Fundamental Principles of

Infectious Disease
(PHS- 653)
Credit Hours = 3 (3+0)
 LECTURE – 12
OUTBREAK INVESTIGATION

Ms Rubab Zulfiqar
Lecturer
NUMS Department of Public Health
OUTBREAK
Occurrence of more cases of disease than expected.
In a given area
Over a particular period of time
Among a specific group of people

A single case of a new emerging disease/eradicated disease

• Outbreaks are usually limited to a small area
• Outbreaks are usually within one district or few blocks
WHY ???
• Determine cause of disease
• Identify source of infection
• Determine mode of transmission
• Understand who is at risk
• Control/prevention of additional illnesses
 STEPS
• Prepare for field work
• Establish the existence of an outbreak
• Verify the diagnosis
• Construct a working case definition
• Find cases systematically and record information
• Perform descriptive epidemiology
• Develop hypotheses
• Evaluate hypotheses epidemiologically
• As necessary, reconsider, refine, and re-evaluate hypotheses
• Compare and reconcile with laboratory and/or environmental
studies
• Implement control and prevention measures
• Initiate or maintain surveillance
• Communicate findings
1. Prepare for field work

• Scientific and investigative issues

• Management and operational issues
Scientific and Investigative Issues
• Appropriate scientific knowledge, supplies, and equipment
• Literature review (sources, modes of transmission, and risk
factors)
• Laboratory material, collection, storage, and transportation
techniques
• Personal protective equipment (if required)
• Plan of action
Management and Operational Issues
• Formulate a team
• Assign roles
• Consultation
outbreak from an animal source may include state and federal departments
of agriculture
Natural disaster (hurricane or flood) may include Natural Disaster
Management Authroirty (NDMA)
2. Establish the existence of an outbreak
 Is this an epidemic or cluster of cases?

 Does the observed number exceed the expected number of cases?

• An outbreak is the occurrence of more cases of disease than
expected in a given area or among a specific group of people
over a particular period of time.
OR
• Outbreak is an epidemic limited to localized increase in the
incidence of disease, e.g., village, town, or closed institution
• For a notifiable disease use health department surveillance records.

• For other diseases and conditions, find existing data locally—hospital

discharge records, mortality statistics, cancer or birth defect
registries.

• If local data are not available, apply rates from neighboring cities or
national data, or, alternatively, conduct a telephone survey of
physicians to determine whether they have seen more cases of the
disease than usual.

• Finally, conduct a survey of the community to establish the

background or historical level of disease.
 EXERCISE
• For the month of August, 12 new cases of tuberculosis and 12
new cases of influenza infection were reported to a county
health department. You are not sure if either group of cases is a
cluster or an outbreak. What additional information might be
helpful in making this determination?
• Classifying the cases as an outbreak depends on whether
the 12 cases exceed the usual number of cases reported in
August in that county.
• TB- no seasonal distribution – so compare the cases with
previous months or years
• Influenza- peak from Dec-Feb - Compare the cases during
the same month of previous years.
3. Verify the diagnosis
• To ensure that the disease has been properly identified
• To rule out laboratory error as the basis for the increase in diagnosed
cases.
• Review the clinical findings and laboratory results
• Involve investigators and direct interview with the patient
• Summarize the clinical features using frequency distributions
 4. Construct a working case definition
• A case definition is a standard set of criteria for deciding whether an
individual should be classified as having the health condition of
interest.
• A case definition includes clinical criteria and--particularly in the
setting of an outbreak investigation--restrictions by time, place and
person.
• Case definition must not include the exposure or risk factor you are
interested in evaluating.
• To be classified as confirmed, a case usually must have laboratory
verification. A case classified as probable usually has typical
clinical features of the disease without laboratory confirmation. A
case classified as possible or suspected usually has fewer of the
typical clinical features.
• Early in an investigation, investigators often use a sensitive or “loose”
case definition which includes confirmed, probable, and even possible
cases. Later on, when hypotheses have come into sharper focus, the
investigator may “tighten” the case definition by dropping the
possible category.
CASE DEFINITON (COVID 19)
SUSPECTED CASE
• Clinical criteria
1. Acute onset of fever AND cough (influenza-like illness)
OR
2. Acute onset of ANY THREE OR MORE of the following signs or
symptoms: fever, cough, general, weakness/fatigue, headache, myalgia,
sore throat, coryza, dyspnoea, nausea, diarrhea, anorexia.
• Epidemiological Criteria
Contact of a probable or confirmed case or linked to a COVID-19 cluster.
Probable:
• A patient who meets clinical criteria above AND is a contact of a confirmed
case or is linked to a COVID-19 cluster.

Confirmed:
• A person with a positive nucleic acid amplification test (NAAT), regardless
of clinical criteria OR epidemiological criteria
OR
• Meeting clinical criteria AND/OR epidemiological criteria
with a positive professional use or self-test SARS-CoV-2 Antigen-RDT.
 5. Find cases systematically and record
information
• Direct case finding at health care facilities where the diagnosis is
likely to be made: physicians , clinics, hospitals, and laboratories.

• Investigators may conduct passive surveillance by sending a letter

describing the situation and asking for reports of similar cases.
Alternatively, they may conduct active surveillance by telephoning
or visiting the facilities to collect information on any additional
cases.
• In some outbreaks, public health officials may decide to alert
the public directly, usually through the local media.

• Identifying contacts to case-patients .

• Conduct a survey of the entire population.

The following items of information should be collected about every
case:

• Identifying information (Name, Address, Contact No.)

• Demographic information (Age, gender, occupation)
• Clinical information (Onset of symptoms, Duration of illness)
• Risk factor information (Food & water in case of Hep A)
• Reporter information (Source of information)
Develop a line listing
• It is a table that helps identify number of diagnosed cases and
information relevant to disease outbreak.

