The following section describes the quantitative and qualitative measures used to evaluate the success of our integrated Epidemiology and Environmental Health practice.
Objective 1: Establish a systematic approach to addressing foodborne illness reports from community members that incorporates measureable outcomes.
Between 2008 and 2009, Environmental Health (EH) began routine auditing of program data with an emphasis on quality assurance. This process would eventually lead to the EH quality assurance team, a group of experienced inspectors responsible for training new staff members and ensuring current staff complete and maintain their standardization.With the establishment of the three-tiered food service investigation algorithm, response times to complaints were also monitored. By 2011, the Health Department began the five-year process of becoming nationally accredited through the Public Health Accreditation Board. The efforts surrounding accreditation, successfully completed in 2016, lead to formalized tracking of complaint response times within the Epidemiology department and highlighted the data already being collected by EH. For the last five years, Epidemiology has responded to over 95% of foodborne illness complaints within 8 business hours of receipt. Putting this in historical perspective, in 2006 the average time between complaint receipt and the first attempt to contact the complainant was 2.3 days. In 2017, the average response time was less than 1 day, often within hours of receipt. Through a series of annual data reviews conducted by the Environmental Epidemiologist (Epi), it was observed that complaints that were called more than 8 hours after receipt were being received through the contact form on our website. To address this issue, department leadership created redundancies in the number of people receiving these online messages as well as redundancies in who receives notifications of illness reports in their email inbox. In addition, the variable report type” was added to Epidemiology's data collection spreadsheet to facilitate tracking of trends in reporting source.
Objective 2: Increase collaboration between Environmental Health (EH) and Epidemiology staff.
In 2017, our EH department became one of only five programs in the country to complete all nine FDA Voluntary National Retail Food Regulatory Program Standards. The Retail Program Standards define what constitutes a highly effective and responsive program for the regulation of foodservice and retail food establishments. The completion of these standards is the best indicator that we have met our objective. Having developed a culture of collaboration between EH and Epidemiology and through using evidence-based models, the documentation required to complete Standard 5 focused on Foodborne Illness and Food Defense Preparedness and Response, was easily accessible and required only minimal alterations and updating before submitting for review. As an example of this collaboration in action, in 2016, the Environmental Epi received a report of an outbreak of gastroenteritis among residents of a memory care and assisted living facility. During the initial investigation, it was revealed that a large family dinner had been hosted the day prior to the first reports of illness and that symptoms, onset, and duration of illness were consistent with norovirus. The Epidemiologist immediately reported this suspect norovirus outbreak to the county EH manager who arranged for an Environmentalist to complete a full inspection of the permitted kitchen within 7 business hours of notification. Epidemiology requested that the Environmentalist investigate a list of potential risk factors most commonly associated with norovirus transmission based on the International Association for Food Protection's Procedures Keys. During the on-site inspection, the Environmentalist observed and ultimately corrected violations related to barehand contact with ready to eat foods, improper storage of employee food items, inaccessible hand sinks, and inadequate levels of chemical sanitizer in the dishwashing unit.In addition, Epidemiology and the EH manager co-lead a disease control training and walkthrough of the facility. Epidemiology was able to collect specimens from ill residents resulting in norovirus as the confirmed etiology, and the facility was successful in halting the spread of the virus within their community.Though outbreaks of norovirus in institutional facilities are extremely common, the level of response to them by our Epidemiology and Environmental Health team is unique. In 2017, the Georgia Public Health Association, in recognition of GNR's outstanding outbreak response efforts, presented the epidemiology team with the Sellers-McCroan award for excellence in Epidemiology functionality. Seeing the success of our collaborative program and realizing the potential of the Environmental epi, a sister health district in our metropolitan area created a similar position, which they have maintained since 2012. This district has also met Standard 5 of the FDA Retail Program Standards, further emphasizing the value of this unique role.
Objective 3: Identify and adequately address specific risk factors that may expose community members to illness or injury.
