Você está na página 1de 55
Sumit Karn link2sumit@gmail.com 10 April 2011

Sumit Karn

10 April 2011

synopsis

Introduction: Epidemiology is …

Outbreak - - Definition, Detection

Investigation - - Steps

Examples

role of epidemiology in

public health

Surveillance

• Outbreak Investigation
• Outbreak Investigation

Epidemiological Study

Evaluation of Public Health Measures

what is an outbreak???

A situation when diseases, health related

behaviour or health events occur at a

greater frequency than normally expected (excess of normal expectancy) in a

specified period and place

excess of normal expectancy

More than

5-Yr median or

Average number + 2 SD of previous 5 year or

Average number of previous few weeks or months

2 cases with epidemiologic linkage in

short time

1 cases of a new emerging disease

outbreak investigation provides

Opportunity to discover new etiological agents

Understand factors that promote the spread of diseases

Identify the weaknesses of existing prevention and health programmes

Specific objectives

Identify:

Causal agent

Transmission way

Source

Carrier

Population at risk

Exposition causing disease (risk factors)

investigate an outbreak why

Stop/control the epidemic and prevent new episodes

Opportunity to learn (research opportunity)

Evaluate the surveillance system

Put in place a surveillance system

Learn to teach (training)

Public, political, or legal concerns

outbreak detection & prevention

and control

outbreak detection & prevention and control “usual” sequence of events

“usual” sequence of events

outbreak detection & prevention and

control…contd

outbreak detection & prevention and control…contd “ideal” sequence of events

“ideal” sequence of events

prevention and control…contd

Relative Priority: Investigation and Control Efforts During an Outbreak

Causative agent

Source/Mode of transmission

Known Unknown Known I + I +++ C +++ C + Unknown I +++ I
Known
Unknown
Known
I
+
I
+++
C +++
C +
Unknown
I
+++
I
+++
C +++
C +

I Investigation, C- Control +++ - highest priority + - lowest priority

Source: Goodman RA, Buehler JW, Koplan JP. The epidemiologic field investigation:

science and judgment in public health practice. Am J Epidemiol 1990;132:916.

detecting an outbreak

Sources of outbreak news

Health care providers and other health personnels

Laboratory

Official disease notification systems

Media: Newspaper, TV, Internet

Surveillance data that are collected and analyzed timely

Village health volunteers and other local people

surveillance data

surveillance data Reported severe diarrhea cases in Khonkaen, Thailand January 1995 - July 1999

Reported severe diarrhea cases in Khonkaen, Thailand January 1995 - July 1999

media news about the outbreak

One of the main source of

information about outbreak

media news about the outbreak One of the main source of information about outbreak Compelling to
media news about the outbreak One of the main source of information about outbreak Compelling to

Compelling to wide population

investigation committee

Multidisciplinary

Principle investigator/person in-charge

Define tasks

Team comprises of:

Field epidemiologist

Laboratory technicians

Specialist in particular areas (veterinarian, sociologists, entomologist)

Public health administrators

Public relation in-charge (in case of panic situation)

before implementing an

investigation….(preparation)

Assessing the existence of the outbreak

Gathering preliminary information

Available data

Consult experts

Documentation

Ensuring that clinical specimens and suspected materials are collected

Inform the concerned and get authorization and

adequate support from local and national authorities

Planning the field operation

steps of investigation

the sequence is not important!

1. Confirm the existence of the outbreak

2. Verify the diagnosis and determine the etiology of the disease

3. Develop a case definition, start case-finding and collect information on cases

4. Describe persons, places and times and generate hypothesis

5. Test the hypothesis using an analytical study

6. Carry out necessary environmental or other studies to supplement the

epidemiological study

7. Draw conclusions to explain the causes or the determinants of the outbreak based on clinical, laboratory, epidemiological and environmental studies

8. Report and recommend appropriate control measures to concerned authorities at the local, national and if appropriate, international levels

9. Communicate the findings to educate other public health professionals and the general public

10. Follow up the recommendations to ensure implementation of control measures

prepare for field work: Rapid

Response Team

Preparations can be grouped into two broad

categories:

Scientific and investigative issues, and

Management and operational issues

Investigation: knowledge, equipment, specimen collection, transportation, etc.

Administration

Consultation

confirm the outbreak

Outbreak

n 0 observed cases > n 0 expected cases

Expected cases

Surveillance data

OPD card

Hospital Discharge Registry

Be careful of artefacts !!!

