INVESTIGASI WABAH

Definisi wabah (1)

Wabah adalah suatu peningkatan kejadian

kesakitan atau kematian yang telah meluas
secara cepat, baik jumlah kasusnya maupun
daerah terjangkit (Dep Kes DirJen PPM dan
PLP th 1981).
 Definisi wabah (2)
Wabah penyakit menular adalah kejadian
berjangkitnya suatu penyakit menular dalam
masyarakat yang jumlah penderitanya meningkat
secara nyata melebihi dari keadaan yang lazim
pada waktu dan daerah tertentu serta dapat
menimbulkan malapetaka (UU No 4 th. 1984, Bab
I, Pasal 1).
 Definisi KLB
•KLB adalah timbulnya atau meningkatnya
kejadian kesakitan/kematian yg bermakna
secara epidemiologis pd suatu daerah dlm
kurun waktu tertentu, dan merupakan
keadaan yg dpt menjurus pd terjadinya
wabah (PP 40, th 1991, Bab 1, Pasal 1)
 Kriteria KLB (1)
• 1. Penyakitnya tak pernah ada/tak dikenal
sebelumnya
• 2. Penyakit/kematian meningkat terus
selama 3 kurun waktu berturut-turut
• 3. Kejadiannya meningkat > 2 x dibanding
periode sebelumnya
 Kriteria KLB (2)
4. Penderita baru dlm 1 bln naik 2 x dibanding
rata2 per bulan dlm th sebelumnya
5. Angka rata2 per bln selama 1 th naik > 2 x
dibanding rata2 per bln tahun sebelumnya
6. Untuk beberapa penyakit, 1 kasus dianggap
KLB
Langkah-langkah investigasi
1. Persiapan turun ke lapangan
2. Tentukan adanya wabah
3. Pastikan diagnosis penyakit
4. Buat definisi kasus & identifikasi kasus
5. Gambarkan kejadian wabah berdasarkan
orang,tempat,waktu
6. Kembangkan hipotesis
7. Uji hipotesis
8. Adakan penanggulangan
9. Laporkan hasil investigasi
 OUTBREAK INVESTIGATION
Step 1: Persiapan turun ke Lapangan
Before leaving for the field:

1) Research the disease

2) Gather the supplies and equipment

3) Make necessary administrative and

personal arrangements
James M Shultz 2001
 OUTBREAK INVESTIGATION
Step 1: Persiapan turun ke Lapangan
Before leaving for the field:
4) Consult with all parties to determine your
role in the investigation

5) Identify your local contacts once you arrive

on the scene.
James M Shultz 2001
 OUTBREAK INVESTIGATION
Step 2: Tentukan adanya WABAH

An outbreak may exist if the

observed number of cases
exceeds the expected number.

James M Shultz 2001

 Pseudo-epidemik
• Pseudo-epidemik: Peningkatan laporan
jumlah kasus yg bukan merupakan wabah

* Perubahan cara pelaporan

* Perbaikan cara diagnosis

* Ada penyakit dg gejala sama

* Peningkatan proporsi penderita yg

berobat
 OUTBREAK INVESTIGATION
Step 2: Tentukan adanya WABAH

Factors influencing outbreak investigation:

–Severity of illness

–Potential for spread

–Political considerations

–Public relations

–Availability of resources
James M Shultz 2001
 Step 2. Tentukan adanya WABAH

• Is a suspected outbreak a real

outbreak?
– Some are true outbreaks with common
cause
– Some are unrelated cases of the same
disease
– Others are unrelated cases of similar, but
unrelated, diseases

• To determine if an outbreak exists (i.e.,13

 Step 2. Tentukan adanya WABAH

• Compare current
cases with previous
occurrences
– Check health
department records

– Consult local data

sources

– Make estimates from 14

Step 2. Tentukan adanya WABAH
• If current number of reported cases
exceeds expected number, further
investigation is needed

• Many factors affect changes in total

number of cases reported
–Change in reporting procedures or case definition
–Increased local interest or public awareness
–Improved diagnostic procedures 15
PERLUKAH DILAKUKAN INVESTIGASI
PADA SEMUA KLB

• Tidak semua KLB perlu dilakukan penyelidikan

dan tindakan khusus.
• Dalam mengambil keputusan untuk melakukan
penyelidikan atau tidak perlu dipertimbangkan
hal-hal dibawah ini :

1. Jumlah kasus yang terkena KLB

2. Adanya gejala-gejala klinis yang berat and
tidak biasa
3. Tidak ada keterangan yang jelas mengenai pola
kejadian penyakit
4. Diperlukan implementasi kontrol yang tepat
5. Dapat memberikan kontribusi kepada ilmu
pengetahuan dibidang medis
CONTOH APLIKASI DARI PENYELIDIKAN KLB

