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Heart diseasePage 2
TRANSCRIPT
Capella University
Outbreak Investigation
Introduction
Laura Hernandez's Office
Outbreak Detection and Notification
Generating the Hypothesis
Testing the Hypothesis
Investigation Results
Control and Preventative Measures
Conclusion
Introduction
For this assignment, you will explore an outbreak occurring at
St. Anthony Medical

Center, an urban hospital that is part of the fictional Vila Health
health care system
simulation. You will work through the various media
components and throughout
the six parts of the case study, there will be stop points where
you will need to
answer questions posed to you. Your responses will consist of
the body of the Unit
7 assignment. You will label the questions and responses on a
Word document
and submit all the questions answered for this assignment.
Vila Health: Outbreak Investigation Transcript
https://media.capella.edu/CourseMedia/MPH5512/VilaHealthOu
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After completing this case study, you should be able to:
Describe the appropriate response to a potential foodborne
illness complaint.
List disease categories to include in the differential diagnosis of
an acute
gastrointestinal illness, given clinical information.

Outline a hypothesis on the source of an outbreak
Interpret epidemiologic study findings.
Identify information to include in an outbreak investigation
report.
Describe the epidemiology e.g., occurrence, transmission, and
control of an
infectious disease
Outbreak Detection and
Notification
One Page
Voicemail from Keith Olson Hospital Infection Control
Hello, Laura. I wanted to reach out to you and let you know that
yesterday our long
term care unit as well as our labor and delivery unit reported an
unusually high
number of gastrointestinal symptoms. Nearly all of the 26
persons in both wards
(16 in long term and 10 in labor and delivery) reported they
were suffering from
nausea, vomiting, and diarrhea. All reported they had become ill
during the night. I
just wanted to make you aware of this situation as the
epidemiologist for our local

health department.
Answer these questions based on
your observations
At this point, what types of questions are you, the
epidemiologist, beginning to
think about asking the infection control nurse at the hospital?
IN the first part of the
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2 of 15 2/27/2022, 12:08 AM
assignment, please prepare an exhaustive list of questions you
are looking to ask
to ascertain additional information to assist you in your
investigation, if one is
needed at all. Should this complaint/concern be investigated
further? Why or why
not?
One Page
Email from State Health Department.
From: Sarah Perkins, State Health Department

Sent: Tuesday, February 12, 2015 12:20
To: Laura Hernandez
Subject: Follow-Up
Staff from both the hospital and your epidemiological section
were skeptical of the
infection control nurse's report but felt that a minimal amount
of exploration was
necessary. You contacted the State Health Department to
determine if their staff
was aware of a problem. State Health Department staff reviewed
the foodborne
illness complaint log to see if others from the hospital had
reported similar
illnesses or exposures. Although a few reports of vomiting and
diarrhea had been
received, no other recent complaints mentioned the hospital or
involved references
to patients at the hospital.
State Health Staff then made a few telephone calls. The
hospital, where the sick
complaints came from, noted on this day the cafeteria had been
closed until 11:00
A.M., outsourcing breakfast and snacks to patients from a

licensed caterer. A
subsequent call to the emergency room learned they had been
flooded with a
waiting room full (15 patients and counting!) of persons
complaining of acute
gastroenteritis in the last 24 hours. You pull the emergency
room surveillance log
for the past month and only four patients had been seen for
similar symptoms,
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none associated with the hospital. Stool specimens from initial
26 patients in the
two hospital wards had been taken and submitted to the in-house
hospital
laboratory for enteric analysis. Results were not available at
this time.
Voicemail from Dr. Henry Johnson East Side Outpatient Clinic
Hello Laura, it's about 2:30 P.M. This is Dr. Henry Johnson
from East Side