Seasonal variation (diarrhea)

Notification variation (new surveillance system in place)

Diagnostic variation (new technique)

Diagnostic mistake (false epidemic)

confirm diagnosis and etiology

Laboratory

Serology

Isolation

Serotype

Toxic agent

Meet the doctors

See the patients

Visit the laboratories

Not necessary to confirm all the cases

confirm outbreak and diagnosis

Is this an

Outbreak?

confirm outbreak and diagnosis Is this an Outbreak ? Link between cases? Higher than expected? What

Link between cases? Higher than expected?

What is the

diagnosis?

cases? Higher than expected? What is the diagnosis ? Clinical manifestation Laboratory result Unknown and unclear

Clinical manifestation Laboratory result

Unknown and unclear diagnosis can cause panic due to rumor

develop a case definition and start

case-finding

3 questions need to be answered:

Who should be counted as case?

Are we missing any cases in the community/hospital?

What are the characteristics of case?

develop a case definition…contd

Criteria

Clinical and/or biological

Time, place, person (restriction)

Different level of confirmation

Confirmed cases

Probables

Suspects

A case definition is a standard set of criteria for deciding whether an individual should be classified as having the health condition of interest.

develop a case definition…contd

Simple and objective

Consistent

Sensitivity and specificity

Suspected cases

Confirmed cases

Clinical case definition

Enough for immediate

Laboratory confirmed

Very few cases

action

sensitivity vs. specificity

sensitivity

specificity

sensitivity vs. specificity sensitivity specificity
sensitivity vs. specificity sensitivity specificity

sensitivity vs. specificity

sensitivity vs. specificity Danger of overload of cases Many false positives Many specimens to be tested
Danger of overload of cases
Danger of
overload of
cases

Many false positives Many specimens to be tested Low% of specimen tested +ve

sensitivity vs. specificity

sensitivity vs. specificity Danger of underreporting of cases Few false positives Fewer specimens to be tested
Danger of underreporting of cases
Danger of
underreporting
of cases

Few false positives

Fewer specimens to be tested High% specimens tested +ve

case definition

Components

Time

Place

Person

Clinical symptoms & signs

Source

Textbooks

Experts

Internet

ex: case definition

cholera

Category

Case definition

Suspected

In an area where the disease is not known to be present:

severe dehydration or death from acute watery diarrhoea

in a patient aged 5 years or more; or

In an area where there is a cholera epidemic: acute watery diarrhea, with or without vomiting in a patient aged 5 years or more

Probable

Not applicable

Confirmed

A suspected case that is laboratory-confirmed.( Isolation

of Vibrio cholerae O1 or O139 from stools in any patient

with diarrhea is the laboratory criteria for diagnosis)

Case counted

Only confirmed cases for a single isolated case

All cases to be counted having epidemiological linkage to a confirmed case during epidemic

actively find the case

Sources of information

All possible sources (NGOs, local leaders)

Hospitals, health centers, laboratories, doctors, nurses

Schools, camps, settlements

Radio (FM), door to door

Snow ball

Laboratory

active-case finding

Intensive search for the case in the community,

hospitals and other possible areas

Aim is to have enough cases to analyze

Source

Review medical records

House-to-house visit

Telephonic inquiry

Patients in hospitals Potential spreader!! communityinPatients
Patients in hospitals
Potential
spreader!!
communityinPatients

benefits of active case-finding

Control measures can be implemented if the etiology of

the disease is known and treatable

Rapid environmental assessment can be started during the visit to the affected families or villages

In situations in which the outbreak is not localized but wide-spread, the investigator might need to use the media to alert the public about the outbreak. People can then avoid suspected exposures and see a health-care provider if they have developed symptoms compatible with the case definition.

collecting information

At least 4 types of information:

Identifying information

Name, Hospital/Clinic Number, contact person, address of contact

Demographic information

Age, gender, religion, occupation, ethnicity, area of residence,

place of work

Clinical information

Signs and symptoms, date of onset, duration of illness, result of diagnostic procedures

Suspected risk factors

History of exposure to risk factors

Identifying Information Demographic Information Clinical Information Risk factors
Identifying Information
Demographic Information
Clinical Information
Risk factors

describe the outbreak in person, place,

and time and hypothesis formation

What are the main clinical features?

What is the population at risk?

What are the risk factors?

