Epidemic Investigation

Epidemic Investigation /
Disease Outbreaks
Typically, sudden and rapid increase in the
number of cases of a disease in a
population
Common Source
Cases are limited to those who share a
common exposure
Food borne, water
Propagated
Disease often passed from one individual to
another
Measles, STDs
 Steps of an Outbreak
Investigation

1) Establish the existence of an outbreak

2) Verify the diagnosis
3) Define and identify cases
4) Describe and orient the data in terms of person,
place and time
5) Develop hypotheses
6) Evaluate hypotheses
7) Refine hypotheses and carry out additional studies
8) Implement control and prevention measures
9) Communicate findings
 Steps of an Outbreak
Investigation
1) Establish the existence of an outbreak
Step 1: Establish the existence of an
outbreak

Before you decide whether an outbreak

exists, you must first determine the
expected or usual number of cases for the
given area and time
 Step 1: Establish the existence of an
outbreak

Data Sources:

1) Health department surveillance records for

a notifiable disease

2) Sources such as hospital discharge records,

mortality records and cancer or birth defect
registries for other diseases and conditions

3) If local data is not available, make

estimates using data from neighboring states
or national data
 Step 1: Establish the existence of an
outbreak

Whether or not an outbreak is investigated or

control measures are implemented is not
strictly tied to verifying that an epidemic
exists

Other factors may come into play, including:

Severity of the illness
Potential for spread
Political considerations
Public concern and pressure from community
Availability of resources
Public Health Surveillance
The ongoing and systematic collection,
analysis, and interpretation of
outcome-specific data for use in the
planning, implementation, and
evaluation of public health practice.
 Notifiable Disease

Disease for which regular, frequent, and

timely information regarding individual
cases is considered necessary for the
prevention and control of disease
 Step 1: Establish the existence of an
outbreak
In mid-November 1984, community health workers of
Bagong Bayan Resettlement Area in Dasmarinas, Cavite
noted that an unusually high number of residents had
fallen ill with fever of over a week's duration : possibility
that these patients had dengue fever.

The Research Institute for Tropical Medicine (RITM) was

notified as two persons were hospitalized for this illness
in the past three months.
 Steps of an Outbreak
Investigation
1) Establish the existence of an outbreak
2) Verify the diagnosis
 Step 2: Verify the diagnosis

Two goals in verifying a diagnosis:

1. Ensure that the problem has been properly
diagnosed -- the outbreak really is what it has been
reported to be
Review clinical findings and laboratory results for
affected people
Visit or talk to several of the people who became ill

2. For outbreaks involving infectious or toxic chemical

agents, be certain that the increase in diagnosed
cases is not the result of a mistake in the laboratory.
 Step 2: Verify the diagnosis

6th of December : The RITM staff visited Bagong Bayan,

conducted clinical examinations in localities where many
cases had been identified.

A few patients were thought to have a positive tourniquet

test but however, several patients had fever of more than 14
days duration, a finding not compatible with the diagnosis of
dengue.

5 days later : Five cases from Bagong Bayan were admitted

to RITM and two were found to be blood culture positive for
Salmonella typhi.
 Steps of an Outbreak
Investigation
1) Establish the existence of an outbreak
2) Verify the diagnosis
3) Define and identify cases
 Step 3: Define and identify cases

Establish a case definition - a standard set of

criteria for deciding whether a person should
be classified as having the disease under study

In many outbreaks, a working definition of the

disease syndrome must be drawn up that will
permit the identification and reporting of cases

As the investigation proceeds and the source, mode

of transmission and/or etiologic agent becomes
better known, you can modify the working definition
 Step 3: Define and identify cases

A case definition includes four components:

Clinical information about the disease,

Characteristics about the people who are affected

(person),

Information about the location (place), and

A specification of time during which the outbreak

occurred (time).
 Step 3: Define and identify cases
To increase sensitivity & specificity of reporting, we use three classifications of
cases that reflect the degree of certainty regarding diagnosis:
1) Confirmed
2) Probable
3) Possible

The case definition is used to actively search for more cases beyond the early
cases and the ones that presented themselves.

