Source: www.curremd.

com

INFECTIOUS DISEASE MANAGEMENT

O N E H E A LT H C O U R S E
 Introduction to
Infectious Disease Management
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
 COMPETENCIES

• Competency #1
• Identify and analyze risk factors during an infectious disease
outbreak
• Competency #2
• Design an infectious disease management plan
• Competency #3
• Evaluate the effectiveness of One Health actions in infectious
disease management
• Competency #4
• Design a new, or evaluate an existing disease surveillance and
monitoring system
 MODULE SESSIONS
Time/Length Topic
180 Minutes Module Introduction and Basic Concepts
Describe Possible Risk Factors for an Infectious Disease
100 Minutes
during an Outbreak Scenario
Creating a Conceptual Model to Visualize Risk Factors and
180 Minutes
Control Points
60-75 Minutes Risk Assessment
300 Minutes Collect Community-based Data
Develop Infectious Disease Public Awareness Materials:
150 Minutes
Part 1
135-195 Develop Infectious Disease Public Awareness Materials:
Minutes Part 2
 MODULE SESSIONS

Time/Length Topic
Critique an Infectious Disease Management Plan using a
60 80 Minutes
One Health Perspective
Describe Systemic Effects of an Infectious Disease
80 Minutes
Management Plan
160 Minutes Examine an Existing Surveillance System

150 Minutes Analyze Surveillance Data Using HealthMap

One Health Team Role-Playing Activity: A Management

60 Minutes
and Surveillance Plan
60 Minutes Learning Reflections & Evaluation
Fundamental Concepts for Infectious
Disease Management

INFECTIOUS DISEASE MANAGEMENT

O N E H E A LT H C O U R S E
INFECTIOUS DISEASE
BASIC CONCEPTS
EPIDEMIOLOGICAL TRIAD

Host
Agent

Environment Gordis, L. (2004). Epidemiology.

Philadelphia: Elsevier Saunders.
CHAIN OF INFECTION
MANAGING INFECTIOUS DISEASES

• Requires knowledge of:

• Infectious organisms (“agent”)
• Modes of Disease Transmission
• Risk
• Management concepts
 INFECTIOUS ORGANISMS

• Bacteria Leptospira
interrogans
• Viruses
• Parasites
• Fungi
• Prions en.wikipedia.org

en.wikipedia.org
INFECTIOUS AGENTS

Clostridium botulinum

Enterohaemorrhagic E. coli O104

PORTAL OF ENTRY
 MODES OF DISEASE TRANSMISSION

• Contact
• Direct
• Indirect
• Airborne * Aerosolized Particles
• Droplet
• Airborne
• Vector Borne
• Vehicle
* Aerosolized Particles from coughing or sneezing <5 microns in size containing influenza virus can be inhaled at
alveolar level of lungs
DIRECT CONTACT TRANSMISSION

• Direct contact with infected individual person or animals, or

their secretions
• Infectious organisms can enter via:
• respiratory tract – inhaled particles from sneezing and coughing
• mucous membranes – eyes, nose, reproductive, digestive tracts
• Skin – cuts, wounds, open sore, injury can facilitate entry
• ingestion – swallowing
 CONTACT WITH FOMITE
• Fomite: an inanimate object contaminated with an
infectious organism
• Organisms can survive on surfaces
• Does not require direct contact between individuals
• Examples of fomites:
• Doorknobs
• computer keyboard
• bedding or towels
• needles, forceps, scissors, other
medical equipment
• food preparation equipment and
serving vessels
healthline.com
CONTAMINATED FOOD AND WATER

• Food and water can become contaminated and transmit

diseases when consumed
• Contaminated food or water possible:
• Restaurants
• Central water supply
• Water storage containers
• Often cause gastroenteritis
• Diarrhea, vomiting, nausea
• E. coli, Salmonella, Campylobacter
• Cholera, Hepatitis A
• Intestinal parasites

en.wikipedia.org
RESERVOIR HOSTS & TRANSMISSION

• Reservoir hosts with infectious agents can transmit the

organism, but may not develop disease
• Hosts provide a reservoir for the organism in the
environment
• Management difficult if host population is large or difficult
to control
• Host may be required for stage(s) of an organism’s
development or transmission cycle before capable of
infecting another host or vector
 BIOLOGICAL VECTORS - ARTHROPODS

• Vector borne diseases common worldwide

• Insect provides a necessary part of disease transmission
process (e.g, biting during blood meal)
• Considering vector(s) key to management plans

