BE-100 - LEC

M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC

OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

I. INTRODUCTION III. DYNAMICS OF DISEASE TRANSMISSION

→ Human Disease does not arise in a vacuum. It

results from an interaction of the host, the
agent, and the environment
→ Many of the underlying principles governing the
transmission of disease are most clearly
demonstrated using communicable diseases
as its model.

II. PANDEMIC AND PUBLIC POLICY

PANDEMIC
→ occurring over a wide geographic area and
affecting an exceptionally high proportion of the
population.

HOW OUTBREAKS AFFECT PUBLIC POLICY → Iceberg concept of disease highlights the
importance of studying diseases, not just
focusing on the clinical aspects but also the
subclinical factors affecting them
.
IV. DEFINITION OF TERMS

I. COMMON VEHICLE EXPOSURE

→ Source common to all

II. SINGLE EXPOSURE

→ Exposed once

III. MULTIPLE EXPOSURE

→ Exposed several times

IV. PERIODIC CONTAMINATION

→ Intermittent contamination

V. CONTINUOUS CONTAMINATION
→ Persistent contamination

VI. CLINICAL DISEASES

→ Disease characterized by signs and
symptoms

VII. NON-CLINICAL DISEASE TYPES:

CASE 1: THE DECEMBER SMOG OF 1952 1. Pre-clinical
→ Symptoms not yet apparent but the
→ The smog descended on Europe during disease is biologically present and
December 1952. The graph above indicated destined to progress to clinical diseas.
the increase of mortalities when sulfur levels
increased during that time. 2. Subclinical
→ The smog pushed for environmental → Symptoms not yet apparent and is not
regulation, creating the Clean Air act of 1956 necessarily destined to become a
and 1968. clinical disease but seropositive.
→ Can be diagnosed by serologic or
antibody response or culture of an
organism.

3. Persistent (Chronic)
→ Manifestation of symptoms for
years
Ex: Post-polio syndrome

4. Latent Disease
→ No active multiplication of the
agent

Transer: Vigilla, R.E. 1

Editor: Recaforte, M.
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M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

VIII. CARRIER STATUS WHO WAS ATTACKED BY THE DISEASE?

→ Harbors organisms but does not → Gonorrhea is more prevalent in men than
get infected by it. women because women are more likely to
become asymptomatic than men.

IX. INCUBATION PERIOD CASE III: PERTUSSIS

→ Interval from receipt of infection to the
time of onset of clinical illness

→ Factors that affect incubation periods

1. Time of replication
2. Site of replication
3. Dose of infectious agent

X. QUARANTINE
→ Detention period of animals or humans

THE STORY BEHIND THE WORD “Quarantine”

→ The practice of quarantine, as we know it,
began during the 14th century in an effort to
protect coastal cities from plague epidemics. → There is an increase in cases of people
Ships arriving in Venice from infected ports infected with pertussis in the United States in
were required to sit at anchor for 40 days 2004.
before THE
V. EXPLORING landing.
OCCURENCESThis OFpractice,
DISEASEcalled → The increase of cases was due to
quarantine, was derived from the Italian advancements in diagnostic tools and
words Quaranta Giorni which mean 40 days. increased disease reporting.
Critical Variables in Disease Investigation:
1. When did the exposure take place?
2. When did the disease begin?
3. What was the incubation period for the disease?

PRIMARY CASE
→ A person who acquires the disease from
exposure

SECONDARY CASE
→ A person who acquires the disease through
exposure to primary case

Critical Variables in Disease Investigation that

Occurs more than an endemic level:
WHO WAS ATTACKED BY THE DISEASE?
1. Who was attacked by the disease? → Children were more likely to be infected
→ Can be affected by: Age, Sex, Race, host with pertussis than adults.
characteristics
CASE IV: ASEPTIC MENINGITIS
2. When did the disease occur?
→ Certain diseases occur with a certain
periodicity

3. Where did the cases arise?

→ diseases are not randomly distributed in a
time or place.

CASE II: GONORRHEA

WHEN DOES THE DISEASE NORMALLY

OCCUR?
→ There is an increase in cases of aseptic
meningitis every summer season.

Transer: Vigilla, R.E. 2

Editor: Recaforte, M.

