Chapter-8

Outbreak Investigation
 Outbreak: definition

Occurrence of a specific disease more

than the expected number in a given
area or among a specific group of
people over a specified period of time.
Expected Vs Excess Cases

Number of
cases

Epidemic/Outbreak

Hyper-endemic

Endemic

Time
Example: Malaria Endemicity

Holoendemic transmission occurs all year long

Hyperendemic intense, but with periods of no

transmission during dry season.

Mesoendemic regular seasonal transmission

Hypoendemic very intermittent transmission.

 CLUSTER

Aggregation of cases in a given area

over a particular period without
regard(consider) to whether the
number of cases is more than expected.
 Disease Clustering
• Clustering is commonly due to an aggregation of
relatively rare events or diseases in time and/or
place.

• Clustering could be a mini-epidemic of a rare

event in which occurrence of the disease is
clearly in excess of that expected.

• Clusters provide useful clues to public health

action but often they are difficult to handle
because of small number.
 Patterns/Types of Epidemics
1. Common source epidemics
– Point source
– Continuous common source
– Intermittent common –irregular interval

2. Propagated (cause to increase in number) or

progressive epidemics
3. Mixed Epidemics
Typical Point source
epidemics
Peak of
Outbreak

Minimum
incubation
period
 Common source epidemics
Number of
cases

Continuous Common Source

Time
 Intermittent Common Source
Number of
cases

Time
Typical Propagated Epidemic Curve
 Basic Principles of Outbreak
Investigation
• Conduct multiple activities are simultaneously; run a
dynamic process
• Maintain communication with officials, stakeholder and
the public
• Apply epidemiological and statistical principles
regarding study design and analysis appropriately
• Record all steps taken in the investigation and all
information gathered
• Careful and critical review of the literature should be
undertaken
• Investigators must maintain open but critical mind to
uncovered new pathogens/transmission means
Steps in Outbreak Investigation
1. Prepare for field work
2. Verify the existence of an outbreak
3. Verify the diagnosis
4. Define and identify cases
5. Perform descriptive epidemiology
6. Develop hypotheses
7. Evaluate hypotheses
8. Implement control and prevention measures
9. Communicate findings
What should be the priority action in an
outbreak?

Source/Mode of Transmission

Causative
Agent
 1. Prepare for fieldwork
A. Investigation related: obtain appropriate scientific
knowledge, supplies, and equipment to carry out the
investigation; discuss with knowledgeable people, review
applicable literature, and collect sample questionnaire.
Who will be responsible for what? Day-to-day activities, supervision,
writing report...

B. Administration related: observe all administrative

procedures; including transportation and organising personnel
matters.

C. Establish local contacts

 2. Verify the existence of an epidemic
• Compare the reported/observed number of cases
with the expected number of cases in the area.

Excess may be due to :

• changes in local reporting procedures
• changes in case definition
• increased interest because of local or national
awareness
• improvements in diagnostic procedures
• sudden changes in population size
 Statistical Process Control (SPC):
tool for verifying epidemic

Mean + 3
UCL
Mean + 2
Disease
Frequency
Mean

Mean - 2
LCL
Mean - 3

UCL= upper control limit

Time interval
LCL= lower control limit
3. Verify the diagnosis
Review clinical and laboratory findings to
establish diagnosis.

3.1 Case definition

3.2 Surveillance - identifying and counting cases

 Case Definition

Case definition is a standard set of

criteria for deciding whether an
individual should be classified as
having the health condition of
interest.

