Guidelines for investigation and control of food borne diseases

1.0 Introduction .................... .... .... .. .. .... .. ...... .... .. .. .. ......... .... .. . ........ ............. .............. 8 Background of Food Borne Diseases ................................................................................. 9

1.1 Causes of Food-borne Diseases ....................................................................................................... 10

1.2 Reservoirs and Sources ....................................................................................................................... 10

1.3 Transmission of FBDs ........................................................................................................................ 10

1.4 Epide mio logy .................................................................................................................................... 10

2.0 Surveillance of Food Borne Diseases ..... .. ....... . .. ............... ... .. . .... ............. . ... .............. 11 2. 1 Routine Surveillance ........................................................................................................................... 11

2.2 Detection of FBD outbreaks ............................................................................................................. 12

3.0 Investigation of Food-Borne Diseases Outbreak ........................................................... 12

3.1 Outbreak Contrai Team ................................................................................................................... 12

3.2 Epidemiological Investigations ..................................................................................................... 13 3.2. 1 Notification ......................................................................................................................... ...... 13

3.2.2 Preliminary Assessment of the Situation .......................... ..... .. ........ ............................. ....... 13

3.2.3 Descriptive Epidemiological Investigations ............................................................................ 14

3.2.4 Establishing a Case Definition .............................................................................................. 14 3.2.5 ldentifying Cases .................................................................................................................... 15

3.2.6 Interviewing Cases, Medical and Health Personnel... ................................................................. 16 3.2. 7 Collating Data .......................................................................................................................... 17

3.3 Environmental and Food Investigations ................................... ..................................... ................. 17

3.3.1 Inspection of Suspected Premises .................. .......................................................................... 17

3.3.2 Inspection of Suspect Food .... ............. ........... ........................................................ .................. 18

3.3.2.1 Product Description ....................................... .................... ........ ............ ............................. ..... 18

3.3.2.2 Observation of Procedures from Receipt to Finish ................................................................ 18

3.3.3 Interviewing Food-handlers ............................................................................................... ..... 19

3.3.4 Taking Appropriate Measurements ........... ............ ........................... ...................................... 19

3.3.5 Drawing a Flowchart of the Operations ................................................................................. 19

3.3.6 Conducting an Outbreak Hazard Analysis ............................................................................ 19

3.4 Laboratory Investigation ..................................................................................................................... 20

3.4.1 Food and Environmental Sampling ............................................................................................ 20

3.4.1.1 Food Samples........................................................... ............... .................................................. 20

3.4.1.2 Environ mental Sam pies ... ...... ............. ..................... ................................................................ 21

3.4.1.3 Clinicat Specimen ................................................................................................................... 21

3.4.1.4 Chemical Investigation ............................................................................................................ 22

4.0 Data Analysis and Interpretation ................................................................. .... ....... 23 4. 1 Symptoms Profile (Frequency of Signs and Symptoms among Cases). ........................................ 23 Tablel: Example of Symptoms profile (sample size =30) .... .................................................... 23 Doc. No.:DIS/GDL/004 Revision Date: 06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 ii <Juidelines for investigation and control ojjood borne diseases

4.2 Epidermic Curve .............................................................................................................................. 23 Table 2 :Grapb of num ber of FBDs Victims and times of Onset ............... .......... ......... .. ........... 24

4.3 Median Incubation Period ............................................................................................................... 24

4.4 Food Specific Attack Rate................................................................................................................ 24

4.5 Explanatory Hypotheses .................................................................................................................. 24

4.6 Relative Risks (RR) .. ........................................................................................................................ 25

5.0 Record Keeping ....... . ... . .... . .......... . ................... . ................................................. 25

6.0 Confedetialify ......................... ......... .. .......... ........ ........ ....................................... 25

7.0 Control Measures ................... .. ......................... . .. ................. .. . ..................... ...... 25

7.1 Control of Source ... ...... ........ .... .... .. .................... ... ................... .. ............ .. ...... ... .. 26 7.1. 1 Closing Food Premises ................................. .... ................... ..................................................... 26

7.1.2 Modifying a Food Production/ Preparation Process .................................................................. 26 7. 1.3 Removing Implicated foods from the Market ....... ....................... .................................... ...... 26

7.1.3.1 Communication with the Public .... .......................... .. ............................ ............................ ...... 27

7.1.3.2 Post-recall Reporting by the Business..................................................................................... 27

7.2 Control of Transmission ............. ... .. ....... ........................... ..... ....................... ..... ... ...................... .... 28

7.2. I Public Education .... ........ ..... ............................... ... ...................... ............................................ . 28

7.2.2 Exlusion of Infected Persons from Work and School ............................................................ 28

7.2.3 Education on Personal Hygiene .............................................................................................. 29

7.2.4 Infection Control Precautions ................................................................................................. 29

7.2.5 Protecting Risk Groups ........................................................................................................... 29

7.2.6 Education on good Practices ................................................................................................... 30

7.2.7 Legat Measures............. ............................... ....... ... .... .... .......... ............................ .......... ..... ...... 30

8.0 FBD Reporting ................................................. .. ..... ..... ..... .... .. .. ........................ . 30 8. 1 Levels of FBD Reporting ...... ............................................................................................................ 30

8.2 Responsibilities at eacb Level .................................. ............ ......... ................... ...... ..................... ..... 30 8.2. 1 Healtby Community Office .. .......... ............. ......................... ........ ....................... ..................... 31

8.2.2 District Medical Office.............. .............................. ........... ..................... .... ...... .............. .... ..... 31

8.2.3 Province Medical Office......... ................ ................................. .......... ............................ ........... 31

8.2.4 Ministry of Health (Rwanda FDA) ......................................................................................... 32

8.2.5 Outbreak Final Report ......................... ............................. ....... ....................................... ........ 32

9.0 Co-ordination of FBD Fonctions ..... ........ ................ . ...... . ....................................... . 32

9.1 Health Community Workers ........................................................................................................... 32

9.2 Hospital/healtb CentreLevel .......................................................................................................... 33

9.3 Province level ................................................................................................................................... 33

9.4 National level ................................................................................................................................... 33 Figure 2: Reporting level of FBDs ............... . .. ... .. ..... ............ . ........................ ................... 33

10.0 Review of Outbreak ................... .. .. ................ .. .. .............. ....... .. ... . .............. .... .. .. . 33

11.0 Future Studies, Researcb . .... ............ ........ ........ ........... ............. ................... .... ..... 34

12.0 Reference ......................................................... .. ..... .. . .. .. ........... . ...................... . 34 Doc. No.:DIS/G DL/004 Revision Date: 06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 Ill <iuidelines for investigation and control ojfood borne diseases ANNEX I :Corn mon Food Borne Diseases Caused by Different Agents...................................... 35 ANNEX II :Food Borne Disease Surveillance Form for Patients ••.••••••.••..•.•••.•..•.••........•.••.•..... 45 ANNEX III :Weekly/ Monthly /Quarterly FBD Surveillance Report Form •••••.••••.•...••..•.••.•..•.•.•. 46 ANNEX IV :Suspected Food Borne Disease Notification Form ••••••••••••.••.•••.•.••••••••••.•.•.••••••••••• 47 ANNEX V: INITIAL CASE REPORT FORM .................................................................. 49 ANNEX VI :FOOD BORNE DISEASE CASE HISTORY FORM ............................................. 51 ANNEX VII LINE LISTING ........................................................................................ 54 ANNEX VIII LABORATORY TEST REQUEST FORM ....................................................... 55 ANNEX IX PROCEDURES AND EQUIPMENT FOR SPECIMEN COLLECTION ................... 57 ANNEX X: OUTBREAK SUMMARY SHEET .................. ................................... .... ........... 64 ANNEX XI :INVESTIGATION REPORT FORMAT •.•••••.••.•.•.••..•.••.•.••.•..•.•.•.••.••.••.•..•.•••. 66

