WEEK 15

OUTBREAK INVESTIGATION
LEVELS OF DISEASE
EPIDEMIC
 Occurrence of disease cases or deaths
 limited to specified group of individuals
during a short period of time
 clearly on excess of normal expectancy
(Last, 1988)
Notes:
Group – gathered together in space and time
How EPIDEMIC occurs?
• Agents and hosts are present in
adequate number
• Agent can be effectively conveyed from
source to host
FACTORS THAT MAY TRIGGER AND
EPIDEMIC
• Recent increase in virulence of agent
• Recent introduction of agent into a
setting
• Enhanced mode of transmission
• Change in susceptibility of the host
response to agent
• Factors that increase host exposure
• Introduction of agent through new
portals of entry
Goals of an outbreak investigation:
 Identify the source
 Guidance for intervention
Reasons for Outbreak Investigation
1. Prevention and Control
 Primary Public Health reason for
investigation
 Principal considerations
What is the stage of the epidemic?
Are cases occuring in increasing numbers?
Is the outbreak just about over?
If cases are CONTINUING TO OCCUR:
• Goal: prevent occurrence of additional cases
• Objective: to assess the extent of the
outbreak, the size, and characteristics of the
population at risk
If an outbreak appears to be ALMOST OVER:
• Goal: prevent similar outbreaks in the future
• Objective: to identify factors which
contributed to the outbreak
1.3 How much is known about the causative
agent, the source, and the mode of
transmission of the agent?
1.4 The decisions regarding whether and how
extensively to investigate an outbreak are
influenced by the characteristics of the problem
itself
ex.
the source of the illness
the source or mode of transmission
the availability of prevention and control
measures
2. Gain additional knowledge / research 5. Program considerations

• Each outbreak is an opportunity to study the • An outbreak of a disease (which is targeted by

natural history of the disease in question a public health program) may reveal a weakness
in that program and provide an opportunity to
• For a newly recognized disease, field
modify/strengthen the program’s efforts.
investigation provides an opportunity to define
the natural history – agent, mode of • Investigating the causes of an outbreak may
transmission, and the incubation period and the identify populations which may have been
clinical spectrum of the disease overlooked, failures in the investigation
strategy, changes in the agent, or events
• Are able to characterize the populations at
beyond the scope of the program.
greater risk: identify specific risk factors (ex.
Legionnaires disease in Philadelphia in 1976;
Toxic Shock Syndrome in 1980, AIDS in early
1980’s, Eosinophilia-myalgia-syndrome in 1989) STEPS IN OUTBREAK
INVESTIGATION
• Assessing impact of control measures

3. Training

• Investigating an outbreak requires a

combination of diplomacy, logical thinking,
problem-solving ability, quantitative skills,
epidemiologic know-how and judgment.

• These skills improve with practice and

experience

• The investigating team can be composed of a PREPARATION FOR FIELD WORK

seasoned epidemiologist with trainee/s.
Preparation can be grouped into:

4. Public, political, and legal concern

• These concerns sometimes override scientific

concerns in the decision to conduct
investigation

• Increasingly, the public has taken an interest

in ‘disease clusters’ and potential
KNOWLEDGE NECESSARY TO
environmental exposures, and has called upon
PREPARE FOR OUTBREAK
the health department to investigate.
INVESTIGATIONS

1. Various types of etiologic agents and the

resultant disease;
2. Epidemiologic characteristics of outbreaks
associated with different etiologic agents or
resultant diseases;
3. Clinical symptoms of resultant diseases;
4. Environmental and food sanitation practices;
5. Sources of exposure which are vulnerable to
contamination with an infectious or chemical
agent;
6. Laboratory test available to determine
causative agents
1. Verify the diagnosis and confirm the
outbreak
• Confirm laboratory testing;
• Rule out misdiagnoses or laboratory error
A. Knowledge/Awareness of an existence of an
epidemic through:
 Regular analysis of surveillance data-
detect unusual patterns of disease
occurrence
 Calls from a health care provider or a
citizen who knows of several cases
 Media reports
B. Initial investigation may turn out to be:
 True outbreaks with a common cause;
 Sporadic and unrelated cases of the
same disease
 Unrelated cases of similar but unrelated
disease (i.e., without a common cause)
C. Comparison of the number of the observed
number of cases with the expected number
which can be:
 The number of cases from the previous
few weeks or months, or
 The number of cases from a
comparable period during the previous
few years
C. Source of data to establish ‘expected number
cases’
 Health department surveillance data if
disease is a notifiable disease
 Hospitals discharge records, mortality
statistics, cancer or registries if disease
is non-notifiable
 Apply rates from neighboring areas or
conduct an informal survey among local
physicians
 Conduct survey of the community to
establish background level of the
disease
D. Factors which could explain excess cases:
 Existence of a true outbreak
 Changes in local reporting procedures
 Changes in the case definition
 Increased interest because of local or
national awareness
 Improvements in diagnostic procedures
 Sudden increases in size of population
in particular areas
E. Factors influencing decision regarding
investigation of the outbreak
 Severity of the illness
 The potential for spread
 Political consideration
 Public relations
 Availability of resources, etc.
2. Define a case and conduct a case finding
• Develop a specific case definition using:
 symptoms or laboratory results
 time period
 location
• Conduct surveillance using case
definition
 existing surveillance
 active surveillance
 • Interview case-patients

