1. Removing the pump handle Formulating recommendations

4. 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?

5. The quality cycle of policy management Plan AssessEvaluate Implement Field epidemiology Programme management

6. The state of mind of the epidemiologist Points that receive attention –Scientific evidence –Methodology Points that may be overlooked –Programme constraints –Competing priorities

7. 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

8. 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

9. Attributes of good recommendations Evidence based Specific Feasible Cost effective Acceptable Ethical

10. 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

11. Attributes of good recommendations Evidence based Specific Feasible Cost effective Acceptable Ethical

12. 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?

13. 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

14. Attributes of good recommendations Evidence based Specific Feasible Cost effective Acceptable Ethical

15. Feasible recommendations Do not recommend impossible actions Consider –Logistics –System –Willingness / capacity to pay –Sustainability Identify small steps that may be taken to improve

16. 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

17. Attributes of good recommendations Evidence based Specific Feasible Cost effective Acceptable Ethical

18. 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

19. 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

20. Attributes of good recommendations Evidence based Specific Feasible Cost effective Acceptable Ethical

21. 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

22. Acceptable goals in food hygiene Avoid:  Avoid vegetables Prefer: Wash vegetables thoroughly before consumption

23. Attributes of good recommendations Evidence based Specific Feasible Cost effective Acceptable Ethical

24. 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

25. Take home messages 1.Imagine yourself as a programme manager receiving the information 2.Be accountable to the usefulness of your recommendations

26. Exercise E-coli outbreak in South West England Investigation: Crab meat associated with illness Your recommendations?

27. Review the two proposed recommendations according to the checklist Recommendation 1Recommendation 2 ? Evidence based?? ? Specific?? ? Feasible?? ? Cost effective?? ? Acceptable?? ? Ethical??