4th years MBchB

OUT BREAK
INVESTIGATIONS
BM Hamooya
Students’ learning objectives
■ By the end of the lecture, the student will be able to:
– Define the following terms; epidemic, case, and cluster as it relate to
epidemiology
– Identify and describe elements used to ascertain the existence of an
outbreak
– List ways used to detect an outbreak
– Delineate the importance of investigating outbreaks
– Itemize and describe the basic components of an outbreak
investigation
– Relate the outbreak investigation by following the example from John
Snow’s groundbreaking study of London’s 1854 cholera outbreak
 Introduction
■ We often use the words “outbreak” and “epidemic” in our general
vocabulary
– For example:
– “a flu epidemic”,
– “outbreak of bloody diarrhea”,
– “an epidemic of failed marriages”,
– ”HIV epidemic” etc.

■ The moment we hear the word outbreak it indicates that something is

amiss
■ However, the question is “what is an outbreak from the epidemiological
point of view?”
■ An outbreak is an increase often sudden in the observed number of
cases of a disease or health problem compared with the expected
number for a given place or among a specific group of people over a
particular period of time.

■ Essentially the definition of epidemic is identical to that of outbreak

■ Epidemic is 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
■ In real sense, Outbreak and Epidemic can be used interchangeably

■ But public health specialists prefer to use Outbreak for localized

epidemics “the one limited to a village, town, or specific institution.

■ Investigators determine the occurrence of an epidemic (or outbreak) by

looking at the numbers whether they have increased for a given place or
season or geographic area.
■ If an outbreak or epidemic occurs over a very wide area thereby
affecting a large proportion of the population in several countries or
continents the it is known as a pandemic (pan=all and demos=people)

– Example: influenza pandemic of 1918 which killed an estimated 50

million people in North America, Europe, Asia, Africa, Brazil and
south pacific
– Asian flu pandemic of 1957-1958
– Hong Kong flu pandemic of 1968
– Influenza A (H1N1) pandemic of 2009

■ Question: Is HIV an epidemic or pandemic?

■ In epidemiology, the term “case” describes a particular disease, health
disorder, or condition under investigation
– It is also used to describe a person in a population/study group who
has the disease, disorder, or certain condition
– Cases may also be referred as patients in the case group or case
patients

■ Investigators classify cases or case patients based on the case

definition they develop as they explore a potential outbreak.
– For instance, in case of cholera outbreak; how will cholera be
defined? Combine clinical and laboratory diagnosis or just one of
them?
■ A case takes into account;
– Signs and symptoms of the disease or condition
– Important epidemiologic characteristics of the patient “such as the
what, who, where, and when” of a disease outbreak

■ Epidemiological definition of a case is not the same as the normal

clinical definition that physicians or other healthcare providers might
use, although it may be similar.

■ Outbreak investigation usually begins when investigators observes a

suspected cluster of cases of a disease.
■ A cluster is a geographical or temporal collection of cases that seem to
be greater than the expected number for a particular place or time.

When does a number of cases become an outbreak?

 To understand whether an outbreak underway is more than just counting
cases ~quite complicated.

 Potential outbreaks may arise from the same cause or unrelated cases of
the same disease.
■ In general, the key determinant that an outbreak is underway is whether
the number if cases is “unusually high” or falls within the expected
range of cases for that population at that time of the year

■ Before declaring an outbreak, investigators must take many factors into

account:
– The etiologic agent
– The size and composition of the population
– The previous occurrence of the disease in the community
– The season
■ Etiologic agent : is the pathogen that is causing the disease.

– Investigators need to know the agent’s identity, and further

determine whether it is rare or common

– If the disease is relatively common such bloody diarrhea or seasonal

influenza, then you may need to have a large number of cases or the
cases may need to be uniquely related before public health officials
considers it an outbreak.

– In case of rare diseases such as polio or Ebola health officials may

treat even a single case as an outbreak and institute immediate health
action.
■ Size and composition of the population: investigators need to know
how many and which groups of people are becoming ill.

