One in every ten people is suffering from kidney related diseases and Approx 1.50 lakh new kidney patients are added every year.Investigating an outbreak and to find the susceptibles in an area 'ii be a great achievement.

1. Investigation Of a CKD Outbreak
In Western Odisha
Dr Rajesh Kumar Ludam
P.G Student
V.S.S.M.C.H ODISHA

2. Background-:
• One person in every ten people is suffering from
kidney related diseases
• Approx 1.50 lakh new kidney patients every year
• Third biggest non-communicable disease after hyper-
tension and diabetes
• More than half of the patients won’t even know until
damaged by more than 60%.
• About five lakh kidney transplants are needed each
year, but a few thousands of the patients could
eventually get it.

3. • Definition-: CKD is defined as abnormalities of kidney
structure or function, present for >3 months, with
implications for health.
 Criteria for CKD (either of the following present for > 3
months)
A.) Markers of kidney damage (one or more)
-Albuminuria (AER >30 mg/24 hours;ACR >30 mg/g [>3 mg/mmol])
-Urine sediment abnormalities
-Electrolyte and other abnormalities
-Abnormalities detected by histology
-Structural abnormalities detected by imaging
- H/o kidney transplantation
B.) Decreased GFR - GFR <60 ml/min/1.73 m2

4. • CKD is classified based on cause, GFR category, and
albuminuria category (CGA)
GFR categories in CKD
Albuminuria categories in CKD
GFR Category GFR ( ml/min/1.73 m2 ) Terms
G1 >90 Normal or High
G2 60-89 Mildly decreased
G3a 45-59 Mild to Moderately decreased
G3b 30-44 Moderate to Severely decreased
G4 15-29 Severely decreased
G5 <15 Kidney failure
Category AER
(mg/24hr)
ACR
( mg/mmol ) (mg/g)
Terms
A1 <30 <3 <30 Normal to Mildly decreased
A2 30-300 3-30 30-300 Moderately decreased
A3 >300 >30 >300 Severely decreased

6. Risk Factors-:
• Diabetes
• Hypertension
• Acute kidney injury
• Cardiovascular disease (IHD, CHF, peripheral vascular
disease or CVD)
• Structural renal tract disease, recurrent renal calculi or
prostatic hypertrophy
• Multisystem diseases with potential kidney involvement –
e.g. SLE
• Family h/o end-stage kidney disease (GFR category G5) or
hereditary kidney disease
• opportunistic detection of haematuria. [new 2014]
• CKDU & CKDNT

7. Why we are so much Concerned???
Silent Epidemic…….

8. • Outbreak-:
- The occurrence of more cases of disease than expected
in a given area or among a specific group of people over
a particular period of time.
- E.g.- In 2013 In Narasinghpur Panchayat of Cuttack
reported 29 out of 33 villages are reported to have
sizeable number of cases of CKD between June and
Sept.
- It was found that 8 to 12 per cent of the people
surveyed had CKD amounting to 400.
- Late reports suggest high prevalence of CKD have been
reported from Bolangir,Jharsuguda,Koraput,Sundergarh
area of Odisha.

9. CKD Outbreak investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Construct a working case definition
5. Find cases systematically and record information
6. Perform descriptive epidemiology
7. Develop hypotheses
8. Evaluate hypotheses epidemiologically
9. Reconsider, refine, and re-evaluate hypotheses
10. Compare with laboratory and/or environmental studies
11. Implement control and prevention measures
12. Initiate or maintain surveillance
13. Communicate findings

10. 1.Prepare for field work
• The preparations can be grouped into two broad
categories: (a)Scientific and Investigative
(b) Management and Operational.
A. Scientific and Investigative-:
- Appropriate scientific knowledge, supplies, and
equipment to carry out the investigation before
departing for the field.
- In previous similar outbreaks, what have been the
sources, modes of transmission, and risk factors for the
disease?
- Develop a toolkit for the proper laboratory material and
know the proper collection, storage, and transportation.

11. - A plan of action with clear objectives of this
investigation
B.Management and Operational-:
- The team members are selected with their clear role and
responsibility.e.g.Epidemiologist,Medicine/Nephrology
,laboratorian,computer specialist, Driver etc….
- Contacting the local staff of the area
- A communications plan must be established.
- laptop/computer, cell phone or phone card, camera,
and other supplies.
- Travel, lodging, and local transportation arranged
- Take care of personal matters before leaving….!!!!!

12. 2.Establish the existence of an outbreak-:
- The expected number is usually the number from the
previous few weeks or months, or from a comparable
period during the previous few years based on locally
available data.
- Reporting should be checked for-:
- changes in local reporting procedures
- changes in the case definition
- increased interest because of local or national
awareness
- improvements in diagnostic procedures.
- diagnostic procedures
- laboratory error
- sudden changes in population size

13. 3. Verify the diagnosis-:
- (a) to ensure that the disease has been properly
identified (b) to rule out laboratory error as the basis
for the increase in reported cases.
- Talking and examining directly with some patients
- Lab confirming by-: Serum Creatinine, e-GFR
estimation, Urine testing for-
Micro-albuminuria/Proteinuria
- Summarizing the clinical features using frequency
distributions - spectrum of illness and verifying the
diagnosis.

