Applied Outbreak Investigation Training Instructor’s Guide
Applied Outbreak Investigation Training
Instructor’s Guide
Course Designed By:
Nicole Comstock, MSPH, Rachel Jervis, MPH, &
Nereida Corral, MPH
Colorado Department of Public Health and Environment
Alice White, MS
Colorado School of Public Health
Acknowledgements:
Elaine Scallan, PhD, Alicia Cronquist, RN, MPH,
Nisha Alden, MPH, Kate Lujan, RN, MPH, Marigny Klaber, MSc
Table of Contents
Course Overview 3
Course Goal and Outcomes 3
Course Goal 3
Course Objectives 3
Instructor Prerequisites 3
How to Use This Guide 4
Course Coordination 4
Target Audience 4
Class Size 4
Host Agency Responsibilities 5
Training Supplies checklist 5
Final Arrangements 6
Two weeks before the course: 6
One week before the course: 6
Immediately prior to the course: 6
Presenter Course Agenda 7
Instructor: Presentation Requirements 7
Before the Training Event Preparation List 7
During the Training Event 8
After the Training Event 8
Outbreak Scenario for Instructors 9
Course Overview
This in-person trainingis an intermediate level course for State and local public health agency staff who could potentially work on an outbreak investigation, including epidemiologists, public health nurses, environmental health specialists, emergency preparedness staff, etc. Ideally, attendees will have previously taken a “Basics of Communicable Disease” course or be familiar with communicable disease investigation in their jurisdiction.
The training is designed to be an intensive, interactive, full-day course to teach epidemiological skills during a foodborne outbreak investigation. It includes lectures, practical outbreak scenario exercises, and discussion. There is an option to integrate interactive polling clicker devices for quizzing participants during the lectures and outbreak scenario.
Course Goal and Outcomes
Course Goal
Provide practical training to participants so that they understand and practice the various steps involved in foodborne illness outbreak investigations.
Course Objectives
After completing this training, participants should be able to:
• Define what constitutes an outbreak.
• Identify when an outbreak investigation is necessary.
• Understand and practice the basic steps of an outbreak investigation.
• Understand the roles and responsibilities of epidemiology, environmental health, and laboratory in an outbreak investigation.
• Identify and know how and when to use outbreak resources and tools available to assist local public health agencies during outbreaks.
• Know how to document and report on outbreak findings.
• Discuss communication strategies to employ during an outbreak.
Instructor Prerequisites
Prior to instructing this course, instructors should have completed the course and read through the instructor’s manual.
How to Use This Guide
This Instructor’s Guide is designed to assist instructors in their organization and delivery of this training.
· All the required materials (listed in bold italics in this document) for this course can be found at the Colorado Integrated Food Safety Center of Excellence website (www.COFoodSafety.org).
· Preparation tips and instructions can be found throughout the guide to assist in efficiently and effectively coordinating and delivering the training
· At the end of this guide there is an Outbreak Scenario guide that should be used to assist the instructor(s) as they go through the training. This scenario guide contains answers for each corresponding question that the participants are asked during the training regarding the outbreak scenario. As well as explanations of important information.
· It is vital that instructors review this packet and contact CDPHE should they have any questions or concerns prior to the training.
Course Coordination
The host agency should begin advertising once a training date has been chosen. Please see Applied Outbreak Investigation Flyer for an example template.
Once participants are confirmed (via selected RSVP method), the host agency should email the Agenda and directions to the meeting location.
There is the highly encouraged option to incorporate interactive polling clicker devices into this course. One version of the slides provided uses TurningPoint by TurningTechnologies. These can be used to test participants’ knowledge during the training. When the instructor gets to a particular slide, participants can select their answer on the clicker and results will be compiled. If interactive polling clicker devices will be used during this course, the host agency should secure these for the course. If using any clicker system other than TurningPoint you must link the slides. Alternatively, multiple-choice cards can be used for participant voting and have been provided on the CoE website.
Target Audience
This course is designed for public health staff involved in outbreak investigation.
Class Size
The suggested class size is ~20-40 people. The maximum class size should be close to 45-50 people. Smaller groups encourage discussion and interaction.
Host Agency Responsibilities
Training Supplies checklist
Visual aids for this course consist of PowerPoint slides and video clips. The following equipment is necessary for delivery of this course:
· LCD projector compatible with a notebook computer and cables for proper connection
· Spare projector bulb (optional)
· Electronic remote device to advance slides in PowerPoint presentation (if available)
· Projection screen (at least 6’ x 6’)
· Laser pointer (optional)
· Interactive polling clickers networked to computer (optional, but highly encouraged). Recommended: TurningPoint by TurningTechnologies as one slide set contains TurningPoint questions.
