Disease Outbreak

Investigation
 Outbreak
 Definition : Outbreak (epidemic) is the occurrence of a specific
disease more than the expected number
 in a given area or among a specific group of people over a
specified period of time.
 Outbreak investigations are important and challenging
component of epidemiology and public health.
 Levels of Disease Occurrence:
• Diseases occur in a community at different levels
at a particular point in time.
• Some diseases are usually present at a
predictable level.
• This is called the expected level.
• But sometimes they occur in excess of what is
expected.

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 Expected levels

• Endemic: Presence of a disease at more or less

stable level. Malaria is endemic in the lowland
areas of Ethiopia.
• Hyper endemic: Persistently high level of disease
occurrence.
• Sporadic: Occasional or irregular occurrence of a
disease.

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 Excess of what is expected
• Epidemic: The occurrence of health related
condition/disease in excess of the usual frequency in
a given area or among a specific group of people over
a particular period of time.
• Outbreak: Epidemics of shorter duration covering
a more limited area.
• Cluster: is an aggregation of cases in a given area
over a particular period without regard to whether
the number of cases is more than expected.
• Pandemic: An epidemic involving several countries
or continents affecting a large number of people.
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 The term epidemic
• It may include any kind of disease or injury
including non – infectious diseases.
• There is no general rule about the number of
cases that must exist for a disease to be
considered an epidemic.
• If the number of cases exceeds the expected
level on the basis of the past experience of the
particular population, then it is an epidemic.
• It is important to note that this level varies for
different diseases and different circumstances.
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 What does it mean by investigation?
It is the process of identifying
 the cause of the epidemic,
 the source of the cause
 the mode of transmission
 the preventive/control measures of an epidemic
 The purpose is to determine the specific cause or causes of the
outbreak at the earliest time and to take appropriate measure
directed at controlling the epidemic and preventing future
occurrence.
 A single case can be considered as an epidemic
if the disease is not expected to occur.
For example: a report of one case of small
pox at the present time is considered as an
Number of epidemic.
cases

Epidemic

Usual rate
=No case
Time

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Number of Excess cases
cases

Epidemic

Usual rate
Expected number of cases
Time

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 There is no specification of geographic extent.
 An epidemic may cover a small area within a city, or an
entire nation or may have a worldwide distribution.

 It may encompass any time period ranging from few

hours (chemical intoxication, bacterial food poisoning),
a few weeks (influenza, hepatitis) to several years
(AIDS).

 A disease that remains epidemic over many years

eventually may be considered endemic.

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Expected Vs Excess Cases
 Types of epidemics

Epidemics (outbreaks) can be classified

according
• to the method of spread or propagation,
• nature and length of exposure to the
infectious agent,
• and duration.

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 TYPES OF EPIDEMICS

1. Common source epidemics

1.1. Point common source (Food)
1.2. Continuous common source (water source)
1.3. Intermittent common source (eg. Malaria)
2. Propagated or progressive epidemics
– serial transfer of infection
3. Mixed Epidemics
• The epidemic begins with a single, common source of an
infectious agent with subsequent propagative spread.
• Many food borne pathogens result in mixed epidemics.
 1.1 point common source epidemic

• Is a type of common source epidemic When the

exposure is simultaneous and the resulting cases
develop within one incubation period .

• The epidemic curve in a point source epidemic will

commonly show a sharp rise and fall.

• Food borne epidemic following an event where the

food was served to many people is a good example
of point source epidemic.

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 Pattern of a single common source epidemic

Sharp rising & falling

Number of Epidemic
cases

Usual rate

Time

N.B. Epidemic curves may not be as clearly seen as this classic shape in actual situations.
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 1.2 continuous common source epidemic:-

• it will result when exposure to a common source

continues over time.

• A waterborne outbreak that is spread through a

contaminated community water supply is an example
of a common source epidemic.

• The epidemic curve may have a wide peak because

of the range of exposures and the range of
incubation periods.
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 Pattern of a continuous common source epidemic

Number of Epidemic
cases
Flat top

Usual rate

Time

N.B. Epidemic curves may not be as clearly seen as this classic shape in actual situations.
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 2. Propagative / Progressive
Epidemics.
• The infectious agent is transferred from one host to
another.
• It can occur through direct person to person transmission
or it can involve more complex cycles in which the agent
must pass through a vector as in yellow fever and
malaria.
• Propagative spread usually results in an epidemic curve
with a relatively gentle upslope and somewhat steeper
tail.
• An outbreak of malaria is a good example for Propagative
epidemic.
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 Pattern of a propagated type epidemic

Observe building of
Number of cases in waves Epidemic
cases Until it reached
peak

Usual rate

Time

N.B. Epidemic curves may not be as clearly seen as this classic shape in actual situations.
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• When it is difficult to differentiate the two
types of epidemics by the curve, spot map
(studying the geographic distribution) can
help.
• In the propagated epidemics there will be
successive generations of cases.

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 Uncovering outbreaks
• Outbreaks are detected in one of the following
ways:
1. Through timely analysis of routine surveillance
data, this may reveal an increase in reported
cases or unusual clustering of cases.
2. Report from clinician.
3. Report from the community, either from the
affected group or concerned citizen.

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 The following questions should be answered when
investigating an epidemic.
 What is the etiological agent responsible for the epidemic?

 What is/are the predominant modes of transmission?