Confirmed Case Probable Case Possible Case

Laboratory
Verification +
Clinical
Features + ++ +
 Step 3: Define and identify cases

The following information should be collected from

every affected person in an outbreak:

1) Identifying information - name, address, phone

2) Demographic information - e.g., age, sex, race,
occupation
3) Risk factor information
4) Clinical information
Verify the case definition has been met for every case
Date of onset of clinical symptoms to create an
epidemic curve
 Step 3: Define and identify cases

The first cases to be recognized are usually only a

small proportion of the total number
To identify other cases, use as many sources
possible
Passive Surveillance - Relies on routine notifications
by healthcare personnel (recall Notifiable Diseases)
Active Surveillance - Involves regular outreach to
potential reporters to stimulate reporting of specific
conditions; investigators are sent to the afflicted
area to collect more information
Contact physician offices, hospitals, schools to find persons
with similar symptoms or illnesses
Send out a letter, telephone or visit the facilities to collect
information
 Step 3: Define and identify cases

Bagong Bayan in the municipality of Dasmarinas, Cavite

Manila. It is composed with 16 subdivisions where urban
poor dwellers from various places in Metro Manila have
been relocated.
Estimated 85,000 people living in blocks of one-story
apartments built of cement and wood. Each apartment is
usually occupied by one household, averaging of 6
members in each household.
All residents derive their drinking water in an
interconnected water system of 16 deep wells supplying
clusters of public faucets from where residents fetch their
water.
 Step 3: Define and identify cases

As water is not piped into individual apartments,

residents store supplies in large containers kept in their
yard. Many families also maintain shallow wells to
supplement the supply of water.

Health facilities in the locality include a government

health center staffed by a physician, midwives and
nurses and two hospitals run by the Emilio Aguinaldo
College of Medicine. The area is not endemic for
malaria.
 Steps of an Outbreak
Investigation
1) Establish the existence of an outbreak
2) Verify the diagnosis
3) Define and identify cases
4) Describe and orient the data in terms of person,
place and time
Step 4: Describe and orient the data
in terms of time, place and person
Characterizing an outbreak by time, place and
person is called descriptive epidemiology.

Descriptive epidemiology is important because:

You can learn what information is reliable and informative
(e.g., similar exposures)

And what may not be as reliable (e.g., many missing

responses to a particular question)

Provides a comprehensive description of an outbreak by

showing its trend over time, its geographic extent (place)
and the populations (people) affected by the disease
Step 4: Describe and orient the data
in terms of time
The time course of an epidemic is shown by the distribution
of the times of onset of the disease, called the Epidemic
Curve.

Graph of the number of cases of the health event by their

date of onset
Provides a simple visual display of the magnitude and time
trend of the outbreak
May stratify epidemic curves by place (residence, work,
school, etc.) or by personal traits (age, gender, race, etc.) to
assess whether time of onset varies in relation to place or
person characteristics
Step 4: Describe and orient the data in terms of
place

Assessment of the outbreak by place provides:

Information on the geographic extent of the problem
A spot map indicating place of occurrence of cases may
show clusters or patterns that provide clues to the nature
and source of the outbreak
Patterns reflecting water supply, wind currents, or proximity
to a restaurant, swimming pool, school room or workplace

If the size of overall population varies between

comparison areas, a spot map of the area may be
misleading because it only shows number of cases
 Step 4: Describe and orient the data
in terms of person

Examine risks in subgroups of the affected

population according to personal
characteristics, as well as interaction
between characteristics
- Age, race, sex, occupation, social group, medical
status

Characterizing an outbreak by person helps

to determine which subgroups of the
population are at risk
 Step 4: Describe and orient the data in
terms of time, place and person
The Research Institute for Tropical Medicine (RITM) team
conducted house-to house visits and collected specimens
from patients who had continuous fever for at least 3 days.

Collection of specimens was done on 3 occasions:

12th December, 23rd January, and the 6th March.

