Outbreak investigation &

management
Presentation Outline
 Learning Objectives
 Definition of Terms
 Purpose of Outbreak Investigation
 When to conduct Outbreak Investigation
 Steps of Outbreak Investigation
 Outbreak Investigation report writing
 M& E of Outbreak Investigation
 Practical Exercises

08/14/2024 2
Learning Objectives
 Define cluster, outbreak, and epidemic
 List the reasons of outbreak investigation
 List and describe the steps in the investigation
of an outbreak
 Draw and interpret an epidemic curve
 Calculate the appropriate measure of the
association from two by two table
 Communicate findings of outbreak
investigation in scientific way
 List indicators of M&E of Outbreak investigation
08/14/2024 3
 Think/Pair/share

What is outbreak, and why

investigate?

5 minutes

08/14/2024 4
Definition of Terms

What is the definition of the following

terms?
 Pandemic
 Epidemic
 Outbreak
 Cluster of Cases
 Outbreak Investigation

08/14/2024 5
 Definition of Terms
Epidemic
 The occurrence of:
 More cases than expected in a
given area or among a specific
group of people, over a
particular period of time.
 Have a common cause or to be
related to one another in some way
 Pandemic
 an epidemic spread over several
countries or continents, affecting a
large number of people

08/14/2024 6
Definition of Terms
Outbreak:
 Epidemic limited to localized
areas
 Increase in the incidence of

disease
Cluster:
 An aggregation of cases in a
given area over a particular
period without regard to
whether the number of cases
is more than expected
08/14/2024 7
Definition of Terms
Outbreak Investigation
 A method of identifying and
evaluating people who have been
exposed to an infectious disease or
affected by an unusual health Event.
 The investigation provides relevant
information for taking immediate
action and improving long-term
disease prevention activities

08/14/2024 8
Purpose of outbreak
investigation
What is the purpose of investigating an
outbreak? Why can’t you take action on
just a rumor or report only?

08/14/2024 9
Purpose of outbreak
investigation…
 Primary- to control the spread of disease;
 To know magnitude of the problem
 To determine who is at risk
 To determine the causes of disease, its
source & mode of transmission
 Research & training opportunities
 Public, Political and legal concerns

08/14/2024 10
Control vs Further
Investigation
Which one is very Important??
1. Control
2. Investigation

08/14/2024 11
Control vs Further Investigation
known Source/Mode of Transmission
Known Unknown
Causative

Investigation + Investigation+++
Control ++++ Control +
Unknown

Investigation+++ Investigation++++
Agent

Control ++ Control+
How can we detect an outbreak?

08/14/2024 13
We can detect the Outbreak:-
Review routinely collected surveillance data

 Deviation from expected

Observe single events or clusters by clinicians,

infection control practitioners, or laboratorian

Reports by one or more patients or members

of the public

08/14/2024 14
When to conduct an investigation?

08/14/2024 15
We can conduct an investigation if:
 A report of a suspected epidemic of an
immediately notifiable disease is received,
 Alert or action thresholds reached
 Communities report rumor (large number of
cases, death)
 A cluster of deaths occurs for which the
cause is not explained or is unusual
08/14/2024 16
Basic Principles of Outbreak Investigation
Outbreak Investigation: process
of identifying the cause of epidemic,
the source of the cause, the mode of
transmission, and preventive/control
measures of an epidemic.
Commonly, multiple activities are
conducted simultaneously – it is a
dynamic process.

08/14/2024 17
Basic Principles…
During outbreak investigation, the
team should take care of the following
key issues:
Maintain regular communication with
officials, stakeholders and the public;
Apply appropriate epidemiological
and statistical principles regarding
study design and analysis;
Record all steps taken in the
investigation; 08/14/2024 18
Basic Principles…
Gather all information completely;
Review available literatures critically
and carefully;
Maintain open but critical mind to
uncover new pathogens/transmission
means.

08/14/2024 19
Steps of an Outbreak Investigation
What is your practical experiences?

What are the Steps of outbreak investigation?

Do we follow the steps?