CASE DEFINITION

- Allows a simple, uniform way to identify cases

- “standardizes” the investigation

- Is unique to outbreak but is based on objective

criteria
CATEGORIES OF CASES
• Always includes: Person, Place, and Time

EXAMPLE OF CASE DEFINITION

Salmonellosis Outbreak
3. Tabulate and orient data; time, place,
person

Create a line listing of identified cases

Example of line list for suspected case of Hepatitis A

Spot Map (Cholera cases by John Snow)

EPIDEMIC CURVE

- Is a graphical depiction of the number of cases of illness by the date of illness onset;
- Can provide information on the following characteristics of an outbreak

a. pattern of spread
b. magnitude
c. outliers
d. time trend
e. exposure and/or disease incubation period

• The overall shape of the epidemic curve can reveal the type of outbreak

1. Common source

a. point
b. continuous
c. intermittent

2. Propagated

3. Mixed

TYPES OF OUTBREAK • People are exposed continuously or

intermittently to a harmful source
I. COMMON SOURCE
• Period of exposure maybe brief or long
• Intermittent exposure often results in an epi
curve with irregular peaks that reflect the
timing and the extent of exposure

Ia. COMMON SOURCE – Common Point Source

• Cases were all exposed to the same source

during a brief period of calendar time;

• Typically shows a sharp upward slope and a

gradual downward slope

• Is a common source outbreak in which the

period of exposure is brief, and all cases occur
within one incubation period
Ib. COMMON SOURCE – Continuous Exposure

• Continuous exposure will often cause cases to rise gradually (and possibly to plateau, rather than to
peak)

Ic. COMMON SOURCE – Intermittent

- brief, sporadic exposure period

- Irregular peaks reflect timing and extent of

exposure
 • The classic epi curve for a propagated
outbreak has progressively taller peaks, one
incubation period apart

II. PROPAGATED EPIDEMIC

• Spread is from person-to-person

• Can last longer than source outbreaks

• Disease agent may replicate in a susceptible

host as part of the transmission cycle;

• May have multiple waves

 3. The minimum and maximum incubation
periods for the disease.

EXAMPLES OF EPIDEMIC ACCDG TO

INCUBATION PERIOD

III. MIXED EPIDEMIC

• Involve both a single, common exposure to an

infectious agent and secondary propagative
spread to other individuals (e.g., person to
person transmission) SECONDARY ATTACK RATE

• Either same disease introduced separately or
different diseases with different incubation
periods introduced around the same time
Examples:
Many food borne pathogens (Salmonella,
typhoid, Hepatitis A) and airborne organism (M.
tuberculosis)
• The frequency of new cases of a disease
among the contacts of known patients;
• The ratio of the number cases among contacts
occurring within the acceptable incubation
period following exposure to a Primary Case to
the total number of exposed contacts.
EPIDEMIC CURVE

FACTORS AFFECTING DURATION

OF AN EPIDEMIC

1. The number of susceptible persons who are

exposed to a source of infectious and become
infected;

2. The period of time over which susceptible

persons are exposed to the source
OUTBREAK OUTLIERS
If they are not errors, they may represent: • In common source outbreaks with known
incubation periods, epi curves can help
a. baseline level illness
determine the AVERAGE PERIOD OF EXPOSURE
b. outbreak source
c. a case exposed earlier than the others • Find the average incubation period for the
d. an unrelated case organism and count backwards from the peak
e. a case exposed later than the others case of the epi curve
f. a case with a long incubation period
• This can also be done to find the minimum
PERIOD OF incubation period
EXPOSURE/INCUBATION PERIOD • Find the minimum incubation period for the
FOR THE OUTBREAK organism and count backwards from the
earliest case on the epic curve
• If the timing of the exposure is known, epi
curves can be used to estimate the incubation • Average and minimum incubation periods
period of the disease should be close and should represent the
probable period of exposure
• The time between the exposure and the peak
of the epi curve represents the median
incubation period
AIMS OF OUTBREAK INVESTIGATION

• To determine the cause of the outbreak (the disease detected)

• To prevent further spread of the outbreak (the fire fighter)

• To educate responsible individuals in the prevention of similar outbreak in the future (the public
health educator)