– For example 1,000 of bloody diarrhea in a population of 4000 is

of public health concern than in a population of 1, 000,000

– In looking at size, changes in the population should be taken into

account.

– Population characteristics such as age distribution and

socioeconomic status can influence disease rates
■ Previous occurrence of a disease in the community: before
ascertaining that a certain number of cases constitute an outbreak,
investigators must know whether and how often the disease has been
diagnosed in the community in the past.

– For example in a certain community with a past history of an

average 12 cases of disease per month and 50 or 100 cases have
been recorded, this can be called an outbreak if all the laboratory
tests have done correctly.
■ The season: incidence of many infectious diseases rises and falls
seasonally, hence investigators must take the time of the year into
consideration when exploring a potential outbreak.

■ Note: Determining an outbreak requires a well-thought process.

– What might look like an outbreak sometimes it might not be the
case
– Sometimes public health officials might think that a number of
cases of severe respiratory illness signals influenza outbreak
meanwhile these cases might be arising from different causes e.g
severe cold, bronchitis or pneumonia.
 How are potential outbreaks detected?
 There are various ways to identify an outbreak and these include:

 Surveillance or health information system

 Clinical laboratories
 Affected citizens
 Health care providers

 Outbreaks are detected through the routine and timely analysis of health
information systems.
■ Health department staff may detect increase or unusual patterns of
disease from weekly tabulations of case reports by time and place

■ Hospital administrators may detect unusual increase in the number of

possible hospital-acquired infections through weekly analysis of
microbiologic isolates from patients by organism and ward or unit

■ Affected group is another source of information for apparent clusters of

both infectious and non-infectious disease

■ Many outbreaks come to the attention of public health officials because

of alert clinicians, infection control nurse, or laboratory workers
■ There is need for proper routine health systems in order to detect an
outbreak

■ The procedures should be able to determine the “what”, “who”,

“when”, “where”, and “why” (or “how”)
– What is the problem? Does the clinical description of the illness
exist including signs and symptoms, diagnosis, and duration? Was
a physician consulted? Were any tests performed or any treatment
given?
– Who is sick and what those individual characteristics (e.g name,
age, occupation)
– When did the affected person get sick?
– Where are the affected person located, including residential area
or work locations?

– Why (or how) do patients think they get ill?

■ What are the relevant risk factors, suspected exposures, and
suspected mode of transmission?
■ Are there clues on who did and did not become ill?
 Why investigate outbreak?

■ There are many reason as to why outbreaks should be investigated:

– To prevent others from getting infected

– To prevent future occurrence

– Identification of risk factors

– Identification of new pathogens that infect people

– To give appropriate treatment to those who are infected

– Provides a new research insight into a disease

– Provides opportunities for public health practitioners to

practice the process and methods of epidemiologic
investigation that are essential to protect the public health
 Applicability of “what”, “who”, “when”,
“where”, and “why”
■ On 6 October 2017, the Minister of Health declared an outbreak of
cholera in the Zambian capital, Lusaka. From 28 September through 7
December 2017, 547 cases including 15 deaths (case fatality rate =
1.8%), have been reported since the beginning of the outbreak. The initial
outbreak period was from 28 September through 20 October. From 21
October through 4 November 2017 there were less than five cases
reported each week. However, from 5 November 2017 an increase in the
number of cases was observed with a total of 136 cases reported in the
week beginning 26 November (source-
https://www.who.int/csr/don/11-december-2017-cholera-zambia/en/)
■ What: infection with Vibrio cholerae

■ Who: 547 people and 15 of them died

■ When: September and December 2017, after drinking and eating

contaminated water and food

■ Where: Lusaka (Chipata, Kanyama, Chawama, Matero, Chilenje and

Chelsto)

■ Why: contaminated water supplies, contaminated food, inadequate

sanitation and poor hygiene practices
The components of an Outbreak
investigation

■ When an outbreak is discovered, investigators should take a systematic

approach

■ Although the components are listed sequentially, they may occur

simultaneously or get repeated as new information is received or uncovered.

