There are several key reasons why health agencies investigate disease outbreaks: 1) to identify the source and guide control measures to prevent additional cases, 2) to gain additional knowledge about the disease or public health program weaknesses, and 3) for public concerns. The typical steps in an outbreak investigation are to verify the outbreak, define cases, analyze data to generate hypotheses, implement control measures, and communicate findings. Preparing for an investigation requires understanding disease epidemiology and available tests, as well as administrative and consultation preparations.
There are several key reasons why health agencies investigate disease outbreaks: 1) to identify the source and guide control measures to prevent additional cases, 2) to gain additional knowledge about the disease or public health program weaknesses, and 3) for public concerns. The typical steps in an outbreak investigation are to verify the outbreak, define cases, analyze data to generate hypotheses, implement control measures, and communicate findings. Preparing for an investigation requires understanding disease epidemiology and available tests, as well as administrative and consultation preparations.
There are several key reasons why health agencies investigate disease outbreaks: 1) to identify the source and guide control measures to prevent additional cases, 2) to gain additional knowledge about the disease or public health program weaknesses, and 3) for public concerns. The typical steps in an outbreak investigation are to verify the outbreak, define cases, analyze data to generate hypotheses, implement control measures, and communicate findings. Preparing for an investigation requires understanding disease epidemiology and available tests, as well as administrative and consultation preparations.
There are several key reasons why health agencies investigate disease outbreaks: 1) to identify the source and guide control measures to prevent additional cases, 2) to gain additional knowledge about the disease or public health program weaknesses, and 3) for public concerns. The typical steps in an outbreak investigation are to verify the outbreak, define cases, analyze data to generate hypotheses, implement control measures, and communicate findings. Preparing for an investigation requires understanding disease epidemiology and available tests, as well as administrative and consultation preparations.
Download as PPT, PDF, TXT or read online from Scribd
Download as ppt, pdf, or txt
You are on page 1of 66
Investigation of Outbreaks
Leonardo DG. Macam Jr., RMT, MPH
Learning Objectives At the end of the lecture, the students should be able to: 1.Explain reasons why health agencies need to investigate outbreaks 2. Explain the different steps in the investigation of epidemic 3. Describe how to determine whether an epidemic really exists Learning Objectives At the end of the lecture, the students should be able to: 4. Differentiate common source and its types from propagated epidemics 5. Construct and interpret an epidemic curve 6. Enumerate the contents of an outbreak investigation report Levels of Disease 1. Baseline (or endemic) – the amount of disease that is usually present in the community; the observed but not necessarily the desired level; regarded as the expected level of the disease 2. Sporadic – a disease that occurs infrequently and irregularly 3. Endemic – the constant presence and/or usual prevalence of disease or infectious agent in a population within geographic area. Levels of Disease 4. Hyperendemic – the persistently high levels of disease occurrence 5. Epidemic – an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area 6. Outbreak – similar to an epidemic but is often used for more limited geographic area. Levels of Disease 4. Cluster – an aggregation of cases grouped in place and time that are suspected to be greater than the number expected, even though the expected number may be unknown 5. Pandemic – an epidemic that has spread over several countries or continents, usually affecting a large number of people Epidemic the occurrence of disease cases or deaths clearly in excess of normal expectancy the occurrence of disease cases or deaths limited to a specified group of individuals during a short period of time clearly in excess of normal expectancy the individual may be group that has gathered together in space and time How/Why epidemics occur Epidemics occur when agent and susceptible hosts are present in adequate numbers and the agent can be effectively conveyed from a source to the susceptible hosts Factors which may trigger an epidemic • A recent increase in the virulence of the agent; • The introduction of the agent into a setting where it has not been there before • An enhanced mode of transmission so that more susceptible persons are exposed • A change in the susceptibility of the host response to the agent, and/or; • Factors that increase host exposure or • Involved introduction of agent through new portals of entry. Basics of Outbreaks
