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									              Outbreak Investigation
               Operational Aspects
                   16th EPIET Introductory Course
                      Lazareto, Menorca, Spain
                          September 2010
Mike Ryan
Jet de Valk
Susan Hahné
Marta Valenciano
Barbara Schimmer
                                                    1
Steen Ethelberg
    Objectives for this session
Yesterday
• Methodological aspects
Today
• The organisational challenges in outbreak
  investigations
• Preparing and organising yourself for field
  work
• Systematic approach to operational
  aspects                                       2
    Intervention epidemiology
Definition
• The timely use of epidemiology to solve
  urgent public health problems


Objective
• To maximise the scientific quality of the
  investigation in a complex environment

                                              3
    What is an outbreak ?

• Occurrence of more cases of disease
  than expected
  – over a particular period of time
  – in a given area
  – among a specific group of people


• Same disease, same source


                                        4
  Why investigate outbreaks

• Stop the outbreak
• Learn, so that it doesn’t happen again
 or that you’ll catch it earlier next time




                                             5
Early detection and response
                           1993 Western States E. coli O157 Outbreak
                  70

                  60

                  50
                           Outbreak detected 1993                   726 ill, 4
Number of Cases




                  40       deaths
                  30

                  20        39 d
                  10

                  0
                       1    8     15   22   29       36     43     50      57    64   71
                                                 Day of Outbreak




                                2002 Colorado E. coli O157 Outbreak

                           Outbreak detected 2002                       44 ill, no deaths


                            18 d
                                                                                            8
Epidemiological – Operational
• Confirm outbreak   • Inform of outbreak
• Case definition    • Outbreak team
                       – Form
• Case finding         – Lead
• Descriptive epi      – Cooperation
• Form hypothesis    • Communication internally and
  – Interviews         with partners
  – Review info      • Communication with the press
• Test hypothesis    • Organisation of your work
                     • Dissolve team, report etc.

                                                 9
                     Scenarios
Local Outbreak        - local authorities coordinate
                      - you are asked to assist / help
National Outbreak     - your institute coordinates
                      - you are asked to lead / cooperate
International /       - ECDC / WHO coordinates
European outbreak     - your institute collaborates
involving your
country               - you participate

Outbreak in another - the authorities in that country
country             coordinate
                      - you are asked to assist
                                                            1
                                                            0
         Possible involvement of a field epidemiologist
       (before, during or after the EPIET fellowship time)

Local Outbreak        - local authorities coordinate   - E Coli (Dublin, 2003)
                      - you are asked to assist /
                      help
National Outbreak     - your institute coordinates     -Dried tomatos (France,
                      - you are asked to lead /        2009)
                      cooperate
International /       - ECDC / WHO coordinates         -Pandemic influenza
European outbreak     - your institute collaborates    2009
involving your
country               - you participate
Outbreak in another   - the authorities in that country -Ebola (Uganda,2000;
country               coordinate                        DRC,2007)
                      - you are asked to assist        -Hep E (Chad,2007)
                                                       -Cholera (Uganda,2005)
                                                                            1
                                                                                 1
     Operational challenges

• Unexpected event
• Need to investigate quickly
• Pressure for answers
• Multiple agencies/actors
• Work carried out at many levels
• You may be in the media spotlight
• Possible legal implications
                                      1
                                      2
     Cooperation is necessary
                             Epidemiologists
Clinicians


                                               Diagnostic labs



Public health authorities



                                                 OTHERS:
                                                 Disease specialists
                                                 Environmentalists
                            Food authorities     Veterinarians
                                                 Engineers
                                                 Media people          1
                                                                       3
  Challenges, Outbreak Team

• Different institutes, ministries
• Different backgrounds, fields
• Different cultures, scientific languages
• Different expectations
• Don’t know/trust each other
• Someone has to decide over the others
• Working under time pressure
• Outbreaks hit suddenly, little time to prepare   1
                                                   4
      Challenges in the field

• You may arrive late
• Understand local expertise/hierarchies
• Local sensitivities
• Foreign country (i.e. language, culture)
• Need to feedback to various people
• Many actors involved
• Stress, long working hours…
                                             1
                                             5
… find some time to RELAX!!!




                               1
                               6
       Systematic approach

• Reasons for inviting you
  – ´Terms of reference´ ?
• Preparing to leave for the field
• When you arrive
• In the field
  – Outbreak Control Team
  – Information management
  – Leaving the field
• Back home
                                     1
                                     8
    Reasons for inviting you

• Expertise
• More resources
• Share responsibility
• Political or mass media pressure
• Mandatory or in guidelines
• Need to confirm local findings
• Specialised investigations
                                     1
                                     9
          Terms of reference
        Clarify before accepting

• What are their expectations
  – expertise, tasks, time?
  – what local resources are available?
• What has already been done?
• What resources do you need to bring?
• What is your role?
• Who is in charge?
                                          2
                                          0
            Preparing to leave
• Consult colleagues (microbiologist, veterinarians, GP,
  internal medicine specialist….)
• Review relevant literature, guidelines
• Decide who will lead the team
• Identify who provides support in head office
• One page report before leaving
   – objectives
• Arrange initial meeting for your arrival
• Discuss with your colleagues (and your boss) at the
  institute to organise follow up of your ongoing projects!