The CDC National Outbreak Reporting System or NORS is a nationwide database of foodborne and waterborne outbreaks and their contributing factors.In 2016, NORS recorded 41 outbreaks for the entire state of Georgia with 1,431 related illnesses. Unfortunately, this database does not publish county-level data, which is crucial for local community assessments and for internal program evaluations.Thus, our district has prioritized management of our primary data sources, especially inspection, food safety complaint, and foodborne illness report data. At an annual team-building event held for Epidemiology and Environmental Health, the Environmental Epi conducts a data review that covers laboratory-confirmed diseases reported by healthcare providers, outbreak investigations, and foodborne illness complaints. Between 2016 and 2018, some of the most common violations recorded by Environmentalists during a foodborne illness complaint inspection included improper cold holding, hot holding, cooling, storing food in a way that risks contamination, and failing to separate and protect raw meats and seafood. Each of these unsafe practices can contribute to the proliferation and transmission of harmful foodborne pathogens, and though only 30-40% of foodborne illness investigations result in the identification of food code violations, it is clear that our Environmentalists are finding and addressing high risk food safety issues during complaint investigations. Besides foodborne illness complaints, Epidemiology and EH can also identify and eliminate hazards in the community through routine notifiable disease investigations and outbreaks. In this section, we describe three recent examples of integrated food and waterborne disease investigations.In 2017, Epidemiology discovered through routine interviews that two residents with Legionella infection had reported attending the same fitness facility in the two weeks prior to their illness. As Legionella cases are somewhat rare and common exposures between cases even rarer, Epidemiology and EH took immediate action by meeting with the facility the same afternoon the outbreak was identified. Epidemiology and EH met with facility leadership and requested that the facility voluntarily close all recreational water areas as well as all showers. The facility complied and hired a consultant experienced in Legionella remediation. This was the first documented Legionella outbreak in GNR history. EH and Epidemiology conducted extensive research into Legionella remediation, reviewing guidance from CDC, OSHA, ASHRAE, and even recommendations used in the European Union to improve their knowledge base. Using this research and state guidance, Epidemiology created written recommendations for the facility focused on remediation and environmental testing. Facility leadership, the consulting company, and representatives from EH and Epidemiology met to discuss the remediation plans and completed a walkthrough of the building. A thorough environmental assessment of the building was conducted during that time using a CDC tool. The presence of experienced EH staff and their expertise in maintaining swimming pools and spas was essential to this investigation as it was later revealed that both the facility's men's and women's hot tubs were positive for Legionella contamination. The facility continued to comply with all health department recommendations and even commended the health department staff on their customer service during the outbreak. No additional Legionella cases were reported associated with this outbreak. This investigation, and the model of collaboration between Epidemiolony and EH was presented in a nationwide NACCHO webinar in May, 2018. In 2018, Epidemiology received a report of a resident diagnosed with Listeria infection at a local hospital. During a routine interview, the resident revealed she consumed head cheese, goat sausage, and stew made with goat's meat and blood from a vendor selling butchered meat products from his home. In the state of Georgia, butchers are regulated by the Georgia Department of Agriculture (GDA).As local Epidemiology does not work closely with GDA, Environmental Health stepped in to make the appropriate introductions with local GDA investigators specializing in illegal meat sales. Epidemiology shared their findings with the investigators who responded immediately. GDA was able to observe and document the illegal sale of food products at the vendor's home. They seized 253 pounds of product, issued a Stop Sale notice, and tested the suspect food items for Listeria and Salmonella (all negative). Finally, the partnership between our programs has improved our ability to address ever larger, more complex outbreak investigations involving multiple retail food facilities and requiring ongoing communication with the general public. Also In 2018, Epidemiology received a report of gastrointestinal illness following a private event with over 200 attendees. A local deli and catering company, as well as a local restaurant and a bakery, served food and beverages at the event. Epidemiology worked very closely with EH through the investigation to re-create menus, identify suspect food items, conduct analyses, and provide daily updates on the ongoing reports of illness. Environmental Health conducted outbreak-specific inspections of the permitted facilities and reported their findings to Epidemiology almost daily. Through their partnership with GDA, EH was able to discuss the food process flow with the bakery owner and verify the eggs they used were not part of a recent Salmonella recall. Environmental Health noticed several risk factors within the local deli that can be associated with the proliferation and spread of Salmonella. These included improper storage of equipment used to cook raw chicken, inadequate access to hand sinks, and the storage of raw meats including chicken in proximity to fresh, unwashed produce. All these violations were addressed on site by the Environmentalist and the facility owner, but Epidemiology continued to receive reports of Salmonella associated with the restaurant, some independent from the original private event. Environmental Health and Epidemiology requested the restaurant close for an intensive deep cleaning as well as staff education, and the restaurant complied. This outbreak received a substantial amount of media attention, and both departments advised the GNR communications team on press releases updating the general public about the investigation. Following this closure, no additional cases of Salmonella were reported in this outbreak and the restaurant continues to be monitored by EH. In total, 95 illnesses were reported with the majority attending the original private event. Utilizing the information gathered by EH in the field along with information gathered through standardized questionnaires, Epidemiology determined that chicken was a statistically significant food exposure in this outbreak though all food specimens tested negative for Salmonella. The success of these investigations, whether due to a single case or a hundred, highlight the capability of our EH and Epidemiology teams to identify, respond to, and prevent foodborne disease risk factors in our community.