Presentation on theme: "Outbreak Investigation Operational Aspects"— Presentation transcript:
1 Outbreak Investigation Operational Aspects 17th EPIET Introductory CourseLazareto, Menorca, Spain27 September 2011Biagio PedalinoSource: 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 workSystematic approach to operational aspects
3 Intervention epidemiology DefinitionThe timely use of epidemiology to solve urgent public health problemsObjectiveTo maximise the scientific quality of the investigation in a complex environment
4 What is an outbreak ?Occurrence of more cases of disease than expectedover a particular period of timein a given areaamong a specific group of peopleSame disease, same source
5 Why investigate outbreaks Stop the outbreakLearn, so that it doesn’t happen again or that you’ll catch it earlier next time
6 Outbreak Detection and Response FirstCaseDetection/ReportingLabConfirmationResponseDAYCASESOpportunityfor control
7 Outbreak Detection and Response FirstCaseDetection/ReportingOpportunityfor controlConfirmationInvestigationResponseDAYCASES
8 Early detection and response 1993 Western States E. coli O157 Outbreak726 ill, 4 deaths39 d2002 Colorado E. coli O157 Outbreak44 ill, no deaths18 d
9 Epidemiological Operational Confirm outbreakCase definitionCase findingDescriptive epiForm hypothesisInterviewsReview infoTest hypothesisInform of outbreakOutbreak teamFormLeadCooperationCommunication internally and with partnersCommunication with the pressOrganisation of your workDissolve team, report etc.
10 Scenarios Local Outbreak - local authorities coordinate - you are asked to assist / helpNational Outbreak- your institute coordinates- you are asked to lead / cooperateInternational / European outbreak involving your country- ECDC / WHO coordinates- your institute collaborates- you participateOutbreak 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, 2003National Outbreak- your institute coordinates- you are asked to lead / cooperateDried tomatoesin France, 2009International / European outbreak involving your country- ECDC / WHO coordinates- your institute collaborates- you participateNorovirus among holidaymakers, 2002Pandemic influenza 2009Outbreak in another country- the authorities in that country coordinate- you are asked to assistEbola, Uganda(2000), DRC(2007)Hepatitis E, Chad (2007)Cholera, Uganda (2005)
12 Operational challenges Unexpected eventNeed to investigate quicklyPressure for answersMultiple agencies/actorsWork carried out at many levelsYou may be in the media spotlightPossible legal implications
13 Cooperation/coordination is crucial Epidemiologist(s)CliniciansDiagnostic labsPublic health authoritiesOTHERS:Disease specialistsEnvironmentalistsVeterinariansEngineersMedia peopleFood authorities
14 Challenges, Outbreak Team Different institutes, ministriesDifferent backgrounds, fieldsDifferent cultures, scientific languagesDifferent expectationsDon’t know/trust each otherSomeone has to decide over the othersWorking under time pressureOutbreaks hit suddenly, little time to prepare
15 Organisational hints/solutions Clear and transparent leadershipBuild trust before the outbreak happensMeetings in peace timePreparedness plan, guidelinesAdjust expectations, clarify rolesSupport from strategic levelAdministrative supportHelp with communicationEfficient information sharing, everyone same picture of situationStandard operating procedures, templatesPossibility of going to “crisis mode”
16 1 1 2 2 5 5 3 3 4 4 Emergency management Start crisis management Meetings, minutesPlace to work, food11INITIATIONLOGISTICSCollecting infoOrganising infoSharing infoMaking sure everyone has info neededDocumentation22HANDLINGINFORMATIONCRISISMODE5533Strategy for activitiesPrioritisingDeciding spec. tasksWho should do whatCOOR- DINATIONACTIONCRISISCOMMU- NICATION44External communicationPress strategy/planMedia communicationDoing the epi work, e.g.:Case finding, interviews, collecting specimens, etc.
