Handling Complaints

The Importance of Reporting

The public relies on health and food regulatory officials, as well as the food industry, for protection from foodborne illness.  In Iowa, state and local governmental departments have complaint processes that include receiving and evaluating illness complaints that may be related to the foods that they have eaten. These complaint processes may prompt investigations and actions by local public health agencies and/or inspection agencies, and laboratories, and can lead to disease prevention and control of a foodborne outbreak in a community.

Established LPHA/Inspection Agency Foodborne Illness Policy

Receiving and investigating foodborne illness complaints is an important step in determining the nature of an illness and whether a suspect food might be a cause.  Local public health agencies and/or inspection agencies have a joint and complementary role in receiving, managing and investigating such complaints.  Failure or inability to investigate valid complaints may endanger the public’s health.  In such situations, the Iowa Department of Public Health (IDPH) and the Iowa Department of Inspections and Appeals (DIA) are authorized to intervene and take necessary measures to ensure that the public’s health is protected.  Local public health communicable disease staff, environmental health professionals should have an established policy on how foodborne illness complaints are handled and by whom.  

Receiving and Monitoring Foodborne Illness Complaints

Local public health communicable disease staff and environmental health professionals, in local communities, usually receive the first report of a foodborne illness complaint from the public. This includes recieving reports of symptoms of a foodborne illness for which a specific diagnosis has not been made.  Typically, callers believe their symptoms are related to consumption of food from a food establishment. 

In some instances, an outbreak may be apparent based on the number of people reporting similar illnesses, and the presence of a single exposure. If this occurs, other agencies should be notified and their portions of the investigation initiated.  However, it may be difficult to evaluate single reports of illness, so it is important when such reports are received; the information is gathered and compared with other complaints to detect any commonalities.  Communicating receipt of single complaint helps local public health communicable disease staff and the environmental health professional to determine whether each have received similar complaints or reports that may help determine if an outbreak is occurring.  Maintaining a log of single complaint reports is one way of promoting the detection of outbreaks that may not be typically recognized.

An appropriate method of collecting information on a foodborne illness complaint is to complete the Preliminary Foodborne Complaint Form (under the Forms & Documents tab) when a complaint is received refer to the end of this chapter.  Another way is through the routine follow-up of reportable diseases.  Several reportable illnesses, such as laboratory-confirmed Salmonella, Campylobacter, and E. coli infections that may be acquired through foods must be reported to public health by laboratories and health care providers.  The Center for Acute Disease Epidemiology (CADE) and LPHA collect information to complete disease investigation report forms to identify outbreaks and determine causes.

The standardized Preliminary Foodborne Illness Complaint Form, which can be used to record complaint information, is included for your reference, and instructions for use are provided at the end of this chapter.  When possible, speak directly with ill complainants to obtain complete and accurate information.  Listen carefully to the complainant.  Often, additional information and details will be obtained during the complainant’s re-telling of the event.

A 72-hour or longer food history should be obtained noting where foods were consumed to ensure the food investigated is based on the illness onset, diagnosis or symptoms, and that an appropriate food vehicle is being investigated. Foods associated with particular diseases can be found in Appendix A Enteric Disease Information.  A longer food history is necessary when organisms such as hepatitis A, Campylobacter, and parasites (that have incubation periods longer than 72 hours) are suspected.  Often, complainants will associate the illness with the last food or meal consumed in a food establishment.  Although foods prepared in food establishments are implicated in reported outbreaks, foods prepared at home may also be responsible for single cases of foodborne illness and should not be ignored, however does not require an investigation for a single case. 

Using the Preliminary Foodborne Illness Complaint Form

Reporting of individual cases of suspected foodborne illness is not required by law.  However, Iowa Administrative Code [641] Chapter 1 requires reporting of outbreaks of any kind, unusual syndromes, or uncommon diseases.  Although, reporting of individual cases of suspected foodborne illness is not mandated, individual jurisdictions may develop enhanced surveillance to capture such information from health care providers, supervisory staff at schools, childcare centers, hospitals, institutions, clinics, medical practices, laboratories, labor groups or other reporting sources to help detect clusters or outbreaks that may have gone unrecognized.

