Initiating Operations

Depending on the extent and complexity of the outbreak or problem and the main purpose(s) of the field investigation initially discussed, subsequent communications between invitees and inviters should focus on clarifying the investigation’s main objectives and the roles and responsibilities of key persons.

• What are the main public health questions the field investigation needs to answer? The primary purpose of field investigations in response to outbreaks or other urgent public health events is to identify control and prevention measures.
• What is the status of the Incident Command System (ICS) and local Emergency Operations Center (EOC) (see also under Other Issues)? Have they already been activated or are likely to be activated? If so, what will be the role of the field team?
• What epidemiology, laboratory, and other resources (including personnel) will the jurisdiction requesting assistance provide?
• What resources will the visiting team and responding agency provide?
• Who will supervise the day-to-day investigation?
• Who will provide overall direction and ultimately be responsible for the investigation?
• Who will be the media point person for the investigation?
• Who will be responsible for data analyses, and how will data be shared?
• Who will write a report of the findings, if needed? To whom will it be disseminated?
• Who will be the lead and senior authors, if field investigation results warrant publication in a peer-reviewed journal or presentation at a scientific venue?

Not all of these crucial problems can be resolved before the field team arrives or the investigation concludes. However, they must be addressed, discussed openly, and agreed on as soon as possible.

Many field investigations require laboratory support. Even if local laboratories are available and capable of processing and testing specimens, invited epidemiologists should immediately contact their laboratory counterparts within their agency to share details of the problem and discuss specimen types, collection, processing and testing, and potential basic or applied research questions that can be appropriately addressed and answered during the field investigation. Early enlistment of laboratory collaboration and support, at both the local level and at the invited agency, is crucial to the success of many field investigations.

The same early consideration applies to statistical support and contacting other health professionals, such as behavioral scientists, veterinarians, mammalogists, entomologists and vector-control specialists, environmental health specialists, and infection prevention and control practitioners, whose expertise can be crucial to a successful field investigation. The invited agency should consider including such professionals on the field team so that appropriate data and environmental specimens can be collected at the same time as other relevant epidemiologic information.

After the field team is chosen, the invited agency should take the following key measures to prepare the team:

• Identify the team leader and the senior staff at the agency home base to whom the team leader should report.
• Meet with all proposed field team members and home-based staff to review details of the public health problem, nature of the request for assistance, current knowledge of any suspected pathogen or disease, goals and objectives for the field investigation, and preliminarily agreed-on roles and responsibilities.
• Arrange in advance an initial in-person meeting with the requestor (e.g., the State Epidemiologist) or persons designated by the requestor (e.g., local senior health officials and epidemiologists). This contact ensures that local authorities are not surprised by an unexpected arrival and underscores for all parties the need for advance planning and orderliness in the investigation, which will set the tone for the conduct of the investigation.
• Write a memorandum for the record or to relevant key officials, which should be done by a senior member of the team before leaving for the field that summarizes the following points:
  • How and when the request was made.
  • What information the requesting health agency has provided.
  • What the agreed-on purpose is of the investigation.
  • What the commitments are of both the visiting team and requesting health officials.
  • Who will be members of the field team.
  • When the team is expected to arrive in the field.

This memorandum should be distributed to key personnel in the offices of the visiting team and the requesting host agency and to others who need to know. The memo serves not only as notification to everyone, but also as a method to prevent redundant responses. It will also identify expertise and resources from other programs that might contribute to the investigation. Even when a problem does not directly involve a state (for example, an investigation on tribal land or at a federal facility), an array of state and local officials typically are notified because of possible ramifications to populations in surrounding communities.

• Review a basic checklist with each team member before departing to ensure they have materials and aids essential for field operations and have covered fundamental travel and logistic considerations. A partial list includes the following items:
  • Cell phones with key contacts
  • Laptop computers with appropriate software (e.g., Epi Info, SAS, or R)
  • Digital cameras
  • Credit cards
  • Travel and lodging reservations
• Review with each team member before leaving the need for any necessary personal protective measures, such as vaccinations; antimalarial prophylaxis; antimicrobials or antivirals for postexposure prophylaxis; and personal protective equipment, including face masks or respirators, gloves, and gowns.

The field team needs to keep in mind its role as consultant or collaborator. The guiding principle should be that the field team is there to provide help but not to take charge. Equally important is the need to balance the focus of the investigation with the competing priorities of the requesting jurisdiction. Although the immediate problem is the team’s sole concern, local health officials must continue to address a myriad of other local priorities and ongoing problems. The team needs to try to understand and appreciate the local viewpoint early in the investigation.

