Session 4;

Units that should be covered:

Public health surveillance
Screening
Outbreak investigation

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 Chapter 5:
Public health surveillance

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 Presentation contents

Definition,
purpose and Types of Surveillance
Activities in Surveillance

IDSR and public health important diseases

that are under surveillance in Ethiopia

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 Learning objectives

At the end of this module students should be able to:

• Describe the concepts and objectives of public health
surveillance
• Describe the approaches and critical elements of
public health surveillance
• Describe the flow of information, function and
responsibilities at thePrepared
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by Terefe M. levels of surveillance
 Definition

• Surveillance is the continuous (ongoing) scrutiny of

the factors that determine the occurrence and
distribution of diseases and other health related
events through a systematic collection of data(WHO)
• Surveillance data provides information for action.
• Surveillance systems are often considered information
loops or cycles
• involving health care providers, public health
agencies, and the public,

04/01/2023 Prepared by Terefe M.

 Uses/purpose of surveillance system
Determine  To identify changes in
magnitude of agents and host
problems factors
Priority setting and  To detect change in
planning health care practice
Monitoring health Monitoring and
events: evaluation of health
 Detect sudden programs
changes in disease Facilitates
occurrence epidemiological and
 To follow secular laboratory researches
trends of diseases
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 Criteria for identifying disease for surveillance

Cost  Frequency
Preventability  Morbidity
Communicabili rates
ty – Incidence
Public Interest – Prevalence
Frequency  Mortality
Severity rates
– Case fatality ratio
– Hospitalization
rate

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 Types of surveillance

There are three major types of surveillance:

• Passive Surveillance
• Active Surveillance
• Sentinel Surveillance

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 Passive surveillance

• Passive surveillance may be defined as a mechanism for

routine survey based on passive case detection and on
the routine recording and reporting system.

• The information provider comes to the health

institutions for help, be it medical or other.

• It involves collection of data as part of routine provision

of health services.

04/01/2023 Prepared by Terefe M.

 Advantages and disadvantages

Advantages Most of the time, data from

covers a wide range of problems
does not require special
arrangement
is relatively cheap
covers a wider area
Disadvantages
The information generated is to a
large extent unreliable,
incomplete and inaccurate
passive surveillance is not
available on time
you may not get the kind of
information you desire
It lacks representativeness as it is
mainly from health institutions
There is no feed back system
The Denominator is unknown

04/01/2023 Prepared by Terefe M.

 Active surveillance

A method of data collection usually on a specific

disease, for relatively limited period of time.
It involves collection of data through:
– House-to-house surveys or
– Mobilizing communities to some central point where data can
be collected.
– Example: Investigation of out-breaks

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 Advantages and Disadvantages
The advantages of active surveillance
include:
 the collected data is complete and
accurate
 Information collected is timely.
 The required information is gathered
Disadvantages
• it requires good organization,
• it is expensive
• requires skilled human power
• it is for short period of time
• it is directed towards specific disease
conditions

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 Active surveillance…

Conditions in which active surveillance is appropriate

• For periodic evaluation of an ongoing program
• For programs with limited time of operation such as
eradication program.
• In unusual situations such as
– New disease discovery
– New mode of transmission
– When a high-risk season/year is recognized.
– When a disease is found to affect a new subgroup of the
population.
– When a previously eradicated disease reappears.

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 Sentinel Surveillance

Sentinel surveillance uses a pre-arranged sample of

reporting sources to report all cases of one or more
conditions. This is carried out by:
• Selecting sample sources most likely to see cases of
the specified condition.
• Identifying institutions that serve the population
subgroups and that can obtain data regarding the
condition of interest.
• Sentinel surveillance provides a practical alternative to
population-based surveillance, in developing
countries.
Eg. ANC based HIV testing sentinel surveillance

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 Advantages and Disadvantages

Advantages
 relatively inexpensive
 provides a practical alternative to population-based
surveillance
 can make productive use of data collected for other
purposes
Disadvantages
• the selected population may not be representative of the
whole population
• use of secondary data may lead to data of lesser quality
and timeliness
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 Activities of Surveillance

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 Data Collection and recording

Basic techniques of data collection include the

following:
• Record review
• Interviews
• Surveys using questionnaires
• Observation.