Outpatient Clinic- I just wanted to inform you that I have 7
patients in my waiting
room complaining of nausea, diarrhea, and vomiting. I find it
bizarre because I've
only seen 1 case like this in the past month and every single
patient I've seen has
stated they have been to the hospital to visit family or friends or
were employees of
the hospital.
your observations
At this point, do you think these cases of gastrointestinal illness
represent an
outbreak at the hospital? Why or why not? Please discuss. What
is the criterion for
definition of an outbreak? What are the critical components of
this definition? As
the health department epidemiologist, please list your next
priorities and discuss
them in relation to the steps of this outbreak investigation.
Three to Five Pages
Email from the Hospital Infection Control Nurse.
From: Susan Jones, Infection Control

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4 of 15 2/27/2022, 12:08 AM
To: Laura Hernandez
Subject: Patient Interview Results
Per your recommendation and request, I interviewed the 26
patients from the two
wards here using the forms you gave me and I've done some
preliminary analysis
of the symptomology presentation. I will share those with you
now:
24 persons (91%) reported vomiting
22 persons (85%) reported diarrhea
18 persons (70%) reported abdominal cramping
15 persons (60%) reported headache
13 persons (50%) reported muscle aches
1 person (5%) reported bloody diarrhea

The range of temperatures recorded was from 98.8°F to
102.4°F. We only have
about half (12 persons) of the complete blood counts, but I
thought it was
interesting to note that all 12 of those tested so far had an
elevated white blood
cell count of 13.7 units or higher {normal: 4.8 – 10.8 units}.
The laboratory is still trying to type the organism but it has
been able to rule out:
Salmonella
Shigella
Campylobacter
Vibrio
Listeria
Yersina
E. coli O0157:H7
Bacillus cereus
Staphylococcus aureus
Parasitology screens were also negative. A few of the stool
specimens tested
demonstrate fecal leukocytes and occult blood.

I will keep you updated as I get more information. Do you have
anything to share
with me?
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5 of 15 2/27/2022, 12:08 AM
your observations
At this point, how might you respond to the infection control
nurse with the
information you have so far? How would you interpret these
preliminary laboratory
results? Where would you be focusing your next round of
laboratory analyses on
(bacteria, virus, parasite, toxin/chemical)? What agencies need
to be notified at
this point? As the health department epidemiologist, please list
your next priorities
and discuss them in relation to the steps of this outbreak
investigation.
Feedback
After some brief casework, you develop the epidemic curve for

this outbreak at the
hospital and it looks like this in a graph format:
Based on the epidemic curve and likely causative agent, what is
the likely mode of
https://media.capella.edu/CourseMedia/MP H5512/VilaHealthOu
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transmission and the period of interest for possible exposures
related to this
outbreak? What was the likely incubation length and day? What
type of outbreak is
this called?
Feedback
The hospital uses municipal water and sewage services. There
had been no work
on water or sewage lines in the past year nor recent roadwork or
digging around
the hospital. The hospital dining service included two
cafeterias. The main
cafeteria served as the primary arena for all food storage,
preparation, cooking

and delivery to 100% of patients in the hospital. Visitors also
ate at this main
cafeteria. The specific facilities within the main cafeteria
served hot entrees, a grill,
deli bar, and salad bar. A second smaller cafeteria at the
hospital offers menu
selections with a per item cost and predominantly is used by
hospital staff.
Under the advisement of your State epidemiologist, you begin
interviewing the sick
hospital patients to better understand the likely source of the
outbreak. Among the
20 patients interviewed (6 had been discharged and were no
longer at the
hospital), 25 had eaten food from the deli bar; 9 had eaten food
from the salad bar,
and 3 from the grill. Seven-day food histories revealed no
particular food item that
was common to all or most of the patients. It was also noted in
the labor and
delivery ward that none of the newborns were exhibiting
symptoms.
Given this information, what is your leading hypothesis on the
mode of

transmission in this outbreak? What studies or other
investigations would you
initiate to explore this hypothesis. Provide some descriptive
epidemiology on the
nature of this outbreak and the likely culprit in terms of the
epidemiological triangle.
As the health department epidemiologist, please list your next
priorities and
discuss them in relation to the steps of this outbreak
investigation.
Testing the Hypothesis
Three to Five Pages
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Email from the Hospital Infection Control Nurse.
From:Brian Doyle, Director of Clinical Operations
To: Laura Hernandez
Subject: Thank You

