Outbreak Investigation

Operational Aspects

12th EPIET Introductory CourseLazareto, Spain

Marta Valenciano, Susan Hahné, Jet de Valk, Mike Ryan,

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

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

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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CASES

LabConfirmation

Outbreak Detection and Response

Response

Opportunity for control

Detection/Reporting

First Case

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CASES

Outbreak Detection and Response

First CaseDetection/

ReportingConfirmationInvestigation

Opportunity for control

Response

Objectives for this sessionYesterday:

• 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

Scenarios

Local Outbreak - Local authorities coordinate

- Your are asked to assist / help

National Outbreak - Your institute coordinates-You are asked to lead

International / European outbreak involving your country

- ECDC coordinates

- Your institute collaborates

- You participate

Outbreak in another country

-The authorities in that country coordinate- You are asked to assist

e.g. EPIET fellow involvement

Local - Local authorities

Hepatitis A in Bretagne

National - Your institute S. Typhi

International / European outbreak involving your country

- ECDC coordinates

Meningococal infections in pilgrims returning from Haj

Another country - The authorities in that country coordinate

Leptospirosis in Nicaragua (French Ministry mission)

Rift Valley Fever, Kenya (WHO mission)

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

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

Systematic approach

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

InVS to investigate

On call epidemiologist + « volunteers »

Co-ordination

Epidemiology

Environmental health

Clinicians

Laboratory : clinicalenvironmental

Media AuthoritiesDiagnostic

Clinical

Specimen transfer

Dead Sick

Exposed

SurveillanceInvestigation

Prediction

ParentsStudents

PrincipalTeachers

Generalpopulation

DecisionsSchool closureMedical examinations

Toxic products

Psychological support unit

Police, legal authorities

Autopsy

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

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

Reasons for inviting youNormandie, 2001

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

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?

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

You are going to the field !

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

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

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”,)

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• Discuss liaison• Set up communications with base

Arrival to Normandie

• Meeting with:– College principal– Parents

• Visiting the school• Understand rumours– second world war

Tristesse et inquiétude à Port-en-Bessin Le collège reste fermé après le décès inexpliqué d'un adolescent de 15 ans. La préfecture recommande aux 275 élèves d'aller à l'hôpital.

Les portes du collège Ernest-Hemingway de Port-en-Bessin (Calvados), où plus d'une cinquantaine d'élèves ont été intoxiqués en 15 jours, resteront fermées jusqu'à nouvel ordre, après le décès d'un adolescent de 15 ans pour des raisons indéterminées. Cet élève de troisième ne faisait cependant pas partie des enfants incommodés lors de l'intoxication suspecte. Inquiets, les parents d'élèves se sont succédés vendredi après-midi dans une des salles communales, où avait été installée une cellule de soutien psychologique. La préfecture a également conseillé

Organising the Outbreak Control

Team

• Membership

• Leadership

• Responsibilities

• Lines of communication

• Communication

• Decision making process

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

The Outbreak Control Team

MSI NormandieDistrict medical officer

- coordination - communication with authorities, parents

InVS epidemiologists

- Epi investigation - communication with media

Hospital paediatrician

- clinical investigation

District health engineer

- environmental investigation

Mayor - facilities and resources

Psychiatrist - psychological support unit

The Outbreak Control Team

MSI NormandiePlan 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

The Outbreak Control Centre - I

Headquarters of the investigation• Where

• How big

• Accessibility/Security

• Separation from normal work

• Catering

The Outbreak Control Centre - II

Equipment• Computers with Internet connection

• Telephones, telefax

• Copy machine

• Reference materials

• Office furniture and stationery

Information \ Data• Types of information

– epidemiological

– operational

• Managing information (databases)

• Briefing, feed-back

• Communicating with the media

– one person !

• Writing reports: ongoing process

Epidemiological data• Line listing is vital

– cases/contacts

– lab results, questionnaires available

– in excel

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

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

Operational informationStorage and organisation

• Computer, laptop, web?

• Inventory of files

• Log book!

– every day

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

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

Leaving the field

• Debriefing meeting

• Preliminary report

• Commit to produce final report

• Archive data

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

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

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

Summary

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

Laboratory confirmation

Source

Outbreak control team

meeting - urgent!

TV inter view

Control measures ?

Meet minister