Profil Pasien

• Seorang mahasiswa (pria) usia 23 tahun pada jam 10.30

malam tanggal 17 Januari datang ke klinik kampus
dengan keluhan rasa sakit pada perut, mual, muntah
dan diare yang datangnya tiba-tiba

• Walaupun pasien tidak parah, tidak ada muntah yang berat

dan demam, tapi kondisinya sangat lemah

• Sejumlah mahasiswa lainnya datang dengan gejala-gejala

yang sama setelah 20 jam kemudian

• Semua pasien diobati dengan bed-rest dan pemberian cairan

intravena
• Semua pasien sembuh secara total dalam waktu 24 jam
setelah timbulnya gejala
Wabah /KLB

• KLB gastroenteritis telah terjadi di kampus

• Hipotesa kerja : epidemi karena bakteri patogen dari
sumber yang sama (common source)

• Dicurigai adanya satu pengantar yang sama dari agen

ke orang yang terkena
dan karena KLB mencapai puncaknya terjadi
dengan cepat  pengantar (vehicle) dari agen akan
telah habis dengan cepat pula

• Investigasi dilakukan oleh petugas kesehatan

Perlukah dilakukan investigasi ?

• Kondisi diatas bukan merupakan kondisi yang mengancam

jiwa/berbahaya

• Gejala jelas menunjukkan kearah gastroenteritis akut

• Berdasarkan kondisi kriteria diatas , investigasi tidak
perlu dilakukan

• Tetapi dilain fihak sejumlah besar mahasiswa yang

terserang kausanya tak jelas, dan anggota komunitas
kampus tersebut takut akan adanya penyebaran penyakit
lebih lanjut

• Dengan pertimbangan diatas dilakukan investigasi

terhadap KLB tersebut
 Tingkat prioritas investigasi
Sumber/Cara penularan
Diketahui Tidak
Diketahui
Investigasi + Investigasi +++
Agent
Control +++ Control +
penyebab
Tidak Investigasi +++ Investigasi +++
Control +++ Control +
 Pemastian kejadian wabah
Data sekunder (1)
Dari data yang ada (rutin) pastikan ada
peningkatan:
1. Jumlah penderita
2. Pola (trend) penyakit. Meningkat?
3. Attack rate.

Ingat!!!
Definisi kasus dan populasi berisiko dpt
berubah sesuai dg informasi yg didapat !!!
 OUTBREAK INVESTIGATION

Step 3: Pastikan Diagnosis Penyakit

Twin Goals:
1) Ensure that the problem is correctly and
properly diagnosed
2) For infectious diseases and toxic
exposures, rule out laboratory error

James M Shultz 2001

 OUTBREAK INVESTIGATION

Step 3: Pastikan Diagnosis Penyakit

1) Review clinical findings (symptoms,

features of illness)
2) Review laboratory findings
3) Review laboratory techniques &
procedures
4) Obtain specimens, isolates, materials for
special laboratory tests
James M Shultz 2001
 OUTBREAK INVESTIGATION
Step 3: Pastikan Diagnosis Penyakit

5) Interview cases
• Observe signs, symptoms, behaviors
directly
• Ask about exposures
• Ask about patient’s perception of
cause(s)
• Ask about knowledge of other cases
• Ask questions based on information from
other interviews—looking for
commonalities
James M Shultz 2001
 OUTBREAK INVESTIGATION
Step 4: Buat definisi kasus & identifikasi kasus
1) Develop a case definition
• Clinical information about the disease
• Characteristics of people who are affected
• Location or place characteristics
• Time characteristics

2) Case definition needs to be broad enough to capture

most or all cases of disease
James M Shultz 2001
 OUTBREAK INVESTIGATION

Step 4: Buat definisi kasus & identifikasi kasus

Distinguish gradations of certainty

• Confirmed: laboratory verification

• Probable: typical clinical features without

laboratory confirmation

• Possible: fewer typical clinical features

James M Shultz 2001
 OUTBREAK INVESTIGATION

Step 4: Buat definisi kasus & identifikasi kasus

4) Start with “loose” case definition

5) Tighten case definition as investigation

proceeds (consider dropping the “possible”
cases)
James M Shultz 2001
 OUTBREAK INVESTIGATION
Step 4: Buat definisi kasus & identifikasi kasus

6) Identify and count cases

• Use as many sources as possible

• Determine whether to notify general public

• Consider surveying entire population in a

restricted setting (cruise ship, school)
James M Shultz 2001
 OUTBREAK INVESTIGATION
Step 4: Buat definisi kasus & identifikasi kasus
7) Obtain information from cases
• Identifying and contact information (name, address,
telephone)

• Demographic
Details to characterize population at risk

• Clinical informaton (signs, symptoms, date of onset,

medical care sought and received)

• Risk factor information

James M Shultz 2001
Step 4. Define and Identify Cases
• Criteria are be based on
objective measures that are
consistently applied without bias
to all people included in the
investigation
• Case definitions are broad
enough to include most actual
cases while avoiding “false-
positive” cases (when the case
definition is met, but the person
does not have the disease).