No matter who reports a potential foodborne illness, the Preliminary Foodborne Illness Complaint Form should be used to record all information and should be managed as a permanent record of the complaint.  When completing the form, please:

1. Collect as much information as possible from the complainant the first time the contact is made.  It might be difficult to contact the person again.  If the complainant cannot provide critical pieces of information, then determine who can and contact that person.  By collecting enough information in the initial stages, you can more easily determine the validity of the complaint and possibly avoid conducting an unnecessary investigation.
2. Remember that a laboratory diagnosis is not required for a foodborne illness complaint to be legitimate.  The complainant may have been infected through food, but may not have received medical care.  Also, many foodborne illnesses (for example, those caused by viruses, such as Norovirus) are not reportable and are difficult to diagnose in a smaller laboratory.  In certain situations, attempts may be made to obtain a laboratory diagnosis to determine what agent may be responsible for the reported symptoms.  When a specimen is needed, environmental health professionals should work with local public health communicable disease staff to access appropriate collection kits.  Further information on obtaining specimens is available in Chapter 9, Conducting a Laboratory Investigation.
3. Remember that many illnesses that can be acquired through foods may also be acquired through other means, such as water, person-to-person contact, and animal-to-person contact.  In addition, a complainant may be “sure” about the source of the illness and report only one suspect food or food establishment.  Do not be deterred from obtaining an appropriate food-consumption history.
4. Be sure to accurately record dates and times of the onset of illness, dates and times of food consumption, and symptom information.  Most people who have experienced a recent illness should be able to provide this information.  If the complainant cannot, try to find out why.
5. File completed worksheets at the local public health agencies or inspection agency for easy retrieval.  This will facilitate the identification of specific complaints or possibly related complaints during certain time periods.

Determining Whether a Complaint Warrants Investigation

It is important to recognize that various investigations are included in a foodborne outbreak investigation.  Typically, a foodborne outbreak is composed of three complementary investigations: epidemiologic, environmental, and laboratory. In many cases, they are conducted by different public health professionals or inspection agencies and are each essential to completion of the investigation.  As such, it is important to realize at this point that use of the term “investigation” can become confusing when trying to determine an appropriate means of “handling” complaints.  In addition, if an outbreak is suspected  all three disciplines should work together to conduct an assessment from the information collected on the Preliminary Foodborne Illness Compliant Form to determine if a full investigation needs to be initiated.

The environmental health professional or inspection agency establishes the validity of a complaint by determining whether a foodborne illness complaint is scientifically plausible, given the information from the complainant.  One method of establishing validity is determining whether the period from consumption of the food until the appearance of symptoms is consistent with the incubation period range.  When the range is consistent with the time from ingestion to onset of illness the complaint may be valid and warrants investigation.

In some instances, a complainant may only be relaying a group of symptoms and a time consumed from a suspect food establishment.  The validity of this type of complaint is determined by evaluating the symptoms of the suspect foodborne illness, their duration, and the suspect foods identified by the complainant.  Although many symptoms may be associated with a variety of etiologic agents, some are relatively specific to a particular agent.  For instance, if the complainant is jaundiced, Hepatitis A may be suspected and laboratory diagnosis from the complainant desired.  Comparing the symptoms, their duration, and suspect foods with information known about a variety of enteric diseases may provide clues to the agent associated with the illness.

 Historically, etiologic agents have been associated with certain characteristic foods, an association that can be beneficial when evaluating suspect food information from the complainant.  A list of common enteric pathogens and further information to help determine the validity of a complaint is presented in Appendices A Enteric Disease Information.

For example:

• A complainant reports onset of bloody diarrhea with abdominal cramps a half an hour after eating a hamburger consumed at a fast food establishment.

Evaluation: Information from the complainant reveals a very short incubation period.  It is consistent with a toxin or chemical exposure. Possible etiologic agents include: heavy metal contamination, paralytic shellfish poisoning, and scombroid fish poisoning.

Possible agents whose symptoms are consistent with bloody diarrhea and abdominal cramps include: Campylobacter jejuni and Escherichia coli.

In determining etiologic agents, obtaining detailed information on the suspect food is important.  How was the hamburger served?  Plain? With ketchup, mustard, pickles, lettuce, onions, etc.? In the example, the hamburger consisted of a beef patty and bun, and the complainant added mustard and ketchup from commercially prepared packets at the condiment counter.  Bread is typically not considered a potentially hazardous food and no etiologic agents are typically associated with it.  Commercially prepared ketchup and mustard are typically not considered potentially hazardous foods and no etiologic agents are typically associated with them.  That leaves the ground beef whose possible etiologic agents include: Escherichia coli, Clostridium perfringens, Salmonella spp., and Staphylococcus aureus.

Results: Symptoms are consistent with two etiologic agents: Campylobacter jejuni and Escherichia coli.  The reported incubation period is inconsistent with either of the etiologic agents identified by the symptoms. Heavy metal contamination typically includes metallic taste, and both shellfish and scombroid fish poisoning are typically associated with ingestion of fish or shellfish.  Although undercooked ground beef has been associated with Escherichia coli outbreaks, its incubation period averages 48-96 hours with a range up to 10 days following exposure.  The incubation period reported by the complainant is inconsistent with the ingestion of hamburger.  Examination of possible causes should include exposures from 48 hours to five days prior to onset of symptoms to account for each of etiologic agents consistent with the symptoms.

