1. 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.

2. Objectives The organizational challenges in outbreak investigations
Preparing and organizing yourself for field work
Systematic approach to operational aspects

3. 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

4. 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

5. Why investigate outbreaks
Stop the outbreak
Learn, so that it doesn’t happen again or that you’ll catch it earlier next time

6. Outbreak Detection and Response
First
Case
Detection/
Reporting
Lab
Confirmation
Response
DAY
CASES
Opportunity
for control

7. Outbreak Detection and Response
First
Case
Detection/
Reporting
Opportunity
for control
Confirmation
Investigation
Response
DAY
CASES

8. 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

9. 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.

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

11. Possible involvement of a field epidemiologist (before, during or after the EPIET fellowship time)
Local Outbreak
- local authorities coordinate
- you are asked to assist / help
- E Coli in Dublin, 2003
National Outbreak
- your institute coordinates
- you are asked to lead / cooperate
Dried tomatoes
in France, 2009
International / European outbreak involving your country
- ECDC / WHO coordinates
- your institute collaborates
- you participate
Norovirus among holidaymakers, 2002
Pandemic influenza 2009
Outbreak in another country
- the authorities in that country coordinate
- you are asked to assist
Ebola, Uganda(2000), DRC(2007)
Hepatitis E, Chad (2007)
Cholera, Uganda (2005)

12. 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

13. Cooperation/coordination is crucial
Epidemiologist(s)
Clinicians
Diagnostic labs
Public health authorities
OTHERS:
Disease specialists
Environmentalists
Veterinarians
Engineers
Media people
Food authorities

14. 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

15. 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”

16. 1 1 2 2 5 5 3 3 4 4 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 5 5 3 3
Strategy for activities
Prioritising
Deciding spec. tasks
Who should do what
COOR- DINATION
ACTION
CRISIS
COMMU- NICATION 4 4
External communication
Press strategy/plan
Media communication
Doing the epi work, e.g.:
Case finding, interviews, collecting specimens, etc.

17. 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…

18. … find some time to RELAX!!!

19. Systematic approach Clinicians Epidemiology Co-ordination Laboratory :
Toxic products
Dead
Sick
Investigation
Surveillance
Prediction
Exposed
Clinicians
Epidemiology
Psychological support unit
Co-ordination
Laboratory :
clinical
environmental
Parents
Students
Environmental
health
Clinical
Specimen
transfer
Principal
Teachers
General
population
Diagnostic
Media
Authorities
Autopsy
Decisions
School closure
Medical
examinations
Police, legal authorities
Systematic approach

20. 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

21. 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

22. 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

23. 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?

24. 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!

25. Bring your ”epi-pack” Laptop Mobile phone, calculator Notebook (log)
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”,)

26. 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

27. 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

28. 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

29. Organizing the outbreak control team
Membership
Leadership
Responsibilities
Lines of communication (how)
Communication (who)
Decision making process

30. Information / Data Types of information
epidemiological
operational
Ways of communicating: s, briefings, meetings, ftp/google/dropbox…
Managing information (databases)
Communicating with the media: one person!
Writing reports: ongoing process

31. 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

32. 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

33. 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

34. 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

35. Operational information
Contacts: name, position, contact details
Types of files
epidemiological (questionnaires, data, protocols)
interviews, meetings, press s
Meetings
minutes
actions and those responsible
Decisions and rationale (information available at the time of decision making)
All steps taken in the investigation

36. Organising data Laptop, network, web?
Backups / confidentiality / access
Selfexplanatory files and folders
Sometimes professional data manager
Inventory of files
Log book!
every day

37. 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

38. Leaving the field Debriefing meeting Preliminary report
Commit to produce final report
Archive data

39. Back home Inform your supervisor and colleagues Follow up
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

40. 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!

41. Thanks for your attention !!!
Laboratory confirmation
Source
Outbreak control team meeting - urgent!
TV inter view
Control measures ?
Meet minister
Questions ???