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 Sources of data for surveillance

The major sources summarized by the WHO in 1968 are as

follows:
• Mortality registration
• Morbidity registration
• Epidemic reporting
• Reports of laboratory utilization (Including lab test results)
• Reports of individual case investigations
• Reports of epidemic field investigations
• Special surveys
• Information on animal reservoir and vector distribution
• Report of biologics and drug utilization
• Knowledge of the population and environment
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 Data compilation, analysis and
interpretation

• The data should be collected at each level of the

health care delivery system. Each level makes sure
that the quality of information collected should be
accurate, complete, reliable, and submitted on time.
• As with all descriptive epidemiological data,
surveillance data is first analyzed in terms of time,
place and person using simple tabular and graphic
techniques to analyze and display these data.
• Analysis of data must be made at every level of the
health delivery system.
• Analysis at the health facility level helps to
recognize problems timely and to take appropriate
action immediately. Prepared by Terefe M.
04/01/2023
 Data analysis …

Proper analysis of surveillance data includes

determination of both numbers and rates.
The interpretation: Is the change a true change?
Apparent changes can occur as a result of:
• change in the population size,
• improvement in the diagnostic capability,
• improved reporting,
• duplicate reporting
• improved health service coverage, etc.
04/01/2023 Prepared by Terefe M.
 Reporting and notification

Reporting formats must be clear and easy to use.

Any report must be clear and answer questions like what,
where, when, to whom, for what and why.
Types of reports
• Oral: - passing information verbally and the sender must
check that the message is correctly understood by the
receiver.
• Radio or telephone-for special cases like emergency
situations.
• Written - in normal circumstances.
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 Dissemination of information

To ensure motivation and active involvement

there must be:
• Preparation of regular weekly, monthly,
quarterly and annual reports
• Regular feedback from higher levels
• Publication of newsletters

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 Features of a good surveillance system

• Using a combination of both active and passive surveillance

techniques
• Timely notification

• Timely and comprehensive action taken in response to notification

• Availability of a strong laboratory service for accurate diagnoses of

cases

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 Integrated Disease surveillance and
response (IDSR)

• An approach adapted to strengthen

national disease surveillance systems by
coordinating and streamlining(reforming)
all surveillance activities and ensuring
timely provision of surveillance data to all
disease prevention and control
programme.
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 IDSR….cont

a/Disease specific b/ IDSR

surveillance

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 IDSR…cont

• Integrated disease surveillance system:

 Focus on woreda level
 Coordinate and streamline all surveillance activities
combining available resource from a single focal point
at woreda level
 Facilitates collaboration b/n surveillance focal points at
different levels

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 Objective of IDSR

• The overall objective of the IDSR is to improve the

ability of health workers
to detect and respond to priority communicable
diseases at the woreda level.

To provide timely evidence on which to base

decisions and public health interventions for
effective control of communicable diseases.
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 WHO

Information flow in IDRS: Supervision and feedback

Federal MOH
 Central
Referral
Hospitals

Regional Health
Bureau
· Regional
Data collection, analysis, hospitals
Action and reporting · Regional
laboratories
Zonal Health
Department
· District Hosp
· PHC
facilities
Woreda Health
Office
· District
hospital
· PHC
facilities
The
commu
nity
04/01/2023 Prepared by Terefe M.
 Which diseases are to be included?

