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Page 1: Belize FBD Manual-MOH- September 1 ,2009 BAHA-MOH … · - 2 - The Epidemiology Unit, Ministry of Health, Belize, 2009 Revised Edition Bodden, John – Senior Public Health Inspector;

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Page 2: Belize FBD Manual-MOH- September 1 ,2009 BAHA-MOH … · - 2 - The Epidemiology Unit, Ministry of Health, Belize, 2009 Revised Edition Bodden, John – Senior Public Health Inspector;

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The Epidemiology Unit, Ministry of Health, Belize, 2009 Revised Edition Bodden, John – Senior Public Health Inspector; DeShield, Michael – Director, Food Safety Laboratory Emmanuel, Englebert – Surveillance Officer/Biostatistician; Gough, Ethan – National Epidemiologist; Herrera, Doreen – Director Laboratory Services Foodborne Disease Surveillance Manual, Belize: A guideline for foodborne disease surveillance and outbreak investigation. Ministry of Health, Belize. (2009). All rights reserved. Reproduction and dissemination of material in this information product for educational or other non-commercial purposes are authorized without any prior written permission from the authors provided the source is fully acknowledged.

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CONTENTS Page Acknowledgements 5 Foreward 6 Abbreviations 7 Definitions 8 1. Introduction 10 2. Objectives of FBD Surveillance System in Belize 10 3. Benefits and Products of a FBD Surveillance System for Belize 11 4. Organization of FBD Surveillance System 11 5. Epidemiological Surveillance 12 5.1 Stages of epidemiological surveillance for FBDs 12 5.2 Reporting 13 5.2.1 Reporting and investigation requirements 13 5.3 Investigation of FBD outbreaks 16 5.3.1 National Advisory Committee 16

5.3.2 Control of FBD Outbreaks 18 5.3.2.1. Control Measures 18 5.3.3 Basic food safety practices 19

5.4 Dissemination of information 20 5.5 Laboratory support 20 5.5.1 Specimen collection and transport 21 5.5.2 Procedure for collecting Clinical Specimens 22 5.5.3 Procedure for collecting Food Samples 23 5.5.4 Criteria for sample rejection 23

5.5.5 Foodborne Disease Diagnostic Capability At CML & CIL 23 5.5.6 Procedure for Collecting Food Samples 24 5.5.7. Food Collection and Sampling 25 5.5.8. Sampling Equipment 26 5.5.9 Procedures for the Collection of Water Samples 26

6. Indicators 26 6.1. Administrative indicators 26 6.2. Epidemiological indicators 26 6.3. Activity indicators 27

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7. Bibliography 29 8. Annexes 30

Annex 1 Aetiological (Bacteria) Agents and Clinical Features 31 o Salmonella 31 o Shigella 31 o Campylobacter 32 o Escherichia Coli 32 o Other 34

Annex 2 FBD Surveillance Form and Guidelines for Filling

the Form 35

FBD Form 1: Faecal Sample Rejection Notification 38 FBD Form 2: Foodborne Disease Investigation 39 FBD Form 3: Surveillance Notification 41 FBD Form 4: Food Handlers Health Status 42 FBD Form 5: Suspected FBD Attack Rate Tables 43 FBD Form 6: Combined Attach Rates 45 FBD Form 7: Final Report 46 FBD Form 8: BAHA CIL sample submission 47

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ACKNOWLEDGEMENTS

The Epidemiology Unit, Ministry of Health, Belize, would like to express its appreciation to all those who contributed to the preparation of this document through the provision of their time and expertise and the revision of the document to ensure it met the needs of Belize. Special appreciation is extended to the Foodborne Disease Unit, CAREC, for their technical support and guidance; and to the Foodborne Disease Surveillance technical officers of Belize, for the time and effort that they freely dedicated to the preparation of this manual.

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FOREWORD

The Ministry of Health is committed to ensuring health for all and to have the proper mechanisms in place to rapidly detect any changes in the human health status of Belize and to provide the necessary response in an opportune and appropriate manner. The Ministry believes it is best to have a specific manual for integrated surveillance and response for Foodborne Diseases within the communicable disease surveillance system. Common problems in the surveillance system have been identified and strengthened and a strong common network for surveillance has been established. A policy document entitled “A Food and Nutrition Security Policy for Belize” was published by the Belize government in February 2001. In this policy, six programme areas were presented as part of an operational framework to organise projects and activities. Food Safety is one of these six programme areas. The Food Safety programme is described as a programme supporting “the development of national standards for food products, adherence to national and international standards and the development of monitoring mechanisms. It also includes the education of the public in matters relating to food quality and safety.” Outputs of the Food Safety programme include:

“Implementation of laboratory network for microbiology, chemical and physical analyses of food products. Implementation of a surveillance system for foodborne and nutrition related problems, operational/institutional and public information systems for immediate notification and alert”

I strongly believe that we can achieve the above desired outputs through the implementation of the protocols advocated in this manual and ensuring that stakeholders are integrated through cooperative agreements.

Dr. Michael Pitts Director of Health Services Ministry of Health

June 2009

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ABBREVIATIONS

BAHA Belize Agricultural Health Authority CAREC Caribbean Epidemiological Centre CARICOM Caribbean Community CIL Central Investigation Laboratory CML Central Medical Laboratory CVDL Central Veterinary Diagnostic Laboratory DHS Director of Health Services DRHM Deputy Regional Health Manager FBD Foodborne Disease GSS Global Salmonella Surveillance HECOPAB Health Education and Community Participation Bureau IICA Inter-American Institute of Cooperation in Agriculture MAF Ministry of Agriculture and Fisheries MCH Maternal and Child Health MOH Ministry of Health NHISU National Health Information and Surveillance Unit OIRSA Regional International Organization for Agricultural Health PAHO Pan American Health Organization RHM Regional Health Manager SOP’s Standard Operating Procedures UB University of Belize WHO World Health Organization

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DEFINITIONS Case Any individual who becomes ill after consuming food that is considered to be contaminated based on epidemiological evidence or laboratory testing. Confirmed Case A confirmed case is a probable case with laboratory confirmation. Criteria depend upon the aetiologic agent.

Epidemiological surveillance Epidemiological surveillance is the gathering of information needed to identify the history or behaviour of diseases and to detect or predict any changes that might occur because of modifications in their determinants or causative factors, for the purpose of making timely recommendations – on solid bases – for appropriate measures aimed at efficient prevention and control. Family outbreak A family outbreak of FBD is an episode in which two or more people who live in the same household exhibit the same clinical signs of the disease after ingesting the same food and where epidemiological evidence or laboratory tests indicate that such food was the main source of the disease identified. FBD Surveillance system A simple, timely, and continuous information system covering specific clinical signs and syndromes that are manifested upon the consumption of contaminated food. It includes the investigation of the determining factors and causative agents of the disease, as well as the analysis of the situation so as to formulate strategic action for its prevention and control. This system should be flexible, acceptable, responsive, and representative. Food Food is any substance whether processed, semi-processed, or raw, which is intended for human consumption, including drink, chewing gum, and any other substance which has been used in the manufacture, preparation, or treatment of "food"; it does not include cosmetics, tobacco, or substances used only as drugs. (For the purposes of this manual, water is considered a food.) Foodborne disease This is a disease syndrome caused by the ingestion of food containing aetiologic agents and/or toxins in such quantities that may affect the health of an individual or group of persons. Foodborne infection A Foodborne infection is produced from ingesting food contaminated with specific infectious agents such as bacteria, virus, fungi, or parasites, which multiply in the intestine, break down and produce toxins, or penetrate the intestinal wall and spread to

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other organs or systems.

