BIOSTATISTICS AND EPIDEMIOLOGY Intensity of Surveillance

3rd term / Midterms / Lecture 2 – Epidemiologic Surveillance and Epidemic

Outbreak Investigation

Surveillance of Disease

Epidemics → “disease outbreak”

→ occurrence of disease at an unusual or
unexpected, elevated frequency.
→ Reliable surveillance to define the usual rates of
disease in an area is necessary before rates that
are considerably elevated can be identified.
˃ We cannot know what is unusual if we
don’t know what is usual.
Passive Surveillance Active Surveillance
Surveillance → Foundation of disease control efforts
→ Process of collecting, analyzing, interpreting, → Healthcare practitioners are → requires periodic telephone
and reporting data on the incidence of death, required to report disease using calls, electronic contact, or
diseases, and injuries and the prevalence of appropriate forms and personal visits to the reporting
certain conditions. instructions. individuals and institutions to
→ Knowledge of which is considered important for → All are expected to record all obtain required data
promoting and safeguarding public health. cases of reportable disease.

▪ United States the Centers for Disease

Control and Prevention (CDC) – responsible ★ Epidemiologists study the patterns of diseases by:
for the surveillance of most types of acute ▪ Time (when)
diseases and the investigation of outbreaks ▪ Geographic location of cases (where)
▪ Characteristics of persons involved (who)

Creating surveillance system Functions of Disease Surveillance

• Clear objectives (1) Establishment of Baseline Data

• Case definition (2) Evaluation of Time Trends
• Intensity of planned surveillance (active vs passive) (3) Identification and Documentation of Outbreaks
• Duration of surveillance (on-going vs time-limited) (4) Evaluation of Public Health and Disease Interventions
• Types of analysis needed. (5) Setting of Disease Control Priorities
• Plans on information dissemination. (6) Study of Changing Patterns of Disease
 (1) Establishment of Baseline Data → instead of using calendar year, use epidemiologic
year.
→ Baseline (or usual) rates and patterns of diseases can be known only if
there is a regular reporting and surveillance system. Calendar Year
→ Continued surveillance allows epidemiologists to detect deviations from ­ January 1 to December 31 of the same year
the usual pattern of data. (epidemic or not)
Epidemiologic Year
˃ not all unusual occurrence of a disease is brought upon by
­ month of the lowest incidence in one year to
epidemic. ex. is alterations in reporting practice.
the same month in the next year.

(2) Evaluation of Time Trends

Secular → evaluation of disease patterns over longer

(Long-Term) periods of time
Trends → is the trend caused by:
­ Changes in disease detection, disease
reporting, or both? (often the case when an
apparent outbreak is reported), or
­ A true change in the number of cases? Other Types of (1) Variation by the day of the week
­ Why is it true? How is it true? Factors that Variation (2) Variation by the time of the day
contributed to the trend?
(3) Identification and Documentation of Outbreaks
Seasonal Variation → many infectious diseases (depending on the
route of spread)
→ show this type of pattern; Epidemic or → Occurrence of disease at an unusual (or
Disease Outbreak unexpected) frequency
Respiratory route - Epidemic → The critical number or density of susceptible
­ Usually have a much higher incidence in the Threshold hosts required for an epidemic to occur.
winter and early spring in the northern → Used to confirm the emergence of an epidemic
hemisphere to step-up appropriate control measures.
Arthropod vectors Surveillance for → rapid detection of major increases in the most
­ Summer or early autumn Bioterrorism likely biologic agents

Fecal-oral route
- Syndromic → characterize syndrome that would be consistent
­ Most common in summer
Surveillance with agents of particular concern
 (4) Evaluation of Public Health and Disease Interventions Example:
o Syphilis cases in NYC in 1980s
→ Using surveillance to determine the if the intended changes were
o Fall and rise of tuberculosis due to HIV
achieved.
Investigation of Epidemics
Example: impact of two types of polio vaccines
a. Inactivated (Salk) vaccine.
Endemic → disease occurs regularly and at a more or less
b. Oral (Sabin) vaccine.
constant level

Failure in vaccination Epidemic → unusual occurrence of a disease

• A lack of change in disease rates Pandemic → an epidemic occurring worldwide, or over a very
• An increase in disease rates after an initial decrease wide area, crossing international boundaries and
• An increase in disease rates in a recently vaccinated. usually affecting a large number of people

Post-marketing Surveillance
Enzootic → disease occurring in an animal population in a more
→ Refers to the process of monitoring the safety of drugs or vaccines
or less constant level
once they reach the market, after the successful completion of
clinical trials. Epizootic → disease outbreak in animal population
Panzootic → an epizootic (an outbreak of an infectious disease of
Primary purpose: animals) that spreads across a large region (for
to identify previously unrecognized adverse effects as well as example a continent), or even worldwide
positive effects

(5) Setting of Disease Control Priorities ▪ One health approach – considering the health of environment,
animal and humans as a whole.
→ Serves as a basis for governments and voluntary agencies to establish
priorities for disease control efforts.
→ A disease is of more concern if:
a) Its rates increase rapidly (e.g., AIDS in the 1980s, COVID-19 in
2020)
b) Severity of disease (CFR, IFR, etc.)
c) Potential for epidemic spread

(6) Study of Changing Patterns of Disease

→ Patterns of occurrence of a disease over time in populations in

subpopulations can give clues on the changing patterns of the disease.
 Procedures for Investigating an Epidemic → however, it may be assumed that a completely new disease or
syndrome meets the criteria for an epidemic.

