David Nicholas, MPHNew York State Department of Health

Bureau of Community Environmental Health and Food ProtectionDavid.nicholas@health.ny.gov

National Voluntary Environmental Assessment Information System

(NVEAIS)

National Center for Environmental Health

Environmental Health Services Branch

Original Presenters:Carol Selman, MPH

Team Lead, Food Safety Team, Environmental Health Services Branch, Division of Emergency and Environmental Health Services,

NCEH

Kristin Delea, MPH, REHSHealth Scientist/Epidemiologist

Overview Background

EHS-Net NVEAIS

Environmental Assessments: A systems approach to foodborne illness outbreak investigations Systems Theory Contributing Factors Environmental Antecedents

NVEAIS – Data Collection Information the data can provide How can we use the data

Training/ E-learning

BACKGROUND

Environmental Health Specialist Network

EHS-Net (pronounced S-Net) is a collaborative forum of environmental health specialists whose mission is to improve environmental health practice.

These specialists collaborate with epidemiologists and laboratorians to identify and prevent environmental factors contributing to foodborne and waterborne illness outbreaks.

EHS-Net Background

Environmental Health Specialists Network Collaboration between:

• US Centers for Disease Control and Preventiono National Center for Environmental Healtho Environmental Health Services Branch• US Food and Drug Administration

o Center for Food Safety and Applied Nutrition• US Department of Agriculture

• 8 siteso California, Cerro Gordo Iowa, Minnesota, New

York, New York City, Rhode Island, San Mateo California and Tennessee

EHS-Net Background

EHS-Net work is based on a system theory.EHS-Net assists state health departments in their efforts to improve the practice of environmental health service programs. EHS-Net conducts environmental assessments to determine why an agent was present in the environment in such a way that the host could be exposed. EHS-Net works to

Identify environmental antecedents (underlying factors) to illness and disease outbreaks.

Translate findings into improved prevention efforts using a systems-based approach.

Offer training opportunities to current and future environmental health specialists.

Strengthen collaboration among epidemiology, laboratory, and environmental health programs.

NVEAIS Background

EHS-Net Foodborne Outbreak Study Objective: To identify contributing factors to foodborne

illness outbreaks in food-service facilities and to describe the characteristics, policies and practices of those facilities.

What we learned No consensus on what a foodborne illness environmental

assessment was No standard methodology for conducting foodborne

outbreak environmental assessments Need for training on how to conduct a foodborne

outbreak environmental assessment using a systems approach

The Need to Improve Reporting of Environmental Factors to Foodborne

Illness Outbreaks

Environmental factor data are key to To improve hazard surveillance . To inform foodborne disease prevention policies Understanding how and why outbreaks occur. Preventing future outbreaks.

Limited environmental factor data are currently reported to CDC’s existing National Outbreak Reporting System (NORS).

Inspectors (environmental health specialists) need training on collecting environmental factor data during outbreak investigations.

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The Need to Improve Reporting of Environmental Factors to Foodborne

Illness Outbreaks

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Contributing factors

• Factors that caused the outbreak

• How the outbreak occurred

Environmental

antecedents• Circumstances

that led to the contributing factors

• Why the outbreak occurred

Environmental factors

The Need to Improve Reporting of Environmental Factors to Foodborne

Illness Outbreaks

Environmental

antecedents• Worker in a

hurry

• Worker had not been trained on avoiding cross contamination

Contributing factor

• Cross contamination

• Worker used same utensils on raw ground beef and salads

Outbreaks

• E. Coli

• Outbreak caused by salads eaten at Restaurant A

NCEH/EEHS Activities to Improve Reporting of Environmental Factors to Foodborne Illness

Outbreaks Developed

National Voluntary Environmental Assessment Information System (NVEAIS)

e-Learning on Environmental Assessment of Foodborne Illness Outbreaks

Launched in April 2014 Purpose

NVEAIS: Discover environmental factors that cause foodborne outbreaks to prevent next one

e-Learning: Improve competency in collecting environmental factor data during foodborne outbreak investigations

http://www.cdc.gov/nceh/ehs/NVEAIS/index.htm; http://www.cdc.gov/nceh/ehs/elearn/ea_fio/

NVEAIS Purpose

Identify factors that can be routinely monitored by food control authorities to prevent or reduce the risk of foodborne outbreaks

Characterize food vehicles and monitor trends Identify and monitor contributing factors and

environmental antecedents Hypothesis generation Guide planning, implementation and evaluation of food

safety programs

NATIONAL VOLUNTARY ENVIRONMENTAL ASSESSMENT INFORMAITON SYSTEM

Improving Surviellance

Definition Environmental Assessment

The component of an outbreak investigation that fully describes how the environment contributed to the introduction and or transmission of agents that cause illness. Environment is everything external to the host, including air, food, water, animals, plants, climate, etc as well as people, social and built environments.

