The Principles of Outbreak

Epidemiology

Felix Odhiambo
Adapted

from slides

By
Dr Abhinav Sinha MBBS, MD
 Learning Objectives
• The main motives behind this
lecture are to develop the basic
concept in investigating an
epidemic, the need to recognize
the urgency behind it and to orient
the students toward the art and
science of outbreak investigation
and epidemiology.
 Performance Objectives
• After going through this lecture, the
students should be able to perform the
initial investigation of many smaller
outbreaks that occur so much frequently in
their vicinity that may often pass
unrecognized.
• Also, they should be able to differentiate
the epidemic and the endemic fluctuations
in the frequencies of a disease.
 Definitions
1. Outbreak: Sudden occurrence of an
epidemic in relatively limited
geographic area. While an outbreak is
usually limited to a small focal area,
an epidemic covers larger
geographical areas & has more than
one focal point.
2. Outbreak Epidemiology: Study of a
disease cluster or epidemic in order to
control or prevent further spread of
the disease in the population.
 Field Epidemiology
A definition has been proposed by
Goodman. The essential elements are:
1. The problem is unexpected
2. An immediate response may be
necessary
3. Epidemiologists must travel to &
work on location in the field
4. The extent of investigation is likely to
be limited because of imperative for
timely intervention
 Objectives of Outbreak
Investigation
1. Primary- to control the spread of
disease
2. To determine the causes of disease,
its source & mode of transmission
3. To determine who is at risk
4. To determine what exposures
predispose to disease
5. To know magnitude of the problem
 Objectives continued….