• About 21 diseases are included because of either:

o Top cause of morbidity and mortality (malaria,
TB,HIV, DD)
o Have epidemic potential (cholera, yf)
o Surveillance required internationally (plague, Yf,
Cholera)
o Availability of effective control

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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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 Chapter 6:
Screening in disease control

04/01/2023 Prepared by Terefe M. 32

04/01/2023 By Terefe M.
 Presentation outline

• Definition, Purpose or aim of screening

• Disease appropriate for screening program
• Criteria for establishing screening program
• Validity and Reliability of tests
• Sensitivity and specificity, Predictive value
of a test

04/01/2023 By Terefe M.
 Objectives

At the end of this session students able to;

• Define screening
• Explain Purpose or aim of screening
• Describe disease appropriate for screening program
• List criteria for establishing screening program
• Describe the concepts of Validity and Reliability of
tests
• Describe the concepts of Sensitivity and specificity,
Predictive value of a test
04/01/2023 By Terefe M.
 Screening

• It is search for unrecognized disease or defect by

means of rapidly applied tests, examinations or other
procedures in apparently healthy individuals.
• is a public health intervention intended to improve
the health of a precisely defined target population.
• is not intended to be diagnostic.
• is an initial examination only, and positive responders
require a second, diagnostic examination

04/01/2023 By Terefe M.
 Aim of Screening

• To reverse, halt, or slow the progression of disease in

individuals. e.g. cancer
• To alter the natural course of disease for a better
outcome for individuals affected.
• Protect society from contagious disease
• Rational allocation of resources
• Research; study on natural history of disease…
• Selection of healthy individuals(employment,
military…)
04/01/2023 By Terefe M.
 Criteria for instituting a screening programme

1.Appropriate Disease ‐Serious

‐High prevalence of preclinical stage
‐Natural history understood
‐Long period between first signs and
overt disease

2. Screening test ‐sensitive and specific

‐Simple and cheap
‐safe and acceptable
‐Reliable

3. Diagnostic and treatment ‐Facilities are adequate

‐Effective, acceptable, and safe
treatment available

04/01/2023 By Terefe M.
 Types of screening

a) Mass screening – involves screening of a whole

population
b) Multiple or multiphasic screening – involves a
variety of screening tests on the same occasion.
c) Targeted screening of groups with specific
exposures – is often used in environmental and
occupational health
d) Case‐finding or opportunistic screening – is
restricted to patients who consult a health practitioner
for some other purpose By Terefe M.
04/01/2023
 Screening Tests

• A screening test should ideally be inexpensive, easy to

administer, and impose minimal discomfort on the patients.
• results of the screening test must be valid and reliable.
• Validity of a test is the ability to differentiate accurately between
those who have the disease and those who do not.
• Sensitivity and Specificity are two measures of the validity of a
screening test.
• Reliability refers to the consistency of results when repeat
examinations are performed on the same persons under the same
condition.
04/01/2023 By Terefe M.
 Results of Screening Testing
• The assessment of what is "true" or "false" depend on the selection of a
"gold standard“
• The following table summarizes the four possible relationships between
a screening test and the actual presence of disease
• Values are defined as follows:
a = true-positive results, b = false-positive results,
c = false-negative results, and d = true-negative results.
• Sensitivity is defined as a/(a + c), while specificity is defined as d/(b + d).
• The positive predictive value is defined as a/(a + b), and the negative
predictive value is defined as d/(c + d).

04/01/2023 By Terefe M.
 Results of Screening Testing…
Test Result Result for a Gold Total
Standard
Disease Disease
Present Absent
Positive A (true B(false A+B
positive) positive)
Negative C (false D(true C+D
negative) negative)

Total A+C B+D A+B+C+

D

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 Sensitivity
• the ability of the test to identify correctly those who
have the disease
• Is the probability of a positive test in people with the
disease
=a/a+c
Specificity
– the ability of the test to identify correctly those who do not
have the disease
– the probability of a negative test in people without the
disease
=d/b+d.
04/01/2023 By Terefe M.
 Examples

• Sensitivity 74.6% means that of those diagnosed with

breast cancer during the study period, approximately 75
% tested positive on the screening procedure
• Specificity 98.5 % indicates that virtually all women
who did not have the disease tested negative
• It would be desirable to have a screening test that was
both highly sensitive and highly specific.
• Usually that is not possible, and there is generally a
tradeoff between the sensitivity and specificity of a given
screening test
04/01/2023 By Terefe M.
 Gold standard

