General Principles and

Guidelines of Infection Control in

Disease Outbreak

Senior Lecturer

kinwong@[Link]

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Learning Objectives
After this lecture, students should be able to:
• Define epidemiology, surveillance and outbreak
• State the notifiable diseases
• Describe the types and objectives of epidemiology and surveillance
• Identify the factors contributing to the emergence of infectious
disease
• Apply principles on investigating and controlling an outbreak of
infectious disease

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Epidemiology

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Definition of Epidemiology
• The word epidemiology comes from the Greek words
• Epi = on or upon
• Demos = people
• Logos = the study of

• Epidemiology is the study of the distribution and determinants of health-

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

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Epidemiology

• CDC’s definition

• Epidemiology is the study (scientific, systematic, data-driven) of the distribution (frequency,

pattern) and determinants (causes, risk factors) of health-related states and events (not just

diseases) in specified populations (patient is community, individuals viewed collectively), and

the application of this study to the control of health problems.

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Epidemiologic Triangle Et

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Frequency and Pattern
Epidemiology is concerned with the frequency and pattern of health events
in a population

Frequency
• Refers not only to the number of health events such as the number of
cases of meningitis or diabetes in a population, but also to the relationship
of that number to the size of the population.
• The resulting rate allows epidemiologists to compare disease occurrence
across different populations.

Pattern
• Refers to the occurrence of health-related events by time, place, and
person => descriptive epidemiology

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Descriptive Epidemiology

It covers the health events by distribution –

time, place, and person

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Descriptive Epidemiology: Time
• The occurrence of disease changes over time
• Important for monitoring disease occurrence in the community
and for assessing whether the public health interventions made a
difference

Line graph Histogram

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Descriptive Epidemiology: Time
• Epidemic curve shows the time course of a disease outbreak or
epidemic
• The shape of the epidemic curve may provide clues about the
pattern of spread in the population.
• The curve shows where you are in the course of the epidemic —
still on the upswing, on the down slope, or after the epidemic has
ended.
• This information forms the basis for predicting whether more or
fewer cases will occur

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Epidemic curve

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Descriptive Epidemiology: Place
• Describe the occurrence of disease by place provides insight into the
geographic extent of the problem and its geographic variation
• Not only the place of residence
• But also the geographic location relevant to disease occurrence
• E.g. place of diagnosis or report, birthplace, site of employment,
school district, hospital unit, recent travel destination

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Descriptive Epidemiology:
Place – spot map
• Spot maps use dots or other symbols to show where each case-patient lived or was exposed

Cases of Pneumonia by Room,

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Nursing Home A in New Jersey, 2001
 An outbreak of cholera in
the Broad Street area of
London in 1854

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Descriptive Epidemiology:
Place – Shaded map/Area map
• Shaded map/area map shows the rates of disease or other health conditions in different
areas by using different shades or colors

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Descriptive Epidemiology: Person
• Person characteristics may affect illness, organization and analysis of
data
• Inherent characteristics of people e.g. sex, age, race
• Biologic characteristic e.g. immune status
• Acquired characteristics e.g. marital status
• Activities e.g. occupation, leisure activities, use of
medication/tobacco/drug
• Socioeconomic status

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Determinants
• Epidemiology is also used to search for determinants, which are the
causes and other factors that influence the occurrence of disease
and other health-related events
• Epidemiologists assume that illness does not occur randomly in a
population, but happens only when the right accumulation of risk
factors or determinants exists in an individual
• Agents, causes, risk factors, sources
• The findings provide sufficient evidence to direct prompt and
effective public health control and prevention measures

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Surveillance

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Definition of Surveillance
• Public health surveillance is the ongoing systematic
collection, analysis and interpretation of health data
essential for planning, implementing and evaluating public
health activities.

