Transcript Slide 1

Case Investigation of Avian
Influenza
Rapid Response Team Training
in Southeast Asia
1
Learning Objectives
• Describe and conduct pre-investigation
activities
• Demonstrate knowledge of key
epidemiologic concepts in field
investigations
• Describe how to communicate epidemiologic
findings
• Describe how to appropriately assess and
respond to potential outbreak situations
2
Case Investigation Module
Format
• Interactive case studies and
instructional slides
• Rapid response team (RRT)
investigation of avian influenza cluster
or case
• Evaluation of an RRT avian influenza
investigation
• Groups of 10 to conduct investigation
3
Module Overview
• Pre-Investigation
– Planning the Response
• Investigation
–
–
–
–
–
Case Definition
Specimen Collection
Case Finding
Interviewing
Contact Identification
–
–
–
–
–
Reporting
Data Management
Creating an Epidemic Curve
Assessing Transmission
Writing a Summary Report
• After the Investigation
– Evaluate Performance
4
Pre-Investigation
Before you leave to investigate
5
Pre-Investigation:
Gather Preliminary Information
Assess the situation
• Information to collect:
–
–
–
–
–
–
Number of suspected cases
Geographic location of cases
Date of onset of cases
Signs and symptoms
Exposure history – contact with birds, travel, occupational
Lab tests
• Consider the security situation in the area
6
Pre-Investigation:
Plan the Response
• Bring RRT together
– Refer to Team Composition module for
roles and responsibilities of RRT members
• Discuss each person’s roles and
responsibilities
7
Pre-Investigation:
Documentation
• Information already
gathered
– Location of case, date of
illness onset, clinical or
exposure details
• List of contacts
• Case reporting forms
• Standardized
questionnaires
8
Pre-Investigation:
Resources
• People
– Local health workers caring for case-patient
– Veterinarians, clinical and laboratory experts, support
personnel
• Ministry of Health
– Advice, guidance, additional personnel
• World Health Organization (WHO)
• Avian influenza references
• Other
–
–
–
–
Transportation
Security
Communication devices
Money
9
Pre-Investigation:
Supplies
• Epidemiological
– Reporting forms
– Notebook (or laptop) for recording data
• Medical
– Antiviral medication (if available)
• Laboratory
– Swabs, needles, cooler, ice, viral transport media
10
Pre-Investigation:
Supplies
• Educational
– Brochures, posters, with influenza safety
information
– Easy to read
– Guidelines for contacts, family members
• PPE
– Masks, gloves, gown, cap, goggles
• Decontamination
– Solution for decontaminating homes or hospital
rooms
11
Pre-Investigation:
Communication
• Veterinary Health Authority
• Government Officials
• Health Care personnel
• Community
• Non-governmental organizations
• Laboratory
12
Case Study
Pre-Investigation
Before you leave to investigate
13
Case Study:
Pao Mai Province
• Province located in northern part of country
• Peaceful region with little political instability
• Many earn income through backyard chicken
farming
• Poor Infrastructure
• Ratio of physicians
X
to population
is 1:5,000
14
Rapid Response Team
(RRT) Investigation
15
Objectives of a RRT
Investigation
•
Assess the possibility of human-tohuman transmission
•
Stop or slow the spread of pandemic
influenza at the source
•
Minimize mortality and morbidity
16
Steps in Rapid Response
Investigation
1.
2.
3.
4.
