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Objectives of training
To understand clinical description and epidemiology To understand the disease case definition, lab specimens needed, labs role, and lab tests needed for confirmation To understand prevention and control procedures including available treatment and post-exposure prophylaxis, isolation and infection control procedures. To understand contact tracing and surveillance procedures
Team Roles and Responsibilities
Outbreak management staff Case Ascertainment staff/active surveillance
Telephone interviewers Data base support
Education of risks of disease from exposure to BT agents or infectious patients Vaccination Personal protective equipment (PPE)
BT AGENTS .
Prioritization Categories • Category A – – – High public health impact and public perception Variable dissemination potential Comprehensive PH preparedness Less public health impact Variable dissemination potential Less comprehensive PH preparedness Addressed with current preparedness efforts (BT/EID) • Category B – – – • Category C – .
botulinum toxins .VHFs .plague Francisella tularensis .botulism Filo and Arenaviruses .anthrax Yersinia pestis .smallpox Bacillus anthracis .Category A Agents Variola virus .tularemia C.
Characteristics of Category A Agents Infectious via aerosol Organisms fairly stable in aerosol Susceptible civilian populations High morbidity and mortality Person-to-person transmission Difficult to diagnose and/or treat Previous development for BW * Priority agents may exhibit all or some of the above characteristics .
Characteristics of Category B Agents Coxiella burnetii – Q fever Brucella spp.Ricin Epsilon toxin from clostridium perfingens Staphylococcus enterotoxin B .encephalitis Ricinus communis . EEE) .glanders Alphaviruses (VEE. WEE.brucellosis Burkholderia mallei . .
Nipah virus.) Salmonella E-coli O157:H7 Vibrio cholerae – cholera Cryptosporidium parvum cryptosporidiosis .Category C Agents Emerging infectious disease agents (Hantavirus. etc.
OUTBREAK INVESTIGATION .
.Definition Occurrence of more cases of disease than expected Nosocomial outbreak-any group of illnesses of common etiology occurring in patients of a medical care facility acquired by exposure of those patients to the disease agent while confined in such a facility.
political. or legal concerns Program considerations .Reasons to investigate Control/prevention Research opportunities Training Public.
Control / Prevention Where are we in the outbreak? Goals will be different depending on answer(s) Cases continuing to occur Goal: prevent further cases Assess population at risk. implement measures to prevent similar events in the future . implement control measures Outbreak appears to be coming to an end Goal: prevent future outbreaks Identify factors contributing to outbreak.
Steps of an Outbreak Investigation .
. Preparation Investigation Scientific knowledge Review literature Consult experts Sample questionnaires Supplies Consult with laboratory Equipment Laptop. camera etc.1.
funding Travel arrangements (orders) Approval Personal matters Consultation-make sure you know your role and its parameters Lead investigator or just lending a hand? Know who to contact when you arrive . cont. Administration-assure personnel resources.Preparation.
2. Establish existence of an outbreak Is an outbreak truly occurring? True outbreak Sporadic and unrelated cases of same disease Unrelated cases of similar unrelated disease Determine the expected number of cases before deciding whether the observed number exceeds the expected number .
states. cont.Establish outbreak existence. mortality statistics data from other facilities. Comparing observed with expected through surveillance records for notifiable diseases hospital discharge data. registries. surveys of health care providers community survey .
Verify the Diagnosis Ensure proper diagnosis and rule out lab error as the bias for increased diagnosis Review clinical findings. lab results Summarize clinical findings with frequency distributions Characterize spectrum of disease Verify diagnosis Develop case definition .3.
Verify the Diagnosis cont. See and talk with patients if at all possible Better understand clinical features Mental image of disease and the patients affected Gather critical information Source of exposure What they think caused illness Knowledge of others with similar illness Common denominators Helpful in generating ideas for hypothesis about etiology and spread .
Establish a case definition Case definition Standard set of criteria for deciding whether an individual should be classified as having the health condition of interest Includes clinical criteria and restrictions by time. place and person Must be applied consistently and without bias to all persons under investigation Must not contain an exposure of risk factor you want to test .4a.
