1. An outbreak investigation was conducted to verify the scale of illness, diagnose the causative agent, identify the source and mode of transmission, and formulate prevention and control measures. Initial reports were collected from various sources and epidemiological data was analyzed.
2. Field studies found a cluster of cases exceeding expected numbers. Laboratory testing identified the pathogen. Environmental sampling traced transmission to a contaminated water source.
3. Recommendations were made to strengthen surveillance, implement water sanitation measures, and prevent future outbreaks through improved hygiene practices.
This document outlines the 10 steps for investigating disease outbreaks: 1) Prepare for field work, 2) Establish existence of outbreak, 3) Verify diagnoses, 4) Define and identify cases, 5) Perform descriptive epidemiology, 6) Develop hypotheses, 7) Evaluate hypotheses, 8) Execute additional studies if needed, 9) Implement control measures, and 10) Communicate findings. It provides details on each step, including how to establish if cases exceed expectations, verify diagnoses, develop case definitions, analyze patterns of time, place, and person, and conduct analytical studies to test hypotheses. The goal is to identify the source, implement immediate control if known, and effectively manage and communicate regarding the outbreak.
Outbreak management ppt comprises the definition , history , investigations and the steps of management of outbreak. This was my seminar and UG class tpoic
The document summarizes a term paper on public health surveillance in Nepal. It discusses the objectives, methodology, findings and conclusions of the paper. The key points are: public health surveillance involves ongoing collection and analysis of health data to guide public health practice; Nepal has integrated disease surveillance within its health management information system; and the country was commended for its efficient AFP surveillance and polio eradication efforts while still needing to address potential wild poliovirus circulation.
The document outlines the 10 steps for investigating disease outbreaks: 1) confirm the existence of an outbreak, 2) verify the diagnosis and determine the cause, 3) develop a case definition and begin case finding, 4) describe the outbreak in terms of time, place, and people, 5) test hypotheses through analytical studies, 6) conduct environmental and other studies, 7) establish the causes of the outbreak based on evidence, 8) report findings and recommendations to authorities, 9) disseminate information to educate the public health community, and 10) follow up to ensure control measures are implemented. The goal of an outbreak investigation is to control the current outbreak and prevent future outbreaks through understanding the disease and improving surveillance systems.
This document discusses surveillance in healthcare. It defines surveillance as the ongoing collection and analysis of health-related data for public health purposes. The document outlines different types of surveillance including passive, active, and sentinel surveillance. Passive surveillance relies on voluntary reporting while active surveillance stimulates more regular reporting. Sentinel surveillance monitors specific sites. The advantages and disadvantages of each type are provided. The document also discusses important qualities of an effective surveillance system such as simplicity, flexibility, acceptability, sensitivity, predictive value, representativeness, and timeliness.
This document provides an overview of key concepts in epidemiology including:
1. Epidemiology is defined as the study of distribution and determinants of health-related states or events in populations.
2. The aims of epidemiology are to understand disease course, identify causes/risk factors, and provide treatment/prevention measures.
3. Epidemiology is used to describe population health status, genetic/environmental factors, disease natural history, and evaluate interventions.
This document provides an overview of public health surveillance. It defines surveillance as the ongoing collection, analysis, and interpretation of health data to inform public health programs and actions. The document outlines the historical origins of surveillance dating back to ancient Greece. It describes various types of surveillance including community-level surveillance, routine reporting systems, active and passive surveillance, sentinel surveillance, and surveys. It also discusses the integrated disease surveillance program in India and how it aims to strengthen surveillance systems at the state and district levels.
This document outlines the 10 steps for investigating disease outbreaks: 1) Prepare for field work, 2) Establish existence of outbreak, 3) Verify diagnoses, 4) Define and identify cases, 5) Perform descriptive epidemiology, 6) Develop hypotheses, 7) Evaluate hypotheses, 8) Execute additional studies if needed, 9) Implement control measures, and 10) Communicate findings. It provides details on each step, including how to establish if cases exceed expectations, verify diagnoses, develop case definitions, analyze patterns of time, place, and person, and conduct analytical studies to test hypotheses. The goal is to identify the source, implement immediate control if known, and effectively manage and communicate regarding the outbreak.
Outbreak management ppt comprises the definition , history , investigations and the steps of management of outbreak. This was my seminar and UG class tpoic
The document summarizes a term paper on public health surveillance in Nepal. It discusses the objectives, methodology, findings and conclusions of the paper. The key points are: public health surveillance involves ongoing collection and analysis of health data to guide public health practice; Nepal has integrated disease surveillance within its health management information system; and the country was commended for its efficient AFP surveillance and polio eradication efforts while still needing to address potential wild poliovirus circulation.
The document outlines the 10 steps for investigating disease outbreaks: 1) confirm the existence of an outbreak, 2) verify the diagnosis and determine the cause, 3) develop a case definition and begin case finding, 4) describe the outbreak in terms of time, place, and people, 5) test hypotheses through analytical studies, 6) conduct environmental and other studies, 7) establish the causes of the outbreak based on evidence, 8) report findings and recommendations to authorities, 9) disseminate information to educate the public health community, and 10) follow up to ensure control measures are implemented. The goal of an outbreak investigation is to control the current outbreak and prevent future outbreaks through understanding the disease and improving surveillance systems.
This document discusses surveillance in healthcare. It defines surveillance as the ongoing collection and analysis of health-related data for public health purposes. The document outlines different types of surveillance including passive, active, and sentinel surveillance. Passive surveillance relies on voluntary reporting while active surveillance stimulates more regular reporting. Sentinel surveillance monitors specific sites. The advantages and disadvantages of each type are provided. The document also discusses important qualities of an effective surveillance system such as simplicity, flexibility, acceptability, sensitivity, predictive value, representativeness, and timeliness.
This document provides an overview of key concepts in epidemiology including:
1. Epidemiology is defined as the study of distribution and determinants of health-related states or events in populations.
2. The aims of epidemiology are to understand disease course, identify causes/risk factors, and provide treatment/prevention measures.
3. Epidemiology is used to describe population health status, genetic/environmental factors, disease natural history, and evaluate interventions.
This document provides an overview of public health surveillance. It defines surveillance as the ongoing collection, analysis, and interpretation of health data to inform public health programs and actions. The document outlines the historical origins of surveillance dating back to ancient Greece. It describes various types of surveillance including community-level surveillance, routine reporting systems, active and passive surveillance, sentinel surveillance, and surveys. It also discusses the integrated disease surveillance program in India and how it aims to strengthen surveillance systems at the state and district levels.
This document summarizes a training on outbreak investigation held from May 23-27, 2016 at Central Luzon State University. It discusses emerging and re-emerging diseases, examples of case definitions, confirming an outbreak, analyzing outbreak data through time, place and other factors, and establishing hypotheses. The training covered the nine steps of outbreak investigation including confirming diagnoses, defining cases, collecting and analyzing data, establishing hypotheses, and communicating findings.
This document discusses the role of epidemiology in public health. It begins by outlining the goals of public health as reducing disease, death and suffering. It then defines epidemiology as the study of disease distribution and the factors that influence distribution, making it the basic science of public health. The document goes on to discuss how epidemiology has expanded over time to study non-infectious diseases, the environment, health care delivery, and personal behaviors. It argues that epidemiology needs to consider broader social and political determinants of health like poverty, conflict, and human rights issues to fully understand population health.
India being a developing country with growing population has been traditionally vulnerable to natural and man made disasters.
Development cannot be sustainable unless disaster mitigation is built into developmental process.
Disaster could be a nature calamity, outbreak of disease, bioterrorism, etc.
New Delhi, Feb 23. The health ministry has proposed a bill that seeks to empower state and local authorities to take appropriate actions to tackle public health emergencies like epidemics and bio-terrorism.
Guidelines for Management of Outbreak in Healthcare Organizationdrnahla
Guidelines for Management of Outbreak in Healthcare Organization
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
The document provides an overview of investigating disease outbreaks through a 13-step approach. It defines key epidemiological concepts like outbreak, epidemic, endemic and pandemic. The 13 steps include: 1) forming an investigation team, 2) verifying the existence of an outbreak, 3) verifying diagnoses, 4) defining cases, 5) finding cases systematically, 6) descriptive epidemiology, 7) developing hypotheses, 8) evaluating hypotheses, 9) refining hypotheses, 10) additional studies, 11) control measures, 12) surveillance, and 13) communication. Descriptive epidemiology involves characterizing cases by time, place and person. Hypothesis development and evaluation use epidemiological and analytical methods.
The document provides Malaysia's monthly infectious disease report for May 2005, listing the number of reported cases and deaths from various infectious diseases by state. It aims to strengthen disease surveillance in Malaysia by mandatorily notifying cases of 26 specified infectious diseases to the Ministry of Health under the Prevention and Control of Infectious Diseases Act 1988. The analysed surveillance data is intended to provide public health officials and policymakers with evidence-based information for decision making and early detection of disease outbreaks.
