Session VI Writing an Outbreak Report Session Overview 1.Outbreak report function and critical...
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Transcript of Session VI Writing an Outbreak Report Session Overview 1.Outbreak report function and critical...
Session VI
Writing an Outbreak Report
Session Overview
1. Outbreak report function and critical components
2. Case studies– E. coli 0157:H7 at the NC State Fair, 2004– Multistate Outbreak of Monkeypox, 2003
Learning Objectives
• Understand the role of outbreak investigation reports
• Recognize the different types of reports
• Recognize elements to include in outbreak investigation reports
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
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
Why are Outbreak Reports Crucial to Public Health?
Example : Foodborne outbreak
• Hepatitis A contamination of green onions in TN, NC, GA, and PA, Sept-Nov 2003
• Food and Drug Administration (FDA) advisory report and MMWR alerted the public and assisted with traceback
Why are Outbreak Reports Crucial to Public Health?
Example: Respiratory disease outbreak
• Legionnaire’s Disease (LD) Associated with a Whirlpool Spa Display – Virginia, Sept-Oct 1996
• Case-patients were likely exposed by walking by or spending time near the spa
• The Virginia Department of Health issued recommendations for the inspection and maintenance of display spas
Why are Outbreak Reports Crucial to Public Health?
Example: Respiratory disease outbreak
• Legionnaire’s Disease (LD) outbreak at a flower show in the Netherlands, 1999
• Source: whirlpool spa on display
• Lawsuit raised against Dutch government for negligence
• Failure to act on available knowledge (MMWR 1996)
Some Reports are a Part of History
John Snow
Some Reports are a Part of History
Morbidity and Mortality Weekly Report (CDC), June 5, 1981
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.”
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.
What are the Types of Reports?
• Complaint form• Internal report
– Record that outbreak occurred and investigation was conducted
• State publication – Newsletter, Website, statewide alert
• MMWR http://www.cdc.gov/mmwr/• Peer-Reviewed Journals
– Epidemiology and Infection, Emerging Infectious Diseases, Journal of Hospital Infection
Peer-Reviewed Articles
http://www.ncbi.nlm.nih.gov
Research Outbreak Updates
• MMWR mailing listwww.cdc.gov/mmwr/mmwrsubscribe
• FoodNetwww.cdc.gov/foodnet/
• ProMED-mail listserve www.promedmail.org
Basic Report Structure
• Summary• Introduction and Background• Outbreak Description• Methods and Results• Discussion• Lessons Learned• Recommendations• Acknowledgements
*Supporting Documentation
~ 2 - 3pages
Summary
• 1 - 2 paragraphs• Overview of the investigation
– WHO, WHAT, WHERE, WHEN, WHY/HOW• What caused the outbreak or the causal
hypothesis based on the evidence• Key recommendations• Ongoing actions• Pending / required actions
Introduction and Background
• Surveillance trends and similar outbreaks
• Include specific events that led to the investigation
- How the outbreak was first reported- Steps taken to confirm the outbreak- Those who became involved in the outbreak
investigation
• Description of the area / site / facility
Methods
• Epidemiologic– Case definition and ascertainment– Study design
• Microbiological / Toxicological– Clinical and environmental specimen collection– Where specimens sent– Types of analyses performed
• Environmental– Site visit & risk assessment– Traceback of food products or other items
Results
• Epidemiological – No. of questionnaires sent / returned– No. of cases and descriptive & clinical data
on cases– Geographic distribution of cases– Epidemic curve– Risk factor analysis– Attack rates by age, sex, exposure
Results
• Microbiological / Toxicological – Laboratory findings, e.g. genotyping, DNA
fingerprinting via PFGE, culture results
• Environmental– Results of any risk assessments– Results of any traceback investigation
Discussion
• Discuss main hypotheses
• Justify conclusions and actions
• Explain action to protect public health
Discussion
• Highlight any lessons learned
– Problems encountered
– Mistakes made
– Limitations of the study
– Useful lessons for planning future investigations
Recommendations• Control Measures
– To control this outbreak– To prevent future outbreaks– To improve management of future outbreaks
• Be specific about problems – Investigation obstacles and shortcomings– Outbreak causes
• Aim to educate fellow public health professionals and inform policy makers
Supporting Documentation
Also include the following:Graphs and tables
Inspection reports
Blank samples of surveys
Letters to management
Menus
Copies of posted notices
Testing results
Press releases
Maps
Case Studies
Case Study 1
Outbreak of E. coli O157:H7 at the North Carolina State Fair, 2004
Epi Notes, December 2004-February 2005http://www.epi.state.nc.us/epi/pdf/en2004-4.pdf
Case Study 1
• Condensed version of a more detailed report
• Includes all important components
– Outbreak description– Methods and results– Discussion– Lessons learned– Recommendations
Case Study 1
• October 2004: E. coli O157:H7 infection associated with state fair attendance.
• Case-control study design with 45 confirmed cases and 188 controls.
• Data analysis and public health laboratory results (PFGE) revealed petting zoo activities at the fair as the source of infection.