ANNEX XII Example of Attack Rate Table. .......... ................ .......... ........ .... ...... ............ ..... 69 ANNEX XIII FOOD BORNE DISEASES REGISTER .•.•.•..•.•..•.•.•..•..•.•.•.•.•. •..••. •..•...•.••.•.•••.• 70 ANNEX VIX FOOD BORNE DISEASES REPORT FORM•••••••••.••. ••.••••.•...•.•.•••. •.....•..•..•••.•••• 71 Doc. No.:DIS/GDU004 Revision Date: 06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 IV :tt Guidelines f or investigation and control offood borne diseases Abbreviations AIDS Acquired Immunodeficiency Syndrome WA Water Activity EDTA EhtlylineDiaminneTetraceticacid FBD Food Borne Diseases GHPs Good Hygiene Practices GAPs Good Agricu ltural Practices GVPs Good Veterinary Practices GMP Good Manufacturing Practices GMO Genetically Modified Organisms OCT Outbreak Control Team RR Relative Risk HIV Human Immunodeficiency Virus Rwanda FDA Rwanda Food and Drugs Authority WHO World Health Organization V Doc. No.:DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.: 0 Effective Date:13/05/2019 Foreword The Rwanda Food and Drugs Authority (RWANDA FDA) is a regulatory body established by the Law N° 003/2018 of 09/02/2018. One of the functions of RWANDA FDA is to regulate matters related to quality and safety of food for the purpose of protecting the public from health hazards associated with the consumption of food, especially in its article 8. Food borne diseases (FBDs) is one of the public health concerns not only to our country but ail over the world. It is believed to be responsible for man y deaths. The magnitude of the problem is not known due to difficulties associated with investigation of FBDs and their reporting. This has contributed to lack of data that are important for planning and controlling FBDs outbreaks and other economic woes. RWANDA FDA recognizes the need to establish a system that will assist in the surveillance, investigation, control and reporting of FBDs. This will enhance among other things, collection of data and other information related to food borne diseases, in order to institute t ime ly interventions that will control present and prevent future disease outbreaks through adequate food safety management. lt is my sincere hope that these guidelines will assist health workers in conducting surveillance, investigation and control appropriate interventions. vi Doc. No.:DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.: 0 Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases Definition of Terms Acute Signs means severe manifestation of a food bornedisease. Cross contamination means transfer of biological, physical or chemical hazards to food products by contact with other raw food products, previously cooked food , dirty contact surfaces or the dirty hands of a food-handler. Demographic Profile means the number o f cases by age group and sex Epidemiology means the branch of medicine that deals withthe study of causes, distribution and control of diseases in the population Epidemic Curve means a histogram or graph that provides avisual depiction of the outbreak over time. Foodborne Disease means any disease of an infectious or toxic nature caused or hought to be caused by consumption of food Food borne Disease outbreak: means two or more linked cases of the same illness bel ieved to have resulted from ingestion of food. Food Safety Control Officer: means Officer responsible for food control activities. Food Specific Attack Rate means the percentage of people who became ill after eating a specific food. Food means any substance or product whether processed, partially processed, or unprocessed, intended to be, or reasonably expected to be ingested by humans. "Food" a lso includes drink, chewing gum, and any substance, including water, intentionally incorporated into the food during its manufacture, preparation or treatment. Furthermore, Food, as defined for this guideline, shall include functional foods (foods which claim to have specia l properties valuable to health, but which do not have a medicinal product license), fortified foods, food ingredients and derivatives such as, Genetically modified organisms (GMOs) and food additives;Food shall not include: feed, live animais unless they are prepared for placing on the market for human consumption, medicinal products, cosmetics, tobacco and tobacco products narcotic or psychotropic substances within the meaning of the United Nations Single Convention on Narcotic Drugs 1961, and the Nations Convention on Psychotropic Substances, 1971 , residues and contaminants High Risk Foods means foods with a high potential of causing food borne diseases because of their relatively high ability to support microbial growth 7 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date: 13/05/2019 -f{ Guidelines for investigation llnd control off'ood borne diseases or havea inherent taxie substances. Median Incubation Period rneans tirne taken for 50% of the cases to get sick after exposure to FBD agent. Notification rneans the process ofinforrning health officiais on an outbreak of food borne disease. Outbreak/Epidemic means one or more cases resulting from ingestion of a common food. The term "epidernic" is often reserved for crises or situations involving large nurnbers of people over a wide geographical area. Relative Risk rneans the percentage of people who become ill after eating a certain food divided by the percentage of people who become il\ after not eating a specific food. Symptom Profile means list of symptoms as presented by a patient. Surveillance means systematic collection, analysis and interpretation of data essential to the planning, implementation and evaluation of public health promotion and protection practices and tirnely dissemination of this information for public health action. 1.0 Introduction 8 Doc. No.: DIS/GDl/004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revisîon No.:0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases Background of Food Borne Diseases Food borne disease (FBD) is any disease of infect ious or toxic in nature caused or thought to be caused by consumption of food. Agents in foods responsible for FBD include pathogenic microorganisms, poisonous chemicals substances, parasites, etc. FBD can manifest itself in a mild or acute form sometimes ending in death; therefore it can result in socio-cultural and economic consequences to the society such that it may impair its development. The magnitude of FBD in Rwanda is not known because there is no established system for its surveillance and investigation hence most FBD cases go undiagnosed and unreported. Since awareness on Good Hygiene Practices by many people is still low and vaccines for most food borne diseases are not available, the magnitude of the problem is likely to be high. Taking into consideration that food consumers may be exposed to high risks in relation to food borne diseases, Rwanda FDA recognizes that developing an investigation, control and survei llance system could significantly help in collection of relevant data and making appropriate and timely interventions. The investi gation and control of food borne disease outbreaks are multi- disciplinary tasks requiring skills in the areas of clinical medicine, epidemiology, laboratory medicine, food microbiology and chemistry, food safety and food control, and risk communication and management. Many outbreaks of food borne disease are poorly investigated, if at ail, because these skil ls are unavailable or because a field investigator is expected to master them ail single-handedly without having been trained. These guidelines have been written for public health practit ioners, food and health inspectors, district and medical officers, laboratory personnel and others who may undertake or participate in the investigation and control of food borne disease outbreaks. The objectives of preparing these guidelines are to assist m the reporting, surveillance and investigation of food borne diseases in order to: i) ldentify high-risk foods and new food-borne pathogens and toxins. ii) Identify and remove from the market food products contaminated with a foodborne disease (FBD) agents. Correct food preparation, processing, handling and practices that permit contam ination with FBD agents. iii) Make the epidemiological data available for use to take appropriate intervention. lt is emphasized that ail health workers dealing with patients or food control activities have a cardinal role to play for the guidelines to bear intended results. Nonetheless, Health workers have the role to report FBD outbreaks.At national, Province and district levels, the guidelines will assist decision makers in identifying and coordinating resources and in creating an environment appropriate for the successful management of Food borne disease outbreaks.These guidelines are, therefore, intended to enhance investigation, surveillance, control and prevention of food borne diseases. 9 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and control of food borne diseases 1.1 Causes of Food borne Diseases Food borne diseases may be caused by infectious or poisonous substances of which the principal categories are listed below: i) Pathogenic bacteria and their toxins ii) Viruses and rickettsiae iii) Fungi and their toxins iv) Blue-green algae; v) Dinotlagellates and their toxins; vi) Protozoa vii)Cestodes, Nematodes and Trematodes viii) Arthropods - Larvae of Linguatula or of flies: ix) Naturally occurring toxins marine biotoxin (ciguatera poisoning, shelfish and scombroid poisoning, phytohaemagglutinin (red kidney bean poisoning), grayanotoxin (honey intoxication) and other food animais; x) Plant toxicants xi) Poisonous chemicals (Pesticides, Toxic metals (e.g Cd, Cu, Hg, Sn), xii)Others including Radionuclides, Flouride, Zinc, N itrite (Food preservatives), Monosodium glutamate The list of food borne diseases, their characteristic symptoms, incubation period, causal agents and specific control measures are as indicated in ANNEX 1. 1.2 Reservoirs and Sources Humans are the reservoirs of some causal agents of Food borne diseases. Food producers, handlers, cooks, bearers and housewives, ail have opportunity to introduce pathogenic agents at some points of food chain. They may carry pathogens in the alimentary canal, on the hands and the rest of the body surfaces. Other sources include water, soit (dust), flies, ants, cockroaches, pets, wild animais, birds and vermin. Another reservoir is the variety of food animais that may carry zoonotic infections such as microorganisms and larvae of tapeworms or roundworms. Food plants or windfall fruits may carry pathogenic microorganisms especially if they are grown on polluted soil or irrigated w ith polluted water (raw sewage, etc.). On the other hand toxic residues of pesticides and veterinary drugs may remain on the plants and in the anima is, respectively. 1.3 Transmission of FBDs Food borne diseases are transmitted by vectors that carry disease causing agents from the ir reservoirs or sources to humans. These vectors include; humans, animais, insects and rodents. Contaminated foods and food contact surfaces can also transmit food borne disease agents. 1.4 Epidemiology The problem of Food Borne diseases and their prevention are closely linked to several environmental, technological and social factors that influence one or more links in the food chain. Among these factors the role played by community hygiene and food habits is one of the most important in determining the incidence and prevalence of FBDs. Therefore, knowledge of 10 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelines for investigation an,d control offood borne diseases Good Hygiene Practices (GHPs) and food habits which minimizes chances of disease outbreaks can significantly lower occurrence and magnitude ofFBDs. Incidences of FBD can be investigated using data collecting tools and carrying out laboratory analysis. The data col\ected wil! reveal the magnitude of the problem that can be used as the bas_is for taking appropriate interventions, including prevention of future outbreaks of the disease. One of the areas of interventions includes provision of effective and persuasive health education. When there is failure to identify or specify food borne disease causing agent through laboratory analysis of samples and specimen because of various reasons the investigator wiil focus on exploring epidemiological factors leading to theoutbreak and therefore concluding on the most likely causative agent. The procedure facts and reasons considered must clearly be shown in a summary sheet. · 2.0 Surveillance of Food Borne Diseases Regular food borne diseases surveillance is essential for identifying potential risks in order to plan for appropriate interventions and strategies to prevent outbreak of FBDs. The surveillance of food borne diseases includes the collection and analysis of information on disease outbreaks, causal agents and their source. An important pait of thîs activity is the monitoring of food borne pathogens and other hazards found in food, food animais or the environment.Food borne disease surveillance should be geared toSectors achieving the following; i) Monitor FBD trends ii) Predict and detect FBD outbreaks iii) Provide early alert iv) To generate causal hypothesis v) To identify appropriate intervention vi) To audit the impact of intervention 2.1 Routine Surveillance This should be done by Food safety surveillance officer, Laboratory personnel and Clinicians on their daily activities as indicated here under:- i) Clinicians Clinicians are responsible for a) Filling in Food Borne Diseases Surveillance form DIS/F0M/020 for patients (Annex II) b) Request laboratory an_alysis for specimen from patients who clinically presents the following symptoms; • Diarrhea • Nausea • Vomiting • Abdominal colics ii) Laboratory Personnel Laboratory personnel are responsible for conducting analysis of specimen and samples as requested by clinici'ans and/or Food safety surveillance officer. îii) Food Safety Surveillance Officer 11 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revis ion No. :0 Effective Date:13/05/2019 Guitlelines for investigation and control off ood borne diseases Food safety surveillance officer are responsible for: a) Conducting periodical environmental and food sampling b) Reconciliation of clinical diagnosis and laboratory results c) Collect, analyse and disseminate FBD data, Compile and submit weekly, monthly and quarterly FBD report in a form DIS/FOM/021 specified in ANNEX III. 2.2 Detection of FBD outbreaks Detecting Food borne disease outbreaks requires efficient mechanisms to capture and respond to a variety of data sources. The main data sources for detecting food borne disease outbreaks include: The public, media, and reports of clinical cases from health care providers, surveil lance data, disease notifications and food service facilities. Other sources may alert public health authorities to the occurrence of outbreaks. Often, some creativity is needed to detect outbreaks as many of these sources were created for other purposes. Examples include reports of increased absenteeism from the workplace, schools or child-care facilities, pharmacy reports of increased drug sales, e.g. of anti-diarrhea medications, and consumer complaints to health departments or food regulators. Outbreaks may be anticipated after an increased risk of population exposure has been detected, for example contaminated drinking water or contamination of a commercial ly available food product. There are causes other than outbreaks that may lead to increased number of observed or reported cases. These are referred to as "pseudo-outbreaks"; examples include changes in local reporting procedures or in the case definition for reporting a specified disease, increased interest as a result of local or national awareness, changes in diagnostic procedures, or heightened concern among a specific population (e.g. "psychogenic" outbreaks). ln areas subject to sudden changes in population size such as resort areas, college towns, farming areas with migrant workers changes in the numerator (number of reported cases) may only reflect changes in the denominator (population size). 3.0 Investigation of Food-Borne Diseases Outbreak Food borne disease outbreaks are investigated to prevent both ongoing transmissions of disease and similar outbreaks in the future. Specific objectives include: Control of ongoing outbreaks, detection and removal of implicated foods, identification of specific risk factors related to the host, the agent and the environment, identification of factors that contributed to the contamination,growth, survival and dissemination of the suspected agent, prevention of future outbreaks and strengthen ing of food safety po lic ies, acquisition of epidemiological data for risk assessment of food borne pathogens, stimulation of research that wi Il help in the prevention of similar outbreaks. The investigation of a food borne disease outbreak will normally include: epidemiological, environmental, food and laboratory investigations. 3.1 Outbreak Control Team This is a multid isciplinary team at district, Province and National level which is responsible for conducting rapid reactions on FBD outbreak. Members of the team will vary according to circumstances but the OCT normally includes: • Public health practitioner or epidemiologist answerable to the respective officer in charge 12 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases at each level. • Medical Officer in Charge, members of a hospital infection contrai group. • a food safety contrai officer; • a specialist in laboratory medicine (microbiologist, toxicologist, or other as appropriate); • Secretarial and logistic support. • Health Management Team An OCT should be convened when any of the following has occurred: i) The outbreak poses an immediate health hazard to the local population; ii) There are many cases e.g known fatal disease like taeniasis iii) The disease is important in terms of its severity or its propensity to spread; iv) Cases have occurred over a widespread area without obvious point source; v) Cases have occurred in high risk establishments (schools, daycare centers, hospitals, food premises, etc.). 3.2 Epidemiological Investigations The epidemiological investigation includes determining causes, distribution and control of food borne diseases in the population by involving the following procedures of notification, preliminary assessment, descriptive and analytical epidemiology. 3.2.1 Notification A food borne illness complaint may be taken via telephone, in person, by mail or any other means available. Details of the complaints are to be recorded by an inspector in a form DIS/ FOM/022 prescribed in Annex IV. However, reported data will be verified later in the investigation.Ail notifications should be sent to the nearby health offices or Rwanda FDA offices. Any food sample taken in re lation to the incidence should be refrigerated but not frozen because some sensitive micro-organisms might die in freezing condition. 3.2.2 Preliminary Assessment of the Situation Investigation of a potential food borne disease outbreak starts with the assessment of ail available information in order to confirm or refute the existence of an outbreak. This assessment must be init iated quickly and completed promptly in order to prevent further illnesses, and should include: i) To consider whether or not the cases have the same illness (or different manifestations of the same disease). ii) Determine whether there is a real outbreak by assessing the normal background activity of disease. iii) Conduct in-depth interviews with initial cases. iv) Collect clinical specimens from cases. v) ldentify factors common to ail or most cases. vi) Conduct site investigation at implicated premises. vii)Collect food specimens when appropriate. viii)Formulate preliminary hypothesis. ix) lnit iate contrai measures as appropriate. x) Decide whether to convene a formai outbreak control team (OCT). 13 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases xi) Make a decision about the need for further investigation. Once the validity of the reporting source has been verified, a group of the initial cases perhaps 5-10 persons should be identified and interviewed as soon as possible. The interviews should be open and comprehensive and should capture information indicated in the form DIS/FOM/023 (Annex V). With the initial information from case interviews, the laboratory and the environmental inspection, describe the event in simple epidemiological terms and form preliminary hypothesis about the cause of the outbreak. Generally, specific control measures can be implemented only when the source and the mode of transmission are unknown which provides a convincing argument for continuing with the investigations. The likely reasons for continuing investigation may include the following: i) The outbreak poses an immediate health hazard to the local population. ii) There are many cases. iii) The disease is important in terrns of its severity or its rapid spread. iv) Cases have occurred over a widespread area without an obvious point source. v) Cases have occurred in high-ris k establishments (schools, street vending facilities, daycare center, hospitals, housing or long-term care facilities for the elderly, food premises, etc.). vi) There is a high level of public concern. vii)There are potential legal implications. viii) An investigation would generate new knowledge, e.g. in the area of food safety and risk assessment. ix) An investigation would provide valuable learning opportunities for investigators. If, on the other hand, a decision is taken to hait the investigation, the reasons for this decision should be carefully documented and included in the final investigation report 3.2.3 Descriptive Epidemiological Investigations Careful description and characterization of the food borne outbreak is an important first step in any epidemiological investigation. Descriptive epidemiology provides a picture of the outbreak in terms of the three standard epidemiological parameters such as time, place and person. The steps of descriptive epidemiology include: establishing a case definition, case identification, analyses of data by time, place and person characteristics, develop hypothesis about exposure or vehicle caused the disease, compare hypothesis with facts and deciding whether analytical results are needed to test hypothesis. 3.2.4 Establishing a Case Definition A case definition is a set of criteria for determining whether a person should be classified as being affected by the disease under investigation. lt should be simple and practical and should include the following four components: i) Clinical and laboratory criteria to assess whether a person has the illness under 14 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revis ion No. :0 Effective Date: 13/05/2019 Guide/in es for investigation a11d control offood borne diseases investigation; the clinical features should be significant or ha!lmark signs of the illness. ii) Deftned period of tirne during which cases of illness are considered to be associated with the outbreak. iii) Restriction by "place" for exarnple, lirniting the group to patrons of a particular restaurant, employees of a particular factory or residents of aparticular town. iv) Restriction by "persan" characteristics limiting the group to, for example, persans over one year of age, persans with no recent diarrheal disease, etc, There are no rules about how sensitiv'e or specific a case de-finition shou!d be. In the early stage of an outbreak investigation the aim is to detect as many cases as possible; this requires a sensitive case definition (e.g. a persan with three or more loose stools in a 24 hours period). Because a single case definition that suits ail needs is rare, it is quite common for case definitions to change during an investigation or for different case de-finitions to be used for different purposes. Other times use the fo!lowing (or similar) case definitions in parallel: • Confirmed cases have a positive laboratory result (isolation of the causative agent or positive serological test). This case definîtion has high specificity. • Probable cases have the typical clinical features of the illness but without laboratory confirmation. • Possible cases have fewer or atypical clinîcal features. This case definition has high sensitivity. Box 1.Example of case definition used in the investigation of an Escherichia coli 0157 outbreak A case is defined as gastrointestinal illness in any resident of Area A within five days of attending the Area A Fair in June 2003. Cases may be furthercategorized as: Confirmed case: gastrointestinal il lness with mîcrobiological confirmation ofE. coli 0157 Probable case bloody dian-hoea or haemolyticuraemia syndrome without microbiological confirmation Possible case non-bloody diarrhoea withqut microbiological confirmation 3.2.5 Identifying Cases The cases that prompt an outbreak investigation often represent only a small fraction of the total number of people affected. Determine the full extent of the problem and the population at risk ofillness, an active search for additional cases shou Id be unde1taken. Methods for finding additional cases will vary from outbreak to outbreak and may include the following: 15 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:O Effective Date: 13/05/2019 Guidelines for investigation <md control offood borne diseases i) Many food borne disease outbreaks involve clearly identifiable groups (for example, persons ail attending the same wedding party), so that case finding is relatively straight for Sector. In other outbreaks, particularly those involving diseases with a long incubation period and/or with mild or asymptomatic illness, case finding may be quite difficult. ii) Directly contacting physicians, hospitals, laboratories, schools or other populations at risk may help to identify unreported cases. iii) The Authority decide to alert the public directly. For example, in outbreaks caused by a contaminated commercial food product, announcements in the media can alert the public to avoid the impl icated product and to see a medical practitioner if they have symptoms typical of the disease in question. iv) Cases themselves may know other people with the same condition particularly among household members, work colleagues, classmates, friends or neighbors. v) Conduct a survey of the entire affected population. If an outbreak affects a restricted population (e.g. students in a school or factory workers) and if a high proportion of cases are unlikely to be diagnosed. Questionnaires may be administered to determine the true incidence of clinical symptoms. vi) Review of laboratory surveillance data can help to find people with similar infections, assuming the cause of the outbreak is known. Cases that may be epidemiologically linked to an outbreak can often be identified through a unique subtype or biochemical or molecular feature of the causative organism, which may be particularly helpful in an outbreak caused by a widely distributed food product that crosses jurisdictional or even international boundaries. 3.2.6 Interviewing Cases, Medical and Health Personnel Once cases are identified , information about them should be obtained in a systematic way by use of form DIS/FOM/024 in ANNEX VI. This is in contrast to the preliminary phase of the investigation during which the interviews may be more wide-ranging and open-ended to allow for generation of hypotheses. Regardless of the disease under investigation, the following types of information should be collected about each case; ldentifying information, demographic information, clinical information, ri sk factor information (Questions will address both food-related and persona! risk factors). Data should also be collected on the number and size of meals eaten, and the source and handling of suspected foods should be noted. Gather information about ail meals and snacks eaten 24 hours before onset of disease. The type of illness will sometimes provide a clue on causative agent. If the first and predominant symptoms are nausea and vomiting concentrate questions on foods that have been most recently eaten. If the first and predominant symptoms are diarrhoea and abdominal cramps, be suspicious of food eaten 6- 20 hours before onset of disease. If diarrhea and fever predominate, be suspicious of food eaten 12-72 hours before 16 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and con/roi offood borne diseases onset of disease. Remember these suggestions relates ta common food borne d isease. The more unusual d iseases often present d ifferent clinical patterns. Persons ta be interviewed include ail people who were ill and ail persans who consumed an impl icated meal. It is important to interview people who are not ill and people who are ill. Interview medical and hospital personnel to obtain diagnosis of the disease and d iscuss findings obtained during the initial investigations. Information required will be as provided in ANNEX VI. 3.2.7 Collecting Data Once the interview is completed, the information taken should be collected promptly to provide insight into the distribution of clinical symptoms and other factors among cases. The data can be s ummarized in a line listing form DIS/FOM/025 provided in Annex VII. 3.3 Environmental and Food Investigations Environmental investigations (often also referred to as food or sanitary investigations) are conducted in parallel w ith epidemiological and laboratory investigations to find out how and why an outbreak occurred and, most importantly, to institute corrective action to avoid s imilar occurrences in the future. The s pecific objectives include: identifying the source, mode and extent of the food contamination, assessing the likelihood that pathogens survived processes designed to kill them or to reduce their numbers, assessing the potential for growth of pathogens during food processing, handling or storage, ident ifying and implementing corrective interventions. Records that may be useful in an investigation include: menus, recipes or product formulations, process ing records, purchasing and inventory records, shipping records and other documentation relating to the source of an implicated product, Hazard Analysis and Critical Contrai Points (HACCP) plans and records, records of corrective action, flow diagrams, floor plans of the establishment, complaint records, cleaning records, food laboratory testing results, past inspection records, personnel records (including who was working when, and absenteeism). 3.3. 1 Inspection of Suspected Premises An inspection of the premises where the implicated food was prepared is an absolute necessity inal l complaints regarding food borne diseases. C learly state the purpose of the visit and explain that the main concern is ta try and discover the cause of the outbreak and prevent further occurrences. The inspection needs to embrace the following aspects: i) Collect sampies of suspect foods or any foods available from the suspect lot. ii) Collect samples of potentially hazardous foods so as to ascertain its safety. iii) Obtain a copy of the relevant menu if the investigation concerns a meal or fonctions. 17 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 1f Guidelines for investigation and control off ood borne diseases iv) Carry out a routine inspection of the premises paying particular attention to the factors that cause food borne illnesses such as time/temperature of storage or processing, cross contamination, poor food hygienic handling. v) Determine any history of illness amongst the staff e ither before or after the outbreak. vi) In case an outbreak occurred in food establishment, interview managers and food handlers vii) Asses water system and suppl y viii)Make arrangements to collect faecal specimens from food handlers who are ill and advise them not to work in the area of food for sale until cleared by medical certificate. ix) Observe the skin of food handlers and note infected cuts, boils and inappropriate bandages. x) Establish the food preparation history, app licable to the implicated food or meal. Particular attention should be given to time and temperature storage and processing condition and the source of al I raw and other ingredients. xi) Be on alert during the interviews for inconsistencies of different persons xii) Explain to the management the results of your investigation including recommendations to prevent recurrence. 3.3.2 Inspection of Suspect Food When the role of a suspect food is investigated, the complete processing and preparation history shou ld be reviewed , including sources and ingredients, persons who handled the specific foods, the procedures and equipment used, potential sources of contamination, and time and temperature conditions to which foods were exposed. 3.3.2.1 Product Description The suspect food should be fully described in terms of: i) Ali raw materials and ingredients used (menus, recipes, formu lations); ii) Sources of the ingredients. iii) Physical and chemical characteristics, including pH, water activity (aw). iv) Use of returned, reworked or leftover foods in processing. v) Intended use (e.g. home use, catering, for immediate consumption, for vulnerable groups). 3.3.2.2 Observation of Procedures from Receipt to Finish Observations must cover the entire range of procedures, focusing on actual processes and work practices and including cleaning methods, schedules, persona! hygiene of food-handlers and other relevant information. The temperature history (temperature and duration) of the suspect food shou ld be recorded as completely as possible, including the conditions in which the food was stored, transported, prepared, cooked, heat-processed, held warm, chilled or reheated.Observation of food- handling practices may be valuable for small-scale operations and in the domestic setting as well as in commercial operations. 18 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date:13/05/2019 Guidelines for investigation and control of food borne diseases 3.3.3 Interviewing Food-handlers i) Interview ail food handlers by obtaining information about the exact flow of the suspect food, its condition when received by each food-handler, the manner in which it was prepared or handled, and any unusual circumstances or practices prevailing during the relevant period. ii) Note down ail recent illnesses of food-handlers (before, during or after the date of the outbreak exposure) and times of absence from work. iii) Obtain Specimens for microbial analysis from any food handlers who are ill. If any employee is found to be infected with the agent of concern, it is essential to determine whether he or she is a potential source of the problem or is infected because of having eaten the same food. At every step of the. process, data should be evaluated with respect to contamination, growth/proliferation and survival factors associated with the suspected pathogen(s). 3.3.4 Taking Appropriate Measurements Estimate food processing conditions at the time the implicated foods were produced. Product temperatures during processing and storage and time sequences of operations should be measured and recorded as appropriate. This includes: i) Time and temperature conditions to which suspect foods were exposed; ii) Water activity (aw), water content and pH of suspect foods; iii) Size of containers used in procedures, depth of food in containers, etc. Attempt to understand actual conditions at the time that implicated foods were prepared is paramount. 3.3.5 Drawing a Flowchart of the Operations A ll information and measurements should be entered on a flowchart to facilitate assessment of factors that may have contributed to the outbreak. The flowchart should be based on actual practices at the time of the outbreak and, as applicable, should show: (bullet form) exact flow of operations for the suspect food(s), name of persons performing operations, equipment used, results of measurements taken, and other relevant information. If practices at the time of the outbreak can no longer be reconstructed, a flowchart of current practices may be use fui. 3.3.6 Conducting an Outbreak Hazard Analysis Hazard analysis in an outbreak situation should address the following questions at each step of the processing of potentially implicated foods: • Cou Id pathogens have been introduced at any stage? • Could pathogens already present have been able to grow at any stage? • Could pathogens have survived processes designed to kil! them? This analysis also include observation of the food handling environ ment, assessing such factors as the location and availability of sinks and appropriate hand-washing facilities, and determining whether separate areas are maintained for the preparation of raw and ready-to eat foods. 