field investigator response and surveillance trainingfinal category: keys to my heart there are six...

Field Investigator Response Field Investigator Response and Surveillance Trainingand Surveillance Training

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INSERT PICTURE USED ON MANUAL COVER

Course FacilitatorsCourse Facilitators

JylmarieJylmarie Kintz, MPH, CHESKintz, MPH, CHES

Sandra Ruzycki, M.A.Sandra Ruzycki, M.A.

Course DevelopersCourse Developers

The Florida Center for Public Health The Florida Center for Public Health Preparedness (FCPHP)Preparedness (FCPHP)

Hillsborough County Health DepartmentHillsborough County Health Department

Pinellas County Health DepartmentPinellas County Health Department

Members of the Florida Association of Members of the Florida Association of County Health OfficersCounty Health Officers

Course SponsorsCourse Sponsors

FundingFunding

Course AimCourse Aim

To help public health workers To help public health workers develop the knowledge, skills, and develop the knowledge, skills, and abilities needed to assist in disease abilities needed to assist in disease outbreak investigations during times outbreak investigations during times of heightened demand when staff of heightened demand when staff capacity is overburdened.capacity is overburdened.

Course GoalsCourse Goals

To help public health workers develop an increased To help public health workers develop an increased awareness and knowledge of basic epidemiology.awareness and knowledge of basic epidemiology.

To increase the number of public health workers To increase the number of public health workers capable of participating in an outbreak investigation capable of participating in an outbreak investigation during a bioterrorism (BT) event or other public during a bioterrorism (BT) event or other public health threat.health threat.

To improve the capacity of the county health To improve the capacity of the county health department to respond effectively during a BT event department to respond effectively during a BT event or other public health disaster.or other public health disaster.

Course ObjectivesCourse Objectives

Module 1:Module 1: Describe the role of epidemiology in Describe the role of epidemiology in public health.public health.

Module 2:Module 2: Demonstrate appropriate epidemiological Demonstrate appropriate epidemiological interviewing and effective communication interviewing and effective communication skills.skills.

Module 3:Module 3: Participate in an outbreak investigation Participate in an outbreak investigation exercise.exercise.

Training MethodsTraining Methods

Module 1:Module 1: SelfSelf--study, Webstudy, Web--based based

Modules 2 & 3:Modules 2 & 3: InstructorInstructor--led, Onled, On--sitesite•• DidacticDidactic•• RoleRole--playsplays•• Group activitiesGroup activities

Learner Objectives: Module 1Learner Objectives: Module 1

1.1. DefineDefine epidemiologyepidemiology’’s key terms and core s key terms and core concepts.concepts.

2.2. RecognizeRecognize the objectives of epidemiology in the objectives of epidemiology in public health practice and describepublic health practice and describe your role.your role.

3.3. DescribeDescribe how epidemiology is applied in the core how epidemiology is applied in the core processes of public health practice.processes of public health practice.

4.4. DescribeDescribe examples of the use and application of examples of the use and application of epidemiology.epidemiology.

5.5. ApplyApply the basic terms, concepts, and processes the basic terms, concepts, and processes of epidemiology.of epidemiology.


1.1. StateState the purpose of an interview.the purpose of an interview.2.2. DemonstrateDemonstrate the use of effective interviewing the use of effective interviewing

techniques.techniques.3.3. DescribeDescribe the concept of bias and how it the concept of bias and how it

influences interview results.influences interview results.4.4. DescribeDescribe the importance of identifying unusual the importance of identifying unusual

occurrences.occurrences.5.5. DemonstrateDemonstrate appropriate cultural sensitivity, appropriate cultural sensitivity,

confidentiality, and ethics when interviewing.confidentiality, and ethics when interviewing.


1.1. RecognizeRecognize the steps in case investigation and in the steps in case investigation and in identifying exposed contacts.identifying exposed contacts.

2.2. DescribeDescribe how initial cases might be recognized.how initial cases might be recognized.3.3. DemonstrateDemonstrate the ability to interpret fact sheets the ability to interpret fact sheets

and mode of transmission sheets.and mode of transmission sheets.4.4. DescribeDescribe methods of collection and transportation methods of collection and transportation

of human, animal, and environmental samples.of human, animal, and environmental samples.5.5. ApplyApply skills necessary to demonstrate the ability skills necessary to demonstrate the ability

to identify additional cases and determine the to identify additional cases and determine the extent of a disease outbreak.extent of a disease outbreak.

Relevant CoreRelevant Core Competency Domains Competency Domains for Public Health Professionalsfor Public Health Professionals

Core Competency Domain #1:Core Competency Domain #1: Analytic/Assessment SkillsAnalytic/Assessment SkillsCore Competency Domain #3:Core Competency Domain #3: Communication SkillsCommunication SkillsCore Competency Domain #4: Core Competency Domain #4: Cultural Competency SkillsCultural Competency SkillsCore Competency Domain #6:Core Competency Domain #6: Basic Public Health Basic Public Health Science SkillsScience SkillsCore Competency Domain #8: Core Competency Domain #8: Leadership and Systems Leadership and Systems Thinking SkillsThinking Skills

Relevant Bioterrorism and Relevant Bioterrorism and Emergency Readiness CompetenciesEmergency Readiness Competencies

Core Competency 7:Core Competency 7: Identify limits to own Identify limits to own knowledge/skills/authority and identify key system knowledge/skills/authority and identify key system resources for referring matters that exceed these resources for referring matters that exceed these limitslimitsCore Competency 8:Core Competency 8: Recognize unusual events Recognize unusual events that might indicate an emergency and describe that might indicate an emergency and describe appropriate action.appropriate action.Core Competency 9: Core Competency 9: Apply creative problem Apply creative problem solving and flexible thinking to unusual challenges solving and flexible thinking to unusual challenges within his/her functional responsibilities.within his/her functional responsibilities.

Relevant Relevant PublicPublic HealthHealthEssential ServicesEssential Services

E2.E2. Diagnose and investigate health problems Diagnose and investigate health problems and health hazards in the community.and health hazards in the community.

E3. E3. Inform, educate, and empower people Inform, educate, and empower people about health issues.about health issues.

E8. E8. Assure competent public health and Assure competent public health and personal health care workers.personal health care workers.

Continuing Education CreditContinuing Education CreditThis course is approved for continuing education credit This course is approved for continuing education credit (CEC) for physicians, nurses, pharmacists, psychologists, (CEC) for physicians, nurses, pharmacists, psychologists, licensed mental health counselors, social workers, marriage licensed mental health counselors, social workers, marriage and family therapists, and certified health education and family therapists, and certified health education specialists. specialists.

To apply for CECs, you must demonstrate successful To apply for CECs, you must demonstrate successful completion of all course requirements, as evidenced by completion of all course requirements, as evidenced by receiving a Certificate of Course Participation. receiving a Certificate of Course Participation.

CEC registration instructions will be provided to you at the CEC registration instructions will be provided to you at the end of the course.end of the course.

Course AgendaCourse Agenda8:15 am Welcome and Course Overview8:15 am Welcome and Course Overview8:30 am Module 1 Review: The Role of Epidemiology in 8:30 am Module 1 Review: The Role of Epidemiology in

Public HealthPublic Health9:30 am Break9:30 am Break9:45 am Module 2: Interviewing and Communication 9:45 am Module 2: Interviewing and Communication

SkillsSkills12:30 pm Lunch (Provided on12:30 pm Lunch (Provided on--site)site)1:30 pm Module 3: Outbreak Investigations1:30 pm Module 3: Outbreak Investigations2:30 pm Break2:30 pm Break2:45 pm Module 3: Outbreak Investigations (continued)2:45 pm Module 3: Outbreak Investigations (continued)4:45 pm Wrap4:45 pm Wrap--Up / Closing CommentsUp / Closing Comments5:00 pm Adjourn5:00 pm Adjourn

Navigating the Course ManualNavigating the Course Manual

Overview

Module 1

Module 1: ReviewModule 1: Review

The Role of Epidemiology The Role of Epidemiology in Public Healthin Public Health PracticePractice

Group activity Group activity Time: 50 minutesTime: 50 minutesModification of the TV game Modification of the TV game ““Jeopardy.Jeopardy.””The answers on the The answers on the ““JJEPIEPIrdyrdy”” game board game board represent terms and concepts from Module 1. represent terms and concepts from Module 1.

Refer to Refer to page 17page 17 in your course manual forin your course manual fordetailed instructions.detailed instructions.

Exercise 1: JExercise 1: JEPIEPIRDYRDY

1.1. As a team, answer the questions in each category.As a team, answer the questions in each category.

2.2. Use your manual to assist you.Use your manual to assist you.

3.3. Write your answer in the form of a question on Write your answer in the form of a question on your teamyour team’’s posts post--it note.it note.

4.4. Post your teamPost your team’’s answers in the appropriate s answers in the appropriate places on the places on the JJEPIEPIRDYRDY boards.boards.

5.5. The team with the most The team with the most ““pointspoints”” wins.wins.

Exercise 1: JExercise 1: JEPIEPIRDYRDY

Final Category:Final Category: Keys to My HeartKeys to My Heart

Instructions:Instructions: As a team, determine how many As a team, determine how many points you will points you will ““wagerwager”” on your final answer. Put on your final answer. Put those points on the back of a postthose points on the back of a post--it note and it note and post on the flippost on the flip--chart next to your teamchart next to your team’’s total s total points.points.

Final JFinal JEPIEPIRDYRDY


Final Category: Keys to My HeartFinal Category: Keys to My Heart

There are six key words within the definition of There are six key words within the definition of epidemiology which lend themselves to better epidemiology which lend themselves to better understanding of the field of epidemiology. understanding of the field of epidemiology. Please name three of 6 components.Please name three of 6 components.


What is a What is a studystudy??What is a What is a distributiondistribution??What are What are determinantsdeterminants??What are What are healthhealth--related related statesstates??What are What are populationspopulations??What is What is controlcontrol??

There are six key words There are six key words within the definition of within the definition of epidemiology which lend epidemiology which lend themselves to better themselves to better understanding of the field of understanding of the field of epidemiology. epidemiology.

Please name three of 6 Please name three of 6 components.components.

Module 1: SummaryModule 1: SummaryIn this Module you learned to:In this Module you learned to:

Define epidemiologyDefine epidemiology’’s key terms and core concepts.s key terms and core concepts.Recognize the objectives of epidemiology in public Recognize the objectives of epidemiology in public health practice and describe your role.health practice and describe your role.Describe how epidemiology is applied in the core Describe how epidemiology is applied in the core processes public health practice.processes public health practice.Describe examples of the use and application of Describe examples of the use and application of epidemiology.epidemiology.Apply the basic terms, concepts, and processes of Apply the basic terms, concepts, and processes of epidemiology.epidemiology.