08/14/2024 20
Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and identify additional cases
5. Analyze data
6. Develop hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and carry out additional studies
9. Implement control and prevention measures
10. Communicate findings

08/14/2024 21
Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and identify cases
5. Analyze data collected in terms of time, place and
person
6. Develop hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and carry out additional studies
9. Implement control and prevention measures
10. Communicate findings

08/14/2024 22
1. Prepare for Field Work
Decide to Investigate the Suspected
Outbreak:
 A report of a suspected epidemic or case of an immediately
notifiable disease is received,
 Alert or action thresholds have been reached
 Communities report rumors of deaths or a large number of
cases
 A cluster of deaths occurs for which the cause is not
explained or is unusual

08/14/2024 23
1. Prepare for Field Work
Assemble the team members
 An epidemiologist
 A clinician

 A laboratory technologist

 Environmental health specialist

 Interviewer

 Etc…

08/14/2024 24
1. Prepare for Field Work…
Identify and Assign Roles and Responsibilities
Identify the roles and responsibilities among:

 Team Members
 Different sectors

08/14/2024 25
1. Prepare for Field Work…
 Scientific knowledge
 Discuss the situation with someone knowledgeable about
the disease
 Source, Root of transmission, Risk factors
 References such as journal articles, guidelines and
questionnaires.

08/14/2024 26
 1. Prepare for Field Work…
 Consult laboratory staff :
 To take proper laboratory materials
 To know the proper collection,
 To know the proper storage, and
 To know the proper transportation

08/14/2024 27
 1. Prepare for Field Work…
Avail relevant resources
 Different formats
 Relevant guidelines
 Personal protective equipment (PPE)
 Laptop
 Mobile phone with communication cost if
necessary
Transportation
Personal matters

08/14/2024 28
 1. Prepare for Field Work…

Prepare plan of action.

 Set objectives of this investigation

 What will you do first, second, and third?
 Allow you to “hit the ground running” and
 Avoid delays resulting from misunderstandings

08/14/2024 29
1. Prepare for Field Work…
A communications plan must be established.

 how often to communicate

 when to have conferences with involved agencies,
 who will be spokesperson,
Arrange in advance when and where you are

to meet with local officials

08/14/2024 30
Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and identify cases
5. Analyze data collected in terms of time, place and
person
6. Develop hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and carry out additional studies
9. Implement control and prevention measures
10. Communicate findings

08/14/2024 31
2. Establish the Existence of an Outbreak
Verify that a cluster of cases

 Some clusters turn out to be true outbreaks with

a common cause,
 Some are sporadic and unrelated cases of the
same disease

08/14/2024 32
2. Establish the Existence of an
Outbreak…

Think/Pair/share

What are the causes of increase

in the number of cases?

5 minutes

08/14/2024 33
 2. Establish the Existence of an
Outbreak…
The increase in the number of cases might

be:
 True increase in incidence
 Change in reporting procedures
 Change in case definition
 Improvements in diagnostic procedures

08/14/2024 34
2. Establish the Existence of an Outbreak…
 Increased awareness
 Increased access to health care
 Laboratory or diagnostic error
 Batch reporting
 Change in denominator

08/14/2024 35
2. Establish the Existence of an Outbreak…

Steps to establish existence of an outbreak

 See trends in cases and deaths due to the

disease over the last 1-5 years
 Know the epidemic threshold for that particular
disease,
 Compare the reported case versus the baseline

08/14/2024 36
Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and identify cases
5. Analyze data collected in terms of time, place and
person
6. Develop hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and carry out additional studies
9. Implement control and prevention measures
10. Communicate findings

08/14/2024 37
3. Verify the diagnosis
First, review the clinical findings and

laboratory results
 Ask a qualified laboratorian to review the laboratory
techniques being used
 Collect and send laboratory specimen to specialized
laboratory

08/14/2024 38
 3. Verify the diagnosis…
Second, talk with some case patients

 Better understanding of clinical pictures

 Useful to generate hypothesis about the disease
etiology and spread
Third, summarize the clinical features using
frequency distribution
 Used to develop the case definition

08/14/2024 39
Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and identify cases
5. Analyze data collected in terms of time, place and
person
6. Develop hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and carry out additional studies
9. Implement control and prevention measures
10. Communicate findings

08/14/2024 40
4. Define and identify cases

Establish a case definition

 Clinical picture
 Sign
 Symptom
 Laboratory
 Epidemiological
 Time
 Person
 Place

08/14/2024 41
Components of an
Outbreak Case Definition
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

Should not include the suspected exposure

08/14/2024 42
Case Classification Levels

Confirme
d Laboratory
confirmed
cases
Probabl
e signs and symptoms
Objective
consistent with the case
definition.

Possible or
Subjective signs and symptoms consistent with the
Suspect
case definition.

