1. Writing an Outbreak Report Dr Noorhaida Ujang Epid Officer Muar Alor Setar, 2013 1

2. Learning Objectives Understand the role of outbreak investigation reports Recognize elements to include in outbreak investigation reports

3. Basic Steps of an Outbreak Investigation 1.Verify the diagnosis and confirm the outbreak 2.Define a case and conduct case finding 3.Tabulate and orient data: time, place, person 4.Take immediate control measures 5.Formulate and test hypothesis 6.Plan and execute additional studies 7.Implement and evaluate control measures 8.Communicate findings

4. Why Communicate the Findings? Document for action Share new insights Record of performance Substantiate recommendations In order to… Prevent future outbreaks Assist in investigation and control of similar incidents Provide a document for potential legal issues

5. When is the Report Written? When the investigation is ‘complete’ When the investigation is ‘ongoing’ –“Further analysis of data collected in this investigation may require revision of these findings and recommendations.” –“Because of the preliminary nature of this investigation, future correspondence, MMWR articles, or other published reports might present results, interpretations, and recommendations that are different.”

6. Who Writes the Report? The field epidemiology / outbreak team –Visiting EIS officer Other authors as assigned All participating agencies must agree with what is in the report.

7. Structure of Report Summary Background Methods Results Discussion Recommendations 7

8. Linking Sections Start with the end Recommendations are based upon conclusions Conclusions are based upon data and limitations of data Data collected is based up methods used Method used is based on study objectives Objectives are linked to the problem and be linked to the conclusions and recommendations 8

9. Order of Writing 1.Background 2.Methods 3.Results 4.Conclusions 5.Discussion 6.Summary 7.Title 9

10. Summary Newspaper article – who, what, when, where One page 1 st parargraph –1 st sentence is general problem statement – 2 nd sentence is specific problem. –Following sentences describe problem – outbreak potential –End with objectives 2 nd paragraph methods 3 rd paragraph results 4 th paragraph recommendations 5 th paragraph actions taken 10

11. Background Describe disease – sources, transmission, outbreak potential Describe population and place of outbreak Historic surveillance information Previous outbreaks Describe facility Maps 11

12. Outbreak Description How was reported Steps to confirm What was known to date Why was an investigation undertaken Objectives Who was on the team Describe initial reported cases 12

13. Methods Epidemiology –Case definition –Case finding –Study design –Describe target and study groups –Sample size –Data collection –Plan of analysis Laboratory –Sample collection –tests Environmental studies –Site visits 13

14. Results Include findings that lead to the conclusions. Rule in and rule out Response rate Number of cases identified Overall attack rate Descriptive epidemiology Hypothesis generated Analytical results 14

15. Table 1: Characteristics of people injured or killed by a landmine or ordnance explosion: May 1996-June 1998, Kabul City, Afghanistan CharacteristicLandmineOrdnanceTotal (278) (293)(571) Sex Female3636 72 (13%) Male241253 494 (86%) Unknown14 5 (1%) Mean age in years (SD)*24·3 (15·7)14·6 (11·9) 19.3 (14.7) Mean educational level (SD)*4·0(4·8)2·1 (2·5)2.7 (3·5) Primary occupation Daily worker*411758 Farmer8210 Housewife11617 Shepherd121628 Student*3077107 Teacher707 Unemployed584098 Other333164 Unknown78104182 *(p<0·01, t test) 15

16. Victims of landmine and ordnance explosions differed in several ways. The mean age in years at time of injury or death and years of education were lower in people injured or killed by ordnance explosions than by those injured or killed by landmine explosions. The victims’ occupation differed strikingly. The most common occupation was a daily work or unemployment for the landmine victims and overwhelmingly students for the ordnance victims (Table 1). 16 Table 1: Characteristics of people injured or killed by a landmine or ordnance explosion: May 1996-June 1998, Kabul City, Afghanistan

17. Discussion 1 st paragraph. Summarize key results 2 nd paragraph and beyond. Are results similar or different to other studies? Third to last paragraph. Limitations and how affected investigation and interpretation of results. Second to last paragraph. Lessons learned Last paragraph. Overall significance of investigation. 17

18. Recommendations What was done to control outbreak How to prevent future outbreaks Make realistic recommendations 18

19. Other sections Acknowledgements References Appendix 19

20. Frequent Problems with Writing an Outbreak Report Timeliness Confidentiality Legal

21. Comparison of Case Study Reports Both outbreak reports included the major elements: –Introduction and Background –Outbreak Description –Methods and Results –Lessons Learned –Recommendations Complexity of the report depends on the type of investigation, the extent of the outbreak, and the audience of the report

22. Summary Outbreak reports are the final step in completing your investigation. Outbreak reports serve many purposes, both internally and externally. Though outbreak reports may differ in purpose and audience, reports generally follow a basic structure.