What are the most likely explanations of how the

outbreak began?

data description

(person)

Distribution of cases by age, sex, profession

(Numerator)

ex: 50 women, 100 men

Distribution of variables in the population

from where cases are coming (Denominator)

ex: 1500 women, 1000 men

Compute attack rate

ex: women 50/1500, men 100/1000

Identification of sub-group(s) at risk

description “person”

infection S. typhi, attack rate by age

Age group (Years)

Number of cases

Population

Attack

rate/100,000

<20

5

7545

66

20-25

38

3489

1089

25-30

22

3123

704

30-35

14

2989

468

>35

8

5445

146

Total

87

22591

385

data description

(time)

Cases distribution by date (hour, week, day) of onset of

signs

Onset, peak, decline

Abnormal cases (Outliers)

Epidemic evolution

Allow to make hypothesis

Incubation period, pathogen responsible

Source of infection/reservoir, kind of transmission

Time of exposure

epidemic curve of Hepatitis A

incubation: 2-6 weeks

No. of cases
No. of cases

Time of onset

data description

(person)

Place of living, place of exposure (work,

food, travel)

Spot map (cluster, scattered)

Identify person(s) at risk, population at risk, area(s) at risk

generating hypothesis

Starting from:

Descriptive information [P, T, P]

Knowledge of the disease

Exploratory study on some cases

Explaining:

The causal agent

The source

The mode of transmission

The carrier

generating hypothesis

generating hypothesis

testing hypothesis

From an epidemiologic point of view, hypotheses are

evaluated in one of two ways:

by comparing the hypotheses with the established facts (when you have apparent/obvious clinical, laboratory, environmental, and/or epidemiologic evidence)

by using analytic epidemiology to quantify relationships and assess the role of chance (when circumstances are not as

straightforward, and information from the series of cases is

not sufficiently compelling or convincing)

Generally tested by analytical study design

Either case-control study or cohort study

Can be supplemented using a combination of

environmental evidence and laboratory science

case-control study

case-control study A person who ate the bamboo shoots was 201 times more likely to be

A person who ate the bamboo shoots was 201 times more likely to be ill than a person who did not eat

Source: Wongwatcharapaiboon P, EIS Conference 1999

Number and percentage of reported exposures associated with influenza A (H5N1) disease by type of exposure, Thailand 2004

Exposure (n=80)

Number of reported exposure (%)

Matched odds ratio (95% CI)

   

Case

Control (n=64)

 

(n=16)

Directly touching abnormal dead poultry

10 (63)

12 (19)

29 (2.7-308.2)

Dressing poultry

5 (31)

4 (6)

17 (1.6-177.0)

Having abnormal dead poultry around the house

8

(50)

9 (14)

14 (2.4- 81.6)

Plucking dead poultry

4 (25)

3 (5)

14 (1.3- 152.5)

Being within 1 metre of dead poultry

10 (63)

16 (25)

13 (1.8-96.3)

Storing sick/dead poultry products in the house

7

(44)

3 (5)

9.3 (2.1-41.3)

Directly touching sick poultry

8 (50)

9 (14)

5.6 (1.5-20.7)

Being within 1 metre of sick poultry

9 (56)

14 (22)

3.8 (1.2-11.7)

 

3

(19)

13 (20)

0.9 (0.2-4.4)

Contact with suspected/confirmed H5N1 human case

Visiting live poultry market

1 (6)

0

(0)

NA

Source: Areechokchai et al. 2006

retrospective cohort study

retrospective cohort study A person who ate the fermented vegetable was 6.2 times more likely to

A person who ate the fermented vegetable was 6.2 times more likely to be ill than a person who did not eat

laboratory study, environmental

study (supplementary)

Outbreak of unknown illness in a rural village of

Cases

Egypt

Severe abdominal pain, persistent vomiting, generalized weakness

Laboratory (abnormally high blood lead level)

Analytical (association between high blood level

and eating flour from one mill factory)

Environmental (lead smelting pot in the corner of the mill)

Source: Abdel-Nasser 1996

establish the causes

Compare the results

Laboratory evidence

Clinical evidence

Environmental evidence

Epidemiological evidence (statistical tests)

on-site reporting and

recommendation

Report the findings to responsible body (local &

national level)

Present the main findings with recommendations

Timely response, stop further spread,

prevent future outbreak

at the end

Prepare report

Evaluate performance

Influence public health policy

Communicate findings

disseminate information

Educate public health community and the

general public

Aware other communities

Through

Mass media

National/international journal

Bulletin

Report

Telecommunication

follow-up

Maintain close communication with health

authorities

Ensure implementation of control measures

don„t forget !!!

Ethical aspects (animals, ……)

Respect the participants (informed consent, confidentiality)

Local debriefing

“The art of epidemiological reasoning is to make some reasonable conclusions starting

from imperfect data”

-George W Comstock