Operation Outbreak The Outbreak Team
Activity details Age or grade level Handouts This activity is intended for middle and high • Role Play Cards school teachers to teach public health using The Junior Disease Detectives, Operation: Materials Outbreak graphic novel in their classrooms. • The Junior Disease Detectives, Operation: Outbreak graphic novel Learning objectives (https://www.cdc.gov/flu/graphicnovel) At the end of this activity, students should be • able to Scissors, tape • Identify steps during an influenza outbreak Introduction investigation. he outbreak investigation portion of the story • Identify roles and responsibilities of public T health, animal health, environmental health, begins after the Thomas County Fair. At the and other relevant professionals in an fair, Eddie Schwartz, a 4-H student, shows his influenza outbreak investigation and the pig named Hamlet and notices that Hamlet skills each needs to fulfill their roles. appears sluggish. • Describe why using a One Health approach Later, Eddie becomes very sick with flu-like connecting human, animal, and symptoms, including a fever of 101°F, a cough, environmental health is best when and muscle aches. His mother takes him to visit investigating or preventing zoonotic his primary care provider, Dr. Walker. Dr. diseases. Walker collects clinical information about Eddie’s illness and a respiratory specimen (she Problem-based skill swabs the inside of his nose), which she sends Collaborative performance to a local clinical laboratory for testing. Laboratory testing is used by primary care National standards providers (e.g., physicians, physician’s HS-EPHS1-2: Discuss how epidemiologic assistants, and nurse practitioners) to identify thinking and a public health approach is used to the cause of a patient’s illness. Patient transform a narrative into an evidence-based specimens for laboratory testing are also used explanation. by public health authorities as part of routine https://www.cdc.gov/careerpaths/k12teacherroadmap/pdfs/ephs- efforts to track diseases that make people sick. competencies.pdf
NGSS Science & Engineering Practice: In the story, neither the clinical laboratory nor Obtaining, evaluating, and communicating the state public health laboratory are able to information; Crosscutting Concept: Cause and identify the source of Eddie’s illness. (Note: In a effect real-life situation, state public health http://www.nextgenscience.org/get-to-know laboratories have the capability to determine from a patient specimen if the patient has been Activity time infected with an influenza A or B virus and if that virus is a human seasonal flu virus or a 45 minutes novel influenza A virus, i.e., a new flu virus in humans that may have come from an animal.) The Outbreak Team I Page 2
Therefore, the state public health laboratory also be used to find new cases quickly so that follows federal and international health the infected people or animals can be treated regulation reporting protocols and reports and isolated, if necessary, to stop spread of a Eddie’s case to the Centers for Disease Control disease. CDC epidemiologists, or their state and Prevention (CDC) for additional testing. and local colleagues, perform contact tracing to CDC is the nation’s health protection agency. identify human cases and their contacts. Animal CDC uses science to provide health information health experts perform contact tracing in and recommendations that protect our nation animals. In the story, people they contact against dangerous health threats. When these include the following: Eddie and his friends in 4- health threats arise, CDC responds. For more H, Eddie’s parents and Dr. Walker (Eddie’s information on CDC’s role and mission, see primary care provider), Andy Duncan (the state https://www.cdc.gov/about/organization/mission fair organizer), other fair attendees, local .htm. hospitals and doctors’ offices, and Dr. Tolani (the state veterinarian) who inspected animals The state epidemiologist, Dr. Jim Jefferies, and at the fair. his staff are particularly concerned with Eddie’s illness because testing at the state public health Later in the story, Eddie’s friends and CDC’s laboratory was unable to identify the pathogen EIS officers suspect that there might be a link (i.e., a bacterium, virus, or other microorganism between the source of Eddie’s illness and his that can cause disease) responsible. This pig, Hamlet, which he showed at the Thomas suggests the cause of Eddie’s illness could be County Fair. CDC conducts laboratory testing something new or not common among people. on the specimen obtained from Eddie, while USDA conducts laboratory testing on the As the story continues, Dr. Jefferies contacts a specimen obtained from Hamlet. CDC and CDC epidemiologist, Dr. Lee, and explains the USDA laboratory scientists share their situation. Because the state public health respective test results with each other, which laboratory was unable to identify the cause, Dr. indicate that Eddie and Hamlet were infected Jefferies and Dr. Lee decide to work together with an influenza virus with very similar on an investigation. Dr. Jefferies submits a genomes. (Note: the term genome refers to the formal request to CDC for help investigating this complete set of genes present in an organism; situation. in this case, a virus.) This leads the public health and animal health authorities to conclude Dr. Lee is joined by his CDC team of Epidemic that the influenza virus that infected Hamlet is Intelligence Service (EIS) the same virus that infected Eddie. This virus is (https://www.cdc.gov/eis/index.html) officers, a novel influenza virus because it is a including Drs. Alison, Kim, and Alex, to help nonhuman flu virus detected in a person. with the investigation. EIS officers are CDC