OUTBREAK

INVESTIGATION
Dr. Waqar Ali
HoD, Community Medicine
Vice Principal Research
PhD Scholar, MBBS, MPH, MNCH, QMIH (Germany),HRHM (U.K)
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Learning Objectives
• By the end of the session, the learner would be able to understand:

• The main steps in an outbreak investigation

• The Recommended control measures

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BACKGROUND
 Pakistan is at high risk of being hit by large outbreak because of:

Many over crowded cities,

Unsafe drinking water,

Inadequate sanitation,

Large number of refugees,

Low vaccination coverage. 6

Continue..
• Outbreaks results in significant burden on the national healthcare
delivery system in terms of morbidity as well as mortality.

• Important epidemic prone diseases include?*

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Field Epidemiology & Disease Surveillance Division (FE&DSD)

• The hub of all the prevention and control activities at national level is
Field Epidemiology & Disease Surveillance Division (FE&DSD)
established in 2013.

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Purpose of an Outbreak Investigation.
• Identify the source (and eliminate it)
• Develop strategies to prevent future outbreaks
• Evaluate existing prevention strategies
• Describe new diseases and learn more about known diseases
• Address public concern

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10 Steps of an Outbreak Investigation
1. Prepare to investigate.
2. Establish existence of an outbreak
3. Verify the diagnosis
4. Define And Identify Cases
5. Find cases systematically and develop line listing
6. Perform descriptive epidemiology/develop hypotheses
7. Evaluate hypotheses/perform additional studies as necessary
8. Implementing Control and Prevention Measures
9. Communicate Findings
10. Maintain surveillance
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1. Prepare To Investigate
• Investigators should be familiar with the disease and have a plan of action
which includes lists of supplies, division of tasks among team members, and
administrative and travel arrangements.

Preparation include:
a) Review literature
b) Prepare the supplies and equipments
c) Consult laboratory staff
d) Arrange for portable computer, camera
e) Consult local staff
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2. Establish The Existence Of An Outbreak

Is this an outbreak?
• Compare the current number of cases with
the number from the previous weeks or months
• Check health department records
• Consult local data sources

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3. Verify The Diagnosis
• An investigator will need to review clinical findings and lab tests in
order to verify the diagnosis, as well as determine the specific nature
of the disease.

• E.g, in infectious disease outbreaks, additional lab tests may be

necessary to determine the specific strain of microbe implicated in
the outbreak.

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4. Define And Identify Cases.

• Epidemiologists establish a case definition: a standard set of

criteria for deciding whether a person should be classified as having
the disease or condition under study.

• A case definition will usually include,

a) Characteristics of the patients with that disease,
b) Information about the location, and
c) A specific range in time.

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"Get it while you can."

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5. Find Cases Systematically And Develop Line Listing

The following information is collected:

Clinical Risk factors Identifying information

Information: Information:
Name, address,
Date of onset, sign & Specific
symptom, Exposures, Telephone no, …..
Hospitalization, death Immunity status

Demographic information:
Age, sex, race, occupation

Use line list to summarize information 16

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6. Perform Descriptive Epidemiology/
Develop Hypotheses

• Characterize the outbreak by time, place, and person (descriptive

epidemiology).

• Line lists and epi curves useful in developing hypotheses

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Characterizing By Time: Epidemic Curve
Epidemic curve or “epi curve” =
A graph of the number of cases by their date of onset.

• Number of cases is plotted on y-axis

• Time is plotted on the x-axis

Advantages:
• Shows course of epidemic
• May enable estimation of probable time period of exposure
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Examples of Epidemic Curves
Point source Continuing common source
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20 15
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10
10

5 5

0 0
1 3 5 7 9 11 13 15 17 19

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10 Multiple waves -person to person

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Propagated epidemic
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Characterizing By Place: Spot Map

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Characterizing By Person
• Determine the populations at risk by characterizing the
outbreak by person

• Define populations by:

• Personal characteristics (Examples: age, race, sex, or medical status)

• Exposures (Examples: occupation, use of medications, tobacco, drugs)

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7. Evaluate Hypotheses

• The credibility of the hypotheses can be evaluated by looking at the

facts or by crunching numbers to get actual statistics on available
information.

• There are two approaches that can be used, depending on the nature
of the data:

a) Comparison of the hypotheses with the established facts and

b) Analytic epidemiology, which allows you to test your hypotheses.

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b. Analytic Epidemiology

• Epidemiological Studies
a) Cohort
b) Case-control

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8. Implementing Control and Prevention Measures

• Remove source of contamination

• Remove persons from exposure

• Isolate and/or treat infected persons

• Interrupt transmission

• Eliminate the susceptibility of individuals by vaccination or

prophylactic chemotherapy
May occur at any time during the outbreak!!
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9.Communicate Findings

1. Findings of the investigation should be communicated to local health

authorities. In addition,

a) Prepare written report

b) It include discussion of factors leading to outbreak

c) Evaluation of the methods used for the control of outbreak

d) Recommendations for prevention of similar outbreak

2. Media attention desirable if public action needed

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10.Maintain Surveillance

• Deciding if outbreak is over.

• Documenting effectiveness of control measures.

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Conclusions

• Epidemiologic investigations are essential to determine source of

outbreaks
• Be systematic
• Follow the steps!

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Reference
• K-Park, 22nd Edition
• Leon Gordis, 6th Edition

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Thank You

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