M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
CASE V: LIME DISEASE & WEST NILE VIRUS
WHERE DID THE DISEASE OCCUR?
→ The Northeastern states of the United
States is most affected by Lime disease.
WHERE DID THE DISEASE OCCUR?
→ The West Nile virus was once absent in the
Western hemisphere, particularly in the
United States, but bird migrations and
mosquitoes brought the virus to the New
World.
→ Most Americans infected with West Nile
virus experienced subclinical disease, but
1 in 150 infections has resulted in
meningitis and encephalitis.
VI. CROSS TABULATION
→ A helpful method for determining which of the
following agents is likely to cause a certain
outbreak
Transer: Vigilla, R.E.
Editor: Recaforte, M.
BE-100 - LEC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022
CASE VI. CROSS TABULATION
→ An outbreak of beta-hemolytic streptococcal
pharyngitis affected 325 of the 690 inmates.
→ The investigation concluded that beverage and
egg salad served during lunchtime caused the
outbreak.
→ There is an increase in the attack rate for those
who ate egg salad compared to those who did
not.
→ However, the beverage as the causative factor
was ruled out since the inmates who drank the
beverage and those who did not yield a similar
increase of the attack rate.
VI. SURVEILLANCE OF DISEASE
1. Establishment of baseline data
2. Evaluation of time trends
3. Identification and Documentation of outbreaks
4. Evaluation of Public health and disease
intervention
5. Setting of disease control priorities
6. Study of changing patterns of disease
SPECIFIC OBJECTIVES OF EPIDEMIOLOGY
→ Identify the etiology or cause of the disease
and the relevant risk factors.
→ Determine the extent of disease found in the
community.
→ Study the natural history and prognosis of
the disease.
→ Evaluate both existing and newly developed
preventive, therapeutic measures, and
modes of health care delivery.
→ Provide the foundation for developing
public policy.
3

II. RESPONSIBILITY FOR SURVEILLANCE
A. EPIDEMIC
→ An occurrence of the disease at an unusual,
unexpected, or elevated frequency.
B. SURVEILLANCE
→ Entire process of collecting, analyzing,
interpreting, and reporting data on the
incidence of death, diseases, and injuries and
the prevalence of certain conditions for
promoting and safeguarding public health.
➢ Centers for Disease Control and
Prevention (CDC)
▪ US Federal agency responsible
for surveillance.
▪ One of 2 agencies tasked by the
United Nations to safely store the
last stocks of the variola virus
(smallpox)
➢ Department of Health (DOH)
▪ Philippine government agency
primarily responsible for
epidemiologic surveillance
III. CREATING A SURVEILLANCE SYSTEM.
Development of surveillance system requires:
→ Clear objectives
→ Standardized reporting procedures
→ Case definition based on clinical findings
→ Determination of intensity of surveillance
➢ active vs. passive
→ Determination of the duration
surveillance
➢ ongoing vs. time-limited
→ Types of analysis
➢ incidence, prevalence, case fatality ratio.
→ Plans for information dissemination
➢ internet, publication, broadcast
→ Pilot test performed and evaluated first
before full system attempt
➢ Must be tested at least twice
→ Continuous evaluation when full system is
operational
Transer: Vigilla, R.E.
Editor: Recaforte, M.
BE-100 - LEC
M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022
I. METHODS AND FUNCTIONS OF DISEASE
SURVEILLANCE
DISEASE SURVEILLANCE STEPS
1. ESTABLISHMENT OF BASELINE DATA
→ Through regular reporting and
surveillance
❖ CONTINUED SURVEILLANCE
→ Detect deviations from the usual
pattern of data
→ Prompts epidemiologists to explore
2. EVALUATE OF TIME TRENDS
❖ SECULAR (LONG-TERM) TRENDS
→ Change in reporting
➢ Underestimate incidence
→ Change in surveillance
➢ Overestimate prevalence
❖ NOTE:
→ Long-term increase is greater public
health significance than a localized
outbreak = suggestive of a
widespread problem.
CASE VI. EVALUATION OF TIME TRENDS
of
→ Decline of reported mortality and incidence rate
for diphtheria in the U.S. from 1920 – 1975.
→ Illustrates the advantage of using a logarithmic
scale.
→ The general use of toxoids decreased the
mortality and incidence rate
→ The logarithmic scale indicates that the decline
in rates is proportional, so that percentage of
cases resulted in death, the case fatality ratio
remained relatively constant.
→ The consistency of the fatality rate indicates
that prevention of disease rather than
treatment was responsible for the overall
reduction of diphtheria in the U.S.
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M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