Module 2Module 2

Interviewing and Interviewing and Communication SkillsCommunication Skills

Course Objective: Module 2Course Objective: Module 2Demonstrate appropriate epidemiological Demonstrate appropriate epidemiological

interviewing and effective communication skills.interviewing and effective communication skills.

Learning Objectives: Module 2Learning Objectives: Module 21.1. StateState the purpose of an interview.the purpose of an interview.2.2. Demonstrate Demonstrate the use of effective the use of effective

interviewing techniques.interviewing techniques.3.3. DescribeDescribe the concept of bias and how it the concept of bias and how it

influences interview results.influences interview results.4.4. DescribeDescribe the importance of identifying the importance of identifying

unusual occurrences.unusual occurrences.5.5. DemonstrateDemonstrate appropriate cultural sensitivity, appropriate cultural sensitivity,

confidentiality, and ethics when interviewing.confidentiality, and ethics when interviewing.

What is the purpose of What is the purpose of an interview?an interview?

The purpose of anThe purpose of anepidemiological interviewepidemiological interviewis to elicit exposureis to elicit exposureinformation from theinformation from theperson being interviewedperson being interviewedwithout bias. without bias.

Effective Interviewing Effective Interviewing TechniquesTechniques

Keys to Effective InterviewingKeys to Effective Interviewing

CommunicationCommunication is the key to effective interviewing. is the key to effective interviewing.

Two kinds of communication:Two kinds of communication:

NonverbalNonverbal

VerbalVerbal

Nonverbal CommunicationNonverbal CommunicationDefinition.Definition.

Any communication that is not verbal or spoken. Any communication that is not verbal or spoken.

Eye contactEye contact

Facial expressionsFacial expressions

PosturePosture

Personal space and distancePersonal space and distance

Nonverbal Communication is . . .Nonverbal Communication is . . .Eye ContactEye ContactIt is important to maintain eyeIt is important to maintain eyecontact when communicatingcontact when communicatingwith interviewees.with interviewees.

Key Elements:Key Elements:Look at someone when you ask a question Look at someone when you ask a question –– it is it is invitation for them to speak.invitation for them to speak.Avoid eye contact when you do not want to be Avoid eye contact when you do not want to be interrupted. interrupted. Eye contact over 3 seconds without verbal Eye contact over 3 seconds without verbal communication is considered staring.communication is considered staring.

Nonverbal Communication is . . .Nonverbal Communication is . . .Facial ExpressionsFacial ExpressionsA skilled interviewer will also be mindful A skilled interviewer will also be mindful of the facial expressions they display.of the facial expressions they display.

Key Elements:Key Elements:

Adopt a Adopt a ““neutralneutral”” or nonor non--judgmental judgmental expression when listening to emotional expression when listening to emotional statements.statements.Do not express surprise, shock, disdain, Do not express surprise, shock, disdain, disapproval, or disagreement.disapproval, or disagreement.

Avoid exaggerated facial expressions.Avoid exaggerated facial expressions.

Nonverbal Communication is . . .Nonverbal Communication is . . .

PosturePosture

It is important that the It is important that the interviewer maintain interviewer maintain an an ““interestedinterested”” or open or open posture during the posture during the interview process.interview process.

Nonverbal Communication is . . .Nonverbal Communication is . . .PosturePosture (continued)(continued)

Key Elements:Key Elements:Orient your body towards the interviewee.Orient your body towards the interviewee.Do not cross your arms or legs.Do not cross your arms or legs.Lean slightly forward to appear Lean slightly forward to appear ““interestedinterested”” and and elicit information.elicit information.Avoid placing clipboards, papers, books, bags, Avoid placing clipboards, papers, books, bags, etc. between yourself and the interviewee.etc. between yourself and the interviewee.Maintain a sitting or standing position that is Maintain a sitting or standing position that is not higher or lower than the interviewee. not higher or lower than the interviewee.

Nonverbal Communication is . . .Nonverbal Communication is . . .

Personal Space and DistancePersonal Space and DistanceThe physical distance between the interviewer and The physical distance between the interviewer and interviewee strongly influences the communication, interviewee strongly influences the communication, and is cultureand is culture-- and genderand gender--specific.specific.

Key Elements:Key Elements:

18 inches to 4 feet is considered most effective 18 inches to 4 feet is considered most effective across cultures and gender. across cultures and gender.

Touching such as pats on the back, arm, or leg Touching such as pats on the back, arm, or leg can can ““violateviolate”” culture and gender barriers.culture and gender barriers.

Instructions:Instructions: You will be paired with a partner You will be paired with a partner and provided the opportunity to practice and provided the opportunity to practice ““closedclosed”” nonverbal communication and nonverbal communication and ““openopen””nonverbal communication. During each nonverbal communication. During each practice, remember how you feel and the ease practice, remember how you feel and the ease at which you were able to communicate.at which you were able to communicate.

Please refer to Please refer to page 22 page 22 in your course in your course manual.manual.

Exercise 1: Communication Skills PracticeExercise 1: Communication Skills Practice

Communication Skills PracticeCommunication Skills PracticeClosed Nonverbal Communication PracticeClosed Nonverbal Communication Practice

Eye Contact:Eye Contact: Avoid eye contact completely or Avoid eye contact completely or ““starestare”” at at your partner.your partner.

Facial Expressions:Facial Expressions: Adopt a Adopt a ““stonestone”” face or overface or over--exaggerate your facial expressions.exaggerate your facial expressions.

Posture:Posture: Turn your body away from your partner, cross Turn your body away from your partner, cross your arms and legs, put objects between you and your your arms and legs, put objects between you and your partner, lean back, and sit or stand higher than your partner, lean back, and sit or stand higher than your partner.partner.

Personal Space and Distance:Personal Space and Distance: Sit or stand either too Sit or stand either too close or far.close or far.

Communication Skills PracticeCommunication Skills PracticeOpen Nonverbal Communication PracticeOpen Nonverbal Communication PracticeEye Contact:Eye Contact: Use the 60/40 rule Use the 60/40 rule –– establish eye contact establish eye contact with your partner 60% of the time. with your partner 60% of the time.

Facial Expressions:Facial Expressions: Use a Use a ““neutralneutral”” facial expression facial expression or mirror your partneror mirror your partner’’s expressions.s expressions.

Posture:Posture: Orient your body towards your partner, do not Orient your body towards your partner, do not cross your arms and legs, remove objects from between cross your arms and legs, remove objects from between you and your partner, lean slightly forward, and sit or stand you and your partner, lean slightly forward, and sit or stand at the same level as your partner.at the same level as your partner.

Personal Space and Distance:Personal Space and Distance: Sit or stand 18 inches to 4 Sit or stand 18 inches to 4 feet away from your partner.feet away from your partner.

Verbal CommunicationVerbal Communication

Definition.Definition.

The content or The content or whatwhat is said, as well as your voice is said, as well as your voice or or howhow it is said. It communicates feelings and it is said. It communicates feelings and attitudes.attitudes.

A. Content or “what is said.”B. Voice or “how it is said.”

Verbal Communication is . . .Verbal Communication is . . .

Content or Content or ““What is saidWhat is said””

The way the content is The way the content is conveyed impacts whatconveyed impacts whatthe interviewee will hear.the interviewee will hear.

Content is Content is moremore than the than the actual words.actual words.

Key Elements of Content or Key Elements of Content or ““What is saidWhat is said””

Brevity:Brevity: Communications should be short, Communications should be short, simple, and to the point.simple, and to the point.

Organization:Organization: Communication content should Communication content should be well organized in a sequential manner. The be well organized in a sequential manner. The interview will have a interview will have a ““structurestructure”” to it (introduction, to it (introduction, body, and conclusion). body, and conclusion).

Organization of an InterviewOrganization of an InterviewIntroduction: Introduction:

Your name, title, and organizationYour name, title, and organizationPurpose of the interviewPurpose of the interviewHow information from the interview will be How information from the interview will be usedusedConfidentiality of informationConfidentiality of informationW.I.I.F.M.W.I.I.F.M.Explain you will be taking notesExplain you will be taking notes

Organization of an Interview (continued)Organization of an Interview (continued)

Body:Body:Interview scheduleInterview scheduleRepeat any of the introduction Repeat any of the introduction elements as often as necessary during elements as often as necessary during the interviewthe interview

Organization of an Interview (continued)Organization of an Interview (continued)

Conclusion:Conclusion:Your name, title, and organizationYour name, title, and organizationPurpose of the interviewPurpose of the interviewHow information from the interview will How information from the interview will be used be used Confidentiality of informationConfidentiality of informationW.I.I.F.M.W.I.I.F.M.Possible followPossible follow--up interviewup interview

Key Elements of Content or Key Elements of Content or ““What is saidWhat is said””

Comprehension:Comprehension: The comprehension level The comprehension level must be adjusted for the specific interviewee. must be adjusted for the specific interviewee. Avoid the use of jargon and acronyms.Avoid the use of jargon and acronyms.

Repetition:Repetition: During the interview process, it may During the interview process, it may be necessary to repeat questions or information. be necessary to repeat questions or information.

Verbal Communication is . . .Verbal Communication is . . .Voice or Voice or ““How it is saidHow it is said””

The voice communicates inThe voice communicates inways that have nothing toways that have nothing todo with the actual wordsdo with the actual wordsthat are being said.that are being said.

Key Elements of Voice or Key Elements of Voice or ““How It is SaidHow It is Said””

Tone of Voice:Tone of Voice: A skilled interviewer will be A skilled interviewer will be mindful of their vocal tone (not being mindful of their vocal tone (not being judgmental or condescending).judgmental or condescending).

Volume:Volume: The loudness or softness of speech The loudness or softness of speech will be adjusted based on the needs of the will be adjusted based on the needs of the specific interviewee and the environmental specific interviewee and the environmental conditions.conditions.

Key Elements of Voice or Key Elements of Voice or ““How It is SaidHow It is Said””

Speed:Speed: Speech should be paced in a manner Speech should be paced in a manner so it is clear and can be understood by the so it is clear and can be understood by the specific interviewee.specific interviewee.

Inflection:Inflection: Emphasis should be given to Emphasis should be given to certain key words or phrases to ensure certain key words or phrases to ensure understanding and understanding and notnot change the meaning of change the meaning of a statement.a statement.