This document summarizes the key aspects of a case control study, including its features, design, steps, use of odds ratios, potential biases, and advantages/disadvantages. A case control study is an analytical study that tests hypotheses about associations between exposures and outcomes by comparing exposures in individuals who have the outcome of interest (cases) to those who do not (controls). Key steps involve selecting and matching cases and controls, measuring exposures through interviews/records, and analyzing associations using odds ratios while accounting for potential biases.
Lecture for Post and Undergraduate.
From the past two decades Non Communicable diseases are increasing in both developing and developed countries due to which developing are experiencing double burden of diseases.
The document defines key terms related to epidemics such as epidemic, endemic, outbreak, sporadic, and pandemic. It discusses the iceberg concept of infectious disease and explains that only a small portion of cases are clinically apparent. The levels of response to different disease triggers are outlined. The document also covers the objectives and steps of an epidemic investigation including developing a case definition, confirming the existence of an epidemic, defining the population at risk, rapidly searching for cases, analyzing data through epidemiological curves, and formulating and testing hypotheses. Control measures and the importance of forecasting and preventing future epidemics are also summarized.
outbreak investigation - types of epidemics and investigating themTimiresh Das
This document discusses an upcoming presentation on outbreak investigation. It begins with definitions of key terms like epidemic, outbreak, endemic, and pandemic. It then discusses determinants of disease outbreaks and types of epidemics. The objectives, steps, and examples of outbreak investigation are provided. Various factors related to outbreaks like incubation period, quarantine, herd immunity, and triggers for surveillance are defined.
This outbreak investigation identified an outbreak of E. coli O157:H7 infections in Michigan in June-July 1997. Initial calls reported 6 patients infected. Molecular fingerprinting of isolates found they were identical, confirming an outbreak. A case-control study identified alfalfa sprout consumption as the likely source, with an odds ratio of 25. Traceback studies traced the implicated sprouts to contaminated seed lots from Idaho alfalfa fields, possibly due to cattle manure, irrigation water, or deer feces. Further studies cultured implicated sprouts and investigated contamination routes on alfalfa farms.
This lecture introduces epidemiology by discussing its importance through achievements like smallpox eradication. It defines epidemiology as the study of health-related states in populations to prevent and control health problems. The lecture describes John Snow's contribution by showing cholera is spread through contaminated water before germ theory. It outlines the epidemiological approach as asking questions to make comparisons, and aims of epidemiology as describing disease distribution, identifying causes, and providing data for prevention planning.
The document provides information about the Integrated Disease Surveillance Programme (IDSP) in India. It discusses that IDSP aims to establish a decentralized disease surveillance system to detect early warning signals of outbreaks. Key elements of IDSP include detection and reporting of health events, investigation and confirmation of cases, collection and analysis of surveillance data, and feedback to initiate public health responses. IDSP implementation is organized at the national, state, and district levels with defined roles and reporting structures. The program coordinates surveillance of both communicable and non-communicable diseases using standardized reporting forms.
OVERVIEW OF HUMAN MONKEY POX VIRUS DISEASE.pptxKemi Adaramola
This document provides an overview of human monkeypox virus disease. It discusses the aetiology, transmission, clinical manifestation, diagnosis, case definitions and management of monkeypox. The virus is transmitted from animals and humans. Symptoms include fever, rash, lymphadenopathy and lesions on the face, palms and soles. Diagnosis is by PCR, culture or antibodies. Differentials include chickenpox, measles and bacterial infections. Complications include secondary infections and death may occur.
Epidemiology is the study of how diseases are distributed in populations and the factors that influence this. It examines why some people develop illnesses and others do not. Epidemiology helps public health officials understand health problems in communities and find ways to control and prevent diseases. The history of epidemiology shows how early physicians like Hippocrates linked environmental factors to health, and later scientists such as John Snow used epidemiological findings to control outbreaks. Modern epidemiology involves counting cases, measuring populations, analyzing health problems, applying solutions, and evaluating their effectiveness. It provides insights used in public health programs and patient care.
This document outlines the steps and objectives for investigating an epidemic outbreak. It details verifying diagnoses, confirming the epidemic's existence, defining the at-risk population, rapidly searching for all cases and their characteristics, analyzing the data, formulating hypotheses, testing hypotheses, evaluating ecological factors, further investigating the population at risk, writing reports, and implementing control measures. The overall goal is to determine the cause and transmission modes of the epidemic in order to prevent future occurrences.
This document defines and provides examples of key measures used to describe disease frequency in populations, including ratios, proportions, rates, odds, prevalence, and incidence. It discusses how prevalence represents the number of cases at a point in time, while incidence represents new cases over a period of time. Examples are provided to demonstrate calculating measures like cumulative incidence, incidence density, and attack rate. The relationship between incidence and prevalence over time is also explained.
This document provides an overview of basic measurements used in epidemiology. It discusses tools like proportion, rate, and ratio. It also covers various measures of mortality like crude death rate, specific death rate, and proportional mortality rate. Measures of morbidity like incidence and prevalence are explained. The relationship between incidence and prevalence is described. Standardization techniques are introduced to make rates comparable between populations.
1. An outbreak investigation was conducted to determine the source and mode of transmission of an illness that exceeded expected numbers. Interviews, specimen collection, and data analysis were performed.
2. Analysis revealed the pathogen and identified a water source as the likely mode of transmission. Over 100 cases were reported in the affected area within two weeks.
3. Recommendations included controlling the contaminated water source, strengthening surveillance, and preventing future outbreaks through improved sanitation.
The document describes the steps taken to investigate an outbreak of jaundice in Rohtak, India. People first noticed an unusual occurrence of jaundice cases that had not been seen in over 10 years. A house-to-house survey confirmed it was an outbreak. Laboratory tests of water samples found one-third failed orthotolidine tests and 3 of 5 samples had unsafe coliform counts. Additional observations revealed poor sanitation practices in the community that could have contributed to the spread of the disease.
This document summarizes a training on outbreak investigation held from May 23-27, 2016 at Central Luzon State University. It discusses emerging and re-emerging diseases, examples of case definitions, confirming an outbreak, analyzing outbreak data through time, place and other factors, and establishing hypotheses. The training covered the nine steps of outbreak investigation including confirming diagnoses, defining cases, collecting and analyzing data, establishing hypotheses, and communicating findings.
This document discusses the role of epidemiology in public health. It begins by outlining the goals of public health as reducing disease, death and suffering. It then defines epidemiology as the study of disease distribution and the factors that influence distribution, making it the basic science of public health. The document goes on to discuss how epidemiology has expanded over time to study non-infectious diseases, the environment, health care delivery, and personal behaviors. It argues that epidemiology needs to consider broader social and political determinants of health like poverty, conflict, and human rights issues to fully understand population health.
India being a developing country with growing population has been traditionally vulnerable to natural and man made disasters.
Development cannot be sustainable unless disaster mitigation is built into developmental process.
Disaster could be a nature calamity, outbreak of disease, bioterrorism, etc.
New Delhi, Feb 23. The health ministry has proposed a bill that seeks to empower state and local authorities to take appropriate actions to tackle public health emergencies like epidemics and bio-terrorism.
Guidelines for Management of Outbreak in Healthcare Organizationdrnahla
Guidelines for Management of Outbreak in Healthcare Organization
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
The document provides an overview of investigating disease outbreaks through a 13-step approach. It defines key epidemiological concepts like outbreak, epidemic, endemic and pandemic. The 13 steps include: 1) forming an investigation team, 2) verifying the existence of an outbreak, 3) verifying diagnoses, 4) defining cases, 5) finding cases systematically, 6) descriptive epidemiology, 7) developing hypotheses, 8) evaluating hypotheses, 9) refining hypotheses, 10) additional studies, 11) control measures, 12) surveillance, and 13) communication. Descriptive epidemiology involves characterizing cases by time, place and person. Hypothesis development and evaluation use epidemiological and analytical methods.
The document provides Malaysia's monthly infectious disease report for May 2005, listing the number of reported cases and deaths from various infectious diseases by state. It aims to strengthen disease surveillance in Malaysia by mandatorily notifying cases of 26 specified infectious diseases to the Ministry of Health under the Prevention and Control of Infectious Diseases Act 1988. The analysed surveillance data is intended to provide public health officials and policymakers with evidence-based information for decision making and early detection of disease outbreaks.
This document summarizes the key aspects of a case control study, including its features, design, steps, use of odds ratios, potential biases, and advantages/disadvantages. A case control study is an analytical study that tests hypotheses about associations between exposures and outcomes by comparing exposures in individuals who have the outcome of interest (cases) to those who do not (controls). Key steps involve selecting and matching cases and controls, measuring exposures through interviews/records, and analyzing associations using odds ratios while accounting for potential biases.
Lecture for Post and Undergraduate.
