Identifying and Investigating Outbreaks

Justin Lessler, PhD

Johns Hopkins University
Objectives

► Describe what an outbreak is and how it is identified

► Identify the major steps in an outbreak investigation

► Outline the elements of a good case definition

► Describe the major types of outbreaks and their epidemic curves

► Describe the key elements in a risk factor study

► Discuss the basics of outbreak reporting and response

2
Recommended Readings and Resources

► Gordis, Leon. (1996). Epidemiology. (Fifth edition).

► CDC Epidemiologic Case Studies

► CDC Solve the Outbreak App

► CDC Morbidity and Mortality Weekly Report (MMWR)

► TEPHINET

3
Step 0: What Is an Outbreak?

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
Definition of an Outbreak

► Epidemic and outbreak both refer to a period when there is occurrence of a disease in
excess of what is usually expected

► Even a few cases might be considered an outbreak if the disease is rare

► The terms are often used interchangeably

► Epidemic usually refers to something that covers more area or more time than an
outbreak

5
 An Outbreak of Meningitis

“The county public health department

declared a meningococcal disease outbreak
at San Diego State University Friday, citing
three cases among undergraduates since
June.”

—San Diego Union Tribune

From: image accessed on February 4, 2019, from https://www.10news.com/news/outbreak-at-san-diego-state-second-student-in-fall-semester-diagnosed-with-meningitis;

quote accessed on February 4, 2019, from http://www.sandiegouniontribune.com/news/health/sd-no-meningitis-outbreak-20180928-story.html 6
 An Outbreak of Ebola—1

“The Government of the Democratic

Republic of the Congo declared a new
outbreak of Ebola virus disease (EVD) in
Bikoro in Equateur Province today (8 May).
The outbreak declaration occurred after
laboratory results confirmed two cases of
EVD.”

—WHO News Release

May 8, 2018

Source: accessed on February 4, 2019, from http://www.who.int/news-room/detail/08-05-2018-new-ebola-outbreak-declared-in-democratic-republic-of-

the-congo; photo, MONUSCO / Gweny Angel Nouko. Creative Commons, BY-SA. https://www.flickr.com/photos/monusco/42639444010 7
 An Outbreak of Ebola—2

“… about 257 people had contracted Ebola

inside Congo, about 100km away from the
Uganda border.”

—Daily Monitor, Uganda

October 30, 2018

Source: accessed on February 4, 2019, from http://www.monitor.co.ug/News/National/Ebola-strikes-as-260-die-Uganda-border/688334-4828804-2y1mocz/index.html ;

photo, MONUSCO / Gweny Angel Nouko. Creative Commons, BY-SA. https://www.flickr.com/photos/monusco/42639444010 8
 Outbreak of Influenza

“The U.S. flu outbreak worsened over the

past week as more people headed to
doctors’ offices and emergency rooms, with
hospitalizations at the highest in nearly 10
years, U.S. health officials said on Friday…
Out of every 100,000 people in the general
population, an estimated 51.4 have been
hospitalized for the flu …”

—Reuters
February 2, 2018

Source: https://www.reuters.com/article/us-usa-flu/u-s-flu-outbreak-worsens-hospitalizations-highest-in-nearly-a-decade-cdc-
idUSKBN1FM2EN, https://www.abcactionnews.com/news/health/46-states-reporting-widespread-flu-outbreaks 9
Defining an
Influenza
Outbreak—1

Source: https://www.cdc.gov/flu/weekly/index.htm 10
Defining an
Influenza
Outbreak—2

Source: https://www.cdc.gov/flu/weekly/index.htm 11
Defining an
Influenza
Outbreak—3

Source: https://www.cdc.gov/flu/weekly/index.htm 12
Defining an
Influenza
Outbreak—4

Source: https://www.cdc.gov/flu/weekly/index.htm 13
Defining an
Influenza
Outbreak—5

Source: https://www.cdc.gov/flu/weekly/index.htm 14
Key Points

► An outbreak is a period when there are more cases than expected for a disease

► If the disease is rare, even a few cases may be an outbreak

► If the disease is common, we need a way to say:

► What is normal
► When we are seeing an important increase in cases over what is normal

► In practice, multiple metrics, not just number of cases, are used

15
Step 1: Identify Cases

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
What Do We Want to Know?

► Who?

► What?

► When?

► Where?

► Why?

