Hello, Oregon State Public Health Division, this is Michelle (Tessa: Hi, this is Tessa with Douglas County. I just wanted to give you a heads up.) We’ve had 5 cases of Salmonella Braenderup in the last 3 weeks. (Michelle: Really? That’s unusual.) I know, right? (Tessa: We’ve done the basic case interviews with 4 of the cases…) (…and we haven’t been able to find any connections what-so-ever.) Braenderup, huh? We almost NEVER see that. What do we know about the people who are sick? Mainly kids, although we do have one case who is in her thirties and its evenly split between male and female, and the onset started at the beginning of the month but we had our last onset on Friday. (Michelle: Alright, well thanks for the heads up…) I’m going to let the outbreak team know, I’m going to check the database,we’ll get a questionnaire drafted and get that back to you so we can get started on the interviews right away Tessa: Alright that sounds like a plan. Michelle: Thank you Hey there. Tessa from Douglas County just called–she’s got five cases of Salmonella Braenderup Onsets all in the last month. Mostly in kids, evenly split between males and females Well, the lab just called and said we had a bunch of cases of Salmonella Braenderup in southern and central Oregon but we haven’t gotten age range yet And nothing from the Portland metro area? Nope Nothing from any other state? Already checked, nothing that matches by molecular typing so far Okay so, if this is food born we’re looking at something that’s sold locally and not nationally, something that seemed mostly by kids but not exclusively by kids Yeah. What could it be? I don’t know, I guess we should get started on investigation and… it could be big Hi, I’m Bill Keene Welcome to the National outbreak museum. The museum is full of exhibits from hundreds of investigations that we’ve participated in or that others around the country have participated in over the last twenty or thirty years. These exhibits commemorate why we do these investigations and the kind of products and things that could cause people to get sick in foodborne outbreaks There are a lot of different kinds of outbreaks but from the point of view of how we organize investigations there are basically two types The first are relatively simple and the mainstay of what we do, and these are event-centered outbreaks. that’s for people get exposed at one place, usually at a single time with a narrow frame. So the classic example might be kids getting sick at a school lunch, or a restaurant meal, or a wedding reception, or perhaps a week at Scout Camp The investigation focuses on the exposures that occurred at that location during that time period, and so in order to investigate we need to find out what the potential exposures are and then find out some way evaluating who had what kind of exposures, and we do that by making questionnaires The second kind of investigation involve commercial products there maybe widely distributed around the region, or multiple states, or even between multiple countries When we have those kind of outbreaks, we often don’t have clusters of cases that are readily apparent locally. Sometimes we do, but often the cases are only identified through laboratory subtyping of bacterial isolates: often salmonella or E. coli O157 And again, here the museum you can see all kinds of products that were identified that at one point in one investigation or another were implicated Dairy products, meat products, produce, packaged goods, processed foods. And the way we identify these products is by, again, doing investigations and these are generally focused around making questionnaires and interviewing our cases with these questionnaires The questionnaire is a way of getting structured information from people and the structure allows us to extract the information that we needed tabulated to do statistical analysis on it and make comparisons between groups without undue difficulty But even though you using a structured interview form the interview has to have some of the characteristics of a conversation with people often people have been sick and they they need your empathy and they need to understand what you’re doing and why you’re doing it, even as you go through the structured interviews. So again you’re trying to have a conversation with people but not have them be totally aware that you’re going through a very structured process, but doing that just the same, so that you could have as natural a conversation as possible under the circumstances Let’s take a look at some of the examples we have in the museum and I’ll tell you about how
questionnaire design and interviews help crack the mystery Years ago we had an outbreak of Salmonellosis that was due to almonds and this source which turned out to be a national outbreak caused by brand A almonds was identified with only half a dozen questionnaire interviews that were done here in Oregon. No one else it even noticed there was an outbreak of this kinda Salmonella but we started interviews, and one of the questions on the shotgun questionnaire was “Had you eaten any almonds?” And the first person said “Yes, I had brand A almonds,” And the second person said, “Why yes, now that you ask, I had brand A almonds” and it went on down the line And within hours we were able to contact this store and the product was coming off the market. By the next day there is a national recall on it It transpired, in fact, that this outbreak had been going on for over a year with cases trickling on. By using the hypothesis generating questionnaire we were really able to solve it very very quickly It is almost the same story last summer when we investigated an