Outbreak investagation assignment will take you through the ten steps of an outbreak investigation. There is a media component for this assignment, linked in Resources. You will introduce yourself within the hospital as the infection control manager,

Outbreak investagation

assignment will take you through the ten steps of an outbreak investigation. There is a media component for this assignment, linked in Resources. You will introduce yourself within the hospital as the infection control manager, and there are reports that a number of patients are getting sick with a gastrointestinal illnesses.
As you are introduced to each update from various members of the healthcare facility, jot down your notes, perform your research, and then report on the steps taken within the outbreak investigation. Each step should be approximately one page in length, but some steps may take multiple pages to capture a comprehensive response.
As you progress through the media simulation, your answers to key questions and thoughts will be recorded and will be made available to you at the end of the simulation. You may wish to save the PDF file as a word document to make changes or updates to it prior to submitting it as your assignment for this unit.

Riverbend City: Outbreak Investigation

Introduction
Laura Hernandez’s Office
Outbreak Detection and Notification
Generating the Hypothesis
Generating the Hypothesis
Testing the Hypothesis
Investigation Results
Control and Preventative Measures

Conclusion

Introduction

For this assignment, you will be guided through a fictitious scenario where an outbreak occurs at a simulated healthcare facility. 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.

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
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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 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?

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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, 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.

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Generating the Hypothesis

Three to Five Pages

Email from the Hospital Infection Control Nurse.

From: Susan Jones, Hospital Infection Control Nurse

Sent: Tuesday, February 12, 2015 12:20

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 {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, or 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 informaiton. Do you have anything to share with me?

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:

Number of Cases.

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

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Testing the Hypothesis

Three to Five Pages

Email from the Hospital Infection Control Nurse.

From: Brian Sanders, Hospital CEO

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:

Laboratory studies to determine the causative agent,
Environmental health assessment of the hospital main cafeteria,
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 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.

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Investingation Results

Two Pages

Voicemail from Karen Walker Staff Epidemiologist and Environmental Health Specialists

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 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
American Cheese 13/28 (46) 4/20 (20) 3.4 0.80-17.5 0.06
Swiss Cheese 8/28 (29) 8/20 (40) 0.61 0.15-2.4 0.30
Ham 11/28 (39) 6/20 (30) 1.5 0.38-6.3 0.36
Turkey 15/28 (54) 11/20 (55) 0.95 0.26-3.5 0.57
Shredded Lettuce 13/28 (46) 10/20 (50) 0.87 0.24-3.2 0.52
Tomato 7/28 (25) 6/20 (30) 0.78 0.18-3.5 0.50
Pickles 7/28 (25) 7/20 (35) 0.63 0.15-2.6 0.63
Mayonnaise 20/28 (71) 9/20 (45) 3.1 0.78-12.4 0.06
Mustard 10/28 (36) 9/20 (45) 0.68 0.18-2.6 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.

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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 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?

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Conclusion

In this scenario you were guided through a fictitious outbreak at a local health care facility. You were asked to answer 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
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

Post your answers to the questions posed in this scenario, your outline results and description of the appropriate response to this complaint in the Unit 7 Assignment Board in the course room.
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