Epidemic

Investigation
Ma. Eufemia M. Collao, MD
 Learning Objectives

At the end of the lecture the student should be

able to:
• Cite reasons why health agencies investigate
reported outbreaks
• Describe the different steps in investigating
outbreaks;
• Determine whether an epidemic exists or not;
• Differentiate common source and propagated
epidemics
• Interpret an epidemic curve
 Definition of outbreak
• Occurrence of more cases of disease than
expected in a given area among a specific
group of people over a particular period of
time
or

• Two or more linked cases of the same

illness
 Objectives of Outbreak
Investigations
• To determine the cause of the outbreak
• To control ongoing outbreaks
• To prevent future outbreaks
• To provide statutorily mandated services
• To strengthen surveillance at local level
• To advance knowledge about a disease
• To provide training opportunities
 Specific Demands when
Investigating Outbreaks

• Unexpected event
• Need to act quickly
• Need for rapid control
• Work carried out in the field

Systematic approach
 Steps of an Outbreak
Investigation
• Confirm outbreak and diagnosis
 Case definition and identification
 Descriptive data collection and analysis
 Develop hypothesis
 Analytical studies to test hypotheses
• Special studies
• Implementation of control measures
 Communication, including outbreak report
Detection ?
 Routine surveillance
Detection Clinical / Laboratory
General public
Media
 Routine surveillance
Detection Clinical / Laboratory
General public
Media

Is this an outbreak?
 Routine surveillance
Detection Clinical / Laboratory
General public
Media

Is this an outbreak?

Diagnosis verified ?
clinical + laboratory
Link between cases?
Expected numbers?
 Sequence of Events 1
Outbreak Detection and Confirmation

Primary 1st case Report Samples Lab Response

Case at HC to DMO taken result begins

90
80
70
60
CASES

50
Opportunity
40 for control
30
20
10
0
10

13

16

19

22

25

28

31

34

37

40
1

DAY
 Sequence of Events 2
Outbreak Detection and Confirmation

Response
PRIM HC REP SAMP RES begins

90
80
70
Potential
60
CASES

Cases Prevented
50
40
30
20
10
0
1

16

19

25

28

31

34

40
10

13

22

37
DAY
 Outbreak confirmed

Immediate control Further

measures? investigation?
 Outbreak confirmed

Immediate control Further

measures? investigation?

Unknown etiology
Prophylaxis (pathogen/source/transmission)
Exclusion / isolation Cases serious
Public warning Cases still occurring
Hygienic measures Public pressure
Training opportunity
Scientific interest
 Outbreak confirmed

Immediate control Further

measures? investigation?

Unknown etiology
Prophylaxis (pathogen/source/transmission)
Exclusion / isolation Cases serious
Public warning Cases still occurring
Hygienic measures Public pressure
Training opportunity
Scientific interest

Assistance ?
 Outbreak
? Investigation
Team?
Epidemiologist
Microbiologist Outbreak
Environmental specialist
Ministry / Government
Investigation
Press officer Team?
Others

FIELD
Epidemiologist
Microbiologist Outbreak
Environmental specialist
Ministry / Government
Investigation
Press officer Team?
Others

Assess situation
Examine available information
Preliminary hypothesis ?
Case definition
Case finding
Epidemiologist
Microbiologist Outbreak
Environmental specialist
Ministry / Government
Investigation
Press officer Team?
Others

Assess situation
Examine available information
Preliminary hypothesis ?
Case definition
Case finding

Descriptive epidemiology
 Case Definition
• Standard set of criteria for deciding if a
person should be classified as suffering
from the disease under investigation.
• Clinical criteria, restrictions of time, place,
person
• Simple, practical, objective
• Sensitivity versus specificity
 Example of Case
Definition

Patient older than 5 years with severe

dehydration or dying of acute watery
diarrhea in town “X” between 1 June
and 20 July 2006
 Examples of Case
Definition
• Possible
– Patient with severe diarrhea
• Probable
– Patient older than 5 years with severe
dehydration or dying of acute watery
diarrhea in town “x” between 1 June
and 20 July 2006
• Confirmed
– Isolation of Vibrio cholerae from stool of
patient
 Clearly identifiable groups
Identify & Hospitals
count cases Laboratories
Schools
Workplace, etc

Obtain information

Perform descriptive
epidemiology
 Identify &
count cases

Identifying information
Obtain Demographic information
information Clinical details
Risk factors

Perform descriptive
epidemiology
 Identify &
count cases

Obtain
information

Orient cases by
Perform descriptive - time
epidemiology - place
- person
 Cases

Person Time
Place
1200 25

1000 20
800
15
600
10
400
200 5

0 0
0-4 '5-14 '15- '45- '64+ 1 2 3 4 5 6 7 8 9 10
44 64
Age Group

Evaluate information

Pathogen? Source? Transmission?