On the first two occasions, blood was collected for

bacteriologic culture, dengue serology and platelet counts.
Thereafter, only bacteriology was done.
Examples of Epidemic Curves
 Step 4: Describe and orient the data in
terms of time, place and person
To determine if typhoid cases had occurred in other parts
of the resettlement area, records of the Emilio Aguinaldo
College of Medicine in Dasmarinas and the San Lazaro
Hospital in Manila were reviewed since it was known that
patients sought consultation in these institutions.
Moreover, EACM had done its own investigations in its
own community medicine field areas. Unfortunately, health
facilities in the area had no records documenting the
endemic level of cases in Bagong Bayan. Weekly Reports
for 1984 and 1985 of the Health Intelligence Service of the
Ministry of Health were reviewed for information on the
number of reported cases in the province of Cavite.
 To identify risk factors for infection, detailed interviews
were done on 50 confirmed and clinically suspected
typhoid cases and their age and sex-matched controls
from the non-affected families within the immediate
vicinity of the sick person's household.

Investigators defined a confirmed case as a culture

positive individual; a clinically suspected case was one
who had fever of over 14 days duration but no laboratory
support for the diagnosis.
 Steps of an Outbreak
Investigation
1) Establish the existence of an outbreak
2) Verify the diagnosis
3) Define and identify cases
4) Describe and orient the data in terms of person,
place and time
5) Develop hypotheses
 Step 5: Develop hypotheses

Though we generate hypotheses from the beginning of

the outbreak, at this point, the hypotheses are sharpened
and more accurately focused.
Use existing knowledge (if any) on the disease, or find
analogies to diseases of known etiology

Hypotheses should address

Source of the agent
Mode of transmission
Exposures associated with disease
and should be proposed in a way that can be tested
 Step 5: Develop hypotheses

Of particular interest sources were the water supply, the

frequency of eating or buying from neighborhood food
stalls (daily, twice weekly, or less frequently), and the use
of water from shallow wells for drinking or washing.
 Steps of an Outbreak
Investigation
1) Establish the existence of an outbreak
2) Verify the diagnosis
3) Define and identify cases
4) Describe and orient the data in terms of person,
place and time
5) Develop hypotheses
6) Evaluate hypotheses
 Step 6: Evaluate hypotheses
Generally, after a hypothesis is formulated, one
should be able to show that:
1) all additional cases, lab data, and epidemiologic
evidence are consistent with the initial hypothesis; and
2) no other hypothesis fits the data as well

Observations that add weight to validity:

The greater the degree of exposure (or higher dosage of
the pathogen), the higher the incidence of disease
Higher incidence of disease in the presence of one risk
factor relative to another factor
 Attack Rates
An attack rate is the proportion of a well-defined
population that develops illness over a limited period of
time, such as during an epidemic or outbreak
Useful for comparing the risk of disease in groups with different
exposures
Similar to a cumulative incidence
Often expressed as a percent

Formula:
Attack Rate = Number of new cases occurring in a given time period
Population at risk at the start of the time period

= Number of people at risk who develop a certain illness

Total number of people at risk
(Source: Gordis L., Epidemiology)
 Calculating an Attack Rate
in a Foodborne Outbreak

In a foodborne outbreak occurring among people

attending a social function or common geographical
site:

Calculate an attack rate for people who ate a

particular item (exposed) and an attack rate for
those who did not eat the item (unexposed)

The attack rate is calculated by dividing the number

who became ill and consumed the item by the total
number of people who consumed that item
 Identifying the Source of an
Outbreak
Look for an item with:
A high attack rate among those exposed
AND
A low attack rate among those not exposed
(so the ratio of attack rates for the two
groups is high)

Ideally, most of the people who became ill

should have been exposed to the proposed
agent so that the exposure could explain
most, if not all, of the cases.
 Step 6: Evaluate hypotheses

Bacteriologic analysis of specimens was performed at

the laboratories of the RITM and the Bureau of Research
and Laboratories. Studies for dengue serology were
done at RITM.
Isolation of salmonella organisms in blood.
Isolation of Salmonella organisms in stool.
Water analysis.
Phage typing.
 Water analysis revealed 5 of the 10 operational storage
tanks and several public faucets to be faecally contaminated.

