ƒ Procedures for proper food handling
ƒ Proper personal hygiene practices
ƒ Personal Protective Equipment (PPE)
ƒ Cleaning/Sanitizing surfaces and equipment
ƒ Isolation of ill individuals in hospitals, healthcare facilities, or
institutions
ƒ Disposal or decontamination of contaminated clothing,
surfaces, or bedding

* Recommendations for infection control practices are frequently changed

and updated; therefore check key sources such as CDC to ensure the
organization or facility’s recommended practices are up to date.

3.1.10 Step Ten: Communicate the Findings, Write a Report

and Enter into the National Outbreak Reporting System
(NORS)

After analysis of epidemiologic and environmental data, conclusions should be

summarized in a report and sent to KDPH. This is one of the most important
steps in the outbreak investigation. Not only does the report detail the agency’s
efforts, but identifies a potential source(s) of the outbreak and suggests control
measures to prevent future illness.

The report should follow one of two suggested formats: 1) scientific format or
2) After Action Report format. The usual scientific format follows the
following outline: introduction, background, methods, results, discussion,
recommendations, and references. The After Action Report format should be
used if an LHD Operations Center or State Health Operations Center (SHOC) is
activated and should follow this outline: Handling Instructions; Contents;
Executive Summary; Section 1: Event Overview, including Event Details, Event
Leadership, and Participating Organizations; Section 2: Event Summary,
including Event Purpose, Objectives, Capabilities and Activities, Scenario
Summary, Supporting Events or Event; Section 3: Analysis of Capabilities;
Section 4: Conclusion; and the following appendices, as appropriate: Appendix A:
Improvement Plan
Appendix B: Lessons Learned (optional); Appendix C: Participant Feedback
Summary (optional); Appendix D: Event Summary Table (optional); Appendix E:
Performance Ratings (optional); Appendix F: Acronyms.

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Do not use the names of case-patients, but LHD personnel or authorized

personnel involved in the investigation may be included. The names of facilities
or locations where the outbreak occurred may be included at the discretion of
the LHD.

NOTE: For detailed information on writing a report and sample reports see
Chapter 4.

NORS

During the process of preparing the outbreak report or immediately after

submitting the final report to KDPH, the regional epidemiologist should enter the
outbreak into NORS. NORS is a Centers for Disease Control and Prevention
(CDC) developed web based outbreak data entry system for waterborne,
foodborne, enteric person-to-person, animal contact, and environmental contact
disease outbreaks. This is an important step to ensure that the CDC is aware of
Kentucky’s foodborne and waterborne outbreak responses. A sample of the
NORS reporting forms are included in Appendix J. Questions regarding NORS
should be directed to the KDPH Division of Epidemiology and Health Planning,
Reportable Disease Section at (502) 564-3261.

3.2.1 Steps in Investigating and Managing Multiple

Outbreaks Occurring Simultaneously
Large-scale outbreaks (any outbreak for which the response needs exceed the
ability of the jurisdiction to manage with existing resources), outbreaks involving
multiple jurisdictions, or multiple outbreaks occurring simultaneously may
overwhelm local health departments or the Kentucky Department for Public
Health. This section provides information related to the process of managing
multiple outbreaks occurring simultaneously.

The KDPH Disease Outbreak Investigation Support Plan (under development)

contains the detailed protocol for the management of investigations of multiple
outbreaks occurring simultaneously, regardless of etiology. This section in this
manual provides a basic overview of the process for foodborne and/or
waterborne illness outbreaks.

Command
All large-scale outbreaks, outbreaks involving multiple jurisdictions, or multiple
outbreaks occurring simultaneously should be managed using the Incident
Command System (ICS). The Incident Command System is a standardized,

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incident management approach that enables a coordinated response among

various jurisdictions and agencies, establishes common processes for planning
and managing resources, and allows for the integration of facilities, equipment,
personnel, procedures and communications operating within a common
organizational structure.

In the event of a large-scale outbreak, outbreaks involving multiple jurisdictions,

or multiple outbreaks occurring simultaneously, the State Health Operations
Center (SHOC) shall be activated in order to manage the overall response to
these events.

The following is a basic command structure that may be used when the KDPH
SHOC is activated in response to disease outbreaks.

The KDPH SHOC Plan provides the framework for management of any type of
incident of public health significance, including disease outbreaks. The KDPH
SHOC Plan provides detailed information related to activation levels and
operations during any event of public health significance, including multiple
outbreaks occurring simultaneously.

Roles and Responsibilities

No matter the size of the outbreak, all outbreak investigations follow the same
process as outlined previously in this chapter. During large-scale outbreaks,
outbreaks involving multiple jurisdictions, or multiple outbreaks occurring

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simultaneously, it is imperative that resources be managed so that the most

effective and efficient response can be executed.

Subject-matter experts will be assigned to specific operational roles based upon

their area of expertise. Subject matter experts will be responsible for providing
disease-specific consultation and recommendations to the Operations Section.

The Operations Section Chief should be an individual who has an epidemiology

background but does not need to be a disease subject-matter expert. The role of
the Operations Section Chief is to facilitate the epidemiological operations for the
Department.