Interviewing TechniquesInterviewing Techniques

1.1. Ask OpenAsk Open--Ended Questions.Ended Questions.

2. Use Probing.2. Use Probing.

Interviewing TechniquesInterviewing Techniques

1.1. Ask OpenAsk Open--Ended Questions.Ended Questions.Questions that require more than a single wordQuestions that require more than a single wordanswer to encourage conversation answer to encourage conversation (Source: FDOH, (Source: FDOH, 2004).2004).

Move beyond simple Move beyond simple ““YesYes”” or or ““NoNo”” responses.responses.Allow the interviewee to provide more detailed Allow the interviewee to provide more detailed answers.answers.Give the perception there is no Give the perception there is no ““rightright”” or or ““wrongwrong”” answer. answer.

Types of QuestionsTypes of QuestionsOpenOpen--Ended QuestionsEnded Questions

““What brings you to the What brings you to the clinic today?clinic today?””

““What kinds of meats have What kinds of meats have you recently eaten?you recently eaten?””

““What symptoms are What symptoms are members of your family members of your family experiencing?experiencing?””

““What symptoms do you What symptoms do you have?have?””

ClosedClosed--Ended QuestionsEnded Questions

““Are you here for a flu shot Are you here for a flu shot today?today?””

““You havenYou haven’’t eaten any t eaten any uncooked meat, have you?uncooked meat, have you?””

““No one else in your family No one else in your family is sick, are they?is sick, are they?””

““Do you have a headache?Do you have a headache?””

Sample OpenSample Open--Ended QuestionsEnded Questions

““Tell me about. . .Tell me about. . .””

““Start at the beginning and tell me about. . .Start at the beginning and tell me about. . .””

““What specifically is going on?What specifically is going on?””

““Could you describe how you are feeling?Could you describe how you are feeling?””

““What changes in your health have you noticed?What changes in your health have you noticed?””

InterviewingInterviewing TechniquesTechniques

2.2. Use Probing.Use Probing.A A ““neutral way of searching for a suitable answerneutral way of searching for a suitable answer””((AschengrauAschengrau & Seage, 2003)& Seage, 2003). .

Probing is useful when the intervieweeProbing is useful when the interviewee’’s answer s answer is not clear, or when the interviewee has not is not clear, or when the interviewee has not understood the question. understood the question.

Probing is important because it allows the Probing is important because it allows the interviewer to obtain more information without interviewer to obtain more information without influencing the response.influencing the response.

Probing QuestionsProbing Questions

Do not place blame on anyone.Do not place blame on anyone.

Allow for multiple responses.Allow for multiple responses.

Avoid Avoid ““yesyes”” or or ““nono”” responses.responses.

Are usually brief, but elicit a long Are usually brief, but elicit a long response.response.

Probing TechniquesProbing Techniques

Elaborate:Elaborate: ““Tell me a little more about that,Tell me a little more about that,””or or ““you started to say something about _____, you started to say something about _____, is there anything else?is there anything else?””

Exemplify:Exemplify: ““Can you give me an example of Can you give me an example of that?that?””

Explain: Explain: ““I am not sure if I got all of that, can I am not sure if I got all of that, can you explain it one more time?you explain it one more time?””

Specify:Specify: When a respondent says something When a respondent says something that requires more information. that requires more information.

Restate:Restate: Repeat part or all of the intervieweeRepeat part or all of the interviewee’’s s response in such a way to encourage response in such a way to encourage elaboration or explanation. It allows people to elaboration or explanation. It allows people to clarify their ideas and listen to what they just clarify their ideas and listen to what they just said in a way that is nonsaid in a way that is non--evaluative.evaluative.

Probing TechniquesProbing Techniques (continued)(continued)

Instructions:Instructions:You will be paired with a partner. Please identify who willYou will be paired with a partner. Please identify who willassume the role of assume the role of ““InterviewerInterviewer”” and who will be theand who will be the““Interviewee.Interviewee.””

Your goal as the Your goal as the ““InterviewerInterviewer”” is to is to Ask OpenAsk Open--endedendedQuestionsQuestions. .

Your task as the Your task as the ““IntervieweeInterviewee”” is to reward the Intervieweris to reward the Interviewerwhen they ask Openwhen they ask Open--ended Questions by responding to the ended Questions by responding to the question. If the Interviewer asks a Closequestion. If the Interviewer asks a Close--ended Question, ended Question, DO NOT RESPOND. DO NOT RESPOND.

Please refer to Please refer to page 26 page 26 in your course manual.in your course manual.

Exercise 2: Interview Skills PracticeExercise 2: Interview Skills Practice

Case: MeningitisCase: Meningitis

InterviewerInterviewer:: The patient is a college freshman living in The patient is a college freshman living in the dorm of a renowned University. The student was the dorm of a renowned University. The student was taken to a hospital earlier in the day with symptoms of taken to a hospital earlier in the day with symptoms of meningitis. As the bacterial form of this disease has the meningitis. As the bacterial form of this disease has the potential of being very contagious, University authorities potential of being very contagious, University authorities have sought help from the health department.have sought help from the health department.

IntervieweeInterviewee:: You are a freshman college student and You are a freshman college student and are feeling VERY bad. You have symptoms of: sudden are feeling VERY bad. You have symptoms of: sudden headache, fever, a stiff neck, nausea and vomiting. You headache, fever, a stiff neck, nausea and vomiting. You are also experiencing a bit of confusion and your eyes are also experiencing a bit of confusion and your eyes are quite sensitive to the lights.are quite sensitive to the lights.

Exercise 2: Interview Skills PracticeExercise 2: Interview Skills Practice

Instructions:Instructions:You and your partner will now switch roles. The You and your partner will now switch roles. The ““InterviewerInterviewer””will become the will become the ““Interviewee.Interviewee.”” The The ““IntervieweeInterviewee”” will becomewill becomethe the ““Interviewer.Interviewer.””

Your goal as the Your goal as the ““InterviewerInterviewer”” is to is to Use ProbingUse Probing. .

Your task as the Your task as the ““IntervieweeInterviewee”” is to reward the Intervieweris to reward the Interviewerwhen they probing effectively by responding to the question. when they probing effectively by responding to the question. If the Interviewer does not probe well, respond with a If the Interviewer does not probe well, respond with a ““Yes,Yes,””““NoNo”” or other succinct and brief response.or other succinct and brief response.

Please refer to Please refer to page 26page 26 in your course manual.in your course manual.

Exercise 2: Probing Skills PracticeExercise 2: Probing Skills Practice

Case: MeningococcemiaCase: Meningococcemia

InterviewerInterviewer:: The patient is a teacher at a local The patient is a teacher at a local elementary school. The teacher was taken to a hospital elementary school. The teacher was taken to a hospital earlier in the day with symptoms of meningococcemia, a earlier in the day with symptoms of meningococcemia, a contagious blood infection disease that can lead to contagious blood infection disease that can lead to kidney and heart failure and also result in severe kidney and heart failure and also result in severe disability or death. School authorities have sought help disability or death. School authorities have sought help from the health department.from the health department.

IntervieweeInterviewee:: You are a teacher at a local elementary You are a teacher at a local elementary school and are feeling VERY bad. You have symptoms school and are feeling VERY bad. You have symptoms of fever, severe headache, stiff neck, rash, nausea, of fever, severe headache, stiff neck, rash, nausea, vomiting, and lethargy.vomiting, and lethargy.

Exercise 2: Probing Skills PracticeExercise 2: Probing Skills Practice

The concepts of bias and how it The concepts of bias and how it influences interview resultsinfluences interview results

Interview BiasInterview Bias

Definition.Definition.

The difference that occurs from The difference that occurs from one interview to another in one interview to another in soliciting, recording, or soliciting, recording, or interpreting information during interpreting information during faceface--toto--face or telephone face or telephone interviews.interviews.

Interview BiasInterview BiasInterviews are subjectiveInterviews are subjective, no matter how many , no matter how many objective questions are introduced or how objective questions are introduced or how hard the interviewer attempts to maintain hard the interviewer attempts to maintain objectivity.objectivity.Interviewers are humanInterviewers are human, and all carry with them , and all carry with them some assumptions about different types of some assumptions about different types of people.people.Interviewers should try to Interviewers should try to conduct each interview conduct each interview the samethe same while working to minimize the effects while working to minimize the effects of interview bias.of interview bias.

Interview bias comes from . . .Interview bias comes from . . .

There are two commonThere are two commontypes of interview bias:types of interview bias:

EnvironmentEnvironment

Past experiencesPast experiences

The EnvironmentThe Environment

The physical setting The physical setting where the interview where the interview occurs can impact the occurs can impact the success of the interview.success of the interview.

Interview bias comes from . . .Interview bias comes from . . .

Key Elements of the EnvironmentKey Elements of the Environment

TimeTime

DistractionsDistractions

Physical ArrangementPhysical Arrangement

Key Elements of the EnvironmentKey Elements of the Environment

Time:Time: Consider the Consider the amount of time required to amount of time required to effectively gather the effectively gather the information needed, as well information needed, as well as, the time of day.as, the time of day.

Distractions:Distractions: Noise, Noise, lighting, temperature, lighting, temperature, furniture, etc. all influence furniture, etc. all influence the interview.the interview.

Key Elements of the EnvironmentKey Elements of the EnvironmentPhysical Arrangement:Physical Arrangement:The arrangement of desk and The arrangement of desk and chairs can impact perceptions chairs can impact perceptions of power and dominance. of power and dominance.

•• Sitting sideSitting side--byby--side or at the side or at the corners of a desk communicate corners of a desk communicate a more a more ““equalequal”” power level. power level.

•• Avoid sitting directly across a desk or table from the Avoid sitting directly across a desk or table from the interviewee.interviewee.

Interview bias comes from . . .Interview bias comes from . . .Past ExperiencesPast Experiences

The The intervieweeinterviewee’’s past experiencess past experiences in both interviewin both interviewsituations and with medical staff impacts how well theysituations and with medical staff impacts how well theymay listen or respond. may listen or respond.

Be aware that some Be aware that some resistance or lack of resistance or lack of responsiveness by the responsiveness by the interviewee may be due interviewee may be due to their past experience.to their past experience.

The interview is influenced by . . .The interview is influenced by . . .

Past ExperiencesPast Experiences

The The interviewerinterviewer’’s past experiencess past experiencescan influence the verbal andcan influence the verbal andnonverbal components of thenonverbal components of theepidemiological interview.epidemiological interview.

