#57 � Food Safety Everyday: How Outbreaks Start
Kira Flagstead Dierickx:
Thank you for joining us for this episode of Talking Health in the 406 where we are one community under the Big Sky I'm excited and honestly pretty honored to be joining you as the newest member of the Talking Health in the 406 podcast team I'm Kira Flagstead Dierickx a public health sanitarian with the Montana Department of Public Health and Human services.
 In the environmental health and food safety section we work behind the scenes to make sure businesses that serve the public are operating safely from restaurants and food trucks to pools campgrounds and body art facilities a big part of my work involves partnering with the FDA. To help Montana. 's food manufacturers produce safe high quality food. Outside of work I'm a huge fan of scary movies books and podcasts which might be why today's topic hits a double sweet spot for me we're diving into something that affects every single one of us food safety and more specifically foodborne illness outbreaks we've had a few foodborne illness outbreaks here in Montana in recent years. Which can be a little scary and I know many folks have questions about how these outbreaks happen how they're investigated and what we can do to prevent them to help us explore all of that I'm joined by our guest today Rachel Hinnenkamp an epidemiologist who works directly on invest? Beginning and preventing foodborne outbreaks here in Montana. Rachel thanks so much for being.
Rachel Hinnenkamp:
Here thanks so much for having me Kaya I'm. Very happy to be here.
Kira Flagstead Dierickx:
For uh listeners who might not be as familiar could you give us a quick overview of what an epidemiologist does especially when it comes to foodborne.
Rachel Hinnenkamp:
Absolutely so I think my favorite definition for an epidemiologist is a disease detective so somebody who tries to figure out what is making people sick and then also works to prevent that from making additional people sick so basically what that looks like with foodborne disease. Is epidemiologists and disease investigators talk to the person who is sick with the foodborne illness? To try and figure out what made them sick so that includes a food history often from a week or 2 prior to their onset sometimes it's a little bit shorter depending on what exactly they're sick with if we have an outbreak of foodborne disease we then compare those histories from multiple people. And we work to understand what they have in. Common so if that's. A food item or a restaurant. Want we try and identify that and then we work to prevent more illnesses from happening so sometimes that's working with our sanitarian or environmental health and food safety partners along with the FDA to get a food product off of grocery store shelves and sometimes. That is working with the specific restaurant where the cases are linked to. And working on improving food safety practices there or working on identifying potentially there was maybe one person who was working at the restaurant while they were ill and then making sure that they are no longer infectious. Before they come back. Work another piece of epidemiology is really just looking at the big picture data so since I work at the state health department I look at statewide data for foodborne illness so I'm able to see you know and identify any trends that we're seeing in foodborne illness so if we are seeing potentially a large increase. Of a pathogen like salmonella I will be able to identify that and then work with our local and tribal public health partners to try and understand maybe why we're seeing an increase.
Rachel Hinnenkamp:
So there's there's really a lot that gets that is part of epidemiology and really my day-to-day looks very different everyday just depending on what pathogens are circulating or what outbreaks we're investigating.
Kira Flagstead Dierickx:
Just like a detective on TV every day is a little bit different in information gathering and. And all of that. Uh. Interesting you you mentioned outbreak we know Montana is a a big rural state it can make information and data gathering a challenge just due to our geography so how do foodborne outbreaks usually come to your attention.
Rachel Hinnenkamp:
There are a few different ways that we are able to detect foodborne outbreaks in Montana you did mention that you know we are a large state so that can be a challenge but oftentimes we will learn about outbreaks through routine surveillance. Which basically means that so when somebody goes to the doctor and they have symptoms of foodborne disease sometimes the doctor will say OK I'm concerned about this illness I'd like to know what it is they can do a test that is able to identify what type of illness is causing your symptoms for example? If that test for somebody is positive for salmonella that does get reported to public? Health and so if we get multiple positive salmonella cases in the same area and then the county or tribal health department investigators will often notice that and suspect an outbreak so in a lot of counties you know they might get a salmonella case. It absolutely depends on the size of the county but for example one salmonella case every month if you then get 6 salmonella cases in the same week you are going to notice that that is a little bit strange that is different from your baseline and you might suspect that and outbreaks happening. Sometimes we also will learn about outbreaks through our routine sequencing so basically what this means is you know sometimes we have an outbreak say those 6 salmonella cases are not all in the same county but they're all across the state of Montana. Each in different counties in different corners of the state. It would be very difficult to notify or to notice an increase of 6 salmonella cases across the state and think that's an outbreak because you know in a in a week in the summer when we see more foodborne disease in general 6 salmonella cases is not. Out of the normal for. Us so we might have those. Pieces and have no idea. That they're related to an outbreak or that they're related to each other at all.