• Goals of an outbreak investigation
• To identify the source of illness • To guide public health interventions
• Ways to recognize an outbreak
• Routine surveillance activities • Reports from clinicians and laboratories • Reports from affected individuals Why investigate an outbreak? • Characterize a public health problem • Identify preventable risk factors • Provide new research insights into the disease • Train health department staff in methods of public health investigations and emergency response • To address public, political or legal concerns Reasons for investigating outbreaks • Prevention and Control • Gain additional knowledge/research • Training • Public, political, or legal concerns • Program considerations Prevention and Control • Primary public health reason for investigation • Principal considerations What is the stage of the epidemic? Are cases occuring in increasing numbers? Is the outbreak just about over? Prevention and Control If cases are continuing to occur: Goal is most probably to prevent the occurrence of additional cases The objective of the investigation would be to assess the extent of the outbreak, the size, and characteristics of the population at risk These information are important in designing and implementing the appropriate control measures Prevention and Control If an outbreak appears to be almost over Goal may be to prevent similar outbreaks in the future The objective of the investigation is to identify factors which contributed to the outbreak in order to design and implement measures that would prevent similar outbreaks in the future. Prevention and Control How much is known about the causative agent, the source and the mode of transmission of the agent
Causative Source/Mode of Transmission
Agent Known Unknown
Known Investigation + Investigation +++
Control +++ Control +
Unknown Investigation +++ Investigation +++
Control +++ Control + Prevention and Control o The decision regarding whether and how extensively to investigate an outbreak are influenced by the characteristics of the problem itself
the severity of the illness
the source or mode of transmission the availability of prevention and control measures Gain additional knowledge/research o Each outbreak is an opportunity to study the natural history of the disease o For a newly-recognized disease, field investigation provides an opportunity to define the natural history – agent, mode of transmission, and incubation period and the clinical spectrum of the disease. Gain additional knowledge/research o Are able to characterize the populations at greatest risk; identify specific risk factors Legionnaires disease in Philadelphia in 1976 Toxic shock syndrome in 1980 Gain additional knowledge/research o Are able to characterize the populations at greatest risk; identify specific risk factors Acquired Eosinophilia-myalgia immunodeficiency syndrome (EMS) in syndrome in early 1980’s 1989 Gain additional knowledge/research o Even for diseases that are well characterized, an outbreak may provide opportunities to gain additional knowledge by assessing the impact of control measures o An outbreak of measles in a community with a fairly good immunization coverage provides a setting/opportunity to study the effectiveness, the effect of age at vaccination, and the duration of vaccine-induced protection Training o Investigating an outbreak requires a combination of diplomacy, logical thinking, problem solving ability, quantitative skills, epidemiologic know-how and judgement o These skills improve the practice and experience o The investigating team can be composed of a seasoned epidemiologist with trainee(s). Public, political, or legal concerns o These concerns sometimes override scientific concerns in the decision to conduct investigation o Increasingly, the public has taken an interest in ‘disease clusters’ and potential environmental exposures, and has called upon the health department to investigate Program considerations o An outbreak of a disease (which is targeted by a public health program) may reveal a weakness in that program and provide an opportunity to modify/strengthen the program efforts o Investigating the causes of an outbreak may identify populations which may been overlooked, failures in the investigation strategy, changes in the agent, or events beyond the scope of the program Steps on an outbreak investigation 1. Verify the diagnosis and confirm the outbreak 2. Define a case and conduct case finding 3. Tabulate and orient date: time, place, person 4. Do immediate control measures 5. Formulate and test hypothesis 6. Plan and execute additional studies 7. Implement and evaluate control measures 8. Communicate findings
