Friday, November 22, 2019

Early Release - Training for Foodborne Outbreak Investigations by Using Structured Learning Experience - Volume 26, Number 1—January 2020 - Emerging Infectious Diseases journal - CDC

Early Release - Training for Foodborne Outbreak Investigations by Using Structured Learning Experience - Volume 26, Number 1—January 2020 - Emerging Infectious Diseases journal - CDC

CDC - Centers for Disease Control and Prevention - CDC 24/7: Saving Lives. Protecting People.™

EMERGING INFECTIOUS DISEASES®

Volume 26, Number 1—January 2020
Research Letter

Training for Foodborne Outbreak Investigations by Using Structured Learning Experience

Florian BurckhardtComments to Author  and Esther Kissling
Author affiliations: European Programme for Intervention Epidemiology Training Alumni Network, Heidelberg, Germany (F. Burckhardt)Epiconcept, Paris, France (E. Kissling)

Abstract

We created a free and interactive training activity based on playing cards (disease detective cards) that introduces foodborne outbreak investigations to public health professionals and students. Competencies taught cover-selected descriptive and analytic epidemiologic topics, such as case definition, epidemic curve, 2-by-2 tables, relative risks, attack rates, stratification, and confounding.
Training programs, such as the Epidemic Intelligence Service of the Centers for Disease Control and Prevention (Atlanta, GA, USA) (1) and the European Programme for Intervention Epidemiology Training of the European Centre for Disease Prevention and Control (Stockholm, Sweden) (2), teach future epidemiologists outbreak investigation skills. Their case studies for foodborne outbreaks are often based on historic investigations whose real-world complexity can be overwhelming for beginners.
An introductory study (3) used 14 exposures to explain the concept of risk factors and their association with disease. We designed a scripted foodborne outbreak investigation as a structured learnig experience with illustrated playing cards that depict exposures (food eaten) and outcome (symptoms, time to first symptoms). With the cards and a flipchart as props, facilitators teach core skills and competencies of outbreak investigations in an interactive group exercise.
We modeled a hypothetical Salmonella species outbreak investigation with a cohort design in Excel 2010 (Microsoft, https://www.microsoft.comExternal Link). We took symptoms and incubation periods from our own unpublished outbreak investigations and literature research (4,5). We reverse engineered relative risks for univariable and stratified analysis with their 2-by-2 tables into a line list with the desired properties and transcribed onto playing cards in which each card represents 1 person attending the exposure event.
Dynamic illustrations of gastroenteric symptoms and food items were hand drawn with pen and ink on Bristol board, scanned, and colored by using the GNU Image Manipulation Program (https://www.gimp.orgExternal Link). The illustrations depict characters from our earlier work, the disease detectives (6). We used OpenOffice software (https://www.openoffice.orgExternal Link) for layout of the cards. The teaching script is a restructured and simplified adaptation of outbreak case studies used during European Programme for Intervention Epidemiology Training introductory courses (2,3). The cards and other resources are available (https://www.disease-detectives.orgExternal Link) under a Creative Commons open-culture license in multiple formats for home printing or as templates for high-quality printing services.
Thumbnail of Playing cards used to describe symptoms, their timing, and food eaten as exposure for training for foodborne outbreak investigations by using structured learning experience.
Figure. Playing cards used to describe symptoms, their timing, and food eaten as exposure for training for foodborne outbreak investigations by using structured learning experience.
The exercise is for 16–26 students who play roles of participants in the outbreak event and investigate their own outbreak. Each participant draws 1 card that illustrates their fictional health status, food eaten, symptoms if ill, and time of onset (Figure). Facilitators subsequently collect the information from the cards and summarize them on a board during the 1–2-hour teaching activity as the outbreak investigation unfolds. The facilitator should have professional experience in investigating foodborne outbreaks, accompanying statistical methods, and adult learning. Their role is to tap into experiences of the participants and weave them into the narrative of the fictional outbreak investigation. Depending on the learner audience and their skills, the facilitator can use a lecture style or an activity-centered style with small group discussions and collaborative summaries (7). The exercise is designed to work without electricity and only a board or flipchart. It covers the skills of developing a case definition, collecting data for preparing an epidemic curve, and calculating relative risks as a measure of strength of association between exposure and outcome.
In addition, exposure-specific attack rates and cases explained by exposure, stratification, and confounding can be introduced at the facilitators’ discretion. The teaching script suggests the sequence of introducing epidemiologic concepts and collection of relevant data from the cards of individual participants. The exercise is limited to the epidemiologic descriptive and analytic part of an outbreak investigation and does not cover environmental investigations, such as trace back or cover laboratory methods, results, or interpretation. The card model can be extended to train other outbreak patterns (e.g., norovirus) with more vomiting as a symptom and a 2-peak epidemic curve caused by secondary human-to-human exposure.
Since 2014, we have used the teaching activity in 4 district health authority trainings and 1 training of hospital hygiene doctors in Rhineland-Palatinate, Germany. The German Federal Office of Consumer Protection and Food Safety in Berlin used the activity in 2 training sessions on outbreak investigations during 2018, and the Robert-Koch Institute in Berlin used the cards in their outbreak investigation module of an annual training for public health professionals in infectious disease surveillance and during Kids Day (8).
Source material can be modified to adapt the exercise to different cultural contexts. During training workshops in Sudan and Tunisia, under the German Biosecurity Programme of the Federal Foreign Office during 2016 and 2018 (9), hamburger and potato salad were substituted with shawarma and salade niçoise as more culturally appropriate food for northern Africa. The interactive card training tool had been positively reviewed in the training evaluation comments, and participants remained engaged throughout the session. We are planning a formal evaluation of the training tool with the field epidemiology training programs for Germany and Europe.
The exercise is a tool for building outbreak response capacities and teaches the topic in an engaging way. It can be used on its own or embedded as an ice breaker into a field epidemiology curriculum for health professionals or for school classes looking for health related project work. Supported languages are German, English, Russian, and French. Further translations and adaptations are encouraged and will be referenced on our web page (https://www.disease-detectives.orgExternal Link).
Mr. Burckhardt is a fellow supervisor and trainer at the European Programme for Intervention Epidemiology Training Alumni Network, Heidelberg, Germany. His research interests are outbreak investigations and disease surveillance. Ms. Kissling is a statistician and trainer at Epiconcept, Paris, France. Her research interests are vaccine effectiveness and influenza.

