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Investigation of Epidemic
Investigation of Epidemic
Investigation of Epidemic
EPIDEMIC / OUTBREAK
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Overview
Introduction
Incubation Period
Investigation of epidemic
Objectives
Principles
Steps of investigation
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INTRODUCTION
Epidemic: Unusual occurrence in a community or region a
Ex: Cholera
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INTRODUCTION
Endemic: Constant presence of a disease/ agent in a geographical
Types –
following exposure
Factors determining incubation period:
c) Portal of entry
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d) Individual susceptibility
Incubation Period
Uses
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Prognosis : Ex – Tetanus, Rabies 6
Investigation Of Epidemic
Investigation –an examination for the purpose of finding
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Objectives
To define magnitude of outbreak or its involvement in
occurrence of epidemic
To identify cause, source, modes of transmission
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When To Investigate
Depends on following factors:
Severity of illness
Transmissibility
Unanswered questions
Of public concern
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Preparation for field work
Can’t be mentioned exactly as first step
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Preparation for field work
Two broad categories
b) Laboratory resources
d) Plan of action
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Preparation for field work
2)Management & Operational issues:
a) Selection of team members and know their roles & responsibilities in field
c) Communication plan
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1. Confirmation of Existence of Epidemic
When observed frequency is in excess of expected frequency
years.
Approach physicians and GP’s in community whether they
susceptibles
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Example:
previous experience
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What confusion occurs
In March 1985 , 15 cases of suspected meningococcal
from Delhi]
After proper verification of diagnosis , cases were divided to
different categories.
Only 4 cases were verified as MM!!!!
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Verification of Diagnosis and Construct
working Case definition
Simultaneous appropriate management of cases also important
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“Syndromic approach” to common ‘epidemic
prone diseases’
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Working Case Definition
Standard set of criteria for deciding whether an individual
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Working Case Definition
Cases divided into 3 categories
a) Confirmed- after laboratory verification
b) Probable- Typical clinical features without lab investigations
c) Possible/ suspect- has fewer of typical clinical features
Investigator tries to ensure that a case definition includes most,
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Working Case Definition
Ex:
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H/O hospitalization/ death 27
4. Rapid search for all cases and their characteristics
3) Risk factor information- depending on disease
Ex: cholera- all meals, snacks, water source, drinks consumed
between day 1 & day 5 prior to onset of symptom
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Ex: Dr X after investigating the field could identify that
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New case search till area is declared free of outbreak- period usually
Ex: Small lab with a portable container having gloves, rectal swabs,
Cary –Blair transport medium , vials and PPE. Dr X decided to collect
stool samples, rectal swabs, food samples, water samples and serum
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Contact administrative and engineering authorities
Information also collected from who did not suffer from disease
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5. Describe the epidemic
Crucial step because
i) Comprehensive characterization of outbreak like trend,
distribution
ii) Infer population at risk
iii) Clue about etiology, source, modes of transmission
iv) To begin control & preventive measures
v) To calculate attack rates
Describing w.r.t time
Histogram to depict time course of epidemic- epidemic curve
/epi curve
Time of onset of illness for each case should be known
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Epidemic curve
Inferences :
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Curve with plateau instead of peak- continuous common source
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To identify likely period of exposure:
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Probable
No of cases
exposure time
Median incubation time
(Intervall between first and last disease onset)
2
15 3
10
0
1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 20 21 22
Time
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Probable exposure period
No of cases
1 3 51 27 3 9
4 5 116 713 8 15
9 10 17 1913 14
11 12 21 15 23 2518 19
16 17 27 2029
21 2231 Time
Probable
exposure
period
5. Describe the epidemic
Describe w.r.t Place
Given by making spot map of area on which case are plotted.
Uses:
i) Provides geographic extent of problem
ii) Demonstrates patterns that provide etiologic clues
Eg : John Snow’s investigation on cholera in Golden square district
of London in 1854
Can’t be used to compare incidence between different areas
with different population densities
Many spot maps in same investigation:
like place of residence, occupation, recreation, onset of illness
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John Snow’s investigation on cholera in Golden
square district of London
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Describe w.r.t Person
Provides a description of who cases are and who is at risk
Age, sex, occupation, race etc
Helps in calculation of attack rates
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Ex: 2 cases had onset on 10th May, 3 on 11th and 1 each on 12 and
13th May. There was no case thereafter. The 7 cases were plotted
according to the date of onset of their symptoms. The resultant curve
showed a sharp rise, a sharp peak and an abrupt fall, indicating a
“common vehicle, single exposure (point source)” transmission.
