Outbreak Investigation and Surveillance

Abdulnasir A. (MPH, PHDc)

MOH/AAU-SPH
 Objectives

♦ Describe terminologies in an outbreak

investigations.
♦ Describe how an outbreaks are
recognized
♦ Discuss purpose of an outbreak
investigation.
♦ Describe key steps of an outbreak
investigation.
Terminologies
 Exercise

♦ 22 cases of legionellosis occurred within 3

weeks among residents of a particular
neighborhood (usually 0 or 1 per year).
♦ Over 20 million people worldwide died from
influenza in 1918–1919.
♦ About 60 cases of gonorrhea are usually
reported in a region per week, slightly less than
the national average.
Type of Epidemic
 Type of Epidemic

Common Source
♦Point
♦Intermittent
♦Continuous
Propagated
 Point source outbreaks

♦ All the exposures tend to occur in a

relatively brief period.
♦ Tend to have epidemic curves with a rapid
increase in cases.
♦ All of the cases tend to fall within one
incubation period.
Point source outbreaks
 Common Source- Intermittent
Exposure

♦The epi curve includes multiple peaks with valleys

when there are fewer or no cases.
♦The exposure is not continuous or steady, but
intermittent, occurring at irregular intervals over time.
♦Intermittent access to a play yard contaminated with
roundworm and hookworm eggs.
♦Case numbers peak at irregular times corresponding to
the earlier exposures.
Common Source- Intermittent
Exposure
 Common Source- Continuous
Exposure
♦ Rise to a peak and then fall, but the cases
do not all occur within the span of a single
incubation period.
♦ An ongoing source of contamination.
Common Source- Continuous
Exposure
Propagated (Person to Person)

♦ Person-to-person, rather than from a

common source.
♦ Epidemic curves usually have a series of
successively larger peaks.
♦ The successive waves tend to involve
more and more people, until the pool of
susceptible people is exhausted or control
measures are implemented.
Propagated (Person to Person)
 Exercise

21 cases of shigellosis among children and

workers at a daycare center over a period of
6 weeks, no external source identified
(incubation period for shigellosis is usually 1
—3 days)
 Exercise

36 cases of giardiasis over 6 weeks traced

to occasional use of a supplementary
reservoir (incubation period for giardiasis 3–
25 days or more, usually 7–10 days)
 Exercise

43 cases of norovirus infection over 2 days

traced to the ice machine on a cruise ship
(incubation period for norovirus is usually
24–48 hours)
 Exercise

The incubation period for hepatitis ranges

from 15-50 days, with an average of about
28-30 days. An epidemic of hepatitis A rise
and fall of new cases occurred within about
a 30 day span of time, what is the type of
epidemic?.
 Exercise

An outbreak of measles began with a single

index case who infected a number of other
individuals. (The incubation period for
measles averages 10 days with a range of
7-18 days.). One or more of the people
infected in the initial wave infected a group
of people who become the second wave of
infection.
♦So here transmission is?
♦What type of epidemic?
Epidemic Curve
How Outbreaks are Usually Recognized?
 How Outbreaks are Usually
Recognized?
Surveillance systems
♦Routinely track of data
♦Compare to historical data
♦Acts as a baseline.
Public health partners
♦Neighboring regions, provincial/territorial/
investigators may send notifications of
clusters of illness.
 How Outbreaks are Usually
Recognized?
♦ The public can report their illnesses and
suspected exposures directly to public health,
either as part of routine public health follow-up
or as a complaint.
♦ Health care providers such as emergency
room, and long term care home nurses and
physicians communicate with public health if
they notice an unusual increase in illnesses.
Purposes of Outbreak Investigation
South Omo Zonal Health Department (ZHD)
reported deaths with unknown causes from South
Ari district to Public Health Emergency
Management (PHEM) of the Southern Nations
Nationalities and Peoples Region (SNNPR) in
November 2012. The main clinical manifestations
were fever, headache, nausea and bloody vomiting.
Source: Lilay, A., Asamene, N., Bekele, A. et al. Reemergence of yellow fever in
Ethiopia after 50 years, 2013: epidemiological and entomological investigations. BMC
Infect Dis 17, 343 (2017). https://doi.org/10.1186/s12879-017-2435-4
The regional PHEM notified Ethiopian Public
Health Institute (EPHI) in late of March 2013 for
conducting further investigation and
characterizing the outbreak. After the request,
team from EPHI and World Health Organization
(WHO) Country Office deployed to the affected
area in the end of March 2013.
What is the purposes of investigating an outbreak?

