Adigrat University

Collage of Medicine and Health Sciences

Department of Public Health

EPIDEMIC INVESTIGATION

BERHANE F. (MPH in Epidemiology & Biostatistics

November 27, 2018 1

 Learning objectives
At the end of this chapter the student will be able to:
• Define the terms outbreak, epidemic and pandemic
• Identify types of epidemic
• Discuss reasons that outbreaks occur
• Describe the different steps in the investigation of
epidemic
• Discuss the management of epidemic

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 What do you understand by
the term ‘Epidemic’ or
‘Outbreak’?

Can you name 5 outbreaks

that have occurred recently in
your district?
Public Health Disaster Planning 3
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at District Level
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 What is an outbreak and an epidemic?
• Outbreak: occurrence of a specific disease more than
the expected number in a given area or among a
specific group of people over a specified period of
time.

• Epidemic is also an excess of cases compared with

the number expected but it is more general than an
outbreak,
 The increase in the number of cases continues far longer
(possibly months or even years), and the cases are
distributed across a wider area.

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 Cont…
• For example, the expected case of TB was 10 cases of
tuberculosis (TB) per month in X Town.

• If you found 30 cases of TB in January, followed by

39 cases in February and 45 cases in March, then you
would strongly suspect that there is an epidemic of
TB in the town.

• You would then need to find out why TB had

suddenly increased.
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 Types of epidemics
1. Common source outbreaks: Occur when the rise in cases of an
infection occurs after a group of people all came into contact
with the same unsafe source of infection (the common source),
 E.g. contaminated food or water.
There are two types of common source outbreak:
a. point Common source outbreak: the exposure period is short.
 This means that all cases who fall ill after eating the food
(the common source) also have the same incubation period
b. Continuous Common Source: exposure to the source is
prolonged over an extended period of time and may occur over
more than one incubation period

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 Common Source Outbreak

Food

8
Common Source Outbreak –
Point Source Exposure

Exposure

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Common Source Outbreak –
Intermittent Exposure
Common Source Outbreak –
Continuous Exposure

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 Types of epidemics…
2. Propagated or progressive epidemics
• Occur when the infection spreads from person to
person , in which one or more of the first wave of cases
serves as a source of infection for subsequent cases
 directly from person to person or indirectly via vectors
• The distribution of malaria cases is a good example of
a propagated epidemic
• Propagated epidemics last longer than the common
source outbreaks

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Propagated source outbreak

13
Propagated Outbreak – Person-to-
Person Transmission

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 Types of Epidemics…

3. Mixed epidemics: Show characteristics of both

common source and propagated epidemics.

• So a mixed epidemic can start with a common source,

and be followed by a propagated spread.

• Mixed epidemics are often caused by food-borne

infectious agents.

• Example: Typhoid fever can easily spread and become a

propagated epidemic.
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 Epidemic Investigation
What does it mean by Epidemic investigation?

• It is the process of recognizing

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

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How are Outbreaks Usually Detected?

• Observation of a single event or cluster of events by

• Medical staff (doctors and nurses)
• Laboratory personnel
• Surveillance officers
• Community workers
• Report of one or more patients
• Routine surveillance activities
• Reports in media outlets

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 Cont…
• the woreda/health worker receives
– a report of a suspected epidemic of a priority disease
• unusual increase seen in the number of deaths
during routine analysis of data,
• alert or action thresholds have been reached for
specific priority diseases.
• communities report rumors of deaths or about a
large number of cases.
• “Rumors are real epidemics unless
verified and investigated”
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 Purpose of Epidemic investigation

1. To institute control and 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
• If it continuing, our major goal will be:
 Prevent additional cases
• If the outbreak is almost over, our goal will be:
 Prevent outbreaks in the future

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 Purpose of Epidemic investigation…
2. A good opportunity for research and training
• Each outbreak should be viewed as an experiment
waiting to be analyzed.
• It presents a unique opportunity to study the natural
history of the disease in question
3. Program consideration
• Occurrence of an outbreak could notify us that there
is a program weakness.
• This could help program directors to change or
strengthen the program’s effort
• Thus can improve future directions
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 Purpose of Epidemic investigation…

4. Political concern and legal obligation

 Politicians and leaders are usually concerned with
control of the epidemic
 The public are more concerned in cluster of disease
and potentials of getting medication

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 Usual Scenario When Investigating an
Outbreak

• Unexpected event
• Need to investigate quickly
• Pressure for answers
• Multiple agencies
• Media spotlight
• Work carried out in the field

