Exciting news just came in: In response to our request on Epi-CS, we have been notified of an additional ten case-patients! While we, obviously don’t want more people to become sick, this will give us more information with which to isolate the source of the infection, which will hopefully result in a quicker resolution to this outbreak altogether.

I received your suggested changes to the questionnaire; thanks for your work on the revisions. I made a few changes and sent out the questionnaire to the original 15 case-patients as well as the new 10 case-patients. We received all of them back and I went ahead and had our intern create an updated line listing from that raw data. I have attached that new line listing, as well as the new version of the questionnaire for your reference.

You'll notice in the line listing that some cases have "Snuffles" as their favorite toy while others have "blue cat". We found out after we typed up the line listing that these are the same toy, Snuffles the Blue Cat. The problem is that Snuffles is a popular toy among kids and we can't be certain that just as many kids who didn't get sick were exposed to Snuffles dolls. We need to investigate further.

So here’s what I need you to do next:

• Analyze the new data provided in the line list to look for new information that will help us to identify the source of the outbreak.
  
• Update your Descriptive Epi Report.
  
• Update your Epi-Curve and analyze it to see if you can see any pattern that might help us identify the source of the outbreak.
  
• Suggest what we should do next to address the three key components of the investigation process using the ISP template I sent you earlier:
  
  • Data collection/analysis
    
  • Hypothesis development/testing
    
  • Management and communication

Then, as before, I need you to submit a plan for what we should do next. Please send me an email summarizing your plan for next steps. In your reply email, please attach the completed ISP template, the Descriptive Epi Report, and your updated Epi-Curve to justify your plan.

Thanks for your important work on this investigation! I look forward to hearing from you soon.

Sam Lyons, MD