Source: Lilay, A., Asamene, N., Bekele, A. et al. Reemergence of yellow fever in
Ethiopia after 50 years, 2013: epidemiological and entomological investigations. BMC
Infect Dis 17, 343 (2017). https://doi.org/10.1186/s12879-017-2435-4
 Purposes

Detection Future
Source
Outbreak

Control/ Surveillan Prevent

Prevent ce Spread
Steps of an Outbreak Investigation
The Waghemra zone is one of the malaria-prevalent areas in
the Amhara region in Ethiopia. On September 12, 2022,
malaria monitoring data obtained from the Zone Health Office
revealed that the districts were experiencing high number of
malaria cases. In WHO epidemiologic week 36 of 2022, a total
of 190 malaria cases were registered, compared to only 122
cases in the same epidemiologic week during the threshold
period (2016–2020). On September 14, 2022, a team was
deployed to the affected districts.
If you were part of the team, what steps you follow to
investigate the outbreak?.

Source: Debash H, Nigatie M, Bisetegn H, Feleke DG, Tesfaw G, Amha A, Abate MA, Gedefie A. Malaria surveillance,
outbreak investigation, response and its determinant factors in Waghemra Zone, Northeast Ethiopia: unmatched case-control
study. Sci Rep. 2023 Jun 19;13(1):9938. doi: 10.1038/s41598-023-36918-3. PMID: 37336906; PMCID: PMC10279665.
 Steps of an Outbreak Investigation

1. Prepare for field work

2. Confirm Existence of an Outbreak
3. Verify the Diagnosis
4. Establish a Case Definition:
5. Find cases systematically and record
6. Perform Descriptive Epidemiology
7. Develop Hypotheses
8. Evaluate Hypothesis
9. Implement Control / Prevention Measures
Prepare for field work
Confirm existence of outbreak
On wednesday morning, July 12/2018, one
Suspected measles case was reported from Golbo
Arba Kebele in Artuma Fursi Woreda. Within 2 h,
three field Epidemiology residents and one Artuma
Fursi Woreda health office Public health
Emergency officer visited the reported Kebele to
confirm the existence of the outbreak.
How do we conform existence of an outbreak?

Source: Tariku, M.K., Misikir, S.W. Measles outbreak investigation in Artuma Fursi Woreda, Oromia Zone, Amhara Region,
Ethiopia, 2018: a case control study. BMC Res Notes 12, 765 (2019). https://doi.org/10.1186/s13104-019-4806-y
 Confirm existence of outbreak

Compare the current rate of occurrence of

the disease to what “normally” occurs to
determine if there is a rise in cases beyond
what is normally experienced.
 Confirm existence of outbreak

• Endemic versus outbreak/epidemic

• Real versus artifact
Confirm Existence of an Outbreak
Number of Cases of a Disease

Time
Confirm Existence of an Outbreak

♦ Changes in local reporting.

♦ Changes in case definitions.
♦ Increased interest in particular diseases.
♦ New physicians in the area or those who
might be specialists in certain diseases.
♦ New diagnostic procedures which might
identify new or existing infectious agents.
♦ Increased populations or new arrivals into the
area.
 Verify the Diagnosis

Obtaining Clinical History

♦Interviewing ill persons
♦Family members
♦Physicians
 Verify the Diagnosis

Laboratory Specimen Collection

♦Review the method of laboratory testing, (e.g.,
sputum swabs, blood tests, stool culture, and
select isolates).
♦Obtain laboratory evidence of positive test results
from established laboratories and accepted tests.
♦In some instances, there will be outbreaks of
unknown etiology, and there will be no laboratory
results forthcoming to confirm the diagnosis.
Verify the Diagnosis

COLLECT
SAMPLES!
Verify the Diagnosis

Regional or national laboratory

 Establish Case Definition:

♦ After establishing that an outbreak is

occurring and attempting to verify the
correct diagnosis.
♦ A crucial step is to define what constitutes
a case in this investigation.
♦ The case definition is then used to identify
and count cases.
What is case definition?
 Establish Case Definition:

♦ A case definition is a set of criteria for deciding

whether an individual ill person should be
classified as a case.
♦ The case definition places boundaries on who
will be counted as a case, so the investigation
does not include those with illnesses unrelated
to the outbreak.
♦ This step helps to get an idea of the magnitude
of the problem and records all cases for follow-
up in the investigation.
 Establish Case Definition:

Confirmed

Mo
in

re
ta
er

inc
Probable
c

lus
re
Mo

ive
Suspect or Possible
Perform Descriptive Epidemiology
On wednesday morning, July 12/2018, one
Suspected measles case was reported from Golbo
Arba Kebele in Artuma Fursi Woreda. Within 2 h,
three field Epidemiology residents and one Artuma
Fursi Woreda health office Public health
Emergency officer visited the reported Kebele to
confirm the existence of the outbreak.
How do you describe cases in person, place
and time, after confirming the existence of
an outbreak?
Source: Tariku, M.K., Misikir, S.W. Measles outbreak investigation in Artuma Fursi Woreda, Oromia Zone, Amhara Region,
Ethiopia, 2018: a case control study. BMC Res Notes 12, 765 (2019). https://doi.org/10.1186/s13104-019-4806-y
 Perform Descriptive Epidemiology

