11.
Outbreak(Epidemic)
Investigation
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Objectives
• Define Epidemic
• Types of Epidemic
• Describe stapes in epidemic investigations
• Discuss the management of Epidemic
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Brainstorming
What is outbreak/epidemics??
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Level of disease occurrence
• Diseases occur in a community at different levels.
• Generally classified as;
Expected levels
Endemic
Hyper-endemic
Sporadic
Excess of what is expected
Epidemic
Outbreak
Pandemic
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Expected level of disease occurrence
Endemic: a persistent low to moderate level of
occurrence of disease at a particular place ,person
and time
Hyper-endemic: A persistently high level of
occurrence of disease at a particular place,person
and time.
Sporadic: Occasional cases occurring at irregular
intervals
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Excess occurrence of disease
Terms used to describe:
Epidemic: occurrence of disease in excess of
what is expected in a limited period.
Outbreak: same as epidemic, often used by public
health officials because it is less aggressive to the
public. But is often used for a more limited
geographic area.
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Excess occurrence…
Pandemic: an epidemic spread over several
countries or continents, affecting a large number
of people
Cluster: aggregation of cases grouped in place
and time that are suspected to be greater than
the number expected, even though the expected
number may not be known.
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Outbreak
Definition : