Principles of Management

OF Epidemics/Outbreaks

JEMIMAH WAMYIL
 Introduction
1. Endemic: The habitual presence of a disease within a given geographical area
2. Epidemic: The occurrence in a community or region of a group of illnesses of similar
nature, clearly in excess of normal expectancy
3. Pandemic: A worldwide Epidemic
• A disease that exists at constant levels of prevalence is
described as endemic
• An outbreak in a locality is an epidemic
• A wide spread epidemic at multiple localities
worldwide is a pandemic Endemic Epidemic
Time
4. A zoonosis is a disease or infection naturally transmitted between animals
and man (WHO,1959)
Examples of common zoonoses: RVF, Rabies, Anthrax, Plague,
Trypanosomiasis, Influenza, Ebola, Marburg
5. An Epizootic is an outbreak (epidemic) of disease in an animal
population, e.g. rift valley fever
6. An Enzootic is a disease that is endemic in animals, e.g. bovine TB
7. Exotic diseases are those which are imported into a country in which they
do not otherwise occur e.g. ‘bird flu’
Definition: An outbreak is the occurrence of a disease or event in excess
of what is expected in terms of persons, place and time

Detecting an outbreak:
• We assess if an event is occurring in excess of what is expected for a
particular population
• The key questions therefore are:
• Who is affected? (Person)
• When? (Time)
• Where? (Place)
Examples Outbreaks
Modern:
• Avian Influenza (Bird Flu)- CFR Over 60%
• SAS
• Ebola Hemorrhagic Fever (CFR over 40%)
• Cholera (Is it becoming endemic in some parts of Uganda?)
• Sporadic Outbreaks of STDs

History:
• The Black Death in Europe (Plague)
• Cholera in London
• Snake attacks (Bible)
• The 10 outbreaks in Egypt (Bible)
• Many others
 Important Considerations in Detection
• Case Definition for existing and new diseases
• Un-expected rise in new cases
• Rise exceeds threshold
• Thresholds differ from disease to disease
• Cholera – One confirmed case
• Ebola – One suspected case
• Measles – 3 cases from one parish in a week or 25 cases occurring in a ‘HSD’
• Meningococcal Meningitis – 10 cases in a district in a higher risk country (meningitis
belt) or 5 cases in a lower risk country
• STDs – Sudden or insidious rise in specific prevalence
 Thresholds for detecting an outbreak
Some epidemic prone diseases exist in the community even without an outbreak.
Outbreaks occur when there is a sharp rise in cases (e.g. Malaria)

• Some epidemic prone diseases do not exist normally in the community. The
occurrence of just one confirmed case is considered an outbreak (e.g. Cholera)

• Some epidemic prone diseases are rare and highly deadly when they occur. Just
one suspected case is enough to consider an outbreak (e.g. Ebola)
 How Outbreaks are Usually Recognized
• Astute observation of a single event or cluster of events by a clinician or laboratory personnel

• Rumours from the community – sometimes to the local politicians who may call directly the
MoH

• Report of one or more patients

• Routine surveillance activities

 Control, Elimination and Eradication of Disease

• Eradication: No new cases of a disease globally or in a locality; even the prevalent

cases have disappeared
Examples: Successful – Small Pox
On the path – Polio
• Elimination: No new cases of a disease globally or in a locality, but some prevalent
cases existing
Examples: Guinea worm, Onchocerciasis
• Control: New cases occurring globally or in a locality, but controlled to a certain
target
Examples: Trypanosomiasis
 Importance of outbreak investigation
 Stop the current outbreak from spreading
 Prevent future similar outbreaks

 Provide scientific explanation(s) of the event

 Provide knowledge for the understanding of the disease

process
 React to and calm public and political concerns
 Measuring outbreaks:
• In measuring outbreaks we may use a special form of incidence rate – the attack rate
• It is similar to the incidence rate, except that the time is expressed implicitly

• Attack rate = Number of new cases of a particular condition X 100

Population at risk

• The attack rate can be specific for a particular exposure: e.g.:

Food specific attack rate:
= Number of people who ate a certain food and became ill X 100
Number of people who ate that food
 Steps in investigating an outbreak
• Step 1: Obtain initial notification of the outbreak
• Step 2: Initial response
• Step 3: Verify diagnosis
• Step 4: Confirm the existence of an outbreak
• Step 5: Identify and count cases
• Step 6: Assess the local response
• Step 7: Set up immediate control measures
• Step 8: Address the resource gaps.
• Step 9: Describe the Outbreak
• Step 10: Formulate and test hypothesis
• Step 11: Report writing and dissemination
• Step 12: Be on your guard
• Step 1: Obtain initial notification of the outbreak
• We receive information about the likelihood of an outbreak from surveillance systems
(passive and active), Information and reporting systems (Health Management
Information System), Clinicians and Nurses in health units, Community resource
persons (leaders, village health teams, parish development committees)

