End-term assessment

Applied Epidemiology (PH-3101)

STI Myanmar University

Kaung Khant San (STI-3423)

Public Health Second Year (Intake 3)
STI-3423 Final Assessment

Introduction

Public health sector has been strengthened gradually around the world,

significantly improving the health of many populations by preventing and controlling

numerous public health events. Despite this positive progress, there are gaps and

challenges still existing due to new epidemics, seasonal endemics and re-emerging

diseases. Most of these epidemics are occurred in low- and middle-income countries

(LMICs), which are underdeveloped with limited health education and resources.

They are in regions where high prevalence of food-borne diseases and lack of food

safety are significant concerns as they can life-threatening. World Health

Organization (WHO) reported that diarrheal diseases are leading causes of death for
(WHO, 2024)
child mortality, with an annual mortality rate of nearly 500,000 children .

Effective prevention and control, and detailed outbreak investigation of these

diseases are imperative in saving preventable deaths. This essay will discuss on two

topics: (1) Prevention and control of diarrhea using epidemiological principle of chain

of infection and (2) steps of outbreak investigation of food poisoning.

(1) Prevention and Control of Diarrhea Using Chain of Infection

All infectious diseases have their chain of infection, which is a cycle of

disease transmission starting from disease-causing pathogens and eventually

infecting humans. A chain of infection includes six sections: microorganism,

reservoir/source, portal of exit, modes of transport, portal of entry and susceptible

host. Breaking even one link of chain of infection can be effective against spreading
(National Institute for Occupational Safety and Health (NIOSH), 2022)
of diseases.

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Diarrhea is commonly caused by infections from bacterial, viral and parasitic

pathogens that contaminate intestinal tract. Norovirus and rotavirus are two viruses

that causes most of the acute gastrointestinal enteritis, and rotavirus has been the
(Stuempfig and Seroy, 2023)
leading cause of episodic infantile illness worldwide .

Common bacterial pathogens include Vibrio cholerae, Salmonella, Shigella,

(WHO, 2024)
Campylobacter and E coli (most common among children) . These

diarrheal pathogens are present in their primary source, human feces, which can

continue to contaminate water sources and food. As their transmission route is

fecal-oral route, pathogens from an infected person’s feces are transported to

another person’s mouth. There are many modes of transmission: ingestion of

contaminated water and food, through contaminated hands, contact with infected

vomit or feces and vector transmissions (mainly flies). According to WHO, most of

diarrhea are spread by feces-contaminated water. It is important to understand how

diarrhea is spread through its chain of infection, to effectively prevent this contagious

disease.

Fig (1): Chain of Infection

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Fig (2): F-diagram for Diarrhea

In LMICs, the quality of water, sanitation and hygiene (WASH) are

significantly lower than those in developed nations. Socioeconomic disparities

including lack of resources (treated water) and inadequate housing significantly

increase the risk of diarrhea. Therefore, WASH interventions are essential for

preventing diarrhea in LMICs. As described in Fig (2), the f-diagram is designed to

show how fecal pathogens spread from feces to a new host through various routes:

fluids, fingers, flies, food, fields and floods. Using WASH methods, each link of chain

of infection can be cut off.

Firstly, the reservoirs of fecal pathogens are required to be maintained

through sanitation measures. It is proven that utilization of improved latrines built

following standards and located at recommended distance from human living

environment considerably reduce diarrhea risk particularly in slum areas. It prevents

not only the contamination of the environment, but also flies from transmitting the
(Mabvouna et al., 2023)
pathogens, especially if the latrines are covered . Secondly,

promoting hygienic defecation practices such as washing hands with soap after

defecation is crucial for stopping infection in rural areas where poor quality of

education still exist. Thirdly, since uncleaned water sources are the most common

cause for diarrhea, effective and consistent application of household water treatment
(World Health Organization, 20
and safe storage can reduce diarrheal diseases up to 45%

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. Lastly, careful preparation and storage of food is also important

to protect vector transmissions of diarrhea through contaminated food.

For under five-year-old children in LMICs, diarrhea and malnutrition, which are

bidirectionally associated, are mainly responsible for severe diarrheal

(Ferdous et al., 2013)
diseases , which can lead to increased DALYs, comorbidities

and mortalities. Therefore, WHO advocated for exclusive breastfeeding for the first

six months for improving nutrition status of the children in long-term. Including

rotavirus vaccine in national immunization programs is also an effective prevention

for diarrhea caused by rotavirus, reducing substantial numbers of rotavirus diarrhea

deaths as a study showed 57% reduction in high child mortality countries

(Burnett, Parashar and Tate, 2018)
. Oral rehydration therapy (ORT) is a cheap and effective
(Ezezika et al., 2021)
treatment in preventing up to 93% of diarrhea mortality ;

however, the availability of ORT supply is still a limited factor for this treatment in

LMICs. The vaccination along with the prevention and control through WASH

interventions to break the chain of infection and the readiness of medical resources

can significantly reduce the risk of diarrhea outbreaks in LMICs.

(2) Steps in an outbreak investigation of food poisoning

Food poisoning refers to a foodborne disease caused by ingestion of

contaminated food or water with toxins, bacteria or viruses, which can cause

symptoms of fever, diarrhea and followed by dehydration. The foodborne diseases

(FBD) further extend disparities between LMICs and HICs (High-Income Countries).

