Investigation of an outbreak

Lab

Dr. Nadia Aziz

C.A.B.C.M.
Department of community medicine
 Definitions
Outbreak or an epidemic is the occurrence of a
health related event clearly in excess of the normal
expectancy.
Pandemic over several countries.
Endemicity refers to the usual permanence of a
disease or infection in a defined geographic area or
population.
 Objectives of investigation
1- Identify the responsible etiologic agent.
2- Find the source of infection by studying the
occurrence of the disease among persons or in a
place or time, as well as determining specific
attack rates.
3- Formulate recommendations to prevent further
transmission.
 Common interventions used to
control an epidemic
1- Control of the source

2- Interruption of transmision

3- Control or modification of host response

 Unique aspects of outbreak
investigation
1- There is a pressure & urgency to conclude the
investigations quickly that lead to hasty decision.
2- Data sources are often incomplete & less
accurate.
3- Decreased statistical power due to analysis of
small numbers.
4- Publicity surrounding the investigation –
community members may have preconceived ideas.
 Diseases requiring investigation
1- Endemic diseases with epidemic potential e.g.
malaria, cholera, measles, hepatitis, meningococcal
meningitis.

2- Even a single case of a disease for which

eradication/elimination goals have been set e.g. polio.

3- Rare but internationally important diseases with

high case fatality rates e.g. yellow fever.

4- outbreak of unknown etiology.

Exercise:
Outbreak of Hepatitis E in Three Villages of
Bhimtal Block,
India, 2005
 Steps of an Outbreak Investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
 INVESTIGATION OF AN OUTBREAK
Confirm the existence of an outbreak
Some diseases, may remain unrecognized, new cases
may come to light, for instance, when new treatments
attract patients who previously relied on traditional
medicines.

Such ”false outbreaks” must be excluded through

attempts at determining the previous incidence or
prevalence of the disease.
• Community leaders alerted PH officials
• 50 cases of jaundice in the primary
health care centre in July 2005
– Normally, 1 or 2 cases per month
• Most patients resided in three villages
– Mehragaon
– Dov
– Chauriagaon
• No change in surveillance
• No population movements
Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
Clinical picture
Typical of acute hepatitis

Laboratory
Serum samples sent to the National Institute of
Virology (NIV), Pune, India

Presence of hepatitis E virus (HEV) IgM in 21 of 23

serum samples
Confirm the diagnosis
 Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
Acute jaundice (yellow sclera/skin), dark urine,
loss of appetite, pain abdomen and fatigue in a
person from any of the three villages since May
2005
What , When , Where
Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
Methods:
Active case search in the villages
Results:
205 cases among 1,238 population
Attack rate 16%
No death

Search for cases

Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
 Time

Place Person
 Epi Curves
• Can suggest type of exposure
• –Point-source
• –Person-to-Person
TIME: Acute hepatitis by week of onset in 3 villages,
Bhimtal block, Uttaranchal, India, July 2005

90
Outlying case-patient
Number of cases

80
70 might have been a
60 source
50
40
30
20
10
0
3rd week

1st week
1st week

2nd week
3rd week

3rd week

3rd week
1st week

1st week
4th week

4th week

4th week
2nd week

2nd week
1st week
2nd week
4th week

May June July August September

Week of onset Generating hypotheses
 PLACE: Incidence of acute hepatitis
by source of water supply, Bhimtal block,
Uttaranchal, India, July 2005

Water supply
Spring
Dov Mehragaon Reservoir
main Pipeline
village
Attack rate
Suspected Mehragaon < 5%
Hydle colony 5-9%
spring
10% +

Mehragaon
Generating hypotheses
Chauriagaon
 PERSON: Incidence of acute hepatitis by age and sex in 3
villages, Bhimtal block, Uttaranchal, India, July 2005

Population Cases Attack rate

Age 0-4 105 2 2%
(Years) 5-9 110 4 4%
10-14 134 23 17%
15-44 729 139 19%
45+ 261 37 14%
Sex Male 724 115 16%
Female 514 90 17%
Total 1238 205 16%
Generating hypotheses
Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
 Relative risk
Cases Total Incidence
(95% C. I.)

No 12 143 9.2% Reference

Use of
water from Partially 13 94 13.8% 1.6 (0.8-3.4)
suspected
spring to
drink Exclusively 152 529 28.7% 3.4 (2.0-6.0)

C.I.: Confidence interval

Testing hypotheses
Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
An outbreak of hepatitis E affecting three
villages in Bhimtal block was reported directly
by the public

A spring may have been the source of infection

Draw conclusions
Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
Non-covered spring Unprotected area
• Unprotected area
• Spring not covered
• Stone bed filtration
• No chlorination
• Index case-patient lived
and defecated in the area
of the spring
• Open water tanks

Stone filtration bed Compare the hypothesis

Capture of the spring
Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute prevention measures
Strengthen surveillance for outbreaks
Enforce treatment standards for spring water used as
source of water supply:
Protect catchments areas
Cover springs
Ensure proper sand filtration
Chlorinate supply before distribution
Promote adequate sanitation in the areas located next
to springs used as water supply

Communicate the finding

Steps of an outbreak investigation
1. Determine the existence of an outbreak
2. Confirm the diagnosis
3. Define a case
4. Search for cases
5. Generate hypotheses using descriptive findings
6. Test hypotheses based upon an analytical study
7. Draw conclusions
8. Compare the hypothesis with established facts
9. Communicate findings
10. Execute preventive measures
Management of case-patients
Coordination with water supply department to
ensure safe water supply
Chlorination of the water supply
Cleaning of the spring area
Closure of open water tanks, repair of leaks

Preventive measures
Thank you…
 Outbreak investigation

One hundred and fifty people attended a

charity luncheon. A total of 82 attendees
reported symptoms including nausea,
vomiting, abdominal cramps and diarrhea.
Most of the 82 patients who became sick
reported symptoms about six hours.
 Ate food Did not
item eat food
Food ill Not ill Attack ill Not ill Attack
item rate rate

Meat 13 65 64 8
loaf

Baked 64 8 13 65
chicken

Mashed 11 56 36 31
potatoes

Green 32 18 35 31
beans
1- calculate the total number of people ate and
did not eat each food item and try to elucidate
the food items

2- calculate in the table above the attack rates

per 100 for those who ate each food item. Can
you tell which food item(s) was(were)
responsible for the outbreak?
3- Calculate in the table above the attack rates
per 100 for those who did not eat each food
item. Can you tell which food item(s) was
(were) responsible for the outbreak?

4- Calculate the relative risk of disease for each

food item(s) responsible for the outbreak.