Investigation of Outbreaks

Leonardo DG. Macam Jr., RMT, MPH

 Learning Objectives
At the end of the lecture, the students should be
able to:
1.Explain reasons why health agencies need to
investigate outbreaks
2. Explain the different steps in the investigation
of epidemic
3. Describe how to determine whether an
epidemic really exists
 Learning Objectives
At the end of the lecture, the students should be
able to:
4. Differentiate common source and its types
from propagated epidemics
5. Construct and interpret an epidemic curve
6. Enumerate the contents of an outbreak
investigation report
 Levels of Disease
1. Baseline (or endemic) – the amount of disease
that is usually present in the community; the
observed but not necessarily the desired level;
regarded as the expected level of the disease
2. Sporadic – a disease that occurs infrequently
and irregularly
3. Endemic – the constant presence and/or usual
prevalence of disease or infectious agent in a
population within geographic area.
 Levels of Disease
4. Hyperendemic – the persistently high levels
of disease occurrence
5. Epidemic – an increase, often sudden, in the
number of cases of a disease above what is
normally expected in that population in that area
6. Outbreak – similar to an epidemic but is often
used for more limited geographic area.
 Levels of Disease
4. Cluster – an aggregation of cases grouped in
place and time that are suspected to be greater
than the number expected, even though the
expected number may be unknown
5. Pandemic – an epidemic that has spread over
several countries or continents, usually affecting
a large number of people
 Epidemic
 the occurrence of disease cases or deaths
clearly in excess of normal expectancy
 the occurrence of disease cases or deaths
limited to a specified group of individuals
during a short period of time clearly in excess
of normal expectancy
 the individual may be group that has gathered
together in space and time
 How/Why epidemics occur
Epidemics occur when
 agent and susceptible hosts are present in
adequate numbers
 and the agent can be effectively conveyed
from a source to the susceptible hosts
 Factors which may trigger an
epidemic
• A recent increase in the virulence of the agent;
• The introduction of the agent into a setting where it
has not been there before
• An enhanced mode of transmission so that more
susceptible persons are exposed
• A change in the susceptibility of the host response to
the agent, and/or;
• Factors that increase host exposure or
• Involved introduction of agent through new portals of
entry.
 Basics of Outbreaks

• Goals of an outbreak investigation

• To identify the source of illness
• To guide public health interventions

• Ways to recognize an outbreak

• Routine surveillance activities
• Reports from clinicians and laboratories
• Reports from affected individuals
 Why investigate an outbreak?
• Characterize a public health problem
• Identify preventable risk factors
• Provide new research insights into the disease
• Train health department staff in methods of public health investigations and emergency response
• To address public, political or legal concerns
 Reasons for investigating
outbreaks
• Prevention and Control
• Gain additional knowledge/research
• Training
• Public, political, or legal concerns
• Program considerations
 Prevention and Control
• Primary public health reason for
investigation
• Principal considerations
What is the stage of the epidemic?
Are cases occuring in increasing numbers?
Is the outbreak just about over?
 Prevention and Control
If cases are continuing to occur:
 Goal is most probably to prevent the occurrence
of additional cases
 The objective of the investigation would be to
assess the extent of the outbreak, the size, and
characteristics of the population at risk
 These information are important in designing and
implementing the appropriate control measures
 Prevention and Control
If an outbreak appears to be almost over
 Goal may be to prevent similar outbreaks in
the future
 The objective of the investigation is to
identify factors which contributed to the
outbreak in order to design and implement
measures that would prevent similar
outbreaks in the future.
 Prevention and Control
How much is known about the causative agent, the source
and the mode of transmission of the agent

Causative Source/Mode of Transmission

Agent
Known Unknown

Known Investigation + Investigation +++

Control +++ Control +

Unknown Investigation +++ Investigation +++

Control +++ Control +
 Prevention and Control
o The decision regarding whether and how extensively to investigate an
outbreak are influenced by the characteristics of the problem itself