19 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:1 3/05/2019 Guidelines f or investigation and control of.food borne diseases 3.4 Laboratory Investigation Most outbreaks of foodborne disease are microbiological in ongm and their investigation will usually require a microbiology laboratory. Outbreaks caused by chemically contaminated food also occur, although they are much less common than microbiological events. District and Province laboratories should be equipped with the basic equipments to enable analysis of samples and specimen from suspected FBD cases. These include but not limited to Biosafety Cabinet level Il, Autoclave, lncubator and Culture Media for common FBD pathogens (Salmonella, Shigella, Campylobacter, E. coli). The laboratory test request form DIS/FOM/026 is provided in Annex VIII. Information on collection, storage and transport of clinicat specimen and food sample is provided in ANNEX IX. 3.4. J Food and Environmental Sampling If laboratory facilities are available, appropriate food and environmental samples should be taken as early as possible since the amount of physical evidence will diminish with time. The laboratory should be alerted in advance of sample collection and can provide sampling materials appropriate to the type and quantity of specimens to be collected, their storage, packing and transport. 3.4.1.1 Food Samples Food samples that may be appropriate for collection and testing include: Ingredients used to prepare implicated foods, leftover foods from a suspect meal, foods from a menu that has been implicated epidemiologically, foods known to be associated with the pathogen in question, foods in an environment that may have permitted the survival or growth of microorganisms. If the victim or other exposed persons have any leftovers from foods or beverages that were consumed during the last 72 hours or any ingredients that were used in such foods, samples should be taken for laboratory examination. Samples should be collected aseptically using sterile apparatus and put into sterile jars or plastic bags. If foods are to be examined for organophosphate pesticidesorheavy metals glass containers should be used. A sample weighing approximately 200 - 450 g or measuring 200 - I 000 ml is enough for laboratory analysis. If it is in adequate ail of it should be collected.Packaged foods should be sampled in their original containers if feasible. Ali relevant details including the name of the manufacturer, batch number and expiry dates should be obtained. Labels and empty packages may also be useful if retained. Each sample container should be labeled with the corn plaint number of theoutbreak and sample number. The inspector should seal the container with adhesive tape, masking tape, gummed paper tape or paper covered with a clear tape in such a way that the container cannot be opened without breaking the seal. He should write the date, time of sealing and his own name on the tape. 20 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases Samples of perishable foods that are not frozen at the time of collection should be rapidly chilled to a temperature below 4°C and kept at this temperature unti l they can be examined.Refrigerated or frozen samples should be transported to the laboratory in an insulated container appropriately packed to maintain the temperature. Laboratory identification of a food borne disease causative agent is very important as it allows confirmation of the type of food borne illness, taking into account epidemiological data collected. Samples and specimens should be taken in a manner that will not impair quality of the laboratory results. 3.4.1.2 Environmental Samples The purpose of collecting environmental samples is to trace the sources of, and evaluate the extent of contamination that may have led to, the outbreak. Samples may be taken from work surfaces, food contact s urfaces of equipment, containers, and other surfaces such as refrigerators, door handles, etc. Environmental samples may also include clinicat specimens (such as faecal specimens, blood or nasal swabs) from food workers and water used for food processing. 3.4.1.3 Clinical Specimen Diagnosis of most infectious diseases can be confirmed only if the etiological agent is isolated and identified from ill persons. This is particularly important when the clinical diagnosis is difficult to make because signs and symptoms are nonspecific, as is the case with many foodborne diseases Clinical specimens should be obtained at the time of initial interview or as soon as possible thereafter because some pathogens remain in the intestinal tract for only few days after the onset of illness. In large outbreaks, specimens should be obtained from at least l 0-20 individuals ( ideally 15-20% of ail cases) who manifest illness typical of the outbreak and from some exposed, but not ill, persons. ln smaller outbreaks, specimens should be collected from as many cases as practicable. Take vomitus specimen if the person is vomiting, stool specimen or rectal swab if the person has diarrhoea, blood and urine if the person has ageneralized infection and fever, or if poisoning suspected; and blood and either stool or rectal swabs if botulism is suspected. (Medical personnel should take rectal swabsand any other clinical specimens whenever possible). Care should be taken during sampling, handling and storage of specimens so that the causative agents are not affected. Ail containers should be labeled with a waterproof marking pen before or immediately after collection with the patient"s name, identification, date and time of collection, and any other information required by the laboratory. The following should be observed when taking specimens: 21 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date: 13/05/2019 Guide/ines for investigation and control of.food borne diseases i) Collect 15 - 20 grams of whole stool, 10 - 15 ml. of diarrheal stool or 3 - 4 rectal swabs with a visible amount of fecal material from each person. ii) Collect 10-15 ml of vom itus. iii) Collect fresh stool specimens as soon as possible after onset of illness. iv) The optimum time for collecting specimens is the first three to four days of illness (although stools for virus isolation can be collected up to four weeks after onset). v) Collect fresh stool specimens from as many people as you can. The criteria for confirming that an outbreak was caused by a specific agent depend on isolating the agent from at least two people involved in the outbreak. vi) Keep fresh stool specimens cold from the time they are produced until the time they reach the laboratory. Refrigeration temperature (4°C) prevents the proliferation of normal intestinal tlora. 3.4.1.4 Chemical Investigation The features of important chemical foodborne illnesses are summarized in ANNEX 1. ln acute chemical exposures, most toxins or their metabolites are rapidly cleared from easily accessible specimens such as blood; prompt collection and shipment of specimens is therefore of critical importance. When collecting samples for chemical analyses it is important to closely collaborate with the analytical laboratory, make arrangements in advance for chemical samples to be analysed and to seek advice about what specimens should be collected and how. The types of specimens to be collected will depend on the suspected chemicals as indicated in ANNEX IX. In an emergency where it is impossible to contact the laboratory, biological specimens (whole blood, serum, urine, vomitus) should be collected as soon as possible, sealed in a clean container and sent to the laboratory promptly.Because care must be talked to avoid cross contamination, contamination free materials (such as specialized collection containers) may be provided by the laboratory to ensure that the extraneous contamination is kept to a minimum. Consultation with the testing laboratory is important in accurately interpreting 3.5 Evaluation Evaluate ail data collected du ring the investigation and the results of the examination of food and other specimens. The evaluation will include: i) Foods implicated in the outbreak ii) Suspect premises iii)Possible causes iv) Action necessary to prevent recurrence v) The necessity to alert the public vi) The necessity to implement food recall plan After conclusion of the investigation and evaluation of data information should be summarized in a form DIS/FOM/ 027 indicated as Annex X and the report s ubmitted to relevant Authority in the format DIS/FMT/026 indicated in Annex XI. 22 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guide/in es for investigation and contro/ offood borne diseases 4.0 Data Analysis and Interpretation Results of data analysis obtained during investigation are used as an input in identifying possible FBD. Areas that are considered during data analysis are: symptom profile, demographicprofile, epidemic curve, median incubation period, food specific attack rate and relative risks. 4.1 Symptoms Profile (Frequency of Signs and Symptoms among Cases). Prepare a table listing the symptoms~ the number of people who suffered each paiticular symptom and the percentage of people who suffered each particular symptom as shown in Table below. Ta ble 1: E◄ xamo e ofSsvmotoms crofile (sample size =30) Symptoms and Number of Percentage Signs cases Vomiting 25 83 Nausea 23 77 Diarrhoea 14 47 Fever 9 30 Abdominal pains 5 17 e.t.c This information helps to determine the causative agents as the symptoms can beused in conjunction with the time between consumption of suspected food and onset of symptoms.ldentification of a causative agent can greatly assist in subsequent investigation as it can identify implicated foods. Also it helps in determining whether outbreak was caused by intoxication, an enteric infection or a generalized illness. 4.2 Epidermic Curve The time of onset of illness is most important as different causative agent appear at different times after in-gestion. As a general guide chernical agents cause illness very quickly within a range of 1 minute to 1 hour, bacterial toxins quite quickly 1 hour to 6 hours, bacterial infections mate slowly usually 5 - 72 hours and can be longer as the case of Campylobacter and viral infections. Based on the time of onset of illness and number of cases an epidemic graph can be prepared. The graph may help in: i) Confirming the exi-stence ofan epidemic; ii) Forecasting of the further evolution of the epidemic; iii) Jdentifying the mode of transmission; iv) Determining the possible period of exposure and/or the incubation period of the disease under investigation; v) ldentifying out li ers in terms of onset of illness, which might provide important clues as ta the source. - Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date:13/05/2019 1f Guidelines for investigation and con/roi offood borne diseases Table 2 :Graph of number of FBDs Victims and times of Onset Epidermic Curve ..g • (J C: C :2 0 C. zC l 0 0 oé 4.3 Median Incubation Period Determine the median time to gain useful data regarding the causative agent. E.g. if the range was 8 - 16 hours and the median time was 12 hours it would appear to implicate Bacillus cereus. The median time can be obtained from the epidemic curve.Note: The median time of onset is the value of a list of individual time and is not the average time, or is a measure of central tendency which is not intluenced by very short or very long incubation period. 4.4 Food Specific Attack Rate Prepare an attack rate table from case history questionnaires. The attack rate table will usually quickly identify the implicated food. (Example of attack rate table is attached as ANNEX XII). Attack rate tables are important as most of the people who ate the implicated food will get il! whi lst most of the people who did not eat the implicated food will stay unaffected. However, not ail people who ate the implicated food will get ill and some people who did not eat the implicated food will get ill. Reasons for anomalies include poor memory, inaccurate answers, illness from other causes and infective doses. By plotting against age group it may help to determine who is at risk of becoming il!. This rate is the key factor in the formulation of hypothesis. Experience has shown that attack rate table may lead to a false assumption in the following circumstances: • Only part of a particular type of a food may have been contaminated so people may be consuming a particular food with different results. • A contaminated food may contaminate a part of another food through cross contamination. 4.5 Explanatory Hypotheses Develop explanatory hypotheses which address the source of the agent, mode andvehicle 24 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date: 13/05/2019 Guidelines fol' investigation and control offood borne (IÎseases of transmission and specitïc exposure that caused the dîsease. 4.6 Relative Risks (RR) The relative rîsk is a measure of strength of associatwn between the exposure and disease. Its value provides indic:ation of the suspect food in relation to FBD. Food product having the highest value is suspected of being the cause of the FBD as indicated in example in ANNEX XII. Data derived from epidemiological studies can be used in risk assessment, a process of evaluating known or potential adverse health effects resulting from human exposure to foodborne hazards. Risk assessment for foodborne pathogen have become an important tool for responding to increasing scientific, !egal and political demands in the area of food safety. Epidemiological data can be valuable in rîsk assessment for foodborne pathogen, partîcularly if data collection follows a standardized protocol. NB: Statistical significant can be used to detennine probability that this Relative Risk cou Id have occurred by chance alone or not. 5.0 Record Keeping From the begînning of an outbreak it is essential that ail information received and ail decisions taken by the OCT and others -be recorded reliably and with the appropriate level of confidentiality. This means that: • Individual members of the OCT keep records of ail activities performed during investigation of the outbreak; • Minutes are kept and diStributed; • Action notes are agreed upon and distributed immediately after OCT meetings;_ • Notes and other records collected during ail environmental, epidemiological and laboratory investigations are maîntained; • Copies are kept of ail communications with the public, including letters, fact sheets, public notices and media reports. 6.0 Confedetiality i) Data about individuals collected for outbreakinvestigations are strict\y confidential and therefore, data collection is the sole responsibility of public health officiais. ii) If it is necessary to provide patient-specific information in a written report other than the case interview forms and disease investigation forms, the name of the patient should be coded 7.0 Control Measures The primary goal of Foodborne diseases outbreak investigations is to contrai ongoing public health threats and to prevent future outbreaks. Prevention ofFBD requires prevention of entry of causative agents to food or detecting and eliminating them before consumption by susceptible human beings. Different methods are employed in controlling further spread of FBD as indicated below: i) Closing food premises or prohibiting the sale or use of foods ii) Removing implicated foods from the market (food recall, food seizure), 25 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date: 13/05/2019 1{ Guidelines for investigation and contro/ offood borne diseases iii) Modifying a food production or preparation process. At the same time, specific interventions such as recalling a food product or closing food premises can have serious econom ic and legal consequences and must be based on accurate information. Thus the implementation of control measures is often a balancing act between the responsibility to prevent further cases and the need to protect the credibility of an institution. 7 .1 Control of Source 7. 1. 1 Closing Food Premises If site inspections reveal a situation that poses a continuing health risk to consumers, the premises should be closed down until the problem has been solved Once premises have been closed they should be monitored by the responsible authorities and remain closed until appropriate authorities approve their reopening. 7. 1.2 Modifying a Food Production/ Preparation Process Once food investigat ions identify faults in production or preparation processes that may have contributed to the outbreak, corrective action must be taken immediately to avoid recurrences. Examples of corrective actions are modification of a recipe or of a process, reorganization of working practices, change in storage temperatures, or modification of instructions to consumers. 7.1.3 Removing Implicated foods from the Market The objective of food recall and food seizure is to remove implicated foods as efficiently, rapidly and completely as possible from the market.A food recall is undertaken by any business responsible for the manufacture, wholesale, distribution or retailing of the suspect food from large corporations or partnerships to familyowned businessesand may be in itiated by the business itself or undertaken at the request of an appropriate health authority. Food seizure is the process by which an appropriate authority removes a food product from the market if the business does not comply with the request to recall. Rwanda FDA will often have an active role in removing implicated foods from distribution. ln many situations, company recalls of products are carried out voluntarily at the suggestion of Rwanda FDA or other government authorit ies. Once investigations implicate a suspect food, a decision is needed on whether that food should be removed from the market. This decision may rest with agencies represented on the OCT or involve other bodies concerned with food safety. Rwanda FDA must decide: • Whether the information available just ifies removal of the food from the market; • Whether the product is still on the market; • Whether the product is likely to be in the homes of the consumer even though so ld out at retail level; • Whether there is an ongoing risk to the consumer; How likely it is that the product 26 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases can be recovered. Rwanda FDA or OCT may be faced with presumptive findings that would justify a recall but without corroborative evidence. In such s ituations, a decision must be based on ail factors in the particular case. Once the Rwanda FDAhave decided to recall a food product, they should: • Communicate with, and ensure the cooperation of the business(es), involved in the recall; • Directly advise local health authorities of the recall and any enforcement action required; • Ensure appropriate pub! ic notification; • Monitor the progress and effectiveness of the recall; • Ensure that corrective actions are taken by the recalling business. Mean s of notification will depend on the urgency of the s ituation and may include press releases, faxes, letters, telephone calls, and announcements on radio or television. Efficient recall of a widely distributed product requires that amanufacturer can identify a product by production date or lot number and that distribution records for fini shed products are maintained for a period of time that exceeds the shelf-life of the product. 7.1.3.1 Communication with the Public Public should be a lerted on the existence of FBD and implicated foods so that they refrain from using them. Even though the business may have already issued a press release, the OCT or Rwanda FDA may decide to notify the public. ldeally, th is should be done on the same day that the decision is taken to recal l a food product. Information to the public should include: • Act ions that consumers should take to prevent further exposure and illness; Name and brand of the food product ( including labeling) being recalled; • The nature of the problem, the reason for recall of the product, and information about how the problem was discovered; • Name and location of the producing establishment and point of contact; Locations where the product is likely to be found; • Numbers, amounts, and distribution; • A description of common symptoms of the illness associated with the suspected pathogen or contaminant; • Appropriate food-handling information for consumers; • Actions that consumers should take if illness occurs. 7. 1.3.2 Post-recall Reporting by the Business After imp lementation of a food recall, the business should provide the 27 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases Rwanda FDA or other appropriate authorit ies with interim and final reports about the recall, which should contain the following information: • Copy of recall notice, letters tocustomers, retailers, etc; • Circumstances leading to recall ; • Action taken by the business; • Extent of distribution of the batch of food that was recalled; • Result of recall (percentage of stock recovered or accounted for); • Method of disposai or reprocessing of recovered stock; • Difficulties experienced during recall; • Action proposed for the future to prevent a recurrence of the problem. 7.2 Control of Transmission 7.2. 1 Public Education lf a contaminated food product cannot be controlled at its source, stepsneed to be taken to eliminate or minimize the opportunities for further transmission of the pathogen. Depending on the situation, appropriate public advice may be issued during a period of hazard, for example: • Boiling of microbiologically contaminated water or avoidance of chemically contam inated water; • Advice on proper preparation of foods; • Ad vice to dispose of foods; • Emphasizing persona! hygiene measures 7.2.2 Exlusion of Infected Persons from Work and School The risk of infection being spread by infected individuals depends on the ir clin ical picture and their standards of hygiene. People with diarrhoea are far more likely to spread infection than asymptomatic ind ividuals with subclinical illness. Decisions about exclusion from work must be made by health authori ties in accordance with local laws and regulations. ln general, the fo llowing groups with diarrhoea or vomiting should stay away from work or school until they are no longer infectious: • Food-handlers whose duties involve touching unwrapped foods to be consumed raw or without further cooking or other forms of treatment; • People who have direct contact w ith high lysusceptible patients or persons in whom gastro intestinal infection would have particularly serious consequences(e.g. the young, the elderly, the immune-compromised); • Children aged under 5 years; • Older children and adults w ith doubtful persona! hygiene or with unsatisfactory toilet, hand-wash ing or hand-drying facilities at home, work or school. Even if clinically wel l, no person with any of the following conditions should handle unpackaged food: 28 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 1f Guide/ines for investigation and contro/ offood borne diseases • Excreta of Salmonella typhior Salmonella paratyphi; • Excreta of the etiological agents of choiera, amoebic dysentery or bacil lary dysentery; Hepatitis A or hepatitis E and ail other forms of acute hepatitis until diagnosed as other than hepatitis A or hepatitis E ; • Taeniasolium(pork tapeworm) infection; • Tuberculosis (in the infectious state). If an ill food-handler was implicated in an outbreak, recommendations should be made for preventing such problems in the future, such as ensuring that mechanisms are in place for routine screening to prevent il! persans from working. 7.2.3 Education on Personal Hygiene Investigator should issue education on persona( hygiene to ail individuals withgastrointestinal disease and should include the following: i) Avoid preparing food for other people until free from diarrhoea or vomiting. ii) Thoroughly wash hands after defecation, urination and before meals. Thorough hand washing with soap in warm running water and drying is the most important factor in preventing the spread of enteric diseases. iii) Use your own separate towels to dry hands. Institutions, particularly schools, should use liquid soaps and disposable towels or hand-dryers. iv) Clean toilet seats, flush handles, hand-basin taps and toilet door handles with disinfectant after use. If young children are infected, these cleaning procedures must be undertaken on their behalf. Similar arrangements may also be necessary in schools and residential institutions (iftemporary exclusion is not possible). v) If employed in food preparation activities, scrub your nails with soap and a brush. 7.2.4 Infection Control Precautions Infection contrai precautions for hospitalized and institutionalized persons with infectious diarrhoea (in particular, easily transmissible infections such as Salmonella typhi, Shigella, etc.) include: i) Isolation of patients (e.g. in a private room with separate toi let if possible); ii) Barrier-nursing precautions; iii) Strict contrai o f the disposai or decontamination of contaminated clothing and bedding; iv) Strictly observe persona! hygiene measures (see above). 7.2.5 Protecting Risk Groups Certain groups are at particularly high risk of severe illness and poor outcomes after exposure to a foodborne disease. Safe food-handling practices, including strict adherence to thorough hand-washing, should be particularly emphasized to such people. Specific advice for risk groups may be considered in some circumstances. Examples include advice to: i) Pregnant women against consurnption of unpasteurized rnilk, unpasteurized cheeses, and other foods potentially contaminated with Listeria; 29 Doc. No.: D1S/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 1f Guidelines for investigation and control of f ood borne diseases ii) lmmunocompromisedpersons,suchas thosewithHIV / AIDS, toavoid eating unpasteurized milk products, raw fish, etc; iii) Persons with underlying liver disease to avoid consumption of raw oysters and other food that may transmit Vibrio bacteria; iv) Persons with underlying chronic viral hepatitis B or C or other liver disease to be vaccinated against hepatitis A if appropriate; v) Personnel of day-care centres about receiving vaccination or immunoglobulin during a hepatitis A outbreak in the institution (although this is more! ikely to protect against secondary spread than against foodborne transmission). 7.2.6 Education on good Practices Information and education should be provided to farmers, manufacturers and food handlers on importance of adherence to Good Agricultural Practices (GAPs), Good Veterinary Practices (GVPs), Good Manufacturing Practices (GMPs) and Good Hygiene Practices (GHPs). Depending on circumstances, this may include educating food workers, managers, patients, or the public at large about adequate cooking, adequate holding temperatures, how to avoid cross-contamination, and the importance of good hand washing practices. 7.2.7 Legal Measures Legal measures should be applied to persistent non cornpliance to GHPs 7.2.8. Condemnation and Disposai of Unfit Food Foods implicated in outbreaks of FBDs should not be used but should be disposed of in a manner that will not affect human and animal health and the environment. 8.0 FBD Reporting 8.1 Levels of FBD Reporting Notification of incidences by medical practitioners shall be mandatory. Reporting of FBDs from Sector to National level is required to be prepared to allow consolidation of investigation and inspection results which can be used for future control and prevention strategies. FBD reports are part of food control act1v1t1es reports normally submitted by Province Administration and Local Authorities to Rwanda FDA. There should be a Food Borne Diseases Register format DIS/FMT/027, as illustrated in Annex XIII. The information required to be submitted is contained in form DIS/ FOM/028 (Annex XIV). FBD alert from any level to a superior one will however be copied to Rwanda FDA on the same day. Province Administration will conductsupervision fonctions in line with the Province Administration and Local Government Authorities. 8.2 Responsibilities at each Level 30 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date: 13/05/2019 Guidelines for investigation and control of food borne diseases FBD fonctions will be done at the following levels namely; National, Province, District and Sector. Functions undertaken at each level will be as indicated hereunder. 8.2.1 Healthy Community Office i) Establish and run community FBD file ii) To receive notification on FBD from medical personnel or individuals iii) Investigate FBD in the Sector iv) Solicit technical assistance and co-operation in investigating FBD from district Medical office v) Report FBD outbreaks to the District Medical Office vi) Share FBD information with other Sectors and interested parties at local and district levels vii)Sector Health Committee will act as Outbreak control team (OCT) for control of FBD outbreaks. viii)Disseminate information and give feedback to query sources on FBD ix) Foster establishment of, and consultation with food consumer groups x) Disseminate public health education xi) lncorporate FBD reports in the general monthly, quarterly and annual food control reports. 8.2.2 District Medical Office i) Establish and run a district FBD data bank ii) Distribute within the district, data capturing forms. iii) lnvestigate and provide technical assistance in the investigation of FBD to Sectors iv) Collect, analyse, interpret FBD data, predict outbreaks and issue early alerts on FBD in the district v) Solicit technical assistance and co-operation in investigating FBD from Rwanda FDA and Province level. vi) Report FBD outbreaks to the Rwanda FDA and Province level. vii) Relay information on FBDs to and from Sectors viii)Share FBD information with other districts and interested parties at the district and Province level. ix) Disseminate information and give feedback to query sources on FBD. x) Foster establishment of, and consultation with food consumer groups xi) Disseminate public health education xii)Train FBD surveillance personnel. xiii)Incorporate FBD reports in the general monthly, quarterly and annual food control reports. 8.2.3 Province Medical Office i) Compile districts FBD reports ii) Relay information to and from districts and the Rwanda FDA iii) Collect, analyse, interpret FBD data, predict outbreaks and issue early alerts on FBD in the Region 31 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 1 Guidelines for investigation and control offood borne diseases iv) Provide technical assistance in the investigation of FBD to Districts v) Seek technical assistance and co-operation in supervision on FBD matters from Rwanda FDA vi) Report FBD outbreaks to the Rwanda FDA vii)Share FBD information with other regions and interested parties at loca l and National levels viii)Train FBD surveillance personnel 8.2.4 Ministry of Health (Rwanda FDA) i) Establish and run a national FBD data bank ii) Review guidelines on FBD in line with emerging, re-emerging FBDs and new scientific developments. iii) Collect, analyse, interpret FBD data, predict outbreaks and issue early alerts on FBD iv) Investigate and provide technical assistance to Province Administration and Local Authorities in the investigation of FBD v) Co-operate and solicit technical assistance from relevant International Organizations in matters related to FBD vi) Submit FBD reports to the Ministry responsible for Health vii)Share FBD informat ion with other interested parties at national and international levels viii)Establish an Outbreak control team(OCT) for FBD control ix) Disseminate information and give feedback to information or query sources on FBD x) Train FBD surveillance personnel xi) Foster establishment of, and consultation with food consumer groups xii)lmprove public awareness on FBDs xiii)Write quarterly and annual reports on FBD 8.2.5 Outbreak Final Report An interim report should be made available by the OCT 2-4 weeks after the end of the investigations, followed by a written final report. The final report should be comprehensive, protect confidentiality and be circulated to appropriate individuals and authorities. The report should follow the usual scientific format of an outbreak investigation report (ANNEX XI) and include a statement about the effectiveness of the invest igation, the control measures taken and recommendations for the future. In addition, a summary report should be completed and forSectored to the appropriate authorities at national level for collat ion, analysis and, when appropriate, reporting to the international level (e.g. SalmNet, EnterNet, WHO, etc.). 9.0 Co-ordination of FBD Functions 9.1 Health Community Workers The incharge of Health community workers will be responsible for Coordination and 32 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelines for investigation and control offoot! borne diseases reporting. However, all health workers responsible for c\inical screening of patients, laboratory work, etc will play their mies as related to FBD Surveillance and furnish the information to the Coordinator who wi Il submit such report to the District. 9.2 Hospital/health CentreLevel The Drug Therapeutic Committeewill be the Coordinator of FBD matters. 9.3 Province level At Province level the committee responsible for health matters will also be responsible for supervision ofFBD activities at Province level. 9.4 National level At the National level Rwanda FDA will be the overa!I co-coordinator on FBD matters. The Director General will appoint an officer ta coordinate FBD matters, Figure 2: Reporting level of FBDs Rwanda FDA Province 1 1 Hospital 1 ...... ... 1 ......... ...... ... + District Hospital Hospital/Health Centre --------------~ ~ - - - - - - - - - - ~ Commu 10.0 Review of Outbreak r Doc. No.: DIS/GDU004 Revision Date:06/05/2019 ' Review Due Date:13/05/2022 Revision No.:O Effective Date:13/05/2019 Guidelines f or investigation and control offood borne diseases The OCT should formally decide when an outbreak is over and issue a statement to this effect.A structured review should follow ail outbreaks for which an OCT is convened and should include a formai debrieftng meeting with ail parties involved in the investigation. The aims of debrieftng are to: • Ensure that control measures for the outbreak are effective; • Identify long-term and structural control measures and plan their implementation; • Assess whether further scientiftc studies should be conducted; • Clarify resource needs, structural changes or training needs to optimize future outbreak response; • Identify factors that compromised the investigations and seek solutions; Change current guidelines and develop new materials as required; Discuss legal issues that may have arisen; • Arrange for completion of the final outbreak report. 11.0 Future Studies, Research Further studies may be conducted after completion of the in itial investigations, particularly if new or unusual pathogens were invo lved or additional information for risk assessment of a particular pathogen is required. The need to catch up on routine work delayed by the outbreak investigation often makes it difficult to conduct such follow-up studies. Nevertheless, it is important that these opportunities be considered following each outbreak - either by OCT members themselves or by others who may be in a better position to do this. Details of the outbreak may also be published in an international journal in order to inform the scientiftc commun ity at large. Economie evaluations of outbreaks and associated control efforts can be important in assessing the cost-effectiveness of outbreak investigations and food safety measures.Foodborne outbreaks will incur costs to: • Health care providers (diagnostic and curative services); • The population (medication, time missed from school or work, reduced activity as a consequence of long-term sequelae, death); • The food industry (closure, adverse publicity, recall, litigation); Agencies, laboratories and other persons and organizations involved in the investigation, response and control activities. • Costs associated with outbreaks can be enormous, and quantifying them may help to increase the commitment of the food industry and other agencies to food safety. 12.0 Reference WHO: Foodborne disease outbreak-Guideline for investigation and Control www.who.int/foodsafety/en 34 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases

ANNEX I :Common Food Borne Diseases Caused by Different Agents. 1. Common Food-borne Diseases caused by Bacteria Disease Incubation Principal symptoms Typical foods Mode of Prevention of (causative agent) period contamination disease ~ (Bacillus cereus) food poisoning, 8- 16hr ( l 2-24hr) Diarrhea, abdominal cramps occas ional Meat products, soups, sauces, From soi t or dust Thorough heating and rapid cooling of diarrheal vomiting vegetables foods (Bacillus cereus) 1-5hr (6-24hr) Nausea, vom iting, Cooked rice and From soil or dust Thorough heating food poisoning, sometimes diarrhea pasta and rapid cooling of emetic and foods abdominalcramps Botuiism; food 12 - 36 hr Fatigue, weakness, Types A & 8: Types A & B Thorough heating poisoning (heat labile (months) double vision, slurred Vegetables, fruits, from soi I or dust; and rapid cooling of toxin of (Clostridium speech, respiratory meat, fish, and type E: water and foods ~ botulinum) failure, sometimes death poultry products, sediments condiments: Type E: fish and fish products Botulism; food 3-30 days (variable) Constipation, weakness, Honey, soil Ingested spores Do not feed raw or poisoning infant respiratory failure, from soi 1, dust or pasteurized honey to infection sometimes honey colonize infants death intestine Brucel losis; Commonly 1 - 2 Fever, sweats, Unpasteurized dairy lnfected food Do not consume Brucellamelitensis months but range headaches, products (mi lk, source (dairy unpasteurized milk, from 5 - 60 days. backpains, and cheese and ice- products and cheese, ice-cream. physical weakness cream), meat) Cook meatthoroughly undercooked meat Campy lobacteriosis(C 3-5 days (2- Diarrhea, abdominal Infected food Chicken, raw milk Cook chicken ampylobacter 10 days) pain, fever, nausea, source animais thoroughly; avoid jejuni) vomiting crosscontamination, irradiate chickens; pasteurize mi lk 35 Doc. No. : DIS/GDL/004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date: 13/05/2019 Guidelinesfor investigation and control offoot/ borne diseases Choiera (Vibrio 2 - 3 days hours to Profuse, watery stools; Rawor H uman feces in Cook seafood cholerae) days sometimes vomiting, undercooked manne thoroughly; general dehydration; often seafood environment sanitation fatal if untreated. (Clostridium 8 - 22 hr ( 12 - 24 Diarrhea, abdominal Cooked meat and Soit, raw foods Thorough heating ~ perfringens) food hr) cramps, rarely nausea and poultry and rapid cooling of poisoning vomiting foods (Escherichia coli) 12 - 60 hr (2-9 Watery, bloody Raw or undercooked lnfected cattle Cook beef foodborne infection: days) diarrhea beef, raw milk thoroughly; enterohemorrhagic pasteurize milk (Escherichia coli) At least 18 hr Abdominal cramps Raw foods Human fecal Cook foods thoroughly, enteroinvasive (uncertain) diarrhea, fever, dysentery contam ination, general sanitation direct or contamination via water ~ (Escherichia 10 - 72hr (3-5 Profuse watery diarrhea; Raw foods Human fecal Cook foods thoroughly, coli) foodborne days) sometimes abdominal contamination, general sanitation infection: cramps, vomiting direct or enterotoxigenic contamination via water Listeriosis (Listeria 3 - 70 days Men ingoencephal itis; Raw milk, cheese Soil or infected Pasteurization of milk; monocytogenes) still births; septicemia and vegetables animais, directly cooking or meningitis in or v ia manure newborns Salmonellosis 5 - 72 hr (1-4 Diarrhea, abdominal Raw and In fected food Cook eggs, meat (Salmonella days) pain, ch ills, fever undercooked eggs; source animais; and poultry species) vom iting, dehydration raw milk, meat and human feces thoroughly; poultry pasteurize milk; irradiate chickens 36 -- Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases Shigellosis (Shigella 12-96hr(4-7 Diarrhea fever, nausea; Raw foods Human fecal General san itation; species) days) someti mes vomiting, contamination, cook foods thoroughly abdominal cramps direct or contam ination via water ~ Staphylococcal 1 - 6 hr (6-24hr) Nausea, vomiting, Ham, meat and Food Handlers with Thorough heating and food poisoning d iarrhea, abdominal poultry products, colds, sore throats rapid cooling of foods (heat stable cramps cream fil led pastries, or infected cuts, enterotoxin of whipped butter, food s licers Staphylococcus cheese aureus) Streptococcal 1 - 3 days (varies) Various, including Raw milk, deviled Food Handlers with General foodborne infection sore throat, eggs sore throats, other sanitation, (Streptococcus erysipelas, scarlet "strep" pasteurize milk pyogenes) fever infections ffe Vibrio l 2-24hr (4-7 parahaemolylicusfoo days) dborne infection Diarrhea, abdominal cramps, sometimes nausea, vomiting, F ish and seafood Marine coastal environment Cook fish and seafood thoroughly fever, headache Vibrio vu/ni.ficus In person with Chills, fever, prostration, Raw oysters and Marine coastal Cook shellfish foodborne infection high serum iron: often clams environ ment thoroughly 1 day death Yersiniosis 3-7 days (2-3 Diarrhea, pai ns Raw or undercooked lnfected animais Cook meat thoroughly, (Yersinia weeks) mimicking appearance of pork and beef; tofu especially swine; chlorinate water enterocolitica) appendicitis fever, packed in spring contaminated water vom iting, etc water 2. Common food-borne diseases caused by viruses -37. Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases Disease Latency period Principal symptoms Typical foods Mode of Prevention of (causative agent) (du ration) contamination disease Hepatitis A 15 - 50 days ( weeks Fever, weakness nausea, Raw or Human fecal Cook shellfish (Hepatitis A virus) to months) discomfort, often undercooked contamination, via thoroughly, general * jaundice shellfish, water or direct san itation sandwiches, salads, etc. Viral 1-2 days Nausea, vom iting, Raw or Human fecal Cook shellfish gastroenteritis diarrhea, pains, undercooked contamination, via thoroughly, general (Norwalk-like headache, m ild fever shellfish, water or direct. san itation viruses) sandwiches, salads, etc. Viral Gastroenteritis 1-3 days (4-6 days) Diarrhea, especially in Raw or Probably human General sanitation (rotaviruses) infants and chi ldren mishandled food fecal ~ contamination 3. Food-borne diseases caused by - Fungi other than mushrooms Disease Latency period Principal symptoms Typical foods Mode of contamination Prevention of (causative agent) (du ration) disease A flatoxicos is Varies with dose Vomiting, abdominal Grains, peanuts, Mou lds grow on grains and Prevent ("aflatoxins" of pain, liver damage, liver milk peanuts in field or storage; mo uldgrowth; don"t Aspergil lusflavus cancer (mostly Africa and cows fed mouldygrain eat or feed mouldy and related Asia) grain or peanuts; mou Ids) treat grain to destroy toxins Alimentary toxic 1-3 days (weeks Diarrhea, nausea, Grains Mild growth on Harvest grain in the aleukia("trichothecene to months vomiting; destruction of gram, especially if fall;don"tuse mouldy "toxin skin and bone marrow; left tn the field grain of fusariummoulds) sometimes death through winter 38 - Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases Ergotîsm Varies with dose Gangrene (limbs die and Rye; or wheat, Fungus grows on grain in Remove (toxi drop off); or convulsions barley, and oats the field; grain kernel is sclerotiafrom ns of Claviceps and dementia; abortion replaced by a "sclcrotium" harvested numurea) 1Irain ~ 4. Food-borne discascs caused by protozoa and parasites Discase Latency period Principal symptoms Typical foods Mode of Prevention (causative agent) (duration) contamination of disease (PROTOZOA) 2-4 weeks Dysentery, fever, chills; Raw or mishandled Cysts in human feces General sanitation; Amoebic dysentery (varies) sometimes liver abscess foods thorough cooking (Entamoeba histo/ytica) Cryptosporidiosis 1-12 days (!- Diarrhea; sometimes Mishandlcd foods Oocysts in human General sanitation; (C,Jiplosporidium fever, nausea and feces thorough cooking ~ 30 days) parvum) vomiting Giardiasis 5-25 days Diarrhea with greasy stools, Mishandled foods Cysts in human and General sanitation (Giardia lamblia) (varies) abdominal cramps, bloat animal feces, thorough cooking directly or via water. T0xoplasmosis 10-9 days Resembles Raw or undercooked, Cysts in pork or Cook meat thoroughly (Toxoplasma (varies) mononucleosis; fetal meats; raw mild; mutton, rarely beef; pasteurize milk; gondjj) abnormality or death mishandled foods oocycts in cat genèral sanitation feces -39 , Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:O Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases (ROUNDWORMS, Hours to weeks Abdominal cramps; Raw or undercooked Larvae occur Cook fish thoroughly Nematodes) (varies) nausea, vomiting marine fish, squid or naturally in edible or freeze at 4ÜF for Anisakiasis octopus parts of seafood 30 days (Anisalissimplex,p ~ seudoterranova decipiens) Ascariasis( 10 days - 8 Sometimes pneumonitis, Raw fruits or Eggs in soi!, from Sanitary disposa] of Ascaris weeks (1-2 bowel obstructions vegetables that grow human feces feces; cooking food lumbricoides) years) in or near soil Trichinosis 8 -.15 days Muscle pain, swollen Raw or undercooked Larvae encysted in Thorough cooking of (Trkhinella 9 weeks, eyelids,fever; sometim es pork or meat or animal"smuscles meat; freezing pork at spiralis) months) digestive disturbances carnivorous animais s0F for 30 days; (e.g bears) irradiation (TAPEWORMS, 10 - 14 weeks Worm segments in stool; Raw or undercooked "cysticerci" in beef Cook beef thoroughly ~ Cestodes) Beef (20 - 30 sometimes digestive beef muscle or freeze below 90F tapeworm (Taenia years) d isturbances saginata) Fish tapeworm 3-6 Limited: sometimes Raw or undercooked "plerocercoids" in fish Heat fi sh 5 ( Diphyllobothrium weeks(year vitamin B-12 deficiency fresh-water fish muscle minutes at l 330F or latum) s) freeze 24 hours at o0F Pork tapeworm 8 weeks - 10 Worm segments in stool; Raw or undercooked "Cysticerci" in pork Cook pork thorough ly (Taeniasolium) years sometimes "cysticercosis" pork;anyfoodmishandl muscle; any food or freeze below 320F (20 - 30 of muscles, organs, heart ed by a T. human feces with general sanitation. years) or brain. soliumcarrier. T. soliumeggs 5. Food-borne Diseases caused by chemicals and metals 40 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases Disease Latency period Principal symptoms Typical foods Mode of Prevention of (causative agent) (duration) contamination disease (TOXINS IN FIN 3-4 hr (rapid Diarrhea, nausea, vomiting, "Reef and islaild" (Sporadic); food Eat only small fish FISH) ciguatera onsct) abdominal pain numbness fish: grouper, chain, from algae ~ po1son111g 12-18hr(days- and tingling of face; taste surgeon fish, (ciguatoxin, etc) months) and vision aberrations, barracuda, sometimes convulsions, pompano, snapper, respiratory etc. arrest and death (l-24hrs) Fugu or 10 - 45 min to::::: Nausea, vomiting, tingling Pufferfish, «fugu" Toxin collects in Avoid pufferfish pufferfishpoisoning hrs lips and tangue, ataxia, (many species) gonads, viscera (or (tetrodotoxin, etc) dizziness, respiratory their distress/arrest and gonads) sometimes death Scombroid or Minutes to few hours Nausea, vomiting, "scombroid" fish Bacterial action Refrigerate fish ~ histamine (few hours) diarrhea, abdominal (tuna, mackerel immediately when poisoning crarnps, tlushing, etc): caught (histamine, etc) headache, burning in mahimahi, others mouth (TOXINS IN Vomiting, abdominal Mussels, clams From algae Heed survejllance SHELLFISH) cramps, diarrhea, warnings amnesic shellfish disorientation, memory Joss; poisoning (domoic sometimes death acid Paralytic <2 hrs to :>24 hr) Vomiting, diarrhea, Mussels, clams, From "red tide" Heed surveillance shellfish paresthesias of face, scallops, oysters algae warnrngs po1son111g sensory and motor (saxitoxin, etc) disorders; rcspiratory paralysis, death 41 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:O Effective Date:13/05/2019 Guidelinesfor investigation and control offood borne diseases (MUSHROOMS <2 hrs to 2:3 hr) Nausea, vomiting, Poisonous lntrinsic Don''teatwild TOXINS) diarrhea, profuse sweating, mushrooms mushrooms mushroom intense thirst, poisoning (varies hallucinations, coma death greatly among species) ~ (PLANT (large doses) 1 - 15 Unconsciousness, Bitter almonds, lntriasic, natural Proper processing; TOXINS)Cyanide min convulsions, death cassava, some avoid some so- poisoning lima bean called foods (cyanogentic varieties, apricot glycosides from kernels plants) (METALS) Depends on dose Nausea, vomiting, Acid foods, food Acid or heat Select foods contact Cadmium diarrhea, headache, grilled on shelves mobilizes surfaces carefully muscular aches, salivation, from refrigerator cadmium plating ~ abdominal pain, shock, liver damage, renal failure Cooper poisoning Depends on dose Nausea, vomiting, diarrhea Acid foods, foods Acid mobilizes Select food contact (24-28 hr) contacting copper, copper surfaces carefully soda fountains, beverages Lead poisoning Depends on dose Metallic taste, abdominal Glazes, glasses, Lead d issolves in Test glazes and pain, vomiting, diarrhea, illicit wh iskey beverages and glasses; avoid illicit black stools, oliguria, foods whiskey collapse coma (alsochronic effects) Mercury poisoning Depends on dose Meta li ic taste, th i rst, Treated seeds 1nternational; food Eat only seeds abdominal pain, vomiting, (fongicide): fish chain intended for food bloody diarrhea, kidney failure 42- Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelinesfor im•estigation and control offoot! home diseases Zinc poisoning Depends on dose Nausea, vomiting, diarrhea Acid foods Acid mobilizes zinc Select food contact (24-48hr) in galvanized plating surfaces carefülly containers ~' t 43 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:O Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases DIS/FOM/020

