Outbreak investigation

Andamlak Dendir
(MPH)

2019
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Levels of Disease Occurrence

What is our reference?

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 Threshold of Diseases
 The amount of a particular disease that is usually present in a community is the
baseline level of the disease.
 This level is not necessarily the preferred level, which should in fact be zero;
 The expected level of the specific disease is also called threshold.
 Thus, the baseline level is often considered the expected level of the disease.
Outbreak Ix and Mgt

 For example, over the past 4 years the number of reported cases of
poliomyelitis has ranged from 5 to 9. Therefore, assuming there is no change in
population, we would expect to see approximately 7 reported cases next year.

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 .
Cont…
 The threshold of most specific diseases
are usually determined by taking average
incidence of the disease of consecutive 3
to 5 years duration for that month.
 However, some diseases have a well-
known and already set thresholds

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Cont…
 Different diseases, in different communities, show
different patterns of expected occurrence.
 To describe the deferent level of disease occurrence
different terminology are there.

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 Endemic
 a persistent level of occurrence with a low to moderate disease
level is referred to as an endemic level
 A persistently high level of occurrence is called a hyper
endemic level


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Endemic
Sporadic
 Sporadic
 an irregular pattern of occurrence, with occasional
cases ( infrequent ) occurring at irregular intervals
is called sporadic.

 The disease are not present normally in population but they may
occur occasionally and irregularly

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 Disease Clustering
 Clustering is an aggregation of relatively rare events or
diseases in time and/or place without regard to whether
the number of cases is more than expected.
 Clustering is not commonly used in the context of common
diseases.
 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.
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Outbreak Ix and Mgt
Epidemics
 Endemic disease can change into
epidemic

 If the following factors are there

 a recent increase in amount or virulence of the agent
 the recent introduction of the agent into a setting where it has not been before
 an enhanced mode of transmission so that more susceptible are exposed
 Some change in the susceptibility of the host response to the agent
 Factors that increase host exposure or involve introduction through new
portals of entry

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 Expected Vs Excess Levels of Cases
Epidemic Curve
or Epi Curve:
is a graphic
depiction of the
number of
outbreak cases
by date of illness
onset.

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Outbreak Ix and Mgt
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 Epidemic patterns

 Common source
 — Point
 — Intermittent
 — Continuous
A. Propagated
B. Mixed
 Common-source Epidemic
 Caused by simultaneous exposure of a group of
susceptible persons from a common source pathogenic
organisms or chemicals or any other noxious influences.
 Transmission may be: by water, food, air or inoculation.
 It can result from:
- a single exposure
- repeated multiple exposure
- continued exposure over a period of time
Characteristics of a “point-
source” epidemic:
 Propagated or Progressive (Contact)
Epidemic

 An outbreak that does not have a common source, but instead spreads
gradually from person to person
 Usually transmission is by direct person-to-person contact, as with syphilis.
 Transmission may also be vehicle borne, as the transmission of hepatitis B
or HIV by sharing needles, or vector borne, as the transmission of yellow
fever by mosquitoes.
 In propagated epidemic, cases occur over more than one incubation period.

In theory, the propagative type of epidemics epidemic usually
wanes after a few generations, either because the number of
susceptible falls below some critical level, or because
intervention measures become effective.

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Investigation

 It is the process of identifying

.... the cause of the epidemic,
the source of the cause
the mode of transmission
preventive/ control measures
.…of an epidemic

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1. To Institute control/ prevention
measures
 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?

to prevent additional cases. to prevent outbreaks

in the future 24
 Cont…
 The choice b/t launching control measures or further
investigation depends on how much is known about
 the cause,
 the source of the outbreak
 the mode of transmission of the agent

If little knowledge Good knowledge

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2. Research opportunity

 Each outbreak should be viewed as an experiment to be

analyzed.
 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 by

assessing
 Vaccine efficacy
 The impact of control measures
 The usefulness of new epidemiology &laboratory techniques. 27
 3. Program considerations

 Occurrence of an outbreak could notify that there is a

program weakness.
 outbreak may identify populations which have been
overlooked, failures in the intervention strategy, changes in the
agent, or events beyond the scope of the program.
 By using an outbreak to evaluate the program’s effectiveness,
program directors can improve the program’s future directions
and strategies.

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 STEPS IN AN
OUTBREAK
INVESTIGATION

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 Steps

 Prepare for field work

 Establish the existence of an outbreak
 Verify the diagnosis
 Define and identify cases
 a. establish a case definition
 b. identify and count cases
 Perform descriptive epidemiology
 Develop hypotheses
 Evaluate hypotheses
 Implement control and prevention measures
 Communicate findings 30
 Preparations can be grouped into three categories:
I. Investigation:-
 First as field investigator you must have scientific knowledge, supplies, and equipment
 you should discuss the situation with someone knowledgeable about the disease and
about field investigations
 Should review the applicable literature and assemble useful references such as journal
articles and sample questionnaires.
 Before leaving for a field investigation, consult laboratory staff to ensure that you take the
proper laboratory material and know the proper collection, storage, and transportation
techniques.
 Arrange for a portable computer, dictaphone, camera, and other supplies.
II. Administration
III. consultation.
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II: Administration
 Second, as an investigator, you must pay attention
to administrative procedures.
 In a health agency, you must make travel and
other arrangements and get them approved.
 You may also need to take care of personal
matters before you leave, especially if the
investigation is likely to be lengthy

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 Consultation
 Third, as an investigator, you must know your expected role in the field.
 Before departure, all parties should agree on your role, particularly if you
are coming from “outside” the local area.
 For example, are you expected to lead the investigation, provide
consultation to the local staff who will conduct the investigation
 In addition, you should know who your local contacts will be.
 Before leaving, you should know when and where you are to meet with
local officials and contacts when you arrive in the field.