Rachel Hinnenkamp:
So that's when our laboratory partners are really able to help us with outbreak detection. So when we get a positive salmonella from somewhere in Montana the local laboratory ends up sending that specific sample to the state public health laboratory. And now our state public health lab does some additional testing where they are able to sequence the specimen and look at. Like the actual. DNA of the specimen and see how it relates to other peoples specimens so if our lab received 6 salmonella specimens they're able to sequence them and if they are all what we call a match so they are essentially genetically the same that tells. Pass the epidemiologists and disease investigators that those are closely related to each other they likely have the same source and then we work with our local and tribal health departments to investigate those cases and to identify what they had inc ommon.
Rachel Hinnenkamp:
So those first ways of identifying an outbreak are really through testing and reporting routine reporting to public health another way that we could learn about outbreaks is through complaints from members of the public so if somebody eats out a restaurant or at a catered event and gets sick after they meet their meal. They may either call their local health department or they may call the restaurant directly on to let them know that hey I think I got sick after eating at your restaurant. So then when public health learns about that because you know we are either getting calls ourselves or we're learning about complaints being made to restaurants we commend start an outbreak investigation if there are multiple people who ate at that restaurant around the same time and seem to be having similar symptoms. With gastrointestinal or GI illness so we have certainly learned about outbreaks in the past few years from members of the public and consumer complaints is what we call them so we do always appreciate the notification. To public health.
Kira Flagstead Dierickx:
Yes definitely I mean we we wouldn't know some of the things that are going on out there without the without the public reporting back so that's always appreciated.
Rachel Hinnenkamp:
So.
Kira Flagstead Dierickx:
Let's say we have either our our lab data or we have a a couple of complaints coming in in that scenario could you kind of walk us through what happens once you suspect that we do have a foodborne outbreak like how does your team figure out you know from this suspected outbreak. How do we figure out what's actually? Making people sick.
Rachel Hinnenkamp:
Absolutely and I think the best way to walk through a real outbreak is to actually do that and walk through a past outbreak that we investigated a couple of years ago and I will just put a disclaimer out there that every outbreak is different even to salmonella foodborne. Outbreaks linked to the same restaurant a few years apart are going to be different investigations because there's really no one-size-fits-all for a foodborne disease investigation so just keep in mind that this is just a single example but I think it does kind of highlight some of the public health strategies and practices. That we use. I'm investigating an outbreak.
 Rachel Hinnenkamp:
So I'm going to talk about an outbreak that we investigated with a few local health department partners back in 2024 we learned about this outbreak in November one county had 3 confirmed salmonella cases all from the same assisted living facility. And all 3 cases were pretty sick they were all hospitalized and luckily they did all recover but at that point we did an investigation into those illnesses. They did of course I'll eat at the cafeteria of that. Assisted living facility. And we learned that they were all. Relatively healthy eaters so we saw a lot of vegetable consumption and salad bar consumption. So at that point we were not able to link it to a specific food item unfortunately but we did hypothesize that it was linked to a produce item from like the salad. Bar at that cafeteria. Fast forward a few days and we learn about 4 cases of seminara that were in students and staff of a public school in a separate county and a separate city so at first glance these did seem like 2 different. Outbreaks however the more you learned about these cases the more we began to suspect OK we're seeing 3 to 4 cases associated. With 2 congregate facilities so areas where a lot of people are either going to school or are residing and all those people are eating in cafeterias could there be some kind of link between these locations. We then learned that they both cafeterias were supplied by the same national food supplier which was certainly of interest to us as part of this investigation. And then we received some of the sequencing information that I was talking about from our laboratory and we learned that not only were these 4 cases from the schools and 3 cases from the assisted living facility and exact match to each other so part of the same. Outbreak they were also matched with cases from other states so at that time we were then looped into a multi state outbreak because we were not the only state investigating a cluster of salmonella cases linked to a. Cafeteria item and some fresh produce items. So when we are linked into multi state outbreaks it is pretty helpful when identifying or trying to identify a suspect food item because that just means so much more data from so many more cases so really what we were able to. Do both with? Our Montana cases and the cases in other states. Whose investigations we're glad by other state health departments and local and tribal health departments. As well as the CDC we were able to compare the suppliers to the places where people were eating and getting sick we were able to compare food histories and just also able to compare a general food practices. So when I say that I mean what I mentioned before is that we have a lot of you know healthy eaters people who were eating from the salad bar the school students were eating you know. Fresh chopped veg. Both so we put all of that data together and CDC put all of the data together from the other state investigations and we're able to narrow the food item down to cucumbers so we were able to identify that cucumbers were causing this illness. CDC worked with FDA to do trace back and were able to identify a common supplier and a common farm for where these cucumbers were grown and then shipped and processed and sent to multiple locations across the country.
