WEEK 15

OUTBREAK INVESTIGATION
LEVELS OF DISEASE
EPIDEMIC Reasons for Outbreak Investigation

 Occurrence of disease cases or deaths 1. Prevention and Control

 limited to specified group of individuals
 Primary Public Health reason for
during a short period of time
investigation
 clearly on excess of normal expectancy
 Principal considerations
(Last, 1988)
What is the stage of the epidemic?
Notes:
Are cases occuring in increasing numbers?
Group – gathered together in space and time
Is the outbreak just about over?
How EPIDEMIC occurs?

• Agents and hosts are present in

adequate number If cases are CONTINUING TO OCCUR:
• Agent can be effectively conveyed from
• Goal: prevent occurrence of additional cases
source to host
• Objective: to assess the extent of the
FACTORS THAT MAY TRIGGER AND
outbreak, the size, and characteristics of the
EPIDEMIC population at risk
• Recent increase in virulence of agent
• Recent introduction of agent into a
setting If an outbreak appears to be ALMOST OVER:
• Enhanced mode of transmission • Goal: prevent similar outbreaks in the future
• Change in susceptibility of the host
response to agent • Objective: to identify factors which
• Factors that increase host exposure contributed to the outbreak
• Introduction of agent through new
portals of entry
1.3 How much is known about the causative
Goals of an outbreak investigation: agent, the source, and the mode of
 Identify the source transmission of the agent?
 Guidance for intervention 1.4 The decisions regarding whether and how
extensively to investigate an outbreak are
influenced by the characteristics of the problem
itself

ex.

the source of the illness

the source or mode of transmission

the availability of prevention and control

measures
2. Gain additional knowledge / research 5. Program considerations

• Each outbreak is an opportunity to study the • An outbreak of a disease (which is targeted by

natural history of the disease in question a public health program) may reveal a weakness
in that program and provide an opportunity to
• For a newly recognized disease, field
modify/strengthen the program’s efforts.
investigation provides an opportunity to define
the natural history – agent, mode of • Investigating the causes of an outbreak may
transmission, and the incubation period and the identify populations which may have been
clinical spectrum of the disease overlooked, failures in the investigation
strategy, changes in the agent, or events
• Are able to characterize the populations at
beyond the scope of the program.
greater risk: identify specific risk factors (ex.
Legionnaires disease in Philadelphia in 1976;
Toxic Shock Syndrome in 1980, AIDS in early
1980’s, Eosinophilia-myalgia-syndrome in 1989) STEPS IN OUTBREAK
INVESTIGATION
• Assessing impact of control measures

3. Training

• Investigating an outbreak requires a

combination of diplomacy, logical thinking,
problem-solving ability, quantitative skills,
epidemiologic know-how and judgment.

• These skills improve with practice and

experience

• The investigating team can be composed of a PREPARATION FOR FIELD WORK

seasoned epidemiologist with trainee/s.
Preparation can be grouped into:

4. Public, political, and legal concern

• These concerns sometimes override scientific

concerns in the decision to conduct
investigation

• Increasingly, the public has taken an interest

in ‘disease clusters’ and potential
KNOWLEDGE NECESSARY TO
environmental exposures, and has called upon
PREPARE FOR OUTBREAK
the health department to investigate.
INVESTIGATIONS

1. Various types of etiologic agents and the

resultant disease;
2. Epidemiologic characteristics of outbreaks C. Source of data to establish ‘expected number
associated with different etiologic agents or cases’
resultant diseases;
 Health department surveillance data if
3. Clinical symptoms of resultant diseases; disease is a notifiable disease
 Hospitals discharge records, mortality
4. Environmental and food sanitation practices;
statistics, cancer or registries if disease
5. Sources of exposure which are vulnerable to is non-notifiable
contamination with an infectious or chemical  Apply rates from neighboring areas or
agent; conduct an informal survey among local
physicians
6. Laboratory test available to determine  Conduct survey of the community to
causative agents establish background level of the
1. Verify the diagnosis and confirm the disease
outbreak D. Factors which could explain excess cases:
• Confirm laboratory testing;  Existence of a true outbreak
• Rule out misdiagnoses or laboratory error  Changes in local reporting procedures
 Changes in the case definition
 Increased interest because of local or
A. Knowledge/Awareness of an existence of an national awareness
epidemic through:  Improvements in diagnostic procedures
 Sudden increases in size of population
 Regular analysis of surveillance data- in particular areas
detect unusual patterns of disease
occurrence E. Factors influencing decision regarding
 Calls from a health care provider or a investigation of the outbreak
citizen who knows of several cases  Severity of the illness
 Media reports  The potential for spread
B. Initial investigation may turn out to be:  Political consideration
 Public relations
 True outbreaks with a common cause;  Availability of resources, etc.
 Sporadic and unrelated cases of the
same disease
 Unrelated cases of similar but unrelated 2. Define a case and conduct a case finding
disease (i.e., without a common cause) • Develop a specific case definition using:
C. Comparison of the number of the observed  symptoms or laboratory results
number of cases with the expected number  time period
which can be:  location