Source: CDC Excite 30

Step 4. Define and Identify Cases
• When an outbreak is first recognized the
epidemiologist must “cast the net wide” to identify
cases
• Possible sources of cases
– Health care facilities
– Public alert
– Survey of population, particularly if outbreak
occurs in restricted population
– Case patient referral

Source: CDC Excite 31

 Case Report Form
• This information is
entered on a case
report form.
• CT DPH has a number
of different case report
forms, depending on
the nature of the
outbreak
Sample report form from the
DPH Food Protection Program

Source: CDC Excite 32

 Line Listing
Next, selected critical items are abstracted into a table
called a “line listing”
– Each column represents an important variable,
such as age and sex
– Each row represents a different case, by number
• This simple format allows the investigator to scan
key information on every case and update it easily

Source: CDC Excite 33

 Example of a Line Listing

Source: CDC Excite 34

 Step 5. Gambarkan kejadian wabah
berdasarkan orang,tempat,waktu

• Characterize the outbreak by time, place, and

person (descriptive epidemiology)
• Benefits
– Allows you to become familiar with the data,
especially what is and is not reliable
– Provides a comprehensive description of the
outbreak
– Allows you to develop a causal hypothesis
based on what is known about the disease

Source: CDC Excite 35

 OUTBREAK INVESTIGATION

Step 5: Describe & Orient the Data

Descriptive epidemiology:
1) Identify data that are informative &
reliable
2) Orient data by
• Person (WHO—population affected)
• Place (WHERE—geographic extent)
• Time (WHEN—trends)
James M Shultz 2001
 Diskripsi wabah
1. Gambarkan data yang ada berdasarkan
person, time, place untuk mendapatkan
gambaran awal ttg kapan, dimana dan siapa
yang terserang
2. Pastikan diagnosis (periksa lab, dlsb.)
3. Buat distribusi frekuensi gejala untuk
membuat kriteria gejala. Pilih gejala utama,
obyektif dan patognomonis, mudah dikenal.
Bila perlu cari informasi rujukan (pustaka,
internet dll.)
4. Buat definisi kasus
 Data sekunder (3)
6. Buat instrumen untuk menemukan kasus yg
ada (tercatat dan belum), berisi:
*identitas,
*gejala sesuai definisi kasus,
*waktu mulai sakit,
*pemapar yg dicurigai
 Kelebihan & kekurangan
data sekunder
Kelebihan:
1. Ada/dikumpulkan secara rutin
2. Kasus didagnosis oleh nakes

Kekurangan:
1. Tak semua kasus berobat (mungkin yg berat,
atau lama tak sembuh)
2. Tgl tercatat adl tgl berobat, bukan tanggal
mulai sakit
3. Tak semua data yg dibutuhkan ada
 OUTBREAK INVESTIGATION

Step 5: Describe & Orient the Data

3) Characterizing by time
• Construct an epidemic curve
• Estimate probable times of exposure
• Interpret the epidemic curve
– Shape (defining time course)
– Slope
– Period of exposure
– Mininum, maximum, median incubation period
James M Shultz 2001
Characterizing By Time: Epidemic Curve
How to draw an epidemic curve
• Know the time of onset for each person
• Number of cases is plotted on y-axis
• Time is plotted on the x-axis
– The unit of time is based on incubation period
and length of time over which cases are
distributed. Select a unit that is one-fourth to one-
third as long as the incubation period.
• Show the pre- and post-epidemic period to illustrate
the activity during those periods

Source: CDC Excite 41

 Example 1: Epidemic Curve
• Insert EPI Curve

Source: CDC Excite 42

 Example 2: Epidemic Curve

Source: CDC Excite 43

 Diskripsi wabah (2)
Time
Grafik yang menggambarkan distribusi
kasus berdasarkan waktu timbulnya
gejala (time onset)  kurve epidemik
1. Menentukan periode wabah
2. Menunjukkan status wabah
3. Menunjukkan kemungkinan cara
penularan
4. Memungkinkan penghitungan masa
inkubasi/menentukan saat pemaparan
Penyebaran berasal dari satu sumber
yang sama(common source)
• Penyebaran secara “common source” terjadi bila
agen kausa ditransmisikan ke orang-orang melalui
suatu lingkungan/kondisi yang sama

• Terjadi peningkatan jumlah kasus dalam periode

waktu yang singkat, diikuti pula dengan penurunan
kasus dengan cepat, setelah orang-orang yang
terpapar agen mendapat pengobatan

