Formulating recommendations for an investigation

1. Formulating recommendations for an investigation Integrated Disease Surveillance Programme (IDSP) district surveillance officers (DSO) course

2. Outline of this session • Communication with programme managers • Attributes of good recommendations • Wrap up exercise 2

3. Field epidemiology Programme management Recommendations link field epidemiology and programme management Evaluate Assess Implement Plan Decision makers 3

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 4

5. 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 5

6. Maximizing the chances that evidence is used for action • Appreciate the point of view of the manager • Don’t 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 6

7. Attributes of good recommendations • Evidence based • Specific • Feasible • Cost effective • Acceptable • Ethical Checklist 7

8. 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 8

9. Example of an outbreak Cases of acute diarrhea (cholera) by date of onset, Pipulhat, South 24 Parganas, West Bengal, 2006 14 12 Washing of clothes of deceased index case in common pond 10 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 9 November Date of onset December

10. N Cases of acute diarrhea (cholera) by location of residence, Pipulhat, South 24 Parganas, West Bengal, November, 2006 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 10

11. Environmental investigations, cholera outbreak, Pipulhat, South 24 Parganas, West Bengal, November, 2006 Contaminated tube well Clothes of the deceased patient soaking in the pond Short drain Broken platform 11

12. 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? 12

13. 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 13

14. 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 14

15. Attributes of good recommendations • Evidence based • Specific • Feasible • Cost effective • Acceptable • Ethical Checklist 15

16. 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 16

17. 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 17

18. Attributes of good recommendations • Evidence based • Specific • Feasible • Cost effective • Acceptable • Ethical Checklist 18

19. 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 19

20. 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 20

21. Attributes of good recommendations • Evidence based • Specific • Feasible • Cost effective • Acceptable • Ethical Checklist 21

22. 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 22

23. Attributes of good recommendations • Evidence based • Specific • Feasible • Cost effective • Acceptable • Ethical Checklist 23

24. 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 24

25. 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 25

26. Attributes of good recommendations • Evidence based • Specific • Feasible • Cost effective • Acceptable • Ethical Checklist 26

27. 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 > 95% coverage while some states are under 40% Checklist 27

28. Take home messages • Imagine yourself as a programme manager receiving the information • Be accountable to the usefulness of your recommendations 28

29. 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 29

30. Review the two proposed recommendations according to the checklist 30

31. Additional reading • Section 5 of operations manual • Module 8 of training manual Checklist 31