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Uses of Public Health Surveillance
Surveillance is an essential feature of epidemiologic practice and may
be used to:
recognize isolated or clustered cases
assess the public health impact of events
assess trends
measure the causal factors of disease
monitor effectiveness and evaluate the impact of prevention and
control measures, intervention strategies and health policy changes
plan and provide care

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Surveillance Cycle

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Surveillance: Vital Statistics
• births, deaths, marriages, divorces, and fetal deaths => census in HK
• mortality and morbidity reports including hospital discharge data, lab
result, notifiable disease report => data provided by the local
hospitals and CHP in HK
• [Link]
• [Link]
100094

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Surveillance in communicable disease : Notifiable
infectious disease
• In accordance with the Prevention and Control of Disease Ordinance
(Cap.599), there are 53notifiable infectious diseases.
• All registered medical practitioners are required to notify the CHP for all
suspected or confirmed cases of these diseases.
• The Centre for Health Protection will conduct surveillance and control of these
diseases.
• [Link]

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 Outbreak

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Disease Outbreak – Definition (WHO)
• A disease outbreak is the occurrence of cases of disease in excess of
what would normally be expected in a defined community,
geographical area or season.
• An outbreak may occur in a restricted geographical area, or may
extend over several countries. It may last for a few days or weeks, or
for several years.

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Outbreak Classification

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Endemic Disease
 A relatively stable pattern of occurrence in a given geographical
area or population group at relatively high prevalence and
incidence.
 Such as malaria are among the major health problems in low-
income tropical countries
 e.g. Disease A: usually 40-50 cases per week, last week 48 cases

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Sporadic
• It refers to a disease that occurs infrequently and irregularly.
• e.g. Disease S: few than 10 cases per year, last week 1 case

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Epidemic
• Epidemics are defined as the occurrence of cases in excess of what is
normally expected in a community or region.
• e.g. Disease B: usually no more than 2-4 cases per week, last week 23
cases

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Pandemic
• An epidemic occurring worldwide, or over a very wide area, crossing
international boundaries and usually affecting a large number
of people.
• “Pandemic flu occurs roughly every 10 to 50 years and there were
three flu pandemics during the last century. In view of the recent
occurrence of avian influenza outbreaks among birds in Asia and
Europe and transmission of avian flu virus to human has been
observed, a pandemic flu caused by avian flu is a real threat. Experts
predict another pandemic will occur but cannot say exactly when it
will happen. Thus it is very important that everyone should be
prepared and take preventive measures.” (CHP, 2019)

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Investigating Outbreak

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Epidemiologic Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Construct a working case definition
5. Find cases systematically and record information
6. Perform descriptive epidemiology
7. Develop hypotheses
8. Evaluate hypotheses epidemiologically
9. Reconsider, refine, and re-evaluate hypotheses
10. Compare and reconcile with laboratory and/or environmental studies
11. Implement control and prevention measures
12. Initiate or maintain surveillance
13. Communicate findings
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1. Prepare for the field work
• Scientific and investigative issues
Knowledge, supplies and equipment
Discuss with someone who know about the disease
Consult laboratory staff to ensure proper laboratory material and proper
collection, storage, transportation technique
Protect yourself
• Management and operational issues
Communication plan, travel, logistics

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1. Prepare for the field work -Personnel

• Infection control team

• Medical director
• Infectious disease doctor / microbiologist
• Executive nurse directive
• Clinical head

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2. Establish the existence of an outbreak
• Verify the cluster of cases is indeed an outbreak
• Cluster is an aggregation of cases in a given area over a particular
period without regard
• Some clusters turn out to be true outbreaks with a common
cause, some are sporadic and unrelated cases of the same disease,
and others are unrelated cases of similar but unrelated diseases to
whether the number of cases is more than expected.
• A survey of community is conducted to establish the background
or historical level of disease

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3. Verify the diagnosis
• To ensure the disease has been identified properly
• Rule out laboratory error as the basis for the increase in reported
cases
• First – review the clinical findings and laboratory result
• Then- interview with the patient, ask for the exposure, what are the
causes
• Third, summarize the clinical features with the frequency distribution

