Outbreak Investigations-The 11 Steps Approach - Lukfaz

Outbreak Investigations:
The 11-Steps Approach

ASST. PROF. LUKMAN FAUZI, MPH.
PUBLIC HEALTH DEPARTMENT

SEMARANGLOGO
STATE UNIVERSITY
Cycles of Vaccination Program
Learning Objectives
❖ List the reasons why outbreak

investigations are important to public
❖ Know the steps of an outbreak
investigation
❖ Give an example of a single overriding
communication objective (SOCO)
Reasons to Investigate an Outbreak
❖ Identify the source (and eliminate it)

❖ Develop strategies to prevent future
outbreaks
❖ Evaluate existing prevention strategies
❖ Describe new diseases and learn more about
known diseases
❖ Address public concern
❖ It’s your job!
What is an Outbreak?
The occurrence in a community or region of cases

of an illness (or an outbreak) with a frequency
clearly in excess of normal expectancy”
[Heymann DL, CDC Manual – 19th Ed]

11 Steps of an Outbreak Investigation
1. Prepare field investigation

2. Confirm the outbreak
3. Verify/confirm the diagnosis
4. Construct case definition
5. Find cases systematically based on person, place, time
6. Perform descriptive epidemiology and develop
hypotheses
7. Identify source and mode of transmission
8. Evaluate hypotheses/perform additional studies as
necessary
9. Implement control measures
10. Communicate findings
11. Maintain surveillance

hypotheses
necessary
Preparation, includes:
❖ Done as soon as possible, within the first 24 hours after

presence information.
❖ Prepare include:
1. Information sources of the outbreak. Can be derived from:
➢ Outbreak report (W1),
➢ Analysis of early warning systems in the area (W2
reports),
➢ The laboratory results, Hospital Reports (RL2a, RL2b) or
society.
2. The description of the outbreak, include:
➢ Clinical symptoms,
➢ Tests that have been performed to confirm the diagnosis
(such as death, disability, paralysis and other)
3. Geography and transportation that can be used in outbreak
area.
Maximum-Minimum Pattern
Usability :
1. To early warning system.

2. Evaluate trend of disease.
HOW TO DESIGN?
Year Observed
Months 2014 2015 2016 2017 2018 2019
Jan 5 10 2 4 1 8
Feb 8 3 7 6 5 2
Mar 10 9 4 6 2 12
Apr 4 6 7 8 5 9
May 3 6 10 7 8 7
Jun 6 5 4 3 7 5
Jul 5 4 9 7 5 7
Aug 2 3 9 6 8 6
Sept 1 6 8 7 9 5
Oct 7 8 2 6 10 3
Nov 9 6 4 8 7 3
Des 5 5 10 7 4 5
Maximum-Minimum Graph of Typoid Cases 2014-2018 Compared
with 2019 in Bahagia City Sakinah Province
14
12
10
Cases (n)
8
6
4
2
0
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Des
Min 1 3 2 4 3 3 4 2 2 4 4 4
Max 10 8 10 8 10 7 9 9 10 9 9 10
Observed 8 2 12 9 7 5 7 5 3 3 3 5
Months
Min Max Observed

Maximum-Minimum of DHF Cases 2010-2017 Compared with 2019 in
Semarang City
700
600
500
Cases (n)
400
300
200
100
0
Jan Feb Mar Apr Mei Jun Jul Aug Sept Oct Nov Dec
Min 44 30 25 17 41 24 18 18 4 17 19 11
Max 184 108 99 109 104 153 98 84 83 92 143 86
Observed 212 269 580 511
Months
Min Max Observed


hypotheses
necessary
Outbreak Criteria (MoH Regulation No 1501 of 2010)
Classified as an outbreak, if there is one of following

elements:
1. The emergence of an infectious disease that previously
did not exist or unknown.
2. Increased incidence of disease continuously for 3 periods
in hour, day, or week respectively according to the
disease.
3. Increased incidence of illness 2 times or more compared
with the previous period (hour, day, week).
4. The number of new cases in one month showed an
increase of 2 times or more when compared with the
average number of per month in the previous year.
Outbreak Criteria (MoH Regulation No 1501 of 2010)
Classified as an outbreak, if there is one of following

