Integrated Disease Surveillance and Response

(IDSR) Training
3rd Edition

Module 4
Investigate suspected outbreaks and
other public health importance events

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 Outline of presentation
• The purpose of the module
• Learning Objectives
• Define what is outbreak/epidemic and cluster
• Purpose of investigating an outbreak/event
• Decide to investigate a reported outbreak/public health event
• Steps in outbreak investigation
• Writing outbreak report
• Summary
• Instructions to exercises
 The purpose of the module

To equip participants with relevant knowledge

and skills in outbreak investigation, process of
confirming and controlling outbreaks and other
public health events
 Learning Objectives

• Verify and report an outbreak or public health event

• Know when to decide to investigate an outbreak
• Describe what might be happening
• Prepare an outbreak report
What is Global Health

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Title of the Presentation
 What is an Outbreak/Epidemic?

• An outbreak is an increase in the number of cases of a

disease or an event above what is normally expected in
that population in a given area over a particular period of
time .
• Epidemics can be referred to as outbreaks.
• Epidemic: used interchangeably with outbreak.
 What is a cluster?

• A cluster is an aggregation of cases or health related

condition in a given area over a particular period
regardless of whether the number of cases is more than
expected in relation to time or place or both
 Purpose of investigating an
Outbreak/epidemic/event...1/2

• Verify the outbreak and identify the source of infection or

cause or the public health event and risk
• Collect information and laboratory specimens for
confirmation
• Identify and treat additional cases that have not been
reported or recognized
 Purpose of investigating an
Outbreak/epidemic/event?...2/2

• Describe the epidemiological situation in time, place and

person.
• Select appropriate response activities to control the
outbreak or the public health event.
• Comply with IHR (2005).
 Steps of outbreak investigation

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 Steps of outbreak investigation
The sequence is not important !
Step 1: Establish Existence of an outbreak
Step 2: Prepare for Fieldwork
Step 3: Confirm and verify the diagnosis
Step 4: Define a case and search for additional cases
Step 5: Analyse data and generate hypothesis
Step 6: Test and refine hypothesis with analytic study
Step 7: Implement Control Measures
Step 8: Write Report and Dissemination of findings
Step 9: Conduct Risk Assessment to determine if the outbreak is a potential
PHEIC
Step 10: Maintain and intensify surveillance
 Step 1: Establish existence of an outbreak - 1

• Verify the reported information by considering the

following factors:
 Source of information
o How reliable is the source of the rumour?
o Is the report from a health facility?
 Severity of the reported illness and use of standard
case definition for reporting
o Number of reported cases and deaths
 Step 1: Establish Existence of an Outbreak - 2

• Is an outbreak occurring?
 True outbreak
 Sporadic and unrelated cases of same disease
• Review data received and determine whether the
observed number of cases exceeds the expected number
• Conduct preliminary data analyses
• Collect additional data over the phone if necessary
 Step 1: Establish existence of an outbreak-3

• How do you determine if you have more cases than expected?

• For notifiable diseases/conditions:
1. Use alert/epidemic threshold
 If the epidemic threshold is reached or crossed then
an outbreak is established
2. Compare number of current reports with previous
weeks/with same time period or season in previous years
 Use IDSR weekly/monthly reports
 Step 1: Establish existence of an outbreak-4

• How do you determine if you have more cases than

expected?
• For non-notifiable diseases/conditions:
 Check hospital admission & discharge records,
mortality data, cancer registries, birth defect
registries or other available records
 Use data from neighbouring areas
 Call local health care providers
 Call community members
 Conduct an investigation when…
• District receives report of suspected outbreak due to
immediate notifiable disease.
• An unusual increase in number of cases or deaths during
routine analysis of data.
• Alert or epidemic thresholds have been reached for
specific priority diseases.
• Communities/social media report rumours of deaths or
large number of cases not being seen in the health
facility.
• Cluster of illnesses or deaths of Unknown Cause.
 Important!!: Districts should investigate suspected outbreaks and
events within 48 hours of notification from lower level

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 Record reported outbreaks,
public health events and alerts

• Record all suspected/confirmed outbreaks, events and

rumours in the District log of suspected outbreaks and
rumours book.
• A sample form for tracking reports of outbreaks and
rumours is in Section 4, Annex 4A of the 3rd Edition IDSR
technical guidelines booklet three.