www.cdc.gov
www.tse-tse.com

www.list25.com
BIOLOGICAL VECTORS - ANIMALS
 RISK FACTORS AND INFECTIOUS
DISEASES

• Consider risk factors when forming a management plan

• Risk factors affect whether an individual will contract a
disease
• Consider intrinsic and extrinsic risk factors
• Consider high-risk behaviors / occupations
• Knowledge about risk factors useful when developing
public awareness materials
 INTRINSIC RISK FACTORS
• Intrinsic factors are those related to the host itself (human or
animal):
• Genetics
• May cause susceptibility to a disease
• Host have correct receptors? (important for many viruses)
• Immune system – robust response can reduce severity
• Underlying diseases (HIV/AIDS, cancer – immunodeficiency
associated with increased severity of disease, death)
• Age (infants, children, elderly generally more susceptible to severe
illness)
• Nutrition (malnutrition, or being under- or overweight can increase
susceptibility to disease)
SUSCEPTIBLE HOSTS
 EXTRINSIC RISK FACTORS
• Extrinsic factors are not directly host- related
• Reservoir or infectious hosts:
• Does an individual have exposure to infected hosts?
• What are the reservoir hosts?
• Exposure risks
• Contaminated food and water
• Contaminated surfaces
• Socioeconomic status
 EXTRINSIC RISK FACTORS (CONTINUED)
• Specific temporal risks
• Occupational exposures
• Environmental exposures
• Natural disasters:
o Floods
o Drought
o Climate change
INFECTIOUS DISEASE
MANAGEMENT PLANNING
 MANAGEMENT PLAN:
FUNDAMENTAL APPROACH
• Need to understand all aspects of disease transmission and
risk factors to form an effective infectious disease
management plan
• Often need to brainstorm and create concept maps with a
management team to identify important disease
transmission factors
• One Health approach – make sure to include members
with different backgrounds on your team so important
transmission or risk factors are considered (e.g., for
zoonotic diseases)
 QUESTIONS TO GUIDE
MANAGEMENT PLAN
• What is the infectious organism (agent)?
• What are the characteristics of that organism?
• Which host species develop disease?
• What are the reservoir hosts?
• How is the disease transmitted from one host to another?
• Who gets the disease?
• What are the most important risk factors for disease?
 DECIDING ON A PLAN

• Determine what interventions are available

• Vaccination
• Treatment
• Control of vectors and reservoir hosts
• Monitoring of food and water supply
• Safe food and water handling and preparation
• Cleaning of contaminated surfaces or fomites
• Animal husbandry practices
• Control of contact with reservoir hosts
• Public education – safe practices related to the disease
 EVALUATING THE PLAN
• Once possible intervention strategies determined, consider best for
the situation and context
• Where in the concept map do each of the possible interventions
fit?
• What is the positive impact of each intervention?
• Cost-benefit? Want to maximize
• Are there negative consequences of the interventions?
• Who is affected?
• How to minimize negative impacts?
• Always consider downstream effects of disease management decisions
 THINK ABOUT

The Fournie article on Avian Influenza:

• What species are infected by Avian Influenza H5N1?
• What is the role of live bird markets in the transmission of
H5N1, and why were they a focus of this investigation?
• What is the difference between susceptibility and infectiousness
in terms of the live bird markets studied in this paper?
• What are the management recommendations for H5N1 in the
live bird markets?
 ASSIGNMENT
Create a presentation, including a diagram for transmission. Make
Group 1 sure to include:
Transmission Dynamics  Type of organism
for H5N1  Host range – include reservoirs
   Route of transmission
 
Create a presentation describing risk factors for the spread of H5N1
between animals and humans. Make sure to include:
Group 2  Risk factors for humans and animals
Risk Factors for H5N1  Environmental factors that increase or decrease risk
Transmission  Human behavior and cultural/traditional factors that increase or
decrease risk of H5N1
 Animal behaviors that increase or decrease risk of H5N1
Create a presentation describing the management recommendations
proposed in the paper for H5N1 in live bird markets. Make sure to
include:
Group 3  Management recommendations
Management of H5N1  Aspects of transmission dynamics influenced by the management
plan implementation.
 How risk factors are mitigated by the management plan
suggested in the paper.
Infectious Disease Risk Factors in an
Outbreak Scenario
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
 RABIES

• How is rabies transmitted to humans?

• What are the symptoms and outcome of rabies infection in
humans?
• Which animal species can be infected with rabies?
• Which animal species transmit rabies to humans?
• What risk factors increase the risk of rabies infection to
domestic animals? To humans?
• Vaccine available for animals? Important?
• Vaccine in humans (post-exposure prophylaxis)?
RABIES VIDEO, NEPAL

YouTube - Hydrophobia in advanced Rabies,

Nepal
/www.youtube.com/watch?v=bd6Vv0C64wU
CASE STUDY

Source: www.balidiscovery.com
 RABIES CASE SCENARIO
• How serious is the rabies outbreak?
• What are the most significant risk factors in the rabies
outbreak?
• Who is responsible for monitoring risk factors?
• What is a major concern in a rabies outbreak situation?
• What would you do to mitigate risk factors for rabies
during an outbreak?
• What is your group’s plan of action?
 Creating a Conceptual Model to
Visualize Risk Factors and Control
Points
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
ONE HEALTH CONCEPT
 PREVENTIVE STRATEGIES

• Primary prevention
• Secondary prevention
• Tertiary prevention
 PRIMARY PREVENTION OF
INFECTIOUS DISEASE
• Seek to prevent new cases of infection from occurring by
interrupting the transmission of pathogens to susceptible
human hosts, or increasing their resistance to infection
• Vaccination
 VACCINATION

• Directly, by increasing the immunity of individuals

vaccinated against the pathogen targeted by vaccine
• Indirectly, by decreasing potential exposure to a
pathogen, by reducing the proportion of susceptible
individuals capable of transmitting the infection in the
population
 SECONDARY PREVENTION OF
INFECTIOUS DISEASE

• Detect new cases of infectious disease at the earliest possible

stage and intervene in ways that prevent or reduce the risk
of infection spreading further in the population. Some
examples of how secondary prevention can be put into
practice are described below.
• Early treatment
• Education and health-related behavior modification
• Screening program
 TERTIARY PREVENTION OF
INFECTIOUS DISEASE

• Prevent the worst outcomes of a disease in an individual

already diagnosed (e.g., rehabilitation)
• Although this may greatly improve the quality of life for
that person, it has at most a limited impact on the spread
of infectious disease
• Extremely expensive, compared to prevention of disease
 The Danger of Avian Influenza
www.youtube.com/watch?v=8RApk1t9XDo
YouTube – A Risk Based Approach to Avian
Flu Control in Developing Countries
www.youtube.com/watch?v=R9Un5fD5Rlk

A Risk Based Approach to Avian Flue Control in

Developing Countries
 WHAT DO YOU THINK?