elements:
5. The average number of incidences of morbidity per
month for 1 year showed a 2-fold increase or more
compared with the average number of incidences of
morbidity per month in the previous year
6. The mortality rate of certain disease (CFR) in a certain
period of time showed an increase of 50% or more
compared with the mortality rate of a disease of the
previous period within the same period.
7. Proportional rate of new patient in 1 period showed an
increase of 2 times or more compared with 1 previous
period in the same period.
IMPORTANT!! PSEUDO EPIDEMIC..
❖ The number of reported cases exceeds the

expected amount, the excess does not always
show an outbreak.
❖ Cause:
▪ Changes in the way of recording and reporting the
disease
▪ The existence of a new diagnosis method
▪ Increased awareness of the population to seek
treatment
▪ The presence of other diseases with similar symptoms
▪ Increasing the number of population at risk

hypotheses
necessary
Verify the Diagnosis
❖ Obtain medical records and lab reports

▪ Contact Public Health Epidemiologist in
Hospital & Infection Preventionists
❖ Conduct clinical testing if needed

▪ Consult with laboratory (BBTKL, BBPOM,
BLK, etc.)
Classification of Diagnosis
❖ Definite : Any symptoms, and positive lab (GS)

❖ Probable: Any symptoms, without lab (non-GS)
❖ Suspect : Any symptoms, negative lab

hypotheses
necessary
Components of Case Definition and Descriptive
Epidemiology
❖ Person → type of illness

→ age
AR
→ sex
→ occupation
❖ Place → location of suspected exposure
❖ Time → based on incubation period (if known)

Case Definition
“People who have symptoms vomit or nausea or

diarrhea, within 24 hours after participating at X’s
birthday party in the Z hotel (Sunday January
22nd; 8 pm)”
Place
Time : EPIDEMIC CURVE
❖Histogram
❖Distribution of cases by time of onset of
symptoms, diagnosis or identification
▪ time interval depends on incubation period
Cases
10
9
8
7
6
5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12
Days
Epidemic Curve
Cases
❖ Describe 10
9
▪ start, end, duration

8
7
6
▪ peak 5
4
▪ importance 3
2
▪ atypical cases 1
0
1 2 3 4 5 6 7 8 9 10 11 12
Days
❖ Helps to develop hypotheses
▪ incubation period
▪ etiological agent
▪ type of source
▪ type of transmission
▪ time of exposure
Type of Epidemic Curve
Common point source Common persistent

cases cases source
10
6
9
5 8
7
4
6
3 5
4
2 3
2
1
1
0 0
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 9 10 11 12
hours days
cases
12
cases Propagated source 10
Common intermittent
10
9
8
source
8 7
6
6 5
4
4
3
2 2
1
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
weeks days
Epi Curve Use
1. Determine / estimate the source or mode of transmission of

disease by looking at the type of epidemic curve (common
source atau propagated).
2. Identify the exposure time or initial case search (index
case) by calculating average incubation period or the
maximum and minimum incubation periods.
Common Mistakes when Designing Epidemic Curve
Time interval decision:

• Time intervals that are too long will hide small differences
in the temporal distribution (hide case peaks).
• Time intervals that are too short will cause fake-peaks.
• Guidelines for time interval decision is choose an eight
(1/8) or a quarter (1/4) from incubation period of the
disease.
• It is better to make several epidemic curves with different
intervals, so that the best graph to present the data can be
obtained (Friedman, 1974; Kelsey et al., 1986; CDC, 1979).
Figure 1. Cases of Staphylococcus Poisoning by Incubation Period
Tennesse, 25 May 1969 (cited from CDC, 1979)
25
20
CASES
15
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
TIM E (ONSET OF SYM PTOM S)
▪ Epidemic curve with common source (one source)

▪ This curve occurs in outbreaks with exposed cases in the
same time and in a short time. Usually found in diseases
transmitted through water and food (for example: cholera,
typoid).
Figure 2. Case Distribution of Hepatitis by Onset Time of Symptoms (Weekly)
in Baren City Kentucky, June 1971 - April 1972 (cited by Carman et al., 1979)
CASES
Onset Time
Tanggal of Disease
Mulai (Weekly)
Sakit (minggu)
14
12
10
• Epidemic curve with propagated type (many sources).