Conduct active case finding
Identify and follow-up with contacts
Collect samples for laboratory tests
Characterize illness and provide
descriptive epidemiology
5. Investigate reservoir or source of infection
6. Report cases to provincial authorities
7. Implement immediate containment
measures
17
Investigating a Suspect Case
Evidence for H5N1 infection based on
– Clinical findings
– Epidemiological evidence
– Laboratory testing
18
Case Definitions
19
Case Definitions
• “Standardizes” the investigation
• Clear criteria for being a case
(symptoms or lab results)
• Is unique to outbreak but is based on
objective measures
20
Case Definition
Categories of case definitions for
avian influenza A/H5
• Patient under Investigation
• Possible Case
• Probable Case
• Confirmed Case
21
Case Definitions for Influenza
A/H5
Patient Under Investigation
• Any individual reporting:
– Fever (temperature above 38º C)
And one or more of these symptoms
– Cough
– Sore throat
– Shortness of breath
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Case Definitions for Influenza
A/H5
Possible Case
• A “patient under investigation” who ALSO
has one or more of the following:
– Lab test for Influenza A (not including subtype)
– Contact in past 14 days with confirmed case of
Influenza A/H5
– Contact in past 14 days with sick birds
– Worked in lab where there is processing of
samples from persons/animals with Influenza A
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Case Definitions for Influenza
A/H5
Probable Case
• Any “patient under investigation” or
possible case who ALSO has
– In-country laboratory evidence for
influenza A/H5
24
Case Definitions for Influenza
A/H5
Confirmed Case
• Laboratory testing demonstrates 1 or more
of following
–
–
–
–
Positive viral culture for A/H5
Positive PCR for A/H5
IFA Test positive for A/H5
At least 4-fold rise in A/H5 in paired serum
samples
25
Pre-Investigation and
Case Definition
Activities
26
Case Study: Background
DATE: JULY 13th
• A staff doctor at Pao Mai Provincial Hospital
notifies the Provincial Health Office that they
have admitted 2 previously healthy persons
with severe respiratory illness.
• The doctor is concerned that his patients
may have avian influenza, as there are
rumors that poultry outbreaks are occurring
all over the province.
27
Activity A: Is there an outbreak?
Brainstorm and Role Play
25 Minutes
• If you had received this call, what additional
information would you want to receive from
the treating physician?
• What would the conversation between the
physician and the RRT member sound like?
Conduct a role play
28
Background on Cases
DATE: JULY 13th
• Two cases are related
– A 55 year-old grandmother
– Her 5 year-old grandson
• The cases reside in the same house with the
child’s grandfather in a small mountain
village
• The grandmother is the child’s primary
caretaker
• The child was brought to the hospital two
days ago with the following symptoms: fever,
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cough, diarrhea and shortness of breath
Background: Case History
DATE: JULY 13th
• Shortly after admission on July 11th, the
child rapidly decompensated requiring
intubation and ventilatory support
• His grandmother was by his bedside when
she also became ill.
• Child’s mother lives outside the province but
arrived at hospital yesterday.
• Child’s grandfather denies symptoms.
• The treating physician requests assistance
from public health authorities
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Activity B: Plan the Response
Brainstorm and Group Discussion
I. Logistics and Documentation
II. Communication
You must plan how you will respond
to the situation before you leave for
the field.
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Pre-Deployment Activity:
Logistics and Documentation
1.
2.
3.
4.
5.
Who are the members of the team?
Where will you go?
How will you get there?
What is the security situation?
What documentation do you need to bring
with you? What forms will you need?
6. What resources and supplies will you need
to bring with you? Where will you obtain
the resources?
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Pre-Deployment Activity
Communications Plan
Determine:
1. Who do you need to communicate
with before you depart for the field?
2. Who on your RRT is responsible for
communicating with agencies and the
media?
3. Will there be communication/cultural
barriers when you arrive in the field?
4. How will you communicate with each
other in the field?
33
Activity C:
Case Definition Group
Discussion
JULY 14th
• Your RRT arrives at Pao Mai and goes directly to the
hospital to begin the investigation.
• The available medical charts and chest x-rays for the
suspect AI cases are provided to the RRT.
34
Case Definition Exercise
Group Discussion Activity
Using the data in Trainee Activities,
address the questions provided
below:
1. Do the cases meet case definition?
•
If so, how would they be classified?
2. Is any additional information needed to
classify cases? If so, what?
3. How would case #2 move from its current
classification to the next?
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Specimen Collection
Confirm the Diagnosis
36
Review Laboratory Module
• How to safely and correctly collect
specimens
– Who to collect from
– What samples to collect
– What to wear
– How to transport specimen
– Procedures for diagnosis
37
What to Collect
Preferred specimens
• Nasal swabs
• Throat swabs
• When possible: Nasopharyngeal aspirates
Other specimens
• Posterior pharyngeal swabs
• Nasal washes
• Acute and convalescent serum
Collect the sample on several different days
38
Laboratory Testing
If positive test for Influenza A and/or suspicion
of avian influenza:
• Sub-type at in-country laboratory
• Non-approved laboratories
– Forward samples to National Influenza Centre
– Inform WHO Office in country
• Confirmatory testing should be conducted at
a WHO approved laboratory
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Case Finding
40
Why is Case Finding Important?
