LECTURE 9

Dr. Gloria Enriquez- Fabrigas | 15 February 2019

• Compare the present occurrence with the usual

OUTLINE: occurrence as time, place, and person to verify
I. INVESTIGATION OF OUTBREAKS the existence of an epidemic
A. Definition of Terms
STEP 2 : APPRAISAL OF EXISTING INFORMATION
B. Approach to Investigation
C. 5 General Steps in the Investigation of an Epidemic
• The investigator must get detailed agent, host
D. Final Report
E. Goal in Investigation and environmental data on each case
F. Why Investigate? • Search for other cases
G. In the Field Investigation • Processing of collected data
H. Steps in an Outbreak Investigation
II. EXPANDED PROGRAM ON IMMUNIZATION STEP 3: FORMULATION OF HYPOTHESIS
A. Elements on EPI
B. Target Setting A hypothesis is a tentative theory explaining the
III. TUBERCULOSIS occurrence of event.
A. Issues in the Management & Control of TB
B. Strategic thrusts NOTE: In an epidemiological investigation, it is
IV. PNEUMONIA & OTHER ARI usually a theory on the source and spread of the
A. Thrusts disease.
V. VACCINE PREVENTABLE DISEASES
VI. WATER- BORNE DISEASE What type of epidemic is one dealing I terms of kind of
exposure or transmission?

INVESTIGATION OF OUTBREAKS • Common source outbreak: single exposure or

multiple exposure (transmission is by vehicle of
Definition of Terms:
infection)
a. Endemic: if he disease or infectious agent is • Propagated: person to person spread
within a given geographic area (transmission is by contact)
b. Hyperendemic: if the disease is constantly
present at a high level of incidence STEP 4: TEST THE HYPOTHESES
c. Holoendemic: if there is a high level of infection
NOTE: Even as investigation is conducted
beginning early in life and affecting most of the
further to test hypotheses, control measures
population
should already be planned and implemented.
d. Epidemic: is the occurrence in an area of cases
of illness, specific health behaviour or other Testing of hypotheses refers to a complete and detailed
health related events clearly in excess of investigation:
normal expectancy
• Search and review of cases
• Special investigation
APPROACH TO INVESTIGATION • Analyze data collected
a. Study in depth: study case in detail/thoroughly • Assemble results of related investigations in the
b. Study in breadth: study as many cases as he area involved
can, sacrificing the more refined details of • Test various hypotheses
investigation.
STEP 5: CONCLUSION AND PRACTICAL
5 GENERAL STEPS IN T HE INVESTIGATION APPLICATIONS
OF AN EPIDEMIC
• Evaluation of the results of the investigation and
STEP 1: VERIFY THE DIAGNOSIS OF THE the measures instituted
REPORTED CASES • Final report