Food poisoning (Food intoxication) Food poisoning or food intoxication occurs whenever FBDs are produced by the ingestion of toxins from plant or animal tissues, metabolic products of micro-organisms in food, or chemicals that are added to foods accidentally, incidentally, or intentionally at any point between the time the food is produced and the time it is consumed. Gastroenteritis Case Definition Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). The most common symptoms are low grade fever to 100°F (37.7°C), diarrhea, crampy abdominal pain, nausea with or without vomiting, and vomiting. Diarrhea is defined as two or more loose stools per day or an unexplained increase in the number of bowel movements. A suspected case is a case presenting with an acute illness characterized by diarrhoea with one or more of the following: Nausea and/or vomiting Abdominal pain Fever Malaise Headache

Outbreak An outbreak of FBD is an episode in which two or more people exhibit the same clinical signs of disease after ingesting food from the same source and where epidemiological evidence or laboratory tests indicate that such food was the main source of the clinical signs of the disease identified. Suspected Case A person whose diagnosis is thought likely to be a particular disease or condition with suspected diagnosis based on signs and symptoms, laboratory evidence, or both.

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INTRODUCTION The Caribbean Epidemiological Centre, CAREC/PAHO, has held three workshops (GSS I, II and III) on Foodborne Disease Surveillance and Response with CARICOM member states under the WHO Global Salmonella Surveillance collaboration programme. GSS III was held in May 2005 and provided participants with guidelines on improved Foodborne disease surveillance and control. Belize has a National Food and Nutrition Security Policy and this policy targets six programme areas. Food Safety is one of these six programme areas. The Ministry of Health is a key regulatory partner in the implementation of the objectives of the food safety programme outlined by the National Food and Nutrition Security policy. The Ministry of Health is guided by three objectives of the Food Safety programme:

o To ensure the provision of a wholesome, safe and sound food and meat supply to the consuming public;

o To prevent and control Foodborne diseases; and o To empower the food industry to take greater control over food safety.

The principal components of the Food Safety programme are: food legislation, inspection services, laboratory services, health education, epidemiological surveillance of Foodborne Diseases (FBD), and surveillance of contaminants in food. It also includes monitoring of food handlers, itinerant food vendors and street-side food vendors. The main purpose of Foodborne Disease Surveillance in Belize is to monitor, control and prevent foodborne disease morbidity and mortality, and to mitigate any related socioeconomic impact through the collection, analysis and use of data from clinical, laboratory, environmental, agricultural and food sources. 1. OBJECTIVES OF FBD SURVEILLANCE SYSTEM IN BELIZE

To gather, compile, and analyse relevant and up-to-date information on reported cases of FBDs,

To promote the notification, investigation and reporting of FBD outbreaks,

To analyse and interpret data in order to describe the FBD cases, their

distribution and their severity,

To identify what food was responsible for transmission of the aetiologic agent(s) or toxin(s),

To detect the sources of contamination, the population groups at risk, critical

control points, and any other contributing factors,

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To disseminate the information obtained to the general public, private sectors and relevant stakeholders,

To recommend preventative and control measures to the general public, private sectors and relevant stakeholders,

To investigate emerging FBD problems,

To predict changes in FBD trends.

3. BENEFITS AND PRODUCTS OF A FBD SURVEILLANCE SYSTEM FOR BELIZE The development of an epidemiological surveillance system for FBDs in Belize will make it possible to:

Take efficient, opportune and appropriate action for eliminating, reducing, or averting identified risks,

Determine all possible risks posed to areas, groups, establishments, and food, as well as other factors involved in the occurrence of FBDs,

Promote the development of policies, laws, and regulations for the prevention and control of FBDs,

Develop food safety plans and programmes on an accurate and solid basis.

Inform the population of the risks involved in the preparation, handling and consumption of food in order to reduce the risk of FBDs,

Encourage community participation in the implementation of preventive and

control measures. 4. ORGANIZATION OF FBD SURVEILLANCE SYSTEM Developing and sustaining an effective FBD surveillance programme for Belize requires meeting several conditions. These conditions include:

Awareness of the existence of food-related disease problems and FBDs in urban and rural areas of Belize.

Political and technical decision: the fundamental responsibility for an FBD

surveillance system is vested in Belize’s health authorities, who should commit themselves to establishing an FBD surveillance system as a key component of their food safety programme.

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Existence of a functional and organised epidemiological surveillance structure within the health services into which the FBD surveillance system should be integrated. It is neither necessary nor desirable that a parallel structure be set up.

Collaboration and coordination in FBD surveillance among technical

competencies such as MOH, MAF, BAHA, UB, PAHO, PAHO/CAREC, OIRSA, IICA.

Standardisation of methods, technical procedures, and materials that are used in the epidemiological surveillance of FBDs.

5. EPIDEMIOLOGICAL SURVIELLANCE

5.1 Epidemiological surveillance of FBDs include the following stages Stage I: Collection of data

Epidemiological surveillance systems for FBDs in Belize will focus on collecting the most relevant data. At this stage, standardised criteria will be defined so that the data collected may be interpreted uniformly by different personnel at different times and in different places.

There are three levels of health administration in Belize:

Level 1. District Level (District Hospital)

This is the level responsible for collecting, processing, interpreting, and analyzing data, taking any preventive and remedial measures, and evaluating their impact within their area of influence.

Personnel at the district level should perform all necessary actions that lie within their technical capabilities and forward all data obtained to the Ministry of Health for consolidation, analysis and action (see regional team). The district team should have basic training in FBD surveillance so as to be able to implement prevention and control actions at the right time and propose bases for the programming and evaluation of the FBD surveillance system, since they are the ones in most direct contact with the community.

Level 2. Regional Level (Regional Hospital)

The regional level (Regional Hospital) is the intermediate level and lies

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between the district and central levels. At this level, data are collected, compiled, analyzed, and evaluated, and proposals are made for the appropriate administrative measures to be taken at the regional level.

Level 3. Central Level (Epidemiology Unit, Ministry of Health)

This level sets policies and advises the other levels on epidemiological surveillance. Information received at this level is compiled, processed, and analyzed in order to identify the status of FBDs in the country. The outcome of this evaluation will determine the policies for FBDs in Belize.

The Epidemiology Unit will be responsible for reporting FBDs to the relevant stakeholders and international agencies. If a case report enters the system at the regional or central level, then the district level should be informed as well.

Stage II: Processing of data

This stage will cover the tabulation, compilation, and integration of data.

Stage III: Analysis and Interpretation of Data

At this stage, data on FBDs and their trends are compared with national, regional and international data.

Stage IV: Dissemination of Information

This stage covers the publication and dissemination of information to the general public, private sectors and relevant stakeholders. This will be the responsibility of the national team.

5.2 Reporting

Reporting is the activity whereby a FBD surveillance system receives a timely, continuous and regular flow of information on the occurrence of cases of FBDs especially outbreaks (see reporting chart on page 15 for further clarification on the flow of data reporting).

5.2.1 Reporting, investigation requirements and channels of information

Cases of outbreaks of FBDs should be reported immediately to the Regional Hospital Authority so that they may proceed to take the appropriate measures. On the receipt of information of a suspected foodborne disease outbreak,

the Regional Health Manager (RHM)/Deputy Regional Health Manager

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(DRHM) activates the investigation team and informs the National Epidemiologist, MOH.

The RHM/DRHM submits a preliminary report of the investigation to

the Director of Health Services (DHS) and the Epidemiology Unit within 24 hours of receipt of report.