Kira Flagstead Dierickx:
Ah yes I do remember this.
Rachel Hinnenkamp:
Outbreak yes I bet you do.
Kira Flagstead Dierickx:
Yeah and the data gathering specifically I mean so much information when it comes to outbreaks comes from at least from my sanitarium perspective that's where the boots on the ground it's usually for for our epidemiologists for all of our other investigators usually within and out. Great so the county sanitarians within those areas were probably the ones who were in those facilities talking to people getting that information on you know what are people eating how are they preparing it and where are they getting their their ingredients or their supplies from so really brings it all together.
Rachel Hinnenkamp:
Absolutely. Yes and foodborne illness outbreaks are really an all hands on deck situation exactly like you mentioned we have epidemiologists public health nurses disease investigators sanitarians environmental health folks who are all working on different aspects and of course our laboratorians who are all working on different aspects of the investigation. And kind of putting. All the pieces of the puzzle together. So we we couldn't do it without.
Kira Flagstead Dierickx:
The whole team yes definitely. Just to to get a little bit more into that like local Montana context this was you know part of a nationwide outbreak which they do happen they do make big news but here in Montana are there any sort of specific foods or situations that that cause issues here are there you know patterns tied to things like. Tourism summer events certain types of restaurants or food.
Rachel Hinnenkamp:
Yes that's a great question and foodborne disease is constantly evolving and back in the 90s not necessarily in Montana but more multi state on a national scale we had a lot of E coli outbreaks linked to ground beef and while ground beef can you know still be a risk factor for E coli and salmonella and. Other foodborne disease. Pathogens we're really seeing such a shift in the you know food items that are causing foodborne outbreaks and it really changes so much on the yearly basis that I hesitate to you know talk about specific trends or specific food items. That might be at risk I'm just because it changes all the time and we are seeing a lot more people and outbreaks linked to fresh produce items like the cucumber investigation. That I just shared some information on however as far as trends go we do tend to see an increase in foodborne disease and you know just single cases as well as outbreaks during the summer months this is in part due to warmer and hotter temperatures so the as temperatures warm it does make it easier for a lot of the food. Foreign disease causing germs to grow and spread people are also traveling more they're also more likely to have large gatherings like cookouts or family reunions in the summer and sometimes these events can cause larger outbreak. If for example undercooked meats are served or if the potato salad is kept out of refrigeration for too long especially again as we're seeing those warmer temperatures which really help these germs these pathogens grow faster?
Sure.
Kira Flagstead Dierickx:
Ah yes the the notorious potato salad at the picnic always.
Rachel Hinnenkamp:
I did have to mention the potato. Salad I couldn't I couldn't get away.
Yep.
Rachel Hinnenkamp:
With that sending.
Kira Flagstead Dierickx:
That ohh yes definitely that is always one that I try and stay away from if I'm at a an event in the summer time but I understand because potato salad is delicious. So once you've identified a likely source like the cucumbers or if it happens to be a restaurant or perhaps a sick food handler that's working in a facility what happens next what does that response look like on the. Ground.
