Principles of Outbreak
Management
Soili Larkin & Joshna Mavji
Aim
Understand the principles of outbreak
management
2 Principles of Outbreak Management
Objectives
• Define an outbreak
• Describe the purpose of outbreak management
• Outline the steps involved in the management of an outbreak
• Outline the roles and responsibilities of an Outbreak Control Team in the
management of an outbreak
• Apply the learning to an outbreak exercise
3 Principles of Outbreak Management
What is an Outbreak?
4 Principles of Outbreak Management
What is an Outbreak?
• Two or more linked cases of an illness
• A single case of an unusual or rare infection.
• A greater than expected rate of infection compared with the usual
background rate that is expected in that population for that place
or time.
• A suspected, anticipated or actual event involving microbial
contamination of food or water
5 Principles of Outbreak Management
Purpose of Outbreak Management
• Identify and control outbreaks of infection
• Reduce illness and complications
• Inform future prevention strategies
• Evaluate existing prevention strategies
• Address public concern
6 Principles of Outbreak Management
Outbreak Management Framework
• Case definition • Microbiological investigation
• Confirm diagnosis in known • Environmental investigation
cases
• Hypothesis generation
• Determine background
• Analytic epidemiology
incidence of disease
• Communications
• Case-finding
• Control measures
• Data collection
• Descriptive epidemiology
7 Principles of Outbreak Management
Outbreak Management: Case Definition
Case definition
Not always possible to secure laboratory confirmation:
• False negatives and positives not uncommon
Confirm diagnosis • Samples are not always taken (e.g. diarrhoea)
• Appropriate tests may be unavailable (e.g. botulism)
Background incidence
Case-finding Conversely, laboratory confirmation sometimes essential:
• e.g. legionella, hepatitis A/B/C, VHF
Data collection
• Possible, probable, confirmed
Descriptive epidemiology
Microbiological investigation
Components
• Time…..based on incubation (if known)
Environmental investigation • Place….location of suspected exposure
• Person….type of illness
Hypothesis generation
Analytic epidemiology
Task – Using the components listed above,
Communications provide a case definition for an outbreak of
Control Measures Hepatitis A
8 Principles of Outbreak Management
Outbreak Management: Confirm Diagnosis
Case definition
• To assist in verifying whether an outbreak has occurred
Confirm diagnosis
Background incidence
• For describing the epidemiology
Case-finding
• Will involve verifying that cases fit the case definition
Data collection
• Use medical records or laboratory reports
Descriptive epidemiology
Microbiological investigation
Environmental investigation
Hypothesis generation
Analytic epidemiology
Communications
Control Measures
9 Principles of Outbreak Management
Outbreak Management: Background Incidence
Case definition
• Some outbreaks defined when rates exceed the
Confirm diagnosis
background incidence in the community (e.g.
Background incidence
cryptosporidiosis)
Case-finding
• Obtained from local and national surveillance data
Data collection
Descriptive epidemiology
Microbiological investigation
Environmental investigation
Hypothesis generation
Analytic epidemiology
Communications
Control Measures
10 Principles of Outbreak Management
Outbreak Management: Case Finding
Case definition Initial cases may only make up a small proportion of all cases.
Active case finding helps:
Confirm diagnosis
Establish the onset (which helps identify source)
Background incidence Define the extent of the outbreak – minor or major
Identify cases requiring healthcare input
Case finding
Identify where control measures are needed
Data collection Provide subjects for epidemiological studies
Descriptive epidemiology Monitor effectiveness of control measures
Determine when the outbreak can be declared over
Microbiological investigation
Environmental investigation
Line listing is useful to summarise the information. It usually
Hypothesis generation
includes:
Demographic information
Analytic epidemiology
Clinical information
Communications Exposure information
Control Measures
11 Principles of Outbreak Management
Outbreak Management: Case Finding
Case definition Additional cases can be sought from:
Confirm diagnosis • Statutory notifications
Background incidence • Microbiology laboratory results
Case finding
• GPs
• Hospitals (A&E, ID Dept, inpatients, outpatients)
Data collection
• Occupational health - large employers
Descriptive epidemiology
• School reports of absenteeism and illness
Microbiological investigation
• Household enquiries
Environmental investigation
• Media appeals
Hypothesis generation
• Screening of population subgroups
Analytic epidemiology
Communications
Control Measures
12 Principles of Outbreak Management
Outbreak Management: Data Collection
Case definition • Data collection should be standardised
Confirm diagnosis • Methods depend on the outbreak and resources
available:
Background incidence
Detailed questionnaires: face-to-face administration
Case finding
Data collection Mailed questionnaires for self-completion
Descriptive epidemiology Telephone interviews
Microbiological investigation
Environmental investigation
Hypothesis generation
Analytic epidemiology
Communications
Control Measures
13 Principles of Outbreak Management
Outbreak Management: Data Collection
Case definition
• Data could include, as appropriate, questions about the
following:
Confirm diagnosis • Name, age, sex;
• GP details;
Background incidence
• Occupation; work or school address;
Case finding
• Illness onset and clinical description;
Data collection • Immunisation history;
• Food history;
Descriptive epidemiology
• Water exposure;
Microbiological investigation • Social activity: gardening, social events, social venues;
Environmental investigation
• Sexual contacts;
• Injecting drug use;
Hypothesis generation
• Close contacts: household, school, workplace;
Analytic epidemiology • Animal contact: pets, farm visits, travel;
• Foreign or local travel: vaccines and drug history; departure &
Communications
return dates, countries visited; places visited; accommodation;
source of food and water; activities (work, leisure, trekking, jungle
Control Measures
excursions, etc.); contact with animals.