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Step 2. Establish the existence of an outbreak

 Answer is it really an out break

 compare the observed with the expected.
 Usually we compare the current number of cases with the number from the
previous few weeks or months, or from a comparable period during the
previous few years.
 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
 Closely linked to verifying the existence of an outbreak is establishing what disease is occurring.
 In fact, as an investigator, you frequently will be able to address these two steps at the same time.
 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.

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 Cont…
 Reviewing the clinical findings and laboratory results
 Reviewing a qualified laboratorian review the laboratory techniques being
used.
 summarize the clinical findings with frequency distributions
 visit several patients with the disease.
 If you do not have the clinical background to verify the diagnosis, a qualified
clinician should do so.
 We should visit several patients with the disease 36
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.

 It includes; clinical criteria but (restricted by time, place and

person).

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 Cont…

 The clinical criteria should be

(simple and objective measures)

 Case definition could be classified into three parts

 Confirmed (Laboratory supported diagnosis);

 Probable (having major signs and symptoms, but not

supported by Laboratory)

 Possible (having part of the signs and symptoms) 38

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

 Finally, you can ask case patients if they know anyone

else with the same condition

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 Cont…

 Once cases are found, the following information should be

collected;
 Personal and group Identifiers
 Demographic information
 Time of onset
 Clinical information
 Possible risk factor information
 Place and distance from possible risk factor
 Reporter’s information
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Step 4. Analysis & generate hypothesis

Can be done through

a. Knowledge about the subject-matter

b. Descriptive epidemiology

c. Talking with patients, opinion leaders and local officials

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 b. Descriptive Epidemiology

 Analysis by Person,
 Age, Marital status, Sex, Occupation, Behavior (Alcohol)

 Analysis by time using epidemic curve,

 Analysis by time of onset

 Analysis by place,
 Using spot map you may ascertain localized epidemic by
place (Clustered epidemic).
 Area map if large area is affected 43
 Cont…

 Time (Epidemic curve)

 Does shape hint at mode of transmission?
 Does narrow peak point to a particular time of exposure?
 Place
 High attack rates in one place?
 Person
 Which group(s) — by age, sex, occupation, etc. — have
highest rates?

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Thank u!!!!

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 Public Health
(Epidemiological)
Surveillance

2019
What is public health surveillance?

 Is an ‘epidemiologic strategy’

~ to ‘watching over’ … careful observation for timely

intervention.
 Definition…
~ is an
 Ongoing
 Systematic collection ,
 analysis,
 interpretation
 dissemination
 of health and health related Information.
 for action (setting priority ,planning,
implementation & evaluation)
The components of surveillance and resulting
public health action

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 Purpose ….

 To detect sudden changes in disease occurrence and

distribution
 To detect change in secular (long-term) trends and
patterns of disease and to project future trends
 To identify changes in agents and host factors (example:
The Behavioral Risk Factor Surveillance System national
system monitors changes in such factors as smoking,
alcohol use, obesity, and seat-belt use.
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 Purpose ….

 To learn more about the natural history, clinical spectrum

& epidemiology of a disease
Surveillance
 Ongoing collection allows to
use enough cases for study
 It is relatively cheap b/c it
often use existing systems
and health personnel
 Allows monitoring of trends of
disease over time
 In depth data may not be
collected
 Prevalence or incidence may
not be assessed well
 May not provide
representative data
and Survey
 is a single time collection of data
 More in-depth data could be
collected
 More accurate assessment of
incidence or prevalence
 It is costly, needs additional
system & personnel
 Represents only single point in
time & informs little if anything
about change in time (single point
in time).
 Types of Surveillance

Surveillance

Population-based Sentinel

Active Passive Active Passive

Types of surveillance
1. Passive surveillance
2. Active Surveillance
3. Population based surveillance
4. Sentinel surveillance
 Types…
1. Passive surveillance
 health workers gather data from community who came to the facility
& send reports based on a known set of regulations.
 the health officials sit back, feet up on the desk, and wait for reports
to come in
 physicians, clinics, laboratories and others required to report disease
are given the appropriate mailing forms and instructions, with the
expectation that they will report all of the cases of reportable disease
that come to their attention.
 So more work for the clinicians, less work for the health agency.
 Types..