Key Elements of the Key Elements of the InterviewerInterviewer’’s Experiencess Experiences

StereotypingStereotyping

First impressionsFirst impressions

Interviewee Interviewee ““noisenoise””

Nonverbal biasNonverbal bias


Avoid stereotyping.Avoid stereotyping. Be conscious of your Be conscious of your opinions about how people of a given gender, opinions about how people of a given gender, religion, race, appearance think, act, or religion, race, appearance think, act, or respond.respond.Strategy:Strategy: Minimize the Minimize the influence your opinions and influence your opinions and personal beliefs may have on personal beliefs may have on the interview by focusing on the the interview by focusing on the interview sheet and the need for interview sheet and the need for information.information.


First impressions.First impressions. It is only natural that first It is only natural that first impressions influence our communication with impressions influence our communication with others. Avoid making a snap judgment, whether others. Avoid making a snap judgment, whether positive or negative, based on a first impression. positive or negative, based on a first impression.

Strategy:Strategy: Minimize the Minimize the influence of first impressions by influence of first impressions by focusing on maintaining an focusing on maintaining an open body posture. Avoid open body posture. Avoid standing or sitting higher than standing or sitting higher than the interviewee.the interviewee.


Interview noise.Interview noise. Some interviewees want to Some interviewees want to appear favorable or positive during the interview. appear favorable or positive during the interview. They may present information in a way that casts They may present information in a way that casts them in a favorable light and/or say things they think them in a favorable light and/or say things they think the interviewer wants to hear.the interviewer wants to hear.

Strategy:Strategy: Be sure to ask for Be sure to ask for examples or specifics. Being examples or specifics. Being nonnon--judgmental in your judgmental in your expressions and responses expressions and responses can help minimize this. can help minimize this.


Nonverbal bias. Nonverbal bias. Undue emphasis might be Undue emphasis might be placed on interviewee nonverbal cues that have placed on interviewee nonverbal cues that have nothing to do with the interview (such as loudness nothing to do with the interview (such as loudness or softness of voice, or the type of handshake or softness of voice, or the type of handshake given).given).

Strategy:Strategy: Try to be aware of Try to be aware of your body language and your body language and nonverbal cues. Make sure nonverbal cues. Make sure your nonverbal communication your nonverbal communication is as neutral as possible.is as neutral as possible.

Communication Techniques Communication Techniques to Minimize Biasto Minimize Bias

Listen actively.Listen actively.Maintain eye contact, orient your body posture Maintain eye contact, orient your body posture towards the person, lean forward slightly, and nod towards the person, lean forward slightly, and nod your head or provide verbal cues that you are your head or provide verbal cues that you are listening (example: listening (example: ““Uh, huh;Uh, huh;”” ““Yes, I seeYes, I see””).).

Probe for more information.Probe for more information.When answers are vague or incomplete, use the When answers are vague or incomplete, use the probing techniques described earlier.probing techniques described earlier.


Repeat questions.Repeat questions.Sometimes people can not hear well or do not hear Sometimes people can not hear well or do not hear the question the first time it is asked. Repeat the the question the first time it is asked. Repeat the question when someone provides incomplete or question when someone provides incomplete or ““offoff--targettarget”” answers.answers.

Paraphrase.Paraphrase.Restate the answer in different words and check forRestate the answer in different words and check forunderstanding. Paraphrasing invites the person to understanding. Paraphrasing invites the person to clarify and elaborate on a previous answer.clarify and elaborate on a previous answer.


Use silence.Use silence.Sometimes not talking is Sometimes not talking is the best way to get the best way to get information or clarification. information or clarification. A pause of up to ten A pause of up to ten seconds invites the seconds invites the interviewee to continue interviewee to continue talking. Use silence with talking. Use silence with intermittent eye contact as intermittent eye contact as appropriate. appropriate.

The importance of identifying The importance of identifying unusual occurrencesunusual occurrences

Listen and Look for Listen and Look for Unusual OccurrencesUnusual Occurrences

Key Elements:Key Elements:Be ALERT!Be ALERT!Read over fact sheets so Read over fact sheets so you'll be aware of modes of you'll be aware of modes of transmission. transmission.

Example:Example: If you are investigating encephalitis, it is If you are investigating encephalitis, it is important to know the disease can be transmitted by important to know the disease can be transmitted by mosquitoes, and standing bodies of water contribute to the mosquitoes, and standing bodies of water contribute to the breeding of mosquitoes.breeding of mosquitoes.

Strategies for Listening and Strategies for Listening and Looking for Unusual OccurrencesLooking for Unusual Occurrences

1. Face1. Face--toto--face cluesface clues

2. Environment clues2. Environment clues

3. People clues3. People clues


1. 1. FaceFace--toto--face clues. face clues. Look at the person you are Look at the person you are interviewing, what clues do you see? interviewing, what clues do you see? •• Many clues about the disease being investigated Many clues about the disease being investigated

can be observed from a facecan be observed from a face--toto--face interview. face interview. •• A person being interviewed may say they have A person being interviewed may say they have

good handgood hand--washing habits, but during a facewashing habits, but during a face--toto--face face interview you may observe that the person being interview you may observe that the person being interviewed has dirt under their fingernails. interviewed has dirt under their fingernails.

•• Observations such as this are prime examples of Observations such as this are prime examples of unusual information revealed during the interview unusual information revealed during the interview that needs to be noted. that needs to be noted.


2.2. Environmental clues.Environmental clues.Be sure to consider all environment clues.Be sure to consider all environment clues.

Water resources.Water resources. From where does From where does the water supply originate?the water supply originate?Food resources.Food resources. How is food stored? How is food stored? Animal resources.Animal resources. What types of What types of animals are living in proximity? animals are living in proximity? Exposures.Exposures. What is the intervieweeWhat is the interviewee’’s s occupation?occupation?


3.3. People clues.People clues.Be sure to consider what interactions the personBe sure to consider what interactions the personbeing interviewed has had. being interviewed has had.

Have they traveled Have they traveled recently? recently? Are there any pieces Are there any pieces of information they of information they give that are contradictory?give that are contradictory?

Cultural Sensitivity, Cultural Sensitivity, Confidentiality, and Ethics when Confidentiality, and Ethics when

interviewinginterviewing

Cultural Sensitivity, Confidentiality, Cultural Sensitivity, Confidentiality, and Ethics When Interviewingand Ethics When Interviewing

The Council on LinkagesThe Council on Linkagesbetween Academia andbetween Academia andPublic Health PracticePublic Health Practicedeveloped a list of coredeveloped a list of corecompetencies forcompetencies forpublic health professionals.public health professionals.Among these are Among these are CulturalCulturalSensitivitySensitivity and and CulturalCulturalCompetencyCompetency. .

Cultural CompetencyCultural CompetencyIn order to interview effectively, it is important toIn order to interview effectively, it is important topractice practice cultural competencecultural competence by respondingby respondingspecifically and sensitively to various cultural and specifically and sensitively to various cultural and diverse groups. diverse groups.

Cultural Competency Quick TipsCultural Competency Quick Tips

Slow down.Slow down.When we speak quickly, we When we speak quickly, we often don't produce all the often don't produce all the sounds that help a listener sounds that help a listener identify a word. identify a word.

Pay attention to your voice.Pay attention to your voice.Avoid a monotone pattern, Avoid a monotone pattern, and remember that louder and remember that louder does not help.does not help.


Less is better.Less is better.Choose short words and Choose short words and use short sentences.use short sentences.

Rephrase and restate.Rephrase and restate.If one way of saying If one way of saying something is not being something is not being understood, try using understood, try using different words.different words.


When in doubt, write it out.When in doubt, write it out.Some people understand written Some people understand written instructions, information, and/or instructions, information, and/or questions better than spoken questions better than spoken ones.ones.

Draw a picture.Draw a picture.A picture is often worth a million A picture is often worth a million words. words.


Avoid acronyms and jargon.Avoid acronyms and jargon.Use the most common words Use the most common words with most common meanings. with most common meanings.

Repeat and summarize.Repeat and summarize.If a question is critical or If a question is critical or information is vital, repeat it at information is vital, repeat it at least 3 times during the course least 3 times during the course of the interview. Summarize of the interview. Summarize often to assure understanding.often to assure understanding.


Get help.Get help.When necessary, call When necessary, call someone else to help. someone else to help.

Check the message.Check the message.ALWAYS have the ALWAYS have the listener relistener re--tell the tell the complete message to complete message to check for accurate check for accurate understanding. understanding.

Ensuring ConfidentialityEnsuring Confidentiality

Surveys and interviews can be intrusive even when Surveys and interviews can be intrusive even when conducted for public health safety. conducted for public health safety.

Questions about attitudes, beliefs, interests, Questions about attitudes, beliefs, interests, values, behaviors and background data can be values, behaviors and background data can be seen as personal and possibly controversial.seen as personal and possibly controversial.

Survey and interview professionals must protect Survey and interview professionals must protect each participanteach participant’’s wells well--being to prevent harm and being to prevent harm and to get accurate information.to get accurate information.

Ensuring ConfidentialityEnsuring Confidentiality

HIPAA:HIPAA: The Health Insurance Portability andThe Health Insurance Portability andAccountability Act of 1996 (HIPAA) was signed into law onAccountability Act of 1996 (HIPAA) was signed into law onAugust 21, 1996. August 21, 1996.

The regulations protect medical records and other The regulations protect medical records and other individually identifiable health information, whether it is individually identifiable health information, whether it is on paper, in computers or communicated orally on paper, in computers or communicated orally (United (United States Department of Health and Human Resources, 2003, States Department of Health and Human Resources, 2003, http://www.hhs.gov/news/facts/privacy.htmlhttp://www.hhs.gov/news/facts/privacy.html).).

Ensuring ConfidentialityEnsuring ConfidentialityInterviewerInterviewer’’s Responsibility.s Responsibility.The interviewer has an affirmative responsibility not toThe interviewer has an affirmative responsibility not todiscuss or disclose any information relating to thediscuss or disclose any information relating to theinterview to persons or parties who are not authorizedinterview to persons or parties who are not authorizedto be privy to such information. to be privy to such information.

During the InterviewDuring the Interview -- Tell the interviewee thatTell the interviewee thatinformation exchanged during the interview will be treatedinformation exchanged during the interview will be treatedwith respect, and that standards of confidentiality will bewith respect, and that standards of confidentiality will bemaintained.maintained.

Ensuring Interview EthicsEnsuring Interview Ethics

The ethical principles which guide data gathering areThe ethical principles which guide data gathering arerooted in two inalienable human rights: free speech androoted in two inalienable human rights: free speech andprivacy. privacy.