• Ensure you have identified as many
cases as possible
• Case finding may provide information
about human-to-human transmission
• Any cases related in time and space to
initial cluster or case
41
How to Find Cases
• Consider all possible symptomatic
persons as cases at the beginning of
an investigation
– Visit health facilities, homes of neighbors
and adjacent communities
– Public information messages in the
affected communities
42
Common Challenges to Case
Finding
• Even with case finding, all cases may
not be identified
– Physician may not suspect avian influenza
– Some infected persons may not seek
medical attention
What are some other potential barriers to
finding cases in the Pao Mai Province?
43
Case Finding Interview
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Who to Interview
• Case-patient
• Family members/Household contacts
• Health care providers/Lay health
workers
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Interview Tips
• Collect as much information as
possible
– Unstructured interviews
– Generate list of contacts
• Repeat critical questions for accuracy,
validity and additional details
46
Interview Tips
• Be friendly, but professional
• Identify yourself and your institution
• Explain purpose of interview
• Stress importance of information you will collect
• Inform respondents that all information will be kept
confidential
• If appropriate, conduct interview in private
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Type of Information to Collect
• Demographic information: age, sex
contact details
• Clinical information: signs &
symptoms, physical exam, vitals, date
of onset, hospital admission
• Exposure history: occupational
exposure, travel, animal exposure
48
Specimen Collection and
Case Finding
Activities
49
Activity D:
Specimen Collection
1. What specimens need to be collected?
2. What specimens should have already been
taken from the cases? When should any
additional specimens be taken?
3. Should specimens be collected from the
child’s grandfather?
4. What PPE does the nurse need to wear
when collecting specimens from the child? 50
Activity E:
Case Finding Group Discussion
• How would the RRT find out if there are
additional cases?
• Consider the following:
–
–
–
–
Locations/settings for case finding
Who you might like to interview
Questions the RRT would ask potential cases
Need for PPE while conducting interviews
51
Case Finding Interview Activity
Role-Play
• See one, do one and teach one!
– Observe a case finding interview
– Select a partner and take turns practicing
the administration of a standardized case
finding questionnaire.
– After completing the questionnaire,
critique each other’s performance.
52
Contact Identification
53
What is Contact Identification?
The identification and diagnosis of
persons who may have come into close
contact with an infected individual
54
Purpose of Contact Identification
• Find new cases that meet case
definition
• Provide interventions for exposed
individuals to decrease risk of illness
and interrupt further transmission
– Antivirals (Oseltamivir)
– Precautionary Information
55
How to Identify Contacts
1. Review patient’s activities for the 7
days before onset of symptoms
2. Based on activities, identify all close
contacts (within 1 meter)
3. Verify all information collected
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Key Information to Gather
• Who did case come into close contact
with?
• What activities was case doing?
• Where did this take place?
• When did case come into contact with
this person?
• Contact’s Address and Phone Number
• Contact’s Health Status
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• Contact’s Gender, Occupation, Age
General Guidelines for
Interviewing Contacts
• Do not alarm contacts
• Communicate precautionary information
• Refer symptomatic individuals to clinic
• Consider if Personal Protective Equipment is
necessary
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Information to Gather from
Contact
• Demographic and contact information
– Name, Address
– Occupation, age, gender
• Exposure History
– Contact with case-patient
– Other high-risk exposures
• Physical Exam and Clinical information
– Temperature
– Presence of sore throat, coughing
– Signs and symptoms
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Monitoring and Managing
Contacts
• Monitor for signs of illness for at least 7 days
after contact with case
– Encourage self-health monitoring
– Instruct to report onset of symptoms
– Visit or phone daily to monitor for illness
• Request voluntary home quarantine of all
contacts for at least 7 days
• Consider antiviral prophylaxis
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Prioritize Contact Identification
• If number of contacts is large focus on:
– Contacts of laboratory confirmed cases
– Contacts with extended duration and
closeness to case
– Contacts that are at high risk, such as
those involved in unprotected care of case
– Contacts from large gatherings and/or
school that case attended
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Reporting:
Informing Those who Need
to Know
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Inform Those who Need to Know
• Local Level
• National Level
• International Level
63
Inform Those who Need to Know
• Insert Local and/or National Reporting
Requirements (country-specific)
64
Inform Those who Need to Know
• International Health Regulations (IHR)
– Compulsory notification of highly-pathogenic
strains of avian influenza
– Vaccination and food safety of poultry products
• Compliance with these standards is required
to strengthen early detection, reporting, and
response
65
Contact Identification Group
Discussion and
Reporting Group Discussion
Activities
66
Activity G:
Contact Identification Group
Discussion
•
Develop a village-based system to monitor
and manage contacts. Address:
1. What is your definition of a close contact?
2. Who will receive prophylaxis, if available?
3. How long should contacts remain at home
voluntarily during quarantine?
