Source: www.curremd.

com

INFECTIOUS DISEASE MANAGEMENT

ONE HEALTH COURSE
 COMPETENCIES

• Competency #1
• Identify and analyze risk factors during an infectious
disease outbreak
• Competency #2
• Design an infectious disease management plan
• Competency #3
• Evaluate the effectiveness of One Health actions in
infectious disease management
• Competency #4
• Design a new, or evaluate an existing disease
surveillance and monitoring system
Fundamental Concepts for Infectious
Disease Management

INFECTIOUS DISEASE MANAGEMENT

ONE HEALTH COURSE
INFECTIOUS DISEASE
BASIC CONCEPTS
EPIDEMIOLOGICAL TRIAD

Host
Agent

Environment Gordis, L. (2004).

Epidemiology. Philadelphia:
Elsevier Saunders.
CHAIN OF INFECTION
MANAGING INFECTIOUS DISEASES

• Requires knowledge of:

• Infectious organisms (“agent”)
• Modes of Disease Transmission
• Risk
• Management concepts
 INFECTIOUS ORGANISMS

• Bacteria Leptospira
interrogans
• Viruses
• Parasites
• Fungi
• Prions en.wikipedia.org

en.wikipedia.org
INFECTIOUS AGENTS

Clostridium botulinum

Enterohaemorrhagic E. coli O104

PORTAL OF ENTRY
 MODES OF DISEASE TRANSMISSION

• Contact
• Direct
• Indirect
• Airborne * Aerosolized Particles
• Droplet
• Airborne
• Vector Borne
• Vehicle
* Aerosolized Particles from coughing or sneezing <5 microns in size containing influenza virus can
be inhaled at alveolar level of lungs
DIRECT CONTACT TRANSMISSION

• Direct contact with infected individual person or

animals, or their secretions
• Infectious organisms can enter via:
• respiratory tract – inhaled particles from sneezing and
coughing
• mucous membranes – eyes, nose, reproductive, digestive
tracts
• Skin – cuts, wounds, open sore, injury can facilitate entry
• ingestion – swallowing
 CONTACT WITH FOMITE
• Fomite: an inanimate object contaminated with an
infectious organism
• Organisms can survive on surfaces
• Does not require direct contact between individuals
• Examples of fomites:
• Doorknobs
• computer keyboard
• bedding or towels
• needles, forceps, scissors, other
medical equipment
• food preparation equipment and
serving vessels

healthline.com
 CONTAMINATED FOOD AND WATER

• Food and water can become contaminated and

transmit diseases when consumed
• Contaminated food or water possible:
• Restaurants
• Central water supply
• Water storage containers
• Often cause gastroenteritis
• Diarrhea, vomiting, nausea
• E. coli, Salmonella, Campylobacter
• Cholera, Hepatitis A
• Intestinal parasites

en.wikipedia.org
RESERVOIR HOSTS & TRANSMISSION

• Reservoir hosts with infectious agents can transmit

the organism, but may not develop disease
• Hosts provide a reservoir for the organism in the
environment
• Management difficult if host population is large or
difficult to control
• Host may be required for stage(s) of an organism’s
development or transmission cycle before capable
of infecting another host or vector
BIOLOGICAL VECTORS - ARTHROPODS

• Vector borne diseases common worldwide

• Insect provides a necessary part of disease
transmission process (e.g, biting during blood meal)
• Considering vector(s) key to management plans

www.cdc.gov
www.tse-tse.com

www.list25.com
BIOLOGICAL VECTORS - ANIMALS
 RISK FACTORS AND INFECTIOUS
DISEASES

• Consider risk factors when forming a management

plan
• Risk factors affect whether an individual will contract
a disease
• Consider intrinsic and extrinsic risk factors
• Consider high-risk behaviors / occupations
• Knowledge about risk factors useful when
developing public awareness materials
 INTRINSIC RISK FACTORS
• Intrinsic factors are those related to the host itself (human or
animal):
• Genetics
• May cause susceptibility to a disease
• Host have correct receptors? (important for many viruses)
• Immune system – robust response can reduce severity
• Underlying diseases (HIV/AIDS, cancer – immunodeficiency
associated with increased severity of disease, death)
• Age (infants, children, elderly generally more susceptible to
severe illness)
• Nutrition (malnutrition, or being under- or overweight can
increase susceptibility to disease)
SUSCEPTIBLE HOSTS
 EXTRINSIC RISK FACTORS
• Extrinsic factors are not directly host- related
• Reservoir or infectious hosts:
• Does an individual have exposure to infected hosts?
• What are the reservoir hosts?
• Exposure risks
• Contaminated food and water
• Contaminated surfaces
• Socioeconomic status
 EXTRINSIC RISK FACTORS (CONTINUED)
• Specific temporal risks
• Occupational exposures
• Environmental exposures
• Natural disasters:
o Floods
o Drought
o Climate change
INFECTIOUS DISEASE
MANAGEMENT PLANNING
 MANAGEMENT PLAN:
FUNDAMENTAL APPROACH
• Need to understand all aspects of disease
transmission and risk factors to form an effective
infectious disease management plan
• Often need to brainstorm and create concept maps
with a management team to identify important
disease transmission factors
• One Health approach – make sure to include
members with different backgrounds on your team
so important transmission or risk factors are
considered (e.g., for zoonotic diseases)
 QUESTIONS TO GUIDE
MANAGEMENT PLAN
• What is the infectious organism (agent)?
• What are the characteristics of that organism?
• Which host species develop disease?
• What are the reservoir hosts?
• How is the disease transmitted from one host to
another?
• Who gets the disease?
• What are the most important risk factors for disease?
 DECIDING ON A PLAN

• Determine what interventions are available

• Vaccination
• Treatment
• Control of vectors and reservoir hosts
• Monitoring of food and water supply
• Safe food and water handling and preparation
• Cleaning of contaminated surfaces or fomites
• Animal husbandry practices
• Control of contact with reservoir hosts
• Public education – safe practices related to the disease
 EVALUATING THE PLAN
• Once possible intervention strategies determined,
consider best for the situation and context
• Where in the concept map do each of the possible
interventions fit?
• What is the positive impact of each intervention?
• Cost-benefit? Want to maximize
• Are there negative consequences of the interventions?
• Who is affected?
• How to minimize negative impacts?
• Always consider downstream effects of disease management
decisions
 THINK ABOUT

The Fournie article on Avian Influenza:

• What species are infected by Avian Influenza H5N1?
• What is the role of live bird markets in the transmission of
H5N1, and why were they a focus of this investigation?
• What is the difference between susceptibility and
infectiousness in terms of the live bird markets studied in
this paper?
• What are the management recommendations for H5N1
in the live bird markets?
 ASSIGNMENT
Create a presentation, including a diagram for transmission.
Group 1 Make sure to include:
Transmission  Type of organism
Dynamics for H5N1  Host range – include reservoirs
 Route of transmission

Create a presentation describing risk factors for the spread

of H5N1 between animals and humans. Make sure to
Group 2 include:
Risk Factors for H5N1  Risk factors for humans and animals
Transmission  Environmental factors that increase or decrease risk
 Human behavior and cultural/traditional factors that
increase or decrease risk of H5N1
 Animal behaviors that increase or decrease risk of H5N1
Create a presentation describing the management
recommendations proposed in the paper for H5N1 in live
Group 3 bird markets. Make sure to include:
Management of  Management recommendations
H5N1  Aspects of transmission dynamics influenced by the
management plan implementation.
 How risk factors are mitigated by the management plan
suggested in the paper.
Infectious Disease Risk Factors in an
Outbreak Scenario
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
 RABIES

• How is rabies transmitted to humans?

• What are the symptoms and outcome of rabies
infection in humans?
• Which animal species can be infected with rabies?
• Which animal species transmit rabies to humans?
• What risk factors increase the risk of rabies infection
to domestic animals? To humans?
• Vaccine available for animals? Important?
• Vaccine in humans (post-exposure prophylaxis)?
CASE STUDY

Source: www.balidiscovery.com
 RABIES CASE SCENARIO
• How serious is the rabies outbreak?
• What are the most significant risk factors in the
rabies outbreak?
• Who is responsible for monitoring risk factors?
• What is a major concern in a rabies outbreak
situation?
• What would you do to mitigate risk factors for rabies
during an outbreak?
• What is your group’s plan of action?
 Creating a Conceptual Model to
Visualize Risk Factors and Control
Points
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
ONE HEALTH CONCEPT
 PREVENTIVE STRATEGIES

• Primary prevention
• Secondary prevention
• Tertiary prevention
 PRIMARY PREVENTION OF
INFECTIOUS DISEASE
• Seek to prevent new cases of infection from occurring
by interrupting the transmission of pathogens to
susceptible human hosts, or increasing their resistance
to infection
• Vaccination
 VACCINATION

• Directly, by increasing the immunity of

individuals vaccinated against the pathogen
targeted by vaccine
• Indirectly, by decreasing potential exposure to
a pathogen, by reducing the proportion of
susceptible individuals capable of transmitting
the infection in the population
 SECONDARY PREVENTION OF
INFECTIOUS DISEASE
• Detect new cases of infectious disease at the earliest
possible stage and intervene in ways that prevent or
reduce the risk of infection spreading further in the
population. Some examples of how secondary
prevention can be put into practice are described
below.
• Early treatment
• Education and health-related behavior modification
• Screening program
 TERTIARY PREVENTION OF
INFECTIOUS DISEASE
• Prevent the worst outcomes of a disease in an
individual already diagnosed (e.g., rehabilitation)
• Although this may greatly improve the quality of life
for that person, it has at most a limited impact on
the spread of infectious disease
• Extremely expensive, compared to prevention of
disease
 WHAT DO YOU THINK?

