Role Selection Page After entering his or her username and by panniuniu

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                        The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

1. Role Selection Page                               Doctor Role – Image X
                                                     Text below doctor image:
     After entering his or her username and          As a doctor, your principal duty is to diagnose and
     password on the portal /login page, learner     treat your patients. However, you also have a duty
     enters the role selection page                  to the public when you suspect an illness
                                                     outbreak.
     Page opens with heading visible, “The
     Foodborne Investigations.” Thumbnails of        As a part of the investigative team your duties are
     the role images for each of the four roles      to:
     the student will play should be visible on       Provide clinical information and diagnosis for
     the page.                                           patients
                                                      Report diseases/outbreaks to the local or state
Learner needs to be able to select next role             health department
when he/she enters the course if learner has          Assist in collecting clinical specimens for
completed other roles. If learners do not                laboratory testing
complete a role in one sitting, they should be
able to reenter that role without going through
everything again. Is that possible? Alternatively,   Epidemiologist Role—Image
is it too time consuming? If it is, we can tell      Text below CDC epidemiologist image:
them that they have completed a role in one          As a CDC epidemiologist, you study health
sitting or begin from the beginning.                 conditions or events within a specific population.
                                                     You look at the distribution of such events and use
Continue button appears. Clicking continue           the information you gather to control health
would take the learner to opening page for           problems.
doctor role or the opening page for whatever
other role they have available to them because       Although you personally have assignments within
they have completed the previous role.               this investigation, remember that teamwork is
                                                     essential. As a part of this investigative team, your
Text for other three roles will be added as          duties include:
developed.                                                 Providing technical, statistical, and overall
                                                              support to an outbreak investigation
                                                           Helping to determine the “genetic
                                                              fingerprint” of the bacteria causing this
                                                              outbreak
                                                           Helping to establish a case definition for
                                                              the outbreak


                                                     Investigator role—Image
                                                     Text for CDC Field Investigator
                                                     As an investigator for the Centers for Disease
                                                     Control and Prevention, you and the other
                                                     members of your investigative team are disease
                                                     detectives. Your principal duty is to gather and
                                                     compile field data to complement laboratory data
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                           The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                     to aid in investigation of health conditions and
                                                     events. Your goal is to help control health
                                                     problems.

                                                     Although you have individual assignments within
                                                     this investigation, remember that teamwork is
                                                     essential. As a part of this investigative team, your
                                                     duties include:
                                                           Assisting in tracing back the identified
                                                              illness to help discover the mode of
                                                              transmission
                                                           Conducting a case control study to match
                                                              reported cases with the established case
                                                              definition
                                                           Collecting food samples to aid the
                                                              formulation of a hypothesis
                                                           Helping to generate a hypothesis
                                                              identifying the mode of transmission
                                                              involved in the outbreak


                                                     USDA role—Image
                                                     Text for USDA Investigator
                                                     As an investigator for the United States
                                                     Department of Agriculture, your principal duty is
                                                     to investigate illness outbreaks and endeavor to
                                                     find the cause of the contamination in the food
                                                     production process.

                                                     Although you personally have assignments within
                                                     this investigation, remember that teamwork is
                                                     essential. As part of the investigative team for this
                                                     outbreak, your duties include:
                                                           Tracing back to discover the specific site
                                                              where the contamination occurred that
                                                              caused the outbreak
                                                           Helping to rule out intentional
                                                              contamination
                                                           Conducting a Hazards Analysis Critical
                                                              Control Points (HACCP) investigation
                                                           Assisting in implementing control and
                                                              prevention measures



Investigation, Phase III
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                           The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 1 Role Set Up CDC Field Investigator
Screen is set up with two sections. The left hand section is the role column, and the right hand section is
the content section. Top of the page includes the Activity Bar that allows the student to choose action,
with icons corresponding to the scientific method:
     Face—Interview—This links to field interviews
     Page and envelope—Media—This links to articles, web sites, and material specific to this phase
         of the investigation
     Light bulb—Hypothesis—In this part of the course, could be an interaction that lets the learner
         see a hypothesis with blanks to fill in, and lists of possible items to fill in the blanks (for example
         a statement such as “The food responsible for the outbreak might be ____.” Then the list of
         answers could include all foods mentioned by ill people, including soft-boiled eggs, hotdogs, and
         potato salad.
     Beaker—Laboratory work—In this part of the course, this links to case definition.
     Clip board—View reports—This links the learner to case histories
     Communication device—Communicate—This provides information from colleagues or other
         information specific to this phase of the investigation
Icons are dimmed when they aren’t useful to a given page
Role Section                                               Content Area
Left section of the screen shows role student is           Video Recording
playing in this phase of the investigation: Field          Mashonda is sitting at desk. She is reviewing her
Investigator Role—thumbnail of field investigator          recent conversation with John and Tasha. She is
                                                           just speaking as if to the student audience. At the
You are Mashonda Wise, a field investigator for            end of the video, she gets up from the desk and
the Centers for Disease Control and Prevention             leaves her office or the video just fades out.
(CDC). You are working with a team that includes
Lanni Pierce, a newly hired CDC epidemiologist, as I just got my next assignment from my team
well as CDC microbiologist Lief Turner, Tim Simons, leader, John. He called me into his office to tell me
public relations officer, and other colleagues to try that he had decided to send me into the field -- to
to halt what appears to be a national outbreak of          Valley Verde. I’ll be working with K.C. Nolan in
foodborne illness and to prevent its recurrence.           Valley Verde. K.C. heads the local health
Your team leader, John Reams, is sending you to            department. K.C. is an old friend of John’s, and
collect field data to complement ongoing                   John thinks he will be a good local contact. John
laboratory work. You’re part of multiple efforts to        said K.C. told him that there’s an especially high
generate a hypothesis to explain the mode of               level of upset locally because of several
transmission of this outbreak and halt its deadly          mortalities—infant and elderly.
progress.
                                                           Tim Simons, the public relations officer, was also
                                                           at the meeting. He confirmed that the local media
                                                           had jumped on the disease uptick and deaths, and
                                                           were speculating about causes. Tim said that the
                                                           atmosphere is very defensive at this time -- in the
                                                           health care community and pretty much in
                                                           general. Tim warned me that I was going to run
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                          into some fears and hostilities and probably hear
                          some unfounded accusations.

                          They both reassured me that they were confident
                          that I could handle the situation. They said they
                          were counting on me to stay calm and on task, and
                          to exhibit a level of professionalism that will help
                          relieve some of the fears.

                          John said my job was to dig deeper into the
                          outbreak and to give the team the data to develop
                          our hypothesis about the origin of the pathogen
                          and the mode of transmission.

                          I will have to ask the right questions and talk to the
                          right people. Unfortunately, not all of them will
                          want to talk to me. Moreover, they might not be
                          able to tell me everything I need to know.

                          I guess all I can do is my best. At least my work
                          with Lanni thus far has helped me be well
                          grounded in the facts about the illness and the
                          cases we’ve encountered so far. However, I will
                          have to do further research to get prepared for
                          this phase of the investigation.

                          Oh, John and Tasha both assured me that they
                          would share new information collected here at the
                          CDC while I am in Valley Verde.

                          I had better get with Chris so he can make my
                          travel arrangements.

                          The continue button appears when the video
                          ends and takes student to page 2.
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 2 Investigation Set up
Role Section                                          Content Area
Image of Mashonda                                     Video
                                                      Mashonda has arrived at Valley Verde. She should
You have arrived at Valley Verde to begin your        be sitting at a desk or table. Some papers should
work as a CDC Field Investigator. In this role, you   be visible. She is again talking to the audience (the
will be working with K.C. Nolan from the local        students) about her arrival in Valley Verde and her
health department. He will be providing you with      meeting with K.C. Nolan.
assistance in conducting in-depth interviews with
individuals in the community.                         I made it. I am in Valley Verde and have had my
                                                      first meeting with K.C. Nolan, my contact at the
                                                      local health department.

                                                      K.C. told me that they have quite a situation in in
                                                      Valley Verde – people are sick and some have died.
                                                      So far, we haven’t been able to figure out the
                                                      common element beyond many having a particular
                                                      strain of listeriosis.

                                                      It is my job to help them get a handle on things
                                                      and identify the mode of transmission.

                                                      Mashonda picks up newspaper or clipping from a
                                                      newspaper. I have just been reading the story in
                                                      the local paper last week about the water supply.
                                                      K.C. said a TV station did an exposé about a petting
                                                      zoo. Of course, that’s got everyone very stirred up
                                                      -- most likely about the wrong things.

                                                      K.C. is hoping that bringing me in from the CDC
                                                      might help them get out the word that this isn’t a
                                                      problem with local water, or one person touching
                                                      one llama, or some incident like that. He thinks it’s
                                                      clearly something in the food supply -- something
                                                      available in multiple states.

                                                      Okay, I have to accomplish three major tasks –
                                                      conduct field interviews, collect samples, and
                                                      develop a case control study -- before I can analyze
                                                      the data and formulate a specific hypothesis. Let’s
                                                      see – I think I will start with the field interviews.
                                                      However before I begin the interviews, I need to
                                                      confer with Lanni.

                                                      When video ends continue button appears and
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                          takes learner to page 3.
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                           The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 3 Investigation Set up second part
Role Section                                           Content Section
Image of Mashonda                                      Video Recording
                                                       Mashonda is on mobile phone in hallway. She is
Mashonda, you need to talk with Lanni Pierce, the      talking with Lanni. We hear only Mashonda’s side
CDC epidemiologist you have been working with.         of the conversation.
She will help you decide whom to interview in
Valley Verde and what other information is              Good afternoon, Lanni. Thank you for doing some
available to you. The field interviews will help you   case findings for me and for keeping an eye on the
get information needed for you to figure out           surveillance reports coming in, and of course
what’s causing the outbreak and how it’s               jumping on anything from PulseNet.
spreading.                                             Pause as if listening.
                                                       You have a new contact for me–Chase Weal at the
Note From Chase Weal, State Department of              State Department of Health?
Health (Set up link to pop up, clicking on this link   Pause as if listening.
takes leaner to a popup of the following)              Oh, he is the one who first reported to PulseNet
                                                       for the state. In addition, he has encouraged the
MEMO FROM CHASE: Good luck with your                   clinical personnel and the labs to report cases as
interviews. Be aware that the responses you’ll get     quickly as possible—as soon as they suspect the
will be based on the memories of people who            diagnosis. Did you say he put out a call for
were ill. They might not recall in detail what they    emergency room records of similar illnesses?
ate at a given time—and they might not know all        Pause as if listening.
the ingredients of the foods they do remember
eating. It has taken us two to three weeks to          Sounds like he will be a great contact for me. I’m
establish that each of these people is part of the     glad he is asking everyone in the surrounding areas
national listeriosis outbreak, afflicted with the      to watch for related illnesses.
same strain. Field interviews can be a chore.
(That’s why I stay in the lab!) They might be          I will work with Chase to identify local groups that
particularly hard here because of the atmosphere       seem to have been exposed, and then survey
created by media scare stories. I know you will do     representatives from those groups. Lanni, I have
your best. If I can be of assistance, don’t hesitate   already made up a list of people that I may need to
to call.                                               talk to – I will share the list with Chase.

The following icons should be visible.                 K.C. Nolan said the local health staffers will also do
the face icon takes learner to field interviews        interviews – I am so relieved that I will not have to
(page 3a)                                              talk to everyone myself.
the beaker[takes learner to case definition] (page
3b)                                                    Thanks for the information Lanni. I will check out
the Clipboard [takes learner to case histories for     the note from Chase you are sending me, review
Emma Wong and Helen Mansfield from first role.]        the case definition again, and check over some of
(page 3c)                                              the earliest reports from Dr. Diggs.
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                           The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a Field Interviews (clicking on interview icon takes learner to this page)
Learner can select individuals to interview.

Role Section                   Content Section
Image of Mashonda              Click on the individuals to wish to interview.

As the CDC investigator,        Rosa Guerra, 23          Dave Cho, 57              Dana Halgren, 61
you are getting ready to        four months pregnant      HIV positive             grandmother
conduct field interviews.       at onset of illness      (clicking here takes      (clicking here takes
You will have access to Dr.     (clicking here takes     learner to page 3a6)      learner to page 3a11)
Digg’s case notes on Helen      learner to page 3a1)
Mansfield and Emma              Emma Wong, 29            Helen Mansfield, 76       William Caulfield, 59
Wong while you are              eighteen weeks           bike rider                cancer survivor
conducting field                pregnant at onset of     (clicking here takes      (clicking here takes
interviews with them.           illness                  learner to page 3a7)      learner to page 3a12)
                                (clicking here takes
Before starting, you            learner to page 3a2)
developed a chart of the        Natalie Tompkins, 35     Della Boucher, 63         Hector Martinez, 66
individuals you wish to         two months pregnant      volunteer                 heart transplant
consider for interviews.        at onset of illness;     (clicking here takes      (clicking here takes
You sorted them into            miscarriage              learner to page 3a8)      learner to page 3a13)
categories to help you          (clicking here takes
decide whom to talk to.         learner to page 3a3)
You have even color-            Barbara Dixon, 25        Dr. Pat Mallory, 60       Evan Buchanan, 67
coded the categories.           eight months             physician, diabetic       widower
                                pregnant at onset of     (clicking here takes      (clicking here takes
In your interviews, you will    illness (clicking here   learner to page 3a9)      learner to page 3a14)
want to note food items         takes learner to page
eaten by the patient as         3a4)
well as check out any case      Aida Watkins, 49         Gunther Gillis, 63        Alyssa Tyson, 11
notes available to you.         mother of three,         veteran                   juvenile diabetes
                                asthmatic                (clicking here takes       (clicking here takes
                                (clicking here takes     learner to page 3a10)     learner to page 3a15)
                                learner to page 3a5)

                               Legend:
                               purple = women who were pregnant
                               green = senior citizens (over 60)
                               blue = individuals with compromised immune systems
                               white = individuals with multiple issues
                                                                                                    9
                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a1 Individual Field (clicking on Rosa Guerra in chart on page 3a takes learner to this page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally
Thanks for agreeing to let       in Role 1. Something like the following
me interview you. I’m
Mashonda Wise of the CDC,
and I’ve come to Valley
Verde to try to help figure
out what is causing this
outbreak of listeriosis. With
your cooperation, we can
generate a hypothesis to get
at the source and control
the outbreak. Thanks for
marking the food list to
show me some of the foods
you ate prior to your illness.
I have your case notes. Now,
I have some additional
questions for you.


                                 Image of Rosa with the following caption
                                 Rosa Guerra, 23
                                 four months pregnant at onset of illness

                                 Select the questions you wish to ask by clicking on each question.
                                  How are you feeling today?        Very pregnant! But that’s a good
                                                                    feeling. I was so scared that I
                                                                    would lose the baby. You gotta
                                                                    figure out what’s going on. I
                                                                    don’t want anybody else to go
                                                                    through what I did.

                                  I would like to know about the   Wow, I don’t know if I can give
                                  meals you ate in the days        you the exact details. I mean, it’s
                                  before you got sick. It would    been awhile, and to tell you the
                                  be great if you could describe   truth, since I’ve been pregnant,
                                  each one.                        when I get hungry I sort of reach
                                                                   for whatever is handy, even
                                                                   stuff I wouldn’t normally eat,
                                                                   especially if I’m away from
                                                                   home. They did ask me about
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                      meals at the time I got sick.
                                      Normally, for breakfast I have
                                      something like a toaster pastry
                                      or a bagel and some decaf
                                      coffee. If I snack, it might be, I
                                      don’t know, maybe a donut or
                                      something. For lunch, I’ll have
                                      like a sandwich and chips—
                                      peanut butter or lunchmeat,
                                      that kind of thing. For supper we
                                      have just a whole mix of stuff—
                                      chicken—which I cook myself so
                                      I can make sure it is completed
                                      cooked—or you know, beef
                                      dishes, like casseroles. Tommy
                                      doesn’t like seafood. I don’t do
                                      much else. We’ll have hot dogs
                                      or turkey dogs occasionally with
                                      beans. I make traditional
                                      Mexican food. I like it spicy.
                                      Usually I use soft cheeses, like
                                      on your list, but I read they can
                                      be bad for pregnant women, so
                                      I’m skipping them for now. I’m
                                      pretty good in the kitchen. I
                                      make great salads. I love
                                      desserts, especially ice cream—
                                      any flavor, any topping.

