Fessahaye Alemseged (MD, MPHE)

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Objectives and Contents
Objectives
Describe the types of epidemics
Describe and apply epidemic investigation and control
measures
Contents
Patterns of disease occurrence
Types of epidemics
Ix and control of epidemics

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Reading

CDC –Principles of Epidemiology

Fletcher
Mausner
IDSR National Guideline
MOHE, Guidelines for the Prevention and Control of
Selected Epidemic Disease in Ethiopia

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Patterns of disease occurrence
Endemic-usual level of morbidity
What disease are endemic in Ethiopia?
Some of the endemic disease of public health importance
in Ethiopia include:
Tb, Malaria, Typhoid, dysentery, HIV, Malnutrition,
Meningitis, leshmaniasis, Trachoma, Scabies,
Schistosomiasis, Onchocerciasis
Patterns of endemicity
E.g. – Malaria – Holoendemic, Hyperendemic, Mesoendemic,
Hypoendemic
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Patterns of disease occurrence
Epidemic- occurrence of health related condition in
excess of its expected frequency in a given population
Related terminologies – outbreak, cluster
What diseases are known to occur in the form of
epidemics in Ethiopia?

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Patterns of disease occurrence
Some of the epidemic disease of public health importance
in Ethiopia include:
Malaria, Measles, Meningitis, Cholera , Shigelloses,
Diarrhea with dehydration, Plague, Typhoid fever,
Relapsing fever, Epidemic typhus
Pandemic-global epidemic
E.g. - HIV/AIDS, obesity

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Epidemics
Epidemic- occurrence of health related condition in
excess of its expected frequency in a given population
 Health related condition-infectious and non-infectious conditions
 Expected frequency-magnitude for the given period, place and
population from previous data
 In excess – more than expected frequency
 Definition depends on type of disease, population affected and
time/season of occurrence
 Compare with past levels

Develop and use thresholds for the most critical diseases

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Patterns of disease occurrence cont.
Epidemics can have the following patterns
Sporadic -irregular intervals
E.g. – Plague
Periodic/Cyclic -regular intervals
E.g. –malaria, measles, diarrhea, meningitis
Secular -slow changes over time
E.g. – lung ca
Epidemic lasting long may remain endemic
Endemic disease can turn out to be epidemic
Due to increase in susceptible, ecological changes, increase
in no of carriers, appearance of new strains

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Types of Epidemics
Common source, Propagated and Mixed
Common source
Occur as a result of exposure to common source for the
agent
Depending on duration of exposure:
 Point source Vs Common source with prolonged (continued or
intermittent) exposure

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Types of epidemics cont.
Point source epidemics
Exposure is brief and simultaneous
Cases develop within one incubation period
E.g. - food-borne outbreak
Epidemic curve-rapid rise and fall of number of cases

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Types of epidemics cont.
Common source epidemic with continuous or intermittent
exposure
Exposure continues over a period of time
Lasts for more than one incubation period
E.g. – Outbreak of hepatitis A from exposure to food
contaminated by infected food handler intermittently or
continuously
Epidemic curve-extended and irregular

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Types of epidemics cont.
Propagated/Progressive epidemics
Occur as a result of transmission from one person to
another
Lasts for more than one incubation period
E.g. – Measles, Malaria, Shigellosis
Epidemic curve-initial slow rise, succession of several
peaks and usually sharp fall

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Types of epidemics cont.
Mixed
Point source epidemic may be followed by propagated
epidemic
E.g. – Shigelloses epidemic from exposure to common
contaminated food supply followed by person-to-person
spread

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Epidemic Ix
Investigation(Ix)
determining the causes and population affected so as
to control the epidemic
Causes:
Agent
Source
Main mode of transmission
Contributing factors

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 Steps of epidemic investigation
1. Investigation of index cases and active case detection
2. Preparation for field work
3. Verify existence of an epidemic
4. Verify the disease
5. Define and identify additional cases
 Develop case definition
 surveillance
6. Describe the epidemic in terms of person , place and time
7. Formulate and test hypothesis
8. Intervention and follow-up
9. Report the investigation and control