♦ 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?
 Develop Hypotheses

♦ Which specific exposure(s) may have

caused the disease?
♦ The illness was caused by?
 Develop Hypotheses

♦ Subject matter knowledge – known

sources, vehicles, transmission modes
♦ Review descriptive epidemiology – what
would account for most?
♦ Outliers (unique exposure opportunities)
 Implement Control / Prevention
Measures
♦ Implement as early as possible!
♦ Usually targeted to:
– Eliminate or treat the source
– Interrupt transmission
– Reduce susceptibility
♦ Create mechanism to evaluate both short
and long-term effectiveness of control /
prevention measures
 Strategy for Controlling Infectious
Diseases
♦ Identifying and reducing or eliminating
infectious agents at their sources and
reservoirs
♦ Breaking or interfering with the routes of
transmission of infectious agents
♦ Identifying susceptible hosts and reducing
or eliminating their susceptibility
 Control Strategies for Reservoir

♦ Human Treat infected patient

Decontaminate
♦ Environment Disinfect

Vaccinate
Control/Cull
♦ Animal
 Prevention
Opportunities
Scenario 1
Primary 1st case Samples Lab Response
Report
Case at HC taken result begins
100

80
Opportunity
60 for control
40

20

0
1 5 9 13 17 21 25 29 33 37
Days
 Prevention Opportunities
First
Detection/
CaseConfirmation
Reporting
Scenario 2
Investigation
Response
Opportunity
90 for control
80
70
60
CASES 50
40
30
20
10
0

DAY
Public Health Surveillance
 Learning Objectives

♦ Define surveillance
♦ Identify purposes of surveillance
♦ Compare types of surveillance systems
♦ Describe existing surveillance systems in
the country where you work
Define surveillance
What is Public Health Surveillance?

“Ongoing systematic collection, analysis,

interpretation, and dissemination of data
regarding a health related event for use in
public health action to reduce morbidity and
mortality and to improve health.”

CDC. Guidelines for evaluating public health surveillance

systems. MMWR 2001;50 (No. RR-13)
 What is Public Health Surveillance?

Information for action!

“The reason for collecting, analyzing and

disseminating information on a disease is to
control that disease. Collection and analysis
should not be allowed to consume resources if
action does not follow.”

William Foege et al., Int. J of Epidemiology 1976; 5:29-37

Establish Surveillance
Purposes of public health surveillance
Purposes of public health
surveillance
Types of public health surveillance
 Passive vs. Active Surveillance

♦ Passive: reporting by providers or labs

without active role for public health system
– E.g., national notifiable disease reporting
systems
♦ Active: public health system actively
involved in solicitation of cases
– Usually special surveillance systems to
address specific questions
 Passive Surveillance Systems:
Characteristics
Advantages Disadvantages
♦ Less work for health ♦ Data quality difficult to
agency control (under-
♦ Inexpensive reporting)
♦ Voluntary ♦ May not be
♦ Still portray trends representative
and detect outbreaks ♦ May not be timely
 Active Surveillance Systems:
Characteristics
Advantages Disadvantages
♦ More complete ♦ Requires more
reporting health agency
♦ More timely and resources
accurate
information
♦ Representative
data
 Sentinel Surveillance: Definition

Surveillance based on selected population

samples chosen to represent the relevant
experience of particular groups
 Sentinel-site surveillance

♦ Surveillance for specific diseases or

syndromes at selected sites
– Hospitals
– Large outpatient clinics
– Laboratories
♦ Does not include all health care facilities
 Sentinel-site surveillance

Advantages Disadvantages
♦ Easier ♦ Cannot obtain rates of
♦ Less expensive disease since
♦ Usually involves denominator is
referral centers with estimated
better laboratories ♦ Not representative of
total population
 Surveillance mechanisms

♦ Indicator-based surveillance (IBS)

♦ Event-based surveillance (EBS)
 Examples of IBS systems include
♦ Facility-based surveillance: health facilities routinely
and regularly report to the next level on prioritised
conditions.
♦ Case-based surveillance: ongoing and rapid
identification of identifiable cases for case follow-up. It is
applied to conduct surveillance of communicable
diseases including those targeted for
elimination/eradication and during outbreaks.
♦ Sentinel surveillance: for specific conditions in a
specific cohort, such as a geographical area or
population subgroup, to estimate trends in a larger
population.
 Examples of IBS systems include