 Cases of viral meningitis by date of admission (n=416)
Cyprus, 5 July - 5 November 5 1996
25

20

15
Cases

10

0
5 11 17 23 29 4 10 16 22 28 3 9 15 21 27 3 9 15 21 27 2
July August September October November

Date of admission
Distribution of Food Poisoning Cases by Onset of Illness at
the Philippine Supreme Court on August 20, 2004 (n=41)

20

“Binalot”
15 Sandwiches lunches
distributed distributed

10
Supreme Court
Employees
Association
5 General Assembly

0
12nn
6am

7am

1pm

2pm

4pm

5pm

6pm
8am

9am

3pm

8pm
7pm
10am

11am
 Point source
25
Examples of 20
epidemic curves 15

10

0
1 3 5 7 9 11 13 15 17 19

Continuing common source Multiple waves -person to person

or further outbreak
20
20
15
15
10
10
5
5
0
0
1

10

13

16

19

1
3
5
7
9
11
13
15
17
19
 Admissions per 100,000 population for viral meningitis
by age group. Cyprus, 5 July - 5 November 1996

500
450
Admissions/100,000 pop

400
350
300
250
200
150
100
50
0
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+
Age Group
Spot Map of Cholera in London,
1854
 Develop hypotheses

• Who is at risk of becoming ill?

• What is the disease causing the
outbreak?
• What is the source and the vehicle?
• What is the mode of transmission?

Compare hypotheses with facts

 Test specific hypotheses

Analytical epidemiological studies

Cohort Case-control

Prospective Retrospective
Logistic Regression Analysis of Potential Risk Factors for
Food Poisoning at the Philippine Supreme Court on
August 20, 2004

Exposure Odds Ratio p value 95% CI

Tuna Sandwich 4.814 .121 .662 – 35.028

Ham Sandwich 4.748 .100 .741 – 30.402

Chicken Sandwich 1.368 .741 .214 – 8.749

Egg 11.046 .001 2.522 – 48.377

Tomato .706 .566 .215 – 2.317

Banana 1.727 .434 .440 – 6.773

Zesto (snack) .523 .496 .081 – 3.384

Zesto (lunch) 1.349 .641 .384 – 4.747

Implement control measures
May occur at any time
during the outbreak!!

Control the source of the pathogen

Interrupt transmission

Modify host response

Prevent recurrence
 Control the Source of
Pathogen

• Remove source of contamination

• Remove persons from exposure
• Inactivate / neutralize the pathogen
• Isolate and/or treat infected persons
Interrupt Transmission

• Interrupt environmental sources

• Control vector transmission
• Improve personal hygiene
Modify Host Response

• Immunize susceptibles
• Use prophylactic chemotherapy
 Source / Transmission
known unknown
known

Investigation +

Control +++
Etiology
unknow n

Source: Goodman 1990

 Source / Transmission
known unknown
known

Investigation + Investigation +++

Control +++ Control +

Etiology
unknow n

Source: Goodman 1990

 Source / Transmission
known unknown
known

Investigation + Investigation +++

Control +++ Control +

Etiology
unknow n

Investigation +++

Control +++

Source: Goodman 1990

 Source / Transmission
known unknown
known

Investigation + Investigation +++

Control +++ Control +

Etiology
unknow n

Investigation +++ Investigation +++

Control +++ Control +

Source: Goodman 1990

 At the End

• Prepare written report

• Communicate public health messages
• Influence public health policy
• Evaluate performance
Cessation of an outbreak occurs when
there is:
- elimination of source of
contamination
- interruption of transmission
- reduction/exhaustion of susceptibles
- modification of the effect of primary
pathogen
 An investigator should have
knowledge on the following:
• various types of etiologic agents and
the resultant disease
• epidemiological characteristics of
outbreaks associated with different
etiologic agents of resultant diseases
• clinical symptoms of resultant diseases
• environmental and food sanitation
practices
 An investigator should have
knowledge on the following:
• sources of exposure which are
vulnerable to contamination with an
infectious or chemical agent
• laboratory test available to determine
causative agents
• read/search for additional data on
studies, prevention and control
• Acknowledgement:
– Dr. Jose Ramoncito P. Navarro
Epidemiologist, CPH, UP-Manila