outbreak of E.coli o157 infections here in Oregon These cases had a matching subtype So when we started to interview people using that questionnaire, very quickly we identified that all of these people had been eating strawberries. And the strawberries have been purchased locally locally grown at farmers markets and roadside stands It took very little effort to do the trace back to identify that the strawberries came from a single grower in Oregon, and within 72 hours we’d pinpointed the exact field where in fact deer were going through the field and contaminating the strawberries as only deer can do Other outbreaks have been not so successful. There was an E. coli O157 outbreak investigation that happened with cases scattered around the country: there is only one in Oregon and unfortunately they weren’t using the Oregon questionnaire, which asks about cookie preparation and cookie dough consumption The investigation went on for over a month with people trying different kinds of interviews before. Using a different technique, just open-ended questionnaires, this clue came out. But had they been using our questionnaire I think they could have very quickly found the source. Now the shotgun questionnaire isn’t perfect We’ve worked on investigations with a reasonable number of cases, five or ten or more, where we’ve used it and we haven’t found the source. But it’s a really great tool that we think helps focus the investigation and quite often leads us directly, if not to the specific source at least to the general area that we need to pursue in. It’s a great tool and I think you’ll like using it Hi, this is Melissa Powell from the Morrow County Health Department May I speak to Carla Jean Harlow? Hi Ms. Harlow. We’re doing an investigation of intestinal infections caused by Salmonella I understand you had this type of infection two weeks ago? Correct. We’re talking with folks who are sick to find out what foods they ate in the week before they got sick It often helps us to pin down what made people ill so we can prevent illness in other people It’ll take about 45 minutes. Could I ask you the questions? Great! A common method in investigating outbreaks is to interview all people who are sick, called cases, to find out what they may have been exposed to. Whether it was food they ate, animals they had contact with, or recreational exposures such as germs or pathogens in a swimming pool or fresh body of water I’m also going to ask about other things that could increase the chance of Salmonella infection Did you handle any pets in the week before he got sick? Any contact with snakes? Lizards or iguanas? Any other reptiles? Hi, I’m Tessa and I’m from the Douglas County Health Department, and I was just wanting to let you know that there are several people in the Reedsport area that have become ill with an intestinal infection that’s caused by Salmonella. We’re talking with folks in the area to figure out the cause of the illness so that we can stop it from making other people ill Is there anyone in the home who is male in less than 15 years old? Okay And many of the people who have this infection have been children, so we’re talking with families of children who have been ill, and families who have children that haven’t been ill to compare foods and activities so that we can figure out what’s caused the infection And what’s the child’s name? And are you his mother? In addition to those who were ill another group, called controls, might also be interviewed Controls are people who share similar characteristics with a case such as age, sex, and place of residence However, people in the control group haven’t been sick
The control group’s information is then compared with the case group’s information to determine what may have caused the case’s illness For example, if most cases or sick people ate runny eggs at a certain restaurant but controls did not, you might suspect the eggs as the cause of the illness As you get started with outbreak interviewing, there are 10 cardinal rules to bear in mind We’ll go through these one by one Okay, between February 4th and February 11th, did you eat any romaine lettuce? Other leafy lettuce like red, green, or butter lettuce? Nope Arugula, endive, chard, watercress, or other salad greens? No Any “mescaleen”, spring mix, or baby salad items? Wait, what? Any “mescaleen”, spring mix, or I think it’s pronounced “Mesclun.” What the heck is that? That’s nothing, wait till we get to the part about Baba Ghanoush By practicing your introduction and going through the questionnaire with a colleague before you go live you can iron out any pronunciation issues and feel more comfortable with the interviewing process Okay now I’m asked about the kind to places you might have eaten in the seven days before he got sick Did you eat at any fast food restaurants? No? Okay, a grocery store? No? A grocery store deli, or other kind of deli? No? A bakery? Dessert place? Pastry place? Picking out a quiet spot where you won’t be distracted or interrupted makes things easier for you and easier on the person being interviewed And how many sexual partners have you had the past month? Four Oh my. Oh, nice. Uh, are you serious? Uh, well actually it was more like one Okay By remaining value neutral, a good interviewer is less likely to influence the responses of the person being interviewed. You are interviewing them, after all, to find out what might have happened to make them sick You don’t eat that much meat, do you? No, not really Am i right that you generally eat a pretty healthy diet? No butter, sour cream, mayonnaise, things like that? It may be tempting to anticipate but someone will answer By avoiding