Epidemic Investigation

Ma. Eufemia M. Collao, MD

Learning Objectives
At the end of the lecture the student should be able to: • Cite reasons why health agencies investigate reported outbreaks • Describe the different steps in investigating outbreaks; • Determine whether an epidemic exists or not; • Differentiate common source and propagated epidemics • Interpret an epidemic curve

Definition of outbreak
• Occurrence of more cases of disease than expected in a given area among a specific group of people over a particular period of time or • Two or more linked cases of the same illness

Objectives of Outbreak Investigations
• To determine the cause of the outbreak • To control ongoing outbreaks • To prevent future outbreaks • To provide statutorily mandated services • To strengthen surveillance at local level • To advance knowledge about a disease • To provide training opportunities

Specific Demands when Investigating Outbreaks
• Unexpected event • Need to act quickly • Need for rapid control • Work carried out in the field

Systematic approach

Steps of an Outbreak Investigation
• Confirm outbreak and diagnosis  Case definition and identification  Descriptive data collection and analysis  Develop hypothesis  Analytical studies to test hypotheses • Special studies • Implementation of control measures  Communication, including outbreak report

Detection

?

Detection

Routine surveillance Clinical / Laboratory General public Media

Detection

Routine surveillance Clinical / Laboratory General public Media

Is this an outbreak?

Detection

Routine surveillance Clinical / Laboratory General public Media

Is this an outbreak?
Diagnosis verified ? clinical + laboratory Link between cases? Expected numbers?

Sequence of Events 1
Outbreak Detection and Confirmation
Primary 1st case Case at HC Report Samples Lab to DMO taken result Response begins

90 80 70 60 50 40 30 20 10 0
10 13 16 19 22 25 28 31 1 4 7
DAY

CASES

Opportunity for control

34

37

40

Sequence of Events 2
Outbreak Detection and Confirmation
Response PRIM HC REP SAMP RES begins

90 80 70 60 50 40 30 20 10 0
1 4 7 16 19 25 28 31 10 13 22
DAY

CASES

Potential Cases Prevented

34

40

37

Outbreak confirmed
Immediate control measures? Further investigation?

Outbreak confirmed
Immediate control measures? Further investigation?

Prophylaxis Exclusion / isolation Public warning Hygienic measures

Unknown etiology (pathogen/source/transmission) Cases serious Cases still occurring Public pressure Training opportunity Scientific interest

Outbreak confirmed
Immediate control measures? Further investigation?

Prophylaxis Exclusion / isolation Public warning Hygienic measures

Unknown etiology (pathogen/source/transmission) Cases serious Cases still occurring Public pressure Training opportunity Scientific interest

Assistance ?

?

Outbreak Investigation Team?

Epidemiologist Microbiologist Environmental specialist Ministry / Government Press officer Others

Outbreak Investigation Team?

FIELD

Epidemiologist Microbiologist Environmental specialist Ministry / Government Press officer Others

Outbreak Investigation Team?

Assess situation Examine available information Preliminary hypothesis ? Case definition Case finding

Epidemiologist Microbiologist Environmental specialist Ministry / Government Press officer Others

Outbreak Investigation Team?

Assess situation Examine available information Preliminary hypothesis ? Case definition Case finding Descriptive epidemiology

Case Definition
• Standard set of criteria for deciding if a person should be classified as suffering from the disease under investigation. • Clinical criteria, restrictions of time, place, person • Simple, practical, objective • Sensitivity versus specificity

Example of Case Definition
Patient older than 5 years with severe dehydration or dying of acute watery diarrhea in town “X” between 1 June and 20 July 2006

Examples of Case Definition
• Possible – Patient with severe diarrhea • Probable – Patient older than 5 years with severe dehydration or dying of acute watery diarrhea in town “x” between 1 June and 20 July 2006 • Confirmed – Isolation of Vibrio cholerae from stool of patient

Identify & count cases

Clearly identifiable groups Hospitals Laboratories Schools Workplace, etc

Obtain information

Perform descriptive epidemiology

Identify & count cases
Identifying information Demographic information Clinical details Risk factors

Obtain information

Perform descriptive epidemiology

Identify & count cases

Obtain information
Orient cases by - time - place - person

Perform descriptive epidemiology

Cases
Person
1200 1000 800 600 400 200 0 0-4 '5-14 '1544 '4564 '64+

Time Place
25 20 15 10 5 0 1 2 3 4 5 6 7 8 9 10

Age Group

Evaluate information

Pathogen?