From the past two decades Non Communicable diseases are increasing in both developing and developed countries due to which developing are experiencing double burden of diseases.
The document defines key terms related to epidemics such as epidemic, endemic, outbreak, sporadic, and pandemic. It discusses the iceberg concept of infectious disease and explains that only a small portion of cases are clinically apparent. The levels of response to different disease triggers are outlined. The document also covers the objectives and steps of an epidemic investigation including developing a case definition, confirming the existence of an epidemic, defining the population at risk, rapidly searching for cases, analyzing data through epidemiological curves, and formulating and testing hypotheses. Control measures and the importance of forecasting and preventing future epidemics are also summarized.
outbreak investigation - types of epidemics and investigating themTimiresh Das
This document discusses an upcoming presentation on outbreak investigation. It begins with definitions of key terms like epidemic, outbreak, endemic, and pandemic. It then discusses determinants of disease outbreaks and types of epidemics. The objectives, steps, and examples of outbreak investigation are provided. Various factors related to outbreaks like incubation period, quarantine, herd immunity, and triggers for surveillance are defined.
This outbreak investigation identified an outbreak of E. coli O157:H7 infections in Michigan in June-July 1997. Initial calls reported 6 patients infected. Molecular fingerprinting of isolates found they were identical, confirming an outbreak. A case-control study identified alfalfa sprout consumption as the likely source, with an odds ratio of 25. Traceback studies traced the implicated sprouts to contaminated seed lots from Idaho alfalfa fields, possibly due to cattle manure, irrigation water, or deer feces. Further studies cultured implicated sprouts and investigated contamination routes on alfalfa farms.
This lecture introduces epidemiology by discussing its importance through achievements like smallpox eradication. It defines epidemiology as the study of health-related states in populations to prevent and control health problems. The lecture describes John Snow's contribution by showing cholera is spread through contaminated water before germ theory. It outlines the epidemiological approach as asking questions to make comparisons, and aims of epidemiology as describing disease distribution, identifying causes, and providing data for prevention planning.
The document provides information about the Integrated Disease Surveillance Programme (IDSP) in India. It discusses that IDSP aims to establish a decentralized disease surveillance system to detect early warning signals of outbreaks. Key elements of IDSP include detection and reporting of health events, investigation and confirmation of cases, collection and analysis of surveillance data, and feedback to initiate public health responses. IDSP implementation is organized at the national, state, and district levels with defined roles and reporting structures. The program coordinates surveillance of both communicable and non-communicable diseases using standardized reporting forms.
OVERVIEW OF HUMAN MONKEY POX VIRUS DISEASE.pptxKemi Adaramola
This document provides an overview of human monkeypox virus disease. It discusses the aetiology, transmission, clinical manifestation, diagnosis, case definitions and management of monkeypox. The virus is transmitted from animals and humans. Symptoms include fever, rash, lymphadenopathy and lesions on the face, palms and soles. Diagnosis is by PCR, culture or antibodies. Differentials include chickenpox, measles and bacterial infections. Complications include secondary infections and death may occur.
Epidemiology is the study of how diseases are distributed in populations and the factors that influence this. It examines why some people develop illnesses and others do not. Epidemiology helps public health officials understand health problems in communities and find ways to control and prevent diseases. The history of epidemiology shows how early physicians like Hippocrates linked environmental factors to health, and later scientists such as John Snow used epidemiological findings to control outbreaks. Modern epidemiology involves counting cases, measuring populations, analyzing health problems, applying solutions, and evaluating their effectiveness. It provides insights used in public health programs and patient care.
This document outlines the steps and objectives for investigating an epidemic outbreak. It details verifying diagnoses, confirming the epidemic's existence, defining the at-risk population, rapidly searching for all cases and their characteristics, analyzing the data, formulating hypotheses, testing hypotheses, evaluating ecological factors, further investigating the population at risk, writing reports, and implementing control measures. The overall goal is to determine the cause and transmission modes of the epidemic in order to prevent future occurrences.
This document defines and provides examples of key measures used to describe disease frequency in populations, including ratios, proportions, rates, odds, prevalence, and incidence. It discusses how prevalence represents the number of cases at a point in time, while incidence represents new cases over a period of time. Examples are provided to demonstrate calculating measures like cumulative incidence, incidence density, and attack rate. The relationship between incidence and prevalence over time is also explained.
This document provides an overview of basic measurements used in epidemiology. It discusses tools like proportion, rate, and ratio. It also covers various measures of mortality like crude death rate, specific death rate, and proportional mortality rate. Measures of morbidity like incidence and prevalence are explained. The relationship between incidence and prevalence is described. Standardization techniques are introduced to make rates comparable between populations.
1. An outbreak investigation was conducted to determine the source and mode of transmission of an illness that exceeded expected numbers. Interviews, specimen collection, and data analysis were performed.
2. Analysis revealed the pathogen and identified a water source as the likely mode of transmission. Over 100 cases were reported in the affected area within two weeks.
3. Recommendations included controlling the contaminated water source, strengthening surveillance, and preventing future outbreaks through improved sanitation.
The document describes the steps taken to investigate an outbreak of jaundice in Rohtak, India. People first noticed an unusual occurrence of jaundice cases that had not been seen in over 10 years. A house-to-house survey confirmed it was an outbreak. Laboratory tests of water samples found one-third failed orthotolidine tests and 3 of 5 samples had unsafe coliform counts. Additional observations revealed poor sanitation practices in the community that could have contributed to the spread of the disease.
An outbreak exists when there are more cases of a disease than normal in a particular area, group, or time period. Investigating outbreaks helps describe the problem, implement control measures, and advance medical knowledge. When investigating an outbreak, epidemiologists verify diagnoses, identify cases, analyze data by time, place, and person to form hypotheses, and evaluate control measures to terminate the outbreak.
This document discusses healthcare-associated infections (HAIs) and outbreak investigations. It defines key terms like clusters, outbreaks, and epidemics. It also outlines the reasons to investigate outbreaks, how to recognize them, and the goals and steps of investigations. The steps include defining cases, identifying cases, analyzing person, place and time factors, developing and evaluating hypotheses, implementing controls, and communicating findings. The overall purpose is to identify the cause of the outbreak and implement measures to control it.
steps in epidemic investigation
Prepare for field work
Confirm the existence of an outbreak
Verify the diagnosis and determine the etiology of the disease.
Define the population at risk
Develop case definition, start case finding, and collect information on the cases(after choosing study design)
Describe person, place and time (by questionnaire)
Evaluation of ecological factors
Formulate several possible hypothesis hypotheses.
Test hypotheses using analytical study
Refine hypotheses and carry out additional studies
Draw conclusions to explain the causes or determinants of outbreak based on clinical, laboratory, epidemiological & environmental evidence
Report and recommend appropriate control measures to concerned authorities at the local/national, and if appropriate at international levels
Communication of the findings
Follow up of the recommendation to assure implementation of control measures
This document provides an overview of the rules and guidelines for the 2014 Disease Detectives event for Science Olympiad. It outlines that the topic for 2014 will be environmental quality. It provides resources for training materials, including sample problems and event guidelines. It describes the format of the event and emphasizes checking the official rules for parameters. It also gives an overview of epidemiology concepts focused on for 2014, including environmental causes of health problems and the scientific method as it relates to outbreak investigation.
An outbreak investigation involves 10 steps:
1. Verify diagnoses clinically and through labs.
2. Confirm an epidemic exists by comparing to previous years.
3. Define standard case criteria.
4. Identify the at-risk population.
5. Rapidly search for all case characteristics.
6. Analyze data by time, place, and person.
7. Form hypotheses on causation, transmission.
8. Test hypotheses through analytical studies.
9. Initiate control measures like sanitation and treatment.
10. Write a report with findings and recommendations.
This document outlines the educational objectives and content for a lecture on epidemiology. The objectives are to define key epidemiology terms, discuss the functions and modes of epidemiologic investigation, and identify sources of data and potential sources of error. The content includes definitions of epidemiology and related terms, the main functions of epidemiology, descriptive and analytic modes of investigation, how surveillance system data is applied through outbreak investigation, and sources of epidemiological data and potential sources of error.
The document summarizes the key steps in investigating an epidemic:
1) Verify the diagnosis and confirm the existence of an epidemic by comparing to previous years.
2) Define the population at risk by obtaining maps, counting population size, and initial line-listing of cases.
3) Conduct a rapid search for all cases through medical surveys, case sheets collecting details of identified cases, and searching for additional cases.
4) Analyze the collected data to understand patterns in time, place and person which can reveal the source and spread of disease. Formulate and test hypotheses based on this analysis.
The document outlines the key principles and steps of conducting an outbreak investigation. It defines what constitutes an outbreak and explains that the purpose is to control the current outbreak, prevent future occurrences, and evaluate existing surveillance and prevention programs. The main steps described are confirming the outbreak, defining cases, collecting descriptive data, developing hypotheses, testing hypotheses through analytical studies, communicating conclusions, and recommending control measures.
