Outbreak

Investigation
and
Management
Learning objectives
• What is an Outbreak?
• Why outbreaks should be investigated?
• Detection and reporting of suspected outbreak / EWS
• 11 steps of outbreak investigation
 • Epidemic refers to an increase, often sudden,
in the number of cases of a disease above
what is normally expected in that population
in that area. Outbreak carries the same
definition of epidemic, but is often used for a
Definition of more limited geographic area
• An epidemic may result from
an • ↑ in virulence
Outbreak • New Agent
• Enhanced mode of transmission
• Conducive environment
• Change in susceptibility of host
• ↑ host exposure, new portal of entry
Need for outbreak investigation
Surveillance and Rapid Response
Rapid
Early Response
Detection
90
First
80
Case
70 Potential
60 Cases Prevented
CASES 50
40
30
20
10
0

6
DAY
Detecting a suspected Outbreak or Early
warning signal
Event Based Surveillance Warning signs of an impending outbreak
•*Clustering of cases or deaths in time and/or place
• Community informants
•Unusual increase in cases or deaths
• Media scanning and verification (print and •Acute febrile illness of unknown aetiology (after
electronic ) testing for locally prevalent diseases)
• Rumour register •Shifting in age distribution of cases
•High vector density
•Natural disasters
Indicator Based Surveillance
• Review of routine data
• If the cases are approaching the threshold level
or has crossed it, then an outbreak should be
suspected.
• any unusual events
General Phases of an
Outbreak Investigation
 General Phases of an
0. Prepare for fieldwork
Outbreak Investigation

1. Determine the existence of an 6. Develop hypothesis 9. Implement Control

outbreak and prevention
7. Testing of hypothesis measures
2. Confirmation of the diagnosis 8. Compare the hypothesis 10. Monitoring the
3. Construct a working case with established facts situation
definition
11. Communicate finding
4. Find cases systematically and
record information
5. Perform descriptive
epidemiology
0. Preparation for field work
• Local Health staff, RRT and Partner agencies
• Learn about the disease
• Resources to be made available
• Vehicle
• Drugs and other medical supplies
• Diagnostic reagents and kits
• Facilities to transport samples
1. Determine the 2. Confirmation of the
existence of an outbreak diagnosis
• The MO of local area needs to • Medical officer needs to visit one
check or more patients with the disease
• If there is an abnormal increase in the number to verify the diagnosis
of cases or
• If there is a clustering of cases or • Review the clinical findings and
• If the cases are epidemiologically linked or laboratory results (if available)
• If some trigger events have occurred (see
above) or • Clinical presentation consistent
• If many deaths have occurred with diagnosis?
• Compatible exposure, e.g., to a
known lab confirmed case?
3. Construct a working case definition
• A case definition is a standard set of criteria for deciding whether an
individual should be classified as having the health condition of interest.
• Clinical criteria
• Characteristic symptoms and clinical signs
• Laboratory data
• Epidemiologic criteria (especially for outbreaks)
• Time
• Place
• Person (epidemiologic link, otherwise uncommon)
• Criteria must be as OBJECTIVE as possible
 3-Tiered Case Definitions

Confirmed
Laboratory confirmed,

Mo
in
Compatible symptoms

re
ta
er

inc
Probable
c

lus
re

Epidemiologically linked,

ive
Mo

Compatible symptoms

Suspect or Possible
Compatible symptoms
4. Find cases systematically and record
information
• Passive surveillance
• physicians’ clinics, hospitals, and laboratories
• Active surveillance
• house to house search
• Prepare a line list that includes all the criteria in the case definition
• Questionnaire/line list will capture questions that will identify the primary case,
secondary cases, possible source, routes of transmission and contacts
 Sample Line List

Signs/Symptoms Labs Demographics

Date of Stool
Symptom Fever culture
Case # Onset Diarrhea Vomiting >37oC Result Age Gender
Not
1 22/10/14 Y Y Positive 19 M
done

2 25/10/14 N Y N Negative 17 M

3 22/10/14 N Y N Positive 23 F

4 27/10/14 Y ? ? Pending 18 ?

5 23/10/14 N Y N Positive 21 M

6 21/10/14 Y Y Y Not done 18 F

5. Perform descriptive epidemiology
• Time (epidemic curve)
• Ideally: when were they infected?
• More practically: when did they become ill?

• Place (spot map, shaded map)

• Ideally: where were they infected?
• More commonly: where do they live, work?

• Person (tables)
• Who was infected?
• Who is at risk?
Time: Epidemic Curve

• Magnitude of the epidemic

• Shape: clues about the pattern of spread
• Where you are in the course of the epidemic
• Determine the incubation period
• Evaluation, answering questions like: How long did it take for the health
department to identify a problem? Are intervention measures working?
• Highlights outliers
Place (Spot Map, Shaded map)

• Ideally: where were

the cases infected?

• More commonly:
where do the cases
live, work?

