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Writing outbreak investigation report

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  • http://www.cdc.gov/excite/classroom/outbreak/steps.htm
  • http://www.who.int/infectious-disease-news/IDdocs/whocds200527/whocds200527chapters/index.htm
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    • 1. Writing OutbreakInvestigation Report-A guidelineJamalludin bin Ab Rahman MD MPHAssociate Professor and HeadDepartment of Community MedicineKulliyyah (Faculty) of MedicineInternational Islamic University Malaysia Institute of Health Management, Bangsar. 22-23rd October 2012
    • 2. Disclaimer www.jamalrahman.net 22nd Oct 2012 This is a guideline, not policy Guideline on writing the report, not how to investigate outbreak This is not an official format endorsed by MOH, Malaysia This guideline is meant for reporting infectious disease outbreak, not non- communicable disease outbreak/problem 2
    • 3. Content www.jamalrahman.net 22nd Oct 2012 Why we report outbreak The content - IMRAD  Introduction - Background (Epidemiology)  Method of investigation  Result & Analysis  Discussion & recommendation  Supporting documents & evidences 3
    • 4. www.jamalrahman.net 22nd Oct 2012“Do not write so that you can be understood, but so that you cannot be misunderstood.” – Marcus Fabius Quintilianus Roman rhetorician. 4
    • 5. www.jamalrahman.net 22nd Oct 2012Outbreak investigations, an important andchallenging component of epidemiology and publichealth, can help identify the source of ongoingoutbreaks and prevent additional cases. Evenwhen an outbreak is over, a thorough epidemiologicand environmental investigation often can increaseour knowledge of a given disease and preventfuture outbreaks. Finally, outbreak investigationsprovide epidemiologic training and fostercooperation between the clinical and public healthcommunities. Reingold 2000. Outbreak Investigation - A Perspective 5
    • 6. What is your SOCO www.jamalrahman.net 22nd Oct 2012 Single Overriding Communication Objective “a brief statement of the message you want to get across…….should have one primary message that is being communicated to the audience” (www.sephli.org) Critical esp. when communicating with public/media 6
    • 7. The purpose - why we report www.jamalrahman.net 22nd Oct 2012 Official report - maybe sent too late for action or response - usually meant for documentation & future reference Preliminary report - usually meant as first response & to get more response - to launch control measures - sent asap (usually within the first few hours) Daily report - in major outbreaks - for 7 communication
    • 8. Who is the audience www.jamalrahman.net 22nd Oct 2012 The boss - policy maker The boss to the boss - politicians The experts The public The media So tailor your writing to your target audience 8
    • 9. THE INVESTIGATION 9 www.jamalrahman.net 22nd Oct 2012
    • 10. The 10 steps www.jamalrahman.net 22nd Oct 20121. Identify investigation team and resources - expected situations, suitable team & relevant equipment2. Confirm the outbreak - observed >> expected3. Verify the diagnosis -4. Define cases - suspect & confirmed, clinical & lab5. Describe and orient the data in terms of time, place, and person - epid curve6. Develop hypotheses7. Test hypotheses - the statistical component8. Implement control and prevention measures9. Communicate findings 1010. Maintain surveillance CDC 2004. Steps of an Outbreak Investigation
    • 11. Confirm the outbreak www.jamalrahman.net 22nd Oct 2012 WHO 2006. Communicable disease control in emergencies. A field manual. Communicable 11 Diseases in Complex Emergencies Programme, Communicable Disease Cluster, HQ/Geneva.
    • 12. Manage the outbreak www.jamalrahman.net 22nd Oct 2012 WHO 2006. Communicable disease control in emergencies. A field manual. Communicable 12 Diseases in Complex Emergencies Programme, Communicable Disease Cluster, HQ/Geneva.
    • 13. THE WRITING - IMRAD www.jamalrahman.net 22nd Oct 2012 13
    • 14. Title Page www.jamalrahman.net 22nd Oct 2012 Title of report Preliminary or final or daily communication. Include - the problem (clinical condition, infection etc), who were affected, the location and date (What, Who, Where, When) - „How‟ the outbreak occurred is answered in the text (unusual cause of outbreak can be included in the title for scientific publication rather than report) Date of report Names and affiliations Main author & investigators 14
    • 15. Abstract www.jamalrahman.net 22nd Oct 2012 Write it last Important points - What, Who, Where, When, How Result of the investigation Source of outbreak Conclusion 15
    • 16. Introduction www.jamalrahman.net 22nd Oct 2012 Report sequence of events lead to the investigation Details (what, who, where & when or time, people & place) for the initial report/notification of the outbreak Report the initial response - what you did immediately - e.g. you setup the investigation team & establish operation centre etc State the investigation team Initial reason (purpose) for investigation - which is usually obvious i.e. to control the outbreak 16
    • 17. Example - E. coli outbreak www.jamalrahman.net 22nd Oct 201217
    • 18. Objective www.jamalrahman.net 22nd Oct 2012 What investigations want to achieve Identify the agent Describe the mechanism of transmission Identify the exposures/risk factors To control the outbreak 18
    • 19. Hypothesis www.jamalrahman.net 22nd Oct 2012To proof (test) thatthe suspectedagent, the Hostmechanism oftransmission andexposures/ Agentrisk factors Environmentrelated to theoutbreak 19
    • 20. Methodology www.jamalrahman.net 22nd Oct 20121. Epidemiologic - Time (onset, epid curve), People (case definition, case finding strategy, sign & symptoms), Place (location)2. Laboratory3. Environment - inspection of the affected/suspected buildings/area 20