The source of information includes but is not limited to: - physicians,

other health care providers (health facilities), laboratories, patients, news media, and community leaders.

The investigation team is comprised of an Epidemiologist or a Medical

Doctor, Statistical Clerk, Public Health Nurse/Rural Health Nurse, Public Health Inspector, Health Educator and BAHA Food Safety Inspector with support from the Central Medical Laboratory and other laboratories.

The investigation team on being activated, puts its investigation tools

together, collects data, collects/examines specimens, evaluates exposed persons, reviews laboratory and other findings, implements control/preventive measures, writes report which includes introduction, case definition, methods, analysis, results, discussion, control/preventive measures, conclusions and recommendations.

The Regional office/DHS/NHISU facilitates resource allocation,

provides guidance and troubleshoots logistical problems which may occur in the field.

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FOODBORNE DISEASE SURVEILLANCE AND INVESTIGATION REPORTING SYSTEM

KHMH

Information source (hospitals, BAHA, media, other reports)

RHM/DRHM BAHA

Investigation Team

CML BAHA: CIL, CVDL

Ministry of Agriculture

DHS

CAREC PAHO/WHO

MOH Epi Unit

BAHA Epi Unit

District Health Information Unit

International counterparts connected to outbreak

Pri. Hospitals/ Tourist Indust.

RHM/DRHM BAHA

Investigation Team

CML BAHA: CIL, CVDL

Ministry of Agriculture

DHS

CAREC PAHO/WHO

MOH Epi Unit

BAHA Epi Unit

District Health Information Unit

International counterparts connected to outbreak

Priv. Hospitals/ Tourist Indust.

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5.3 Investigation of Outbreaks

The 10 steps listed below should be used whenever investigating a suspected or confirmed FBD outbreak. Please refer to ‘A Practical Guide for Outbreak Investigation: 10 Steps in Investigating an Outbreak”, November 2000, Dr. Betz, Thomas et al.

1. Confirm the existence of an outbreak

2. Develop a case definition

3. Determine the number of cases

4. Orient the data in terms of person, place, and time

5. Determine who is at risk of becoming ill

6. Develop a hypothesis

7. Analyse the data

8. Formulate conclusions

9. Put recommendations and control measures into operation

10. Write a report

The team investigating the report of a suspected Foodborne disease will complete the form for submission to the Epidemiology Unit, SUSPECTED FOODBORNE ILLNESS CASE HISTORY FORM (See Appendix 3)

5.3.1 National Advisory Committee

A National FBD Committee consisting of the members listed below will be responsible to oversee and assist with the implementation of all activities for a successful FBD Surveillance system for Belize.

o National Epidemiologist (Team leader)

o Principal Public Health Inspector / Food Safety Officer

o Director of Laboratory Services

o Director of Food Safety and Director Animal Health (BAHA)

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o Representative from the Ministry of Industry and Trade

o Representative from the Ministry of Tourism

o Representative from the Ministry of Agriculture and Fisheries

o Representative from PAHO

o Representative from the Medical and Dental Association

o Representative from the Tourist Industry

o Representative from the Food Industry

Investigation Teams: There will be two investigating teams:

1. National FBD Surveillance Team The responsibilities of the National FBD Surveillance Team are as follows:

Ensure standardisation in regions in FBD outbreak investigation, Provide technical support in a regional and national outbreak Submit a report of all investigations to the Director of Health

Services and Epidemiology Unit. Will meet quarterly and as necessary during outbreaks.

Team Members:

o National Epidemiologist (Team leader)

o Bio-statistician

o Principal Public Health Inspector / Food Safety Officer

o Director of Laboratory Services

o Director of MCH

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o Director HECOPAB

o Director Animal Health, BAHA

o Director of Food Safety, BAHA

2. Regional Outbreak Investigation Team:

The responsibilities of the Regional FBD Surveillance Team are as follows:

Responsible for the response to FBD outbreaks in the Region

(during and after normal working hours, weekend and holidays). Ensure regional investigation and reporting of FBD outbreak(s) to

the Epidemiology Unit who reports to the Director of Health Services and the National FBD Committee.

Ensure the ongoing FBD surveillance at the Regional level by

conducting quarterly meetings. Will meet as necessary during an outbreak.

Team Members:

o Regional Epidemiologist or/and Medical Officer o Statistical Clerk o Senior Public Health Inspector (Team Leader) o Senior Public Health Nurse o Medical Technologist o Health Educator/ HECOPAB

o Food Safety Inspector o BAHA Veterinary Officer

5.3.2. Control of FBD Outbreaks

5.3.2.1 Control Measures:

Educate food handlers in strict food hygiene, sanitation and cleanliness of kitchens, proper temperature control, cleaning of fingernails; and to the

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danger of working with exposed skin, nose and eye infections and the need to cover wounds,

Reduce food handling time (from preparation to service) to an absolute

minimum, with no more than 2 hours at ambient temperatures,

Keep hot food at greater than 60o C and cold food cold at less than 10o C,

Temporarily exclude people with boils, abscesses and other purulent lesions of hands, face or nose from handling food,

Seafood:

ensure that cooked seafood reaches a temperature of at least 70o C

for at least 15 minutes, handle cooked seafood in a manner that precludes contamination

with raw seafood or contaminated sea water, keep all seafood, raw and cooked, adequately refrigerated before

eating, avoid the use of sea water in food handling areas.

Refrigerate leftover foods promptly and reheat rapidly and thoroughly

before use. 5.3.3 Basic food safety practices:

Choose processed food to ensure safety, Cook food thoroughly,

Eat cooked food immediately,

Store cooked foods properly,

Refrigerate leftover foods promptly,

Reheat cooked food thoroughly,

Avoid contact between raw and cooked foods,

Wash hands as often as necessary,

Keep all kitchen surfaces clean,

Protect food from insects, rodents and other animals,

Use potable water.

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5.4 Dissemination of Information

One of the products of the FBD surveillance system will be to compile data on the occurrence and distribution of FBDs and to provide detailed information on outbreaks investigated. This will allow the identification of areas, groups, establishments and foods that are at risk, as well as critical points, and will assist in the formulation of the appropriate prevention and control measures. The Epidemiology Unit, Ministry of Health will disseminate information on FBD surveillance through periodic epidemiological bulletins that will show data collected and compiled by major sub-divisions and divisions. These bulletins will include tables and graphs on the occurrence, distribution, and reports of FBD outbreaks that are investigated (See indicators in appendix). HECOPAB, in collaboration with the Epidemiology Unit, will provide information to the community using the media (print and electronic) and social promotion and community development. This information will foster interest in reporting, motivate the population to continue to collaborate, and help publicise general prevention and control measures. Belize’s FBD surveillance system will be a part of the Pan American network geared to disseminating knowledge at the CAREC member country level on the impact of FBDs.

5.5 Laboratory Support

The successful implementation and maintenance of an FBD surveillance system hinges on the capability of CML and BAHA laboratory services for testing clinical specimens and food samples. By including these laboratories in the FBD surveillance system, it will be possible to detect the principal causative agents of FBDs on a timely basis. For example, through microbiology, it would be possible to identify prevalent serotypes, resistant strains, and emerging agents. These laboratories should have the capability for detecting chemical and biological residues (pesticides, heavy metals, mycotoxins, anabolic agents, veterinary drugs, additives, and other contaminants). In addition, they should participate actively in the standardisation of techniques and procedures (SOPS) and in the development of new diagnostic methods. Laboratory management should ensure that laboratory technicians and other laboratory personnel operate with appropriate safety equipment and safeguards for personal protection The laboratory infrastructure at CML, Regional Hospitals and BAHA will strengthen FBD surveillance. When investigating outbreaks, there will be need for these laboratories to test clinical specimens and samples of foods from individuals and samples of foods at risk.

