EPIDEMIC INVESTIGATION

DEFINITION OF AN EPIDEMIC (Last,

1995)
• The occurrence in a community or region of cases
of an illness, specific health related behavior, or
other health –related events clearly in excess of
normal expectancy.
• The community or region and the period in which
the cases occur are specified precisely
• Epidemicity is thus relative to usual frequency of
the disease in the same area, among the
specified population, at the same season of the
year.
 DEFINITION OF AN EPIDEMIC (Last,
1995)
• A single case of a communicable disease long
absent from a population or first invasion by a
disease not previously recognized in that area
requires immediate reporting and full field
investigation.
• Two cases of such a disease associated in time
and place may be sufficient evidence to be
considered an epidemic.
• An epidemic may then be considered an increase
in the number of cases over past experience for a
given population, time and place.
 ESSENTIAL INGREDIENTS OF AN
EPIDEMIC
First let’s define a pathogen.
The term pathogen will be used to
indicate both infectious and
non-infectious substances (agents) that
are capable, acting either alone or in
combination with other agents, of
producing tissue damage or initiating a
pathologic process that can lead to
disease.
 ESSENTIAL INGREDIENTS OF AN
EPIDEMIC
• The three common conditions for the
occurrence of an outbreak or epidemic:
1. The introduction of a new pathogen , or the
increased amount of or a change in the
virulence of a known pathogen, from an
infected human, animal, bird, or arthropod
vector, or from air, water, food, soil, drug or
othe environmental source.
 ESSENTIAL INGREDIENTS OF AN
EPIDEMIC
2. An adequate number of exposed and
susceptible persons. The proportion
susceptible needed for an epidemic to occur
will depend on the communicability of the
agent. Measles can still result in an outbreak
even when 90% or more of the population is
already immune whereas levels of 50% -60%
immune will prevent the spread of less
infectious organisms such as typhoid bacillus.
 ESSENTIAL INGREDIENTS OF AN
EPIDEMIC
3. An effective means of transmission between the
source of pathogen and the susceptible persons.
Recent reports illustrate these essential
ingredients of an epidemic:
1. Outbreaks of eosinophilia-myalgia syndrome
from the ingestion of tryptophan-containing
products provide an example of epidemics
resulting from a new agent. This was first
recognized in 1989 (Varga et al., 1992)
 ESSENTIAL INGREDIENTS OF AN
EPIDEMIC
2. The appearance of a new type of Hanta virus
pulmonary syndrome in the southwestern United
States represents an emerging virus infection,
newly introduced into this country (Centers for
Disease Control, 1993).
3. An example of a change in an old agent is the
emergence of antibiotic-resistant strains of
Mycobacterium tuberculosis in patients with AIDS
and in TB patients who interrupt their therapy;
these strains may then be spread to other
persons.
 ESSENTIAL INGREDIENTS OF AN
EPIDEMIC
4. Outbreaks attributable to an increased number
of susceptibles are illustrated by the spread of
influenza in nusing homes among elderly who
have lost their immunity or fail to respond to
vaccination ( Centers for Disease Control, 1992).
5. The enhanced spread of an infection because of a
changing environment is exemplified by the rapid
transmission of TB in crowded shelters for the
homeless (Centers for Disease Control, 1991).
 COMMON CIRCUMSTANCES FOR AN
EPIDEMIC
1. The introduction of susceptibles into an
endemic area where a pathogen new to them
exists, such as :
1.1 when people travel to the rainforests of
Africa or Brazil
1.2 when military forces were sent to the
Persian Gulf or Haiti or
1.3 when explorations into new ecological
settings take place
 COMMON CIRCUMSTANCES FOR AN
EPIDEMIC
2. A recent change in dosage or virulence of a known
organism, such as occurred in the massive water-borne
outbreak of Cryptosporidium in the public water supply
in Milwaukee (MacKenzie et al, 1994).
3. The introduction of a pathogen into a setting where it
has not been before, such as the introduction of the
Hanta virus into the southwestern United States
(Centers for Disease Control, 1993) and the
introduction of an Ebola-like virus into a monkey
colony in Reston, Virginia, with exposure of animal
handlers (Centers for Disease Control, 1990)
 COMMON CIRCUMSTANCES FOR AN
EPIDEMIC
4. An enhanced method of transmission so that
more susceptibles are exposed, such as when
E. Coli was transmitted in undercooked
hamburgers in 19 sttaes from a fast food chain
(Centers for Disease Control, 1993).
5. A change in the susceptibility of the host
response to infection or cancer , as exmplified
by the increased incidence of certain cancers
in patients with AIDS (Biggar, 1990)
 COMMON CIRCUMSTANCES FOR AN
EPIDEMIC
6. social, cultural, sexual or behavioral factors
that increase exposure or involve introduction
through new portals of entry, such a sthe
transmission of HIV-1 and hepatitis B and C by
intravenous drug abusers.
• There are factors related to the pathogen, the
modes of transmission, and the host are
summarized.
 Common Circumstances of an Epidemic as
Dependent on Three Different Groups of Factors