2
Stages of an ► Establish case definition and identify cases
Outbreak ► Who?

Investigation ► Obtain information on time place and person

► When and where?

► Identify and characterize the pathogen

► What?

► Risk factor study

► Why?

► Intervene and report

► Take action!

3
Establish Case Definition and Identify Cases

► The first step of an outbreak investigation is to:

► Define who is part of the outbreak
► Identify cases

4
 A Good Case Definition Identifies Person, Place, and Time
► WHO cholera case definition:
► In an area where the disease is not
known to be present, a patient aged
five years or more develops severe
dehydration or dies from acute watery
diarrhea
► In an area where there is a cholera
epidemic, a patient aged five years or
more develops acute watery diarrhea,
with or without vomiting
Source: http://www.who.int/cholera/technical/prevention/control/en/index1.html; Birmingham et al. (1997). Lancet.
► A more specific case definition for a
particular outbreak:
► “ … Rumonge residents of at least five
years of age who were admitted to
hospital for acute watery diarrhea with
onset of illness between April 30 and
May 2, 1992 …”
5
Three Types of Cases—1

1. Suspected case
► A person for whom there is suspicion of the disease but no strong evidence or
laboratory confirmation

2. Probable case
► A suspected case for whom there is strong circumstantial evidence of infection
● For example, exposure to a known case

3. Confirmed case
► A person for whom there is definitive clinical or laboratory confirmation that he or she
is a case

6
 An Outbreak of Monkeypox!

► “Monkeypox virus was transmitted from ill prairie dogs in child care and veterinary
facilities … most cases of human monkeypox were associated with direct animal contact
…”

Source: Kile et al. (2005). Arch Pediatr Adolesc Med. https://doi.org/10.1001/archpedi.159.11.1022 7

Three Types of 1. Suspected case
Cases—2 ► A patient with known prairie dog exposure with fever or
unexplained rash and two or more of other symptoms
(chills, lymphadenopathy, headache, sore throat, cough,
dyspnea, or myalgia), within 21 days of exposure

2. Probable case
► A patient with known prairie dog exposure with fever or
vesiculopustular rash within 21 days of exposure

3. Confirmed case
► A suspect or probable monkeypox infection with laboratory
confirmation of illness
● For example, virus isolation in culture, virus identified by
PCR

Source: Kile et al. (2005). Arch Pediatr Adolesc Med. https://doi.org/10.1001/archpedi.159.11.1022 8

Case Finding

► Once a case definition is established, investigators should look for cases through active
and passive surveillance
► Active surveillance: go into the community and look for cases
► Passive surveillance: look for cases that present at health care centers, etc.

► Investigators should carefully assess where to look for cases

► Entire country?
► State?
► County?
► Childcare center attendees?
► Pet supplier customers?

9
Key Points

► Establishing a case definition is the first step to identifying cases

► A good case definition specifies person, place, and time

► We have differing level of confidence that individuals are cases

► Usually suspect, probable, and confirmed

► Careful consideration should be given to where and how to look for additional cases

► Case definitions and study population may changes as an outbreak evolves

10
Exercise: Make Make a definition for suspected, probable, and confirmed cases
a Case for the following outbreak:
Definition ID Onset Symptoms Lab result
1 March 15 Fever, muscle aches, discolored/swollen lymph node Positive
2 March 15 Fatigue Negative
3 March 16 Fever, fatigue Missing
4 March 16 Headache Missing
5 March 16 Fever, muscle aches, discolored/swollen lymph node Missing
6 March 16 Fever, headache Positive
7 March 17 Fever, muscle aches, discolored/swollen lymph node Positive
8 March 17 Muscle aches Missing
9 March 17 Fever Missing
10 March 18 Fever Missing

11
Step 2: Describe the Outbreak by Person,
Place, and Time

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
 Line List: Lists Individual Cases and Relevant Characteristics

Ag Possible Exposure Laboratory

Status Onset date Symptoms
e exposure date(s) results
40 Probable Home 5/18 5/26 Fever, vesiculopustular IgM-, IgG+
rash, headache, sore
throat, myalgia
8 Suspect Child care 5/19–5/24 5/27 Fever, rash, adenopathy, None
headache, sore throat,
myalgia
6 Confirme Child 5/18–5/28 5/29 Fever, vesiculopustular Culture+,
d care/ rash, adenopathy, sore PCR+
home throat, headache,
encephalitis
… … … … … … …
Source: Kile et al. (2005). Arch Pediatr Adolesc Med. https://doi.org/10.1001/archpedi.159.11.1022 2
 The Epidemic Curve