4. Monitoring contacts for signs of illness
67
Activity H:
Reporting
Discussion Questions
Local Level: Who is responsible for
submitting AI case reports? When should
this be done?
68
Reporting Activity
Discussion Questions:
National Level: Who in your country needs
to be updated on the progress of the
investigation and receive the final report
on number of cases? Who is responsible
for assuring that this occurs?
69
Reporting Activity
Discussion Questions:
International Level: What international
agencies need to be informed of suspect
human cases? Who in your country is
responsible for notifying international
authorities?
70
Managing Data on Cases
and Contacts
71
Data Management
• Line listing
• Record keeping
• Validation and Cross-Checking
72
Line Listing
An organized way to view all cases in an investigation
Case Age Sex Status
#
Occupation
1
5
M
Probable
Child
Yes
7 July
2
55
F
Possible
Caretaker of
case #1
Yes
9 July
3
48
M
Possible
Poultry Farmer
No
7 July
Information included:
Difficult
Date of Onset
breathing
• Demographic
• Clinical
• Exposure
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How to Create a Line List
• Add new cases as they are identified
• Update case information throughout
the investigation
• Number of variables to include will
depend on available data, nature of
investigation
74
How to Create a Line List
Always include:
• Components of case definition
• Case name, identifying number
• Date of symptom onset, specimen collection
date
May also include additional information:
• Age, gender, occupation, risk factors
75
How to Create a Line List
• Create a table in which each row represents
a case and each column represents a
variable of interest
– Variables: Demographics (age), symptoms,
exposures
Cases
Variable 1 Variable 2
Variable 3
Case 1
Case 2
Case 3
76
Record Keeping
• Where will records be kept?
• How will records be kept?
• Who is assigned to record keeping?
• Maintain confidentiality
77
Validation and Cross-Checking
• Check line lists against medical charts
and interviews
• Validation
– Ask same question in different ways
– Ask same question at different times
– Ensure answers are consistent
78
Creating an Epidemic
Curve
79
What is an Epidemic Curve and
How Can it Help in an Outbreak?
An epidemic curve
(‘Epi’ curve) is a
graph or picture
of the number of
cases of illness
by the date of
illness onset
80
What is an Epidemic Curve and
How Can it Help in an Outbreak?
Provides information characteristics of an
outbreak:
– Magnitude
– Pattern of spread
– Outliers (case outside expected time frame)
– Time trend
– Exposure and/or disease incubation period
81
How do I Make an Epi Curve?
• Plot the number of
cases of disease
reported during an
outbreak on the yaxis
• Plot the time or date
of illness onset on
the x-axis
82
How do I Make an Epi Curve?
• Technical tips
– Time unit for x-axis depends upon the time from
exposure to illness onset (incubation period)
– Begin with a unit approximately one quarter the
length of the incubation period
– If the incubation period is not known, graph
several epi curves with different time units
83
How do I Make an Epi Curve?
• Usually the day of illness onset is the
best unit for the x-axis
– If the incubation period is very short, hour
of onset may be more appropriate
– If the incubation period or outbreak is very
long, week or month may be more
appropriate
84
How do I Make an Epi Curve?
• No space between
categories on the x axis
• Label each axis
• Provide a descriptive title
• Include the pre-epidemic period to show the
baseline number of cases
85
Data Management
and
Epidemic Curve
Actvities
86
Activity I:
Linelist & Cross-checking
Exercise
July 15th
• An incomplete linelist and an update on the
status of the Pao Mai outbreak is provided in
your student guide
• Find any errors in the completed sample
linelisting provided in your student guide.