ANNEX II :Food Borne Disease Surveillance Form for Patients (To be filled by Medical Practitioners) (Fill under each item as appropriate) 1. Hospital------------------------- District--------------------------- Province --------------------- 2. Patient name--------------------------------------------- Reg. No. ------------------------------------- Age ---------------------------- Sex (Male/F emale) ------------------------------------------------- 3. P hy sical address--------------------------------------Postal address---------------------------------- 4. Disease sign and symptoms---------------------------------------------------------------------------- 5. Istheillnessresultfromconsumptionoffoodordrink?Yes/No- ---- ------ ------ --------------- If yes give the nam e of food or drink----------------------------------------------------------------Tim e consume d-----------------------------place cons umed----------------------------------------T im e of fi rs t si gns of ilin es s----------------------------------------------------------------------------- 6. Hasthepatientsu fferedthesam eillness before?Y es/No------- --- ----- -- --- ----- -------- --- --- If yes w hic h da te ------------------------------------------------------------------------------------------ 7. Didthepatientgetmedicaltreatment?Yes/No If yes describe the type of treatm ent------------------------------------------------------------------ 8. Is the patient referred to the Laboratory for screening? ------------------------------------------- If yes state specimen taken ----------------------------------------------------------------------------- Code No. ------------------ date drawn----------------------date submitted------------------------- Date analyzed-------------------- aetiological agent found ------------------------------------------ Load/concentration-------------------------------------------------------------------------------------- 9. Conclusion as to the causative agent ---------------------------------------------------------------- 10. Doctor/Clinician Code or N ame----------------------------------------------------------------- Date --------------------------- tim e ------------------Signature---------------------------------------- 44 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelines for investigation and control of food borne diseases DIS/FOM/021