• Think about the risk factors, transmission and control

of Avian Influenza. List one or two:
• Host-related risk factors
• Virus-related risk factors
• Risk factors related to the environment
• Transmission routes
• control or intervention points
 CASE STUDIES

• Leptospirosis
• Streptococcus suis infection
• Rabies
• Dengue
 DISEASE CASE SUMMARY:
LEPTOSPIROSIS
Leptospirosis is a zoonotic waterborne infection caused by the bacteria
Leptospira that can affect the liver, kidneys, and central nervous system.
Humans can be exposed through contact with water, vegetation or soil
contaminated by the urine of infected animals. Possible animal reservoirs
include livestock, dogs, rodents, and wild animals. Leptospires enter the
body through contact with the skin and mucous membranes and,
occasionally, via drinking water or inhalation. Person-to-person
transmission is rare. Occurrence of leptospirosis in humans depends on a
complex set of interactions between ecological and social factors.
Leptospirosis is present worldwide, but more common in tropical and sub-
tropical regions where abundant precipitation, regular flooding and high
temperatures enhance the distribution and survival of leptospires.
Additional information available in the One Health Compendium.
 DISEASE CASE SUMMARY:
STREPTOCOCCUS SUIS
• Streptococcus suis is an important bacterial cause of zoonotic disease
in both swine (pigs) and humans in many areas of the world. The
organism may be isolated from healthy pig carriers, but reported
infections in pigs due to Streptococcus suis include arthritis, meningitis,
pneumonia, septicaemia, endocarditis, abortions and abscesses.
Humans at higher risk for infection include persons in direct contact with
infected pigs or raw pig-products, including farmers and abattoir
workers, and those with pre-existing illness or immunodeficiency.
Human infection is thought to occur through cuts or abrasions on the
skin, handling infected pig material, or possibly inhalation or
ingestion. In humans, infection due to
Streptococcus suis may cause meningitis, endocarditis, pneumonia,
septic arthritis, and/or toxic shock–like syndrome.
Information available from the WHO Factsheet: http://www.who.int/foodsafety/micro/strepsuis/en/
 DISEASE CASE SUMMARY:
RABIES
Rabies is an important preventable zoonotic disease caused by the rabies
virus. The disease is endemic in many countries, affects both domestic
and wild mammals, and is transmitted to humans through contact with
infectious material, usually saliva, via bites or scratches by a rabid animal.
Rabies is present on all continents with the exception of Antarctica, but
more than 95% of human deaths occur in Asia and Africa, most often
following contact with dogs, other canines/carnivores, or bats with rabies
infection. Once symptoms of the disease develop, rabies is nearly always
fatal; WHO estimates rabies causes 60,000 human deaths per year. The
high mortality highlights the importance of the global canine rabies
elimination strategy based on dog vaccination. Rabies is 100%
preventable, so humans exposed to rabid animals should receive proper
wound care and post-exposure prophylaxis including rabies vaccine.
Additional information available in the WHO Fact Sheet: http://www.who.int/mediacentre/factsheets/fs099/en/
 DISEASE CASE SUMMARY:
DENGUE
Dengue is a mosquito-borne viral infection found in tropical and sub-
tropical regions around the world. Dengue virus (DENV) exists in four
serotypes (DENV 1, 2, 3 and 4). Dengue fever has become a major
international public health concern. Severe Dengue (previously known as
Dengue Haemorrhagic Fever) was first recognized in the 1950s during
epidemics in the Philippines and Thailand. Today, severe dengue affects
many Asian and Latin American countries and is leading cause of
morbidity, hospitalization and death among children. Control strategies
have focused mainly on vector control, and enhanced disease
surveillance. No vaccine has yet been shown to be effective against all
four DENV serotypes. DENV transmission in forest monkey occurs, but
human infection is sufficient to maintain transmission cycles in cities,
particularly in crowded urban areas where mosquito vectors breed in
uncovered water storage containers, flower vases, metal cans, or in
discarded glass bottles, plastic containers or auto tires containing water.
Information available from the WHO Factsheet: http://www.who.int/mediacentre/factsheets/fs117/en/index.html
African Proverb
 SUMMARY

• Prevention and control of

infectious diseases is in your hand
• Partnership and collaboration is a
key to success
• The path forward requires a
system, resources, and courage
Risk Assessment Principles
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
 RISK ANALYSIS

Risk Analysis addresses/differentiates between:

• Perception vs. Reality

• Fate vs. Probability

• Risk = Likelihood X Magnitude

Source: D. Travis and B. Wilcox. 2012. MODULE VIII: EMERGING ZOONOTIC

DISEASE RISK. EZD Short Course, April 2012, Hanoi
 GENERAL CONCEPTS OF RISK

• Identify Hazard(s) = what, specifically, are we

concerned about?

• Assess Vulnerability = of whom?

• Assess Impact = likelihood and magnitude

Source: D. Travis and B. Wilcox. 2012. MODULE VIII: EMERGING ZOONOTIC

DISEASE RISK. EZD Short Course, April 2012, Hanoi
DIFFERENT TYPES OF RISK ANALYSIS

Source: D. Travis and B. Wilcox. 2012. MODULE VIII: EMERGING ZOONOTIC DISEASE RISK. EZD
Short Course, April 2012, Hanoi
 RISK ASSESSMENT MODEL

Risk = Chance x Hazard x

Exposure x Consequence
The quality of the Risk Estimates depends on the quality of the input
 FUNDAMENTAL CONSTRAINTS IN
RISK ANALYSIS
• Data Availability/Quality
• Great models rarely make data better
 OVERALL RISK ASSESSMENT
PROCESS

Hazard Pathway
WHAT HOW

Assumptions
Release
Exposure Model Rating scale
Consequences Uncertainty

Risk Characterization
 RISK ASSESSMENT PROCESS

• Problem Formulation
• Hazard Identification
• Exposure Assessment
• Dose/Response
• Risk Characterization
• Risk Management
 PROBLEM FORMULATION

• What risk are you going to evaluate?

• What are the chances of wining the lottery?
• What is the risk of getting hit by a meteor?
• What is the risk of getting lung cancer if I smoke three packs
of cigarette per day?
• What is the risk of a Nipah virus outbreak in villages in
Bangladesh which tap date palm trees?
 HAZARD IDENTIFICATION

• Identify the pathogen and human illness and

disease
• Characterize the pathogen
• Case fatality
• Transmission routes
• Incubation periods
 SOURCES OF DATA

• World Health Organization

• International Agency for Research on Cancer (IARC)
• USEPA Integrated Risk Information System (IRIS)
• Other governmental agencies
• Scientific literature
• RAIS Risk Assessment Information
 EXPOSURE ASSESSMENT

• Identifies potentially affected population

• Determines exposure/transmission pathways
• Estimate dose of exposure
• Estimate exposure factors such as contact rates and
the frequency and duration of exposure
• Estimate physiological parameters such as
inhalation and ingestion rates, absorption rates,
body weight, and life expectancy
 ROUTES OF EXPOSURE

Ingestion Dermal Inhalation

RISK FACTORS
SUBPOPULATIONS OF POTENTIAL
CONCERN
 DOSE RESPONSE

• Quantitative relationship between likelihood of

adverse effects and the level of exposure
• Invective Dose – ID50
• Lethal Dose - LD50
 RISK CHARACTERIZATION

• Summarize the numerical risk estimates for all

exposure scenarios and receptor groups evaluated
• Identify the major risks, and the pathways and
chemicals most responsible
• Review the nature of the potential adverse health
effects
 Infectious Disease Risk Analysis Factors
Agent or Route(s) of Methods of Result of Population
Disease transmission exposure or contact Dynamics
contact

Pathogenicity Potential
Agent class for spread
Air borne
Direct contact
Infectivity (ID50)
Vector borne
Reservoir Cross contamination
Virulence (LD50)

Environmental factors contributing

Exposure dose
to agent survivability
(Amount X Time X Route)

Host susceptibility
 RISK MANAGEMENT

• Process of evaluating alternative

options and selecting among
them; a risk assessment may be
one of the bases of risk
management
 RISK COMMUNICATION

Audience:
• Management
• Government
• Public
RISK ASSESSMENT: QMRA WIKI
Quantitative Microbial Risk Assessment (QMRA) Wiki
 Collect Community-Based Data to
Support Infectious Disease
Investigations or Risk Assessments
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
 FIELD TRIP

• Advantages
• Evaluate the issue the context of a community
• Help in understanding the broader impact of the issue
• Some types of data are collected regularly and are
publicly available
 FIELD TRIP

• Disadvantages
• Data may be difficult or time-consuming to locate
• May be limited to qualitative data
• Data are limited to what has already been collected
previously and may not be relevant
 FIELD TRIP ASSIGNMENT

• Prior to the field trip, learn about disease (e.g., acute

gastroenteritis due to E. Coli or other infectious agent)
• Assume outbreak in the neighboring community among
school-aged children and elderly. The potential source
of the E. Coli outbreak is under-cooked hamburger meat
served in institutional settings. It is possible that same
batch of hamburger patties was sent to community, but
no method to check batch numbers. What is the risk of
outbreak in this community? Create a plan to:
• Determine what are the important issues about E. Coli and
impact possible in community
• What are potential points of exposure?
 PREPARING FOR A FIELD TRIP