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Laboratory Testing Responsibilities and Capabilities Public Health BAHA Other (Private) Clinical specimens X X* Environmental specimens - water - pesticides/chemicals - feeds - soil

X

X X X X

X**

Veterinary specimens X Food specimens X *Selected private laboratories (based on quality assurance) **BWSL (Belize Water Services Limited); Department of Environment, Bowen and Bowen

5.5.1. Specimens Collection and Transport

A. Clinical Specimen: Faecal specimens should be collected in the early stages of the diarrhoeal disease, when pathogens are present in the highest number. The specimen should be collected in the morning to reach the laboratory before noon, so that it can be processed the same day. In the event where cases reach the clinic in the afternoon or late evening, samples should be collected and store at 4o C and forward early the following day. Formed (hard) faeces should be rejected. Ideally, a fresh faecal specimen is preferred to a rectal swab, but a rectal swab is acceptable if the collection cannot be made immediately or when transportation of the faecal sample to the laboratory is delayed. B. Food Specimens: Leftover foods and other food samples should be collected aseptically and put into sterile jars or food collection bags. Perishable foods which are not frozen at the time of collection should be rapidly chilled to 4o C and kept at this temperature until examined. Do not freeze these samples as certain bacteria such as Clostridium perfringens die off rapidly when frozen. The laboratory should be consulted about proper sample collection procedures and be alerted when samples are to be submitted for testing. All effort should be made for samples to be received at the laboratory within the shortest possible time. Ensure that samples are properly labeled and are placed in approved containers. A completely filled laboratory form must accompany each sample submitted and

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must include:

A. Date & Time of Collection B. Description of Sample C. Source of Sample (place, address) D. Type of Specimen E. Analyses required F. Name and Signature of authorized person collecting samples.

5.5.2. Procedure for Collecting Faecal Sample

A. General

Provide the patient with a suitable container with a leakproof lid (e.g. a plastic container with a cover).

For those not willing or unable to provide stool specimen, swabbing can be done.

The reuse of medicinal bottles (destroys bacteria) and glass containers

should be discouraged as they expose the laboratory staff to the risk of infection.

The specimen should contain at least 5g of faeces and should include if present those parts that contain blood, mucus or pus.

Avoid mixing samples with urine as it could lead to contamination.

Once the specimen has been placed in the container, it should be covered properly.

Specimen collected should be delivered to the laboratory immediately by collector / investigator. If it is not possible for the specimen to be delivered to the laboratory within 2 hours of its collection, a small quantity of the faecal specimen (together with mucus, blood and epithelial threads, if present) should be collected on two or three swabs and placed in a container with transport medium (Carry-Blair Swab). Pathogens may survive in such media for up to 1 week, even at room temperature, but refrigeration is recommended. CML is to provide media to district laboratories for processing of samples at the district level.

B. Submission of sample

Sample is taken to the laboratory by the collector / investigator The district laboratories collect samples and send it to CML for

testing – within 24 hours.

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Private hospitals submit samples using couriers.

Samples should be accompanied by a laboratory form with all relevant patient data.

5.5.3 Procedure for Collecting Rectal Swabs

1. Insert Carry-Blair swab through the rectal sphincter, rotate and withdraw. Examine the swab for faecal staining and repeat the procedure until sufficient staining is evident. The number of swabs to be collected will depend on the number and type of investigation required.

2. Place the swab in an empty sterile tube with a cotton plug or screw-cap, if it is to be processed within 1-2 hours. If the swab must be kept for a time longer than 2 hours places it in transport medium (Carrie Blaire).

5.5.4. Criteria for sample rejection

Samples will be rejected if upon arrival at the laboratory; samples are not at the required temperature, if the container is not properly sealed and labeled, and if for any other reason, the integrity of the sample is compromised. Samples must be accompanied by completely filled out form. Other reasons for sample rejections are as follows:

Sample too old to be processed (for culture) Sample spill Insufficient sample (less than 5 g) Specimens from bedpans or non-sterile containers Dry rectal swabs without transport media Sample container improperly labelled or not labelled

Submission form is incomplete

Formed (hard) stools

5.5.5. Tests currently done at CML and CIL

Salmonella identification (O typing only) Shigella typing (group A, B, C, D)

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Norovirus Staphylococcus aureus

Campylobacter

Vibro Cholera

Ecoli 0157: H7

5.5.6. Procedures for the Collection of Food Samples

Products that need refrigeration

These are Dairy, Poultry, Cold Cuts etc.

Collect 5 random samples of at least 500 gms and place in a food sampling bag (Ziploc bags)

Place food samples in a cooler with ice and transport to lab as soon as

possible within 24 hrs of collection time If samples are pre-packaged, collect 5 random samples

Room temperature products These are canned products or shelf stable products.

Collect 5 random samples of at least 500 gms and place in a food sample bag

Transport to lab as soon as possible within 24 hrs of collection time

Fruits and vegetables

Collect 5 random samples of at least 500 gms of fruit or vegetable and place in food sample bags

Place food samples in a cooler with ice and transport to the lab as soon as

possible within 24 hrs. of collection time

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5.5.7. Food Collection and Sampling All food sample submissions require pre-approval before delivery to the BAHA food laboratory in Belize City. (Contact Number 223-4457) Pertinent paper work such as Food Sample Form that is properly completed must accompany the samples. Samples to be collected aseptically: temperature (32 – 45 F)

a) Use sterile containers. b) Make sure caps are tight, to prevent leakage. c) Do not handle or touch the inside of the container. d) Use sterile utensils, tongs, spoon, etc. e) Use glass containers. Try not to use Ziploc bags for liquids, which can leak and

spill easily. f) Ziploc bags may be used for solid foods, such as dry milk, meat, etc. g) Collect adequate amount of sample – at least 100-150 grams or milliliters, (4-6

oz). h) Fill containers no more that ¾ full, to allow for proper mixing of the sample. This

applies to liquid samples, milk, soups, etc

Transportation

a) Use ice for ice cream or frozen food samples. b) Use plenty of ice cubes or crush ice in a well insulated cooler (for potentially

hazardous foods or perishable foods). c) Place container in cooler so that cover or lid is just above ice level. d) If possible wrap sample in a plastic bag and place in cooler. This will help

prevent leakage into the container. e) Ice packs may be use fir food samples as well.

Labels

a) Write clearly with waterproof marker (or use waterproof labels with a ball point pen).

b) Tag may be used- especially on glass bottles. c) Be careful to number each container, watch sequence and be careful not to skip

numbers. d) Clear indicate contents of container, i.e., raw milk, pasteurized, bulk, cultures, etc.

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Delivery

1. Make sure that all samples are kept refrigerated or frozen. When removed from the ice cooler they should be immediately moved to the refrigerator in the food Laboratory.

5.5.8. Sampling Equipment A sample kit, including the following, should be kept stocked at all times. 1. Sterile Sample Containers

Ziploc bags Wide mouth glass jars with screw caps (+ 300ml , 150 ml)

2. Sterile and Wrapped Sample Collection Implements

Spoon, scoops, tongs, knife, spatula, fork , Ladle, funnel

3. Supporting Equipment Fine-point felt- tip marking pen, role of making tape, water proof

labels/ tags, sample forms Sample kit box (Hold all implements and materials)

4. Sterilizing and Sanitizing Agents

95% ethyl alcohol Disinfectant wipes

5. Refrigerant

Ice or ice packs

6. Clothing (not included in food kit) Inspection coat, hair restraint and disposable plastic gloves.

5.5.9 Procedures for the Collection of Water Samples

Water

In a sterile container (available upon request at Lab), collect 100 mls of a representative portion of the sample to be tested. (Do not fill container to the rim).

