Lesson 7a: Investigating and Responding To An Outbreak - Steps and Descriptive Epidemiology

Integrated Training for Surveillance Officers
in Nigeria (ITSON)
Lesson 7a:
Investigating and Responding to an
Outbreak - Steps and Descriptive
Epidemiology
Learning objectives
At the end of this lesson, participants will be able to:

• Determine when to investigate an outbreak
• Develop clear investigation objectives
• Conduct an outbreak investigation systematically
• Summarize cases by time, place and person
• Draw and interpret an epidemic curve
Lesson 7: Steps and Descriptive Epidemiology

The surveillance cycle: Respond
Identify
Evaluate Report
Communicate Analyze/Interpret
Prepare/Respond 3

Outbreaks in the news
At the end of this lesson, participants will be able to:

• Determine when to investigate an outbreak
• Develop clear investigation objectives
• Conduct an outbreak investigation systematically
• Summarize cases by time, place and person
• Draw and interpret an epidemic curve

What is an outbreak?
• The occurrence of more cases of a disease than

expected for a particular place and time
“More than expected”

No. Cases
= “Outbreak”
of a Disease
“Usual”, “Expected”
Time
5

Cases exceed threshold?
1800 National cholera thresholds, Nigeria, 2015

1600
1400
1200
No. 1000
of
800
Cases
600
400
200
0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
Epidemiologic Week
6
Lesson 7: Steps and Descriptive Epidemiology Source: Nigeria IDSR Report, Week 46, 2015
When to investigate - Cases
exceed threshold
CSM Threshold Kebbe LGA, Sokoto Nigeria, 2017
26
24
22
20
18
16
Number 14
of case 12
10
8
6
4 Alert threshold ≥ 2 cases
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Epidemiological week
7
Lesson 7: Steps and Descriptive Epidemiology Source: NCDC Weekly Epidemiological Report
How potential outbreaks are identified
• Review of surveillance data

• Clinician or laboratory reports of unusual
diagnoses
• Reports from the public
• Reports from the media

Should you investigate?
Yes or No?
Depends on:
• Number of cases exceed • Political considerations
threshold • Public relations
• Severity of illness • Resource availability
• Potential for spread
• Availability of
prevention and control
measures
9

Why Investigate?
• To prevent and control the disease

• To characterize a public health problem
• To conduct research and answer scientific
questions
• For political/legal reasons
• To train health department staff in methods
10

Relative priority of investigative and
control measures
Source/Mode of Transmission
Known Unknown
Investigation + Investigation +++
Known Control +++ Control +
Causative
Agent Investigation +++ Investigation +++
Unknown Control +++ Control +
+++ Higher Priority

+ Lower Priority
11

Why Investigate?
1. Cholera cases among persons using a well previously
contaminated by an adjacent latrine
2. Unknown disease with unknown source
3. Unknown disease associated with food served at a restaurant
4. Anthrax cases without a known source
1 4
3 2
12

Exceptions to the rule
If the source is suspected and still a

threat to public health…
Take immediate
control measures!
13

Exercise 1: Would you investigate?
• Work on your own

• Refer to Page 82 & 83 In your participant’s manual
• Review the scenarios in your workbook
• For each scenario determine if you would probably
investigate
• After 10 minutes, we will discuss as a group
14

Would you investigate?
Yes No
1. ___ If the illness is life-threatening, such as

rabies
2. ___ If signs/symptoms or confirmed diagnoses

suggest patients might not have the same illness
3. ___ If cases all report that they ate food from a

specific food establishment
15

Yes No
4. ___ If there is outside pressure from politicians

or the media
5. ___ If there are confirmed clusters/large
numbers of a similar illness
6. ___ If ill persons are not able to provide
adequate information for investigation
16

Yes No
7. ___ If the illness seems to be associated with a

commercially distributed product
8. ___ If a complainant refuses to provide his/her
name but otherwise provides detailed
information
9. ___ If there are repeated complaints made by the
same individual(s) for which prior investigations
revealed no significant findings 17

Steps of an
outbreak investigation
18

General phases of an outbreak
investigation
Explanator
Descriptive Response
y
19

Descriptive phase
• Prepare for fieldwork Done

• Confirm existence of an outbreak simultaneously
or in any order
• Verify the diagnosis
• Construct a case definition
• Find cases systematically and
record information
• Perform descriptive epidemiology
20

Explanatory phase
• Develop hypotheses
• Evaluate hypotheses
epidemiologically
• Reconcile epidemiology with
laboratory and environmental
findings
• Conduct additional studies as
necessary
21

Response phase
• Implement and evaluate

prevention and control measures
• Initiate or maintain surveillance
• Communicate findings
22