      Tell me about your food         I try to watch our budget. In this
      shopping habits.                town, we’ve got three main
                                      choices. Wellman’s for the
                                      gourmets. I don’t go there
                                      unless it’s like a special recipe.
                                      Keefer’s I don’t go to as much as
                                      Walmer’s—I mean, they have
                                      everything there. It at least
                                      saves time. I do most of my food
                                      shopping at Walmer’s, but if it’s
                                      too crazy busy there, sometimes
                                      I just go to Keefer’s and pay a
                                      little more. Or if we’re really
                                      desperate and Tommy doesn’t
                                      feel like the drive, he goes to the
                                      convenience store, the Gas-n-
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                More near us.

                               Had you done any traveling in    We drove to Iowa to meet
                               the month before you got sick?   Tommy’s folks at the Amana
                                                                colonies in the middle of June.
                                                                Sort of a day trip. We ate fast
                                                                food and did a lot of walking.
                                                                Oh, and July 4 we went to a
                                                                fireworks show with my cousins.
                                                                They made us a picnic supper
                                                                before the show—backyard grill
                                                                type thing.

                               How often do you eat out, and    We don’t do restaurants so
                               where do you go when you         much. Too pricey. We get fast
                               do?                              food, though. Tommy likes the
                                                                Biggie Burger place. I like fish—
                                                                the filet sandwiches and that
                                                                kind of thing. Once in a while we
                                                                go to one of the family buffet-
                                                                type places, so we can get what
                                                                we like.

                               In the month before you got      Well, there was that Fourth of
                               sick, had you attended any       July backyard party and the
                               events where food was            fireworks. I had kind of a hard
                               served?                          time figuring out what to eat
                                                                there. The burgers didn’t smell
                                                                good to me—I figured it was a
                                                                pregnancy thing. They were
                                                                grilling shrimp, too, and that
                                                                looked really nasty. They had
                                                                some sandwich stuff, some
                                                                potato salad, hot dogs, deviled
                                                                eggs, and stuff like that. I did eat
                                                                that stuff. I can’t think of any
                                                                other events.

                              Read case notes (should go to pop up1)
                              View food list (should go to pop up2)


1
 Case Notes for pop up
Rosa Guerra
Date of onset: July 12
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Case notes: pregnant for the first time; illness at start of second trimester; admitted to Jackson County
Medical Center by her OB/GYN July 14; successfully treated and released; pregnancy is progressing
normally

2
 Food List for pop up
Rosa Guerra highlighted the following items as food she consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
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                             The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a2 Individual Field (clicking on Emma Wong in chart on page 3a takes learner to this page)

Role Selection                Content Area
Image of Mashonda
                              Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to        Role 1. Something like the following
let me interview you.
I’m Mashonda Wise of
the CDC, and I’ve come
to Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis
to get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness.
I have your case notes.
Now, I have some
additional questions for
you.
                              Image of Emma with the following caption
                              Emma Wong, 29
                              18 weeks pregnant at onset of illness

                              Select the questions you wish to ask by clicking on each question.

                               Ms. Wong, please know how sorry I     It’s important. I know. I’m okay. I
                               am about the loss of your baby.       want to help. Ask what you need to.
                               This must be a very difficult time.
                               Are you okay with talking to me?

                               I would like to know about the        My OB gave me diet guidelines, and
                               meals you ate in the days before      I tried to follow them. I’ve thought
                               you got sick. It would be great if    about this all so much since. I think,
                               you could describe each one.          for the most part, I was eating really
                                                                     well. I’d have, like, soft-boiled eggs
                                                                     with toast for breakfast and
                                                                     sometimes for lunch, too. I had kind
                                                                     of a weakness for deli sandwiches
                                                                     from the Gas-N-More. For dinners,
                                                                        14
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                      I’d make pasta salad with beef or
                                      shrimp. It was getting to be warm,
                                      so I didn’t do big roasts of
                                      anything—tried to keep it light but
                                      nutrient dense, you know. Salad but
                                      with beans and protein and that
                                      kind of thing. I’d give in and have ice
                                      cream every once in a while. I
                                      probably had it three or four times
                                      before I got sick.

  Tell me about your food shopping    I’m totally addicted to Keefer’s, I
  habits.                             admit it. They have a saver’s card I
                                      love. You get the good food but at
                                      Walmer’s prices. Wellman’s has the
                                      best meats, seafoods, and veggies,
                                      so for a special dinner I might pick
                                      up a few things there.
  Had you done any traveling in the   No, not recently. We had traveled to
  month before you got sick?          New York back in March for our
                                      anniversary.
  How often do you eat out, and       Valley Verde is not real big on the
  where do you go when you do?        type of restaurants Ben and I like,
                                      and we’re not into fast food for the
                                      most part. My brother and his wife
                                      like that one chain restaurant that
                                      serves the “Italian” food. I usually
                                      order a dinner salad and tell them I
                                      had a really big lunch. A few times,
                                      we’ve driven to to the city and tried
                                      some restaurants there, but we
                                      didn’t really do that once I was
                                      pregnant. I eat at the corner store
                                      deli, if you consider that eating
                                      out—like a bagel or a veggie hoagie
                                      or a turkey hoagie.

  In the month before you got sick,   Not really. Not like, big public
  had you attended any events         events. The weekend of the Fourth
  where food was served?              of July, there was some baseball
                                      game on, and my brother and his
                                      wife had us over to watch. She did a
                                      “theme” spread with all this type of
                                      food you’d get at a ballpark—way
                                      more food than the four of us could
                                                                                                15
                        The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                   eat. The weird thing on my part was
                                                                   that for some reason I was just
                                                                   hungry for all of it—the mini
                                                                   burgers, the weenies, the chip and
                                                                   dip stuff, hot dogs wrapped in
                                                                   biscuits, sausage pizza—even burnt-
                                                                   black chicken wings!

                          Read case notes (should go to pop up1)
                          View food list (should go to pop up2)


1
 Case Notes for pop up
Emma Wong, 29
Date of onset: July 7
Case notes: 18 weeks pregnant at onset of illness; experienced symptoms following onset and finally
saw GP July 26; admitted to Jackson County Medical Center same day; suffered perinatal infection,
spontaneous abortion; in counseling for loss of child

2
 Food List for pop up
Emma Wong highlighted the following items as food she consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American white cheeses)
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       16
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 3a3 Individual Field Interview (clicking on Natalie Tompkins in chart on page 3a takes learner to this
page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of Natalie with the following caption
                                 Natalie Tompkins, 35
                                 two months pregnant at onset of illness; miscarriage

                                 Select the questions you wish to ask by clicking on each question.

                                  Ms. Tompkins, I understand this       When Dr. Diggs contacted me about
                                  illness caused you to experience a    talking with you, I admit I was
                                  miscarriage. I’m so sorry. How are    reluctant. A lot of that period is
                                  you doing now?                        hard to think about. Well, that
                                                                        doesn’t matter. The point is I want
                                                                        to help you. So ask me what you
                                                                        need to.

                                  I would like to know about the        This might surprise you, but I kept a
                                  meals you ate in the days before      journal. I wrote down everything I
                                  you got sick. It would be great if    did, everything I thought, everything
                                  you could describe each one.          I ate. If you page through, you’ll see
                                                                        17
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                       how careful I was. I had wholegrain
                                       cereals with soymilk and fruit for
                                       breakfast just about every day. I’d
                                       drink a big protein shake for lunch. I
                                       had good protein and pasta and
                                       salads for dinner. I really tried to
                                       balance things. I never ate a single
                                       dessert.

   Tell me about your food shopping    I mostly buy from Wellman’s. I think
   habits.                             they have the best produce and
                                       meats. Once in a blue moon I might
                                       step into Keefer’s, but mostly for
                                       missing ingredients for a recipe, not
                                       the fresh foods for our dinners.
                                       There are other food stores in town,
                                       but I just don’t go to them.

   Had you done any traveling in the   We talked about it, but we never
   month before you got sick?          did get away. We stuck close to
                                       home.

   How often do you eat out, and       Well, again, if you look at my
   where do you go when you do?        journal, you’ll see I ate at home just
                                       about the whole time. I didn’t want
                                       to eat out because I didn’t know
                                       what other people were doing with
                                       the food, you know? I guess the
                                       weekend of Independence Day we
                                       ate at seafood chain place. I sent
                                       back my shrimp, I remember, to
                                       make sure they cooked it
                                       completely.
   In the month before you got sick,   They had a shower for me at my
   had you attended any events         workplace. It was cake and ice
   where food was served?              cream. I skipped the ice cream, but I
                                       admit I did have a slice of cake.
                                       Didn’t taste as good as I hoped.

                                       There was the Cancer Walk. We had
                                       a team from work who walked, and
                                       then we stuck around for the picnic
                                       after. Let me see my note… Oh,
                                       well, I guess I was hungry—I had a
                                       chili dog. I sort of remember—
                                                                                                18
                        The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                   again, it didn’t taste as good as I’d
                                                                   hoped. I ate a couple chips, an ice
                                                                   cream sandwich… Oh, here’s
                                                                   another event—the Library Fund
                                                                   Murder Mystery Dinner. It had an
                                                                   Italian theme, so the dinner was
                                                                   pasta with meatballs, various
                                                                   sauces, some breads, and salads. It
                                                                   looks like I had about three bits of
                                                                   the pasta, a meatball, and a couple
                                                                   bites from my husband’s
                                                                   cheesecake.

                          Read case notes (should go to pop up1)
                          View food list (should go to pop up2)


1
 Case Notes for pop up
Natalie Tompkins, 35
Date of onset: July 24
Case notes: two months pregnant at onset of illness; saw GP July 26, was referred to her OB/GYN and
admitted to Jackson County Medical Center; suffered miscarriage July 28

2
 Food List for pop up
Natalie Tompkins highlighted the following items as food she consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American white cheeses)
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
                                                                                             19
                     The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

   other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       20
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a4 Individual Field Interview (clicking on Barbara Dixon in chart on page 3a takes learner to this
page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of Barbara with the following caption
                                 Barbara Dixon, 25
                                 eight months pregnant at onset of illness

                                 Select the questions you wish to ask by clicking on each question.

                                  I have to say you seem a bit          Totally freaked out! You’re from the
                                  agitated. How are you feeling?        CDC? I don’t know why you want to
                                                                        talk to me now.

                                  I am just trying to pinpoint what     Did I eat the wrong thing? I’m sorry.
                                  the problem was. I would like to      You need answers and I’m just
                                  know about the meals you ate in       freaking out. It’s just—my friend
                                  the days before you got sick. It      Natalie, who got sick with the same
                                  would be great if you could           thing, lost her baby. Honestly, they
                                  describe each one.                    asked me about what I’d been
                                                                        eating at the hospital, and I could
                                                                        barely remember then. I guess I was
                                                                        eating what I still eat—breakfast
                                                                        21
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                       cereal with milk in the morning; fast
                                       food for lunch—usually a burger;
                                       and for supper usually some kind of
                                       pasta with meat or a steak and
                                       salad. I just ate what for me is
                                       normal.

   Tell me about your food shopping    I shop at Walmer’s and a little bit at
   habits.                             Keefer’s. Time wise, Walmer’s is
                                       great because you can get
                                       everything in one stop. I mean, you
                                       can get groceries, you can buy belts
                                       for your car engine, and you can do
                                       your taxes. They have everything.

   Had you done any traveling in the   We never go anywhere. I don’t think
   month before you got sick?          I’m supposed to fly anyway. My
                                       husband travels sometimes for
                                       work. He had a trip to Atlanta the
                                       last week in June. Does that count?

   How often do you eat out, and       I’m the queen of the Biggie Burger. I
   where do you go when you do?        don’t know what they put in those
                                       things, but I totally have to have one
                                       just about every other day for lunch.
                                       At night sometimes, there is a
                                       Chinese place we really like, the
                                       Jade Dragon. I get cashew chicken.
                                       Makes me hungry to think of it.

   In the month before you got sick,   Oh, at the start of the month ,there
   had you attended any events         was a big family picnic at my folks’
   where food was served?              house. That was July 4. They just did
                                       the usual grill stuff—hamburgers
                                       and hot dogs. I didn’t want a burger
                                       if it wasn’t a Biggie Burger. Anyway,
                                       my nephew was at the grill, and he
                                       was overloading it, so everything
                                       was either way pink or black on the
                                       outside. I took a hot dog—I figured
                                       that was safest because they’re
                                       already cooked. They had
                                       homemade ice cream. I guess the
                                       only other stuff I ate there was the
                                       chips. That was the only event,
                                                                                                 22
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                    except for my baby shower. My
                                                                    cousin did it. She caters. It was all
                                                                    pretty foo-foo. I didn’t recognize all
                                                                    of it, so I just ate what I knew. There
                                                                    were crackers and brie, and little
                                                                    cakes with real heavy icing. I had
                                                                    some peanuts and mixed nuts.
                                                                    Punch. No coffee. I don’t remember
                                                                    what else.

                           Read case notes (should go to pop up1)
                           View food list (should go to pop up2)


1
 Case Notes for pop up
Barbara Dixon, 25
Date of onset: July 25
Case notes: three months pregnant at onset of illness; saw GP July 26 and was referred to Jackson
County Medical Center by her OB/GYN; responded well to treatment; no apparent harm to fetus

2
 Food List for pop up
Barbara Dixon highlighted the following items as food she consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American white cheeses)
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       23
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a5 Individual Field Interview (clicking on Aida Watkins in chart on page 3a takes learner to this
page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of Aida with the following caption
                                 Aida Watkins, 49
                                 mother or three; asthmatic

                                 Select the questions you wish to ask by clicking on each question.

                                  How are you today?                    Well, the boys are off camping with
                                                                        their dad. So I’m amazingly relaxed!
                                                                        This is a good time to do this
                                                                        interview.

                                  I would like to know about the        I don’t think I can go through meal-
                                  meals you ate in the days before      by-meal. I can give you the general
                                  you got sick. It would be great if    idea. We’re vegetarian. Not vegan,
                                  you could describe each one.          you know, but I really try to keep
                                                                        things natural. The boys are not
                                                                        thrilled with this always, of course.
                                                                        It doesn’t matter how I dress up the
                                                                        soy burger—they swear they can
                                                                        24
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                       taste it. I break down now and then
                                       and give them some turkey bacon
                                       or turkey hot dogs, but I don’t eat
                                       those myself unless I have to. I use
                                       lots of different cheeses to make it
                                       interesting, and I use various beans.
                                       I think it works tasting good.

   Tell me about your food shopping    I usually stick to Keefer’s. They’re
   habits.                             regional, so the fresh food they
                                       carry hasn’t traveled as far. I like
                                       that. Their house brand stuff is
                                       usually pretty good, which is kind of
                                       surprising. Wellman’s is the other
                                       option, but I think they’re too
                                       expensive. I do like their hummus,
                                       though, and I get that once in a
                                       while. I really don’t go to Walmer’s
                                       for food. The produce looks pretty
                                       sketchy to me. I guess there’s the
                                       Gas-N-More, but I’d rather just do
                                       without than take a chance on that
                                       stuff.
   Had you done any traveling in the   Only in my mind.
   month before you got sick?
   How often do you eat out, and       Well, we hit the pizza parlor with
   where do you go when you do?        the robot animals much more often
                                       than I would choose. I do my best at
                                       home, but when the boys are
                                       outside—including my husband—
                                       the rule is, they make the choice. Of
                                       course, I can choose for myself, so
                                       usually I eat a peanut butter
                                       sandwich about a half hour before
                                       we go.

   In the month before you got sick,   There was a church potluck. But, to
   had you attended any events         tell you the truth, when I go to
   where food was served?              those things I usually just take some
                                       of whatever I brought and leave the
                                       rest.

                                       Right before I got sick there was a
                                       scout sleepover at a gym—a “lock-
                                       in” they called it. Anyway, I was
                                                                                                 25
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                    doing my motherly duty as a
                                                                    chaperone. I didn’t get a chance to
                                                                    eat ahead. There was a picnic-style
                                                                    supper. They had grilled this stuff
                                                                    ahead, and supposedly they had
                                                                    some turkey franks, so I ate one,
                                                                    and had some of the baked beans
                                                                    and processed cheese. Afterwards, I
                                                                    found out the person who cooked
                                                                    got everything on sale at Walmer’s.
                                                                    So, were there really any turkey
                                                                    franks? I don’t think so. The next
                                                                    morning they had the Pancake Guy,
                                                                    which is this local person with a big,
                                                                    portable grill, and he just cooks any
                                                                    standard breakfast item you want. I
                                                                    think I had bananas and some eggs
                                                                    that morning.

