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Bahan Diskusi Epidemiologi

Investigasi Outbreak

Skenario I

Ada bukti yang kuat bahwa avian influenza sedang mewabah di peternakan di daerah
anda. Anda terpilih sebagai salah satu anggota tim petugas kesehatan hewan yang
bertugas melakukan investigasi status kesehatan di peternakan nonkemersial (sektor
4) di daerah anda.

Pertanyaan A
1. Berikanlah contoh pemeriksaan/uji yang dapat digunakan untuk mencurigai
adanya kejadian outbreak avian influenza.

Tim anda mengevaluasi 82 peternakan sektor 4 di desa outbreak. Anda dan anggota
team lainnya menguji unggas-unggas dalam setiap peternakan dan mencatat jika ada
unggas yang memperlihatkan gejala klinis penyakit respiratori (lesu, batuk-batuk,
bernafas dengan mulut terbuka, kotoran pada hidung). Selanjutnya, diambil sampel
(usap trakhea) dari unggas untuk menentukan status infeksi dari setiap peternakan.
Jika satu atau lebih sampel yang diambil dari satu peternakan menunjukkan hasil
positif dengan Real-Time PCR, maka seluruh peternakan dianggap positif untuk virus
avian influenza dan diklasifikasikan sebagai “terinfeksi”. Jika unggas-unggas di
dalam peternakan tersebut tidak memperlihatkan gejala klinis penyakit respiratori dan
seluruh sampel yang diambil menunjukkan hasil negatif dengan Real-Time PCR,
maka seluruh peternakan tersebut dianggap negatif untuk virus avian influenza.

Pertanyaan B
1. Apakah adanya gejala klinis penyakit respiratori pada unggas (lihat gejala yang
disebutkan di atas) merupakan definisi kasus untuk avian influenza?
2. Apakah perlu untuk mengumpulkan sampel biologis dari unggas di seluruh
peternakan, atau sebaiknya melakukan sampling? Kenapa ya atau kenapa tidak?
3. Untuk tujuan dari penyelidikan awal ini, status infeksi suatu peternakan
ditentukan seperti yang disebutkan di atas. Apakah ini merupakan cara yang dapat
diterima untuk mengklasifikasi sebuah peternakan tersebut sebagai “terinfeksi”?
Kenapa ya atau kenapa tidak?
4. Jelaskan bagaimana anda mengklasifikasikan peternakan sebagai “terinfeksi”?
Apa definisi kasus anda?

Sebagai bagian dari penyelidikan, anda dan tim harus menjaring data mengenai 1)
apakah ada kontak antara unggas di dalam peternakan dengan unggas liar; 2)
Bagaimana penerapan biosekuriti di peternakan tersebut; 3) Apakah melakukan
vaksinasi AI.

Pada 82 peternakan yang anda evaluasi, 45 diantaranya teridentifikasi positif terkena

virus avian influenza dan diklasifikasikan sebagai “terinfeksi”. Sejumlah 45
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peternakan diketahui mempunyai kontak dengan unggas liar dan 30 diantaranya

diklasifikasikan sebagai “terinfeksi”. Sejumlah 40 peternakan mempunyai biosekuriti
yang baik dan hanya 5 diantaranya yang diklasifikasikan sebagai “terinfeksi”.
Terakhir, 2 peternakan dari 22 yang melakukan vaksinasi AI diklasifikasikan sebagai
“terinfeksi”.

Pertanyaan C
1. Hitunglah proporsi peternakan yang diklasifikasikan “terinfeksi”?
Apakah ini merupakan alat pengukuran kejadian penyakit yang berguna?
Informasi apa yang dapat Anda peroleh dari ini?

2. Dengan menghitung Attack rate untuk masing-masing faktor risiko, serta nilai
attributable rate dan risiko relatif, tentukan faktor apa yang paling berpengaruh
terhadap kejadian AI?