 What specific source/s of disease can be identified?

E.g. human carriers, breeding sites for vectors, etc.

 What specific practices or environmental deficiencies have
contributed to the outbreak?
E.g. improper food handling, man made breeding sites for
mosquitoes.
 What is the chain of events that led to the outbreak?
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E.g. accumulation of susceptible hosts in an area.
 Steps of an Epidemic Investigation
1. Prepare for fieldwork
2. Verify the existence of an epidemic
3. Verify the diagnosis
4. Describe the epidemic with respect to time, place, and person
5. Formulate and Test Hypotheses
6. Search for additional cases: locate un recognized or unreported cases.
7. Analyze the Data
8. Make a decision on the hypotheses tested
9. Intervention and follow-up
10. Report of the investigation
 1. Prepare for Field Work
 Investigation
 Scientific knowledge--have it or get it!
 Supplies, equipment
 Assemble your team
• Administration
 Review OIs, local directives
• Consultation
 Know your role, especially if off-base
2. Verify the existence of an epidemic
 Compare the number of cases with the past levels to identify
whether the present occurrence is in excess of its usual
frequency.

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 Reasons Observed>Expected
• Change in reporting procedures
• Change in case definition
• Increased awareness or interest
• Improved diagnostics
• New clinician
• Change in Population
• True increase
 Therefore absolute numbers (without proportion or
rates) should be carefully analyzed.

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 3. Confirm the diagnosis.
• Carry out clinical and laboratory studies.
• It is frequently impractical to confirm every case with
laboratory evidence.
• Establish criteria for labeling persons as cases. Classify
depending on symptoms, laboratory results, or both.
 Case definition is defined as a standard set of criteria to
differentiate between cases and non cases. Cases can be
one of the following:
1. Confirmed / definite: A case with laboratory
verification.
2. Probable: A case with typical clinical features but
without laboratory confirmation.
3. Possible: A case with fewer of typical clinical features26
 Case Definition for Hep A

Report as… Definitions

Confirmed Case Anti-HAV IgM +

Probable Case Jaundice or elevated ALT

Suspected Case Any two of the following:

Abdominal pain, Fever,
Nausea, Anorexia, Malaise

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 4. Describe the data in terms of time, place and
person.
• Each case must be defined according to standard
epidemiologic parameters: the date of onset of the
illness, the place where the person lives or became ill,
and the socio demographic characteristics (age, sex,
education level, occupation).
• The tools to be used when characterizing the epidemic
are epidemic curve, spot map and attack rates.
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Place

xxx xxx
xx xxx
x

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 Person
100
90
80
70
Percent of Smokers

60
Men
50
40 Women
30
20
10
0
18-24 25-44 45-64 65-74

Town X 30
Epidemic Curve: Interpretation
Epidemic Curve:
Typical Point Source Outbreak
35
30
25
20
15
10
5
0
1 2 3 4 5 6 7 8 9
Onset by Day of Month

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Epidemic Curve: Interpretation

Epidemic Curve:
Typical Progagated Outbreak
15

10

0
1 3 5 7 9 11 13 15 17 19 21
Onset by Day of Month

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Epidemic Curve: Interpretation

Epidemic Curve:
Typical Continuous Common Source Outbreak
16
14
12
10
8
6
4
2
0

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 5. Formulate and test hypothesis.
• This step involves the assessment of the data
collected to date and the generation of hypotheses
that may explain the outbreak.
• The goal is to explain the specific exposure (s) that
caused the outbreak.
• The hypothesis should address source of agent,
mode of transmission and exposure that caused the
disease.
• In an outbreak investigation, evaluation of
hypotheses can be done in two ways: either by
comparing the hypotheses with the established fact,
or by using analytic epidemiology to quantify
relationships and explore the role of chance.
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 6. Search for additional cases.
• Locate unrecognized or unreported cases:
• Passively – by inquiring if physicians or hospitals have
seen similar cases,
• Actively – by doing intensive investigation in the
community on asymptomatic persons or contact of
the cases.
7. Analyze the data.
 Assemble all the results.
 Interpret findings.
8. Make a decision on the hypothesis tested.
 The findings must be consistent with the hypothesis.
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 9. Intervention and follow-up.
• Although it is discussed late, intervention must start as
soon as possible depending on the specific
circumstances.
• Aim control measures at the weak link or links in the
chain of infection. One might aim control measures at
the specific agent, source, or reservoir.
• For example, an outbreak might be controlled by
destroying contaminated foods, sterilizing contaminated
water, or destroying mosquito breeding sites or an
infectious food handler could be removed from the job
and treated.
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 9. Managing Outbreak/epidemics cont…
 Management of epidemics require an urgent and intelligent use of
appropriate measures against the spread of the disease.
 Action to be taken is dependent on the type of the disease as well as
the source of the outbreak.
1. Measures Directed Against the Reservoir
2. Measures that interrupt the transmission of organisms
3. Measures that reduce host susceptibility
 10. Report of the investigation.
• At the end prepare a comprehensive report and submit to the
appropriate/concerned agency (or agencies). The report should
follow the usual scientific format: introduction, background,
methods, results, discussion, and recommendations.
• The report should discuss in detail:
o Factors leading to the epidemic.
o Evaluation of measures used for the control of the epidemic.
o Recommendations for the prevention of similar episodes in the
future.
o Managing Outbreak/epidemics 39
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