Screw on cover as tightly as possible and place sample in a cooler with

ice, seal and transport to Water Laboratory. Sample must arrive at Water Laboratory as soon as possible within 24 hrs

of collection time

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6. INDICATORS 6.1. Administrative Indicators

Time between onset of an outbreak and reporting Time between reporting and the beginning of the investigation

Availability of data (are they accessible when needed?)

System coverage, by population group and geographical area (units

reporting/total units)

Quality and timeliness of reports

Percentage of outbreaks in which sufficient number of samples were obtained

Percentage of outbreaks in which samples of acceptable quality were obtained

Timeliness and regularity of the shipment of samples for laboratory analysis

Frequency, timeliness, quality, and regularity with which the laboratory received the samples

Timeliness and regularity of laboratory tests

Timeliness and regularity of reporting of laboratory results

Ratio of notified to investigated outbreaks

Distribution of reporting by source (as a percentage)

Timeliness and regularity in the delivery of reports and recommendations to

the next higher level of authority 6.2. Epidemiological Indicators

Trends in morbidity and mortality from FBDs Incidence and prevalence of FBDs

Identification of the population groups that are most exposed and vulnerable

Identification and percentage distribution of sites and incriminated foods,

causative agents, and the most frequent determining factors

Determination of the geographical and temporal distribution of FBDs

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Identification of the actual and estimated number of individuals exposed, sick,

hospitalised, and deceased

Percentage of risk establishments (having identified the most important critical points where outbreaks occurred)

6.3. Activity Indicators

Percentage of establishments that implemented the recommended control measures

Percentage of establishments inspected compared to establishments where

outbreaks were reported in outbreak areas Percentage of trained food handlers at establishments where outbreaks were

reported Percentage of outbreaks investigated compared to the total number of notified

outbreaks

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BIBLIOGRAPHY

1. ‘A Caribbean Communicable Disease Surveillance Manual for Public Health Action’. CAREC, October 1999

2. Ayala, Gonzalez et al. ‘Guidelines for the Establishment of System for the

Epidemiological Surveillance of Foodborne Diseases and the Investigation of Outbreaks of Food Poisoning’, 1993.

3. Betz, Thomas et al. ‘A Practical Guide for Outbreak Investigation: 10 Steps in

Investigating an Outbreak”. Belize, Ministry of Health, November 2000

4. Environmental Health Procedure Manual. Ministry of Health, January 2004.

5. ‘Foodborne Disease Surveillance System for Belize’. Ministry of Health, October 2003

6. ‘Proceedings of WHO Global Salmonella Surveillance III Workshop’. Caribbean

Epidemiological Centre (CAREC), Trinidad and Tobago, 2005.

7. Vanzie, Errol et al. ‘A Practical Guide for the Surveillance, Classification and Reporting of Communicable Diseases in Belize’. Belize, Ministry of Health, November 2000

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ANNEXES

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ANNEX 1

Aetiological (Bacteria) Agents and Clinical Features

A. Salmonella

The genus Salmonella contains more than 2000 serotypes. Many of these may infect both humans and domestic animals. In humans they cause gastroenteritis, typhoid fever, and bacteraemia with or without metastatic disease. Salmonella gasteroenteritis usually begins with nausea, vomiting, abdominal colic and diarrhoea 8-48 hours after ingestion of the contaminated food. The symptoms often persist for 3-5 days before resolving without therapy. Antimicrobials will not hasten clinical recovery, and may lengthen the convalescence and asymptomatic carrier state. Antimicrobial susceptibility testing and antimicrobial therapy are not recommended for uncomplicated cases. Antimicrobial treatment is only indicated if the patient appears bacteraemic. Some patients may harbour Salmonella species in stool or urine for periods of 1 year or longer but remain asymptomatic. Approximately 3% of patients with typhoid fever and 0.2-0.6% of persons with non-typhoid Salmonella gastroenteritis will have positive stool cultures for more than 1 year.

B. Shigella

Shigella causes a wide spectrum of clinical diseases which vary from asymptomatic infections to diarrhoea without fever to severe dysentery. Symptoms consist of abdominal cramps, ineffectual and painful straining to pass stool (tenesmus), and frequent, small-volume, bloodstained inflammatory discharge. Shigella is the main cause of bacillary dysentery followed by enteroinvasive and enterohaemorrhagic E.coli. The incubation period for Shigella is usually 1-3 days but may range from 12-96 hours. Many cases present as mild illnesses that require no specific treatment. However, for severe dysentery or when secondary spread is likely, antimicrobial therapy after susceptibility testing is indicated as resistance towards commonly used antimicrobials is high in many countries. Four groups of Shigella organisms, with a total of 39 serotypes and subtypes, are recognized.

o Group A (S. dysenteriae) o Group B (S. flexneri) o Group C (S. boydii) contains multiple serotypes

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o Group D (S. sonnie)

The genus Campylobacter is composed of organisms once classified as Vibrio species. The incubation period for Campylobacter jejuni is usually 2-10 hours.

C. Campylobacter The genus contains at least 8 species:

Campylobacter jejuni (subspecies jejuni) Campylobacter jejuni (subspecies doylei) Campylobacter coli Campylobacter lari Campylobacter upsaliensis Campylobacter foetus (subspecies foetus) Campylobacter hyointestinalis Arcobacter butzleri

Campylobacter jejuni and Campylobacter coli have emerged as major enteric pathogens that can be isolated as often as Salmonella and Shigella species in most parts of the world. The intestinal disease varies from a brief, self-limiting enteritis to fulminant enterocolitis with severe diarrhoea, abdominal colic, fever, and muscle pain. The stools are at first mucoid and liquid and may progress to profuse watery diarrhoea containing blood and pus. Symptoms usually subside within a week. Relapse occurs in about 25% of patients, but is generally milder than the initial episode. The infection is usually self-limiting without antimicrobial therapy, and susceptibility testing is usually not indicated.

D. Escherichia Coli (E. coli)

The Escherichia coli that cause diarrhoea are classified according to certain virulence factors that result in different mechanisms of disease production. Variants of E. coli associated with diarrhoea:

o enteropathogenic E. coli (EPEC) o enterotoxigenic E. coli (ETEC) o enteroinvasive E. coli (EIEC) o enterohaemorrhagic E. coli (EHEC) o enteroaggregative E. coli (EAEC)