 The number of cases from the previous • Conduct surveillance using case
few weeks or months, or definition
 The number of cases from a  existing surveillance
comparable period during the previous  active surveillance
few years
 • Interview case-patients

CASE DEFINITION

- Allows a simple, uniform way to identify cases

- “standardizes” the investigation

- Is unique to outbreak but is based on objective

criteria
CATEGORIES OF CASES
• Always includes: Person, Place, and Time

EXAMPLE OF CASE DEFINITION

Salmonellosis Outbreak
3. Tabulate and orient data; time, place,
person

Create a line listing of identified cases

Example of line list for suspected case of Hepatitis A

Spot Map (Cholera cases by John Snow)

EPIDEMIC CURVE

- Is a graphical depiction of the number of cases of illness by the date of illness onset;
- Can provide information on the following characteristics of an outbreak

a. pattern of spread
b. magnitude
c. outliers
d. time trend
e. exposure and/or disease incubation period

• The overall shape of the epidemic curve can reveal the type of outbreak

1. Common source

a. point
b. continuous
c. intermittent

2. Propagated

3. Mixed

TYPES OF OUTBREAK • People are exposed continuously or

intermittently to a harmful source
I. COMMON SOURCE
• Period of exposure maybe brief or long
• Intermittent exposure often results in an epi
curve with irregular peaks that reflect the
timing and the extent of exposure

Ia. COMMON SOURCE – Common Point Source

• Cases were all exposed to the same source

during a brief period of calendar time;

• Typically shows a sharp upward slope and a

gradual downward slope

• Is a common source outbreak in which the

period of exposure is brief, and all cases occur
within one incubation period
Ib. COMMON SOURCE – Continuous Exposure

• Continuous exposure will often cause cases to rise gradually (and possibly to plateau, rather than to
peak)

Ic. COMMON SOURCE – Intermittent

- brief, sporadic exposure period

- Irregular peaks reflect timing and extent of

exposure
 • The classic epi curve for a propagated
outbreak has progressively taller peaks, one
incubation period apart

II. PROPAGATED EPIDEMIC

• Spread is from person-to-person

• Can last longer than source outbreaks

• Disease agent may replicate in a susceptible

host as part of the transmission cycle;

• May have multiple waves

 3. The minimum and maximum incubation
periods for the disease.

EXAMPLES OF EPIDEMIC ACCDG TO

INCUBATION PERIOD

III. MIXED EPIDEMIC

• Involve both a single, common exposure to an

infectious agent and secondary propagative
spread to other individuals (e.g., person to
person transmission) SECONDARY ATTACK RATE

• Either same disease introduced separately or • The frequency of new cases of a disease
different diseases with different incubation among the contacts of known patients;
periods introduced around the same time
• The ratio of the number cases among contacts
Examples: occurring within the acceptable incubation
period following exposure to a Primary Case to
Many food borne pathogens (Salmonella, the total number of exposed contacts.
typhoid, Hepatitis A) and airborne organism (M.
tuberculosis) EPIDEMIC CURVE

FACTORS AFFECTING DURATION

OF AN EPIDEMIC

1. The number of susceptible persons who are

exposed to a source of infectious and become
infected;

2. The period of time over which susceptible

persons are exposed to the source
OUTBREAK OUTLIERS
If they are not errors, they may represent: • In common source outbreaks with known
incubation periods, epi curves can help
a. baseline level illness
determine the AVERAGE PERIOD OF EXPOSURE
b. outbreak source
c. a case exposed earlier than the others • Find the average incubation period for the
d. an unrelated case organism and count backwards from the peak
e. a case exposed later than the others case of the epi curve
f. a case with a long incubation period
• This can also be done to find the minimum
PERIOD OF incubation period
EXPOSURE/INCUBATION PERIOD • Find the minimum incubation period for the
FOR THE OUTBREAK organism and count backwards from the
earliest case on the epic curve
• If the timing of the exposure is known, epi
curves can be used to estimate the incubation • Average and minimum incubation periods
period of the disease should be close and should represent the
probable period of exposure
• The time between the exposure and the peak
of the epi curve represents the median
incubation period
AIMS OF OUTBREAK INVESTIGATION

• To determine the cause of the outbreak (the disease detected)

• To prevent further spread of the outbreak (the fire fighter)

• To educate responsible individuals in the prevention of similar outbreak in the future (the public
health educator)