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Outbreak Investigation Operational Aspects 12 th EPIET Introductory Course Lazareto, Spain Marta Valenciano, Susan Hahné, Jet de Valk, Mike Ryan,

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Presentation on theme: "Outbreak Investigation Operational Aspects 12 th EPIET Introductory Course Lazareto, Spain Marta Valenciano, Susan Hahné, Jet de Valk, Mike Ryan,"— Presentation transcript:

1 Outbreak Investigation Operational Aspects 12 th EPIET Introductory Course Lazareto, Spain Marta Valenciano, Susan Hahné, Jet de Valk, Mike Ryan,

2 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

3 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

4 Why investigate outbreaks? Stop the outbreak Understand what happened and why Prevent future outbreaks Improve our knowledge Improve surveillance and outbreak detection Training

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

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

7 Objectives for this session Yesterday: Methodological aspects Today Scenarios for your involvement Challenges in getting organised during outbreak investigation Preparing and organising yourself for field work Systematic approach to operational aspects

8 Scenarios Local Outbreak - Local authorities coordinate - Your are asked to assist / help National Outbreak - Your institute coordinates -You are asked to lead International / European outbreak involving your country - ECDC coordinates - Your institute collaborates - You participate Outbreak in another country -The authorities in that country coordinate - You are asked to assist

9 e.g. EPIET fellow involvement Local - Local authorities Hepatitis A in Bretagne National - Your instituteS. Typhi International / European outbreak involving your country - ECDC coordinates Meningococal infections in pilgrims returning from Haj Another country - The authorities in that country coordinate Leptospirosis in Nicaragua (French Ministry mission) Rift Valley Fever, Kenya (WHO mission)

10 Operational challenges Unexpected event Need to investigate quickly Pressure for answers Multiple agencies Work carried out at many levels You are in the media spotlight Legal implications

11 Operational challenges You may arrive late –rumours? Local sensitivities Foreign country Need to feedback to various people Stress, long working hours, finding time to rest and relax Systematic approach

12 Unexplained illness in a high school in Normandie, 2001 5/03 : 15 ill; headache, nausea, abdominal pain 8/03 : 35 ill –school closed –investigation for toxic products –medical examination of all ill students 15/03 : 45 ill 16/03 : one student found dead InVS to investigate On call epidemiologist + « volunteers »

13 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

14 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

15 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

16 Reasons for inviting you Normandie, 2001 Expertise More resources Share responsibility Political or mass media pressure

17 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?

18 Clarify before accepting, Normandie, 2001 Expectations –Epidemiological expertise –Experience with mass sociogenic illness (MSI) –Human ressources: 5 persons Environmental investigation already started Computers, phones, car... DMO in charge

19 You are going to the field !

20 Preparing to leave Consult colleagues (microbiologist, vet, entomologist….) Review pertinent litterature Decide who will lead the team Identify who provides support in the head office One page report before leaving –objectives Arrange initial meeting for your arrival

21 Preparing to leave, Normandie 2001 Consult infectious disease experts, pathologist, toxicologist Review litterature causes of sudden death Support in head office: 3 departments.. One page report before leaving Arrange initial meeting for your arrival

22 Bring your epi-pack Computer, calculator, mobile phone Software USB, CDs Notebook File templates Standard questionnaires Handbooks, relevant articles Camera (Laboratory equipment) Telephone, address list: –reference centers & persons Maps, GPS Others... (money, health kit,)

23 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 Discuss liaison Set up communications with base

24 Arrival to Normandie Meeting with: –College principal –Parents Visiting the school Understand rumours –second world war

25 Tristesse et inquiétude à Port-en- Bessin Le collège reste fermé après le décès inexpliqué d'un adolescent de 15 ans. La préfecture recommande aux 275 élèves d'aller à l'hôpital. Les portes du collège Ernest- Hemingway de Port-en-Bessin (Calvados), où plus d'une cinquantaine d'élèves ont été intoxiqués en 15 jours, resteront fermées jusqu'à nouvel ordre, après le décès d'un adolescent de 15 ans pour des raisons indéterminées. Cet élève de troisième ne faisait cependant pas partie des enfants incommodés lors de l'intoxication suspecte. Inquiets, les parents d'élèves se sont succédés vendredi après-midi dans une des salles communales, où avait été installée une cellule de soutien psychologique. La préfecture a également conseillé

26 Organising the Outbreak Control Team Membership Leadership Responsibilities Lines of communication Communication Decision making process

27 The Outbreak Control Team Tasks Agree plan of Action Commit resources Co-ordinate further investigation and response Report to and advise higher authorities ECDC and WHO alerts ? Maintain communication with –other investigators –stakeholders –general public –the media

28 The Outbreak Control Team MSI Normandie

29 Plan of action: Describe events and exposures Retrospective cohort study Environmental investigation and sampling Systematic review of clinical findings Autopsy deceased student Psychological support Communication and information

30 The Outbreak Control Centre - I Headquarters of the investigation Where How big Accessibility/Security Separation from normal work Catering

31 The Outbreak Control Centre - II Equipment Computers with Internet connection Telephones, telefax Copy machine Reference materials Office furniture and stationery

32 Information \ Data Types of information –epidemiological –operational Managing information (databases) Briefing, feed-back Communicating with the media –one person ! Writing reports: ongoing process

33 Epidemiological data Line listing is vital – cases/contacts – lab results, questionnaires available – in excel


35 Operational information Contacts: name, position, contact details Types of files –epidemiological (questionnaires, data, protocols) –interviews, meetings, press –source and date –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 Managing data \ data bases Software Database design Data –entry and validation –multiple data bases : how linked? –analysis –programmes Backups / confidentiality / access Overall responsibility for data management Sometimes professional data manager

37 Operational information Storage and organisation Computer, laptop, web? Inventory of files Log book! –every day

38 Information Management – The Media Appoint one (professional) spokesperson –prepare briefings for him / her Coordinate with other agencies Inform early and often – interviews – press statements – press briefings - regularly Be clear about what is – fact – speculation – not known

39 Normandie, 2001 The media and the general public Different spoke persons DMO decision maker –parents –school authorities Epi investigator (experts..) –media Conflicting information from other investigators

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

41 Back home Inform your supervisor and colleagues –debriefing Follow up –lab, clinical other studies results Finalise the report ASAP Beware of confidentiality –anonymise database –anonymise questionnaires

42 Normandie, 2001 Deceased student: congenital heart malformation Mass sociogenic illness Triggering factors: poor ventilation, high temperature Environmental contamination below toxic levels Children dispatched to other schools: malaises reported School reopened after renovation

43 Normandie: lessons learned Involve other (competing) investigators Consult all partners and other investigators before communicating important results Stick to basic principals: - test your questionnaire Back up from headquarters Distinguish investigators / decision makers Follow up after return

44 Summary Outbreak investigations are challenging Preparation and good operational skills help Offer help, do not take charge Stay organised Don´t come back until the job ids done Write your report all the time Take time to have a rest !!!

45 Laboratory confirmation Source Outbreak control team meeting - urgent! TV inter view Control measures ? Meet minister

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