Outbreak Investigation

Module 4: Outbreak Investigation and Response

Module 4: Outbreak Investigation and Response

Steps in outbreak investigation: detection, confirmation,
characterization, and control measures
Role of epidemiologists and public health officials in outbreak
response
Case studies of notable outbreaks and lessons learned

Definition of terms cont..

Ø Outbreak: It is an epidemic that occurs in a limited

geographic area (e.g. an institution, a home facility, a
neighbourhood, a village...)

Case definition:- suspected, probable and confirm case

Case category General features

Confirmed Laboratory confirmation of agent

Probable Typical clinical features of illness, AND Partial laboratory results (confirmation
pending), OR Epidemiologic link to a laboratory-confirmed case
Suspect Typical clinical features of illness, AND Missing laboratory and epi information

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 Goals of an outbreak investigation

Goals of an outbreak investigation:

• To identify the source of illness

• To guide public health intervention

Ways to recognize an outbreak:

• Routine surveillance activities
• Reports from clinicians and laboratories
• Reports from affected individuals

Reasons for conducting an outbreak investigation

• Characterize a public health problem

• Control and prevention
• Research opportunity: Provide new research insights into disease
• Train health department staff in methods of public health investigations
and emergency response

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 Outbreak classification

Ø Three main classification with respect to the source of infection and

modes of transmission

1. Common source: is one in which a group of persons are all exposed

to an infectious agent or a toxin from the same source
• Point source:- single exposure, occurs in short period and have
the same incubation period.
• Continuous source:- Case-patients may have been exposed over
a period of days, weeks, or longer
• Intermittent source:- often has a pattern reflecting the intermittent
nature of the exposure

2. Propagated outbreak results from transmission from one person to

another. Usually, transmission is by direct person-to-person contact

3. Mixed outbreak: Some epidemics have features of both common-

source epidemics and propagated epidemics
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Outbreak classification cont..

Ø Others: Some epidemics are neither common-source in its usual sense nor
propagated from person to person.

• Outbreaks some zoonotic or vector borne diseases may result from sufficient
prevalence of infection in host species, sufficient presence of vectors, and
sufficient human-vector interaction.

- Examples include the epidemic of Lyme disease that emerged in the north
eastern United States in the late 1980s (spread from deer to human by deer
ticks) and
- the outbreak of West Nile encephalitis in the Queens section of New York City
in 1999 (spread from birds to humans by mosquitoes

References
White DJ, Chang H-G, Benach JL, Bosler EM, Meldrum SC. Means RG, et al. Geographic spread and temporal increase of the Lyme
diseas. epidemic. JAMA 1991;266:1230–6.

Centers for Disease Control and Prevention. Outbreak of West Nile-Like Viral Encephalitis–New York, 1999. MMWR 1999;48(38):845–
9. 6

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 How are Outbreaks Detected?

Ø Analysing surveillance data

- reviewing exposure information from reports of infectious diseases cases sent by
laboratories and healthcare providers
Ø Health Ministry
- conducts periodical routine surveillance for infectious disease cases in the
community, and detect an unusual increase in the number of reported cases

Ø Infection and control at the hospital

- review microbiological isolates of organisms from patients and wards to detect any
unusual increase in number of infections

Ø Vigilant physician
- notices an unusual cluster of patients with the same symptoms and reports to health
authorities

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Ø Reports from affected individuals

Factors that may affect the decision to investigate an outbreak

• Number and pattern of people involved (cluster of cases)

• Type of disease (ease of transmission; type of causative agent)

• Severity of disease; unusual presentation

• Availability of effective control measures

• If the disease needs prompt control measures to prevent fast spread to others (or
is it already over?)

• Availability of staff and resources to conduct investigation

Note: Certain diseases, such as Lassa fever, Ebola, Marburg, Rabies, etc., are
so uncommon in a population that a single case necessitates an outbreak
investigation.
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 Steps for conducting an outbreak investigation

Example: Lassa fever in Freetown, Sierra Leone

• On February 13, 2023, an infectious diseases physician at a Freetown hospital

telephoned the Directorate of Epidemiology of the Ministry of Health and
Sanitation (MOHS) to report two possible cases of Lassa fever.

• The patients, both men, presented with fever, vomiting, difficulty swallowing,
respiratory problems and haemorrhage

• One patient had onset of symptoms on February 5 and the other on February 6.

• The physician had drawn sera and collected stool specimens from the men to
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test for Lassa virus but no results were available

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 1. Prepare for field work
• Do you have the knowledge, resources and staff for the field?

• Will you need any laboratory tools?

• Do I need equipment to protect myself?

• Do I have an action plan?

• Identify team members (who will do what?)

• Is it a zoonotic disease? (will I need a veterinarian?)

Lassa fever in Freetown: is it worth investigating?

• Could this possibly be an outbreak? is it worth investigation?

• Seriousness of the disease?

