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Task 2.3: Analyze Questionnaire Data and Suggest Next Steps

You and your colleagues have been given a line list for 15 completed questionnaires, and asked to analyze the data in order to determine the next steps in the investigation.

For this task, you need to analyze the data provided to you in the line list. You then need to consider your options in terms of where the investigation should go next, and come to a consensus as a team as to which avenues to pursue.

The steps below will walk you through this process.

1. Meet with your team to begin the task.
   
   
2. Review the email from Dr. Lyons to confirm your understanding of the task.
   
   
3. Download and review the document attached to Dr. Lyons’ email (Line Listing, Investigation Status and Plan Template (ISP)) both to see what is there and to get a feel for what resources you have available to you in this task.
   
   
   • Please note: In the Line Listings and elsewhere throughout this rotation the "Date" for each patient is listed as a number (e.g., +1 day) rather than an actual date. In a real outbreak investigation the exact date would be provided rather than a number of days. Due to the mechanics of this rotation, the day Ella Cruz became ill is used as the reference point. The "Date" other patients became ill is the number of days before (-) or after (+) the day Ella Cruz became ill.
     
     
   • Each team member should download a copy of these documents and keep his/her own notes. Each of you may notice different things, which will be helpful to share with each other and discuss.
     
     
   • Be mindful of the fact that you will be participating in a roundtable discussion with the other teams about your plan for next steps, either as a presenter or a participant in the discussion. Prepare your ISP accordingly. (See the section on "Cross-team Conference" below for a more detailed discussion of the process.)
     
     
4. Use the Resources link (above) to do additional research as needed throughout the task.
   

Analyze Line Listing Data

1. Review the preliminary hypotheses that you generated when developing the questionnaire. Thinking just of these initial hypotheses:
   
   
   • Revise your Descriptive Epi Report to help analyze the new information. Refer to the steps in Task 2 if you need to remind yourself how to develop the DER.
     
     
   • Does any of the data you see support the initial ideas you had for a source for this infection?
     
     
   • Does any of the data you see refute those initial ideas?
     
     
2. Identify any patterns of response in the line list data.
   
   
   • Is there any question or set of questions that were answered in a similar way by a significant percentage of the case-patient group (more than 2)?
     
     
   • Is there any question or set of questions where the responses cause you to want to ask follow-up questions? For example, if a lot of respondents answered “Yes” to a gardening question, you might want to ask more specific questions about what kind of gardening they all do to find more similarities among the case-patients.
     
     
3. Identify any dead-ends that you can gather from the line listing results. Sometimes knowing where an outbreak isn’t can be just as valuable as knowing where it is.
   
   
   • Is there any question or set of questions that yield no results because you got a lot of negative or non-starter responses?
     
     
   • Is there any question (or set of questions) that has such varied responses that it could not show a pattern or expose any similarities among the case-patients?
     
     
4. Identify any new potential sources of infection from the line listing data.
   
   
   • Are there other potential sources that you see as you review the data that you didn’t identify previously?
     
     
   • Is any data moving in a direction that you hadn’t anticipated, for example toward a specific activity that you hadn’t thought of in your initial brainstorming?
     

Revise Your Hypotheses

As you have been reviewing the data in the line listing, you and your teammates have been discussing how the new information impacts your thinking about the investigation and the source of the outbreak. This means you have been informally revising the hypotheses that you came up with in Task 2.1. It is now time to formally record your current thinking about the hypotheses.

1. Download the Investigation Status and Plan (ISP) Template from the email. The “Hypothesis Development and Testing” section is where you can begin to record the possible sources of infection that you have been discussing with your teammates.
   
   
2. Your hypotheses can be any possible theory that you have for the source of the outbreak. Use formal structure to write your hypotheses. For additional support, check the Resources link (above) under “Hypothesis Development.”
   
   
3. The evidence for and against the hypothesis can be the line list or any information that you had about Cocci prior to sending out the questionnaire.
   
   
• You should note all supporting evidence, even if it seems to be balanced by refuting evidence.
  
  
• You should note where supporting evidence is not necessarily clear or valid (e.g., the questionnaire question was not clear).
  
  
• Any discrepancies between the refuting and supporting evidence can be addressed in the "Data collection and analysis" section, including any questions that are raised, and ways you can go about resolving them.

Determine the Next Steps

1. Download and print the document titled Investigation Process Flow, in the Resources link (above). There’s a recommended process for conducting an outbreak investigation, with multiple areas to manage and many points at which decisions have to be made about how to proceed. Review this resource to get an idea of how the rest of the investigation might proceed, as well as review the areas where you need to be focusing.
   
   
2. Discuss all the different potential actions with your team, and come to consensus about how to proceed. Consider next steps in the three areas listed below.
   
   
   • Data collection and analysis: Now that you have collected this information through the questionnaire and done some preliminary analysis of that data, what do you think is the best path in order to get even closer to the source of this outbreak?
     
     Tip: Information about coccit, including what causes the illness and how it is spread, is considered data.
     
     
   • Hypothesis development and testing: Based on your analysis of the line listing, how have your potential hypotheses changed? How will you go about exploring those hypotheses?
     
     
   • Management and communication: What data, if any, do you have that you need to share with the medical community? A governing body? The public? The media?
     
     
     • Include groups may need contacted in the future and what information is needed before contacting them to ensure speed once the information becomes available. Waiting until the information is available to plan management and communication could result in unnecessary delays.
       
       
3. Record the plan in the Investigation Status and Plan Template (ISP), as applicable.
   
   
   • This is a living document that will guide you through the next steps in the investigation; take good notes to capture relevant thoughts that might be useful to you as you move forward.
     
