County Fair Chocolate Scare Case Study - PowerPoint Presentation

1. County Fair Chocolate Scare Case StudyColorado Integrated Food Safety Center for Excellence - 2017

2. County Fair Chocolate Scare CaseDenver, ColoradoSummary: the case study is based on a foodborne illness outbreak caused by the unintentional ingestion of marijuana-infused foods (edibles) at a county fair in Colorado.Case study designed to facilitate a discussion among disease investigators, epidemiologists, medical staff and other public health professionals about how to respond to an outbreak involving a marijuana-infused food.

3. ObjectivesAfter completing this case study, participants should be able to: Give an example of an unintentional marijuana exposureName agencies that may be involved in an unintentional marijuana exposure investigationList available resources that address marijuana exposureFormulate interview questions for an unintentional marijuana exposure investigation.

4. Objectives (cont.)Establish a case definition for marijuana exposure. List special considerations that should be made during an environmental assessment of a marijuana facility.Recommend control measures to prevent unintentional marijuana exposure in the future.

5. Denver County FairDates: Weekend of: August 1 – August 3Attendees: ~ 20,000 peopleFeatured: Themed vendor pavilions highlighting selected businessesThe Pot PavilionFor 21 years and olderHoused 44 vendors Vendors were ONLY allowed to talkVendors could NOT display, sell or consume any marijuana or infused products. Products were defined as: marijuana flower (bud, grass), concentrates (hash oil, shatter), and infused foods and drinks.

6. Initial ComplaintCall came in on Tuesday August 5th to Public HealthMale attended fair on Sunday August 3Symptoms: anxious and “weird” Tightness of chest, heavy head & body, dry mouth and intense nauseaSymptoms began one hour after consumption of chocolate bar (LoveALL booth @ Pot Pavilion) Consumed only ¼ of bar due to an “off taste”Wife did not consume bar and felt fineRecovered by next day

7. Also Complained to the VendorThe man called the vendor to assure him that the chocolate bar did not contain marijuanaWanted to document the official complaint since started new job the next weekNew job required drug test

8. Question #1Question 1: What other agencies might you involve or consult after receiving this initial complaint? PLEASE WRITE DOWN RESOURCE IDEA(S) ON POST-IT NOTE

9. Complaint #2On Monday, August 4th Denver Public Health contacted the Marijuana Enforcement Division (MED) Colorado Department of Revenue MED received a similar complaint from a man reporting nausea, loss of coordination, and dizziness after consuming samples from a vendor at the Pot PavilionThe man reported using marijuana in the past and stated the chocolate bars got him “high”previously had NOT experienced nausea or disorientation from marijuana use.

10. More Complaints…MED contacted the Denver County Fair coordinator, Four individuals reporting symptoms after attending the Pot Pavilion.The coordinator provided contact information for the additional persons. The MED, with the Denver Police Department, had already launched a criminal investigation. PH was left to determine whether to initiate a PH investigation PH contact Environmental Health (who inspect marijuana facilities) to discuss the situation.

11. Question #2Question 2: Would you investigate this incident further as a foodborne outbreak?

12. The Investigation BeginsAfter consulting with the State Health Department and the Centers for Disease Control and Prevention (CDC)considers unintentional ingestion of a marijuana-infused food a reportable foodborne illness, Denver PH and EH decided to initiate an outbreak investigation to determine the source of contamination

13. Question #3Question 3: What resources would you use to find additional information on marijuana-infused foods?PLEASE WRITE DOWN RESOURCE IDEA(S) ON POST-IT NOTE

14. Question #3Question 3: What resources would you use to find additional information on marijuana-infused foods?California Bureau of Cannabis Controlhttp://bcc.ca.gov/California Poison Control System (UCSF/SFGH)https://calpoison.org CDPH – Center for Environmental HealthDivision of Food, Drug and Cannabis Safetyhttps://www.cdph.ca.gov/Programs/CEH/DFDCS/Pages/DFDCS.aspx

15. CDPH Division of Food, Drug & Cannabis Safety

16. Marijuana / THC 101Tetrahydrocannabinol (THC) is the primary active ingredient in marijuana-infused foods (edibles). In Colorado, the maximum serving size for retail, marijuana-infused foods is 10mg of active THCsingle serving sizes must be clearly marked. A retail product cannot contain more than 100mg THC total.

