A simulated outbreak investigation (EC05)

Module: EPM301 Epidemiology of Communicable Diseases

Course: PG Diploma/ MSc Epidemiology

This document contains a copy of the study material located within the computer assisted learning (CAL) session. The first three columns designate which page, card and screen position the text refers to. If you have any questions regarding this document or your course, please contact DLsupport via DLsupport@lshtm.ac.uk. Important note: this document does not replace the CAL material found on your module CDROM. When studying this session, please ensure you work through the CDROM material first. This document can then be used for revision purposes to refer back to specific sessions. These study materials have been prepared by the London School of Hygiene & Tropical Medicine as part of the PG Diploma/MSc Epidemiology distance learning course. This material is not licensed either for resale or further copying.

London School of Hygiene & Tropical Medicine September 2013 v2.0

Section 1: EC05 A simulated outbreak investigation Aim

To gain practical experience in the skills necessary for an outbreak investigation.

Objectives By the end of this exercise you should:

be able to demonstrate the methods used to carry out an outbreak investigation

have gained experience of working in a group. As part of this you should

be able to:

appreciate that individuals within a team can make different types of contributions

identify the processes that help make teamwork more productive

have experience with working to deadlines as part of a group

be able to contribute to producing a team report

This session should take you between 45 mins and 1h30 mins to complete. Section 2: Important information The outbreak investigation report is the assessed work for this unit and it is therefore compulsory.

The exercise will take 6 weeks to complete, and you should expect to spend a minimum of 6 hours per week on this exercise. Details of the outbreak exercise, and how to sign up for the two different sessions will be provided by the module organisers during term 1. 2.1: Important information This exercise will be undertaken in a group of 3 5 students, and you will submit a joint report for assessment.

Because this exercise is a simulated outbreak investigation, it is important that the group is able to work together within a limited time period (6 weeks), as would be the case in real life. As you will be working as part of a team, you need to make a commitment to complete the work together within specified dates. So that groups and tutors can be assigned, it is necessary for you to register to work within a specific set of dates.

A limited number of time 'windows' will be allocated for this exercise each year. Please await information from the tutoring staff on the dates available.

The only prerequisite is that you have completed sessions 1 4 of this unit before starting the exercise. Session EC04 gives information on how to conduct an outbreak investigation. Section 3: Introduction The exercise aims to simulate an investigation of a disease outbreak, and involves the following stages:

1. data collection 2. data entry and cleaning 3. data analysis 4. interpretation and presentation

You will be required to work in a group of 3 5 students, each of whom is expected to contribute to all stages of the exercise.

This 'distance-based collaboration' is similar to the way in which many people in research institutions now work.

It is increasingly common for individuals from different institutions, often in different countries and continents, to work together to produce reports or research proposals. The increasing access to e-mail enables partners to share ideas and to prepare documents collaboratively. 3.1: Introduction Because you are working at a distance, you will need to be patient about getting feedback and contributions from other members of the group. Do not be tempted to complete the task on your own!

Group work provides many benefits that are not available to someone working alone.

These are:

sharing previous experiences exchanging ideas giving / receiving feedback sharing the workload!

The groups will be allocated according to the time window when you are willing and able to undertake this exercise.

It is likely that your background, training and experiences will differ from those of other group members. This variety of experience and combined knowledge can lead to interesting discussions and help the group to manage the task effectively.

There are just a few things to consider if you are not used to working in a group, and these will be reviewed on the next page. Section 4: Working in a group

The members of a group can contribute differently to the way in which the group works and to the final product.

In fact, different characteristics are often required for the group to work well together. Some of these have been listed on the opposite page you may be aware of others.

Click on each to see a description of what the role involves.

Co-ordination

Motivation

Creativity

Resourcefulness

Evaluation

Team Work

Monitoring

Implementation_

Introduction: Hyperlink: Co-ordination(pop up box appears): Co-ordination Bring together everybodys efforts, remind the group of the objectives and ensure that all contributions are used. Interaction: Hyperlink: Motivation (pop up box appears): Motivation Challenge the group and motivate the team to action. Interaction: Hyperlink: Creativity (pop up box appears): Creativity Make original contributions to the groups ideas and discussions. Interaction: Hyperlink: Resourcefulness (pop up box appears): Resourcefulness Explore possibilities and use networks to find things that will be useful. Interaction: Hyperlink: Evaluation (pop up box appears): Evaluation Critically review all proposals and identify problems early on.