6. To identify new agent

7. To determine the effectiveness of
control measures
8. To identify methods for present &
future prevention & control
9. Research & training opportunities
10. Public, Political and legal concerns
 Unique aspects of Outbreak
Investigation
1. There is a pressure & urgency to
conclude the investigations quickly
which may lead to hasty decisions.
2. Data sources are often incomplete & less
accurate.
3. Decreased statistical power due to
analysis of small numbers.
4. Publicity surrounding the investigation –
community members may have
preconceived ideas.
 The pace & commitment of Outbreak
Investigation (OI)
• There is often a strong tendency to collect
what is “essential” in the field & then
retreat to “home” for analysis.
• Such premature departure reflects lack of
concern by the public, makes any further
data collection or direct contact with the
study population difficult.
• Once home, there is loss of urgency &
momentum & the sense of relevancy of
the epidemic.
• NB.Don’t leave the field without final
results & recommendations.
 Trigger events & Warning Signals
1. Clustering of cases/deaths in time/space
2. Unusual increase in cases/deaths
3. Shift in age distribution of cases
4. High vector density
5. Acute hemorrhagic fever or acute fever
with renal involvement/altered
sensorium
6. Severe dehydration following diarrhea
in patients above 5 years age
7. Unusual isolate
 Diseases requiring investigations
1. Endemic diseases with epidemic
potential – malaria, cholera, measles,
hepatitis, meningococcal meningitis
2. Even a single case of diseases for which
eradication/elimination goals have been
set – polio, guineaworm and yaws
3. Rare but internationally important
diseases with high case fatality rates –
yellow fever
4. Outbreaks of unknown etiology
 General lines of action
• The basic general lines of action during
epidemics include – Preparedness and
Interventions (investigations).
• Success in dealing with an epidemic
depends largely on the state of
preparedness achieved in advance of any
action.
• It would be an error to consider as an
epidemic, a hitherto unrecognized
endemic situation or a mere seasonal
increase in the incidence of a disease.
 Preparedness
1. Identify a nodal officer at state/district
level
2. Strengthen routine surveillance system
3. Constitute rapid response teams
4. Train medical & other health personnel
5. Prepare a list of laboratories
6. List the “high risk” pockets
7. Establish rapid communication network
8. Undertake IEC activities
9. Ensure availability of essential supplies
10.Setup inter-departmental committees
 Investigations
1. Recognition & response to a request for
assistance
2. Check initial information
3. Formulate a plan of action
4. Prepare for field work
5. Confirm the existence of epidemic
6. Verify the diagnosis
7. Identify & count cases/exposed persons
8. Orient data in terms of person, place &
time
 Investigations continued…..
9. Choose a study design
10.Collect specimens for lab analysis
11.Conduct environmental investigations
12.Formulate & test hypotheses
13.Implement control measures
14.Conduct additional studies
15.Prepare a written report
16.Communicate the findings
 Step 1 – Recognition & Response
• If the local health officials request
assistance, the regional epidemiologist
should try to acquire as much information
about the disease and the population at risk
as possible.
• It is also important to find out why the
request is coming – need extra hands?,
unable to uncover the details of the disease
in question?, share the responsibility?, or
legal or ethical issues?
Step 2 – Check initial information: As
soon as the initial information on an
outbreak reaches, the regional health
coordinator must determine whether the
information is correct.
Step 3 – Formulate a plan of action:
The plan should be based on situational
analysis & taking technical, economical
& political factors into account.
Step 4 – Prepare for field work:
Identify the team members & assign
responsibilities.
 Composition of typical field team
Specialists Auxillaries
1. Epidemilogist 1. Nurses
2. Clinician (pathologist) 2. Specialist assistants
3. Microbiologist 3. Secretary/Interpreter
4. Veterinarian 4. Driver
5. Entomologist
6. Mammalogist
7. Sanitary engineer
8. Toxicologist
9. Information Specialist
 Step 5 – Confirm the existence
• Are there cases in excess of the baseline
rate for that disease & setting?
• The excess frequency should be found
out with Epidemic Threshold Curve.
• The periodic frequency for previous 3
years is plotted on a graph.
• Another graph at mean + 2SD level is
superimposed on it. Any fluctuations
beyond these 2 graphs should be treated
as epidemic fluctuations (method of
moving averages).
 Step 6 – Verify the diagnosis
• The initial report may be spurious & arise
from misinterpretation of the clinical
features.
• This involves a review of available
clinical & lab findings that supports the
diagnosis.
• Do not apply newly introduced,
experimental or otherwise not broadly
recognized confirmatory tests at this
stage. 15-20% of the suspected cases may
be lab confirmed.
 Step 7 - Identify & count cases
• Identify additional cases not known or
reported initially.
• The case definition must be precise but
not too exclusive.
• Persons who meet the case definition
should be “line-listed”.
• Also, identify the population at risk or the
exposed persons, places where the cases
live, work & have traveled to, & the
possible exposures that might have lead to
the disease.
• Search for the source of infection
• The main purpose here is to eliminate,
terminate or isolate the source.
• The steps involved are –
• identify the time of disease onset,
• ascertain the range of incubation periods &
look for the source in time interval between
the maximum & the minimum IPs.
• In outbreaks with person-to-person
transmission, all the contacts of the index
case are to be searched (contact tracing).
 Step 8 – Compile & Orient data
• Identify when patients became ill
(time), where patients became ill
(place) & what characteristics the
patients possess (person). The earlier
one can develop such ideas, the more
pertinent & accurate data one can
collect.
(a) Time: The epi-curve gives the
magnitude of outbreak, its mode of
spread & the possible duration of the
epidemic. The unit of time on X-axis
are smaller than the expected
(b) Place: It provides major clues
regarding the source of agent and/or
nature of exposure. Spot maps show a
pattern of distribution of cases.
(c) Person: Examine characters such as
age, sex, race, occupation or virtually
any other character that may be useful
in portraying the uniqueness of case
population.
 Step 9 – Choose a Study Design
The design (Case-control, Cohort &
Case-cohort) is chosen based on size &
availability of the exposed population,
the speed with which the results are
needed & the available resources. The
study design that is chosen will then
dictate the appropriate analysis &
hypothesis testing.
 Step 10 – Perform Lab analysis
• It consists of collecting & testing
appropriate specimens.
• To identify the etiologic agent, the
collection need to be properly timed.
Examples of specimens include - food &
water, other environmental samples (air
settling plates), and clinical (blood, stool,
sputum or wound) samples from cases &
controls.
Step 11 – Environmental Investigation

• A study of environmental conditions &

the dynamics of its interaction with the
population & etiologic agents will help
to formulate the hypothesis on the
genesis of the epidemic.
• Such actions assist in answering How?
And Why? questions.
Step 12 – Formulate & Test Hypothesis

