Investigating and Managing Food-Borne Illness Outbreaks in India

Overview of Foodborne Disease:

A food-borne disease is a disease that is likely to be transmitted though the consumption of contaminated food or water. Diseases resulting from the consumption of microbiological/chemical contaminated food can be commonly referred to as food poisoning or food-borne illness. Food-borne illness is caused by either chemical or biological agents. Symptoms that indicate a person is potentially suffering from a food-borne disease can include: vomiting, diarrhea, nausea, fever and abdominal cramps. A person with hepatitis A or E may also be jaundice.

Food borne diseases are classified into:

Food borne infections:

Caused when a person eats food containing harmful microorganisms, which invade and multiply in the intestinal tract or other tissues. Examples include Salmonella, Campylobacter, Vibrio, and Yersinia enterocolitica.

Food borne intoxications:

Ingestion of foods containing either poisonous chemicals or toxins produced by microorganisms in the food. Examples include bacteria such as Clostridium botulinum, Staphylococcus aureus, and Clostridium perfringens; chemicals such as sanitizing products; metals; seafood toxins such as ciguatera and scombroid.

The list of important pathogens causing foodborne illness, its characteristics and control measures to be taken at industrial level, establishment level and/or consumer level.

Foodborne disease outbreaks:

Foodborne disease outbreaks occur when two or more (usually unrelated) people experience similar illness after eating the same food. In general terms, an outbreak refers to an often[1]sudden increase in the number of cases of an illness or disease above what is normally expected in a population in a given area (or place).

Food-borne disease outbreaks can be small and localized (occurring only in one local government jurisdiction), or large scale (affecting persons across multiple local government jurisdictions). Generally, there are two different types of food-borne outbreaks: Point source outbreaks are associated with a common event or venue, with people becoming ill over a short period of time. They are easy to identify if such persons report their illness and it becomes relatively easy to investigate. Community-wide outbreaks are not associated with a common event and involve people diagnosed with the same pathogen, which have eaten a contaminated food or ingredient that is sold at a number of food businesses. These investigations are very resource intensive, and identifying the source can be challenging.

Investigation of Foodborne illness outbreak:

The investigation and control of foodborne disease outbreaks are multi-disciplinary tasks and different stakeholders are responsible to respond to any food borne outbreak. The responsibilities are shared between the Health authorities and Food Safety Authorities at National and State Level as the response to food borne emergencies require collaboration and cooperation at all levels.

Purpose and Objectives of an outbreak investigation

The purpose of an outbreak investigation is to stop the continuance of the outbreak and to prevent the likelihood of future outbreaks.

The specific objectives of an outbreak investigation are to:

• Identify the food business, food or ingredient associated with illness.
• Identify and control the contributory cause(s) and risk factors.
• Control the outbreak through:
• Removing or recalling unsafe foods and ingredients
• Eliminating unsafe food handling processes that have contributed to the outbreak’s occurrence (or allowed the outbreak to continue)
• Prevent the likelihood of future outbreaks by enhancing the food business’ food safety management practices,
• Educate the food business on appropriate management of food safety risks to prevent the likelihood of a re-occurrence,
• Collect information to guide further research in the prevention of outbreaks.

Foodborne Disease Outbreak Investigation Team:

Investigation of an outbreak of foodborne illness is a team effort in which each member plays an essential role. It requires collaboration between Food Authorities and Health authorities for better communication and a better understanding of what is happening in regard to foodborne illness. Increased understanding of others’ responsibilities would result in improved local foodborne illness investigation and control programs.

Minister of Health & Family Welfare launched Integrated Disease Surveillance Project (IDSP) in November 2004 with an objective to strengthen/maintain decentralized laboratory based IT enabled disease surveillance system for epidemic prone diseases to monitor disease trends and to detect and respond to outbreaks in early rising phase through trained Rapid Response Team (RRTs). National Centre for Disease Control (NCDC) is the agency implementing the programme. RRT has been constituted at district level to confirm and investigate public health outbreaks including Food borne Outbreaks.

The Food Safety Officers of State Food Authorities have now been made as a part of RRT and is gathered on ad hoc basis when needed.