Interview participants have the right to: Interview participants have the right to: •• Speak freely, without constraint, even if others may not Speak freely, without constraint, even if others may not

like what they say; andlike what they say; and•• Remain silent, or if they speak, to set limits on the Remain silent, or if they speak, to set limits on the

personal information they divulge, and have what they personal information they divulge, and have what they say as individuals remain confidential (unless they say as individuals remain confidential (unless they consent to disclosure).consent to disclosure).

Instructions:Instructions: You will be put into teams of 2, with each person taking a You will be put into teams of 2, with each person taking a turn as turn as InterviewerInterviewer and and IntervieweeInterviewee. You will be assigned a different role . You will be assigned a different role for each interview scenario, and provided information specific tfor each interview scenario, and provided information specific to your role. o your role.

Your goal as the Your goal as the InterviewerInterviewer is to put into practice all the skills is to put into practice all the skills discussed in this module discussed in this module –– Nonverbal communication, Verbal Nonverbal communication, Verbal communication, Other Communication Factors (Environmental, communication, Other Communication Factors (Environmental, Interviewer Experiences, Cultural), Ask OpenInterviewer Experiences, Cultural), Ask Open-- Ended Questions, Ended Questions, and Use Probing.and Use Probing.

Your goal as the Your goal as the IntervieweeInterviewee is to reward the Interviewer when is to reward the Interviewer when they demonstrate communication competence across all skillsthey demonstrate communication competence across all skills. At . At the end of the interview experience, you will be asked to pthe end of the interview experience, you will be asked to provide rovide the Interviewer with feedback.the Interviewer with feedback.

Please refer to Please refer to page 34 page 34 in your course manual.in your course manual.

Exercise 3: Exercise 3: Pulling it All TogetherPulling it All Together-- Skills PracticeSkills Practice

Pulling it All Together Skill PracticePulling it All Together Skill Practice

Case #1: Disease Case #1: Disease –– Rash IllnessRash Illness

General InformationGeneral Information:: A person comes to the health A person comes to the health department with a rash on their chest, face, and hands.department with a rash on their chest, face, and hands.

RolesRoles:: Please refer to your Please refer to your specific information sheets.specific information sheets.

•• Interviewer Interviewer –– pages 36pages 36--3838•• Interviewee Interviewee –– page 39page 39

Pulling it all Together Skill PracticePulling it all Together Skill Practice

Case #2: Disease Case #2: Disease -- Hepatitis AHepatitis AGeneral InformationGeneral Information:: There have recently been several There have recently been several cases of Hepatitis A in your county. The cause of the outbreak cases of Hepatitis A in your county. The cause of the outbreak has not been determined, but investigators are focusing on the has not been determined, but investigators are focusing on the hygiene practices of restaurant workers during the first week hygiene practices of restaurant workers during the first week August at the I.M. Gross Diner, a local restaurant.August at the I.M. Gross Diner, a local restaurant.

RolesRoles:: Please refer to your specificPlease refer to your specificinformation sheets.information sheets.


Pulling it all Together Skill PracticePulling it all Together Skill Practice

Case #3: Disease Case #3: Disease –– MeningitisMeningitisGeneral InformationGeneral Information:: There has been a suspected case of There has been a suspected case of bacterial meningitis in a college freshman living in campus bacterial meningitis in a college freshman living in campus housing of a local college. The student, an international housing of a local college. The student, an international student, was taken to a hospital earlier in the day with student, was taken to a hospital earlier in the day with symptoms of meningitis. As the bacterial form of this disease symptoms of meningitis. As the bacterial form of this disease has the potential of being contagious, the college has sought has the potential of being contagious, the college has sought help from the health department.help from the health department.

RolesRoles:: Please refer to your specific information sheets.Please refer to your specific information sheets.


Module 2: SummaryModule 2: SummaryIn this Module you learned to:In this Module you learned to:

State the purpose of an interview.State the purpose of an interview.Demonstrate the use of effective Demonstrate the use of effective interviewing techniques. interviewing techniques. Describe the concept of bias and Describe the concept of bias and how it influences interview results.how it influences interview results.Describe the importance of Describe the importance of identifying unusual occurrences.identifying unusual occurrences.Demonstrate appropriate cultural Demonstrate appropriate cultural sensitivity, confidentiality, and sensitivity, confidentiality, and ethics when interviewing.ethics when interviewing.

Module 3Module 3Outbreak InvestigationsOutbreak Investigations

Exercise 1: Exercise 1: Foodborne IllnessFoodborne Illness

Please refer to your manual Please refer to your manual page 53page 53 for complete instructions.for complete instructions.

1.1. A buffet has been set up for you. A buffet has been set up for you. 2.2. Go through the buffet and Go through the buffet and ““fill your plate.fill your plate.””3.3. When you get back to your seat, turn each food item over When you get back to your seat, turn each food item over

and note any instructions for you on the back.and note any instructions for you on the back.4.4. Place your food photos in the Place your food photos in the ““stomachstomach”” envelope. envelope. 5.5. Keep your Keep your ““stomachstomach”” envelope with you for use later in this envelope with you for use later in this

module.module.

STOP:STOP: At this point, the activity will stop and be resumed later At this point, the activity will stop and be resumed later in the presentation.in the presentation.

Exercise 1: Exercise 1: Foodborne Illness OutbreakFoodborne Illness Outbreak

Course Objective: Module 3Course Objective: Module 3ParticipateParticipate in an outbreak investigation exercise.in an outbreak investigation exercise.

OutbreakOutbreak

Two or more cases of a disease that are Two or more cases of a disease that are epidemiologically linked.epidemiologically linked.((BlackmoreBlackmore, Carina, Gill, Julia, Kintz, Jylmarie, and Teates, Kathryn. 20, Carina, Gill, Julia, Kintz, Jylmarie, and Teates, Kathryn. 2003. 03. The The County Health Department Epidemiology Guide to Disease SurveillaCounty Health Department Epidemiology Guide to Disease Surveillance and nce and Investigations. Investigations. Florida Department of Health)Florida Department of Health)

Outbreak InvestigationOutbreak Investigation

A multiA multi--step process step process for determining the for determining the dynamics of a dynamics of a disease outbreak and disease outbreak and implementing control implementing control and prevention and prevention measures to control measures to control the situation.the situation.

Outbreak Investigation Steps Outbreak Investigation Steps

1.1. Prepare for field work.Prepare for field work.2.2. Establish the existence of an outbreak.Establish the existence of an outbreak.3.3. Verify the diagnosis.Verify the diagnosis.4.4. Define and identify cases.Define and identify cases.5.5. Describe and orient the data in terms of time, Describe and orient the data in terms of time,

place, person.place, person.6.6. Develop hypothesis.Develop hypothesis.7.7. Test hypothesis.Test hypothesis.8.8. Refine and carry out additional studies.Refine and carry out additional studies.9.9. Implement control and prevention measures.Implement control and prevention measures.10.10. Communicate findings. Communicate findings.

(CDC EXCITE, 2004)(CDC EXCITE, 2004)

Step 1: Prepare for Field WorkStep 1: Prepare for Field Work

A.A. Research the disease.Research the disease.

B.B. Gather the supplies and Gather the supplies and equipment you need.equipment you need.

C.C. Make necessary Make necessary administrative and personal administrative and personal arrangements.arrangements.

D.D. Consult with supervisor or team leader to Consult with supervisor or team leader to determine your role in the investigation and who determine your role in the investigation and who your local contacts will be once you arrive on the your local contacts will be once you arrive on the scene.scene.

Step 1: Prepare for field workStep 1: Prepare for field work

Research the disease:Research the disease:

1. Read Sample Collection protocols1. Read Sample Collection protocols

Safety protocols and precautions must be Safety protocols and precautions must be followed when collecting and transporting followed when collecting and transporting human, animal, and environmental samples. human, animal, and environmental samples. Ask your particular health department for Ask your particular health department for instructions regarding how to collect and instructions regarding how to collect and transport samples.transport samples.

Step 1: Prepare for field work (continued)Step 1: Prepare for field work (continued)

Research the disease (continued):Research the disease (continued):

2. Read and obtain copies of fact sheets and protocols2. Read and obtain copies of fact sheets and protocols

More information on More information on foodbournefoodbourne pathogens and pathogens and natural toxins can be found in natural toxins can be found in The Bad Bug BookThe Bad Bug Book. .


Gather the necessary supplies and equipment:Gather the necessary supplies and equipment:

1. Review protocols for infection control 1. Review protocols for infection control (see pp. 114(see pp. 114--115 in Resource section).115 in Resource section).

2. Put together a personal Epi Go Kit 2. Put together a personal Epi Go Kit (see p. 108 in (see p. 108 in Resource section). Resource section).

3. Put together a personal Care Kit 3. Put together a personal Care Kit (see p. 109 in (see p. 109 in Resource section). Resource section).

4. Understand transmission routes, precautions, and 4. Understand transmission routes, precautions, and whether personal protective equipment (PPE) is whether personal protective equipment (PPE) is required required (see pp. 110(see pp. 110--111 in Resource section).111 in Resource section).


Make necessary administrative and personal Make necessary administrative and personal arrangements.arrangements.

1. Complete travel paperwork.1. Complete travel paperwork.2. Make child and/or pet care arrangements.2. Make child and/or pet care arrangements.

Consult with supervisor or team leader to Consult with supervisor or team leader to determine your role in the investigation.determine your role in the investigation.

1. Understand your role and responsibilities.1. Understand your role and responsibilities.2. Identify expectations/desired outcomes.2. Identify expectations/desired outcomes.


Determine who the local contacts will be once Determine who the local contacts will be once you arrive on the scene:you arrive on the scene:

1. Get a map of the local area.1. Get a map of the local area.2. Obtain phone numbers, addresses, and other 2. Obtain phone numbers, addresses, and other

information.information.3. Identify the closest FDOH laboratories 3. Identify the closest FDOH laboratories (see pp. (see pp.

112112--113 in Resource section). 113 in Resource section).

Instructions:Instructions: Use the Use the ““Specimen Collection Table and FactSpecimen Collection Table and FactSheetsSheets”” found from found from pages 58pages 58--6868 in your course manual toin your course manual toanswer the following six questions:answer the following six questions:

1.1. Which disease has symptoms of headache, stiff neck and fever?Which disease has symptoms of headache, stiff neck and fever?2.2. Is there a treatment for anthrax?Is there a treatment for anthrax?3.3. Which disease is caused by a virus that is transmitted in Which disease is caused by a virus that is transmitted in

respiratory droplets?respiratory droplets?4.4. Describe the special preparations and container specifications Describe the special preparations and container specifications

used when transporting a Gonorrhea culture.used when transporting a Gonorrhea culture.5.5. Describe the container used to transport a Legionella Antibody Describe the container used to transport a Legionella Antibody

Serology.Serology.6.6. Who gets legionellosis?Who gets legionellosis?