• Steps for planning to use community measures

• Review the objectives and research questions to determine
whether community measures are useful to your evaluation
• Determine the type of data about the community that would be
useful to obtain
• Evaluate the available data and determine if additional information
is needed
• Design appropriate, standardized instrument to collect data, pilot
test and train on the use of questionnaire
• Conduct data collection
• Obtain proper permission from local health authorities, keep village
elders informed (consider using local guide)
 FIELD TRIP

• Tips for using community measures

• Community data are available from a variety sources i.e.
agency, www, government, local government
• Pay attention to how, when, and where the data was
collected
• Interpreting data that was not collected by others requires
caution
 DEVELOP A RISK ASSESSMENT

• Assemble the data gathered from the community

and from other sources
• Characterize the hazard
• What are the potential sources and exposure pathways in
the community
• What is the important information about dose for this
pathogen
• How would you characterize the potential risks in this
community
Developing Infectious Disease and
Public Awareness Materials
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
 KEY CONCEPT

• Public awareness:
• Informing
• Sensitizing
• Drawing attention of community to a particular
issue through awareness materials
 AUDIENCES

• To have effective material, target audiences

should be carefully identified
• Some educational topics, material and
approaches may suit a broad spectrum of
audiences, but in other activities should be
tailored to a specific audience
• Consider a One Health perspective
 TYPE OF AUDIENCES

• Children/Teenagers/Adults
• General / specific audiences
• Government sectors
 MESSAGES

• Messages delivered should be appropriate

for each target audience
• After analyzing your audience, design and
package your messages accordingly
• Standard rules:
• Keep it simple and short, but interesting
• Avoid unnecessary/ meaningless words
 PREPARING EFFECTIVE MESSAGES

• Concise: As few words as possible, but no fewer

• Clear: Your grandparents can understand it
• Compelling: Explains the problem
• Credible: Explains how you solved the problem
• Conceptual: Not unnecessary detail
• Concrete: Specific and tangible
• Customized: Addresses audience’s interests
• Consistent: Same basic message
• Conversational: Aims to engage the audience
 KEY CONTENTS

• General information about infectious diseases

• Pathogen
• Host
• Vector
• Route(s) of transmission/transmission dynamics
• Disease symptoms
• Risk factors
• Protection and prevention
 MATERIALS/APPROACHES

• Seminars/ workshops/ conferences

• Exhibitions
• Publications (posters, guidelines, flyers, brochures, booklets,
activity books, paper models, comic books, story books,
coloring books)
• Public awareness events (Visitors' / field days)
• Media (newspapers, radio, TV)
• Websites and other internet based tools
• Social media (Facebook, Twitter, YouTube, LinkedIn, blogs)
• Performing and cultural arts (plays, dances, poems, songs,
street theatre, puppet theatre)
• International day
 SEMINARS, WORKSHOPS AND
CONFERENCES
• Discussions with target audiences on specific themes
• Develop common understanding
• Develop strategy or plan action
• Improve interaction
• Ensure participation in decision-making
• Facilitate identification of problems
• Deliver general information to target audiences
• Invite questions and discussion from audiences
 EXHIBITIONS

• Present and demonstrate the information to mixed

audience in various ways
• Allow interaction with public
• Inform and get instant feedback
• International, national and local exhibitions
• Create general public awareness
• Attract government and public support
• Providing info on org and its activities
• Promote networking
• Identify new clients/beneficiaries and potential partners
 VISITORS AND FIELD DAYS
• Gather information about target audience(s)
• Develop message to meet their interests
• Decide how to present message
• Wall-mounted exhibits
• Posters
• PowerPoint presentations
• Automatic audio-visuals/computer displays practical
demonstrations, field tours
• Provide comfortable environment
• Space for face-to-face interaction
• Seats for longer discussions
 SOCIAL MEDIA
• Good way to engage and maintain relationships with the
public
• Use various tools to deliver targeted message:
Facebook, Twitter, YouTube, LinkedIn, Blogs
• Agree with your team about which tools are to be used
• Can be demanding, requires dedication
• Keep engaged, innovative, up-to-date
• Follow-up on messages/requests; Check on your contacts
• Feed your blog posts
• Engage prominent personalities
EXAMPLE OF PUBLIC AWARENESS
MATERIAL
EXAMPLE OF PUBLIC AWARENESS
MATERIAL

Source: ericaglasier.com
EXAMPLE OF PUBLIC AWARENESS
MATERIAL

Source: unicef.org
 ASSIGNMENT

Develop a public awareness message

• What is the infectious disease that you want to conduct
the public awareness for?
• Who is the target audience(s)?
• What are the messages that you want to deliver to the
target audience(s)?
• What is the best method for relaying these messages?
What types of materials are appropriate?
• How might we adapt the material to the target
audience(s)?
 DELIVER YOUR PUBLIC
AWARENESS MESSAGE
Create a plan for delivering your public awareness
message at a specific activity:
• Location
• Objectives
• Audient profile
• Primary issues to be discussed or highlighted
• Speakers or other participants
• Target number of expected attendees
• Language to be used
• Documents and materials to be distributed
 DEBRIEFING

• What problems did you encounter when you

introduced the material to the target audience(s)?
• How well did the target audience(s) understand the
messages delivered by your material?
• What was the feedback you received from the
audience(s)?
Critique of an Infectious Disease
Management Plan from a
One Health Perspective
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
 TOWNSEND ARTICLE

• What led to the introduction of rabies in Bali, Indonesia?

• What are possible interventions to consider including in
a rabies management plan?
• What is R0? What is the calculated R0 for rabies in this
paper?
• Reduction of dog density is discussed as a possible
rabies management measure. What do the authors
conclude about this for a management plan and why?
• What are the dog vaccination campaigns discussed in
the paper and how would their use in a management
plan vary?
 TOWNSEND ARTICLE (CONTINUED)

• In what ways does the rabies management plan

discussed in the paper use a One Health approach?
• What aspects of this management plan could be
improved from a One Health perspective?
 Systemic Effects of a
Disease Management Plan
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
 DISCUSSION QUESTIONS

• Why are ducks important to consider in the

transmission of avian influenza?
• How many ducks contribute to the spread of avian
influenza to humans?
• Why was duck culling part of the management plan
for controlling avian influenza in Thailand?
Infectious Disease Surveillance
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
 LEARNING OBJECTIVES

• Understanding core concepts in surveillance

methods
• Describe the components and methods for
evaluating public health surveillance system
 EFFECTIVE: “SMART” OBJECTIVES

• S = strategic
• M = measurable
• A = adaptable
• R = responsive
• T = targeted
 OBJECTIVES OF “SMART” DISEASE
SURVEILLANCE

• Identify key drivers of zoonotic disease

emergence
• Detect disease outbreaks
• Forecast events that may lead to disease
emergence
• Assist governments in the development of
preventive strategies
• Establish a sustainable, global early-warning
 OBJECTIVES OF PUBLIC HEALTH
SURVEILLANCE

• To reduce morbidity, mortality and to

improve the public’s health
• To guide logical and effective public health
action, based on timely and accurate
information
• Strengthen program planning and evaluation
• Formulate priorities, research hypotheses
 EXAMPLES OF TYPES AND SOURCES
OF DISEASE SURVEILLANCE DATA

• Field surveillance: data collected in the

field, both quantitative and qualitative data
• Digital surveillance data: data collected
through automatic web-based monitoring
• Active surveillance: enhanced activities to
search for new or existing cases of disease
at a health facility or in community
 COMPONENTS OF DISEASE
SURVEILLANCE: CORE ACTIVITIES

Detection Registration Reporting

Confirmation Analysis Feedback

 COMPONENTS OF DISEASE
SURVEILLANCE: SUPPORT ACTIVITIES

Communication Supervision

Resource
Training
Promotion
 PURPOSE OF EVALUATING PUBLIC
HEALTH SURVEILLANCE SYSTEMS

…to ensure that problems of public health

importance are being monitored efficiently
and effectively

… to ensure that managers have accurate

and timely health information to enable
“informed” decision-making to improve
disease prevention & control activities
 EVALUATING PUBLIC HEALTH
SURVEILLANCE SYSTEMS

Public health surveillance systems should be

evaluated periodically, and the evaluation
should result in recommendations useful to
improve the quality, efficiency, and
usefulness of disease prevention and control
activities
EVALUATION OF DISEASE SURVEILLANCE
SYSTEMS: SELECTED CRITERIA

• Simplicity • Accuracy
• Flexibility • Positive predictive value
• Acceptability • Representativeness
• Sensitivity • Sustainability
• Specificity • Timeliness
 SIMPLICITY: DEFINITION

• The simplicity of a public health

surveillance system refers to both its
structure and ease of operation
• Disease surveillance systems should be as
simple as possible while still meeting their
objectives
 FLEXIBILITY: DEFINITION

A flexible public health surveillance system

can adapt to changing information needs,
operating conditions, or new diagnostic tests or
criteria -- with little additional time, personnel,
or allocated funds.
 FLEXIBILITY: DEFINITION
• Flexible systems can accommodate, for
example, new health-related events, changes
in case definitions or technology (including new
diagnostic tests, rapid tests), and variations in
funding or reporting sources
• Use of standard data formats (e.g., in electronic
data interchange) can be integrated with other
systems
 FLEXIBILITY: METHODS