4. Characterize Epidemic by Time, Place, and Person

Epidemic Time Curve

­ Graph with time on the x-axis and number of cases on
the y-axis.
­ Useful in knowing the type of exposure and the time
Time when the affected persons were exposed.
­ Helps the epidemiologist in determining the:
o Type of exposure
o Route of spread
Epidemiologic triad o When affected persons were exposed.
­ Purpose is to discover and correct recent changes so the balance is o Incubation period
restored. o Primary cases and secondary cases (if present)

1. Establish the Diagnosis ▪ Common Source Exposure

→ Seems obvious, but correctly establishing diagnosis is important. ­ Many people encounter the same source usually
→ Incorrect diagnosis might: over a short period of time (e.g., contaminated food
o Show that a disease is unusual when in fact it’s not. or water)
o Show that a disease is not unusual. ­ Epidemic time curve usually has a sudden onset, a
peak, and then a rapid decline.
2. Establish Epidemiologic Case Definition
▪ Person-to-Person Spread
­ Epidemic time curve has a prolonged, irregular
▪ Epidemiologic Case Definition
pattern (propagated outbreak).
­ list of specific criteria used to decide whether a person has the
disease of concern or not.
★ Some respiratory (person-to-person) diseases might
­ not the same as clinical diagnosis (but related)
resemble the epidemic time curve of a common-source
­ establishes consistent criteria that enable epidemiologic
epidemic
investigations to proceed before definitive diagnoses are
available.
★ Sometimes epidemic has more than one peak (Multiple
3. Is an Epidemic Occurring? common source exposures/ Secondary cases)
˃ Two different common-source outbreaks have the
→ cases must occur in sufficient numbers to constitute an epidemic.
same time and place of exposure, but different
→ again, it is difficult to assess whether the number of cases is high
incubation periods.
unless the usual number is known by ongoing surveillance.
 ★ Geographic clustering of cases may provide important Pattern of Spread → How the infection is carried from source to
Place information about the epidemic. infected individuals.
o Common-source pattern
▪ Spot map o Point-source exposure
­ Map showing the geographic location of people o Continuous common-source exposure
with a specific attribute, for Example, cases of an o Propagated pattern
infectious disease. o Mixed pattern
­ Limited use because these maps show only the
number of cases (numerator), and no number of 6. Test Hypothesis
persons in the area (denominator). → Cultures from patients, or from food or water
­ John Snow – used spot map to identify cause of Laboratory studies source
cholera. → Stool examination for ova and parasites o Serum
testing for Ab test for toxins or drugs
★ Epidemiologists must also distinguish “chance” from “real” → Test for presence of causative agent through PCR
clusters.
˃ ex. cancer cases in an area due to a suspected Case-Control → Common, efficient way of testing hypotheses
environmental factor. (factory and lung cancers) Studies
▪ Cases – persons with the disease
▪ Control – persons without the disease
Person → Characteristics of persons affected that may help clarify
the problem and its cause. 7. Initiate Control Measures

o Age o Immunization status Sanitation o Modification of the environment

o Sex and gender o Type of work and schooling o Removing the pathogenic agent
o Race and ethnicity o Socioeconomic status o Quarantine (removing the human source
o Religion o Contact with other affected from the population)
o Source of water, milk, persons o Preventing contact from the source
and food o By cleaning the environment
o Evacuation (removing susceptible people
5. Develop Hypotheses Regarding Source, Patterns of Spread, and Mode from source)
of Transmission
→ The person (index or primary case) or vehicle Prophylaxis → Putting a barrier to the infection such as vaccines
Source of Infection (e.g., food, water) that initially brought the or drugs (e.g., antimalarial drugs)
infection into the affected community
Diagnosis and → Performed for infected persons so that they do
→ Movement or the transmission of pathogens
Treatment not spread the disease to others
Mode of from a reservoir to a susceptible host
Transmission → Respiratory, fecal-oral, vector-borne, skin-to-
Control of Disease
skin, exchange of serum or body fluids, fomites
Vectors
 (1) Establish the Diagnosis
(2) Establish Epidemiologic Case Definition
(3) Is an Epidemic Occurring?
(4) Characterize Epidemic by Time, Place, and Person
(5) Develop Hypotheses Regarding Source, Patterns of Spread, and Mode
of Transmission
(6) Test Hypotheses
(7) Initiate Control Measures
(8) Initiate Specific Follow-up Surveillance to Evaluate Control Measures

★ Another important aspect of control is the communication of findings

to authorities, health professional, and the public:
o Enables other agencies to assist in disease control
o Contributes to the professional fund of knowledge regarding the
outbreak
o Adds to the available information on prevention

8. Initiate Specific Follow-up Surveillance to Evaluate Control Measures

→ Follow-up surveillance for the medical or public health
intervention
o To detect subsequent outbreaks
o Evaluating effect of control measures

BY: LD