• Think about the risk factors, transmission and control of

Avian Influenza. List one or two:
• Host-related risk factors
• Virus-related risk factors
• Risk factors related to the environment
• Transmission routes
• control or intervention points
 SMALL GROUP ASSIGNMENTS

1. For your assigned scenario, discuss potential risk factors, host,

agent, environment, mode of transmission, and management of
assigned zoonotic diseases
2. Create a zoonotic disease public awareness plan
3. Present this information through a conceptual model or map
that visualizes this information
CONSIDERING USING AN OPEN SOURCE MAPPING SOFTWARE
SUCH AS VISUAL UNDERSTNADING ENVIRONOMENT (VUE)
 CASE STUDIES

• Leptospirosis
• Streptococcus suis infection
• Rabies
• Dengue
 DISEASE CASE SUMMARY:
LEPTOSPIROSIS
Leptospirosis is a zoonotic waterborne infection caused by the bacteria Leptospira
that can affect the liver, kidneys, and central nervous system. Humans can be
exposed through contact with water, vegetation or soil contaminated by the urine of
infected animals. Possible animal reservoirs include livestock, dogs, rodents, and
wild animals. Leptospires enter the body through contact with the skin and mucous
membranes and, occasionally, via drinking water or inhalation. Person-to-person
transmission is rare. Occurrence of leptospirosis in humans depends on a complex
set of interactions between ecological and social factors. Leptospirosis is present
worldwide, but more common in tropical and sub-tropical regions where abundant
precipitation, regular flooding and high temperatures enhance the distribution and
survival of leptospires.
Additional information available in the One Health Compendium.
 DISEASE CASE SUMMARY:
STREPTOCOCCUS SUIS
• Streptococcus suis  is  an important bacterial cause of zoonotic disease in both
swine (pigs) and humans in many areas of the world. The organism may be
isolated from healthy pig carriers, but reported infections in pigs due to
Streptococcus suis include arthritis, meningitis, pneumonia, septicaemia,
endocarditis, abortions and abscesses. Humans at higher risk for infection
include persons in direct contact with infected pigs or raw pig-products, including
farmers and abattoir workers, and those with pre-existing illness or
immunodeficiency. Human infection is thought to occur through cuts or abrasions
on the skin, handling infected pig material, or possibly inhalation or ingestion. In
humans, infection due to
Streptococcus suis may cause meningitis, endocarditis, pneumonia, septic
arthritis, and/or toxic shock–like syndrome.  
Information available from the WHO Factsheet: http://www.who.int/foodsafety/micro/strepsuis/en/
 DISEASE CASE SUMMARY:
RABIES
Rabies is an important preventable zoonotic disease caused by the rabies virus. The
disease is endemic in many countries, affects both domestic and wild mammals, and
is transmitted to humans through contact with infectious material, usually saliva,
via bites or scratches by a rabid animal. Rabies is present on all continents with the
exception of Antarctica, but more than 95% of human deaths occur in Asia and
Africa, most often following contact with dogs, other canines/carnivores, or bats
with rabies infection. Once symptoms of the disease develop, rabies is nearly always
fatal; WHO estimates rabies causes 60,000 human deaths per year. The high
mortality highlights the importance of the global canine rabies elimination strategy
based on dog vaccination. Rabies is 100% preventable, so humans exposed to rabid
animals should receive proper wound care and post-exposure prophylaxis including
rabies vaccine.
Additional information available in the WHO Fact Sheet: http://www.who.int/mediacentre/factsheets/fs099/en/
 DISEASE CASE SUMMARY:
DENGUE
Dengue is a mosquito-borne viral infection found in tropical and sub-tropical regions
around the world. Dengue virus (DENV) exists in four serotypes (DENV 1, 2, 3 and
4). Dengue fever has become a major international public health concern. Severe
Dengue (previously known as Dengue Haemorrhagic Fever) was first recognized in
the 1950s during epidemics in the Philippines and Thailand. Today, severe dengue
affects many Asian and Latin American countries and is leading cause of morbidity,
hospitalization and death among children. Control strategies have focused mainly on
vector control, and enhanced disease surveillance. No vaccine has yet been shown to
be effective against all four DENV serotypes. DENV transmission in forest monkey
occurs, but human infection is sufficient to maintain transmission cycles in cities,
particularly in crowded urban areas where mosquito vectors breed in uncovered
water storage containers, flower vases, metal cans, or in discarded glass bottles,
plastic containers or auto tires containing water.
Information available from the WHO Factsheet: http://www.who.int/mediacentre/factsheets/fs117/en/index.html
Free down load at: sourceforge.net/projects/tuftsvue/files/latest/download
African Proverb
 SUMMARY

• Prevention and control of infectious

diseases is in your hand
• Partnership and collaboration is a key
to success
• The path forward requires a system,
resources, and courage
Risk Assessment Principles
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
 RISK ANALYSIS

Risk Analysis addresses/differentiates between:

• Perception vs. Reality

• Fate vs. Probability

• Risk = Likelihood X Magnitude

Source: D. Travis and B. Wilcox. 2012. MODULE VIII: EMERGING ZOONOTIC

DISEASE RISK. EZD Short Course, April 2012, Hanoi
 GENERAL CONCEPTS OF RISK

• Identify Hazard(s) = what, specifically, are we concerned

about?