ANNEX III :Weekly/ Monthly /Quarterly FBD Surveillance Report Form ,,,Jf • ~ i, ' ,., ,. .. ,IF ,, ,, ) .~ ~ ,.. 1 1 \ -v I ~4~ RWANDAFDA Rwanda Food and Dru~ Anthority Facility: _ _ _ _ _ _ __ _District_ __ __ _ _Province: _ _ _ _ __ _ Period covered: From to SIN Diseases No. of cases Deatb Steps taken Age Sex Age Sex Reported by: Name: .. . ............ ... .... ............... ..... . ..... . Title: ................................................. . Signature: ........ .. .. .. .... ..... . ... .. . ...... .... .. . Date: ............................................. .. . 46 Doc. No. : DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases DIS/FOM/022

ANNEX IV :Suspected Food Borne Disease Notification Form j~ ,., ~, w ' 11/; ' ,, 1 ,v i~ - i RWANDAFDA - I R11 and., Food and Dru~ Aulhority Patient details Name......... ...... ....... ..................... .. Tel. No.............. ................ . .... ..... .... .. .. Age ................................................. Sex ..... . ...... ...... ...... ... ........................ ... ........ .. . Address: ............ .. . ... .................. .... ................. ...... .... .. ........ . •·· •· ••· • •· ••••••••· · ··· ········ ·· · E-mail: . . . ... ... ....... .. .... Fax ..... .... ...... ...... .. . . Occupation ........................ ..... .... .. ...... . Suspected premises (there may be more than one) Address ... ................ . ........... .. .. .... .................. ............... ... ... ... ...... .... ......................... . Tel. No............... . ....... ........ ......... .......... ..... .. ....... ....... .. .... ................... .................... . E-mail..................... ...... ........................ Fax ..... ..... ......... ........... . .......... ......... ....... . Foods eaten 1. ....... .... ........................... ········· ..... .. .. ........... .................... .. ..... ......... ....... ................... . 2. ..,... .............. . ...... .. .... ...... ......... .. ... .. .... ........................ ..... . ....... ... ......... ... ·· ··· ············ ··· .. . .) . 4. 5. .......... ........ ········· ..................... ······ ········· ··.... ................................. ······················· .. . 6. Beverages Additional information Time and date food consumed .. . ........ . .............................. ................. . ................. .......... . F irst symptoms 47 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelinesfor investigation und control offood bome diseases ················································· .. ············· ..... , ................................................. . ·············••············••·•·····················································•··••······································· Time &Date ..................................... , ............................................. . Description: .. ... ..... . . .. . . ..... . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . ... .. ... .. . ... .. . . . . . . ... . . .. .. . . . . . . . .. . . . ...... . . . . . . . ' . ' ' ' ····················································································································•·••······· Have you been to the doctor?Yes/No. Have stool samples been taken?Yes/No. Sym ptoms ceased. Time &Date .............. , ................................................................................................. . Illness in other family members ................................................................................................................................ ·······~··································•··••················································································· ................................................................................................................................ Date: ...................... Notified by ........................... . Tel. .......................................... . E-mail ................ Fax ......................... , ......... . 48 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guidelines f or investig{lfion {lnd control offood borne diseases DIS/FOM/023

ANNEX V: INITIAL CASE REPORT FORM ,., '~ ~ I ~ ~ 1 '-\, ~ 1- - \ ~ J ,6' ~*' RWANDAFDA Rwanda Food and Drogs Authority Health facility: .......... ... ... .. . ..... District: ... ....... .. ......... Province: .. . ............... .. . Information on person affected Last name: .. . ..................... ....... .......................... . . . .. ............... . ........................ ... ... First names: . . .... ................ ..... .............. Sex: ..... . ... .. .............. ........ ....... ............ ... ... ..... . Occupation: ... . .. ... ..... . .. ............. ... ... ... .. ................. .. ... .. . ... .............. . .. ............ . ..... ..... . . Address, telephone number: ..... . .............. ... . ..... ....... ............. . ... ....... ..... . Daytime contact details (work address, phone): ....... .. ... . . ................... .. ................... .. ..... . Clinicat details Date & time of onset of symptoms: ............... ...... ... ........................ .... ..................... ..... .................. ... ........... ····· Date & time when symptoms stopped: ............... . . . ... ... .. ............ . ... .. . .... .. .. ................. .. .. . .. .... Predominant symptoms (severity, duration) ............ ..... ... . . . ... .............. . ... .. .. ... . . ... ········· ......... ............... ····· ···· ···· ······· ················ .... ........ ········· ·· ·········· ······ ... ............ . Doctor consulted? (if yes, provide name and details) . .. .. .................... ..... ............. ......... . ........ . Hospital attended? ( if yes, provide name and details) ...... ... ....... .......... .. ... ................ . ....... .. ... . Laboratory specimen taken? (if yes, provide details) ............ .. ..................... .. . .................... .. .. . Diagnosis available ········· ········· ············ ......... ..... .·················· ... ......... ······ ··· ......... ········· ...··· ······ ············ ................ ......... .... ........... ······ ··· ... ..................... ... ... ·············· ·...................... .......... . ... ... ... .................. ... ... ... ............... ... . .. ·· ······················ ············ ··· ··· ··· ··· ............. ..... .. . Suspect food? (if yes, provide source of food, preparation mode, when consumed) .................................... ··· ···················· ···· ... .. .......... ········· ··· ············ ... ... ............... .. . ························ ·· ·········· ... ......... .............................. ... ... ········· ... ················ ···· ·········· ...... ··· ··· ............... ······ ··· .................. ·· ················ .. .... .................. ......... ········ ··· ······· .. . ...... ......... ... ... ............... ... ......... ... ························ ... ... ......... ...... ... ...... ······ ··· ·· ......... . 49 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date:13/05/2019 1f Guidelinesfor investigation and control ojfood borne diseases .............................................................................................................................. Suspect meal, event, place? (ifyes, describe; provide, name, date, address, telephone number) ............................................................. ' ...................... ' ................................ ., ...... . .............................................................................................................................. Person attending suspeèt ill/we\l Address & telephone meal/event Other relevant infonnation ............................................................................................... . Name of officer filling form: ......................................................................................... . Title: Signature: ................................................................................................................. . Date ............................................................................................ , ............................ .. 50 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:O Effective Date:13/05/2019 J,I Guidelines for investigation and control offood borne diseases DIS/FOM/024