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4. Construct a working case definition
• A standard set of criteria for deciding whether an individual should
be classified as having the health condition of interest
• e.g. fever >40C
• Three or more loose bowel movement a day

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5. Find cases systematically and record information
• Healthcare practitioners and facilities
• Clinics
• Hospitals
• Laboratories
• Passive surveillance- by sending a letter to ask for reports
• Active surveillance- telephoning or visiting the facilities to collect
information
• By asking the patient if they know anyone else with same condition

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6. Perform descriptive epidemiology
• Traditionally, a special type of histogram is used to depict the time
course of an epidemic.
• epidemic curve, or epi-curve for short, provides a simple visual
display of the outbreak’s magnitude and time trend.

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[Link] hypotheses

• Hypotheses may address the source of the agent, the mode (and
vehicle or vector) of transmission, and the exposures that caused the
disease.
• The hypotheses should be testable:
Review existing data – epidemiologic findings, microbiologic data
Open interview with the infected

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[Link] hypotheses epidemiologically
• Case control study
• Retrospective cohort
• Cross-sectional approach
• To assess the relationship between a given exposure and the disease
under study

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[Link], refine and re-evaluate
hypothesis
• Reconsider another hypothesis
• Reason for fail to explain the possibilities of real exposure
• May due to small number of sample – small village
• Or the accuracy of the information provided i.e. lack of knowledge,
poor memory, language difficulty , mental impairment

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10. Compare and reconcile with laboratory
and environmental studies
• Sampling- e.g. Collect and analyze the samples of food and beverage
served at common meal on gastroenteritis (GE) outbreak
• Or cooling water tower – Legionnaires’ disease 退伍軍人症

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[Link] control and prevention measures
• Timely implementation of appropriate measures
• To minimize further illness and death
• e.g. infection control measures, quarantine and isolation

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[Link] or maintain surveillance
• Continue to be monitored
• Active surveillance

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[Link] findings
• Public and press
• Summary of the investigation, findings, outcomes
• Oral briefing
• Written report

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Prevention of Disease Outbreak

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Health Education to the Public in Hong Kong

• [Link]
• [Link] useful/[Link]#

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3-tier response system in Hong Kong
Three response levels:
• Alert Response Level
The risk of serious health impact in Hong Kong is low
without imminent risk of causing any human infection in Hong Kong
• Serious Response Level
The risk to cause serious impact to human health in Hong Kong is moderate
Serious infections are not expected to be widespread in the short term
• Emergency Response Level
The risk and serious impact to human health in Hong Kong is high and
imminent
The infections may be widespread

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Here we are NUR3009 Care of people with communicable diseases 66
•

•
•

•
•

•
Quarantine and Isolation
• Isolation (隔離) separates sick people with a contagious disease from
people who are not sick (for confirmed cases)
• e.g. hospitals use isolation for patients with infectious tuberculosis
• Quarantine (隔離檢疫) separates and restricts the movement of
people to see if they become sick (for suspected/high risk cases)
• These people may have been exposed to a disease and do not know
it, or they may have the disease but do not show symptoms
• Not necessarily be carried out in hospital
• e.g. suspected cases in SARS & COVID-19

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Port Health
• The Port Health Office enforces relevant provisions of the Prevention
and Control of Disease Ordinance and the International Health
Regulations at the seaport, Hong Kong International Airport and land
boundary control points of Hong Kong so as to prevent infectious
diseases from being introduced into or carried away from the
territory.

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(CHP,2023) 75
Suggested Readings
• Bonita, R., Beaglehole, R., & Kjellström, T. (2006). Basic epidemiology. World Health
Organization. Chapter 7
• Centers for Disease Control and Prevention. (2006). Principles of epidemiology in
public health practice: An introduction to applied epidemiology and biostatistics.
([Link].). (Lesson 1,5 and 6)
• Centre of Health Protection. (202 ). Retrieved from :
[Link]
• H (2023)

• H (2023) C

• MedlinePlus.(2018) Retrieved from :

[Link]

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