Outbreak Investigation Operational Aspects 12th EPIET Introductory Course Lazareto, Spain

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

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Why investigate outbreaks?

• Stop the outbreak
• Understand what happened and why
• Prevent future outbreaks
• Improve our knowledge
• Improve surveillance
  and outbreak detection
• Training

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Outbreak Detection and Response
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Outbreak Detection and Response
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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

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Scenarios
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e.g. EPIET fellow involvement
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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

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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

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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

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Toxic products
Dead
Sick
Surveillance
Investigation
Exposed
Prediction
Clinicians
Epidemiology
Psychological support unit
Co-ordination
Laboratory clinical environmental
Environmental health
Parents Students
Clinical
Specimen transfer
General population
Principal Teachers
Diagnostic
Authorities
Media
Autopsy
Decisions School closure Medical examinations
Police, legal authorities
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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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Reasons for inviting youNormandie, 2001

• Expertise
• More resources
• Share responsibility
• Political or mass media pressure

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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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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

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You are going to the field !
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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

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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

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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,)

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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

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Arrival to Normandie

• Meeting with
• College principal
• Parents
• Visiting the school
• Understand rumours
• second world war

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Organising the Outbreak Control Team

• Membership
• Leadership
• Responsibilities
• Lines of communication
• Communication
• Decision making process

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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

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The Outbreak Control Team MSI Normandie
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The Outbreak Control TeamMSI Normandie

• 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

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The Outbreak Control Centre - I

• Headquarters of the investigation
• Where
• How big
• Accessibility/Security
• Separation from normal work
• Catering

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The Outbreak Control Centre - II

• Equipment
• Computers with Internet connection
• Telephones, telefax
• Copy machine
• Reference materials
• Office furniture and stationery

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Information \ Data

• Types of information
• epidemiological
• operational
• Managing information (databases)
• Briefing, feed-back
• 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

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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

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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

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Operational informationStorage and organisation

• Computer, laptop, web?
• Inventory of files
• Log book!
• every day

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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

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Normandie, 2001The media and the general public

• Different spoke persons
• DMO decision maker
• parents
• school authorities
• Epi investigator (experts..)
• media
• Conflicting information from other investigators

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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
• Finalise the report ASAP
• Beware of confidentiality
• anonymise database
• anonymise questionnaires

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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

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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

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Summary

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

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