Malimu investigation of an outbreak of communicable diseases pnco-2Miharbi Ignasm
This document outlines the steps for investigating communicable disease outbreaks. It begins with an introduction that defines communicable diseases and provides examples. There are then 12 steps described for investigating an outbreak, including verifying diagnoses, establishing the existence of an epidemic, identifying and counting cases, analyzing data, formulating hypotheses, assessing local response capacity, setting control measures, addressing resource gaps, reporting, disseminating findings, and intensifying surveillance. The roles of the Ministry of Health, District Health Team, and health units in outbreak investigations and control are also outlined.
An outbreak investigation involves following 8 key steps:
1. Verify the diagnosis and confirm the outbreak through laboratory tests and comparing to past data.
2. Define a specific case definition and conduct surveillance to identify additional cases.
3. Create a line listing and map of cases to identify common attributes of person, place, and time.
4. Take immediate control measures if the source is identified to prevent further spread.
5. Formulate and test hypotheses through analytic studies to identify the source and transmission.
6. Plan and execute additional environmental sampling and studies to guide prevention.
7. Implement and evaluate control measures by eliminating the source and preventing future outbreaks.
8. Communicate investigation findings and recommendations
The unusual occurrence in a community or region of disease, specific health related behaviour (eg. Smoking) or other health related events (eg. Traffic accidents) clearly in excess of “expected occurrence.
This document outlines the steps involved in investigating an epidemic:
1. Verification of diagnoses and defining cases is the first step to understand the scope and characteristics of the epidemic.
2. Confirmation of an actual epidemic involves comparing case numbers to historical data to determine if there is unusual disease occurrence.
3. Defining the population at risk, rapidly searching for all cases, collecting data on characteristics, and analyzing patterns in time, place and person help identify potential causes and transmission routes.
This document outlines the steps for investigating an outbreak. It defines key epidemiological terms and discusses when to investigate an outbreak. The 10 steps of an outbreak investigation are described as: 1) defining the problem, 2) generating hypotheses, 3) testing hypotheses, 4) verifying diagnoses, 5) finding and counting cases, 6) performing descriptive epidemiology, 7) analyzing data, 8) communicating findings, 9) implementing control measures, and 10) preventing future outbreaks. Preparedness, the roles of NGOs, recent outbreak examples, and the importance of surveillance and inter-sectoral coordination are also covered.
This document provides an overview of investigating and managing disease outbreaks. It discusses key concepts like endemic, epidemic, pandemic and outbreak. It also outlines the 10 steps to investigate an outbreak: 1) prepare for field work, 2) confirm outbreak occurrence, 3) verify diagnoses, 4) define cases and find cases, 5) descriptive epidemiology, 6) form hypotheses, 7) evaluate hypotheses, 8) refine hypotheses, 9) intervention and follow up, and 10) communicate findings. Descriptive epidemiology involves analyzing cases by time, place and person using tools like epidemic curves and spot maps.
Lecture 8 & 9. Outbrek invesitgation and screening test.pptxMesfinShifara
This document provides an overview of investigating and managing disease outbreaks. It discusses key concepts like levels of disease occurrence (endemic, epidemic, pandemic), thresholds for declaring an outbreak, and steps for outbreak investigation and control. The steps include preparing for field work, verifying the outbreak, defining cases, descriptive epidemiology of time, place and person, formulating a hypothesis, and implementing control measures. Understanding disease patterns and investigating outbreaks aims to control transmission and prevent future occurrences.
An outbreak of Burkholderia cepacia bloodstream infections occurred among newborns in the NICU, with 16 of 59 newborns infected over a month. This was a significant increase over the unit's typical infection rate of 2% per month. The ICC nurse investigated by learning about B. cepacia, verifying the diagnoses, establishing the outbreak, and defining cases. Preliminary findings identified a cluster of infections in October, with all blood cultures from within 24 hours of birth testing positive for B. cepacia. The source and mode of transmission were still unknown.
Similar to Outbreak investigation for UG Public Health (20)
1) In the first race, the hare sprints ahead but grows complacent and falls asleep, allowing the steady tortoise to win.
2) In the rematch, the determined hare runs consistently and wins.
3) In another rematch, the tortoise leads the hare to a river, where the hare cannot swim, allowing the tortoise to swim across and win again.
4) In the final race, the hare and tortoise work as a team, using each other's strengths to cross the finish line together faster than either could alone.
This document discusses principles and techniques for effective leadership and interpersonal relationships. It emphasizes building on one's authentic self to influence others through understanding relationships, providing purpose and motivation. It also discusses changing perceptions and mindsets, focusing on people rather than things, developing interdependence through mutual understanding and accountability, and the importance of listening, communication skills, and meeting psychological needs to develop synergistic relationships.
Effective public health communication oldamitakashyap1
Effective public health communication is essential for informing and influencing individuals and communities about important health issues. The document discusses various aspects of public health communication including defining it, the need for effective communication, principles of effective communication, challenges, and approaches like social marketing. It provides details on formative research conducted to develop a nutrition strategy in Rajasthan which included understanding audiences, behaviors, barriers and enablers. The strategy developed communication objectives and a plan for different audiences using various channels and materials. Monitoring indicators were also identified to track outcomes. Such a thorough, evidence-based approach can enable replicable and sustainable public health communication programs.
1) Cohort studies begin with groups of individuals who are alike in many ways but differ with respect to exposure to a certain factor, thought to influence the probability of occurrence of a disease or other outcome.
2) The groups are followed over time and the researchers record who does or does not develop the disease. This allows calculation of disease rates in the exposed and unexposed groups.
3) Cohort studies can provide strong evidence about whether an association reflects a causal relationship by assessing disease development over time in relation to exposure. However, selection bias and information bias must be considered.
This document discusses various study designs used in medical research, including observational and experimental designs. It describes descriptive, analytical, and interventional studies. It provides examples of case reports, case series, cross-sectional studies, case-control studies, and cohort studies. It discusses key aspects of case-control studies such as selection of cases and controls, matching, determining exposure, and analyzing results. It also covers limitations and advantages of different study designs.
Effective public health communication 5th aprilamitakashyap1
Effective public health communication is needed to promote awareness of health issues, educate about available services, change behaviors to improve health, address emergencies, and build community capacity. It should be relevant, accurate, culturally competent, accessible, and action-oriented. Types of public health communication include health education, advocacy, risk communication, and crisis communication. Social marketing uses commercial techniques to promote social causes like improving nutrition. Developing effective public health communication requires understanding the community through formative research, developing multilevel strategies, pre-testing materials, and monitoring outcomes. An example from Rajasthan developed a state-specific strategy to address undernutrition through behavior change communication targeting pregnant women, husbands, mothers-in-law and health workers
The document discusses the benefits of meditation for reducing stress and anxiety. Regular meditation practice can help calm the mind and body by lowering heart rate and blood pressure. Studies have shown that meditating for just 10-20 minutes per day can have significant positive impacts on both mental and physical health.
This document provides information on various contraceptive methods, including spacing and terminal methods. Spacing methods are used to space births or delay the first child, and include barrier methods, IUDs, hormonal methods, fertility awareness methods, and lactational amenorrhea. Terminal methods permanently stop conception and include vasectomy for men and tubal ligation for women. The document describes the composition, mode of action, effectiveness, advantages, and disadvantages of common contraceptive methods such as condoms, IUDs, oral contraceptive pills, injectables, implants, sterilization procedures, and fertility awareness methods.
This document discusses various indicators that can be used to measure health and disease in a population. It outlines different types of indicators including health status indicators like mortality and morbidity, quality of life indicators, socioeconomic indicators, health care delivery indicators, and environmental indicators. Specific measures are provided for different types of indicators, such as crude mortality rate, standardized mortality rates, incidence rate, and prevalence. The indicators can help health administrators assess problems, design health plans, and evaluate schemes. Ideal indicators should be valid, reliable, sensitive, specific, and feasible.
This document discusses concepts related to disease transmission. It defines the epidemiologic triad as requiring an agent, reservoir, mode of transmission, portal of entry and susceptible host. Modes of transmission include direct contact or indirect transmission through vehicles or vectors. Disease levels range from sporadic to endemic to epidemic or pandemic. Herd immunity is achieved through vaccination above a threshold proportion of immune individuals. Types of epidemics include common source, propagated or mixed spread. Body surfaces and routes of exposure allow entry of infectious agents.
Public health originated in the 19th century to address poor sanitary conditions and disease outbreaks. Simple public health measures like clean water and vaccination have saved more lives than medical advances. Community medicine focuses on preventing disease in populations through organized community efforts. It aims to promote health and adjust individuals and society. Public health is defined as organized efforts to prevent disease, prolong life, and promote health through surveillance, policies, education, and ensuring resources are allocated to public health. It uses technology and social sciences to identify, prevent and monitor health issues in populations.
