Investigating an outbreak

Ephrem , MPHE
 Epidemic/ Outbreak
Epidemic: occurrence in excess of the usual frequency in a
given area or among a specific group of people over a
particular period of time.

Outbreak: Epidemics of shorter duration covering a more

limited area.

Types of epidemics
• Epidemics (outbreaks) can be classified according to the
method of spread or propagation, nature and length of
exposure to the infectious agent, and duration.
 Types of epidemics cont…

A. Common Source Epidemic.

• Disease occurs as a result of exposure of a group of susceptible persons
to a common source of a pathogen, often at the same time or within a
brief time period.

• When the exposure is simultaneous, the resulting cases develop within

one incubation period and this is called a point source epidemic.

• The epidemic curve in a point source epidemic will commonly show a

sharp rise and fall.

• E.g Food borne epidemic following an event where the food was served
to many people.
 Types of….
• If the exposure to a common source continues over
time it will result in a continuous common source
epidemic.

• E.g A waterborne outbreak that is spread through a

contaminated community water supply

• The epidemic curve may have a wide peak because

of the range of exposures and the range of incubation
periods.
 Types of….
B. Propagative/ Progressive Epidemics.
• infectious agent is transferred from one host to another.

• It can occur through direct and indirect transmissions.

• Propagative spread usually results in an epidemic curve with a relatively

gentle upslope and somewhat steeper tail.
E.g outbreak of malaria.

• When it is difficult to differentiate the two types of epidemics by the

curve, spot map can help.

• In the propagated epidemics there will be successive generations of

cases.
 Types of….
C. Mixed Epidemics.
• The epidemic begins with a single, common
source of an infectious agent with subsequent
propagative spread.
• Many food borne pathogens result in mixed
epidemics.
What is the reason for investigating?
1. To institute control and prevention measures
2. A good opportunity for research and training
• It presents a unique opportunity to study the
natural history of the disease in question
• It could be a good opportunity to gain
additional knowledge

3. Political concern and legal obligation

4. Program considerations
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1. To Institute control/ prevention measures

• It is the primary public health reason to

investigate an outbreak

• Before we do a control strategy, we should

identify where the outbreak is in its natural
course.

Is the outbreak continuing? or………..

…………………. Is it just about over?

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 Cont…
 If it is continuing, our major goal should be

 to prevent additional cases.

 If the outbreak is almost over, our goal

 to prevent outbreaks in the

future.
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 1. Early recognition
Time that come
to attention of
Investigators

Time
Major aim:
To prevent additional disease occurrence
(ie institution of preventive and control mechanism)
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2. Late recognition
Time that come
to attention of
Investigators

Time
Major aim:
to prevent outbreaks in the future.
(ie further investigation)
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 Cont…
 Choosing between control measures versus further
investigation depends on how much is known about
 the cause,
 the source of the outbreak
 the mode of transmission of the agent

 If we know only little about the outbreak, further

investigation is needed to design an appropriate
control measure

 In contrast, if we know well about the outbreak,

control measures should be instituted immediately.
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STEPS IN AN OUTBREAK
INVESTIGATION

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 Team work
• Out break investigation is usually a team work

• It is not only health professionals but also it may

need involvement of others.

• Composition of a team could include a team of

– Health workers,
– Representative of community
– Politicians
– Concerned sectors, etc

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Step 1. Prepare for field work

• Investigation, (Knowledge in epidemiology and the

disease of concern is important)

• Administrative (Logistics, administrative procedures,

travel arrangements)

• Consultation (health workers should know their role, and

should participate in the planning)

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Step 2. Establish existence of an outbreak

 An outbreak/an epidemic is the occurrence of

more cases of disease than expected.

Be cautious and rule out the following misleading

phenomena
 Change in population size,

 Change in diagnosis,

 Change in case definition,

 Increase in interest due to new in-service training

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Step 3. Verifying the diagnosis

• Goals in verifying the diagnosis include;

– To ensure that the problem has been properly
diagnosed.

– To rule out laboratory error as a basis for the

increase in diagnosed cases.

– To ensure the diagnosed disease is possibly endemic

– We should visit several patients with the disease

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Step 4a. Establishing a case definition
• Its aim is to count all cases of the illness

• A case definition is a standard set of criteria for

deciding whether an individual should be
classified as having disease of interest or not.
• Case definition could be classified into three
parts based on clinical criteria

– Confirmed (Laboratory supported diagnosis);

– Probable (having major signs and symptoms, but not

supported by Laboratory)
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Step 4b. Identifying and counting cases
• Direct the case finding to take place both in
health institutions and outreach sites.
• If a localized form of epidemic, case finding
should go to the epidemic area
 Once if cases are found, the following
information should be collected;

Identification information
Demographic information
Time of onset
Clinical information
Possible risk factor information
Place and distance from possible risk factor 19
Step 5. Performing Descriptive Epidemiology

• Once data is collected, it should be analyzed by time,

place and person (Descriptive epidemiology).

• Analysis by Person,
– Age,
– Marital status
– Sex,
– Occupation,
– Behavior (Alcohol) etc

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Step 6. Developing Hypothesis

How do we Generate Hypotheses?

1. Subject-matter knowledge

2. Descriptive epidemiology

3. Talking with patients

4. Talking with local officials

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Step 7. Evaluating the Hypothesis
• Here doing analytic studies may be useful.

• Association between the postulated exposure

factor and the disease is tested
1. Case control 2. Cohort

• Appropriate measure of association should be

made
– for case control, odds ratio
– for cohort design, relative risk

• Significance of statistics should be done, (Chi-

square is the appropriate test, and P-value is
estimated at 5 %.) 22
Step 8. Implementing control and prevention

• In outbreak investigation, the primary goal is to control and

prevent the outbreak.

• Implementing control measures should be done as soon as

possible
– Interrupting the transmission or exposure

– Instructing (educating) people to reduce their risk of contacting

possible exposure

– Reduce susceptibility by immunizing individuals

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Step 9. Communicating the findings
There are two forms
1. An oral briefing for local authorities and
implementers of control and prevention.
a) What is done,
b) what is found,
c) what should be done in the future

2. A written report, it is a blueprint having formal

scientific format with introduction, objectives,
methods, results, discussion and recommendations

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Thank You!!

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