• All aspects of the external environment can be listed as variables that, in relation to transmission, are neutral, conducive or protective.

• From this description contributing factors and environmental antecedents to an outbreak can be determined.

NOT an inspection

Foodborne Outbreak Environmental Assessment

Conducted as part of the foodborne illness outbreak team

A reconstruction of past events in the context of the outbreak investigation

Taking a systems approach

Inputs - Are the items which feed into the system

Process - Are the steps and methods to which the inputs are subjected

Internal System Variables - Are the factors that exert positive, negative and neutral influences on all other aspects of the system

Outputs - The immediate results of the system

Outcomes -What happens as a result of the outputs

External Feedback to System

Contributing Factor Definition The factors likely to be conducive to the

contamination and survival of the etiologic agent or suspected agent and/or to its growth or proliferation. Contamination Factors

• Toxic substance part of the tissue , Contaminated raw product, Cross-contamination of ingredients, Bare-hand contact by a food handler/worker/preparer who is suspected to be infectious

Proliferation Factors • Improper cold holding due to malfunctioning refrigeration

equipment, Improper hot holding due to improper procedure or protocol, Prolonged cold storage

Survival Factors• Insufficient time and/or temperature during cooking/heat

processing, Insufficient time and/or temperature during reheating

Contributing factors are NOT food code violations

Environmental Antecedents Definition

Root causes

Supporting factor(s) to the contamination, survival or increase of biological or chemical agents in food

They may be related to People Equipment Process Food Economics Behavior Other circumstances

Environmental Antecedents

Equipment

Economics

Processes

Food

Environmental Antecedents Related to Food System

Variables

People

• Location of hand wash sinks

• Availability of supplies for hand wash sinks

• Training• Supervision• Water available for hand

wash sinks• Availability of a supply of

gloves

People

Economics

Processes

Food

Equipment

• Design• Construction• Cleanability• Maintenance• Placement• Installation

Environmental Antecedents Related to Food System

Variables

People

Equipment

Economics Food

Processes • Handling after kill step• No kill step where kill

step is required• Multiple- step

processes

Environmental Antecedents Related to Food System

Variables

People

Equipment

Economics

Processes

Food

• Source• pH• Water activity (Aw)• Viscosity

Environmental Antecedents Related to Food System

Variables

Food

People

Equipment

Processes

Economics

• Shifting food trends• Profit margins• Operational costs such

as • Cost of food• Cost of equipment• Cost of facilities• Cost of staffing and

training

Environmental Antecedents Related to Food System

Variables

The Food Establishment System

Final Food Item

Ingredients

Organisms

Chemicals

Customer Health

Customer Satisfaction

Profit

External Feedback to System

Receive

Store

Prep

Cook

Cool

Reheat

Assemble

Hold

Serve

Processes

Internal System Variables

People

Food Economics

Equipment

Example Thorough

understanding of the problem On the ground

assessment by Environmental Health Specialist or Environmental Engineer

Identification of underlying causes of problems (not just symptoms) Contributing Factors Environmental

Antecedents

DATA COLLECTION

Data Collection

Data collection for FBIO environmental assessments Standardized data collection instrument to report

information FBIO environmental assessments Validated questions Identifying contributing factors Understanding how selected environmental antecedents

are related to contributing factors, vehicles, and agents

Is not a form or template for conducting a FBIO environmental assessment

Data Collection Tool

Part I General Characterization of Outbreak

Part II Establishment Description

Part III Manager Interview

Part IV Establishment – Observation

Part V Food Vehicle

Part VI Sampling

Part VII Contributing Factors (CF)

Part VIII National Outbreak Reporting System (NORS)

INFORMATION THE DATA CAN PROVIDE

Food Processing Characterization of the establishment (Part

II) 81.6 % Complex 15.6 % Cook / Serve 2.9 % Prep / Serve

Characterization of suspect food preparation (Part V) 25.3 % Complex 27.2 % Cook / Serve 47.5 % Prep / Serve

31.2% served raw or undercooked animal products (Part I) Of these, 61% did not have a customer advisory

Part – III Establishment Characteristics

Facilities

91% restaurants

• Independent 68%

Median meals/day 240

Busiest on weekends

In 50% food handler to kitchen manager ratio ≤ 4:1

Part III- Busiest Day

MONDAYTUESDAY

WEDNESDAY

THURSDAY

FRIDAYSATURDAY

SUNDAY

UNSURE / MISSING

Disposable Gloves

Yes No Missing

Glove Policy*

193 (79.1) 48 (19.7) 3 (1.2)