14 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
Case definition
• Defines the outbreak in terms of person, place and time
Confirm diagnosis
• Provides clues re:- causative organism
Background incidence
• Hypothesis generation – source of infection / mode of
Case finding
transmission
Data collection
Descriptive epidemiology • Define extent of the outbreak
Microbiological investigation • Monitor outbreak progress & control measures
Environmental investigation
• Helps decide when the outbreak can be declared over
Hypothesis generation
• Epi Curves are useful to suggest:
Analytic epidemiology
Type of exposure
Communications
Time of exposure
Control Measures Possible exposure agent
15 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
Case definition Patterns of Spread
• Common Source Outbreaks - Cases of disease arise from a single, shared
Confirm diagnosis or 'common' source, such as a batch of bad food, industrial pollution or a
contaminated water supply. Controlling the source stops the outbreak.
Background incidence
• Point source outbreak – all cases appear to occur within one incubation period
Case finding
therefore is usually of short duration
• Continuing source outbreak – all cases are exposed to a single noxious
Data collection influence but the exposure continues over a longer time so the outbreak persists
for longer
Descriptive epidemiology • Intermittent outbreak – all cases are exposed to a common source that is not
well controlled, so outbreaks recur.
Microbiological investigation
• Person-to-Person Spread – Disease spreads via person-to-person contact.
Controlling the source is no longer sufficient to control the outbreak
Environmental investigation
• Index case with limited spread / point source with secondary transmission
Hypothesis generation – a single index case infects other individuals and cases arise after an incubation
period. The outbreak wanes when the infected people no longer transmit
infection to other susceptible individuals, usually because of implementation of
Analytic epidemiology
successful control measures.
Communications • Propagated spread – index case infects other individuals (secondary cases)
who, in turn, infect more individuals.
Control Measures
16 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
17 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
18 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
19 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
20 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
21 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
22 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
23 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
24 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
25 Principles of Outbreak Management
Outbreak Management: Descriptive Epidemiology
TASK
Match the epidemic curves with the type of outbreak they represent and give an example of
each type
Type of Outbreak
Point Source outbreak
Continuing Source outbreak
Intermittent outbreak
Point Source with Secondary
Transmission
Propagated Spread
26 Principles of Outbreak Management
Outbreak Management: Microbiological Investigation
Case definition • Laboratory confirmation not always possible
Confirm diagnosis
• Liaison with microbiologists (and veterinarians) to discuss:
Background incidence
Implications of laboratory results
Case finding
Further human, (animal) and environmental samples
Data collection
Descriptive epidemiology
Microbiological investigation
Environmental investigation
Hypothesis generation
Analytic epidemiology
Communications
Control Measures
27 Principles of Outbreak Management
Outbreak Management: Environmental Investigation
Case definition
Includes:
Confirm diagnosis
• Inspection/ sampling of physical environment (e.g. cooling
Background incidence
towers)
Case finding
Data collection
• Appraisal of procedures and activities (e.g. personal
Descriptive epidemiology hygiene, food hygiene and infection control policy)
Microbiological investigation
Environmental investigation
Hypothesis generation
Analytic epidemiology
Communications
Control Measures
28 Principles of Outbreak Management
Outbreak Management: Hypothesis Generation
Case definition • Need to consider epidemiological, microbiological and
Confirm diagnosis environmental evidence
Background incidence • May be revised repeatedly as more evidence becomes available
Case finding
• Credibility of hypothesis evaluated by:
Data collection
Comparing with established facts
Descriptive epidemiology
Analytic epidemiology - unnecessary if evidence strongly supports
Microbiological investigation hypothesis
Environmental investigation
Hypothesis generation
Analytic epidemiology
Communications
Control Measures
29 Principles of Outbreak Management
Outbreak Management: Analytic Epidemiology
Case definition • If resources available
Confirm diagnosis • To further test hypotheses when doubts persist or control measures fail
Background incidence • Comparison group: quantify exposure-disease relationship
Case finding • Statistical evaluation of attack rates or odds ratios
Data collection • Cohort studies include EVERYONE who could have been exposed
therefore requires a complete list e.g. meeting/wedding attendees etc.