ANNEX VI :FOOD BORNE DISEASE CASE HISTORY FORM ,I ~~. ~ ,\•,, ' i ~ \1 '~ ~ § RWANDAFDA R'll.nda Food and ~ Authority Health facility: ... .................... District: ... .. .............. ....... Province: .............. . (Use addition sheet of paper if space provided is not adequate) 1. Date of notification ................ .... .... ................................................ ... .. .... ......... . 2. Date of investigation ............... ...... ........... . ..... . ... ... ............... . .. ... ..................... . 3. Name of complainant.. .................... . . ... . .............. . Age ........ . ................... . ... .. ....... .. ......................... . Address ................. ....... . . .. ............ . ... . .............................. ... ........ . Tel. No...... .. ..................... E-mail. ........................................... . 4. Place w here the outbreak occurred ... ... ................ . . ... ..................... .... . . Street. .. . ........ .. .. ... . . . ........ ........ ... . . Village .. ............. .. . . .. ... ........... . ......... . .. .... .. .. . Sector... ..... ... . .. ..................... . . .... . Division ................................... ...... . District .................. .... .. .. ........ . Region .... .. . .. ............. ..... . . ....... .................... . 5. When did the outbreak start. ............ .. ............. ........... .... ..... ... ....... .. .. . 6 . How man y people were ill? .. ... ..... . .... .. .... .. ................... ... .... ............. . 7. How man y people ate the suspect meal were not ill? ........ . .... ..... ... ....... .............. . 8. What was the suspect food(s)? ... ..... ...... ... ....... ...... ·············· · ..... ....... ........... .. .... ....... ······ ········· ......... .......... . ............ ... ... ··· ·· ····· ·········· · ····· ··· · ... ... ···· ··· ··· ·· ··· .................... .... ... ............. . 9. If some people who ate the suspect meal were not ill, what food they didn"t eat or they ate in small amounts? .......... ..................... ..... ...... .......................................... ···· ·· ··············· ........ . 10. How soon after the last meal did illness begin? No. of hours ... ...... ......... ............... date ............ ....... ........... ... ....... ............ .. .. . . 51 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date: 13/05/2019 1l Guitlelines for investigation and contro! offood borne diseases 11. What were signs and symptoms ofillness? (Tick where appropriate). D Nausea D Constipation D Vomiting D Fever D Burning sensation (mouth) D Headache D Rash D Numbness D Abdominal cramps D Paralysis D Diarrhoea D Dizziness D Bloody D Reversesensation(hot/cold) D Mucoîd D ltching 12. 1-Iow long did the iHness last: (a) Acute signs? .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . .. . . . . . . . . . ' . . . . ... . .. . . .. . . ' ' . ' (b) Before feeling well again? 13. List the total foods and drinks ingested at the last meal (or snack) ......... ,,, .. , .... ,,,,, ...... , ....•..............•......•............•••.•.••.•••.••.••.•••.........•........• 14. List the foods eaten during the four previous meals ............................................................................................................... 15. List foods consumed in the prèvious 72 hours indicating place and time. (ln case Campylobacter is the suspect causative agent list other high. risk foods consumed in previous 10 days) .................................................................................................. . ......................................................................................................... , .. , ..... 16. Did the complainant think any particular food was abnormal? (e.g i'spoiled", "off- tlavour" etc)Yes/No. lfyes mention the food .................................................................................... . 17. What treatment had this suspected food received? (If applicable) ........................... .. i.Was it fresh purchased? .................................................. . ii. If canned, how long sin ce opening the can? ................................................ . iii. Was it Frozen food? ....................................................................... . iv. Was itPrepared at home ................................................................... . v. A "warmed-up" preparation? ........ , ....................................................... .. vi. How longsince preparation/cooking? ............................................................. . v. Was it continuously refrigerated? ......................................................... . vi. 18. What was the method of cooking? .................................................. . 52 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revis ion No. :0 Effective Date:13/05/2019 Guidelines f or investigation and control offood borne diseases 19. Did the person who prepared the food suffer from infected cuts, boils, cold, sore throat, diarrhoea? 20. Are remnants of the suspect food available? (If so take sample). 21. Were specimen taken from the patient?Yes/No. 1f yes, what was the laboratory res u lts 22. Was patient hospitalized? Y es/No If yes, Name of hospital: Date of admission : ...... / .... ./ ...... .. Date of discharge: ...... / .... ./ ...... .. 23. What was the diagnosis? .... .. ......... ........................... .. .................... .... . ...... ......... . 24. lnvestigator"sremarks: Name of investigator. ................ .... ... ...................... . Signature: . ..... ...... ....... .................... .. Title ........ .. ........... .... ........... . ...... ........... ...... ... ... .... ............ ... .. ... . ... . . ... ... . . . Address .............................. . ..... ... . .............. . ................................... .. . ... . .... . 53 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases DIS/F0M/025

ANNEX VII LINE LISTING '~ ,., ' " 1§' ~•. e .: ,;,. ~ . i - - ~ ; a .1œ \ 'y' ~~~ RWANDAFDA Rwanda Food and~ Authority Facility: ............ .... ... District: .. .. ............ ... ... ....... Province: ..................................... . ID Name Age Sex Date & time Major Laboratory tests of onset of signs & illness symptoms specimen Result Name o f the officer filling form: ................ ........................................... . Title : ... .......... ...... ............................................ .... ................... .... Signature: ............................... ........ .... ........................ .. .................. . Date: ........ . ... ................................................................................ . 54 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases DIS/F0M/026

ANNEX VIII LABORATORY TEST REQUEST FORM Customer"s name and address Customer code number (ifapplicable) ........... . .. . ............ . ........... ... ............. ....... . Sample Information Product name (including brand name, form and strength if applicable) .......................... ... ........... .. Description (appearance of container & contents): Batch number. .... .. ..... ... Expiry date ................... Manufacturing date Manu facturer Sample size (quantity): .... .... .... ...... ... ...... Submission date .... ... .. .... ....... .......... .... . Reason(s) for requesting the analysis 1 SIN I Test requested 1 SIN I Test requested Analysis fees and charges 55 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guide fines for investigation and control offood borne diseases Customer name: ............................. ., .. Signature: ...................... Date: ......... . I accept/reject ta carry out tests specified above Laboratory Director (LD) Remarks (In case of reJect1on) ................................................................ . LD name: ................................................ . Division ............. , ... , .......................... .. Signature ................................................... . Date: ........................................................ . Subcontractin Agreement for sub~contracting work: yes /no (tick as appropriate) lfno give reason(s) ........................................................................................................... . Customer signature ..................... Date ........... . LD signature ................................. . Date ............................................ . Test request amendment/additional test(s) (when applicable) ............................................... . Customer signature ................................ . LO Signature ........................................... . Date ....................................................... . 56 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases

ANNEX IX PROCEDURES AND EQUIPMENT FOR SPECIMEN COLLECTION Clinical specimens General Enclose specimens in a secure container and label the container with a waterproof pen. Place this container in a waterproof bag with tissue, towels or other blotting material to absorb any leakage. Put ail specimen containers in an insulated box packed with ice or frozen refrigerant packs and deliver them to the laboratory as soon as possible. If sending specimens by post or courier ensure that they are delivered during business hours on a weekday. Address the package clearly, including the name and telephone number of the receiving laboratory. Write instructions as appropriate, for example "Medical specimens. Cali addressee on arrivai. Hold refri gerated." Faeces Collect stool specimens as soon as possible, since delay may impede identification of the causative agent. ldeally, swabs of fresh stool or rectal swabs should be collected for bacteriological examination, large volumes of diarrhoeal stool (at least 30g) for viral examination, and fresh bulk stool (with preservative) for parasite examination. Bacteria Collect at least two rectal swabs or swabs of fresh stools (Jess than one hour o ld) from each case: •If possible refrigerate Cary-Blair transport medium in advance, so that the swabs can be placed into a cool medium. • Insert swab into Cary-Blair medium to moisten it. lnsert swab 3-5 cm into rectum and rotate gently. • Remove swab and examine it to ensure that the cotton tipis stained with faeces. lnsert swab immediately into tube of transport medium. • Push the swab to the bottom of the tube. • Repeat procedure with the second swab and place in same tube as the first. Break off top parts of sticks, tighten screw-cap firmly. If specimens will arrive at the laboratory within the 48 hours after collection, 57 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date:13/05/2019 Guidelinesfor im,e!;tigation and wntrol offood borne diseases they can be refrigerated at 4 °C. Pathogens can still be recovered from refrigerated samples up to 7 days after collection, although the yield decreases aftet the first 2 days. During transport, refrigeration for up to 36 hours can be achieved by shipping in a well-insulated box with frozen refrigerant packs or wet ice. If it is impossible for specimens to reach a laboratory within 2 days, they eau be frozen at -20 °C (home-type freezer) although freezing at -70 °C (ultra-low freezer) is preferable. Frozen specimens should be shipped with dry ice, observing the fo11owing precautions: • Protect specimens from direct contact with dry ice, as intense cold can crack the glass tubes. • Protect specimens from carbon dioxide by sealing screw-caps with tape or by sealing tubes in plastic bags. • Ensure that container is at least one-third full of dry ice. Viruses Obtain a large quantity (as much as possible but at least 10 ml) of diarrhoeal stool that has not been mixéd with urine in a clean, dry, leak-proof container. To permit diagnosis of certain viral agents, specimens must be collected during the first 4.8 hours of illness. Immediately refrigerate the specimen at 4 °C (do not freeze) and send as soon as possible to the laboratory. Parasites Obtain fresh bulk-stool that has not been mixed with urine and place in a clean container. Then add preservative solution (10% formai in or 10% polyvinyl alcohol) at a ratio of 1 part stoo\ ta 3 parts preservative. If there is a delay in obtaining the preservatives, refrigerate untreated stool sp·ecimens at 4 °C (do not freeze) for up ta 48 hours. Once preserved, the specimens can be stored and transported at room temperature or refrigerated. Vomitus If the person is still vomiting at the time of the investigation, collect vomîtus. Let the patient vomit directly into a specimen container that has been thoroughly cleaned and boiled in water. Take the specimen directly to the laboratory. If this is not possible refrîgerate (but do not freeze) the specimen. Serurn ln the investigation of food borne disease outbreaks, serological examination is sometimes useful to detect the development of antibodies as a result of infection. Blood should be obtained only by a person legally qualitied to undertake the procedure; check appropriate laws. If possible, obtain blood specimens from the same patients from whom stool samples were obtained. Submit two serum specimen one. acute-phase and one convalescent-phase - for each patient thought ta have illness caused by viruses or bacteria. Obtain the acute phase serum specimen as close to the time of onset of illness as possible (at most, within a week after onset of illness). The convalescent-phase serum specimen should be obtained 3 weeks - or, if a viral agent is suspected, 6 weeks afterthe onset ofillness. 58 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases Collect blood specimens from adults ( 15 ml) and from children (3 ml) in tubesthat do not contain anticoagulants. For antibody studies the specimens need not be refrigerated during the day of the collection (unless the weather is extremely hot) but should be kept out of direct sunlight. Centrifuge the blood and send only the serum for analysis. If no centrifuge is available, store the blood specimens in a refrigerator until a clot has formed; then remove the serum and pipette it into an empty sterile tube. Refrigerate the tubes of spun or unspun serum and ship them refrigerated. Urine Clean the area around the urethral orifice with a pad that has been pre-moistened with a 4% tincture of iodine or other appropriate antiseptic. Begin to urinate into the toilet and collect 30ml of midstream urine. The specimen shou ld be refrigerated but not frozen. Other clinicat specimens (food-handlers) Skin lesions (boils, lesions, abscesses, secretions) • Clean skin with normal saline or weak dis infectant to prevent contamination of the specimen with saprophytic organisms. • Apply pressure to the lesion using steri le gauzes and collect specimen on sterile swab, trying to obtain as much secretion as possible. • If the les ion is closed, disinfect skin and extract specimen us ing sterile syringe.T ransport immediately to laboratory at ambient temperature. If this is not possible, the specimen can be left for up to 24 hours, at which time the swab should be placed in a container of ice. • Oropharynx and nostrils • Collect specimen with a sterile swab and immediately place in transport medium(Stuart''s) . • can Transport immediately to laboratory at ambient temperature. If this is not possible, the specimen be left for up to 24 hours, at which time the swab should be placed in a container of ice. Food and environmental specimens Equ ipment • Sterile sample containers Disposable plastic bags Wide-mouth jars (100-1000 ml) with screw-caps Botties for water samples Foi l or heavy wrapping paper Meta! cans with tightly fitting lids • Sterile and wrapped instruments for sample collection Spoons, scoops, tangue depressors B utcher"skn ife Forceps, tongs, spatu la Drill bits Metal tubes ( 1.25-2.5 cm in diameter, 30-60 cm in length) Pipettes, scissors Moore swabs (compact pads of gauze made of 120 x 15 cm strips, tied in the centre with a long, sturdy twin or wire for samples taken from sewers, drains, pipes, etc.) Sponges • Sterilizing agents 95% ethanol Propane torch 59 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date: 13/05/2019 Guidelines for investigation mu/ comrol offood borne diseases • Refrigerants Refrigerant in plastic bags Heavy-duty plastic bags or bottles that can be filled with water and frozen Heavy-duty plastic bags for ice • Food temperature measurement Bayonet-type thermometers (-20 °c ta 110 °C), between 13 and 20 cm length Bulb thermometer (-20 °C to 110 °C) • General Marking pen (waterproof) Adhesive tap Cotton Peptone or buffered distilled water (5 ml in screw-capped tubes) Electric drill (iffrozen foods to be sampled) Distilled water Insulated chest or polystyrene box General • Collect samples aseptically. Put them into sterile jars or plastic bags ta avoid any cross contamination. • If samples are to be examined for organophosphate pesticides or heavy metals, plastic containers should not be used. Chemicals from the plastic may leach înto the food and interfere with the analysîs. • Obtain samples of approximately 200 grams or 200 ml. • Take packaged foods ta the laboratory in their original containers. Empty containers can be used to identify micro-leaks, or rînsings from these containers can be used to detect pathogens. • Check original packages or containers for code numbers that can be used to identify the place and time of processing. [nclude any unopened packages or cans belonging to the same batch. • Keep ail packages not sent for laboratory examination until the end of the investigation. Refrigerate sampi es of perishable foods at 4 °C until they can be examined. Do not freeze food samples as certain pathogens (e.g. Gram-negative bacteria, vegetative forms of Clostridium per.fringens) die offrapidly when frozenbut foods that were frozen when collected should be kept frozen until ex_amined. • Enrichment broth and dry materials require_ no refrigeration. 60 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases Solid foods or mixture of two foods • Cut or separate out a portion of food, using a sterile knife or other utensil if necessary. • Collect sample aseptically and put into a steri le plastic bag or wide-mouth j ar. • Collect samples from top centre, and elsewhere, as necessary, refri gerate. Liquid food or beverages Stir or shake. Collect sampies using one of the following methods: • Using a sterile utensil, transfer approximately 200 ml into a sterile container; refrigerate • Place a long sterile tube into liquid, cover the open ing with finger. Transfer liq uid to the sterile container; refrigerate. • Dip a Moore swab in the liq uid or into the pipe so that liquid circulates around it. Leave in place for several hours, if possible. Transfer swab to a j ar containing enrichment broth. Refrigeration is not usually necessary. • If the liquid is not too thick, pour 1 to 2 litres through a membrane filter. Transfer the filter pad aseptically to a jar containing enrichment broth. Refrigeration is not usually necessary. Frozen foods Keep frozen, using dry ice as necessary. Transport or ship the spec imen in an insulated container. Use one of the follow ing methods: • Send or take small frozen samples to the laboratory, without thawing or opening. • Break frozen material into pieces using a sterilized hammer and chisel and collect pieces using a sterilized utensil. • Using a large-diameter steri lized drill, drill from one side at the top of the container diagonally through the centre down to the bottom of the opposite side. Repeat on the other side until sufficient material has been collected. Raw meat or poultry Use one of the following methods: • Using a sterile utensil or sterile glove, place poultry carcass or large piece of meat in a large sterile plastic bag. Add 100-300 ml enrichment broth. Remove sample and seal the bag. • Wipe a sterile sponge over a large section of the carcass or piece of meat. Place swab in a jar containing enrichment broth. • Moisten a swab in buffered distilled water or 0. 1% peptone water. Wipe the swab over a large section of the carcass or piece of meat. Place swab in enrichment broth. • Using a sterile g love wipe the carcass or the piece of meat with sterile gauze pads and place the pads in a jar containing enrichment broth. • Aseptically eut a piece of meat or skin from different parts of the carcass or large piece of meat, or remove part of the carcass. Place at least 200g of sample in a sterile plastic bag or glass jar; refrigerate. Dried foods • Insert a sterile hollow tube near one edge at the top of the container d iagonally through the 61 Doc. No. : DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date:13/05/2019 Guidelines for im!estigation und con.trot offood borne diseases centre down to the bottom of the opposite side. • Keep the top part of the sample and transfer to sterile container. • Repeat the procedure on the other side of the container until a sufficiently large sample has been collected. • Alternatively, use sterile spoon, spatula, tangue depressor or similar utensil to collect sarnple. Transfer to sterile jar. • Keep in water- and airtight container. Scrapings from food equipment, pipes, filters etc. • Cut or collect sufficient amount ofmaterial with a sterile tangue depressor, spatula, spoon or similar utensil and place in sterile bags or wide-mouth jars. • Refrigerate as required (depending on materia!, see above). Environmental swabs • Moisten swab with 0.1 % peptone water or buffered distilled water and wipe over contact surfaces ofequipment or environmental surfaces. Place in enrichment broth. •Air: Touch plate or liquid with the device for sampling air, or let airborne particles settle on broth or agar plates obtained from microbiology \aboratory. Sea] with insulation tape. Refrigerate liquid samples. • Water: Collect water from suspected areas~ including from bottles in refrigerators, ice cubes, basins, etc. When taking water from a tap, let the water run for 10 seconds before collecting the sample. Ta sample water that has not been standing in proximal pipes, let water run for 5 minutes. Place sterile jar under running water and let it fill to 2.5 cm from the top. Collect 1-5 litres. Alternatively, membrane filters can be used. Moore swabs may be used to colkct water samples from streams or plumbing; they should be left in place for up ta 48 hours and then transferred ta sterilejars containing enrichment broth. Specimen collection for suspected chemical toxicants •Avoid contamination at ail cost. • Refrigerate or freeze specimens as rapidly às possible. • Used only screened collection material if possible. This material has been tested for extraneous contaminants, and is specially washed and packaged. If unscreened material is used, randomly select at least three of each of the containers being used (collection cup, vacutainer, etc), seal them in a clean bag and submit them with the other samples to the laboratory. This may allow evaluation of possible extraneous contaminants from the collection material at hand. • Urine is the preferred specimen if the suspected toxicant is an inorganic chernical (e.g. lead, arsenic, mercury). Urine should also be collected if the toxicant is unknown.Freeze promptly. 62 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and control of.food borne diseases Suspected toxicant Preferred specimen Adults and children >10 (in decreasing order) years (children < JO vears) Organic Serum Two(one) 10-ml s ilicon-free vacutainers; freeze Urine 50-100ml(25-50ml) prescreened collection cup;store in wheaton glass bottle, freeze Wholeblood(usuallyheparinised) One- two(one) 10mltubes;Refrigerate fnorganic Urine 50- 100ml (25-50ml) in prescreened collection cup;(no preservative if frozen promptly Whole b lood (usually with One2-3-ml pre-screened container; EDTA) Serum refrigerate.One 7ml trace e lements vacutainer; freeze Unknown Serum Three (one 0 10-ml s ilicon free vacutainers; Urine 50- l 00ml Prescreened collection cup; store m wheaton glass bottle, freeze. Whole blood (usually One 3-ml rescreened EDTA) container; refrigerate Whole b lood(heparin) One 7-10-ml (5-ml) heparin vacutainer; Tissues, stomach content 10-50g, no preservatives; seal in smal l zip-lock bag, freeze Food As much as possible, place in large ziplock bag, freeze 63 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:1 3/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and control offood borne diseases DIS/FOM/027