Interaction: Hyperlink: Team Work (pop up box appears): Team work Work well with other team members and keep morale high. Interaction: Hyperlink: Monitoring (pop up box appears): Monitoring Regularly assess progress and ensure that the task is completed properly. Interaction: Hyperlink: Implementation (pop up box appears): Implementation Get things done! 4.1: Working in a group Some people are very strong at particular roles, others may be equally good at a number of roles.

Individuals often take on the role or roles they are best at, but sometimes you will need to assign specific responsibilities.

It can be helpful to identify someone who is willing to co-ordinate the group's efforts (co-ordinator) and someone who will ensure that the work is progressing on time (monitor). It is not useful to assign a responsibility to someone who does not feel comfortable with what it involves, as they may not be able to fulfil the role.

Co-ordination

Motivation

Creativity

Resourcefulness

Evaluation

Team Work

Monitoring

Implementation_ 4.2: Working in a group Be aware that different individuals have different strengths.

Some people may be good at reviewing literature and summarising the important points, some may contribute frequently to the discussion, others enjoy statistical analysis, and others are good at report writing and presentation.

Every effort should be made to include all members in each stage of the task, but where tasks need to be allocated it may be useful to divide the responsibilities between the group members according to each individual's perceived strengths.

Co-ordination

Motivation

Creativity

Resourcefulness

Evaluation

Team Work

Monitoring

Implementation_ 4.3: Working in a group Try to be aware of how your group is working, and of the processes that can be used to help the group work more effectively.

You may have been in meetings where the outcome depended more on the characters of the individuals involved, than on the topic being discussed.

Activity: Think of groups you have been in either professionally or socially. Try to identify why the group worked well or why it didn't.

List some of the reasons you think the group worked as it did, then click on the button below to see some of the common reasons. Interaction: Button: clouds picture (card appears on right handside): Some common reasons for a group working well (or not) are:

the members got on well (or there were personality clashes) people listened to each other (or people tried to impose their own

viewpoints and ignored others) all had a chance to share their views (or some individuals dominated) everybody participated (or a few individuals did all the work) there was a clear agenda (or nobody was clear about what needed to

be done) there was agreement among members (or there were opposing

views) everybody understood each other (or there were misunderstandings)

You may have thought of other reasons. 4.4: Working in a group You will have noticed in the previous list that there was a common theme through much of the list. A number of the points focussed on ensuring that

everybody's contribution to the group is effective (listening, sharing, participating, agreeing, understanding).

The following are ways in which people can be encouraged to make contributions to a discussion (based on Blumenthal & Edis). Click on each one for details:

Reinforcement Reducing risk Giving space Bringing people in

Interaction: Hyperlink: Reinforcement (card appears on right handside): Reinforcement

Support the contributions made by others and build on them. It is important to give consideration to what others say and not to ignore anybody's ideas.

This will encourage a climate for discussion. Interaction: Hyperlink: Reducing risk (card appears on right handside): Reducing risk

Confrontations should be supportive rather than over-critical, and avoid personal attack. People should be able to contribute to the discussion without feeling any threat from the group.

This will also encourage a climate for discussion. Interaction: Hyperlink: Giving space (card appears on right handside): Giving space

There needs to be an acceptance of difficulties or differences within the group.

Make it clear if there are difficulties. Let other members know when you do not understand something or if you did not express something as you meant to. Encourage others to do the same.

Be sensitive to cultural, language or gender factors that may get in the way of the communication. Interaction: Hyperlink: Bringing people in (card appears on right handside): Bringing people in

Encourage all group members to participate in discussions as well as specific tasks. You can do this by specifically asking for somebody's opinion on a topic, for example:

"What do you think about ...?".

Refer to a person's previous contribution to re-integrate them into a discussion. 4.5: Working in a group

The process of a group collaboration can be grouped into three main phases: starting, progressing and summarising.

(i) Starting

It is useful to start by trying to generate ideas about the project. This is often referred to as brainstorming, and involves sharing any ideas that you have with the rest of the group. The other members of the group can then give their comments on the ideas. This often gets the discussion started. It is important to critically evaluate the ideas and developments at every stage, but remember that this should not involve criticising any specific individual. This should lead to the development of a framework of how to proceed with the task, which will help to give the work focus. 4.6: Working in a group (ii) Progressing

The group should be clear about its objectives. You need to have a sense of progression towards specific targets. This can be the role of the co-ordinator and the monitor. Alternatively, or in addition, all group members can share in the task of controlling and directing the progress. You can do this by asking questions, suggesting a framework, and proposing procedures for agreement (such as voting). 4.7: Working in a group (iii) Summarising For a discussion to develop, you should integrate the ideas periodically. It is useful to group ideas under appropriate headings, and to make links between ideas.