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 Step 2: Prepare for Fieldwork-1
• Mobilize Public Health Emergency Rapid Response Team
(PHERRT)
 Multidisciplinary team: Coordination-Team Leader,
Epidemiologist, Surveillance Officer, Clinician, Lab Scientist,
EHO, Communication Experts, Veterinary Officer etc.
 Ensure that each member has been trained
 Ensure protection of team members (use of PPE and
universal precautions)
• Define terms of reference of the PHERRT :
 Objectives of investigation and timelines for the work
 Specify tasks/Role(s) of each member
 Decide where the investigation will take place

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 Step 2: Prepare for field work - 2
• Gather Scientific knowledge
 Review literature-information about suspected
disease/event.
o Refer to section 11 of 3rd IDSR TG Booklet Six and others.
 Consult experts
 Gather sample questionnaires e.g. IDSR Case Investigation
form.
 Ensure standard methods relevant to the disease or
condition being investigated, e.g.:
o collecting the correct laboratory specimen
 Step 2: Prepare for field work - 3

• Define supervision and communication lines-1

• Make a communication plan and define:
 Who will report to whom
 How information flow within PHERRT and between
district and other levels
• State methods and frequency for communicating during
the outbreak
 Daily updates by radiophone, mobile phone, facsimile,
e-mail and conference calls
 Step 2: Prepare for field work - 4

• Define supervision and communication lines-2

 Define lines of authority and roles of each staff on the
PHERRT
 Define role of non-health workers and how they should
be supervised
 Have in place procedure for communicating with
community and key partners
 Step 2: Prepare for field work - 5

• Decide where the investigation will take place

 Review information known about the suspected
outbreak:
o E.g.: Mode of transmission and risk factors
 Use information to define Geographical boundaries
and Target population for conducting the investigation.
NB: Begin the investigation in the most affected place.
 Step 2: Prepare for Fieldwork-6

Obtain the required authorizations:

 Authorizations letters, clearances, ethical norms and
permissions required to do the investigation.
 Obtain agreements with local persons of influence in
the community.
 Know who to contact when you arrive.

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 Step 2: Prepare for Fieldwork-7

• Finalize forms and methods for collecting and analysing

data/information and specimens
 If known disease/event: Use IDSR Case investigation forms,
Line listing forms, contacts listing and tracing forms, lab SOPs
etc.
 If unknown disease/event: Develop new questionnaire to
collect information on Demography, Signs and symptoms,
Risk factors, Reporter etc.

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 Step 2: Prepare for Fieldwork-8
• Arrange transportation and other logistics
 Make travel arrangements for:
o Getting to and from the site of the investigation
o Travelling during the investigation .
o Transportation for moving specimens to appropriate
laboratories in advance of the team’s departure.
 Medical supplies, vaccines, PPEs.
 Equipment: Computers, camera.

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 Step 2: Prepare for Fieldwork-9

• Gather supplies for collecting laboratory specimens

 Look at disease specific program guidelines
o Refer to Section 11 of 3rd Edition IDSR TGs Booklet Six
 Talk to laboratory specialists
o Find out requirements for laboratory supplies for proper
collection, storage, and transport of relevant specimens
 If a lab kit is not available, look elsewhere for it.
 Ensure health staffs have access to and know how to use
required PPE.
 Step 3: Verify and confirm the diagnosis
• Verify and Confirm
 Review the clinical history and epidemiology:
o Examine patient(s)/patients records to confirm
signs & symptoms meet the case definition.
o Meet attending physicians.
 Collect lab specimens and obtain results to confirm the
diagnosis:
o Lab Test results consistent with clinical
findings.
o Refer to the lab requirements in Section 11 of
3rd Edition IDSR TGs Booklet Six.
Step 4: Define a case and search for additional cases - 1

• Define a Case using standard case definition-1

 What is Standard Case Definition (SCD)?
o Standard set of criteria for deciding whether an
individual should be classified as having the health
condition of interest
o Includes clinical criteria and restrictions by time,
place and person
o Must be applied consistently and without bias to all
persons under investigation

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Step 4: Define a case and search for additional cases - 2

• Define a Case using standard case definition-2

• If confirmed outbreak due to priority disease use the SCD
for IDSR priority diseases.
 Refer to section 11 of 3rd Edition IDSR TGs Booklet Six.
 For specific outbreaks, include in case definitions:
o Geographical location, time, attendance at an event
or travel to a certain location.
• If a new disease not listed in Section 11, IDSR TG, develop
an operational case definition.