Acknowledgment

We thank Nadine Zeitlmann, Michaela Diercke, and Hannah Lewis Winter for thoroughly reading the draft version of the manuscript and adapting the German script into an English 10-steps facilitator guide; Ariane Halm and Juliane Wunderlich for performing the same activity for the French version; and Yanina Lenz for supporting the Russian version.

References

  1. Jones  DSDicker  RCFontaine  REBoore  ALOmolo  JOAshgar  RJet al. Building global epidemiology and response capacity with field epidemiology training programs. Emerg Infect Dis. 2017;23.
  2. Bremer  VBosman  ACoulombier  DNew perspectives after the transition of EPIET to ECDC: the future of the programme. Euro Surveill2009;14:19374.dExternal Link
  3. Centers for Disease Control and Prevention. Oswego: an outbreak of gastrointestinal illness following a church supper; 2003 [cited 2019 Oct 21]. https://www.cdc.gov/eis/casestudies/xoswego.401-303.student.pdf
  4. Centers for Disease Control and Prevention. Guide to confirming an etiology in foodborne disease outbreak; 2017 [cited 2019 Oct 21]. https://www.cdc.gov/foodsafety/outbreaks/investigating-outbreaks/confirming_diagnosis.html
  5. Mertens  EKreher  HRabsch  WBornhofen  BAlpers  KBurckhardt  FSevere infections caused by Salmonella Enteritidis PT8/7 linked to a private barbecue. Epidemiol Infect2013;141:27783DOIExternal LinkPubMedExternal Link
  6. Burckhardt  FKissling  E. ‘The disease detectives’: a comic perspective on outbreak investigations. Euro Surveill. 2007;12:E071122.4.
  7. World Health Organization. Immunization hand-book and facilitators’ guide. South-East Asia Regional Office [cited 2019 Jan 17]. http://www.searo.who.int/india/topics/routine_immunization/Facilitators_Guide_Medical_Officers_Handbook_2010.pdfExternal Link
  8. Robert Koch InstituteInvestigate outbreaks module [in German]Epidemiol Bull2019; (17):143.
  9. Foreign Office. The German biosecurity programme; 2017 [cited 2019 Oct 21]. https://www.auswaertiges-amt.de/en/aussenpolitik/themen/abruestung/uebersicht-bcwaffen-node/-/239362External Link
Figure
Suggested citation for this article: Burckhardt F, Kissling E. Training for foodborne outbreak investigations by using structured learning experience. Emerg Infect Dis. 2020 Jan [date cited]. https://doi.org/10.3201/eid2601.190755
DOI: 10.3201/eid2601.190755


Original Publication Date: 11/21/2019

No comments:

Post a Comment