■ Some outbreak investigations may just require a phone and others may
require assembling a multidisciplinary team
Basic components of an outbreak
investigation
1. Verify the disease and confirm the outbreak
2. Define a case and conduct case finding
3. Tabulate and orient data: time, place and person
4. Take immediate control measures
5. Formulate and test hypothesis
6. Plan and execute additional studies
7. Implement and evaluate control measures
8. Communicate findings
1. Verify the disease and confirm the outbreak

■ This is the first essential step in confirming an outbreak

■ Investigators need to learn more about the disease and review

the existing baseline surveillance data to determine whether the
cluster of cases are unusually high

■ Confirm the disease using laboratory testing

■ Reviewing Medical records, talking to health providers and

patients themselves can help confirm an outbreak
2. Define a case and conduct case finding

■ Investigators create an operation definition of the case and

begin identifying cases associated with the outcome

■ The definition may evolve as the investigation continues

■ Initially it might be broad to include many cases as possible

and late on narrowed to exclude false positives
3. Tabulate and orient data: time, place and person

■ Investigators should organize information obtained for medical

records or patient interviews – and sort it by person, place and
time

■ That is who is getting sick, where and when.

■ “who, where and when“ are essential questions investigators

should first answer before generating a hypothesis about the
cause of the outbreak
4. Take immediate control measures

■ If the source of contamination has been identified , the health

department should take immediate control measures

■ Make public announcement about preventive and control

measures (steps)
5. Formulate and test hypothesis

■ As the information gathered and organized, investigators

should develop hypotheses

■ It can be essential to review previous outbreaks and studying

the epidemiology and microbiology of the pathogen

■ Additional insight can be obtained by interviewing case

patients

■ Hypotheses can be tested by analytic studies (e.g retrospective

cohort studies and case-control studies)
6. Plan and execute additional studies

■ In addition to epidemiologic investigation, environmental

investigation maybe undertaken that includes environmental
sampling

■ In case of foodborne outbreak, investigators should collect and

test food and beverage samples as soon as possible
7. Implement and evaluate control measures

■ Investigators later on need to work with government regulators,

industry, and health educators to undertake control measures to
prevent further illness and future outbreaks

■ The team should design mechanisms to evaluate the short- and long
term success of the investigation, summarize the investigation and
prepare and disseminate specific recommendations.
8. Communicate findings

■ Investigators should prepare health promotion messages for the

general public

■ New media can be play a major role in disseminating the

information to the public

■ The team should agree on the information to be released and

should choose one member who should talk to the media
Snow on cholera
■ John Snow identified mode of transmission of Cholera (London
1854)

■ Mostly referred as first modern infectious disease epidemiology

■ Using the 8 steps of outbreak investigation, Snow determined the

outbreak of deadly disease caused by contamination of water

■ He used analytic studies to determine the source of infection and

convinced local authority to take appropriate action
Assignment 1

– Describe how John Snow applied the 8 basic

components of an outbreak investigation to
determine the outbreak of cholera in London

– Due date: 05th December, 2019 by 12pm

 Conclusion
■ The terms “epidemic” and “outbreak” describe an increase in the
observed number of cases of a disease or health problem compared with
the expected number for given a place or time in a specific group of
people.
■ ”Outbreak” is usually used to describe localized epidemic
■ Outbreak investigation usually begins with information from
surveillance or health information systems, clinical laboratories, affected
citizens, or astute health care practitioners
■ To determine a potential outbreak, investigators gather such information
as what pathogen is causing the infection, who is becoming ill, and
where and when the cases are occurring.
■ Investigators take 8 steps to investigate an outbreak
Reference

■
https://www.who.int/csr/don/11-december-2017-cholera-zambi
a/en/

■ Pia D.M.M, Methods in Field Epidemiology: copyright @

2012 by Jones & Bartlett Learning, an Ascend Learning
Company