     
4. Provide a summary of your thoughts in an email to Dr. Lyons, including the following elements in your response:
   
   
   • Each possible area of action
     
     
   • Your suggested next steps in relation to that area
     
     
   • Your rationale for the actions you have chosen, including where you have decided not to act
     

Review and submit your work.

1. Review your work.
   
   
   • Did you conduct a thorough analysis of the data that was provided, accounting for how the data impacted your original hypotheses?
     
     
   • Did you review all possible avenues of exploration at this juncture, develop a plan to move forward and back it up with sound reasoning in your ISP?
     
     
   • Did you summarize your plan in your email response to Dr. Lyons?
     
     
2. Submit your work.
   
   
   • Review the checklist located in the Submit Your Work section of this task to ensure completion of the task before submitting your deliverables to your mentor.
     
     
   • Please note: Only one set of deliverables need to be submitted per team. Any additional notes not captured in that set of deliverables should be retained by the team members for possible use in future tasks.
     

Cross-Team Conference

During outbreak investigations, investigators are charged to continually apprise their colleagues of any progress that has been made. In the spirit of this tradition, you will have periodic 'cross-team' conferences where one team presents the state of the world and any recommendations made for next steps.

On these “What next?” tasks, all the teams in the cohort will meet to have a roundtable discussion of what steps were suggested. One team per conference will be responsible for presenting their thoughts on next steps and strategies and the other teams will provide feedback and comments.

1. Contact your mentor to determine which team will be presenting in this round.
   
   
   • If your team will be presenting, meet with your teammates briefly to determine how to divide up the presentation of a brief history of the outbreak, and strategies and next steps in each of the three areas (data collection and analysis, hypothesis development and testing, and management and communication). Since you are presenting material you have already been discussing for a substantial period of time, the preparation required should be minimal. Remember: This is intended to be an informal discussion.
     
     
   • If your team will not be presenting, it is still important to review the strategies and next steps you recommended, so as to be ready to give thoughts and feedback to the team who does present.
     
     
2. The presenting team leads the discussion with a brief overview of pertinent facts about the outbreak and the key strategies that they recommended to Dr. Lyons.
   
   
3. The other teams are given an opportunity to respond with thoughts and comments. The discussion is mediated by the mentor.
   
   
4. The mentor summarizes the points made before closing the discussion.

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• Tip: While discussing how the new information affects existing hypthoses informally, taking good notes will help when it comes to formally documenting the supporting and refuting evidence for each hypothesis.
  
  
• Trap: What looks like a difference at first glance may not be significant upon further analysis. When looking at new data do not accept seeming differences at face value. Keep in mind that if a potential difference falls in a gray zone after analysis, more data can be collected to help determine whether it is significant or not.
  
  
• Tip: Think about the big picture and not just the current task. Keep in mind where the investigation is and where it needs to go in order to accurately identify the source of the outbreak so the outbreak can be contained. Recommended actions should be directed toward moving the investigation forward in a strategic way.
  

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Task 2.3 Resources

While Wikipedia is a valuable resource, unlike some other websites anyone can contribute to or modify the site (whether they're knowledgeable about the topic or not). As a result, the site is subject to constant change by questionable sources. Be sure to cross-check information on Wikipedia with other reputable sites to ensure accuracy.

Ask the Expert

What groups does the CDC typically communicate with during an outbreak investigation?

What is taken into consideration when determining when or what to communicate with the public?

What factors might make the decisions around communicating with the public more difficult?

General Resources

Hypotheses and the Scientific Method FAQ
This FAQ supports you in creating and testing scientific hypotheses, with examples and explanations.

Hypotheses for Epidemiology FAQ
General information on hypotheses and testing with emphasis on hypotheses for epidemiology studies.

Medline Plus
A medical dictionary from Medline Plus to help with scientific terms.

Steps in an Outbreak Investigation
A list of steps involved in real outbreak investigation. Note that not all of the steps will be included in this rotation.

Investigation Process Flow
A flowchart that explains the standard procedure that is taken at the CDC during an outbreak investigation.

Epidemiology Curve

Sample Epi Curve
An example of an epi-curve with a one-month time interval. (Note: The difference between colonization and infection is whether the organism is making the person sick at this time.)

Overview of Epi Curves
From the West Virginia Department of Health and Human Resources. The document contains information on how different shapes of epi curves are related to the source of an outbreak as well as examples of epi curves.

Descriptive Epidemiology Report (DER)

Sample DER 1: Hospital Admissions
A descriptive epidemiology report regarding fractures and hospital admissions in Australia. The descriptions, tables, and graphs that begin on page 13 are useful examples.

Sample DER 2: Lyme Disease
A descriptive epidemiology report of Lyme disease in Ontario.

Sample DER 3: E. Coli
A descriptive epidemiology report of an E. coli outbreak.

Sample DER 4: Foodborne outbreak
A report on a food borne outbreak including case definitions, an epi curve, and a descriptive epidemiology report. The DER is in the “Results” section on page 2, and in the “Appendix” on page 4.

Coccidioidomycosis (cocci)

Cocci Overview from CDC
Information from the Centers for Disease Control and Prevention (CDC) on cocci clinical features, transmission, risk groups, challenges, and other important info.

Cocci Overview 1
Includes common symptoms as well as tests and exams to detect the disease.

Cocci Overview 2
Includes x-rays of a cocci patient.

Cocci Overview 3
Includes a map of endemic areas (from Wikipedia).

Cocci Overview 4
Includes incubation periods, clinical signs, and communicability in both humans and animals from The Center for Food Security and Public Health at Iowa State University.