17. Common Effects of MarijuanaInclude:a happy, relaxed, or “high” feeling slower reactions and hand/eye coordination distorted perceptions of time and distance difficulty thinking, learning, and remembering anxiety, panic, or paranoiaincreased heart rate increased blood pressure decreased interest in normal activities increased appetite dry mouth red eyes

18. Symptoms of Overconsumption Include:extreme confusion, anxiety, panic, or paranoia hallucinations or delusions increased blood pressure severe nausea and vomiting psychosis suicidal ideations

19. Marijuana ConsumptionMarijuana is eaten, effects typically take longer to start (up to 4 hours) and last longer (4-10 hours) than smoked or inhaled marijuana. Marijuana-infused foods are absorbed by: gastrointestinal uptake (digested through the stomach), oral uptake (digested through saliva), or a hybrid of gastrointestinal and oral uptake. Time to onset and duration of effects depend on method of absorption, dose, and individual factors, such as prior marijuana use.

20. Absorption of Marijuana-Infused FoodsTime to onset and duration of effects depend on method of absorption, dose, and individual factors, such as prior marijuana use.

21. Question #4Question 4: What questions would you ask during these initial case interviews? PLEASE WRITE DOWN QUESTION(S) ON POST-IT NOTE

22. Public Health Line ListOn August 3rd, all four cases reporting consuming samples at the LoveAll booth in the Pot Pavilion

23. How to Create a Case DefinitionQuestion #5Person PlaceTimeClinical Features

24. How to Create a Case DefinitionQuestion #5Person (age, sex, race, occupation, etc.)Place (specific geographic location or facility)Time (period of time associated with illness onset for cases under investigation)Clinical Features (signs, symptoms and laboratory tests)

25. How to Create a Case DefinitionQuestion 5: Based on the information provided so far, establish a case definition for this outbreak…

26. Case Definition (Working)Anyone who attended the Pot Pavilion at the Denver County Fair on August 3rd; ANDSubsequently had two or more of the following symptoms: nausea, vomiting, disorientation, dizziness, anxiety, hallucinations, stomach ache, dry mouth, numbness/tingling in extremities, confusion, dyspnea, sweating, fainting, chest tightness, loss of coordination, panic, paranoia, difficulty in speaking, or memory loss.

27. Question #6Question 6: How would you find additional cases? Any ideas for enhanced reporting and surveillancePLEASE WRITE DOWN IDEA(S) ON POST-IT NOTE

28. Question #6Question 6: How would you find additional cases? Ask cases know other individuals who attended the event and became illContact local hospitals, ER, and urgent caresContact other local jurisdictions for similar complaintsAsk vendors if they received any complaintsAsk vendors if they collected contact information on patronsAsk fair coordinator for list of patronsMedia

29. Situation Status UpdateOn August 12th, a health department in a nearby county notified Denver Public Health of 5 additional casesthree adultstwo childrenDenver Police Department reported one additional case to Denver Public Health on August 14thNEW total case count: 10 cases.