Classification Definite (confirmed) Laboratory confirmed Probable Typical clinical features without lab confirmation Possible (suspected) Fewer of the typical clinical features .4a. cont. Establish a case definition.
Establish a case definition.4a. Early in investigation may use a “loose” case definition Better to collect more than necessary so you don’t need to make repeat visits Identify extent of problem and population affected Generating hypotheses Later when hypotheses are sharpened investigator may “tighten” case definition . cont.
phone or visit facility to collect information Alerting the public Media alert to avoid contaminated food product and seek medical attention if symptoms arise . letter describing situation and asking for reports Active surveillance e.g. Identify and count cases Target health care facilities where diagnosis likely to be made Enhanced passive surveillance e.g.4b.
4b. OB population restricted and large proportion of cases are unlikely to be diagnosed e.g. Identify and count cases. cont. on a cruise ship Survey entire population Always ask case-patients if they know of any others ill with the same symptoms .
cont. Identify and count cases.4b. Information to be collected about every case Identifying information Re-contact if additional questions come up Notification of lab results and outcomes of investigation Check for duplicate records Map geographic extent Demographics Provide “person” characteristics for defining population at risk .
Clinical findings Verify case definition met Chart time course Supplemental date e. deaths Risk factor information Tailored to specific disease in question Reporter information Id of person making report . cont. Information to be collected about every case cont.g. Identify and count cases.4b.
Identify and count cases. Collection forms Standard case report form Questionnaire Data abstraction form Line listing Abstraction of selected critical items from above forms Contains key information . cont.4b.
5. Perform Descriptive Epidemiology After collection of data characterize the outbreak by: Time Place Person .
Time Epidemic curve Histogram of the number of cases by their date of onset Visual display of the outbreak’s magnitude and time trend Where you are in the time course of the outbreak Future course? Probable time period of exposure Helps in development of questionnaire focusing on that time period Common source vs. Propagated .
work or may have been exposed .Place Geographic extent of problem Clusters or patterns providing important etiologic clues Spot maps Where cases live.
Person Determine what population at risk Usually define population by host characteristics or exposure Use rates to identify high-risk groups Numerator = number of case Denominator = number of people at risk .
Develop Hypotheses Hypotheses should address Source of the agent Mode of transmission Vector or vehicle Exposure that caused disease .
transmission. epi curve .g.Develop Hypotheses Generating the hypothesis What do you know about the disease? Reservoir. common vehicles and known risk factors Talk to several case-patients Use open ended questions Ask lots of questions Talk to local health department staff Use descriptive epidemiology e.
Test Hypotheses Evaluate the credibility of your hypotheses Compare with established facts When clinical.7. lab. environmental and/or epi data undoubtedly support hypothesis Use analytic epidemiology to quantify relationships and explore the role of chance Cohort studies Case control studies .
cont. Test Hypotheses. well defined population Contact each attendee and ask a series of questions Ill Vs not ill Look for source exposure Attack rate is high among those exposed Attack rate is low among those not exposed Most of the cases were exposed. so that the exposure could explain most. of the cases Relative risk = measure of association between exposure and disease . Cohort Small. if not all.7.
cont. Test Hypotheses. Case-control Population not well defined Case patients and comparison group (controls) questioned about exposure(s) Compute measure of association = Odds Ratio Quantify relationship between exposure and disease .7.
8. Refine hypotheses and do additional studies Epidemiologic When analytical epi unrevealing need to reconsider your hypotheses Go back and gather more information Conduct different studies Laboratory Additional tests Environmental studies .
Implement Control /Prevention Measures Implement control measures as soon as possible May be aimed at agent. source.9. or reservoir or long term Short .
adding to knowledge base . Communicate the Findings Orally within facility/community Local health authorities and persons responsible for implementation of control and prevention measures Written reports (consider publication) for planning. record of performance. reference.10. legal issues.
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