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FINAL REPORT
In the final report, the following should be included:
• A description of the area involved, its
topography and accessibility; description of
habits, modes of living and customs of the
people that are pertinent to the study should
also be described briefly.
• Make a brief statement of the background of the
case.
• Presentation of findings.
• Conclusion and recommendations.
In presentation of findings:
Geographical orientation of the epidemic its orientation
as to time and person, the characteristics of the disease,
its infectiousness, its mode of spread, the probable
reservoir and sources and the laboratory findings.
The final report should be framed in such a way that it
answers specific questions of all the steps in the
investigation:
STEP 1: Is there actually an epidemic?
STEP 2: What are the characteristics?
STEP 3: What seems to have caused it?
STEP 4: What must be done to prove the actual cause?
STEP 5: How can it be stopped and others prevented?
GOAL IN INVESTIGATIO N
A. CONTINUING CASES: the goal is most probably to
prevent occurrence of additional case.
STEPS:
1. Assess the extent of the outbreak.
2. Assess the size and the characteristics of
population at risk
B. OUTBREAK ALMOST OVER: to prevent similar
outbreaks from occurring in the future.
• The balance between the control measures
versus further investigation depends on how
much is already known about the cause, the
source and the mode of transmission of agent.
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• If source and mode of transmission are already
both known: CONTROL OF EPIDEMIC TAKES
PRECEDENCE OVER FURTHER
INVESTIGATION
• If the causative agent is known but the source/
mode of transmission is unknown, then
INVESTIGATION BECOMES THE PRIORITY
over the institution of control measures.
• If the causative agent is unknown but the
source/ mode of transmission is known: BOTH
DOING AN INVESTIGATION AND
IMPLEMENTING CONTROL MEASURES ARE
EQUAL IMPORTANCE.
W HY INVESTIGATE?
1. Prevention and control of the disease.
2. To search for additional knowledge about the
disease i.e. study the natural history of disease;
characterize the populations at greatest risk or
identifying risk factors.
3. It provides opportunities for learning and
developing skills in logical thinking, decision
making; epidemiologic know-how.
4. Provide opportunities to do formative
evaluations of already established prevention
and control program.
IN THE FIELD INVESTIGATION
1. The various types of etiologic agents and the
resultant disease.
2. Epidemiologic characteristics of the outbreak
associated with different etiologic agents or
resultant disease.
3. Clinical symptoms of resultant disease.
4. Environmental and food sanitation practices.
5. Sources of exposure which are vulnerable to
contamination with an infectious or chemical
agent.
6. Laboratory test available to determine causative
agents.
STEPS IN AN OUTBREAK INVESTIGATION
1. Define the problem.
✓ Is there an epidemic?
✓ Verification of the case diagnosis?
✓ What disease is involved?
✓ What is the etiologic agent?
2. Characterize the cases in terms of WHO, WHEN
and WHERE.
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✓ Determine the demographic and other
important attributes of the cases.
✓ Data of disease onset of cases;
✓ Data on the geographic location
3. Develop hypothesis for the mechanism of the
outbreak (i.e. the source/ mode of transmission)
EXPANDED PROGRAM ON I MMUNIZATION
The Expanded Program on Immunization (EPI) was
established in 1976 to ensure the infants/ children and
mothers have access to routinely recommended
infant/childhood vaccines. Six vaccine- preventable
diseases were initially included in the EPI: tuberculosis,
poliomyelitis, diphtheria, tetanus, pertussis and measles.
In 1986, 23.3% “fully immunized” children less than
fourteen months of age based on the EPI
Comprehensive Program review.
ELEMENTS OF EPI:
a. Target setting
b. Cold chain logistic management
c. IEC
d. Assessment and evaluation of the program’s
overall performance
e. Surveillance, studies and research
TARGET SETTING
✓ Population estimation 2.7% growth rate
✓ Estimated proportion of 0-6 months 1.35%
✓ Estimated proportion of 6-11 months TP x
1.35%
✓ Estimated proportion of pregnant or MWRA
3.5%
✓ TOTAL ELIGIBLE POPULATION
0-6 months’ baseline population x 2.7% year
x 1.25%
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TUBERCULOSIS
• Causative Agent TB bacilli
• Mode of transmission: airborne droplet method
through coughing and sneezing.
• TARGET: 70/85 GLOBAL TARGET FOR TB
70% case detection rate (CDR)
85% cure rate (CR)
• Can be achieved mainly by rendering infectious
smear positive cases noninfectious soon after
diagnosis is made curing as many TB cases
identified.
• BURDEN OF DISEASE is disproportionately
high for the poor, elderly and male although
death is highest among older persons.
• ONLY 24% OF FILIPIONOS CORRECTLY
IDENTIFY THE CAUSE OF TB AS MICROBES,
GERMS OR BACTERIA…misconceptions on
the cause of TB are still common.
ISSUES IN THE MANAGAMENT & CONTROL
OF TB
• Misconception ----incorrect self- management of
the early symptoms of the disease and
consequent low case detection rate.
• Non- compliance with standard drug regimens
resulting in problems in treatment completion
and drug resistance.
• Gaps in the availability or adequacy of drugs
occur at health facilities.
• At the local level, LGUs cannot afford to
purchase anti-TB drugs
• At the national level, timely distribution of anti-
TB drugs at regional and provincial distribution
centers.
STRATEGIC THRUSTS
• Pursue multi-agency financing for the assurance
of adequate anti- TB drug supply.
• Implement quality assurance measures and
effective monitoring systems in the
implementation of DOTS.
• Organize the participation of both government
and private health providers in TB control.
• Intensify public information and education on the
correct etiology of Tb, diagnosis using sputum
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examination, treatment with combination drugs