• KLB seperti ini dapat berulang lagi bila agen

penyakit pada sumber penyakit tidak dieliminasi

• Contoh : makanan yang terkontaminasi dapat

menjadi sumber agen penyakit misal bakteri patogen
bagi orang-orang yang memakan makanan tersebut
 Kurve epidemik (1)
Point source epidemics
• Kontrol yang cocok untuk KLB tipe ini adalah :

• Eliminasi /membuang makanan yang terkontaminasi

• Melakukan pemeriksaan laboratoris terhadap
sisa makanan masih yang ada untuk menentukan
agen kausa
• Memberi pengobatan pada kasus yang telah sakit

• Penyebaran cara “common source” ini tidak terbatas

untuk penyakit-penyakit infeksi saja,
• tapi juga dapat untuk penyakit-penyakit bukan
infeksi, sebagai contoh :
• kontaminasi bahan kimiawi pada air, udara
 dapat menyebabkan KLB
• Penyebaran epidemi secara person-to-person,

• dapat juga pada penyakit non infeksi,

misalnya penyakit-penyakit yang ada kaitannya
dengan perilaku.
• contohnya pada penyalah-gunaan obat bius
• Contoh person-to-person epidemic:

• Penyakit TBC adalah penyakit yang pola

penyebarannya bersifat dari satu orang ke orang
yang lain

• Penyelidikan terhadap KLB penyakit TBC

dilakukan terutama untuk mendapatkan
• kasus inisial/pertama dan
• kasus-kasus berikutnya ang terjadi diantara
orang-orang yang dekat dengan orang
yang terinfeksi
 Kurve epidemik (2)
Propagated (person-to-person)
• Kontrol yang efektif untuk mengatasi KLB ini
antara lain adalah :

• melakukan isolasi terhadap kasus inisial

sampai orang tersebut tidak lagi dapat
menularkan penyakitnya
• melakukan pengobatan terhadap kasus inisial
• mencegah penularan selanjutnya
• memberikan anti TBC preventif untuk orang-orang
yang sering melakukan kontak secara dekat
dengan kasus inisial
• memberikan vaksinasi pada anak-anak /orang
yang peka disekitarnya
 Kurve epidemik (3)
Common source epidemics
with continuous exposure
Epidemic Curve: Interpreting the Shape
• Point source epidemic
• Shape – a steep up slope, a peak and a gradual
down-slope
• Interpretation - people are exposed to the same
source over a relatively brief period
• Continuous common source epidemic
• Shape - curve will have a plateau instead of a peak
• Interpretation - people are exposed to the same
source over an extended period
• Propagated epidemic
• Shape - a series of progressively taller peaks
• Interpretation - person-to-person spread

Source: CDC Excite 52

Characterizing By Time: Epidemic Curve
Outliers = cases that stand apart
• Early case may represent:
– a background (unrelated) case
– source of epidemic (index case)
– an early exposure
• Late cases may be:
– unrelated
– have long incubation periods
– indicate later exposure
– secondary cases

Source: CDC Excite 53

 Diskripsi wabah (3)
Place
Menggambarkan wilayah terjangkit dg spot map dari
tempat t.u. yg diduga menjadi tempat pemaparan,
bisa:
* wilayah tempat tinggal (alamat)
* Tempat kerja
* Tempat lain, misalnya tempat pesta, piknik, dsb

Source: CDC Excite

 OUTBREAK INVESTIGATION

Step 5: Describe & Orient the Data

4) Characterizing by place
(geographic extent)
• Construct an “spot map”

James M Shultz 2001

 Characterizing By Place: Spot Map

• Assessment of an outbreak by
place provides information on
the geographic extent of a
problem
• A spot map of cases in a
community may show clusters
or patterns that reflect water
supplies, wind currents, or
proximity to a restaurant or
grocery store.
John Snow and Broad Street
Pump map

Source: CDC Excite 56

 Contoh spot map
Peta rumah penduduk yg mati akibat
kolera, London 1849

Source: CDC Excite

 Characterizing By Place
• To compensate, maps
can show the
proportion of people
affected in each area
• This also represents
the rate of disease or,
in the investigation of
an outbreak, the
"attack rate"
Connecticut Epidemiologist, July 2001

Source: CDC Excite 58

 OUTBREAK INVESTIGATION

Step 5: Describe & Orient the Data

5) Characterizing by person
• Personal characteristics (age, race, sex)
• Exposures (occupation, risk factors)

James M Shultz 2001

 Characterizing By Person
• Determine the populations at risk by characterizing
the outbreak by person
• Define populations by
– Personal characteristics (Examples: age, race,
sex, or medical status)
– Exposures (Examples: occupation, leisure
activities, use of medications, tobacco, drugs)
• Age and sex are usually assessed first, because
they are often the characteristics most strongly
related to exposure and to the risk of disease.