Rachel Hinnenkamp:
Depending on the suspects source our next step after we. Identify the culprit is we work to eliminate any potential ongoing threat to public health so really the main goal is to figure out what is getting people sick and then prevent other. People from getting sick. So sometimes that means often that means working with our environmental health partners and potentially the FDA to recall a specific food item and get it off with grocery store shelves or sometimes that means working with a specific restaurant to improve their food handling practices. I'm so for example if we you know our local sanitarians do an inspection at a restaurant where an outbreak was linked to if there is you know. Issues noted with refrigeration we will work with them to improve their refrigeration improve hand washing among food handlers and proper glove use if the outbreak has been traced back to a sick food handler we will make sure work with that individual as well as the restaurant to make sure that that person is no longer infectious. Before returning back to work. I'm communication is also a really important piece of outbreak investigation so with these you know large foodborne outbreaks we will work with our public information officers on to put out a press release at the about the outbreak. Especially if there's actionable information for the. Public to know or if. There is an ongoing risk that we need to alert them to so for example a few years ago we had a few E coli outbreaks linked to romaine lettuce and it was romaine lettuce on that had been distributed across the entire country and was a massive amount of product. So we did press releases at that time to let members of the public know. Hey any romaine lettuce you have in your refrigerator the safest option right now is to throw it away not consume it anymore and clean out your fridge so that there's no ongoing risk for contamination or future illnesses.
Kira Flagstead Dierickx:
Yeah definitely I mean we want to make sure that the public is aware if there's something that they have you know in their fridge or can do to avoid you know a suspect food. Product and yeah the the communication and response within a restaurant if that happens to be where the outbreak is tied to the sanitarians we were there to help educate you know we want to educate before we use any sort of enforcement actions and usually it comes down to hey maybe we maybe we do need an additional. Training on hand washing or you know what's your employee health policy those sort of things so I'm glad to see that. You know resolution of outbreaks isn't always you know negative but it can also be a great learning experience for everyone involved definitely that's a.
Rachel Hinnenkamp:
Great.
Kira Flagstead Dierickx:
Point yeah OK so let's let's shift to something everyone can use prevention tips what in your opinion what are the most important things that people can do. At home to avoid getting sick from food.
Rachel Hinnenkamp:
Yes I think these are good this is a great question and a very good opportunity to share some very controllable factors as far as feedburner disease goes which. Is you know? In your kitchen which you are cooking. In you know if not every day multiple. Times a week. Cooking for your family and friends really safe foods. Handling at home I would recommend cooking meats to appropriate temperatures I'm really using a food thermometer to make sure that the meats are coached to that appropriate temperature because you can't always. Tell by the look of the meat whether it's fully cooked avoiding cross contamination is a really big one so for example that would mean using a separate cutting board for your raw meats and your vegetables especially if those vegetables are going to be consumed. Uncooked or not fully cooked. And that also means using a separate plate for your raw meat and your cooked meat if you're growing in the backyard and you take a plate or a cutting board of raw meat out to the grill replace that cutting board with a clean one when you're putting. Your cooked meat back on there to bring inside. Oh yes great example love that one yes I definitely seen some family members do that the way that I would not and that's been a little scary for me but luckily everybody was fine in that situation and we had a nice little chat about food safety and. Avoiding cross contamination. Some some other things I want to highlight are keeping refrigerator temps cold enough so refrigerator should be at or below 40 degrees Fahrenheit another thing that I like to keep in the back of my mind and is easy to remember is keep hot food hot and keep cold food cold and so really that means. Can you keeping food out of the danger zone so the danger zone is what we consider between 40 and 140 degrees Fahrenheit if you do have food within that temperature range of the danger zone perishable food should not be left out for more than 2 hours if it's 90 degrees or warmer? Out and so in the summer months food should not be left out for longer than one hour so quick refrigeration after you're finished with the meal or during a barbecue or something like that is is really important to remember. Hand washing with soap and water is also an extremely important part of food safety handling so even if you're just cooking for yourself for your family hand washing before you are preparing food and after cooking and before eating is a very important step.
Kira Flagstead Dierickx:
Oh yes extremely and the thoughts of you know if you're at home you're preparing food you're probably multitasking you may have just changed the diaper you may have just pet the dog so please wash your hands as as much as you can.
Rachel Hinnenkamp:
Another really important tip is to stay home with when you're sick this applies to all public health diseases so whether it's a cold or a gastrointestinal illness but specifically in the world of food safety if you're sick with the gastrointestinal symptoms like. Diarrhea and nausea. I mean it's really important to stay home and keep your germs to yourself especially if you work with food.