                           Read case notes (should go to pop up1)
                           View food list (should go to pop up2)


1
 Case Notes for pop up
Aida Watkins, 49
Date of onset: July 25
Case notes: mother of three; was taking corticosteroids via an inhaler for asthma at time of onset; saw
GP July 26; developed pneumonia as a complication and was admitted to Jackson County Medical
Center July 28 but was successfully treated and released

2
 Food List for pop up
Aida Watkins highlighted the following items as food she consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American )white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
                                                                                             26
                     The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

   turkey franks
   hot dogs
   sausages
   shrimp
   (undercooked) chicken
   luncheon meat
   other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       27
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a6 Individual Field Interview (clicking on David Cho in chart on page 3a takes learner to this page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of David with the following caption
                                 David Cho, 57
                                 HIV Positive

                                 Select the questions you wish to ask by clicking on each question.

                                  How are you feeling today?            I’m okay. What would you like to
                                                                        know?

                                  I would like to know about the        That’s tough. I sort of make up my
                                  meals you ate in the days before      recipes as I go along. Maybe I have
                                  you got sick. It would be great if    pasta with red sauce two nights.
                                  you could describe each one.          They aren’t going to be the same
                                                                        two red sauces, you know? It really
                                                                        depends on what’s in the pantry.
                                                                        Breakfast is easy—I don’t eat it.
                                                                        Unless you count my overpriced
                                                                        coffee beverage purchase. Lunch,
                                                                        usually I eat out. I could look at
                                                                        receipts, maybe? I eat at nice places.
                                                                        28
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                       Usually some salad/soup
                                       combination. And then dinner by
                                       me. I’m an excellent chef. And I use
                                       very good ingredients. And I used to
                                       work in a restaurant, so I know all
                                       the food safety rules inside and out.

   Tell me about your food shopping    Fussy. Very. Wellman’s is my
   habits.                             domain. Once in a while, I manage a
                                       pilgrimage to the big city, where I
                                       buy as many exotic mustards and
                                       sauces and canned goods as I can. I
                                       order online, too. Probably have
                                       those records if you really need
                                       them. But that’s primarily cheeses,
                                       fruits, that sort of thing.

   Had you done any traveling in the   I was in Montreal the week of June
   month before you got sick?          14. I recommend the maple syrup.
                                       Had standard hotel restaurant fare –
                                       burgers, chicken sandwiches, bagels,
                                       fruit, mostly.
   How often do you eat out, and       Eating out locally—not so much of a
   where do you go when you do?        thrill. I get to restaurants in the city
                                       now and then, but I concentrate my
                                       food spending on what I cook
                                       myself. I’m one who likes my own
                                       cooking best.

   In the month before you got sick    Had canapés and cheap wine at the
   had you attended any events         art opening end of June. Then there
   where food was served?              was the family reunion, which is
                                       where I’m pretty sure I got the
                                       illness. There were 12 of us, six of us
                                       got sick. We had family in from the
                                       coast, and my sister wanted to give
                                       them a real taste of Great Plains life.
                                       She grilled hamburgers. She deep-
                                       fat fried a turkey. She put cut-up hot
                                       dogs into the canned baked beans,
                                       with undercooked bacon crumbled
                                       over it. We were sick within hours. I
                                       think that vile cookout may have
                                       been the culprit, because it was the
                                       only time our particular group of
                                                                                                 29
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                    family members ate the same stuff
                                                                    at the same place. I mean—grocery
                                                                    store potato salad. From Walmer’s.

                           Read case notes (should go to pop up1)
                           View food list (should go to pop up2)


1
 Case Notes for pop up
Dave Cho, 57
Date of onset: July 25
Case notes: HIV positive; saw GP July 26; successfully treated without complications

2
 Food List for pop up
Dave Cho highlighted the following items as food he consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       30
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 3a7 Individual Field Interview (clicking on Helen Mansfield in chart on page 3a takes learner to this
page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of Helen (from Role 1) with the following caption
                                 Helen Mansfield, 76
                                 bike rider

                                 Select the questions you wish to ask by clicking on each question.

                                  How are you today?                    Very well, thank you. Much clearer-
                                                                        headed than I was when I was ill.

                                  I would like to know about the        I am not sure I can tell you what I
                                  meals you ate in the days before      had for breakfast today, let alone all
                                  you got sick. It would be great if    those weeks ago! Everyone’s been
                                  you could go through and describe     very curious about my eating habits
                                  each one.                             since all this illness broke out. I’m
                                                                        something of a creature of habit. I
                                                                        like my soft eggs in the morning with
                                                                        toast, and I don’t bother to separate
                                                                        the yolks because everybody needs
                                                                        31
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                       at least one vice! I like a bit of fruit
                                       with any meal. Annie helps me cook
                                       dinners ahead so they just pop in
                                       the microwave—lasagnas are my
                                       favorite. We do casseroles, too, and
                                       freeze them in me-sized portions.
                                       Everything I eat gets cooked at least
                                       twice, it seems like.

   Tell me about your food shopping    I get groceries delivered from
   habits.                             Wellman’s, or my friend Annie takes
                                       me there. We don’t bother with the
                                       bigger stores. They’re too big. At
                                       least for me. I don’t shop much. I
                                       don’t need much.

   Had you done any traveling in the   Only as far as I could get on my
   month before you got sick?          bicycle. And come to think of it, not
                                       even that. I was laid up with my hurt
                                       ankle during those weeks. That was
                                       the mystery of it. There I sat in my
                                       little living room, minding my own
                                       business, bored out of my tree,
                                       trying to get well. And I just got
                                       terribly sick anyway. That’s not fair,
                                       is it?

   How often do you eat out, and       Annie has tried to drag me to the
   where do you go when you do?        lunches at the senior center
                                       downtown, but it’s just not my
                                       thing. The church groups work on
                                       me to join the potlucks, too, but I’m
                                       a hard case. I just don’t care for any
                                       cooking but my own. Those are my
                                       only “eating out” options. I’m not a
                                       bit interested in restaurants. I
                                       wouldn’t waste the money when I
                                       have perfectly good food of my own.
                                       And as for fast food—I’d rather fast!
   In the month before you got sick    I am not much of a social butterfly.
   had you attended any events         And at that time, I was more or less
   where food was served?              homebound. Of course, that made
                                       me vulnerable to invasions. I put a
                                       stop to that as soon as I could, but
                                       one church member did wheedle
                                                                                                 32
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                     her way in. She came bearing salad, I
                                                                     recall. She called it, what was it,
                                                                     American Salad? Picnic Surprise?
                                                                     Something like that. She’s stirred up
                                                                     pasta and hot dogs and mayonnaise
                                                                     and, oh my, I think there was
                                                                     hamburger and ketchup in there,
                                                                     too, with these oily potato chips all
                                                                     crumpled on top, and wilt-y lettuce,
                                                                     too. Garden tomatoes, she said.
                                                                     They were sorry little grape-sized
                                                                     things from the store, I could tell.
                                                                     She insisted on leaving her
                                                                     concoction. Made me eat some of it
                                                                     with her. What an experience. There
                                                                     was relish in it, too.

                            Read case notes (should go to pop up1)
                            View food list (should go to pop up2)


1
 Case Notes for pop up
Helen Mansfield, 76
Date of onset: July 18
Case notes: bike rider; suffering from a broken ankle at time of illness onset; suffered some
disorientation during illness; suffered meningitis as complication; made good recovery

2
 Food List for pop up
Helen Mansfield highlighted the following items as food she consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
                                                                                             33
                     The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

   shrimp
   (undercooked) chicken
   luncheon meat
   other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       34
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a8 Individual Field Interview (clicking on Della Boucher in chart on page 3a takes learner to this
page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of Della Boucher with the following caption
                                 Della Boucher, 63
                                 volunteer

                                 Select the questions you wish to ask by clicking on each question.

                                  How are you today?                    Well, I feel just fine, but there must
                                                                        be something wrong if somebody
                                                                        from the national CDC wants to talk
                                                                        to me! I just can’t imagine what I
                                                                        can tell you, but you just ask me
                                                                        anything.

                                  I would like to know about the        Oh, I wish I could do that. I wish I
                                  meals you ate in the days before      had that kind of mind. Wouldn’t that
                                  you got sick. It would be great if    be something? I'll tell you what,
                                  you could describe each one.          though—I know what I had for
                                                                        breakfast. I have it every day. It’s my
                                                                        own personal breakfast cereal. I mix
                                                                        35
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                       it up myself. It’s one part shredded
                                       wheat, two parts Chocochums, and
                                       one part Sugar Crinkles. I use skim
                                       milk on it. For lunch, I make a
                                       sandwich. I use two kinds of
                                       lunchmeat plus some good
                                       American cheese and mayo. And I
                                       love my corn chips and creamy
                                       salads. Tandy says I’ll eat anything
                                       with mayo in it. For dinners, since
                                       it’s just me, I’ll pop in a frozen
                                       something, like one of those Hefty
                                       Eater entrees or a pot pie. I bake a
                                       chicken once in a while. I eat every
                                       bit of it, even if it’s a little pink near
                                       the bone. Never sick a day in my
                                       life, except that one time.

   Tell me about your food shopping    I think they invented Walmer’s just
   habits.                             for me. They have such deals on just
                                       everything. And they aren’t fussy
                                       like some stores. If it’s past the date
                                       on the package, they don’t throw it
                                       out—they drop the price and I get a
                                       great deal. There’s probably a
                                       Walmer’s where you live. They have
                                       them everywhere, don’t they? I
                                       don’t shop any place but Walmer’s.
                                       If I can’t get it there, I do without.

   Had you done any traveling in the   I’m not so much the traveler, but I
   month before you got sick?          would love to be. I saw a show last
                                       night about a man that had been to
                                       South America and did something
                                       they call zip-lining, right over the top
                                       of the rainforest. And then he got
                                       home and he became sick and they
                                       were sure it was food poisoning. But
                                       it turned out some bug bit him. Do
                                       you think that could have happened
                                       to me? Maybe a bug rode in an
                                       airplane to here. I saw a movie once
                                       where spiders came back that way,
                                       in a plane.
                                                                        36
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

   How often do you eat out, and           I don’t go to fancy restaurants, if
   where do you go when you do?            that’s what you mean. When
                                           Tandy’s in town we go to Biggie
                                           Burger. I love the deli at Walmer’s, if
                                           that counts. You can’t really eat
                                           there, but you can get great food
                                           and take it out and enjoy it
                                           wherever you want to. Davie and I
                                           used to go to Fanzano’s, but that
                                           was a couple of years ago.

   In the month before you got sick,       Well, mostly I go out for church
   had you attended any events             suppers and that sort of thing. Now
   where food was served?                  in the weeks before I got sick, there
                                           wasn’t much doing. I tried to start
                                           up a shut-in ministry at church, but
                                           that didn’t work out so well. It was
                                           the Fourth of July, and I thought it
                                           would be nice to take a picnic to a
                                           shut-in. Helen Mansfield had a
                                           broken ankle so I thought I could at
                                           least take her something to eat. I
                                           made her eat and I ate with her, so
                                           I’d know she got one good meal in
                                           her that weekend. I invented a
                                           recipe for her—Picnic Salad. It
                                           turned out real well. It had
                                           everything you might have at a
                                           picnic in one bowl. I cooked
                                           hamburgers and potatoes and all
                                           kinds of things. It was so hot that
                                           weekend. Fortunately there were
                                           things that went in that didn’t need
                                           cooking, like the hot dogs and the
                                           grape tomatoes and the pickle bits.
                                           It was so good—every bite was
                                           something different. I crunched
                                           potato chips on top. After that I got
                                           sick so I had to give up the shut-in
                                           ministry.



  Read case notes (should go to pop up1)
  View food list (should go to pop up2)
                                                                                                 37
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts



1
 Case Notes for pop up
Della Boucher, 63
Date of onset: July 22
Case notes: saw GP July 23; relatively mild case; no complications; no major underlying medical issues

2
 Food List for pop up
Della Boucher highlighted the following items as food she consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       38
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a9 Individual Field Interview (clicking on Dr. Pat Mallory in chart on page 3a takes learner to this
page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of Pat Mallory with the following caption
                                 Dr. Pat Mallory, 60
                                 physician, diabetic

                                 Select the questions you wish to ask by clicking on each question.

                                  How are you today?                   Busy. If you don’t mind, I’m going to
                                                                       eat while we talk. Help yourself to a
                                                                       donut. My receptionist brought
                                                                       them in this morning.

                                  I would like to know about the       Meals. Well, that’s a relative term,
                                  meals you ate in the days before     isn’t it. I have a very busy practice,
                                  you got sick. It would be great if   Miss Wise. I get here early, leave
                                  you describe each one.               late, and eat whatever I can grab or
                                                                       order in, to tell you the truth. I
                                                                       couldn’t begin to give you a day by
                                                                       day food diary, especially this far
                                                                       out.
                                                                        39
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


   Tell me about your food shopping    Let’s see… Most of my food
   habits.                             shopping takes place in the break
                                       room or at the drive up window. I’m
                                       not a cook. And I’m not that big on
                                       home cooking.

   Had you done any traveling in the   Does it sound like I have the time to
   month before you got sick?          get away? Oh, I had a short trip to
                                       Cancun over the weekend of the
                                       Fourth. I stayed at a very fine resort
                                       and I didn’t drink the water. Don’t
                                       try to make this my fault, Miss.

   How often do you eat out, and       As often as I can and all over. I’m
   where do you go when you do?        probably a lot better off that way
                                       than if I tried to cook on my own. I
                                       can’t imagine the state the kitchen
                                       would be in. I’m never home. I eat
                                       fast food every day, typically at
                                       Biggie Burger or Wokon By. For
                                       restaurants, I typically eat in or take
                                       out at Fanzano’s. You should try the
                                       manicotti while you’re here. There’s
                                       a café at the truck stop where I get
                                       the occasional chicken-fried steak
                                       and often breakfast with scrambled
                                       eggs.

   In the month before you got sick    My social life is rather limited. I hate
   had you attended any events         to be approached for free medical
   where food was served?              advice. So I limit going out. Now, I
                                       make an exception for the Great
                                       Plains Rodeo. That’s quite an event.
                                       The Chuck Wagon Round Up—it’s a
                                       sort of camping ground of food
                                       booths—is full of temptations— they
                                       sell funnel cakes, deep-fried
                                       anything, chili dogs, corn dogs,
                                       baked beans, and so much more. I
                                       spend about equal time in the stands
                                       and in the Chuck Wagon Round Up. I
                                       pay cash for all that, so there’s not
                                       much way to trace back those
                                       choices, I’m afraid.
                                                                                                 40
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


                           Read case notes (should go to pop up1)
                           View food list (should go to pop up2)


1
 Case Notes for pop up
Dr. Pat Mallory, 60
Date of onset: July 25
Case notes: physician with adult onset diabetes; obese; no major complications of illness

2
 Food List for pop up
Dr. Pat Mallory highlighted the following items as food he consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                    41
                            The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a10 Individual Field Interview (clicking on Gunther Gillis in chart on page 3a takes learner to this
page)

Role Selection              Content Area
Image of Mashonda
                            Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to      Role 1. Something like the following
let me interview you.
I’m Mashonda Wise of
the CDC and I’ve come
to Valley Verde to try
to help figure out what
is causing this outbreak
of listeriosis. With your
cooperation, we can
generate a hypothesis
to get at the source
and control the
outbreak. Thanks for
marking the food list to
show me some of the
foods you ate prior to
your illness. I have your
case notes. Now, I have
some additional
questions for you.

                            Image of Gunther Gillis with the following caption
                            Gunther Gillis, 63
                            veteran

                            Select the questions you wish to ask by clicking on each question.

                             How are you today?                       Okay I will take a bit of time to talk
                                                                      with you, but not much.
                             I would like to know about the           You will have to call Haven Village
                             meals you ate in the days before         and talk to the cook.
                             you got sick. It would be great if you
                             could describe each one.

                             Tell me about your food shopping         Only thing I shop for is candy bars. I
                             habits.                                  like Peanut Blasters the best.

                             Had you done any traveling in the        Traveling? From my apartment to
                             month before you got sick?               the lounge to the cafeteria—that’s
                                                                                                42
                        The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                  it.

                          How often do you eat out, and           I got a bum leg, hard to get around.
                          where do you go when you do?            My pension doesn’t cover much
                                                                  going out anyway.

                          In the month before you got sick        I went to a rodeo. We went by bus.
                          had you attended any events where       Now that was a time. Probably the
                          food was served?                        most fun I had all year. The food
                                                                  stunk, but at least you could get
                                                                  some variety. They had curly fries
                                                                  that weren’t too shabby. A little
                                                                  beer. Not sure the person cooking
                                                                  the chili dog knew what he was
                                                                  doing..


