Outbreak investigation (OI) of infectious disease

(In reference to OI guideline for VL in Nepal)

WHO defines outbreak as “the occurrence of cases of disease in excess of what would normally
be expected in a defined community, geographical area or season.”
The objective of OI is
a) To confirm that there is indeed an outbreak of disease (i.e. temporally and
epidemiologically linked, local transmission confirmed),
b) To determine the most effective and practical means of controlling the outbreak and
avoid spreading to neighboring VDCs.

Steps of OI

Step 1: Detect outbreak

Routine surveillance, general public, media

Step 2: Verify diagnosis

 Goal is to rule out misdiagnosis and laboratory error
 Early warning and reporting system of EDCD has role to check data and alert DPHO/
Municipality/Province.
 Are all cases indeed the cases of VL?
Examine case-patient(s);
Meet physicians and review medical records
Confirm laboratory testing
 Epidemiological/ temporarily linked? (eg all occurring within a same household or
neighborhood or common occupation etc.)

Step 3: Confirm Outbreak

Points to be considered while declaration of an outbreak:
1. Confirmation of outbreak
2. Seasonal variation of disease
3. Information about past epidemics
4. Completeness of reporting

Step 4: Form an outbreak control team

It should include professionals from central, province, local and health institution level.

Step 5 : Define case definition and identify cases

Standard case definition for suspected, probable and confirmed cases
Step 6: Collect Information
1. Epidemiological information
a) What is the potential area where outbreak reported?
b) Who is affected, men/women, children/adults?
c) Is a particular population group affected (migratory population etc)
d) Are the cases clustered or spread throughout the VDC/district?
e) In a previously not affected community?
f) Rural vs urban outbreak?
g) Total number of cases reported and any mortality?

More specific questions for endemic areas

a) What seems to have caused the outbreak?
b) What is history of VL incidence and of IRS spraying in this community? Have there
been VL in the past, has the village been sprayed, since when spraying has not been
done

More specific questions for non endemic area

 Is there a local transmission of VL?
Evidence of local transmission should include:
 Travel history of the cases: presence of one or more cases without travel history
should be considered as a sign of local transmission
 Mode of transmission Direct ( droplet, inoculation, soil, contact ) Indirect ( Air-
borne, vehicle-borne, fomite borne, vector borne)
 Test for cell-mediated immunity (LST)
 Test to detect asymptomatic infection
 Has there been any other vector management program other than disease under
study?

2. Entomological information
 In endemic districts, confirmation of local transmission is not needed, and
entomological investigations are needed to launch standard outbreak response.
 In non- endemic districts, collection and identification of vector can be strong
argument for conformation of local transmission; however epidemiological
evidences are sufficient to launch outbreak response.

Step 7: Formulation of hypothesis

On the basis of time, place and person distribution or the Agent-Host-Environment
model, formulate hypotheses to explain the epidemic in terms of
(a) Possible source
(b) Causative agent
 (c) Possible modes of spread, and
(d) The environmental factors which enabled it to occur.

These hypotheses should be placed in order of relative likelihood. Formulation of a tentative

hypothesis should guide further investigation.

Step 8: Testing of hypotheses

All reasonable hypotheses need to be considered and weighed by comparing the attack
rates in various groups for those exposed and those not exposed to each suspected factor.

Step 9 : Implement control measures

 Treatment of confirmed cases and confirmation of suspected cases
 Active case detection
 Control activities following national guideline
 Advocacy and communication to ensure community participation

It includes role of EDCD, DHO/DPHO, Province or local level, Health institution, FCHV,
Community and referral centers.

Step 10: Writing the report

The report should be complete and convincing.
Information to be included in the final report on an epidemic

Section Contents
1. Background
 Geographical location
 Climatic conditions
 Demographic status (population pyramid)
 Socio-economic situation
 Organization of health services
 Surveillance and early warning systems
 Normal disease prevalence.
2. Historical data
 Previous occurrence of epidemics of the same disease
 Discovery of the first cases of the present outbreak.
3. Methodology of investigations
 Case definition
 Questionnaire used in epidemiological investigation
 Survey teams
 Household survey, Retrospective survey, Prospective surveillance
 Collection of laboratory specimens and use of Laboratory techniques.
4. Analysis of data
 Clinical data:
- Frequency of signs and symptoms
- Course of disease
- Differential diagnosis
- Death or squeal rates
Epidemiological data:
Mode of occurrence in time, by place and by population groups
Source, Modes and factors influencing of transmission
Laboratory data:

Step 11 : Communicate results

Submitted by :
Sajeena Maharjan
MPH 1st year