Specifically, this would be called a variant virus, epidemiologists, or disease detectives, who because that is the terminology used when an complete a two-year training and serve on the influenza virus that usually spreads among pigs front lines of public health. CDC epidemiologists is found in a person. (For more information, see work with their local (i.e., county and city) and the Educational Overview description of state public health and animal health zoonotic diseases, variant influenza, novel colleagues to assist with the investigation, influenza, and pandemics.) including on-site data collection, analysis, and interpretation. After the cause of Eddie’s illness Public health, animal health, environmental is determined, they will also work together to health and other relevant authorities (e.g. implement prevention and control measures. wildlife authorities) work together using a One Health approach to investigate novel influenza One way the team collects data and information virus infections among people. A One Health is through contact tracing. Contact tracing is the approach requires human, animal, and identification and follow-up of people or animals environmental health professionals to work that may have been infected with a pathogen. together at the local, state, federal, and global This information is important for helping to levels to improve the health of people, animals, identify the source of a disease outbreak. It can and their shared environment. One important
The Outbreak Team I Page 3 goal of the outbreak investigation is to among pigs and other animals, like birds and determine if the viruses in question are dogs. Wild birds are the natural hosts of all changing in ways that would allow them to influenza A viruses. Experts believe all four flu spread more easily among people and pandemics that occurred in the last 100 years potentially cause a pandemic. were caused by viruses that originated from Depending on the size and scale of an outbreak birds or pigs, and later gained the ability to investigation, the number of health spread among people. professionals involved will vary and their roles can expand and change. Overall, the Resources collaboration of professionals with expertise in Careers at CDC the areas of epidemiology, laboratory testing, (https://jobs.cdc.gov/career-fields) public health, animal health, environmental health, communications, policy, statistics, and Careers in public health clinical care is what makes the investigation (http://www.careersinpublichealth.net/careers/) possible. CDC influenza (flu) As part of the investigation, CDC experts, (https://www.cdc.gov/flu/index.htm) including informaticians, data managers, biostatisticians, and laboratory scientists work CDC swine/variant influenza virus behind the scenes. The data managers set up (https://www.cdc.gov/flu/swineflu/index.htm) databases to store information that EIS officers and other epidemiologists collect in a manner CDC One Health website that will allow for efficient data analyses with the (https://www.cdc.gov/onehealth) support of biostatisticians. Public health laboratory scientists work to characterize the USDA One Health website virus that infected Eddie, while staff at USDA’s (https://www.usda.gov/topics/animals/one- laboratories analyze specimens collected by the health) state veterinarian from some of the animals present at the Thomas County Fair. The virus USDA influenza in swine specimen testing results from both CDC and (https://www.usda.gov/topics/animals/one- USDA’s laboratories are compared to health/influenza-swine) determine if there are similarities between the viruses collected from people and animals. CDC stay healthy at animal exhibits (https://www.cdc.gov/features/animalexhibits/) Throughout the investigation, health communications specialists create CDC Says “Take 3” Actions to Fight the Flu communication products to educate the public, (https://www.cdc.gov/flu/protect/preventing.htm) media, and other audiences about what is known and not known about the outbreak, and Activity instructions what actions people should take to protect Explain themselves and their families. During an During an outbreak investigation, professionals outbreak response, health communications from different disciplines related to public specialists develop messages and products in health, animal health, environmental health and accordance with well-established risk other relevant authorities work together. By communications principles. Health leveraging their diverse skill sets, these experts communications specialists help coordinate can carry out a more efficient investigation than communications efforts and messages between if they were working independently. local, state and federal partners, and then communicate necessary information to external Establishing data collection, management and audiences. reporting protocols as well as communication procedures allows different health professionals Did you know? at the local, state, and federal levels from Influenza viruses that are different from the multiple disciplines and sectors to work together influenza viruses that spread in people circulate to identify the cause of Eddie’s illness and
The Outbreak Team I Page 4
establish measures to ensure additional people 7. Instruct each group to add arrows that show do not get sick. communication pathways among the roles.
In this activity, students will learn about the 8. Assign students to write up a 1- or 2-page roles of different characters from the graphic story about how the outbreak was novel. Then, together, they will decide the investigated based on the steps of the action sequence of the outbreak investigation influenza outbreak investigation and the using the graphic novel as a guide. communication pathways.