• Step 2: Initial response

• Assemble team and prepare for an initial field visit as soon as possible.
• Assemble the immediate necessary logistics including fuel, transport, supplies and
equipment and alert the district authorities
• Prior training of first responders necessary
Step 3: Verify diagnosis
• Review the clinical findings: visit the patients, interview, examine, and reassure
them. Take samples for laboratory confirmation as soon as possible. Choose a
working case definition that is sensitive enough to detect the cases of interest.
Establish the index case
Step 4: Confirm the existence of an outbreak
• Compare the observed incidence with the expected, and relate to seasonality. Use
the action threshold in the case definition to confirm the existence of an outbreak
Step 5: Identify and count cases
• Use the working case definition to line-list all cases, starting with the index case.
Collect additional information on demographic characteristics (age, sex, and tribe),
date of onset, and outcome (death, or cure), complications and exposure risk
factors.
Step 5a: Construct a Working Case Definition
• Develop a case definition using:
• Symptoms or laboratory results
• Affected population (person)
• Location (place)
• Time frame
• Loose (sensitive) versus tight (specific) case definition
• Categories of certainty, e.g., confirmed, probable, possible

• Example: Case Definition for Hepatitis A

• Confirmed case: Anti-HAV IgM +
• Probable case: Jaundice or elevated ALT
• Suspect case: Any two of the following: Abdominal pain, fever, nausea, anorexia, malaise
 Sensitivity and Specificity of the case definition

• Sensitivity – The ability of the case definition to detect all cases.

If 9 out of 10 people who have a disease are correctly identified using the
case definition, then the sensitivity = 9/10 = .90 = 90%

• Specificity – The ability of the case definition to exclude those who are non-cases
If 8 out of 10 people who do not have a disease are correctly classified as not
having the disease using the case definition, then the specificity = 8/10 = .80 = 80%
Examples of case definitions
• Search for and read the case definitions for the following diseases as attached in
the reader marked “Extension Activity 1.2: Standard Case Definitions for some
Epidemic Prone Diseases”:
• 1. Polio
• 2. Measles
• 3. Cholera
• 4. Ebola
• 5. Bacterial Meningitis
• NB: Case definitions may be changed according to the locality and the nature of
the symptoms.
• The Outbreak response team can develop a working case definition where there is
no standard one depending on common symptoms and risk factors
• What is a Line Listing?
• Line listing = rectangular database similar to spreadsheet
• Provides summary of key data about cases in an outbreak
• Each row represents one case
• Each column represents one variable
• First column usually identifier — name, initials, or ID number
• Can be paper or electronic
• Can be quickly reviewed and updated

• Types of Variables:
• Identifying information
• Demographic information
• Clinical information
• Risk factor information
• Reporter information
• (Contact information, sometimes
Which Variables to Always include:
• Components of case definition
• Case name or identifying number
• Date of symptom onset (or specimen collection date)

Usually include: Age, gender

• May include:
• Other relevant demographic variables (race, occupation)
• Relevant risk factors
Step : 6 Set up immediate control measures
• The target is to keep the outbreak confined to the geographical locus of the initial
cases
• Identify all suspected cases
• For less virulent diseases, initiate barrier nursing
• For more virulent diseases (e.g. VHF) undertake quarantine
• Treat cases, to interrupt transmission and reduce mortality/complications
• For virulent diseases, trace all contacts and ‘isolate them’ for the duration of the
incubation period
• Massive disinfection of fomites/equipment/
• Use of protective wear (PPE) and following strict protocols for application
depending on the infectivity of the agent causing the outbreak
Step 7: Assess the local response
• Establish an incident command centre that coordinates actors
• Establish a communication office that maintains situational awareness to avoid misinformation, panic,
distrust
• Establish a district level task force and allocate them their responsibilities, including community
mobilization and IEC. The task force may include politicians, civil society organizations and the DHT.
• Ascertain the number and type of personnel as well as logistics available for case management (drugs,
medical supplies, guidelines)

