CHAPTER 9

Approach to Outbreak
Investigations
 Definitions

• Epidemic is the occurrence of disease

cases or deaths clearly in excess of
normal expectation
• Outbreak is the occurrence of disease
cases or deaths limited to a specified
group during a short period of time clearly
in excess of normal expectation
 Cont…
• There are two types of epidemics
– Common source
– Propagated
 I. Common source

• An outbreak resulting from the direct or

indirect exposure of a group to the same
disease causing agent (the source)
• There are two types
– Point source
– Continuing source
 1. Point source

• Cases were all exposed to the same

source during a brief period of calendar
time
 2. Continuing source (or
intermittent point-source)
• Cases were exposed to the same source
during more than a brief period of calendar
time
 May be caused by an infectious organism,
or a noxious agent in the environment
 The disease agent does not undergo an
incubation period in a susceptible host as
part of the transmission cycle
 II. Propagated
• An outbreak resulting from transmission of an infectious
agent from one susceptible host to another
• The disease agent undergoes an incubation period in a
susceptible host as part of the transmission cycle
 AIMS OF AN OUTBREAK
INVESTIGATION
To determine the cause of the outbreak

To prevent further immediate spread of the

outbreak

To explain how to prevent similar outbreaks in

the future
 Potential risk factors or high risk
situations
• Environmental and food sanitation practices
• Immunological susceptibility
• Sources of exposure vulnerable to effects of
infectious or chemical agent
 NECESSARY KNOWLEDGE FOR
OUTBREAK INVESTIGATIONS
1. Diseases
• Clinical signs and symptoms
• Pathological changes
2. Etiologic agents
• Types of agents and diseases caused by
agents
• Laboratory tests to assess presence of agents
3. Outbreak characteristics for specific diseases
• Period from contact with agent to onset of
overt disease
• Mode of transmission
• Socio-demographic susceptibility
Steps of Outbreak Investigation (CDC)
1. Prepare for fieldwork
– Research the disease
– Make administrative arrangements
– Clarify your role
2. Establish the existence of an outbreak
– Does the observed number of cases exceed the
expected number?
 Cont…
3. Verify the diagnosis
– Speak directly with persons who are affected

4. Define and identify cases

– Establish a case definition
– Identify and count cases
• Line listing
 Cont…
5. Describe the data in terms of time, place and
person
– Outbreak curve
– Map
– Identify demographic and other characteristics of
persons at risk
6. Develop hypotheses
– Open-ended and wide-ranging interviews with a few
people
 Cont…
7. Evaluate hypotheses
– Comparison: hypotheses with established
facts
– Analytic epidemiology
• Cohort studies (RR; 95% CI)
• Case-control studies (OR; 95% CI)
8. Refine hypotheses and carry out
additional studies
 Cont…
9. Implement control and prevention measures
– Should occur as soon as information is available
10. Communicate findings
• Written outbreak report distributed with laboratory
results approximately one month later to:
– Local Health Department
– Clinic Director
– Environmental Health
– Regional Epidemiologist
– National level
 Limitations
• Incomplete response rate on the
cohort study
 Conclusions
• 10 steps of outbreak
investigation
– Conceptual
• Provide a logical progression for the
investigation
– Can / should be taken out of order
(with caution)