Community medicine focuses on preventing disease and promoting public health rather than treating individual patients. It evolved from public health movements in the 19th century that emphasized sanitation and organized community efforts to improve health. Community medicine aims to keep populations healthy through measures like vaccination programs, vector control, and increasing access to resources like safe water and adequate nutrition. It has contributed greatly to reducing communicable diseases and improving health worldwide.
This document discusses key concepts in public health and community medicine. It defines public health as the science and art of preventing disease, prolonging life, and promoting health through organized community efforts. The document outlines the importance and evolution of public health interventions and movements. It also compares clinical and preventive medicine and discusses the contributions, functions, and future of community medicine and public health.
Community medicine focuses on health promotion and disease prevention at the community level through organized social action. It evolved from clinical medicine to address health issues facing entire populations. Key concepts include viewing health as an equilibrium between individuals and their environment, the importance of both preventive and curative approaches to medicine, and addressing social determinants of health. The field was influenced by developments in epidemiology, public health infrastructure, and the germ theory of disease.
Concept of sufficient cause and component causesamitakashyap1
This document discusses key epidemiological concepts related to measuring disease occurrence, including sufficient causes, component causes, risk, prevalence, and incidence rate. It provides examples to illustrate how these measures are calculated and how they relate to one another. For example, it notes that prevalence is equal to incidence multiplied by disease duration when rates are stable over time. The document also discusses problems that can arise in measuring these variables and how changes in incidence and prevalence over time can provide insights into disease dynamics.
This document discusses epidemiological concepts related to causation and measures of disease occurrence. It defines a sufficient cause as a minimal set of conditions that inevitably produce disease. It discusses how interactions between component causes can affect disease risk. It also covers Hill's criteria for evaluating causation. The document defines key measures used to assess disease occurrence, including risk, prevalence, and incidence rate. It provides examples to illustrate how to calculate each measure and explains how they can help guide decisions in patient care and disease prevention.
This document discusses key concepts related to disease transmission including:
1. The epidemiologic triad of an agent, host, and environment being required for disease transmission.
2. Various host, agent, and environmental factors that influence transmission risk.
3. Common modes of transmission like direct contact or indirect transmission through vehicles or vectors.
4. Key epidemiological terms like outbreak, epidemic, pandemic, and the differences between clinical and subclinical disease.
This document discusses sampling distributions and their use in making statistical inferences from data. It begins by defining key aspects of sampling distributions, including the statistic of interest (e.g. mean, proportion), random selection of samples, sample size, and population. It then generates a sampling distribution using an example of calculating the mean number of months since patients' last medical examination across different samples. The document outlines important characteristics of sampling distributions and how the central limit theorem applies. It also discusses how to construct confidence intervals and conduct hypothesis testing using sampling distributions.
This document discusses the gold standard for establishing causality - the randomized clinical trial. It provides an overview of key elements of randomized trials including randomization, masking/blinding, study design issues, and problems with noncompliance. It discusses the purpose of randomized trials for evaluating new treatments, tests, programs, and health services. Examples are provided of some early non-randomized trials from the 15th-18th centuries. Key aspects of planning a randomized trial such as defining the research question, outcomes, sample size calculation, and randomization procedure are also covered.
This document describes different study designs used in medical research including observational and experimental studies. Observational studies are further divided into descriptive studies that examine disease patterns and analytical studies that study suspected causes of disease. Experimental studies compare treatment modalities. Case-control and cohort studies are described as important analytical observational designs. Case-control studies compare exposures among cases and controls to study the association between exposure and disease. Cohort studies prospectively follow subjects exposed and unexposed to an exposure to study disease outcomes. Key aspects of selecting subjects and exposures as well as analyzing these study designs are discussed.
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)GeorgeKieling1
Home
Organization
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
About AOMA: The Academy of Oriental Medicine at Austin offers a masters-level graduate program in acupuncture and Oriental medicine, preparing its students for careers as skilled, professional practitioners. AOMA is known for its internationally recognized faculty, award-winning student clinical internship program, and herbal medicine program. Since its founding in 1993, AOMA has grown rapidly in size and reputation, drawing students from around the nation and faculty from around the world. AOMA also conducts more than 20,000 patient visits annually in its student and professional clinics. AOMA collaborates with Western healthcare institutions including the Seton Family of Hospitals, and gives back to the community through partnerships with nonprofit organizations and by providing free and reduced price treatments to people who cannot afford them. The Academy of Oriental Medicine at Austin is located at 2700 West Anderson Lane. AOMA also serves patients and retail customers at its south Austin location, 4701 West Gate Blvd. For more information see www.aoma.edu or call 512-492-303434.
Storyboard on Acne-Innovative Learning-M. pharm. (2nd sem.) CosmeticsMuskanShingari
Acne is a common skin condition that occurs when hair follicles become clogged with oil and dead skin cells. It typically manifests as pimples, blackheads, or whiteheads, often on the face, chest, shoulders, or back. Acne can range from mild to severe and may cause emotional distress and scarring in some cases.
**Causes:**
1. **Excess Oil Production:** Hormonal changes during adolescence or certain times in adulthood can increase sebum (oil) production, leading to clogged pores.
2. **Clogged Pores:** When dead skin cells and oil block hair follicles, bacteria (usually Propionibacterium acnes) can thrive, causing inflammation and acne lesions.
3. **Hormonal Factors:** Fluctuations in hormone levels, such as during puberty, menstrual cycles, pregnancy, or certain medical conditions, can contribute to acne.
4. **Genetics:** A family history of acne can increase the likelihood of developing the condition.
**Types of Acne:**
- **Whiteheads:** Closed plugged pores.
- **Blackheads:** Open plugged pores with a dark surface.
- **Papules:** Small red, tender bumps.
- **Pustules:** Pimples with pus at their tips.
- **Nodules:** Large, solid, painful lumps beneath the surface.
- **Cysts:** Painful, pus-filled lumps beneath the surface that can cause scarring.
**Treatment:**
Treatment depends on the severity and type of acne but may include:
- **Topical Treatments:** Such as benzoyl peroxide, salicylic acid, or retinoids to reduce bacteria and unclog pores.
- **Oral Medications:** Antibiotics or oral contraceptives for hormonal acne.
- **Procedures:** Such as chemical peels, extraction of comedones, or light therapy for more severe cases.
**Prevention and Management:**
- **Cleanse:** Regularly wash skin with a gentle cleanser.
- **Moisturize:** Use non-comedogenic moisturizers to keep skin hydrated without clogging pores.
- **Avoid Irritants:** Such as harsh cosmetics or excessive scrubbing.
- **Sun Protection:** Use sunscreen to prevent exacerbation of acne scars and inflammation.
Acne treatment can take time, and consistency in skincare routines and treatments is crucial. Consulting a dermatologist can help tailor a treatment plan that suits individual needs and reduces the risk of scarring or long-term skin damage.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
The Children are very vulnerable to get affected with respiratory disease.
In our country, the respiratory Disease conditions are consider as major cause for mortality and Morbidity in Child.
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
“Environmental sanitation means the art and science of applying sanitary, biological and physical science principles and knowledge to improve and control the environment therein for the protection of the health and welfare of the public”.The overall importance of sanitation are to provide a healthy living environment for everyone, to protect the natural resources (such as surface water, groundwater, soil ), and to provide safety, security and dignity for people when they defecate or urinate .Sanitation refers to public health conditions such as drinking clean water, sewage treatment, etc. All the effective tools and actions that help in keeping the environment clean come under sanitation. Sanitation refers to public health conditions such as drinking clean water, sewage treatment. All the effective tools and actions that help in keeping the environment clean and promotes public health is the necessary in todays life.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
2. 2 2
Definition of an outbreak
Occurrence of cases of an illness clearly in
excess of expected numbers
The occurrence of two or more
epidemiologically linked cases of a disease
of outbreak potential
(e.g., Measles, Cholera, Dengue, Japanese
encephalitis, or plague)
3. 3 3
Outbreak and epidemic:
A question of scale
Outbreaks
Outbreaks are usually limited,
usually within one district or few blocks
Epidemics
An epidemic covers larger geographic areas
Epidemics usually linked to control
measures on a district/state wide basis
4. 44
What does it Require?
A pathogen in sufficient quantities,
A mode of transmission,
And a pool of susceptible people
4
5. 5 5
Sources of information
Rumour register
To be kept in standardized format in each
institution
Rumours need to be investigated
Community informants
Private and public sector
Media
Important source of information, not to neglect
Review of routine data
Triggers
6. 6
6
Early warning signals for an outbreak
Clustering of cases or deaths
Increases in cases or deaths
Single case of disease of epidemic potential
Acute febrile illness of an unknown etiology
Two or more linked cases of epidemic
potential
Unusual isolate
Shifting in age distribution of cases
High vector density
Natural disasters
7. 7 7
Why Investigate?
