[Guidelines for investigating clusters of health events]

Clusters of health events, such as chronic diseases, injuries, and birth defects, are often reported to health agencies. In many instances, the health agency will not be able to demonstrate an excess of the condition in question or establish an etiologic linkage to an exposure. Nevertheless, a systematic, integrated approach is needed for responding to reports of clusters. In addition to having epidemiologic and statistical expertise, health agencies should recognize the social dimensions of a cluster and should develop an approach for investigating clusters that best maintains critical community relationships and that does not excessively deplete resources. Health agencies should understand the potential legal ramifications of reported clusters, how risks are perceived by the community, and the influence of the media on that perception. Organizationally, each agency should have an internal management system to assure prompt attention to reports of clusters. Such a system requires the establishment of a locus of responsibility and control within the agency and of a process for involving concerned groups and citizens, such as an officially constituted advisory committee. Written operating procedures and dedicated resources may be of particular value. Although a systematic approach is vital, health agencies should be flexible in their method of analysis and tests of statistical significance. The recommended approach is a four-stage process: initial response, assessment, major feasibility study, and etiologic investigation. Each step provides opportunities for collecting data and making decisions. Although this approach may not always be followed sequentially, it provides a systematic plan with points at which the decision may be made to terminate or continue the investigation.