• This curve occurs in outbreaks by transmission through
person-to-person contact.
• Some peaks are visible. Distance between the peaks is
more or less the average incubation period of the disease.
Figure 3. Case Distribution of Salmonelosis by Onset Time of Symptoms (daily)
Clarkville, Tennesse, 4-15 July 1970 (cited by CDC, 1979)
35
30
NUMBER OF CASES
Secondary
25 Primary
20
15
10
0
3 4 5 6 7 8 9 1 1 1 1 1 1 1
ONSET TIME OF DISEASE
• A type of mixed epidemic curve between common source and

propagated
• This type of curve occurs in outbreaks where initially the
cases get a shared source of exposure, then it spread from
person to person (secondary cases).
Figure 4. Cases of Distribution of Rubella by Onset Day of Symptoms
in Sun City 21-19 June (cited by CDC, 1979)
10
NUMBER OF CASES
9
7
8
18 days (average
6
5 incubation period)
4
3
2
1
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
ONSET TIME OF DISEASE
• Epidemic curves is used to determine the most likely exposure period,

(common source), with using the average incubation period and the
maximum-minimum incubation period.
• The average incubation period method is ofted to be used, because the
result is more often close to the truth.
• Method of average incubation period:
First, identify the peak of outbreak (June 25). Then, outbreak peak is
counted backward during the average incubation period of Rubella (18
days, minimum 14 days-maximum 21 days). The exposure time is most
likely on June 7.
Hypotheses on the moment of infection
unknown pathogen and point source
2
~ median incubation period
(= duration of the epidemic)
15
5
0
Time
3 1Possible moment of
3infection
5 7 9 11 13 15 17 19 21 23 25 27 29
50% 50%
1 median
Epi Curve
60
The longest
The shortest incubation
incubation period
50
period
Number of Cases
40
30
20 Meal
Time
10
0
19.00 20.00 21.00 22.00 23.00 24.00 01.00 02.00 03.00 04.00 05.00
Time
Figure 2. Epidemic Curve in foodborne outbreak in District of Sleman, Indonesia, 2012

Case Study
Mrs. Taylor Swift, a resident of Gotham VIllage, reported to local clinic staff that there had
been an increase in cases of diarrhea, vomiting, accompanied by fever in residents who had
just attended the anniversary of Batman's second son. The program started at 20:00 in the
front yard of the village hall. The main menu was seafood. After an epidemiological
investigation, the highest AR was green clam soup (70%). The following is a snippet of the list
of residents who experienced illness:
1. Design the epidemic curve!
2. What disease might be expected in this outbreak!
Onset of Onset of
No Name Meal time No Name Meal time
symptoms symptoms
1 Aina 5 June, 22.00 6 June, 09.00 8 Iina 5 June, 23.00 6 June, 10.00
2 Bina 5 June, 20.30 6 June, 08.30 9 Jina 5 June, 23.00 6 June, 11.00
3 Cina 5 June, 20.00 6 June, 08.00 10 Kina 5 June, 20.00 6 June, 08.00
4 Dina 5 June, 23.00 6 June, 08.00 11 Lina 5 June, 21.00 6 June, 08.00
5 Eina 5 June, 22.30 6 June, 11.30 12 Mina 5 June, 22.00 6 June, 10.00
6 Fina 5 June, 20.30 6 June, 10.30 13 Nina 5 June, 21.00 6 June, 07.00
7 Gina 5 June, 22.00 6 June, 09.00 14 Oina 5 June, 21.00 6 June, 09.00
8 Hina 5 June, 20.00 6 June, 10.00 16 Pina 5 June, 20.00 6 June, 10.00