❖ SEASONAL VARIATION → Used to confirm the emergence of an epidemic

→ Period of highest incidence so as to set-up appropriate control measures.
depends on the route of spread.
→ Exhibited by many infectious ❖ SYNDROMIC SURVEILLANCE
diseases → Technique to rapidly detect epidemics and
→ Should be incorporated into possible bioterrorism
calculations by epidemiologists,
CASE VII. EVALUATION OF TIME TRENDS II GOAL:
→ Characterize syndromes consistent with
DISEASE TYPE EXAMPLES SEASONALITY REASON bioterrorism agents
→ To prime the system to report any such
RESPIRA- → INFLUENZA → Winter People spend syndromes quickly
TORY → COLD and more time close → Provides early warning of a bioterrorism
→ MEASLES Early together problem.
→ CHICKENPOX spring indoors
(Varicella) ❖ 6 Diseases Considered Threats for Bioterrorism
→ Anthrax
VECTORS → VIRAL → Summer People wear → Smallpox
ENCHAPALITI and less protective → Botulism
S (Mosquitos) Early clothing in the
Autumn summer → Plague
→ LYME months → Tularemia (inhalational)
DISEASE → Late → Viral hemorrhagic fevers
(Ixodes Spring
tick) and Trivia: The last Pandemic War Game was conducted in
Early 2001 to simulate a bio-terror attack in the continental
Summer United States. The simulation resulted in the United
FECAL-ORAL → ASEPTIC → SOrganisms States Healthcare system crashing down in just 13 days
MENINGI umultiply more
TIS mrapidly in food 4. EVALUATION OF PUBLIC HEALTH AND DISEASE
mand water INTERVENTIONS
eduring warm
r months Purpose:
→ To track the progress of major interventions
❖ EPIDEMIOLOGIC YEAR
→ Determine if intended changes were achieved
→ From month of lowest incidence in 1 year to the same
→ To gauge the impact of new vaccines, health
month in the next year
policies, etc.
3. IDENTIFICATION AND DOCUMENTATION OF
❖ Failure of a Vaccine to Produce satisfactory
OUTBREAKS
immunity can be detected by indicators such
→ It is possible to determine that the level of disease is as:
unusual only if the rates of disease are known and
→ A lack of change in disease rates
reliable surveillance show that current rates are
→ Increase in disease rates after an initial
considerably elevated.
release
CASE VIII. EPIDEMIC THRESHOLD → Increase in disease rates in a recently
vaccinated group

❖ Importance of post-marketing surveillance

→ Investigators are able to detect any failure in
the system,

Ex: Measles Immunization (2006

recommendations)
→ First dose: 12-15 months old
→ Second dose: 4-6 years old
→ Third dose: about the age of 18

→ The CDC used the seasonal adjusted expected

percentage of pneumonia and influenza deaths in
the U.S. and compared it to the actual reported
data.

❖ EPIDEMIC THRESHOLD
→ Critical number or density of susceptible host
required for an epidemic to occur

Transer: Vigilla, R.E. 5

Editor: Recaforte, M.
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M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

5. SETTING OF DISEASE CONTROL PRIORITIES EPIDEMIC OUTBREAK INVESTIGATION

→ Current and past data on the patterns of disease I. INTRODUCTION
can help governmental and voluntary agencies
establish priorities for disease control efforts ❖ Epidemic
➢ Can sometimes refer to just one case of
→ Severity of disease can be established by good disease
surveillance (e.g., AIDS received high priority due ➢ Unusual occurrence of a disease
to its severity and its epidemic spread potential) ➢ “Upon the population”

❖ Endemic
6. STUDY OF CHANGING PATTERNS OF DISEASE ➢ Disease that occurs regularly at a more
→ help us understand the changing patterns of the or less constant level
disease ➢ “Within the population”
CASE IX. SYPHILIS SURVEILLANCE
❖ Epizootic
➢ A disease outbreak in animal population
➢ “upon the animals”

❖ Enzootic
➢ Disease deeply entrenched in an animal
population but not changing much
➢ “Within the population”

II. NATURE OF EPIDEMICS

❖ Attack rate
➢ Proportion of exposed persons that
become ill

FORMULA:

