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Outbreak Investigation Operational Aspects

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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 ???

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