Exercise 2: Exercise 2: Research the DiseaseResearch the Disease

Step 2: Establish the Existence of an OutbreakStep 2: Establish the Existence of an Outbreak

Verify that a suspected Verify that a suspected outbreak is real.outbreak is real.

Check Syndromic Surveillance.Check Syndromic Surveillance.

Before you can decide Before you can decide whether an outbreak exists,whether an outbreak exists,you must you must firstfirst determine the expected number of cases determine the expected number of cases for the area in the given time frame.for the area in the given time frame.

Step 3: Verify the DiagnosisStep 3: Verify the Diagnosis

A.A. Visit several of the people who became ill to gain a Visit several of the people who became ill to gain a better understanding of the disease and those better understanding of the disease and those affected by it.affected by it.

B.B. Gather critical information by asking questions, Gather critical information by asking questions, such as:such as:

What were your exposures before becoming ill?What were your exposures before becoming ill?What do you think caused your illness?What do you think caused your illness?Do you know anyone else with the disease?Do you know anyone else with the disease?Do you have anything in common with others Do you have anything in common with others who have the disease?who have the disease?

Step 3: Verify the DiagnosisStep 3: Verify the DiagnosisC. Identify, as accurately as C. Identify, as accurately as

possible, the specific nature of possible, the specific nature of the disease.the disease.

Ensure that the problem has Ensure that the problem has been properly diagnosed.been properly diagnosed.

For outbreaks involving For outbreaks involving infectious or toxicinfectious or toxic--chemical chemical agents, be certain that the agents, be certain that the increase in diagnosed cases is increase in diagnosed cases is not the result of a laboratory not the result of a laboratory mistake.mistake.

Step 4: Define and Identify CasesStep 4: Define and Identify Cases

This step involves four subThis step involves four sub--steps:steps:

A.A. Define casesDefine cases

B.B. Identify casesIdentify cases

C.C. Survey the populationSurvey the population

D.D. Organize the informationOrganize the information

Step 4: Define and Identify CasesStep 4: Define and Identify CasesA.A. Define cases. Define cases. Establish a Establish a case definitioncase definition, or standard , or standard

set of criteria, for deciding whether a person should beset of criteria, for deciding whether a person should beclassified as having the disease or health conditionclassified as having the disease or health conditionunder study.under study.

A case definition usually includes A case definition usually includes fourfour components:components:

1.1. Clinical information about the disease.Clinical information about the disease.2.2. Characteristics of the people who are affected.Characteristics of the people who are affected.3.3. Information about the location or place.Information about the location or place.4.4. A specification of time during which the outbreak A specification of time during which the outbreak

occurred.occurred.

FalseFalse--positive Casespositive CasesA A falsefalse--positive casepositive case occurs when the case definition is occurs when the case definition is met, but the person actually does met, but the person actually does notnot have the disease in have the disease in question. question.

Ideally, the case definition should be broad enough to Ideally, the case definition should be broad enough to include most, if not all, of the actual cases, without include most, if not all, of the actual cases, without capturing what are called "falsecapturing what are called "false--positive" cases. positive" cases.

Recognizing the uncertainty of some diagnoses, Recognizing the uncertainty of some diagnoses, investigators often classify cases as investigators often classify cases as ““confirmed,confirmed,””““probable,probable,”” or or ““possible.possible.””

TTypes of Casesypes of Cases1.1. Confirmed CaseConfirmed Case

Usually requires laboratory Usually requires laboratory verification.verification.

2.2. Probable CaseProbable CaseUsually has the typical Usually has the typical clinical features of the clinical features of the disease without laboratory disease without laboratory confirmation.confirmation.

3.3. Possible CasePossible CaseUsually has fewer of the Usually has fewer of the typical clinical features.typical clinical features.

Special CautionsSpecial Cautions

Early in an investigation, a loosely defined or Early in an investigation, a loosely defined or broad case definition that includes confirmed, broad case definition that includes confirmed, probable, and even possible cases is often used probable, and even possible cases is often used to allow investigators to capture as many cases to allow investigators to capture as many cases as possible.as possible.

Later on, when hypotheses have come into Later on, when hypotheses have come into sharper focus, the investigator may tighten the sharper focus, the investigator may tighten the case definition by dropping the case definition by dropping the ““possiblepossible””category.category.

Step 4: Define and Identify CasesStep 4: Define and Identify CasesB. Identify cases.B. Identify cases. Many outbreaks are first recognized and Many outbreaks are first recognized and

reported by concerned health care providers or citizens. reported by concerned health care providers or citizens.

Epidemiologists must "cast the net wide" to determine Epidemiologists must "cast the net wide" to determine the true size and geographic extent of the problem.the true size and geographic extent of the problem.

Sources for identifying cases: Sources for identifying cases: Physicians' officesPhysicians' officesClinicsClinicsHospitalsHospitalsLaboratoriesLaboratories

Methods for Identifying CasesMethods for Identifying CasesThere are two methods for identifying cases: 1) There are two methods for identifying cases: 1) Active surveillanceActive surveillance, and 2) , and 2) Passive surveillancePassive surveillance..

Public health officials may decide to Public health officials may decide to alert the public directly usually alert the public directly usually through the local media.through the local media.

ExampleExample:: In outbreaks caused by a In outbreaks caused by a contaminated food product, media contaminated food product, media alerts help the public avoid the alerts help the public avoid the implicated product and suggest they implicated product and suggest they see a physician if symptoms of the see a physician if symptoms of the disease occur.disease occur.

Step 4: Define and Identify CasesStep 4: Define and Identify Cases

Disadvantages: Not timely.Does not provide useful information when early intervention is necessary.

Disadvantages: Labor-intensive.

Advantages: Not labor-intensive.

Advantages: Provides timely, up-to-date information.Data has less variability.

Methods: Information requested by letter and/or scheduled reports.

Methods: Face-to-face and/or phone interviews.

Occurs when health care providers report notifiable diseases on a case-by-case basis to the local or state health agency, based upon a published list of conditions.

Occurs when health care providers report notifiable diseases on a case-by-case basis and on a regular schedule due to outreach from local, state, or federal agencies.

Passive surveillance:Active surveillance:

Step 4: Define and Identify CasesStep 4: Define and Identify CasesC. C. Survey the population.Survey the population.

Interviews are conducted with Interviews are conducted with the population of a potential the population of a potential exposure when:exposure when:

1.1. An outbreak affects a population in a restricted An outbreak affects a population in a restricted setting, such as a tour bus, school, or workplace.setting, such as a tour bus, school, or workplace.

2.2. A high proportion of cases are unlikely to be A high proportion of cases are unlikely to be diagnosed. For example, when many cases are diagnosed. For example, when many cases are mild or without symptoms.mild or without symptoms.

Step 4: Define and Identify CasesStep 4: Define and Identify CasesCollect InformationCollect Information•• Identifying informationIdentifying information•• Demographic informationDemographic information•• Clinical informationClinical information•• Risk factor informationRisk factor information

Organize InformationOrganize Information•• Standard case report formStandard case report form•• QuestionnaireQuestionnaire•• Data abstraction formData abstraction form

Step 5: Describe and Orient the DataStep 5: Describe and Orient the Data

Characterize an outbreak by:Characterize an outbreak by:1.1. TimeTime2.2. PlacePlace3.3. Person Person

Characterizing an outbreak by these variables isCharacterizing an outbreak by these variables iscalled called descriptive epidemiologydescriptive epidemiology..

Note:Note: This step may occur several times within the course ofThis step may occur several times within the course ofthe outbreak.the outbreak.

Characterizing an Outbreak by TimeCharacterizing an Outbreak by Time

Graph by the number of cases and their date ofGraph by the number of cases and their date ofonset onset –– called an called an ““Epi curveEpi curve..””

Indicates the time course of an epidemic.Indicates the time course of an epidemic.Gives a simple visual display of the outbreak's Gives a simple visual display of the outbreak's magnitude and time trend. magnitude and time trend. Tells the status of the course of epidemic. Tells the status of the course of epidemic.

What Does an EpiWhat Does an Epi--Curve Curve Allow Me to Do?Allow Me to Do?

Identify the epidemicIdentify the epidemic’’s s course.course.Project the epidemicProject the epidemic’’s s future course.future course.Provide an estimate of Provide an estimate of the probable time period the probable time period of exposure.of exposure.Draw inferences about Draw inferences about the epidemic pattern. the epidemic pattern.

Interpreting an EpiInterpreting an Epi--CurveCurveHow do I interpret an epi curve?How do I interpret an epi curve?In order to interpret an epi curve, the overall shape mustIn order to interpret an epi curve, the overall shape mustbe considered. The shape is determined by the:be considered. The shape is determined by the:

A.A. Pattern of the epidemic (e.g., whether it has a Pattern of the epidemic (e.g., whether it has a common source or personcommon source or person--toto--person transmission).person transmission).

B.B. Period of time over which susceptible people are Period of time over which susceptible people are exposed. exposed.

C.C. Minimum, average, and maximum incubation Minimum, average, and maximum incubation periods for the disease.periods for the disease.

Epidemiology curve of human West Nile virus encephalitis cases in Florida in 2001.

The Epi CurveThe Epi Curve

Surveillance Results From The First West Nile Virus Transmission Season In Florida, 2001 C. G. M. BLACKMORE, L. M. STARK, W.C. JETER, R. L. OLIVERI, R. G. BROOKS, L. A. CONTI, AND S. T. WIERSMA in http://www.ajtmh.org

Interpreting an Epi CurveInterpreting an Epi Curve

Steep upSteep up--slope and a slope and a gradual downgradual down--slope.slope.People are exposed to People are exposed to the same source over the same source over a relatively brief a relatively brief period.period.All cases occur within All cases occur within one incubation period.one incubation period.

Single Source Epidemic Single Source Epidemic –– Point sourcePoint source

The epidemic curve can be used to identify a likely The epidemic curve can be used to identify a likely period of exposure in a pointperiod of exposure in a point--source epidemic of a source epidemic of a known disease.known disease.