Source: CDC Excite 60

 Data primer
Cari kasus-kasus yg ada di populasi termasuk yg
sdh tercatat  data lengkap

Gambarkan kejadian wabah berdasarkan person,

time dan place (epidemiologi diskriptif)  gambaran
wabah yg lebih utuh

Source: CDC Excite

 Keracunan makanan di Hotel X

Kasus lain: Tak ada

Kemungkinan pemapar? Makanan/minuman
Waktu pemaparan? Tak diketahui pasti
Tempat pemaparan?

Source: CDC Excite

 Diskripsi wabah
Person
Ciri penderita:
* Umur
* Jenis kelamin
* Pekerjaan
* Ras
* Dlsb
 cari hal yg mungkin menunjukkan
tempat/waktu/apa yg menyebabkan sakit
 cocokkan dng sifat penyakit

Source: CDC Excite

Step 5. Describe and Orient the Data in
Terms of Time, Place, Person
Summarize
• After characterizing an outbreak by time, place, and
person (descriptive epidemiology), epidemiologists
need to summarize what they know to see whether
their initial hypotheses are on track.
• New hypotheses may need to be developed to
explain the outbreak.

Source: CDC Excite 64

 Step 6. Develop Hypotheses
• Hypotheses may be based on
– Interviews with affected people
– Consultation with health officials in community
– Descriptive epidemiology - person, place and
time
• It should incorporate the known characteristics of
the agent
• It should be testable.

Source: CDC Excite 65

 OUTBREAK INVESTIGATION

Step 6: Develop Hypotheses

Generate testable hypotheses regarding:
1) Source of the agent
2) Mode of transmission
3) Exposures that caused the disease

James M Shultz 2001

 OUTBREAK INVESTIGATION

Step 6: Develop Hypotheses

Generate hypotheses based on knowledge
of the disease:
1) Reservoir
2) Mode(s) of transmission
3) Vehicles and vectors
4) Known risk factors
James M Shultz 2001
 Step 7. Evaluate Hypotheses
Two approaches
1) Compare hypotheses with the established facts.
This method is used when the evidence is so
strong that the hypothesis does not need to be
tested
1) Use analytic epidemiology to test hypotheses
by using a comparison group to quantify
relationships between various exposures and
the disease.

Source: CDC Excite 68

 Step 7. Evaluate Hypotheses
Analytic Studies
There are two types of analytic studies
– Cohort Studies = compare groups of people
who have been exposed to suspected risk factors
with groups who have not been exposed.
– Case-Control Studies = compare people with a
disease (case-patients) with a group of people
without the disease (controls).

Source: CDC Excite 69

 OUTBREAK INVESTIGATION

Step 7: Evaluate Hypotheses

Two approaches:
1) Compare hypotheses with established
facts
2) Test hypotheses analytically
• Cohort study
• Case-control study
James M Shultz 2001
 OUTBREAK INVESTIGATION

Step 7: Evaluate Hypotheses

Cohort Study:
1) Ask about exposures
2) Calculate attack rates
3) Pattern: high attack rate in exposed combined
with low attack rate in nonexposed
4) Compute relative risk
5) Test for statistical significance
James M Shultz 2001
 Study Type: Cohort Studies
• Best for analyzing an outbreak in a small well-
defined population
– Example: gastroenteritis among people who
attended a wedding
• Ask each attendee the same set of questions about
potential exposures
• In cohort studies, an attack rate can be calculated
for people who ate a particular item (were exposed)
and an attack rate for those who did not eat that
item (were not exposed).

Source: CDC Excite 72

 Attack Rates
For the exposed group, the attack rate equals the
number of people who ate item and became ill
divided by (÷) the total number of people who ate
that item.

Total # of people who ate the item and

Exposed Group = became ill

Total # of people who ate that item

Source: CDC Excite 73

 Attack Rates
For the not exposed group, the attack rate equals
the number of people who did not eat item but still
became ill divided by (÷) the total number of people
who did not eat that item.

Total # of people who did not eat

the item but still became ill
Not Exposed Group =
Total # of people who did not eat
that item

Source: CDC Excite 74

 Relative Risk
• To identify source of outbreak, look for
– High attack rate among those exposed and
– Low attack rate among those not exposed and
In addition
– Most of the people who became ill should have
consumed the item
• Calculate the relative risk: mathematical
association between exposure and illness for each
food and beverage

Source: CDC Excite 75

 Relative Risk
Relative risk is calculated by dividing (÷) the attack
rate for people who were exposed to the item by the
attack rate for those who were not exposed.