Glove Supply**

198 (81.1) 41 (16.8) 5 (0.4)

Glove Use** 159 (65.2) 72 (29.5) 13 (5.3)

*Part III**Part IV

Part V- Suspected Food Vehicles in Foodborne Disease Outbreaks

Ingredient n (%)

Produce 188 (50.8)

Poultry 42 (11.4)

Dairy 36 ( 9.7)

Beef 23 ( 6.2)

Pork 19 ( 5.1)

TRAINING

The Need for Training In 2001 Selman and Green surveyed local

and state Environmental Health Specialists (EHS) and found

EHS focus on pathogens during outbreaks instead of contributing factors and their environmental antecedents

A lack of communication between epidemiologist and EHS was found to be a barrier to EHS active engagement in foodborne illness outbreak environmental assessments

Local EHS staff require training because they are not involved in outbreaks often enough to attain competency in environmental assessments

EHS were in need of a basic training in how to conduct foodborne illness outbreak environmental assessments

Selman, CA and Green, LR (2001). Environmental health specialists’ self-reported foodborne illness outbreak investigation practices. Journal of Environmental Health, 20(6),16-21.

Using Environmental Assessments to Investigate

Illness Outbreaks Environmental Health Specialists are

accustomed to look for violation of regulations not contributing factors and their environmental

antecedents Performing an environmental assessment (EA) requires a

different mindset than other environmental food safety activities

No two outbreaks are alike No single ‘checklist’ applies to all environmental

assessments Conducting an EA requires a complex set of

knowledge and skills including the ability to apply ‘critical thinking’

Training must promote development of competency in the field and not just the acquisition of knowledge

Goal of this Training Effort Use cutting-edge e-learning technologies to

develop competency with Foodborne Illness Outbreak Environmental Assessments and deliver training free of charge over the Internet to enhance global food safety

Incorporation of ‘Gaming’ Each virtual learning experience scenarios

is framed as a forensic investigation mystery of an outbreak

Participants decide

Who to interview What topics to interview about Which actions to take What observations to perform and samples to collect

At end, learners must identify contributing factors and environmental antecedents

Actions and conclusions are tracked and evaluated

Learners receive individual feedback on results

Accompany the Worker

The Cognitive Domain

Involves knowledge and the development of intellectual skills

Includes 6 categories of behavior Knowledge (recall data or information)

Comprehension (understanding the meaning)

Application (use a concept in a new situation)

Analysis (separate materials into component parts)

Synthesis (build a pattern from diverse elements)

Evaluation (make judgments)

Analysis of Learner Performance

Learner receives individualized feedback on: Interview effectiveness

• Did the learner choose the correct questions?

Interview efficiency• Did the learner choose the questions in the correct order?

Observational skills• Did the learner find all the important embedded clues in

the environment?

Critical thinking• Did the learner correctly identify contributing factors and

environmental antecedents

VIRTUAL WORLD TRAINING

E-Learning on Environmental Assessments of Foodborne Illness Outbreaks

Promotional Video

https://www.youtube.com/watch?v=77w9aVeROiA&index=1&list=PLvrp9iOILTQaRWTguYiBvPlVB7R-88Wbq

PARTICIPATING IN THE TRAINING

Information

www.cdc.gov/nceh/ehs Provides information about e-Learning on

Environmental Assessments of Foodborne Illness Outbreaks and NVEAIS

Registration information Complete the registration Take the pre-test

Important Websites

• More information on CDC EHS-Net:– http://www.cdc.gov/nceh/ehs/EHSNet/

• Information on National Voluntary Environmental Assessment Information System (NVEAIS):

– http://www.cdc.gov/nceh/ehs/NVEAIS/index.htm

• Additional information on e-Learning:– http://www.cdc.gov/nceh/ehs/eLearn/EA_FIO/index.htm

• Register for the e-Learning course at:– https://ehseleafio.cdc.gov/

• National Outbreak Reporting System (NORS) Guidance:– http://www.cdc.gov/nors/pdf/NORS_Guidance_20130219_508c.pdf

• National Outbreak Reporting System (NORS) Form:– http://www.cdc.gov/nors/pdf/NORS_CDC_5213.pdf

Acknowledgements• Centers for Disease Control and Prevention

– Carol Selman– Kristin Delea– Erik Coleman– Laura Brown

• EHS-Net Site Partners

• Local Health Departments

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention (CDC).

Thank You! Questions

David C. Nicholas, MPHNYSDOH BCEHFPPh:518-402-7600Email: David.nicholas@health.ny.gov