As soon as the preliminary data indicate

the magnitude & severity of the
outbreak, a hypothesis should be made
regarding time, place and person; the
suspected etiological agent & the mode
of transmission. Risk specific attack
rates are calculated & compared &
relative risk/odds ratio is calculated.
 Important points
1. Rare disease assumption: The OR &
RR approximate each other if the attack
rates is less than 5% but the attack rates
are much higher in outbreaks.
2. To correct for multiple comparisons, the
most effective approach is to lower the
p-value according to the number of
comparisons made.
 Step 13 – Control Measures
Simultaneous to data collection &
hypothesis formation, steps should be taken
to contain the epidemic. These measures
depend upon knowledge of etiologic agent,
mode of transmission & other contributing
factors. Protective measures are necessary
for patients (isolation & disinfection), their
contacts (quarantine) and the community
(immunization, etc).
 Step 14 – Additional studies
Because there may be a need to find
more patients, to define better the
extent of the epidemic, or because a
new lab method or case finding
method may need to be evaluated, the
epidemiologists may want to perform
more detailed & carefully executed
studies.
 Step 15 – Prepare Written Report
The final responsibility of the investigative
team is to prepare a written report to
document the investigations, findings and
the recommendations. The written report
should be submitted, in a standardized
format, to the public health authorities
including the ministry of health & remain
confidential until it has been given official
permission.
 Step 16 – Communicate findings
Communicating the investigative findings
clearly is essential. All public health
officers will benefit if the experience
acquired by the investigative team is
shared by the publication of an account of
the outbreak. As a rule, the epidemiologist
informs those who reported the first cases
of the epidemic first.
 Step 17 – Post-epidemic Measures
The efficacy of control measures should
be assessed day by day during the
outbreak, a final assessment being made
after it has ended. This will provide a
logical basis for post-epidemic
surveillance & preventive measures
aimed at avoiding the repetition of
similar outbreaks.
 Bibliography
• Basu R N. Manual on Epidemiological
Surveillance Procedure for selected
diseases. National Institute of Communicable
diseases. New Delhi. 1984. 1-4.
• Bres P. Public Health Action in
Emergencies caused by Epidemics – A
Practical Guide. Geneva. WHO. 1986.
• Diane M Dwyer and Carmela Groves.
Outbreak Epidemiology. Infectious Disease
Epidemiology. 119-147.
•Epidemiologic Surveillance & Outbreak
Investigation. Textbook of Epidemiology and
Biostatistics in Preventive Medicine. W B
Saunders Publication. 43-53.
•Internet website:
www.cdc.gov/excite/classroom/outbreak.html
•Johan Giesecke. Detection and Analyses of
Outbreaks. Modern Infectious Disease
Epidemilogy. Edition 1. Arnold Publishers. Co-
published by Oxford University Press. 124-137.
•Kulkarni A P & Baride J P. Investigation of an
epidemic. Textbook of Community Medicine.
Second edition. Vora Medical Publications.
Mumbai. 159-160.
•Michael B Gregg. The principles of an
epidemic field investigation. Oxford Textbook of
Public health. Volume II – The methods of Public
health. Edition 3. Editors – Roger Detels, Walter
W Holland, James McEven, Gilbert S Omenn.
Oxford Medical Publishers. 537-545.
•Outbreak investigation and control. Training
Module. National Institute of Communicable
Diseases. New Delhi. Park K. Investigation of an
Epidemic. Park’s Textbook of preventive and
Social Medicine. Bhanot Publishers. Jabalpur.
2000. 103-104.
•Raymond S Greenberg, Stephen R Daniels, W
Dana Flanders, John William Eley, John R Boring
III. Disease Outbreaks. Medical Epidemiology.
Edition 3. Lange International Edition. Tata
McGraw Hill. 65-74.
• Reingold Arthur L. Outbreak Investigations
– a perspective. Internet website
www.cdc.gov/ncidod/eid/about.html#citation
• Robert B Wallace & Bradley N Doebbeling.
Investigation of an epidemic. Public Health
and Preventive Medicine. Maxcy-Rosenau-
Last. Edition 14. International Edition.
Appleton & Lange. 16-21.
• Vaughan J P & Morrow R H. Controlling the
Epidemic. Manual of Epidemiogy for District
Health Management. World Health
Organization. Geneva. 1989. 59-69.