Thank you, Laura, for continuing to investigate our unfortunate
situation of
illnesses within our patient load here at the hospital. I want to
let you know we are
willing to do whatever is necessary to assist your investigation
to help determine
the agent and cause of this event. Per your recommendation, we
are setting up
times and contacts with your staff to perform the three
recommended lines of
investigation:
1. Laboratory studies to determine the causative agent,
2. Environmental health assessment of the hospital main
cafeteria,
3. Epidemiologic study of patients still admitted at the hospital.
We have requested our clinicians to collect stool specimens
from new cases of
vomiting and diarrhea; as well as bacterial cultures from
patients seen in the
emergency rooms. Also, per your guidance, we have submitted
stool samples of
those already sick from the initial phase of the outbreak and are
shipping them to

the Centers for Disease Control and Prevention (CDC) for viral
studies including
reverse transcription-polymerase chain reaction (RT-PCR).
What else can we do
to assist you in this investigation?
your observations
At this point of the investigation, what instructions would you
give to health care
providers for the collection of stool specimens from patients?
Include instructions
on how specimens should be collected, stored, and transported.
Given that
investigators suspect a virus as the causative agent, what
contributing factors are
likely to have played a role in this outbreak? What activities
would you undertake
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8 of 15 2/27/2022, 12:08 AM
during the environmental health assessment? What key areas
should be explored

during interviews with the cafeteria food workers? As the health
department
epidemiologist, please list your next priorities and discuss them
in relation to the
steps of this outbreak investigation.
Investingation Results
Two Pages
Voicemail from Karen Walker Staff Epidemiologist and
Environmental Health
Specialist
Investigators toured the facility and obtained a list of the foods
served at the main
cafeteria during the implicated period. Cafeteria staff was
questioned about their
responsibilities such as the foods they handled, which meals
they served, and
where they usually worked (e.g., deli bar, grill). They also were
asked about use of
gloves, hand washing practices, work schedule during the week
before the
outbreak, and if they had been ill. None of the food workers
reported being ill in the
last two weeks. The cafeteria did not have a sick food workers
policy.

An inspection of the main cafeteria food preparation area,
equipment, and serving
line was unremarkable. Walk-in refrigerators and freezers were
organized to
prevent cross contamination and maintained at appropriate
temperatures. Food
preparation surfaces were clean and appropriately situated with
respect to flow of
kitchen traffic. Steam tables on the serving line heated to proper
temperatures.
Other equipment (e.g., meat slicer) was clean and in good
working order.
The deli bar had its own refrigerator and preparation area.
During mealtimes,
sandwiches were made to order by a food worker. Each day,
newly prepared deli
meats, cheeses, and condiments were added to partially depleted
deli bar items
from the day before (i.e., without discarding leftover food
items). While the deli bar
was open for service, sandwich ingredients were not kept
refrigerated or on ice.
The deli bar containers were not routinely cleaned. The
refrigerator cooled only to

47°F. Water and ice from the cafeteria were collected to test for
fecal coliforms.
Samples of leftover food were collected from the deli bar for
bacterial cultures and
special viral studies at CDC. Stool specimens were requested
from all cafeteria
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9 of 15 2/27/2022, 12:08 AM
staff. Sir/Ma'am, what do you recommend for action at this
time?
your observations
At this point in the outbreak investigation, do you recommend
shutting down the
deli bar? What about the cafeteria? What type of
epidemiological study design
would you employ to assist in narrowing down the list of likely
agents that may be
the culprit for food-borne illness? What steps in the outbreak
investigation are
utilized in this phase of the investigation? Please report on this

development.
Feedback
We have completed the surveys of all ill persons and matched
them with control
(case-control) study to assist in determining the food source
causing the illness.
This data is reflective of patients and persons consuming meals
at the hospital
from Day 0-1, which falls in line with the incubation period.
Sir/ma'am, please
instruct me what we (as a health department) need to do next?
Exposure Ill
Exposed/
Total
Ill(%)
Well
Exposed/
Total
Well(%)
Odds
Ratio
95%
Confidence
Interval
p-value

