1. Risk assessment of events involving infectious diseases Preben Aavitsland Department of Infectious Disease Epidemiology Norwegian Institute of Public Health at EpiTrain V, Vilnius, October 24 2007

2. Contents Background Risk assessment –what, why and when Risk assessment tool –EpiRisk Example

3. What is risk assessment of events? Pragmatic: The determination of the potential impact of an event by assessing the likelihood that the event will worsen and the impact if it does Risk = likelihood * impact Risk analysis = risk assessment + risk management + risk communication

4. Why do risk assessment of events? Basis for risk communication Basis for risk management –Appropriate use of resources –Level of countermeasures (cost vs potential impact averted) Basis for decision to notify Guides information gathering

5. When do risk assessment of events? Whenever there is a communicable disease event (outbreak, threat, etc) As early as possible –Gather information Update the assessment –Whenever new important information becomes available –Anyway after some time

6. How to do risk assessment? We already do it automatically and unsystematically Use a systematic approach –EpiNorth Risk Assessment of Events Tool (EpiRisk) –Pilot version for testing by EpiTrain-participants –Qualitative assessment Quantitative assessments usually look falsely precise Document the findings

7. 1. Event description Disease / syndrome –Outbreak? Threat? Disease? Agent / cause –What is the agent or cause? Time –When did it happen? Place –Where dit it happen? Person –Who were involved (gender, age, profession, other characteristics…)

8. 2. Rapid disease overview Chain of transmission Time periods –Incubation period –Period of infectiousness –Natural history Diagnosis and treatment General epidemiological situation

9. The chain of transmission Agent Susceptible host Source Portal of entry Portal of exit Route of transmission

10. Six links of the chain Agent: virus, bacteria, fungi, protozoa, helminths, ectoparasites Source (reservoir): Humans and aminals (symptomatic, incubating, convalescent, asymptomatic carrier) insects, environment (water, soil) Portal of exit: Respiratory tract (nose, mouth), gastrointestinal tract (anus), genitourinary tract (urethra and cervix), skin, mucosa, placenta. Route of transmission: Direct (contact or droplet), indirect (vehicle, vector), airborne Portal of entry: Respiratory tract (nose, mouth), gastrointestinal tract (anus), genitourinary tract (urethra and cervix), skin, mucosa. Susceptible host: anyone who is not immune

11. 3. Impact of event Assess the current and future (or as yet undetected) impact in terms of –Severity –Cost –Public interest Give a summary measure

12. Severity of event Now Number of cases (incidence rate) Severity of disease; case fatality Age of patients (DALYs lost) 0 – 3 points Future Assess the as yet undetected part of the event and the development of the event or the (with the same indicators) in the abscence of preventive measures 0 – 3 points

13. Cost of event Now Cost incurred for treatment Cost incurred for sick leave Cost incurred for sequelae 0 – 3 points Future Assess the as yet undetected part of the event and the development of the event or the (with the same indicators) in the abscence of preventive measures 0 – 3 points

14. Public interest in event Now Media interest Public interest, especially parents, children Politicians interest Historical context 0 – 3 points Future Assess the as yet undetected part of the event and the development of the event or the (with the same indicators) in the abscence of preventive measures 0 – 3 points

15. Sum of impact Now Severity0 – 3 points Cost0 – 3 points Interest0 – 3 points Sum0 – 9 points Future Severity0 – 3 points Cost0 – 3 points Interest0 – 3 points Sum0 – 9 points

16. 4. Potential for spread Assess the potential using –Experience from previous events –Expert judgement –Analysis of the chain of transmission for this event –Other information Avoid assessing impact now –You have already assessed impact

17. The chain of transmission Agent Susceptible host Source Portal of entry Portal of exit Route of transmission

18. Analyse the chain Every disease has its chain of transmission The disease can spread only if all six links are present Analyse the chain for this event (disease + circumstances) –Who are the sources? Infectious periods? –How is it spread? –Are there susceptible hosts? Is further spread likely?