♦ Syndromic surveillance: active or passive system

that uses standard case definitions, based entirely on
clinical features, without any laboratory diagnosis.
♦ Laboratory-based surveillance: conducted at
laboratories to detect events or trends, which may not
be seen as a problem at other locations.
♦ Disease-specific surveillance: involves surveillance
activities aimed at targeted health data for a specific
disease for vertical surveillance
 Event-based surveillance

Event-based surveillance (EBS) is an

organised collection, monitoring,
assessment, and interpretation of mainly
unstructured, ad-hoc information regarding
health events or risks, which may represent
an acute health risk.
Public Health Emergency Managemnt
System in Ethiopia
 PHEM

PHEM is the process of

– Anticipating
– Preventing
– Preparing for
– Detecting
– Responding to
– Controlling and
– Recovering from consequences of Public
Health threats in order that health and
economic impacts are minimised;
 Public Health Emergencies

1.Epidemics of communicable disease

2.Drought with malnutrition
3.Food contamination
4.Flood
5.Pandemic Influenza
6.Conflict and displaced populations
7.Accidents incl. chemical spills
8.Earthquake, volcano
9.Bioterrorism
 Priority diseases/conditions for surveillance

♦ High epidemic potential (anthrax, avian human

influenza, cholera, measles, meningococcal meningitis,
pandemic influenza, smallpox, severe acute respiratory
syndrome (SARS), viral hemorrhagic fever (VHF), and
yellow fever)
♦ Required internationally under IHR2005 (smallpox,
poliomyelitis due to wild-type poliovirus, human
influenza caused by a new subtype, SARS)
 Priority diseases/conditions for surveillance

♦ Targeted for eradication or elimination (poliomyelitis due

to wild-type poliovirus, dracunculiasis, neonatal tetanus
(NNT),
♦ Have a significant public health importance (rabies,
dysentery, malaria, relapsing fever, typhoid fever, typhus and
severe malnutrition);
♦ Diseases that have available effective control and
prevention measures for addressing the public health
problem they pose
 List of diseases/conditions under Surveillance
in Ethiopia
Immediately Notifiable Weekly reportable
1. Acute Flaccid Paralysis

2. Anthrax 1. Dysentery
3. Avian Human Influenza 2. Malaria
4. Cholera 3. Meningitis
5. Dracunculiasis/Guinea warm
4. Relapsing
6. Measles
5. Typhoid Fever
7. Neonatal tetanus

8. Pandemic Influenza A(H1N1)

6. Typhus
9. Rabies 7. Severe Acute Malnutrition
10. Small pox

11. SARS

12. Viral Hemorrhagic Fever(VHF)

Plus others…..
13. Yellow Fever

14. Maternal death

 Reporting tools

♦ Weekly reporting form for health post / HEW

♦ Weekly reporting format for other levels

♦ Daily epidemic reporting format for Woreda(DERF-W)

♦ Daily epidemic reporting format for Region(DERF-R)

♦ Case based reporting format (CRF) for many diseases

♦ AFP case investigation form

♦ Guinea worm case based reporting format

♦ Guinea worm line list

 Reporting tools

♦ Influenza case based reporting format

♦ Line list(for all diseases)

♦ Rumor log book for suspected epidemics (for any type of

public health rumors)
♦ Case based laboratory reporting form (CLRF)

♦ Maternal death identification and notification

♦ Verbal autopsy

♦ Maternal death reporting format (MDRF)

 Public health emergency preparedness

♦ Coordination and collaboration

♦ Vulnerability assessment and risk analysis;

♦ Planning & resource mobilization;

♦ Exercise/drill – test the plan regularly;

♦ Capacity building - System and Human

♦ Stockpile system –Drugs, Vaccines, PPE…

 Public health emergency response

♦ Rapid assessment/outbreak investigation

– Epidemiological

– Laboratory

♦ Control, preventive and supportive measures

– Isolation and quarantine

– Case management

– Mass vaccination

– Monitoring of drug sensitivity

– Environmental management
 Recovery

♦ Impact assessment
♦ Monitoring and evaluation
♦ Restoration of the health system
– Infrastructure
– Supplies
– Health Personnel

♦ Liaison with multisector committee

 Assignments
1. Impact of the pandemic on the HIV/AIDS program in Ethiopia
2. Impact of the pandemic on the NCD program in Ethiopia.
3. Impact of the pandemic on the RMNCHN in Ethiopia
4. Maternal Mortality Surveillance Implementation Challenges in
Ethiopia
5. The role of private hospitals during pandemic responses in
Ethiopia
6. Challenges of the pandemic to clinical services delivery in
Ethiopia.
7. COVID -19 morbidity and mortality in Ethiopia: Lessons from
cases management
8. One health implementation challenges in Ethiopia.
9. Lessons from mortality surveillance implementation in Ethiopia.
10.Malaria elimination progresses and achievements in Ethiopia
Thank you