Exposure American Cheese
Ill Exposed Total Ill(%) 13/28 (46)
Well Exposed Total Well(%) 4/20 (20)
Odds Ratio 3.4
95% Confidence Interval 0.80-17.5
p-value 0.06
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Exposure Swiss Cheese
Odds Ratio 0.61
p-value 0.30
Exposure Ham

Odds Ratio 1.5
p-value 0.36
Exposure Turkey
Odds Ratio 0.95
p-value 0.57
Exposure Shredded Lettuce
Odds Ratio 0.87
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p-value 0.52
Exposure Tomato
Odds Ratio 0.78
p-value 0.50
Exposure Pickles
Odds Ratio 0.63
p-value 0.63
Exposure Mayonnaise
Odds Ratio 3.1

p-value 0.06
Exposure Mustard
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Odds Ratio 0.68
p-value 0.52
Interpret the table. Please provide a brief discussion on
implicated foods vs. non-
implicated foods, the benefits of this study design and what the
confidence interval
and p-value mean in relation to this data. What steps in the
outbreak investigation
are utilized in this phase of the investigation? Please report on
this development.

Control and Preventative
Measures
One Page
Voicemail from Kristin Malecha Hospital Food and Beverage
Director
Good afternoon. It's been 3 days since our cafeterias have been
closed and I am
getting pressure from the higher-ups at the hospital system to
reopen the
cafeterias. Can you give me a sign-off please, or let me know
what I can do to get
our cafeterias back open again? I look forward to hearing from
you.
Voicemail from Keith Olson Hospital Infection Control Nurse
Hello! I know you were hoping to never hear from us again but
I have some very
interesting news to share with you. Did you know of all the
hospital cafeteria staff
you stool sampled, 28 of the 29 (97%) came back negative for
any norovirus
presence. But I couldn't figure out the reason why there wasn't
100%. So, I did
some digging and found out Ms. Mary Mallon was the morning
shift deli prep cook

who did not submit a stool sample due to her religious beliefs.
She has not been
sick but did take off 2 days before Day 0 to care for her ill
daughter (who ironically
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13 of 15 2/27/2022, 12:08 AM
had a diarrheal illness). Ms. Mallon again vehemently denied
she has been sick
and further states she wore gloves while doing all the slici ng of
the cheese, meat,
etc, but didn't wash her hands because she had gloves on. What
is your take on
this? Do you think she is the source of transmission?
your observations
Given your conversation with the infection control nurse and
the food and
beverage direction, what actions and next steps do you
require/recommend? Once
the cafeterias are reopened, what is the epidemiologist's next
step in the outbreak

investigation?
Conclusion
In this scenario, you investigated several aspects of an
outbreak at St. Anthony Medical Center, a hospital in
the Vila Health health care system. You answered
questions along the way that allowed you to build a
hypothesis on the origin of the outbreak, interpret
epidemiologic study findings, and determine and
describe the appropriate response to the complaint.
Your assignment is to answer the questions posed during this
scenario, and:
Describe the appropriate response to a potential foodborne
illness complaint.
List disease categories to include in the differential diagnosis of
an acute
gastrointestinal illness, given clinical information.
Outline a hypothesis on the source of an outbreak BACK TO
TOP
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Interpret epidemiologic study findings.
Identify information to include in an outbreak investigation

report.
Describe the epidemiology e.g., occurrence, transmission, and
control of an
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tbreakIn...
15 of 15 2/27/2022, 12:08 AM

HEART DISEASE & STROKEGOALSBENE

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