5. Find cases systematically based on person, place,
time
hypotheses
necessary
Cases Description by Person
Table 1. Distribution of clinical signs and symptoms in foodborne

outbreak in District of Sleman, Indonesia, 2012
No Clinical Signs and Symptoms Cases Percentage (%)
1 Diarrhea 101 75,94

2 Stomachache 60 45,11
3 Nausea 50 37,59
4 Vomiting 47 35,34
5 Headache 29 21,80
6 Muscle weakness 24 18,05
7 Cold sweat 23 17,29
8 Pallor 23 17,29
9 Fever 5 3,76
10 Shiver 4 3,01
11 Fainting 3 2,26
Cases Description by Person
Table 2. Attack Rate (AR) value by sex in foodborne outbreak

in District of Sleman, Indonesia, 2012
No Sex Population at Risk Illness Subject AR (%)
1 Male 119 62 52,10

2 Female 112 71 63,39
Total 231 133 57,58

hypotheses
necessary
Identify the Source
A. IDENTIFICATION OF SOURCES OF TRANSMISSION
Know the source and how:
• Proving the presence of an agent at the source of infection in the

laboratory or a statistical relationship between cases and
exposure (MacMohan and Pugh, 1970; CDC, 1979).
• According to MacMahon and Pugh (1970), CDC (1979) and
Kelsey et al (1986), determining the alleged source and mode of
transmission of the disease is considered good if:
1. Found the same agent between the source of infection and
sufferers.
2. There is a significant difference in the attack rate between
people who are exposed and those who are not to the
source of the infection
3. There is no other way in all cases, or other modes of
transmission cannot explain the distribution of age, time and
geography in all cases
Identify the Source
B. IDENTIFICATION OF THE CAUSE CONDITION OF THE OUTBREAK
In general, the condition that causes an outbreak is a change in the

balance of the agent, host and the environment that can occur
because:
1. Increase in the amount or virulence of the agent,
2. There is a new causative agent or one that was not previously
available,
3. Conditions that facilitate disease transmission,
4. Changes in population immunity to pathogenic agents, the
environment and population habits that have the opportunity for
exposure.

hypotheses
8. Evaluate hypotheses/perform additional
studies as necessary
Additional Studies
❖ Type :
▪ Retrospective Cohort Studies
▪ Case Control Studies
❖ Designed to assess exposure equally among ill

and non-ill
Retrospective Cohort Studies
❖Include EVERYONE who could have exposed

▪ Only use if a complete list is available
▪ Meeting attendees, students, LTCF residents, etc.
❖ Measure of association = Relative Risk (RR)
❖ A retrospective cohort study is the study of

choice for an outbreak in a small, well-defined
population, such as an outbreak of gastroenteritis
among wedding guests for which a complete list
of guests is available.
❖ In a cohort study, the investigator contacts each
member of the defined population (e.g., wedding
guests), determines each person’s exposure to
possible sources and vehicles (e.g., what food
and drinks each guest consumed), and notes
whether the person later became ill with the
disease in question (e.g., gastroenteritis).
❖ After collecting similar information from each

attendee, the investigator calculates an attack rate for
those exposed to (e.g., who ate) a particular item and
an attack rate for those who were not exposed.
❖ Generally, an exposure that has the following three
characteristics or criteria is considered a strong
suspect:
1. The attack rate is high among those exposed to the
item.
2. The attack rate is low among those not exposed, so
the difference or ratio between attack rates is high.
3. Most of the case-patients were exposed to the
item, so that the exposure could “explain” or
account for most, if not all, of the cases.
❖ Commonly, the investigator compares the attack rate

in the exposed group to the attack rate in the
unexposed group to measure the association between
the exposure (e.g., the food item) and disease.
❖ This is called the RISK RATIO or the RELATIVE
RISK.
❖ When the attack rate for the exposed group is the
same as the attack rate for the unexposed group, the
relative risk is equal to 1.0, and the exposure is said
not to be associated with disease.
❖ The greater the difference in attack rates between the
exposed and unexposed groups, the larger the
relative risk, and the stronger the association between
exposure and disease.
Beef, which had the highest attack rate among those who ate it, the lowest attack rate among those who
did not eat it, and could account for almost all (53 of 57) of the cases, was indeed the culprit. The data
showing the relationship between an exposure and disease are often displayed in a two-by-two table.
Case Control Studies
❖ Compare exposures among ill persons (case-