One or two group members could try to summarise the progress of the discussion and circulate this for comments. This ensures a clear understanding of each other's ideas and opinions, before moving on to develop the group's ideas.

There will be times when all members do not agree. It is useful to discuss why there is disagreement and to try to reach some form of consensus (general agreement). Sometimes it is not possible to reach a consensus and this may prevent you from proceeding with the task.

The group might want to consider deciding upon a set of procedures at the beginning, to deal with these situations. This could take the form of democratic voting. Alternatively you may decide to divide up tasks and allow the person responsible to have the final decision after reviewing feedback from the group.

If there is disagreement on a point of interpretation it may be possible to include all viewpoints in a written discussion.

Section 5: Email and Moodle netiquette As part of this exercise you will be working with a group of students who you will need to communicate with regularly. You will be conducting discussions using Moodle and chat-rooms, and the following advice may help to make these communications easier:

Write in proper sentences (although grammar and spelling need not be perfect)

Put the message in context(i.e. quote part of the original message you are replying to if it helps place your question or response in context)

Refer to your student handbook for more information on 'netiquette'. 5.1: Email and Moodle netiquette As e-mail and Moodle messages can be sent easily and quickly it is often used as an informal means of communication. Many people treat electronic communication like a verbal conversation and they let their thoughts flow quickly. This can be positive, helping to stimulate discussion.

However, in the heat of a live discussion it is often easy to misinterpret what someone says, and this applies equally to messages sent electronically. People often send a message without re-reading it. Be careful to think through all the potential implications of the message. Misunderstandings can lead to unnecessary conflict. E-mail or Moodle messages can also be used to transfer feelings, but be careful when using humour or sarcasm. Without inflections of voice and body language it is easy for a remark in a message that was meant to be funny, to be misinterpreted. Subtle humour tends to get lost, so take steps to make sure that people realise that you are trying to be funny.

Internet users have developed a symbol called the smiley face. It looks like this :-) and points out sections of an article that are meant to be humorous or not to be taken seriously. 5.2: Email and Moodle netiquette The internet allows you to communicate with people across the globe, from different countries and different cultures.

However, people from different cultures may be used to different types of social interaction. Try to choose your words carefully. What may seem to you to be a 'throw-away' comment, may be taken very seriously by another person. Finally, remember that the written word is more permanent than the spoken word!

When an electronic message is received at the other person's computer you do not know who will read it, or if it will be printed or copied, or sent to other people. So it is a good idea to be polite. A good rule to use is that if you write about another person, expect that some day in the future that person may read what you wrote. Section 6: Instructions

Once you have registered your availability, you will be informed of the time window to which you have been allocated. The final allocation will depend on the availability of other group members.

In the weeks before the start of the exercise, you should work through Session EC04, or review the material if you have completed the session previously. Before the start of the exercise you will be contacted by DL support who will inform you which group you have been assigned to. You will also be provided with instructions about how to contact the other members of your group via a conference on Moodle, which only the members of your group and your tutor will be able to access during the exercise. Once you have received this information, it is your responsibility to establish contact with the other members of your group, and to introduce yourself to them. We suggest that you do this as soon as possible, in case there are any problems with communication or with the availability of other group members. A tutor, who will be assigned to your group during the six-week period, will introduce his/her self to you through your groups Moodle conference. 6.1: Instructions The exercise

There are two choices for the outbreak exercise developed and developing country setting. Both options follow a similar format.

You are a team of health professionals that are responsible for investigating the outbreak and have to advise the local health authority on the necessary control measures.

Your group will need to obtain relevant data to enable you to identify the cause of the outbreak, and to decide on appropriate measures necessary to stop further cases of the disease. 6.2: Instructions You have 6 weeks to complete the exercise, but remember that you will need to allow some time for communicating with all the group members and receiving feedback.

In a real outbreak situation, you would need to act quickly to identify the cause of the outbreak and implement appropriate control measures. For the purposes of this exercise, you should consider one week of the exercise to be approximately equivalent to one day in a real outbreak situation. The following is suggested as an approximate time frame for the exercise. You may prefer to distribute the time differently.

1. Data collection:

i. Questionnaire design (1 week) ii. Piloting and editing (1 week) iii. Collection of data (1 week)

2. Data entry and cleaning (1 week) 3. Data analysis and mapping (1 week) 4. Interpretation and presentation (1 week) 6.3: Instructions 1. Data collection

As a group, you need to design a questionnaire that can be administered to the relevant people to help you identify the cause of the outbreak. You will need to consider what questions you wish to ask, and to whom you want to administer the questionnaire.