17 Challenges in the field You may arrive lateUnderstand local expertise/hierarchiesLocal sensitivitiesForeign country (i.e. language, culture)Need to feedback to various peopleMany actors involvedStress, long working hours…
20 Systematic approach Reasons for inviting you ´Terms of reference´ ?Preparing to leave for the fieldWhen you arriveIn the fieldOutbreak Control TeamInformation managementLeaving the fieldBack home
21 Reasons for inviting you ExpertiseMore resourcesShare responsibilityPolitical or mass media pressureMandatory or in guidelinesNeed to confirm local findingsSpecialised investigations
22 Waterborne outbreak Denmark 2007 Example15 Jan SSI contacted by district medical officerMuch GI illness in town in ZealandWater suspected, OCT formsSSI invited to participateEpi expertiseLab assistanceResources
23 Terms of reference Clarify before accepting What are their expectationsexpertise, 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 leaveConsult colleagues (microbiologist, veterinarians, GP, internal medicine specialist….)Review relevant literature, guidelinesDecide who will lead the teamIdentify who provides support in head officeOne page report before leavingobjectivesArrange initial meeting for your arrivalDiscuss with your colleagues (and your boss) at the institute to organise follow up of your ongoing projects!
26 When you arrive Provide help - don’t take charge Meet with key people Review and update status of problemAssess sensitivitiesIdentify local resources and skillsSet up communications with base
27 Outbreak team Example Municipality technical manager (leader) People from various townhall officesMedical officersWater plantWater supply systemPoliceEmergency Management AgencyFood safetySSIPrivate engineering companyMedia relations officer
28 The Outbreak Control Centre Situation room / designated officeWhere, how bigAccessibility / SecurityComputers with Internet connection, network and firewall problemsTelephones, fax, copy machineReference materialsCateringPlace to sleep
29 Organizing the outbreak control team MembershipLeadershipResponsibilitiesLines of communication (how)Communication (who)Decision making process
30 Information / Data Types of information epidemiologicaloperationalWays 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/contactslab results, questionnaires availablein excelConstitutes and updates a database of casesProtects the confidentiality of the patientsPrepares an easy, automated, descriptive analysis
32 The line list Only one in the team!!! avoid confusion with multiple versionsContains a unique identifier for each record (case)Ensures confidentialityContains essential information on each casetime, place, person, other (e.g., clinical, lab)Can be updated as the investigation developsAllows regular, automated, computerized analysis
33 Typical line listing for an outbreak investigation Unique identifierTimePlacePersonOutcomeLabUni. IDOnsetDateWardBlockCityAgeYearsSexHospitalDeathHEVIgMHAVIgM11-Mar-05182HYD121121923-Mar-05221HYD252122135-Mar-05233HYD361299946-Mar-05--SEC2321112
34 Situation report Overview of the current situation Concise, focus on factsStructured, may use templateNo cases, epicurve, map, what has been doneParagraph with development since last reportMay contain risk assessmentMay contain scenarios, predictions
35 Operational information Contacts: name, position, contact detailsTypes of filesepidemiological (questionnaires, data, protocols)interviews, meetings, presssMeetingsminutesactions and those responsibleDecisions and rationale (information available at the time of decision making)All steps taken in the investigation
36 Organising data Laptop, network, web? Backups / confidentiality / accessSelfexplanatory files and foldersSometimes professional data managerInventory of filesLog book!every day
37 The Media Appoint one (professional) spokesperson prepare briefings for him / herCoordinate with other agenciesInform early and oftenwebsites of relevant institutesinterviewspress statementspress meetingsBe honest, explain what is being doneBe clear about what isfact / speculation / not known
38 Leaving the field Debriefing meeting Preliminary report Commit to produce final reportArchive data
39 Back home Inform your supervisor and colleagues Follow up debriefingFollow uplab, clinical other studies resultsStay in touch with the field - new casesFinalise the report ASAPBeware of confidentialityanonymise databaseanonymise questionnaires
40 Summary Outbreak investigations are challenging Each outbreak investigation is differentCooperation is difficult, requires organisationPreparation and good operational skills helpOffer help, do not take chargeStay organisedDon´t come back until the job is doneDocument steps, use a log, write the reportsTake time to rest, and remember to have fun!
41 Thanks for your attention !!! Laboratory confirmationSourceOutbreak control team meeting - urgent!TV inter viewControl measures ?Meet ministerQuestions ???