this common pitfall you can get more objective, accurate responses Next I’m going to ask you about vegetables you ate in the week before you get sick, even if it was only a bite I don’t really eat vegetables Let me write that down In this case, the interviewer has misinterpreted a general statement about preferences as a specific answer to her question I did not Yes you did I did not! Yes, you really did I have to agree on that one, sorry It’s important to record accurately what people say, and to ask each question, unless the outbreak team has decided some questions can be cut out if no cases are reporting these exposures This is Doug Oh yes thanks for calling Steve. This is Steve Jenkins, right? Good Are we speaking privately, Steve? Yeah the reason I ask that is that I’m calling from public health and I’m calling about your visit to doctor Perez’s office Okay Dr. Perez said that somebody would be calling you? Okay so I’d like to talk to you now that’s good for you Alright good, probably about maybe twenty minutes or so Correct. You got treated– when you get treated for the infection, Steve? Just two days ago, okay. How are you feeling now? Well what I wanted to talk to you about was your sexual partners like in the last about six or seven months. Well it’s not likely to get this bad, but it’s important to be aware of your surroundings and to protect the privacy of people you’re interviewing Okay ma’am, did you visit a doctor when you had your intestinal infection? Oh yes, yeah I talked to Dr. Salinger, I believe He’s such a nice man. Girls you guys are too loud, can you please go upstairs? Thank you. Yes Dr. Salinger, he’s from Cleveland, so I don’t really get to see him that much. He’s in for or covering for doctor lopez and I think I saw him for the flu, or for a cold, I can’t really remember. But he’s such a nice man Yeah he called me at 7:30 this morning and I said, “Oh doctor sounds are you are in at work awfully early,” Well, so you Maybe he was talking about the early bird and the worm I can’t really remember Okay so it sounds like you did go see a doctor for this Did you have to go to the emergency room too?
And did you have to stay overnight in the hospital at that time? And has anyone else been sick in your house with the same symptoms? Good, I’m glad to hear that. Now I’d like to ask you about some foods that you ate in the last seven to ten days before you got sick, even if it was just for a bite Let’s start with Part of the art of effective interviewing is to strike the right balance between conducting an efficient, concise interview and providing opportunity for the person being interviewed to provide additional detail, some of which may provide clues as to the cause of the outbreak Give folks a chance to give you that detail and be courteous But if the conversation is straying, gently bring the subject back to the interview topic Particularly if you have more people to interview that evening So what time last week did you first get sick? And when on monday was that? It was late that night. 2:30? 2:30 am? Okay so that was Tuesday at 2:30 a.m. The more precise you can be in pinning down answers the better This is particularly important for onset of illness because illness onsets are useful in determining both what pathogen might be involved and how it may have been transmitted Hello this is Michelle Barber from the state Public Health Division, can I please speak to Patricia Mitchell? Uh, hello is there someone there who speaks English? Okay, uh thank you ma’am I’ll have someone who speak Spanish call back shortly. Thank you If you contact a potential interviewee and the two of you don’t share a common language, politely end the call And notify the lead Epidemiologist who can arrange for another interviewer or an interpreter-assisted call Any contact with animals or pets at school, birthday parties, or similar events? Any contact with dry dog or cat food? How about any contact with any commercial type a fresh or frozen pet food that it’s not dry or canned? Okay then, thank you for helping us with these questions will combine the information with other peoples information The interviews are very helpful to us trying to understand and determine what has caused the illness. Sometimes depending on what we find we may need to follow up again. Do you have another number that we can use in case I need to reach you again? Great thank you so much for your help and thanks for talking to us. Folks who are game to be interviewed deserve a vote of thanks and a little background about how their participation in the investigation process makes a difference We may need to get back to them what specific questions so it’s good to mention that too What’s done well, and not so well, in the following interviews? Be sure to write down your observations in the following scenes Hi my name is Jamie and I’m calling from organ Public Health Division Recently several people in Reedsport and the surrounding area got sick with an intestinal infection called Salmonellosis. We’re interviewing people in the community to gather some information and figure out what’s causing people to get sick and that can help protect others from becoming ill. I’m hoping to talk with a male between the ages of 20 and 49 Is there someone in the household who fits that description? Yeah I’m 33. We’ve been interviewing the people who’ve been sick to find out what sorts of food they ate and other activities they did that might put them at risk for infection We’re also asking the same questions of people that didn’t get sick. That way we can compare foods that sick people and well people ate and that helps us figure out what might