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Enteropathogenic E. coli (EPEC) Infants are especially susceptible to infection with EPEC. It is often implicated as the aetiologic agent of diarrhoeal disease in outbreaks in nurseries. In infants the illness usually resolves in 5 to 15 days, but relapse may occur. Chromosomal genes code for adherence factors that allow the organisms to bind tightly to mucosal cells of the small intestine. EPEC can sometimes invade the cells. A variety of serotypes, based on O (and occasionally H) antigens have been identified. E. coli with 0111 and 0125 antigens are often implicated as the aetiologic agents. The clinical presentation includes watery diarrhoea. Microvilli loss can be visualized in biopsy specimens. The disease is usually self-limiting, but may become chronic. Enterotoxigenic E. coli (ETEC) Traveler’s diarrhoea is frequently caused by ETEC. Colonization factors produced by the organisms enhance their adherence to the epithelial cells of the small intestine. Many of these organisms produce either one or two different toxins in plasmids. A heat-labile exotoxin (LT), which has a molecular weight of approximately 80,000 Daltons, is secreted by some strains. The LT consists of a B subunit that binds to ganglioside Gm1 present on epithelial cells of the small intestine. This binding facilitates the entry of the active A subunit (26,000 molecular weight) into cells. The A subunit increases the cyclic adenosine monophosphate (cAMP) concentration in mammalian cells by activation of the adenyly cyclase enzyme. The end result is the hypersecretion of water and chloride, hypermotility of the gut, and diarrhoea, which usually persists for several days. The structure and mechanism of action of LT is similar to the enterotoxin of Vibrio cholerae. Some ETEC produce a heat-stable exotoxin (ST). It induces the hypersecretion of fluid by activating guanylyl cyclase, which, in turn, increases the intracellular level of cyclic guanosine monophosphate (cGMP). Organisms that produce both toxins generally induce more severe diarrhoea than those that produce only one. In cases of severe diarrhoea, antibiotic therapy, as well as measures to correct dehydration and electrolyte imbalance, may need to be initiated. Enterohaemorrhagic E.coli (EHEC) Enterohaemorrhagic E. coli produces severe bloody diarrhoea known as haemorrhagic colitis. They are also responsible for a potentially fatal haemolytic uraemic syndrome (HUS), which includes microangiopathic haemolytic anaemia, thrombocytopenia, and acute renal failure. Blood transfusion and haemodialysis are often required. HUS is seen in approximately 10% of EHEC cases; most of these are in children younger than 5 years of age. The 0157: H7 serotype is transmitted by ingestion of undercooked ground beef, raw milk (the serotype is frequently isolated from asymptomatic dairy cattle), apple cider, and other foods. Verotoxin (given this name because it kills Vero cells, i.e., a kidney cell line from

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the African Green monkey) is a major virulence factor that is produced in large quantities by the 0157:H7 serotype. The toxin can kill endothelial cells that line the inner lumen of blood vessels. Its properties are similar to those of Shiga toxin, which is produced by some strains of Shigella dysenteriae. The toxin is sometimes referred to as Shiga-like toxin or SLT because of its similarity to Shiga toxin. The organisms also possess an eae gene that codes for “attaching and effacing” proteins that are similar to those produced by the EPEC. The combined effects of the toxin and the eae gene are thought to be responsible for haemorrhagic colitis. The 0157:H7 serotype has been responsible for several recent outbreaks of severe disease in which the organisms were traced to contaminated ground beef served in fast-food restaurants. Other serotypes that have been associated with this form of E. coli infection include 01, 026, 091, and 0145. Enteroinvasive E. coli (EIEC) EIEC invade the epithelial cells of the intestinal mucosa and produce a disease that is very similar to shigellosis, but it is generally milder. They are important primarily in young children in developing countries, although travelers to these countries may also become ill. Invasive strains of E. coli often have the 0112 antigen. Enteroaggregative E. coli ( EAEC) EAEC are prevalent in some developing countries. They cause acute and chronic diarrhoeal disease with watery faeces. Treatment is with antibiotics; selection of antibiotic depends on site of infection and age of patient.

E. Norovirus

Noroviruses (genus Norovirus, family Caliciviridae) are a group of related, single-stranded RNA, nonenveloped viruses that cause acute gastroenteritis in humans. Norovirus was recently approved as the official genus name for the group of viruses provisionally described as “Norwalk-like viruses” (NLV). This group of viruses has also been referred to as caliciviruses (because of their virus family name) and as small round structured viruses, or SRSVs (because of their morphologic features). Another genus of the calicivirus family that can cause gastroenteritis in humans is Sapovirus, formerly described as “Sapporo-like virus” (SLV) and sometimes referred to as classic or typical calicivirus.

Noroviruses are named after the original strain “Norwalk virus,” which caused an outbreak of gastroenteritis in a school in Norwalk, Ohio, in 1968. Currently, there

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are at least five norovirus genogroups (GI, GII, GIII, GIV and GV), which in turn are divided into at least 31 genetic clusters.

Clinical Presentation

The incubation period for norovirus-associated gastroenteritis in humans is usually between 24 and 48 hours (median in outbreaks 33 to 36 hours), but cases can occur within 12 hours of exposure. Norovirus infection usually presents as acute-onset vomiting, watery non-bloody diarrhea with abdominal cramps, and nausea. Low-grade fever also occasionally occurs, and vomiting is more common in children. Dehydration is the most common complication, especially among the young and elderly, and may require medical attention. Symptoms usually last 24 to 60 hours. Recovery is usually complete and there is no evidence of any serious long-term sequelae. Studies with volunteers given stool filtrates have shown that asymptomatic infection may occur in as many as 30% of infections, although the role of asymptomatic infection in norovirus transmission is not well understood.

F. Other Although this manual focuses on the bacteriological aetiological agents, salmonella, shigella, campylobacter and E. coli, it is recognized that there are other aetiological agents that are implicated in FBD. These agents are included in the Communicable Disease Surveillance Manual and the reader is encouraged to consult that manual and other officially recognized sources of information on FBD and its causes.

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ANEX 2

Recommended Daily Procedures Flowsheet: CLINICAL SAMPLES

Identification Of Salmonella, Shigella & Campylobacter From Clinical Samples

Day SALMONELLA, SHIGELLA CAMPYLOBACTER Under microaerobic conditions

1 Direct Plating Streak unto XLD and MAC ( and other additional plate)

Enrichment (GN and TT) 1: 10 stool: broth dilution Incubate GN at 37 oC and TT at 42oC for 18-24hrs

Enrichment (Preston / Bolton broth) 1: 10 stool: broth dilution ; Incubate @42oC for 48hrs

2 Selective Plating (XLD, Mac) (additional: HE/BGA) Streak from GN unto XLD and MAC Streak from TT unto XLD and MAC incubate @37oC for 18-24hrs

3 Read Plates and Prelim Biochemicals Select at least 3 suspect colonies for Salmonella from each enrich broth, inoculate into TSIA, LIA, UREA

Select at least 3 suspect colonies for Shigella from GN and TT broth; inoculate into TSIA, LIA, UREA

Incubate all tubes @37oC for 18-24hrs

Purity plate onto MAC and TSA/NA plate

Read CCDA from Direct plating Selective Plating (CCDA or Campylobacter agar)

Streak from broth unto CCDA plate (x2) Incubate @42oC for 48hrs

4 Confirmatory Biochemicals Read Salmonella TSIA, LIA, UREA and- discard if does not fit profile OR full biochemicals/rapid kit

Read Shigella TSIA, LIA, UREA and- discard if does not fit profile OR full biochemicals/rapid kit

Incubate all tubes @37oC for 18-24hrs Start O agglutination from TSA plate Inoculate into Flagellar broth from TSA plate

5 Report and Serotyping Report as Salmonella spp and/or Salmonella group Report as Shigella Species Continue with H analysis

Read Plates and further tests Select suspect colonies from CCDA

Gram stain Dark field Microscopy (motility) Oxidase test

Blood plate and HIA : 24hrs at 42C 6 Confirm and Report

Hippurate Catalyse Indoxyl acetate Report as Campylobacter spp

Report as C. jejuni if Hippurate positive In Outbreaks/critical situations : use direct plating also Clinical samples, raw foods: high microbial loads Direct Plating for Camplyobacter ( unto CCDA) ONLY if stools < 2hrs and

transported at 4C) (4 days)

