Epidemio l o gy

The outbreak investigation report

Arnold Bosman / Meirion Evans

Outbreak reports
First: What are they? Why write them? Who writes them? Who reads them? Then: Structure Frequent problems Confidentiality Legal issues

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

Formal outbreak reports

preliminary report interim report(s) final report

may only require two sides of A4

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 of similar incidents

Who writes them?

the outbreak control team (OCT) named authors each participating agency must agree with what is said who owns the report?

Who reads them?

all agencies represented on the OCT policy making bodies professional colleagues the public the lawyers (supervisors)

Structure of the report

Summary Introduction and Background Outbreak description Methods and Results Discussion Lessons learned Recommendations Appendices

Summary
key features of the outbreak
- who - what - where - when

key lessons learned key recommendations ongoing action further action required

Background
population demographics surveillance trends previous similar outbreaks description of the area / site / facility
eg healthcare system eg industries involved any unusual points

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

Methods
Epidemiological
case definition & ascertainment descriptive study analytical study

Microbiological/toxicological
clinical & environmental specimens

Environmental
site visit & risk assessment traceback

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

Discussion
discuss main hypotheses justify conclusions and actions
based on evidence? balance of probabilities?

explain action to protect public health highlight any problems

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

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

Appendices 1
chronology of events general background membership of OCT terms of reference of OCT detailed results maps references

Appendices 2
epidemiological questionnaire letters to patients/physicians press releases Qs & As costs of the outbreak acknowledgements

Problems
confidentiality legal issues what should not be included delay in writing the report not writing a report at all

Confidentiality
to individual patients to commercial businesses details may remain in meeting minutes media disclosure legal disclosure

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

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

Report published
Jan. 1997: outbreak report in MMWR:
Legionnaires disease (LD) associated with whirlpool 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)

Some reports stay alive

Conclusion
remember the possible pitfalls but you have a duty to document the outbreak inform your colleagues prevent and control future outbreaks

References

Massachusetts Foodborne Illness Investigation and 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