Descriptive epidemiology
Measure of association = relative risk
Microbiological investigation
• Case-control studies compare exposures among ill persons (cases) and
Environmental investigation
non-ill persons (controls). This is used when a complete list is not available
Hypothesis generation or is too large e.g. restaurant attendees, national outbreaks etc. Measure
Analytic epidemiology of association = Odds Ratio
Communications
Control Measures
30 Principles of Outbreak Management
Outbreak Management: Communications
Case definition Robust communication systems are required for:
Confirm diagnosis • Investigation – active case finding (e.g. from GPs, microbiologists)
Background incidence • Control – disseminating advice to the public, health professionals
and other agencies
Case finding
• Liaison – with public, media, and health & non-health agencies
Data collection
Descriptive epidemiology
Microbiological investigation
Environmental investigation
Hypothesis generation
Analytic epidemiology
Communications
Control Measures
31 Principles of Outbreak Management
Outbreak Management: Communications
Case definition Consideration of content:
Confirm diagnosis • Appropriate for target audience
• Accurate
Background incidence
• Consistent
Case finding • Understandable (consider non-English speakers, blind, deaf etc.)
Data collection
Methods include:
Descriptive epidemiology
• Media (print, radio, TV)
Microbiological investigation • Telephone advice lines (in liaison with NHS Direct)
• Loudspeaker vans
Environmental investigation
• Leaflets
Hypothesis generation
• Internet
Analytic epidemiology
Communications
Control Measures
32 Principles of Outbreak Management
Outbreak Management: Control Measures
Case definition Basic principles:
Confirm diagnosis • Removing source of infection
Background incidence
Isolate cases
Product recall
Case finding
• Interrupting transmission
Data collection
Personal hygiene e.g. hand washing
Descriptive epidemiology
• Protecting persons at risk
Microbiological investigation Prophylaxis
Environmental investigation Vaccination
Hypothesis generation
• Preventing recurrence
Guidelines
Analytic epidemiology
Recommendations
Communications
Control Measures
33 Principles of Outbreak Management
Outbreak Management: Control Measures
Case definition TASK
Confirm diagnosis What control measures could be put into place for the
Background incidence following:
Case finding • Food poisoning outbreak
Data collection • Pandemic flu
Descriptive epidemiology
Basic Principles
Microbiological investigation • Removing the source of infection
Environmental investigation • Interrupting transmission
• Protecting persons at risk
Hypothesis generation
• Preventing recurrence
Analytic epidemiology
Communications
Control Measures
34 Principles of Outbreak Management
OUTBREAK CONTROL
TEAM (OCT)
35 Principles of Outbreak Management
Outbreak Control Team: Roles and Responsibilities
• Review outbreak evidence – results of epidemiological, microbiological and environmental investigations
• Recommend control measures based on risk assessment
• Agree further investigations
• Decide on incident room establishment
• Decide on OCT membership
• Assign individual responsibilities to OCT members
• Determine resources required
• Ensure surveillance data to monitor progress
• Decide who is to be kept informed of the progress of the outbreak and circulate regular reports as appropriate
• Ensure arrangements to communicate with public/media
• Meet regularly during the outbreak and ensure that a written record of each meeting is made
• Decide criteria for declaring the outbreak over
• Produce and circulate a final report
36 Principles of Outbreak Management
Outbreak Control Team: Membership
• Chair (usually a CCDC) • Toxicologist
• Environmental Health • CCG Representative
• Public Health Laboratory representative • NHS England Area Team Representative
• Consultant Microbiologist • Representatives from affected NHS Trust
• Administrative and secretarial support • Health & Safety Executive representative
• Director of Public Health (or nominated deputy) • Food Standards Agency representative
• Consultant Epidemiologist • Environment Agency representative
• Communications Officer • Department for Environment, Food & Rural
• Health Protection Nurse/Practitioner Affairs representative
• Community Infection Prevention & Control • State Veterinary Service representative
• Hospital Infection Prevention & Control • Water Company representative
• Clinical Virologist • Legal Officer
37 Principles of Outbreak Management
Further Reading
• Hawker, Begg et al., (2012)
Communicable Disease Control and
Health Protection Handbook. 3rd
edition.
• Public Health England. Immunisation
against infectious disease. (online)
https://www.gov.uk/government/collecti
ons/immunisation-against-infectious-
disease-the-green-book
• Heymann. (2008) Control of
Communicable Diseases Manual. 19th
edition.
38 Principles of Outbreak Management
