2. Objectives 2
At the end of this session, you should able to :
Define terms like disease outbreak , epidemic,…
Describe the purpose of epidemic investigation
Differentiate types of epidemic
Describe steps in the investigation of epidemic
3. Content 3
Definition of terms
Purpose of epidemic investigation
Types of epidemic
Steps in the investigation of epidemic
4. 4
How do you define the following terms:
1. Endemic disease
2. Hyper-endemic disease
3. Epidemic disease
4. Disease outbreak
5. Pandemic disease
6. Cluster of cases
5. Definition of terms
5
Endemic disease
Presence of a disease at more or less stable/
constant level within a particular place
This level is not necessarily the desired level, which
may in fact be zero, but rather is the observed level
Hyper-endemic disease
Persistent, high levels of disease occurrence
Sporadic disease
A disease that occurs occasionally & has no certain
pattern(occur infrequently and irregularly)
6. Definition of terms …
6
Epidemic disease
occurrence of more cases of disease than
expected(above endemic level) in a given area or
among a specific group of people over a particular
time
Usually, the cases are presumed to have a common
cause or to be related to one another in some way
Disease Outbreak
epidemics of shorter duration covering a more
limited area
7. Definition of terms …
7
Cluster of cases
aggregation of cases in a given area over a
particular period without regard to whether the
number of cases is more than expected
Pandemic disease
an epidemic that has spread over several countries
or continents, affecting a large number of people
8. To control /stop the spread of disease
To know magnitude of the problem
To identify who is at risk
To assess the causes of disease, its source &
mode of transmission
To prevent future epidemic
Purpose of outbreak investigation
8
9. Types of epidemics
9
Epidemics (outbreaks) can be classified according to the
method of spread and length of exposure to the agent
A. Common Source Epidemic
Disease occurs as a result of exposure of a group of
susceptible persons to a common source of a pathogen,
often at the same time or within a brief time period
10. 10
When the exposure is simultaneous, the resulting
cases develop within one incubation period and this
is called a point source epidemic.
The epidemic curve in a point source epidemic will
commonly show a sharp rise and fall
E.g Food borne epidemic following an event where the
food was served to many people
12. 12
If the exposure to a common source continues over time,
it will result in a continuous common source epidemic.
E.g A waterborne outbreak that is spread through a
contaminated community water supply
The epidemic curve may have a wide peak because of
the range of exposures and the range of incubation
periods.
14. 14
B. Propagative / Progressive Epidemics.
infectious agent is transferred from one host to another
It can last longer than common source
In propagated outbreaks, cases occur over more than
one incubation period.
Propagative spread usually results in an epidemic curve
with a relatively gentle upslope and somewhat
steeper tail (series of progressively taller peaks)
15. 15
E.g outbreak of malaria.
In the propagated epidemics there will be successive
generations of cases.
The epidemic usually wanes after a few generations,b/c
the number of susceptible persons falls below some
critical level required to sustain transmission, or
the intervention measures become effective.
17. 17
C. Mixed Epidemics
Have features of both common-source epidemics and
propagated epidemics
The epidemic begins with a single, common source of an
infectious agent with subsequent propagative spread.
Many food borne pathogens result in mixed epidemics.
18. Steps of an epidemic Investigation
18
1. Prepare for fieldwork
2. Establish existence of an epidemic
3. Verify the diagnosis
4. Define & identify cases
5. Analyze data by person, place, and time
6. Develop hypotheses
7. Evaluate hypotheses (analytical studies)
8. Reconsider/refine hypotheses (additional studies)
9. Implement control and prevention measures
10. Communicate findings
19. 1. Prepare for Field Work
Decide to investigate the suspected outbreak if:
1. A report of a suspected epidemic of an immediately
notifiyable disease is received
2. Unusual increase is seen in the number of deaths during
routine analysis of data
3. Alert or action thresholds have been reached
4. Communities report rumors of deaths or large cases
5. A cluster of deaths occurs for which the cause is not
explained or is unusual
19
20. Example of Outbreak thresholds
S. No Name of disease Threshold level
1 AFP Single confirmed cases
2 Anthrax Single confirmed cases
3 Avian Human Influenza Single confirmed cases
4 Cholera Single confirmed cases
5
Dracunculiasis/Guinea
worm Single confirmed cases
6 Measles 5 suspected or 3 confirmed cases
7 NNT Single suspected case
8 Pandemic Influenza A Single confirmed case
9 Rabies Single suspected/confirmed case
10 SARS Single confirmed case
20
21. 1. Prepare for Field Work...