You will be given a chance to pilot the questionnaire on 2 people. Send the draft questionnaire as a word document as anattachment to your tutor, along with the names of the first two interviewees. The questionnaire should be approximately 1 side of A4 (21cm x 30cm) paper, and take 5 10 minutes to administer. 6.4: Instructions 1. Data collection (continued)

The tutor will send you the 2 pilot responses for the questionnaire. Look carefully at these responses to see if you need to make any changes to the questionnaire. Your tutor will only give you the responses to your questionnaire, and won't give any other specific feedback unless he/she feels that you might be making a major omission.

We suggest that you send the pilot questionnaire to your tutor after one week, to give sufficient time to receive the pilot responses and re-design the questionnaire by the end of week 2. After making final changes, you need to submit the final questionnaire as before to your tutor, as an unformatted text file attachment. You will also need to send a list to your tutor of all the individuals you want to administer the questionnaire to.

Because the data you receive will depend on the nature of your questionnaire, you need to allow one full week for your tutor to collate and return all the responses. 6.5: Instructions 1. Data collection (continued)

To summarise the data collection process:

1) Design a questionnaire collaboratively 2) Send the pilot questionnaire to your tutor in an unformatted text file (aim for end of week 1) 3) Receive the responses for the 2 chosen people from your tutor 4) Revise the questionnaire after looking carefully at the responses received 5) Send the final questionnaire to your tutor in an unformatted text file with a list of individuals you want to interview (aim for end of week 2) 6) Receive the responses for all the people being surveyed from your tutor

6.6: Instructions 2. Data entry and cleaning

The data will be returned to you with a separate page for each respondent.

We suggest that you prepare an Epi-Data questionnaire and check file while you wait for the responses to be returned to you. Once you receive the responses, this file can be used for data entry. The group needs to decide on the best method for entering the data accurately. You also need to think about checking the data quality. You may wish to refer to EP103 to remind yourself of the methods for entering, checking and cleaning data. 6.7: Instructions 2. Data entry and cleaning (continued)

More information available in this exercise

After an initial look at the responses you receive, you may realise that you need more information. In real life, you might have laboratory tests done or be able tore-interview people.

However, laboratory tests will be dependent on the accessibility and reliability of local laboratory facilities. Individuals may refuse to give samples. You also need results fast remember that you are carrying out a rapid investigation to stop the disease from spreading! Following-up individuals can also have drawbacks. Individuals may die or be absent, and most commonly, there is a recall error. For example, try remembering what you ate 2 weeks ago! 6.8: Instructions 2. Data entry and cleaning (continued)

Laboratory tests

You can request tests using the format shown opposite in a posting to your tutor on the Moodle page for the outbreak exercise.

Laboratory facilities may be limited, and you will be sent further details of this relevant to your specific outbreak.

Allow 5 working days for the tests to be carried out and the results returned to you. Name and identifier of person/object:

Type of specimen:

Type of test: 6.9: Instructions 2. Data entry and cleaning (continued)

Re-interviewing

If necessary (and if there is enough time), you will have the opportunity to re-interview each person once. This is not a chance to re-administer the questionnaire, so you will only be able to ask the SAME 2 questions to each person. Again allow 5 working days for the responses to be returned to you. These further questions can be submitted in a posting to your tutor via Moodle using the following format:

Name of person and identifier:

Question 1:

Question 2: 6.10: Instructions 3. Data analysis

After entering the data in Epi-Info, you will need to agree on the analyses you wish to do. Refer to EC04 for help with this.

Data analysis can be carried-out in either Epi-Info or STATA, depending on which software package you feel more comfortable with.

Follow the instructions opposite if you wish to export your data to STATA. Interaction: Tabs: Out of Epi-Info: Follow these steps in Epi-Info:

1. Choose Export files from the Programs drop-down menu.

2. Enter the Epi-Info file name; using the arrows, move the cursor to select the Delim file format; choose an output file name and select OK. Interaction: Hyperlink: Delim file format (pop up box appears):

This produces a comma and quote delimited file with a * .sdf file extension. All fields are delimited by quotation marks and separated by commas. The first 3 records contain field lengths, data types and field names. Interaction: Tabs: Into STATA: 3. In the EPED text editor in Epi-Info, open the delimited file which will have an *.sdf extension. Delete only the first two lines of the file, which contain the field lengths and data types. Be very careful not to delete any of the variable names! STATA needs the field names, so this should now be the first line. Save this file in the same format.

