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FOOD SAFETY | STUDENT HANDOUTS

OUTBREAK INVESTIGATION: DESCRIPTION OF THE OUTBREAK


Scenario:
On Wednesday, June 5, a local community organization held a fundraising crab feast for cancer

research. Roughly 100 people attended the event. The menu included fresh steamed crabs, egg

salad, macaroni salad, creamy coleslaw and ice cream.

On Thursday, June 6, a woman who had attended the crab feast woke up feeling ill. She scheduled

an appointment with her doctor. She described her symptoms as nausea, fever, chills and body

aches.

On Friday, June 7, the physician noticed that during the morning of her shift she had seen several

people with similar symptoms. She began asking questions about their previous activities and

found that they had all attended the crab feast. The doctor called the local health department to

report her observations.

Start of the investigation:


The health department immediately began an investigation. A district health officer contacted

patients and confirmed the doctors report of their illnesses, as well as their attendance at the crab
feast. The investigators suspected that the crab feast may be the source of the illness.

The health department also prepared a questionnaire, which was distributed a week after the crab
feast to as many people as possible who had attended the event. The questionnaire asked for the
following information:

Whether the person became ill


Symptoms of the illness

Time the symptoms began

What foods the person ate

Out of the 100 people who attended the event, 45 responded to the questionnaire. The results are
given in Outbreak Investigation: Questionnaire Data. Each row represents a different person.

Parts of this activity have been adapted from:


Principles of Epidemiology: Problem 1: An Outbreak of Sore Throats Following a Charity Luncheon. Johns Hopkins
Bloomberg School of Public Health; 2010.
Farber RE, Korff FA. Foodborne Epidemic of Group A Beta Hemolytic Streptococcus. Public health reports, 1958;
73(3), 203-9.

TEACHING THE FOOD SYSTEM| A PROJECT OF THE JOHNS HOPKINS CENTER FOR A LIVABLE FUTURE

FOOD SAFETY | STUDENT HANDOUTS

OUTBREAK INVESTIGATION: QUESTIONNAIRE DATA


Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45

Date sick
7th
6th
7th
Not sick
8th
7th
Not sick
8th
7th
10th
8th
8th
7th
8th
7th
Not sick
7th
8th
8th
8th
9th
Not sick
8th
9th
7th
Not sick
8th
7th
8th
7th
Not sick
8th
8th
8th
Not sick
8th
8th
8th
Not sick
Not sick
Not sick
Not sick
8th
Not sick
Not sick

Crabs
Ate
Ate
Ate
Ate
Ate
Ate
Did not eat
Did not eat
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Did not eat
Ate
Did not eat
Ate
Ate
Did not eat
Did not eat
Ate
Did not eat
Ate
Ate
Ate
Ate
Ate
Did not eat
Did not eat
Ate
Ate
Did not eat
Ate

Macaroni
Ate
Did not eat
Ate
Did not eat
Did not eat
Ate
Ate
Did not eat
Ate
Did not eat
Did not eat
Ate
Did not eat
Did not eat
Ate
Ate
Did not eat
Ate
Did not eat
Did not eat
Ate
Ate
Did not eat
Ate
Did not eat
Ate
Did not eat
Did not eat
Ate
Did not eat
Ate
Did not eat
Ate
Did not eat
Ate
Did not eat
Did not eat
Did not eat
Ate
Did not eat
Ate
Ate
Did not eat
Did not eat
Did not eat

Egg Salad
Ate
Ate
Ate
Ate
Ate
Ate
Did not eat
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Did not eat
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Did not eat
Did not eat
Ate
Ate
Ate
Ate
Ate
Ate
Ate
Did not eat
Did not eat
Ate
Ate
Did not eat
Did not eat
Ate
Did not eat
Ate
Did not eat
Did not eat

Cole Slaw
Did not eat
Ate
Ate
Ate
Ate
Ate
Ate
Did not eat
Did not eat
Did not eat
Ate
Ate
Did not eat
Did not eat
Did not eat
Ate
Ate
Ate
Did not eat
Ate
Ate
Ate
Did not eat
Ate
Did not eat
Ate
Did not eat
Ate
Did not eat
Ate
Ate
Did not eat
Ate
Did not eat
Ate
Ate
Ate
Ate
Ate
Did not eat
Ate
Ate
Did not eat
Ate
Did not eat

TEACHING THE FOOD SYSTEM| A PROJECT OF THE JOHNS HOPKINS CENTER FOR A LIVABLE FUTURE

Ice Cream
Ate
Ate
Did not eat
Ate
Did not eat
Did not eat
Ate
Ate
Ate
Did not eat
Ate
Ate
Ate
Did not eat
Did not eat
Ate
Ate
Ate
Did not eat
Did not eat
Ate
Ate
Did not eat
Ate
Ate
Ate
Ate
Did not eat
Did not eat
Ate
Ate
Did not eat
Ate
Did not eat
Ate
Ate
Ate
Did not eat
Ate
Ate
Ate
Ate
Did not eat
Ate
Ate

FOOD SAFETY | STUDENT HANDOUTS

OUTBREAK INVESTIGATION: ATTACK RATE


What percent of people who attended the event got sick?

Instructions:

Using the Questionnaire Data, count how many people became sick and how many did not. In order
to determine the attack rate (the percentage of people who became sick), divide the number sick by
the total number of people who answered the questionnaire. Write your results in the table below.
Number of people
who got sick:

Number of people
who did not get sick:

Total number of
people who
responded to the
questionnaire:

Attack rate:

OUTBREAK INVESTIGATION: ATTACK RATE BY FOOD


Which food at the lunch had the highest attack rates?

