The Louisville Metro Department of Public Health and Wellness (LMPHW) is located in Louisville, Kentucky which has a population of approximately 750,000 to 999,999 people. Louisville is known nationally for its hospitality hosting the Kentucky Derby which draws over 500,000 spectators. Louisville Metro is also nationally recognized as a Foodie getaway. A number of the local chefs have had the privilege to cook at the James Beard House in New York City and several others have been on television programs like Iron Chef America, Top Chef and the Food Network Star. Louisville has also had restaurants showcased on the Food Network and Travel Channel. Recently the city has seen an insurgence in the popularity of Food Trucks demonstrating an ever evolving food culture. In Louisville, the consumer demand for food is about $3 billion a year(1). The city has approximately 3800 permitted food service establishments. LMPHW’s Food Safety and Protection Program (FSPP) receive approximately 180 foodborne illness complaints annually, including confirmed enteric disease reports. Foodborne illness affects approximately 48 million individuals per year resulting in 128,000 hospitalizations and 3,000 deaths annually (2). Because of the popularity of food in Louisville, LMPHW has placed the prevention of foodborne illness as a top priority.LMPHW’s Food Safety and Protection Program signed on to the Food and Drug Administration’s Voluntary National Retail Food Regulatory Performance Standards(VNRFRPS) in order to strengthen and standardize the FSPP.
During the completion of the FSPP evaluation for VNRFRPS, a deficiency was found in the ability to meet Standard No. 5, Foodborne Illness and Food Defense Preparedness and Response, due to an inability to effectively conduct data review and analysis. The FSPP relied on a manual process for reporting and investigation of foodborne illness making data collection and analysis nearly impossible. The FSPP corrected this issue through a collaborative effort with various LMPHW Departments by developing and implementing its Foodborne Illness (FBI) database. The team was comprised of a Food Safety Specialist, Environmental Health Supervisor, Manager and Administrator, Environmental support staff, Communicable Disease nurses, as well as Epidemiology and Information Technology staff. The current electronic database features forms for the entry of reported foodborne illnesses along with the subsequent investigation. Automated reports are also generated from the database to assist in data analysis.
The goal of the FBI database is to identify risk factors in food service establishments known to contribute to foodborne illness. Objectives of this practice include promoting active managerial control of these identified risk factors through, inspection and education of food service operators that will result in the reduction of foodborne illness in Louisville Metro. It will aid in the ability to standardize investigations in line with the Voluntary National Retail Food Regulatory Performance Standards (VNRFPRS) and to, collect and house data in one central location.
The database was created by the Epidemiologist of the office of Planning and Policy within LMPHW and was implemented following training for the Food Safety Specialist, FSPP supervisor’s and clerical support staff, who are responsible for the intake of reported illnesses. Food Safety Specialist are responsible for the illness investigation portion. Meetings were also held with the Information Technology department on implementation, maintenance and future upgrades to the database.
The development of the FBI database and subsequent training's allowed the FSPP to meet all of the goals and objectives of the project. The FSPP now have an effective tool that allows for the evaluation of data and standardized investigations of foodborne illness in Louisville. The database, with its automated reports, assists the FSPP in Louisville.(1).Market Ventures, Inc. (2008). Building Louisville's Local Food Economy: Strategies for increasing Kentucky farm income through expanded food sales in Louisville Metro Government, Economic Development Department. Portland, ME: Market Ventures, Inc. /Karp Resources, 24. (2).Centers for Disease Control and Prevention,”2011 Estimates of Foodborne Illness in the United States”, 2011, http://www.cdc.gov/features/dsfoodborneestimates/.
The Louisville Metro Department of Public Health and Wellness (LMPHW) is located in Louisville, Kentucky. Louisville is the largest and only first class city in Kentucky and comprises 23% of the total population of Kentucky. As of 2010, Louisville Metro had a total population of approximately 741,096. LMPHW services both the urban and rural portions of the City. Every year approximately 48 million individuals become sick due to foodborne illness. Residents of Louisville, whether consuming food from a restaurant or purchasing and preparing food from a grocery store, have the potential to be affected by foodborne illness.LMPHW’ Food Safety and Protection Program (FSPP) work diligently to protect the health and wellness of its residents from foodborne illness. The FSPP signed on to the FDA’s VNRFRPS in 2012. At the time the FSPP did not have the capability to electronically collect foodborne illness data and compare it to illness investigations. The current practice provides a creative use of one of the standards in the existing "Voluntary National Retail Food Regulatory Program Standards - January 2011" developed by the U.S. Food and Drug Administration. Specifically, the development of new data capture and analysis tools that now addresses elements of Standard 5: Foodborne Illness and Food Defense Preparedness and Response by allowing the department to address the data review and analysis requirements of the standard. Those requirements demand that the department conduct periodic reviews of complaints and investigations to identify trends and possible contributing factors that are most likely to cause foodborne illness or food-related injury. The database and its associated reports facilitate the timely and frequent review of the data in ways that would have been difficult, if not impossible, using a paper-based complaint log system.
