Steps of an Outbreak

Investigation

Masters in Public Health Faculty of

Health Sciences
Africa University
E M Chadambuka
 While the steps are presented in conceptual
order, in practice several may be done at the
same time or in a different order

 For example instituting control measures is

done as soon as the source and mode of
transmission are known
Uncovering Outbreaks
 Timely analysis of routine data

 Call for alert clinicians

 Call by members of the public

1. Prepare for Field Work

 Acquire knowledge about the suspected

disease and gather the supplies and
equipment you will need
 Make necessary administrative and personal
arrangements for such things as travel, and
 Consult with all parties to determine your role
in the investigation and who your local
contacts will be once you arrive on the scene.
2. Establish the Existence of an Outbreak

 Number of cases exceeds the expected

 Possible reasons for a rise in number of cases:
 changes in local reporting procedures
 changes in the case definition
 increased interest because of local or national
awareness
 improvements in diagnostic procedures
 changes in the size of the population
 resort areas, college towns, and migrant farming areas,
Reasons for Investigating a Suspected
Outbreak

 The severity of the illness

 The potential for spread
 Political considerations
 Public relations
 Availability of resources
3. Verify the Diagnosis

 To ensure that the problem has been properly

diagnosed
 To ascertain that the increase in diagnosed
cases is not the result of a mistake in the
laboratory
 Review clinical findings and laboratory results
for the people who are affected
 Visit several of the cases
Type of Information to be Gathered

 To generate hypotheses about the cause,

source, and spread of disease, ask about the
following:
 History of exposures before becoming ill
 What do they think caused their illness
 Do they know anyone else with the disease
 Do they have anything in common with others
who have the disease
4. Define and Identify Cases

 Establish a case definition that includes the

following four components:
 clinical information about the disease
 characteristics about the people who are affected
 information about the location or place and
 a specification of time during which the outbreak
occurred
4. a) Case Definition

 Should be broad at first

 Classify cases as:
 “Possible” – has few of the typical S & S
 “Probable” – has the typical S & S minus
laboratory confirmation
 “Confirmed” – usually must have laboratory
verification
4. b) Identifying and Count Cases

 Collect the following types of information

about every person affected:
 Identifying information
 Demographic information
 Clinical information (including date of onset,
progress and outcome)
 Risk factor information
 Example of a Line List for an
Outbreak of Hepatitis A
  Diagnostic Lab 
Signs and
   
Symptoms

Date of Date of Physician

Case# Initials N V A F DU J HAIgM Other Age Sex
Report Onset Diagnosis

1 JG 10/12 12/6 Hep A + + + + + + + SGOT  37 M

2 BC 10/12 10/5 Hep A + - + + + + + Alt 62 F

3 HP 10/13 10/4 Hep A + - + + + S* + SGOT 30 F

4 MC 10/15 10/4 Hep A - - + + ? - + Hbs/ Ag- 17 F

5 NG 10/15 10/9 NA - - + - + + NA NA 32 F

6 RD   10/15   10/8 Hep A + + + + + +    +   38 M

SGOT =
7 KR 10/16 10/13 Hep A + - + + + + + 43 M
240

S*=Sclera;, N=Nausea; V=Vomiting; A=Anorexia; F=Fever; DU=Dark urine; J=Jaundice;

HAIgm=Hepatitis AIgM antibody test
5. Conduct Descriptive Epidemiology

 Characterize an outbreak by time, place,

and person
Characterising Outbreak by
‘Time’
 Epidemic curve – a simple visual display of the
outbreak's magnitude and time trend
 Shows where one is in the course of the epidemic
 Enables one to project the outbreak’s future course
 If incubation period is known one may be able to estimate
a probable time period of exposure and can then develop
a questionnaire focusing on that time period
 One may be able to draw inferences about the epidemic
pattern—for example, whether it is an outbreak resulting
from a common source exposure, from person-to-person
spread, or both.
Drawing an Epidemic Curve

 Time of onset of illness for each person date

or hour of onset
 Y axis = number of cases
 X axis = unit of time basing on the incubation
period of the disease (rule of thumb – unit of
time one-fourth to one-third of the
incubation period
 Show pre- and post-epidemic periods
Interpreting an Epidemic Curve