Systematic approach
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 Steps of an Outbreak Investigation
1. Confirm existence of an outbreak
2. Prepare for field work
3. Verify the diagnosis
4. Establish case definition; identify and count cases
5. Tabulate data by person, place, and time
6. Develop hypotheses
7. Evaluate hypotheses (analytical studies)
8. Reconsider/refine hypotheses (additional studies)
9. Implement control and prevention measures
10. Communicate findings
Outbreak investigation is not a linear process
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 1. Confirm Existence of an Outbreak
• Compare the occurrence of the cases with:
o The expected number of cases in that particular time or
o Disease surveillance or
o Comparison with neighboring areas or national data

• Confirm that it is real; not artifact difference in the

occurrence
• Be cautious and rule out not to be due to
‰
Change in population size,
 ‰
Change in diagnosis,
 ‰
Change in case definition,
 ‰
Increase in interest due to new in-service training , etc
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 2. Prepare for Field Work
• Investigation needs
– Expertise
– Sample questionnaires, supplies
– Laboratory
– Plan of action
• Management / operational issues
– Team composition, role of each
– Communications plan
– Where to go / whom to meet
• Approach

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 3. Verify the Diagnosis
 Goals in verifying the diagnosis include;
 ƒTo ensure that the problem has been properly
diagnosed
 ƒTo rule out laboratory error as the basis for the
increase in diagnosed cases
 We should visit several patients with the disease
 ƒTaking a qualified clinician is advisable
 ƒIncluding possible diagnostic medical
equipment/ instrument

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 4. Establish case definition; identify and
count cases

Case definition
• A case is an event
• A case is not a person
• An event is something that happens:
– To a person;
– In a given place;
– At a given time.
• Cases are difficult to consider if you lack:
– Information on the person
– Information of the place
– Information about the onset date

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 Working Case Definition
• Simple, objective criteria
• Develop a case definition using:
– Symptoms or laboratory results
– Affected population (person)
– Location (place)
– Time frame
– Sensitivity versus specificity

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 Sensitive case definition

Most cases detected, but …

many false positives

many specimens to test
low % tested specimens +ve Danger of overload

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 Specific case definition

Cases missed, but …

few false positives

fewer specimens to test
high % tested specimens +ve
Danger of underload

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 Find Cases Systematically
• Conduct surveillance using case definition
– Active surveillance (e.g. house-to-house)
– Try to identify all cases

• Collect data on case-patients

• Create line listing

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November 27, 2018 32
 What is a Line Listing?
• Line listing = rectangular database similar to
spreadsheet
– Provides summary of key data about cases in an
outbreak
– Each row represents one case
– Each column represents one variable
• First column usually identifier — name, initials,
or ID number
– Can be paper or electronic
– Can be quickly reviewed and updated

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 Case Report Form
• Types of Variables:
– Identifying information
– Demographic information
– Clinical information
– Risk factor information
– Reporter information
– (Contact information, sometimes)

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 Which Variables to Include
Always include:
• Components of case definition
• Case name or identifying number
• Date of symptom onset (or specimen collection date)
Usually include:
• Age, gender
May include:
• Other relevant demographic variables (race,
occupation)
• Relevant risk factors

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 Example of a Line Listing
Signs/Symptoms Labs Demographics
Date of Positive
Symptom Fever stool
Case # Onset Diarrhea Vomiting >37oC culture Age Gender
Not
1 22/10/05 Y Y Y 19 M
done

2 25/10/05 N Y N N 17 M

3 22/10/05 N Y N Y 23 F

4 27/10/05 Y ? ? Pending 18 ?

5 23/10/05 N Y N Y 21 M

Not
6 21/10/05 Y Y Y 18 F
submitted
 Case Classification

• Primary case
– The person who introduces the disease into the
population.
• Index case
– The first case to come to the attention of
investigators.
• Secondary cases
– Cases occurring among contacts, within an
incubation period following exposure.
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5. Tabulate data by person, place, and time

• Time (epidemic curve)

– Ideally, when were they infected?
– More practically, when did they become ill?
• Place (spot map)
– Ideally, where were they infected?
– More commonly, where do they live, work?
• Person (tables)
– Who was infected?
– Numerators and denominators
– What do the cases have in common?

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 Ebola Distribution by person
Age (yrs) Male Female Total
<1 10 14 24
1 - 14 18 25 43
15 - 29 33 60 93
30 - 49 57 52 109
50+ 23 26 49
Total 141 177 318
 Epidemic curve Ebola disease

25

20

Survived
Number of Cases

15
Died
10

0
9/1 9/5 9/9 9/13 9/17 9/21 9/25 9/29 10/3 10/7 10/11 10/15 10/19 10/23
Date of Onset
 Epidemic Curves
 Show the magnitude of the outbreak
 Help distinguish between epidemic and endemic
disease
 Show the time trend of the outbreak
 Can help determine the incubation period or exposure
period
 Show the pattern of spread
 Highlight outliers

