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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

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Objectives

• The organizational challenges in outbreak investigations

• Preparing and organizing yourself for field work

• Systematic approach to operational aspects

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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

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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

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Why investigate outbreaks

• Stop the outbreak

• Learn, so that it doesn’t happen again

or that you’ll catch it earlier next time

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CASES

LabConfirmation

Outbreak Detection and Response

Response

Opportunity for control

Detection/Reporting

First Case

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CASES

Outbreak Detection and ResponseFirst Case

Detection/ReportingConfirmationInvestigation Response

Opportunity for control

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1 8 15 22 29 36 43 50 57 64 71

Day of Outbreak

Nu

mb

er o

f C

ases

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

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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.

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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

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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)

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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

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Cooperation/coordination is crucial

Clinicians

Food authorities

Epidemiologist(s)

Diagnostic labs

Public health authorities

OTHERS:Disease specialistsEnvironmentalistsVeterinariansEngineersMedia people

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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

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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”

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Emergency management

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CRISIS MODE

INITIATION LOGISTICS

HANDLINGINFORMATION

COOR-DINATION

CRISIS COMMU-NICATION

ACTION

Start crisis managementMeetings, minutesPlace to work, food

Collecting infoOrganising infoSharing infoMaking sure everyone has info neededDocumentation

Strategy for activitiesPrioritisingDeciding spec. tasksWho should do what

External communicationPress strategy/planMedia communication

Doing the epi work, e.g.:Case finding, interviews,collecting specimens, etc.

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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…

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… find some time to RELAX!!!

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Co-ordination

Epidemiology

Environmental health

Clinicians

Laboratory : clinical environmental

Media AuthoritiesDiagnostic

Clinical

Specimen transfer

Dead Sick

Exposed

SurveillanceInvestigation

Prediction

Parents Students

Principal Teachers

General population

Decisions School closure Medical examinations

Toxic products

Psychological support unit

Police, legal authorities

Autopsy

Systematic approach

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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

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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

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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

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Terms of referenceClarify 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?

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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!

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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”,)

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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

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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

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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

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Organizing the outbreak control team

• Membership

• Leadership

• Responsibilities

• Lines of communication (how)

• Communication (who)

• Decision making process

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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

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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

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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

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Typical line listing for an outbreak investigation

Uni. ID OnsetDate Ward Block City AgeYears Sex Hospital Death HEVIgM HAVIgM1 1-Mar-05 18 2 HYD 12 1 1 2 1 92 3-Mar-05 22 1 HYD 25 2 1 2 2 13 5-Mar-05 23 3 HYD 36 1 2 9 9 94 6-Mar-05 - - SEC 23 2 1 1 1 2

Unique identifier

TimePlace

Person

Outcome

Lab

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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

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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

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Organising data

• Laptop, network, web?

• Backups / confidentiality / access

• Selfexplanatory files and folders

• Sometimes professional data manager

• Inventory of files

• Log book!– every day

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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

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Leaving the field

• Debriefing meeting

• Preliminary report

• Commit to produce final report

• Archive data

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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

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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!

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Laboratory confirmation

Source

Outbreak control team

meeting - urgent!

TV inter view

Control measures ?

Meet minister

Thanks for your attention !!!

Questions ???