Hello, my name is Dr Elijah Matovu, a consultant microbiologist, an infection control doctor, and also the sepsis lead and educator for University Hospital of North Midlands in the United Kingdom. I'm delighted to be talking about an area that I'm quite fond of and usually get so involved in in my day-to-day work and that's infection control as well as outbreak management and the steps we usually use to manage it. So I wouldn't give the details of it all because we'll be here for so long, but what I'll do is I'll take you through the principles of how to best manage outbreaks and outbreak investigation management. So as we go through, I'll try and go through step by step, but the steps provided can all be done sequentially.
They're not to be done sequentially, but can be occurred simultaneously as the outbreak goes through until such a point that it's well managed. And this can also be recycled and redone. So the lecture will actually cover the... steps of the outbreak investigation itself, the relevant epidemiological methods, the process involved, the sources of the outbreak, might touch one or two, and a few key facts.
So outbreak investigation, initially you sort of suspect you do have an outbreak and then Once that comes, that could be information from the lab, from the clinical teams, from the environment, where you'd have two or more cases, more than usual. And then to start it off, one would call all key stakeholders. Now, I've given a list here, by no means exhaustive at all.
But... I would suggest that we keep it to the bare minimum because when you have got so many cooks, you know, you tend to spill the broth or make it too lengthy or veer off the point. But I would suggest that you have a communicable consultant or PHE consultant, environmental officer if need be, microbiology or virologist or infection specialist. You will definitely need secretarial support. And then think about the regional epidemiologists, media or press officer or communication officers in some institutions.
Infection control nurse, you definitely need one of those. State veterinary service, a representative if it's affecting the local animals or birds or as it may be. Food.
microbiologists or food standards authority if that's been affected, toxicologists, director of public health, water company, and so on. So this is a team that you put together and pick a child of your choosing. Usually they are microbiologists or infection control nurse, pull everybody together, coordinate it, and then make sure every step or decision is minuted and all the duties outlined and delegated and then as a meeting goes, you know, go on because documentation is very important.
So to start with, the investigator should establish a case definition and characterize the cases that have been identified. Because at this point, my turn up, it wasn't an outbreak after all. But you're looking for the clinical signs, symptoms, epidemiological information, related person, place and time.
That's important. And how they are linked. Using the case definition, then as investigators, then search for additional cases. Because you might have picked up a few, but then have others scattered all over the place. though not always the case, you might be able to identify the initial case or where the problem might have all started.
So with that, as already mentioned, documentation is important. In my practice, I'm very visual, so I tend to create tables and pictures and color coordinate things so that we can actually easily see what is happening where. and can actually follow it up. So day one, we have so many cases, say an example of a ward, or if there's an outbreak in the communities, that's where it started.
Index case, and then followed on, and this is where most cases are, and so on and so forth. And then is to identify who the persons are that are involved, the places and locations, and spread, so we have a direction. And then the time involved, if known.
And then, of course, what sort of symptoms we're looking at, because in certain illnesses or outbreaks, things might change. You know, as in how the disease progresses or how the outbreak progresses. And then define the population at risk and then manage them as we go on and so many other factors that might come through. So, and while all that is happening, as I told you, simultaneously, is try and contain it. So with this, I mean, is find the outbreak, the apparent source and the potential threat to the public.
Then institute examples of controls, infection control measures, basics. Do we need any isolation, containing areas, closing off? you know, certain areas quarantined and then provide the necessary personal protection.
Then admission criteria at hospitals, do we designate certain hospitals for to do certain things and we need to, you know, put up containment tents. And then the staffing, the specialists to be concerned, testing labs. you know, to be designated to look at this sort of testing areas and then create incident numbers to be able to identify particular samples and link them back to this particular outbreak to best manage it.
And then travel restrictions, as some of you could have, you know, noticed, you know, all the travel restrictions that we've had in the last 24 months about are very popular COVID pandemic that's been ongoing. And then, of course, testing, labs. The labs should be notified. And then public health, contact tracing. Can we identify cases?
