Enhanced surveillance and outbreak investigations

Module B:
for emerging respiratory pathogens
 Learning objective

By the end of this unit, participants will

be able to describe:
§ Enhanced surveillance
§ How to conduct outbreak
investigations in different settings

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 After a case of an emerging
respiratory virus has been confirmed

Several actions need to happen concurrently

to find additional cases and to prevent
further spread, including:
§ Actively find cases
§ Thorough case and outbreak
investigations
§ Conduct enhanced surveillance

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 Active case finding

Active case finding involves a wider search,

focusing on:
§ Patients and their visitors in health care
facilities where the confirmed patient
sought treatment
§ Health care providers who cared for or
cleaned the room of an infected patient
§ Social, familial and work contacts of the
infected patient

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 Contact tracing

What is a contact?

A contact is a person who experienced any one of the following exposures during the 2 days before and the 14
days after the onset of symptoms of a probable or confirmed case:
1. Face-to-face contact with a probable or confirmed case within 1 meter and for more than 15 minutes;
2. Direct physical contact with a probable or confirmed case;
3. Direct care for a patient with probable or confirmed COVID-19 disease without using proper personal
protective equipment;
4. Other situations as indicated by local risk assessments.

Note: for confirmed asymptomatic cases, the period of contact is measured as the 2 days before through the 14
days after the date on which the sample was taken which led to confirmation.

See WHO’s latest guidance on contact definitions here: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/surveillance-and-case-definitions

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Contact tracing

Identify contacts of the infected patient and

record:
§ Names, contact, demographic information
§ Date of first and last exposure or date of contact
with the confirmed or probable case, and
§ Date of onset when fever or respiratory
symptoms develop
The common exposures and type of contact with
confirmed or suspected cases should be
thoroughly documented for any contacts that
become infected
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 How does contact tracing for COVID-19 work?

No symptoms

Monitoring can stop

after 14 days2
Case is identified Monitor for
Identify
in the community* 14 days
contacts1 from time of last
exposure to case

Isolate, test and

Symptoms treat for COVID-19

Positive, or
1st negative test

Any symptoms
*Most respiratory diseases have an incubation
period of 14 days or less, but the incubation period
for a new virus would need to be determined so that
the length of follow up can be decided accordingly.
1
Considerations for quarantine of individuals in the context of
containment for coronavirus disease (COVID-19):
https://www.who.int/publications-detail/considerations-for-
If positive, Monitor for 2 negative tests >24
identify their 14 days
quarantine-of-individuals-in-the-context-of-containment-for-
hours apart coronavirus-disease-(covid-19)
contacts 2
If feasible, respiratory samples from quarantined persons,
irrespective of whether they develop symptoms, should be sent
for laboratory testing at the end of the quarantine period. To be
released from isolation, confirmed cases must test negative using
PCR testing twice from samples collected at least 24 hours apart.
Repeat contact tracing Where testing is not possible (including for probable cases on
which no initial testing was done), WHO recommends that
cycle until no new cases patients remain isolated for an additional two weeks after
Monitoring symptoms resolve. For asymptomatic confirmed cases, WHO
can stop recommends they remain isolated for 14 days after the sample
was taken which led to the confirmation of COVID-19 infection

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 How does contact tracing for COVID-19 work?
No symptoms

Monitoring can stop

after 14 days2

Test HCW contacts regardless

of the development of
symptoms
Monitor for If positive, isolate and
14 days provide care until 2
Identify from time of last consecutive negative
Contacts1 exposure to case
tests

Case in hospital
Isolate, test and
Symptoms treat for COVID-19

If positive, Monitor for
Any symptoms Identify their 14 days
contacts
*Most respiratory diseases have an incubation
Repeat contact tracing
period of 14 days or less, but the incubation period
cycle until no new cases
for a new virus would need to be determined so that
the length of follow up can be decided accordingly.
Positive, or
1st negative test
1
Considerations for quarantine of individuals in the context of
containment for coronavirus disease (COVID-19):
https://www.who.int/publications-detail/considerations-for-
quarantine-of-individuals-in-the-context-of-containment-for-
2 negative tests >24 coronavirus-disease-(covid-19)
2
If feasible, respiratory samples from quarantined persons,
hours apart
irrespective of whether they develop symptoms, should be sent
for laboratory testing at the end of the quarantine period. To be
released from isolation, confirmed cases must test negative using
PCR testing twice from samples collected at least 24 hours apart.
Where testing is not possible (including for probable cases on
which no initial testing was done), WHO recommends that
patients remain isolated for an additional two weeks after
Monitoring symptoms resolve. For asymptomatic confirmed cases, WHO
can stop recommends they remain isolated for 14 days after the sample
was taken which led to the confirmation of COVID-19 infection