• Assess Vulnerability = of whom?

• Assess Impact = likelihood and magnitude

Source: D. Travis and B. Wilcox. 2012. MODULE VIII: EMERGING ZOONOTIC

DISEASE RISK. EZD Short Course, April 2012, Hanoi
DIFFERENT TYPES OF RISK ANALYSIS

Source: D. Travis and B. Wilcox. 2012. MODULE VIII: EMERGING ZOONOTIC DISEASE RISK. EZD
Short Course, April 2012, Hanoi
 RISK ASSESSMENT MODEL

Risk = Chance x Hazard x

Exposure x Consequence
The quality of the Risk Estimates depends on the quality of the input
FUNDAMENTAL CONSTRAINTS IN RISK
ANALYSIS
• Data Availability/Quality
• Great models rarely make data better
 OVERALL RISK ASSESSMENT
PROCESS

Hazard Pathway
WHAT HOW

Release
Assumptions
Exposure Model Rating scale
Consequences Uncertainty

Risk Characterization
 RISK ASSESSMENT PROCESS

• Problem Formulation
• Hazard Identification
• Exposure Assessment
• Dose/Response
• Risk Characterization
• Risk Management
 PROBLEM FORMULATION

• What risk are you going to evaluate?

• What are the chances of wining the lottery?
• What is the risk of getting hit by a meteor?
• What is the risk of getting lung cancer if I smoke three packs of
cigarette per day?
• What is the risk of a Nipah virus outbreak in villages in Bangladesh
which tap date palm trees?
 HAZARD IDENTIFICATION

• Identify the pathogen and human illness and disease

• Characterize the pathogen
• Case fatality
• Transmission routes
• Incubation periods
 SOURCES OF DATA

• World Health Organization

• International Agency for Research on Cancer (IARC)
• USEPA Integrated Risk Information System (IRIS)
• Other governmental agencies
• Scientific literature
• RAIS Risk Assessment Information
 EXPOSURE ASSESSMENT

• Identifies potentially affected population

• Determines exposure/transmission pathways
• Estimate dose of exposure
• Estimate exposure factors such as contact rates and the
frequency and duration of exposure
• Estimate physiological parameters such as inhalation and
ingestion rates, absorption rates, body weight, and life
expectancy
ROUTES OF EXPOSURE

Ingestion Dermal Inhalation

RISK FACTORS
SUBPOPULATIONS OF POTENTIAL
CONCERN
 DOSE RESPONSE

• Quantitative relationship between likelihood of adverse

effects and the level of exposure
• Invective Dose – ID50
• Lethal Dose - LD50
All substances are poisons;
There is none which is not a poison.
The right dose differentiates
A poison and a remedy.

Paracelsus
(1493-1541)
 RISK CHARACTERIZATION

• Summarize the numerical risk estimates for all exposure

scenarios and receptor groups evaluated
• Identify the major risks, and the pathways and chemicals
most responsible
• Review the nature of the potential adverse health effects
 Infectious Disease Risk Analysis Factors
Agent or Route(s) of Methods of Result of Population
Disease transmission exposure or contact Dynamics
contact

Pathogenicity Potential
Agent class for spread
Air borne
Direct contact
Infectivity (ID50)
Vector borne
Reservoir Cross contamination
Virulence (LD50)

Environmental factors contributing

Exposure dose
to agent survivability
(Amount X Time X Route)

Host susceptibility
 RISK MANAGEMENT

• Process of evaluating alternative

options and selecting among them; a
risk assessment may be one of the
bases of risk management
 RISK COMMUNICATION

Audience:
• Management
• Government
• Public
RISK ASSESSMENT: QMRA WIKI
Quantitative Microbial Risk Assessment (QMRA) Wiki
 EXERCISE

• In teams of 4 or 5, review one of the case studies from http

://qmrawiki.msu.edu/index.php?title=Case_Studies#tab=Q
MRAII_Workshop
• Each group has 30 minutes to review a case study and
determine what type of data was used in each component,
and what was the source of the data.
• Be prepared to present your results
 Collect Community-Based Data to
Support Infectious Disease
Investigations or Risk Assessments
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
 FIELD TRIP

• Guideline is available in http://

www.uic.edu/depts/crwg/cwitguide/04_EvalGuide_STAGE
2.pdf
(Method 7)
• Purposes
• To learn about the types of information that can be obtained using
data collected about a community
• To understand when community measures are useful to evaluation
 FIELD TRIP

• Advantages
• Evaluate the issue the context of a community
• Help in understanding the broader impact of the issue
• Some types of data are collected regularly and are publicly
available
 FIELD TRIP

• Disadvantages
• Data may be difficult or time-consuming to locate
• May be limited to qualitative data
• Data are limited to what has already been collected previously
and may not be relevant
 FIELD TRIP ASSIGNMENT

• Prior to the field trip, learn about disease (e.g., acute

gastroenteritis due to E. Coli or other infectious agent)
• Assume outbreak in the neighboring community among
school-aged children and elderly. The potential source of
the E. Coli outbreak is under-cooked hamburger meat
served in institutional settings. It is possible that same
batch of hamburger patties was sent to community, but no
method to check batch numbers. What is the risk of
outbreak in this community? Create a plan to:
• Determine what are the important issues about E. Coli and impact
possible in community
• What are potential points of exposure?
 PREPARING FOR A FIELD TRIP

