Greetings! Dr. Sophia Campbell from Riverside Memorial Medical Center let me know that you were available to help us handle a new outbreak we just identified -- 14 new cases of cocci. We don't know what's happening with this one yet, so it's a great time to have you on board to help us. Apparently we are especially lucky to have you given your experience with a patient who may be related to this outbreak. We know the patient only as "E.C." because, for confidentiality purposes, we receive initials of patients, not their full names...but you probably know who we are referring to.

When we have a new outbreak, we have several objectives we need to tackle, which you'll be responsible to work on throughout your rotation with our Cocci Investigation Team (CIT). Specifically, you will need to determine the cause of the outbreak; craft a message to give to the public and scientific communities about it; and develop a management and prevention plan to contain the outbreak as much as possible. The first step, though, is to do initial work on determining the cause (we call this phase of work the "investigation"). If we know what is getting people sick, we can develop an effective management and prevention plan.

Your Job

To start the investigation, there are three things you need to do:

• First, start brainstorming hypotheses about what might be causing the outbreak based on what we know so far. When we begin an investigation, we need to know what we are looking for. To help determine what information we need to seek, we need to have some ideas of what might be causing the outbreak. For example, if we thought it was coming from something the ill people ate, we'd want to know what they have been eating. By brainstorming possible causes, you'll see what additional information we need to obtain. We'll revisit your hypotheses as we gain more knowledge.
  
  
• Second, develop a case definition. The case definition establishes a uniform set of criteria to help us determine if a person should be included as part of the outbreak, and thus, as part of our investigation. If someone is sick but not in pretty close to the same ways as the others in the outbreak group, perhaps that person is not ill from the same cause. Similarly, if the outbreak only seems to be striking the elderly, but a child comes down with a similar illness, we use the case definition to determine whether the person is really part of the outbreak, or to change our case definition! The case definition will also be critical to help us send an appropirate alert out to medical professionals to let them know what to look for.

• Third, you’ll need to develop a questionnaire to use in a phone survey with the potential case-patients. In order to determine which or whether any of your hypotheses are on track, and to drive down to a very specific root cause of the outbreak, you'll need a lot more information about the current cases.

I have attached the background information we collected on the 14 new cases. You should also use E.C.’s discharge summary from your time at Riverside Memorial. Use the information about the case-patients, what you know about cocci from your experience with E.C., and other information you find about developing surveys to complete the questionnaire.

Importance of your work

The medical community needs to know about this outbreak right away; even though cocci is not always severe, there may be people at risk and physicians need to know to be on the look-out. So, I’ll be sending an alert on Epi-CS - the system we use to quickly notify medical professionals of potential outbreaks. I’ll include the case definition you provide as part of the alert. If there are more cases out there physicians will respond to the alert and let us know they've seen a patient who is a potential case, which will in turn help us gather more information to learn more about this outbreak. All of this will help us to best manage and contain it.

The public is also a concern. Parents need to know if their kids are at risk of becoming seriously ill and what is causing the illness, but we can’t send people into a panic when we don’t know what is causing this or who is at risk for getting the disease. For now, I will just send the Epi-CS alert to medical professionals, once you provide the case definition. As we move forward you will need to think about the best time to communicate to others about this situation and what we should specifically tell them.

Additional Responsibilities

In addition to working on this critical outbreak situation, I’m also assigning you to the NDCC Statistics Group. They are responsible for answering questions from others within the NDCC about statistics-related issues on which they need help. You will be responsible for answering some of those questions. This may not be an area you are familiar with, so the exposure you will get working with the Statistics Group will help you in the work you will be doing on the CIT. Cecilia Young is the lead of the Statistics Group; she will be contacting you with more information soon.

Again, we're delighted to have you working with us, and we will help in whatever ways you need. You will contribute a great deal to our efforts.

Sam Lyons, M.D.