jump to first page outbreak management e.mcnamara phl,hse,swa. and st james’s hosp
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Outbreak Management
E.McNamara
PHL,HSE,SWA. and St James’s Hosp.
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Outbreak definitions
Cluster - 2+ cases
- related in time/place
- may not be above expected
Outbreak - as cluster but
- exceeds expected number Epidemic - as outbreak
- but implies crisis.
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1 Preliminary assessment
Is it an outbreak? Confirm the diagnosis Is further investigation needed?
Epidemiological Environmental Microbiological
Any immediate control measures?
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Preliminary assessment - is it an outbreak?
Who identified problem? How many cases or deaths? Expected number of cases or deaths? What tests done and any results? Any change in clinical or lab practice? Any obvious link between cases?
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Preliminary assessment- confirm the diagnosis
Review clinical case histories Interview several cases Discuss tests/specimens with lab Arrange tests/get results quickly Repeat tests or confirmatory tests? Consult experts?
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Preliminary assessment - Is further investigation needed?
illness serious? Cases still occurring? More than 1 location involved? Any secondary cases? Risk of recurrence?
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Preliminary assessment - immediate control measures?
Prevent further cases: Stop symptomatic food handlers working? Close ward, Stop admissions? Clean/disinfect premises or equipment? Cease drinking water? Close premises/stop production? Review operational practices Recall product? Prevent person-to-person spread Offer prophylaxis e.g. immunisation
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Case definition and identification
Case ascertainment Case definition Define population at risk Quantification of incident.
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Case definition and identification:
Time Place Person Symptoms Lab results.
Confirmed Probable Possible
Master List
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Descriptive study:
Time, place and person Data collection
standard format
line listing
denominator data Data analysis
epidemic curve
attack rates
Generate Hypothesis.
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Analytical studies?To Test hypothesis
Cohort Study Start with population (cohort) exposed to factor Calculate relative risk (RR) of exposure.
Case-control study Start with cases Identify controls Calculate odds ratio (estimate of RR)
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Special studiesVerify hypothesis, Source.
Microbiological Identify Pathogen Typing of isolates Food and environmental samples?
Other Specialities Veterinary, Enviromental Meteorological data Tracer studies e.g. water, air Entomological
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Control Measures
Remove sourceIsolate/treat case
Destroy/treat food or other source Protect persons at risk
Hygiene/prophylaxis Prevent recurrence
Make recommendations
Produce guidelines/change law
Audit interventions
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Communication
During the investigation Information for public and professionals
At the end of the investigation
Produce written reports For those involved, critical appraisal. For enforcement For wider publication
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Outbreak Preplanning External; Multidisciplinary. Internal; Robust protocols PHL, HSE,SWA. Annual
11 major enteric outbreaks 58 minor incidents
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Role of Outbreak Control Team (OCT).
Prelim. Assessment. Case ascertainment Hypothesis
Descriptive studies Analytical studies Special studies
Control measures
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Emergency Plan for Outbreaks OCT; roles, responsibilities and
legislation. Multidisciplinary Strategy to investigate and manage,
SOP. Risk assessment, Interventions, Monitor
effectiveness. Adequate surge resources. Communication: internal, external,
media.
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OCT Meetings minuted. Multidisciplinary updates. Continuous reassessment of public
health risk. Rationale for interventions, agreed,
designated and time frame. Conclusion, Debriefing, lessons learnt. Recommendations to prevent
recurrence. Outbreak report.
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Initial OCT Meeting Confirm:
PHL sample receipt requirements Pathogen analysis. Health and safety issues PHL result communication, format,
status, to whom. Clinical advice and interpretation Pathogen/sample storage PHL liason person attending OCT.
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OCT Meetings (Lab.) Provide update on lab.results. Provide specialist result
interpretation. Advise on pathogen related risk
assessment. Advise on infection control. Advise on interventions.
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PHL Outbreak Plan Notification, Outbreak code. Specimen receipt
Urgency, quantity, type. Time and mode of delivery Pathogen screen Request details, O/B code, GP,
contact Nos. Documented chain of custody Rejection criteria
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Health and Safety Advice For patient sample procurement For sample collector Sample packaging and transport At lab. reception During analysis Sample disposal
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Internal Laboratory Briefing
Clarify nature of outbreak. Outbreak code Designate Senior Technologist as
Outbreak Co-ordinator. Confirm agreed communication
route with OCT. Methodology, IQC and safety.
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Briefing cont. Establish potential sample numbers Devise outbreak staff rota and duties. Consider deferring routine work. Do stock audit. Review lab. space. Documentation; Receipt,Tech. work. Document daily dispatch of cumulative
validated results to agreed personnel.
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Reference Laboratory Establish early communication. Source of advice. Clarify:
Typing methods Turnaround time Urgency PHL contact person
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Outbreak conclusion Attend debriefing. Assess lab. response. Review lessons learnt. Modify lab. plan if necessary.
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Investigation of a Outbreak.
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Index Case
19 Y/O Admitted SHB Bloody Diarrhoea
23/6/04 Fri. 25/6/04 PHD notified ?E.coli
0157. What next?
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Day 1
Confirm VTEC Farm-Fork investigation, sporadic
case. Exposure Hx.