                         Read case notes (should go to pop up1)
                         View food list (should go to pop up2)


1
 Case Notes for pop up
Gunther Gillis, 63
Date of onset: July 18
Case notes: veteran; saw GP July 26; no complications

2
 Food List for pop up
Gunther Gillis highlighted the following items as food he consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
                                                                                             43
                     The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

   shrimp
   (undercooked) chicken
   luncheon meat
   other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       44
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a11 Individual Field Interview (clicking on Dana Halgren in chart on page 3a takes learner to this
page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of Dana Halgren with the following caption
                                 Dana Halgren, 61
                                 grandmother

                                 Select the questions you wish to ask by clicking on each question.

                                  How are you today?                    Well, I’m not sure. I thought I felt
                                                                        fine, but on your list I noticed
                                                                        undercooked chicken, and I got to
                                                                        thinking about the chicken I had for
                                                                        lunch today, and I’m wondering if
                                                                        there was something wrong with it
                                                                        and If I’ll get sick, because it was
                                                                        awfully pink near the bone. And I
                                                                        assumed the milk was pasteurized,
                                                                        but they didn’t say it was, so how
                                                                        would I know? I guess I’m okay. I
                                                                        feel okay.
                                                                        45
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

   I would like to know about the       Oh dear. I wish I knew. I eat
   meals you ate in the days before     different breakfast cereals every
   you got sick. It would be great if   day, and I’m always eating different
   you could describe each one.         fruits with different meals, and
                                        different sandwiches at lunch, like
                                        bologna and peanut butter—well,
                                        not together, but those types of
                                        sandwiches. Or I experiment. Like
                                        today I got take out from Wellman’s,
                                        as a kind of treat. And my husband
                                        cooks the dinners. He would know
                                        what we ate. We like beef and
                                        potatoes, and macaroni and cheese.
                                        And sometimes fried chicken. But I
                                        don’t know when we ate what.

   Tell me about your food shopping     I go to Walmer’s, usually, and Bob
   habits.                              sends a list. I don’t save the lists. I’m
                                        not helping you, I bet. I’m sorry.

   Had you done any traveling in the    Oh, no. Since Patty had her kids, we
   month before you got sick?           stay in town and babysit as much as
                                        possible.

   How often do you eat out, and        We go to Handy’s Pizza about once a
   where do you go when you do?         week with the grandkids. I do. Bob
                                        says he can’t take the noise. Bob
                                        and I sometimes go for breakfast in
                                        the café at Keefer’s. They do a
                                        waffle plate he just loves. I get the
                                        sunnyside eggs and bacon with
                                        toast. Quite a deal.

   In the month before you got sick     We went to a birthday party for
   had you attended any events          Tyson—that’s the middle boy. We
   where food was served?               went to a rodeo first, then had cake
                                        and ice cream back at the house.
                                        Well, the kids had cake and ice
                                        cream. We had eaten at the
                                        midway. We went to the booth
                                        Keefer’s had—I thought that would
                                        be good food. All they were serving
                                        was chili dogs and fries. I guess I had
                                        a bit of Angie’s taco from another
                                        booth. Maybe it was just the smell
                                                                                                46
                        The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                   of the place, but I felt awful when I
                                                                   went home that night. Then I got
                                                                   sick later in the month. I think the
                                                                   hot weather made me weak.



                          Read case notes (should go to pop up1)
                          View food list (should go to pop up2)


1
 Case Notes for pop up
Dana Halgren, 61
Date of onset: July 23
Case notes: grandmother; saw GP July 26; developed meningitis but was treated successfully

2
 Food List for pop up
Dana Halgren highlighted the following items as food she consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       47
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 3a12 Individual Field Interview (clicking on William Caulifield in chart on page 3a takes learner to
this page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of William Caulfield with the following caption
                                 William Caulfield, 59
                                 cancer survivor

                                 Select the questions you wish to ask by clicking on each question.

                                  How are you today?                    All things considered, not bad at all.
                                                                        If you ignore the portable oxygen—
                                                                        which I do.

                                  I would like to know about the        Well, that’s a little difficult. Around
                                  meals you ate in the days before      the time the illness hit I had some
                                  you got sick. It would be great if    confusion going on. I usually have an
                                  you could describe each one.          egg white omelet for breakfast, with
                                                                        multigrain toast and fresh fruit if
                                                                        anything looks good at the market.
                                                                        Lunch is usually salad. Used to be
                                                                        tuna, but that got too scary with the
                                                                        48
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                       mercury. I do a mix of something like
                                       chicken and some form of soy
                                       cheese. Lots of fresh, whole
                                       ingredients. My wife is in charge of
                                       dinner, and she cooks very carefully
                                       for me. We like chicken and seafood
                                       when we can get good fish—not
                                       easy in these parts. We
                                       experimented with ground buffalo
                                       and that sort of thing for a while.
                                       She’s convinced I should avoid beef.
                                       So I’m a closet beef-eater. It’s just an
                                       occasional thing.

   Tell me about your food shopping    Well, we like Wellman’s. Now and
   habits.                             then we’ll pick up something at
                                       Keefer’s, but that’s rare. We are
                                       organized. We don’t make a lot of
                                       convenience runs.

   Had you done any traveling in the   I just don’t have the stamina.
   month before you got sick?          Fortunately, the kids are willing to
                                       come here.
   How often do you eat out, and       It’s not frequent. The local
   where do you go when you do?        restaurants are mostly chains, and
                                       that’s not very interesting. Neither
                                       of us cares much for fast food,
                                       although if Betsy is in town she
                                       drags us to the Biggie Burger.
                                       Nostalgia for her, salads for her
                                       mother and me.

   In the month before you got sick    I can’t really think of anything. We
   had you attended any events         stayed home Fourth of July because
   where food was served?              Alice was sick. My buddy wanted to
                                       drag me off to the rodeo mid-
                                       month, but that was the same
                                       weekend as the Cancer Walk so
                                       went to that. It was a gorgeous day. I
                                       stuck around for the picnic after. I
                                       thought I could score a burger
                                       because they had a grill. Wound up
                                       with a hot dog instead. Don’t ask me
                                       how that happened. Huge turnout.
                                       They had the best ice cream. That
                                                                                                 49
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                  was the highlight of the meal,
                                                                  definitely.


                           Read case notes (should go to pop up1)
                           View food list (should go to pop up2)


1
 Case Notes for pop up
William Caulfield, 59
Date of onset: July 28
Case notes: cancer survivor now in remission (three years) from lung cancer; saw GP July 29; treated for
endocarditis--complication of listeriosis

2
 Food List for pop up
William Caulfield highlighted the following items as food he consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       50
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a13 Individual Field Interview (clicking on Hector Martinez in chart on page 3a takes learner to
this page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Something like the following
let me interview you. I’m
Mashonda Wise of the
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.
                                 Image of Hector Martinez with the following caption
                                 Hector Martinez, 66
                                 heart transplant

                                 Select the questions you wish to ask by clicking on each question.

                                  How are you today?                    I didn’t see my name in the
                                                                        obituaries—that means it’s a great
                                                                        day.

                                  I would like to know about the        You mean before the listeriosis. I’ve
                                  meals you ate in the days before      been sick a lot, you know. Seriously,
                                  you got sick. It would be great if    I don’t think I can go day by day, but
                                  you could describe each one.          to give you a general idea, it’s
                                                                        usually oatmeal for breakfast or
                                                                        granola in the hotter weather. I put
                                                                        skim or soy milk on it. I like a taco
                                                                        for lunch, usually, but sometimes a
                                                                        peanut butter sandwich if nobody is
                                                                                                 51
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                    looking. Peanut butter is bad for
                                                                    you, according to my nutritionist.
                                                                    For supper, lean chicken, lean beef,
                                                                    lean everything, but once in a while
                                                                    I sneak in some traditional Mexican
                                                                    food with the good sauces and the
                                                                    good cheese.

                            Tell me about your food shopping        Marta mostly shops Keefer’s, as far
                            habits.                                 as I know.

                            Had you done any traveling in the       No, no traveling lately. We’re going
                            month before you got sick?              to Mexico for the holidays, so we’re
                                                                    saving.

                            How often do you eat out, and           I don’t care much for the local
                            where do you go when you do?            restaurants. And fast food is just too
                                                                    tricky. Too much could go wrong for
                                                                    me if they make a mistake. Usually I
                                                                    don’t bother with it. It doesn’t taste
                                                                    that good anyway.

                            In the month before you got sick        All I can think of is the Cancer Walk.
                            had you attended any events             Marta thought we should do it
                            where food was served?                  together. With lots of sunblock and
                                                                    big hats, of course. Still it was nice.
                                                                    She was on a team from her
                                                                    workplace. We stayed for the lunch
                                                                    after. I had a little of everything they
                                                                    served. It wasn’t bad. The weather
                                                                    was beautiful. I didn’t even think
                                                                    about how they made it.


                           Read case notes (should go to pop up1)
                           View food list (should go to pop up2)

1
 Case Notes for pop up
Hector Martinez, 66
Date of onset: August 1
Case notes: saw GP August 2; avoided major complications; heart transplant survivor (10 years ago);
skin cancer survivor (18 months ago)

2
Food List for pop up
                                                                                                52
                        The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Hector Martinez highlighted the following items as food he consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       53
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a14 Individual Field Interview (clicking on Evan Buchanan in chart on page 3a takes learner to this
page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Set up was questions in content area in the left two thirds and
let me interview you. I’m        image with caption below in the right hand third. Something like the
Mashonda Wise of the             following
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.


                                 Image of Evan Buchanan with the following caption
                                 Evan Buchanan, 67
                                 widower

                                 Select the questions you wish to ask by clicking on each question.

                                  How are you today?                    I’m okay. I have to get to my job,
                                                                        though, so I can’t talk long. I’m part-
                                                                        time at Keefer’s.

                                  I would like to know about the        Oh, I don’t have time to list out all
                                  meals you ate in the days before      that. I just have cereal for breakfast.
                                  you got sick. It would be great if    If I’m not working I get my lunch at
                                  you could describe each one.          the senior center. You can check on
                                                                        their menus. For dinner ,I bring
                                                                        home food from the store or cook
                                                                        up something simple, like macaroni
                                                                                                 54
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                                                    and cheese. I cook up bacon to put
                                                                    in it. Sometimes hot dogs.
                                                                    Sometimes sausage. Whatever I can
                                                                    get that’s leftover or employee
                                                                    discount. Susie was the cook. She
                                                                    passed eight months ago. I just
                                                                    don’t care all that much about food
                                                                    since.

                            Tell me about your food shopping        Whatever I buy is from Keefer’s, but
                            habits.                                 sometimes they just give it to me.
                                                                    Sometimes if I have to buy
                                                                    something, and it’s not on sale, I go
                                                                    to Walmer’s. I don’t like it there,
                                                                    though. Too big.

                            Had you done any traveling in the       No. Susie and I used to travel
                            month before you got sick?              together, though.

                            How often do you eat out, and           I only eat at the senior center. I get
                            where do you go when you do?            the lunch. It’s pretty cheap. You can
                                                                    ask them what they serve.
                            In the month before you got sick,       I don’t go to events. Not for fun.
                            had you attended any events             Keefer’s caters, and sometimes I get
                            where food was served?                  to go and help serve. We did the
                                                                    Cancer Walk, and I got a bunch of
                                                                    leftovers from that. Some of it is still
                                                                    in my freezer. I froze the buns and
                                                                    the hot dogs separate. The kid who
                                                                    was cooking messed up a bunch and
                                                                    he got bawled out. But they taste
                                                                    okay to me.




                           Read case notes (should go to pop up1)
                           View food list (should go to pop up2)

1
Case Notes for pop up

Evan Buchanan, 67
Date of onset: August 8
Case notes: saw GP August 9; treated for meningitis as a complication
                                                                                               55
                       The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


2
 Food List for pop up
Evan Buchanan highlighted the following items as food he consumed prior to being diagnosed with
listeriosis.
      soft (i.e. Latin-American) white cheeses
      Feta cheese
      surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
      cole slaw
      potato salad
      other deli salads
      raw (unpasteurized) milk
      eggs
      ice cream
      turkey franks
      hot dogs
      sausages
      shrimp
      (undercooked) chicken
      luncheon meat
      other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                       56
                               The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3a15 Individual Field Interview (clicking on Aylssa Tyson in chart on page 3a takes learner to this
page)

Role Selection                   Content Area
Image of Mashonda
                                 Questions should be set up in accordion style as we started to originally in
Thanks for agreeing to           Role 1. Set up was questions in content area in the left two thirds and
let me interview you. I’m        image with caption below in the right hand third. Something like the
Mashonda Wise of the             following
CDC and I’ve come to
Valley Verde to try to
help figure out what is
causing this outbreak of
listeriosis. With your
cooperation, we can
generate a hypothesis to
get at the source and
control the outbreak.
Thanks for marking the
food list to show me
some of the foods you
ate prior to your illness. I
have your case notes.
Now, I have some
additional questions for
you.


                                 Image of Alyssa Tyson with the following caption
                                 Alyssa Tyson, 11
                                 Juvenile diabetes

                                 Select the questions you wish to ask by clicking on each question.

                                  Thanks for agreeing to talk to me,     You’re kind of a detective. I hope I
                                  Alyssa. Your mom told me some          can help.
                                  answers, and I’d like to hear what
                                  you have to say, too, because it can
                                  help us track down what’s making
                                  people like you sick.

                                  I would like to know about the         Um, well, I’m not supposed to. I
                                  meals you ate in the days before       really try to be good. Sometimes at
                                  you got sick. It would be great if     school I have a bite of somebody’s
                                  you could describe each one. Now,      lunch or something, but school was
                                                                                                 57
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                            your mom told me what you eat at        out when I got sick.
                            home and it’s pretty healthy. Is
                            there anything else you eat?

                            Your mom says she shops at              Well, yeah. She goes there every
                            Wellman’s. Is that right?               week. Once in a while she goes to
                                                                    Keefer’s for soap or something. She
                                                                    gets the food at Wellman’s.
                                                                    Sometimes, I use my own money to
                                                                    buy a can of pop. But I try to be
                                                                    careful. I really hate to get sick.

                            Had you done any traveling in the       I didn’t go anyplace except to the
                            month before you got sick?              my cousin’s; she took care of me
                                                                    when my parents went away July 4.
                                                                    My cousin is named Carrie.

                            How often do you eat out, and           Well, we go to restaurants when
                            where do you go when you do?            we’re traveling but not when we’re
                                                                    at home. Are we almost done?
                            In the month before you got sick,       If my mom is there, I don’t usually
                            had you attended any events             have anything to eat if she doesn’t
                            where food was served?                  say it’s okay. At my cousin’s,
                                                                    though, we did have a July 4 picnic.
                                                                    Don’t tell my parents, okay? Carrie
                                                                    got food at Keefer’s, and we had a
                                                                    real picnic with hamburgers and hot
                                                                    dogs and ice cream. I got full real
                                                                    fast. But I didn’t get sick. That was
                                                                    later. Don’t tell about the picnic,
                                                                    okay? I don’t want Carrie to get in
                                                                    trouble.

                           Read case notes (should go to pop up1)
                           View food list (should go to pop up2)

1
 Case Notes for pop up
Alyssa Tyson, 11
Date of onset: July 8
Case notes: juvenile diabetes; saw GP July 9 and was treated successfully without complications

2
 Food List for pop up
Alyssa Tyson highlighted the following items as food she consumed prior to being diagnosed with
listeriosis.
                                                                                             58
                     The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

   soft (i.e. Latin-American) white cheeses
   Feta cheese
   surface-ripened cheeses (i.e. Brie, Camembert--both domestic and imported)
   cole slaw
   potato salad
   other deli salads
   raw (unpasteurized) milk
   eggs
   ice cream
   turkey franks
   hot dogs
   sausages
   shrimp
   (undercooked) chicken
   luncheon meat
   other previously cooked, ready-to-eat foods not listed here requiring no further cooking
                                                                                                    59
                            The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 3b Case Definition
Learners are sent here if select the beaker icon

 Role Section                Content Section
                             Case Definition
 Image of Mashonda
                               Clinical information   Matching PFGE pattern (laboratory confirmation)
 It is important to keep       (predominant           Fever of 101 degrees or higher
 in mind the case              symptoms)              Diarrhea (3 or more stools in less than four hours)
 definition developed by                              Miscarriage
 Lanni before you were                                Muscle stiffness
 sent into the field. A                               Chills
 case definition is the                               Not part of case definition (abdominal cramps,
 way that public health                               fainting, insomnia, incontinence)
 officials define who is       Time (when             Date of onset : mid-July, ongoing and increasing
 included as a case in an      infection occurred)    Time of day of onset : No particular time of day of
 outbreak.                                            onset
                               Place (where           Continental US
                               infection occurred)    Not part of case definition (ONLY Midwest, ONLY
                                                      Plains, ONLY Alaska. ALL of North America)

                               Person (who is         Elderly (60 and over)
                               affected)              Pregnant
                                                      Infant or very young children
                                                      Immune-compromised
                               Serotype (the          The following is the pattern of the Listeria serotype
                               strain of bacteria)    responsible for the outbreak
                               involved)
                                                                                                 60
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 3c Case Histories for Emma Wong and Helen Mansfield
Learners are sent here if Clipboard icon.