    • 21. Epidemiologic Method www.jamalrahman.net 22nd Oct 2012Descriptive - you will describe Case finding strategy Case definition used Time, place and people affected Who is at risk (of becoming ill)Analytical- you will describe Method used - case-control, cohort Define control Analysis done esp. to test „dose-response’ - risk of getting sick increases with duration of exposure 21
    • 22. State Case Definition www.jamalrahman.net 22nd Oct 2012 Symptom &/or sign Probable & Confirmed Time E.g. Place A probable case was any person presenting with bloody diarrhoea within the last fortnight (since 1st September 2005) resident within South Wales. A confirmed case was a probable case with microbiological confirmation (ie demonstration of Verotoxin positive E. coli O157 by recognised microbiological methods). 22 Lab
    • 23. Case Definition....may not be so www.jamalrahman.net 22nd Oct 2012straight forward Example H5N1 Epidemiologic criteria & Clinical criteria Suspect - Epid AND Clinical Possible - Any Epid with some/all Clinical 23
    • 24. Case Finding www.jamalrahman.net 22nd Oct 2012 Describe variables collected Use List-line format 24
    • 25. Analytical Method www.jamalrahman.net 22nd Oct 2012 Causal inference - the disease is caused by the exposure Research design used - case-control or cohort Usually case control - measures exposure among ill & not - define control (not ill) Cohort if ALL exposed are known & within small & well-defined area 25
    • 26. Dummy Table www.jamalrahman.net 22nd Oct 2012 Outcomes Ill Not Ill Stat Exposed N (%) N (%) Statistics Not Exposed N (%) N (%) 26 Exposure
    • 27. Dummy Table www.jamalrahman.net 22nd Oct 2012 Ill Not Ill Stat Exposed a b Not Exposed c d 27
    • 28.  Measures of Association www.jamalrahman.net 22nd Oct 201228
    • 29.  Measures of Association… www.jamalrahman.net 22nd Oct 201229
    • 30. Laboratory Method www.jamalrahman.net 22nd Oct 2012Describe the type of specimens available - e.g. from food samples, environmental samples method of handling the labs involved lab investigation done 30
    • 31. Environmental Method www.jamalrahman.net 22nd Oct 2012 Also know as food or sanitary investigations Report how the site visit done What are the facilities/area affected Who were involved in inspection What were inspected 31
    • 32. Describe People www.jamalrahman.net 22nd Oct 2012 Demography information Clinical information - sign & symptoms Exposure information - summarise the line- list, outcome of illness (hospitalization, death, chronic effects) 32
    • 33. www.jamalrahman.net 22nd Oct 2012Example - Food poisoning in Dungun 1988 33
    • 34. Describe Place www.jamalrahman.net 22nd Oct 2012 Use GPS, map Important if wide area affected 34
    • 35. Food Poisoning in Dungun 1998 www.jamalrahman.net 22nd Oct 201235
    • 36. H5N1 world wide in 2003 www.jamalrahman.net 22nd Oct 201236
    • 37. Describe Time www.jamalrahman.net 22nd Oct 2012Present the epidemic curve1. Point source (some put this under common source)2. Common source (continuous or intermitted)3. Propagated source 37
    • 38. What is epid curve www.jamalrahman.net 22nd Oct 2012 A graphical depiction of the number of cases of illness by the date of illness onset Can tell us about 1. Route of transmission 2. Probable exposure period 3. Incubation time 38
    • 39. How to construct epid curve www.jamalrahman.net 22nd Oct 2012Histogram Area proportional to number No space between columns One populationX-axis = time Start before epidemic, continue after Interval < 1/4 of incubation periodY-axis = number of cases Usually one square = one case 39
    • 40. Food Poisoning in Dungun 1998 www.jamalrahman.net 22nd Oct 201240
    • 41. www.jamalrahman.net 22nd Oct 201241
    • 42. www.jamalrahman.net 22nd Oct 201242
    • 43. www.jamalrahman.net 22nd Oct 201243
    • 44. www.jamalrahman.net 22nd Oct 201244
    • 45. Environmental Report www.jamalrahman.net 22nd Oct 2012 Report the findings, provide photos Premise check Report trace back investigations - source of food etc 45
    • 46. Analytical result www.jamalrahman.net 22nd Oct 2012 Proof/test the hypothesis - the causal relationship including dose-response The usual statistical test - OR or RR or AR for categorical outcomes (sick or not sick, exposed or not, dead or alive) E D 46
    • 47. www.jamalrahman.net 22nd Oct 2012Attack Rate , Attributable Risk & OR Attack Rate Attributable Risk Odds Ratio 47
    • 48. RR www.jamalrahman.net 22nd Oct 201248
    • 49. www.jamalrahman.net 22nd Oct 2012Hazard Analysis - HACCP for food poisoning 49
    • 50. www.jamalrahman.net 22nd Oct 2012Hazard Analysis - HACCP for food poisoningOnce suspected food causing the outbreak identified 50
    • 51. Laboratory Results www.jamalrahman.net 22nd Oct 2012 Usually confirmatory Include support documents 51
    • 52. Control Measures www.jamalrahman.net 22nd Oct 2012 Explain what was done to control the outbreak - immediate response, during outbreak & post outbreak Describe the progression of illness 52
    • 53. Discussion www.jamalrahman.net 22nd Oct 2012 Discuss the main hypothesis Describe the likely causative agent and mode of transmission Describe the risk factors Describe control measures taken 53
    • 54. Conclusion www.jamalrahman.net 22nd Oct 2012 The answer to the hypothesis 54
    • 55. Supporting Documents www.jamalrahman.net 22nd Oct 2012 Include all relevant & supporting documents as appendix 55
    • 56. www.jamalrahman.net 22nd Oct 2012Mt. Bromo, Mt. Batok & Mt. Semeru.East Java, Indonesia. Photo by Jamal Rahman.Thank you 56

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