and services at the DOTS center.
• Ensure BCG immunization of infants to
decrease their susceptibility from contracting Tb
(extra pulmonary) incorporation of Tb in children
through DOTS.
PNEUMONIA AND OTHER ARI
• Remains in the list of the leading cause off M
and M in the Philippines.
• 42.7 per 100,000 populations (PHS 2000)
mortality from pneumonia among the general
population.
PNEUMONIA AND OTHER ARI THRUSTS:
• Improve the quality and reliability of
implementation of the IMCI in all health care
units through training, supervision and
monitoring.
• Continue medical, nursing and midwifery
education on pneumonia diagnosis and
management.
• Promote timely and appropriate management for
pneumonia and ARI among general population
to avoid further complication of the disease.
• Ensure availability of affordable drugs for
pneumonia patients at the local level.
VACCINE PREVENTABLE DISEASES
1. TUBERCULOSIS
Causative agent: Mycobacterium tuberculosis
Vaccine: BCG given at birth (provides the
greatest possible protection from TB)
2. DIPTHERIA
Causative agent: Corynebacterium diptheriae
Vaccine: incorporated with DPT given at 3
consecutive monthly doses starting at 6 weeks.
3. PERTUSSIS
Causative agent: Bordetella pertussis
(covered in DPT immunization for infants)
eliminated as a major public health problem like
diphtheria.
4. TETANUS
Causative agent: Clostridium tetani
(covered in DPT immunization for infants)
focused on women of reproductive age to
increase the passive immunity of newborns who
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are prone to neonatal tetanus due to unsanitary
practices in umbilical cord cutting and dressing
upon birth.
5. POLIOMYELITIS
OCTOBER 2000, the Philippines was declared
polio- free. It is considered eradicated if zero wild
polio virus is reported for at least 3 consecutive
years with good quality surveillance for Acute
Flaccid Paralysis.
A good quality surveillance for Acute Flaccid Paralysis
means that:
1. There should be anon-polio AFP rate of one
case per 100, 000 populations below 15 years
old.
2. At least 80% adequate stool specimen stool
collection.
3. At least 80% of AFP cases reported are
investigated within 48H.
4. 80% of AFP cases are followed up after 60
days.
Thrusts: disease surveillance must be strengthened and
coverage of OPV vaccines among infants continued.
Efforts must be made to prevent entry of poliomyelitis
from countries that have not yet eradicated the disease.
6. MEASLES (RUBEOLA)
Caused by the measles virus a single stranded
RNA virus of genus Morbillivirus.
The routine immunization of atleast 95% of
infant is still the most important strategy to
control measles in the Philippines.
Less than one confirmed case per million
population per year excluding the imported
cases.
Supplemental immunization addressed the large
number of unvaccinated children and the buildup
of susceptible children over the years.
7. HEPATITIS B
Major cause of the development of liver
malignancy.
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Immunization upon birth ensure the greatest
protection of individuals from acquiring Hepatitis
B infection that may develop into chronic liver
disease.
Among the vaccines covered under the EPI,
hepatitis B has the lowest coverage mainly due
to higher cost of vaccines.
TARGET:
FIC COVERAGE: 95% in every barangay
MEASLES: 95% in every barangay
HEPA B: among children under 1year old: 70%
in all provinces BCG below 1 year old: 95%
COVERAGE OF PREGNANT WOMEN GIVEN
AT LEAST 2 DOSES OF TT: 80%
Morbidity rate of TB: 137.3 cases per 100, 000
population
THRUSTS:
• Intensify Reaching every Barangay to achieve
95% full immunization coverage for infants.
• Pursue supplementary TT immunization
activities especially among high-risk populations.
• Provide second opportunity for measles
immunization nationwide to ensure high measles
coverage and reduce disease incidence toward
elimination.
• Integrate surveillance system.
• Public- private participation
W ATER-BORNE AND VECTOR- BORNE
DISEASES
What is Cholera?
✓ Acute, diarrheal illness caused by bacterium
Vibrio cholerae
✓ Source of contamination is usually the feces of
an infected person
✓ Infection is often mild or without symptoms, but
sometimes it can be severe, characterized by
profuse water diarrhea, vomiting and leg
cramps.
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✓ Rapid loss of fluids leads to dehydration and
shock. Without treatmen, death can occur witin
hours.
✓ It can be treated with replacement of fluids and
slats lost through diarrhea.
✓ Anibiotics shorten the course and diminish the
severity of the illness.
What is Typhoid fever?
✓ Life threatening illness caused by bacterium
Salmonella typhi.
✓ Bacterium lives only in humans. Persons carry
bacteria in bloodstream and intestinal tract.
✓ Acquired from sewerage contaminated with S.
typhi bacteria that gets into the water you use for
drinking and washing food.
✓ The patient usually has the following signs and
symptoms:
1. Sustained fever as high as 103 to 104-
degree F (39 to 40-degree C)
2. The patient feels weak, has stomach
pains, headache, loss of appetite and in
rare cases, has rashes of flat, rose-
colored spots.
3. Detection for S. typhi is to have samples
of stools or blood to be tested.
✓ S. typhi is treated with commonly prescribed
antibiotics:
1. Ampicillin
2. Trimethrophim-sulfamethoxazole
3. Ciprofloxacin
✓ How to avoid having typhoid fever:
1. Avoid risky foods and drinks.
2. Get vaccinated against typhoid fever.
What is Leptospirosis?
✓ Bacterial disease that affects humans and
animals, caused by bacteria of the genus
Leptospira.
✓ Caused by exposure to contaminated urine of
infected animals like cattle, pigs, horses, dogs,
rodents and wild animals.
✓ The interval from a person’s exposure to a
contaminated source and becoming sick is
between 2 days to 4 weeks.
✓ Leptospirosis has 2 phases:
First phase:
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➢ Fever, chills, headaches, recommended in areas where the prevalence of