87
Activity J:
Epidemic Curve Activity
Create an epidemic curve using the data from
the case study
(Summary data on next slide)
88
Summary of Data from Case
Study
• Date of Onset
• Number of Cases
(When symptoms began)
July 7th
July 8th
July 9th
July 10th
July 16th
1 confirmed (Case #3)
1 confirmed (Case #1)
2 possible (Cases #5 & #6)
1 probable (Case #7)
1 confirmed (Case #4)
89
Discussion Questions
Based on this epi curve:
1. What is the estimated incubation
period?
2. When did the outbreak peak
according to the epi curve?
3. Are there any outliers? If so, what
might explain them?
90
Epi Curve for Outbreak
H5N1 Outbreak Epi Curve, July 2006
Number of cases
3
2
Confirmed
Probable
Possible
1
0
4- 5- 6- 7- 8- 9- 10- 11- 12- 13- 14- 15- 16- 17Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul Jul
Date
91
Assessing Human to Human
Transmission
92
Current Status of H5N1
Transmission
• Now
– Human-to-human transmission of Influenza A/H5
highly ineffective
– Has occurred only among very close contacts
• In the future
– Virus could mutate and pass between humans
– Global outbreak could occur
93
Assessing Human to Human
Transmission
• Cases occur close together in time and
place among individuals who had close
contact with a human case
– Family members or health care workers
• Onset between two cases falls within
the incubation period
• No alternative source of exposure is
found
94
When a Cluster May Exist
• 3 or more people with moderate or
severe acute respiratory illness
– Unexplained by other causes
– May have died from the illness
– Onset within 7-10 days of each other
AND
• History strongly suggesting exposure
to H5N1 virus
95
Epidemic Curves and
Transmission
Assess whether human-to-human
transmission is occurring
– Epi curve pattern for infectious agent
transmitted between people
– Epi curve pattern for infectious agent
transmitted from one source to people
96
Example Epi Curve for Human to
Human Transmission
97
Example Epi Curve for Human
Cases from Single Source
98
Case Study Conclusion
99
Outbreak Ends in Pao Mai
1 September 2006
• H5N1 cases identified = 6
• RRT interviewed 52 possible case contacts
– 96% of these received antiviral prophylaxis
• Deaths = 5
• Case Fatality Rate = 83%
X
100
Writing a Summary Report
101
Why communicate the findings?
•
A document for action
– Control and prevention measures
•
•
•
•
To share new insights
Documents the investigation
To assist other nations districts or
countries with investigation
Inform the public
– Prevents future outbreaks
102
Content of a Summary Report
•
•
•
•
•
•
•
•
•
Summary
Introduction and Background
Outbreak Description
Methods and Results
Discussion
Lessons Learned
Recommendations
Acknowledgements
Supporting Documentation
103
Human-to-Human
Transmission
and
Summary Report
Activities
104
Activity K:
Assessing Human to Human
Transmission
Which are likely human-to-human transmission?
Why?
•
•
•
•
•
•
5 year-old child
13 y.o. female neighbor of farmer
Poultry farmer
Farmer’s apprentice
Physician at Pao Mai Hospital
82 y.o. female neighbor of family cluster
105
Activity K:
Assessing Human to Human
Transmission: Problem Solving
Review the four scenarios in your guide
and consider the possibility of human
to human transmission for each.
106
Activity L:
Summary Report Activity
• Fill out the WHO daily situation report.
• Over the outbreak, these reports can be
used to create a summary report.
107
After the Investigation
108
Evaluate Performance
109
Why Evaluate the Investigation
• To summarize the events that occurred
• To learn from experience
– Make recommendations for future
investigations
– Take lessons from what worked well
– Take lessons from mistakes
110
What to Evaluate
• Timeliness of response
• Completeness of the investigation
• Accuracy of the data
111
Timeliness of Deployment
• Response time
Notification
Arrive at location
• Ideal: about 24 hours
• Delays
– Assembling team
– Finding supplies
– Getting to location
• How could response time be improved?
112
Timeliness: Investigation and
Initial Assessment Report
Arrival in field
Deliver initial
assessment report
• Initial report
– Oral or written
– May receive feedback on how to proceed
• Delays
– Interviews, initial investigation
– Poor communication in team
– Too busy
113
Timeliness: Investigation and
Final Assessment Report
Arrival in field
Deliver final
assessment report
• Final report
– Oral or written
– Summary and recommendations
• Delays
– Follow-up interviews
– Containment measures
– Poor data management
114
Timeliness: Final Report
End of field
investigation
Official investigation
report
• Official record of investigation
• Delays
– Back to “normal” work
– Lack of motivation
115
Completeness
• Necessary activities completed?