Step 1: Prepare for fieldwork
1. Prepare for fieldwork

2. Confirm existence of an outbreak
3. Verify the diagnosis
4. Construct a case definition
5. Find cases systematically and record information
6. Perform descriptive epidemiology
23

Objectives of a field investigation
• Identify the:
– Agent
– Source, and/or mode of transmission
• Characterize the extent of the outbreak
– E.g. who has been affected, who is at risk
• Identify exposures or risk factors that increase risk
of disease
• Develop and implement control and prevention
measures
24

Components of an outbreak
field investigation
• Epidemiology
• Laboratory
• Environmental
25

Tasks to prepare for fieldwork
1. Form a team
2. Learn about the disease
3. Make necessary administrative, personnel, and
logistical arrangements
4. Coordinate with partner agencies and local
contacts
26

Form a team
Team Lead
Epidemiologist Lab personnel
Environmental
Clinicians
Health Specialist
Enforcement
Interviewers
agents
27

Tasks to prepare for fieldwork
1. Form a team
2. Learn about the disease
3. Make necessary administrative, personnel, and
logistical arrangements
4. Coordinate with partner agencies and local
contacts
28

Step 2: Confirm existence of an outbreak

29

More than expected?
• The occurrence of more cases of a disease than

expected for a particular place and time
“More than expected”

No. Cases = “Outbreak”
of a Disease
“Usual”, “Expected”
Time
30

Review case reports to confirm the
existence of an outbreak
• Review the reports or data
• Confirm that cases are the same disease
• Confirm that the number of cases exceeds the
usual or expected number
• Remember: Not all increase in number of cases
represent an outbreak, but you cannot assume
that it is not an outbreak
31

Number of reported cases of disease X by
epidemiologic week, LGA Y, 2015
9
8
7
6
Number 5
of Cases
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11
Epidemiologic Week
32

Step 3: Verify the diagnosis

33

Evaluate the clues to verify the diagnosis
• Laboratory confirmation?
• Clinical presentation consistent with diagnosis?
– Signs and symptoms
– Clinical laboratory findings
– Clinical course
• Compatible exposure
– E.g. to a known case?
34

Laboratory confirmation
• Most definitive method

for verifying diagnosis
• Pathogens have
characteristic incubation
periods that may help
identify exposure period
• Don’t wait for laboratory
diagnosis to proceed
35

Step 4: Construct an outbreak
case definition
36

case definition
• Clinical criteria
– Characteristic symptoms and clinical signs
– Laboratory data
• Epidemiologic criteria (especially for outbreaks)
– Time
– Place
– Person (epidemiologic link, otherwise uncommon)
• Criteria must be as OBJECTIVE as possible
• Should NOT include the suspected exposure
37

case definition
laboratory confirmed,
Confirmed compatible symptoms
compatible symptoms,
Probable epidemiologically linked
Possible
or Suspect compatible symptoms
38

Example: Outbreak case definition
for cholera
Case definition Case definition elements
• Suspected case: • Clinical:
– Resident of Ajegunle – Symptoms
with at least 1 episode of – Lab
severe diarrhea from
1 Jan to 30 Apr, 2011 • Epi:
• Confirmed case: – Time
– Place
– Suspect case with rectal
swab positive for Vibrio – Person
cholerae O1
39
Lesson 7: Steps and Descriptive Epidemiology Adeoye et al. 61st Annual EIS Conference, Atlanta, GA, April 2012
for cholera
1 Jan to 30 Apr, 2011 • Epi:
– Place
cholerae O1
40
for cholera
1 Jan to 30 Apr, 2011 • Epi:
– Place
cholerae O1
41
for cholera
1 Jan to 30 Apr, 2011 • Epi:
– Place
cholerae O1
42
Step 5: Find cases systematically and
record information
43

Find cases systematically
• Contact health facilities

• Contact laboratories
• Contact community health workers
• Contact other districts
• Talk to patients
• Media-with caution
44

Record information systematically
- Line list
45

Class discussion
You have been tasked with finding and investigating

cases of malaria in the past 30 days in a small rural
community
Q1. How would you find cases?
Q2. What information would you collect?
46

Exercise 2: Is it an outbreak?
In your group:
• Read the scenario on Page 85-90 In your participant’s
manual
• Answer questions 1 and 2:
Q1. What first steps should the clinic’s public health
nurse take?
Q2. Calculate mean and median for January, February
and December
Reconvene:
Q3. Would you recommend further investigation?
47

Exercise 2: Is it an outbreak?
In your group:
• Read about shigellosis on Page 89 In your
participant’s manual
Q4. Create outbreak case definitions for suspect,
probable and confirmed cases
48

