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1 Outbreak Investigation Operational Aspects Source: Mike Ryan, Jet de Valk, Susan Hahné, Marta Valenciano, Barbara Schimmer, Steen Ethelberg. Previous.

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Presentation on theme: "1 Outbreak Investigation Operational Aspects Source: Mike Ryan, Jet de Valk, Susan Hahné, Marta Valenciano, Barbara Schimmer, Steen Ethelberg. Previous."— Presentation transcript:

1 1 Outbreak Investigation Operational Aspects Source: Mike Ryan, Jet de Valk, Susan Hahné, Marta Valenciano, Barbara Schimmer, Steen Ethelberg. Previous EPIET Introductory course sessions. 17th EPIET Introductory Course Lazareto, Menorca, Spain 27 September 2011 Biagio Pedalino

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

3 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 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 5 Why investigate outbreaks Stop the outbreak Learn, so that it doesnt happen again or that youll catch it earlier next time

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

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

8 8 726 ill, 4 deaths 1993 Western States E. coli O157 Outbreak 39 d 44 ill, no deaths 18 d 2002 Colorado E. coli O157 Outbreak Early detection and response

9 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 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 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 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 13 Cooperation/coordination is crucial Clinicians Food authorities Epidemiologist(s) Diagnostic labs Public health authorities OTHERS: Disease specialists Environmentalists Veterinarians Engineers Media people

14 14 Challenges, Outbreak Team Different institutes, ministries Different backgrounds, fields Different cultures, scientific languages Different expectations Dont know/trust each other Someone has to decide over the others Working under time pressure Outbreaks hit suddenly, little time to prepare

15 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 16 Emergency management 4 1 2 3 5 4 1 2 3 5 CRISIS MODE INITIATION LOGISTICS HANDLING INFORMATION COOR- DINATION CRISIS COMMU- NICATION ACTION Start crisis management Meetings, minutes Place to work, food Collecting info Organising info Sharing info Making sure everyone has info needed Documentation Strategy for activities Prioritising Deciding spec. tasks Who should do what External communication Press strategy/plan Media communication Doing the epi work, e.g.: Case finding, interviews, collecting specimens, etc.

17 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 18 … find some time to RELAX!!!

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

20 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 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 22 Waterborne outbreak Denmark 2007 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 Example

23 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 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 25 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,)

26 26 When you arrive Provide help - dont 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 27 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 Example

28 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 29 Organizing the outbreak control team Membership Leadership Responsibilities Lines of communication (how) Communication (who) Decision making process

30 30 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

31 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 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 33 Typical line listing for an outbreak investigation Uni. IDOnsetDateWardBlockCityAgeYearsSexHospitalDeathHEVIgMHAVIgM 11-Mar-05182HYD1211219 23-Mar-05221HYD2521221 35-Mar-05233HYD3612999 46-Mar-05--SEC2321112 Unique identifier Time Place Person Outcome Lab

34 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 35 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

36 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 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 38 Leaving the field Debriefing meeting Preliminary report Commit to produce final report Archive data

39 39 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

40 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 41 Laboratory confirmation Source Outbreak control team meeting - urgent! TV inter view Control measures ? Meet minister Thanks for your attention !!! Questions ???


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