Instruct Discuss 1. For homework, assign students to read The 1. Why would one case of respiratory illness Junior Disease Detectives, Operation: caused by an unidentified virus in a person Outbreak graphic novel. who recently attended an agricultural fair be cause for concern? 2. Print enough sets of the role play cards so that each student in the class has at least 2. Why is it beneficial to have professionals one role. There are 14 roles in a set. Mark with different roles, skills, and disciplines each set with a letter: A, B, C, etc. involved in an influenza outbreak investigation? 3. Hand out the role play cards, and then have students find other students with the same Information role play card. Have each team consider the Authors Activities were developed as a collaboration between the CDC Science following: Ambassador Fellowship program in CDC’s Center for Surveillance, Epidemiology, and Laboratory Services; science, technology, engineering, What general responsibilities does this and mathematics (STEM) teachers from across the country who - participated in the 2017 CDC Science Ambassador Fellowship; CDC’s person have in their job? National Center for Immunization and Respiratory Diseases; and CDC’s National Center for Emerging and Zoonotic Infectious Diseases. What professional skills might this - CDC’s Center for Surveillance, Epidemiology, and Laboratory person need to do their job? Services
The following experts in education from the U.S. Centers for Disease - What role might this person have during Control and Prevention provided leadership, content development, and an influenza outbreak investigation? editing for these activities: Kelly Cordeira, MPH, Student Programs and Partnerships Lead, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory - Who might this person communicate Services. with during an influenza outbreak CDC Science Ambassador Fellows investigation? The following STEM teachers who participated in the 2017 CDC Science Ambassador Fellowship within CDC’s Division of Scientific Education and Professional Development co-developed the educational activities in 4. Group students based on their role play consultation with CDC experts: Richard Blauvelt, MPH, MAT (Harper Woods, Michigan); Tami Caraballo, MEd (Snohomish, Washington); Karen card set marked with a letter A, B, C, etc. Krieger, MSSE (Phnom Penh, Cambodia); Sarah Sletten, PhD (Fargo, Within each group, have each student North Dakota); Tina Gibson, MS EdD, 2017 Peer Leader (Columbus, Mississippi); Clara Bennion, MSEd (Camdenton, Missouri); Pam Gilmore, present 3 or 4 key facts about their role to MS (Muskego, Wisconsin); Larisa Masson (Portland, Oregon); Susannah the group. Miller, MA (Indianapolis, Indiana); Valencia LaPrelle’ Williams, PhD, 2017 Peer Leader (Ontario, California).
CDC’s National Center for Immunization and Respiratory Diseases 5. Have each group work together to The following experts from the U.S. Centers for Disease Control and determine the steps of the influenza Prevention provided consultation: Douglas Jordan, MA, Influenza Division, National Center for Immunization and Respiratory Diseases; Lt. Col. (R) outbreak investigation by ordering their set Joe Gregg, Influenza Coordination Unit, National Center for Immunization of role play cards according to when each and Respiratory Diseases; Alicia Budd, MPH, Influenza Division, National Center for Immunization and Respiratory Diseases; James Kile, DVM, role would become involved in the outbreak MPH, Influenza Division, National Center for Immunization and Respiratory investigation. Diseases
CDC’s National Center for Emerging and Zoonotic Infectious Diseases The following experts from the U.S. Centers for Disease Control and 6. When each group comes to a consensus on Prevention provided consultation: Michael Jhung, MD, MPH, Division of the order of the steps of the influenza Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases outbreak investigation, have each group tape their role play cards on a wall, Disclaimer This lesson plan is in the public domain and may be used without accordingly. restriction. Citation as to source, however, is appreciated. Links to nonfederal organizations are provided solely as a service to our users. These links do not constitute an endorsement of these organizations nor
The Outbreak Team I Page 5 their programs by the Centers for Disease Control and Prevention (CDC) or the federal government, and none should be inferred. CDC is not responsible for the content contained at these sites. URL addresses listed were current as of the date of publication. Use of trade names and commercial sources is for identification only and does not imply endorsement by the Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, CDC, the Public Health Service, or the U.S. Department of Health and Human Services. The findings and conclusions in this Science Ambassador Workshop lesson plan are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).
Citation Centers for Disease Control and Prevention (CDC). CDC Science Ambassador Fellowship—Operation Outbreak: Educational Activities, Activity 1. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2019. Available at: www.cdc.gov/flu/graphicnovel.