                                                              2
                                                              1
           Bring your ”epi-pack”
• Laptop
    – Software (e.g. epidata, stata)
    – File templates
    – Standard questionnaires
•   Mobile phone, calculator
•   Notebook (log)
•   Guidelines, handbooks, articles
•   Camera
•   Phone numbers, address lists
•   Maps (GPS)
•   Sometimes: Laboratory equipment
•   Others... (money, ”health kit”,)
                                       2
                                       2
         When you arrive

• Provide help - don’t take charge
• Meet with key people
• Review and update status of problem
• Assess sensitivities
• Identify local resources and skills
• Set up communications with base


                                        2
                                        3
               Outbreak team

•   Municipality technical manager (leader)
•   People from various townhall offices
•   Medical officers
•   Water plant
•   Water supply system
•   Police
•   Emergency Management Agency
•   Food safety
•   SSI
•   Private engineering company
•   Media relations officer
                                              2
                                              4
 The Outbreak Control Centre

• Situation room / designated office
• Where, how big
• Accessibility / Security
• Computers with Internet connection, network and
  firewall problems
• Telephones, fax, copy machine
• Reference materials
• Catering
• Place to sleep
                                                    2
                                                    5
Organizing the outbreak control team

• Membership
• Leadership
• Responsibilities
• Lines of communication (how)
• Communication (who)
• Decision making process


                                       2
                                       6
         Information / Data

• Types of information
  – epidemiological
  – operational
• Ways of communicating: emails,
  briefings, meetings, ftp/google/dropbox…
• Managing information (databases)
• Communicating with the media: one
  person!
• Writing reports: ongoing process
                                             2
                                             7
        Epidemiological data

• Line listing is vital
  – cases/contacts
  – lab results, questionnaires available
  – in excel
• Constitutes and updates a database
  of cases
• Protects the confidentiality of the
  patients
• Prepares an easy, automated,
  descriptive analysis                      2
                                            8
                   The line list

• Only one in the team!!!
  – avoid confusion with multiple versions
• Contains a unique identifier for each record
  (case)
• Ensures confidentiality
• Contains essential information on each case
  – time, place, person, other (e.g., clinical, lab)
• Can be updated as the investigation develops
• Allows regular, automated, computerized
  analysis
                                                       2
                                                       9
                    Typical line listing for
                  an outbreak investigation
 Unique
identifier

               Time
                                 Place

                                                     Person

                                                                       Outcome
                                                                                          Lab


 Uni. ID       OnsetDate Ward    Block     City   AgeYears Sex       Hospital Death   HEVIgM HAVIgM
           1   1-Mar-05       18         2 HYD         12        1           1      2       1      9
           2   3-Mar-05       22         1 HYD         25        2           1      2       2      1
           3   5-Mar-05       23         3 HYD         36        1           2      9       9      9
           4   6-Mar-05 -        -         SEC         23        2           1      1       1      2

                                                                                                       3
                                                                                                       0
           Situation report

• Overview of the current situation
• Concise, focus on facts
• Structured, may use template
  – No cases, epicurve, map, what has been done
• Paragraph with development since last
  report
• May contain risk assessment
• May contain scenarios, predictions
                                                  3
                                                  1
        Operational information
• Contacts: name, position, contact details
• Types of files
   – epidemiological (questionnaires, data, protocols)
   – interviews, meetings, press
   – emails
• Meetings
   – minutes
   – actions and those responsible
• Decisions and rationale
  (information available at the time of decision making)
• All steps taken in the investigation

                                                           3
                                                           2
            Organising data

• Laptop, network, web?
• Backups / confidentiality / access
• Selfexplanatory files and folders
• Sometimes professional data manager
• Inventory of files
• Log book!
  – every day
                                        3
                                        3
                  The Media

• Appoint one (professional) spokesperson
  – prepare briefings for him / her
• Coordinate with other agencies
• Inform early and often
  –   websites of relevant institutes
  –   interviews
  –   press statements
  –   press meetings
• Be honest, explain what is being done
• Be clear about what is
  – fact / speculation / not known          3
                                            4
          Leaving the field

• Debriefing meeting
• Preliminary report
• Commit to produce final report
• Archive data




                                   3
                                   5
                 Back home

• Inform your supervisor and colleagues
  – debriefing
• Follow up
  – lab, clinical other studies results
  – Stay in touch with the field - new cases
• Finalise the report ASAP
• Beware of confidentiality
  – anonymise database
  – anonymise questionnaires                   3
                                               6
                     Summary
•   Outbreak investigations are challenging
•   Each outbreak investigation is different
•   Cooperation is difficult, requires organisation
•   Preparation and good operational skills help
•   Offer help, do not take charge
•   Stay organised
•   Don´t come back until the job is done
•   Document steps, use a log, write the reports
•   Take time to rest, and remember to have fun!

                                                      3
                                                      7

								
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