• Includes clinical criteria, particularly in

an outbreak investigation, restricted by
time, place, and person as necessary.
 Case Definition: application
• Make case definition:
– Simple and objective measures
• apply consistently to all persons under
investigation

– Do not include an exposure or risk factor

– Use "loose“ (not fixed) case definition early

to capture all potential cases
 Classification of Case
definition
• Definite(confirmed) laboratory
confirmed case

• Probable: cases with objective signs

and symptoms consistent with the case
definition

• Possible: cases with subjective signs

and symptoms consistent with the case
definition
Possible Reasons for Pseudo-Outbreak:
false verification

• Incorrect diagnosis
• Failure to separate colonization from
infection
• Chance clustering
• Contamination during specimen collection,
transportation, or processing (contaminated media,
solutions, or equipment)

• Error in laboratory methods

Surveillance During Outbreaks

1. Stimulated or enhanced passive surveillance

2. Active surveillance

Collect information about PERSON, PLACE AND TIME on

every case including:
– Identifying information
– Demographic information
– Clinical information
– Risk factor information
– Reporter information
 4. Describe the epidemic with respect
to time, place, and person
• Epidemic curve plots the cases by the time of onset and
provides a timeframe 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.
Keep a Record of Each Case
Epidemic Curve: Meningitis Epidemic in Addis
Ababa, Ethiopia, 2000

200
180
160
Number of cases

140
120
100
80
60
40
20
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 27 28 29 30
Week since 19/07/92 Eth. Calender
 Outbreak described by PERSON:
Overall Attack Rate of Reported Meningococcal Meningitis
Cases by age group in Addis Ababa. 2000

Age Estimated Cumulative Attack rate

Population Number of per 100,000
group
From 1994 census Cases

0-4 170,667 117 68.5

5-14 599,146 293 48.9

15-29 820,316 531 64.7

30+ 522,608 173 33.1

Total 2,112,737 1114 52.7

Spot Map: use frequency
5. Formulate and Test Hypotheses

• Identify cause

• Identify events/factors leading to

epidemics
 Additional Data Collection

6. Search for additional cases: locate

unrecognised or unreported cases.

7. Analyse the Data

8. Make a decision on the hypotheses tested

 9. Intervention and follow-up
• Appropriate and Adequate interventions
• Make sure the epidemics is controlled
 10. Report of the investigation
• At the end prepare a comprehensive report and submit
to the appropriate/concerned agency (or agencies).

• The report should follow the usual scientific format:

introduction, background, methods, results, discussion,
and recommendations.

• The report should discuss in detail:

– Factors leading to the epidemic
– Effectiveness of the measures used for the control of the
epidemic
– Recommendations for the prevention of similar episodes in
the future
 Detecting Outbreaks
Outbreaks are detected in one of the following
ways:

 Through timely analysis of routine surveillance

data

 Report from clinician

 Report from the community, either from the

affected group or concerned citizen
 Managing Outbreak/epidemics
1. Measures Directed Against the Reservoir

2. Measures that interrupt the transmission of

organisms

3. Measures that reduce host susceptibility

Measures Directed Against the Reservoir
Domestic •Immunization
animals as •Testing of herds
reservoir •Destruction of infected animals

Wild animals as •Post-exposure prophylaxis

reservoir

Humans as •Removal of the focus of infection

reservoir •Isolation of infected persons.
•Treatment to make them non-
infectious.
•Disinfection of contaminated objects.
 Measures that interrupt the transmission of
organisms
For diseases •purification of water
transmitted by •pasteurization of milk
ingestion •inspection procedures designed to ensure
safe food supply.
•improve housing conditions.
For disease •chemical disinfection of air and use of
transmitted by ultraviolet light.
respiratory routes •work on ventilation patterns, like
unidirectional ("laminar") air flow to reduce
the transmission of organisms in hospitals
For diseases whose •clearing irrigation farms from snails to
cycles involve an control schistosomiasis.
intermediate host
Measures that reduce host susceptibility
Active immunization • Mass vaccination
• 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.
 Why Investigate Possible Outbreaks
• To institute control and prevention measures
• Opportunity for program evaluation
• Opportunity for research
– uncovered new infectious agents and diseases (Legionnellosis,
toxic shock syndrome, Ebola…),
– uncover spread of agent/disease to new geographic areas (West
Nile-like virus encephalitis),
– uncover new means of disease transmission (E. Coli from
swimming pools)

• Training opportunity
• Public, political, or legal concerns
 Challenges of Investigating
Outbreaks
• Urgency- to find the source and prevent
additional cases.
• 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
Thanks@!!!