𝑵𝒖𝒎𝒃𝒆𝒓 𝒐𝒇 𝑵𝒆𝒘 𝑪𝒂𝒔𝒆𝒔 𝒐𝒇 𝒂 𝑫𝒊𝒔𝒆𝒂𝒔𝒆

∗ 𝟏𝟎𝟎
→ The New York syphilis surveillance indicated an 𝑵𝒖𝒎𝒃𝒆𝒓 𝒐𝒇 𝒑𝒆𝒓𝒔𝒐𝒏𝒔 𝑬𝒙𝒑𝒐𝒔𝒆𝒅 𝒊𝒏 𝑶𝒖𝒕𝒃𝒓𝒆𝒂𝒌
increase in congenital syphilis.
→ It showed that prostitution, cocaine addiction, and CASE I. BETA-HEMOLYTIC STREPTOCOCCAL
lack of prenatal care increased the syphilis cases PHARYNGITIS
in New York during the 80s.

Transer: Vigilla, R.E. 6

Editor: Recaforte, M.
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M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

III. DETERMINE IF AN EPIDEMIC IS OCCURING

→ A sufficient number of cases is needed to
constitute an epidemic
→ A completely new syndrome or disease may or
may not meet the criteria to be considered an
epidemic.

❖ Attack Rate in Students who ate tuna but not the

egg salad:
➢ 70/200 * 100% = 35%
IV. CHARATERIZE EPIDEMIC
→ By time, place, or person
❖ Attack Rate in Students who ate egg salad only:
➢ 75/100 * 100% = 75% IV.A. TIME

❖ Attack Rate in Students who both egg salad and ❖ EPIDEMIC TIME CURVE
tuna → Describes the time dimension of an outbreak
➢ 60/75 * 100% = 80% → Answers the following questions:
➢ What was the type of exposure?
❖ CONCLUSION: • Primary or secondary
➢ The results of the attack rate concluded that exposure
the egg salad caused the sore throat outbreak ➢ What was the probable route of
among students. spread?
• Respiratosry, fecal-oral,
III. STEPS FOR INVESTIGATING AN EPIDEMIC skin-to-skin, exchange
I. ESTABLISH HYPOTHESIS of blood or body fluids,
II. ESTABLISH CASE DEFINITION or via insect or animal
III. DETERMINE IF EPIDEMIC IS OCCURING vectors
IV. CHARACTERIZE EPIDEMIC ➢ When were the affected persons
➢ Time, place, person exposed?
V. DEVELOP HYPOTHESIS ➢ What was the incubation period?
➢ Source, patterns of spread, mode
of transmission ❖ TYPE OF EXPOSURE
VI. TEST HYPOTHESIS → Primary Case
VII. INITIATE CONTROL PROCEDURES ➢ Persons infected initially by a
VIII. INITIATE FOLLOW-UP SURVEILLANCE common source (many people, same
➢ Evaluate control measures source, short period of time)

I. ESTABLISH DIAGNOSIS → Secondary Case

→ Solve many cases, unusual or not ➢ Person-to-person transmission of
→ Stop false reports of an outbreak disease from primary cases to other
persons, often members of the same
II. ESTABLISH CASE DEFINITION household
→ List of specific criteria used to decide whether
or not a person has the disease of concern → Prolong Outbreak
→ Different from clinical diagnosis. It is establishing ➢ Prolonged, irregular pattern, usually
consistent criteria that enable epidemiologic if the epidemic is spread by person-
CASE III. EPIDEMIC TIME CURVES
to-person
investigation to proceed before definitive
diagnosis is available
→ 12-hour period
→ Ideal for novel diseases such as COVID-19
Epidemic time
curve from an
❖ Prone to False positives and false negatives,
outbreak of
hence the need for careful case definition:
gastrointestinal
→ adheres to collection and analysis of data
disease caused
→ permits comparisons among findings by a spaghetti
from different outbreak investigations contaminated by
CASE II. EOSINOPHILIA-MYALGIA SYNDROME Shigella boydii
❖ Disease characteristics. → There is a rapid
→ Total eosinophil count >1,000 cells/uL increase during
→ Generalized myalgia (muscle pain) the 5th day but the
→ Exclusion of other neoplastic or infectious case is self-
conditions before diagnosis of eosinophilia myalgia limiting due to
is diagnosed sudden decrease
in the number of
cases.
Transer: Vigilla, R.E. 7
Editor: Recaforte, M.