• Food-borne/Water-borne/Zoonotic (from a possible contaminated products) could

spread to many people
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2. Establish the existence of an outbreak

• Is the number of cases higher than the usual?

– Compare the current situation with the expected number from past weeks or
months; hospital data; neighbouring cities; background of disease in community
• Is there a cluster of cases with the same complaints?

• Is the increase in reporting due to actual increase in number of cases or due to

improvement of diagnosis and surveillance methods?

• Severity of the disease? availability of control measure? dose this need prompt
response?

Back to the Lassa fever example..

• The epidemiologists established that this is a public health emergency because the
disease is contagious and the complications of the disease is severe.

• However, the results from the lab were still not available, but they still have to verify
the diagnosis before continuing.
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 3. Verify the diagnosis

• This is required to:

1. To ensure that the disease has been properly diagnosed

2. To rule out that increase in disease diagnosis was due to laboratory error

• Review clinical findings (are they consistent with the disease?)

• Laboratory methods used

• Frequency tables for clinical findings (are they all presenting with same symptoms?)

Back to the Lassa fever example..

• The clinical syndrome of LF is dominated by fever, vomiting and neurological signs

and symptoms.

• If respiratory muscles are involved, haemorrhaging, ventilatory failure and death may
result unless supportive care is provided.

• The average incubation period for LF is 6-21 days after exposure. 13

4. Construct a working case definition

Ø Case definition: This is a set of criteria needed to classify an individual as having the
disease or not

• Identify and count cases

• criteria should be objective measures

- DO NOT include the risk factor of interest in your case definition: e.g. if symptoms
started after days working at Hospital A, do not make your case definition
exclusively for people who worked at Hospital A

• Instead, define cases within a certain time period

– who had symptoms from day X to day Y

• Different categories: confirmed, probable, suspect

• Start loose and then tighten your definition later on 14

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 5. Find cases systematically and record information

• Ask local health facilities if they have patients with similar history and symptoms

• Ask the patients if other members they know have the same symptoms

• Review admission log

• Contact laboratory and ask to inform you about any orders for testing for the disease in
question

• Contact media to ask community to be vigilant for the symptoms and contact health
facility if they experience them

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5. Find cases systematically and record information cont..

What information should we collect from each case?

• Name

• Demographic data

• Risk factors; exposures. If food borne ask about meal history in the past few days

depending on incubation period of the disease

• Symptoms and signs

• Who reported the information

• Confirmed or pending lab results

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 5. Find cases systematically and record information cont..

Perform a Line List

• A line list is a document that contains key information about each case

• Each row in the line list represents the information about one case

• You include: ID info, demographic info, symptoms, date of onset, any lab results, etc..

Table1: Example of a line list created during an outbreak investigation

Key:
ID Name Age Sex Ill Date of Onset Signs and Symptoms Lab
report D • ID = Identification Number
F D V P H RDT PCR • Name = Person's Initials
• Age = Age in Years
1 FJ 38 F Y 12-Nov 4-Nov Y Y Y Y Y + + • Sex = Male or Female
2 MR 29 M Y 12-Nov 3-Nov Y Y Y Y N + + • OnsetD = Date of Illness Onset
3 DK 56 F N 13-Nov Y N N Y N - - • OnsetT = Time of Illness Onset
4 SA 30 F Y 13-Nov 5-Nov Y N N Y N + + • F = Fever
• D = Diarrhoea
5 VB 17 M Y 13-Vov 6-Nov Y Y Y Y N + +
• V = Vomiting
6 MB 33 M Y 13-Nov 6-Nov Y N Y Y N + + • P = Abdominal pain
7 MM 62 M N 14-Nov N Y N Y N - - • H = Haemorrhage
8 GB 41 M N 14-Nov Y N N Y N - - • N = no
9 IJ 35 F Y 14-Nov 5-Nov Y Y Y Y Y + + • Y = yes
10 JL 14 M Y 15-Nov 7-Nov Y Y Y Y N + + 17

6. Perform descriptive epidemiology

Epidemiology:- the study of the distribution

and determinants of health-related states or
events in specified populations and the
application of this study to control health
problems

Epidemiological Studies

Ø Experimental studies:
• Clinical Trials for Individuals
• Community Trials for Communities

Ø Observational studies:
• Descriptive studies
• Analytical studies
- Case control
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- Cohort studies Chart adapted from "MedPage Tools: Guide to Biostatistics"

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 6. Perform descriptive epidemiology cont..

How to identify exposure period from epidemic curve?

Ø If patients cluster at a certain point:

- Identify the peak of the outbreak Or the median case

- From that point, count back on the x-axis one average incubation period => note this date

- Start from the earliest case and count back one minimum incubation period => note this
date as well

Ø If no cluster of cases
(continuous common source):

- Earliest case count backwards

a minimum incubation period

- Last case count backwards

one maximum incubation
period

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6. Perform descriptive epidemiology cont..