· Power cord
· WiFi in room
· Speakers/audio in room
· Lab supplies: Local stool specimen testing lab form, pudding, Amies swabs, specimen container labels, and gloves
· Participant Workbooks
· Flash drive with instructor materials
· Preloaded video and CoE website
· Preloaded Epi Info™ 7
· Name Tents 2 sided
· Table Tents 2 sided
· Cowbell or other noise makers (optional)
· Norovirus section supplies (Slide notes for this section have instructions for use)
o Toy shopping cart
o Toy food
o Bucket
o Small broom or mop
o Baseball cap
o Apron
o Plastic Knife
o Plastic Plate
· Food: Coffee, breakfast, snacks (granola bars, water bottles, fruit), and lunch (optional) If not providing lunch, allow for a longer lunch break
Final Arrangements
Two weeks before the course:
1. Print all the training materials:
o Participant Workbooks (Different from presentation- there are no correct answers, and no scenario slides)
§ Materials should be printed and placed in individual binders in the following order: Cover Page, Participant Agenda, Welcome and State Data, Steps in OB investigation handout, Establish existence of OB, E. Coli Fact sheet, Blank Calendar, Form a team, Blank page, Team members Handout, Etiology, Lab Form, Blank page, Identify cases, Describe and Orient Data, Blank page, Line List with Table 1, Graph Paper, Hypothesis, Blank page, Epi, Questionnaire, Exposure Data- Food Analysis, EH, Blank page, Control Measures, Blank page, Communication, Blank page, Closing and OB, NORS Form, Norovirus, Blank page
o Attendance Sign-in Sheet
o Multiple Choice Cards (if not using interactive polling clickers)
§ These will be used in place of interactive polling clickers for participants to “vote” for answers.
§ See printing instructions on the first page of the document.
§ One set for each participant.
§ Laminate (optional).
o Certificate of Completion
§ One for each participant
§ Print on quality stock paper and sign
2. Reconfirm the training facilities, equipment and catering (if applicable).
3. Check to make sure a technician is available in case there are problems setting up the room or if something goes wrong during the course.
One week before the course:
1. Finalize presenter agenda.
2. Send reminder email with the Agenda and driving directions (if necessary) to the participants.
Immediately prior to the course:
1. Make sure all the materials are brought to class:
o Participant Workbooks
§ Should include updated version of PowerPoint presentations received from instructor(s).
§ Additional resources for participants on www.cofoodsafety.org
o Attendance Sign-in Sheet
o Signed Certificates of Completion
o Computer
§ Connected to projector
§ Updated PowerPoint presentations received from the instructor (see Instructor: Presentation Requirements for details) and Video, Epi Info™7, and CoE Website loaded onto computer
§ Interactive polling clicker receiver (optional) networked to computer
o Interactive polling clicker devices (optional)
2. Set-up the classroom (horse-shoe or small group tables if room allows)
3. Set a Participant Workbook at each seat.
4. Post directional signs.
5. Test all equipment.
Presenter Course Agenda
Example Times / Allotted Time / Lesson Title8:30 - 9:00 AM / 30 min / Check-in / Breakfast
9:00 – 9:15 AM / 15 min / Welcome and introductions
9:15 – 9:20 AM / 5 min / Overview of State Outbreak Data
9:20 – 10:10 AM / 50 min / Outbreak Background, Establishing the Existence of an Outbreak, and Forming a Team
10:10 – 10:20 AM / 10 min / Break
10:20 – 11:05 AM / 45 min / Verifying the Diagnosis
11:05 - 11:45 AM / 40 min / Define and Identify Cases
11:45 AM - 12:15 PM / 30 min / Lunch
12:15 - 12:30 PM / 15 min / Recap of the morning, Describing and Orienting the Data
12:30 – 12:40 PM / 10 min / Developing a Hypothesis
12:40 – 1:40 PM / 60 min / Evaluate Hypothesis- Epidemiology
1:40 – 1:50 PM / 10 min / Break
1:50 - 2:20 PM / 30 min / Evaluating Hypothesis- Environmental Health
2:20 – 2:35 PM / 15 min / Implement Control and Prevention Measures
2:35 – 2:50 PM / 15 min / Communication During an Outbreak
2:50 – 3:00 PM / 10 min / Closing and Outbreak
3:00 – 3:45 PM / 45 min / Norovirus Outbreaks
3:45 – 4:00 PM / 15 min / Questions, Closure, and Evaluations
Instructor: Presentation Requirements
Before the Training Event Preparation List
Confirm the training dates, location, and number of participants.