• Pathogen Factors
- Introduction of new pathogen
- Change in old pathogen
- Old pathogens with new means of entry into host
- Increased dosage
- Increased virulence
- Longer exposure to old pathogens
- Multiple pathogens
Common Circumstances of an Epidemic as Dependent
on Three Different Groups of Factors

• Transmission of factors in environment

- New Growth media, either man-made or in
nature (e.g. Coolong towers, home
humidifiers)
- New methods of dispersion (e.g.intravenous
flasks, air conditioners)
- Specialized facilities (e.g. Intensive Care Units,
Day Care Centers)
Common Circumstances of an Epidemic as Dependent
on Three Different Groups of Factors

Transmission of factors in environment

- Invasive procedures
- New sexual practices
- Intravenous drug abuse
- Migration of infected persons, animals,
birds, insects
- Exposure to new environment
 Common Circumstances of an Epidemic as
Dependent on Three Different Groups of Factors

• Host Factors
- Highly susceptible subgroups (e.g. Newborns,
nonimmunized)
- Travel of susceptibles to endemic area
- Increased susceptibility (e.g. from
immunosuppressive drugs, natural
immunodeficiency)
- Cultural or behavioral factors
 Common Circumstances of an Epidemic as
Dependent on Three Different Groups of Factors

• Some overlap in these categories exists

because it may not always be clear if the
method of transmission or the pathogen
has changed, if new portals of entry into
the human host are involved or if the
response of the host to the same
pathogen has been modified.
 Common Circumstances of an Epidemic as
Dependent on Three Different Groups of Factors

• Sometimes all three factors are important. For

example , the occurrence of various
opportunistic infections, Kaposi’s sarcoma,
and EBV- related lymphomas in AIDS patients
involved both old and new pathogens,
increased dosage and repeated exposure and
an altered host response as indicated by the
development of abnormalities in the immune
system.
 Common Circumstances of an Epidemic as
Dependent on Three Different Groups of Factors