• Flexibility is probably best evaluated

retrospectively by observing how a
system has responded to a new demand
• Animal and human health professionals
are an excellent source of information
about disease surveillance systems
 DATA QUALITY: DEFINITION

Data quality reflects the completeness and

validity of the data recorded in the public
health surveillance system
 DATA QUALITY: METHODS

• Examining the percentage of "unknown" or

"blank" responses to items on surveillance forms
is a straightforward and easy measure of data
quality
• A full assessment of the completeness and
validity of the system's data might require a
special study
 DATA QUALITY: METHODS

• Data values recorded in the surveillance system can

be compared to "true" values:
• a review of sampled data
• a special record linkage
• patient interview
• calculation of sensitivity and predictive value
positive
 ACCEPTABILITY: DEFINITION

Acceptability reflects the willingness of persons

and organizations to participate in the surveillance
system
 ACCEPTABILITY: METHODS

Quantitative measures of acceptability:

• Subject or agency participation rate (if it is high, how
quickly was it achieved?)
• interview completion rates and refusal rates (if the
system involves interviews)
• Completeness of report forms
• Physician, laboratory, or hospital/facility reporting rates
 ACCEPTABILITY: METHODS

• Accurate
• Consistent
• Complete
• Timely
 FACTORS INFLUENCING
ACCEPTABILITY
• The public health importance of the health-related
event
• Acknowledgment by the system of individual
contributions
• Dissemination of aggregate data back to reporting
sources and interested parties
 FACTORS INFLUENCING
ACCEPTABILITY

• Responsiveness of the system to

suggestions or comments
• Burden on time relative to available time
• Ease and cost of data reporting
• Federal and state statutory assurance of
privacy and confidentiality
 FACTORS INFLUENCING
ACCEPTABILITY
• The ability of the system to protect privacy
and confidentiality
• Federal and state statute requirements for
data collection and case reporting
• Participation from the community in which
the system operates
 SENSITIVITY: DEFINITION

• First, at the level of case reporting,

sensitivity refers to the proportion of cases
of a disease (or other health-related event)
detected by the surveillance system
• Second, sensitivity can refer to the ability to
detect outbreaks, including the ability to
monitor changes in the number of cases
over time
 SENSITIVITY: METHODS

• Certain diseases or other health-related events

occurring in the population under surveillance
• Cases of certain health-related events are
under medical care, receive laboratory
testing, or are otherwise coming to the
attention of institutions subject to notifiable
disease reporting requirements
 SENSITIVITY: METHODS

• The health-related events will be diagnosed/

identified, reflecting the skill of health-care
providers and the sensitivity of screening
and diagnostic tests (i.e., the case definition)
• The case will be reported to the disease
surveillance system
 POSITIVE PREDICTIVE VALUE:
DEFINITION

Predictive positive value (PPV) is the

proportion of reported cases that actually
have the disease of interest or health-
related event or condition under
surveillance
POSITIVE PREDICTIVE VALUE:
METHODS

Source: wikipedia.com
REPRESENTATIVENESS: DEFINITION

A disease surveillance system is representative

if it accurately describes the occurrence of a
disease or other health-related event, and the
reported distribution of disease accurately
represents that occurring in the population by
time, place and person
 REPRESENTATIVENESS: METHODS

• Representativeness is assessed by
comparing the characteristics of reported
events to all such actual events
• Representativeness can be examined
through special studies that seek to identify
a sample of all cases
• One aspect to consider is what proportion of
all districts or provinces actually report the
disease
 TIMELINESS: DEFINITION

Timeliness reflects the speed between

steps in a public health surveillance
system:
• For example, in cases with disease of
interest: the time interval(s) between
date of symptom onset, or
hospitalization, or diagnosis vs. the date
case was reported to disease
surveillance system
 TIMELINESS: METHODS

The timeliness of a public health surveillance

system should be evaluated in terms of
availability of information useful to improve
control of a health-related event, including
prevention of high risk exposures,
implementation or strengthening early
diagnosis or vaccination, as well as program
planning
 TIMELINESS: METHODS

• Increasing use of electronic data

collection from reporting sources (e.g., an
electronic laboratory-based surveillance
system) or via the Internet (a web-based
system), or use of electronic data
interchange by surveillance systems, may
promote timeliness
• Internet security, confidentiality, privacy
and limiting access to only authorized
personnel must be considered
 STABILITY: DEFINITION

Stability refers to the reliability (i.e., the ability

to collect, manage, and provide data
properly without failure) and availability (the
ability to be operational when it is needed)
of the public health surveillance system over
time, independent of challenges posed by
availability of funding, resources, or other
changes
 STABILITY: METHODS

• The number of unscheduled outages and down

times for the system's computer
• The costs involved with any repair of the system's
computer, including parts, service, and amount of
time required for the repair
• The percentage of time the system is operating
fully
• Is the system able to function even after funding or
other resources become limited?
 STABILITY: METHODS

• The desired and actual amount of time required for the

system to collect or receive data
• The desired and actual amount of time required for the
system to manage the data, including transfer, entry,
editing, storage, and back-up data
• The desired and actual amount of time required for the
system to release data
 ASSIGNMENT:
SURVEILLANCE WEBSITES

• Select a surveillance website

• WHO http://www.who.int/topics/public_health_surveillance/en/
• U.S. CDC http://www.cdc.gov/surveillancepractice/
• ECDC
http://www.ecdc.europa.eu/en/activities/surveillance/Pages/index.aspx

• Answer the questions on the following slides

• Prepare a 10-minute presentation
 QUESTIONS

• What is the population under surveillance?

• What is the period of time of the data
collection?
• What data are collected and how are they
collected?
• What are the reporting sources of data for the
system?
 QUESTIONS

• How are the system's data managed

(e.g., the transfer, entry, editing, storage,
and back up of data)?
• Does the system comply with applicable
standards for data formats and coding
schemes? If not, why?
 QUESTIONS

• How are the system's data analyzed and

disseminated?
• What policies and procedures are in place
to ensure patient privacy, data
confidentiality, and system security?
• What is the policy and procedure for
releasing data?
 QUESTIONS

• Do these procedures comply with applicable

federal and state statutes and regulations,
and/or international standards? If not, why?
• Does the system comply with an applicable
records management program? For example,
are the system's records properly archived
and/or disposed of?
 QUESTIONS

• Are these surveillance systems (WHO, US CDC or

ECDC) effective? Why is it effective? or Why is it not
effective?
 SUMMARY

• All public health surveillance systems should be

evaluated periodically
• No perfect system exists; tradeoffs must always be
made
• Each system is unique and must balance benefits
versus personnel, resources, and costs required
• Ensure use of evaluation findings and share lessons
learned
• Systems should be an excellent source of accurate
and timely information for program managers
Analyzing Surveillance Data using
HealthMap
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
www.healthmap.org
HEALTHMAP DATA ASSIGNMENT

• Select a disease that has more than 10 reports

globally or in your region of interest
• Look at surveillance data for the past year
• Collect the following information
• Disease
• Countries included (can be national, regional or global)
• Species of host affected
• Total reports of the disease for the year
• Total cases of disease in each affected species
 REPORT TO A LOCAL HEALTH
DEPARTMENT: ASSIGNMENT
• Prepare a 15 to 20 minute mock scientific report that you
will give to a local health department concerned with the
disease:
• Using surveillance data perform the following analysis:
• Provide pertinent background information about the disease
• Create a global, regional, or country level map showing the
outbreaks for the year
• Create a chart or other graphic to display the number of cases
or outbreaks reported by week or by month
• Create a chart or other graphic to display the number of cases
by host species over the year
 REPORT TO A LOCAL HEALTH
DEPARTMENT ASSIGNMENT (CONTINUED)
• Using surveillance data perform the following analysis:
• Analyze data in the disease reports to determine likely sources
and numbers of disease reports
• Analyze data in the disease reports to determine likely sources
of the disease and transmission routes
• Create a map, system diagram, or other visual aid to show
transmission and risk factors gathered from the disease
surveillance data
• Form a conclusion from the surveillance data about the current
status of the disease. Include any information collected about
control of intervention measures mentioned in the reports
Developing a Management and
Surveillance Plan
INFECTIOUS DISEASE MANAGEMENT,
ONE HEALTH COURSE
 H5N1 SCENARIO

The first reports:

• Rumors of an outbreak of unusually severe respiratory
illness in two villages in a remote province prompted the
World Health Organization (WHO) to dispatch a team to
investigate. The team found that people in the villages
had been falling sick for about a month and that the
number of persons with acute illness (i.e., “cases”) had
increased each day. The team was able to identify at
least 50 cases over the previous month; all age-groups
had been affected. Twenty patients are currently in the
provincial hospital. Five people have already died of
pneumonia and acute respiratory failure.
 H5N1 SCENARIO (CONTINUED)

Specimens sent to the laboratory to establish etiology:

• Surveillance in surrounding areas was enhanced, resulting in
new cases being identified throughout the province.
Respiratory specimens collected from several case-patients
were tested at the national laboratory and found to be positive
for type A influenza virus. Isolates sent to the WHO Reference
Centre were found to be a subtype of an influenza A (H5N1)
never isolated from humans before. Gene sequencing studies
further indicate that most of the viral genes are from a bird
influenza virus, with the remaining genes derived from a
human strain. More cases appeared in surrounding towns and
villages.
•
 H5N1 SCENARIO (CONTINUED)

Spread to neighboring countries and quarantine attempts:

