Formulating recommendations for an investigation

1
Formulating recommendations for an investigation

• Integrated Disease Surveillance Programme (IDSP)
  district surveillance officers (DSO) course

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Outline of this session

• Communication with programme managers
• Attributes of good recommendations
• Wrap up exercise

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Recommendations link field epidemiology and
programme management
Assess
Evaluate
Plan
Implement
Decision makers
4
The state of mind of the epidemiologist

• Points that receive attention
• Scientific evidence
• Methodology
• Points that may be overlooked
• Programme constraints
• Competing priorities

Decision makers
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The state of mind of the programme manager

• Points that receive attention
• Overall funding envelope
• Political pressure
• Press attention
• Management
• Points that may be overlooked
• Evidence

Decision makers
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Maximizing the chances that evidence is used for
action

• Appreciate the point of view of the manager
• Dont flag problems, provide solutions
• Understand that your recommendations have
  implications for resources allocation
• Deliver useful recommendations
• Evidence based
• Specific
• Feasible
• Cost effective
• Acceptable
• Ethical

Decision makers
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Attributes of good recommendations

• Evidence based
• Specific
• Feasible
• Cost effective
• Acceptable
• Ethical

Checklist
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Evidence based recommendations

• Focus on the recommendations that may be proposed
  as per the results of the investigations
• Leave aside -or present separately- general
  recommendations that are not direct deductions of
  your investigations
• If a measles outbreak was caused by failure to
  vaccinate, proposing a cold chain review is
  useless and distracting

Checklist
9
Cases of acute diarrhea (cholera) by date of
onset, Pipulhat, South 24 Parganas, West Bengal,
2006
Example of an outbreak
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12
10
Washing of clothes of deceased index case in
common pond
no. of cases
8
6
4
2
0
20
21
22
23
24
25
26
27
28
29
30
1
2
3
4
5
6
7
8
November Date of
onset December
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Cases of acute diarrhea (cholera) by location of
residence, Pipulhat, South 24 Parganas, West
Bengal, November, 2006
N
Index case Houses with no case Houses with 1
case Houses with 2 cases Houses with 3
cases Tube well
Small pond
Small pond
Pond 1
Pond 2
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Contaminated tube well
Environmental investigations, cholera outbreak,
Pipulhat, South 24 Parganas, West Bengal,
November, 2006
Clothes of the deceased patient soaking in the
pond
Short drain
Broken platform
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Cholera outbreak, Pipulhat, South 24 Parganas,
West Bengal, November, 2006 Conclusions

• An outbreak V. Cholerae 01 cholera occurred among
  residents of Pipulhat, South 24-Parganas, West
  Bengal
• The outbreak was centered by a pond that may have
  been contaminated following first cases,
  including by clothes of a deceased patient
• An old tube well close by was also probably
  contaminated

What would be your recommendations?
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Proposed recommendations, Cholera outbreak,
Pipulhat, South 24 Parganas, West Bengal,
November, 2006

• Immediate
• Stay away from the pond until outbreak is over
• Stop using the tube well, disinfect it
• Assess if the tube well can be repaired for
  future, safe use
• Longer term
• Educate the population to prevent contamination
  of ponds during cholera outbreaks
• Maintain tube wells and avoid dangerous locations

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Other possible generic recommendations to avoid
in this setting

• General hygiene
• Food safety
• Restriction on street vended food
• Boiling drinking water

Are these recommendations supported by the
data? Focus on what caused the current outbreak
Checklist
15
Attributes of good recommendations

• Evidence based
• Specific
• Feasible
• Cost effective
• Acceptable
• Ethical

Checklist
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Specific recommendations

• Focus
• Small number
• Ranked by order of priority
• Describe the action to be taken
• Use one verb by recommendation
• Avoid should
• Avoid passive voice
• Ask yourself
• What, Who, When and How?

Checklist
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Example of specific recommendations

• Avoid
• Water supply should be safe
• People should be educated
• Prefer
• Ask the water board to protect wells used for
  drinking water with longer drains and platforms
• Communicate the specific risk associated with the
  soiled linen of cholera case patients

Checklist
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Attributes of good recommendations

• Evidence based
• Specific
• Feasible
• Cost effective
• Acceptable
• Ethical

Checklist
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Feasible recommendations

• Do not recommend an action that you know will not
  be done
• Consider
• Logistics
• System
• Willingness / capacity to pay
• Sustainability
• Identify small steps that may be taken to improve
  the situation

Checklist
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Example of feasible recommendations

• Avoid
• Repair wells with broken platforms immediately
• Prefer
• Ensure all new wells are constructed with
  adequate protection
• Make an inventory of damaged wells
• Establish a timeline with the water board to
  repair damaged wells

Checklist
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Attributes of good recommendations

• Evidence based
• Specific
• Feasible
• Cost effective
• Acceptable
• Ethical

Checklist
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Cost effectiveness is the result you get for the
input you give

• Measure costs
• Effects must be worth the costs
• Substantial burden
• Effective intervention
• Common sense may be used in the absence of
  quantified documentation

Checklist
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Attributes of good recommendations

• Evidence based
• Specific
• Feasible
• Cost effective
• Acceptable
• Ethical

Checklist
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Acceptable recommendations

• The recommendation has to be acceptable to the
  decision makers and to the stakeholders
• Politically
• Culturally
• Socially
• Discuss draft with stakeholders
• Improve acceptability
• Create ownership

Checklist
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Acceptable goals in sanitation

• Avoid
• Eliminate open air defecation
• Prefer
• Work with the population and rural engineering to
  identify sanitation solutions adapted to the
  village

Checklist
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Attributes of good recommendations

• Evidence based
• Specific
• Feasible
• Cost effective
• Acceptable
• Ethical

Checklist
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Ethical recommendations

• Principles
• Guarantee confidentiality
• Ensure equity
• Protect minorities
• Address gender issues
• Avoid stigmatization or finger-pointing
• Example
• Recommend that the national EPI programme provide
  a second opportunity for measles in Tamil Nadu
  that has gt 95 coverage while some states are
  under 40

Checklist
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Take home messages

1. Imagine yourself as a programme manager receiving
   the information
2. Be accountable to the usefulness of your
   recommendations

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Exercise

• Consider an outbreak of hepatitis E in a village
  in the hills
• Investigation lead to suspect an unprotected
  spring as the source of the outbreak
• Contaminated by a source case-patient living
  above the spring and who did not use latrines
• Two recommendations proposed
• Implement latrines in the whole village
• Protect the catchment area of the spring

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Review the two proposed recommendations according
to the checklist
Implement latrines in the whole village Protect the catchment area of the spring
Evidence based ? ?
Specific ? ?
Feasible ? ?
Cost effective ? ?
Acceptable ? ?
Ethical ? ?
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Additional reading

• Section 5 of operations manual
• Module 8 of training manual

Checklist