MSc in Food Safety Management
Module: Management of Outbreaks of Food Borne Disease
Tutor: Mr Andy C.
“Critically evaluate the ability of University Hospital in managing a large food poisoning/ contamination incident effectively”.
² IACM (Instituto para os Assuntos Civicos e Municipais) : Civic and Municipal Affairs Bureau
- Food Hygiene Inspection Division under the bureau which is responsible for the Mainland to Macao fresh, chilled meat, vegetables and other food management standards.
- IACM Lab. (Laboratory of Civic and Municipal Affairs Bureau): conducts investigations and laboratory tests including the analysis on food samples sent for inspection, including rapid tests for pesticide residues in fruits and vegetables, and avian flu tests;
- Food Safety Center: which is directly under the administrative council of IACM, includes 3 departments: 1) The Division of Planning and Management; 2) The Division of Risk Assessment; 3) The Division of Information Risk.
² Food safety law No. 5/2013 (Lei n. º 5/2013 Lei de segurança alimentar): This law shall enter into force 180 days after the date of its publication, on the date of October 20, 2013.
² SSM (Serviços de Saúde de Macau): Macau Health Bureau is responsible for import and export food safety inspection, quarantine, etc., all the food from production to consumption, the whole process of health bureau responsible for food inspection standards;
- CDC Macau :Macau SAR Centers for Disease Control and Prevention, under SSM
NDIV: Center for Prevention of Infectious Diseases and Disease Surveillance, a department which is under CDC Macau of SSM.
- Macao Public Health Laboratory carries epidemiology analysis, studies and reports the result to CDC or SSM esp. during the infectious disease outbreak.
² Macao Customs: responsible for the import and export of food; which has the authorities to detain the problematic food product.
² Macau Government Tourist Office : responsible for tourism-related restaurants, hotels, bars licensing;
² Macau Economic Service : responsible for the licensing of food factories, implementation of pre-packaged food labeling requirements and the corresponding regulatory measures;
² Macao SAR Government Consumer Council: responsible for food spot checks, announcements, controversial rulings, advice and education, etc.
² Government Information Bureau (GCS): is mainly responsible for the work of the government news released.
² MUST: Macau University of Science and Technology
UH: University Hospital of MUST foundation.
University Hospital is currently the unique hospital in the island district . The hospital was established in 2006, which is the first hospital in Macau SAR that provides both Traditional Chinese Medicine (TCM) and Western medical services. Since the inpatient department (INPT) is in a small-scale (with 57-patients capacity) and ward turnover is not high, outsourcing catering service is offered by the canteen contractors of MUST. The catering service is only for the meal processing, the meal delivery and distribution are responded by the UH staffs.
There is a long and opened distance between the hospital and the canteen , and the takeaway meals are delivering by the staffs. The food-borne illness risks do exist in the hospital. Some microbes like SRSVs (Small round structured viruses), norovirus etc; which are the common gastrointestinal infections that appeared in hospital ward outbreaks ; for the virus usually spread by the routes as faecel-oral, vomiting/aerosols, or by the route of food and water [2,3]. Form government statistics in 2012, 203 cases of the acute gastroenteropathy due to Norwalk agent were identified; and the happening rate of norovirus is higher for 160 cases in average in last 5 years (compare with 37 cases in average in last 25 years) [33,35]; outbreaks of norovirus in various places; including nursing homes, long-term care facilities and hospitals, as well as cruise ships, airplanes, military establishments and schools .
Even no food-borne outbreak has happened in UH[a2] at the moment; hospital meals are processed in the canteen kitchen and then delivered to wards. As the meals are considered as the “hospital food”, i.e. the food should be made aware that the need for the highest possible standards of food hygiene. If food borne outbreaks occur in wards, this will lead to ward closure and major disruption in hospital activity . Once the norovirus case is identified in the hospital, the measures will be adopted as follow mentioned.