Skenario II

Food-Borne Outbreak

Background

An outbreak (epidemic) of gastroenteritis occurred in Greenport, a suburban

neighborhood, on the evening of April 28. A total of 89 people went to the emergency
departments of the three local hospitals during that evening. No more cases were
reported afterward. These patients complained of headache, fever, nausea, vomiting
and diarrhea. The disease was severe enough in 19 patients to require hospitalization
for rehydration. Gastroenteritis outbreaks like this are usually caused by the
consumption of a contaminated or poisoned meal. Meal contamination can often be
caused by pathogenic viruses or bacteria. However, acute outbreaks are more often
produced by toxins from bacteria such as Staphylococcius spp., Clostridium
perfringens, Salmonella spp. and Vibrio cholerae. Food poisoning can also be caused
by chemicals or heavy metals, such as copper, cadmium or zinc, or by shellfish toxins.

1. Please discuss these findings.

Outbreak Investigation

The local health department was notified of a potential food-borne outbreak of

gastroenteritis in Greenport, and the epidemic team, including a medical
epidemiologist, a microbiology technician and a nurse, visited the local hospitals to
interview the attending physicians, the patients and some of their relatives. Some stool
samples were obtained from patients for microbiologic identification of the causative
agent. The epidemic team knew that these types of outbreak usually occur in a very
short time period that lasts no more than a few hours or one to two days after people
ingest a contaminated meal.
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Epidemic investigators gather data to define the distribution of the disease by time
(onset time and epidemic curve), place (potential places where the implicated meal
was served, such as cafeterias, restaurants and picnics) and person (the distribution of
the disease by age, gender and food items eaten). The findings of the initial
investigation included the following information.

The distribution of the disease by person (age and gender) was found as follows:

Gastroenteritis Outbreak Findings by Person, Case Distribution by Age and

Gender
Females Males Total by Age
Age group
No. % Females No. % Males No. %
0-5 1 1
6 - 10 38 37
11 and older 10 2
Total by gender

2. Please calculate the totals for each column and row and their corresponding
percentages to try to determine if there are any important differences by age
or by gender. Such a task is carried out to investigate if there are any high-
risk groups and if the age and gender distribution can give some clues about
the source of the outbreak. Interpret your findings.
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The epidemic curve above shows the onset time of illness in the 89 patients involved
in the outbreak. The epidemic team studied the curve and recognized that this was a
typical single source acute outbreak. The team also could see that the onset of
symptoms in all patients occurred during a six-hour period. Given the symptoms
mentioned above and the epidemic curve, the epidemic team concluded that this type
of epidemic usually corresponds to intoxication or food poisoning and that the
potentially implicated meal was probably served and consumed within a period of a
few hours before the onset of the symptoms. Therefore the epidemic team
investigated the places where affected persons, their relatives and neighbors ate that
day (April 28). The following table shows the team's findings:

3. Please calculate the attack rates per 100 (incidence rates per 100) by place to
try to determine where the contaminated meal was served. For each place
compare attack rates (AR) for those who attended with attack rates for those
who did not, by using the relative risk (i.e., RR = AR in attendees/AR in
nonattendees). Interpret your findings.

Once the implicated place was determined, the investigation centered on the food. The
following table includes the food items served in that place on April 28:
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Important note: None of the kitchen personnel were ill. The names of the kitchen
personnel and their participation in the food preparation are as follows: Manuel
prepared the beef burritos and the potatoes, John prepared the salad and the fruit,
Sally served all dishes except the ice cream, and Jane prepared the cheeseburgers and
served the ice cream. The ice cream was a commercial brand and was bought at a
nearby supermarket.

4. Please calculate the attack rates per 100 (incidence rates per 100) by food
item to try to determine the one that was probably contaminated. Compare
attack rates (AR) for those who ate the food item with attack rates for those
who did not eat the food item, by using the relative risk (i.e., RR = AR in those
who ate the food/AR in those who did not eat the food). Interpret your
findings.

Given that the epidemic team worked fast enough and the implicated meal(s) was
(were) identified before all food leftovers were discarded, food samples from some
meal leftovers were taken to the laboratory. In addition, stool samples were taken
from the kitchen personnel who prepared or handled each different food item. The
laboratory confirmed that Salmonella toxin was present in some of the food samples
and that one of the kitchen personnel of that place had the same Salmonella species.
Furthermore, the Salmonella species found in the food and the kitchen worker was the
same species found in stool samples of the patients.

5. Please discuss these findings and identify the kitchen worker possibly
responsible for the outbreak.