Once the proper authorities have decided that a public health response is needed, then usually an outbreak team will be in charge of the response. The response is often focussed around the 10 steps of an outbreak investigation. For many of those steps, multidisciplinary expertise is required. For example steps 2 and 3 (confirm diagnosis and establish a case definition) often require close collaboration between field epidemiologist and public health microbiologist.
Steps 5 and 6 (determine population at risk and generate hypotheses) may need additional disciplines, depending on the context of the outbreak. For example with a vector borne disease, input from an entomologist may be required, in order to determine the spread of the vector and hence define the population at risk.
All of those different disciplines need to work in harmony, focussed on the same priorities to get through the 10 steps as quickly as possible. In large teams, coordinating the full outbreak response is the role of the outbreak manager. This person may have any of the disciplines as a professional background, with sufficient experience of having worked in many different outbreaks. Once you take the job of the outbreak coordinator, however, you need to be able to 'take some distance from your own discipline' and focus on the management tasks. So whether you are originally an epidemiologist, public health microbiologist, clinician, entomologist or public health decision taker, your job as coordinator is to focus on the process, and to align the work of all involved disciplines.
in smaller outbreaks and usually at the sub-national public health level it could happen that all of those responsibilities are carried by one person. In that case the challenge is to know when to 'switch your hat', for example in one moment you are designing questionnaires and data entry screens, and the other moment you are negotiating with the director of a nursing home to include the kitchen staff in the survey, and an hour later you may be at the ward, taking blood samples from cases, while at the end of the day you explain to the reporter of the local newspaper whether or not there are risks for the visitors of the nursing home.
It is just important to remember that in principle nothing changes in the steps that need to be taken in outbreak response. A main difference between small local outbreaks and large national ones, if the size of the outbreak team, and the need to coordinate and communicate at every level and during every step of the way.
Whether the manager of the outbreak team has a background in epidemiology, microbiology, health science or generic public health, he/she shares one single objective with the whole team:
The specific outbreak investigation objectives may vary according to the context of the outbreak and usually include "identify the source of the outbreak" or "identify the main risk factor for infection". The various disciplines contribute their expertise to achieve those objectives.
The field epidemiologist within the team is in charge of all epidemiological aspects of the investigation (study design, questionnaire, data handling, descriptive analysis, statistical inference) and brings this expertise in the team discussion.
The public health microbiologist is in charge of all microbiological and diagnostic aspects of the investigation (human, veterinarian, food, water, environmental, specimen processing, selection and interpretation of diagnostic tests, biosafety aspects).
In addition, the manager needs to know just enough of each of the disciplines within the team, to allow setting priorities and to decide in situations where specialists in the team cannot reach agreement.
The aim of coordinating an outbreak investigation is to maximize the scientific quality of the investigation in a complex environment. What could be the operational challenges? Well, here are a few:
You will need a structural approach to manage all challenges at one. Consider the following aspects:
You may have specific expertise
They may need more resources
Perhaps they want to share responsibility
There may be political or mass media pressure to invite you as an expert
It may be mandatory or in guidelines
They may need you to confirm local findings
They may expect you to perform specialised investigations
Computer, calculator, mobile phone
Handbooks, relevant articles
Telephone, address list:
reference centers &persons
Others... (money, ”health kit”,)
Provide help - don’t take charge
Meet with key people
Review and update status of problem
Identify local resources and skills
Set up communications with base
Lines of communication
Decision making process
Logistical Aspects of Outbreak Investigations