Step 6: Perform descriptive epidemiology

49

The five W’s of journalism/epidemiology
Journalism Epidemiology
• What = Clinical
• When = Time Descriptive
• Where = Place or Epidemiology
• Who = Person
• Why/How = Cause,
Analytic
Risk factors, Epidemiology
Mode of transmission
50

Clinical features
• Symptoms: what patient feels

• Signs: what the clinical exam reveals
• Laboratory results
– Definitive diagnosis
– Clinical results
51

Clinical findings, human brucellosis,
E. Anatolia, January 2010
Characteristics Number (n=44) %
Fever 28 64
Arthralgia 24 55
Myalgia 19 43
Fatigue 8 19
Back pain 7 16
Headache 5 11
Lack of appetite 2 9
Weight loss 2 5
52

Clinical findings, human brucellosis,
E. Anatolia, January 2010
Characteristics Number (n=44) %
Hepatomegaly 7 16
Arthritis 5 11
Fever (≥ 38oC axillary) 3 7
Lymphadenopathy 2 5
Splenomegaly 1 2
Leukocytosis (>10,000 WBC/mm2) 10 23
Anaemia (hemoglobin <12 g/L) 1 2
C-reactive protein 7 16
Erythrocyte sed. Rate >20 mm/h 1 2
Alanine aminotransferase >2x ULN 1 2
53

Time, place and person
• Time (epidemic curve)

– Ideally: when were they infected?
– More practically: when did they become ill?
• Place (spot map, shaded map)
– Ideally: where were they infected?
– More commonly: where do they live, work?
• Person (tables)
– Who was infected, numerators and denominators
– What do the cases have in common?
54

Time: Epidemic curves
• Histogram (no space between adjacent columns)

• X-axis: Date of onset (by hour, day, week, month)
• Y-axis: Number of cases
• Can display columns or “stack of boxes”
Cases of Gastroenteritis, Village A, Cases of Gastroenteritis, Village A,
January 2016 January 2016
9
8 9
8
7
7
6
Number of Cases
6
5 5
4 4
3 3
2 2
1
1
0
0
1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Date
Date
55

Time: Epidemic curves
Dates of Onset (n=57) Oct. No. Cases
9 Oct 14 Oct 15 Oct 16 Oct 17 Oct 19 Oct 1–8 0
9 1
11 Oct 14 Oct 15 Oct 16 Oct 17 Oct 20 Oct 10
0
1
12
13
13 Oct 14 Oct 15 Oct 16 Oct 17 Oct 23 Oct 14 3
15 10
14 Oct 15 Oct 15 Oct 16 Oct 17 Oct 25 Oct
16 13
14 Oct 15 Oct 15 Oct 16 Oct 18 Oct 17 11
19 3
14 Oct 15 Oct 16 Oct 16 Oct 18 Oct
20 2
22 0
23 1
What range for X-axis do you suggest? 24 1
25 56
0
Lesson 7: Steps and Descriptive Epidemiology 1
X-axis, Y-axis
14 What range do you suggest for the Y-axis?

12
10
No. of cases
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
October 2015
57

X-axis, Y-axis
14 What range do you suggest for the X-axis?

12
10
No. of cases
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
October 2015
58

X-axis, Y-axis
14 Now add data?

12
10
No. of cases
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
October 2015
59

X-axis, Y-axis
14 Now add axis labels

12
10
Number of Cases
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
October 2015
60

X-axis, Y-axis
14
Now add title:
12 • What (Disease)
• Where
10 • When
8
Number
of Cases 6
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
October 2015
Date of Onset
61

Completed epidemic curve
(axis, data, labels, title)
14 Number of cases of disease X by date of onset, LGA A, October 2015
12
10
8
Number
of Cases 6
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
October 2015
Date of Onset
62

Value of an epidemic curve
• Shows the magnitude of the outbreak

• Shows the time course of the outbreak
• Can show the pattern of spread
• Can help determine the incubation period or
exposure period
15
• Highlights outliers 10
0
1 4 7 10 13 16
63

Magnitude of the outbreak
14
12
10
8
6 LGA A
4
2
0
4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
2 LGA B
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
October 2015
64

Time course of the outbreak:
More cases likely?
14
12
Today is 16th of
10
October. Do you
Number 8 expect several
of Cases
6 more cases?
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
October 2015
Date of Onset
65

Time course of the outbreak:
More cases likely?
14
12
Today is 26th of
10
October. Do you
8 expect several
Number
of Cases 6 more cases?
4
2
0
1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526
October 2015
Date of Onset
66

Epidemic curves and manner of spread
Point source (single exposure) 10
Continuing common source
6
9
5 8
7
cases
4
cases
6
3 5
4
2
3
1 2
1
0 0
1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 10 11 12
Day Day
Intermittent source Propagated spread