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Recommended Daily Procedures Flowsheet: FOOD SAMPLES

IDENTIFICATION OF SALMONELLA, SHIGELLA & CAMPYLOBACTER FROM FOODS

Day SALMONELLA, SHIGELLA CAMPYLOBACTER

Under microaerobic conditions 1 Pre-enrichment (BPW/LB/UPB)

1: 9 food: broth ratio ; incubate @37oC for 18-24hrs Pre-enrichment (Preston / Bolton broth)

1: 9 food: broth ratio ; incubate @37oC for 4/5hrs

Enrichment (Preston / Bolton broth) 1: 10 stool: broth dilution ; Incubate @42oC for 48hrs

2 Enrichment (RVS and TT) 1ml into 10mls TT; 0.1ml into 10mls RVS

Incubate TT @37oC for 18-24hrs for low microbial foods; Incubate TT @42C for 18-24hrs for high microbial foods; Incubate RVS @42oC for 18-24hrs for all foods

3 Selective Plating (XLD, Mac) (additional: HE/BGA) Streak from RVS unto XLD and MAC Streak from TT unto XLD and MAC Incubate @37oC for 18-24hrs

Selective Plating (CCDA or Campylobacter agar)

Streak from broth unto CCDA plate (x2) Incubate @42oC for 48hrs

4 Read Plates and Prelim Biochemicals Select at least 3 suspect colonies for Salmonella from each broth, inoculate into TSIA, LIA, UREA

Select at least 3 suspect colonies for Shigella from each broth; inoculate into TSIA, LIA, UREA

Incubate all tubes @37oC for 18-24hrs

Purity plate : onto MAC and TSA/NA plate

5 Confirmatory Biochemicals Read Salmonella TSIA, LIA, UREA and- discard if does not fit profile OR full biochemicals/rapid kit

Read Shigella TSIA, LIA, UREA and- discard if does not fit profile OR full biochemicals/rapid kit

Incubate all tubes @37oC for 18-24hrs

Start O agglutination from TSA plate Inoculate into Flagellar broth from TSA plate

Read Plates and further tests Select suspect colonies from CCDA

Gram stain Dark field Microscopy (motility) Oxidase test Blood plate and HIA : 24hrs at 42C

6 Report and Serotyping Report as Salmonella spp and/or Salmonella group Report as Shigella Species

Continue with H analysis

Confirm and Report Hippurate Catalyse Indoxyl acetate Report as Campylobacter spp Report as C. jejuni if Hippurate positive

Proper Food sampling and Preparation is necessary and varies with food type Food specimens should be representative of sample lot (>100g) Food samples should reach the lab immediately/asp after sampling , and

transported at 4C Should avoid freezing food samples

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ANNEX 3

FBD Surveillance Forms and Guidelines for Filling the Forms Form 1 Faecal sample rejection notification form Form 2 Foodborne disease investigation form Form 3 Notification form Form 4 Health Status of Food Handlers involved in a foodborne disease outbreak Form 5 Suspected foodborne illness specific attack rate table Form 6 Combined attack rates, by food consumed Form 7 Final report on a foodborne outbreak Form 8 BAHA CIL sample submission form

GUIDELINES FOR COMPLETING FOODBORNE DISEASE FORMS Forms:

1. Feacal sample rejection notification form 2. Foodborne disease investigation form

3. Notification form

4. Suspected Foodborne illness specific attack rate table

This is an instrument established by the Ministry of Health, for reporting and recording the occurrence of Foodborne disease in Belize. The information contained in the forms is essential for the proper documentation, diagnosis, and analysis of Foodborne diseases which will determine the level of intervention of the Ministry of Health, BAHA and Ministry of Agriculture and other authorities, as may be necessary. An immediate investigation should be carried out for all Foodborne cases reported. These forms should be completed by authorized environmental health, medical and veterinary personnel and other personnel who have been trained in the proper use and completion of the forms, such as Food Safety and Animal Health personnel from BAHA.

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GENERAL GUIDELINES:

1) Ensure that all sections are completely filled by placing an X on the corresponding box and enter the correct information on the respective spaces (lines).

2) All entries should be printed legibly. Abbreviations should be avoided. 3) Ensure complete and proper spelling of patient names.

4) The forms should be completed in duplicate, the original will go to the

Epidemiology Unit, Ministry of Health and the copy will form part of the report to be submitted at the end of the investigation.

5) These forms will be available at the Epidemiology Unit of the Ministry of Health,

all regional health facilities (environmental health) and BAHA (animal health and food safety) for the use of all personnel trained in their use.

CLARIFICATION NOTES FOR SELECTED ITEMS PER FORM 1. Feacal sample rejection notification form

- Section 1:5 Date: refers to the date that the form is being completed. 2. Foodborne disease investigation form

This form should be applied for each existing or suspected case of Enteric Disease for its subsequent processing and analysis. Section 1: Date – refers to the date that the case was reported.

- Section 2: Name of parent – refers to the name of the parent or guardian living with the child. Where both parents or guardians live with the child, use the name of the male person.

Section 3: First symptoms – these are the first symptoms reported by the patient Duration of major symptoms – state length of time in days Severity – State whether mild, moderate or severe

Section 4: Water source - please specify if source is from RWT, RWSS, MWSS, Hand pump, well, stream or river. (MWSS = Municipal water supply system; RWSS = Rudimentary water supply system, RWT = Rain water

tank) Chlorine residual = Indicate the level of chlorine in the water. Safe water should contain 0.5 parts per million (ppm) Section 5 (overleaf): *III means confirmed or suspected cases.

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3. Notification form

Date – Date of visit to physician First name and surname: This refers to patient.

4. Suspected Foodborne illness specific attack rate table

This form is designed to calculate specific attack rate based on a suspected Foodborne disease outbreak where all foods served at a particular event are itemized; people are classified as having eaten or not eaten the particular food and as ill or not ill after eating or not eating the particular food item served.

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FORM 1: FAECAL SAMPLE REJECTION NOTIFICATION FORM Section 1 Demographics

1. Patient Name (Full): ________________________ 2. District: ___________ Urban: ______ Rural: _______ 3. Address: _________________________________________________________ 4. Sex: (1) Male (2) Female 5. Date: ___/____/_______ 6. Hospital: _________________ Ward/Unit: _________________

Section 2: Laboratory Procedure (please tick)

1. Test Order: Culture ______

2. Specimen: Blood ______ Faeces ______ Urine ______ Sputum ______ Fluid ______ CSF (Cerebrospinal fluid) ______ Eye ______ Ear ______ Throat ______ Pus ______ Wound ______ Tips ______

3. Date sample taken: ___/____/_____ 4. Date received sample: ___/___/______

Sample accepted Sample rejected Rejection Criteria: Insufficient sample sent

Sample Spill

Sample too old to be processed (for culture) Non sterile container (for cultures) Sample not labeled Sample/form improperly labeled

Corrective actions: Send new sample Collect new sample

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FORM 2: Foodborne Disease Investigation Form

SECTION 1: Source of Information Date: ___/___/______ Name of Reporting Officer:___________________________________________ Position: Physician Nurse Public Health Inspector Other (specify) ___________________ Institution: ________________________________________ District_____________________________