– Team assembled and worked well
– Interviews
– Case definitions
– Data collection
– Reports
• Data collected from questionnaires
complete?
116
Accuracy of Data
• Data management
• Validation and cross checking
• A report based on incomplete or
inaccurate data is not informative!
117
Example
118
SARS Outbreak April 2004
• 10 April, 2004
– A woman in Anhui province, Eastern China, has
been admitted to the hospital with severe
respiratory symptoms and fever
– Another patient in the hospital develops similar
symptoms
• 12 April, 2004
– The woman is suspected of having SARS and is
transferred to a hospital in Beijing
– A rapid response team is deployed to investigate
this patient, her exposures, and her contacts
119
SARS Questionnaire
Demographic Information
120
SARS Questionnaire
Clinical Information
121
Linelist
Case Age Sex Status
#
Occupation
Difficult
Respiratory
breathing Distress
1
26
F
Confirmed Post-graduate
laboratory worker
Yes
Yes
2
31
M
Confirmed Laboratory
researcher
Yes
Yes
3
53
F
Probable
Doctor. Mother of
lab worker
Yes
Yes
4
20
F
Probable
Nurse
Yes
No
5
45
M
Probable
Unknown. Father
of nurse
Yes
Yes
6
44
F
Possible
Unknown. Mother
of nurse
Yes
No
122
List of Contacts
Name
Age
Gender
Occupation
1
23
M
Lab worker
2
48
M
Doctor
3
62
F
4
20
5
Contact
information
Symptoms
XXXX
No
XXXXX
No
Housewife
XXX
Yes
M
Student
XXX
No
28
M
Secretary
XXXX
No
6
33
F
Nurse
XXX
No
7
31
F
Nurse
XXXXX
Yes
123
Summary Report: May 2, 2004
Background.
This section describes when the case first presented to the hospital and
how the ministry of health was informed of the possibility of SARS
Methods.
Here the team described the hospitals visited in Beijing and Anhui
province, the interviews they conducted, and the medical research
laboratory they visited.
Outcome and Control Measures.
In this section, the team described the number of additional cases and
contacts they found, their status, and what control measures were put
into place to control the outbreak. This included isolating nearly 160
exposed persons and temporarily closing the research laboratory.
Conclusions.
In this section, the team describes the good and bad points of their
investigation, and makes recommendations for preventing future
outbreaks and for making future outbreak investigations better.
124
Evaluating Timeliness,
Completeness, and Accuracy
Activity
125
Activity M:
Evaluate Group Performance
Group Discussion
Review and critique these documents from
an investigation:
1. Completed questionnaire from interview
with index patient
2. Linelistings of Cases and Contacts
3. The summary report for the investigation
126
Glossary
Linelist
An organized list of all cases in an outbreak investigation that shows
key characteristics for each case, including demographic, clinical, and
exposure information.
Epidemic Curve (Epi curve)
A graph (histogram) of the number of cases of illness on the y-axis by
the date of illness onset on the x-axis. Time intervals on the x-axis
will vary by disease and incubation period.
Outlier
Any value that is markedly smaller or larger than other values in a
data set.
Contact identification / Contact tracing
The identification and medical assessment of persons who may have
come into close contact with an infected individual.
127
Glossary
Case finding
The process of determining if more cases of a
particular disease under investigation exist.
Case definition
A set of objective criteria for who should be considered
a case and who should not, often including a list of
symptoms or results from laboratory tests.
Incubation period
The time interval between the initial exposure to
infection and the appearance of the first symptom or
sign of disease.
128
References and Resources
• WHO pandemic influenza draft protocol for rapid
response and containment. Updated March 2006.
http://www.who.int/csr/disease/avian_influenza/guide
lines/pandemicfluprotocol_17.03a.pdf
• Epidemiology of WHO-confirmed human cases of
avian A(H5N1) infection. June 2006, Weekly
Epidemiological Record vol. 81(26): 249–260.
http://www.who.int/csr/disease/avian_influenza/guide
lines/wer8126/en/index.html
129