Role Play Cards I Page 6
Eddie
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
Primary Care Provider
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
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Clinical Laboratory Scientist
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
State Laboratory Scientist
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
Role play cards I Page 8
State Epidemiologist
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
State Public Health Veterinarian
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
Role play cards I Page 9
Thomas County Fair Director
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
State Veterinarian
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
Role play cards I Page 10
CDC Epidemiologists
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
CDC Biostatisticians
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
Role play cards I Page 11
CDC Laboratory Scientists
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
USDA Laboratory Scientists
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
Role play cards I Page 12
Health Educators
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
Communications Specialists
General responsibilities Role in an outbreak investigation
Professional skills Communicate with during an outbreak investigation
Answer Key I Page 13
Answer Key
Note: Sample answers are provided below, but are not meant to be comprehensive or exhaustive. Additional information on these and other public health careers can be found using the Careers in Public Health websites. See Resources.
General Professional skills1 Main role in an Communicate with responsibilities influenza outbreak during an influenza investigation outbreak investigation Eddie A 4-H exhibitor who Knowledge about Report symptoms and Primary care provider, should follow safe owning, caring for, and information that could epidemiologists, or animal handling and flu keeping records of help identify the cause others who interview prevention practices livestock. Following of illness him as part of the guidelines or investigation requirements for showing livestock
Primary care A trained medical Medical knowledge Collect clinical Eddie, local clinical provider professional (e.g., and awareness of information and laboratory, and local or physician, physician’s’ public health, ability to specimens for state public health assistant, or nurse communicate clearly, laboratory testing; treat department practitioner) who ability to think critically the patient, as needed provides direct and problem solve, and treatment for the attention for detail patient
Clinical A laboratory scientist Laboratory procedure Test specimens; report Primary care provider, laboratory who tests and analyzes skills, such as skills in results back to local or state health scientists samples from patients identifying appropriate physician, and, department sent by physicians at lab test to run, depending on the epidemiologist, and hospitals or clinics, and specimen preparation result, to the local or state public health who should follow and testing, state public health laboratory recommended maintaining lab department or public protocols for equipment, ensuring health laboratory specimens to send for lab safety, following lab additional testing protocols, accurately reporting of results, interpreting results, knowing when to send specimens for further testing if needed, and attention for detail
State public A laboratory scientist Laboratory procedure Test specimens, Local clinical health laboratory who tests and analyzes skills, research and confirm test results; laboratory, state public scientists samples from patients data analysis, send specimens to health department at hospitals or clinics developing and CDC, if requested by epidemiologist and that have been sent implementing new the state public health staff, and CDC from clinical testing methods, ability department and CDC laboratory scientist laboratories for testing, to communicate and who should follow clearly, attention to recommended detail protocols for specimens to send to
1 Professional skills are derived from positions or similar positions on the Careers in Public Health website provided in the resource section: http://www.careersinpublichealth.net/careers.
Answer Key I Page 14
General Professional skills1 Main role in an Communicate with responsibilities influenza outbreak during an influenza investigation outbreak investigation CDC for additional testing
State An epidemiologist who Knowledge of Collect and analyze Local health epidemiologist works for the state descriptive and analytic information about who department health department with epidemiology, ability to is sick, when they epidemiologist; state a specific focus on the analyze data and became sick, and laboratory scientist; population of an entire interpret findings, exposures they may CDC epidemiologist, state ability to think critically have had before CDC laboratory and problem solve, becoming sick to scientist, health strong math skills, determine where, educators or ability to communicate when, and how each communication clearly, willingness to person may have specialists work in different become infected; environments and coordinate with the ability to work local health collaboratively with department, others in other specialists, the state health including federal, state, department including and local public health the laboratory, CDC, partners animal health partners (depending on the situation), and physicians (sometimes this is left for local health departments and sometimes it’s handled by the state)
State public A veterinarian who Knowledge of clinical Coordinate public State animal health health works for the state veterinary medicine health activities using a official; state public veterinarian health department, and general public One Health approach, health epidemiologist, focusing efforts on health knowledge, collect human CDC representatives, protecting human willingness to work in epidemiologic including populations from different environments information; coordinate epidemiologists, infections caused by and ability to work with animal health and laboratory staff, and zoonotic diseases and collaboratively with environmental health communications other One Health other animal and public authorities and specialists and other issues health specialists at the activities relevant partners federal, state, and local level
Thomas County A person who Knowledge and Support Animal health official or fair director coordinates fair oversight of local, communication veterinarian, state activities and state, and federal between the state epidemiologist, state communicates with all requirements and health department and public health stakeholders recommendations from state fair attendees veterinarian, and fair public health officials at attendees the fair; and ability to communicate clearly
