College of Medicine

Community And Family Medicine

Outbreak
Investigation
Dr. Beesan Maraqa, MD, PBFM
Assistant Professor
Consultant family Medicine, MPH, SQIL Harvard university
beesanm@hebron.edu
  Introduction
 Endemic vs pandemic and outbreak vs epidemic
 Source of information to detect outbreak
Content  Why should we investigate outbreaks?
 Steps for investigation.

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 ✓ Endemic refers to the constant presence and/or usual
prevalence of a disease or infectious agent in a population
within a geographic area.

✓ Epidemic
• Unusual occurrence of a disease clearly in excess of what is
normally expected in
• population in that area
• In a given point of time.
 Pandemic refers to an epidemic that has spread over
Introduction several countries or continents, usually affecting a large
number of people.

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  Occurrence of more cases of disease than expected
 In a given area
 Over a particular period of time
 Among specific group of people.

What is an  Occurrence of two or more Epidemiology linked

outbreak cases of a disease of outbreak potential.

 A single case of a new emergence

disease\eradicated disease.

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 Outbreak Epidemic

 Usually limited to a
small area  Larger geographic
area
 One district \ few
blocks  Linked to control
measures

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  Event – based surveillance system
Source of  Community informants
information  Media

to detect
outbreak  Case – based surveillance system
 Review of routine data
 Trigger events

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  Control or prevention of the health problem
Why  Opportunity to learn (research opportunity)
investigate  Public, political, or legal concerns
 Public health program considerations
an outbreak?  Training

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 outbreak
investigations
 Outbreak investigations should be a collaborative effort,
since several tasks requiring different skills must be done
at the same time.
Epidemiological Investigation
Environmental Investigation
Laboratory Investigation

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 Outbreak Investigations
•Surveillance
Surveillance •Provides first evidence of cultures
•Line list
outbreak
of cases
•Environmental
•Often detected by microbiology
•Epi-curves
samples
•Case-Control
•Culture study
ID
Epidemiologic Studies •Exposure risks
•Susceptibility
testing
•Isolate typing

Confirmatory Studies
•Patient isolation
•Enhanced disinfection
•Suspend procedure or Local Interventions
close unit
Adapted
11/19/2023 from Ostrowsky and Jarvis
Dr Beesan Efficient
Maraqa, Management
FCM , HU, Outbreak Investigation of Outbreak Investigations 9
 outbreak
investigations

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 1. Preparing for the field 6. Develop
hypothesis
2. Establish the
existence of the 7. Test hypothesis
outbreak
8. Plan and perform
3. Verify the diagnosis additional studies
Steps of an 4. Define a case and 9. Implement and
outbreak conduct case finding evaluate control
measures
investigation 5. Descriptive
Epidemiology: time, 10. Communicate
place, person findings

These steps may occur simultaneously or be repeated as

new information is received.

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 Preparations for an outbreak must begin before the
Preparedness outbreak occurs.
Multidisciplinary investigative team and assign
responsibilities. Members should include:
 Nursing
 Communicable disease
 Environmental
 Support staff
 Laboratory
 Public information, and
 Computer information

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Preparedness
✓ Training: Introduction to Epidemiology, Principles of
Epidemiology and other disease specific courses on
investigative procedures.
✓Assemble materials: laboratory kits, forms, reference
materials, PPEs (gloves and masks).
✓Maintain a current contact information of the team.
✓Maintain adequate local surveillance systems for the
early detection of increased disease incidence.

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 Research the disease
Clinical presentation?
Who gets the disease?
What is the typical vehicle?

Gather supplies
Travel preparations
Step 1. Clarify your role
Preparing Identify local contacts
for the field

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 Is this a real outbreak?
Do the number of cases exceed expected?

 When would number of cases exceed

Step 2. previous months but NOT be a true
Establish outbreak ?
existence of  Seasonal variation
the  Increase in size of population
outbreak  Change in case definition
 Improved reporting
 Improvement in diagnostic procedures

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  Is the diagnosis correct?
 Laboratory error?
Step 3.
 Examine patients
Verify the
diagnosis  Review medical records
 Confirm laboratory testing

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 Case definition
 A set of standard criteria for classifying whether a
person has a particular disease, syndrome, or health
condition
Step 4.  Usually includes four components:
Define and  Clinical information about the disease,
 Characteristics about the people who are affected,
Identify  Information about the location or place, and
Cases  A specification of time during which the outbreak
occurred.

 Example “Abdominal cramps and diarrhea (at least three stools in

a 24-hour period) in a school-age child with onset during between
November 3 and November 8, 1990 ”.

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 Case definition
 Goal: Identify maximum number of case and
Exclude non-cases
 Can change overtime
• Early: more vague, inclusive
• Later: more refined, exclusive
 Classification
 Confirmed: with laboratory-confirmation
Step 4.  Probable: without laboratory-confirmation (but
NOT with a negative test)
Define and  Possible: typically less specific clinical criteria.

Identify Example:
- Confirmed case: E. coli O157:H7 isolated from a
stool culture or development of hemolytic-uremic
Cases syndrome in a school-age child resident of the
county with gastrointestinal symptoms beginning
between November 3 and November 8, 1990
- Probable case: Bloody diarrhea, with the same
person, place, and time restrictions
- Possible case: Abdominal cramps and diarrhea (at
least three stools in a 24-hour period) in a school-age
child with onset during the same period (CDC,
unpublished data, 1991).