1. Verify and Recognize
the magnitude
2. Diagnose the agent
3. Identify the source
and mode of
transmission
4. Formulate prevention
and control measures
5. Public concerns
Host
Environment Agent
An outbreak comes from a change
in the way the host, the environment
and the agent interact:
This interaction needs to be understood
to propose recommendations
9. 99 9
Importance of timely action: The
first information report (Form C)
Filled by the reporting unit
Submitted to the District Surveillance
Officer as soon as the suspected outbreak
is verified
Sent by the fastest route of information
available
Telephone
Fax
E-mail
10. Epidemic preparedness
Formation & Training of RRT
Regular review of data
Alertness during known ‘outbreak season’
Identifying ‘outbreak prone areas’
Ensuring that these areas have necessary drugs
and materials (including transport media)
Identifying & strengthening the labs
Designating vehicles
Ensuring communication channels
11. 1111 11
The rapid response team
Composition
Epidemiologist, clinician and microbiologist
Gathered on ad hoc basis when needed
Role
Confirm and investigate outbreaks
Responsibility
Assist in the investigation and response
Primary responsibility rests with local health staff
12. 12
12
Levels of response to different triggers
Trigger Significance Levels of response
1 Suspected /limited
outbreak
• Local response by health
worker and medical officer
2 Outbreak • Local and district response
by district surveillance
officer and rapid response
team
3 Confirmed outbreak • Local, district and state
4 Wide spread
epidemic
• State level response
5 Natural disaster • Local, district, state and
centre
13. 13 13
The balance between investigation
and control while responding to an
outbreak
Source / transmission
Known Unknown
Etiology Known Control +++
Investigate +
Control +
Investigate +++
Unknown Control +++
Investigate
+++
Control +
Investigate +++
15. Steps of an outbreak
investigation -1/3
1. Establishing a probable diagnosis
2. Confirmation of the existence of
outbreak
3. Define population at risk
4. Search for all cases – RRT (Interim
report by RRT within one week
16. Steps of an outbreak
investigation Actions-2/3
5. Management of cases, and
Monitoring the situation
6. Environmental and
Entomological studies
8. Laboratory studies
10. Implementation of control and
preventive measures
11. Data analysis & interpretation
CONTD.....
17. Steps of an outbreak
investigation Actions-3/3
12. Formulation of hypothesis
13. Testing of hypothesis
14. Declaring the outbreak to be over
15. Final report & its Review within 10
days of the outbreak declared to be over
16. Documentation
a. Report
b. Publication
18. Unusual
Health Event
No
Yes
Is this an
outbreak
Etiology, Source
& Transmission
known?
No
YesInstitute control
measures
Further InvestigationDescribe outbreak
in terms of TPP
Continued….
19. Develop Hypothesis regarding
Source, Transmission, Etiology & PAR
yes No
Does the
Hypothesis
Fit with facts
Institute control
measures
Special studies
Remember that outbreak is usually
a sudden & unexpected event!
There is need to act quickly.
A systematic Approach Helps
20. 21
1. Establishing a probable
diagnosis
Hospital/health center visit
Clinical exam/records
Lab. Reports, etc.
21. 22
2. Confirmation of the
existence of outbreak
Comparing data/ previous records –
minimum for 3 years
If no data – use COMMON SENSE!
22. 23
3. Define population at risk
By studying Line - List of cases
Name, Age, Sex, Address
Date of onset of illness
Signs / symptoms
Investigation reports
Treatment taken
Outcome
23. 2424
4. Search for all cases
Rapid community house to house survey
Pilot survey
Sample size (n) = 4p(1-p)/ L2
Area selection (Affected & surrounding
areas)
Format
Recall period
24. 25
Develop working case- definition
Set of criteria for deciding if a person
should be classified as suffering from
the disease under investigation
Clinical criteria, restrictions of time,
place, person
Simple, practical
27. 28
5. Laboratory Investigation
Appropriate clinical specimens
Time of sample collection
Method of collection
Selection of transport media
Labeling
Storage and transportation of samples
District lab / selection of lab
28. 29
Study of environmental conditions
(water, sanitation etc.)
Entomological survey (density of
vectors, Indices)
Study of Zoonotic reservoir (if
required)
6. Environmental, Entomological
& Zoonotic surveys/ studies
29. 30
Person
Place
Time
Cases
0
5
10
15
20
25
1 2 3 4 5 6 7 8 9 10
0
200
400
600
800
1000
1200
0-4 '5-14 '15-44 '45-64 '64+
Age Group
Evaluate information
Pathogen? Source? Transmission?
7.Data Analysis
30. 31
8. Management/ control of outbreak
As per the epidemiological/ clinical
observation manage the cases
Prevent further deaths
Environmental control measures
Strengthen routine & active
surveillance
38. 39
9. Formulation of hypothesis
Based on data analysis and
interpretation
CONTD.....
39. 40
Benefits of an outbreak
investigation-1
i. To control ongoing/current outbreak
ii. To define the magnitude (time, place,
person)
iii. To determine factors responsible
iv. Source and modes of transmission
40. 41
Benefits of an outbreak
investigation-2
v. To evaluate the effectiveness of existing
surveillance activities at local level
vi. To evaluate the effectiveness of
preventive program
vii. To respond to public or political or legal
concern
viii. To prevent occurrence of future outbreaks
ix. To advance the knowledge about the
disease
x. To provide training opportunity
43. 44
Types of report
Initial “First information report”
Full outbreak investigation report
Rapid assessments
Scientific publications (The most
‘Neglected’ action )
44. 45
General framework of an
outbreak investigation report
(1/4)
1. Executive summary
< one page or < 300 words
Structure with subheadings
2. Background
Territory, origin of the alert, time of
occurrence, places, official staff met
45. 46
General framework of an
outbreak investigation report
(2/4)
3. Methods used for the investigation
Epidemiological methods
Case definition
Case search methods, data collection
Analytical studies if any
Data analysis
Laboratory methods
Environmental investigations
46. 47
General framework of an
outbreak investigation report
(3/4)
4. Major observations / results
Epidemiological results (population at
risk, time, place and person
characteristics)
laboratory diagnosis
Environmental investigation results
Current status of transmission, control
measures adopted/ initiated
47. 48
General framework of an
outbreak investigation report
(4/4)
5. Conclusion: Genesis of outbreak
(Diagnosis, source, vehicles)
6. Recommendations
48. 49
Annexes of the report
1 TIME: Epidemic curve
2. PLACE: Map
Spot map
Map of incidence by area
3. PERSON: Table of incidence by age and
sex
4. Analytical study results if any
49. 50
Be technical
The District Medical Officer and the
Assistant Secretary of Health joined a team
comprised of myself and three field workers
to go to the site of the outbreak that could
not be reached before three days because
of rains
Focus on technical aspects
The rapid response team initiated the
investigation on 16 March 2009
50. 51
Examples
Avoid negative statements:
The district medical officer has not even
started programme implementation in this
district
Prefer specific, documented, diplomatic
opportunity statements:
Review of 6 out of 7 indicators indicated
that the programme is still at an early phase
in the district
51. 52
Get rid of “should”
Tuberculosis patients should be counselled
Counsel tuberculosis patients
Counselling will decrease default rates
Use both
Counsel tuberculosis patients to decrease
default rates
52. 53
The six “S” of technical writing
1. Simple
2. Short
3. Structured
4. Sequential
5. Strong
6. Specific
53. 54
The six “S” of technical writing
1. Simple
• Use simple words
• Don’t use jargon technical or statistical
jargon
2. Short
• < 10 pages, < 5 tables / figures
• Use short sentences with one idea each
• Split complex sentences
• Cut unnecessary elements
54. 55
The six “S” of technical writing
3. Structured
• Have headings, subheadings
• Follow the logic argument
4. Sequential
• Go step- by- steps
• Start each sentence where the
previous ended
55. 56
The six “S” of technical writing
5. Strong
Use the verb as the centre of gravity
If the verb is weak, the sentence is weak
6. Specific
• Say clearly and exactly what you want to
say
• Do not paraphrase
• Prefer numbers to qualifiers
56. 57
3. Monitoring the situation
Trends in cases and deaths
Implementation of containment
measures
Stocks of vaccines and drugs
Logistics
Communication
Vehicles
Community involvement
Media response
57. 58
4. Declaring the outbreak over
Role of the district surveillance officer /
Medical health officer
Criteria
No new case during two incubation periods
since onset of last case
Implies careful case search to make sure
no case are missed
58. 59
5. Review of the final report
Sent by medical officer of the primary
health centre to the district surveillance
officer / medical and health officer
within 10 days of the outbreak being
declared over
Review by the technical committee
Identification of system failures
Longer term recommendations
59. 60
Points to remember
1. Outbreaks cause suffering, bad publicity and cost
resources
2. Constant vigil is needed
3. Prompt timely action limits damage
4. Emphasis is on saving lives
5. Don’t diagnose every case once the etiology is clear
6. Management of linked cases does not require
confirmation
7. The development of an outbreak is followed on a
daily basis
8. Effective communication prevents rumours
9. Use one single designated spoke person
10. Learn lessons after the outbreak is over
60. 6161
A Scenario!