The new practice of electronic data collection and analysis of foodborne illness is evidence based. The CDC has devised similar systems, FoodNet and OutbreakNet that have demonstrated that knowledge is the key to food safety. Trend details obtained from these systems help FSPP implement measures to effect change for safer food service operations.
The FBI database does address the CDC Winnable Battle of Food Safety. Food Safety relies on strong partnerships. The collaborative effort between Departments, helped to improve communication and build bridges between Communicable Disease, Epidemiologist, and Environmental Health programs. The database helps to track trends and contributing risk factors which can assist in decreasing food related infections. It will also assist in accelerating our response and reporting to our State and Federal partnering agencies to foodborne illness.
The goals of the practices accompanying the foodborne illness database (FBI) are to identify risk factors in food service establishments that are known to contribute to foodborne illness. There are several objectives for this practice:•Promoting active managerial control of these identified risk factors through, inspection and education of food service operators that will result in the reduction of foodborne illness in Louisville Metro.
Assist the LMPHW Food Safety Program with meeting Standard 5, Foodborne Illness and Food Defense Preparedness and Response, of VNRFRPS.
Housing data in a central location for easy access.
The process began with the executive staff in conjunction with the food safety specialist seeking to improve the foodborne illness response guidelines. The aspiration was to implement a standardized process for how foodborne illness interviews are conducted and complaints are investigated. We met with epidemiologist to discuss how to better collaborate our efforts in handling confirmed and unconfirmed foodborne illness complaints between the Food Safety Program and Communicable Disease Program. Currently, the Food Safety Program responds to all the unconfirmed foodborne illness complaints arriving via phone, email or in person. Conversely, the Communicable Disease Program responds to all confirmed foodborne illness reports. The Communicable Disease Program receives all confirmed illness reports from labs, hospitals, doctor’s office, the KY Department of Health Lab, as well as other locations. Communicable Disease nurses then contact the victims of all confirmed foodborne illnesses to conduct an interview based on a standardized KY State Enteric Disease report form and refer the interview report to the FSPP. The FSPP determines if an investigation is warranted based on the information provided or the ability to make contact with the victim to obtain necessary information in order to conduct an investigation.
The VNRFRPS, Standard 5, Foodborne Illness and Food Defense Preparedness and Response and the Council to Improve Foodborne Outbreak Response (CIFOR) guidelines were used to asses our current foodborne illness response program. Initially all foodborne illness investigations conducted by the FSPP was in paper format. The support staff would enter the complaint into a database used to track inspections in a generic format. Each investigation report was filed in the facilities folder then never reviewed for further analysis. In order to meet the Standard 5 of VNRFRPS a database was necessary that had the ability to detect, collect, investigate, and respond to complaints and emergencies that involve foodborne illness, food-related injury, and intentional and unintentional food contamination. The database is required to have the capability to query the necessary reports per the VNRFRPS guidelines. FSPP also has the ability to create additional reports that are necessary to thoroughly assess trends and protect public health in our community. The necessary reports to identify trends and possible contributing factors to illness outbreaks include:
Multiple complaints on the same establishment
Multiple complaints on the same establishment type
Multiple complaints implicating the same food
Multiple complaints associated with similar food preparation processes
Number of laboratory- and/or epidemiologically-confirmed, foodborne disease outbreaks
Number of foodborne disease outbreaks and suspect foodborne disease outbreaks
Contributing factors most often identified
Number of complaints involving real and alleged threats of intentional food contamination
Number of complaints involving the same agent and any complaints involving unusual agents when agents are identified
Initially the food safety specialist reworked the interview form to meet our needs utilizing the Communicable Disease Enteric investigation interview form for guidance. The standardized interview form includes demographics, food history, illness status, signs and symptoms, incubation period, duration, environmental risk factors and any medical information when necessary. Additional questions related to environmental health were added to the FSPP form. These questions include travel history, consumption of raw milk, recreational water activity in the recent months, visiting a petting zoo, and whether any other friends or family members are ill. The Communicable Disease program is mandated to use the KY State enteric disease report form, which is currently under review, and includes the majority of the information outlined above in addition to lab results. A standardized investigation report form was created to ensure each food safety specialist was consistent in his or her investigations. The investigation form identifies the person in charge, any critical violations that are present, the action taken, product information, intentional contamination, and food processes. With the assistance of the epidemiologist, the FBI database was created simulating these new forms. The database is split into two parts, the interview and the investigation report that are linked by an establishments unique permit number. All food safety specialists, support staff and management have access and enter data as necessary.