• Steps for planning to use community measures

• Review the objectives and research questions to determine whether
community measures are useful to your evaluation
• Determine the type of data about the community that would be useful to
obtain
• Evaluate the available data and determine if additional information is
needed
• Design appropriate, standardized instrument to collect data, pilot test and
train on the use of questionnaire
• Conduct data collection
• Obtain proper permission from local health authorities, keep village elders
informed (consider using local guide)
 FIELD TRIP

• Tips for using community measures

• Community data are available from a variety sources i.e. agency,
www, government, local government
• Pay attention to how, when, and where the data was collected
• Interpreting data that was not collected by others requires caution
 DEVELOP A RISK ASSESSMENT

• Assemble the data gathered from the community and from

other sources
• Characterize the hazard
• What are the potential sources and exposure pathways in the
community
• What is the important information about dose for this pathogen
• How would you characterize the potential risks in this community
Developing Infectious Disease and
Public Awareness Materials
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
TOPICS FOR TODAY’S DISCUSSION

• Key Concepts
• Components:
• Audiences
• Messages
• Materials/approaches
• Example(s)
 KEY CONCEPT

• Public awareness:
• Informing
• Sensitizing
• Drawing attention of community to a particular issue
through awareness materials
 AUDIENCES

• To have effective material, target audiences should

be carefully identified
• Some educational topics, material and approaches
may suit a broad spectrum of audiences, but in
other activities should be tailored to a specific
audience
• Consider a One Health perspective
 TYPE OF AUDIENCES

• Children/Teenagers/Adults
• General / specific audiences
• Government sectors
 MESSAGES

• Messages delivered should be appropriate for each

target audience
• After analyzing your audience, design and
package your messages accordingly
• Standard rules:
• Keep it simple and short, but interesting
• Avoid unnecessary/ meaningless words
 PREPARING EFFECTIVE MESSAGES
• Concise: As few words as possible, but no fewer
• Clear: Your grandparents can understand it
• Compelling: Explains the problem
• Credible: Explains how you solved the problem
• Conceptual: Not unnecessary detail
• Concrete: Specific and tangible
• Customized: Addresses audience’s interests
• Consistent: Same basic message
• Conversational: Aims to engage the audience
 KEY CONTENTS

• General information about infectious diseases

• Pathogen
• Host
• Vector
• Route(s) of transmission/transmission dynamics
• Disease symptoms
• Risk factors
• Protection and prevention
 MATERIALS/APPROACHES

• Seminars/ workshops/ conferences

• Exhibitions
• Publications (posters, guidelines, flyers, brochures, booklets, activity
books, paper models, comic books, story books, coloring books)
• Public awareness events (Visitors' / field days)
• Media (newspapers, radio, TV)
• Websites and other internet based tools
• Social media (Facebook, Twitter, YouTube, LinkedIn, blogs)
• Performing and cultural arts (plays, dances, poems, songs, street
theatre, puppet theatre)
• International day
 SEMINARS, WORKSHOPS AND CONFERENCES

• Discussions with target audiences on specific themes

• Develop common understanding
• Develop strategy or plan action
• Improve interaction
• Ensure participation in decision-making
• Facilitate identification of problems
• Deliver general information to target audiences
• Invite questions and discussion from audiences
 EXHIBITIONS

• Present and demonstrate the information to mixed audience in

various ways
• Allow interaction with public
• Inform and get instant feedback
• International, national and local exhibitions
• Create general public awareness
• Attract government and public support
• Providing info on org and its activities
• Promote networking
• Identify new clients/beneficiaries and potential partners
 VISITORS AND FIELD DAYS

• Gather information about target audience(s)

• Develop message to meet their interests
• Decide how to present message
• Wall-mounted exhibits
• Posters
• PowerPoint presentations
• Automatic audio-visuals/computer displays practical
demonstrations, field tours
• Provide comfortable environment
• Space for face-to-face interaction
• Seats for longer discussions
 SOCIAL MEDIA

• Good way to engage and maintain relationships with the public

• Use various tools to deliver targeted message: Facebook,
Twitter, YouTube, LinkedIn, Blogs
• Agree with your team about which tools are to be used
• Can be demanding, requires dedication
• Keep engaged, innovative, up-to-date
• Follow-up on messages/requests; Check on your contacts
• Feed your blog posts
• Engage prominent personalities
EXAMPLE OF PUBLIC AWARENESS
MATERIAL
EXAMPLE OF PUBLIC AWARENESS
MATERIAL

Source: ericaglasier.com
EXAMPLE OF PUBLIC AWARENESS
MATERIAL

Source: unicef.org
 ASSIGNMENT

Develop a public awareness message

• What is the infectious disease that you want to conduct the
public awareness for?
• Who is the target audience(s)?
• What are the messages that you want to deliver to the target
audience(s)?
• What is the best method for relaying these messages? What
types of materials are appropriate?
• How might we adapt the material to the target audience(s)?
 DELIVER YOUR PUBLIC
AWARENESS MESSAGE
Create a plan for delivering your public awareness message at a
specific activity:
• Location
• Objectives
• Audient profile
• Primary issues to be discussed or highlighted
• Speakers or other participants
• Target number of expected attendees
• Language to be used
• Documents and materials to be distributed
 DEBRIEFING

• What problems did you encounter when you introduced

the material to the target audience(s)?
• How well did the target audience(s) understand the
messages delivered by your material?
• What was the feedback you received from the audience(s)?
Critique of an Infectious Disease
Management Plan from a
One Health Perspective
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
 TOWNSEND ARTICLE

• What led to the introduction of rabies in Bali, Indonesia?