30. Epidemiologic StudiesQuestion # 7

31. Common Epidemiology Study – Foodborne Illness OutbreaksCOHORTCASE-CONTROLPreferred Study Design When…Well-defined group of individuals- Members are easily identifiable- Members are easily accessibleExposure is rareThere may be multiple diseases involvedDisease or outcome of interest is rare, or The group is not well-defined- Identifying entire cohort would be too costly or time consuming- Accessing entire cohort would be too costly or time consumingMeasure of Association Study compares the incidence of disease in exposed persons and unexposed personsRelative Risk (RR)Study compare the odds of exposure between the ill (cases) and the not ill (contacts)Odds Ratio (OR)

32. Common Epidemiology Study – Foodborne Illness OutbreaksCOHORTCASE-CONTROLStudy population is grouped by exposure statusStudy population grouped by outcomeStudy GroupExposed personsPersons with illness (cases)Comparison GroupUnexposed personsPersons without illness (controls)ExamplesDetermine if the coleslaw was the cause of a foodborne outbreakDetermine an association between salmonella infection and eating at a fast food restaurant

33. Question #7Question 7: What type of epidemiologic study would you conduct to investigate this outbreak?

34. Question #7Question 7: What type of epidemiologic study would you conduct to investigate this outbreak? Both Study Designs Work HereBUTCase-Control would be the BESTCompare fairgoers with illness (cases)toSample of fairgoers without the illness (controls)

35. Measure of AssociationAssess the strength of an association between an exposure and the outcome of interestIndicate how more or less likely one is to develop disease as compared to anotherTwo widely used measures:Relative Risk (RR, or risk ratio)Odds Ratio (OR)

36. Measure of AssociationRelative Risk (Cohort Study)The risk of disease in the exposed group divide by the risk of disease in the non-exposed groupOdds Ratio (Case-Control Study)The risk of disease cannot be directly calculated because the population at risk is not known

37. Interpretation of MeasuresBoth the RR and the OR are interpreted as follows:=1 - indicates no association>1 - indicates a positive association<1 - indicates a negative association

38. Interpretation of MeasuresIf the RR = 5People who were exposed are 5X more likely to have the outcome then compared with persons who were not exposedIf the RR = 0.5People who were exposed are half as likely to have the outcome then compared with persons who were not exposedIf the RR = 1People who were exposed are no more or less likely to have the outcome then compared with persons who were not exposed

39. Tests of SignificanceIndication of reliability of the association that was observedAnswers the question:How likely is it that the observed association may be due to chance?Two main tests:95% Confidence Intervals (CI)p-values

40. 95% Confidence Interval (CI)The 95% CI is the range of values of the measure of association (RR or OR) that has a 95% chance of containing the true RR or OROne is 95% “confident” that the true measure of association falls within this interval

41. Interpreting95% Confidence Interval (CI)To have a significant association between exposure and outcome, the 95% CI should not include 1.0A 95% CI range below 1 suggest less risk of the outcome in the exposed populationA 95% CI range above 1 suggests a higher risk of the outcome in the exposed population

42. Case-Control Study Results

43. Case-Control Study Results (cont.)

44. Environmental AssessmentEnvironmental assessment is to conduct a systematic, detailed, science-based evaluation of environmental factors that contributed to the transmission of illness in an outbreak.

45. Question #8Question 8: What special considerations should be made during an environmental assessment of a marijuana facility? PLEASE WRITE DOWN CONSIDERATION (S) ON POST-IT NOTE

46. Environmental Assessment 101An assessment should include: interviewing workers and managers, sampling, making observations, reviewing records, identifying contributing factors and environmental antecedents, andimplementing control measures

47. Joint Facility Investigation EH was joined by MED as a criminal investigation was ongoing during the assessmentEmployees could not be interviewed by EH staff because of ongoing criminal investigation.

48. Outbreak ConclusionMED and Police Department reviewed video of surveillance of the facility from July 29 to August 3rdNo post-production tampering or comingling of THC and non-THC chocolatesPolice Department did not share findings with PH

49. Question #9Question 9: Discuss control measures and future recommendations to prevent unintentional ingestion of marijuana-infused foods. PLEASE WRITE DOWN CONTROL MEASURE (S) ON POST-IT NOTE

50. DiscussionIMPORTANT NOTE:People assume that a product infused with marijuana would give off an odor or flavor similar to marijuana. However, as demonstrated by this investigation, this was not the caseThe initial complaint case only stated the product has an off-taste and no cases reported an odor