Interpreting an Epi CurveInterpreting an Epi CurveContinuous Common Source EpidemicContinuous Common Source Epidemic

Duration of exposure is prolonged.Duration of exposure is prolonged.Epi curve will have a plateau instead of a peak.Epi curve will have a plateau instead of a peak.

Interpreting an Epi CurveInterpreting an Epi CurvePropagated EpidemicPropagated Epidemic

Curve has a series of progressively taller peaks Curve has a series of progressively taller peaks one incubation period apart.one incubation period apart.

Outliers:Outliers: Cases that stand apartCases that stand apart

Early CaseEarly CaseBackground (unrelated) case.Background (unrelated) case.A A sourcesource of the epidemic of the epidemic -- Person who was Person who was exposed earlierexposed earlier than most than most of the affected people.of the affected people.

Late CaseLate CaseUnrelatedUnrelated to the outbreak.to the outbreak.Especially Especially long incubation periodslong incubation periods..May indicate May indicate exposure laterexposure later than most of the people affected.than most of the people affected.

Secondary casesSecondary casesMay have become ill May have become ill after being exposedafter being exposed to someone who was part of to someone who was part of the initial outbreak.the initial outbreak.

Interpreting an Epi CurveInterpreting an Epi Curve


Characterize an outbreak by:Characterize an outbreak by:

1.1. TimeTime

2.2. PlacePlace

3.3. PersonPerson

Characterizing an Outbreak by PlaceCharacterizing an Outbreak by PlaceProvides information on the geographic extent of Provides information on the geographic extent of the problem.the problem.Shows clusters or Shows clusters or patterns that provide patterns that provide clues to the identity and clues to the identity and origins of the problem.origins of the problem.

Plot, on a spot map, the Plot, on a spot map, the area where the affected area where the affected people may have been people may have been exposed.exposed.

Interpreting a Spot MapInterpreting a Spot Map

1. Focal Source:1. Focal Source:Looks like clusteringLooks like clusteringPersonPerson--toto--person spreadperson spreadExample: Hospital or nursing homeExample: Hospital or nursing home

2. Common Source:2. Common Source:Looks like a scattering of casesLooks like a scattering of casesExample: Dining hall or workplaceExample: Dining hall or workplace

Spot map shows number of cases.Spot map shows number of cases. May show May show clusters or patterns that reflect water supplies, wind clusters or patterns that reflect water supplies, wind currents, or proximity to a,restaurant or grocery store.currents, or proximity to a,restaurant or grocery store.

Weakness of the Spot MapWeakness of the Spot Map

If the size of the overallIf the size of the overallpopulation variespopulation variesbetween the areas youbetween the areas youare comparing, the spotare comparing, the spotmaps can be misleading.maps can be misleading.

Reported cases of rabies in the United States, 1999. From: Microbiology and Immunology Online, School of Medicine, University of South Carolina, http://pathmicro.med.sc.edu/virol/rabies.htm


Characterize an outbreak by: Characterize an outbreak by:

1.1. TimeTime

2.2. PlacePlace

3.3. Person Person

Characterizing an Outbreak by PersonCharacterizing an Outbreak by PersonDefine populations by:Define populations by:

Personal characteristicsPersonal characteristics, such as:, such as:•• AgeAge•• RaceRace•• SexSex•• Medical statusMedical status

ExposuresExposures, such as:, such as:•• OccupationOccupation•• Leisure or work activitiesLeisure or work activities•• Use of medications, tobacco, drugsUse of medications, tobacco, drugs

Step 6: Develop HypothesisStep 6: Develop HypothesisWhen developing a hypothesis be sure to:When developing a hypothesis be sure to:A.A. Address the following:Address the following:

•• Source of the agent.Source of the agent.•• Mode (vehicle or vector) of transmission.Mode (vehicle or vector) of transmission.•• Exposures that caused the disease.Exposures that caused the disease.•• Should be proposed in a way that can be tested.Should be proposed in a way that can be tested.

B.B. Ask:Ask:•• What do you know about the disease itself?What do you know about the disease itself?•• What is the agentWhat is the agent’’s usual reservoir?s usual reservoir?•• How is the disease usually transmitted?How is the disease usually transmitted?•• What vehicles are commonly implicated?What vehicles are commonly implicated?•• What are the known risk factors?What are the known risk factors?

Step 7: Test HypothesisStep 7: Test Hypothesis

Two approaches you can use, depending onTwo approaches you can use, depending onthe nature of your data: the nature of your data: 1.1. Compare the hypothesis with the established Compare the hypothesis with the established

facts.facts.•• Used when your evidence is so strong that the Used when your evidence is so strong that the

hypothesis does not need to be tested. hypothesis does not need to be tested.

2.2. Test the hypothesis through Test the hypothesis through analytic analytic epidemiologyepidemiology studies.studies.

Compare the Hypothesis Compare the Hypothesis with the Established Factswith the Established Facts

Example:Example: In 1991, there was an In 1991, there was an investigation of an outbreak of vitamin investigation of an outbreak of vitamin D intoxication in Massachusetts. All of D intoxication in Massachusetts. All of the affected people drank milk the affected people drank milk delivered to their homes by a local delivered to their homes by a local dairy. Investigators hypothesized that dairy. Investigators hypothesized that the dairy was the source, and the milk the dairy was the source, and the milk was the vehicle of excess vitamin D. was the vehicle of excess vitamin D. When investigators visited the dairy, When investigators visited the dairy, they quickly recognized that far more they quickly recognized that far more than the recommended dose of than the recommended dose of vitamin D was inadvertently being vitamin D was inadvertently being added to the milk. No further analysis added to the milk. No further analysis was necessary. was necessary.

Analytic EpidemiologyAnalytic EpidemiologyTwo types of analytic studies:Two types of analytic studies:1.1. Cohort StudiesCohort Studies::

•• Compare groups of people who have been exposed to Compare groups of people who have been exposed to suspected risk factors with groups who have not been suspected risk factors with groups who have not been exposed.exposed.

•• The best technique for analyzing an outbreak in a small, The best technique for analyzing an outbreak in a small, wellwell--defined population. defined population.

2. 2. CaseCase--Control StudiesControl Studies::•• Compare people with a disease (caseCompare people with a disease (case--patients) with a group patients) with a group

of people without the disease (controls).of people without the disease (controls).•• In most outbreaks the population is not well defined, and so In most outbreaks the population is not well defined, and so

cohort studies are not feasible. In these instances, you cohort studies are not feasible. In these instances, you would use the casewould use the case--control study design. control study design.

•• Ask both caseAsk both case--patients and controls about their exposures. patients and controls about their exposures.

Cohort StudyCohort StudyExample:Example: A cohort study would be A cohort study would be used in an outbreak of gastroenteritis used in an outbreak of gastroenteritis among people who attended a social among people who attended a social function, such as a wedding, when a function, such as a wedding, when a complete list of wedding guests was complete list of wedding guests was available. In this situation, each available. In this situation, each attendee would be asked the same set attendee would be asked the same set of questions about potential exposures of questions about potential exposures (e.g., what foods and beverages were (e.g., what foods and beverages were consumed at the wedding) and whether consumed at the wedding) and whether specific symptoms were experienced.specific symptoms were experienced.

Cohort StudyCohort Study

1.1. Collect informationCollect information2.2. Calculate an attack Calculate an attack

raterate3.3. Identify the source of Identify the source of

the outbreakthe outbreak4.4. Calculate relative riskCalculate relative risk

Steps for conducting a cohort study:Steps for conducting a cohort study:

Cohort Study StepsCohort Study Steps

1.1. Collect informationCollect informationUse the Investigation Use the Investigation Worksheets provided by DOH Worksheets provided by DOH to collect data.to collect data.Ask the same set of questions Ask the same set of questions with each person to avoid with each person to avoid interview bias.interview bias.Focus on:Focus on:1.1. Identifying informationIdentifying information2.2. Demographic information Demographic information 3.3. Clinical information Clinical information 4.4. Risk factor informationRisk factor information

Cohort Study StepsCohort Study Steps2. Calculate an attack rate2. Calculate an attack rateAfter collecting information,After collecting information,calculate an attack rate forcalculate an attack rate forpeople who ate a particular people who ate a particular Item Item ((exposedexposed)) and an attack and an attack rate for those who did not eatrate for those who did not eatthat item that item ((not exposed)not exposed)..

Attack Rate:Attack Rate: Number of new cases of disease that develop per the number in a healthy population at risk at the start of the period.

Attack Rate CalculationAttack Rate CalculationExposed Group:Exposed Group:The number of people who ate the item andThe number of people who ate the item andbecame ill divided by the total number of peoplebecame ill divided by the total number of peoplewho ate the item.who ate the item.

Not Exposed Group:Not Exposed Group:The number of people who did not eat the item butThe number of people who did not eat the item butbecame sick divided by the total number of peoplebecame sick divided by the total number of peoplewho did not eat the item.who did not eat the item.

Cohort Study StepsCohort Study Steps3. Identify the source of the outbreak3. Identify the source of the outbreakLook for an item with:Look for an item with:

A A high attackhigh attack raterate among those among those exposed, exposed, andandA A low attacklow attack raterate among those among those not exposed (so the difference not exposed (so the difference or ratio between the attack rates or ratio between the attack rates for the two exposure groups is for the two exposure groups is high). high).

In addition, most people who became ill should have consumed the item, so that the exposure could explain most cases.

Cohort Study StepsCohort Study Steps

4.4. Calculate relative riskCalculate relative riskThe mathematical associationThe mathematical associationbetween exposure and illness forbetween exposure and illness foreach food and beverage.each food and beverage.

Relative risk calculation:Relative risk calculation: Attack rate for people Attack rate for people who were exposed who were exposed divided by divided by the attack rate forthe attack rate forthose not exposed.

Exercise 3Exercise 3

(Continued)(Continued)

Please refer to page 84 in your course manual.

Exercise 3: Exercise 3: Foodborne Illness OutbreakFoodborne Illness Outbreak

Calculate Attack RateCalculate Attack RateEpidemiologists often useEpidemiologists often useAttack rates to describe theAttack rates to describe therisk of illness in variousrisk of illness in variousgroups.groups.Attack rates are calculated byAttack rates are calculated bydividing the number ill by the total dividing the number ill by the total number of people in each group.number of people in each group.These rates are generallyThese rates are generallyexpressed as percentages. expressed as percentages.

Refer to pages 83 & 85 of your course manual for the attack rate calculation information.

Calculate Attack RateCalculate Attack RateThe items within the attack rate table will be filled in The items within the attack rate table will be filled in based on what you did and did not based on what you did and did not ““eateat”” from the buffet from the buffet and whether or not you are and whether or not you are ““ill.ill.””