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 Outbreak investigations for clusters or
outbreaks of emerging respiratory viruses

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 Convening an investigation team

Assemble a multi-disciplinary team with expertise

in:
§ Field epidemiology
§ Clinical assessment
§ Biological specimen collection
§ Infection prevention and control
§ Risk communication and community engagement
It is essential that animal health specialists are included in the team – if
warranted.
Additional team members: logisticians, laboratory experts, data managers and
environmental health specialists.
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 Convening an investigation team

Before deploying, the team should:

§ Gather preliminary background information
§ Assemble the necessary materials and supplies
(e.g. personal protective equipment, specimen
collection and transport materials) and
§ Inform relevant local public health and animal
health authorities

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 Investigation objectives
Prevent future cases through
Public Health Objectives identification of potential
human, animal and/or
Identify other cases and environmental sources of
quickly detect any human exposure, risk factors for
to-human transmission. infection, and implementation
of appropriate prevention and
control measures.

Reduce onward transmission, morbidity and mortality

through rapid identification, isolation, treatment and
clinical management of cases and follow-up of contacts.
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 Investigation objectives
Determine key epidemiological,
Knowledge Objectives clinical and virological
characteristics for cases
Determine the size of the including:
geographic area in which the § clinical presentation,
virus is transmitting. § natural history,
§ the mode(s) of transmission
and disease diagnosis,
§ incubation period, period of
transmissibility and
§ best practices for treatment.

Determine if the efficiency of human-to-human

transmission of the virus has changed or increased.
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 Investigations in health care settings

Location of the investigation:

§ Within the health care facilities where the patient visited and was treated

Objectives of your investigation:

§ Identify other cases who may have been in contact with the confirmed
case or their biological specimens, including other patients, HCW, visitors
§ Identify how they were infected – that is, what exposures resulted in
infection
§ Quickly recommend measures to stop transmission

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Animal health and environmental
investigations
Investigators in public health and animal health should work
together, with the following objectives:
§ Identify the source of infection from animals
§ Measure the extent of infection in people exposed to these
animals
§ Develop measures to prevent further human infections and to
reduce transmission within animals
Field visits to investigate the occurrence of illness among
animals can include:
§ The patient's home and its surroundings
§ Live animal markets or slaughterhouses
§ Any other place the patient visited in the 14 days prior to illness
onset and animals were present
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Enhanced surveillance

General surveillance in the area under investigation

should be enhanced for at least one month, focusing
on:
§ Setting up lab testing in the local health care facility,
if feasible, or organizing rapid transfer of specimens
to a laboratory with testing capacity
§ Informing local clinicians of the case definition and
the need for vigilance
§ Surveillance for severe acute respiratory illnesses
(SARI) in health care facilities in the community
§ Increasing testing of SARI cases at local health care
facilities
§ If resources allow, testing of people with milder,
influenza-like illness
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 Data analysis
Descriptive analysis of cases should be performed in terms of time, place and person:

Place: geographical location: maps of the locale, case patients’

homes
Person: relationship
Time: Date of onset: (i.e. transmission or family
graphical and/or tabular trees) and demographic
descriptions of cases by characteristics
date of onset: epidemic (e.g. distribution by age and
curve sex) should be developed
Key epidemiological data (e.g. estimation of an incubation period, description
of transmission patterns, attack rates by age, occupation, exposure history etc.)
and clinical data (e.g. spectrum of illness severity, proportion with pneumonia,
deaths) should also be provided
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 What do you do with this analysis?

Data is critical for:

§ Analysis and interpretation – conduct a risk assessment
§ Design and implement mitigation measures
§ Share findings of outbreak investigations so that others can learn
from experiences

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 Further reading

Contact: Dr Maria Van Kerkhove

vankerkhovem@who.int

Further reading:

Coronaviruses
https://www.who.int/emergencies/diseases/novel-coronavirus-2019

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