SECTION 2: Patient Demographics Patient’s Name: ____________________________ Age:_______ Sex: Male Female Name of Parent(if child):_________________________________ Address:________________________________ Urban/Rural: ______________________ District:_____________________ Occupation: _______________________ Educational Level: _______________________ Ethnicity: _____________ SECTION 3: Signs and Symptoms Enteric Infections Intoxication Neurological Fever ______ Burning Sensation ______ Numbness ______ Headache ______ Metallic Taste ______ Dizziness ______ Diarrhoea ______ Nausea ______ Blurred Vision ______ Dehydration ______ Flushing ______ Dysphoria ______ Chills ______ Itching ______ Delirium ______ Loss of appetite ______ Prostration ______ Paralysis ______ Vomiting ______ Cyanosis ______ Coma ______ Malaise (weakness) ______ ABD Pain (cramps) ______ Date of Onset: ____/____/______ First Symptoms: ________________________ Date: ____/____/______ Duration of major symptoms: ______________ Severity: _____________ Fatal: Yes __ No __ Treated: Yes ___ No ___ SECTION 4: Case History Recent Contact with Enteric Disease? Yes No Not sure If Yes, Where? __________________________ When? __________________________________ With Whom? _________________________ What Foods were eaten? _____________________ Where food(s) was eaten? ____________________________ Association with Common Meal? Yes No Not sure ___________________________________________________________________________________ If Child <2 years old: is Child being breastfed Water Source: Bottled Water WASA RWSS RWT Hand pump Other (specify)__________________________ Chlorine Residual(if applicable)___________ SECTION 5: Laboratory Specimens Clinical Specimen(s) Collected: Blood Date ____/____/____ Result______________ Stool Date ____/____/____ Result______________ Urine Date ____/____/____ Result______________

Food Specimen(s) Collected? ____________: Date ____/____/____ Result_________ ____________: Date ____/____/____ Result_________ ____________: Date ____/____/____ Result_________

(SEE OVERLEAF)

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No.

Nam

e R

elation A

ge Sex

Occupation

* III

Date of

Onset

STOO

L

Rem

arks D

ate L

aboratory R

esult

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

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Ministry of Health Foodborne Disease Notification Card

FORM 3: NOTIFICATION FORM COMMUNICABLE DISEASE NOTIFICATION FORM Date: _____/_____/_____ Surname: ____________ First: _______________ Other names: ____________ ________________________ Address: ________________ Suspected Type of FBD: ______________________

District: ____________ Address: ________________ ________________________ Urban/Rural: ____________ Notification Date: _____ /_______ /_____ Day Month Year First Name: ______________ Surname: _______________ Other names: ___________________ Age: _____ Sex: Male Female

MEDICAL PRACTITIONER/NURSE NOTIFYING THE CASE: Print Name (Full): ________________________ Signature: ________________________

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FORM 4: FOOD HANDLERS HEALTH STATUS FORM INVOLVED IN A FBD OUTBREAK

A. DATA ON THE FBD OUTBREAK BEING INVESTIGATED 1. Establishment being investigated: …………………… 2. Date outbreak began: ………………………. 3. Suspected food: ……………...

B. INFORMATION ON THE HEALTH STATUS OF THE PERSONS WHO HANDLED THE SUSPECTED FOOD

No. 4. Full name of person who handled the food

5. Apparent state of health 6. Diseases present 7. Type

of specimen

8. Work missed

Healthy Sick Digestive Skin Respiratory N Y Caused

C. OBSERVATIONS OF EPIDEMIOLOGICAL INTEREST

…………………………………………………………………………………………………………………………………………………………...

…………………………………………………………………………………………………………………………………………………………...

…………………………………………………………………………………………………………………………………………………………...

9. Date: ……../……./……. 10. Name of Person filling out the form: …………………………………………………………………………...

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FORM 5: SUSPECTED FOODBORNE ILLNESS SPECIFIC ATTACK RATE TABLE

Food served

People who ate the suspected food People who did not eat suspected food Difference in

occurrence Sick Not sick Total Attack

rate Sick Not sick Total Attack

rate

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47

CONCLUSIONS ON SUSPECTED FOOD

…………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………….

Date: ……./……/……. Name of person filling out form: ………………………………………………..

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48

FORM 6: COMBINED ATTACK RATES, BY FOOD CONSUMED

Place and date: _________________________________________________________________________

Name of person filling out form: ___________________________________________________________

Combination People who ate food Y

Difference in occurrence (%)

Sick: attack rate Not sick: attack rate

Food I

Food II

Food III

Foods I + II

Foods I + III

Foods I + II + III

Suspected food:

Conclusions:

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FORM 7: FINAL REPORT ON A FBD OUTBREAK

Date: …………………… Name of person filling out form: ………………………………............................

OUTBREAK REPORT City: Year: Report No.

Place of outbreak: District: No. of people affected: First person Last person At risk: _______ Sick: ___________ Hospitalized: ______ Died: __________

____________ _____________ day/month/year day/month/year

Symptoms:

Nausea Vomiting

Diarrhea Fever

Abdominal pains Other

Incubation period: Duration of the disease: In hours Days

__________◄____________Short_________►_________ __________◄______________Long_________►__________ __________◄____________Medium_________►_________

Food/vehicle:

Confirmation ___________ Laboratory ____________ Epidemiology _________ Unconfirmed ______

Brand name of the product:

Produced by:

Method of marketing/procedure for serving: Place where the food was contaminated: Place where the food was consumed: Date: City: Contributing factors:

Laboratory results No. Samples No. Positive Observations Specimen/sample People sick Foods Suspected food Other food Developments Causes Confirmed Suspected Causative agent

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FORM 8: BAHA CIL SAMPLE SUBMISSION FORM

Client Information Sampler

Lab Contact Lab ID BAHA-CIL

COC No. Lab Sample No.

Client Contact

Phone Email : Lab Required CIL Residues/ Microbiology

CIL Job NO.

Company

Sample Disposal □ Return to client □ Disposal by lab □ Archive for _____ months

Address

Due Date Requested Y=Microbiological Analyses: □ SPC □ MPN □ E.Coli □ Vibrio spp. □ Fecal coliform □ Salmonella □ Bacillus cereus □ Campylobacter □ Staphylococcus aureus □ Clostridium perfringens □ Yersinia enterocolitica □ Listeria monocytogenes □ Streptococci spp. □ Shigella □ Water Profile □ Food Borne Disease Profile

Analysis Available A= Organophosphates B=Organochlorines C=Carbamates D=Heavy Metals (specify) E= Veterinary Drugs (specify) F=Antibiotics (specify) G=Fungicides H=Herbicides I=Toxins X= Special Projects Y=Microbiological

Possible Hazard Identification □ Non-Hazard □ Flammable □ Skin Irritant □ Poison □ Unknown □ Bio-Hazard □ Radiological □ Food Borne Disease

Town

TAT- Turn around time (Days) Requested

District

Project: □ monitoring □ compliance □ surveillance

Phone

Preservation Codes: I=Ice N=None Z=Other (specify) F= Frozen FR= Fresh Other:

Email Available Instrumentation

(Please use these options in the special instructions column.) □ Charm II Analyzer □ HPLC □ GC □ AAS □ Other (Specify)

Project Name Site

Sample Identification (Lot No., Site No., Pond No., etc.)

Sample Date

Sample Time

Sample Type (C=Composite; G=Grab)

Matrix (W=Water, S=Solid, O=Oil, BT=Tissue, F=Feed, G=Grain, RTE=Ready to Eat Foods, J=Juice, M=Milk, V=Vegetable, FR=Fruit)

Analysis Required

QC Requirements:

Special Instructions

Samples relinquished by

Date/ Time Company Received by Date/ Time Company

Samples relinquished by

Date/ Time Company Received by Date/ Time Company

Samples relinquished by

Date/ Time Company Received by Date/ Time Company