M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
→ A 5-day period epidemic time curve from a propagated
outbreak of bacillary dysentery caused by Shigella
sonnei, which was transmitted from person to person
at a training school for mentally retarded individuals
→ The first index case was recorded on May 31. No
cases were recorded for more than 20 days until a new
index case was recorded again on June 25.
→ . A widespread exposure apparently occurred at a
school assembly, so the air in the school auditorium
can almost be regarded as a common source. The
first person infected in this situation is called the
index case—the case that introduced the
organism into the population
→ An epidemic time curve for an outbreak of measles
in an elementary school
→ The data above indicated that during the school
assembly, the number of cases spiked indicating
widespread exposure to the viral pathogen since the
auditorium has a close ventilation system.
→ The number of cases decreased when the school
ramped up the vaccination drive.
Transer: Vigilla, R.E.
Editor: Recaforte, M.
BE-100 - LEC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022
→ epidemic time curve for an outbreak of
shigellosis among students who attended a
summer camp in the eastern United States.
→ The campers who drank contaminated
water on the trip were infected with Shigella
organisms. After they returned home, they
infected others
CONTINUATION
→ The epidemic time curve is useful in type of
cases presented to determine the type of
exposure and the time when the affected
persons were exposed
→ If the causative agent is known and the
exposure is from a common source,
epidemiologists can use their expertise to
determine the incubation period and the
probable time of exposure.
❖ Epidemiologists have 2 types of methods to
determine the probable time of exposure
→ METHOD 1:
➢ Taking the shortest and longest known
incubation period for a causative
organism and calculating backward in
time from the first and last case
➢ Shigella incubation: Shortest is 12
hours, longest is 96 hours
→ METHOD 2
➢ Taking the average incubation period
and measuring backward from the
epidemic peak, if that is clear.
➢ Shigella common incubation period
is 24-72 hours
IV.B. PLACE
❖ SPOT MAP
→ Shows where each person lives, works, or
attends schools
→ Geographic clustering of cases may provide
important clue
→ Limited in an outbreak investigation because it
only shows the number of cases and does not
provide information on the number of persons in
the area. It lacks the data to determine the
incidence.
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M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

❖ Epidemiologists have 2 types of methods to ❖ PROSPECTIVE HYPOTHESIS

determine the incidence in a particular area.
→ Use of an appropriate statistical test to
decide whether the number of cases
→ METHOD 1 continues to be excessive
➢ Isolation Rate Graphs of reported
Salmonella enteritidis infections by IV.C. PERSON
region in the United States.
Important Characteristics
→ Age
→ Race
→ Religion
→ Gender
→ Ethnicity
→ Immunization status
→ Type of work or schooling
→ Source of water, milk, food
→ Contacts with other people affected

EXAMPLES:

→ Age distribution of
measles cases
among children in
the Navajo nation
→ METHOD 2
➢ Uses a map to show the spread of → The children ages
epidemic cholera in South and Central 1 year old and
America from January 1991 thru July below were most
1992. affected by
Measles

→ Vaccination
decreases the
number of cases

CHANCE VS REAL CLUSTER

❖ THEORY OF RANDOM SAMPLING

→ Epidemiologists expect clusters of disease to
happen by chance alone
❖ REAL CLUSTERS
→ Cases have connection with one another
❖ CHANCE CLUSTERS
→ Cases do not have a connection
→ May have multiple sources/causes
→ Age distribution of measles cases among
residents o Cuyahoga County, Ohio
→ The data suggests that there is a problem in the
vaccination programs in this community since
the number of cases increases as the age also
increases.