08/14/2024 43
Example: Outbreak Case Definition
for Cholera
Suspected case:
 Resident of Moyale with at least 1 episode of
diarrhea with severe dehydration
21 Nov-7 Dec, 2015

Confirmed case:
 Suspect case with rectal swab positive for Vibrio
cholerae O1

Ref: Aman-Oloniyo et al. 61st Annual EIS

08/14/2024 44
Conference, Atlanta, GA, April 2012
Example: Outbreak Case Definition
for Cholera
Suspected case: Case definition elements
 Resident of Moyale with Clinical
 at least 1 episode of  Symptoms
 severe diarrhea
21 Nov-7 Dec, 2015  Lab

Epi
Confirmed case:  Time
 Suspect case with
 Place
 rectal swab positive for
 Vibrio cholerae O1  Person

08/14/2024 45
4. Define and identify cases…
Search for additional cases
1. Search for additional suspected cases and deaths
in the registers.
2. Look for other patients by identifying areas
where:
 The patients have lived,

 The patient worked,

 The patient travelled

3. Search in neighboring health facilities

4. Collect data using line list

08/14/2024 46
4. Define and identify cases…
Talk to other informants in the
community:
 Health extension workers,
 Pharmacists,

 Health workers,

 School teachers,

 Veterinarians,

 Farmers and community leaders etc.

08/14/2024 47
Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and identify cases
5. Analyze data collected in terms of
time, place and person
6. Develop hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and carry out additional studies
9. Implement control and prevention measures
10. Communicate findings
08/14/2024 48
Analyze Data …
Characterize an outbreak by
 Time,
 Place, and

 Person

It is called descriptive epidemiology

 When
 Where

 Who

08/14/2024 49
Analyze Data by Time
 Line graph or Histogram (no space between adjacent
columns)
 X-axis: Date of onset (by hour, day, week, month)
 Y-axis: Number of cases
 Can display columns or “stack of boxes”
9
8 Cases of Gastroenteritis, Vil- Cases of Gastroenteritis, Vil-
7 lage A, January 2019 lage A, January 2016
6 9
5 8

Number of Cases
7
4
6
3 5
2 4
1 3
0 2
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
0
Date 1 2 3 4 5 6 7 8 9 10 11 12

Date

08/14/2024 50
 Analyze Data by Time

Suggest time of
exposure if agent
known
 Event
 Travel/place

Suggest possible agents

if time of exposure
known

08/14/2024 51
Analyze Data by Time
The trend of the disease over time
 Increasing or decreasing
 Maintain
The overall shape of the epidemic curve can
reveal the type of outbreak which are:
 Common source outbreak
 Point source outbreak
 Propagated outbreak
 Intermittent

08/14/2024 52
Analyze Data by Time …
Histogram Below:
 Surveillance and health care service (Dengue Fever-Dire
Dawa 2013
 Community awareness (Cases decreased over weekend)
 Effectiveness of our interventions

08/14/2024 53
Patterns of Epidemics
 Based on the patterns, epidemics can be
classified as common source, propagated
and mixed epidemics.

08/14/2024 54
 Common source Outbreak
Source of the outbreak
 Common source.
 Water

 Environment

 Common source of food

There are three types of exposure to the

common source:
1. Point Source
2. A continuous exposure
3. An intermittent exposure

08/14/2024 55
Point Source Outbreak
 It is common source outbreak
 Exposure period is relatively brief,
 All cases occur within one
incubation period
 It has a sharp upward slope and
gradual downward slope typically
describes a point source outbreak

08/14/2024 56
Continuous exposure

 Cases to rise
gradually
 Possibly to plateau,
rather than peak
 Has no clear peak

08/14/2024 57
Intermittent exposure

 Irregular peaks that

reflect the timing
and extent of the
exposure

08/14/2024 58
Propagated outbreak
Transmitted from person to person
It can last longer than common source

May lead to multiple waves of infection if

secondary and tertiary cases occur.

The classic propagated epidemic curve has a

series of progressively taller peaks,

08/14/2024 59
Propagated outbreak…

14

12

10
Number of Cases

Days of Onset

08/14/2024 60
Mixed Epidemics
Show characteristics of both common source
and propagated epidemics.
So a mixed epidemic can start with a common
source and be followed by a propagated
spread.
Mixed epidemics are often caused by
foodborne infectious agents.

08/14/2024 61
Analyze Data by Person
Who is affected?
 Age
 Sex
 Occupation
 Vaccination status
 Educational level
 Marital status
 etc

08/14/2024 62
Analyze Data by Place
 Describe the geographic extent of the problem.

 Identify and describe any clusters or patterns of

transmission or exposure.
 Depending on the organism that has contributed to

this epidemic, specify the proximity of the cases to

likely sources of infection.

08/14/2024 63
Analyze Data by Place,
Measles Cases at Kaffa Zone, SNNPR, 2012

08/14/2024 64
08/14/2024 65
Summary

08/14/2024 66
08/14/2024 67