ANNEX X: OUTBREAK SUMMARY SHEET ,k • ~. ~ ,-. , , ~j f ' , ~ 1 - 1 1 - ,1 '~ RWANDAFDA Rwanda Food and Drugs Authon!} (This form is to be fi lled by the investigation team at the conclusion of the control operations). Facility: ---------------------------- District: --------------------------- Province: --------- Date: ------------------------------------ 1. Outbreak Code N um ber---------------------------------------------------------------------------- 2. Local ity/ Area where it Occurred ------------------------------------------------------------------- 3. Dates of commencement and End of the outbreak---------------------------------------------- 4. Confirmed aetio logical agent(s) involved ---------------------------------------------------------- 5. Confirmed veh icle of transmission----------------------------------------------------------------- 6. Source of infection/conta mi nation--- -------------------------------------------------------------- 7. Method of confirmation used = Laboratory/ epidemiological or both (Delete appropriately) ------ 8. Cases and deaths recorded by age and sex Cases Deaths Age Males Females Males Females 0 -1 yrs 1-5 yrs 5- 10 yrs 10-25 yrs 25-45 yrs 45 yrs TOTAL 64 Doc. No.: DIS/GDU004 Revision Date:06/05/201 9 Review Due Date:13/05/2022 Revis ion No.:0 Effective Date: 13/05/2019 Guidelinesfor investigation and control o.ffood borne tliseases 9. APPL!ED CONTROL MEASURE(S) THOUGHT TO BE MOST EFFECTIVE IN ARRESTING THE OUTBREAK. ---------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- 10. Any other remarks from the investigation team. (Use extra sheet ifspace provid!;!d is inadequate). -------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- Names and Signatures of the Investigator (s) Name Signature Date Address 65 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:O Effective Date: 13/05/2019 Guidelines for investigation and control offo od borne diseases DIS/FMT/026

ANNEX XI :INVESTIGATION REPORT FORMAT Outline of an outbreak investigation report Cover page • Title of report lndicate whether this is a pre liminary or a final report. Keep the title short and memorable, but include information on the type of problem under investigation, the location and date. • Date of report •Names and affiliations of the main authors and investigators Abstract The abstract should be written after the report has been completed. lt shou ld stand alone and contain the most relevant data and conclusions. Ali data mentioned in the abstract must also appear in the main section of the report. Sentences from the Discussion section can be used verbatim in the abstract. Report • Introduction Statement of the problem and its public health importance. Details and time frame regarding initial source of information. Reasons for investigating event. Type of investigations conducted and agencies involved. • Background Generally available information to help the reader interpret epidemiology and data presented in the report (e.g. population size, socioeconomic status of community, ethn icity, etc.) If outbreak occurred in a food premises, description ofpremises (e.g. s ize of restaurant, usual practices and operations, etc.). 66 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 11 Guidelinesfor investigation and comrol offood borne diseases Description 6fthe problern. Sequence of events leading to the study or invest-igation.Brief statement of the working hypothesis. •Objectives Specify targets to be achieved by the investigations. Keep objectives concise and follow a logical, sequentialpattern. The objectives rnay includehypotheses, if any, to be tested.Methods Epidemiology: - description ofstudy population - type of study conducted - case definition - procedutes for case-ascertainrnent and select ion of contro!s (if any) - methods of data collection, including questionnaire design, administration and contents - rnethods of data analysis. Medical laboratory testing: - methods of specirnen collection and processing - name of laboratory carrying out tests - laboratory techniques ernployed and methods of data analysis. Food and food testing: - description of inspection process - methods of food and environmental sampling - narne of laboratory carrying out tests - laboratory techniques ernployed and methods of data analysis. Results Present ail pertinent results from clinical, laboratory, epidemiological and environmental findings. Present results in same order as described in the methods section. Do not interpret or discuss the data in this section. Epidemiology: - number of cases, overall attack rate - clinical details ofi\lness (symptoms, duration, hospitalization, outcome, etc.) - descriptive epidemiology by time (epidemic curve), place, and person (age, sex, race, specific characteristics) expressed as rates - risk factor exposures - further data analysis and data presentation depending on specific studies undertaken (e.g. cohort or case-contrai study). Laboratory (microbiology, chemical, toxicologica!): -nurnber ofspecirnens collected - findings by type of laboratory analysis. Food investigation and food testing: - findings of food inspections 67 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Guhlelines for investigation and coll/roi of.food borne diseases - results of laboratory tests performed on food and environmental samples. Discussion The discussion is the most important part of the report and should caver: - summary of the major findings - likely accuracy of the results - conclusions withjustificatîon for those conclusion and rejection of alternative explanations - relationship ofthese results to other studies and the literature - implications of the findings - an assessment of contrai measures - needs for future research. Recommendations Initial recommendations and those for future prevention and contrai should be listed numerically. Appendices Questionnaires and/or other survey forms Appropriate field reports Any other relevant documents, including press releases. References Select appropriate references, including reviews in major -scientific journals. Fôllow a standard style of referencing (e.g. Vancouve_r style), numbering the references in the order in which they appear in the text. 68 Doc. No.: DIS/GDL/004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date: 13/05/2019 Guidelines for investigation and control offood borne diseases --- ·- ANNEX _.,,____ ,,.., ___ -- --- E ·--- -XII Attack ----- f -------- Rate - Tabl, ---- Type of Group A Group B Relative Food Persons who ate specified Persons who did not eat Risk Food specified food Ill Not Total Attack rate % ill Not Total Attack rate % ill ill ~ Baked beans Spinach 32 24 20 15 52 39 62 62 19 18 14 10 33 28 58 64 1.07 0.97 Cooked 20 11 31 65 20 11 31 65 1.00 potato Cabbage 15 11 26 58 25 16 41 61 0.95 Bread 20 12 32 63 30 22 52 58 1.09 Milk 4 4 8 50 46 29 75 61 0.82 Coffee 20 13 33 61 28 18 46 61 1.00 55 32 17 49 65 0.85 ffe Water Cakes (ce cream 12 30 45 10 16 13 22 46 58 65 78 21 5 18 20 39 25 54 20 1.20 3.90 Juice 5 2 7 71 38 9 61 62 1.15 To compute the attack rate in percentage divide the number who became ill by the number who ate the food item and multiply by 100. ( ln the above example the attack rate for milk was (4/8) x 100 = 50%). The suspect food will show the greatest difference between the two attack rate percentages. The suspect food shou ld have a highest attack rate in group A and the lowest attack rate in group B. For example, in the table above, the attack rate for persons who ate ice cream (suspect food) was 78% white the attack rate for persons who did not eat ice cream was 20%. The disparity between the persons in the group A and group B is the important point for consideration. To compute the relative risk divide the attack rate of people who ate specified food and fell sick by the attack rate of people who did not eat the specified food and fell sick. For example for ice cream 78%/20% = 3.9 -69 , Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No.:0 Effective Date: 13/05/2019 Gui<lelines f or i11vestig{lfion and control offood borne diseases DIS/FMT/027

ANNEX XIII FOOD BORNE DISEASES REGISTER If ,Si ,,.,, ~ ~. ~. ' -'ï'..'- 11~s w i RWANDAFDA Rwanda Food and Drugs Authority Name of Facility : ............................... ........ ... ....... ....... . District:... ... ..... ................ ........................... .... .......... . Province: .................................... ................ .. ............... . ID Date (dd/mm/yy) Pârticalan of the nattent Name Locallty Oinical diagnosls Age Sex Sector Street/village Majorsigns Saspeeted laboratory TMtl■a Speeimen Result - Remarks ~ and Disease symotoms ~ 70- . Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019 Guidelines for investigation and control <>.ffood borne diseases DIS/FOM/028

ANNEX XIV: FOOD BORNE DISEASES REPORT FORM ,k ...., • ,, ~ ,, 1 .~ ' ~ " ~ 1I' - - 11 \ ~, -v I RWANDAFDA Rll.nda Food and Drop;, Authority Health Facility: ... . ............ ... .. .. . . ... .. .. District: ........ .. . .. .. ... .. . .. . .. .. ....... ... Province: .... ... ..... .... ......... ..... . .. ,* "l1J ; <I> ~ ~ 1 1:: 1 Number of Cases Deaths by a2e and sex .... 1 1 "O E ~ 0 • 0 C1,j c:.i V, "O 0 <I> ~ ; ; ·- l. = r.,; <I> r.,, ,_ Male Female Male Female ~ ~ l. : <I> 0 ,.,, 0 <I> ( Cl> .~ "O -=~ "O ( C ~ V, .:= <I> ·"O<I>- ....= "O ._ .... Cl> ~ c:.i .:!; .... ' <I> -"t .... C1,j V, 0 V, V, l. >, V, l. >, V, V, l. V, l. ..... l. V, ..... V, V, l. V, l. >, V, l. ..... V, V, l. V, l. >, "' l. ..... ·- .. = .... ._-= ~ ~ 01) .... V, l. ..... 0..... If) el) 0 -~ ~ V, ' ~ (J : ~ l . .Q ~ ~ <I> Q., ..... 0>, If) 1,, ..,. If) V, 1,, 1,, If) -o:r "' 1,, ..... 1,, ..... 0>, If) If) ~ ..... 0>, MIf) If) 1,, -o:r V, 1,. Cl> Q., ë.= (J ~ - ( Q., ... c:.i l. .... <I> e>, • M >. If) If) M 1 1 If) ~ M 1 ~ 1 If) ~ 1 1 >, = u - =-' -,( .5 If) If) ~ 1 1 ~ If) If) >, ~ ~ ~ 0.. ·- f .... (J -,( 0 00 ., ,..!_ ~ 1 1 If) 0 ~ ~ ~ ,..!_ ~ 1 1 tri 0 ~ ~ ~ ,..!_ ,-; 1 .:.. 0 ~ If) M ~ ,..!_ 1 ,-; .:.. 0,-; N If) tri ~ 2 3 4 5 TOTAL *Control measures taken Preferred age groups: 0-5, 1-5 yrs, 5-10 yrs, 10-25 yrs, 25-45 yrs, 45 yrs ~ 71 Doc. No.: DIS/GDU004 Revision Date:06/05/2019 Review Due Date:13/05/2022 Revision No. :0 Effective Date: 13/05/2019 Guidelines for investigation mut control of f ood borne diseases Author Authorised by Approved by Title Division Manager of Head of Food and Drugs Director General Pharmacovigi lance & Food Inspection & Safety Safety Monitoring Monitoring Department Name JJ1!l<.~AX,M#-L4W-GI I)~ ~ (S~ ~ 4 1 /Jy-UC<t k lx.a.tif')~ . Atr~. ~ 1 auJ-..·. \ Signature 1 / 1 1 • ~ 1 J > ..g;\\"I'"'= = ~ - -· Date ) :ilo;-Jte> .r ; 13 (oÇ / ~,cr 11 J0S ( 2,,ot CJ 72 Doc. No.: D1S/GDU004 Revision Date:06/05/2019 Review Due Date: 13/05/2022 Revision No. :0 Effective Date:13/05/2019