have caused the illness. Great, first I’d like to ask about the kinds of places where you might have eaten in the seven days before august 20th. This may help jog your memory about specific foods you might have eaten which I asked about a few minutes So I’m asking about places at which you had something to eat between Monday, August 13th and Sunday, August 19. Did you eat anything at any fast food restaurants? No I don’t eat fast food. Sit-down restaurants? Yeah I ate breakfast that weekend at Cup and Saucer, and then we I believe we also ate at a Japanese restaurant called Matsuya Okay any other meals at sit-down restaurants that week? No I don’t believe so. Any meals at a bakery, dessert, or pastry shop? Hey Carrie, are there more cookies left? Yeah there’s lots of cookies left. Can you get me one? Sure, just one? yeah just one, and coffee too—cream and sugar Cream and sugar, got it. Thank you. Your welcome. Sorry about that Any meals at a grocery store deli or other kind of deli? No on both counts Now I’m gonna ask a few questions about foods typically prepared
outside the home like the foods you got from a restaurant or takeout place So between Monday August, 13th and Sunday, August 19, did you have any hamburger at a fast food place? That is, at a place where you would pay before you eat No I don’t believe so Hamburgers at any other restaurant that wasn’t a fast food place? No, I don’t think so Any sandwich that might have had sprouts in it? Ugh, no I hate sprouts Any sushi, or (mispronounces:) Sashimi or (mispronounces again:) Ceviche? Uh, I’ve only heard of sushi of those three so, no I don’t think so Any kind of burrito or wrap? No Smoothies? No, definitely not Finally, I have a few questions about pets and animal contact: Again, between Monday, August 13th and Sunday, Oct 19, did you have any contact with dogs or puppies? Uh no, besides walking through parks, no. Cats or kittens? Yeah I actually visited my sister that week and she has cats that I play with Any contact the chickens, turkeys or poultry? No definitely not Other pet birds of any kind? No. Reptiles, including lizards, snakes, turtles and tortoises? Yeah I actually have a pet boa Any contact with amphibians like frogs, toads, or salamanders? No to all three Gold fish or aquarium fish? No, also not Contact with rats, mics, or gerbils? Yeah I actually buy mice for my pet boa down the street at a pet food store Are those frozen or live mice? They’re alive. I actually like to dangle the little guys into Amanda’s– my boa’s–cage until she locks in on them, and then I slowly lower them in and she comes in and wraps around them It’s really quite something to watch. Ew that sounds so gross I hate snakes and mice. Any contact with exotic pets or pocket pets like ferrets, pygmy hedgehogs, or giant Gambian pouched rats? Gambian pouch rats? No. And any visits to pet stores, swap meets, or other places where animals or birds were sold or shown? No Okay, that’s all the questions that I have. Thanks so much for doing this interview By comparing your responses with other people who got sick, we can often get important clues as to what caused their illness, and that can help keep other people from getting sick. Sometimes after we review the results and compare them other important questions might come up. If we need to talk with you again could we get a hold of you at the same number? Yeah, this number is fine. Perfect! Thank you again for your time. Bye Thank you, bye Please refer to “The Good, the Bad, and the Ugly” answer key to see how you did for scene 1 Hello? Hi this is Alyssa Bostian with The Oregon Public Health Division. Are the parents of Ryan Robinson available? Yes this is Julie, Ryan’s mother. I’m with Oregon Public Health Division and I’m calling today to gather some information about your son Ryan’s recent illness Ryan and several other people in your area have been sick from the same type of infection and it’s caused by an organism called Salmonella Yes, Ryan’s pediatrician told us about it. Well we at the Public Health Division are working with folks at Clackamas County Health Department to find out what may have made Ryan and others sick in order to help prevent others from becoming sick. Oh, thank you for doing, he was really sick Well to begin with I’d like to ask some questions about places you may shop, and restaurants where Ryan may have eaten and I’ll also ask about specific foods that Ryan may have eaten at home, school, or other places during the week before he became ill All of the information will be kept confidential. Is this a good time for you? Sure Great, so when exactly did Ryan first get sick? Well, he had been a bit of a runny nose and a cough about a month ago but that may have not and the same thing Thinking specifically of his recent illness, when did those symptoms start? It was on Thursday. Which Thursday? Let me get to a calendar. The 16th Okay, that’s consistent with information my colleagues at the county collected Do you remember what time Thursday morning? It had to have been we’d already fixed breakfast um, and the kids had eaten. So it had to have been between 7:30 and 10:30 And what’s your best guess at the exact time? Well, my husband had taken the kids to school so it had to have been 10:30 Okay, and what time were his first symptoms with vomiting or diarrhea? It was 10:30 and the first symptoms were diarrhea And was anyone else in the household sick with diarrhea and vomiting the week before Ryan got sick? No, no one else was sick in the house. Okay. Did Ryan go to the emergency room because of this illness? Yes he did, twice. And don’t you have a regular health care provider you could have used?
