Describe and Demonstrate the steps in the

Investigation of an Epidemic of
Communicable diseases
and
Describe the principles of control measures

CM 7.7(SGD/L)
 Goals

• The goals of this presentation are to:

– Provide a general overview of the basic
steps of disease outbreak investigations
– Describe factors that may contribute to a
decision to investigate

Snow’s “shoe leather epidemiology”

serves as a model of critical thinking and
public health action.
 Outbreaks: The basics

• Goals of an outbreak investigation:

– To identify the source of illness
– To guide public health intervention
• Ways to recognize an outbreak:
– Routine surveillance activities
– Reports from clinicians and laboratories
– Reports from affected individuals
Why investigate an outbreak?

• Characterize a public health problem

• Identify preventable risk factors
• Provide new research insights into disease
• Train health department staff in methods of public
health investigations and emergency response
Steps of an outbreak investigation

1. Verify the diagnosis and confirm the

outbreak
2. Define a case and conduct case finding
3. Tabulate and orient data: time, place,
person
4. Take immediate control measures
Steps of an outbreak investigation

5. Formulate and test hypothesis

6. Plan and execute additional studies
7. Implement and evaluate control measures
8. Communicate findings
Steps of an outbreak investigation

These steps may occur

simultaneously or be repeated as
new information is received.
 Verify the diagnosis and
confirm the outbreak

• Confirm laboratory testing

• Rule out misdiagnoses or laboratory error
 Define a case and conduct case finding
• Develop a specific case definition using:
– Symptoms or laboratory results
– Time period
– Location
• Conduct surveillance using case definition
– Existing surveillance
– Active surveillance (e.g. review medical records)
• Interview case-patients
 Tabulate and orient data

• Create line listing

• Person
– Who was infected?
– What do the cases have in common?
• Place
– Where were they infected?
– May be useful to draw a map
• Time
– When were they infected?
– Create an epidemic curve
Take immediate control measures

• If an obvious source of the contamination is

identified…institute control measures
immediately!
Formulate and test hypothesis

• Develop hypotheses
– literature reviews of previous outbreaks
– interviews of several case-patients
• Conduct an analytic study to test
hypotheses
– Retrospective cohort study
– Case-control study
Plan and execute additional studies
Environmental sampling
– Collect appropriate samples
– Allow epidemiological data to guide testing
– If analytic study results are conclusive, don’t wait
for positive samples before implementing
prevention
 Implement and
evaluate control measures

• Prevent further exposure and future

outbreaks by eliminating or treating the
source
• Work with regulators, industry, and health
educators to institute measures
• Create mechanism to evaluate both short-
and long-term success
 Communicate findings

• Identify a single member of the

investigation team to interact with media
and communicate progress and findings
• Summarize investigation, make
recommendations, and disseminate report
to all participants
 Conclusions
• The steps listed for an outbreak investigation
comprise a brief introduction and rough guide.
• Only by conducting investigations repeatedly over an
entire career will public health professionals truly
learn the methods of outbreak investigations.
 Online resources

• Information for Public Health Professionals- Investigating

Foodborne Disease Outbreaks. Available online at:
http://www.cdc.gov/foodborneoutbreaks/
info_healthprofessional.htm
• To conduct an online outbreak investigation, “Botulism in
Argentina,” visit the CDC website at:
http://www.phppo.cdc.gov/phtn/casestudies/
computerbased/default.htm
• To explore an historical outbreak investigation, visit the
online UNC John Snow Case Study at:
http://www.sph.unc.edu/courses/Course_support/
Case_studies/John Snow
 References

• Michael Gregg. Field Epidemiology. 2nd edition.

Oxford University Press, 2002.
• Control of Communicable Disease in Man, 17th
edition. Chin, J (ed). APHA, 2000.
• Principles & Practice of Infectious Diseases, 5th
edition. Mandell GL, Bennett JE, Dolin R (eds).
Churchill Livingstone; 2000