After arriving on site, the team should meet promptly with the official who requested assistance and his or her key staff. At this meeting, essential steps include the following items:

• Review and update the status of the problem.
• Identify or review the primary points of contact.
• Identify a principal local collaborator who also can serve as what might be termed a “guardian angel” to facilitate and coordinate local contacts and team needs.
• Identify or confirm availability of local resources (e.g., office space, clerical support, assistance for surveys, and laboratory support).
• Create a method and schedule for the team to update local officials and home base.
• Review sensitivities, including potential problems with institutions and individuals (e.g., hospitals, administrators, practitioners, and local public health staff) likely to be encountered during the investigation. Meeting the requesting official at the outset should ensure that key doors will be opened, rather than spending valuable time later in the investigation mending fences.

Because large outbreaks are likely to attract media attention, the presence of an experienced and knowledgeable public information officer (PIO) who can respond to public inquiries and regularly meet the media is invaluable. In the United States, the inviting local or state health department often has its own PIO who can serve as the media point person for the investigation. During the initial meeting, the local PIO should be identified. The field team should avoid direct contact with the news media and defer to local health officials. The field team essentially is working at the request and under the authority of the local health officials. The local officials not only know and appreciate the local situation, but also are the appropriate persons to comment on the investigation.

Because of the potential complexity of field investigations, as well as the distracting circumstances under which they typically are conducted, the field team leader might want to take the following approaches to ensure the systematic and orderly progression of the investigation:

• Maintain lists of necessary tasks, check off completed actions, and update the list at least daily.
• Communicate frequently with other field team members, requesting official, and designated media contact, and hold a team meeting each day at a regularly scheduled time. Communicate with home base senior staff as often as needed.
• Request additional help, without hesitation, as required by the circumstances.
• Avoid setting a departure date in advance or succumbing to the pressure of team family members to return earlier to ensure the investigation will be completed.

Investigations of large and complex problems can be particularly challenging for field teams and require even more rigorous organization of field operations. The following practical pointers can help designated team leaders manage key aspects of the investigation:

• Record the team’s decisions as they are made. This will help to ensure consistency and make the investigation reproducible, a consideration particularly important to case definitions and why certain criteria were used.
• Remember the need for quality control measures, such as training and monitoring of data collectors and abstractors, including conducting error checks, validating data independently, and evaluating nonrespondents and missing records.
• Resist collecting more data than are needed (e.g., excessive clinical details); focus on accomplishing the investigation objectives.
• Write continually while the investigation is ongoing and before key details are forgotten.
  • Write the background section of the report.
  • Write the methods as they are being defined and developed by team members; keeping a decision log helps.
  • Maintain and retain an inventory of data files.
• Assess data continually to determine when enough is known to make or update recommendations for control and prevention measures (see Chapter 11).
• Make a special effort to maintain morale and to provide ongoing encouragement, positive reinforcement, and appreciation to participating investigators. Because field investigations are often difficult and associated with long hours and stress, the necessity might arise to give team members breaks or periods of rest to maintain productivity.

Occasionally, after some time in the field, an investigation does not yield definite results or it identifies additional questions that require one or more subsequent investigations to address. At that point, the team leader, in consultation with home base senior staff, should assess the team’s morale and capacity to persevere to determine whether the team should continue or a fresh team should prepare to extend the investigation.

Written summaries of the investigation include both preliminary and final reports. The preliminary report fulfills the immediate obligation to the requesting official and agency. It should summarize the methods used to conduct the investigation, preliminary epidemiologic and laboratory findings, recommendations, clearly delineated tasks and activities to be completed, and acknowledgments. In addition to the preliminary report, which optimally should be delivered to the requestor on departure or earlier, the team should prepare follow-up emails or letters to other principals (e.g., local health officials or coinvestigators) to inform them and to reinforce long-term relations.

The final reports with complete and final data should be written as quickly as possible—before team members are called out to another epidemiologic field investigation! In addition to a written final report, field team members should consider other methods for communicating the findings of the investigation. Options include formal presentations in person, teleconference, or videoconference at professional meetings; presentations or media communication to local communities affected by the public health event or to the general public; and written reports for public health bulletins intended for public health practitioners (e.g., CDC’s Morbidity and Mortality Weekly Report) or comprehensive articles for peer-reviewed journals.