Outbreak
Investigation &
Control
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Learning objectives
After the end of this session, students will
be able to:
oState different level of disease occurrences
oList the rationale to investigate outbreak
occurrence
oDiscuss steps in the investigation of an
outbreak occurrence
oDescribe types of outbreak occurrence
oDiscuss the outbreak controlling strategies
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Epidemiology in Action
Outbreak Investigations
Public Health Surveillance
Community Screening Programs
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Level of disease occurrences
Diseases occur in a community at different levels at a
particular point in time.
Occurrence at 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
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.
example : HIV/AIDS is a pandemic.
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What is outbreak occurrence?
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What does outbreak investigation &
control?
It is the process of identifying:
o The cause of the epidemic
o The source of the epidemic
o The mode of transmission and
o Taking preventive and control measures
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Source of an outbreak
information
Routine surveillance
Health professionals
Affected community members
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What are the objectives for outbreak
investigation?
1) To initiate control & prevention
measures
The most important public health reasons for
investigating an outbreak are to help guide
disease prevention and control strategies.
These disease control efforts depend on
several factors, Including
knowledge of the agent,
The natural course of the outbreak,
The usual transmission mechanism of the disease,
and
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2) Research and training opportunity
oEach outbreak should be viewed as an
experiment waiting to be analyzed
oIt presents a unique opportunity to study the
natural history of the disease
oIt could be a good opportunity to gain
additional knowledge on
◦ The impact of prevention and control
measures
◦ The usefulness of new epidemiology and
laboratory techniques
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3) Public, political and legal obligations
oPoliticians and leaders are usually concerned with control of
the epidemic
oPoliticians and leaders may sometimes override scientific
concerns
oThe public are more concerned in cluster of disease and
potentials of getting medication
oIt is write of the community to get treatment/service and it
is government and our duty to protect the community
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4) Program considerations
o Occurrence of an outbreak notifies the
presence of a program weakness
o This could help program directors to change or
strengthen the program’s effort in the future to
prevent potential episodes of outbreak
occurrence
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Steps of outbreak investigation and
control
1. Prepare to field work
2. Establish the existence of outbreak
3. Verifying the diagnosis
4. Case definition and case finding
5. Perform descriptive epidemiology
6. Formulate hypotheses
7. Testing hypotheses
8. Refine hypothesis and additional studies
9. Implementing prevention and control activities
10. Communicate findings
In practice, however, several steps may be done at the same time, or
The circumstances of the outbreak may dictate that a different order be
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followed
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Step 1: Prepare for field work
Before leaving for the field, an investigator must be
well prepared to under take the investigation:
o Investigation (Knowledge in epidemiology and the disease
of concern is important)
o Administrative (Logistics, administrative procedures,
travel arrangements)
o Consultation (Health workers should know their role, and
should participate in the planning phase)
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Step 2: Establish the existence of
outbreak
o An outbreak is the occurrence of more cases
of disease than expected level
o The investigator has to compare previous
case load with the current to assure the
existence of the outbreak
o But be careful, excess cases may not always
indicate an outbreak occurrence rather it may
be because:
Change in population size
Change in case definition
Change in reporting procedure
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Step 3: Verifying the
diagnosis
o The initial report may be spurious and arise
from misinterpretation of the clinical features
o Review clinical and laboratory findings to
establish diagnosis
o Goals in verifying the diagnosis includes:
To ensure that the problem has been properly
diagnosed
To rule out laboratory error as a basis for the
increase in diagnosed cases
To ensure the diagnosed disease is possibly
epidemic
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Step 4: Case definition and
case finding
Prepare “case definition” before starting identification of cases
It’s aim is to count all cases of the illness
It is clinical criteria restricted by time, place and person
Use sensitive or "loose case definition” early in the investigation
and use "tight or strict case definition” for testing hypothesis
-=== We can find additional cases in
- health facilities
- home visit in epidemic area( kebele or gote level )
=Information required include personal Identifier(name, tell,
address), demographic(age, sex, occupation), exposure history,
clinical information(date of onset, outcome, sign and
symptom),who report? Information
== we will do line listing by taking the above information
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Step 5: Performing Descriptive
Epidemiology
oOnce data is collected, it should be analyzed by
time, place and person
oThe tools to be used when characterizing the
epidemic are epidemic curve, spot map and attack
rate
oThe characterization often provides clues about
etiology, source and modes of transmission that can
be turned into testable epidemiologic hypothesis
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1. Analysis of epidemic by time
We use epidemic curve to analyze by time taking
- The X- axis; indicating time of onset
-The y-axis; indicating the number of cases
appearing
Epidemic curve can tell as
- nature of epidemic
- hint to etiologies – etiologic agent
- hint about source of exposure
There are three principal types of epidemic