 Image of Mashonda       Can either set up as the following of just show the text of the chart in the
                         content area.
 While conducting the    Click on image to review Dr. Diggs original notes.
 field interviews, you
 also visit with Dr.
 Diggs and check over
 the notes from her
 interviews with her
 patients. Dr. Diggs
 shares her patients’
 charts with you.

                         If click on Emma the following should pop up.
                         Emma Wong
                         Age: 29
                         Description: healthy young woman; generally good health; well-nourished;
                         physically fit; exercises two to four times per week; first pregnancy; second
                         trimester (18 weeks pregnant)
                         Most recent visit: tests show healthy, appropriate progress; minor morning
                         sickness occasional
                         Blood pressure today: 120/82
                         Temperature: 101◦

                         Notes from today’s interview
                         Patient reports starting to feel really ill after she ate at her brother’s house
                         two weeks ago. She had a lot of different kinds of junk food. She wanted to
                         come in to the clinic instead of going to her OB. Patient reports that the
                         nausea she is experiencing just doesn’t feel like morning sickness. She is
                         feeling crummy, achy, tried, chills, and feeling hot and fever-y. She is very
                         nervous that there is something wrong with the pregnancy. Others in the
                         family have also gotten ill but are feeling okay now.

                         If click on Helen the following should pop up.

                         Helen Mansfield
                         Age: 76
                         Description: active older adult; enjoys fair health for her age; no major chronic
                         conditions; minor hearing loss; former smoker (stopped at age 53)
                         Most recent visit: Bicycle accident 10 days ago resulting in sprained ankle—
                         treated with elevation, wrap, over the counter pain medication (ibuprofen)
                                                                        61
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Blood pressure today: 134/80
Heart rate: 66 per minute
Temperature: 105◦F

Notes from today’s interview
Helen reported that her stomach aches; she is shaky and chilled. Her neck
started hurting this morning. She has a headache. She said she hasn’t done
anything to cause her sore muscles. She has been home for the last two week,
staying off her sprained ankle. She has been taking over the counter pain
medication recommended by her regular doctor.

She has a good appetite until recently. She had microwave popcorn with a
friend, macaroni and hot dog dish brought by a friend about a week ago that
she refrigerated until just two days ago. She also had potato salad and bean
salad someone else brought, and some hamburgers and deli sandwiches. She
didn’t like the taste of any of it. She usually eats a good breakfast, really likes
eggs and toast, and has a light lunch and dinner. Her friend has the flu, which
she got after visiting Helen.
                                                                                                 62
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 4: Investigation Milestone
Once learner has completed the previous section, he or she will be presented with a series of questions.
The learner has to get 100% to move on. These questions should be presented randomly. At this point
the purpose of these questions is to insure the learner is going through the information. If the learner
does not get 100% he or she is told to return to beginning.

As a CDC Field Investigator, it is important that you have a good understanding of the situations
surrounding the individuals who have become ill. The following questions will help you check your
knowledge of this information. To move forward with your investigation, you will need to get 100%.

Question Set 1

Which of the following individuals might be considered a probable “person who is affected” based on
the case definition Mashonda is working from?
    a. Matt Simmons, 20, football player
    b. Paula Sandez, 77, retired railroad worker
    c. Heather Langley, 25, college student,
    d. Davonna Darcy, 49, married no children

Which of the following individuals would not be considered a probable “person who is affected” based
on the case definition that Mashonda is working from?
    a. Helen Mansfield, 76, bike rider
    b. Ali Mandock, 54, personal trainer
    c. Della Boucher, 63, volunteer
    d. John Hopkins, 29, HIV positive

Which of the following individuals might be considered a probable “person who is affected” based on
the case definition that Mashonda is working from?
    a. Matt Simmons, 30, basketball announcer
    b. Paula Sandez, 22, heart transplant
    c. Heida Cole, 25, college student
    d. Sushma Darcy, 29, runner

Question Set 2

Which of the following foods appeared on the food list that Mashonda provided the individuals she
interviewed?
    a. turkey franks
    b. eggs
    c. sausages
                                                                                                 63
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

   d. all of the above

Which of the following foods appeared on the food list that Mashonda provided the individuals she
interviewed?
    a. beef roast
    a. fried chicken
    b. lobster
    c. none of the above

Which of the following foods appeared on the food list that Mashonda provided the individuals she
interviewed?
    a. hot dogs
    a. candy bars
    b. hamburgers
    c. angel food cake

Question Set 3

Which of the following individuals were included in the “pregnant category of persons who were
affected”?
    a. Rosa Guerra
    a. Aida Watkins
    b. Alyssa Tyson
    c. all of the above

Which of the following individuals were included in the “compromised immune system category of
persons who were affected”?
    a. Gunther Gilllis
    b. William Caulfield
    c. Dana Halgren
    d. none of the above

Which of the following individuals were included in the “compromised immune system category of
persons who were affected”?
    a. Hector Martinez
    b. Alyssa Tyson
    c. Pat Mallory
    d. all of the above

Question Set 4
                                                                                                  64
                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Which of the following individuals was one of six that became sick at a family reunion?
   a. David Cho
   b. Aida Watkins
   c. Alyssa Tyson
   d. none of the above

Which of the following individuals invented the “Picnic Salad” that was called a “picnic in a bowl”?
   a. Helen Mansfield
   b. Evan Buchanan
   c. Della Boucher
   d. none of the above

Which of the following individuals ate the “Picnic Salad” that was called a “picnic in a bowl”?
   a. Alyssa Tyson
   b. Pat Mallory
   c. Helen Mansfield
   d. Aida Watkins

Question Set 5

Which of the following months did the illness being investigated first appear in Valley Verde?
   a. July
   b. August
   c. March
   d. January

John, the CDC team leader, could have sent Mashonda to which of the following states or areas to
conduct field interviews as part of this investigation?
    a. Hawaii
    b. Texas
    c. Alaska
    d. Puerto Rico

Who is Mashonda’s contact at the State Department of Health?
  a. K.C. Nolan
  b. John Reams
  c. Chase Weal
  d. Lief Turner
                                                                                                  65
                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Question Set 6

Where is Moshanda conducting field interviews?
  a. Valley Verde
  b. Omaha
  c. Kansas City
  d. all of the above

The feeling in Valley Verde towards the outbreak of illness is
    a. tense
    b. fearful
    c. hostile
    d. all of the above

Which of the following grocery stores were mentioned by the individuals that Mashonda interviewed?
   e. HyVenue Groceries, ShopCart Foods, Ideal Market
   f. Keller’s Fast Stops, Walcourt’s, Trader Foods
   g. Keefer’s, Wellman’s, Walmer’s
   h. Gas-N-More Foods, Biggie Burger, Fanzano’s

When learner has answered all the questions, the learner should see his or her score. If leaner does not
get 100% learner sees the following:
Your score was ____________. You appear to be missing some important information. Be sure to review
all of the information presented in the previous section of the investigation before returning to retake
this milestone. You will not be able to move on until you have scored 100% -- do not select “continue”
until you are sure you have reviewed “all” of the information.
Continue button takes learner to Investigation Set Up.

If learner gets 100%, learner sees the following.
Your score was 100%. You appear to have learned some important information about the individuals
who have become ill.

Learner can select
Make Recommendations (selecting this option takes learner to page 5)
Investigate Further (selecting this option takes learner to page 6)
                                                                                                  66
                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 5 Recommendations (if learner selects make recommendations from page 4)

Role Section                        Content Section
Image of Mashonda                   Video Recording of Mashonda at Desk on phone talking to her Team
                                    Leader John. Only Mashonda is heard.
You have completed all of your
field interviews in Valley Verde.   Hello John, I have finally finished interviewing the cases that K.C. and I
You are ready to recommend a        selected. I interviewed several pregnant women, individuals with
course of action. Thus, you call    immune compromised systems, a young child, and several individuals
John, your CDC Team Leader, to      over 60. I got food lists from them all. I have reviewed all the
provide let him know what you       interview notes, case notes, and food lists.
have discovered.
                                    Pause to listen.
Click here for a summary of the
responses on the food list.         Thanks, it was a lot of work, but I think I have pinpointed the problem.

Click to pdf document titled        Pause to listen.
Food Lists.
                                    How do I know at this stage? Well, from the food lists of course. There
                                    were several foods that appeared on all lists and several grocery
                                    stores that all of the individuals interviewed got food from. I think we
                                    should send out an alert not to eat food from these stores.

                                    Pause to listen.

                                    Okay, okay, you’re right. I don’t have enough information to really
                                    pinpoint the cause of the outbreak. I certainly can see how such a
                                    general alert would cause a panic with no good results.

                                    Pause to listen.

                                    Right, I will get started on a Case-Control Study to determine the
                                    relationship between exposure and the outbreak. That study should
                                    help me determine which factors really are involved.

                                    Thanks John. Talk to you later.

                                    Hangs up. Looks down at the papers on her desk and starts to sort
                                    through them.

                                    Continue takes learner to Investigate Further page 6
                                                                                                  67
                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 6 Investigate Further (When learner selects Investigate Further from Page 4, learner goes to this
page)
Case- Control Study

Role Section                  Content Section
Image of Mashonda             Video recording of Mashonda sitting at desk just looking out talking to
                              learner. Computer on desk.
The next step in your
field investigation is to     I have decided to complete a case-control study. This analytic study design
design a case-control         used in epidemiology will help me determine the relationship between
study. Once you have          exposure and disease.
finished the design, you
need to carry it out. Your    Let’s see. I had better review what I know about case-control studies. I think
final step is to develop      I will check out a website Chase shared for more details.
your hypothesis about
the vehicle that’s carrying   Acts as if pulling up website on computer. Acts as if reading aloud to herself.
this illness around the
country. The sooner you       I remember this –individuals who have the disease being studied are cases.
figure out the mode of        Cases are compared to controls, who are individuals who are free of the
transmission, the sooner      disease.
the outbreak can be           Pauses as if reading more.
halted. Your experience       In the study, I will look at past exposures for both groups. The exposure
with data collection and      differences between the groups can help identify risk factors as well as
analysis will be very         protective factors. My objective is to find out if one or more factors are
useful.                       associated with the disease being studied.

Icons from before can         Right, right, right –Because it can be carried out with relatively few
remain visible. However,      individuals (fantastic – no more field interviews), a case-control study is
in this section, the          efficient and can be helpful when investigating an outbreak.
learner progresses
sequentially through the      Shuts down website and turns to audience.
materials in this section     I know that we, at the CDC, are opting for a case-control study rather than a
using the continue            cohort study because the case-control study starts with the outcome and
buttons at the bottom of      looks backward to find the exposure while the cohort study starts from
each page. This approach      exposure and looks ahead for the outcome.
is necessary because of
the nature of the content     Well, I better get started designed my case-control study.
that builds on
information from page         Turns to the paperwork on her desk.
to page.
                              Add this link to URL or to pdf below video.
                              For more about both types of studies, visit:
                              http://www.gfmer.ch/Books/Reproductive_health/Cohort_and_case_contr
                              ol_studies.html
                                                                        68
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

  The continue button should become visible and should take the learner to
  page 7.
                                                                                                 69
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 7 Identify Cases
Learner goes to this page when clicks page 6.

Role Section                         Content Section
Image of Mashonda                    First, you need to identify cases, which shouldn’t be a hard step.
                                     Unfortunately, there are plenty of them for you to choose from.
Let’s go through this case-control
study design step-by-step. You       You have to start by identifying a specific group of people who have
need to first identify the           the outbreak strain of listeriosis. They have to fit the case definition
possibilities and then make          established at the CDC. You can find cases using medical records,
choices. Once you have set up the    laboratory results, surveillance, registries, mass screening.
design, you will see how it plays    Alternatively ,you can develop a predefined group with medical
out as you plug in some numbers.     records. For this case, you need to develop a predefined group.
(That’ll be the next step.)
                                     There are a several options that present themselves in Valley Verde.
In a case-control study, you start   Any of the predefined groups in Valley Verde would work. You just
with the outcome of interest. For    need to figure out which one is your best choice if you want to
you, the outcome is “getting the     avoid selection bias. Click on the underlined words for a review of
listeria,osis strain within the      selection bias.
given dates.” You need to look at
who did and who didn’t get sick—     When the learner clicks, the following text box pops up, with a close
the cases versus the controls—       button included.
and figure out what they did         Bias distorts the relationship between exposure and disease.
differently that led to either       Selection bias can affect a case-control study if the controls are
exposure or protection.              selected from a population different from the cases. If selection bias
                                     has occurred, the study results will be skewed because the outcome
                                     of interest might affect each group differently. For example, if a
                                     study is focused on a disease or condition but the study cases and
                                     controls are from differing age groups—students as the cases
                                     compared with adults as controls—the study results could be
                                     flawed because the illness affects different age groups differently.
                                     End of pop up box.

                                     Choose the best choice of the following pre-determined groups for
                                     the case-control study. The best option is bolded.
                                     The choices on-screen are shown in the table below in the left -
                                     hand column. The feedback for each choice is shown in the right-
                                     hand column. Andrew if there is a better way to set this up please
                                     do so.
                                      These are the choices shown       When a choice is selected, the
                                      on the screen                     feedback for that choice should
                                                                        be given.
                                      Listeriosis patients at the       This group could work, but it
                                      Valley Verde Clinic               might be harder to find
                                                                        matching cases and controls
                                                                        70
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                              given the varied demographics
                                              of clinic patients. There might
                                              be a tendency to have a
                                              concentration of cases from a
                                              particular socio-economic
                                              group or from a particular part
                                              of town.

                                              You are looking for the best
                                              selection. Try again.

           Participants at the Great Plains   This group could work, but it
           Rodeo                              will take more time to gather
                                              information about this group,
                                              since you will be working
                                              backwards from online ticket
                                              orders and you won’t know
                                              much about the controls as you
                                              start the process.

                                              You are looking for the best
                                              selection. Try again.

           Participants at the Cancer         This group is your best option.
           Walk                               The registration process invites
           To move on learners must           cancer survivors to identify
           select this choice. The            themselves, so that gives you a
           continue button should appear      pretty specific group with a
           at the bottom of the screen        good amount of medical
           when they make this choice.        information already collected. It
           Continue button takes them to      should be easier to match cases
           Page 3 Part 2                      and controls with this group.
                                              Having this information
                                              available could help avoid some
                                              selection bias issues.

           Listeriosis patients at Jackson    This group could work.
           County Regional Medical            However, your cases and
           Center                             controls could have different
                                              reasons for being at that
                                              hospital, which could make
                                              selection more complicated.

                                              You are looking for the best
                                              selection. Try again.
                                                                        71
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts



          Continue does not appear until learner has selected the best
          option. Clicking on this button takes learner to Page 8.
                                                                                                  72
                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 8 Identify Controls (Design of Case-Control Study)
Learner goes to this page when clicks on continue on Page 8 after selecting correct answer)

Role Section                      Content Section
Image of Mashonda                 When conducting a case-control study, you might find more exposure
                                  among the cases than among the controls and think that it’s the result
Finding the right control         of factors that cause the disease —that there’s an association — but it
group sounds simple enough,       might actually be that the difference in exposures is the result of
but it can be very challenging.   selection bias. In other words, the method used for selecting controls
Actually finding the right        could invalidate the study results.
control group is one of the
most difficult problems in        The control group needs to be representative of the source population
epidemiology.                     from which you have selected the cases. Each control has to be
                                  someone who would have been considered a case if he or she had
                                  gotten the disease.

                                  Your best case group is cancer survivors between the ages of 40 and 70
                                  who took part in the Cancer Walk on July 18 and who later came down
                                  with the listeriosis strain involved in the outbreak. Who should make up
                                  your control group?

                                  You have to decide if you should use a random sample or special group
                                  when selecting individuals to be part of the control group. Click on the
                                  sample that you should be using. Be sure to consider such factors as
                                  time and expense involved.