1. Read, review, and modify (when necessary) the following materials:
· Instructor’s Guide
· PowerPoint Presentation:
o Insert State information on slides: 2,9-13, 46 (state specific lab info), 49 (getting specimens to the lab)
o (Optional): Link slides to interactive polling clicker devices if using something other than TurningPoint.
§ Link slides: 18,19, 20, 26, 33, 57, 58, 59, 81, 82, 83, 102, 103, 104, 105, 106, 140, 147, 166, 170, 172, 175, 179, 183, 190-195
2. Email updated PowerPoint presentations to designated person so that he/she can upload them onto the computer to be used during the course and send them for print in the participant packets. Instructors should also save updated PowerPoint Presentations on a thumb drive as a backup.
During the Training Event
1. Arrive early. Give yourself plenty of time to get organized.
2. Circulate the Attendance Sign-in Sheet and be sure all participants sign-in.
3. Start on time and stay on track. Keep exercises within their time limits.
4. Be available during break and after class for questions.
5. Mentor participants during the activities. Walk among groups during exercises, answer questions and offer guidance as appropriate. Ensure participants are on track as they work. Give constructive feedback during the presentations and discussions.
6. Perform evaluation of the training at the end.
- Use either clicker questions or handout your own evaluation document
After the Training Event
1. Please email with feedback, comments and/or evaluations regarding this course. This will facilitate improvements on future courses.
Outbreak Scenario for Instructors
Questions for attendees are italicized.
STEP: Establish Existence of an Outbreak
You work at Mountain County Public Health.
It is Friday, December 19, at 3:00 pm.
You receive a Shiga Toxin-Producing E. coli (STEC) case in the Electronic Disease Reporting System which has been confirmed at the State lab as E. coli O157:H7.
You promptly contact the case, a 25-year-old male; he reports that he ate the majority of his meals out in the week prior to his illness.
He says his roommate has also had some diarrhea in the last week.
Shiga toxin-producing E. coli (STEC): pathogenic; different than E. coli found in our guts
Symptoms / Diarrhea (often bloody), abdominal pain, sometimes vomiting and feverIncubation Period / 1 – 10 days (avg 3-4)
Duration / Up to 12 days (can shed for longer)
Transmission / Contaminated food/water (especially ground beef, produce); fecal-oral (animal-to-human, human-to-human)
Reservoir / Gut of cattle, deer, elk, goats, other animals
Special Considerations / Low infectious dose; important cause of hemolytic uremic syndrome (HUS) in children; can persist in environment
Timeline review—Review the calendar of events that occur during the outbreak as you go through the scenario. An example calendar is provided on the last page of this guide.
Question for group: Is this an outbreak? (Yes / No / I don’t know)
Correct Answer: I don’t know, need more information to determine if it is an outbreak
On Monday morning, December 22, you receive a phone call from Rita, a resident of Valley County (a county adjacent to you).
Rita and members of her frisbee golf team have experienced “stomach flu” over the past week.
Over a week ago, during the weekend of December 6-7, they participated in a frisbee golf tournament in Mountain County.
Question for group: What questions would you ask?
Answers: How many people are on the Frisbee team?
Where do team members live?
How many have been sick with GI symptoms since the tournament?
What are the ill members’ symptoms?
Have any been hospitalized?
Where did the team eat during the tournament?
What other exposures did they have? Animals? Recreational Water?
From your interview with Rita, you learn:
· There are 18 adult players on the team.
· Team members live in Mountain, Valley, and Plateau Counties.
· Rita knows that at least 4 have been sick with some sort of GI symptoms since the tournament, but does not know their exact symptoms. Rita has been ill as well.
· One ill person is currently hospitalized in Plateau County.
· While in Mountain County, the team dined at Burger Central and Deli Queen on December 7.
After talking to Rita, you logged the complaint into Mountain County’s foodborne illness complaint system.
Question for group: Here’s a copy of the abbreviated complaint log. What are you concerned about?
Answer: Burger central has other complaint, sick while eating and ill household member
You notice that the STEC case you interviewed on Friday, December 19, also ate at Deli