Attack rate for people who were

exposed to the item
Relative Risk =
Attack rate for those who were
not exposed

Source: CDC Excite 76

 Attack Rate Table 1
Number of people Number of people who
who ate specified item did not eat specified item
Attack Attack Relative
Food Ill Well Total Ill Well Total
Rate % Rate % Risk
Baked Ham 29 17 46 17 12 29
Mashed potatoes 23 14 37 23 14 37
Spinach 26 17 43 20 12 32
Cabbage Salad 18 10 28 28 19 47
Milk 2 2 4 44 27 71
Ice Cream (Van) 43 11 54 3 18 21
Fruit salad 4 2 6 42 27 69
Ice Cream (Choc) 25 22 47 20 7 27

Source: CDC Excite 77

 Example: Attack Rates
Food Exposed Group
• Baked Ham 29/46 = 63%
• Mashed potatoes 23/37 = 62%
• Spinach 26/43 = 60%
• Cabbage salad 18/28 = 64%
• Milk 2/4 = 50%
• Ice Cream (Van) 43/54 = 80%
• Ice Cream (Choc) 25/47 = 53%
• Fruit salad 4/6 = 67%

Source: CDC Excite 78

 Example: Attack Rates
Food Not Exposed Group
• Baked Ham 17/29 = 59%
• Mashed potatoes 23/37 = 62%
• Spinach 20/32 = 62%
• Cabbage salad 28/47 = 60%
• Milk 44/71 = 62%
• Ice Cream (Van) 3/21 = 14%
• Ice Cream (Choc) 20/27 = 74%
• Fruit salad 42/69 = 61%

Source: CDC Excite 79

 Attack Rate Table 2
Number of people Number of people who
who ate specified item did not eat specified item
Attack Attack Relative
Food Ill Well Total Ill Well Total
Rate % Rate % Risk
Baked Ham 29 17 46 63 17 12 29 59
Mashed potatoes 23 14 37 62 23 14 37 62
Spinach 26 17 43 60 20 12 32 62
Cabbage Salad 18 10 28 64 28 19 47 60
Milk 2 2 4 50 44 27 71 62
Ice Cream (Van) 43 11 54 80 3 18 21 14
Fruit salad 4 2 6 67 42 27 69 61
Ice Cream (Choc) 25 22 47 53 20 7 27 74

Source: CDC Excite 80

 Attack Rate Table 3
Number of people Number of people who
who ate specified item did not eat specified item
Attack Attack Relative
Food Ill Well Total Ill Well Total
Rate % Rate % Risk
Baked Ham 29 17 46 63 17 12 29 59 1.07
Mashed potatoes 23 14 37 62 23 14 37 62 1.00
Spinach 26 17 43 60 20 12 32 62 0.97
Cabbage Salad 18 10 28 64 28 19 47 60 1.07
Milk 2 2 4 50 44 27 71 62 0.81
Ice Cream (Van) 43 11 54 80 3 18 21 14 5.71
Fruit salad 4 2 6 67 42 27 69 61 1.10
Ice Cream (Choc) 25 22 47 53 20 7 27 74 0.72

Source: CDC Excite 81

 OUTBREAK INVESTIGATION

Step 7: Evaluate Hypotheses

Case-control Study:
1) Ask case-patients and controls about
past exposures
2) Estimate odds for cases and controls
3) Compute odds ratio
4) Test for statistical significance
James M Shultz 2001
Study Type: Case Control Studies
• When the population in an outbreak is not well
defined, a case control study design is used
• Both case-patients and controls are asked about
their exposures
• Controls must not have the disease, but should be
from the same population as the case-patients
• The measure of association used is called an odds
ratio

Source: CDC Excite 83

 Odds Ratio
• In a case-control study, attack rates cannot be
calculated because the total number of people in the
community who were and were not exposed to the
source of the disease under study is not known
• An odds ratio is used to measure of association
• To calculate an odds ratio, it is helpful to look at
data in a 2 x 2 table.

Source: CDC Excite 84

 Odds Ratio
Example
• Suppose an epidemiologist were investigating an
outbreak of hepatitis A in a small town.
• The suspected source was a favorite restaurant of
the townspeople.
• After questioning case-patients and controls about
whether they had eaten at that restaurant, the data
might look like this in a 2 x 2 table:

Source: CDC Excite 85

 Odds Ratio: 2 x 2 Table

Source: CDC Excite 86

 Odds Ratio
• The odds ratio is calculated as: ad/bc
Using the example from previous 2 x 2 Table:
30 x 70 ÷ 36 x 10 = 5.8
• People who ate at restaurant A were 5.8 times more
likely to develop hepatitis A than were people who
did not eat there
• Now epidemiologists can compare the odds ratio
with the odds ratios for other possible sources

Source: CDC Excite 87

 Step 7: Evaluate Hypotheses
Testing Statistical Significance
• Determine how likely the study results could have
occurred by chance
– Called testing for “statistical significance”
• Steps to testing “statistical significance”
– State null hypothesis – no association between
exposure and outcome
– Calculate chi-square test
– Look up corresponding p-value in table of chi-
squares.