 the severity of the illness

 the source or mode of transmission
 the availability of prevention and control
measures
 Gain additional
knowledge/research
o Each outbreak is an opportunity to study the natural history of the disease
o For a newly-recognized disease, field investigation provides an opportunity to define the natural
history – agent, mode of transmission, and incubation period and the clinical spectrum of the disease.
 Gain additional
knowledge/research
o Are able to characterize the populations at
greatest risk; identify specific risk factors
 Legionnaires disease in
Philadelphia in 1976  Toxic shock
syndrome in 1980
 Gain additional
knowledge/research
o Are able to characterize the populations at
greatest risk; identify specific risk factors
 Acquired  Eosinophilia-myalgia
immunodeficiency syndrome (EMS) in
syndrome in early 1980’s 1989
 Gain additional
knowledge/research
o Even for diseases that are well characterized, an outbreak may provide opportunities to gain additional knowledge by
assessing the impact of control measures
o An outbreak of measles in a community with a fairly good immunization coverage provides a setting/opportunity to
study the effectiveness, the effect of age at vaccination, and the duration of vaccine-induced protection
 Training
o Investigating an outbreak requires a combination of diplomacy, logical thinking, problem solving ability,
quantitative skills, epidemiologic know-how and judgement
o These skills improve the practice and experience
o The investigating team can be composed of a seasoned epidemiologist with trainee(s).
 Public, political, or legal
concerns
o These concerns sometimes override scientific concerns in the decision to conduct investigation
o Increasingly, the public has taken an interest in ‘disease clusters’ and potential environmental
exposures, and has called upon the health department to investigate
 Program considerations
o An outbreak of a disease (which is targeted by a public health program) may reveal a weakness in that
program and provide an opportunity to modify/strengthen the program efforts
o Investigating the causes of an outbreak may identify populations which may been overlooked, failures in
the investigation strategy, changes in the agent, or events beyond the scope of the program
 Steps on an outbreak
investigation
1. Verify the diagnosis and confirm the outbreak
2. Define a case and conduct case finding
3. Tabulate and orient date: time, place, person
4. Do immediate control measures
5. Formulate and test hypothesis
6. Plan and execute additional studies
7. Implement and evaluate control measures
8. Communicate findings

These steps may occur simultaneously or be repeated as new information

is received
 Step 0. Prepare for Field Work
 Preparation can be grouped into:
 Investigation – appropriate scientific knowledge, supplies and equipment,
consult regarding epidemic, laboratory specimen collection, storage and transport
 Administration – travel arrangements and travel orders
 Consultation – specific roles and responsibilities
 Knowledge Necessary to Prepare
for Outbreak Investigations
 Various types of etiologic agents and the resultant disease
 Epidemiologic characteristics of outbreaks associated with different
etiologic agents or resultant diseases
 Clinical symptoms of resultant diseases
 Environmental and food sanitation practices
 Sources of exposure which are vulnerable to contamination with an
infectious or chemical agent
 Laboratory test available to determine the causative agents
Common Circumstances of an
Epidemic
Pathogen factors
Introduction of a new pathogen
Change in old pathogen
Increased dosage
Increased virulence
Longer exposure to pathogen
Multiple pathogens
Transmission of factors in environment
New growth media, either man or in nature
New methods of dispersion
Specialized facilities (ICU, day care center)
Intensive procedures
New sexual practices
IV drug use
Migration of infected persons, animals, birds
Exposure to new environment
Host factors
Highly susceptible subgroups
Travel to susceptible to endemic area
Culture or behavioral factors
 Step 1. Verify the diagnosis and
confirm the existence of the
outbreak
 Knowledge/Awareness of an existence of an epidemic
through:
 Regular analysis of surveillance data – detect unusual patterns of disease occurrence
 Calls from the health care provider or a citizen who knows of ‘several cases’
 Media reports
 Step 1. Verify the diagnosis and
confirm the existence of the
outbreak
 Initial investigation may turn out to be:
 True outbreaks with a common cause
 Sporadic and unrelated cases of the same disease
 Unrelated cases of similar but unrelated disease (without a common cause)
 Step 1. Verify the diagnosis and
confirm the existence of the
outbreak
 Sources of data to establish ‘expected number cases’
 Health department surveillance data if disease is a notifiable disease
 Hospitals discharge records, mortality statistics, cancer or other registries if disease is non-notifiable
 Apply rates from neighboring areas or conduct an informal survey among local physicians
 Conduct a survey of the community to establish background level of disease.
 Step 1. Verify the diagnosis and
confirm the existence of the
outbreak
 Factors influencing decision regarding investigation of the
outbreak
 Severity of the illness
 The potential for spread
 Political consideration
 Public relations
 Availability of the resources
Step 2. Define a case and do case
finding
 Develop a specific case definition using:
 Symptoms or laboratory results
 Time period
 Location

 Conduct a surveillance using case definition

 Existing surveillance
 Active surveillance (review of medical records)
 Interview case patients
 Case Definitions
A case definition
 Allows a simple, uniform way to identify cases
 ‘Standardizes’ the investigation
 Is unique to outbreak but is based on objective criteria
 Always include : Person, Place and Time

 Person: personal characteristics

 Place: where the exposure is thought to have occurred
 Time: dates during the exposure was thought to have occurred
 Case Definitions
Examples: Salmonellosis outbreak

 Person: Has culture-confirmed Salmonella enteritidis, is a resident of Province X

 Place: Province X
 Time: July 1, 2001-September 1, 2001
Step 3. Tabulate and orient data
 Create a line listing of identified cases
 Person
 Who was infected?
 What do the cases have in common
 Place
 Where were they infected?
 May be useful to draw a map
 Time
 When were they infected?
 Create an epidemic curve
Step 3. Tabulate and orient data
 What is epidemic curve?

 How can it help in an outbreak investigation?