A 23 yr old male student; presented at
10:30 PM on 23rd Feb, at the emergency
complaining of a sudden onset of
abdominal cramping , nausea and
diarrhea. He was not severely
distressed, had no fever or vomiting but
was weak.
61
61. A Scenario!
A No. of other students, all with the
same symptoms, visited emergency
over next 20 Hrs
All treated with Fluid replacement
and rest.
They recovered fully within 24 hrs.
of the onset of illness.
62
63. The investigation!
Quick information revealed 47 students
out of 1164 college enrollment got
affected by 8 PM on 24th Feb
what is the quantitative measure of the
extent of an outbreak?
No. of New Cases
AR = Persons at Risk
what is the AR for this period?
64
64. 47/ 1164 X 100 = 4%
It was readily apparent, however that
the PAR need to be defined narrowly!
All those reported lived in hostels and
one third of all students were day
scholars! (756 are hostlers)
47/ 756 X 100 = 6.2% (i.e. 50% increase
in AR)
Because the patient’s hostel was
recorded in records AR could be
calculated hostel and sex wise
65
65. The Hostel of 47 known cases and the AR, as well as the
population and sex of the occupants of each hostel
Hostel Sex PAR No. of Cases AR
1 F 80 19 23.8
2 F 62 2 3.2
3 F 89 0 0
4 F 61 1 1.6
5 F 53 5 9.4
6 M 35 0 0
7 M 63 0 0
8 F 103 4 3.9
9 M 35 1 2.9
10 M 37 0 0
11 F 34 1 2.9
12 M 62 13 21.0
13 M 32 1 3.1
14 M 10 0 0
Total - 756 47 6.2
66
66. AR (1, 12) = 19+13/ 80+62 = 22.5%
Risk Ratio = AR hostel (1, 12) / AR (Other
hostels) X 100
= 22.5%/ 2.4% = 9.4
AR BY GENGER?
Visit to hostels revealed that not all
students who became ill reported to
emergency.
Seven hostels were randomly selected
for unbaised information!
67
67. Response to the questionnaire survey by hostels
Questionnaire returned
Hostel Population Number Percent No. of ill St.
5 53 49 92.5 13
6 35 26 74.3 13
7 63 28 44.4 15
8 103 65 63.1 21
9 35 19 54.3 5
12 62 44 71.0 22
Nurses’
hostel
60 60 100 17
Unidentified - 13 - 4
Total 411 304 74.0 110
68
AR = 110/304 X100 = 36.2%
68. 69
AR of hostel 6 and 12 were 0% and 21%
by emergency data but by survey data
both are 50% - Approach for data
collection!
Was emergency data useless?
Is 36.2% the true AR of
gastroenteritis on campus ?
Explain factors why AR estimated from
emergency records were low?
Why more cases from hostel 1 and 12 at
emergency?
69. Additional information…..
No large gathering of students
Most students ate at college cafeteria
How will you zero down to source of
infection?
70
St. who ate specific meal St. who did not eat specific meal
Ill Well Total AR(%) Ill Well Total AR(%)
Jan 16
Breakfast 52 100 152 34.2 51 94 145 35.2
Lunch 89 150 239 37.2 20 44 64 31.3
Dinner 87 150 237 36.7 23 44 67 34.3
Jan 17
Breakfast 56 105 161 34.8 42 89 131 32.1
Lunch 106 145 251 42.2 3 49 52 5.8 RR!
Dinner 78 130 208 37.5 31 64 95 32.6
70. So…can you calculate the IP?
Having identified the meal at which the
students most probably were exposed
to the causal pathogen and
Knowing each student’s time of onset of
symptoms; we can!!
71
IP(hrs) No. of Students Cumulative No. of St.
8 22 22
9 11 33
10 18 51
11 8 59
12 42 101
71. What next?
A follow up survey to obtain
information about particular foods that
251 students ate at lunch on Jan 17!
If students were uncertain about
whether they ate the food in question,
they were not included in the analysis of
the particular food. As a result total of
those who ate or did not eat each
specific item did not equal 251 for all
items
72
72. Food specific histories of students who ate lunch
at the college cafteria on Jan 17th
Food/ beverage St. who ate Sp. Food /
Beverage
St. who did not eat Sp. Food /
Beverage
Ill Well Total AR (%) Ill Well Total AR (%)
Fish 16 36 52 30.8 87 103 190 45.8
Lamb curry 95 56 151 62.9 7 82 89 7.9
noodle 12 57 69 17.4 92 80 172 53.5
Pineapple kheer 58 54 112 51.8 39 69 108 36.1
Fruit salad 32 39 71 45.1 63 82 145 43.4
Cabbage salad 4 5 9 44.4 95 126 221 43.0
Chocolate ice cream with
vanilla sauce
19 29 48 39.6 80 102 182 44.0
Chocolate ice cream without
vanilla sauce
62 77 139 44.6 39 56 95 41.1
Badam Milk 91 127 218 41.7 12 13 25 48.0
Cofee 10 31 41 24.4 89 103 192 46.4
tea 23 19 42 54.8 78 114 192 40.6
73
73. 74
Tools for Quantifying
The Epidemic
1. Case definition
2. Epidemic curve
Point source (common
source, common vehicle)
Propagated
3. Attack Rate
4. Serial interval/ I P
74. 75
Getting At The Source
1. Mode of transmission
2. Portal of entry
3. Reservoir
4. Vector
5. Vehicle
6. Agent
75. 76
Only work in the field can uncover
the way in which an agent links to a
host in the real world (Environment)
outside of the laboratory.
Snow discovered the waterborne
route as a major mode of
communication of disease, which
turned out to apply not only to
cholera, but also to typhoid fever and
other infections.
Remember:
76. 77
Steps in Investigation
Prepare for field work
Establish existence of outbreak
Verify diagnosis
Define and identify cases
Perform descriptive epidemiology
77. 78
Steps in Investigation
Develop hypotheses
Evaluate hypotheses
Refine hypotheses and conduct
additional studies
Implement control measures
Communicate findings
79. 80
Only work in the field can uncover the
way in which an agent links to a host in the
real world (Environment) outside of the
laboratory.
Snow discovered the waterborne route as
a major mode of communication of
disease, which turned out to apply not only
to cholera, but also to typhoid fever and
other infections.
Remember:
80. 81
Prepare for Field Work
Investigation
Scientific knowledge--have it or get it!
Supplies, equipment
Assemble your team
Administration
Review local directives or plans
Consultation
Know your role, especially if off-base
81. Prepare for Field Work
Sample questionnaires
Key community contacts
Laboratory containers and collection
techniques
82
84. 85
2. Establish the Existence of An Outbreak
Determine if disease incidence is higher than background
level
How do you determine background level ? -surveillance
Reasons for Observed >Expected
Change in reporting procedures
Change in case definition
Increased awareness or interest
Improved diagnostics
New clinician
Change in Population
True increase
85. 86
Questionnaires
Used to collect complete, uniform
histories
Identifiers
Demographics
Clinical information
Risk factors
Administer as soon as possible
disseminate
interview personally
Both cases and controls
Recall bias important
Can summarize on line listing
90. 91
4. Define and Identify Cases
Outbreak Case Definition:
-Clinical information (signs and symptoms)
- Person
- Place
- Time
Case Definition Sources
Routine reporting:
Use Standard case definitions
Unknown etiology:
Make up your own case definition
make sure everyone uses the same case
definition
91. 92
Establish Case Definition
Criteria to decide whether person is part
of outbreak
time, place, person
clinical criteria
Can change during investigation
Keep loose at first, tighten later
93. 94
Identify and Count Cases
Develop a wide network
Initiate active surveillance
Case: meets case definition
Control: exposed, not ill
94. 95
Identify Population At Risk
Survey hospitals
Review surveillance data
Question known cases to identify
others
Review guest lists, enrollment
records, etc.
95. 96
Identify Population At Risk
Survey hospitals, ERs, MDs
Review surveillance data
Question known cases to identify others
Review guest lists, enrollment records,
manifests, etc.
96. 97
Questionnaires
Used to collect complete, uniform histories
Identifiers
Demographics
Clinical information
Risk factors
Administer as soon as possible
disseminate
interview personally
Both cases and controls
Recall bias important
Can summarize on line listing
100. 101
Epidemic Curves: Time
Plot number of cases by onset date
Index case: first case of outbreak
Determine time course and future
course, exposure period
102. 103
• This is the most common form of transmission
in food-borne disease, in which a large
population is exposed for a short period of
time.