Conclusion: Complaint is invalid.

When help is needed to determine validity of a complaint, public health communicable disease staff and/or an epidemiologist from IDPH’s Center for Acute Disease Epidemiology (CADE) can provide consultation.

Consumers often focus on foods prepared or eaten at food establishments rather than home-prepared meals. It may be necessary to explain to the complainant the possibility of other exposures, such as home-prepared foods, daycare centers and pet reptiles. It is appropriate, as well as good public health practice, to evaluate and review procedures used in preparing suspect home-cooked food.

If it is determined that an environmental investigation is not warranted, notify (preferably in person) the food establishment that has been implicated in a suspected foodborne illness complaint. Establish through an interview with the manager if food handlers have been ill and if the establishment has received any similar complaints.

A follow-up investigation may also be unnecessary when repeated complaints are made by the same persons(s) and prior investigation revealed no significant findings.  Invalid complaints may be generated by disgruntled employees, competitors, unfriendly neighbors and dissatisfied customers.  Whatever the situation, always briefly summarize for the file the reasons why an investigation was not conducted.

It may be useful to consider three classifications of foodborne illness complaints and the management of each complaint by “investigation” type.

1. A single complaint of “suspected” foodborne illness without a reportable disease diagnosis.
   1. Epidemiologic investigation No specific epidemiologic investigation initiated.  Assist the environmental investigator, when needed, in determining the validity of the complaint and when necessary, collection of clinical specimens from complainant.  Continue to monitor single case reports for evidence of similar time of onset/type of symptoms and similar exposure history and other factors that may indicate an outbreak.  Communicate additional foodborne illness complaints to the environmental investigator.
   2. Environmental investigation When a food establishment is initially suspected, determine the validity of the complaint. When indicated, conduct an inspection of the suspect facility within 24 hours of the complaint.  Determine whether the establishment has received other foodborne illness complaints.  Implement prevention and control measures consistent with the Iowa Food Code.  If the environmental inspection findings indicate the potential for additional cases, communicate findings to the epidemiologic investigator and determine if additional interagency prevention and control measures may be appropriate.  If so, implement them.
   3. Laboratory investigation No specific laboratory investigation initiated.  Continue to monitor laboratory reports for evidence of an outbreak.  Communicate additional foodborne illness complaints received.
2. A single case of suspected foodborne illness with a reportable disease diagnosis
   1. Epidemiologic investigation Obtain laboratory results confirming reportable disease. Conduct routine disease follow-up, consistent with the Iowa Department of Public Health’s Guide to Surveillance, Investigation and Reporting (Epi Manual) for the disease identified.  Continue to monitor case reports for additional cases, evidence of similar time of onset/type of symptoms and similar exposure history and other factors that may indicate an outbreak.  Review and interpret the epidemiologic investigation findings and communicate additional foodborne illness complaints that may indicate the presence of an outbreak to the environmental investigator.
   2. Environmental investigation When a food establishment is initially suspected, determine the validity of the complaint. When indicated, conduct an inspection of the suspect facility within 24 hours of complaint.  Determine whether the food establishment has received other foodborne illness complaints.  Implement prevention and control measures consistent with the Iowa Food Code.  Use information on the reportable disease identified to evaluate modes of transmission typically associated with that disease and target a time frame of possible exposure based on the incubation period.  Review and interpret the environmental inspection findings with the epidemiologic investigator.  Determine if additional interagency prevention and control measures may be appropriate.  If so, implement them.
   3. Laboratory investigation No specific laboratory investigation initiated.  Continue to monitor laboratory reports and Pulse Field Gel Electrophoresis Data (PFGE) for the presence of additional cases of the reportable disease identified that may indicate the presence of an outbreak.  When a suspect outbreak is indicated, communicate it to the epidemiologic investigator.
3. Two or more cases of suspected foodborne illness in non-related people with or without a diagnosis with similar time of symptom onset and possible common source of exposure
   1. Epidemiologic investigation Initiate a foodborne outbreak epidemiologic investigation as described in Chapter 7, Conducting an Epidemiologic Investigation.  Continue to monitor case reports for additional cases that may be related to the outbreak.  Review and interpret the epidemiologic investigation findings for those conducting the environmental and laboratory investigations.
   2. Environmental investigation When a food establishment is initially suspected, initiate an environmental investigation as described in Chapter 8, Conducting an Environmental Investigation.  Determine whether the establishment has had other foodborne illness complaints.  Implement prevention and control measures consistent with the Iowa Food Code.  Use information from the epidemiologic investigation to enhance the environmental investigation and target a time of possible exposure based on the incubation period.  Review and interpret the environmental investigation/inspection findings with the epidemiologic and laboratory investigators.  Determine if additional interagency prevention and control measures may be appropriate and implement them.
   3. Laboratory investigation Initiate a foodborne outbreak laboratory investigation as described in Chapter 9, Conducting a Laboratory Investigation.  Coordinate laboratory investigation with epidemiologic and environmental investigations.  Review and interpret the laboratory investigation findings with epidemiologic and environmental investigators.

