Transcript Outbreak investigation - European Centre for Disease

Outbreak Investigation
Operational Aspects
12th EPIET Introductory Course
Lazareto, 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?
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Stop the outbreak
Understand what happened and why
Prevent future outbreaks
Improve our knowledge
Improve surveillance
and outbreak detection
• Training
Outbreak Detection and Response
First
Case
Detection/
Reporting
Lab
Confirmation Response
DAY
40
37
34
31
28
25
22
19
16
13
10
7
Opportunity
for control
4
1
90
80
70
60
CASES 50
40
30
20
10
0
Outbreak Detection and Response
First
Detection/
CaseConfirmation
Reporting
Investigation
Response
DAY
40
37
34
28
25
22
19
16
13
10
7
4
1
90
80
70
60
CASES 50
40
30
20
10
0
31
Opportunity
for control
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
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
Outbreak in
another country
- ECDC coordinates
- Your institute collaborates
- You participate
-The authorities in that country coordinate
- You are asked to assist
e.g. EPIET fellow involvement
Local
- Local
authorities
National
- Your institute S. Typhi
- ECDC
International /
European outbreak coordinates
involving your
country
- The
Another country
authorities in
that country
coordinate
Hepatitis A in Bretagne
Meningococal infections
in pilgrims returning
from Haj
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 »
Investigation
Toxic
products
Surveillance
Dead
Exposed
Prediction
Clinicians
Epidemiology
Psychol
ogical
support
unit
Co-ordination
Parents
Students
Principal
Teachers
Sick
Laboratory :
clinical
environmental
Environmental
health
General
population
Clinical
Specimen
transfer
Diagnostic
Media
Authorities
Autopsy
Decisions
Police, legal authorities
School closure
Medical
examinations
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
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Expertise
More resources
Share responsibility
Political or mass media pressure
Mandatory or in guidelines
Need to confirm local findings
Specialised investigations
Reasons for inviting you
Normandie, 2001
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Expertise
More resources
Share responsibility
Political or mass media pressure
Terms of reference
Clarify 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”
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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
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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-enBessin
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 ErnestHemingway 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 Normandie
District medical
officer
- coordination
- communication with
authorities, parents
InVS
- Epi investigation
epidemiologists - 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 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
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
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entry and validation
multiple data bases : how linked?
analysis
programmes
• Backups / confidentiality / access
• Overall responsibility for data management
• Sometimes professional data manager
Operational information
Storage 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, 2001
The 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
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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 !!!