Assemble the team members
An epidemiologist/public health expert
A clinician
A laboratory professional
Environmental health expert
More professional depending of the type of
events/diseases
21
22. 1. Prepare for Field Work…
Identify the roles and responsibilities among:
Team Members
Different sectors & partners
Discuss Scientific knowledge
with someone knowledgeable and using available
references such as journal articles, guidelines, about the
disease:
Source, Root of transmission, Risk factors,…
22
23. 1. Prepare for Field Work…
Avail relevant resources
Different formats(Case based,line list,…)
Relevant guidelines
Personal protective equipment (PPE)
Laptop and wireless network
Mobile phone with communication cost if
necessary
Transportation
Personal matters
23
25. 2. Establish the Existence of an Outbreak…
To establish existence of an outbreak:
See trends in cases and deaths due to the disease
over the last 1-5 years
Know the epidemic threshold for that particular
disease
Compare the reported case versus the baseline
(Local/national source, neighboring areas)
Check real versus artifact
25
26. 2. Establish the Existence of an Outbreak…
The increase in the number of cases might be:
True increase in incidence
Change in reporting procedures
Change in case definition
Improvements in diagnostic procedures
Increased awareness
Increased access to health care
Laboratory or diagnostic error
Double reporting
Change in denominator
26
27. 3.Verify/confirm the Diagnosis
27
First, review the clinical findings and laboratory
results
Ask a qualified laboratory professional to review
the laboratory techniques being used
Collect and send laboratory specimen to
specialized laboratory
28. 3.Verify the Diagnosis…
28
Second, talk with some case patients
Better understanding of clinical pictures
Useful to generate hypothesis about the disease
etiology and spread
Third, summarize the clinical features using
frequency distribution
Used to develop the case definition
29. 4. Define & identify cases
29
A case is an event that happens:
To a person
In a given place
At a given time
Establish a case definition using:
Clinical picture :Sign,Symptom,Lab.result and
Epidemiological parameter: Time ,Person ,
Place
30. 4. Define & identify cases…
30
Conduct surveillance using case definition
Search for additional cases
1. Search for additional suspected cases and deaths in
the registers.
2. Look for other patients by identifying areas where:
the patients have lived,
The patient worked,
The patient travelled
3. Search in neighboring health facilities
4. Collect data using line list
31. 4. Define & identify cases…
Talk to other informants in the community:
Health extension workers,
Pharmacists,
Health workers,
School teachers,
Veterinarians,
Farmers and community leaders etc.
31
32. 4. Define & identify cases…
32
Line listing
rectangular database similar to spreadsheet
Provides summary of key data about cases
Each row represents one case
Each column represents one variable
Can be paper or electronic
Can be quickly reviewed and updated
33. 33
Signs/Symptoms
Lab. Demogra
phics
Ca
se
no
.
Name Date of
Symptom
Onset
Place Diarrhe
a Vomiting
Fever Positive
stool
culture
Age Sex
1 Abebe 12/05/13 A Y Y Not
done
Not
submitt
ed
16 M
2 Kebede 13/05/13 A Y Y Y Y 18 M
3 Ayele 14/05/13 B Y N Y Y 23 M
4 Biruk 15/05/13 B N N Y N 32 F
5 Bayu 16/05/13 B Y Y N N 29 F
6 Dagim 17/05/13 B N Y Y Y 28 F
34. 5.Analyze data by person, place, time
34
Time
Ideally, when were they infected?
More practically, when did they become ill?
Is the trend of the disease increasing/ decreasing
/maintaining over time
The overall shape of the epidemic curve can reveal
the type of outbreak
35. 5.Analyze data by person, place, time
35
Place (spot map, shaded map)
Ideally, where were they infected?
More commonly, where do they live, work?
Describe the geographic extent of the problem.
Identify and describe any clusters or patterns of
transmission or exposure.
Depending on the organism that has contributed to this
epidemic, specify the proximity of the cases to likely
sources of infection.
36. 5.Analyze data by person, place, time
36
Person (tables)
Who was infected ?age,sex,occupation,…
Numerators and denominators
What do the cases have in common?
37. 6.Develop hypotheses
37
The hypothesis should address:
The source of the agent
The exposures that caused the disease, etc.
Why and how the outbreak occurred
Talk to case-patients –what do they think?
Talk with health officials ,What do they think?
Recommended to generate more than one hypothesis
38. Use already available evidence about the suspected disease
the agent’s usual reservoir/source
usual mode of transmission
Known risk factors
Review descriptive epidemiology(ppt)
When was the event highest
Which areas have the highest attack rates
What groups are at greatest risk
38
39. 7.Evaluate hypotheses (analytical studies)
39
If evidence of the cause is less clear/not strong, test
your hypothesis
Apply:
cohort study & risk ratio
case-control study & odds ratio
Otherwise, compare facts with hypotheses
40. 8. Refine hypotheses and carry out
additional studies
40
Conduct additional studies
Environmental studies: food,water,living
environment,…
Laboratory based study
If analytic study results are conclusive, don’t wait for
positive samples before implementing prevention
41. 9.Implement control and prevention measures
41
Implement as early as possible
“The perfect is the enemy of the good ” meaning, roughly right
and timely is better than precisely right and late
An outbreak may be controlled by:
Eliminating or reducing the source of infection
Interrupting transmission and
Protecting persons at risk.