Unconfirmed foodborne illness complaints are received by the environmental office via telephone and email. An interview is taken by our clerical support person, who then enters the information into the database. The victim may provide several facilities where they consumed food during the interview and each individual establishment is recorded in the database. The Food Safety Specialist is then provided a hard copy of the report to take with them to the facility, along with their standardized investigation form. Once the investigation is completed, the food safety specialist comes into the office to enter the information in the database under the linked facility. In the near future, Food Safety Specialist will have the ability to enter the investigation into the database in the field, and all information collected will be submitted in real-time.
All confirmed foodborne illnesses are sent directly to the Communicable Disease Program, it is then referred to the food safety program. Once a confirmed foodborne illness is received by the food safety supervisor, it is entered into the database and the same procedure applies as stated previously. Currently, the Communicable Disease Program has a separate database to upload their data. The Epidemiologist conducts surveillance daily for confirmed foodborne illness trend analysis. If an outbreak is suspected from the epidemiologist surveillance or the Food Safety Programs analysis, both programs would collaborate together to conduct investigations, interviews, vaccines, etc. In moving forward, the capability to link both databases together would be ideal.
The database was rolled out to food safety specialist and support staffs, both are trained to screen foodborne illness cases, conduct interviews and upload data into the database.
Internally the practice involved many stakeholders. The Food Safety Specialist and Supervisor attended the International Food Protection Training Institute (IFPTI)in 2009 and 2010 where they obtained tools and training focusing on foodborne illness response. The training prompted them to form a work group in 2011 committed to improving the internal foodborne illness response of LMPHW.
The FSPP was made aware of the VNRFRPS during the training at IFPTI. In order to have the database rolled out successfully, we collaborated with the epidemiologist who created the database, executive staff who supported our work group, Communicable Disease Program to understand their process and IT for technology support. Essentially the external stakeholders are the operators of Food Service Establishment and the consumers who dine in their facilities. Early detection of a foodborne illness outbreak may save lives which parallels with our mission of protecting public health by preventing a foodborne illness outbreak.
The program currently has one year’s worth of data accumulated in the database. A complete trend analysis has not yet been completed; however, moving forward the data will be examined once a month or as necessary. The program supervisor will conduct a review of the data in the database using the foodborne illness and food-related injury investigations to identify trends and possible contributing factors that are most likely to cause foodborne illness or food-related injury.
Most foodborne illnesses go under reported or many individuals do not seek out a physician’s care. This database provides us with the capability to analyze trends and identify risk factors known to contribute to foodborne illness between an unconfirmed foodborne illness complaint received by the food safety program and a confirmed enteric disease report received by the Communicable Disease program.
There was no cost to create or implement the database. Staffing and computer programs were in place. The implementation of the practice is supported by our job descriptions and mission of the LMPHW.
The goal of the foodborne illness database practice is to identify risk factors known to contribute to foodborne illness. There are several objectives for this practice which are discussed below:
1. Promoting active managerial control of these identified risk factors through, inspection and education of food service operators that will result in the reduction of foodborne illness in Louisville Metro.
The identification of risk factors that cause foodborne illness and food-related injury in our community will assist the program with conducting risk based inspections; this will significantly aid Food Safety Specialist during field inspections. Specialist will have the ability to focus on those identified risk factors within in Louisville Metro food service facilities that lead to foodborne illness and food related injury as well as have better ability to promote active managerial controls for the risk factor(s) identified. By providing risked based inspections to focus on identified risk factors per the FBI, we expect to observe a reduction in these identified risk factors over time.
Performance measures used for this objective include the standard reports identified by VNRFPRS that effectively assess foodborne illness trends overtime. As more data is collected, the anticipated short term outcome will be an observed improvement in identification of risk factors that cause foodborne illness and food related injury. When the risk factors are identified, food safety specialist will have the ability to conduct a risk based inspection, focusing on active managerial controls, to assist in reducing the identified risk factors that lead to foodborne illness and food-related injuries in food service establishments. The long term outcome is to reduce foodborne illness in the Louisville Metro community.
2. Assist the Louisville Metro Department of Public Health and Wellness Food Safety Program with meeting Standard 5, Foodborne Illness and FoodDefense Preparedness and Response of the Voluntary National Retail Food Regulatory Program Standards.