• The new strain of influenza virus begins to make headlines in
every major newspaper, and becomes the lead story on news
networks. Countries are asked by WHO to intensify influenza
surveillance and control activities. Key government officials
throughout the region are briefed on a daily basis, while
surveillance is intensified. Over the next two months, outbreaks
began to take place in neighboring countries. Although cases
are reported in all age-groups, young adults seem to be the
most severely affected. One in every 20 patients dies. The rate of
spread is rapid, and countries initiate travel restrictions and
quarantine measures.
 H5N1 SCENARIO (CONTINUED)

Social effects:
• Educational institutions are closed. Widespread panic begins
because supplies of antiviral drugs are severely limited and a
suitable vaccine is not yet available. One week later, there are
reports that the H5N1 virus has been isolated from airline
passengers with respiratory symptoms arriving from affected
countries.
 H5N1 SCENARIO (CONTINUED)
Other continents affected:
• A few weeks later, the first local outbreaks are reported from
other continents. Rates of absenteeism in schools and businesses
begin to rise. Phones at health departments ring constantly. The
spread of the new virus continues to be the major news item in
print and electronic media. Citizens start to clamor for vaccines,
but they are still not available. Antiviral drugs cannot be
obtained. Police departments, local utility companies and mass
transit authorities experience significant personnel shortages that
result in severe disruption of routine services. Soon, hospitals and
outpatient clinics are critically short-staffed as doctors, nurses
and other healthcare workers themselves become ill or are
afraid to come to work.
 H5N1 SCENARIO (CONTINUED)

Other continents affected (continued):

Fearing infection, elderly patients with chronic medical conditions
do not dare to leave home. Intensive care units at local hospitals
are overwhelmed, and soon there are insufficient ventilators for the
treatment of pneumonia patients. Parents are distraught when their
healthy young adult sons and daughters die within days of first
becoming ill.
Several major airports close because of high absenteeism among
air traffic controllers. Over the next 6-8 weeks, health and other
essential community services deteriorate further as the pandemic
sweeps across the world.
 H5N1 SCENARIO (CONTINUED)
Assignment
• What is your role in this scenario?
• What is the role of each stakeholder in this scenario?
• How does the scenario affect the stakeholder that you are
representing?
• How can each stakeholder’s response to the infectious
disease in this scenario influence the management of the
disease?
• Who are the other stakeholders you will need to deal with
in order to manage a particular infectious disease?
 H5N1 SCENARIO (CONTINUED)

Roles
• Villagers of Village 1 and 2
• Healthcare workers
• WHO team
• Laboratory workers
• Government officials
• Transportation security administrator
 WHAT DO YOU THINK?

• How effective was the One Health team in

developing the management plan for the scenario
disease?
• What were the problems encountered from the
perspective of each stakeholder?
• What soft skills are needed to ensure a high
functioning One Health team?
EPIDEMIOLOGY AND
RISK ANALYSIS
www.mstrust.org.uk

AN INTRODUCTION FOR NON-EPIDEMIOLOGISTS

ONE HEALTH COURSE MODULE
 MODULE COMPETENCIES

• Define epidemiology and the basic

terminology and concepts used in
epidemiology
• Explain critical components of the practice
of epidemiology
• Explain the major components in and the
process of disease risk analysis, and how
disease risk analysis links science to health
policy
Epidemiology is a Basic Public
Health Science
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 LEARNING OBJECTIVES

• Define epidemiology
• List the critical one-word questions central to
the practice of epidemiology (e.g., Why?,
Where?, How?)
• Give examples of useful applications of
epidemiology
• Explain what is meant by the epidemiologic
triad and web of causation
• List the core human public health and
veterinary public health functions
 Epidemiology
Epi = “upon”

Demos = “village” or “the people”

Logos = “thought” or “study”

• Traditional: “Studying something

happening upon the people”
• Modern: “The study of the distribution,
determinants, and deterrents of
disease occurrence in populations”
 EPIDEMIOLOGY’S
ONE WORD QUESTIONS

Who/Which?...gets the condition or disease?

When?...do people or animals get the condition?

How?...is the condition contracted and spread?

Where?...does the condition occur?

 COMMON APPLICATIONS OF
EPIDEMIOLOGY

Describe and Identify risk factors

Understand natural
explain a disease and causes of
history of disease
in the population disease

Identify and
Evaluate efficacy of investigate Estimate individual
treatments outbreaks or risks of disease
epidemics

Develop, prioritize,
Health policy
and evaluate
development,
human & veterinary
disease prevention
public health
& control measures
programs
 EXAMPLES – RECENT HUMAN AND VETERINARY
ZOONOSES/EID EPIDEMIOLOGY STUDIES

• The association between antibiotic use and distribution of

antimicrobial resistance in Escherichia coli from pigs in
Japan, J Vet Epi, January 2013
• Seroepidemiology for MERS coronavirus using
microneutralisation and pseudoparticle virus neutralisation
assays reveal a high prevalence of antibody in dromedary
camels in Egypt, Euro Surveill, 18, 36, June 2013
• Possible role of songbirds and parakeets in transmission of
influenza A(H7N9) virus to humans. Emerg Infect Dis,
March 2014
• Infective endocarditis in northeastern Thailand.
Emerg Infect Dis, March 2014
 WHAT CAUSES DISEASE?

Supernatural – witches, demons, spirits

Divine wrath

Metaphysical – planets, disasters

Imbalance of the four humors, miasma

Germ theory

Multifactorial
EPIDEMIOLOGIC TRIANGLE/TRIAD

Image source blogs.cdc.gov

 MALARIA EXAMPLE

Host Human, mosquito, other(s)?

Environment Agent Rainfall Plasmodium

 PUBLIC HEALTH MISSION

• To promote physical and mental

health, and prevent disease, injury,
and disability
• Health is the state of complete
physical, mental and social well-being
and not merely the absence of
disease or infirmity (World Health
Organization)
www.health.gov/phfunctions/public.htm
 Public Health Triangle
The Agitator
The Politician

Policy
The Epidemiologist The MD/DVM/Nurse

Activism

Scientific Clinical
Image source D Tybor, Tufts University
 VETERINARY PUBLIC HEALTH
CORE DOMAINS
Zoonoses Health education and
extension

Food protection
Production and control
of biological products
and medical devices
Laboratory animal health

Diagnostic laboratories
Biomedical research

May also include

• Management of domestic and wild animal populations
• Protection of drinking water and the environment
• Management of public health emergencies
World Health Organization
 SUMMARY

Core Functions of human public health are

assessment, policy development, and
assurance

There are similarities and overlaps between

the functions, domains and services of
human and veterinary public health
 Epidemiology in Practice:
An Overview
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 LEARNING OBJECTIVES

• Identify some of the diverse specialties in

the field of epidemiology
• Describe how epidemiology is used by
human, animal, and environmental health
professionals
 WHAT IS EPIDEMIOLOGY?

The study of the WHAT, WHO/WHICH, WHERE, WHEN

and WHY of disease occurrence in populations

Monitoring &
Study risks
surveillance for Identify and control
associated with
diseases and disease epidemics
exposures
exposures
KEY ELEMENTS IN EPIDEMIOLOGY

Person Animal Place Time

• Age • Species • Geographic • Exposure or
• Sex • (Breed) location illness onset
• Race or • Age • Proximity to • Seasonality
ethnicity potential
• Sex • Endemic vs.
• Occupation exposure
• Habitat Epidemic
• High-risk • Clustering disease
behavior(s)
rates
 EXAMPLES OF DISCIPLINES IN
EPIDEMIOLOGY

• Rabies, leptospirosis, schistosomiasis

Infectious

• Cancer, malnutrition, obesity, arthritis

Chronic

• Vehicle collisions, fires, falls, violence

Injury
 EXAMPLES OF DISCIPLINES IN
EPIDEMIOLOGY

• Gender, class, age

Social

• Malnutrition, obesity, nutrients, microbiome

Nutrition

• Exposures in the work environment

Occupation
 EXAMPLES OF DISCIPLINES IN
EPIDEMIOLOGY

Environment
• Toxins, pollutants, disease reservoirs and vectors

• Tobacco smoking, alcohol abuse, obesity

Behavior

• Criminal investigations, testimony, prosecutions

Forensic
 EXAMPLES OF DISCIPLINES IN
EPIDEMIOLOGY
• Hospital infections, use of antibiotics, populations
Health served and access, treatment costs vs. prevention
care

• Assess impacts (injury, illness, exposures), effectiveness

Disaster of response, improve preparedness capacity

• Data for decision-making; prioritize local and national

Policy health programs, budgets
EPIDEMIOLOGY IN PRACTICE:
BRIEF HISTORY
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 JOHN SNOW (1813 – 1858)

On the Mode of Communication of Cholera

 BROAD STREET PUMP & CHOLERA
OUTBREAK, LONDON, ENGLAND 1854

• Low-level transmission in August

• Increase number of cases August
31 and September 1
• 79 deaths on Sept. 1 and 2
• 87% of deaths clustered around
pump on Broad Street
• Pump handle removed Sept. 8
The Broad Street Pump

Photo source: The John Snow Archive and Research Companion

Case List
 SMALLPOX ERADICATION: ANOTHER
HUMAN PUBLIC HEALTH SUCCESS
• Viral disease of humans
• Spread via air droplets
• No treatment
• 30% fatality rate

Smallpox eradication workers,

Nepal.
Smallpox vaccination,
Bangladesh
Photo credits; CDC Public Health Image Library
 SMALLPOX ERADICATION