Source: CDC Excite 88

 Interpreting P-Values
• Epidemiologists set in advance a cutoff point above
which they will consider that chance is a factor
– The common cutoff point is .05
– If the p-value is below the cutoff point, the finding
is considered “statistically significant” and the
null hypothesis is rejected
• The smaller the p-value, the stronger the evidence
is for statistical significance

Source: CDC Excite 89

 Uji hipotesis
Cara:
1. Membandingkan riwayat pemaparan pada
kelompok yang sakit (kasus) dengan yang tidak
sakit (kontrol), atau
2. Membandingkan risiko sakit pada kelompok yang
terpapar dg yang tak terpapar

Source: CDC Excite

 Kasus-kontrol
Prinsip: Membandingkan riwayat terpapar pd
kasus & pada kontrol

Ukuran: OR = rasio odds terpapar pd kasus

dan pd kontrol
* OR = 1 tak ada hubungan
* OR < 1 pemapar menurunkan risiko
* OR > 1 Pemapar meningkatkan risiko

Kemaknaan: lihat 95% CI. Bila angka 1 ada

dlm bentang  hubungan tak bermakna
Source: CDC Excite
 Contoh Kasus-kontrol (1)
Dari 46 tamu yg sakit, 43 orang makan nasi
goreng, yg tdk sakit (254 orang) 107 orang
makan nasi goreng

Makan nasi Diare Tidak diare

goreng
Ya 43 107

Tidak 3 147

Jumlah 46 254

Source: CDC Excite

 Contoh Kasus-kontrol (2)
Odds mkn pd kasus = (43/46) : (3 /46) = 43/3
Odds mkn pd kontrol = (107/254):(147/254) =
107/147
OR = (43/3) : (107/147) = (43/3) x (147/107) = 19,69
95% CI = 5,67 – 81,99

Apa artinya?
1. odds mkn nasi goreng pd kasus 20 x dr
odds mkn nasi goreng pd kontrol.
2. odds pd kasus berbeda bermakna dr
kontrol
3. ada hubungan bermakna antara nasi goreng dg
diare
Source: CDC Excite
 Kohort historikal
Prinsip: Membandingkan risiko sakit pd
kelompok terpapar & kelompok tak terpapar

Ukuran: RR = insiden terpapar : insiden

takterpapar = Ie : Ine
* RR = 1 tak ada hubungan
* RR < 1 pemapar menurunkan risiko
* RR > 1 Pemapar meningkatkan risiko

Kemaknaan: lihat 95% CI. Bila angka 1 ada

dlm bentang  hubungan tak bermakna
Source: CDC Excite
 Contoh kohort historikal (1)

Dari 150 tamu yg makan nasi goreng, 43 orang

sakit. Dari 150 yg tdk makan nasi goreng, 3 orang
yg sakit

Makan nasi Diare Tidak Jumlah

goreng
Ya 43 107 150
Tidak 3 147 150

Source: CDC Excite

 Contoh Kohort historikal (2)
Insidens diare pd yg makan nasi goreng = 43/150
Insidens diare pd yg takmakan nasi goreng = 3/150
RR = (43/150) : (3/150) = (43/150) x (150/3)
= 43/3 = 14,33
95%CI = 4,55 – 45,19

Apa artinya?
1. Risiko diare pd yg makan nasi goreng 14 x risiko
diare pd yg tak makan nasi goreng
2. Risiko diare berbeda bermakna antara makan nasi
goreng dg tak makan nasi goreng
3. Makan nasi goreng berhubungan secara bermakna
dg risiko diare
Source: CDC Excite
 Uji lain: c2

Makan Diare Tak diare Total

Ya 43 107 150
Tidak 3 147 150
Jumlah 46 254 300

c2 = 41,08 df = 2 p = 0,00

Source: CDC Excite

 Kesimpulan
1. OR bukan merupakan estimasi yg baik
untk RR ok prevalens kejadian cukup
tinggi (>10%)
2. Uji kasus-kontrol, kohort historikal dan
c2 menghasilkan kesimpulan yg sama
(ada hubungan bermakna antara
pemapar dng risiko kejadian)

Source: CDC Excite

 Kekuatan & keterbatasan uji
c2 paling mudah dilakukan
tak menunjukkan arah hubungan