patients) and non-ill persons (controls)
❖ Used when a complete list is not available or
too large
▪ Restaurant outbreaks, national outbreaks, etc.
❖ Measure of association = Odds Ratio (OR)
❖ In a case-control study, the investigator asks

both case-patients and a comparison group of
persons without disease (“controls”) about their
exposures.
❖ Using the information about disease and
exposure status, the investigator then calculates
an odds ratio to quantify the relationship between
exposure and disease. Finally, a p-value or
confidence interval is calculated to assess
statistical significance.
Case Control Studies: Choosing Control
❖ When designing a case-control study, one of the

most important decisions is deciding who the
controls should be.
❖ The controls must not have the disease being
studied, but should represent the population in
which the cases occurred.
❖ In other words, they should be similar to the
cases except that they don’t have the disease.
❖ The controls provide the level of exposure you
would expect to find among the case-patients if
the null hypothesis were true.
❖ If exposure is much more common among the case-

patients than among the controls, i.e., the observed
exposure among case-patients is greater than
expected exposure provided by the controls, then
exposure is said to be associated with illness.
❖ In practice, choosing who the most appropriate
control group is may be quite difficult. In addition,
investigators must consider logistical issues, such as
how to contact potential controls, gain their
cooperation, ensure that they are free of disease, and
obtain appropriate exposure data from them. In a
community outbreak, a random sample of the healthy
population may, in theory, be the best control group.
❖ In practice, however, persons in a random sample

may be difficult to contact and enroll.
❖ Nonetheless, many investigators attempt to
enroll such “population-based” controls through
dialing of random telephone numbers in the
community or through a household survey.
❖ Other common control groups consist of:
1. Neighbors of case-patients,
2. Patients from the same physician practice or
hospital who do not have the disease in question,
3. Friends of case-patients.
❖ When designing a case-control study, you must

consider a variety of other issues about controls,
including how many to use.
❖ Sample size formulas are available to help you
make this decision.
❖ In general, the more subjects (case-patients and
controls) in a study, the easier it will be to find a
statistically significant association.
❖ Often, the number of case-patients that can be

enrolled in a study is limited by the size of the
outbreak.
❖ For example, in a hospital, four or five cases may
constitute an outbreak. Fortunately, potential
controls are usually plentiful.
❖ In an outbreak of 50 or more cases, one control
per case will usually suffice. In smaller outbreaks,
you might use two, three, or four controls per
case. Including more than four controls per case
is rarely worth the effort in terms of increasing
the statistical power of your investigation.
Bivariate Analysis
Table 4. Result of bivariate analysis of food type in foodborne
outbreak in District of Sleman, Indonesia, 2012
No Food Types RR 95% CI p-Value

1 Rice 0,76 0,59 – 0,96 0,01
2 “Bacem” fried chicken 3,88 1,37 – 11,03 <0,01
3 Raw vegetable 0,79 0,59 – 1,07 0,1
4 Chili sauce 1,04 0,84 – 1,31 0,69
Bivariate Analysis
Table 5. Result of food sample testing in foodborne outbreak

in District of Sleman, Indonesia, 2012
Food Sample
No Bacteria
“Bacem” Raw Vegetable
1 E. coli Negative Negative
2 S. aureus Positive Negative
3 Salmonella Negative Negative
4 B. cereus Negative Negative

hypotheses
necessary
Control Measures
❖ Can occur at any point during outbreak

❖ Isolation, cohorting, product recall
❖ Balance between preventing further disease
and protecting credibility and reputation of
institution
❖ Should be guided by epidemiologic results in
conjunction with environmental investigation

hypotheses
necessary
Inform Public and Media
❖ Public & press are not aware of most

outbreak investigations
❖ Media attention desirable if public action needed
❖ Response to media attention important to address
public concerns about outbreak
▪ Single overriding communication objective (SOCO)
❖ Results of investigations public information

hypotheses
necessary
Maintain Surveillance
❖ Deciding if outbreak is over
❖ Documenting effectiveness of control measures (e.g.