10 12
9
8 10
7
cases
8
cases
6
5 6
4
3 4
2
2
1
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 1 2 3 4 5 6 7 8 9 10 11 12 13
Day Week 67

Identifying likely exposure period
(Point source outbreak)
4 days
14 Incubation range 2–10

Probable days, median 4 days.
12
exposure Assume 1st outbreak-
10 on / around associated case occurred
8 11rd October on 13th October.
Number
of Cases 6 2 days
4
2
0
1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526
October 2015
Date of Onset
68

Outliers provide clues to the exposure
14
12
10
8 If cases on 9th and 11th If cases on 22nd, 23rd,

Number were part of the 25th were part of the
of Cases 6 outbreak, how were outbreak, how were
they exposed? they exposed?
4
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
October 2015
Date of Onset
69

Describe and orient the data by place
• Description
– Hospital
– School
– Community
• Maps
– Spot
– Area
70

Spot map: MERS-CoV detections in KSA
Confirmed cases of MERS-CoV in KSA, June-July 2014
71

Area maps
Cumulative Number of Ebola Virus Disease Cases
by Region, West Africa, 2014-2015
72
lwww.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/
Lesson 7: Steps and Descriptive Epidemiology distribution-map.htm
Person characteristics
• Age
• Sex
• Tribe or other affiliation
• Occupation
• Income
• Marital status
• Underlying medical conditions
• Many others
73

HIV+ residents, in community X, 2010
74

Number of residents enrolled,
community X, 2010
75

Prevalence of HIV, community X,
Nigeria, 2010
Age(yrs) MALE FEMALE

≥55 23 20
45-54 40 33
35-44 46 36
25-34 24 39
15-24 10 20
27 32
76
Exercise 3: Perform descriptive
epidemiology
Work in groups to answer to answer the questions
on page 92
• Create a line list of current cases
• Apply a case definition
• Create an epidemic curve
• Interpret the epidemic curve
• Analyze person data
77

Outbreak investigation steps 1–6
• Prepare for fieldwork Done
• Confirm existence of an outbreak simultaneously
or in any order
• Verify the diagnosis
• Construct a case definition
• Find cases systematically and
record information
• Perform descriptive epidemiology
78

Outbreak investigation steps 7–13
7. Develop hypotheses
8. Evaluate hypotheses epidemiologically
9. Reconcile epidemiology with laboratory and
environmental findings
10. Conduct additional studies as necessary
11. Implement and evaluate prevention and control
measures
12. Initiate or maintain surveillance
13. Communicate findings
79

Points to remember
• Verification and confirmation of an outbreak
• How to construct a case definition
• Steps in outbreak investigation
• Types of epidemic curves
• Prepare and interpret epidemic curves
80

How I can use this at my job
TOPIC HOW CAN I USE THIS AT MY JOB
Introduction to public health surveillance
Identify priority diseases, conditions and

events
Report priority disease ,events and

conditions
Role of Laboratory
Collect and Organize Data
Analyze Data
Interpret Data
Outbreak investigation (Descriptive

Epidemiology)
81

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Integrated Training for Surveillance Officers

At the end of this lesson, participants will be able to:

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

At the end of this lesson, participants will be able to:

Lesson 7: Steps and Descriptive Epidemiology

• The occurrence of more cases of a disease than

“More than expected”

Lesson 7: Steps and Descriptive Epidemiology

1800 National cholera thresholds, Nigeria, 2015

• Review of surveillance data

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

• To prevent and control the disease

Lesson 7: Steps and Descriptive Epidemiology

+++ Higher Priority

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

If the source is suspected and still a

Lesson 7: Steps and Descriptive Epidemiology

• Work on your own

Lesson 7: Steps and Descriptive Epidemiology

1. ___ If the illness is life-threatening, such as

2. ___ If signs/symptoms or confirmed diagnoses

3. ___ If cases all report that they ate food from a

Lesson 7: Steps and Descriptive Epidemiology

4. ___ If there is outside pressure from politicians

Lesson 7: Steps and Descriptive Epidemiology

7. ___ If the illness seems to be associated with a

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

• Prepare for fieldwork Done

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

• Implement and evaluate

Lesson 7: Steps and Descriptive Epidemiology

1. Prepare for fieldwork

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

Epidemiologist Lab personnel

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

1. Prepare for fieldwork

Lesson 7: Steps and Descriptive Epidemiology

• The occurrence of more cases of a disease than

“More than expected”

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

1. Prepare for fieldwork

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

• Most definitive method

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

Lesson 7: Steps and Descriptive Epidemiology

• Contact health facilities

Lesson 7: Steps and Descriptive Epidemiology