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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