Test Disea No Tot

results se disease al

Positiv 8 10 18
e 0 0 0
Negati 2 80 82
ve 0 0 0

Tot 10 90 100
al 0 0 0

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 Test Disease No disease Total
results

Positiv 80 100 180

e
Negati 20 800 820
ve

Tot 100 900 1000

al

800
Sensitivity 80 Specificity
100 900

04/01/2023 By Terefe M.
 …

• Sensitivity should be increased at the expense of specificity

when the penalty associated with missing a case is high such
as:
– when the disease is serious and definitive treatment exists
– when the disease can be spread (e.g syphilis)
– when subsequent diagnostic evaluations of positive
screening tests are associated with minimal cost and risk.
• Specificity should be increased relative to sensitivity when
the costs or risks associated with further diagnostic
techniques are substantial.

04/01/2023 By Terefe M.
 Predicative value of a Test
• Predictive value is the ability of a test to
predict the presence or absence of disease
from test results.
1.Positive predictive value(+PV = a/a+b)
the ability of the test to identify correctly those with a
positive test who have the disease
2.Negative predictive value((-PV = d/c+d)
the ability of the test to identify correctly those with a
negative test who do not have the disease

04/01/2023 By Terefe M.
 …

• PVPT = 11.8 % means the probability that a woman

who tested positive on the screen actually had breast cancer
is 11.8%.
• PVNT = 99.9% means the probability that a woman
who tested negative truly did not have breast cancer is
99.9%.
• The ability to predict the presence or absence of diseases
from test results is dependent on the prevalence of the
preclinical disease in the population tested, as well as on
the sensitivity and specificity of the test.

04/01/2023 By Terefe M.
 Test Disease No disease Total
results
Positive 80 100 180

Negative 20 800 820

Total 100 900 1000

Positive 80 Negativ 800

predicti e
ve value 180 predicti 820
ve value

04/01/2023 By Terefe M.
 Reliability (Precision)

• Reliability refers to the consistency of

results when repeat examinations are
performed on the same persons under the
same condition.
• There are 4 sources of variability that can
affect the reproducibility of results of
screening test:

04/01/2023 By Terefe M.
 1. Biological variation inherent in the actual manifestation being measured
such as BP
which varies considerably for a given individual with time and other
circumstances
2. Variation due to the test method or measurement
relates to the reliability of the instrument itself, such as standard mercury
sphygmomanometer for BP
3. Intraobserver variability refers to differences in repeated
measurements by the same screener
4. Interobserver variation refers to inconsistencies attributable to
differences in the way different screeners apply or interpret test results
These variations can usually reduced by
• Carful standardization of procedures
• Intensive training
• Periodic checks on their work
04/01/2023 • Use of two or more observers
By Terefe M.
 An acceptable screening test

• one that is highly accurate, i.e., results are positive for

almost all individuals with the disease, and the physician
can be confident that the patient is actually free of the
disease when test results are negative.
• Specificity is important when one is screening for rare
diseases because false-positive results are possible when
the test is not specific.
• the ideal screening test is inexpensive, easy to administer,
and
• poses little risk and causes minimal discomfort for the
patient.
• In addition, results of theByscreening
04/01/2023 Terefe M.
test must be valid,
 Unit 7:
Epidemic investigation and
Management

04/01/2023 Prepared by Terefe M. 54

 Learning objectives

At the end of this session students will be able to:

Define common terms related to occurrence of disease

Identify epidemics and types of epidemics
Describe steps in investigation of epidemics/outbreak
Describe different approaches of epidemic management
Prepared by Terefe M. 04/01/2023 55
 Presentation contents

• Pattern of ds occurrences
• Types of epidemics
• Steps in epidemic investigation
• Prevention and control strategies of epidemics

Prepared by Terefe M. 04/01/2023 56

 Patterns of disease occurrence

• Diseases occur in a community at different levels at

a particular point in time.
Expected level /predictable level-occurrence of ds
in usual pattern
Excess of what is expected- more occurrences
than usual

Prepared by Terefe M. 04/01/2023 57

 Expected levels

1. Endemic: Presence of a disease at more or less stable

level. Malaria is endemic in the lowland areas of Ethiopia.
2. Hyper endemic: Persistently high level of disease
occurrence.
3. Sporadic: Occasional or irregular occurrence of a disease.
When diseases occur sporadically they may occur as
epidemic.

