In the previous step, we presented an overview of the different roles included in the multidisciplinary teams required to control an outbreak. In this step, Soka Moses (Liberia Ministry of Health) will detail the role of clinicians in controlling disease outbreaks. He will explain the different periods in which a clinician is involved; how they are alerted to a possible outbreak; and some of the key activities needed for response and preparedness.
How are clinicians involved in preparedness?
There are three distinct periods of outbreak preparedness and response that clinicians are involved in: pre-outbreak preparedness, outbreak response and the post-outbreak period.
1. Pre-outbreak preparedness
Prior to outbreaks, clinicians coordinate with national outbreak response authorities and periodically assess trends of epidemics to develop local response capabilities. This includes assessing and improving the readiness of health facilities, triage and isolation infrastructure. They may also undertake and lead training to improve readiness of health workers to provide quality services. Clinicians also help develop and review treatment guidelines, infection prevention and control (IPC) measures, and increase access to essential medicines, vaccines, personal protective equipment and other supplies. During this period, they also receive notifications about potential outbreaks and the status of ongoing outbreaks, and prepare to respond.
Many epidemic diseases cause convalescent symptoms (e.g. rheumatologic and eye complications after Ebola virus disease, sensorineural hearing loss after Lassa fever disease, neuropsychological disorder after meningitis disease, congenital deficits of Zika-affected children, etc.). Clinicians need to prepare to provide services to address the convalescent symptoms or disabilities of survivors of the disease and frontline health workers during all three stages of the outbreak. Furthermore clinicians prepare to conduct vital research to expand knowledge and develop effective epidemic response tools for existing and emerging diseases.
2. Outbreak response
During disease outbreaks, clinicians are the first line of contact with patients. Clinicians assess, isolate, and provide treatment and care for sick persons. They also administer vaccines where available to exposed or healthy people to interrupt transmission. This role allows clinicians to participate in surveillance because they are able to detect clusters of cases of a disease, and collect and report vital clinical and epidemiological information.
Disease outbreaks within a complex emergency (e.g. the Cholera outbreak in Yemen occurring in the context of a major conflict, malnutrition and collapse of health services) requires integrated health services to maintain essential health functions alongside the epidemic response.
During outbreaks, clinicians must also be involved in the development and conduct of critical research to characterize disease pathogens and develop and test new tools to prevent and manage future outbreaks.
3. Post-outbreak period:
During the post-outbreak period, clinicians engage in health system audits to boost preparedness and health system strengthening. These may include improvement to surveillance, diagnostic readiness, isolation capacity, and increasing access to essential medicines, vaccines and supplies.
Local and international response teams work together to review, document, and disseminate lessons learned and new research findings. This information is also used to update treatment guidelines, IPC measures and other response tools and practices.
How would a clinician be alerted to a possible outbreak?
1. Alert tools
Alert tools are used to warn of the occurrence of an outbreak. The World Health Organisation (WHO) deployed the Early Warning, Alert and Response System (EWARS) across the Rohingya settlements in Bangladesh and in other humanitarian crisis and disease outbreaks in South Sudan, Chad, Nigeria, Fiji, and Yemen. It is a mobile application to enhance disaster and outbreak detection in emergency settings.
2. At the local level
Event-based surveillance reports: Many countries have integrated disease surveillance and response (IDSR) systems in place to detect and test clinical events predefined for reporting. These are called priority or epidemic-prone diseases. WHO periodically updates a list of priority diseases with epidemic potential. Clinicians report one or more cases of the disease depending on a set reporting threshold. Once collected and reported, public health authorities ensure that the information is rapidly analysed, interpreted, verified and shared in a timely manner to facilitate appropriate and timely response.
Routine surveillance reports: Clinicians receive feedback reports from routine surveillance and may notice that the number of cases of a disease have suddenly increased over a given period in comparison to a similar period previously reported.
Outbreak of an emerging disease detected and reported during routine clinical work: Clinicians may be alerted to the occurrence of a cluster of unusual symptoms or diseases. These may be unusually high numbers of cases in one family or a group of people working closely together, attending a function or living closely together.
3. At the global level
The WHO global and regional disease bulletins also keep local clinicians informed. The International Health Regulations (IHR) inform states on reporting priorities for early detection, reporting and preventing the spread of disease outbreaks beyond borders while working to interrupt and end it. Other regional bulletins include the European Centre for Disease Control and the US Centre for Disease Control and Prevention, which also provide useful updates.
In their day to day routine, what would alert a clinician to suspicious cases?
Often, the first news of an infectious disease outbreak are rumours in communities, media outlets and/or internet platforms including social media posts. Community and family members may also inform clinicians about the occurrence of unusual symptoms or unprecedented numbers of cases in one or more persons in their areas or household. For example, the 2017 Monkeypox outbreak in Nigeria started in one family. This can only work when a high level of trust exists between the community and their health facilities.
In addition, experienced clinicians may identify one or more patients presenting with unfamiliar symptoms and signs which triggers suspicion.
Also, periodic morbidity and mortality reports by health authorities may detect increases above thresholds in numbers of cases of known diseases. However, in some regions, IDSR systems are weak and outbreaks are detected and reported late.
What are the key activities of a clinician in an outbreak, and in preparedness?
In addition to a clinician’s primary responsibility of managing the exposed and sick persons, clinicians also communicate essential information to educate patients about ongoing outbreaks, risks, signs and symptoms, prevention measures and how and where to seek care. Clinicians are also involved in effective coordination of the clinical aspects of the outbreak response. This includes epidemic surveillance including collecting, documenting and reporting cases and epidemic preparedness, including training, development of guidelines and procedures; set-up of infection prevention and control measures; isolation capacity; and improving point-of-need diagnostic capacity.
Clinicians may also be involved in the conduct of clinical research to investigate existing interventions and develop and evaluate new tools and interventions such as vaccines, treatments and improved knowledge and understanding of pathogens.
© London School of Hygiene and Tropical Medicine 2019