Preparations & arrangements
The Food Safety Law No. 5/2013 will come into effect on 20th October 2013[9, 10]; the legislation is yet in very detail. In the past years, all the food related laws, duties and the general affairs were carried from several government departments , when a foodborne outbreak occurs; mostly involved in the outbreak are the SSM, IACM and GCS; the local food safety agency is established. Different form Hong Kong adopting the single agency system in food safety control ; before the establishment of Food Safety Center, like most of the countries, carrying the multiple agency system; and now the food control systems trends to integrated system, which is more cost-effectively and make use of the existing resources, coordination between the existing food control agencies is needed [8, 35].
According to the new Food Safety Law No. 5/2013, some guidelines and alerts are provided for food manufacturers, retailers and caterers etc. The food safety center is under governed by IACM . In the other hand, all the public and private entities have a duty to cooperate with the IACM whenever requires it in carrying out its oversight functions .
In order to have effective control measures to the food borne outbreak, preparations have to be done beforehand. According to the guidelines form FSA  and the legislation of reforming health services Macau [7, 26], coordinated outbreak control plans should have already been drawn up by local authorities: IACM Food Safety Center, IACM-Lab., SS, Macao Public Health Laboratory, and CDC[7,10]. And the plans should be clear, succinct, and practical and be generic in nature.
Case Identification & Diagnosis:
Characteristics of the virus: norovirus gastroenteritis can happen all time of the year but high occurrence in the winter [14,33].Symptoms of norovirus gastroenteritis are: vomiting, watery diarrhea, abdominal pain, headache, malaise and myalgia etc.  norovirus are transmitted directly from person to person, or transmitted indirectly via contaminated water and food such as raw shellfish and salad ingredients [13,14, 33]. For the treatments, no specific treatment for norovirus gastroenteritis but requires to consume plenty of fluids to recharge the loss of body water; and the infectivity of the virus is not long lasting (for 48 hours after resolution of symptoms); so recovery is completed in few days [2,14]. Hands washing (with soap and water or use alcohol rubs) and dry the hands thoroughly . Avoid direct contact with infect people are the effective preventions of the disease.
Diagonosis: During the high peak season of norovirus gastroenteritis, physicians are alerted by those symptoms and decide to take the diagnostic tests: the reverse transcriptase polymerase chain reaction (RT-PCR) test and the enzyme-linked immunosorbent assay (ELISA) . Also the virus structure is easily to be identified by examining stool specimens through the electron microscope. Diagnosis skills are also required for the physicians can help case identification and early recognition of the outbreak; this will help implementation and controls effectively [13,35]. [a3]
Investigation of outbreak
When the source of an outbreak is suspected to be a food, a food safety investigation will be conducted to determine whether the food may be responsible for the outbreak and to strive to identify the root cause of the contamination in the affected food .The primary purpose of any outbreak investigation should always be to limit and control the spread of infection. Since hospital meals are produced in campus canteen, supposed the outbreak is originated from the canteen kitchen, the affected people should not be only the consumers in hospital but also the diners from university and near places. According to the Queensland Health  and FSA guidelines in food borne outbreaks management, several stages and management are carried by both food agency, local health sector and the UH. The outbreak investigation and controls are responded by Food Safety Center officers , the epidemiological investigation and analysis will be carried out by NDIV and Public Health Laboratory (SSM) .
Currently in Macau, food borne outbreaks related to microbes are much more common than those due to chemicals or toxic [33,35]. In the primary investigation of an outbreak, it’s better to consult the microbiologist in the early stage. Due to food borne outbreak investigation, food sampling should be an integral feature; all the samples and relevant information should be totally collected and provided to the microbiologist/ analyst. All the information collected from diagnosed patients, medical information from hospital . The microbiological report helps the identification of the outbreak and can narrow the scope of the investigation. And food samples must be submitted to IACM Lab. by the Department of Food and Animal Inspection and Control of the IACM .
Control measures of the outbreak:
When particular infectious disease outbreaks happen, NIDV promotes the epidemiological investigation of major emergencies in the area of public health . Division of Planning and Management (of Food Safety Center) is responsible for the Investigate and deal with food safety incidents .