characteristics
 Simple
 Limited consistency of reporter, reporting
(some may report every case, others only sever cases)
 May not be representative
 May not be timely
 May fail to identify outbreaks (if there is under-reporting)
 Less work for health authorities
 Active surveillance
Characteristics
 Is more complete & representativeness
 Can be used with specific investigations (during outbreaks)
 Relatively resource intensive
 Expensive
 More human resource need

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 Active Surveillance
 health workers collect data about a disease by going to the community

 the health officials make periodic (usually weekly) telephone

calls or personal visits to the reporting individuals to obtain the
required data
 Q. Which is more common? Why? A. Most routine
surveillance systems are passive. Because they are cheaper
and less work for the health agency, require fewer resources.
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 Type…

3. Population-based Surveillance

•Surveillance pertaining to a general population defined by

geographical boundaries

•it is
• Representative of population in geography area
• Based on existing public health structure
• Increase potential for detection of rare diseases
 Type…

4. Sentinel Surveillance
Means of monitoring trends of health events in chosen population
groups and chosen sites in a regular and consistent (Uniform)
way.

 It is based on selected samples chosen to represent the relevant

experience of particular groups
 Need not be representative (However sites, facilities, procedures
and populations remain similar (Eg, ANC for HIV)
 Selection of study population must be with minimal bias
 Sufficient demographic data must be collected to
 detect changes in population composition
 Sentinel…
Advantage
 It is characterized by its quality data collection

 It is cheaper compared to population based surveillance

Limitation
 Under reporting

 Lack of representativeness of reported cases

 Lack of timeliness

 Inconsistency of case-definitions

 Lack and shortage of qualified staff

 Lack of motivation
There are three periods of reporting

1. Immediate reporting:
A. For diseases that are not endemic, but are considered
as epidemic prone diseases.
eg. Cholera, plague, viral hemorrhagic fever,
Polio, Yellow fever

B. Any suspected epidemic when a threshold is crossed

 Cont….

2. On weekly basis:
For endemic diseases and epidemic prone diseases.
eg Malaria, meningitis

3. On monthly or Quarterly basis:

For routine and chronic disease included in a
surveillance
e.g Tuberculosis, Leprosy, AIDS cases
Analysis of surveillance data

 First Descriptive analysis by time, place & person.

 Compare current data with some expected value, identify
how they differ, & assess the importance of the difference

 Compute using both numbers & rates, thus we need proper

numerators and denominators

 Present using simple tabulations and graphic techniques.

 A. Analyzing by time

 Comparing
 current weeks data with the previous 3-4 weeks.
 current months data with the last 2-3 years of the same
month
 Analyze long term (secular) trends

Analysis should consider

 Population size, thus better to use rates
 Onset rather than date of report (to see type of epidemic)
 Display using table & graph (histogram)
 Analysis cont’d
 Descriptive analysis will be done by
 time, place and person.

 Observe trends: comparison current data with expected value,

 identify differences,
 identify how they differ, and
 assess the importance or relevance of the difference

 Using proper numerators and denominators compute numbers

and rates, and presented by simple tabulations and graphic
 B. Analyzing by Place

 If there is an increase in incidence of a certain disease by

time, it need to be determine by place.

 Even if we didn’t find increase in incidence by time,

analyzing by place could show us an outbreak in a
specific locality.

 Data can be presented by table, area map or a spot map.

 Interpretation
 When a surveillance system shows that the expected pattern for a
disease is different than what we expect for that disease in that
population at that particular time and place, we may need to
investigate further.
 A local health department usually determines the amount of excess
necessary for action based on the priorities assigned to the various
diseases, and the interests, capabilities, and resources of the
department.
 Public, political, or media attention and pressure, however, can
sometimes make it necessary to investigate minor variations in disease
occurrence that the health department might otherwise not pursue.
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 Dissemination
 The cycle is not completed until information about these cases is
relayed to those responsible for disease prevention and control and
others “who need to know.”
 health careproviders, health agencies, and the public all have some
responsibility for disease prevention and control, they all should be
included among those who receive feedback of surveillance
information.
 Depending on the circumstances, others who need to know may
include other government agencies, potentially exposed individuals,
employers, vaccine manufacturers, private voluntary organizations,
legislators on the health sub committee, and innumerable others.
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 Link to Public Health Action

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 Planning

 As noted earlier, the goal of surveillance is to provide a factual basis for

rational decision making.
 By monitoring changes in disease occurrence over time and place, agencies
can anticipate when and where resources will be needed, and thus will be
able to plan how to allocate them effectively.

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 Control and Prevention of disease

 The actions could be

 Removal of threat:
 contaminated food,
 immunization or treating a water supply,
 elimination of harmful or hazards in the environment.
 closure of a restaurant,
 counseling and treatment of an asymptomatic patient,
 withdrawal of a commercial product, or warnings to the public
 intensify surveillance of the disease to detect potentially exposed persons who
may be at risk of developing disease.

 risk-reduction programs: Targeted modification, education, immunization or other

 .
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 Evaluating prevention and control measures

 To evaluate the effectiveness of a programs: public

health interventions

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 Generating hypotheses and stimulating public health research

 Because we collect and analyze surveillance data on an

ongoing basis, our findings often generate questions
and hypotheses that provide direction for further
research.

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THANK YOU !!!

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