For each food item, information will be entered into the For each food item, information will be entered into the appropriate cell on the attack rate table for those of you appropriate cell on the attack rate table for those of you who are:who are:

Ill and who ate the food item Ill and who ate the food item Ill and who did not eat the food item Ill and who did not eat the food item Not ill and who did not eat the food itemNot ill and who did not eat the food itemNot ill and who ate the food item Not ill and who ate the food item

An attack rate chart is provided in your manual on An attack rate chart is provided in your manual on page 85page 85..

Baked Baked PotatoPotato

Ice CreamIce CreamChickenChickenCornCorn

Filet Filet MignonMignon

CroissantCroissantBroccoliBroccoli

Relative Relative RiskRisk

Attack Attack RateRate

Did not Did not Eat & Eat & WellWell

Did not Did not Eat & Ill Eat & Ill


Ate & Ate & WellWell

Ate &Ate &IllIllFood ItemFood Item

Calculate Attack RateCalculate Attack RateFood items that were eaten:Food items that were eaten: You will calculate attack rates for You will calculate attack rates for each food item that was eaten. These attack rates represent each food item that was eaten. These attack rates represent the risk of getting ill for people who ate each of the food itemthe risk of getting ill for people who ate each of the food items.s.

Calculate Attack RateCalculate Attack RateFood items that were not eaten:Food items that were not eaten: You will calculate attack rates You will calculate attack rates for each food item that was not eaten. These attack rates for each food item that was not eaten. These attack rates represent the risk of getting ill for people who did not eat eacrepresent the risk of getting ill for people who did not eat each h of the food items.of the food items.

Baked Baked PotatoPotato

Ice CreamIce CreamChickenChickenCornCornFilet MignonFilet Mignon

CroissantCroissantBroccoliBroccoli








Calculate Attack RateCalculate Attack RateRelative risk:Relative risk: You will calculate the relative risk for each food You will calculate the relative risk for each food item. This is calculated by dividing the attack rate in the item. This is calculated by dividing the attack rate in the ““AteAte””group by the attack rate in the group by the attack rate in the ““Did not eatDid not eat”” group for each group for each food item. food item.

Baked PotatoBaked PotatoIce CreamIce CreamChickenChickenCornCornFilet MignonFilet MignonCroissantCroissantBroccoliBroccoli








Foodborne Illness OutbreakFoodborne Illness OutbreakDiscussion PointsDiscussion Points

Effect of recallEffect of recallMisclassificationMisclassificationOtherOther

Analytic EpidemiologyAnalytic EpidemiologyTwo types of analytic studies:Two types of analytic studies:1.1. Cohort StudiesCohort Studies2.2. CaseCase--Control StudiesControl Studies::

•• Compare people with a disease (caseCompare people with a disease (case--subjects) subjects) with a group of people without the disease with a group of people without the disease (controls).(controls).

•• In most outbreaks the population is not well In most outbreaks the population is not well defined, and so cohort studies are not feasible. In defined, and so cohort studies are not feasible. In these instances, you would use the casethese instances, you would use the case--control control study design. study design.

•• Ask both caseAsk both case--subjects and controls about their subjects and controls about their exposures. exposures.

CaseCase--control Studiescontrol StudiesCalculate an Odds Ratio:Calculate an Odds Ratio:

Used to quantify the Used to quantify the relationship between relationship between exposure and disease.exposure and disease.

Does not prove that a Does not prove that a particular exposure caused particular exposure caused a disease.a disease.

Is very helpful in evaluating Is very helpful in evaluating possible vehicles of possible vehicles of disease.disease.

Odds Ratio CalculationOdds Ratio Calculation

Step 1: Step 1: Look at your data in a 2Look at your data in a 2××2 table. 2 table.

8080d=70d=70c=10c=10NoNo

1461461061064040TotalTotal

6666b=36b=36a=30a=30YesYesAte at Ate at Restaurant Restaurant ““AA””??

TotalTotalControlsControlsCaseCase--subjectssubjects

Odds Ratio CalculationOdds Ratio CalculationStep 2: Step 2: The odds ratio is calculated as ad/bcThe odds ratio is calculated as ad/bc. .

The odds ratio for Restaurant The odds ratio for Restaurant ““AA”” equals 30 equals 30 ×× 70 / 36 70 / 36 ×× 10 = 10 = 5.8.5.8.

8080d=70d=70c=10c=10NoNo1461461061064040TotalTotal

6666b=36b=36a=30a=30YesYesAte at Ate at Restaurant Restaurant ““AA””??


This means that people who ate at Restaurant “A” were 5.8 times more likely to develop Hepatitis A than were people who did not eat there.

Odds Ratio CalculationOdds Ratio CalculationWORD OF CAUTION:WORD OF CAUTION:Even though the Odds Ratio Even though the Odds Ratio Calculation indicates that people who Calculation indicates that people who ate at Restaurant ate at Restaurant ““AA”” were 5.8 times were 5.8 times more likely to develop Hepatitis A than more likely to develop Hepatitis A than were people who did not eat there. . .were people who did not eat there. . .

It cannot be concluded that Restaurant A was the “true” source without comparing its odds ratio to other possible sources.It could be the source is elsewhere and it just so happens that many of the people who were exposed also ate at Restaurant A.

Odds Ratio CalculationOdds Ratio Calculation

The odds ratio is calculated as ad/bcThe odds ratio is calculated as ad/bc. .

d=d=c=c=NoNoTotalTotal

b=b=a=a=YesYesDid you eat the Did you eat the Filet Mignon?Filet Mignon?


This means that people who ate the Filet Mignon were ____ times more likely to get sick than were people who did not eat the Filet Mignon.

Step 8: Refine Hypothesis and Step 8: Refine Hypothesis and Carry Out Additional Studies Carry Out Additional Studies

Additional epidemiological studies.Additional epidemiological studies. When analytic When analytic epidemiological studies do not confirm the hypothesis, the epidemiological studies do not confirm the hypothesis, the hypothesis must be reconsidered and refined. New vehicles hypothesis must be reconsidered and refined. New vehicles or modes of transmission should be investigated. This is the or modes of transmission should be investigated. This is the time to meet with casetime to meet with case--subjects to look for common links, subjects to look for common links, visit their homes to look at the products on their shelves, and visit their homes to look at the products on their shelves, and to obtain additional samples.to obtain additional samples.

Note:Note: Steps 6 Steps 6 –– 7 would be repeated when the hypothesis 7 would be repeated when the hypothesis is refined and/or additional studies are conducted.is refined and/or additional studies are conducted.

Step 9: Implement Control Step 9: Implement Control and Prevention Measuresand Prevention Measures

Once the hypothesis is confirmed, control and prevention Once the hypothesis is confirmed, control and prevention measures need to be implemented as soon as possible.measures need to be implemented as soon as possible.

Control measures should be Control measures should be aimed at:aimed at:

Specific links in the chain of Specific links in the chain of infection (the agent, the source, infection (the agent, the source, or the host).or the host).Interrupting transmission or Interrupting transmission or exposure.exposure.Reducing susceptibility.Reducing susceptibility.

Step 10: Communicate FindingsStep 10: Communicate Findings

1.1. Oral briefing for local health authorities.Oral briefing for local health authorities.2.2. Written report.Written report.

Oral BriefingOral BriefingThe oral briefing should be attended by the local The oral briefing should be attended by the local health authorities and people responsible for health authorities and people responsible for implementing control and prevention measures. implementing control and prevention measures. This presentation is an opportunity to describe what This presentation is an opportunity to describe what was done, what was found, and what should be was done, what was found, and what should be done about it. done about it. The findings should be presented in a scientifically The findings should be presented in a scientifically objective fashion.objective fashion.The conclusions and recommendations should be The conclusions and recommendations should be supported by facts.supported by facts.

Written ReportWritten ReportFollows the usual scientific format of introduction, Follows the usual scientific format of introduction, background, methods, results, discussion, and background, methods, results, discussion, and recommendations. recommendations. Provides a blueprint for action. Provides a blueprint for action. Serves as a record of performance, a document for Serves as a record of performance, a document for potential supporting or refuting legal issues, and a potential supporting or refuting legal issues, and a reference if the health department encounters a reference if the health department encounters a similar situation in the future. similar situation in the future. Serves the broader purpose of contributing to the Serves the broader purpose of contributing to the scientific knowledge base of epidemiology and scientific knowledge base of epidemiology and public health when it becomes part of the public public health when it becomes part of the public health literature.health literature.

Module 3: SummaryModule 3: SummaryRecognize the steps in case investigation and in identifying Recognize the steps in case investigation and in identifying exposed contacts.exposed contacts.

Describe how initial cases might be recognized.Describe how initial cases might be recognized.

Demonstrate the ability to interpret fact sheets and mode of Demonstrate the ability to interpret fact sheets and mode of transmission sheets.transmission sheets.

Describe methods of collection and transportation of human, Describe methods of collection and transportation of human, animal, and environmental samples.animal, and environmental samples.

Apply skills necessary to demonstrate the ability to identify Apply skills necessary to demonstrate the ability to identify additional cases and determine the extent of a disease additional cases and determine the extent of a disease outbreak.outbreak.

FIRST Course SummaryFIRST Course SummaryModule 1:Module 1: Describe the role of epidemiology in Describe the role of epidemiology in public health.public health.

Module 2:Module 2: Demonstrate appropriate Demonstrate appropriate epidemiological interviewing and effective epidemiological interviewing and effective communication skills.communication skills.

Module 3:Module 3: Participate in an outbreak investigation Participate in an outbreak investigation exercise.exercise.

Lessons LearnedLessons Learned

Reflection: ThinkReflection: Think--PairPair--ShareShare

Take a minute to reflect on the course content.Take a minute to reflect on the course content.

Identify the 2 most important lessons that you Identify the 2 most important lessons that you learned.learned.

Share with a partner.Share with a partner.

PostPost--Training ActivitiesTraining ActivitiesLearner PostLearner Post--TestTestCourse EvaluationCourse EvaluationCourse CertificateCourse Certificate

Recommended Trainings: Assuring CulturalRecommended Trainings: Assuring CulturalCompetence; Understanding Compassion Fatigue.Competence; Understanding Compassion Fatigue.

Additional Course Offerings: Additional Course Offerings: www.FCPHP.usf.eduwww.FCPHP.usf.edu

Thank YouThank You

FCPHPFCPHP

www.FCPHP.usf.eduwww.FCPHP.usf.edu

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