 Consider overall shape, determined by

 the pattern of the epidemic (e.g., whether it has a
common source or person-to-person
transmission),
 the period of time over which susceptible people
are exposed,
 the minimum, average, and maximum incubation
periods for the disease
Common Source Outbreak

 People are exposed, in a group, to a single

agent
 When the exposure is very brief, most people
get sick at one incubation period following
exposure e.g. Staphylococcus aureus food
poisoning
 Single curve that wanes quickly, as long as
there is no person-to-person spread
Continuous Source
 Prolonged common source exposure e.g. a
contaminated water supply
 Cases arise over an extended period but still
originate from a common or single source
 Epidemic curve becomes longer and flatter,
indicating the longer duration of the source and
the variation in incubation periods between people
 Curve ends when the source of the contamination
is corrected or when all susceptible people
develop immunity.
Intermittent Exposure
 Irregular pattern of cases that reflects the timing and
extent of repeated exposures
 Not immediately clear whether this is a common source
at intervals, or arises from varied sources, such as a
series of outbreaks of food poisoning
 The gaps between the outbreaks could initially suggest
person-to-person transmission followed by an incubation
period, but
 Successive peaks do not become larger and merge as
they would if the outbreaks were due to infectious
spread, with one person infecting several
Index Case with Limited Spread
 Person to person spread shows the typical
pattern arising when a single index case (for
example, a traveller returning from a visit) infects
other people after an incubation period
 A point source with secondary transmission
 The outbreak wanes when the infected people
no longer transmit the infection to other
susceptible people, perhaps because of
successful control measures
Propagated Spread
 Begins like an infection from an index case but the
secondary cases of the disease then act as sources to
infect new people who, in turn, serve as sources for yet
other cases.
 Epicurve has successively taller peaks, initially
separated by one incubation period, but the peaks then
tend to merge into waves with increasing numbers of
cases in each generation
 Epidemic continues until the remaining numbers of
susceptible individuals declines or until intervention
measures take effect
 Pattern occurs with diseases that spread from person to
person e.g. measles.
Characterising by Place

 Provides information on the geographic

extent of a problem
 A "spot map" shows the area, where the
affected people live, work, or may have been
exposed
 May show clusters or patterns that reflect
water supplies or proximity to a food outlet
Interpreting Spot Map

 Clustering may indicate either a focal source or

person-to-person spread
 Scattering of cases throughout a facility is more
consistent with a common source such as a
dining hall.
 If the size of the overall population varies
between the areas being compared, a spot map,
can be misleading because it shows numbers of
cases proportion of people affected in each
area
Characterising by Person

 Helps determine what populations are at risk

for the disease
 Populations may be defined by
 Personal characteristics:- age, race, sex, or
marital status or
 Exposures: - occupation, leisure activities, use of
medications, tobacco, alcohol
6. Develop a Hypothesis

 Hypotheses should address the source of the

agent, the mode (vehicle or vector) of
transmission, and the exposures that caused
the disease
 First consider what you know about the
disease - agent, source, vehicle, risk factors
 Visit and talk to patients, local health workers
 Examine the descriptive epidemiology
 Examine outliers
7. Evaluate Hypothesis

 Compare hypotheses with the established facts

to see if clinical, laboratory and epi evidence
support the hypothesis
or
 Conduct analytic epidemiology, which allows you
to test your hypotheses to quantify relationships
(e.g. how strong the illness is linked to a
particular factor) and to explore the role of
chance
8. Carry out Additional Research

 May be:
 Repeat studies
 More rigorous laboratory studies
 Environmental studies
9. Institute Control Measures

 Though listed as Step 9, in a real should be

done as soon as possible
 Can be implemented early if one knows the
source of the outbreak and aim at specific
links in the chain of infection, the agent, the
source, or the reservoir.
 Might be directed at interrupting transmission
or exposure
Communicate Findings

 An oral briefing for local health authorities

and a written report.
 Oral briefing should also be given to people
responsible for implementing control and
prevention measures.
 It is an opportunity for one to describe what
they did, what they found, and what they
recommend