Types of epidemics from epidemic curve

1. Common Point Source

People are usually exposed to the same risk

factor over a limited and defined period of time
(usually one incubation period)

Shape: rapid rise, with a sharp peak, then

gradual decline

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Point source with secondary transmission

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 6. Perform descriptive epidemiology cont..

2. Continuous Common Source

• Exposure occurs over prolonged period (>one
incubation period)
• People are exposed continuously or
intermittently to a common source

Shape: has several peaks without a clear

incubation period

Intermittent Common Source

Source: Torok M. Epidemic curves ahead. Focus on Field Epidemiology 2003;1(5). Available at: 21
https://nciph.sph.unc.edu/focus/vol1/issue5/1-5EpiCurves_issue.pdf

6. Perform descriptive epidemiology cont..

3. Propagated Source (progressive source)

Here cases serve as sources for subsequent cases, and subsequent cases serve as source
for later cases.

Reflects a disease transmitted from person to person.

Shape: A series of
successively larger peaks

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 6. Perform descriptive epidemiology cont..

Questions we ask ourselves after looking at the epidemic curve

• Is the outbreak from a single source? or multiple sources?

• Is it spread from person to person?

• Is the exposure continuing or did it just occur at one event?

• Is there a vector involved?

• Is it foodborne, waterborne, vector borne or airborne?

• Is the source of infection unapparent?

These help us develop our hypotheses!

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Back to the Lassa fever example..

• After some investigation, the epidemiologists found that the cases were all healthcare
workers who worked at the morning shift, and provided care for same patients at the
hospital in the morning.

• No healthcare worker who worked at the afternoon or evening shift had the same
symptoms.

• Investigators hypothesized that:

– Exposure was at the hospital

– During the morning shift

– Common exposure to the same source (based on epidemic curve)

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 7. Develop a hypothesis

The hypotheses may address:

• Source of the agent => What is the reservoir?

• Mode of transmission => vehicles? vectors?

• Exposure and risk factors =>

– Ask cases about what they think could be possible exposure?

– Epidemic curve may trigger the question:

- What common exposure happened during the possible period of exposure?

– What special characters do the cases have? (age, sex, risk factors)

– Why do people in a specific area have the highest attack rate?

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8. Evaluate the hypothesis

We evaluate our hypotheses:

1. Compare with established facts=>

– laboratory testing

– Environmental assessment

– Epidemiologic evidence

If findings are not straightforward........

2. Analytical epidemiological study =>

- Compare two groups to look for association between the disease and exposure to
the hypothesized source

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 9. Reconsider, refine and re-evaluate your hypothesis

Ø Sometimes epidemiological analyses does not answer the questions of the

investigator

Ø The investigator may need to conduct further studies, study a different exposure,
or refine the population being studied in order to reach answers

Ø The investigator refines the hypothesis based on the results of epidemiologic

analysis and if they were not confirmed by laboratory testing, and conduct further
studies

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10. Compare with laboratory and environmental studies

Ø Coordinate results from epidemiological analyses with evidence from laboratory

testing and/or assessing the environment

Ø For example, when a food borne outbreak is suspected, and epidemiologic

analyses pointed to a certain food product, the investigator would test that food
product and culture it for the infectious agent in question

Ø If a water-borne outbreak is suspected from epidemiologic study, the investigator

would examine the water source for reasons of contamination

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 11. Implement prevention and control measures

Ø Prevention and control measures are

Chain of Infection

usually taken from the beginning of the

outbreak (prompt treatment of cases;
remove the source when identified;
isolate cases if needed; prevent spread
to susceptible individuals...etc)

Ø Control measures are implemented in

a way that interrupts one or more of the
elements in the “chain of infection”

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12. Initiate or maintain surveillance

Ø Surveillance should be ongoing from the beginning of the investigation

Ø If not started yet, now is the time for active surveillance and continuing it until we
are sure the outbreak has stopped

Reasons for surveillance:

1. To determine that prevention and control measures are working

2. Assured the outbreak did not spread outside the area targeted by the intervention

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 13. Communicate findings

Summarize everything that happened and what has been done:

– The outbreak (onset, cases involved, symptoms, duration, complications)

– laboratory investigations

– sources detected

– type of epidemiologic study conducted and results of analyses

– coordination of results with evidence (lab and environment)

– prevention and control measures implemented and containment of outbreak

We communicate this summary:

- To local health authority

- Media (print, radio, TV, internet)

- Written report (scientific format) that is later added to the literature

- Telephone advice lines

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Reference

Principles of Epidemiology in Public Health Practice (third Ed). 2008. Available at:
https://www.cdc.gov/ophss/csels/dsepd/ss1978/ss1978.pdf

Gordis L. Epidemiology. Fourth Edition. Philadelphia, PA: Elsevier Saunders, 2009

Torok M. Epidemic curves ahead. Focus on Field Epidemiology 2003;1(5). Available at:
https://nciph.sph.unc.edu/focus/vol1/issue5/1- 5EpiCurves_issue.pdf

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