3 different spot maps were made - according to workplace, place of
staying and place of routine eating and drinking, and cases were
plotted as coloured dots on these maps. A clear - cut “clustering” was
seen in all the three maps – in mess No. ‘B’, at workplace No. 1 and in
Living dormitories No. 4 and 5
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6. Developing various tentative hypothesis
Proposition or a tentative theory designed to explain
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6. Developing various tentative hypothesis
Can be developed by:
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7. Testing of hypothesis
Comparisons between cases & controls using Analytical
epidemiology
Compared in each & every possible hypothesis
Odds ratio calculated & statistical significance seen by Chi-
square test
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Risk ratio/ relative risk
Method for calculating risk ratio:
RR= Attack rate (risk) in exposed group
Attack rate (risk) in unexposed group
Measures association between exposure & disease
unexposed groups, the larger the relative risk, and the stronger
the association between exposure and disease
Attack rate= Developed disease among exposed X 100
Population at risk
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Ex: Table includes data from an investigation of an
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Food items No of persons who ate No of persons who did not eat Relati
ve risk
Ill Not ill Total Attack Ill Not ill Total Attack
rate rate
the lowest attack rate among those who did not eat it was the
culprit
RR indicates the persons who ate beef were 5.7 times more
( ARP − ARU )
ARP
exposure
In Ex :Population attributable risk percent (49.1 − 11.4) = 76.7%
49.1
Statistical significance testing : by Chi-square test- likelihood of
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8. Further search for environmental & other
causative factors
In Ex: after the results pointed out to B mess, conditions there
were tested.
study of hygiene and sanitation of cook house, dining
the waiters ‘Q’ had not reported for duty because of “upset
stomach” from 10th may to 13th May.
Clinical exam of all these food handlers was undertaken
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9. Final lab proof of cause & effect
relationship
Difficult but gives final proof
Ex:
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10. Implement control & preventive
measures
Most primary goal
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Measures directed towards source of infection:
iii) Protective
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Measures directed towards source of infection:
i) Absolute
ii)Modified – selective partial limitation of freedom of movement
Ex: exclusion of children from school during treatment for
diphtheria, scabies
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iii) Segregation : Separation for special consideration, control of
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Measures directed to portal of entry:
Use of bed-nets
Insect repellants
Measures directed to susceptible host:
Chemoprophylaxis
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11. Initiate & maintain surveillance
Continuous scrutiny of all aspects of occurrence & spread of
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11. Initiate & maintain surveillance
Ex:
Super-chlorination, Pipelines were repaired
any investigation.
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IDSP
Integrated disease surveillance project
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Team under the Integrated Disease
Surveillance Programme (IDSP), typically
include:
• District Surveillance Officers (DSOs)
• Epidemiologists
• Microbiologists
• Entomologists
• Laboratory technicians
• Health workers
• Medical officers
• Community health officers
• Paramedical staff
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References
1. Park K. Park’s textbook of preventive and social medicine. 23nd ed.
Jabalpur M/s Banarasidas Bhanot Publishers 2015; p.131-133
2. Col Rajvir Bhalwar Public Health and Preventive Medicine – “The
RED BOOK” Diamond Jubilee Edition New light publishers 2008;p
184-196
3. Leon Gordis. Epidemiology. 5th ed. Elsevier Saunders 2014; p 22-37
4. P.V.Sathe & P.P Doke. Epidemiology & Management for Health
care. 4th ed. Mumbai, Vora Medical Publications 2014; p 34-45
5. CDC. Principles of epidemiology in public health practice . 3rd ed.
6. Oct 2006. http://www.cdc.gov/ophss/csels/dsepd/ss1978/
7. Wallace R. Public health & preventive medicine. 15th ed. The
Mcgraw Hill Companies. 2008; p 14-17
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THANK YOU
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