Controls from government officials:
Once the outbreak is identified, food safety center and SSM can consider the degree of outbreaks throughout the cases amount of the foodborne illness, the origin place of the food product, and frame of time which the cases happened, the communication and reporting system is essential. The initial case should be reported to CDC . IACM can take measures of prevention and control by considering the outbreak degree and size .
Coordinate with the instructions from local Food Safety Center, the Outbreak Control Team (OCT) of UH is major formed by doctors and nurses, also a microbiologist consultant of OCT is needed in a private health sector . Some measures such as suspected food withdrawal, isolation precautions and location cleaning should be done in priority.
Control measures inside the hospital: In order to control the size and outspread of the outbreak, reducing the risk of staffs, patients and visitors. OCT should implement the control measures as soon as possible. Gould  has generalized some key points including:
a) Hand hygiene is the best control to prevent infection form direct contact ; proper hand washing is required for staffs, patients and visitors [3,14,19,24].
b) Personal protective clothing and masks were used during contact to infected patients, vomits  and the surrounding environments. All the disposable gears should be discarded carefully into yellow bag to avoid cross contamination .
c) Isolation precautions
Most of the time, isolation is effective in decreasing the spreading rate and speed of the food borne disease . Due to the highly infectious norovirus spread by person-to-person contact, isolation for infected patients, and their waste disposals should be discarded properly. Wards should be closed to new admissions to avoid spreading of the virus [2, 3,13,19]. Restrict staff and patient movement between wards, especially into infected areas; and limit the exchange of staff [19,40]
d) Environmental cleaning & disinfection
Enhanced cleaning and disinfection should continue for at least 72 hours after the last documented case . The whole canteen area, the wards, the route of meals delivery, and the food incident location, should be totally cleaned and sterilized before use. Basically, use the cleaning solution with 1000ppm of available hypochlorite for solid area, a higher concentration chlorine (>5000ppm) contained solutions is more effective to reduce the norovirus on the surface [14,19].
e) Advice to visitors: masks and protective clothing before their visit to infected patients; and wash and dry their hands after patient contact. Children, elderly and pregnant are advised not to visit until the risk of UH is released .
f) Advice to symptomatic members of staff:
Staffs with norovirus symptoms should stay away from work; several studies stated that ≥48hours isolation after recovery for infected staffs is recommended [2,3, 14,19].
g) Food handlers also have ≥48hours after the symptoms have resolved before food preparations . Reinforcement of the personal hygiene and food processing practices are keys to food-borne outbreak prevention .
h) General advice to the public:
NDIV is responsible for the public advices and communications (including personal hygiene, alerts to raw shellfish and water, cleaning and disinfection approaches ); and Sub-sectors of food safety center will be responsible for the risk communications. UH OCT should help to make the guidelines or recommendations according the existing evidence at the time and the managing experiences .
The food Alert System, traceability and withdrawals:
The food withdrawal mechanism is not mandatory implemented by the local legislation; IACM encourages premises to have the problem food product recalled and withdrawal. All the food products (including the hospital meals) are open to public consumers, so food recall should not only include the area of MUST, and also to the public. The food alert system may not be official, but it should be carried out and cooperate with CDC and IACM officers; But Hong Kong Food Safety Order encourages premises for voluntary recall of food products.
Trace back of food products may be required in the investigation. The purpose of having the food product traced back is to find out the contamination point (time, environment information). The microbiological reports can help us to identify the species of the bacteria, but there is more than one way, more than one condition to contaminate the food with same species of bacteria (base on the information of epidemiological and microbiological evidences). And often the trace backs result in a food product recall ; the food product traceability is highly correlated with the food alert system.
Record keeping can provide accurate and detailed information for the courts and help trace back through the investigation. The importance of the traceability is that Macau’s food supply depends on mainland China and countries over the world, and the increasing of consumer demand for food that is less processed, that makes the food production and distribution more complex, and that will increase the risk of food source outbreak. Local entities that produce and sell food have the duties of maintaining records of receipt and delivery of goods or of their invoices for the period prescribed  ; comparing with the Hong Kong the Proposed Food Safety Bill, the information of the movement of the food is required in order to reinforce the registration scheme of imported/ exported food; all the retailers are required to have declarations of import and export of food product (that costs over MOP5,000; the fresh foods are excluded in this law). But the food movement information is still not mentioned . According to FDA guidelines , form the food ingredients to the final food product, it’s better for campus canteen to maintain the food records according the type of food, and the record should be kept form 6 months to 2 years.
