Removing the pump handle

Formulating recommendations

It’s not always like that…

• The investigation starts after the peak

• ‘It’s political’

• We lack data

• There are no resources

Nevertheless

How do we ensure we learn from each investigation?

The quality cycle of policy management

Plan

AssessEvaluate

Implement

Field epidemiology

Programme management

The state of mind of the epidemiologist

• Points that receive attention– Scientific evidence

– Methodology

• Points that may be overlooked– Programme constraints

– Competing priorities

The state of mind of the manager

• Points that receive attention– Overall funding envelope

– Political pressure

– Press attention

– Management

• Points that may be overlooked– Evidence

Maximizing the chances that evidence is used for action

• Appreciate the point of view of the manager– Don’t flag problems– Provide solutions

• Understand implications for resources allocation

• Deliver useful recommendations * Evidence based Specific Feasible Cost effective Acceptable Ethical

* WHO CHOICE

Attributes of good recommendations

• Evidence based

• Specific

• Feasible

• Cost effective

• Acceptable

• Ethical

Evidence based recommendations

• Focus on the recommendations that may be proposed as per the results of the investigations

• Leave aside -or present separately- general recommendations that are not direct deductions of your investigations – If a measles outbreak was caused by failure to

vaccinate, proposing a cold chain review is useless and distracting

Attributes of good recommendations

• Evidence based

• Specific

• Feasible

• Cost effective

• Acceptable

• Ethical

Specific recommendations

• Focus– Small number– Ranked by order of priority

• Describe the action to be taken• Use one verb by recommendation• Avoid “should”

– Use imperative– Explain why it ’should’ de done

• Avoid passive voice• Ask yourself:

– What, Who, When and How?

Example of specific recommendations

• Avoid: Meat should be safe

People should be educated

• Prefer: Cook the meat thoroughly

Communicate the specific risk associated with the manipulation of meat to hunters

Attributes of good recommendations

• Evidence based

• Specific

• Feasible

• Cost effective

• Acceptable

• Ethical

Feasible recommendations

• Do not recommend impossible actions • Consider

– Logistics– System– Willingness / capacity to pay– Sustainability

• Identify small steps that may be taken to improve

Example of feasible recommendations

• Avoid: All GPs must participate in the surveillance system

• Prefer: Explore reasons for non participation to increase

involvement

Engage GPs through useful and timely feedback

Attributes of good recommendations

• Evidence based

• Specific

• Feasible

• Cost effective

• Acceptable

• Ethical

Cost effectiveness is the result you get for the input you provide

• Measure costs

• Effects must be worth the costs• Substantial burden

• Effective intervention

• Common sense may be used in the absence of quantified documentation

US CDC: Which groups do NOT need routine vaccination against Hepatitis A?

• Although persons who work as food handlers have a critical role in common-source foodborne outbreaks, they are not at increased risk for Hepatitis A because of their occupation. Consideration may be given to vaccination of employees who work in areas where community-wide outbreaks are occurring and where state and local health authorities or private employers determine that such vaccination is cost-effective.http://www.cdc.gov/hepatitis/hav/havfaq.htm

Attributes of good recommendations

• Evidence based

• Specific

• Feasible

• Cost effective

• Acceptable

• Ethical

Acceptable recommendations

• The recommendation has to be acceptable to the decision makers and to the stakeholders – Politically

– Culturally

– Socially

• Discuss draft with stakeholders – Improve acceptability

– Create ownership

Acceptable goals in food hygiene

• Avoid: Avoid vegetables

• Prefer: Wash vegetables thoroughly before consumption

Attributes of good recommendations

• Evidence based

• Specific

• Feasible

• Cost effective

• Acceptable

• Ethical

Ethical recommendations

• Principles– Guarantee confidentiality

– Ensure equity

– Protect minorities

– Address gender issues

– Avoid stigmatization or finger-pointing

• Example? Recommend case-based measles surveillance while

pockets of hard to reach population still struggle with reporting of outbreaks

Take home messages

1. Imagine yourself as a programme manager receiving the information

2. Be accountable to the usefulness of your recommendations

Exercise

• E-coli outbreak in South West England

• Investigation: Crab meat associated with illness

• Your recommendations?

Review the two proposed recommendations according to the checklist

Recommendation 1 Recommendation 2

? Evidence based

? ?

? Specific ? ?

? Feasible ? ?

? Cost effective ? ?

? Acceptable ? ?

? Ethical ? ?