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 Case finding
 Usually, the first cases to be
recognized are only a small
Step 4. proportion of the total number
Define and  Conduct surveillance using case
Identify definition
Cases  Existing surveillance
 Active surveillance (e.g. review medical records)

 Interview case-patients

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 Case finding
 Regardless of the particular disease, you should
collect the following types of information about
every person affected:
Step 4.  Identifying information: name, address, and
telephone number, …etc.
Define and  Demographic information: age, sex, race, and
occupation,…etc.
Identify  Clinical information: Signs and symptoms, date of
Cases onset, hospitalization, death,…etc.
 Risk factor information:
 For example, in an investigation of hepatitis A, you
would look at exposure to food and water sources.

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 Line listing
 Traditionally, we collect these information on a
standard case report form, questionnaire, or data
abstraction form.
Step 4.  We then abstract selected critical items in a table
Define and called a "line listing.“

Identify  Each column represents an important variable

(name, ID #, age, sex, and case classification), while each
Cases row represents a different case.
 New cases are added to a line listing as they are
identified.
 This simple format allows the investigator to scan
key information on every case and update it easily.

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 Example of a line listing for acute Hepatitis A*

N=nausea V=vomiting A=elevated aminotransferase F=fever D=discreet onset J=jaundice HAIgM=hepatitis AIgM antibody test
SGOT=serum glutamic oxaloacetic transaminase ALT=alanine aminotransferase Hbs=hepatitis B surface antigen Ag-=antigen
negative 1=“yes”, 0=“no”

* This table illustrates a line listing that might be used during an outbreak of hepatitis A. It was adapted from
the CDC’s “Excellence in Curriculum Integration through Teaching Epidemiology” program. Additional
variables that might be helpful to include are drug use, occupation, meal at restaurant X, neighborhood of
residence and sexual orientation.
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Step 5.
Perform  Person
 Who was infected?
Descriptive  What do the cases have in common?
epidemiology  Place
: Person,  Where were they infected?
Place and  May be useful to draw a map

Time  Time
 When were they infected?
 Create an epidemic curve

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 Spot map
• Assessment of an
outbreak by
place provides
information on
the geographic
extent of a
problem
• A spot map of
cases in a
community may
show clusters or
patterns that
reflect water
supplies, wind
currents, or
proximity to a
restaurant or
grocery store.

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 Epidemic Curve
36
33

Epidemic 33

30

curve or 27

24
“epi curve” =

Cases
21
a graph of the 18
number of cases by 15
their date of onset. 12
10
9
 Number of cases is 9
6 6
plotted on y-axis 6
4
3 3
3 2 2 2
 Time is plotted on 1
0
the x-axis
Time

A simple visual display of the outbreak's magnitude and time

trend

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Cases

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Cases

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Cases

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Time 34
 Peak
Cases

beginning End

Time 1 2 3 4 5 Entire period

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  An epi curve can provide
information on the following
characteristics of an outbreak:
 Pattern of spread
Epi curve:  Magnitude
Advantage  Outliers
 Time trend
 Exposure and/or disease
incubation period

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 The overall shape of the epi
curve can reveal the type of
Outbreak outbreak
Pattern of ➢ Common-source
Spread o Point
o Continuous
➢ Propagated

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 Common Point Source
Epidemic
curves
 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
 Interpretation - people are exposed
to the same source over a relatively
brief period
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 Common Continuous Source
Epidemic
curves  People are exposed
continuously or intermittently
to a harmful source
 Period of exposure may be brief
or long
 An epi curve with irregular
peaks that reflect the timing
and the extent of exposure
 Interpretation - people are
exposed to the same source
over an extended period
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 Propagated
Epidemic
curves

• Can last longer than common

source outbreaks
• May have multiple waves
• The classic epi curve for a
propagated outbreak has
progressively taller peaks, an
incubation period apart
• Interpretation - person-to-person spread
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 Based on
• Descriptive epidemiology - person,
place and time
• literature reviews of previous
Step 6. outbreaks
Develop • Interviews of several case-
patients
hypotheses ✓ What are the possible sources?
✓ What is the likely means of transmission?
✓ What is the usual reservoir?
✓ What are known or suspected risk for disease?

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 Cases

Time
1200

1000
Person
800

600
Place
400

200

0
0-4 '5-14 Age'15-44
Group '45-64 '64+

Evaluate information

Pathogen? Source? Transmission?

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 • Conduct an analytic study to test
hypotheses
• Retrospective cohort study
Step 7. • Case-control study
Evaluate Cohort
hypotheses  Comparison of people EXPOSED to those NOT
EXPOSED (small, well-defined population)
epidemiolog  Calculate attack rates (AR)
 Relative risk: AR exposed/AR unexposed
ically  Outbreaks in closed communities/facilities

Case-Control
 Comparison of people with DISEASE (cases) to those
without DISEASE (controls)
 Odds ratio; 2X2
 General community outbreaks

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 Laboratory and environmental
studies
Step 8:
Plan and • While epidemiology can implicate
vehicles and guide appropriate
perform public health action, laboratory
additional evidence can clinch the findings

studies • Environmental studies often help

explain why an outbreak occurred
and may be very important in
some settings

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  If an obvious source of the contamination is
Step 9: identified… institute control measures immediately!
Implement  Remove source of contamination
control and  Remove persons from exposure
prevention  Isolate and/or treat infected persons
measures  Interrupt transmission
 Eliminate the susceptibility of individuals by
vaccination or prophylactic chemotherapy

May occur at any time during the outbreak!!

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 • Oral briefing for local authorities
and media
• A written report
✓ scientific format of introduction, background,
Step 10: methods, results, discussion, and
recommendations.
Communicate ✓ the report provides
findings ➢ a blueprint for action.
➢ a record of performance and training.
➢ a reference if a similar situation occur in the
future.
➢ Publishing can contribute to the knowledge
base of epidemiology and public health

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 Questions?

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