❖ NULL HYPOTHESIS
→ Usual number of cases will not continue (no
significant difference

Transer: Vigilla, R.E. 9

Editor: Recaforte, M.
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M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

V. DEVELOP HYPOTHESIS REGARDING SOURCE,

PATTERNS OF SPREAD, AND MODE OF TRANSMISSION ❖ PROPAGATED (OR POGRESSIVE SOURCE)
EXPOSURE
❖ SOURCE OF INFECTION → Usually has a series of successively
→ The person (index case) or vehicle that larger peaks, which are one
initially brought the infection into the incubation period apart
affected community. → From initial wave to second wave of
infection
❖ PATTERN OF SPREAD → The COVID-19 cases in the
→ Pattern by which infection can be carried Philippines often yields a similar type of
from the source to the individuals infected propagated exposure
→ Types:
➢ COMMON SOURCE PATTERN
• One single source of
infection

➢ PROPAGATED PATTERN
• Infection propagates itself
by spreading directly from
person to person over an
extended period

➢ MIXED PATTERN
• Persons acquire the
disease through a
common source and
spread it to others via VI. TEST HYPOTHESIS
personal contact
❖ LABORATORY STUDIES
COMMON SOURCE OUTBREAKSS → Important in testing epidemiologic
studies
❖ POINT-SOURCE EXPOSURE → May include:
→ Involve a common source and tend to ➢ Patient culture
have epidemic curves with a rapid ➢ Stool examinations
increase in cases followed by a ➢ Serum tests for antibodies
somewhat slower decline ➢ Tests for
nonmicrobiological tests

❖ CASE-CONTROL STUDIES
→ Common efficient way of testing
hypothesis

❖ CONTINUOUS COMMON SOURCE

EXPOSURE
→ May also rise to a peak and then fall,
but the cases do not all occur within the
span of a single incubation period

Transer: Vigilla, R.E. 10

Editor: Recaforte, M.
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M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

IV. CASE CONTROL STUDIES

VIII. INITIATE SPECIFIC FOLLOW-UP
AA SURVEILLANCE TO EVALUATE CONTROL
MEASURES

→ Surveillance after an outbreak should be active

since it is more reliable than passive
surveillance.

→ In 1977, epidemiologists noted that 8 women

had adenocarcinoma of the vagina were treated
in one hospital between 1966 – 1969. Since it is
rare for this disease to occur in women, they
consider it an outbreak
→ When they conducted a case-control study, they
used 32 controls for every case. They were able
to show significant findings that 7 of the 8 cancer
patients were exposed with diethylstilbestrol
(DES).
→ . Their mothers had been given DES, a synthetic
estrogen, during the first semester of pregnancy
in an effort to prevent miscarriage or premature
labor. In contrast, none of the 32 controls was
the offspring of mothers given DES during
pregnancy. The probability of finding this
distribution by chance alone was infinitesimal.
DES is no longer used for any purpose during
pregnancy.

VII. INITIATE CONTROL MEASURES

4 Common interventions to control an outbreak

`1. SANITATION
→ Modification of the environment

2. PROPHYLAXIS
→ Putting a barrier to the infection, such as
vaccines, within the susceptible host

3. DIAGNOSIS AND TREATMENT

→ Performed to affected persons to avoid
spreading of disease to others.

4. CONTROL OF DISEASE VECTORS

EXAMPLE OF INTERVENTION: HAND HYGEINE BY

DR. IGNAZ SEMMELWEIS

→ Dr. Semmelweis introduction of proper hand

hygiene significantly reduced the maternal
mortality rate due to child fever.

Transer: Vigilla, R.E. 11

Editor: Recaforte, M.
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M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

V. OUTBREAK INVESTIGATION I → Within 2 days of being summoned,

SCENARIO:
→ Eighty-two cases of acute gastrointestinal
illness was reported from a liberal arts college
in New England in January 1991.
→ College sought help from local and state health
authorities.
→ Initial investigation focused on making a
diagnosis.
investigating team made the following
recommendations:
➢ The college, including the cafeteria,
should remain open
➢ College-wide assemblies and indoor
sports events should be canceled for 2
weeks
➢ No person should be allowed to work
as a food handler while ill

CLINICAL DATA SUGGESTS THAT: Q: HOW WAS THE EPIDEMIOLOGIC INVESTIGATING

→ illness was of short duration and mild TEAM WERE ABLE TO MAKE THIS
→ Most students were well in 24 hours RECOMMENDATIONS SO QUICKLY?
→ Symptoms consisted of nausea and vomiting
→ Minimal or no diarrhea and only a low-grade ❖ Evidence suggests that the outbreak is not
fever caused by a bacterial infection
→ Initial food and stool cultures for bacteria → Infection was self-liming and mild
yielded negative results → Lack of reported diarrhea
→ No bacterial pathogens isolated in
food cultures and stool samples

❖ Clinical and epidemiological pattern:

