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Outbreak Investigation Operational Aspects. 17th EPIET Introductory Course Lazareto, Menorca, Spain 27 September 2011. Biagio Pedalino. Source: Mike Ryan, Jet de Valk, Susan Hahné, Marta Valenciano, Barbara Schimmer, Steen Ethelberg. Previous EPIET Introductory course sessions. Objectives.

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outbreak investigation operational aspects

Outbreak Investigation Operational Aspects

17th EPIET Introductory Course

Lazareto, Menorca, Spain

27 September 2011

Biagio Pedalino

Source: Mike Ryan, Jet de Valk, Susan Hahné, Marta Valenciano, Barbara Schimmer, Steen Ethelberg.

Previous EPIET Introductory course sessions.

objectives
Objectives
  • The organizational challenges in outbreak investigations
  • Preparing and organizing yourself for field work
  • Systematic approach to operational aspects
intervention epidemiology
Intervention epidemiology

Definition

  • Thetimely use of epidemiology to solve urgent public health problems

Objective

  • To maximise the scientific quality of the investigation in a complex environment
what is an outbreak
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
why investigate outbreaks
Why investigate outbreaks
  • Stop the outbreak
  • Learn, so that it doesn’t happen again or that you’ll catch it earlier next time
outbreak detection and response
Outbreak Detection and Response

First

Case

Detection/

Reporting

Lab

Confirmation

Response

Opportunity

for control

CASES

DAY

outbreak detection and response7
Outbreak Detection and Response

First

Case

Opportunity

for control

Detection/

Reporting

Confirmation

Investigation

Response

CASES

DAY

early detection and response
Early detection and response

1993 Western States E. coli O157 Outbreak

726 ill, 4 deaths

39 d

2002 Colorado E. coli O157 Outbreak

44 ill, no deaths

18 d

epidemiological operational
Epidemiological Operational

Confirm outbreak

Case definition

Case finding

Descriptive epi

Form hypothesis

Interviews

Review info

Test hypothesis

Inform of outbreak

Outbreak team

Form

Lead

Cooperation

Communication internally and with partners

Communication with the press

Organisation of your work

Dissolve team, report etc.

possible involvement of a field epidemiologist before during or after the epiet fellowship time
Possible involvement of a field epidemiologist (before, during or after the EPIET fellowship time)
operational challenges
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
cooperation coordination is crucial
Cooperation/coordination is crucial

Epidemiologist(s)

Clinicians

Diagnostic labs

Public health authorities

OTHERS:

Disease specialists

Environmentalists

Veterinarians

Engineers

Media people

Food authorities

challenges outbreak team
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
organisational hints solutions
Organisational hints/solutions
  • Clear and transparent leadership
  • Build trust before the outbreak happens
    • Meetings in peace time
  • Preparedness plan, guidelines
  • Adjust expectations, clarify roles
  • Support from strategic level
    • Administrative support
    • Help with communication
  • Efficient information sharing, everyone same picture of situation
  • Standard operating procedures, templates
  • Possibility of going to “crisis mode”
emergency management
Emergency management

Start crisis management

Meetings, minutes

Place to work, food

1

1

INITIATION

LOGISTICS

Collecting info

Organising info

Sharing info

Making sure everyone has info needed

Documentation

2

2

HANDLING

INFORMATION

CRISIS

MODE

Strategy for activities

Prioritising

Deciding spec. tasks

Who should do what

5

5

3

3

COOR-DINATION

ACTION

4

4

CRISIS

COMMU-NICATION

External communication

Press strategy/plan

Media communication

Doing the epi work, e.g.:

Case finding, interviews,collecting specimens, etc.

challenges in the field
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…
slide19

Toxic products

Systematic approach

Dead

Sick

Investigation

Surveillance

Exposed

Prediction

Clinicians

Epidemiology

Psychological support unit

Co-ordination

Laboratory :

clinical

environmental

Parents

Students

Environmental

health

Clinical

Specimen

transfer

General

population

Principal

Teachers

Diagnostic

Authorities

Media

Autopsy

Decisions

School closure

Medical

examinations

Police, legal authorities

systematic approach
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
reasons for inviting you
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
waterborne outbreak denmark 2007
Waterborne outbreak Denmark 2007

Example

  • 15 Jan SSI contacted by district medical officer
  • Much GI illness in town in Zealand
  • Water suspected, OCT forms
  • SSI invited to participate
    • Epi expertise
    • Lab assistance
    • Resources
terms of reference clarify before accepting
Terms of referenceClarify 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?
preparing to leave
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!
bring your epi pack
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”,)
when you arrive
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
outbreak team
Outbreak team

Example

  • 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
the outbreak control centre
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
organizing the outbreak control team
Organizing the outbreak control team
  • Membership
  • Leadership
  • Responsibilities
  • Lines of communication (how)
  • Communication (who)
  • Decision making process
information data
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
epidemiological data
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
the line list
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
typical line listing for an outbreak investigation
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

situation report
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
operational information
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
organising data
Organising data
  • Laptop, network, web?
  • Backups / confidentiality / access
  • Selfexplanatory files and folders
  • Sometimes professional data manager
  • Inventory of files
  • Log book!
    • every day
the media
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
leaving the field
Leaving the field
  • Debriefing meeting
  • Preliminary report
  • Commit to produce final report
  • Archive data
back home
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
summary
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!
slide41

Meet minister

Outbreak control team meeting - urgent!

TV inter view

Laboratory confirmation

Source

Control measures ?

Thanks for your attention !!!

Questions ???

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