State A veterinarian who Knowledge of clinical Coordinate animal State public health veterinarian works for the state animal medicine, ability health activities using a veterinarian, state agriculture department, to think critically and One Health approach epidemiologist, USDA focusing efforts on problem solve, ability within their jurisdiction, laboratorians, state protecting livestock to communicate authorize testing of agricultural authorities, and other animal clearly, willingness to swine samples, direct fair director or populations from work in various sample collection of organizers, and animal diseases environments and animals, make producers and (including zoonoses) ability to work decisions regarding
Answer Key I Page 15
General Professional skills1 Main role in an Communicate with responsibilities influenza outbreak during an influenza investigation outbreak investigation and animal welfare collaboratively with animal health and exhibitors and other issues other specialists, coordinate with public relevant partners including federal, state, health activities and local animal and public health partners and other relevant partners
CDC A person who Knowledge of Support the state State epidemiologists; epidemiologists investigates the causes descriptive and analytic epidemiologist in state and local public of disease, how they epidemiology, ability to collecting and health officials, CDC are spread and how analyze data and analyzing information data manager or they can be prevented interpret findings, about who is sick, biostatistician, CDC ability to think critically when they became laboratory scientists, and problem solve, sick, and exposures USDA as appropriate, strong math skills, they may have had health educators or ability to communicate before becoming sick communication clearly, willingness to to determine where, specialists, animal work in different when, and how each health personnel, fair environments, and person may have organizer, and state ability to work become infected; public health collaboratively with translate this veterinarian other specialists, information into including federal, state, recommendations for and local public health prevention and control partners and other One measures Health partners
CDC data A data manager is Knowledge of Organize and CDC epidemiologists, managers or proficient at creating biostatistics, aggregate data from and state public health biostatisticians databases to store knowledge of disparate sources, officials collected information in descriptive and analytic analyze data to identify a manner that it can be epidemiology, ability to patterns in who was efficiently analyzed and analyze data and infected and how the shared as needed; a interpret findings, and virus was transmitted biostatistician is a strong math skills professional who utilizes statistical techniques and tools to drive forward research in the health field and by applying statistics to their scientific research, a statistician in this field will help develop reports that can be used to improve health
CDC laboratory Laboratory scientists at Laboratory procedure Verify test results and CDC epidemiologist scientists CDC who test and skills, research and performing genomic and state laboratory analyze samples from data analysis, sequence analyses on scientists human cases and developing and the specimens potential cases, and implementing new provided by the state who provide laboratory testing methods, ability laboratory science assistance to to communicate states that have clearly, and attention to requested CDC aid detail
Answer Key I Page 16
General Professional skills1 Main role in an Communicate with responsibilities influenza outbreak during an influenza investigation outbreak investigation USDA laboratory Laboratory scientists at Laboratory procedure Test animal specimens CDC laboratory scientists the USDA who test and skills, research and to identify and scientists, state analyze samples from data analysis, characterize the virus laboratory scientists, animal or food, usually developing and causing the infection state epidemiologist, related to agriculture, implementing new and veterinarian and researches testing methods, ability findings to communicate clearly, and attention to detail
Health educators Professionals who Knowledge of Develop educational Communication develop, oversee, education theory and materials and specialists, and state manage, and provide strategies, ability to resources used to epidemiologist health education communicate clearly, communicate with the programs to a group of willingness to work in public about prevention people various environments measures and ability to work collaboratively with other specialists, including federal, state, and local public health partners
Communications Professionals who Knowledge of risk Develop messages General public, media, specialists develop communication and materials to public and animal communication principles and practice, communicate with the health stakeholders strategies, messages public speaking, public, media, and partners, and products, and leadership, ability to government officials, businesses, schools, communicates public communicate clearly, and partners about the politicians, state health risks, concerns, ability to condense and outbreak and the epidemiologist; health trends, and summarize complex investigation educator; laboratory recommendations to scientific information scientists, statisticians, the public, as well as into easy to follow and veterinarians media, policy makers information and and other health recommendations, professionals; a willingness to work in communications different environments director will oversee and ability to work the communications of collaboratively with a public health group other specialists, within a public health including federal, state, department or agency and local public health partners
Sample connection of roles Note: This is an example of the connection of the roles, but it is not meant to capture all possible lines of communication. As you can see in the novel, there are many professionals involved in an outbreak situation. Early planning for how to communicate among and between local teams (e.g., physicians and clinical laboratories), state-level teams, and knowing how to request federal assistance (CDC and USDA) are key elements to initiating an outbreak investigation. Clear protocols for responsibilities including data collection, analysis and communication of results are essential for the investigation to progress efficiently.