Africa and South-East Asia had the highest incidence of FBD, and it is reported that
(Grace, 2015)
LMICs bear over 90% of burden from FBD . The factors such as weak

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law enforcements on food regulation and low-quality structure of food systems are
(Grace, 2023)
also contributing to these high figures .

Food poisoning often occurs as outbreaks, and, therefore, requires a detailed

outbreak investigation to identify the source of contaminated food and eliminate the

source to prevent further cases. American Center for Disease Control (CDC) has

outlined 7 steps for multistate foodborne outbreak investigation. The seven steps

include (1) detection of a possible multistate outbreak, (2) defining and finding cases,

(3) generating hypotheses followed by (4) testing and evaluation, (5) confirming the

outbreak source and (6) performing interventions to stop the outbreak, and finally (7)

deciding the outbreak is over

(Centers for Disease Control and Prevention (CDC), 2025)
. These steps can be reorganized according with requirements and findings

from the field investigation. In order to understand how these steps are performed

through a real scenario of an outbreak, a case study of an outbreak investigation,

connecting with above steps will be discussed.

A case study of food poisoning outbreak investigation in Ethiopia

Kassahun and Wongiel (2019) studied on a food poisoning outbreak occurred

in Ethiopia for verifying diagnosis and identifying risk factors. On April 24/2018, the

Kemise General Hospital contacted Oromia Zone health department to inform that

there were seven cases of food poisoning who were participants of a lunch

ceremony from Gure and Qelo kebeles. After the detection of the outbreak from the

hospital, a team consisted of field epidemiologists and Public Health Emergency

Department (PHEM) officers visited the village where food poisoning cases were

reported, while other two field epidemiologists were assigned to monitor the

incidence rate of the outbreak are if increasing or not. (Step 1)

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The total defined cases were 35 cases and an unmatched case control study

was conducted among lunch ceremony participants. With a ratio of one case to four

controls, the total sample size was 175 (35 cases and 140 controls), and

investigators randomly selected controls, who were participants who do not present

symptoms of food poisoning. The data of the cases were collected from the hospital

and were interviewed with structured questionnaires, as laboratory examinations

were already undergone to confirm the cases. (Step 2)

The descriptive epidemiology was performed with collected data. The

distribution by person revealed that 60% and 65.7% of cases consumed raw meat

and drank raw meat respectively. Another important finding is that majority of cases

had no hand washing practice after defecation, whereas 100 of controls had the

practice. The similar factors for both cases and controls are using pipe water and not

treating water. The cases distribution by place showed that 80% of cases were from

Gure Kebele and attack rate of the outbreak in Gure was 17.3% and in Qelo was

14%. The epidemiological curve for the outbreak displayed that the outbreak was

probably ended after 2 days when most of the cases began onset of symptoms of

food poisoning. (Step 3 and Step 7)

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The results of the analytical study (multivariable analysis) were indicating

numerous factors leading to this outbreak, including consuming raw products, hand

washing practices and uncleaned source of drinking waters. The laboratory results

indicated that the outbreak specifically might be caused by Salmonella and E coli,

but further investigation is limited due to lack of laboratory services. The source of

the contamination was also unable to identify due to unavailability of food sample

(Step 4 and Step 5) The authors suggested that further interventions such as

strengthening health education for food handling practices to prevent similar cases in

the future (Step 6). Ethiopian Public Health Institute also has established a guideline

of outbreak investigation, including reporting and dissemination of findings as a final

step of outbreak investigations.

Discussion of the case study

Although public health interventions are more improved and common in

LMICs due to the support from international organizations, lack of resources and

medical equipment are still barriers to comprehensive outbreak investigations. In this

case study of food poisoning outbreak investigation, the steps were not completed

as specific etiology agent and source of the outbreak were not identified. The

specific interventions to prevent food poisoning cases are necessary; however, the

implementations of these interventions were not included in the report. Another

limitation for LMICs is various disease burdens and numerous outbreaks, leading to

lower quality of outbreak investigations. It is evident that there are many rooms for

improvements in management of the outbreaks in LMICs.

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Conclusion

LMICs are the countries that bear the majority of the burden from amenable

diseases, including diarrheal diseases. Millions of children are victims of diarrhea,

leading to high number of children mortality in LMICs. Diarrhea can be prevented

through WASH interventions, which are uncomplicated to implement, aiming to cut

off the chain of infection. Improving latrines, giving health education for personal

hygiene and treating water are effective for reducing diarrhea outbreaks in LMICs,

and child immunization programs and maternal services for exclusive breastfeeding

can also prevent severe diarrhea cases. Along with diarrhea, food poisoning cases

are causing outbreaks which requires outbreak investigation to stop spreading.

These outbreak investigations should be performed with 7 steps according to CDC,

however, as presented in a case study of Ethiopia, it is challenging for LMICs to

follow the exact steps due to limitations. These findings proved that LMICs require

more support to become self-sustaining countries in healthcare which can establish

robust public health systems to effectively prevent and control diseases, building

healthier communities.

Word count- 1785

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