• In a line listing, each column represents an important variable, such as

name or identification number, age, sex, case classification, etc., while
each row represents a different case. New cases are added to a line
listing as they are identified. Thus, a line listing contains key
information on every case and can be scanned and updated as
necessary.
EXERCISE
6. Perform descriptive epidemiology
• Summarizing data by key demographic variables provides a
comprehensive characterization of the outbreak
• Characterize an outbreak by time, place, and person.
• Identify the population at risk for the disease.
• Provides clues about etiology, source, and modes of transmission
TIME
 What is the exact period of the outbreak?

 What is the probable period of exposure?

 Is the outbreak likely common source or propagated?

PLACE
 What is the most significant geographic distribution of cases?
Place of residence? Workplace?
PERSON

 What were the age and gender specific attack rates?

 What age and gender groups are at highest and lowest risk of

illness?
 Interpreting an epidemic curve
 An epidemic curve, also known as an epi curve, shows the number of
illnesses in an outbreak over time.
 Interpretation of the epidemic curve can prove to be very helpful in
determining the source of the outbreak.
Through review of the different patterns illustrated in an epidemic curve, it
is possible to hypothesize:
 How an epidemic spread throughout a population
 At what point you are in an epidemic
 Point Source
• In a point source epidemic, persons are exposed to the same
exposure over a limited, defined period of time, usually within one
incubation period. The shape of this curve commonly rises rapidly
and contains a definite peak at the top, followed by a gradual
decline.
The graph above illustrates an outbreak of gastrointestinal illness from a single
exposure. While there are outliers to this dataset, it is clear that there is an
outbreak over a limited period of time, and the shape of the curve is
characteristic of one source of exposure
 Continuous Common Source
 Exposure to the source is prolonged over an extended period of time,
 may occur over more than one incubation period,
 The down slope of the curve may be very sharp if the common

source is removed, or
 gradual if the outbreak is allowed to exhaust itself.
The data above is from the well-known outbreak of cholera in London that was
investigated by the "father of epidemiology," John Snow. Cholera spread from a
water source for an extended period of time. Note that the typical incubation
period for cholera is 1--3 days that the duration of this outbreak was more than 1
month.
 Propagated
(Progressive Source)
 A propagated (progressive source) epidemic occurs when :
- a case of disease serves as a source of infection ,
- subsequent cases, in turn, serve as sources for later cases.
- The shape of the curve usually contains a series of successively larger
peaks,
(reflecting the increasing number of cases caused by person-to-person
contact),
- This pattern may continue until the pool of susceptible is exhausted or
control measures are implemented.
The graph above illustrates an outbreak of measles. The graph shows a single common
source (the index case), and the cases appear to increase exponentially. Measles is
caused by person-to-person contact. Its incubation period is typically 10 days but may
be 7--18 days.
7: Develop hypotheses

 All aspects of the investigation should be addressed:

- the source of the agent,

- the mode of transmission, (vehicle & vector),
- the exposures that caused the disease,
- any additional time, person, and place factors.
First, consider what you know about the disease itself:

 What is the agent’s usual reservoir?

 How is it usually transmitted?
 What vehicles are commonly implicated?
 What are the known risk factors?

In other words, simply by becoming familiar with the disease, you

can, at the very least, “round up the usual suspects.”
 8. Evaluating Hypotheses

 Either by comparing the hypotheses with the established facts, or

 By using analytic epidemiology to quantify relationships and

explore the role of chance.
 Comparing the hypotheses with the
established facts
• When the clinical, laboratory, environmental, and/or epidemiologic
evidence so obviously supports the hypotheses
ANALYTIC EPIDEMIOLOGY
• The comparison group allows epidemiologists to compare
the observed pattern among case-patients or a group of
exposed persons with the expected pattern among non
cases or unexposed persons.
• Cohort studies and case-control studies
EXERCISE
• You are called to help investigate a cluster of 17 persons who
developed brain cancer in an area over the past couple of years.
Most, perhaps all, used cell phones. Which study design would you
choose to investigate a possible association between cell phone use
and brain cancer?
• Case Control Studies
9. Reconsider, refine, and re-evaluate
hypotheses
10. Compare and reconcile with laboratory and environmental studies

• Epidemiology can implicate vehicles and guide appropriate

public health action, laboratory evidence can confirm the
findings
• Epidemiologic, environmental, and laboratory arms of the
investigation complement one another
11. Implement control and prevention
measures
• Primary goal is control of the outbreak and prevention of
additional cases.
• Aim to apply control measures at the weak link or links in the chain
of infection.
An outbreak might be controlled by :
- destroying contaminated foods,
- sterilizing contaminated water, or -
destroying mosquito breeding
sites.

“ An infectious food handler could be removed from the

job and treated.”
 In other situations, control measures might be aimed at:

- interrupting transmission or
- reducing the exposure
In some outbreaks, control measures might be
directed at:

- reducing the susceptibility of the host,

- Immunization ,

- chemoprophylaxis for travelers.

12. Initiate or maintain surveillance

• Active surveillance
• Monitoring
• Progress of cases
• Geographical distribution of new cases
13. Communicate Findings

1- An oral briefing for local authorities

and

2- A written scientific report.

THE REPORT:
• A record of performance and a document for potential legal issues.

• Reference if the health department encounters a similar situation in

the future.

• Broader purpose for contributing to the knowledge base of

epidemiology and public health.
 The report should include:
 Summary of relevant data, methods of collection, performed
analysis and interpretations.
 Describe implemented preventive and control measures .
 Make recommendations regarding future surveillance and control.
 Distribute report to others in disease control programs