                                  When the learner chooses a response, feedback is given as shown in the
                                  following table. The correct choice is bolded below. The continue
                                  button should appear at the bottom of the screen when they make this
                                  choice. Continue button takes them to Page 9

                                   These are the choices       When a choice is selected, the feedback
                                   shown on the screen         for that choice should be given.
                                   Use a random sample.        Typically, a random sample is ideal in this
                                                               type of study, but it is often the most
                                                               expensive. You don’t have the time or the
                                                               budget for this process.
                                   Use a special group.        This is your best option. You can recruit
                                                               controls from among the cancer survivors
                                   To move on learners         who were at the walk who didn’t come
                                   must select this choice.    down with listeriosis. This approach gives
                                                               you what you need: cases that are similar
                                                               in all respects, except for their exposure
                                                               to certain factors.
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 9 Identify Factors (Design of a Case-Control Study)
Clicking on Continue, which appears after the learner, chooses “use a special group” advances the
learner to this page

Role Section                      Content Section
Image of Mashonda
                                  For this outbreak, there are many different people eating foods from
As you are working with a         many different kitchens — locally, statewide, and nationally. It’s not like
special group, you could try      one restaurant where the diners got ill, and you could then trace back
for matched pairs for the         what happened and isolate the mode of transmission. However, by
study. However, that would        using the Cancer Work as your event, you have a group of people who
involve matching our cases        all ate at one place, at one time. This gives you a good chance of
for characteristics such as age   figuring out what protected the controls from becoming cases.
and gender.
                                  To identify the factors to be studied, you need to use binary variables—
For this study, you should use    basically, questions with just two answers, like yes or no. In your study,
group matching (or as it is       the binary variables will probably be exposed or not exposed.
also known – frequency or
category matching). Rather        You already know lots about your cases and controls. They’ve all had
than match individuals with       cancer, so they have weakened immune systems. You know they were
the same characteristics, you     at the walk on July 18, and there was something that caused some, but
need to match groups by           not all, of them to get a foodborne illness. Therefore, you should ask
making sure that the              them what, if anything, they ate while they were at the walk. You have
proportion of controls with       gotten the list of foods provided during and after the walk by the
particular characteristics is     organizers.
the same as the proportion of
cases with those                  Review the following food list provided to you by the Cancer Walk
characteristics. This approach    organizers. Select potentially relevant factor that should be include in
should give you more latitude     your study.
in recruiting cases and           Set up in a two-column table. Learners click on choices they want to
controls. The numbers won’t       use. When ready they can click on Check Answers. Incorrect answers
be equal, but the proportions     should be marked incorrect in some way, correct answers should be
will be.                          marked correct in some way. They need to get all answers correct
                                  before get continue button to move on to Page 10. The bolded items
                                  are correct.

                                   Choices                          Choices
                                   Ate food before taking part      Brought food from home
                                   in the walk                      and ate it during the walk
                                   Ate banana(s) distributed        Drank bottled water
                                   during the walk                  distributed during the walk
                                   Ate granola bars distributed     Drank diet lemon-lime soda
                                   during the walk                  distributed after the walk
                                   Ate packaged multi-grain         Ate soyburger(s) cooked on
                                   chips offered at post-walk       grill at post-walk picnic
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

       picnic
       Ate buns offered at post-       Ate cole slaw offered at
       walk picnic                     post-walk picnic
       Ate egg salad offered at        Ate dill pickle offered at post-
       post-walk picnic                walk picnic
       Ate grated cheese offered as    Ate ketchup offered at post-
       condiment at post-walk          walk picnic
       picnic
       Ate mustard offered at post-    Ate candy bar(s) offered at
       walk picnic                     post-walk picnic
       Ate apple(s) offered at post-   Ate ice milk sandwiched
       walk picnic                     offered at post-walk picnic
       Drank skim milk offered at      Did not eat or drink anything
       post-walk picnic                during or after the walk

      Continue (does not appear until learner has all correct)
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 10 Investigation Milestone
Once learner has completed the previous section, he or she will be presented with a series of questions.
The learner has to get 100% to move on. These questions should be presented randomly. At this point,
the purpose of these questions is to insure the learner is going through the information. If the learner
does not get 100% he or she is told to return to beginning.

As a CDC Field Investigator, it is important that you have a good understanding of the situations
surrounding the individuals who have become ill. The following questions will help you check your
knowledge of this information. To move forward with your investigation, you will need to get 100%.

Question Set 1

Which of the following foods was chosen by all of the individuals involved in the field interviews?

    a.   sausages
    b.   ice cream
    c.   luncheon meat
    d.   none of the above

Which of the following foods was not chosen by any of the individuals involved in the field interviews?

    a.   raw (unpasteurized) milk
    b.   hot dogs
    c.   eggs
    d.   feta cheese

Which of the following foods was chosen by all of the individuals involved in the field interviews?

    a.   coleslaw
    b.   luncheon meats
    c.   hot dogs
    d.   ice cream

Question Set 2

Individuals who have the disease being studied in a case-control study are known as

    a. controls
    b. cases
    c. risk factors
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

   d. protective factors

Individuals who are free from the disease being studied are known as

   a.   controls
   b.   cases
   c.   risk factors
   d.   protective factors

The type of study that starts with the outcome and looks backwards is known as a

   a.   cohort study
   b.   risk factor study
   c.   case-control study
   d.   field study

Question Set 3

The following statement describes a

   The starting point is the recording of healthy subjects with and without exposure to the
   putative agent or the characteristic being studied.

   a.   cohort study
   b.   case-control study
   c.   field study
   d.   factor analysis study

The following statement describes a

        The starting point is subjects with the disease or condition under study (cases). The
        cases’ history of exposure or other characteristics, or both, prior to onset of the disease,
        is recorded through interviews and sometimes by means of records and other sources. A
        comparison group consisting of individuals without the disease under study (controls)
        are assembled, and their past history is recorded in the same way as for the cases.

   a.   cohort study
   b.   case-control study
   c.   field study
   d.   factor analysis study
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

The following statement describes a

         Depending on the time when the study is initiated relative to occurrence of the disease(s)
         to be studied, one distinguishes between current and historical studies. In a current
         study, the data concerning exposure are assembled prior to the occurrence of disease—
         the current study design thus representing a true prospective study. In a historical study,
         data on exposure and occurrence of disease are collected after the events have taken
         place—the groups of exposed and non-exposed subjects are assembled from existing
         records, or health care registries.

    a.   cohort study
    b.   case-control study
    c.   field study
    d.   factor analysis study

Question Set 4

What is the “outcome of interest” involved in the study being conducted in this investigation?

    a.   getting the listeriosis strain within the given dates
    b.   getting sick within the given dates
    c.   CDC reported illnesses within the given dates
    d.   Illnesses reported to PulseNet within the given dates

Selecting controls from a population that is differs from the case population is known as

    a.   Information bias
    b.   control bias
    c.   selection bias
    d.   none of the above

Which of the following are possible predefined groups from Valley Verde?

    a.   individuals who attended the Great Plains Rodeo
    b.   participants in the Cancer Walk
    c.   patients at the Valley Verde Clinic
    d.   all of the above

Question Set 5
                                                                                                  78
                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

What is one of the most difficult challenges in epidemiology, particularly for a CDC field investigator?

    a.   interviewing the individuals with the outbreak strain of the pathogen
    b.   finding the right control group
    c.   identifying the risk factors
    d.   all of the above

The control group needs to be representative of the source population from which the cases are
selected.

    a. yes
    b. no

Which of the following represent the best control group for this study?

    a. cancer survivors between the ages of 40 and 70 who took part in the Cancer Walk on July 18 and
       who did not come down with the listerious strain involved in the outbreak
    b. cancer survivors over the age of 60 who took part in the Great Plains Rodeo and the Cancer
       Walk on July 18 who did not come down with the listerious strain involved in the outbreak
    c. cancer survivors between the ages of 40 and 70 who took part in the Cancer Walk on July 18 and
       who come down with the listerious strain involved in the outbreak
    d. cancer survivors of any age who did not take part in the Cancer Walk and who did not become ill

Question Set 6

What are the binary variables that are being used for the analysis being conducted in this investigation?

    a.   ate eggs or did not eat eggs
    b.   exposed or not exposed
    c.   ate soyburgers or ate hot dogs
    d.   ate at home before the walk or ate at the walk

Which of the following methods of analysis should not be used to match cases and controls being
conducted in this investigation?

    a.   matched pairs
    b.   group matching
    c.   frequency matching
    d.   category matching
                                                                                                 79
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Which of the following foods was not offered by the Cancer Walk organizers to walk participants?

    a.   packaged multi-grain chips
    b.   diet lemon-lime soda
    c.   cole slaw
    d.   Ham salad sandwiches

When learner has answered all the questions, the learner should see his or her score. If leaner does not
get 100% learner sees the following:
Your score was ____________. You appear to be missing some important information. Be sure to review
all of the information presented in the previous section of the investigation before returning to retake
this milestone. You will not be able to move on until you have scored 100%. Do not select “continue”
until you are sure you have reviewed “all” of the information.
Continue button takes learner to Investigation Set Up.

If learner gets 100%, learner sees the following.
Your score was 100%. You appear to have learned some important information about the individuals
who have become ill.

Learner can select
Make Recommendations (selecting this option takes learner to page 11)
Investigate Further (selecting this option takes learner to page 12)
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 11 Recommendations (if learner selects make recommendations from page 10)
Role Section                     Content Section
Image of Mashonda                Video Recording of Mashonda at Desk on phone talking to Lanni.
                                 Only Mashonda is heard.
You are ready to recommend a Hello Lanni, how is it going at the CDC. I hope well. I have finally
course of action. Thus, you call finished interviewing the cases that K.C. and Chase helped me select
Lanni, the CDC epidemiologist,   and I have selected the Cancer Walkers as my pre-defined group. I
to talk your ideas over with her also decided to recruit controls from the special group – cancer
before talking to the team       survivors on the walk who didn’t get the disease. I got a list of the
leader, John                     foods provided to the walkers by the organizers, and I have identified
                                 potentially relevant factors.

                                  Pause to listen.
                                  Thanks, I have collected a lot of information. In addition, although I
                                  have not pinpointed the precise food, I have identified potential
                                  problems.

                                  Pause to listen.
                                  To answer your question, there were many relevant factors: 13 to be
                                  exact. However, given the atmosphere here I think we should let
                                  people know what might be relevant. Letting them know should help
                                  calm everyone down a bit.

                                  Pause to listen.
                                  Well… maybe letting everyone know that 13 foods might have caused
                                  the outbreak won’t really help. You’re right, I don’t have enough
                                  information to really pinpoint the cause of the outbreak. And, you’re
                                  also right that Tim, our public relations officer, would really freak out
                                  if we put out such a general alert.

                                  Pause to listen.
                                  Okay, I will complete the Case-Control Study to determine the
                                  relationship between exposure and the outbreak. That study should
                                  help me determine which factors from my list of 13 are really
                                  involved.

                                  Thanks Lanni for your letting me talk through the process with you.
                                  See you later.

                                  Hangs up. Looks down at the papers on her desk, sighs, and starts to
                                  sort through them.

                                  Continue takes learner to Investigate Further page 12
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 12 Investigate Further
COMPLETE THE CASE-CONTROL STUDY

Role Section                           Content Section
Image of Mashonda
                                       Video of Mashonda in hallway holding many papers (these are the
Mashonda, you have a good array        self-administered questionnaires). She is talking to someone with
of factors for the study. You need     their back to the camera.
now to collect the data with a self-
administered questionnaire, an         Well I have gotten all the questionnaires returned to me. The data
interview form, or a medical           collection has gone very well. The cancer group has turned out to
examination form. The self-            be especially good for this study—they’ve been very motivated
administered questionnaire is          about responding quickly and in detail. Selecting this group has
probably going to work out best.       really made my job easier!
Once you have created the
questionnaire, you can ask K.C. to     I have been able to avoid data problems because everyone in the
help distribute the questionnaire to   group had a similar tendency to think carefully about what he or
your cases and controls.               she did and what they ate. Information bias could have resulted If
                                       cancer survivors had been in the case group while people who
Icons can remain visible throughout    never had cancer were in the control group.
this section. However, learner         Pauses as if being asked a question and then answers the
progresses sequentially through        question.
content.                               Sure I can explain what information bias is. Information bias has
                                       to do with how individuals report data. In some cases, it takes the
                                       form of recall bias, where the case group or control group has
                                       more—or less — detailed memories of past exposures. People
                                       who are ill often think about their disease more and consider
                                       what might have caused it; therefore, they might remember more
                                       about events than those who were healthy at the time and had
                                       no special reason to recall that time frame.

                                       So now, I have the outcome of interest, factors to be studied, and
                                       needed data (collected through the self-administered
                                       questionnaire). What’s next? Well next, I need to complete the
                                       Odds Ratio.

                                       Continue button takes learner to Page 13.
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 13 Odds Ratio

 Role Section                                     Content Section
 Image of Mashonda                                Thumbnail images of the Cancer Walk individuals from
                                                  the interviews. Natalie Tompkins, William Caulified,
 You are now ready to use the data the cancer     Hector Martinez, Evan Buchanan
 survivors in the case group and control group
 provided and calculate the odds ratios for the   The odds ratio serves as the measure of association
 factors of interest you identified.              between the disease and each of your factors of
                                                  interest. It will show you whether or not there is an
 Click on this link to learn more.                association, and if there is, you can quantify the
                                                  magnitude of the association.
 http://cphp.sph.unc.edu/focus/vol3/issue2/3-
 2Case-Control_issue.pdf                      The odds ratio, or OR, measures association between
                                              exposures and the outcome of interest. It contrasts
                                              the odds of exposure among cases with the odds of
                                              exposure among controls.

                                                  The odds ratio is one of several calculations that can
                                                  help analyze data collected to investigate a disease
                                                  outbreak. Incidence rate looks at disease frequency
                                                  and measures the probability of developing a disease
                                                  in a given period of time. The incidence rate is the
                                                  number of new cases divided by the total number of
                                                  people susceptible to the disease at the start of the
                                                  study period.

                                                  The odds ratio is used in case-control studies because
                                                  incidence rates can’t be calculated. In case-control
                                                  studies, the size of the population from which the
                                                  cases are drawn is unknown. The number of cases and
                                                  controls selected will determine the number of people
                                                  exposed or unexposed, so it doesn’t represent a real
                                                  population. The study does not include the entire
                                                  population that’s at risk. Even if you could include all
                                                  the people who did get sick, it would be almost
                                                  impossible to find and access all the people who did
                                                  not get sick.

                                                  Incidence rates can be used to calculate relative risk,
                                                  which establishes the association between a disease
                                                  and a factor being studied. The incidence rate in the
                                                  exposed is divided by the incidence rate in those not
                                                  exposed to arrive at the relative risk.
                                                                        83
The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                       Without knowing incidence rates, the relative risk
                       can’t be calculated. However, the odds ratio can
                       sometimes approximate the relative risk. The OR (or
                       odds ratio) is useful in case-control studies because it
                       enables an investigattor to estimate the risk.

                       The continue button takes learner to page 14
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 14 2x2 Tables (learner comes here from page 13 when clicks on continue)

Role Section                           Content Section
Image of Mashonda
                                       The following 2x2 table demonstrates frequency mapping.
You can calculate the OR using a
2x2 table. This table will help you                                 Case      Control
look at how each factor influenced           Exposed                  a          b
the probability of developing                Not exposed              c          d
listeriosis. The table lets you look         Total                  a+ c       b+d
at one factor and how it affected            Odds of Exposure        a/c        b/d
the cases and controls.
                                       The odds of exposure among cases are calculated by dividing the
Click here for a review of group, or   number of exposed cases ,“a,” by the number of unexposed cases,
frequency, mapping, and matched        “c.” Similarly, the odds of exposure among controls are calculated
pairs.                                 by dividing the number of exposed controls. “b,” by the number of
                                       unexposed controls, “d.” The odds ratio would be cells “ad”
Information below should come          divided by cells ‘bc.”
up in pop up window.
Matched pairs involve matching         The 2x2 table would appear as follows if you had used matched
cases and controls using individual    pairs instead of frequency matching. Note that the cases are listed
characteristics such as age and        along one side and the controls along the top.
gender.
                                                                   Controls    Controls not    Total
Group matching (also known as                                      exposed       exposed
frequency or category matching)             Cases exposed             e             f          e+f
matches groups by making sure               Cases not exposed         g             h          g+h
that the proportion of controls             Total                    e+g           f+h
with particular characteristics is
                                            Odds of Exposure                                    f/g
the same as the proportion of
cases with those characteristics.
                                       The cells with same exposure status (“a” and “h”) are concordant
This approach allows more
                                       cells. The ones with different exposure status (“f“and “g”) are
latitude in recruiting cases and
                                       discordant.
controls. The numbers won’t be
equal, but the proportions will be.
                                       The discordant cells provide the useful data for comparing cases
                                       and controls. The matched odds ratio would be cell “f” divided by
                                       cell “g.”