Source?

Transmission?

Cases of viral meningitis by date of admission (n=416) Cyprus, 5 July - 5 November 5 1996
25

20

Cases

15

10

5

0
5 11 17 23 29 4 10 16 22 28 3 9 July August September 15 21 27 3 October 9 15 21 27 November 2

Date of admission

Distribution of Food Poisoning Cases by Onset of Illness at the Philippine Supreme Court on August 20, 2004 (n=41)

20

15

Sandwiches distributed

“Binalot” lunches distributed

10

5

Supreme Court Employees Association General Assembly

0 12nn 6am 7am 1pm 2pm 4pm 5pm 6pm 8am 9am 3pm 10am 11am 8pm 7pm

Examples of epidemic curves

25 20 15 10 5 0

Point source

1

3

5

7

9 11 13 15 17 19

Continuing common source
20 15 10 5 0
1 4 7 10 13 16 19

Multiple waves -person to person or further outbreak
20 15 10 5 0
1 3 5 7 9 11 13 15 17 19

Admissions per 100,000 population for viral meningitis by age group. Cyprus, 5 July - 5 November 1996
500 450 Admissions/100,000 pop 400 350 300 250 200 150 100 50 0

0-4

5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+
Age Group

Spot Map of Cholera in London, 1854

Develop hypotheses
• Who is at risk of becoming ill? • What is the disease causing the outbreak? • What is the source and the vehicle? • What is the mode of transmission?

Compare hypotheses with facts

Test specific hypotheses
Analytical epidemiological studies

Cohort

Case-control

Prospective

Retrospective

Logistic Regression Analysis of Potential Risk Factors for Food Poisoning at the Philippine Supreme Court on August 20, 2004
Exposure Tuna Sandwich Ham Sandwich Chicken Sandwich Egg Tomato Banana Zesto (snack) Zesto (lunch) Odds Ratio 4.814 4.748 1.368 11.046 .706 1.727 .523 1.349 p value .121 .100 .741 .001 .566 .434 .496 .641 95% CI .662 – 35.028 .741 – 30.402 .214 – 8.749 2.522 – 48.377 .215 – 2.317 .440 – 6.773 .081 – 3.384 .384 – 4.747

Implement control measures
May occur at any time during the outbreak!!

Control the source of the pathogen Interrupt transmission Modify host response

Prevent recurrence

Control the Source of Pathogen
• Remove source of contamination • Remove persons from exposure • Inactivate / neutralize the pathogen • Isolate and/or treat infected persons

Interrupt Transmission

• Interrupt environmental sources • Control vector transmission • Improve personal hygiene

Modify Host Response
• Immunize susceptibles • Use prophylactic chemotherapy

Source / Transmission
known unknown

known

Investigation + Control +++

Etiology
Source: Goodman 1990

unknow n

Source / Transmission
known unknown

known

Investigation + Control +++

Investigation +++ Control +

Etiology
Source: Goodman 1990

unknow n

Source / Transmission
known unknown

known

Investigation + Control +++

Investigation +++ Control +

Etiology
unknow n

Investigation +++ Control +++

Source: Goodman 1990

Source / Transmission
known unknown

known

Investigation + Control +++

Investigation +++ Control +

Etiology
unknow n

Investigation +++ Control +++

Investigation +++ Control +

Source: Goodman 1990

At the End
• Prepare written report • Communicate public health messages • Influence public health policy • Evaluate performance

Cessation of an outbreak occurs when there is: - elimination of source of contamination - interruption of transmission - reduction/exhaustion of susceptibles - modification of the effect of primary pathogen

An investigator should have knowledge on the following:

• various types of etiologic agents and the resultant disease • epidemiological characteristics of outbreaks associated with different etiologic agents of resultant diseases • clinical symptoms of resultant diseases • environmental and food sanitation practices

An investigator should have knowledge on the following:

• sources of exposure which are vulnerable to contamination with an infectious or chemical agent • laboratory test available to determine causative agents • read/search for additional data on studies, prevention and control

• Acknowledgement: – Dr. Jose Ramoncito P. Navarro Epidemiologist, CPH, UP-Manila

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