• Initiated in 1967
• Last naturally
occurring case in 1977
• Eradicated in 1980
• Laboratory stocks
remain in US and
Russia
 MEASLES OUTBREAK
INDIANA, USA 2011
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 BACKGROUND ON MEASLES
• Acute viral infection, usually of
children, causing fever,
conjunctivitis, cough and rash
• Severe illness may include
pneumonia, encephalitis
• Higher mortality: infants & children,
pregnant women, malnourished
• Spreads via respiratory droplets
Measles virion (particle)
CDC/ Cynthia Goldsmith • Highly contagious
• Not endemic in the US due to high
vaccination coverage rates &
effective vaccine
 THE BEGINNING

• June 3: Unvaccinated US resident, 24 years old,

returned to Indiana (USA) from Indonesia
• Rash illness treated for suspected dengue fever
• Measles rate in Indonesia: ~9/100,000 population

• June 20: Five family members with rash illness

epidemiologically-linked to initial case
(reported to Indiana Department of Health)

• Active case-finding identified 8 additional

cases
 HERE COMES TROUBLE…

• Infectious family members had…

• Attended church
• Attended parties
• Attended family
gatherings
• Attended sports events
• Sought health care
 PUBLIC HEALTH RESPONSE

• Follow-up of persons exposed at different

venues in 7 counties (~districts)
• Church (150 persons)
• Factory (300 persons)
• Bus with school-aged children
• 2 Clinician offices, 1 Obstetrics office, 1 urgent care
facility, 4 hospitals or emergency rooms
• Media releases to inform public
• Statewide Health Alert Network messages to
healthcare providers
 DEPARTMENT OF HEALTH
RECOMMENDATIONS
• For exposed persons without evidence of
measles
• Vaccination within 3 days of exposure, or
• Immunoglobulin within 6 days for high-risk patients
• For potentially exposed healthcare personnel
• Exclude from patient care responsibilities
• For the community
• Testing and vaccination clinics
LEPTOSPIROSIS OUTBREAK
Indonesia 2011
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 LEPTOSPIROSIS BACKGROUND

• Infection caused by a spirochete (bacteria)

• Rodents are the usual wild animal reservoir
• Causes disease in both humans and animals
• Spread via contact with water contaminated
with urine from infected animals (or soil)
• Causes febrile illness with variable death
rate
 LEPTOSPIROSIS OUTBREAK
JAVA, INDONESIA 2011

• 15 human cases
confirmed in hospitals
• 4 deaths among the
confirmed cases
• 27% fatality rate (high)
• Cases were often
farmers
 LEPTOSPIROSIS OUTBREAK
INVESTIGATION
Survey of local residents
• Farmers noticed increasing rat
populations
• Weather conditions increasingly
wet with unusual amount of rain
• Rat populations around farms had
expanded as animals took
shelter from flooded areas
• High rat density led to
contamination of standing water
with infected urine
 LEPTOSPIROSIS OUTBREAK
PUBLIC HEALTH RESPONSE

• avoid rodents
• Trapping • Signs can be
• avoid standing
vague
water • Poisoning
(other risks!) • Seek medical
attention for
• Protect fever
Public drinking water
awareness Early
Rat population
campaigns identification
control around
of cases
farms & houses

©B Suh

http://pacificsource.files.wordpress.com
/2013/02/child-sick-fever-jpg.jpg
 SUMMARY

Epidemiology is the study of distribution and

determinants of states of health or events in specified
populations

John Snow pioneered the first modern epidemiological

methods, in 1800s, using person, place, and time data
to identify likely source of cholera outbreak (London)

Epidemiology specialties complement each other in

outbreak investigations and other human and
veterinary public health research settings
Epidemiology Tools and Methods

EPIDEMIOLOGY AND RISK ANALYSIS

ONE HEALTH COURSE MODULE
 LEARNING OBJECTIVES

• List methods that can be used for an

epidemiological assessment of a health
problem
• Identify ways that public health laboratories
carry out epidemiological functions
• Identify ways that data can be collected
during an epidemiologic investigation
 OVERVIEW

• Epidemiological methods and resources

• Public health laboratories
• Data and technology
• Examples of tools in action
EPIDEMIOLOGICAL METHODS

Individual,
Exposure
place and
assessment
time

Investigative Data
field work and
epidemiologic analysis
studies techniques
REFERENCES AND RESOURCES

• Scientific literature
• Academic references, textbooks
• Country-specific manuals and
epidemiology websites
• WHO, OIE, FAO, CDC and other
websites, references, experts
 WHAT DO PUBLIC HEALTH
LABORATORIES DO?

Disease
Reference and Environmental
prevention, Integrated data
specialized health and
control, and management
testing protection
surveillance

Laboratory Emergency
Policy
Food safety improvement preparedness
development
and regulation and response

Partnerships
Public health Training and
and
research education
communication
DEFINITION OF SURVEILLANCE

“…the continuous, systematic collection,

analysis and interpretation of health-
related data needed for the planning,
implementation, and evaluation of public
health practice. ”

World Health Organization

 LABORATORY SURVEILLANCE,
MONITORING, REPORTING

Surveillance Monitoring Reporting

• Vector borne • Newborn • From local to

diseases screening and national
• Communicable genetics • From national to
diseases • Radiation local
• Food borne and monitoring and • From national to
waterborne detection international
diseases • Food safety
• Environmental
issues
DATA AND TECHNOLOGY
“TOOLS”
 SOURCES OF DATA

Medical and health

facility records

Questionnaires, surveys,
interviews

Surveillance systems
www.malteser-international.org/
 SURVEILLANCE DATA CAN…

Serve as an early warning system for impending public

health emergencies

Document the impact of an intervention, or track progress

towards specified goals

Monitor and clarify the epidemiology of health problems,

to allow priorities to be set and to inform human and
veterinary public health policy and strategies
 SURVEILLANCE INFORMATION, USE,
DISSEMINATION, AND REPORTING
• Physicians, Standardized data collection Local & district/provincial
veterinarians, health departments &
nurses national health agency
• Laboratories Dissemination to those analyze data
• Community who need to know
health clinics

Public health Dissemination

evaluation to those who
need to know
Change in health Public health planning
• Public health officials
practice (vaccination, and intervention
• Health directors
reduction of risk • Health policy officials
factors, medical • The public
intervention, etc.)
 SURVEILLANCE DATA AS A TOOL

• Establish baseline rate of

disease
• Detect epidemics
• Estimate magnitude of a
health problem

• Determine geographic
distribution
• Facilitate planning
SURVEILLANCE DATA GRAPHS
SURVEILLANCE DATA MAP, LAOS
 QUESTIONNAIRE AND INTERVIEW
DATA

Outbreak investigations

www.herald-citizen.com/

Rapid assessments
www.actionagainsthunger.org
 QUESTIONNAIRES & INTERVIEWS:
CONTACT TRACING AND CASE FOLLOW-UP

Beard et. al. 2011. Contact tracing of in-flight measles

exposures: lessons from an outbreak investigation and case
series, Australia, 2010. www.who.int
DATA MANAGEMENT AND ANALYSIS

Computer software packages

• Epi Info™
• SAS®
• SPSS®
• Stata®
•R
 EPI INFO SOFTWARE
HTTP://WWWN.CDC.GOV/EPIINFO/

Features
• FREE!
• Relational database
• On screen data entry form
• Survey creation
• Data analysis
• Data graphing
• Data mapping
 EPIDEMIOLOGIC SOFTWARE
IS USED TO…

• Surveillance systems
Store • Outbreak investigations
databases • Medical records

Generate • Frequencies, proportions, rates

descriptive • Graphs: bar, line, histogram (Epi Curves)
statistics • Maps: census tracts; counties; districts

• Test statistics: t-test, chi-square

Generate
• Measures of association: Odds ratios, risk
statistics ratios
 Generate
hypotheses
•Make judgments
about linkages
between exposure
What is the role and outcome

of the
Epidemiologist?

Make decisions
Interpret data
•Determine if an
epidemic is in •Identify or correct
progress mistakes
•Recommend •Interpret statistical
control measures and laboratory
tests
 EXAMPLE: TB EXPOSURE
INVESTIGATION

Background
• Captive elephants at a sanctuary in Thailand
developed chronic disease with wasting and
respiratory signs – determined to be tuberculosis
Several unknowns
• Etiology of the disease –
which Mycobacterium?
• Method of transmission?
• Involvement of humans in transmission?
 DATA-BASED DECISIONS

Interviews:
• Elephant care takers
• Family members

Results:
• One of the elephant care takers had a family member
with tuberculosis and had contracted the disease
• The elephant was likely infected from contact with the
human
 FURTHER INVESTIGATION AND
QUESTIONS
Further questions
• Do other elephants in the facility have tuberculosis?
• How should the elephant handlers be tested for risk to
elephants?
• How can spread be prevented to more elephants and
humans?
• Could the laboratory design a method to identify the
actual pathogen from a live elephant?
• (e.g., Mycobacterium tuberculosis vs. M.bovis)
 SUMMARY

Epidemiologists employ investigative and analytic tools to collect

data and assess factors that cause disease

Laboratories play a role in diagnosis and surveillance for carrying

out public health investigations and core epidemiologic functions

Statistical software is used for data management and analysis

Human effort is used to investigate, generate hypotheses, and

interpret results
Epidemiological Partners and
Resources
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 LEARNING OBJECTIVES