Rachel Hinnenkamp:
Or are in direct care of children the elderly or people who are immune compromised and then finally just reporting illness when you think it's weak related so if you think it is linked to a. Restaurants were catered event or something like that if you report that to your local public health department or tribal public health department for the state health department we can see if there are other individuals who got sick from the same source and then can. Yeah open and outbreak investigation if we need to.
Kira Flagstead Dierickx:
Yes yes definitely reporting illness if you think it's food related extremely important yeah so while cooking safe food at home extremely important we all want to do it most foodborne outbreaks are usually tied to retail food not home cooking So what are some things that folks should keep in mind. When we're eating out or grabbing food? On the go.
Rachel Hinnenkamp:
Alright so when people are eating out at a restaurant or grabbing food on the go there are a few things that are within our control washing hands prior to eating is important even when you're eating out at a restaurant and another important way to prevent foodborne illness when eating out is to manage leftover safely. So make sure that your leftovers are refrigerated within 2 hours of your meal and eaten within a few days so don't let them hang out in your fridge for weeks on end before finding them in the back corner and decide to eat them again. Because perishable foods do eventually perish and do have a shelf life and another tip that I would recommend is you could also search online for recent reviews of the restaurant if you're trying out the new place and then some jurisdictions have public inspection scores. For the restaurant so you could always check those out too especially if you're potentially traveling and eating. In a new. City with restaurants that you're less familiar with.
Kira Flagstead Dierickx:
Yes definitely and yeah some jurisdictions do post their inspection reports online so if you would like to do some food detective work yourself feel free to look at those reports and see if that's a restaurant that you feel comfortable eating in so in the case that someone does get sick from something that they think that.
They ate.
Kira Flagstead Dierickx:
Is reporting really that important?
Rachel Hinnenkamp:
Yes reporting is a huge part of foodborne outbreak investigations and and that can kind of come through in a. Few different ways. So earlier I had chatted about how we're alerted to foodborne outbreaks and one of them is through just routine surveillance and testing and then others are. Identified through complaints from the pub. Like I'm so really my first advice is for somebody who thinks they got sick from something they ate for somebody who you know has a gastrointestinal illness I would recommend that if you're really not feeling well or you're just not getting better or your immune compromised then you should visit your doctor. You can work with them to you know they might be able to help figure out what is making you sick and they can also order testing if they think it's recommended and if it is positive you're a seaborne illness that is when public health gets looped in and can help with the investigation of this illness. On the other side of things if you do recover quickly and you're feeling OK and back to normal it is always still helpful to report that outbreak to public health especially if you think you got sick from a restaurant some event from a grocery item that you know is still out there and could be impacting others so that is always appreciated. And can really help public health to identify outbreaks and prevent additional cases.
Kira Flagstead Dierickx:
Yes definitely and you know consider it your good deed of the day perhaps you'll you know start an investigation by reporting in and save other people from getting sick so so please do report if you if you feel that you got sick from. Something you ate. Along those lines are there any misconceptions. You hear a lot from the public about foodborne illness or outbreaks.
Rachel Hinnenkamp:
Yes I do often hear about people associating their foodborne illness with the last thing they ate and while this can certainly be true in some cases I would say that foodborne illness is most often not caused by the last thing that somebody ate so just for example umm thinking about a few different causes of foodborne illness. E coli for example specifically she could talk some producing E coli. I am takes 3 to 4 days after being exposed to the germ so after somebody you know potentially consumed through food item it takes 3 to 4 days for them to actually start feeling sick generally speaking that's not going to be the last thing that somebody ate some pathogens haven't. Are you given longer time between consuming the pathogen or being exposed and making somebody sick for example listeria often takes 2 to 3 weeks to make some? Pretty sick so that poses its own challenges because it is very difficult for me to remember what I ate 2 to 3 weeks ago and I know it is for a lot of the people we interview as well that is just a good reminder that if you do have a GI illness it's not necessarily going to. Be from the last thing that you ate. Another important thing to remember is that not all GI illnesses are caused by food. So for example norovirus is a common cause of foodborne outbreaks and it causes symptoms like diarrhea and vomiting and can make you feel pretty terrible however it's not always caused by food it can also spread very easily from person to person it can be spread through contaminated water. Or through surfaces so really I think just because somebody has a gastrointestinal illness with those classic foodborne illness symptoms like diarrhea vomiting abdominal pain does not necessarily mean that food is what caused them to be sick.