Per the Self- Assessment Guide for the VNRFRPS, in order to meet standard 5 relating to Foodborne Illness and Food Defense Preparedness and Response, a jurisdiction must have a system in place to annually review the compilation of foodborne illness data and complaint information to determine if there are patterns of occurrence related to specific food products, types of food processes, or contributing factors to foodborne illness within their community. As a trend analysis is achieved routinely by management staff to identify the risk factors that are prevalent in Louisville Metro permitted food facilities, specialist will have the ability to conduct a risk based inspection. According to the CDC, reducing foodborne illness by just 10% would keep 5 million Americans from getting sick each year (3).
The top five risk factors in a food service facility identified by the CDC that lead to a foodborne illness include:
Food from Unsafe Sources
Improper Holding Temperatures
Poor Personal Hygiene
er the FDA website Listing of Jurisdictions Enrolled in the Voluntary National Retail Food Regulatory Program Standards, a total of 558 jurisdictions have enrolled in the program. Out of the 558 jurisdiction, 52 or 9.32% have met Standard 5. VNRFRPS applies to the operation and management of a retail food regulatory program that is focused on the reduction of risk factors known to cause or contribute to foodborne illness and to the promotion of active managerial control of these risk factors. The database is one component of the Standard 5 but it is an extremely challenging one for those jurisdictions that do not have the support in place to create a database and identify the reports necessary to meet this Standard to efficiently assess foodborne illness trends within
their community. In the efforts of the Food Safety Modernization Act to build an integrated food safety system, implementing a standard data collection tool such as a database to effectively assess foodborne illness risk factor trends in our respective jurisdiction will support and aid jurisdiction in fulfilling all food safety programs mission to prevent a foodborne illness in their communities. This type of data collection system could be universal in order to not duplicate efforts and streamline the process when all Food Safety Programs nationwide are striving for the same goal.
Performance measures include the ability to accurately query reports set by VNRFRPS outlined above per the data imputed in the FBI database. To ensure the reports are user friendly and are able to be maintained by LMPHW’s Information Technology program. The anticipated outcome is to have a standardized Foodborne Illness and Food Defense Preparedness and Response program that can accurately and efficiently identify foodborne illness risk factors and work to reduce foodborne illness in the community.
3. Housing data in a central location for easy access
The current practice houses all the data in a central database that is easily accessible by multiple users. This type of data housing system if far more efficient then utilizing paper forms and highly effective when analyzing foodborne illness risk factor trends along with other reports that can be tailored to a jurisdiction.
The performance measures utilized included employee feedback regarding the use of the database and providing training on data entry to support staff and Food Safety Specialist. The outcome includes information housed in one location with multi-user access. Housing the data in a database provides efficient reporting leaving more time to conduct field food safety inspections.
Data sources include information from a complainant interviews collected by support staff, communicable disease nurses, food safety specialist and management as well as the food facilities investigation report completed by the food safety specialist. The information is entered into the FBI database by the support staff and food safety specialist. The KY State Environmental Health Managements Information System (EHMIS) reporting database was utilize to create a link between a complaint interview and any subsequent facility investigation that is performed in response to the complaint.
Several modifications have been made; additional fields were added after the pilot period to ensure all data was collected to accurately build the reporting queries per VNRFRPS. As the FSPP becomes more knowledge of VNRPRS expectations and the abilities of the database, additional reports can be created to assess future trends. Several reports have been and will continue to be created from the data imputed as we begin to utilize it more and more. This practice is a working practice; the practice will be adjusted based on the needs of the program to complete VNRFRPS Standard 5 and effectively accomplish the mission to reduce foodborne illness in the Louisville Metro Community.
(3) Centers for Disease Control and Prevention, “Food Safety: What CDC has done…What CDC is doing”, 2011 www.cdc.gov/ncezid/dfwed/factsheets/FACTSHEET_I_ACHIEVEMENTS_links remediated.PDF.
Prior to the establishment of the database, foodborne illness reports and investigations were documented on paper. We did not have the ability to look for any type of trends between the reports or investigations. The new practice replaces a paper based complaint log with a computer database system. The database creates a link between a complaint interview and any subsequent facility investigation that is performed in response to the complaint. The report component of the database allows the department to identify for trends among establishment types, individual establishments, food items, and agents responsible for illness over time. The investigation report has helped to standardize investigations among inspectors and shorten the amount of time it takes to complete the investigation report. The use of the database is sustainable. Personnel involved in foodborne illness interviews, data entry, illness investigations and database management are funded through both State and local funds. The Health departments Information Technology program has agreed to manage the database and perform any needed upgrades in the future. The database will be reviewed annually to determine the need for improvements. The importance of the database was quickly realized when the database showed a commonality between recalled products and reported illness. This helped to obtain the commitment of the inspector’s in the use of the database. The approach used to develop the database brought together individuals from various programs which enhanced communication within the LMPHW. The collaboration helped the involved programs understand how each other operate and was able to give ideas based on their specific skill set to develop the FBI database.
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