case mapping)
Conclusions
Epidemiologic investigations are essential

to determine source of outbreaks
Follow the Steps
Be Systematic, but Still Ethic

References
❖ Bres, P. 2000. Public Health Action in Emergencies Caused by
Epidemics: A Practical Guide. Geneva: WHO.
❖ Fauzi, L. 2013. Epidemiological Investigation Report of Food
Poisoning in Sleman, Indonesia. Unpublished.
❖ Gregg, MB. 2002. Field Epidemiology 2nd Edition. New York:
Oxford University Press.
❖ Institute of Environmental Science and Research. 2012.
Guidelines for the Investigation and Control of Disease
Outbreaks. Porirua: Institute of Environmental Science and
Research Limited.
❖ MoH of the Republic of Indonesia Regulation No 1501 of 2010.
❖ Moore, Z. 2013. Outbreak Investigation. Atlanta: CDC.
❖ Teutsch, SM & Churchill RE. 2000. Principles and Practice of
Public Health Surveillance 2nd Edition. New York: Oxford
University Press.
❖ U.S. Department of Health and Human Service, CDC. 2012.
Principles of Epidemiology in Public Health Practice 3rd Edition.
Atlanta: CDC.
LUKMAN FAUZI
lukman.ikm@mail.unnes.ac.id
@lukman_uzi
LOGO
www.themegallery.com

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Outbreak Investigations:

The 11-Steps Approach

PUBLIC HEALTH DEPARTMENT

❖ List the reasons why outbreak

❖ Identify the source (and eliminate it)

The occurrence in a community or region of cases

[Heymann DL, CDC Manual – 19th Ed]

1. Prepare field investigation

1. Prepare field investigation

❖ Done as soon as possible, within the first 24 hours after

1. To early warning system.

Min Max Observed

Min Max Observed

1. Prepare field investigation

Classified as an outbreak, if there is one of following

Classified as an outbreak, if there is one of following

❖ The number of reported cases exceeds the

1. Prepare field investigation

❖ Obtain medical records and lab reports

❖ Conduct clinical testing if needed

❖ Definite : Any symptoms, and positive lab (GS)

1. Prepare field investigation

❖ Person → type of illness

❖ Place → location of suspected exposure

❖ Time → based on incubation period (if known)

“People who have symptoms vomit or nausea or

▪ start, end, duration

Common point source Common persistent

1. Determine / estimate the source or mode of transmission of

Time interval decision:

▪ Epidemic curve with common source (one source)

• Epidemic curve with propagated type (many sources).

ONSET TIME OF DISEASE

• A type of mixed epidemic curve between common source and

• Epidemic curves is used to determine the most likely exposure period,

Figure 2. Epidemic Curve in foodborne outbreak in District of Sleman, Indonesia, 2012

1. Prepare field investigation

Table 1. Distribution of clinical signs and symptoms in foodborne

No Clinical Signs and Symptoms Cases Percentage (%)

1 Diarrhea 101 75,94

Table 2. Attack Rate (AR) value by sex in foodborne outbreak

No Sex Population at Risk Illness Subject AR (%)

1 Male 119 62 52,10

1. Prepare field investigation

Know the source and how:

• Proving the presence of an agent at the source of infection in the

B. IDENTIFICATION OF THE CAUSE CONDITION OF THE OUTBREAK

In general, the condition that causes an outbreak is a change in the

1. Prepare field investigation

❖ Designed to assess exposure equally among ill

❖Include EVERYONE who could have exposed

❖ A retrospective cohort study is the study of

❖ After collecting similar information from each

❖ Commonly, the investigator compares the attack rate

❖ Compare exposures among ill persons (case-

❖ In a case-control study, the investigator asks

❖ When designing a case-control study, one of the

❖ If exposure is much more common among the case-

❖ In practice, however, persons in a random sample

❖ When designing a case-control study, you must

❖ Often, the number of case-patients that can be

No Food Types RR 95% CI p-Value