Outbreak Investigation Operational Aspects

1. Outbreak Investigation Operational Aspects 17th EPIET Introductory Course Lazareto, Menorca, Spain 27 September 2011 Biagio Pedalino Source: 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 work • Systematic approach to operational aspects

3. Intervention epidemiology Definition • Thetimely use of epidemiology to solve urgent public health problems Objective • To maximise the scientific quality of the investigation in a complex environment

4. 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

5. Why investigate outbreaks • Stop the outbreak • Learn, so that it doesn’t happen again or that you’ll catch it earlier next time

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

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

8. Early detection and response 1993 Western States E. coli O157 Outbreak 726 ill, 4 deaths 39 d 2002 Colorado E. coli O157 Outbreak 44 ill, no deaths 18 d

9. 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.

10. Scenarios

11. Possible involvement of a field epidemiologist (before, during or after the EPIET fellowship time)

12. 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

13. Cooperation/coordination is crucial Epidemiologist(s) Clinicians Diagnostic labs Public health authorities OTHERS: Disease specialists Environmentalists Veterinarians Engineers Media people Food authorities

14. 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

15. 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”

16. Emergency management Start crisis management Meetings, minutes Place to work, food 1 1 INITIATION LOGISTICS Collecting info Organising info Sharing info Making sure everyone has info needed Documentation 2 2 HANDLING INFORMATION CRISIS MODE Strategy for activities Prioritising Deciding spec. tasks Who should do what 5 5 3 3 COOR-DINATION ACTION 4 4 CRISIS COMMU-NICATION External communication Press strategy/plan Media communication Doing the epi work, e.g.: Case finding, interviews,collecting specimens, etc.

17. 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…

18. … find some time to RELAX!!!

19. Toxic products Systematic approach Dead Sick Investigation Surveillance Exposed Prediction Clinicians Epidemiology Psychological support unit Co-ordination Laboratory : clinical environmental Parents Students Environmental health Clinical Specimen transfer General population Principal Teachers Diagnostic Authorities Media Autopsy Decisions School closure Medical examinations Police, legal authorities

20. 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

21. 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

22. Waterborne outbreak Denmark 2007 Example • 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

23. 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?

24. 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!

25. 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”,)

26. 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

27. Outbreak team Example • 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

28. 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

29. Organizing the outbreak control team • Membership • Leadership • Responsibilities • Lines of communication (how) • Communication (who) • Decision making process

30. 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

31. 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

32. 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

33. Typical line listing for an outbreak investigation Unique identifier Time Place Person Outcome Lab Uni. ID OnsetDate Ward Block City AgeYears Sex Hospital Death HEVIgM HAVIgM 1 1-Mar-05 18 2 HYD 12 1 1 2 1 9 2 3-Mar-05 22 1 HYD 25 2 1 2 2 1 3 5-Mar-05 23 3 HYD 36 1 2 9 9 9 4 6-Mar-05 - - SEC 23 2 1 1 1 2

34. 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

35. 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

36. Organising data • Laptop, network, web? • Backups / confidentiality / access • Selfexplanatory files and folders • Sometimes professional data manager • Inventory of files • Log book! • every day

37. 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

38. Leaving the field • Debriefing meeting • Preliminary report • Commit to produce final report • Archive data

39. 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

40. 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!

41. Meet minister Outbreak control team meeting - urgent! TV inter view Laboratory confirmation Source Control measures ? Thanks for your attention !!! Questions ???