E. coli O157:H7 at the NC State Fair:Epidemic Curve
E. coli O157:H7 at the NC State Fair:Resulting Legislation
• “Aedin’s Law” - July 2005
• Permitting process and rules for animal exhibitions at state-sanctioned fairs
• Educational campaign about diseases associated with contact with animals
Case Study 2
Multistate Outbreak of Monkeypox – Illinois, Indiana, Kansas, Missouri, Ohio, and
Wisconsin, 2003
MMWR June 13, 2003
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5223a1.htm
Multistate Monkeypox Outbreak Background and Outbreak Description
• CDC received reports of patients with a febrile rash illness in Illinois, Indiana and Wisconsin
• As of June 10, a total of 53 cases identified• Many reported close contact with pet prairie
dogs and other animals• Laboratory tests indicated the causative
agent was a poxvirus
Multi-state Monkeypox OutbreakMethods
• MMWR write-up includes combined data from multiple states– Methods are not detailed
• Laboratory investigation to identify the virus • Case-patient interviews to determine exposures,
symptoms, and obtain clinical specimens• Traceback investigation to identify original
source of illness
Multistate Monkeypox OutbreakLaboratory Results
• CDC tests concluded the virus was monkeypox
Multistate Monkeypox OutbreakEpidemiologic Results
Demographic information included in report:• 29 cases (49%) male• Median age 26 years (range: 4 - 53 years)• 14 cases (26%) hospitalized• Earliest onset of illness was May 15
Multistate Monkeypox Outbreak Epidemiologic Results
Multistate Monkeypox Outbreak Epidemiologic Results
Multistate Monkeypox OutbreakResults
Multistate Monkeypox Outbreak Results
• All patients had contact with animals• 51 of 53 cases reported direct or close contact
with prairie dogs • One patient reported contact with a Gambian
giant rat• One patient had contact with a rabbit that
became ill after exposure to an ill prairie dog at a veterinary clinic
Multistate Monkeypox OutbreakTraceback Results
• Common distributor - prairie dogs and Gambian giant rats housed together
• Imported animal records - Gambian giant rats shipped from Ghana to a wildlife importer in TX and sold to the distributor
• The shipment contained ~800 small mammals of 9 different species
Traceback Investigation
Multistate Monkeypox OutbreakDiscussion and Recommendations
• Preliminary findings suggested that the primary route of transmission is from close contact with infected mammalian pets
• However, the possibility of human-to-human transmission cannot be excluded
• Interim guidelines for infection control in the community and in health care settings were issued
Control Measure Guidelines
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
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.
References and Resources• Ashford DA, Kaiser RM, Bates ME, Schutt K, Patrawalla A,
McShan A, Tappero JW, Perkins BA, Dannenberg AL. Planning against biological terrorism: Lessons from Outbreak Investigations. Emerg Infect Dis 2003;9:515-9.
• Conducting an Outbreak Investigation. The North Carolina Communicable Disease Control Manual, North Carolina Division of Public Health. Accessed at http://www.epi.state.nc.us/epi/gcdc/manual/outbreakinvest.pdf
• Consumers Advised That Recent Hepatitis A Outbreaks Have Been Associated With Green Onions. FDA Talk Paper. November 15, 2003. Assessed 10/13/2004 http://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01262.html
• Den Boer JW, Yzerman PF, Schellekens J, et al. A large outbreak of Legionnaires’ disease at a flower show, the Netherlands, 1999. Emerg Infect Dis 2002;8:37-43.
References and Resources• Fontham ETH, Correa P, Wu-Williams A, Reynolds P, Greenberg
RS, Buffler PA, et al. Lung cancer in nonsmoking women: a multicenter case-control study. Cancer Epidemiol Biomarkers Prev 1991;1:35-43.
• Gaudet, M. (2003). Suggestions for Critically Evaluating an Epidemiologic Study Report. Handout developed for the UNC Chapel Hill School of Public Health EPID 160 course “Principles of Epidemiology.”
• Goode B. Outbreak of E. coli 0157:H7 at the North Carolina State Fair – 2004. EpiNotes, North Carolina Department of Health and Human Services, Division of Public Health. Accessed at http://www.epi.state.nc.us/epi/pdf/en2004-4.pdf
• Gordis, L. Epidemiology. 2nd ed. Philadelphia: WB Saunders Company; 2000.
References and Resources• Greenberg RS, Daniels SR, Flanders WD, Eley JW, Boring JR.
Medical epidemiology. 3rd ed. New York: McGraw-Hill; 2001.
• Guidelines for EPI-AID Investigations. Division of Applied Public Health Training, Epidemiology Program Office, CDC.
• Hepatitis A Outbreak Associated with Green Onions at a Restaurant --- Monaca, Pennsylvania. MMWR 2003;52(47);1155-1157
• International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals: writing and editing for biomedical publication. Updated November 2003. http://www.icmje.org/ Accessed August 19, 2004.
• Last JM, editor. A dictionary of epidemiology. 4th ed. Oxford University Press; 2001.
References and Resources• Levine, S. Redinger, C. and Robert, W. (September / October
2001). Community Exposure Assessment and Intervention Effectiveness at Trinity American Corporation, Glenola, North Carolina. American Industrial Hygiene Association Journal. 62: 649-657.
• Massachusetts Foodborne Illness Investigation and Control Reference Manual. http://www.state.ma.us/dph/fpprefman.htm
• Millikan B. How to read a scientific article. http://cbcs.med.unc.edu/howto.htm Accessed July 26, 2004.
• Pneumocystis Pneumonia – Los Angeles. 1981 MMWR 30(21);1-3.
• PubMed database, National Library of Medicine. Available online at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi
• Reigelman RK. Studying a study and testing a test: how to read the medical evidence. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2000.
References and Resources
• Rothman KJ. Modern epidemiology. Boston: Little, Brown and Company; 1986.
• Savitz DA. Interpreting epidemiologic evidence: strategies for study design and analysis. Oxford University Press; 2003.
• The Outbreak Investigation Report, power point presentation by Arnold Bosman and Meirion Evans. Epiet. Accessed at www.epiet.org/course/presentations2003.html
• Update: Multistate Outbreak of Monkeypox – Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconson, 2003. MMWR 52(23);537-540
• Zhong L, Goldberg MS, Parent M, Hanley JA. Exposure to environmental tobacco smoke and the risk of lung cancer: a meta-analysis. Lung Cancer 2000;27:3-18.