                                       The continue button takes learner to page 15.
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 15 2x2 Frequency Table
Role Section                           Content Section
Image of Mashonda                      Frequency Table
                                                              Cancer survivors at       Cancer survivors at
Let’s start by building a 2X2                                 the walk who got          the walk who didn’t
frequency table using one of the                              listeriosis (cases)       get listeriosis
factors in the current study.                                                           (controls)
                                        Ate egg salad at                a                          b
In this case, a stands for the          the post picnic
individuals who got listeriosis (the    (exposed)
cases) who ate egg salad at the         Did not eat egg                 c                       d
picnic, b stands for the controls       salad at the post
who ate egg salad at the picnic, c      picnic (not
represents the cases who did not        exposed)
eat egg salad at the picnic, and d      Total                          a+ c                    b+d
represents the controls who
skipped the egg salad at the picnic.   Adding the individuals who ate egg salad to those that did not
                                       results in the total number of cancer survivors who got listeriosis
                                       (that is, a + c) or the total number of controls that did not get
                                       listeriosis (that is, b + d).

                                       In this example, then, the odds ratio contrasts the odds of
                                       exposure (eating egg salad) in the case group with the odds of
                                       exposure (also eating the egg salad) among the control group.

                                       The odds of exposure in the case group is shown by the ratio of
                                       cases who were exposed to the cases who were not exposed, or a
                                       divided by c. The odds of exposure in the control would be the
                                       ratio of exposed controls to controls who weren’t exposed, or b
                                       divided by d.

                                       The formula for calculating the odds ratio is:

                                                                 OR = (a/c)/(b/d)

                                       Which can be simplified to:
                                                                     OR = ad/bc

                                       Continue this button takes learner to page 16
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 16 Frequency Mapping Example

Role Section                         Content Section
Image of Mashonda
                                     2x2 Table: Frequency Mapping
Now let’s build a 2X2 a                                   Cancer survivors at        Cancer survivors at
frequency table while adding                              the walk who got           the walk didn’t get
some data to this particular                              listeriosis (cases)        listeriosis (controls)
table.
                                      Ate egg salad at      15 (a)                   30 (b)
You need to work with a               the post- picnic
frequency table in this study
because matching individuals          Did not eat egg       16 (c)                   37 (d)
with the same characteristics is      salad at the post-
too difficult at this time. Using     picnic
the group, or frequency,
mapping approach gives you            Total                 35 (a+ c)                67 (b + d)
more latitude in recruiting cases
and controls.
                                     The odds of exposure among the cases would be a/c = 15/16 =
You need to match groups by          0.9375.
making sure that the proportion
of controls with particular          The odds of exposure among the controls would be b/d = 30/37 =
characteristics is the same as the   0.8108.
proportion of cases with those
characteristics. The numbers         The odds ratio for this factor would be 0.9375/.8108 = approximately
won’t be equal, but the              1.1563.
proportions will be.
                                     Anything in the study that increases the probability of getting the
                                     disease is considered a risk factor. Factors that decrease the
                                     probability of getting the disease are protective factors. Is eating egg
                                     salad at the post picnic is a risk factor?

                                     The odds of exposure among the cases were 1.1 times greater than
                                     the odds of exposure among the controls. Thus, there is not a very
                                     strong association between eating the egg salad and getting the
                                     disease.

                                     Continue takes learner to page 16
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 17 Probability versus Odds
Role Section                        Content Section
Image of Mashonda
                                    The odds ratio compares the exposure among cases to exposure
Calculating odds and at the         among controls to determine if and how exposure levels differ
same time thinking about            between the cases and the controls.
probabilities can get confusing.
However, there is a clear           The value of the odds ratio (OR) is compared to 1.
distinction between odds and
probabilities.                       OR = 1                Odds of exposure        No association
                                                           SAME for cases and      between disease and
Probability can be defined as                              controls                exposure
the number of times something
happens divided by the total         OR > 1                Odds of exposure        Positive association
number of occurrences.                                     among cases             between disease and
                                                           GREATER than            exposure (possible
Odds is defined as the number                              among controls          risk factor)
of times something happens
divided by the number of times       OR < 1                Odds of exposure        Negative (protective)
it does not happen. Odds is the                            among cases LESS        association between
ratio of probability of                                    than among controls     disease and exposure
occurrence of an event, such as                                                    (possible protective
an illness, to that of                                                             factor)
nonoccurrence. It is the ratio of
probability that something is so    The formula for probability is:
to the probability that it is not                      Probability = odds/(1 + odds)
so.
                                    The formula for odds is:
                                      Odds = probability/(1 - probability)

                                    Remember anything in the study that increases the probability of
                                    getting the disease is considered a risk factor. Factors that decrease
                                    the probability of getting the disease are protective factors.

                                    Continue button takes learner to page 18.
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 18 Part 2 Calculations of ORs

Role Section             Content Section
Image of Mashonda        Calculate the Odds Ratio, or OR, for each of following factors under study and
                         identify whether each is a possible risk factor, a possible protective factor, or
The odds of exposure     not associated. First, calculate the odds ratio (rounding to nearest tenth, for
among the cases          example 0.0) and enter that number in the space available. You may use 2x2
would be a/c.            tables, or formulas, to arrive at the OR. Then, indicate whether the factor is a
                         possible risk factor, a possible protective factor, or not associated with the
The odds of exposure     outbreak.
among the controls
would be b/d.
                           Factor      a    b     c   Possible Possible
                                                       d    OR            Not
The odds ratio would                                  risk     protective associated
be the odds of                                        factor   factor
exposure among the         Soyburger 2 33 33 54 0.1            Yes
cases divided by the       Hot dog   35 2 0 65 1137.5 Yes
odds of exposure           Cole slaw 20 21 15 46 2.9  Yes
among the controls (or     Grated    33 13 2 54 68.5  Yes
ad/bc).                    cheese
                           Apple     5 37 30 30 0.1            Yes
                           Ice milk  29 46 6 21 2.2   Yes
                           sandwich
                           Skim milk 7 11 28 56 1.0                       Yes

                         Learner should get answers correct before see continue button.
                         Continue (takes learner to Investigative Milestones, page 19.
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 19 Investigation Milestone
Once learner has completed the previous section, he or she will be presented with a series of questions.
The learner has to get 100% to move on. These questions should be presented randomly. At this point
the purpose of these questions is to insure the learner is going through the information. If the learner
does not get 100% he or she is told to return to beginning.

As a CDC Field Investigator, it is important that you have a good understanding of the situations
surrounding the individuals who have become ill. The following questions will help you check your
knowledge of this information. To move forward with your investigation, you will need to get 100%.

Question Set 1

In this field investigation, Mashonda will be using with her cases and controls a/an

    a.   self-administered questionnaire.
    b.   interview form.
    c.   medical examination questionnaire.
    d.   none of the above forms or questionnaires.

Which of the following types of bias was Mashonda concerned about as she completed the case-control
study?

    a.   selection bias
    b.   information bias
    c.   risk factor bias
    d.   matching pair bias

Information bias can be described as

    a.   how individuals report data
    b.   bias based on recall
    c.   differing memories of past exposures
    d.   all of the above

Question Set 2

Which of the following describes an “odds ratio”?

    a. a measure of association between the disease and each factor of interest
    b. a measure of association between exposures and the outcome of interest
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                           The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

    c. an approximate measure, or estimate, of the relative risk
    d. all of the above

In a case-control study,

    a.   the size of the population from which the cases are drawn is known.
    b.   the number of cases and controls selected represent the entire known population.
    c.   the relative risk rates cannot be calculated.
    d.   all of the above.

Which of the following is a description of matched pairs?

    a. the proportion of controls with particular characteristics is the same as the proportion of cases
       with those characteristics
    b. each case is matched with a control that has the same specific characteristic
    c. all controls must be selected first so that the investigator knows the proportions to be matched
    d. All of the above are correct statements about matched pairs.



Question Set 3

The following 2x2 table illustrates

                             Case      Control
    Exposed                    a          b
    Not exposed                c          d
    Total                    a+ c       b+d
    Odds of Exposure          a/c        b/d

    a. frequency mapping
    b. matched pairs

The following 2x2 table illustrates

                            Controls    Controls not   Total
                            exposed       exposed
    Cases exposed              e             f         e+f
    Cases not exposed          g             h         g+h
    Total                     e+g           f+h
    Odds of Exposure                                    f/g
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                             The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

    a. frequency mapping
    b. matched pairs

Concordant cells are those with ________ exposure status.

    a. the same
    b. different

Question Set 4

The type of cells in a 2X2 matching pair table that provide the most useful data for comparing cases are

    a.   discordant cells.
    b.   concordant cells.
    c.   category cells.
    d.   unknown.

Based on the following frequency mapping 2x2 tables, what is the odds of exposure among the cases?
                                  Cancer survivors at     Cancer survivors at the
                                  the walk who got        walk didn’t get
                                  listeriosis (cases)     listeriosis (controls)

         Ate cole slaw offered at     15 (a)                  30 (b)
         the post- walk picnic
         Ate cole slaw offered at     16 (c)                  37 (d)
         the post- walk picnic
         Total                        35 (a+ c)               67 (b + d)

    a.   0.8101
    b.   1.563
    c.   0.9375
    d.   1.100

Based on the following frequency mapping 2x2 table, the odds ratio for the factor, “ate cole slaw
offered at the post-walk picnic” would be
                                   Cancer survivors at    Cancer survivors at the
                                   the walk who got       walk didn’t get
                                   listeriosis (cases)    listeriosis (controls)

         Ate cole slaw offered at     15 (a)                  30 (b)
         the post- walk picnic
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

         Ate cole slaw offered at    16 (c)                    37 (d)
         the post- walk picnic
         Total                       35 (a+ c)                 67 (b + d)

    a.   0.8101
    b.   1.563
    c.   0.9375
    d.   1.100

Question Set 5

Anything in the study that increases the probability of getting the disease is considered a risk factor.

    a. yes
    b. no

Anything in the study that decreases the probability of getting the disease is considered a risk factor.

    a. yes
    b. no

Probabilities is the same as odds.

    a. yes
    b. no

Question Set 6

The odds ratio is the odds of exposure among the cases divided by the odds of exposure among the
controls.

    a. yes
    b. no

The factor in Mashonda’s field investigation that has the highest odds ratio is

    a.   soyburgers
    b.   cole slaw
    c.   grated cheese
    d.   hot dogs
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


An odds ratio of greater than one (1) means that

    a.   the odds of exposure among cases is greater than the odds of exposure among controls.
    b.   there is a positive association between the disease and exposure.
    c.   the “food” is a possible risk factor.
    d.   all of the above.

When learner has answered all the questions, the learner should see his or her score. If leaner does not
get 100% learner sees the following:
Your score was ____________. You appear to be missing some important information. Be sure to review
all of the information presented in the previous section of the investigation before returning to retake
this milestone. You will not be able to move on until you have scored 100%. Do not select “continue”
until you are sure you have reviewed “all” of the information.
Continue button takes learner to Investigation Set Up.

If learner gets 100%, learner sees the following.
Your score was 100%. You appear to have learned some important information about the individuals
who have become ill.

Learner can select
Make Recommendations (selecting this option takes learner to page 18)
Investigate Further (selecting this option takes learner to page 19)
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                        The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 20 Recommendations (if learner selects make recommendations from page 19)

Role Section                      Content Section
Image of Mashonda                 Video Recording of Mashonda at Desk on phone talking to John.
                                  Only Mashonda is heard. She starts out really excited.
You have completed the Odds       I have just finished the odds ratio analysis. And I know what factor is
Ratio and have identified the     causing the problem. I need to talk to Tim Simons, our public relations
most probable factor. You are     officer, right away. He needs to get a press release out to all media
really excited and have decided   outlets!
that now your team leader,
John, will listen to your         Pause to listen.
recommendations.                  But, I know the culprit! It’s …
                                  Stops as if interrupted to listen.
                                  No, no .. I haven’t completed an environmental study or done any
                                  additional lab analysis.

                                  Pause to listen.
                                  No, I have not pinpointed the location. Well… maybe letting everyone
                                  know that a particular food might have caused the outbreak won’t
                                  really help. You’re right, I don’t have enough information to really
                                  narrow down the cause of the outbreak. And, you’re also right that
                                  Tim, our public relations officer, would really freak out if we put out a
                                  general alert, saying don’t eat ....

                                  Stops as if interrupted to listen.
                                  Okay, I will complete an environmental study and ask Chase and K.C.
                                  for help with additional lab analysis. I will let you know the results.

                                  Hangs up. Sighs. Gets up and leaves office – to talk with K.C. or Chase

                                  Continue takes learner to Investigate Further page 19
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


Page 21 Investigate Further (if learner selects make investigage further from page 19)

Role Section                      Content Section
                                  Mashonda is talking to the audience – the students. She is sitting at a
Image of Mashonda                 desk or table, or standing and just speaking to an unseen person.

As an investigator for the        I am making progress but I need to get additional laboratory data as
Centers for Disease Control and   well as complete an environmental assessment. And, I know, John
Prevention, you are a disease     would be thrilled if I could bring in some appropriate food samples
detectives. Your principal duty   and do some testing those samples. Then I would really have a basis
is to gather and compile field    for a hypothesis on the mode of transmission for this outbreak.
data to complement laboratory
data.                             I’ve asked for some help with gathering traceback information. As I
                                  coordinated data for the case control study, I noticed that the food
As a CDC Field Investigator,      served at the picnic for the Cancer Walk was donated by Keefer’s.
your duties include:              Keefer’s is a regional grocery chain. One of the local stores put
 Assisting in tracing back the   together the salads, and I think it was their staff who did the grilling at
    identified illness to help    the event.
    discover the mode of
    transmission.                 I wonder – there were some cases after the Great Plains Rodeo – did
 Conducting a case control       Keefer’s have product there, too? If I remember right – they did a
    study to match reported       food booth. Something to keep in mind, but it’s probably a little soon
    cases with the established    to implicate Keefer’s. We don’t even know exactly which food is
    case definition.              involved. I better begin by collecting food samples.
 Collecting food samples to      Continue takes learner to page 19
    aid the formulation of a
    hypothesis.
 Helping to generate a
    hypothesis identifying the
    mode of transmission
    involved in the outbreak.
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 22 Food Samples
Role Section                      Content Section
Image of Mashonda                 Now you have to decide which method is best to use to collect the food
                                  samples you need to continue your investigation. Click on each possible
A foodborne illness               sample to learn more about how taking this sample may, or may not,
pathogen, specifically            help you in your analysis.
bacteria or bacterial toxins,
can be identified through         When the learner clicks on each possible sample, feedback is given as
food samples. Food samples        shown in the following table. The continue button should appear at the
are generally tested once the     bottom of the screen when the learner has clicked on each one (or can
investigation yields a specific   be there all the time if easier and faster). Continue button at bottom of
food or set of foods              screen takes learner to Page20.
suspected and a specific
pathogen identified by                  Food Samples          Response
clinical specimens.                Ask the public to          Well, you might get something useful, but
                                   submit samples.            you would be overwhelmed with things you
You have reached the point                                    don’t need or want to test. In addition,
in the investigation where                                    you’d have no control over how the sample
you need to collect food                                      was collected.
samples. There are a number        Get samples from the       This approach could be very useful,
of ways you could do this          homes of some people       assuming you could pinpoint that it’s the
collecting. You need to find       who got the disease.       food they ate as well as prepared, as it was
the best way.                                                 when they ate the suspected meal.
                                   Get samples of foods       You could follow this approach. However,
                                   served at the Cancer       it’s been weeks since the walk, so you
                                   Walk from the grocer       won’t be able to get the actual food served.
                                   who supplied it.           Nevertheless, you can find out about
                                                              preparation of the food.
                                   Get samples of foods       You could take this approach. But, it’s been
                                   served at the Great        weeks since the rodeo, so you won’t be
                                   Plains rodeo.              able to get the actual food served. You can
                                                              certainly find out about preparation of the
                                                              food.
                                   Get samples from the       Why? This is a national outbreak. The local
                                   local water supply.        water supply could hardly be the vehicle of
                                                              transmission. The only way that the local
                                                              water supply would come into play is if the
                                                              local outbreak had a different source than
                                                              other states in the outbreak.
                                   Get samples from           You could get these samples, but how
                                   Biggie Burger and          would you decide which foods to test? Is
                                   other local restaurants.   there any correlation that you’ve noticed
                                                              so far between anyone who dined out and
                                                              who later got the illness?
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 23 Sample Collecting

  Role Section                           Content Section
  Image of Mashonda
                                         Image of open refrigerator and freezer. The refrigerator should
  You now have an idea of where to       show large cole slaw container marked “Can. Wlk. 7/18” and
  look; therefore, you will need to      the freezer should be packed with hot dog packages and
  conduct field visits. On these field   soyburgers to one side also labeled. Can.Wlk. 7.18.
  visits, you will be accompanied a
  county food inspector. The food
  inspector will collect the samples
  following very precise collection
  and submission protocols.

