Outbreak Investigation
Outbreak Investigation
Outbreak Investigation
synopsis
Introduction: Epidemiology is Outbreak - - Definition, Detection Investigation - - Steps Examples
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
2 cases with epidemiologic linkage in short time 1 cases of a new emerging disease
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
Reported severe diarrhea cases in Khonkaen, Thailand January 1995 - July 1999
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)
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. 2. 3. Confirm the existence of the outbreak Verify the diagnosis and determine the etiology of the disease 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
Expected cases
Surveillance data OPD card Hospital Discharge Registry
Meet the doctors See the patients Visit the laboratories Not necessary to confirm all the cases
Suspected cases
Clinical case definition Enough for immediate action
Confirmed cases
Laboratory confirmed Very few cases
sensitivity
specificity
Many false positives Many specimens to be tested Low% of specimen tested +ve
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
Probable Confirmed
Case counted
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!!
Patients in community
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
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?
Distribution of variables in the population from where cases are coming (Denominator)
ex: 1500 women, 1000 men
description person
infection S. typhi, attack rate by age
Age group (Years) <20 Number of cases 5 Population 7545
Attack rate/100,000
66
38 22 14 8
Total
87
22591
385
Time of onset
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
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
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 (%)
Case (n=16)
Directly touching abnormal dead poultry Dressing poultry Having abnormal dead poultry around the house Plucking dead poultry Being within 1 metre of dead poultry Storing sick/dead poultry products in the house Directly touching sick poultry Being within 1 metre of sick poultry Contact with suspected/confirmed H5N1 human case Visiting live poultry market
Control (n=64) 12 (19) 4 (6) 9 (14) 3 (5) 16 (25) 3 (5) 29 (2.7-308.2) 17 (1.6-177.0) 14 (2.4- 81.6) 14 (1.3- 152.5) 13 (1.8-96.3) 9.3 (2.1-41.3)
8 (50)
9 (56) 3 (19) 1 (6)
9 (14)
14 (22) 13 (20) 0 (0)
5.6 (1.5-20.7)
3.8 (1.2-11.7) 0.9 (0.2-4.4) NA
A person who ate the fermented vegetable was 6.2 times more likely to be ill than a person who did not eat...
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
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
The art of epidemiological reasoning is to make some reasonable conclusions starting from imperfect data -George W Comstock