4. In STATA, type the following at the command prompt: insheet using filename.sdf, names. Replace 'filename' with the directory and file name as appropriate. This file can then be saved in STATA format using the save filename command. Interaction: Tabs: Date format: If you have dates in your dataset, STATA will read them as text instead. You will be able to view the correct dates, but not to manipulate them as dates. To use the dates in any analysis, you will need to create a new date variable using the following commands:

generate newdate = date(olddate,DMY) format newdate %dD/N/CY

Replace 'olddate' with the name of the Epi-Info date variable and 'newdate' with the name of your new date variable. The second command will create a user-friendly format to view the new date variable. 6.11: Instructions 3. Data analysis (continued)

Graphics

If you wish to include any graphs in your final report, we recommend that you produce them in STATA (save the graph as a Windows Metafile type *.wmf file for printing or importing into a word-processing package).

Alternatively if you have access to any spreadsheet software (e.g. Excel, QuatroPro) these will also allow you to produce and print out graphs. Map of outbreak (developing outbreak only)

A map of the outbreak can be produced using powerpoint to show the location of cases and other relevant information. A map template will be sent to you at the beginning of the outbreak, with instructions on how to edit the map. You will be able to share copies of this map file between members of your group by email. You may wish to save multiple versions, if group members are plotting different types of data.

We suggest that you include the final map(s) you produce as part of your final report. The map file(s) should be sent as an e-mail attachment along with the report document. 6.12: Instructions 4. Interpretation and Presentation The interpretation of your analyses will require discussion among the group. We recommend that your interpretation is ongoing, from the moment you receive your data and start to analyse it.

Remember that you are a team of professionals, and you need to produce one coherent report for the health authorities. It is important that you aim to reach a consensus when interpreting the data. If there are very strong differences of opinion that cannot be resolved you may want to try expressing these viewpoints but if the report is confusing, the recipients will not be happy! So that all group members can contribute to and comment on the summary document you produce, it is important that you work in a format that is compatible within the group. Not all students have the same word-processing software, so find out what software each member has and use one that everybody can read.

Once the exercise has been completed and marked, you will receive feedback on the exercise from your tutor. Section 7: Tips for getting started Tips for getting started

Think about how you can identify the source of the outbreak. What questions will you need to ask? Who do you need to question? What tests will you need to do?

Think about the types of responses you hope to get. Make sure that you phrase any questions clearly in the questionnaire - if the question is ambiguous, the response may not be what you wanted to know. What format (binary, categorical, open-ended) will the responses be in? Think about how you want to analyse the data this may influence the way you ask the question.

Would it help to ask open-ended questions? Sometimes it is useful to get people's opinions or to get additional information that you would be unaware of.

General hint for analysis: Think about whether distinguishing between primary, secondary and tertiary cases is appropriate in your outbreak.

Refer to session EC04 for details on how to conduct an outbreak investigation, and how to initiate control measures. 7.1: Requirements for submission Requirements for submission

The report of your investigation will be assessed and you will receive feedback.

The report will need to include the following information:

an introduction to the situation the methods you used to investigate the results of your investigation and analyses a discussion of your findings and interpretation of these recommendations for controlling the outbreak

The report should be no more than 5 pages of single-spaced text (not counting tables, figures and references). Font should be no smaller 11 point with sensible margins (2cm all round is ok). Please include the final version of your questionnaire as an appendix to your report. 7.2: Submitting the Report One copy of the report, together with the map file should be submitted via AMS. Only the person in charge of submitting the AA needs to upload it. It will then be automatically uploaded on the AMS page of each member of the group. The report must be submitted on or before midnight GMT on the last day of the 6-week outbreak session.

Each group member needs to submit an e-mail statement naming the person in the group who is submitting the final report, and confirming that you participated fully in the exercise. Please also complete the evaluation questionnaire which your tutor will post up on Moodle and send to dlsupport@lshtm.ac.uk Good luck!

2.1: Important information3.1: Introduction4.1: Working in a group4.2: Working in a group4.3: Working in a group4.4: Working in a group4.5: Working in a group4.6: Working in a group4.7: Working in a group5.1: Email and Moodle netiquette5.2: Email and Moodle netiquette6.1: Instructions6.2: Instructions6.3: Instructions6.4: Instructions6.5: Instructions6.6: Instructions6.7: Instructions6.8: Instructions6.9: Instructions6.10: Instructions6.11: Instructions6.12: Instructions7.1: Requirements for submission7.2: Submitting the Report