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The outbreak investigation report
Arnold Bosman / Meirion Evans
Epidemiol ogy
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Outbreak reports
First:
What are they?
Why write them?
Who writes them?
Who reads them?
Then:
Structure
Frequent problems
Confidentiality
Legal issues
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What are outbreak reports?
formal outbreak reports
reports to colleagues: electronic message or web page
national bulletin, Eurosurveillance
conference/seminars (EPIET)
(inter)national outbreak reporting systems
journal publications
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Formal outbreak reports
preliminary report interim report(s)
final report
may only require two sides of A4
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Why write them?
to document the outbreak
to share new insights to substantiate recommendations
in order ...
to prevent future outbreaks
to assist in investigation & control ofsimilar incidents
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Who writes them?
the outbreak control team (OCT)
named authors
each participating agency must agree with
what is said
who owns the report?
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Who reads them?
all agencies represented on the OCT
policy making bodies
professional colleagues
the public
the lawyers
(supervisors)
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Structure of the report
Summary
Introduction and Background Outbreak description
Methods and Results
Discussion
Lessons learned
Recommendations
Appendices
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Summary
key features of the outbreak
- who - what - where - when
key lessons learned
key recommendations
ongoing action further action required
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Background
population demographics
surveillance trends
previous similar outbreaks
description of the area / site / facility
eg healthcare system
eg industries involved
any unusual points
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Description of the outbreak
the initial story
how was the outbreak reported?
what steps were taken to confirm it?
management of the outbreak
who was on the OCT?
what were the objectives?
who assisted in the investigation?
what control measures were taken?
media relations
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Methods
Epidemiological
case definition & ascertainment descriptive study
analytical study
Microbiological/toxicological
clinical & environmental specimens
Environmental
site visit & risk assessment
traceback
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Results
Epidemiological
number of cases, personal details & clinical features geographical distribution
epidemic curve
risk factor analysis
attack rates by age, sex, exposure
Microbiological/toxicological laboratory findings, e.g. genotyping, fingerprinting
Environmental inspection reports
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Discussion
discuss main hypotheses
justify conclusions and actions based on evidence?
balance of probabilities?
explain action to protect public health
highlight any problems
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Lessons learned
lessons for participating agencies:
problems encountered mistakes made
suggestions for improvement
lessons that may be useful to others
key points from internal/external audit
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Recommendations
what should be done:
to control this outbreak
to prevent future outbreaks
to improve management of outbreaks in future
aim to educate
be specific
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Appendices 1
chronology of events
general background
membership of OCT
terms of reference of OCT
detailed resultsmaps
references
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Appendices 2
epidemiological questionnaire
letters to patients/physicians
press releases
Qs & As
costs of the outbreak acknowledgements
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Problems
confidentiality
legal issues
what should not be included
delay in writing the report
not writing a report at all
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Confidentiality
to individual patients
to commercial businesses
details may remain in meeting minutes
media disclosure legal disclosure
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Legal issues
who owns the report / the data?
prosecuting agencies may deem the
information to be confidential
but .. health authorities have a duty to provide
the public with information
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Report not available
diesel fuel spillage into drinking water
well managed, many lessons learnt
similar incident nine months later
sub-optimal management
slow ascertainment of public health risks
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Report published
Jan. 1997: outbreak report in MMWR:
Legionnaires disease (LD) associated withwhirlpool spa on display, VA, USA
Feb. 1999: major outbreak LD, in Holland
source: whirlpool spa on display
lawsuit against government: failure to act on
available knowledge (MMWR)
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Conclusion
remember the possible pitfalls
but you have a duty to
document the outbreak
inform your colleagues
prevent and control future outbreaks
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References
Massachusetts Foodborne Illness Investigationand Control Reference Manual
http://www.state.ma.us/dph/fpp/refman.htm
Legionnaires Disease outbreak Cumbria, UK
http://www.healthprotection.org.uk/Barrow/main.html
http://www.state.ma.us/dph/fpp/refman.htmhttp://www.state.ma.us/dph/fpp/refman.htm