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Step 4: Define a case and search for additional cases - 3

• Define a Case using standard case definition-3

• Earlier in an investigation, you may use a “loose” case
definition.
 Better to collect more than necessary so you don’t need
to make repeat visits.
 Identify extent of problem and population affected.
 Generating hypotheses.
• Later when hypotheses are sharpened investigator may
“tighten” case definition.

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Step 4: Define a case and search for additional cases - 4

• Isolate and treat cases as necessary

• Use the case definition to isolate cases e.g. Cholera, EVD
 Isolation is a critical step in limiting spread of disease
and keeping healthcare facilities open and healthcare
workers available.
• Provide the health facility with advice, support, and
supplies.

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Step 4: Define a case and search for additional cases-5

• Search for suspected cases and deaths in the health facility

(HF) records using case definition
 Interview case-patients
 Conduct register review in:
o HF where cases have been reported
o Neighbouring HFs
o HF where cases passed during travelling
 Extract cases with signs & symptoms that meet the case
definition

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Step 4: Define a cases and search for additional cases - 6

Search for suspected cases, deaths and contact persons in the

community using case definition
• Visit communities where cases are coming from.
• Interview case relatives, community members to find persons
(alive or dead) with signs or symptoms that meet the case
definition.
• Identify and follow-up contacts to the cases/deaths.
• Refer newly identified cases to the health facility for treatment.

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Step 4: Define a case and search for additional cases - 7

Develop a line list and record information about the

additional cases
• Complete the IDSR Immediate Case-Based Reporting
Form for all cases including any new cases.
• Record the details on the line listing form.
• List any contacts on the Contacts recording sheet.
• Monitor daily all contacts using Contact tracing form for
the required period for signs and symptoms of the
disease.

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 Step 5: Analyse data and generate hypothesis-1

• After collection of data characterize the outbreak by:

• Time: Draw “Epi”curve to determine cause of outbreak.
• Place: Plot the cases on a spot map.
• Person:
 Make tables with most relevant variables.
 Calculate case fatality rates.
 Calculate attack rates.
NB: Update and analyse data daily, for any changes in ideas
regarding causes of the outbreak

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 Step 5: Analyse data and generate hypothesis-2

• Interpret the time analysis results-1:

• Draw conclusions about when exposure to the agent that
caused the illness occurred, the source of infection and
related incubation period
• Observe the shape of the epidemic curve:
 IF curve suddenly increases to develop a steep up-
slope, and then descends rapidly
 THEN exposure to causal agent was over a brief period
of time: A Common/Point Source Infection
Example of an Epi Curve for a Point Source Outbreak
 Step 5: Analyse data and generate hypothesis-3

Interpret the time analysis results-2:

• Observe the shape of the epidemic curve:
 If exposure to the common source was over a long
period of time, the shape of the epidemic curve is
plateau: Continuing common source
 If the illness resulted from person-to-person
transmission, the curve is progressively taller peaks
separated by periods of incubation
Example of an Epi Curve for a Common Source Outbreak with
Continuous Exposure
Example of an Epi Curve for a Propagated Outbreak
 Step 5: Analyse data and generate hypothesis-4

• Interpret the place analysis results

• Use the map to:
 Describe the geographic extent of the problem and identify
high risk areas
 Identify and describe any clusters or patterns of
transmission or exposure
 Depending on the organism that has contributed to this
outbreak, specify the proximity of the cases to likely sources
of infection

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 Example of district spot map showing
location of suspected and confirmed cases
 Step 5: Analyse data and generate hypothesis-5

Interpret the person analysis results

• Information of person analysis is used for planning the
outbreak response.
• Describes high-risk group(s) for transmission of the
disease/condition.
• e.g. If yellow fever cases occurred in patients less than 15
years, then immunization response targets children less
than 15 years of age

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 Step 5: Analyse data and generate hypothesis-6

Make conclusions about the outbreak:

• What was the causal agent of the outbreak?
• What was the source of infection/outbreak?
• Where the outbreak or event is occurring.
• What was the transmission pattern? Where it is moving
towards?
• Persons at risk of becoming ill.
• What control measures were implemented and to what
effect?
 Step 5: Analyse data and generate hypothesis-7

Generate hypothesis
• What do you know about the disease?
 Reservoir, mode of transmission, common vehicles and
known risk factors.
• Use descriptive epidemiology e.g. epi curve, spot map,
tables.
• Generate hypothesis about the:
 Causes of observed patterns.
 Factors that increase risk for given outbreak.