Source: Kile et al. (2005). Arch Pediatr Adolesc Med. https://doi.org/10.1001/archpedi.159.11.1022 3

A Point Source Outbreak—1

4
A Point Source Outbreak—2

5
Common Source Outbreak—1

6
Common Source Outbreak—2

7
Propagated Outbreak—1

8
Propagated Outbreak—2

9
Maps of
Epidemics—1

Source: John Snow. (1855). 10

Maps of
Epidemics—2

11
Maps of
Epidemics—3

Source: https://blogs.plos.org/speakingofmedicine/2014/11/11/factors-might-led-
emergence-ebola-west-africa/ 12
Key Points

► A line list describe key characteristics of cases, including:

► Time of symptom onset
► Key clinical and epidemiological process
► Identification by person, place, and time

► An epidemic curve describes the course of an outbreak over time

► The shape of an epidemic curve gives information about the source of the outbreak

► Maps can also provide critical information about disease spread

13
Exercise: Draw an Epidemic Curve for this Line List

ID Onset Symptoms Lab result

1 March 15 Fever, muscle aches, discolored/swollen lymph node Positive
2 March 15 Fatigue Negative
3 March 16 Fever, fatigue Missing
4 March 16 Headache Missing
5 March 16 Fever, muscle aches, discolored/swollen lymph node Missing
6 March 16 Fever, headache Positive
7 March 17 Fever, muscle aches, discolored/swollen lymph node Positive
8 March 17 Muscle aches Missing
9 March 17 Fever Missing
10 March 18 Fever Missing
14
Step 3: Identify and Characterize the
Cause

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
 Clinical Evidence

Monkeypox Measles

Sources: CDC Public Health Image Library, https://phil.cdc.gov/details.aspx?pid=2329 and https://phil.cdc.gov/details.aspx?pid=3168 2

Epidemiologic Evidence

► Common exposure
► What do cases have in common (that healthy people don’t)?

► Age distribution of cases

► Children? elderly?

► Type of epidemic
► Point source? common source? propagated?

► Incubation period

3
Epidemiologic Evidence: Incubation Period

4
Incubation Period—1

► The incubation period is the time period from infection to symptom onset

► The latent period is the time period from infection to becoming infectious

► Sometimes these are confused

5
Incubation Period—2

Median
Disease incubation period
Adenovirus 5.6 days

SARS 4.0 days

Influenza 1.5 days

Parainfluenza 2.6 days

Respiratory syncytial virus 4.4 days

Rhinovirus 1.9 days

6
Laboratory ► Organism typing ► Immunological evidence
Evidence ► Molecular (e.g., genetic) ► Acute antibodies
► Microscopy ● That is, IgM
► Culture
► Drug resistance testing

Source: Gurial et al. (2011). EID. https://wwwnc.cdc.gov/eid/article/17/10/11-0022-f1 7

Key Points

► Three key sources of evidence for the cause of an outbreak:

1. Clinical
2. Epidemiologic
3. Laboratory

► None of these alone is definitive

8
Exercise: When Was Exposure?

► The disease is the plague

► The median incubation period of the plague is 3 days

► Range 2–6 days
● This assumes airborne exposure

► The median day of symptom onset is March 16

► When is the most likely day of exposure?

9
Step 4: Risk Factor Study in a Defined
Population

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
The Basic Idea

► Identify exposures that are associated ► A simple measure of association is the

with a disease relative risk (RR):

► These may indicate the source of the 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝑟𝑟𝑟𝑟𝑟𝑟𝑟𝑟 𝑖𝑖𝑖𝑖 𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒
𝑅𝑅𝑅𝑅 =
disease—or activities that aid in 𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴𝐴 𝑟𝑟𝑟𝑟𝑟𝑟𝑟𝑟 𝑖𝑖𝑖𝑖 𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢
transmission
► If the RR is much greater than one, then
the exposure is highly associated with the
disease

2
Calculating an Attack Rate

► The attack rate (AR) is calculated as the number of people in a group who developed
disease divided by the total number of people at risk for infection in that group

𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑖𝑖𝑖𝑖 𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑

𝐴𝐴𝐴𝐴 =
𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑖𝑖𝑖𝑖 𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔

► Groups are commonly defined by:

► Individual characteristics (for example, age)
► Exposure (for example, drinking milk at lunch)
► Location

3
 Outbreak in a Defined Population: Prairie Dog Exposure

► Attack rate in exposed Prairie dog exposure and clinical monkeypox among
children: childcare attendees
► 2/6 = 33.3%
Exposed to Number Number
► Attack rate in unexposed prairie dog sick not sick Total
children: Yes 2 4 6
► 2/12= 16.7%
No 2 10 12
► Relative risk:
► 33.3%/16.7% = 2

Source: Kile et al. (2005). Arch Pediatr Adolesc Med. https://doi.org/10.1001/archpedi.159.11.1022 4

 Outbreak in a Defined Population: Drinking Raw Milk

► Relative risk is infinite: Raw milk consumptions and campylobacteriosis in

► 60%/0% = ∞ participants in a third grade field trip to a farm

► Increasing attack rate with Glasses Number

more consumption provides consumed sick Total AR
additional evidence that milk is 0 0 20 0%
the cause.
1 7 20 35%
► This is called a dose-
response relationship ≥2 18 30 60%

Source: adapted from Korlath et al. (1985). JID. 5

Key Points ► Attack rate is the percentage of a group that gets the disease

► Relative risk provides a comparison of attack rates between

groups

► A relative risk above one indicates that the group in the

numerator has a higher attack rate than the group in the
denominator

► This approach only works if exposed and unexposed

populations are identified without regard to their disease
status

► This condition is most often fulfilled when there is a clearly

defined at-risk population (for example, students at a school)

6
Step 4: Risk Factor Study in an Open
Population

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
Open Population

► What if we see cases but don’t know how many people were exposed or at risk?
► That is, inclusion in the study is based on disease status

► Then we cannot calculate the relative risk because the attack rate in the exposed is
unknown:

𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑖𝑖𝑖𝑖 𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑

𝐴𝐴𝐴𝐴 =
𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑖𝑖𝑖𝑖 𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔𝑔 (𝒖𝒖𝒖𝒖𝒖𝒖𝒖𝒖𝒖𝒖𝒖𝒖𝒖𝒖)

2
Case Control to the Rescue!

► Conducting a case control study:

► Identify cases based on the case definition
► Identify controls in the same population who were at risk but did not get sick
► Calculate the odds of exposure in cases and controls
► Use the odds ratio as a measure of association between exposure and disease

3
The Odds

► The odds is the percentage of a group that have had some exposure, divided by the
percentage that have not:

𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑜𝑜𝑜𝑜 𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒/𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡 𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒

𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂 𝑜𝑜𝑜𝑜 𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 = =
𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑜𝑜𝑜𝑜 𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢/𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡 𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢𝑢

► In case-control studies, we calculate the odds of individual exposures in cases and controls

4
The Odds Ratio

► The odds ratio (OR) is the relative odds of having some exposure in cases and controls:

𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂 𝑜𝑜𝑜𝑜 𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 𝑖𝑖𝑖𝑖 𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐

𝑂𝑂𝑂𝑂 =
𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂 𝑜𝑜𝑜𝑜 𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 𝑖𝑖𝑖𝑖 𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐

► Values above one mean the exposure is associated with disease (like the relative risk)

► The odds ratio only approximates the relative risk if the disease is rare

5
 Outbreak in a Defined Population: Prairie Dog Exposure

► Odds of exposure among sick Prairie dog exposure and clinical monkeypox among
children childcare attendees
► 2/2 = 1.0
Exposed to Number Number
► Odds of exposure among not prairie dog sick not sick Total
sick children Yes 2 4 6
► 4/10= 0.4
No 2 10 12
► Odds-ratio of exposure in cases
vs. controls:
► 1.0/0.4 = 2.5

Source: Kile et al. (2005). Arch Pediatr Adolesc Med. https://doi.org/10.1001/archpedi.159.11.1022 6

Why Does this Work?–1

► The odds ratio of exposure in cases versus controls is equal to the odds of being a case if
you are exposed versus if you are unexposed

7
Why Does this Work?–2

𝑶𝑶𝑶𝑶𝑶𝑶𝑶𝑶 𝒐𝒐𝒐𝒐 𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆 𝒊𝒊𝒊𝒊 𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄

𝑂𝑂𝑂𝑂 =
𝑶𝑶𝑶𝑶𝑶𝑶𝑶𝑶 𝒐𝒐𝒐𝒐 𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆 𝒊𝒊𝒊𝒊 𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄𝒄
(Number of exposed cases)/(Number of unexposed cases)
=
(Number of exposed controls)/(Number of unexposed controls)
Number of exposed cases × (Number of unexposed controls)
=
Number of exposed controls × (Number of unexposed cases)
Number of exposed cases /(Number of exposed controls)
=
#Number of unexposed cases /(Number of unexposed controls)
𝐨𝐨𝐨𝐨𝐨𝐨𝐨𝐨 𝐛𝐛𝐛𝐛𝐛𝐛𝐛𝐛𝐛𝐛 𝐚𝐚 𝐜𝐜𝐜𝐜𝐜𝐜𝐜𝐜 𝐢𝐢𝐢𝐢 𝐞𝐞𝐞𝐞𝐞𝐞𝐞𝐞𝐞𝐞𝐞𝐞𝐞𝐞
=
𝐨𝐨𝐨𝐨𝐨𝐨𝐨𝐨 𝐨𝐨𝐨𝐨 𝐛𝐛𝐛𝐛𝐛𝐛𝐛𝐛𝐛𝐛 𝐚𝐚 𝐜𝐜𝐜𝐜𝐜𝐜𝐜𝐜 𝐢𝐢𝐢𝐢 𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮𝐮

8
Key Points

► Case-control studies allow us to measure risk even when we cannot determine how many
were at risk

► Controls should be recruited from the same population as cases

► The odds ratio measures association by comparing the odds of exposure in cases and
controls
► Only approximates relative risk if the disease is rare

► Values above one indicate association between exposure and disease

9
Exercise: What Is the Source of the Outbreak?

► 48 students visited animals on a zoo field trip Exhibit

Cases
Non-
Total
► 10 students got sick with the plague visited cases
Lion 2 19 21
► Some students visited one or more animals for an Lemur 1 18 19
“up close” visit that involved touching (see table)
Prairie dog 8 25 33
► Calculate the relative risk for being a case for each Capybara 7 4 11
animal visited compared to those visiting no animals None 2 10 12

► Based on this calculation, what is the most likely

exposure?

10
Step 5: Intervene and Report

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
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 Outbreak Response: Remove the Exposure—1

► After his investigation, John Snow presented his

results to the Board of Guardians of St. James’s
parish

► As a result a result of Snow’s work, the handle was

removed from the Broad Street pump on
September 7th, 1854

► The epidemic the quickly receded

Source: Keith Seabridge. John Snow (1813-1858). Creative Commons BY 2.0.

https://www.flickr.com/photos/16349984@N07/33348896961/in/photostream/ 2
Outbreak Response: Remove the Exposure—2

► … though it may have

been about to end

3
 Outbreak Response: Recommend Behavior Change

“… EHOs demonstrated
proper handwashing and
environmental surface
sanitation procedures and
identified other strategies
operators could use to
reduce the likelihood of
cross-contamination.”

Source: Honish et al. (2017). MMWR. 4

Outbreak
Response: Treat
or Vaccinate

► “ … postexposure prophylaxis (PEP) with MMR or immune

globulin was recommended for susceptible, exposed persons”

Source: Hall et al. (2017). MMWR. 5

Elements of a Good Report

► A report should cover all of the key elements of an investigation

► The CDC MMWR is an excellent source for seeing the elements of a good report

► Key sections of a reports:

► Introduction/background
► Investigation and results
► Public health response
► Discussion

6
Key Points

► No outbreak investigation is done until we intervene and report

► Interventions range from recommended changes to procedures and policies to active

response

► Reports should clearly outline all elements of the outbreak investigation and the public
health response

7
Exercise: Recommend an Intervention

► In the previous exercise about the children who visited the zoo and acquired the plague,
what intervention would you recommend to the zoo?

8
Summary 1. Establish a case definition by person, place, and time—and
actively find cases (who?)

2. Build a line list of cases and use this to build epidemic curves
and maps that characterize the outbreak in space and time
(when and where?)

3. Use clinical, epidemiologic, and laboratory evidence to

characterize the pathogen causing the outbreak (what?)

4. Use risk factor studies to find behaviors and exposures

associated with disease (why?)

5. Recommend or perform appropriate interventions and report

results (take action!)