These steps may occur simultaneously or be repeated as new information
is received Step 0. Prepare for Field Work Preparation can be grouped into: Investigation – appropriate scientific knowledge, supplies and equipment, consult regarding epidemic, laboratory specimen collection, storage and transport Administration – travel arrangements and travel orders Consultation – specific roles and responsibilities Knowledge Necessary to Prepare for Outbreak Investigations Various types of etiologic agents and the resultant disease Epidemiologic characteristics of outbreaks associated with different etiologic agents or resultant diseases Clinical symptoms of resultant diseases Environmental and food sanitation practices Sources of exposure which are vulnerable to contamination with an infectious or chemical agent Laboratory test available to determine the causative agents Common Circumstances of an Epidemic Pathogen factors Introduction of a new pathogen Change in old pathogen Increased dosage Increased virulence Longer exposure to pathogen Multiple pathogens Transmission of factors in environment New growth media, either man or in nature New methods of dispersion Specialized facilities (ICU, day care center) Intensive procedures New sexual practices IV drug use Migration of infected persons, animals, birds Exposure to new environment Host factors Highly susceptible subgroups Travel to susceptible to endemic area Culture or behavioral factors Step 1. Verify the diagnosis and confirm the existence of the outbreak Knowledge/Awareness of an existence of an epidemic through: Regular analysis of surveillance data – detect unusual patterns of disease occurrence Calls from the health care provider or a citizen who knows of ‘several cases’ Media reports Step 1. Verify the diagnosis and confirm the existence of the outbreak Initial investigation may turn out to be: True outbreaks with a common cause Sporadic and unrelated cases of the same disease Unrelated cases of similar but unrelated disease (without a common cause) Step 1. Verify the diagnosis and confirm the existence of the outbreak Sources of data to establish ‘expected number cases’ Health department surveillance data if disease is a notifiable disease Hospitals discharge records, mortality statistics, cancer or other registries if disease is non-notifiable Apply rates from neighboring areas or conduct an informal survey among local physicians Conduct a survey of the community to establish background level of disease. Step 1. Verify the diagnosis and confirm the existence of the outbreak Factors influencing decision regarding investigation of the outbreak Severity of the illness The potential for spread Political consideration Public relations Availability of the resources Step 2. Define a case and do case finding Develop a specific case definition using: Symptoms or laboratory results Time period Location
Conduct a surveillance using case definition
Existing surveillance Active surveillance (review of medical records) Interview case patients Case Definitions A case definition Allows a simple, uniform way to identify cases ‘Standardizes’ the investigation Is unique to outbreak but is based on objective criteria Always include : Person, Place and Time
Person: personal characteristics
Place: where the exposure is thought to have occurred Time: dates during the exposure was thought to have occurred Case Definitions Examples: Salmonellosis outbreak
Person: Has culture-confirmed Salmonella enteritidis, is a resident of Province X
Place: Province X Time: July 1, 2001-September 1, 2001 Step 3. Tabulate and orient data Create a line listing of identified cases Person Who was infected? What do the cases have in common Place Where were they infected? May be useful to draw a map Time When were they infected? Create an epidemic curve Step 3. Tabulate and orient data What is epidemic curve?
How can it help in an outbreak investigation?