Yes, she’s great. Ryan just became sick after hours so we had to go to the emergency room. And did Ryan have to stay in the hospital overnight? No he did not. Alright, next i’m going to ask about where the food that Ryan are during the seven days before he got sick came from So this isn’t necessarily where you shopped on those days but where the food he ate during that time came from Okay. Did any of the food come from grocery stores or supermarkets? Yes it did, it came from WinCo, Grocery Outlet, and Safeway. Anything from large warehouse stores? Well yes I do have items from Costco around the house. And he wouldn’t have had any home-grown produce would he? Well he possibly could have had collard greens and kale But I’m not sure… Well if you’re not sure No, yeah he didn’t have any of that Okay, I also want to ask about specific restaurants and fast food places that Ryan during the week before he got sick. Again that’s between February 9th and 15th I’ll give you the name of restaurants and you let me know yes or no, if Ryan ate there during that time. Sound okay? Yes, it does. Great, Did he eat at A&W? No. Baskin-Robbins? No Dairy Queen? You know I think he did get a dip cone there at one time Okay. KFC? No Famous Julius? Oh wow we did go there a few months back. Man that place was filthy! Talk about grungy That place was gross. I’m surprised we all didn’t get sick Oh. Unbelievable. It’s amazing how a place like that can stay open Oh wow. And man, those fries? Ugh, so greasy. Uh huh And that calamari, gag we with a spoon So definitely not one of your better dining out experiences? You can say that again. Okay well thinking about other places Ryan ate, again during the seven days before he got sick, did he eat at Panda Express? No. Taco Bell? No. Burgerville? No Okay great, well that’s all the questions I have for now Can you can give me a second more of your time to review all the information I’ve collected? I want to make sure I’m not missing anything. Yes Okay, well it looks like we’ve covered everything for now. If there’s additional information we need we may have to contact you again Is this the best number and time to reach you? Yes this is the best number, during weekdays please. Thanks so much for your time in taking part in this interview This information is extremely valuable in helping us track down the source of these infections and in preventing additional illess within the community You’re very welcome. If you find out what caused Ryan to become sick will you call me? Hmm, I’m not quite sure if we’re able to do that I’ll have to run that by the lead investigator and get back to you. Thank you very much for doing this work We hope nobody becomes sick like Ryan was. He was really sick Great well I’m glad he’s doing better Thanks again very much for your time. I’ll make sure and talk to the lead investigator and get back to you Okay, bye now. Okay, bye Please refer to “The Good, the Bad, and the Ugly” answer key to see how you did for scene 2 So when you are getting ready to do your reviews it’s good to keep in mind why are we doing this at all? There are a number of reasons why we do outbreak investigations and you should think about. It’ll help motivate you to do a good job and to do a job as quickly as possible. The main reason, the most obvious reason I should say is to stop ongoing transmission. If a commercial product is on the market or some Typhoid Mary is working in the local restaurant, we wanna find ’em and get ’em out of circulation as quickly as possible to prevent additional cases That’s obvious, but a lot of outbreaks are over before we hear about them In those cases the rewards are somewhat more distant, but still quite real. The reason we know so much about these various agents, that we know that E.coli O157 is often a link to produce or hamburger or other sources, or that norovirus infections come from food handlers working when they’re sick and not washing their hands well. We know these kinda things because collectively we’ve pooled information from thousands of outbreak investigations And that kinda stuff gets distilled and becomes the underpinning of our general knowledge so that’s really important to do And, lastly this kind of information becomes something that we help to use to make good regulations for government agencies and that industry and businesses involved in food preparation and food production
use to change their practices in order to reduce the risk to future consumers