Response LL

Public health emergency response part
II
: PHE_P_CD_D
December 7/2021
E P I D E M I C A L E R T A N D R E S P O N S E
Steps of an Outbreak Investigation
1. Prepare for field work

2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and identify cases
5. Analyze data collected in terms of time, place and person
6. Develop hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and carry out additional studies
9. Implement control and prevention measures
10. Communicate findings
Ethiopian Public Health Institute

6. Develop a Hypothesis
Why and how the outbreak occurred
Interviewed some affected people,
Spoken with other health officials in the community,
 The hypothesis should address
The source of the agent,
The exposures that caused the disease, etc.

6. Develop a Hypothesis…
Consider what you know about the suspected
disease outbreak:
What is the agent’s usual reservoir?
How it is usually transmitted?
What are the known risk factors?

6. Develop a Hypothesis…
Descriptive epidemiology often provides some
hypotheses.
If the epidemic curve points to a narrow period of exposure,
ask what events at time.

If people living in a particular area have the highest attack
rates, ask why

 If some groups with particular age, sex, or other personal
characteristics are at greatest risk, ask why


7. Evaluate Hypotheses
Test the credibility of your hypotheses

There are two approaches:
 Descriptive Epidemiology
evidence of the cause is so strong
hypothesis does not need to be tested
 Analytic epidemiology
cause is less clear
test your hypothesis

7. Evaluate Hypotheses…
There are two types of analytic studies:
Cohort studies
 Compare exposed group with not exposed
group.
case-control studies.
 compare people with a disease with a group
of people without the disease

Which study design?

Cohort studies
Used in a well defined population where participants
can be followed over time

Church supper
Nursing home
Wedding
Can identify the population at risk
Use relative risk

Steps
1. Select cohort population(free of disease)
2. Measure exposure to risk factors(select by
exposure)
 Cases: Exposed group
 Controls: Unexposed group
3. Follow up
4. Measure disease outcome
5. Estimate disease risk associated with exposure

Types of cohort study
1. Classical (Prospective) cohort

The exposure may or may not have occurred at the time when
the study begin, but the outcome has certainly not yet occurred.
2. Historical (Retrospective) Cohort

Both the exposure and outcome have already occurred when
the study is initiated

Cohort
D+
E+ D-
Compare
Outcomes
E- D+
D-
time
Cohort (a/a+b)
RR =
(c/c+d)
D+ D- /Total
E+ a b a+b
E- c d c+d
a+c b+d n
RR< 1: Protective association

RR=1: No association
RR>1: Positive association
Case Control
Used in a poorly defined population where risk
cannot be assessed
Cases spread over time and/or space
Cannot determine the population at risk
Use odds ratio

Steps in conducting a case control study
1. Define the study population (source of cases and
controls)
2. Define and select the cases
 Persons with the disease
3. Define and select the controls
 Persons without the disease
4. Measure Exposure
5. Estimate disease risk associated with exposure

Case Control
E+
E- D+
E+ D-
E-
time
Case Control OR =
ad
bc
D+ D- /Total
E+ a b a+b
E- c d c+d
a+c b+d n
OR< 1: Protective association

OR=1: No association
OR>1: Positive association

Cases Controls Total
Ate at Yes a = 30 b = 36 66
Restaura
nt A? No c = 10 d = 70 80
Total 40 106 146
The OR for Restaurant A is thus 30 × 70 / 36 × 10, or 5.8.

This means that people who ate at Restaurant A were 5.8
times more likely to develop hepatitis A than were people
who did not eat there

8. Refine hypotheses and carry out
additional studies

8. Refine Hypotheses and Carryout Additional Studies
Laboratory evidence can confirm the findings.
Environmental studies often help explain why an
outbreak occurred and may be very important in some

settings
Look for patients home
Look food on shelf
Look for other root of transmission

9. Implement control and prevention
measures

9. Implement Control and Prevention
Implement as early as possible!
An outbreak may be controlled by
 Eliminating or reducing the source of infection,
Interrupting transmission and
Protecting persons at risk.
Create mechanism to evaluate effectiveness of control /
prevention measures

Outbreak can be prevented
Prevention of exposure
Isolation/quarantine
Control of vector
Prevention of infection
Vaccination
Save water
Sanitation
Prevention of death
Case management
Health education