• Identify allied health and community

partners in the practice of epidemiology
• List ways in which epidemiologists work with
the media, and the 5 components of the
WHO Outbreak Communication Guidelines
• Describe how the WHO, OIE, FAO and CDC
serve as resources for training, technical
support, disease surveillance, and the
reporting of epidemiological data
 OVERVIEW

• Partners in the practice of epidemiology

• WHO, OIE, FAO and CDC
• Media
 WHO

• World Health Organization

• Web site: www.who.int
• Global Outbreak and Response Network
(GOARN)
• Collects, analyzes, maintains, and
disseminates data on health worldwide
• Publishes ongoing health reports and
information during outbreaks
 FAO

• Food and Agriculture Organization of the

United Nations
• Web site: www.fao.org
• Mandate to
• improve nutrition
• increase agricultural productivity
• raise the standard of living in rural populations
• contribute to global economic growth
• maintains EMPRES database
 OIE

• UN World Organisation for Animal Health

• Web site: www.oie.int
• Responsible for
• improving animal health worldwide
• promoting veterinary services, animal health
standards, food safety, and animal welfare
• Maintaining WAHID (World Animal Health
Information Database)
 CDC
• United States Centers for Disease Control and
Prevention
• Web site:www.cdc.gov
• Mission is to collaborate to create the expertise,
information, and tools that people and communities
need to protect their health – through health
promotion, prevention of disease, injury and
disability, and preparedness for new health threats
• Major internationally active subdivisions include
Global Disease Detection and the Field
Epidemiology Training Programs
THEE PMEDIA
I D E M I O L O G Y AS
A N D RA
I S KPARTNER
ANALYSIS

AND RESOURCE
ONE HEALTH COURSE MODULE
 3 KEY APPLICATIONS OF MEDIA

1. Risk and crisis communication

2. Reaching people potentially exposed in an

outbreak

3. Press releases and

conferences
• Public information officers
• Communication specialists
 COMMUNICATING IN A CRISIS

In a crisis, affected people take in,

process, and act on information
differently

Be first, be right, be credible

OUTBREAK COMMUNICATION GUIDELINES –
WORLD HEALTH ORGANIZATION (WHO)

Announcing
Trust Transparency
early

The Public Planning

 WHAT THE PUBLIC SEEKS

Gain wanted facts

Empower personal decision-making

Involved as a participant, not spectator

Understand how resources are being allocated

Recover or preserve well-being and normalcy

 GOVERNMENTS NEED TO

Carry out investigation and response efforts

Minimize illnesses and deaths

Ensure proper allocation of limited resources

Reduce rumors

Protect public interests, maintain civil society, restore

normalcy
 COMMUNICATION FAILURES

Mixed messages from multiple experts

Information released late

Paternalistic attitudes

Not countering rumors and myths in real-time

Public power struggles and confusion

 PUBLIC MESSAGES IN A RISKY
SITUATION OR CRISIS SHOULD BE

Simple
Timely
Accurate
Relevant = STARCC
Credible
Consistent
 PUBLIC MESSAGES

Must Must Not

Be short Use jargon
Be accurate Be judgmental
Be relevant Make promises
Give positive that cannot be
action steps kept
Be repeated Include humor
 DISEASE OUTBREAKS
ARE NOW MEDIA EVENTS

• Both the public and officials can benefit

from media involvement
• Media can provide important protective
actions for the public
• Media outlets know how to reach their
audiences and what their audiences need
• Even if the “official” media is not present,
people with cell phones and video
cameras will be
 WORKING WITH REPORTERS

• Reporters want a front seat to the

action and all information
• Preparation will save relationships
• If you do not have the facts, tell them
the process
• Never make up answers!
WHAT THE PUBLIC WILL ASK FIRST

What can I do
What have you
Are my family to protect
found that may
and I safe? myself and my
affect me?
family?

Who caused
Can you fix it?
this?
WHAT THE MEDIA WILL ASK FIRST

How many How many

What people or people or Who is in
happened? animals have animals have charge?
been affected? died?

Has this been Are victims What can we What should we

contained? being helped? expect? do?

Why did this Did you have

happen? forewarning?
EMERGENCY RISK COMMUNICATION
PRINCIPLES

• Do not over-reassure
• Acknowledge that there is a process
in place
• Express wishes
• Give people things to do
• Ask more of people
IF YOU ARE ASKED SENSATIONAL OR
UNRELATED QUESTIONS

Guide the interview back to what YOU

want to say (i.e., your “Single, Over-riding
Communication Objective” -- or “SOCO”):
• “What I think you are really asking is…”
• “The overall issue is…”
• “What’s important to remember is …”
• “It’s our policy to not discuss [topic],
though what I can tell you …”
“Is SARS From Outer Space?”
–CNN headline, May 23, 2003

Cat’s Eye Nebula

Images.hubblesite.org
SINGAPORE “SUBORDINATES” THE
GOOD NEWS

When WHO stated that the SARS situation

seemed to be improving in Singapore, the
Minister of Health spokeswoman, Eunice
Teo, passed on this encouraging
information as follows:
“The WHO said the peak is over in
Singapore, but our minister has said it is
too early to tell."
 PHILIPPINES SAYS
“DON’T SPECULATE”
13 February, 2007, Philippine Star-News:

Investigating the cause of death of an egret, a senior

animal official said:

“There are many causes of death and not necessarily

bird flu,” and that it would be wrong to speculate
until after the bird had been examined
and a report made.
WHO/PAHO Pandemic Flu Communication
Draft vs Final

Draft: Final:
“To respond to “It is important to
rumors and proactively
inaccuracies to address reports
minimize that will create
concern, misplaced fear or
disruption and unrealistic
stigmatization.” expectations.”
SARS: SINGAPORE’S PRIME MINISTER
VALIDATES FEAR – AND COURAGE

“Our health-care workers put their lives at risk

every day they went to work… 'They were
frightened. But they conquered their fear with
courage. Courage in tending to an infected
patient. Courage in taking respiratory fluid
samples from the throat. Courage in cleaning the
wards every night.

“We saw this courage in our doctors, nurses and

other health-care professionals; in the attendants,
security officers and cleaners in our hospitals.”
Prime Minister Goh, at SARS Memorial Ceremony, July 23, 2003. Straits Times
 SINGAPORE PM GOH LEGITIMIZING
OTHERS’ FEARS DURING SARS OUTBREAK:

When Australia and several Asian countries warned

against travel to Singapore, Mr Goh responded:
“We can understand that, because we also give travel
advisories to Singaporeans not to go to [other] affected
places.
So we must expect other countries to advise their
travelers not to come to Singapore... If we are open
about it and all Singaporeans cooperate by being as
careful as they can, we may be able to break this cycle
early and if we do, then of course people outside will
have confidence in Singapore and the way we manage
the problem.”
 NIGERIA VALIDATES
PEOPLE’S REACTIONS
“…we have observed that in other countries
experiencing their first human H5N1 cases, there
has been widespread fear of poultry and poultry
products, with a concomitant drop in consumption
and sales. For a short time, that may happen in
Nigeria too. It is entirely understandable that the
population may be overtly worried about all
chickens, not just sick chickens.”

Nigeria Avian Influenza Crisis Management Center, Bulletin 29, early 2007
Are we hungry yet?

http://birdflubook.com/a.php?id=79
THAILAND TELLS PEOPLE WHAT
TO EXPECT

“We are now about 80% ready to deal with a

bird flu outbreak should it happen today.”

--Thai Deputy Prime Minister Chaturon Chaisaeng, 9

February, 2005, Bangkok Post
 SINGAPORE TELLS ITS PEOPLE
THAT MALAYSIA CAN BE TRUSTED

“The Highly Pathogenic Avian Influenza (HPAI) or Bird

Flu is currently the most threatening disease to our food
supply.
Its worldwide spread and recent detection in Selangor
have raised concerns in Singapore.
In accordance with protocols established between the
veterinary authorities of Singapore and Malaysia, AVA
suspended poultry and egg imports from Selangor.”
From a speech by the Singapore Minister of State for National
Development, 6 March 2006
 SINGAPORE TELLS ITS PEOPLE
THAT MALAYSIA CAN BE TRUSTED
“Over the last two years, [Singapore ]has been working
with its Malaysian counterpart to establish Disease Free
Zones.
Poultry can be imported from these zones even if
isolated cases of HPAI are detected in other areas.
We hence did not suspend all poultry imports from
Malaysia, unlike the outbreak in Kelantan in 2004.
The impact on our egg and poultry supply this time was
negligible.”
From a speech by the Singapore Minister of
State for National Development, 6 March 2006
ACKNOWLEDGES UNCERTAINTY, AND LETS
PEOPLE CHOOSE THEIR OWN ACTIONS

During a television call-in show, Minister of State for

Health Balaji Sadasivan was asked by a caller about
whether to wear masks in public, and what kind to
use.

“At this point, it seemed very likely, but not yet

100% definite, that SARS was mostly transmitted by
close personal contact, through droplets and
touching contaminated surfaces.”
9/11 DUST CHASING PEOPLE
 BAD EXAMPLE: PREMATURE &
OVERCONFIDENT OVER-REASSURANCE

"We are very encouraged that the results from our monitoring of air
quality and drinking water conditions in both New York and near
the Pentagon show that the public in these areas is not being
exposed to excessive levels of asbestos or other harmful
substances… I am glad to reassure the people of New York and
Washington, D.C. that their air is safe to breath and their water is
safe to drink"

U.S. Environmental Protection Agency

Director Whitman, September 18, 2001
 HERE’S WHAT HAPPENED

“The EPA's Office of the Inspector General eventually

criticized the agency's response, saying it did not
have available data and information to support the
Sept. 18, 2001, statement that the air was safe to
breathe.