14. 4. A working case definition-: A case definition
includes clinical criteria and particularly in the setting of
an outbreak investigation restricticted by time, place,
and person.
- e.g. 100 new cases of pedal edema has been reported in
Chudapali area among males of 20-60 yrs. H/o
hypertension and proteinuria, increased serum
creatinine and shrunken kidneys on USG for > 3 months.
- So as per the criteria for CKD Case definition could be-:
People >18 yrs having the feature for > 3 months
i) Males
ii) B.P= >150/90 mm Hg
iii)Proteinuria= in dip stick +1 or more
iv) Serum Creatinine level > 1.5 mg/dl

15. 5. Find cases systematically and record information-:
for additional cases to determine the true geographic
extent of the problem and the populations affected by
it.
- identify cases is directed at healthcare practitioners and
facilities
- passive surveillance or active surveillance
Data Collection must include-:
- Identifying information-: name, address, and
telephone number etc
- Demographic information-:Age, sex,caste, occupation,
etc.
- Clinical information-:Signs and symptoms to verify that
the case definition has been met.

16. - Risk factor information-: Previous H/O-Diabetes,
HTN, family history, surgical procedure etc…
- Reporter information-: reporter or source of the
report- a physician, clinic, hospital, or laboratory.
 Ask case-patients if they know anyone else with the
same condition.
 Line-listing of cases is done.

17. 6. Perform descriptive epidemiology-:
- Comprehensive characterization of the outbreak —
trends over time, geographic distribution (place), and
the populations (persons) affected by the disease.
- Identify or infer the population at risk for the disease.
- Begin intervention and prevention measures.
By Time-:
By Place-: Area map/ Spot map to illustrating where
cases live, work, or may have been exposed.
By Person-: Host characteristics (age, race, sex, and
medical status) and
• Possible exposures (occupation and use of
medications, tobacco, and drugs).

18. 7. Develop hypotheses-:
“Round up the usual suspects.”- Capt. Renault 1942
-e.g.- Suppose out of 100 CKD cases around 80 cases are
agricultural workers, exposed to pesticides.
Hypothesis-: “Use of pesticide is related to CKD
development”
- e.g.- Suppose out of 100 CKD cases around 70 cases
have a positive h/o Diabetes and HTN
Hypothesis-: “Long term Diabetes and HTN is related
to CKD development”

19. 8. Evaluate hypotheses epidemiologically-:
- Either by comparing the hypotheses with the
established facts or by using analytic epidemiology to
quantify relationships and assess the role of chance.
I) If previous report of epidemic is available-: the clinical,
laboratory, environmental, and/or epidemiologic
evidence obviously support the hypotheses.
II) If not -: A Case Control study can be carried out.
Cases -: All 100 cases
Controls -: (Can be taken 200 if available)
- Neighbours of case-patients
- Patients from the same physician practice or
hospital who do not have the disease in question
- Friends of case-patients.

20. 9. Reconsider, refine, and re-evaluate hypotheses-:
- When analytic epidemiology is unrevealing, hypotheses
rethink
- Consider convening a meeting of the case-patients to
look for common links
10. Compare and reconcile with laboratory and
environmental studies-:
• Epidemiologic, environmental, and laboratory arms of
the investigation complements one another, and leads
to an inescapable conclusion

21. 11. Implement control and prevention measures-:
Lifestyle Changes-:
- Keep blood pressure at the target set by health care
provider
- If diabetic, control blood glucose level to normal
- Keep blood cholesterol in target range.
- Quit smoking,alcohol
- Get or become more active.
- Lose weight if you are overweight.
- Meditation can help a lot
- Avoid a stressful life……..

22. Diet Changes-:
- Choose and prepare foods with less salt and sodium.
- Eat the right amount and the right types of protein.
- Choose foods that are healthy for your heart
e.g.-Poultry without the skin,Fish,Beans,Vegetables,Fruits, Low-
fat milk, yogurt, cheese etc…
- Choose foods with less phosphorus.
- Choose foods having the right amount of potassium.
- Drink as much water
Treatment Changes-:
- Regular follow-up of confirmed cases
- Take medicines the proper way
- Regular check-ups of at risk people
- Renal Transplant if necessary……

24. 12. Initiate or maintain surveillance-:
- If active surveillance was initiated as part of case finding
efforts, it should be continued or else should be started
at the earliest.
Helps to-:
- determine whether the prevention and control
measures are working.
- Is the number of new cases slowing down or, better
yet, stopping?
-know whether the outbreak has spread outside its
original area

25. 13. Communicate findings-: The final task where the
investigation, its findings, and its outcome summarized in a
report and communicated in an effective manner.
- i) An oral briefing for local authorities.
- ii) A written report -: In the usual scientific format of-
introduction, background, methods, results, discussion, and
recommendations.
Serves as-:
- a blueprint for action
- a record of performance
- a document for potential legal issues
- a reference
- the broader purpose of contributing to the knowledge base
of epidemiology and public health.

26. Thank You…