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Ebola Descriptive Epi — Place (spot map)
Haemorrhagic Fever, Attack Rates by Village of Residence
Epidemic Zone, Zaïre, 1976
10 km
Yasoku 0.2

Yaimba 0.1
Yambala 0.7
Paipaie 0.2

Bakata 0.3
Bokoy 0.2 Bigi 1.0
Bunkudi 0.4
4.6
Baisa 1.0 Bovange 0.7
Eboy 1.4
Yambuku 2.6 Yapiki Moke 0.7
2.7 Yaeto Liku 1.3
Yalosemba 2.1

Badjoki 1.8 Yandongi 0.9

Bongolo 1.6

Bosambi 0.9 Bodala 0.4

Lobo 0.7
Mdobamjole 0.8
Lotaka 0.3

Koloko 0.8 Mogbakele 0.2

Bongulu 0.1
Yaenengu 0.2

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 6. Develop Hypotheses
 More than one hypotheses must be generated
There may be more than one source

• Subject matter knowledge – known sources,

vehicles, transmission modes

• Review descriptive epidemiology – when, who

and where would the cases account for most?

• Talk to case-patients – what do they think?

• What do local health officials think?

 Cases
25
1200
1000 20
800
Person Place Time
15
600
400 10

200 5
0
0-4 '5-14 '15-44 '45-64 '64+ 0
1 2 3 4 5 6 7 8 9 10
Age Group

Evaluate information

Pathogen? Source? Transmission?

Set Hypothesis from all

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 7. Evaluate the Hypotheses
• Hypothesis testing
Sort out the characteristics that are also common
among non-cases from those that are unique to cases
• Usually Analytic Epidemiology
 cohort study (risk ratio)
 case-control study (odds ratio)
• You can Conduct additional studies (Environmental
sampling or Laboratory-based)
• If analytic study results are conclusive, don’t wait for
positive samples before implementing prevention
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Interpret analysis results
• Review the analysis results and make
conclusions about the epidemic
 What was the causal agent of the epidemic?
 What was the source of infection?
 What was the transmission pattern?
 Who are the most vulnerable groups?
 What control measures were implemented and to
what effect?

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 9. Implement and evaluate
control measures
• Implement as early as possible!
“The perfect is the enemy of the good ”
• In outbreaks, roughly right and timely is better than
precisely right and late.
• Establish priorities; move quickly to control.
• Usually targeted to one or more:
– eliminate the source
– interrupt transmission
– reduce susceptibility
9. Implement and evaluate
control measures
• Modify host response:
 Immunize susceptible hosts
 Use prophylactic chemotherapy
• Work with regulators, industry,
and health educators to institute
control measures
• Create mechanism to evaluate
both short and long-term
success
 Prevent further exposure and future outbreaks
by eliminating or treating the source

• Remove source of contamination

• Remove persons from exposure

• Inactivate / neutralise the

pathogen
• Isolate and/or treat
infected persons
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 Interrupt transmission

• Interrupt environmental
transmission
• Control vector transmission
• Improve personal sanitation

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 10. Communicate Findings
•Summarize investigation
•Make recommendations
•Disseminate report
Communicate findings back to:
Outbreak investigation staff
Public health personnel
Government officials
Healthcare providers
Media
Community
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 Management of epidemics
• Epidemics management activities include taking appropriate
control measures, such as

 treating those who are ill to reduce the reservoir of infection,

 providing health education to limit the transmission of the

disease to others.

• The type of control measures you need to implement depend

on the type of infectious agent, how the disease is transmitted,
and any other factors contributing to the disease.

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Management of epidemics cont…
• Generally, your control measures should target:

 the infectious agent,

the source of any infection, and

the treatment of those who became ill.

• The source of infection could be:

 humans or animals, or

 non-living things in the environment.

• If you do not implement the correct control measures, the

epidemic may continue to spread in your area.
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Examples:
• If contaminated food is the source of an outbreak

 HE to the community about food hygiene

• If it is caused by contaminated water,

 educate the community not to drink the water until it is

treated

• If mosquito breeding sites are the source of a malaria epidemic

 teach the community to clear the breeding sites for

mosquitoes.
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 THE EPIDEMIC CYCLE

Post- epidemic
Response Forecasting
Assessment

Epidemic

Early Early Preparedn

Prevention
Response warning ess

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 Summary
• Purpose: stop the outbreak, prevent further spread,
and improve surveillance to detect future events.
• Process: follow a set of steps which have been
developed and refined over long experience.
• Analysis: time, place, person can provide key
information on cause, source, transmission, risks, and
exposures.
• Result: The most important reasons for investigation
are to control and prevent current and future
outbreaks.

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Thank you!

November 27, 2018 57