Step 8: Address the resource gaps

• This depends on the nature and extent of the outbreak, as well as the capacity at the district. Resources
may be needed in the areas of laboratory support, IEC, and specific infection control needs like JIK,
protective wear and vaccines.
• Provide ‘Just-in-time’ training to enhance the ‘surge capacity’
Step 9: Describe the Outbreak
• Using available information, analyze data to establish the exposure risk factors.
Define the numerator (the cases) and the denominator (population at risk).
• Who is affected? When and Where?
• We can also pose the question – why, how and what?
• Use appropriate tools to display the data (graphs, spot maps etc.)
• Determine the size of the population at risk, using spatial and temporal criteria
and relating them to how the disease in spread
• Calculate the attack rates and case fatality rates.
Step 10: Formulate and test hypothesis
• Formulate a hypothesis on the source of the event, its transmission, the causative
agent, and the exposure risk factors
• Look for combinations or interactions of various factors
• Subject matter knowledge – known sources, vehicles, transmission modes
• Review descriptive epidemiology – what would account for most cases?
• Outliers (unique exposure opportunities)
• Talk to case-patients – what do they think?
• What do local health officials think?
• We can conduct analytical studies (especially case control) to ascertain this
Step 11: Report writing and dissemination
• Prepare a report describing the situation using the experiences
and answers you have obtained
• Recommend priorities and control measures to be addressed and
make deductions on the outbreak
• Disseminate your findings to those who need to know and act
(Ministry of health, the DHT and the District Local Council)
• Disseminate to the community, especially through their leaders
(Village and Sub-county health teams, parish development
committees etc).
Step 12: Be on your guard
• Put in place measures to prevent other outbreaks
• Learn from the response to avoid similar situations that led to
the crisis in the future
• Build local response capacity for future events
 The Incubation period
• Three critical questions in investigating an outbreak are:
When did the exposure begin?
When did the disease begin?
What was the incubation period of the disease?
• Incubation period: Time interval between invasion by an infectious agent and appearance of the first sign and symptom of
the disease in question.
• The Epidemic curve
• Used to detect and characterize an outbreak
• We often make a plot of cases over time
• This is known as the epidemic curve. Time may be a direct expression. Time may be a logarithmic function (Log – time)
• There are mainly two types of curves
a) The Single exposure-common vehicle epidemic curve
b) The Multiple exposure curve
 Epidemic curves

• Definition:
• An epidemic curve (a histogram ) is a graphical
depiction of the number of cases of illness by the date
of illness onset.
• There should not be any space between the x- axis
categories
 Types of Epidemics
Single exposure common vehicle outbreaks:
• They are explosive, with a rapid increase in the number of cases in a population
• They are limited to people who share a common exposure
• Secondary cases rarely occur
• An example is the food-borne outbreaks

Multiple exposures epidemics:

• There is a factor (vehicle or vector) that propagates the transmission process
• The person who acquires the disease from the initial source is the primary case
• The person who acquires the disease from a primary case is the secondary case
 How can it help in an outbreak?
• An epi curve can provide information on the following characteristics
of an outbreak:
1. Pattern of spread
2. Magnitude
3. Outliers
4. Time trend
5. Exposure and/or disease incubation period
 Outbreak pattern of spread

• The overall shape of the epi curve can reveal the

type of outbreak
• Common source
• Point source
• Propagated
 Common source Outbreak
• An outbreak due to transmission from a single environmental
or human 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
• Continuous exposure will often cause cases to rise gradually
(and possibly to plateau, rather than to peak)
 An epi curve for a common source
outbreak with intermittent exposure
An epi curve for a common source
outbreak with continuous exposure
 Point source outbreak
 Typically shows a sharp upward slope and a
gradual downward slope
 Is a common source outbreak in which the
period of exposure is brief, and all cases occur
within one incubation period
An epi curve for a point source outbreak
 Propagated
 Is spread from person to person
outbreak
 Can last longer than common source outbreaks
 May have multiple waves
 The classic epi curve for a propagated outbreak has
progressively taller peaks, an incubation period apart
 Outbreaks may begin as a common-source one followed by
person-to-person spread (e.g., viral gastroenteritis caused by
ingestion of contaminated salad)
An Epi Curve for a Propagated Outbreak
 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, e.g. age, gender, & geographic
information
 Outbreak time trend
• Allow information about the time trend of the outbreak to be
gleaned
• Consider:
 Date of illness onset for the first case
 Date when the outbreak peaked
 Date of illness onset for the last case
 Outbreak Outliers
 Outliers are cases at the very beginning and
end that may not appear to be related
 First check to make certain they are not due
to a coding or data entry error
 Outbreak Outliers

• If they are not an error, they may represent;

 Baseline level 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
 How to plot an epidemiology curve

• Plot the number of cases of disease reported

during an outbreak on the y-axis
• Plot the time or date of illness onset on the x-axis
 How to plot an epi curve
• Technical tips
 Choice of time unit for x-axis depends upon the incubation period
 Begin with a unit approximately a quarter of the incubation
period
 If the incubation period is not known, graph several epi curves
with different time units
 How to plot an epi curve
 Usually day of onset is the best unit for the x-axis
 If the incubation period is very short, hour of onset
may be more appropriate (e.g., Staphylococcus aureus)
 If the incubation period is very long, week or month
may be more appropriate (e.g., hepatitis B or TB)
 How to plot an epi curve
 Epi curves are histograms
 Label each axis
 Provide a descriptive title
 Include the pre-epidemic period to show the
baseline number of cases
 Summary
• Epi curves are useful in outbreaks to;
1. Identify the pattern of spread
2. Assess the magnitude
3. Evaluate time trends
4. Examine Outliers
5. Estimate the exposure period