19. Likelihood of spread Conclude: What is the likelihood that the event will spread in the abscence of preventive measures? Very low likelihood (It will not happen) Low likelihood (It will probably not happen) High likelihood (It may happen) Very high likelihood (It will happen)

20. 5. Preventability Assess using –Experience from previous events –Expert judgement –Analysis of the chain of transmission for this event –Other information Primary prevention –Stop event from happening –Reduces likelihood Secondary prevention –Stop event from having consequences –Reduces impact

21. The chain of transmission Agent Susceptible host Source Portal of entry Portal of exit Route of transmission

22. Possible interventions Agent: antimicrobial treatment, disinfection Source (reservoir): behavioural change, isolation Portal of exit: mask, condom, bandage Route of transmission: hand hygiene, environmental hygiene, vector control, food and water control, sanitation Portal of entry: mask, gloves, gown, glasses, condom Susceptible host: vaccination, passive immunisation, chemoprophylaxis, nutrition, behavioural change

23. Analyse the chain Which link(s) can be cut to stop transmission? Analyse the chain for this event (disease + circumstances), taking each link in turn Conclude: Is it possible to reduce the risk? –Primary: Reduce likelihood of spread –Secondary: Reduce impact if it spread

24. 6. Conclude: Current and future risk EpiNorth Risk Assessment of Events Tool (EpiRisk) Impact Very low (0-2 p) Low (3-4 p) High (5-6 p) Very high (7-9 p) Situation now Likelihood of future spread Very low Low High Very high High risk Medium risk Low risk

25. Example The infectious disease doctor at the local hospital calls you and reports that she over the last couple of weeks have seen three students with acute hepatitis B. They had the same address and they seemed to know each other. She had noted injection scars in one of them.

26. 1. Event description Event: Outbreak of hepatitis B Cause: Unknown, maybe shared injection equipment or sex Time: November 2007 Place: Latgale University Students Dormitory Person: Five students in the dormitory, both genders

27. 2. Rapid disease overview HBV Almost all (no vaccination) Carriers (asymptomatic) Genitourinary tract, through skin Genitourinary tract, blood Direct contact (sex, injection)

28. 2. Rapid disease overview Time periods –Incubation period: 45 – 180 days –Period of communicability: Weeks before symptom onset and for life (for carriers) –Natural history: Mostly asymptomatic, less than 10% of adults become carriers, then increased lifetime risk of liver disease Diagnosis and treatment: –Blood test for antigen and antibodies General epidemiological situation: –Few domestic cases, many immigrant carriers

29. 3. Impact of event Now Severity1 point Cost1 point Interest2 points Sum4 points Future Severity2 points Cost1 point Interest3 points Sum6 points

30. 4. Potential for spread HBV Almost all (no vaccination) Carriers and newly infected (asymptomatic) Genitourinary tract, through skin Genitourinary tract, blood Direct contact (sex, injection) High likelihood

31. 5. Preventability HBV Almost all (no vaccination) Carriers (asymptomatic) Genitourinary tract, through skin Genitourinary tract, blood Direct contact (sex, injection) Vaccinate all students in dormitory Provide condoms and needles/syringes Find the infected and carriers and stimulate to behavioural change

32. 6. Conclude: Current and future risk EpiNorth Risk Assessment of Events Tool (EpiRisk) Impact Very low (0-2 p) Low (3-4 p) High (5-6 p) Very high (7-9 p) Situation now X Likelihood of future spread Very low X Low High X Very high

33. Conclusion Risk assessment is important in our work We should do it more systematically and documented The EpiRisk tool has six steps and may be useful –Event description –Rapid disease overview –Impact of event –Potential for spread –Preventability –Conclusion Try it!

34. Exercise The groups do the story that corresponds to their number Prepare a presentation in template If time, do the other stories also on paper (follow the sequence 1-2-3-4-5-1-2…)

35. Event number 1 The school health nurse calls you. She has just received information that the new cook in the school kitchen is a former intravenous drug user with hepatitis C. She has heard rumours that a student who is now away from school, got hepatitis C last month. She wants you to remove the new cook.

36. Event number 2 The local medical doctor in a small farming community calls you. He tells you that the local newspaper has reported rumours that two young African asylum seekers in the refugees shelter in the area are HIV positive and have been observed dancing in the pub with local girls. The mayor wants the Africans removed from the community. He fears an HIV epidemic.

37. Event number 3 At the national surveillance centre you receive reports of around 100 shigellosis cases from several cities in one region of the country during just one week. Usually there are only 100 cases a year. You believe that there may be a foodborne outbreak related to a dairy product. Journalists have started calling you to get comments.

38. Event number 4 Five hundred teenaged folk singers are gathered in a village outside Vilnius for the annual song festival. They live in tents. On Friday evening, a young girl is admitted to hospital with meningitis symptoms. The next morning the hospital calls you to inform that it is meningococcal disease, group C. They also tells you that another, possible case from the festival has been admitted the same morning.

39. Event number 5 The local doctor tells you that he has detected an outbreak of measles involving five children age 1-6 years in a group of traveller families (Rom) that has just arrived in their vans and settled in his city (10 000 inhabitants). They are some 75 people. He fears further spread, and informs you that the vaccination coverage in the local population is around 80%.