When a foodborne outbreak occurs, local food entities are responsible for the call back of the food that endanger the food security; and withdrawal the problem food products from the public . Hong Kong Food Safety Authority is also empowered by the Food Safety Bill to issue a food recall order and withdrawal from the food manufacturers, suppliers and retailers immediately[35,39]. Guidance form FSA Scotland  also mentioned that the premises are involved in a serious outbreak, the most priority should be the product recall even though there may be short of scientific proof, and the withdrawals still need to carry out as large as it could, in order to remove the contaminated food from the food chain as soon as possible.
SS-CDC-NDIV will be responsible for updating the latest infection cases numbers, prevention information to premises, public and schools of norovirus. By following the instructions provided by NDIV, UH OCT should keep risk communication with staff and inpatients. And proper hands washing, giving advices to who consults for norovirus from the public.
The public communication is responded by CDC officers and IACM which reports their analysis and in-depth investigation result according to be outbreak situation. Tong stated that there must be a transparency in communication to public . IACM can apply prevention and control and issue warnings to the public, based on monitoring results and risk assessment for food security .
Identify all parties that need to receive outbreak information e.g. those dealing with the incident, wider support services, national and regional agencies, those affected by the outbreak, the local community as well as the outside world. Staff in other areas (physiotherapy, radiology etc.) Should be alerted for the issue. Visitors, particularly young, pregnant or elderly, should be discouraged during the outbreak. Signs or other visible communications should be necessary to notify visitors about the existence of an outbreak, guidelines and precaution measures need to be notified to the visitors .
Close of the Outbreak and review:
Identify the end of the outbreak (usually when the number of new cases has returned to background levels). At the end of the outbreak, as the hospital is sure to be out of risk, IACM will order to release the alert and control measures of the hospital . After the outbreak, it should enhance two-week surveillance for new cases following the last know case. Produce outbreak report. OCT needs to give out a guideline for precautions and make a brief report to all staffs in UH. Alert all the staffs for the importance of food safety and the potential risk. After all, the complete outbreak reports needs to summit to UH admin office and CDC.
Discussion & Conclusion:
After the investigation and analysis of the outbreak, people are always neglected the seriousness of food borne diseases for the food borne symptoms are mild and only last few days, so the numbers of affected people are under-documented. The case identification really relies on diagnosis skills and experience of physicians. For further investigations, UH should keep cooperation with CDC investigation team and provide all the relevant documents and evidences. Even though the problem food caused the outbreaks may be originated from different sources. If the final investigation proves that the poisoned food is originated from campus canteen, UH also has the responsibility and implement the control measures for prevention.
Early recognition of the outbreak and prompt implementation of effective infection control measures, including staffing restrictions and ward closure, was successful in containing the spread of the infection and limiting the outbreak to a few days’ duration . The measures adopted, the assessments evaluated are very important for preventing the food poisoning incidents happen again. Due to the special situation of UH, precautions and strengthen the staff training (in both the food safety and the emergency measures) are just for reducing the probably and control the outbreak scale. By the way, though outbreaks of food borne infection in hospitals are associated with high attack rates and disruption of services, the outbreaks can be preventable by the effective controls planed by the OCT .
For the prevention, it should be based upon the points as follow: canteen contractors should adopt the measures to protect the cooked food free from contamination, because poor practice in hospital kitchen was important to food borne outbreak. Standard and hygiene practice of food processing can also reduce the probability of contamination of bacteria or virus. Besides, third party specifications and compliance checking periodically is also suggested. IACM has provided the guidelines for food processing places such as keeping the purchasing and stocking records [7, 17, 36], cleaning and the operations . Even the IACM is yet to legislative control of the health certification of food production places, it suggested to have the regular cleaning & regular check by inspectors from IACM and CDC.
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