Create mechanism to evaluate effectiveness mgt measures
42. 42
Work with regulators, industry, and health educators
to institute control measures
Create mechanism to evaluate both short and long-
term success of control / prevention measures
43. What should be the priority action in an epidemic?
Causative agent Source/ mode of transmission
Known Unknown
Known Investigation +
Control +++
Investigation +++
Control +
Unknown Investigation +++
Control +++
Investigation +++
Control +
+++ = highest priority
+ = Lower priority
44. Measures Directed Against the Reservoir
Domestic animals as reservoir •Immunization
•Testing of herds
•Destruction of infected animals
Wild animals as reservoir •Post-exposure prophylaxis
Humans as reservoir •Removal of the focus of infection
•Isolation of infected persons.
•Treatment to make them noninfectious.
•Disinfection of contaminated objects.
•Quarantine
45. Measures that interrupt the transmission of organisms
For diseases transmitted by
ingestion
•Purification of water
•Pasteurization of milk
•Inspection procedures designed to
ensure safe food supply
•Improve housing conditions
For diseases transmitted by
respiratory routes
•Chemical disinfection of air and use of
ultraviolet light
•Work on ventilation patterns, like
unidirectional (“laminar”) air flow to reduce
the transmission of organisms in hospitals.
For diseases whose cycles
involve an intermediate host
•Clearing irrigation farms from snails to
control schistosomiasis
46. Measures that reduce host susceptibility
Active immunization •Mass vaccination
•Selective vaccination
Passive immunization •Transfer of maternal antibodies to the
fetus through the placenta
•Prophylaxis administration of immune
serum globulin(ISG)
Chemoprophylaxis •Use of antibiotics for known contacts of
cases
•Use of prophylaxis to persons traveling to
endemic areas.
47. 10.Communicate Findings
47
No report means little contribution of improving
scientific and public health knowledge
To whom we communicate?
Communicate to Decision Makers
Communicate to Health Workers
Communicate to the Public and Media
48. 10.Communicate Findings
48
Communicate through:
Oral briefing for local health authorities
Written report
The report should hold the following scientific format:
Introduction, Methods, Results, Discussion ,
Conclusion and Recommendations.
More specifically, an epidemic may result from:
• A recent increase in amount or virulence of the agent,
• The recent introduction of the agent into a setting where it has not been before,
• An enhanced mode of transmission so that more susceptible persons are exposed,
• A change in the susceptibility of the host response to the agent, and/or
• Factors that increase host exposure or involve introduction
Therefore, the status of an outbreak is
relative to the usual frequency of the disease in the
same area, among the same population, at the
same season of the year
Cluster refers to an aggregation of cases grouped
in place and time that are suspected to be greater than the number
expected, even though the expected number may not be known.
Cluster refers to an aggregation of cases grouped
in place and time that are suspected to be greater than the number
expected, even though the expected number may not be known.
Finally, some epidemics are neither common-source in its usual
sense nor propagated from person to person. Outbreaks of zoonotic
or vectorborne disease may result from sufficient prevalence of
infection in host species, sufficient presence of vectors, and
sufficient human-vector interaction.
Case Definition Categories
Confirmed cases
– Events that are confirmed by laboratory assessment
Probable cases
– Events that are compatible upon clinical assessment
Possible cases
– Events that can possibly be cases if they are investigated
Sensitivity – The ability to detect all cases.
– If 9 out of 10 people who have a disease are correctly
identified using the case definition, then the sensitivity
= 9/10 = .90 = 90%
Specificity – The ability to exclude those who are
non-cases
– If 8 out of 10 people who do not have a disease are
correctly classified as not having the disease using the
case definition, then the specificity = 8/10 = .80 = 80%
Types of Variables:
– Identifying information
– Demographic information
– Clinical information
– Risk factor information
– Reporter information
– (Contact information, sometimes)
Which Variables to Include
Always include:
• Components of case definition
• Case name or identifying number
• Date of symptom onset (or specimen collection date)
Usually include:
Age, gender
May include:
Other relevant demographic variables (race, occupation)
Relevant risk factors
The investigator may be following a red herring
Important Considerations
Clearly define responsibilities.
Establish priorities; move quickly to control.
“The perfect is the enemy of the good ” In outbreaks, roughly right and timely is better than precisely right and late.
If participating by invitation, remember:
– Be sensitive to local expertise and opinion.
– You are there to help, not take over.
– Local staff have other duties too.
– Don’t just “collect and leave”. See it through.
Important Considerations
Clearly define responsibilities.
Establish priorities; move quickly to control.
“The perfect is the enemy of the good ” In outbreaks, roughly right and timely is better than precisely right and late.
If participating by invitation, remember:
– Be sensitive to local expertise and opinion.
– You are there to help, not take over.
– Local staff have other duties too.
– Don’t just “collect and leave”. See it through.