Dietary Water Recreational Occupational
Initiate investigation.
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Day 1 cont.
P H Dept, SHB link to NEHB EHO’s SHB, MWHB, NEHB
MWHB- Restaurant NEHB- Sports ground
PHL,SWAHB notified of case and samples
Interventions?
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Interventions Day 1.
MWHB, Restaurant inspection and sampled
NEHB, Sports ground. 2 pitches Intercounty Summer festival
tournament. Private well Water sampled Drinking water ceased imediately.
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•26/6 Sat, No. of foods and waters received PHL
•28/6 Day 4,
• Isolate index case received from SHB.
• Index case + Bar water confirmed as E. coli O157 VT1 + VT2 positive. PCR.
•What next?
Outbreak Day 4
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• Outbreak Situation Develops• OCT Co-ordinates• Public Health Laboratory Investigation• Public Health Interventions
Public Health Response Dynamic
OCT: PH Doc, EHO, Med Micro PHL, NDSC
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Outbreak Strands
Epidemiology, PHDept.
Case ascertainment
Epi curve Epi. Studies
Case Control Cohort
Interventions
Environmental, EHO,s
Premises inspection.
Operational review.
Sampling Interventions Closure?
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Premises
•Sports grounds
•Recent Tournaments
•Playing/training pitches
•Club house
•Investigations?
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Case Date(recvdPHL)
Potential source
Lab findings
Index 28/6, Water E. Coli O157, VT1+2 positive
Case 2 5/7, Water E. Coli O157, VT1+2 positive
Case 3 7/7 Water E. Coli O157, VT1+2 positive
Case 4 9/7 Water E. Coli O157, VT1+2 positive
Date exposed
19/6
25/6
25/6
25/6
All cases exposed at sports grounds
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Linked Cases
Public Health
•Sports festival 100+ kids 21/6-26/6
•Case assertainment
•Symptomatic Tested
•Asyptomatic not tested, advice given to them and GPs
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Water source
Date General water Microbiology findings (100mls)
IMS/PCR findings (1l)
Bar (potable)
26/6 E.coli=0
Col. Bact=0
E. Coli O157, VT1+ VT2
Bar (potable)
29/6 E.coli=0
Col. Bact=3
E. Coli O157, VT1+ VT2
Septic tank 6/7 E. Coli O157, VT1+ VT2
Surface water
15/7 E. Coli O157, VT1+ VT2
Interpret.ation?
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BAR(drinking water)
SEPTIC TANK
PRIVATE WELL
QUARRY
SURFACE WATER
ANNUAL RAINFALL
???
???
???
???
???
untreated
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Water Interventions
•Drinking alternative
•Treatment of private well: pre + post test samples
•Geographical Survey: dyeNo blackflow from septic tank
•Secure Private well.
•Other interventions?
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•Playing pitch fenced
•Training pitch not fenced
•Animals on training pitch
•No. of animal droppings sampled
•Clean grounds
•Washing hand notices
•Fence training pitch
Other Interventions.
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Sheep droppings
Received 14/7
• Non-O157,
•VT1 positive
•Interpret?
Other samples
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Other samples
14/7 clinical Sample
Contact of positive case
•Non-O157
•VT1 positive
•Interpret?
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 Lane 1: DNA ladderLane 2: Index case. Lane 3: Case 3. Lane 4: Case 2. Lane 5: case 4. Lane 6:Bar Water Lane 7: Septic tank Lane 8: Surface Water. Lane 9: DNA ladderLane 10: Sheep droppings. Lane 11: Sheep droppings. Lane 12: Sheep droppings. Lane 13: clinical non-O157 Lane 14: DNA ladder
PFGE
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Post intervention•Continue to screen water post treatment.
•Post treatment samples tested-Negative
•Enviromental water sampling?
Water source Date General water Microbiology findings (100mls)
Molecular biology findings (1l)
Surface water drain
20/7 Total coliform>24,192 cfu
E. Coli 7270 cfu
E. Coli O157 VT1+VT2 pos
Roadside Gully
14/9 E. Coli O157 VT2 pos
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Sample Serotype Genotype PT PFGE
Index O157 VT1+VT2 32 Pattern 1
Case 2 O157 VT1+VT2 32 Pattern 1
Case 3 O157 VT1+VT2 32 Pattern 1
Case 4 O157 VT1+VT2 32 Pattern 1
Bar O157 VT1+VT2 32 Pattern 1
Bar O157 VT1+VT2 32 Pattern 1
Septic tank O157 VT1+VT2 32 Pattern 1
Surface water O157 VT1+VT2 32 Pattern 1
Surface water drain O157 VT1+VT2 32 Pattern 1
Roadside gully O157 VT2
Clinical non-O157 O146 VT1 Pattern 3
Sheep droppings O75 VT1 Pattern 2
Sheep droppings O75 VT1 Pattern 2
Sheep droppings O75 VT1 Pattern 2
Sheep droppings O75 VT1 Pattern 2
Sheep droppings O75 VT1 Pattern 2
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Summary
•Water
•Indicator Micro. = Neg. VTEC POS
•Private Well vulnerability
•Environment- contamination of surface water
•Animal – recreational source
•Importance of Non-0157 diagnosis
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