muscle aches, vomiting or hepatitis A is high.
diarrhea ✓ Ways to prevent hepatitis A incude:
➢ Patient recovers for a time but 1. Handwashing with soap and warm water
become ill again. before preparing or eating food, and
after sexual activity.
Second phase: 2. Keep bathrooms clean and disinfected
after every use.
➢ More severe, a person, may
3. Cook shellfish thoroughly before eating.
have kidney or live failure or
4. Drink water from approved sources only.
meningitis.
5. Use a dental dam or sheet of plastic
➢ Also called Weil’s disease
wrap during analingus.
✓ It can be treated with antibiotics like:
➢ Doxycycline
➢ Penicillin What is Malaria?
✓ It can be prevented by not swimming or wadding ✓ A vector- borne infectious disease that is
in water that might be contaminated with animal widespread in tropical and subtropical regions.
urine. Protective clothing or footwear should be ✓ One of the most common infectious diseases
worn by those exposed to contaminated water or and enormous public health problem.
soil due to their job and recreational activities. ✓ Disease is caused by protozoan parasites of
genus Plasmodium.
What is Hepatitis A? ✓ Most serious forms of the disease are caused by
Plasmodium falciparum and Plasmodium vivax.
✓ A disease affecting the liver and caused by
✓ Malarial parasites are transmitted by female
Hepatitis A virus (HAV).
Anopheles mosquitoes.
✓ Symptoms may include:
✓ Symptoms of malaria include fever, shivering,
1. Jaundice which first shows up as yellow
arthralgia (joint pain), vomiting, anemia caused
eyes
by rupture of red blood cells and convulsions.
2. Dark urine
✓ The classical symptoms of malaria is cyclical
3. Nausea
occurrence of sudden coldness followed by rigor
4. Fever
and then fever and sweating last four to six
5. Fatigue
hours.
6. Loss of appetite
✓ Severe malaria is almost exclusively caused by
7. Abdominal
P. falciparum infection and usually arises 6-14
8. Vomiting
days after infection
✓ Young children who develop hepatitis A often
✓ Chronic malaria is seen I both P. vivax and P.
have milder form of the disease lasting 1-3
ovale but not in P. falciparum.
weeks. Adults tend to experience more severe
✓ Active malaria infection with P. falciparum is a
cases. They are confined to bed and have
medical emergency requiring hospitalization.
minimal activity for 4 weeks due to the illness.
Infection with P. vivax, P. ovale, or p. malariae
✓ There is no specific treatment for hepatitis A.
can often be related as out-patient.
✓ Sufferers are advised to rest, avoid fatty
✓ Treatment of malaria involves supportive
foods,and alcohol (these may be poorly
measures as well as specific antimalarial drugs
tolerated for some additional months during the
like:
recovery phase and cause minor relapse(s) for
1. Quinine
nine months to a year after contracting the
2. Chloroquine
disease.
3. Cotrifazid
✓ Hepatitis A can be prevented by good hygiene
4. Pyrimaquine
and sanitation as well as using condoms during
5. Doxycycline
sex. Vaccination is also available and is

