Epidemic
Investigation
Ma. Eufemia M. Collao, MD
Learning Objectives
At the end of the lecture the student should be
able to:
• Cite reasons why health agencies investigate
reported outbreaks
• Describe the different steps in investigating
outbreaks;
• Determine whether an epidemic exists or not;
• Differentiate common source and propagated
epidemics
• Interpret an epidemic curve
Definition of outbreak
• Occurrence of more cases of disease than
expected in a given area among a specific
group of people over a particular period of
time
or
• Two or more linked cases of the same
illness
Objectives of Outbreak
Investigations
• To determine the cause of the outbreak
• To control ongoing outbreaks
• To prevent future outbreaks
• To provide statutorily mandated services
• To strengthen surveillance at local level
• To advance knowledge about a disease
• To provide training opportunities
Specific Demands when
Investigating Outbreaks
• Unexpected event
• Need to act quickly
• Need for rapid control
• Work carried out in the field
Systematic approach
Steps of an Outbreak
Investigation
• Confirm outbreak and diagnosis
Case definition and identification
Descriptive data collection and analysis
Develop hypothesis
Analytical studies to test hypotheses
• Special studies
• Implementation of control measures
Communication, including outbreak report
Detection ?
Routine surveillance
Detection Clinical / Laboratory
General public
Media
Routine surveillance
Detection Clinical / Laboratory
General public
Media
Is this an outbreak?
Routine surveillance
Detection Clinical / Laboratory
General public
Media
Is this an outbreak?
Diagnosis verified ?
clinical + laboratory
Link between cases?
Expected numbers?
Sequence of Events 1
Outbreak Detection and Confirmation
Primary 1st case Report Samples Lab Response
Case at HC to DMO taken result begins
90
80
70
60
CASES
50
Opportunity
40 for control
30
20
10
0
10
13
16
19
22
25
28
31
34
37
40
1
DAY
Sequence of Events 2
Outbreak Detection and Confirmation
Response
PRIM HC REP SAMP RES begins
90
80
70
Potential
60
CASES
Cases Prevented
50
40
30
20
10
0
1
16
19
25
28
31
34
40
10
13
22
37
DAY
Outbreak confirmed
Immediate control Further
measures? investigation?
Outbreak confirmed
Immediate control Further
measures? investigation?
Unknown etiology
Prophylaxis (pathogen/source/transmission)
Exclusion / isolation Cases serious
Public warning Cases still occurring
Hygienic measures Public pressure
Training opportunity
Scientific interest
Outbreak confirmed
Immediate control Further
measures? investigation?
Unknown etiology
Prophylaxis (pathogen/source/transmission)
Exclusion / isolation Cases serious
Public warning Cases still occurring
Hygienic measures Public pressure
Training opportunity
Scientific interest
Assistance ?
Outbreak
? Investigation
Team?
Epidemiologist
Microbiologist Outbreak
Environmental specialist
Ministry / Government
Investigation
Press officer Team?
Others
FIELD
Epidemiologist
Microbiologist Outbreak
Environmental specialist
Ministry / Government
Investigation
Press officer Team?
Others
Assess situation
Examine available information
Preliminary hypothesis ?
Case definition
Case finding
Epidemiologist
Microbiologist Outbreak
Environmental specialist
Ministry / Government
Investigation
Press officer Team?
Others
Assess situation
Examine available information
Preliminary hypothesis ?
Case definition
Case finding
Descriptive epidemiology
Case Definition
• Standard set of criteria for deciding if a
person should be classified as suffering
from the disease under investigation.
• Clinical criteria, restrictions of time, place,
person
• Simple, practical, objective
• Sensitivity versus specificity
Example of Case
Definition
Patient older than 5 years with severe
dehydration or dying of acute watery
diarrhea in town “X” between 1 June
and 20 July 2006
Examples of Case
Definition
• Possible
– Patient with severe diarrhea
• Probable
– Patient older than 5 years with severe
dehydration or dying of acute watery
diarrhea in town “x” between 1 June
and 20 July 2006
• Confirmed
– Isolation of Vibrio cholerae from stool of
patient
Clearly identifiable groups
Identify & Hospitals
count cases Laboratories
Schools
Workplace, etc
Obtain information
Perform descriptive
epidemiology
Identify &
count cases
Identifying information
Obtain Demographic information
information Clinical details
Risk factors
Perform descriptive
epidemiology
Identify &
count cases
Obtain
information
Orient cases by
Perform descriptive - time
epidemiology - place
- person
Cases
Person Time
Place
1200 25
1000 20
800
15
600
10
400
200 5
0 0
0-4 '5-14 '15- '45- '64+ 1 2 3 4 5 6 7 8 9 10
44 64
Age Group
Evaluate information
Pathogen? Source? Transmission?