 An epidemic curve (epi curve) is a graphical

depiction of the number of cases of illness by the date
of illness onset
 Epidemic Curve

• An epidemic curve can provide information on the

following characteristics of an outbreak:
 Pattern of spread
 Magnitude
 Outliers
 Time trend
 Exposure and/or disease incubation period
 Epidemic Curve – Pattern of
Spread of Disease
• The overall shape of the epi curve can reveal the type of
outbreak
 Common source
 Point source
 Propagated
 Pattern of Spread of Disease –
Common Source
 People are exposed continuously or intermittently to a
harmful source
 Period of exposure may be brief or long
 Intermittent exposure often results in an epi curve with
irregular peaks that reflect the timing and the extent of
exposure
Common Source Outbreak with
Intermittent Exposure
 Pattern of Spread of Disease –
Common Source
 People are exposed continuously or intermittently to a
harmful source
 Period of exposure may be brief or long
 Intermittent exposure often results in an epi curve with
irregular peaks that reflect the timing and the extent of
exposure
Common Source Outbreak with
Continous Exposure
 Pattern of Spread of Disease –
Point Source
 Typically shows a sharp upward slope and a gradual
downward slope
 Is a common source exposure outbreak in which the
period of exposure is brief, and all cases occur within
one incubation period
Common Source Outbreak with
Point Source
 Pattern of Spread of Disease –
Propagated Source
 Is spread from person to person
 Can last longer than common source outbreaks
 May be multiple waves
 The classic epi curve for a propagated outbreak has
progressively taller peaks, one incubation apart
Common Source Outbreak with
Propagated Source
 Epidemic Curve – Outbreak
Magnitude
• Can provide a sense of the magnitude of an outbreak
• Additional information can be obtained by stratifying the epi curve

 Separating the sample into several subsamples according to

specific criteria (age and gender)
• A special cumulative incidence that measues the proportion of persons in a
population who experience an acute health event during a limited time period
• Number of new cases of a health problem during an outbreak divided by the
size of a population at the beginning of the period who are at risk of the event
 Epidemic Curve – Outbreak
Outliers
• Outliers are cases at the very beginning and end that may
not appear to be related to the rest of the cases
 First check to make certain they are not due to a
coding or data entry error
 Epidemic Curve – Outbreak
Outliers
• If they are not errors, they may represent:
 Baseline of illness
 Outbreak source
 A case exposed earlier than the others
 An unrelated case
 A case exposed later than the others
 A case with a long incubation period
 Epidemic Curve – Outbreak
Time Trend
• Provides information on the time trend of the outbreak
based on the following:
 Date of illness onset for the first case
 Date when the outbreak peaked
 Date of illness onset for the last case
 Epidemic Curve – Incubation
Period
• If the timing of the exposure is known, epi curves can be used to estimate the incubation period of the disease
• The time between the exposure and the peak of the epi curve represents the median incubation period
• In common source outbreaks with known incubation periods, epi curves can help determine the average period of exposure
• Find the average incubation period for the organism and count backwards from the peak case on the epi curve
 Epidemic Curve – Incubation
Period
• This can also be done to find the minimum incubation period
• Find the minimum incubation period for the organism and count backwards
from the earliest case on epi curve
 Step 4. Institute immediate
control measures
 If an obvious source contamination is identified, institute
control measures immediately
Contents of an Outbreak
Investigation Report
 Contents of an Outbreak
Investigation Report
Contents of Final Report
1.Title
2.Author(s) and affiliation
3.Executive Summary
 brief description of the problem
 brief description of the population and study group
 brief discussion of findings
 major recommendations
 Contents of an Outbreak
Investigation Report
Contents of Final Report
4. Introduction
 Statement of the problem
 Includes background information
5. Methods
 Study design
 Description of the population
 Sampling methods
 Contents of an Outbreak
Investigation Report
5. Methods
 Participation (refusals, non-respondents)
 Standard definition of disease
 Description of data collection, instrument (questionnaire, interview,
examination)
 laboratory tests used
 statistical tests
 Contents of an Outbreak
Investigation Report
6. Results
 Case description
 Signs and symptoms
 Time of occurrence of cases

7. Presentation of risks or odds ratios by exposure status

 Characterize the magnitude of the problem
 Identify possible source of contamination
 Contents of an Outbreak
Investigation Report
8. Laboratory findings
9. Source of contamination
10. Discussion

 Probable source of contamination

 Probable mechanism of spread
 Conclusiveness of findings
11. Recommendations
12. Acknowledgements
13. References
14. Appendices
 Contents of an Outbreak
Investigation Report
8. Laboratory findings
 Case description

7. Presentation of risks or odds ratios by exposure status

 Characterize the magnitude of the problem
 Identify possible source of contamination
END OF THE PRESENTATION
 LABORATORY EXERCISE
• What is the nature of gastroenteritis and outbreak
investigation
• What are the pathogens associated with gastroenteritis
or diarrhea (clinical manifestations, MOT, Incubation
period)
• Formulate hypothesis and explain
• Create an epi curve based on the given data
• What is your findings based on place
• What is your findings based on person
 LABORATORY EXERCISE
• ATTACK RATE : biostatistical measure of
frequency of morbidity, or speed of spread
• RELATIVE RISK: ratio of probability of
an event occuring in an exposed group to
the probability of the event occuring in a
comparison, non-exposed group