Kasus-kontrol
menunjukkan arah hubungan
tak harus menjangkau populasi berisiko

Kohort
menunjukkan arah
hrs dapat menentukan populasi terpapar & tak
terpapar
Source: CDC Excite
 INGAT!
• Bila pemapar yang dicurigai sering terjadi, menuduh
pemapar terakhir sebagai penyebab wabah dapat
menghasilkan kesimpulan yang salah.
• Cari masa inkubasi untuk menentukan waktu
pemaparan dapat dicari pemaparnya

Source: CDC Excite

 Mencari masa inkubasi
• Agent penyebab:
1. Diagnosis penyakit
2. Pemeriksaan lab dari penderita
3. Pemeriksaan lab dari sample pemapar
4. Teori ttg sifat agent

• Kurve epidemik

Source: CDC Excite

 Masa inkubasi
beberapa penyakit dg gejala diare
Penyakit/agent Masa inkubasi
1. Kolera Bbrp jam – 5 hr (2-3 hr)
2. Shigelosis 1 – 7 hr ( 1 – 3 hr)
3. E. coli 12 – 72 jam
4. Campilobacter 1 – 10 hr (3 – 5 hr)
5. Staphilococcus ½ - 7 jam (2 – 4 jam)
6. Clostridium 6 – 24 jam (10 – 12 jam

Source: CDC Excite

Memperkirakan waktu terpapar
dari masa inkubasi

Source: CDC Excite

 OUTBREAK INVESTIGATION

Step 8: Refine Hypotheses

Reasons:
1) Initial analytical study fails to confirm
hypothesis
2) Need to perfect your hypothesis even if
initial data are supportive
3) Supplement epidemiologic findings with
laboratory and environmental evidence
James M Shultz 2001
 Step 8. Refine Hypotheses and
Carry Out Additional Studies
• When analytic epidemiological studies do not
confirm the hypotheses, they must be reconsidered
along with new vehicles or modes of transmission
• Even when an analytic study identifies an
association, hypotheses will need to be refined
• Often, more specific exposure histories or a more
specific control group are needed
• Epidemiologists consider what questions remain
unanswered, and what kind of study might be used
in the particular setting to answer some of these
questions

Source: CDC Excite 105

 Step 8. Refine Hypotheses and
Carry Out Additional Studies

Laboratory and environmental studies

• While epidemiology can implicate vehicles and
guide appropriate public health action, laboratory
evidence can clinch the findings
• Environmental studies often help explain why an
outbreak occurred and may be very important in
some settings

Source: CDC Excite 106

 OUTBREAK INVESTIGATION

Step 9: Implement Control and

Prevention Measures
1) Implement control measures as soon as
source of outbreak is known
2) Break the chain of infection
3) Target agent, source or reservoir
4) Interrupt transmission or exposure
5) Reduce susceptibility
James M Shultz 2001
 Step 9. Implementing Control and
Prevention Measures
• Control measures, which can be implemented early,
should be aimed at specific links in the chain of
infection, the agent, the source, or the reservoir
• In some situations, control measures are directed at
interrupting transmission or exposure
– Limit airborne spread
– Use the method of “cohorting” by putting
infected people together in separate area
• Some control measures are directed at reducing
susceptibility, such as travel immunizations

Source: CDC Excite 108

 Prinsip penanggulangan
• Prinsip:
1. Menghilangkan sumber penularan
2. Memutus kontak sumber dan inang
3. Melindungi inang yang peka

Source: CDC Excite

 OUTBREAK INVESTIGATION
Step 10: Communicate Findings
Types of communication:
1) Oral briefing for health authorities
2) Written report
• Introduction
• Background
• Methods
• Results
• Discussion
• Recommendations

James M Shultz 2001

 Step 10. Communicate Findings
• The final task in an investigation is to communicate
the findings to others who need to know.
• This communication usually takes two forms:
1) an oral briefing
2) a written report

Source: CDC Excite 111

 Laporan investigasi
• 2 macam: Lisan & tertulis
• Laporan sebaiknya di sampaikan sebelum
meninggalkan wilayah terserang, t.u. laporan
lisan
• Isi: 1. Informasi wabah: sumber, waktu
2. Kronologi kegiatan mulai dari
mendengar, sampai diindentifikasinya
sumber penularan, penanggulangan,
hasil penanggulangan, dan saran untuk
mencegah berulangnya kejadian

Source: CDC Excite

 Role of Non-Epidemiologists in
CT Outbreak Investigations
1. Assure outbreak comes to attention ASAP of those
with experience and authority to investigate.
– Report outbreaks to the state DPH.
– Joint investigations by the LHD and DPH.
2. Provide assistance, as needed, depending on
expertise.
– Sanitarians can help to develop questionnaires,
conduct environmental investigation.
– Surge capacity needed to: answer
phones/public inquiry; conduct interviews for
analytic studies.

Source: CDC Excite 113

 Roles in Foodborne Outbreak
Investigations

Source: CDC Excite 114