→ Consistent with norovirus (usually
fecal-oral route of spread but many
outbreaks reveal a respiratory or
propagated route as well)

❖ Similar illness was reported in the

surrounding community

→ Investigating team developed a case definition

(any person in college who complained of GIT
symptoms between Monday, January 28 –
Thursday, January 31)
→ People who met the criteria
➢ resident students
➢ commuter students
➢ and employees

REVIEW:
→ Resident students had only eaten at the
campus cafeteria
→ Most commuter students with symptoms had
brought food home and almost none of them
had eaten at the cafeteria
→ Family members of commuter students also
reported a similar illness
→ Two food handlers had worked while feeling ill
with GIT symptoms
→ One public school closed briefly due to a
similar illness

OTHER FACTORS
→ Health department records revealed
school cafeteria had always received high
scores for sanitation
→ Emergency reinspection of facilities and
equipment during the outbreak showed no
problems

Transer: Vigilla, R.E. 12

Editor: Recaforte, M.
 BE-100 - LEC
M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

VI. OUTBREAK INVESTIGATION II RECOMMENDATIONS:

SCENARIO:
→ In October 2010, more than 300 residents
reported gastrointestinal illness in a small
village at India.
→ Local people contacted an NGO and health
authorities that immediately set up a medical
camp to provide treatment and sent severe
cases to nearby hospitals.
→ Initial investigation was focused on making a
diagnosis
CLINICAL DATA SUGGESTS THAT:
→ Symptoms consist of dehydration, diarrhea,
vomiting with high grade fever
→ Onset of symptoms was rapid and severe
→ Food/water and stool culture samples yielded
positive for Salmonella spp.
→ Clean the water well as often as possible
→ Filter the water through several layers of
clean, fine cotton cloth before drinking
→ Call for the local health authorities to
immediately set up teams to visit the village and
educate people about proper method of well
cleaning as well as make arrangements for
supplying safe drinking water
VII. PREPAREDNESS AND RESPONSE TO A GLOBAL
HEALTH THREAT
→ Epidemiologists have improved their ability to
detect and respond to new pandemic threats
→ Increased communication thru internet, media,
and organized public health systems to
advances in laboratory testing

REVIEW:
→ Residents only drank water from a common
water well.
→ Residents also informed the team that they
attempt to clean the water 2 days before the
onset of symptoms

FINDINGS
→ Water samples tested positive for total
→ Ironically, during 2020, the COVID-19 Pandemic
coliforms and other fecal indicators.
strained the relations between the WHO and the
CDC due to political reasons.
→ Total viable bacterial count ranged from
106 -109 CFU/ml of water which exceeded
→ Poor cooperation between nation-states
the standard limits of untreated potable
allowed SARS-COV-2 to spread in many
water. Total viable count was
places, eventually resulted to the COVID-19
predominantly constituted with coliform
Pandemic.
bacteria; however, a number of other
Gram positive and Gram-negative
organisms were also present in addition
❖ NOTABLE PROGRESS IN PANDEMIC
with normal environmental flora
PREPAREDNESS AND RESPONSE
→ Rapid, effective global response to the
→ Microbiological analysis revealed:
2009 influenza A (H1N1) pandemic
➢ Presence of Salmonella enterica
which affected 200 countries and
serovar Typhi in all well water
territories
samples.

➢ Food items were loaded with → Ongoing disease surveillance

environmental bacteria but no characterizes severity, risk groups,
coliform was detected. burden of disease.

➢ Salmonella Typhi was isolated as → Diagnostic testing made available

sole pathogen from stool within 20 weeks of virus detection
samples
→ Through international donation
CONCLUSION program, vaccines can be developed
→ . Based on the clinical symptoms, laboratory and made available to many countries
findings and epidemiological evidences the
investigation links presence of Salmonella
enterica in contaminated well water and the
patients with the illness.

Transer: Vigilla, R.E. 13

Editor: Recaforte, M.
 BE-100 - LEC
M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

VIII. SUMMARY

Transer: Vigilla, R.E. 14

Editor: Recaforte, M.
 BE-100 - LEC
M8.3 EPIDEMIOLOGIC SURVEILLANCE AND EPIDEMIC
OUTBREAK INVESTIGATION
Prof. Arian Mae Tan | 03/08/2022

Transer: Vigilla, R.E. 15

Editor: Recaforte, M.