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 Excess of what is expected:

1. Epidemic: The occurrence of disease or other health

related condition in excess of the usual frequency in a given
area or among a specific group of people over a particular
period of time.
2. Outbreak: Epidemics of shorter duration covering a
more limited area.
3. Pandemic: An epidemic involving several countries or
continents affecting a large number of people. For example
the worldwide occurrence of HIV/AIDS is a pandemic.
Prepared by Terefe M. 04/01/2023 59
 Pattern of occurrences…cont.
It is important to note that epidemics/outbreak should:
Includes any kind of disease/ injuries
varies for different diseases and different circumstances
cover a small area within a city/ entire
nation/worldwide distribution
encompass any time period ranging from few hours/a
few weeks to several years
no general rule about the number of cases
Prepared by Terefe M. 04/01/2023 60
 Cont…

• If the number of cases exceeds the expected level on the basis

of the past experience of the particular population, then it is
an epidemic.
• 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
Prepared by Terefe M. 04/01/2023 61
 Types of epidemics

• Classified according to the method of spread or propagation,

nature and length of exposure to the infectious agent and duration.
1. Common Source Epidemics
 Continuous
 Intermittent
2. Propagated/ Progressive Epidemics
3. Mixed type of epidemics

Prepared by Terefe M. 04/01/2023 62

 Types of epidemics…cont.

1. Common Source Epidemics

• An epidemic which occurs as a result of exposure of a
group of susceptible persons to a common source of a
pathogen often at the same time or within a brief time
period.
• Point source epidemic: When the exposure is
simultaneous the resulting cases develop within one
incubation period of the disease.
Prepared by Terefe M. 04/01/2023 63
 …

• The epidemic curve in a point source epidemic will

commonly show a sharp rise and fall.
E.g Food borne epidemic following an event where the food
was served to many people is a good example of point
source epidemic.

Prepared by Terefe M. 04/01/2023 64

 Cont…

A. Continuous common source epidemic: If the exposure to a

common source continues over time.
• A waterborne outbreak that spreads through a contaminated
community water supply is an example of a common source
epidemic with continuous exposure.
• The epidemic curve may have a wide peak because of the
range of exposures and the range of incubation periods.

Prepared by Terefe M. 04/01/2023 65

 …

Prepared by Terefe M. 04/01/2023 66

 …

B. Intermittent common source: the exposure to the infectious

agent occur occasionally with no predictable pattern
• E.g. – Outbreak of hepatitis A from exposure to food
contaminated by infected food handler intermittently or
continuously
• Epidemic curve-extended and irregular

Prepared by Terefe M. 04/01/2023 67

 2. Propagated/ Progressive Epidemics

 The infectious agent is transferred from one host to another either

through direct person to person transmission or through more
complex cycles
 Propagated spread usually results in an epidemic curve with a
relatively gentle upslope and somewhat steeper tail.
 An outbreak of malaria is a good example of propagated epidemic.
 When it is difficult to differentiate the two types of epidemics by the
epidemic curve, spot map (studying the geographic distribution) can
help.
Prepared by Terefe M. 04/01/2023 68
Prepared by Terefe M. 04/01/2023 69
 3. Mixed Epidemics

• The epidemic begins with a single common source of an

infectious agent with subsequent propagated spread.
• pattern of a common source outbreak followed by
secondary person-to-person spread
• Many food borne pathogens result in mixed epidemics.
• E.g. – Shigelloses epidemic from exposure to common
contaminated food supply followed by person-to-person
spread
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71 04/01/2023
 Uncovering outbreaks

Outbreaks are detected in one of the following ways:

a. Through timely analysis of routine surveillance data
b. Report from clinician.
c. Report from the community, either from the affected
group or concerned citizen.