• What are possible interventions to consider including in a
rabies management plan?
• What is R0? What is the calculated R0 for rabies in this paper?
• Reduction of dog density is discussed as a possible rabies
management measure. What do the authors conclude about
this for a management plan and why?
• What are the dog vaccination campaigns discussed in the
paper and how would their use in a management plan vary?
 TOWNSEND ARTICLE (CONTINUED)

• In what ways does the rabies management plan discussed in

the paper use a One Health approach?
• What aspects of this management plan could be improved
from a One Health perspective?
 Systemic Effects of a
Disease Management Plan
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
 DISCUSSION QUESTIONS

• Why are ducks important to consider in the transmission

of avian influenza?
• How many ducks contribute to the spread of avian
influenza to humans?
• Why was duck culling part of the management plan for
controlling avian influenza in Thailand?
Infectious Disease Surveillance
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
 LEARNING OBJECTIVES

• Understanding core concepts in surveillance methods

• Describe the components and methods for evaluating
public health surveillance system
 EFFECTIVE: “SMART” OBJECTIVES

• S = strategic
• M = measurable
• A = adaptable
• R = responsive
• T = targeted
 OBJECTIVES OF “SMART” DISEASE
SURVEILLANCE

• Identify key drivers of zoonotic disease emergence

• Detect disease outbreaks
• Forecast events that may lead to disease emergence
• Assist governments in the development of preventive
strategies
• Establish a sustainable, global early-warning
 OBJECTIVES OF PUBLIC HEALTH
SURVEILLANCE

• To reduce morbidity, mortality and to improve the

public’s health
• To guide logical and effective public health action,
based on timely and accurate information
• Strengthen program planning and evaluation
• Formulate priorities, research hypotheses
 EXAMPLES OF TYPES AND SOURCES OF
DISEASE SURVEILLANCE DATA

• Field surveillance: data collected in the field, both

quantitative and qualitative data
• Digital surveillance data: data collected through
automatic web-based monitoring
• Active surveillance: enhanced activities to search
for new or existing cases of disease at a health
facility or in community
 COMPONENTS OF DISEASE
SURVEILLANCE: CORE ACTIVITIES

Detection Registration Reporting

Confirmation Analysis Feedback

 COMPONENTS OF DISEASE
SURVEILLANCE: SUPPORT ACTIVITIES

Communication Supervision

Resource
Training
Promotion
PURPOSE OF EVALUATING PUBLIC HEALTH SURVEILLANCE
SYSTEMS

…to ensure that problems of public health

importance are being monitored efficiently and
effectively

… to ensure that managers have accurate and

timely health information to enable “informed”
decision-making to improve disease prevention &
control activities
 EVALUATING PUBLIC HEALTH
SURVEILLANCE SYSTEMS

Public health surveillance systems should be

evaluated periodically, and the evaluation should
result in recommendations useful to improve the
quality, efficiency, and usefulness of disease
prevention and control activities
EVALUATION OF DISEASE SURVEILLANCE SYSTEMS: SELECTED
CRITERIA

• Simplicity • Accuracy
• Flexibility • Positive predictive value
• Acceptability • Representativeness
• Sensitivity • Sustainability
• Specificity • Timeliness
 SIMPLICITY: DEFINITION

• The simplicity of a public health surveillance

system refers to both its structure and ease of
operation
• Disease surveillance systems should be as simple
as possible while still meeting their objectives
 FLEXIBILITY: DEFINITION

A flexible public health surveillance system can adapt

to changing information needs, operating conditions,
or new diagnostic tests or criteria -- with little
additional time, personnel, or allocated funds.
 FLEXIBILITY: DEFINITION
• Flexible systems can accommodate, for example, new
health-related events, changes in case definitions or
technology (including new diagnostic tests, rapid
tests), and variations in funding or reporting sources
• Use of standard data formats (e.g., in electronic data
interchange) can be integrated with other systems
 FLEXIBILITY: METHODS

• Flexibility is probably best evaluated

retrospectively by observing how a system has
responded to a new demand
• Animal and human health professionals are an
excellent source of information about disease
surveillance systems
 DATA QUALITY: DEFINITION

Data quality reflects the completeness and validity

of the data recorded in the public health
surveillance system
 DATA QUALITY: METHODS

• Examining the percentage of "unknown" or "blank"

responses to items on surveillance forms is a
straightforward and easy measure of data quality
• A full assessment of the completeness and validity of
the system's data might require a special study
 DATA QUALITY: METHODS

• Data values recorded in the surveillance system can be

compared to "true" values:
• a review of sampled data
• a special record linkage
• patient interview
• calculation of sensitivity and predictive value positive
 ACCEPTABILITY: DEFINITION

Acceptability reflects the willingness of persons and

organizations to participate in the surveillance system
 ACCEPTABILITY: METHODS

Quantitative measures of acceptability:

• Subject or agency participation rate (if it is high, how quickly
was it achieved?)
• interview completion rates and refusal rates (if the system
involves interviews)
• Completeness of report forms
• Physician, laboratory, or hospital/facility reporting rates
 ACCEPTABILITY: METHODS

• Accurate
• Consistent
• Complete
• Timely
 FACTORS INFLUENCING
ACCEPTABILITY
• The public health importance of the health-related event
• Acknowledgment by the system of individual
contributions
• Dissemination of aggregate data back to reporting
sources and interested parties
 FACTORS INFLUENCING
ACCEPTABILITY