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Epidemic Ix
Activities in ix include:
cont.
1. Ix of index case and active case detection
Index case – the first case
Active case detection – to look for additional cases
2. Preparation for field work
Ix related-scientific knowledge, supplies to carry out ix,
questionnaire
Administration related- transportation, personnel
Consultation-team, local contacts

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Epidemic Ix cont.
3. Verify existence of an epidemic
Compare with past levels
Observe thresholds for the most critical diseases
alert threshold-suspected epidemic
 one suspected case (as for an epidemic-prone disease or for a disease
targeted for elimination or eradication) or
 For other priority diseases of public health importance -when there is
an unexplained increase over a period of time in monthly summary
reporting/ any unusual increase in the number of cases when
compared with previous time periods
 Response includes: Reporting, requesting laboratory confirmation,
being more alert to new data, alert the epidemic response team

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Epidemic Ix cont.
An action threshold-confirmed epidemic
A confirmed case -For epidemic-prone diseases, and for
disease targeted for elimination or eradication
For other priority diseases of public health importance –
confirmed epidemic
Response- a definite emergency response

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Epidemic Ix cont.
 Meningococcal meningitis
 alert threshold :
 Population greater than 30 000, 15 cases/100 000 inhabitants/week
 Population less than 30 000, 5 cases in 1 week or an increase in the number
compared to the same time in previous years
 action threshold :
 Population greater than 30 000, 15 cases/100 000 inhabitants/week confirms
epidemic in all situation. If no epidemic during last 3 years and vaccine
coverage against meningococcal meningitis is <80%, action threshold is 10
cases per 100 000 inhabitants per week
 Population less than 30 000: 5 cases in 1 week or doubling of the number of
cases over a 3-week period
 Measles- usually 5 suspected cases/month/Woreda, if 2 are positive
epidemic confirmed
 Malaria

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 List of Priority Diseases in Ethiopia
Epidemic-Prone Diseases
Cholera
Diarrhoea with blood (Shigella)
Measles
Meningitis
Plague
Viral hemorrhagic fevers***
Yellow Fever
Typhoid Fever
Relapsing Fever
Epidemic Typhus
Malaria
Diseases Targeted for Eradication and Elimination
Acute flaccid paralysis (AFP)/polio
Dracunculiasis (Guinea Worm)
Leprosy
Neonatal tetanus
Other Diseases of Public Health Importance
Pneumonia in children less than 5 years of age
Diarrhea in children less than 5 years of age
New AIDS cases
Onchocerciasis
Sexually transmitted infections (STIs)
Tuberculosis

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Epidemic Ix cont.
4. Verify the disease
Clinical and laboratory evidence
5. Define and identify additional cases
5.1. Develop case definition
Criteria for classifying suspects - general and
specific descriptions
Based on lab results criteria: suspected/possible,
probable and confirmed

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Epidemic Ix cont.
 Suspected/possible case: is a case with fewer major or
atypical symptoms but that responds to treatment
 Probable case: is a case with major/typical signs and
symptoms of a disease and/or suggestive but not
confirmative laboratory findings
 Confirmed/definite case: is a suspected or probable case
which has been confirmed by laboratory test

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Epidemic Ix cont.
5.2. Surveillance
Identifying and counting cases to determine the geographic
extent and population affected
Enhanced passive surveillance and active surveillance
Identification, demographic, clinical and risk factor
information

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Epidemic Ix cont.
6. Describe the epidemic by time, place and person
Epidemic curve
Provides time frame for identifying type of epidemic,
aetiologic dx and determining IP
Spot map
Shows geographic spread of the disease
Person
Gives profile of those affected

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Epidemic Ix cont.
7. Formulate and test hypothesis
Determine
the possible source
mode of transmission
type of epidemic and
population at risk
Retrospective cohort Study-RR
Case-Control Study-OR

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Epidemic Ix cont.
Retrospective cohort study design exercise:
Of 75 persons who attended a wedding supper, 46 became ill within
several hours (AR = 46 / 75): AR = 61.3%
Test the hypothesis that contaminated Kitfo was the source of the GI
infection.