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 Investigation of an Epidemic

Purpose
• Determine the specific cause of the outbreak at the earliest
time
• To take appropriate measure directed at controlling the
epidemic and preventing future occurrence.
• Answer the following questions

Prepared by Terefe M. 04/01/2023 73

 Cont…
• What is the etiological agent responsible for the epidemic?
• What is/are the predominant modes of transmission?
• What specific source/s of disease can be identified? E.g.
human carriers, breeding sites for vectors, etc.
• What specific practices or environmental deficiencies have
contributed to the outbreak? E.g. improper food handling,
human made breeding sites for mosquitoes.
• What is the chain of events that led to the outbreak? E.g.
accumulation of susceptible hosts in an area.
Prepared by Terefe M. 04/01/2023 74
 Why Investigate Possible Outbreaks

• To institute control and prevention measures

• Opportunity for research
• Opportunity for program evaluation
• Training opportunity
• Public, political, or legal concerns

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 1.Control/prevention

The balance between control measures Vs further

investigation depends on how much is known about
• the cause,
• the source, and
• the mode of transmission of the agent

Prepared by Terefe M. 04/01/2023 76

 What should be the priority action in
an outbreak?
Source/Mode of
Transmission

Causati
ve
Agent

Prepared by Terefe M. 04/01/2023 77

 Cont.…
Where are we in the outbreak?
• Goals will be different depending on answer(s)
Cases continuing to occur
• Goal: prevent further cases
• Objective: To assess extent of outbreak and characterization
of population at risk, implement control measures
Outbreak appears to be coming to an end
• Goal: prevent future outbreaks
• Objective: Identify factors contributing to outbreak, and to
implement measures to prevent similar events in the future
Prepared by Terefe M. 04/01/2023 78
 2.Opportunity to learn (Research opportunities)

Gain additional knowledge

 For Newly recognized disease field investigation provides an
opportunity to characterize:
• natural history
• the population at risk and
• to identify specific risk factors.
 For well recognized diseases
• Assess impact of control measures
• Usefulness of new epidemiology and laboratory techniques
Prepared by Terefe M. 04/01/2023 79
 3.Training
Requirements of an epidemiologist during investigation!
• Diplomacy
• Logical thinking
• Problem solving ability and quantitative skills
• Epidemiologic know-how
• Judgment
 These skills improve with practice and experience.

Prepared by Terefe M. 04/01/2023 80

 4.Public, political, or legal concerns

 can be the driving force behind the decision to conduct an

investigation
 Sometimes override scientific concerns
 Health department needs to be responsible and responsive to public
concerns

• Even if the concern has little scientific basis

• E.g. disease cluster and environmental exposure
Prepared by Terefe M. 04/01/2023 81
 5.Program considerations

If Outbreak of disease targeted by a public health program is

occurred then
 Investigation gives an opportunity to change or strengthen the
program by identifying:
• population that may have been overlooked
• Failure of intervention strategy
• Changes in the agent
• Events beyond scope of the program
Prepared by Terefe M. 04/01/2023 82
Steps of Epidemic/outbreak investigation

NB:

• There is no fixed step in the investigation of

epidemics but the following step can be considered
as one option.
• These steps may occur simultaneously or be repeated
as new information is received

Prepared by Terefe M. 04/01/2023 83

 Steps of outbreak investigation…
1. Prepare for field work
cont.
2. Verify the diagnosis
3. Establish the existence of an outbreak
4. Define and identify cases and take immediate control
measures
5. Perform descriptive epidemiology
6. Develop hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and execute additional studies
9. Implement control and prevention measures
10. Communicate findings
Prepared by Terefe M. 04/01/2023 84
 Steps in Epidemic Investigation

