Figure 7.

A stepwise approach to outbreak surveillance with consideration of resource limitations

The actions to employ during an institutional outbreak, with delineation of relative cost and information feedback cycles. During an outbreak, initial mitigation measures can be deployed prior to and independent of a surveillance program. A basic surveillance program will first incorporate testing, the results of which will inform additional mitigation policies. Next, analyses of case attributes can be used to assess the risk of infection for specific sub-populations; these analyses will allow for development of specialized, directed testing strategies. Finally, while more expensive, viral genomic sequencing of clinical or environmental samples can be used to identify transmission trends and to detect emergent viral genomic variation with potential public health or clinical relevance. This can be used to inform institutional policy and mitigation efforts. Actions involving solely personnel time are the least expensive to implement (i.e., mitigation, risk analyses), while actions requiring both personnel and laboratory consumables are more expensive (i.e., testing), and actions requiring highly trained personnel, laboratory consumables, and prolonged instrument time are the most expensive to implement (i.e., viral sequencing).