Instructions:

For each food that was served, determine how many of the people who ate that food became sick.
Divide this by the total number of people who ate that food. The result is the attack rate for the
particular food.
Food:

Number of
people who ate
this food and got
sick:

Number of
people who ate
this food but did
not get sick:

Total number of
people who ate
this food:

TEACHING THE FOOD SYSTEM| A PROJECT OF THE JOHNS HOPKINS CENTER FOR A LIVABLE FUTURE

Attack rate by
food:

FOOD SAFETY | STUDENT HANDOUTS

OUTBREAK INVESTIGATION: EPIDEMIC CURVE


Instructions:
Determine when each person first reported his or her sickness. Graph your results below to
determine when the majority of people became ill. Label the X-axis as date of onset and the Y-axis
as number of people.

18
16
14
12
10
8
6
4
2
5th

6th

7th

On what date did the most people become sick?

8th

9th

10th

11th

________________________

What is the mode incubation period? ________________________

Hint: The time from exposure to the day when the most people became sick is the mode incubation
period.
What is the median incubation period? ________________________

Hint: The median incubation period can be found by making a list of the individual incubation
periods, from shortest to longest. The middle value in the list (or the average of the two middle
values if there is an even number of cases) is the median incubation period.
TEACHING THE FOOD SYSTEM| A PROJECT OF THE JOHNS HOPKINS CENTER FOR A LIVABLE FUTURE

FOOD SAFETY | STUDENT HANDOUTS

OUTBREAK INVESTIGATION:
IDENTIFYING THE PATHOGEN AND CONTAMINATED FOOD
Instructions:
Work as a group to answer the questions below about the pathogen and food that probably caused
the outbreak. Consider the results of your investigation so far: the symptoms of people who became
ill, the attack rate and the median incubation time. Compare these against the descriptions of each
pathogen in the handout labeled Outbreak investigation: Pathogens.
Which pathogen do you suspect caused the illness? ________________________

Which food do you suspect was contaminated by the pathogen? ________________________


Some of the people who said they ate this food did not get sick. What could be some possible
explanations for this?

TEACHING THE FOOD SYSTEM| A PROJECT OF THE JOHNS HOPKINS CENTER FOR A LIVABLE FUTURE

FOOD SAFETY | STUDENT HANDOUTS

OUTBREAK INVESTIGATION: PATHOGENS


Salmonella

Campylobacter

Incubation period: 1-3 days

Incubation period: 2-5 days

Commonly associated foods:


Eggs
Poultry
Cheese
Unpasteurized milk or juice
Raw fruits and vegetables 1

Commonly associated foods:


Raw and undercooked poultry
Unpasteurized milk
Contaminated water2

Signs and symptoms:


Fever
Vomiting
Diarrhea

Signs and symptoms:


Fever
Vomiting
Diarrhea
Abdominal cramps

Norovirus

E. coli

Incubation period: 1-2 days

Incubation period: 1-8 days

Commonly associated foods:


Poorly cooked shellfish
Ready to eat foods handled by infected
persons like salads or sandwiches
Contaminated water 3

Commonly associated foods:


Undercooked beef, salami
Contaminated water
Unpasteurized milk or juice 4

Signs and symptoms:


Nausea
Vomiting
Large volume diarrhea

Signs and symptoms:


Vomiting
Severe diarrhea
Abdominal cramps

Centers for Disease Control and Prevention (CDC). (2010). Salmonella serotype Enteritidis. Retrieved January 31,
2011, from http://www.cdc.gov/nczved/divisions/dfbmd/diseases/salmonella_enteritidis/
2
Centers for Disease Control and Prevention (CDC). (2010). Campylobacter, General Information. Retrieved
October 4, 2010, from http://www.cdc.gov/nczved/divisions/dfbmd/diseases/campylobacter/
3
Centers for Disease Control and Prevention (CDC). (2010). Norovirus: Technical Fact Sheet. Retrieved January 31,
2011, from http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm
4
Centers for Disease Control and Prevention (CDC). (2010). Escherichia Coli 0157:H7. Retrieved January 31, 2011,
from http://www.cdc.gov/nczved/divisions/dfbmd/diseases/ecoli_o157h7/

TEACHING THE FOOD SYSTEM| A PROJECT OF THE JOHNS HOPKINS CENTER FOR A LIVABLE FUTURE

FOOD SAFETY | STUDENT HANDOUTS

OUTBREAK INVESTIGATION: SUMMARY OF ACTION STEPS


Instructions:
How do health departments respond to an outbreak of a foodborne illness? Think about the steps
you took to determine the cause of the outbreak. For each step in the investigation of an outbreak,
write a sentence describing the activity that took place at that step.
People who attended the event became sick and went to the doctor. The doctor reported the
cases to the health department.

The health department used the information it had gathered to identify the pathogen and the
contaminated food that caused the outbreak. This information can be used to help prevent
future outbreaks.

TEACHING THE FOOD SYSTEM| A PROJECT OF THE JOHNS HOPKINS CENTER FOR A LIVABLE FUTURE

FOOD SAFETY | STUDENT HANDOUTS

OUTBREAK INVESTIGATION: PRESS RELEASE


Instructions:
Draft a press release (about a paragraph in length) for the local newspaper about the outbreak.
Summarize the outbreak in terms of who, what, where, when, why and how. Include
recommendations for how to prevent foodborne outbreaks at future community events.

TEACHING THE FOOD SYSTEM| A PROJECT OF THE JOHNS HOPKINS CENTER FOR A LIVABLE FUTURE