1. Prepare for fieldwork.

• Before leaving for the field you should be well prepared
to under take the investigation.
• Preparations can be categorized into three

Prepared by Terefe M. 04/01/2023 85

A. Investigation related
• Have the appropriate scientific knowledge, supplies, and
equipment to carry out the investigation.
• Discuss the situation with knowledgeable people, review
applicable literature, and collect sample questionnaire.
B. Administration related
• Arrange transportation and organize personnel matters.
C. Consultation related
• Clarify your team role in the field.
• Arrange where and when to meet local contacts.
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 Cont…

2. Verify
(confirm) the existence of an
epidemic
• Compare the number of cases with the past levels to identify
whether the present occurrence is in excess of its usual frequency
• Observe thresholds for the most critical diseases
Even if the current number of reported cases exceeds the expected
number, the excess may not necessarily indicate an outbreak.
 But due the following reasons:

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 What could account for the increase
in cases?

Real increase Artificial increase

1.Increase in population size 1.Increased samples of
2.Changes in population stools
characteristics 2.New testing protocol
3.Random variation 3.Contamination of sample
4.Outbreak 4.Changes in reporting
procedures
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 Verify Epidemic…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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 Verify Epidemic…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

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 Verify Epidemic…cont.

• 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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 3. Verify (confirm) the diagnosis.

• Carry out clinical and laboratory studies to confirm the

diagnosis.
• Always consider whether initial reports are correct.
• It is necessary to establish criteria for labeling persons as
“cases.”

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 Verify diagnosis…cont.

Prepare “case definition” before starting identification of cases.

Case definition is defined as a standard set of criteria to
differentiate between cases and non cases. Cases can be one
of the following:
• Confirmed / definite: A case with laboratory verification.
• Probable: A case with typical clinical features but without
laboratory confirmation.
• Possible: A case with fewer of typical clinical features
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 4: Identify and count cases

• Cases can better be identified by active case detection using

all available means including house to house visits. The
health extension worker can identify and count cases based on
the sign and symptoms of the disease.
• If there is effective drug for the treatment of that disease
cases can be treated while identifying them.
• Additionally other control measures can be taken side by side
to arrest the epidemic before many people are affected.
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 5. Perform descriptive epidemiology

• Describe the epidemic with respect to person, place

and time
• Each case must be defined according to standard
epidemiologic parameters
• Date of onset of the illness
• Place where the person lives or became ill
• Socio demographic characteristics
• The tools to be used when characterizing the epidemic
are epidemic curve, spot map and attack rates.
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 Cont…

• Epidemic curve: plots the cases by the time of

onset and provides a time frame for the outbreak
investigation.

• Spot map: plots the cases by location and shows the

geographic spread of cases.

• Attack rates: calculate rates of illness in population

at risk.
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 1.Time
Epidemic curve-is
• Histogram of the number of cases by their date of onset
• Visual display of the outbreak’s magnitude and time trend
 Helps to know-
• Where you are in the time course of the outbreak
• Future course?
• Probable time period of exposure
• Helps in development of questionnaire focusing on that time
period
• Common source vs. Propagated
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 2.Place
• Geographic extent of problem

• Clusters or patterns providing important etiologic

clues

• Spot maps
• Where cases live, work or may have been exposed
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 3.Person
• Helps to determine what population at risk
• Usually define population by host characteristics(age,
race, sex, or medical status) or exposure
• Use rates to identify high-risk groups
• Numerator = number of case
• Denominator = number of people at risk

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 6. Develop Hypothesis

 Identify the causes of the epidemic

 Formulate Hypotheses
 the hypotheses should address the source of the agent, the mode
of transmission, and the exposures that caused the disease
 Why did this epidemic occur?
 Are there many susceptible individuals?
 Is the temperature favorable for the transmission of the
diseases?
 Are there breeding sites for the breeding of vectors? Etc
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 7. Evaluate Hypothesis