Exposure status N Became ill

Did not eat Kitfo 18 3

Ate Kitfo 54 43

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Epidemic Ix cont.
Case-control study design exercise:
Several college students presented with GI-related symptoms thought
to have been associated with food served in the cafeteria
Test the hypothesis that contaminated macaroni was source of the GI
infection.

Exposure status Cases Controls

Ate salad 12 4

Did not eat salad 6 14

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Epidemic Ix cont.
8. Intervention and follow-up
Intervention
Early
Aim at weak chains
Read: Prevention and control measures for epidemic disease
in Ethiopia
Follow-up
Evaluation of control measures
Continued surveillance
Sharing experience

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Epidemic Ix cont.
9. Report the Ix and control
Write report of the Ix and control
Disseminate to concerned bodies
Public
Health organization managers
Publication

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Group discussion
Discuss epidemic investigation and control measures for
suspected relapsing fever epidemic in Woreda X.

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Group assignments
1. Suppose you are working as Kersa Woreda Health Office
manager and you received a report from Serbo Health
Center Head about emergence of a suspected malaria
epidemic in Serbo town.
 Q1. How do you proceed with investigation and control of
the epidemic (if you confirmed presence of an epidemic)?
 Q2. What preparedness activities would you undertake to
prevent and control further malaria epidemics in the town?

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Group assignments
2. On 4th September 1999, the Woreda Health Manger
(WHM) of Shola woreda received a report of an epidemic
of unknown disease that had affected villages 1 and 2 in
the woreda. He was informed that the sick were presenting
with sudden onset of vomiting, weakness and acute
watery diarrhoea. Two people had already died from the
disease. On further investigation it was noted that the
index cases were seen two days ago.

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 Q1. What would be the case definition?
Q2. what actions should be taken by the WHM?
Q3. How does the WHM verify the existence of an
epidemic of cholera?
The Woreda epidemic management committee did a
thorough investigation and collected the data that is
summarised in Table 1.

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 Table 1: Case and deaths of cholera in Shola, from 1st to 14th September 1999.

Date Cases Deaths

1st 2 1
2nd 2 1
3rd 8 0
4th 4 0
5th 5 0
6th 3 0
7th 0 0
8th 1 0
9th 4 0
10th 2 0
11th 5 0
12th 5 0
13th 5 0
14th 2 0
Total 48 2

Q4. Draw a graph to show epidemic of cholera in Shola using the data
provided in Table 1.
Q5. Describe the graph since the onset of the first case? How do you explain

the multiple peaks seen in the graph?

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 The Woreda epidemic management team also summarized the cases of cholera by locality and sex as seen in Table 2.
Table2: Distribution of cases by villages and sex , in Shola woreda.

Cases of cholera
*Attack rate per
Village Population at risk Total cases
100000
Male Female

1 30,000 12 7 19

2 20,000 12 3 15

3 40,000 4 9 13

4 10,000 0 1 1

Total 100,000 28 20 48

* Attack rates = total number of cases/ Total population at risk of the disease* 100,000.

Q6. Did the disease equally affect males and females (assume the male to female ratio
is 1:1)?
Q7. Calculate the Attack rate (incidence rate) for each village, in Shola woreda and
insert your answer in the blank column in Table 2.

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 Table 3: Distribution of cases by age

Attack rate per

Population at risk Number of cases 100000
Age group
population
0-4 20,000 10
5-9 15,000 17
10-14 15,000 11
15-19 10,000 6
20-above 40,000 4

Q8. Refer to Table 3; what age groups were most affected by cholera?
Q9. Based on your answers to previous questions what hypothesis could you make
regarding the place and the group at risk of getting the disease in Shola?
Q10. What additional data would you like to get in order to make decisions on the
cause of the epidemic?
Q11. Outline the appropriate control measures for this epidemic.

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