Cases of viral meningitis by date of admission (n=416)
Cyprus, 5 July - 5 November 5 1996
25
20
15
Cases
10
0
5 11 17 23 29 4 10 16 22 28 3 9 15 21 27 3 9 15 21 27 2
July August September October November
Date of admission
Distribution of Food Poisoning Cases by Onset of Illness at
the Philippine Supreme Court on August 20, 2004 (n=41)
20
“Binalot”
15 Sandwiches lunches
distributed distributed
10
Supreme Court
Employees
Association
5 General Assembly
0
12nn
6am
7am
1pm
2pm
4pm
5pm
6pm
8am
9am
3pm
8pm
7pm
10am
11am
Point source
25
Examples of 20
epidemic curves 15
10
0
1 3 5 7 9 11 13 15 17 19
Continuing common source Multiple waves -person to person
or further outbreak
20
20
15
15
10
10
5
5
0
0
1
10
13
16
19
1
3
5
7
9
11
13
15
17
19
Admissions per 100,000 population for viral meningitis
by age group. Cyprus, 5 July - 5 November 1996
500
450
Admissions/100,000 pop
400
350
300
250
200
150
100
50
0
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+
Age Group
Spot Map of Cholera in London,
1854
Develop hypotheses
• Who is at risk of becoming ill?
• What is the disease causing the
outbreak?
• What is the source and the vehicle?
• What is the mode of transmission?
Compare hypotheses with facts
Test specific hypotheses
Analytical epidemiological studies
Cohort Case-control
Prospective Retrospective
Logistic Regression Analysis of Potential Risk Factors for
Food Poisoning at the Philippine Supreme Court on
August 20, 2004
Exposure Odds Ratio p value 95% CI
Tuna Sandwich 4.814 .121 .662 – 35.028
Ham Sandwich 4.748 .100 .741 – 30.402
Chicken Sandwich 1.368 .741 .214 – 8.749
Egg 11.046 .001 2.522 – 48.377
Tomato .706 .566 .215 – 2.317
Banana 1.727 .434 .440 – 6.773
Zesto (snack) .523 .496 .081 – 3.384
Zesto (lunch) 1.349 .641 .384 – 4.747
Implement control measures
May occur at any time
during the outbreak!!
Control the source of the pathogen
Interrupt transmission
Modify host response
Prevent recurrence
Control the Source of
Pathogen
• Remove source of contamination
• Remove persons from exposure
• Inactivate / neutralize the pathogen
• Isolate and/or treat infected persons
Interrupt Transmission
• Interrupt environmental sources
• Control vector transmission
• Improve personal hygiene
Modify Host Response
• Immunize susceptibles
• Use prophylactic chemotherapy
Source / Transmission
known unknown
known
Investigation +
Control +++
Etiology
unknow n
Source: Goodman 1990
Source / Transmission
known unknown
known
Investigation + Investigation +++
Control +++ Control +
Etiology
unknow n
Source: Goodman 1990
Source / Transmission
known unknown
known
Investigation + Investigation +++
Control +++ Control +
Etiology
unknow n
Investigation +++
Control +++
Source: Goodman 1990
Source / Transmission
known unknown
known
Investigation + Investigation +++
Control +++ Control +
Etiology
unknow n
Investigation +++ Investigation +++
Control +++ Control +
Source: Goodman 1990
At the End
• Prepare written report
• Communicate public health messages
• Influence public health policy
• Evaluate performance
Cessation of an outbreak occurs when
there is:
- elimination of source of
contamination
- interruption of transmission
- reduction/exhaustion of susceptibles
- modification of the effect of primary
pathogen
An investigator should have
knowledge on the following:
• various types of etiologic agents and
the resultant disease
• epidemiological characteristics of
outbreaks associated with different
etiologic agents of resultant diseases
• clinical symptoms of resultant diseases
• environmental and food sanitation
practices
An investigator should have
knowledge on the following:
• sources of exposure which are
vulnerable to contamination with an
infectious or chemical agent
• laboratory test available to determine
causative agents
• read/search for additional data on
studies, prevention and control
• Acknowledgement:
– Dr. Jose Ramoncito P. Navarro
Epidemiologist, CPH, UP-Manila