Impact of Interventions
 Early Detection and Response
 Opportunity to control
 Potential outbreak with
intervention
 Late Detection and Response

 Less Opportunity to control
 Potential Outbreak with no
intervention


10. Communicate Findings
 It is final task in an outbreak
 No report means little contribution of
improving scientific and public health

knowledge
 To whom we communicate?
1. Communicate to Decision Makers and Health

Workers
2. Communicate to the Public and Media
10. Communicate Findings
Communicate to Decision Makers and Health
Workers
Communication usually takes two forms:
1. Oral briefing for local health authorities
2. Written report
Your oral briefing should be Attended by:
 Local health authorities
 Local Epidemic prevention and control committee

10. Communicate Findings…
It is an opportunity to describe
what you did,
what you found, and
what you think should be done about it.
You should present your findings in
 Scientifically objective fashion and
you should be able to defend your conclusions and
recommendations

Written Report
Should scientific format:
Introduction,
Methods,
Results,
Discussion,
Conclusion
Recommendations.

Introduction
It gives the reader background information
 Description of the problem
 Description of the investigation site
 Area and the environment

 Population covered by the investigation
 Justification for investigation
 Objectives of the investigation
 What is expected to be done?
 What will be the utility of the results?

Methods
Addresses how data was collected and analyzed
Includes:
 Case definition
 Methods for case finding
 Study design
 Design of instruments for data collection
 Selection Criteria
 Statistical methods
 Laboratory methods

Results
What you find
 Descriptive result
 Analytical result
 Environmental
 Laboratory result
Summarized and presented by
 Tables
 Graphs etc.

Discussion
interpret the result and put them back into context.
Interpretation of the results
Support for the conclusion
 Data from any investigations done
 Previous scientific literature
 Explain data that does not support the conclusion
Limitations

Conclusion
Report conclusions made directly from the data
only.
Anything that was previously known is not
appropriate to discuss in this section.

Recommendations
Recommendations about the condition and its
control
Should be based on your findings
 For the immediate situation
 For similar situations in other locations or in the future

Monitoring and Evaluation
What are the elements to be monitored during

outbreak response?

Exercise
Case Study 1
Scenario 1
Scenario 2
Scenario 3
Case Study 2
Scenario 1
Scenario 2
Scenario 3

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Public health emergency response part

1. Prepare for field work

Ethiopian Public Health Institute

Why and how the outbreak occurred

Interviewed some affected people,

Spoken with other health officials in the community,

 The hypothesis should address

The source of the agent,

The exposures that caused the disease, etc.

Ethiopian Public Health Institute

Consider what you know about the suspected

How it is usually transmitted?

What are the known risk factors?

Ethiopian Public Health Institute

ask what events at time.

rates, ask why

characteristics are at greatest risk, ask why

Ethiopian Public Health Institute

Ethiopian Public Health Institute

Test the credibility of your hypotheses

Ethiopian Public Health Institute

There are two types of analytic studies:

 Compare exposed group with not exposed

 compare people with a disease with a group

of people without the disease

Ethiopian Public Health Institute

can be followed over time

Can identify the population at risk

Use relative risk

Ethiopian Public Health Institute

Ethiopian Public Health Institute

1. Classical (Prospective) cohort

2. Historical (Retrospective) Cohort

the study is initiated

Ethiopian Public Health Institute

RR< 1: Protective association

Used in a poorly defined population where risk

Cannot determine the population at risk

Use odds ratio

Ethiopian Public Health Institute

 Persons with the disease

3. Define and select the controls

 Persons without the disease

5. Estimate disease risk associated with exposure

OR< 1: Protective association

Ethiopian Public Health Institute

Total 40 106 146

The OR for Restaurant A is thus 30 × 70 / 36 × 10, or 5.8.

Ethiopian Public Health Institute

Ethiopian Public Health Institute

Laboratory evidence can confirm the findings.

Environmental studies often help explain why an

outbreak occurred and may be very important in some

Look food on shelf

Look for other root of transmission

Ethiopian Public Health Institute

Ethiopian Public Health Institute

Implement as early as possible!

An outbreak may be controlled by

 Eliminating or reducing the source of infection,

Interrupting transmission and

Protecting persons at risk.

Create mechanism to evaluate effectiveness of control /