  The two of you go to Evan
  Buchanan’s kitchen. He’s one of the
  local people who got the listeriosis
  strain. He has given you permission
  to take food samples. Although you
  would normally go to commercial
  kitchens rather than a private
  home, in this case, the private
  home is a good choice. Mr.
  Buchanan works for Keefer’s, and
  he took home food from the           You will need to get high quality samples, and you must get
  Cancer Walk that he still has.       them to the lab within the next three days. You will need to use
                                       Styrofoam coolers with ice packs, as well as dry ice for the
                                       frozen food.
  Learner sees documentation for
  sample collection (Ask Joyce at
                                       If possible, you should take things in their original containers.
  Lancaster County Health
                                       However, if you have to leave the original container, you’ll need
  Department for samples)
                                       to take samples from the geometric center as well as other
   Learner sees the type of Styrofoam
                                       locations in the container. The implements and containers you
  cooler used for sample collection
                                       use must be sterile.
  (Ask Joyce or Phil at Health to
  borrow)
                                       You are in luck, there is a large container of cold slaw in the
                                       refrigerator marked as coming from the Cancer Walk. You will
                                       need about a quarter pound of it.

                                         You have to note the name and type of product on the label.
                                         You should also include the brand, the manufacturer, and code
                                         or lot number, if available. You need to include your name, the
                                         date and time, and place you collected the food sample. If this
                                         were a restaurant, you’d write the establishment name on the
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

              label.

              Evan froze some of the soyburgers and hot dogs and buns from
              the Cancer Walk. Fortunately, that won’t kill the bacteria if it’s
              there. You need to be sure to label each package you take from
              the freezer.

              You must always be careful about documentation when
              collecting samples and you should always observe all chain of
              custody procedures. That way there’s no question about the
              reliability of the samples or the procedures you used to collect
              them. A food sample is in your custody whether you actually
              have the sample, you only have it in your view, or you’ve
              collected it and locked it up in a secure area.

              Now that you have samples, you can take them to the health
              department yourself or ship them by a common carrier or
              parcel service.

              Continue button takes learner to page 21.
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 24 Food Sample Results

Role Section                                          Content Section
Image of Mashonda                                     Images of Hot Dogs, Soy burgers, Buns, Cole Slaw

                                                                       The report on the food samples
You may have found the food equivalent of a                            was just returned The sample of
smoking gun. Do you have a hypothesis about the                        cole slaw that was collected (the
mode of transmission now? If not, it might help                        sample was taken from a container
you if you review a “biography” of the disease, and                    served at the Cancer Walk July 18)
look again at the data you’ve collected.              was not a sufficient sample for an analysis. The
                                                      frozen buns were not suspect and so were not
                                                      tested. The soy burger patties, which Mr.
                                                      Buchanan had preserved, were tested and not a
                                                      trace of the pathogen was found.

                                                                                 However, he had three
                                                                                 packages of hot dogs
                                                                                 frozen together in a
                                                                                 paper bag marked
                                                                                 “Cancer Walk.” The
                                                                                 packaging was intact,
                                                                                 and the brand was
                                                                                 “Keefer’s Own,” the
                                                                                 store’s house brand.
                                                                                 That was the brand
                                                      Keefer’s served at the walk. The case lots of the
                                                      three packages matched. The pathogen was
                                                      detected in some but not all of the hot dogs from
                                                      Mr. Buchanan’s freezer. This could be the food
                                                      equivalent of a smoking gun.

                                                      Also, your investigation has shown that Keefer’s
                                                      gets its hog dogs from Peetz Innett, which is a
                                                      major packing concern with two plants in the east.
                                                      They supply exclusively to Keefer’s as well as to
                                                      Walmer’s, except Walmer’s markets them as Super
                                                      Super Value Dogs.

                                                      Continue takes learner to page 22
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                        The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 25 Reporting Agency

Role Section                            Content Section
Image of Mashonda
                                        Set up in accordion style with the bolded words as headers
Before you’re ready to report your      (instead of questions as the header). The text below the
theory on the mode of transmission,     bolded headers is the text for the “answer” section of the
your last step is to decide whom to     accordion format.
report to—the FDA or the USDA. You
will report to one of these agencies    FDA = Food and Drug Administration
after, of course, you let your team     Like the USDA, the FDA regulates the safety of the food
leader at the CDC know about your       supply, inspects food products, promulgates, and enforces
findings.                               food safety regulations, tests suspected foods, works with
                                        industry to improve safety practices, and works extensively
                                        with state food and regulatory partners.

                                        However, the FDA works with non-meat products such as
                                        seafood, fruits, vegetables, and shell eggs.

                                        USDA = United States Department of Agriculture
                                        Like the FDA, the USDA regulates the safety of the food
                                        supply, inspects food products, promulgates, and enforces
                                        food safety regulations, tests suspected foods, works with
                                        industry to improve safety practices, and works extensively
                                        with state food and regulatory partners.

                                        The USDA works with meat, poultry, and processed egg
                                        products.

                                        Click on the agency you should notify of your findings after, of
                                        course, you have talked with your team leader and colleagues
                                        at the CDC. Learners should see the following listed agencies.
                                        They should should be able to click on anyone but should be
                                        able to move on (see continue) until select the correct answer.
                                        The correct answer is bolded.

                                         Agency              Feedback
                                         Both FDA and        Though both the USDA and the FDA
                                         USDA                regulate the safety of the food supply,
                                                             inspect food products, promulgate and
                                                             enforce food safety regulations, test
                                                             suspected foods, work with industry to
                                                             improve safety practices, and work
                                                             extensively with state food and
                                                             regulatory partners, it is not necessary
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                    to contact both in this case.
                 FDA only           Remember the FDA works with non-
                                    meat products such as seafood, fruits,
                                    vegetables, and shell eggs. Therefore,
                                    the FDA would not be the proper
                                    authority to contact.
                 USDA only          Correct, the USDA works with meat,
                                    poultry, and processed egg products.
                                    The USDA would be the proper
                                    authority to contact.

                Continue takes learner to Page 23 Investigation Milestone
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                           The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 26 Investigation Milestone
Once learner has completed the previous section, he or she will be presented with a series of questions.
The learner has to get 100% to move on. These questions should be presented randomly. At this point
the purpose of these questions is to insure the learner is going through the information. If the learner
does not get 100% he or she is told to return to beginning.

As a CDC Field Investigator, it is important that you have a good understanding of the situations
surrounding the individuals who have become ill. The following questions will help you check your
knowledge of this information. To move forward with your investigation, you will need to get 100%.

Question Set 1

When are food samples “generally” tested?

    a.   immediately when an illness is noted
    b.   once the investigation identifies specific suspect food and a specific pathogen
    c.   not until all the suspected cases are interviewed
    d.   none of the above

Which of the following would not be a good way to collect food samples?

    a.   asking the public to submit samples
    b.   going to all restaurants in a location and taking samples
    c.   visiting all homes of all ill individuals and taking samples of all food in the cupboards
    d.   all of the above

Who went with with Mashonda on her field visit to collect food samples?

    a.   an USDA investigator
    b.   the local health department director
    c.   county field inspector
    d.   the state epidemiologist



Question Set 2

What is the time requirement in getting food samples to the lab?

    a. 2 weeks
    b. 24 hours
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                            The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

    c. 3 days
    d. 2 hours

Which of the following information does not need to be noted on the food sample label?

    a.   name of food sample product
    b.   the name of the person taking the sample
    c.   the date and time of taking of the food sample
    d.   the person who had the sample

Once the food inspector has placed the food sample in a secure area, he or she is no longer responsible
for that sample.

    a. yes
    b. no

Question Set 3

Which of the following foods was collected at Evan Buchanan’s residence?

    a.   cole slaw
    b.   hot dogs
    c.   soyburgers
    d.   all of the above

Which of the following foods collected contained the pathogen?

    a.   cole slaw
    b.   hot dogs
    c.   buns
    d.   soyburgers

The hot dogs from Evan Buchanan’s freezer were identified as coming from

    a. Keefer’s.
    b. Peetz Innett
    c. the Cancer Walk
    d. all of the above

Question Set 4
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


When collecting food samples, the food inspector must have the food in its original container.

    a. yes
    b. no

When collecting food samples, the food inspector needs to take samples from the center of the
container but does not have to take samples from other locations in the container.

    a. yes
    b. no

Food that is frozen can be used as a food sample.

    a. yes
    b. no

Question Set 5

The Food and Drug Administration is the only agency in the United States that regulates the safety of
food.

    a. yes
    b. no

The United States Department of Agriculture works with meat, poultry, and processed egg products.

    a. yes
    b. no

Food and Drug Administration works with meat, poultry, and processed egg products.

    a. yes
    b. no

When learner has answered all the questions, the learner should see his or her score. If leaner does not
get 100% learner sees the following:
Your score was ____________. You appear to be missing some important information. Be sure to review
all of the information presented in the previous section of the investigation before returning to retake
                                                                                                105
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

this milestone. You will not be able to move on until you have scored 100% . Do not select “continue”
until you are sure you have reviewed “all” of the information.
Continue button takes learner to Investigation Set Up.

If learner gets 100%, learner sees the following.
Your score was 100%. You appear to have learned some important information about the individuals
who have become ill. You need now to report your findings (page 23)
                                                                                                106
                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 27: Report your findings

The following end role quiz should appear in the content area.
Correct answers are shown in red; students may select more than one answer

Role Section                    Content Section

If we need role section, use
following words below image
of Mashonda. If do not need      Question                              Answers
role section on this final       Individuals Mashonda conducted        o soft (i.e. Latin-American)
report add the following         field interviews with completed a        white cheeses
directions to top of page.       food list. Based on the choices       o Feta cheese
                                 made by these individuals on          o Coleslaw
Use the information you’ve       those lists, which of the following   o potato salad
gathered to answer the           foods are possible modes of
following questions and          transmission for this outbreak.
formulate a theory about this                                          Answers
outbreak. You may select         For this question set the same        o raw (unpasteurized) milk
more than one response.          question is used three times with     o ice cream
When you are finished,           different choices. Correct            o turkey franks
submit your report.              answers are in red.                   o hot dogs

                                                                       Answers
                                                                       o sausages
                                                                       o shrimp
                                                                       o (undercooked) chicken
                                                                       o Luncheon meat
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

       For this question set, the three
       questions are different. Correct
       answers are in red.

       Is the age of the victim a factor in   Answer
       this outbreak?                         o Yes
                                              o No

       Is the ethnicity of the victim a       Answer
       factor in this outbreak?               o Yes
                                              o No

       Is the location of the victim a        Answer
       factor in this outbreak?               o Yes
                                              o No

       For this question set tree
       questions are different. Correct
       answers are in red.

       Is the income or social level of       Answer
       the victim a factor in this            o Yes
       outbreak?                              o No


       Is the victim being pregnant a         Answer
       factor in this outbreak?               o Yes
                                              o No

       Is the victim having a                 Answer
       compromised immune system a            o Yes
       factor in this outbreak?               o No

       For this question set the same         Answer
       question is used three times with       o Biggie Burger
       different choices. Correct              o Gas-N-More
       answers are in red.                     o Fanzano’s
       What if any restaurants are             o All of these
       named by victims as places they
       ate?                                   Answer
                                               o Balance Burgers
                                               o Gas Shops Limited
                                               o Fanzano’s
                                               o None of these
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

                                           Answer
                                            o Great Big Dogs
                                            o Limited Meals Diner
                                            o My Best Chinese
                                            o None of these

       For this question set the same      Answer
       question is used three times with   o Wellman’s
       different choices. Correct          o Walmer’s
       answers are in red.                 o Keefer’s
                                           o All of these
       What stores are named most
       frequently by victims as places    Answer
       they shopped prior to the illness? o Hy Lites Groceries
                                          o Wall Street Shop
                                          o Keefer’s
                                          o None of these

                                           Answer
                                           o Walk on by
                                           o Balance Burgers
                                           o Gas Shops Limited
                                           o None of these

       For this question set the same
       question is used three times with
       different choices. Correct          Answer
       answers are in red.                 o Cole slaw from Keefer’s
                                           o Hot dogs from Peetz Innett
                                           o Soyburgers from Wellman’s
       What is the best hypothesis         o None of these
       about the mode of transmission
       at this point in the outbreak?      Answer
                                           o Sausages and eggs from Gas-
                                              N-More
                                           o Buns from Keefer’s
                                           o Hot dogs From Peetz Innett
                                           o All of these

                                           Answer
                                           o Cole slaw from Keefer’s
                                           o Soyburgers from Peetz Innett
                                           o Buns from Wellman’s
                                           o None of these
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts


                                                                      Answer
                                  For this question set the same      o the USDA and the CDC
                                  question is used three times with   o the FDA and the CDC
                                  different choices. Correct          o Both the USDA and the FDA
                                  answers are in red.                 o None of these

                                  Mashonda’s report should go to      Answer
                                  the                                 o the CDC only
                                                                      o the FDA only
                                                                      o Both the USDA and the FDA
                                                                      o None of these

                                                                      Answer
                                                                      o the USDA only
                                                                      o the FDA only
                                                                      o the CDC only
                                                                      o None of these




Questions are randomly presented to students within each question set.

Learner has to complete answers for each question and then click a “Submit my report” button. When
the learner hits “submit.” If the learner’s score is below 100 percent correct, the learner gets the
following prompt.

Sorry, your report contains factual errors and has been rejected. You’ll have to review the content
presented in this role and resubmit.

In the event of failure, the learner has to review before re-taking the quiz. [Can the learner go back
through the module somehow and then return to the test or does the learner have to go back and work
through it again? Should there be an “essential points” review or summary?]

When the student achieves a score at least 100 percent correct, the learner gets the following prompt
and can advance to the next module.

Thank you for your report. Your team leader concurs with your findings and has notified the USDA
Investigator. This feedback should take learner to transition page where they can exit to the role
selection page.
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                         The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

The learner can’t move forward to the next module until the report is accepted (i.e., until the quiz score
is 100 percent).
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                          The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

Page 28: Transition from CDC Field Investigator Role to USDA Investigator Role page

TRANSITION FROM ROLE 3 TO ROLE 4(USDA INVESTIGATOR)

The learner sees the following message from John Reames, CDC team leader.

To: CDC outbreak investigation team

From: John Reams, team leader

Re: Outbreak status, next steps

First, let me congratulate the team for excellent work in this investigation. We’ve finally identified our
suspect food—hot dogs, specifically those produced by the Peetz Innitt Corporation. The actual source
of contamination has yet to be determined, as you know.

It falls to the USDA to carry out a full traceback investigation to discover the source. Once they’ve found
it, cleaning and disinfecting of involved facilities and equipment will be ordered as needed. There may
closures of whatever facilities are involved—temporary or permanent, as the circumstances dictate.

As a health organization, we don’t have to wait for proof of contamination from the lab to take action.
We need to act responsibly, of course, to avoid panic. But at this stage we can alert the public as to what
action to take: Cook ALL hot dogs thoroughly prior to eating. Those who are pregnant or who have
compromised immune systems might be encouraged to consider abstaining from hot dog products until
the source of contamination is identified and controlled.

As we learn more, we will provide the public with batch numbers, brand names, and continuing
reminders to cook all hot dogs before eating them. We might also tell them to:

       Discard any suspect food—i.e., hot dogs bearing specific brand names and batch numbers.
       Check refrigerator and freezer for suspect food.
       Assist elderly or disabled friends and family in searching for and discarding suspect food.

Meanwhile, I’m glad to report the outbreak appears to be slowing down, but cases continue to emerge.
We will not consider the outbreak to be over until the number of cases of new illnesses reported drops
to the number we normally expect.

Please continue to watch for any rise in case numbers. Since we haven’t yet identified and controlled
the source of the contamination, another wave of illness is quite possible. Even we control if whatever
caused the original contamination, there could be a second contamination—possibly involving a
different food—that is linked to the first outbreak.
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts
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The Foodborne Inv estigations CDC Field Investigator Role— Combined 4 Parts

								
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