Kira Flagstead Dierickx:
Yes yeah great point so something we always ask about as sanitarians when we are in an inspection is the vomit and diarrhea clean up procedure specifically because norovirus can also be spread airborne so if a customer was in a restaurant and they vomited on the floor if we have a really good clean up procedures. We can hopefully stop anyone else from getting sick if that person was sick with norovirus usually called the cruise ship disease because of tight quarters and how easily. It is spread.
Rachel Hinnenkamp:
Yes when we see that type of transmission through norovirus it really is because you know for example if somebody does vomit in a public place those vomit particles really can spread very far through the air and and if you come into contact with that particle you can become sick. Norovirus that way as well.
Kira Flagstead Dierickx:
Yes definitely and in spaces where the public is there and you know if someone is accidentally throwing up in a public space they may not be able to do it in the tidiest cleanest way so that those particles could go a lot of different areas definitely I appreciate that clarification. OK so as. A member of the public if I'm interested in learning more about food growing outbreaks in Montana where should I go for information.
Rachel Hinnenkamp:
You can check out the foodborne illness page of the Montana Department of Public Health and Human services website which we can link we also have a Montana outbreak dashboard this dashboard summarizes high level data and will also show the number of GI outbreaks that we've investigated in recent. Years and kind of summarizes them by month we also I would just say keep an eye out for press releases either from Montana DPHHS or your local or tribal health department if there is a notable foodborne outbreak in your community with. And you know action items that we need the public to be aware of we will send out messaging umm just to make sure that our public remains safe from foodborne diseases.
Kira Flagstead Dierickx:
Yes and along those same lines if you are a member of the public who is interested in reporting maybe symptoms about your foodborne illness in the environmental health and food safety section we do have a consumer complaint link so if you are sick with a suspected foodborne illness you can submit a complaint there. And you can also do it anonymously if you were not interested in sharing any personal information. So so please report and and please be diligent out there Montana another one that I would urge people to be aware of is there has been an increase in salmonella infection through some different types of dietary and T supplements that are sold online. So not Montana specific but if you are shopping online for some of these other products just be aware that some of these products have been through recalls and and just double check before you buy is my advice.
Rachel Hinnenkamp:
That's great advice kyra.
Kira Flagstead Dierickx:
In Montana because of the nature of our geography weather food culture are there any unique challenges for residents here in your opinion when it comes to foodborne disease and foodborne outbreaks.
Rachel Hinnenkamp:
Yes and one of the unique challenges in Montana might include the foraging and hunting that we often see in our state. And while these practices are and can be a very important part of Montana 's feed culture and I don't want to convince anyone away from them I do just want to share that anybody who does choose to forage or hunt their food should be very familiar with for example if they're foraging plants or mushrooms. They should know how to identify them and prepare them properly before eating them whether that's thoroughly cooking or just knowing exactly the plants that they are forage. Additionally hunters should be aware of the risk of certain types of vild game that might be more linked to sleep or an illness for example bears and mountain lions can be a source of trigonella and should be processed properly and cooked thoroughly prior to eating.
Kira Flagstead Dierickx:
I know it's not foodborne related but we do have chronic wasting disease here in the state of Montana and if you are a hunter be aware of that be aware of the notices and you know partner with fish wildlife and parks if you ever have questions they have some really great resources on their website. Rachel thank you so much for sharing your experience and helping us recognize how foodborne outbreaks are found investigated and prevented here in Montana I know I'm not just speaking for myself when I say that having safe food is so important to the everyday life and well-being of the people of Montana. Do you have any? Final thoughts to share with us.
Rachel Hinnenkamp:
Thank you for having me and I hope all of our listeners stay healthy and safe from foodborne diseases.
Kira Flagstead Dierickx:
Thank you so much to Rachel today on behalf of myself and the crew behind the scenes if you'd like more information on what was discussed visit our website at talking health in the406.nt.gov and if you haven't already Please remember to rate review and subscribe to this pod. Broadcast that's it for today's episode remember keep your hands washed your leftovers labeled and if something in your fridge looks like it could star in its own horror movie maybe it's time to let it go stay safe. Out there Montana.