According to engineers, chlorination of the tanks had been

erratic. Because all tanks could potentially supply water to
any part of the resettlement area via an interconnecting
system of pipes, correlation between the distribution of
illness with water source was not possible.

All shallow wells were also shown to be faecally polluted.

None of the 8 food handlers examined were found positive

for salmonella organisms in their stools but the occurrence of
food-borne transmission is always a possibility.
 Steps of an Outbreak
Investigation
1) Establish the existence of an outbreak
2) Verify the diagnosis
3) Define and identify cases
4) Describe and orient the data in terms of person,
place and time
5) Develop hypotheses
6) Evaluate hypotheses
7) Refine hypotheses and carry out additional
studies
Step 7: Refine hypotheses and carry
out additional studies

Additional epidemiologic studies

What questions remain unanswered about the

disease?

What kind of study used in a particular setting

would answer these questions?

When analytic studies do not confirm the

hypotheses
reconsider the original hypotheses
look for new vehicles or modes of transmission
Step 7: Refine hypotheses and carry
out additional studies

Laboratory and environmental studies

Epidemiologic studies can

Implicate the source of infection, and
Guide appropriate public health action

But sometimes laboratory evidence can clinch the

findings

Environmental studies often help explain why an outbreak

occurred and may be very important in certain settings
 Case-Control Methods
Applied to a Foodborne Outbreak
The usual approach is to apply the case-control
methodology to determine what exposures ill
people had that well people did not have:
List all of the relevant items on the menu
Determine the proportions of ill and of non-ill persons
who ate each of the items by questionnaire
Identify the food item with the largest difference in
attack rates between cases (ill) and controls (non-ill)
Usually one food item stands out as showing the
greatest difference in proportion between cases
and controls.
 Steps of an Outbreak
Investigation
1) Establish the existence of an outbreak
2) Verify the diagnosis
3) Define and identify cases
4) Describe and orient the data in terms of
person, place and time
5) Develop hypotheses
6) Evaluate hypotheses
7) Refine hypotheses and carry out additional
studies
8) Implement control and prevention measures
 Step 8: Implementing control and
prevention measures

The practical objectives of an epidemic

investigation are to:
Stop the current epidemic, and

Establish measures that would prevent similar

outbreaks in the future.

Preliminary control measures should be

done as soon as possible!
 Elements of Epidemic Control
The elements of epidemic control include:
1. Controlling the source of the pathogen (if
known)
**Remove or inactivate the pathogen
2. Interrupting the transmission
**Sterilize environmental source of spread;
vector control
3. Controlling or modifying the host response
to exposure
**Immunize the susceptible; use
prophylactic chemotherapy
 Step 8: Prevention measures

Most of the typhoid outbreaks cited pointed to water as

the primary source of infection.
Sanitation and hygiene are the critical measures that can
be taken to prevent typhoid.
Typhoid does not affect animals and therefore
transmission is only from human to human.
Typhoid can only spread in environments where human
feces or urine are able to come into contact with food or
drinking water.
Careful food preparation and washing of hands are
crucial to preventing typhoid.
 There are two vaccines licensed for use for the
prevention of typhoid:
the live, oral Ty21a vaccine
injectable Typhoid polysaccharide vaccine
 Steps of an Outbreak
Investigation
1) Establish the existence of an outbreak
2) Verify the diagnosis
3) Define and identify cases
4) Describe and orient the data in terms of person,
place and time
5) Develop hypotheses
6) Evaluate hypotheses
7) Refine hypotheses and carry out additional
studies
8) Implement control and prevention measures
9) Communicate findings
 Step 9: Communicate the
findings
At the end of the investigation, communicate findings to
others who need to know
Prepare a final report
Provide information on the nature, spread, and control measures
employed
The report can take several forms:
1) An oral briefing for local health authorities
2) A written report to a journal or the Mortality and Morbidity Weekly
Report (MMWR)

3) Formal presentation of recommendations (a blueprint for

action)
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