• In addition, high-risk activities took

place in new environments, such as
the transmission of HIV-1 in urban
bathhouses used for sexual activity
by homosexual men and the
“shooting gallery” involving shared
hypodemic needles.
 Examples of Epidemic According to
Incubation Period
• Time Frame
1. Hours
1.1 Acute Food Poisoning: toxins, Staphylococci,
Clostridium perfringens
1.2 Heavy metal exposures: cadmium,copper,
zinc
1.3 Certain other poisonings: monosodium
glutamate, mushroom, shellfish toxins
 Examples of Epidemic According to
Incubation Period
2. Days
2.1 Some food poisonings: Salmonella (1 -2
days), Vibrio cholera, Campylobacter jejuni
2.2 Bacterial infections: Legionnaires’ Disease,
Mycoplasma pneumonia
2.3 Viral infections: Influenza ( 1 – 3 days),
Adenovirus ( 1 – 5 days), entedroviral
enfections ( 5 – 6 days).
 Examples of Epidemic According to
Incubation Period
3. Weeks
3.1 Common Childhood Diseases: measles, mumps, rubella (2
-3 weeks)
3.2 Hepatitis A ( 2 – 6 weeks)
4. Months
4.1 Hepatitis B ( 2 – 6 months)
4.2 Rabies (0.5 – 12 months)
5. Years
5.1 Radiation –induced leukemia after atomic bomb (peak
after 6 years)
5.2 Kuru ( 1 -27 years)
5.3 Bladder cancer in dystuff workers ( 1 – 40 years)
EPIDEMIC CURVE
 EPIDEMIC CURVE
• Definition – It is a graph of the distribution of
cases according to time of onset.
• It depends on the following:
1. Pathogen
2. Generation Time (time from entry to
maximum excretion of infectious particles)
3. Method of Transmission
4. Type and Duration of Exposure
 EPIDEMIC CURVE
4. Length and Variability of the Incubation Period
5. Number of susceptible individuals who are
exposed
A Single defined peak suggests an almost
simultaneous exposure of a group of persons to a
single source of the pathogen.
The shape of the epidemic curve depends on the
Incubation period as well as the variability of the
host response.
 EPIDEMIC CURVE
• Common Source Outbreaks- epidemic curves result from
exposure of a susceptible population or group to a common
source of a pathogen often at the same time or over a
continuous period of time or at intermittent points in time.
The epidemic curve is characterized by a relatively sharp
peak and short duration if exposure is at the same time.If
exposure is at different times, the epidemic curve may
spread out considerably.
• Propagative or Progressive – epidemic curves result from
epidemics involving the spread of a pathogen from one
susceptible individual to another. The epidemic curve is
characterized by more than one peak. Sometimes irregular
peaks frequently occur.
 EPIDEMIC CURVE
• Mixed Types of Curve –characterized by a
single peak followed by successive smaller
peaks, may be seen when a) a common-source
outbreak of an infectious agent occurs with
secondary person-to-person spread or b) the
main group of susceptibles is initially exposed
and is followed either by later exposures of
the same group to the common source or by
later recontamination of the source involving
the same exposed population.
 EPIDEMIC CURVE
• In addition to “copy-cat” (gaya-gaya puto
maya), “cultural” and “peer pressure” spread
are the occurrence of outbreaks of
phenomena having the marks of hysteria or
religious fervor. The “dancing manias” of the
Middle Ages fall into this category. An
occurrence of this type is described under the
term koro syndrome (Sachdev and Shukla,
1982) which took place in four Indian Villages
with a total population of 600 persons.
 EPIDEMIC CURVE
• (Continuation of the koro syndrome)
It involved 60 males and 60 females aged 20 -40
years who were from lower socioeconomic
groups. The symptoms usually began between
7 and 11 pm with tingling in the legs that
spread to the rest of the body, sensations of
intense heat, anxiety, and the feeling that the
genitalia were going inward. This was
accompanied by a fera of impending death.
 Cessation of an Outbreak
• This usually occurs when one or more of the
following four events takes place:
1. The source of contamination is eliminated or
modified or the pathogen is rendered
nonpathogenic, as when a water supply is
chlorinated.
2. The mode of transmission is interrupted or
eliminated
 Cessation of an Outbreak
3. The number of exposed and susceptible
persons is markedly reduced or exhausted.
This can occur by their removal from the
source of infection, by development of the
disease, by active or passive immunization to
the infectious agent, by chemoprophylaxis
against a sensitive infectious agent, or by
some other modification of the pattern of host
response.
 Cessation of an Outbreak
4. Some other pathogen that is in the causal
pathway or that modifies the effect of the
primary pathogen is modified or eliminated.
For example, reduction of malaria infection
in hyperendemic regions by antimalarial
drugs or by mosquito control might reduce
the occurrence of EBV-related African
Burkitt’s lymphoma.