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6. Mefloquine 2. Use of insect repellants

7. Hydroxychloroquine 3. Cover exposed skin
✓ Methods used to prevent the spread of the 4. Use DEET –impregnated bed nets
disease, or to protect individuals in areas where 5. Avoiding areas with many mosquitos.
malaria is endemic, include:
1. Prophylactic (preventive) drugs against
malaria
2. Mosquito eradication
3. Prevention of mosquito bite.

What Is Dengue/ Dengue Hemorrhagic Fever?

✓ Dengue and dengue hemorrhagic fever are
acute febrile diseases, found in the tropics, with
a geographical spread similar to malaria.
✓ Caused by one of four closely related virus
serotypes of the genus Flavivirus, each serotype
is sufficiently different that there is no cross-
protection and epidemics caused by multiple
serotypes (hyper-endemicity) can occur.
✓ Dengue is transmitted to humans by mosquito
Aedes aegypti.
✓ The infectious disease is manifested by:
1. Sudden onset of fever.
2. Severe headache.
3. Muscle and joint pains (myalgias and
arthralgias, severe pain give it the name
break-bone fever or bone crusher
disease.
4. Rashes –dengue rash is
characteristically bright red petechiae
and usually appears first on the lower
limbs and the chest – some patients, it DENGUE TETRAVALENT VACCINE
covers most of the body. CPR approved Dec 22, 2015
5. Gastritis with combination of associated Given subcutaneously minimum age of 9 years old
abdominal pain, nausea, vomiting or
Given as a 3 dose series at 0, 6, 12 months.
diarrhea.
✓ The mainstay of treatment is supportive therapy.
✓ To keep up oral intake, especially fluids. If the
patients are unable to maintain oral intake,
supplementation with intravenous fluids may be
necessary to prevent dehydration and significant
hemo-concentration.
✓ A platelet transfusion is rarely indicated. But if
the platelet level drops significantly or if there is
significant bleeding, transfusion is
recommended.
✓ Steps in the primary prevention of dengue:
1. Use of mosquito nets,

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END OF TRANSCRIPTION

REFERENCES
• Doc Fabrigas’ ppt.
• Department of Health website

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