• Evaluation of hypotheses can be done in two ways either

• by comparing the hypotheses with the established fact, or
• by using analytic epidemiology to quantify relationships
• Case control study
• Cohort

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 Hypothesis testing
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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 …
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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 8: Refine Hypothesis/
Conduct Additional Studies
Is the hypothesis confirmed? Do you need:
• Additional statistical studies(epidemiologic study)
• Additional laboratory studies
• Additional cultures
• environment
• personnel
• patients or residents
Finally, recall that one reason to investigate outbreaks is
research.
 If questions remain unanswered
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 9. Implement control and prevention measures or
Management of epidemic and follow up

• Intervention must start as soon as possible.

• One might aim control measures at the specific agent,
source, or reservoir.

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 Management of epidemics/out break

1. Measures Directed Against the Reservoir

2. Measures that interrupt the transmission of organisms

3. Measures that reduce host susceptibility

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 Measures Directed Against the Reservoir
Domestic •Immunization(e.g giving anti-rabies
animals as vaccine for dogs)
•Destruction of infected animals(e.g
reservoir
anthrax)
•Testing of herds

Wild animals •Post-exposure prophylaxis reservoir

as a reservoir for human being e.g rabies
Humans as •Removal of the focus of infection
reservoir •Isolation of infected persons.
•Treatment to make them
noninfectious.
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•Disinfection of contaminated objects.
04/01/2023 107
 Measures that interrupt the transmission of
organisms
For diseases •Purification of water
transmitted •Pasteurization of milk
by ingestion •Inspection procedures designed to ensure
safe food supply.
•Improve housing conditions.
For disease •Chemical disinfection of air and use of
transmitted ultraviolet light.
by respiratory •Work on ventilation patterns, like
routes unidirectional ("laminar") air flow to reduce
the transmission of organisms in hospitals
For diseases •Clearing irrigation farms from snails to
whose control schistosomiasis.
cycles involve
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intermediate host
 Measures that reduce host
susceptibility
Active • Mass vaccination (e.g vaccination for
immunization meningitis)
• Selective vaccination

Passive • Transfer of maternal antibodies to the

immunization fetus through the placenta.
• Prophylaxis administration of immune
serum globulin (ISG).
Chemoprophylaxis • Use of antibiotics for known contacts of
cases
• Use of prophylaxis to persons travelling
to endemic areas.
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 Cont…
• Quarantine impose a person for the duration of the usual
maximal incubation period of the disease. Cholera, Plague,
and yellow fever are the three internationally quarantinable
diseases by international agreement.
• Now quarantine is replaced in some countries by active
surveillance of the individuals
NB: After the epidemic is controlled, strict follow up
mechanisms should be designed so as to prevent similar
epidemics in the future
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 10. Communicate/Report of the investigation

• At the end prepare a comprehensive report

• submit to the appropriate/concerned bodies like the Woreda
Health Office.
• The report should follow the usual scientific format:
Introduction, methods, results, discussion, and
recommendations. The report should discuss in detail:
• Factors leading to the epidemic.
• Measures used for the control of the epidemic.
• Recommendations for the prevention of similar episodes
in the future.
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 Communicate…

Oral briefings- to responsible bodies

• update findings
• recommend control measures
• delineate responsibilities
Written reports
• provides a blueprint for action.
• Serve as document for potential legal issues.
• Contributing to the knowledge base of epidemiology and public health

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 Challenges of Investigating Outbreaks

• Urgency
• Inadequate statistical power due to limited number of cases
• Early media reports may bias responses of persons
• Loss of useful clinical and environmental samples due to
late initiation

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 References

• Kebede Y, Weldemichael K, Lulu K. Lectre note of

epidemiology for health sciences. 2003
• Fletcher M. Principles and practice of Epidemiology. Addis
Ababa, Ethiopia. 1992.
• Greenberg RS, Daniels SR, Flanders WD, Eley JW, Boring
JR, III. Medical Epidemiology.4th edition. McGraw Hill,
USA. 2005.
By Terefe M. 04/01/2023