The Operations Section may be divided into multiple sub-sections, depending

upon the number of outbreaks occurring. Each sub-section will have a “lead”
that will be responsible for the coordination of the KDPH response to a specific
outbreak. This sub-section lead will be responsible for maintaining situational
awareness related to their assigned sub-section, to include providing situational
report drafts to the Planning Section Chief; the individual sub-section Lead’s skills
may be used across multiple outbreaks due to the multiple operations proceeding
simultaneously. The division of the Operations Section into multiple sub-sections
is the key to a successful response to multiple, simultaneous outbreaks, as this
provides outbreak-specific management and a single point of contact each
investigation/response for situational awareness.

Collaboration with other Agencies

Multi-disciplinary coordination is crucial to an effective and efficient response to
foodborne and/or waterborne outbreaks. Support for outbreak investigations
may come from various divisions or departments within the Kentucky
Department for Public Health or from other Agencies within the State and
Federal Government. The nature of the outbreak will dictate the involvement of
other agencies.

Support Agencies:
x Local Health Departments
x Regional Child Care Consultants
x KDPH Division of Epidemiology and Health Planning
o Public Health Preparedness Branch
x KDPH Division of Public Health Protection and Safety
o Food Safety Branch
o Environmental Management Branch
x KDPH Division of Laboratory Services
x KDPH Division of Maternal and Child Health – Early Childhood
Development Branch – Early Childhood Promotion Section

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x Cabinet for Health and Family Services (CHFS) Office of the Inspector
General
x CHFS Office of Communications
x Kentucky Department of Corrections
x Kentucky Department of Agriculture
x Kentucky Department of Fish and Wildlife
x Kentucky Energy and Environment Cabinet
x Kentucky Emergency Management
x Centers for Disease Control and Prevention (CDC)
x U.S. Food and Drug Administration (FDA)
x U.S. Department of Agriculture (USDA)

Surge Capacity
When LHDs and KDPH have exceeded their ability to respond, there are
resources available to assist in the response.
x Epidemiology Rapid Response Team (ERRT) – the ERRT is a state-
wide cadre of individuals, environmentalists, nurses, and epidemiologists,
who are trained in epidemiological methods and have the expertise to
conduct outbreak investigations. Each ERRT member has a sign-off sheet
on file with KDPH signifying agreement by their health department that
they may be used as surge capacity during epidemiological investigations
anywhere in the Commonwealth of Kentucky.
o This resource may be accessed by making a request the
respective LHD housing the ERRT members. This process is
further outlined in the Disease Outbreak Investigation
Support Plan (under development).
x KDPH Program Staff – In addition to the ERRT, there are KDPH staff
members who can assist with data entry, data analysis, interviews, and
other epidemiological activities. These individuals are employed in various
Divisions across the Department and may be accessed by a request to
their supervisor.
x Other Departments and Agencies – staff from other departments or
agencies in the State may be available to assist with various aspects of
outbreak investigations, these may include regulatory and inspection
functions related to food or water.
x Medical Reserve Corps – Kentucky maintains a volunteer program,
sponsored by the Office of the Surgeon General of the United States, for
both medical and non-medical volunteers. Each county in Kentucky is
covered by a Medical Reserve Corps unit, with most units being sponsored
by local health departments in conjunction with local emergency
management agencies. All MRC volunteers are pre-credentialed and
trained to respond during large-scale public health emergencies to provide
surge capacity. These volunteers may be called upon during large-scale
outbreaks; outbreaks involving multiple jurisdictions; or multiple outbreaks

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occurring simultaneously, to assist with various aspects of data collection,

entry, or analysis.
x Kentucky Public Health Assistance and Support Teams – “K-
PHASTs” are comprised of public health students and faculty from
Kentucky Universities. Members of these support teams may be called on
at both the State Health Department and Local Health Department levels
to assist during public health emergencies or special projects. The
Kentucky Department for Public Health is responsible for training these
teams at each university on an annual basis. The training consists of an
overview of the public health system in Kentucky, use of the incident
command system during public health response, the steps in investigating
an outbreak, and interview techniques. Just-in-time training may be
provided for each K-PHAST team when deployed.

After Action Report and Corrective Action Plan

After an activation of the SHOC in response to large-scale outbreaks, outbreaks
involving multiple jurisdictions, or multiple outbreaks occurring simultaneously,
an evaluation of the response must be completed. All outbreak responders
should assemble and participate in an event de-brief and response hotwash.
During this debrief and hotwash, an overall summary of the response will be
given, along with a discussion of response successes and lessons learned.
Successes and lessons learned should be recorded for inclusion in an After Action
Report. An After Action Report must be completed, including an Improvement
Plan, within 120 days of an event. Following completion of the After Action
Report and Improvement Plan, an After Action Conference shall occur, where
these documents are discussed with all stakeholders. During this conference,
corrective actions noted in the Improvement Plan shall be discussed, including
the identification of the primary responsible agency for each corrective action
and the assignment of a completion date for each task.

After Action Reports and Corrective Action Plans from all foodborne and/or
waterborne outbreak investigations shall be reviewed on an annual basis in
conjunction with the annual review of this manual, thereby allowing any
corrections or additions to be addressed during the manual update.

Reporting Requirements
Report all outbreaks in NORS and as appropriate, the AAR/IP should be recorded
in the Homeland Security Exercise and Evaluation Program (HSEEP) Corrective
Action Program System (CAP).

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