• Responsiveness of the system to suggestions or

comments
• Burden on time relative to available time
• Ease and cost of data reporting
• Federal and state statutory assurance of privacy
and confidentiality
 FACTORS INFLUENCING
ACCEPTABILITY
• The ability of the system to protect privacy and
confidentiality
• Federal and state statute requirements for data
collection and case reporting
• Participation from the community in which the
system operates
 SENSITIVITY: DEFINITION

• First, at the level of case reporting, sensitivity

refers to the proportion of cases of a disease (or
other health-related event) detected by the
surveillance system
• Second, sensitivity can refer to the ability to
detect outbreaks, including the ability to monitor
changes in the number of cases over time
 SENSITIVITY: METHODS

• Certain diseases or other health-related events

occurring in the population under surveillance
• Cases of certain health-related events are under
medical care, receive laboratory testing, or are
otherwise coming to the attention of institutions
subject to notifiable disease reporting requirements
 SENSITIVITY: METHODS

• The health-related events will be diagnosed/

identified, reflecting the skill of health-care
providers and the sensitivity of screening and
diagnostic tests (i.e., the case definition)
• The case will be reported to the disease
surveillance system
 POSITIVE PREDICTIVE VALUE:
DEFINITION

Predictive positive value (PPV) is the proportion

of reported cases that actually have the disease of
interest or health-related event or condition
under surveillance
POSITIVE PREDICTIVE VALUE:
METHODS

Source: wikipedia.com
REPRESENTATIVENESS: DEFINITION

A disease surveillance system is representative if it

accurately describes the occurrence of a disease or
other health-related event, and the reported
distribution of disease accurately represents that
occurring in the population by time, place and person
 REPRESENTATIVENESS: METHODS

• Representativeness is assessed by comparing the

characteristics of reported events to all such actual
events
• Representativeness can be examined through
special studies that seek to identify a sample of all
cases
• One aspect to consider is what proportion of all
districts or provinces actually report the disease
 TIMELINESS: DEFINITION

Timeliness reflects the speed between steps in a

public health surveillance system:
• For example, in cases with disease of interest:
the time interval(s) between date of symptom
onset, or hospitalization, or diagnosis vs. the
date case was reported to disease surveillance
system
 TIMELINESS: METHODS

The timeliness of a public health surveillance system

should be evaluated in terms of availability of
information useful to improve control of a health-
related event, including prevention of high risk
exposures, implementation or strengthening early
diagnosis or vaccination, as well as program planning
 TIMELINESS: METHODS

• Increasing use of electronic data collection from

reporting sources (e.g., an electronic laboratory-
based surveillance system) or via the Internet (a
web-based system), or use of electronic data
interchange by surveillance systems, may
promote timeliness
• Internet security, confidentiality, privacy and
limiting access to only authorized personnel
must be considered
 STABILITY: DEFINITION

Stability refers to the reliability (i.e., the ability to

collect, manage, and provide data properly
without failure) and availability (the ability to be
operational when it is needed) of the public health
surveillance system over time, independent of
challenges posed by availability of funding,
resources, or other changes
 STABILITY: METHODS

• The number of unscheduled outages and down times for

the system's computer
• The costs involved with any repair of the system's
computer, including parts, service, and amount of time
required for the repair
• The percentage of time the system is operating fully
• Is the system able to function even after funding or other
resources become limited?
 STABILITY: METHODS

• The desired and actual amount of time required for the system
to collect or receive data
• The desired and actual amount of time required for the system
to manage the data, including transfer, entry, editing, storage,
and back-up data
• The desired and actual amount of time required for the system
to release data
 ASSIGNMENT:
SURVEILLANCE WEBSITES

• Select a surveillance website

• WHO http://www.who.int/topics/public_health_surveillance/en/
• U.S. CDC http://www.cdc.gov/surveillancepractice/
• ECDC http://www.ecdc.europa.eu/en/activities/surveillance/Pages/index.aspx
• Answer the questions on the following slides
• Prepare a 10-minute presentation
 QUESTIONS

• What is the population under surveillance?

• What is the period of time of the data collection?
• What data are collected and how are they
collected?
• What are the reporting sources of data for the
system?
 QUESTIONS

• How are the system's data managed

(e.g., the transfer, entry, editing, storage, and
back up of data)?
• Does the system comply with applicable
standards for data formats and coding schemes?
If not, why?
 QUESTIONS

• How are the system's data analyzed and

disseminated?
• What policies and procedures are in place to
ensure patient privacy, data confidentiality, and
system security?
• What is the policy and procedure for releasing
data?
 QUESTIONS
• Do these procedures comply with applicable federal
and state statutes and regulations, and/or
international standards? If not, why?
• Does the system comply with an applicable records
management program? For example, are the system's
records properly archived and/or disposed of?
 QUESTIONS

• Are these surveillance systems (WHO, US CDC or ECDC)

effective? Why is it effective? or Why is it not effective?
 SUMMARY
• All public health surveillance systems should be evaluated
periodically
• No perfect system exists; tradeoffs must always be made
• Each system is unique and must balance benefits versus
personnel, resources, and costs required
• Ensure use of evaluation findings and share lessons learned
• Systems should be an excellent source of accurate and timely
information for program managers
Analyzing Surveillance Data using
HealthMap
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
www.healthmap.org
HEALTHMAP DATA ASSIGNMENT

• Select a disease that has more than 10 reports globally or

in your region of interest
• Look at surveillance data for the past year
• Collect the following information
• Disease  

• Countries included (can be national, regional or global)