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Step 6: Test and refine hypothesis with analytic study

• Based on descriptive epidemiology and situation, select

appropriate study design:
 Analytical study designs to use includes:
o Case control studies
o Cohort studies
o Experimental studies
• Obtain resources to conduct and analyze study.
• Draw conclusion from study and as needed refine
hypothesis.

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 Step 7: Implement Control Measures

• Implement control measures as soon as possible.

• Conduct an immediate response.
• Isolate and treat cases as necessary.
• May be aimed at agent, source, or reservoir.
 Control source of pathogen
 Interrupt transmission
 Modify host response
 Control the source of pathogen

• Remove source of contamination.

• Remove persons from exposure.
• Inactivate/neutralise the pathogen-chlorination
• Isolate and/or treat infected persons e.g. cholera.
 Interrupt transmission

• Interrupt environmental
transmission
• Control vector transmission
• Improve personal sanitation
 Modify Host Response

• Immunize susceptible in case of VPDs e.g.

Measles, Yellow Fever
• Use of chemoprophylaxis
Step 8: Reporting and Dissemination of Findings

• Write report and communicate findings:

 Report should be written immediately and on site by
PHERRT.
• Disseminate immediately report to:
 Health facility and Community where outbreak occurred.
o Initially: Orally within health facility/community.
 Written reports to HF, district, region and WHO.
• Prepare also situation reports (SitReps) of the given outbreak
and share with relevant stakeholders.
 Writing an outbreak Report

• Demonstration of how to write an outbreak report

• Using sample format.
• Turn to Section 7, Annex 7B of the 3rd Edition IDSR
Technical Guidelines Booklet Three.
 Areas of An Outbreak Report

Title/Description (disease/events under investigation)

Period/Location (Communities, Neighbourhoods, District, Region)

Executive Summary
I. Introduction
II. Methods
III. Results
IV. Self-assessment of the readiness and quality of the preparation, detection,
investigation and response to the outbreak
V. Assessment of other aspects of the response
VI. Interpretations, discussion and conclusions
VII. Recommended public health actions
 Step 9: Conduct Risk Assessment to determine if the
outbreak is a potential PHEIC-1

• Initiate Risk Assessment as soon as possible by the designated

investigation team to address the following questions:
 Is the public health impact of the event serious?
 Is the event unusual or unexpected?
 Is there a significant risk of international spread?
 Is there a significant risk of international travel or trade
restrictions?

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 Step 10: Maintain and intensify surveillance-1

• National and regional levels should maintain contact with

district for daily updates on:
• Cases, Deaths, Number admitted, Number discharged,
Areas affected, etc. until end of the epidemic.
• Ensure same IDSR reporting system and tools is used to
enhance surveillance of diseases/conditions/events.
• Avoid parallel reporting which can lead to confusion on
progress of the outbreak.

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 Step 10: Maintain and intensify surveillance-2

• Periodically, report on progress of response, and prepare daily

situation reports.
• Update the line list, conduct data analysis by time, person and
place.
• Monitor effectiveness of the outbreak or response activity(ies).
• Intensify surveillance with neighbouring districts to ensure the
outbreak does not spill to another district.

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 Step 10: Maintain and intensify surveillance-3

• Share information and also plan for joint surveillance and

response activities with neighbouring districts/regions/
countries.
• Neighbouring districts to establish cross-border disease
surveillance and response committees.
 For sharing of surveillance data, epidemiological and
other related information during the outbreak

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 Summary
Points to remember
• Understand alert and action thresholds will help you
know when to investigate an outbreak
• Document all rumours, reports and verified information
about an outbreak
• Assemble PHERRT and provide required logistics
• Analyse investigation results to determine what caused
the outbreak
• Prepare and submit an outbreak report to national
 Remember the steps of outbreak investigation
The sequence is not important !
Step 1: Establish Existence of an outbreak
Step 2: Prepare for Fieldwork
Step 3: Confirm and verify the diagnosis
Step 4: Define a case and search for additional cases
Step 5: Analyse data and generate hypothesis
Step 6: Test and refine hypothesis with analytic study
Step 7: Implement Control Measures
Step 8: Write Report and Dissemination of findings
Step 9: Conduct Risk Assessment to determine if the outbreak is a potential PHEIC
Step 10: Maintain and intensify surveillance
Thank you