Can people actually identify people that, you know, more than we can do or what might be involved? So it's engaging with the public is important. Then strategic.
management commands so we can have the, you know, gold command, you know, strategic planners, then, you know, the managers in between to try and delegate different jobs and have a more vertical command arrangement so that decisions can be made easily and straightforward and documented so that the process is smooth and without delays and reduces much. red tape as possible. So with my preferred way is command and control so that we know things if decisions are to be made you know at any time of the day it can easily get to the top and everybody has an oversight of what is actually happening.
And then in certain infections or outbreaks you may need prophylaxis so you know the primary care facilitators need to be informed, pharmacies and people sort of pick up prophylactic medications sooner than later before they're actually affected by the outbreak itself. So this can all be ongoing and needs to be well managed. So, you know, anybody, any stakeholder that needs to be informed ought to be informed. So while all this is going on, formulate a hypothesis and then...
test the hypothesis and understand the disease, the pathology, the mode of transmission. and see how it will, you know, the initial hypothesis might not be the final one, but it's a starting point. So then draw out a plan with the better information that you've got. And then as we go along, so as some of you may have noticed, is what it starts like might not be what it goes on to be and how it ends. And we might need to develop, understand the science behind it, develop vaccines if need be, and so on and so forth.
But there's got to be a plan and execute studies in order to inform the management team on what is going on. And then this information should be sent out to the public and all the stakeholders. Now, depending on the available resources, investigators might continue to, this should carry on and including surveillance. So most of the usual sort of studies are cohort study. I won't go into the depth of it all as that, you know, that's another lecture on its own, but we're talking about cohort studies.
So everyone potentially exposed and use of, it's a. your comprehensive list if it's available, and then the relative risks and the attack rates and measure of associations, food outbreaks, weddings, and so on and so forth. Then we could use a case control study.
This is comparison of exposure, mangosteen cases, and controls. It's a useful study if a complete list isn't available or if it's too large. The odds ratio, which is measure of associations again in a restaurant outbreak. At this point also you might want to consult a statistician to help with you know with all the measures and put numbers together and even draw up a model on what the progression of the outbreak might look like. So as all this is going on Once the cause of the outbreak has been identified, investigators should work to implement long-term control measures to bring the outbreak to a close.
These control measures may be extensive, depending on what it looks like or what the measures are like, trimming pools or closures or what the organism might be. Or sometimes it might be a resistant organism. that then we need to look into other better ways of science of managing it, or even emerging organisms. As recently we've seen SARS-CoV-2 and we've had instances of Ebola and so on and so forth.
And furthermore, we've got to document all this, what we've done, the countermeasures in place, carry on with surveillance. and enhance surveillance and in labs and then keep it at the fingertips of the healthcare providers in case anything comes up or we'd have new or imagined variants. So communication is important. As part of the team we already have a communication or press officer They have the skills to do all the PR and the methods of how they do it could be over the internet, the internet, the media, notifying all stakeholders and then the wider public. And then so during the outbreak, so media goes out, people should be informed and to the public and also importantly manage expectations.
And then after the outbreak, have an outbreak report published and disseminated and recommendations made. And I would recommend an after action review. So what did we do well and what did we not do too well? And then so to prepare for the next outbreak, because certainly that won't be the last one. And then media.
ensure that accurate and timely information is relayed and in at the you know in the right forums we also should note that You know, we've got social media all over the place and bits of misinformation, you know, pop up now and again. And because it's instant, it's available to everybody, it can draw a very large, you know, following. And to counter that might be very, very difficult.
So, you know, because. people have different interests for whatever reason might be. So having the right information in a timely manner out into the public is important. And presenting it in such a manner that it's understandable is also important.
To say, this is a situation and this is how we're managing it. So that's important. And mainly... That's how best to manage outbreaks. And these were some of the references.
Most of them can be found on the WHO website and with the Global Public Health, Health Intelligence Network data. And it's going through. And thank you very much for listening.
And that's, I've been Dr. Elijah Metovu, consultant microbiologist and infection control doctor at University of North Midlands, UK. Thank you.