• Species of host affected
• Total reports of the disease for the year
• Total cases of disease in each affected species
 REPORT TO A LOCAL HEALTH
DEPARTMENT: ASSIGNMENT
• Prepare a 15 to 20 minute mock scientific report that you will give
to a local health department concerned with the disease:
• Using surveillance data perform the following analysis:
• Provide pertinent background information about the disease
• Create a global, regional, or country level map showing the outbreaks
for the year
• Create a chart or other graphic to display the number of cases or
outbreaks reported by week or by month
• Create a chart or other graphic to display the number of cases by host
species over the year
 REPORT TO A LOCAL HEALTH
DEPARTMENT ASSIGNMENT (CONTINUED)

• Using surveillance data perform the following analysis:

• Analyze data in the disease reports to determine likely sources and
numbers of disease reports
• Analyze data in the disease reports to determine likely sources of the
disease and transmission routes
• Create a map, system diagram, or other visual aid to show transmission
and risk factors gathered from the disease surveillance data
• Form a conclusion from the surveillance data about the current status
of the disease. Include any information collected about control of
intervention measures mentioned in the reports
Developing a Management and
Surveillance Plan
I N F E C T I O U S D I S E A S E M A N A G E M E N T,
O N E H E A LT H C O U R S E
 H5N1 SCENARIO

The first reports:

• Rumors of an outbreak of unusually severe respiratory illness in
two villages in a remote province prompted the World Health
Organization (WHO) to dispatch a team to investigate. The
team found that people in the villages had been falling sick for
about a month and that the number of persons with acute illness
(i.e., “cases”) had increased each day. The team was able to
identify at least 50 cases over the previous month; all age-groups
had been affected. Twenty patients are currently in the
provincial hospital. Five people have already died of pneumonia
and acute respiratory failure.
 
 H5N1 SCENARIO (CONTINUED)

Specimens sent to the laboratory to establish etiology:

• Surveillance in surrounding areas was enhanced, resulting in new
cases being identified throughout the province. Respiratory specimens
collected from several case-patients were tested at the national
laboratory and found to be positive for type A influenza virus. Isolates
sent to the WHO Reference Centre were found to be a subtype of an
influenza A (H5N1) never isolated from humans before. Gene
sequencing studies further indicate that most of the viral genes are
from a bird influenza virus, with the remaining genes derived from a
human strain. More cases appeared in surrounding towns and villages.
•  
 H5N1 SCENARIO (CONTINUED)

Spread to neighboring countries and quarantine attempts:

• The new strain of influenza virus begins to make headlines in every
major newspaper, and becomes the lead story on news networks.
Countries are asked by WHO to intensify influenza surveillance and
control activities. Key government officials throughout the region are
briefed on a daily basis, while surveillance is intensified. Over the next
two months, outbreaks began to take place in neighboring countries.
Although cases are reported in all age-groups, young adults seem to be
the most severely affected. One in every 20 patients dies. The rate of
spread is rapid, and countries initiate travel restrictions and quarantine
measures.
 H5N1 SCENARIO (CONTINUED)

Social effects:
• Educational institutions are closed. Widespread panic begins because
supplies of antiviral drugs are severely limited and a suitable vaccine is
not yet available. One week later, there are reports that the H5N1 virus
has been isolated from airline passengers with respiratory symptoms
arriving from affected countries.
 H5N1 SCENARIO (CONTINUED)

Other continents affected:

• A few weeks later, the first local outbreaks are reported from other
continents. Rates of absenteeism in schools and businesses begin to
rise. Phones at health departments ring constantly. The spread of the
new virus continues to be the major news item in print and
electronic media. Citizens start to clamor for vaccines, but they are
still not available. Antiviral drugs cannot be obtained. Police
departments, local utility companies and mass transit authorities
experience significant personnel shortages that result in severe
disruption of routine services. Soon, hospitals and outpatient clinics
are critically short-staffed as doctors, nurses and other healthcare
workers themselves become ill or are afraid to come to work.
 H5N1 SCENARIO (CONTINUED)

Other continents affected (continued):

Fearing infection, elderly patients with chronic medical conditions do not
dare to leave home. Intensive care units at local hospitals are overwhelmed,
and soon there are insufficient ventilators for the treatment of pneumonia
patients. Parents are distraught when their healthy young adult sons and
daughters die within days of first becoming ill.
Several major airports close because of high absenteeism among air traffic
controllers. Over the next 6-8 weeks, health and other essential community
services deteriorate further as the pandemic sweeps across the world .
 H5N1 SCENARIO (CONTINUED)

Assignment
• What is your role in this scenario?
• What is the role of each stakeholder in this scenario?
• How does the scenario affect the stakeholder that you are
representing?
• How can each stakeholder’s response to the infectious disease in this
scenario influence the management of the disease? 
• Who are the other stakeholders you will need to deal with in order to
manage a particular infectious disease?
 H5N1 SCENARIO (CONTINUED)

Roles
• Villagers of Village 1 and 2
• Healthcare workers
• WHO team
• Laboratory workers
• Government officials
• Transportation security administrator
 WHAT DO YOU THINK?

• How effective was the One Health team in developing the

management plan for the scenario disease?
• What were the problems encountered from the perspective
of each stakeholder?
• What soft skills are needed to ensure a high functioning
One Health team?
 Module Review
M A N A G E M E N T, O N E H E A LT H C O U R S E
 ONE THING..

• …. That you liked/believed was a strength of the

module.
• …. That you would suggest we change

Thank you.