An epidemic curve (epi curve) is a graphical
depiction of the number of cases of illness by the date of illness onset Epidemic Curve
• An epidemic curve can provide information on the
following characteristics of an outbreak: Pattern of spread Magnitude Outliers Time trend Exposure and/or disease incubation period Epidemic Curve – Pattern of Spread of Disease • The overall shape of the epi curve can reveal the type of outbreak Common source Point source Propagated Pattern of Spread of Disease – Common Source People are exposed continuously or intermittently to a harmful source Period of exposure may be brief or long Intermittent exposure often results in an epi curve with irregular peaks that reflect the timing and the extent of exposure Common Source Outbreak with Intermittent Exposure Pattern of Spread of Disease – Common Source People are exposed continuously or intermittently to a harmful source Period of exposure may be brief or long Intermittent exposure often results in an epi curve with irregular peaks that reflect the timing and the extent of exposure Common Source Outbreak with Continous Exposure Pattern of Spread of Disease – Point Source Typically shows a sharp upward slope and a gradual downward slope Is a common source exposure outbreak in which the period of exposure is brief, and all cases occur within one incubation period Common Source Outbreak with Point Source Pattern of Spread of Disease – Propagated Source Is spread from person to person Can last longer than common source outbreaks May be multiple waves The classic epi curve for a propagated outbreak has progressively taller peaks, one incubation apart Common Source Outbreak with Propagated Source Epidemic Curve – Outbreak Magnitude • Can provide a sense of the magnitude of an outbreak • Additional information can be obtained by stratifying the epi curve
Separating the sample into several subsamples according to
specific criteria (age and gender) • A special cumulative incidence that measues the proportion of persons in a population who experience an acute health event during a limited time period • Number of new cases of a health problem during an outbreak divided by the size of a population at the beginning of the period who are at risk of the event Epidemic Curve – Outbreak Outliers • Outliers are cases at the very beginning and end that may not appear to be related to the rest of the cases First check to make certain they are not due to a coding or data entry error Epidemic Curve – Outbreak Outliers • If they are not errors, they may represent: Baseline of illness Outbreak source A case exposed earlier than the others An unrelated case A case exposed later than the others A case with a long incubation period Epidemic Curve – Outbreak Time Trend • Provides information on the time trend of the outbreak based on the following: Date of illness onset for the first case Date when the outbreak peaked Date of illness onset for the last case Epidemic Curve – Incubation Period • If the timing of the exposure is known, epi curves can be used to estimate the incubation period of the disease • The time between the exposure and the peak of the epi curve represents the median incubation period • In common source outbreaks with known incubation periods, epi curves can help determine the average period of exposure • Find the average incubation period for the organism and count backwards from the peak case on the epi curve Epidemic Curve – Incubation Period • This can also be done to find the minimum incubation period • Find the minimum incubation period for the organism and count backwards from the earliest case on epi curve Step 4. Institute immediate control measures If an obvious source contamination is identified, institute control measures immediately Contents of an Outbreak Investigation Report Contents of an Outbreak Investigation Report Contents of Final Report 1.Title 2.Author(s) and affiliation 3.Executive Summary brief description of the problem brief description of the population and study group brief discussion of findings major recommendations Contents of an Outbreak Investigation Report Contents of Final Report 4. Introduction Statement of the problem Includes background information 5. Methods Study design Description of the population Sampling methods Contents of an Outbreak Investigation Report 5. Methods Participation (refusals, non-respondents) Standard definition of disease Description of data collection, instrument (questionnaire, interview, examination) laboratory tests used statistical tests Contents of an Outbreak Investigation Report 6. Results Case description Signs and symptoms Time of occurrence of cases
7. Presentation of risks or odds ratios by exposure status
Characterize the magnitude of the problem Identify possible source of contamination Contents of an Outbreak Investigation Report 8. Laboratory findings 9. Source of contamination 10. Discussion
Probable source of contamination
Probable mechanism of spread Conclusiveness of findings 11. Recommendations 12. Acknowledgements 13. References 14. Appendices Contents of an Outbreak Investigation Report 8. Laboratory findings Case description
7. Presentation of risks or odds ratios by exposure status
Characterize the magnitude of the problem Identify possible source of contamination END OF THE PRESENTATION LABORATORY EXERCISE • What is the nature of gastroenteritis and outbreak investigation • What are the pathogens associated with gastroenteritis or diarrhea (clinical manifestations, MOT, Incubation period) • Formulate hypothesis and explain • Create an epi curve based on the given data • What is your findings based on place • What is your findings based on person LABORATORY EXERCISE • ATTACK RATE : biostatistical measure of frequency of morbidity, or speed of spread • RELATIVE RISK: ratio of probability of an event occuring in an exposed group to the probability of the event occuring in a comparison, non-exposed group