Handling of Complaints Initially Received at the State Level

The Iowa Department of Inspections and Appeals (DIA) Foodborne Illness Investigation Protocol includes a form that outlines the baseline information environmental health professionals or inspection agency are to collect when receiving single complaint reports of foodborne illness. Besides this form, they are to complete and submit to DIA on a monthly basis a Foodborne Illness Complaints form that summarizes complaints. 

Iowa Department of Public Health’s CADE does not have a standardized process by which reports of foodborne illness are received and shared with DIA.  CADE typically refers individual reports that involved food establishments to DIA in an informal manner regardless of whether a diagnosis of a reportable disease was made and whether the presence of an outbreak was apparent.  DIA does not notify CADE for individual reports of foodborne illness unless a reportable disease diagnosis is made and/or the presence of an outbreak is readily apparent.

Foodborne illness complaints are currently managed at the local level.  Local public health agencies or inspection agencies who are responsible for food inspection should coordinate local surveillance data.  Foodborne illness complaint information should be collected at the local level to ensure recognition of similar/related events that local entities may have already received.  CADE will use the following standardized process for the handling of foodborne illness complaints initially received at the state level.  When it receives such a complaint associated with a food establishment, the complainant’s name and contact information will be obtained and the appropriate referral information made to the entity responsible for food inspection within the jurisdiction of the complainant.

When CADE receives a foodborne illness complaint identifying a reportable disease, information required for local communicable disease staff to conduct disease follow-up will be obtained from the complainant. It will be referred to the entity responsible for food inspection in the jurisdiction of the complainant with contact information for the communicable disease staff conducting the disease follow-up.When a foodborne illness complaint is received in which an outbreak is indicated, CADE will contact DIA to coordinate the notification of jurisdiction responsible for food inspection and local communicable disease staff.To support local surveillance, the following model is provided.

Complaint Process and Referrals

Local public health-communicable disease staff and the environmental health professional are asked to use a standardized process for handling foodborne illness complaints.

1. They can use the Preliminary Foodborne Complaint Form to collect information from persons making the complaints.
2. They will obtain as much information as possible from complainants to complete the Preliminary Foodborne Complaint Form.
3. They will evaluate the information recorded and determine whether a reportable disease diagnosis has been made, whether the presence of an outbreak is suspected or readily apparent, and whether the information involves an individual report of foodborne illness where no reportable disease diagnosis has been made. If assistance is needed for the evaluation of the information collect on the reporting form, a CADE epidemiologist will assist with the process.
4. If a reportable disease diagnosis has been made and no food establishment is suspected, communicable disease staff will initiate a disease follow-up. Environmental health staff will refer the completed Preliminary Foodborne Complaint Form to communicable disease staff to allow disease follow-up to begin.
5. If communicable disease staff receives an initial complaint that involves a reportable disease diagnosis in which a food establishment is suspected, a copy of the Preliminary Foodborne Complaint Form, a summary of follow-up actions, will be provided to environmental health staff.
6. If environmental health staff receives an initial complaint that involves a reportable disease diagnosis in which a food establishment is suspected, a copy of the Preliminary Foodborne Complaint Form and a record of follow-up actions will be provided to communicable disease staff to initiate follow-up.
7. If communicable disease staff receives an initial complaint in which an outbreak is suspected or readily apparent, it will notify environmental health staff, CADE, and DIA (when a food establishment is suspected) with the Preliminary Foodborne Complaint Form (when possible, a copy of the form itself), any other relevant information collected, and a record of follow-up actions to start the outbreak investigation.
8. If environmental health staff receives an initial complaint in which an outbreak is suspected or readily apparent, it will notify and provide communicable disease staff with the information on the Preliminary Foodborne Complaint Form (when possible a copy of the form itself), any other relevant information collected, and a record of follow-up actions to start the EH investigation.
9. Upon notification of the presence of a suspect or readily apparent outbreak, communicable disease staff will notify and provide CADE with the information on the Preliminary Foodborne Complaint Form (when possible, a copy of the form itself), any other relevant information collected, and a record of follow-up actions to start the EH/Epi investigation.

The intent of this section is not to replace efficient local mechanisms, but to introduce a process by which such reports can be managed and encourage use of standard tools for the receipt and communication of foodborne illness complaints among local and state agencies.  Adoption of these forms by local public health agencies clarifies information collected and provides standardization in communicating them.  Establishing an open line of communication between public health and environmental health staff responsible for inspections will allow agencies to determine the manner in which information on single reports of foodborne illness will be managed.