1. Common source – based on source of exposure
2. Propagative - touches mode of transmission
3. Mixed
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1. Common source epidemic
It occurs as a result of the exposure of a group of
population to a common source (etiological agent)
o It can result from a single source/ exposure of
the population to the agent
E.g: contaminated water supply, or food in a
certain restaurant
Three types
1. Point common source
2. Continuous common source
3. Intermittent common source
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A) Point common source epidemic
oSingle/ones/limited time exposure to the
source
oAll exposed hosts will develop disease within one
incubation period
oThe epidemic usually decline after a few
generations, either because the number of
susceptible hosts fall below some critical level, or
because intervention measures become effective
oA rapid rise and gradual fall of an epidemic curve
suggests a point source epidemic
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E.g. Food borne outbreak in a wedding
feast
Typical Point source epidemics
Peak of
Outbrea
k
Minimu
m
incubati
on
period
A single sharp peak of sudden
onset
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B) Continuous common source epidemic
If exposure to a common source continues over time
for days, weeks
The epidemic curve has a plateau (multimodal epi
curve)/ long peak
Range of exposures and range of incubation periods is
different
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C) Intermittent common source epidemic
Results in an irregular pattern of the epidemic curve
that reflects the intermittent nature of the exposure
E.g. waterborne outbreak
Often the graph is atypical
Several sharp peaks
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2. Propagative /progressive
epidemic
o It occurs as a result of transmission of an
infectious agent from one person to another
directly or indirectly
o There is a successive generations of cases
o The epidemic curve in a progressive epidemic
is usually presence of successive several
peaks, a prolonged duration, and usually a
sharp fall
o Can show geographic spread of the case
Example; Malaria outbreak and different
vector born disease
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Typical Propagated Epidemic Curve
No sharp peak
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3. Mixed Epidemic
oIt shows the features of both types of
epidemics
o It begins with a common source of infectious
agent with subsequent propagated spread
because of person – to- person transmission of
the etiologic agent
E.g. Majority of food borne outbreaks
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2. Analysis of epidemic by
place
◦ A spot map is a simple and useful technique
for illustrating where cases live, work or may
have been exposed
◦ Area map if large area is affected
◦ It is important to indicate source of outbreak
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3. Analysis of epidemic by
person
oCharacterizing an outbreak occurrence by
person is how we determine what populations
are at risk for the disease
oHost characteristics: age, race, sex, or medical
status and exposures-occupation, leisure
activities, use of medications, tobacco and
drug use etc…
oThese influence susceptibility to disease and
opportunities for exposure to risk factors
oWe use attack rates to identify high risk groups
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Step 6: Formulating hypothesis
Depending on the outbreak, the hypothesis may
address
oThe exposures that caused the disease
oThe mode of transmission
Using :
1. Subject-matter knowledge
2. Descriptive epidemiology
3. Talking with patients
4. Talking with local officials
The hypotheses should be testable
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Step 7: Testing the hypothesis
Here doing analytic studies may be useful.
Association between the postulated exposure factor and
the disease is tested using analytic design
1. Case control 2. Retrospective Cohort
Appropriate measure of association should be made
for case control, odds ratio
for cohort design, relative risk
Significance of statistics should be done,
(Chi-square is the appropriate test, and P-value
is estimated at 5 %.)
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Step 8: Refining hypotheses and additional
studies
oSearch for additional cases: Locate
unrecognised or unreported cases
oEnvironmental studies are equally important in
some settings
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Step 9: Implementing control and
prevention
In outbreak investigation, the primary goal is to control
and prevent the outbreak.
Implementing control measure should be done as soon
as possible
It should go in parallel to investigating the outbreak
Source/ Mode of
Transmission
Causative
Agent
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Control measures (do early)
1. Measures Directed Against the Reservoir:
◦ Reduce contact rate
◦ Reduce infectious sources- destruction of infected animal /isolation
◦ Reduce infectiousness- early treatment
2. Measures that interrupt the transmission of
organisms
◦ Purification of water
◦ Pasteurization of milk
◦ Inspection procedures designed to ensure safe food supply.
◦ Improve housing conditions
3. Measures that reduce host susceptibility and
Increase herd immunity
- Immunization
- Chemoprophylaxis - Use of antibiotics for known contacts of cases
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Step 10: Communicating findings of
investigation
The final responsibility of the investigative team is to
prepare a written report to document the investigations,
findings and the recommendations
The written report should follow the scientific reporting
format which includes:
o introduction
o methods
o results
o discussion
o conclusion, and
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Summary of the investigation and control of
an epidemic considering procedure
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Post-Epidemic Surveillance
oThe efficacy of control measures should be assessed
day by day during the outbreak, a final assessment
being
made after it has ended
o this will provide a logical basis for post-epidemic
surveillance, and preventive measures aimed at
avoiding similar outbreaks in the future
o develop long term early warning system
o monitor environmental risk factors
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The end
Any questions or comments??
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