“The EPA's internal watchdog found the agency, at

the urging of White House officials, gave misleading
assurances there was no health risk from the dust in
the air after the towers' collapse.”
NORMAL VIEW OF U.S. AT NIGHT,
FROM OUTER SPACE
 ANOTHER EXAMPLE: PREMATURE &
OVERCONFIDENT OVER-REASSURANCE

“I can tell you 100 percent

sure that there is no
evidence as of this moment
whatsoever of any
terrorism.”

NY Mayor Michael Bloomberg talking to CNN

anchor Kyra Phillips, 7:41 p.m., August 14, 2003
 QUIZ

What words “protect” him if

he turns out to be wrong?
 ANSWER

“…no evidence
as of this
moment…”
 FOR ABOUT TEN MINUTES, CNN
100% SURE

RAN THE WORDS:

“100% sure”
 SUMMARY

Partnerships in the community and among other

public health professionals are vital to surveillance
and outbreak investigation

The media is used for communicating with

professionals and affected populations

The WHO, FAO, OIE and CDC are global resources for
training, support, and surveillance
Descriptive Epidemiology
EPIDEMIOLOGY AND RISK ANALYSIS
ONE HEALTH COURSE MODULE
 LEARNING OBJECTIVES

• Define descriptive epidemiology

• List the two types of study design for
descriptive epidemiology
• List examples of the use of descriptive
data
 OVERVIEW

• Who/Which?
• Where?
• When?
• Why?
• How?, and How much?
• Individual (person), place, and time
 WHAT IS EPIDEMIOLOGY?

Study of distribution and determinants

of state of health or events in specified
populations, and the application of this
study to the control of health problems
Purposes:
• Study risk associated with exposures
• Identify and control epidemics
• Monitor population rates of disease and
exposure
EPIDEMIOLOGIC INVESTIGATIONS
ANSWER THE QUESTIONS

Who?
What? When?
Which?

Where? Why? How?

How
much?
 DESCRIPTIVE VS. ANALYTIC
EPIDEMIOLOGY

Descriptive epidemiology Analytical epidemiology

Who? Which? Why?
What? How?
When?
Where?
How much?
 DESCRIPTIVE EPIDEMIOLOGY
Provides a systematic method for characterizing a health problem

Ensures understanding of the basic dimensions of a health problem

Helps identify populations at higher risk for the health problem

Provides information useful for allocation of resources

Enables development of testable hypotheses

Identifies and clarifies disease entities

Describes transmission, distribution and evolution (natural history) of

disease
TYPES OF STUDIES

Lancet 2002; 359: 57–61

 CROSS-SECTIONAL STUDIES
• At one point in time, a cross-section of the
population at risk (or of interest) is sampled and
examined
• Allows measure of the prevalence of something
(e.g. a disease or health condition of interest)
• If this type of study is repeated over time, but
without following specific individuals, then the
survey procedure is called “Repeated Cross-
Sectional”
 LONGITUDINAL STUDIES

• A group (“cohort”) of individuals is followed over

time and new disease episodes are recorded
• The groups (“cohorts”) are categorized based on
exposure status (e.g., tobacco smoker or non-
smoker) at beginning of the study
• Allows measurement of the outcome (e.g., the
incidence rate of disease)
• Not all individuals need to be under observation at
the same time (“phased entry”)
 CASE DEFINITION

• Standard diagnostic criteria that must be fulfilled to identify a

person with the illness, disease or condition of interest (e.g., a
“case” of yellow fever)
• Typically includes clinical criteria and restrictions on
individual, place, and time. For example, a “case” of yellow
fever in Study X is a person defined as:
“A resident of village X with acute fever, jaundice and
bleeding during May 2013”
• Ensures that all individuals who are counted as “cases” likely
have the same disease
 CASE DEFINITION

Probable case:
• Person (or individual) who meets the clinical
description of a “case” and that is
epidemiologically linked to a confirmed case

Confirmed
• A case that meets the clinical description and at
least one of the criteria for laboratory
confirmation
 CASE DEFINITION: CYCLOSPORIASIS

• Probable case:
watery diarrhea, with possible loss of appetite, weight loss,
abdominal cramps/bloating, nausea, body aches,
fatigue, vomiting or low-grade fever, and is
epidemiologically linked to a confirmed case.
• Confirmed case:
meets the clinical description and at least one of the
established criteria for laboratory confirmation.
For example, oocysts
found on light
microscopy.

www.cdc.gov
 DESCRIPTIVE EPIDEMIOLOGY
WHAT IS THE PROBLEM?

Most basic: a simple count of cases

• Useful for looking at the burden of disease
• Not useful for comparing to other groups or
populations

Province # of Salmonella cases Pop. size

A 120 1,500,000
B 500 5,300,000
WHO?/WHICH? WHERE? WHEN? HOW
MUCH?
Individual (Person):
• May be characterized by age, race (human),
species/breed (animal), sex, education, occupation, prior
medical history, pre-existing disease, or other personal
characteristics
Where? (Place):
• May include information on home, workplace, school
When? (Time):
• Date/time of illness onset, or exposure to risk factors
How much? (Magnitude of problem):
• Number of cases occurring in a defined time period
DATA ON INDIVIDUALS
• Age and sex are almost
always useful:
• Age data are usually grouped –
intervals depend on type of
disease / event

• May be shown in tables or

graphs
• May look at more than one
type of individual data at
once
INDIVIDUAL DATA: AGE AND SEX
http://s3.amazonaws.com/zanran_storage/dhs.wisconsin.gov/ContentPages/3730888.pdf
Age-specific cancer incidence rates, by sex
SOURCE: Wisconsin Cancer Incidence and Mortality Report, 1996, p. 26

Heidari and Najafi. 2013. Trends

of skin cancer incidence in 6
geographical regions of the
Islamic Republic of Iran, 2000–
2005. www.who.int
INDIVIDUAL DATA BY AGE

Santos et al 2000. Testicular tumors in dogs: frequency and age distribution. Arq. Bras. Med. Vet.
Zootec. vol.52 n.1 Belo Horizonte Feb. 2000
 TIME DATA

• Usually shown as a graph

• Number / rate of cases on vertical (y) axis
• Time periods on horizontal (x) axis

• Time period will depend on what is

being described

• Used to show trends, seasonality, day

of week / time of day, epidemic
period
 TIME DATA: DAY OF THE WEEK

BMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7229.218

BMJ. 2001 Dec 22-29;323(7327):1443-6.
TIME DATA: DAY OF THE MONTH
 TIME DATA: MONTH
Monthly seasonality

Human Zoonotic Enteric Diseases: A Systematic Review. PLoS ONE

indices with plotted

SOURCE:Lal A, Hales S, French N, Baker MG (2012) Seasonality in

confidence intervals for
vero-cytotoxigenic E
coli infections. Seasons
are December,

7(4): e31883. doi:10.1371/journal.pone.0031883

January, February
(winter), March, April,
May (spring), June,
July, August (summer),
September, October,
November (autumn).
CI of plus and minus
one standard deviation
is plotted.
 TIME DATA: YEAR

www.cdc.gov/mmwr/preview/mmwrhtml/mm5153a1.htm
 TIME DATA: PATTERNS OF DISEASE

• Endemic: normal or expected occurrence of

disease in a population
Incidence

Time
TIME DATA: PATTERNS OF DISEASE

Three different epidemic scenarios for malaria

(source: Epidemic malaria, preparing for the unexpected. http://www.scidev.net/)
 TIME DATA: PATTERNS OF DISEASE

• Sporadic: disease normally absent from a

population, occurs due to infrequent contact
between host and agent
Incidence

Time
TIME DATA: PATTERNS OF DISEASE

Rift Valley Fever

1600

1400

1200

1000
No of cases

800

600

400

200

0
1940 1950 1960 1970 1980 1990 2000
Year
 TIME DATA: PATTERNS OF DISEASE

• Epidemic: an increase in disease occurrence compared to

that expected for a specific population
• Patterns of epidemics include: Point source, propagating epidemic
and Bell curve outbreaks
• Pandemic: widespread epidemic affecting populations in
different countries or continents

Incidence
Incidence

Time Time
Propagating epidemic Bell curve
 PLACE (LOCATION) DATA

• Can be shown in a table; usually better

presented pictorially in a map

• Two main types of maps used: choropleth

and spot
 Choropleth maps use different shadings/colors to indicate
the count / rate of cases in an area
 Spot maps show locations of individual cases
PLACE DATA: ENVIRONMENT

www.thailande-fr.com
PLACE DATA:
INDIVIDUAL CASES
Spot map of men who
tested positive for HIV at
time of entry into the
Royal Thai Army, Thailand,
November 1991–May
2000.

www.cdc.gov/ncidod/EID/vol9no7/02-0653-G1.htm
PLACE DATA: AIRPLANE SEAT

Olsen, S.J. et al. N Engl J Med. 2003 Dec 18; 349(25):2381-2.

 SUMMARY

Descriptive epidemiology describes what happened, the

population it happened in, and when it happened

Descriptive epidemiology identifies populations at high risk,

helps with allocation of resources, and provides a
foundation for developing hypotheses

The main characteristics of descriptive epidemiologic data

are individual, place and time