Cumulative Number of Ebola Virus Disease Cases

by Region, West Africa, 2014-2015
 Person – Tables, Pie diagram etc
• Who was infected?
• Who is at risk? Male
Female

• Person data is used to

measure disease
frequency and disease
severity
– Numerators (e.g. # cases, #
cases who died)
– Denominators (e.g.
population size, # people
exposed to agent)
 6. Develop hypothesis
• Hypothesis (in context of outbreak) = educated guess about an association
between an exposure and outcome, and/or about mode of spread

• Hypothesis should be in a form that allows it to be tested

• Exposure: factor that may be possible cause
• Outcome: health effect
Exposure Outcome
Eat contaminated meat Develop E. coli infection
Drive without seat belt Injured in vehicle accident
Drink alcohol Become drunk
Drink alcohol every day x 10 years Liver damage
Live near mosquito breeding site Contract malaria
Use insecticide-treated bednets Do not contract malaria
Smoke cigarettes Lung cancer
 How to Develop a Hypothesis

• Subject matter knowledge – experience with past

outbreaks, known sources of infection, and
transmission modes
• Review descriptive epidemiology – what would
account for most cases? What do cases have in
common?
• Outliers (unique exposure opportunities)
• What do local health officials think?
• Talk to case-patients – what do they think?
 Subject-Matter Knowledge for
Hypothesis Generation
• What kinds of agents cause this clinical
presentation?
• What are the agent’s usual reservoirs?
• How is the agent usually transmitted?
• What are the known risk factors?
 Descriptive Epidemiology for
Hypothesis Generation
• Time (Epidemic curve)
– Does shape hint at source or mode of transmission?
– Does narrow peak point to a particular time of
exposure?
• Place
– High attack rates in one place? What is special about
that place (neighborhood, wing of hospital, etc.)?
• Person
– Which group(s) — by age, sex, occupation, etc. —
have highest rates?
7. Testing of hypothesis
• 2 ways
• comparing the hypotheses with the established facts
• when the clinical, laboratory, environmental, and/or epidemiologic evidence so obviously
supports the hypotheses that formal hypothesis testing is unnecessary
• analytic epidemiology to quantify relationships
• When source of infection is highly unlikely then findings must be reassessed, more
information should be gathered, reconsider clinical diagnosis and pose & test new
hypothesis
• Case-Control studies
• Retrospective Cohort studies
8. Compare the hypothesis with established facts
• While epidemiology can implicate vehicles and guide appropriate
public health action, laboratory evidence can confirm the findings.
Similarly, environmental studies are equally important in some
settings
• the epidemiologic, environmental, and laboratory arms of the
investigation complements one another
9. Implement Control and prevention measures
• Prevent further exposure and future outbreaks by eliminating or
treating the source so that additional cases can be prevented
• Should be initiated as soon as possible
 Control Strategies for Reservoir
• Humans
Reservoir – Treat infected persons
– Isolate infected persons
– Quarantine exposed persons
• Animals
– Cull
– Vaccinate
• Environment
– Decontaminate, disinfect
 Routes of Transmission

Route of Direct: Indirect:

Transmission  Airborne
 Touching,
 Vector-borne
kissing,
Agent  Vehicle-borne
intercourse
– Food
 Droplet
– Water
 Transplacental
– Biologics
– Fomites
– Other
 Control Strategies for
Direct Transmission
Direct:
 Touching, kissing, • Treatment / isolation
intercourse of infected person
• Barriers to prevent
 Droplet
agent from leaving
 Transplacental host (bandages,
dressings, condoms)
 Control Strategies for
Indirect Routes of Transmission
Airborne Vehicle-borne
Private room with negative •Food & water
pressure Heat, pasteurize, irradiate
Door closed, wear N95 masks Prevent infected food-handler from
working
Vector-borne
Chlorinate water
Eliminate breeding sites
•Biologics
Kill vector (larvicide, adulticide)
Throw out
Sterilize
•Fomites
Sterilize
•Other
 Control Strategies for
Prevent Entry, Protect the Host
• Behavior change Susceptible Host
• Exclusion (of at-risk persons) (via portal of entry)
• Use barriers (long sleeves/pants)
• Vaccination
• Passive immunization
• Pre-exposure prophylaxis
• Post-exposure prophylaxis
• Improved host resistance
• Contact tracing or partner notification,
then screening / treatment
10. Monitoring the situation
• DSO should monitor the situation on regular basis ideally on daily
basis and give feedback to RRT
• The main point to monitor are:
• The trends in the cases and deaths.
• The containment measures that are being implemented
• Drugs / vaccine stock
• Logistic issues – communications, vehicles,
• Community involvement
• Media response
• This should continue till the outbreak is officially declared to be over
• When DSO can declare that the outbreak is over?
10. Monitoring the situation (cont…)
• Daily report should at least contain:
1. New cases & Cumulative cases
2. Clinical severity of cases
3. Deaths (new & cumulative)
4. Samples collected
5. Lab reports
6. Control measures taken
7. Situation of supplies
8. Requirement
9. Hospitalisation and discharged records.
10.Any other
11. Communicate finding
• Title of the report
• Introduction
• Investigation methods
• Results: epidemiological, microbiological / toxicological,
Environmental
• Discussion
• Recommendations
Key messages
• Every EWS/outbreak should be reported to District immediately.
• Every EWS needs to be investigated by local medical team for its veracity
• Outbreaks to be verified by RRT and final outbreak report to be submitted
• Outbreak investigation is a skill learnt in field by experience
• Outbreak investigations serve many functions, most importantly to prevent and
control the spread of a disease
• Outbreak investigations should be systematic and have 11 steps to consider
• Outbreak investigation should lead to action including appropriate control
strategies, and communicating recommendations