Point Source Transmission
103. 104
Point Source Outbreaks
All exposed at one time
Cases occur suddenly after minimum
incubation time
All cases occur within one incubation
period
Outbreak stops unless secondary spread
Curves have steep upslope, more
gradual down slope
104. 105
Continuous Common Source
May begin suddenly or gradually
Cases do not disappear because of
secondary exposure
Curves have gradual or steep
upslope, plateau trickling down
slope, and may repeat
106. 107
• In this case, there are several peaks, and the
incubation period cannot be identified.
Continuing Common Source or
Intermittent Exposure
107. 108
Propagated Outbreaks
Typical of person-to-person
outbreaks
Secondary cases appear one
incubation period after peak of first
wave
Taller successive waves of cases
113. 114
Spot Maps: Place
One spot = case
Community
Facilities
Recreational sites
Population density not reflected
114. 115
Time
Draw epidemic curve
No. of cases over time
graphed by date or time of
onset of symptoms
Tells Us:
“Where are we now?”
“What’s the forecast?”
Probable time of
exposure
Epidemic pattern
116. 117
6.Develop Hypothesis
Round up usual suspects!
Type of agent
Source of agent
Mode of transmission
Usual reservoirs
Known risk factors
Exposures that caused disease
Look at person, place and time for clues
Be able to test
117. 118
Develop Hypothesis
Requires familiarity with disease
Hypothesis should be testable
Still clueless?
Talk with cases again
Visit work sites or billeting area
Don’t forget outliers
121. 122
Evaluate Hypothesis via Analytical
Epidemiology
Determine exposure variables.
Compare ill to not ill.
Construct a 2 X 2 table
Perform Cohort or Case Control Study
Use Cohort study when:
- Population at risk is known
(you have a denominator)
Interview “ill” and “not ill”
Calculate attack rates - “ate” v/s
“didn’t eat”
Put on food-specific attack rate table
122. 123
Cohort Studies
Defined population
Can contact all in timely manner
Calculate attack rate
Calculate risk ratio to determine
risk of contracting illness from
exposure
123. 124
Attack Rates
Calculate for those ill and exposed and
those ill and not exposed
Number of new cases in population during
period
Population at risk x100 at
beginning of period
124. 125
Calculate attack rates
Attack rate = (ill / ill + well) x 100 during a
time period
If there is an obvious commonality for the
outbreak, calculate attack rates based on
exposure status (a community picnic)
If there is no obvious commonality for the
outbreak, calculate attack rates based on
specific demographic variables (hepatitis cases
in a community)
125. 126
Example: Calculation of A R for Food X
Ate the food Did not eat the food
Ill Well Total Attack
Rate
Ill Well Total Attack
Rate
10 3 13 76% 7 4 11 64%
Attack Rate = ill / (ill + Well) x 100 during a time period
Attack rate = (10/13) x 100 = 76%
(7/11) x 100 = 64%
126. 127
Risk Ratios
attack rate of ill and exposed a/(a+b)
attack rate of ill, not exposed c/(c+d)
>1.0 = increased risk
1.0 = same as chance
<1.0 = decreased risk
127. 128
Case-Control Studies
Population not defined
Select sample groups of cases and
controls
Calculate odds ratio to determine
likelihood of contracting illness
from exposure (see table 6.7)
128. 129
Odds Ratios
Cross multiply and divide
a b
c d
ad
bc
>1.0 = increased likelihood
1.0 = same as chance
<1.0 = decreased likelihood
130. 131
Clinical Specimens
Identifies agent and confirms cases
Obtain results if already collected
Collect specimens if necessary
Type of specimen depends on
suspected agent, nature of
outbreak
131. 132
Collect Clinical Specimens
Containers available from ISDH
to order call 317-233-8104
Must use containers in date!
7A: enteric bacteria, viruses
4A: parasites
5A: pertussis
133. 134
Collect Clinical Specimens
Submission form(s) must be
completed and enclosed with
specimen
Local health department should
collect and transport specimens to
ISDH lab
134. 135
Environmental Investigation
Help explain why outbreak
occurred
Begins when suspected mode of
transmission identified
Identifies vehicle of transmission
Samples: food, water, air
138. 139
Media Relations
Communication between ISDH and LHD
extremely important
LHD generally handles media calls
within jurisdiction but ISDH can provide
guidance
All media calls to ISDH routed through
Office of Public Affairs
139. 140
Media Calls
Confirm investigation underway
Provide only confirmed or statistically
proven information
Be careful mentioning businesses
Never speculate or provide identifiers
Remain calm and do not be rushed
145. 146
On Dec.31,2009, the local health
officer of Jaipur, reported the
occurrence of an outbreak of acute
gastrointestinal illness to the District
Health Officer. Dr. X, epidemiologist-
in-training, was assigned to conduct
an investigation.
Investigating an Epidemic:
The Dinner was held at Hotel . Food
was prepared by Chefs of the Hotel. The
Dinner began at 8:00 PM and continued
until 11:00 PM.
146. Investigating an Epidemic:
147
When Dr. X arrived in the field, he
learned from the health officer that all
persons known to be ill had attended a
dinner at Hotel on Dec. 31, 2004 Family
members who had not attended the
Dinner had not become ill.
Accordingly, the investigation was
focused on the circumstances related to
the supper.
147. 148148
Q: Is this an Epidemic?
Endemic for the region?
Due to seasonal variation?
Due to random variation?
What might be the agent?
How is this agent transmitted?
What am I looking for?
148. 149149
Verify the outbreak
Determine whether there is an
outbreak – an excess number of cases
from what would be expected
Establish a case definition
Non-ambiguous (distinct/ clear)
Clinical / diagnostic verification
Person / Place / Time descriptions
Identify and count cases of illness
149. 150
Select the correct case definition
and find the error in the others:
1. All Invitees in Dinner held in Hotel on Dec.31,2004
between 8:00 PM and 11:00 PM; whether they attended
Dinner or not; whether they participated in food
preparation, transport, or distribution or not; whether they
ate or not.
2. Persons who developed acute gastrointestinal symptoms
within 72 hours of eating supper and who were among
Invitees in Dinner held in Hotel Clarks on Dec.31,2004.
3. Invitees who developed acute gastrointestinal symptoms
within 24 hours of the Dinner held in Hotel on
Dec.31,2004 between 8:00 PM and 11:00 PM
150. 151
Select the correct case definition
and find the error in the others:
1. All invitees to the Marriage Dinner held in Hotel on October
21, 2002between 8:00 PM and 11:00 PM; whether they
attended Marriage or not; whether they participated in food
preparation, transport, or distribution or not; whether they
ate or not. Missing definition of sickness
2. Persons who developed acute gastrointestinal symptoms
within 24 hours of eating Dinner on Dec.31,2004 and who
were among invitees of the marriage dinner. CORRECT
3. Invitees who developed acute gastrointestinal symptoms
within 24 hours Dinner on Dec.31,2004. Did not specify that
they went to the dinner
151. 152
Investigating an Epidemic:
Interviews regarding the presence of
symptoms, including the day and hour of
onset, and the food consumed at the
Dinner, were completed on 75 of the 80
persons known to have been present.
A total of 46 persons who had
experienced gastrointestinal illness were
identified.
152
153. 154
Which menu item (s) is the
potential culprit?
To find out, calculate attack rates!
154. Attack Rates among?
The foods that have the greatest
difference in the attack rates among
who ate and who did not eat, may be
the food(s) that were responsible for
the illness.
155
155. 156
Attack Rates by Items Served:
Number of persons who ate
specified item
Number of persons who did not
eat specified item
ill Well Total Attack rate
(%)
ill Well Total Attack rate
%
Baked
Vegetable
29 17 46 17 12 29
Malai paneer 26 17 43 20 12 32
Dum Aaloo 23 14 37 23 14 37
Cabbage salad 18 10 28 28 19 47
Paneer Khumb 16 7 23 30 22 52
Raita 21 16 37 25 13 38
Missi Roti 18 9 27 28 20 48
Raj bhog 2 2 4 44 27 71
Coffee 19 12 31 27 17 44
Water 13 11 24 33 18 51
Cream salad 27 13 40 19 16 35
Ice cream (van) 43 11 54 3 18 21
Ice cream
(choc)
25 22 47 20 7 27
Fruit salad 4 2 6 42 27 69
157. 158
Improper cooling of foods
Improper cooking of foods
Improper reheating of foods
Improper holding temperature
of foods
Cross contamination
Infected food handlers, poor
employee hygiene
Major Causes of Food borne Disease
158. 159
Summary
The Epi Approach...
Identify a problem
Investigate and collect data
Describe data in terms of person,
place and time
Formulate a hypothesis
Test your hypothesis
159. 160
Bottom Line...
Collect good descriptive data
Be observant -- Be objective
Keep Authority informed
Be sure to collect data on both the “ill”
and the “not ill”
Ask for help
Disease prevention!
160. 161
Conclusion
An attack of gastroenteritis occurred
following a Dinner at Hotel Clarks.
The cause of the outbreak was
contaminated vanilla ice cream.