Rapid Response Team:

Once there is a threat of an outbreak or an emergency. It becomes necessary to form and activate rapid response team to address specific response tasks. At State, State Surveillance Officer (SSO) and at district level Chief District Medical Officer (CDMO) and District Surveillance Officer (DSO) are responsible to activate Rapid Response Team.

The members of the RR team are assigned with tasks appropriate to the response, such as: surveillance, sampling, product recalls, trace-backs, prohibition, disposal of contaminated materials, decontamination and disinfection, evidence gathering, quarantine, security, public education, sample analysis, or any other operational aspect of mitigating a food emergency. Generally, the team includes experts to cover all aspects of the emergency which includes District/State Epidemiologist, pathologist/clinician, microbiologist (Lab sampling), Entomologist (Vector Borne Disease), Paediatrician, Public health Nurse, Data manager/Lab Technician, Official from local bodies, and Food Safety Officer (Food Borne Disease). From here onwards, RRT will serve as foodborne disease outbreak investigation team throughout the rest of the document.

Functions of RRT in investigating Foodborne illness outbreak:

RRT is gathered on ad-hoc basis when needed and composition may vary on case to case basis to deliver following functions:

• To assist state health/food authorities in investigations of foodborne illness or outbreaks,
• To identify causes of outbreaks through environmental investigations, laboratory analysis and epidemiologic analysis,
• To track cases and complaints linked to the consumption of food, and
• To make recommendations and take necessary steps for the prevention and control of foodborne illness.

Process of Outbreak Investigation:

In the event of a foodborne disease outbreak, the food safety officers would be required to undertake the following activities as and when an alert/message received through IDSP system or consumer organisations or public or media regarding food borne disease outbreak:

1. Collect relevant preliminary information related to foodborne disease outbreak from RRT members. The information collected may include diagnosis/clinical report, suspected microbial infection, suspected food (food consumption history of the patient may be used), location of the food taken from, anything unusual about the meal/food
2. Examine/investigate the case in coordination with district/state Surveillance Officers and RRTs as soon as an alert for foodborne disease outbreak/incident is communicated and:
   1. conduct site investigations including for operational hygiene at implicated premises
   2. identify potentially implicated food product and take appropriate food samples, if available, as prescribed by FSSAI time to time (draft sampling procedure is attached with it) and send the samples to the accredited laboratories for analysis along with the Form placed at Appendix-II. In case food samples are not available then raw materials from which food was prepared may be collected and send for analysis.
   3. liaise with other FSOs of the region to determine whether the implicated product is distributed in other parts of the district/state or even other states.
3. Take appropriate and necessary action in consultation with FSCs to ensure that the further spread of the food borne disease could be mitigated. Actions taken must be under the power delegated to the FSCs in the FSS act 2006.
4. Prepare brief report describing the incidents, its severity, action taken, etc. and send interim action report to DOs, FSCs, RRT members and FSSAI within 48 hours of the alert/notification received.
5. Maintain the record of meetings with RRT and any other concerned officers, investigations, laboratory reports, action taken, etc. from the beginning of the outbreak.

Post outbreak monitoring and review:

Post outbreak monitoring includes:

Monitoring the population at risk for signs and symptoms to ensure the outbreak has ended and the source has been eliminated;

Monitoring the implicated foods or facilities to make sure no further contamination is occurring; Maintaining communication with the implicated facility, and tell them if additional information becomes available;

Increasing the number of routine inspections at the implicated facility to ensure they comply with all required procedures. Old, unsafe practices often are difficult to change, and new practices might need to be used for >1 months before they become routine.

Post outbreak review includes the review process for response activities, communication methodologies, and regulatory procedures to prevent production/distribution of implicated foods, capacity & reporting of laboratories, inspection services, and effectiveness of product recall. Based on the review learning lesions from the foodborne illness outbreak, gaps may be identified which could be addressed to improve the practice of responses to outbreaks of foodborne diseases and also preparedness for resources and development systems or of structure that can be implemented by the measures more efficiently. Further, it also includes maintenance of record of such emergencies faced like product description, type of hazard and health effects observed, actions taken and their result, duration of emergency etc.

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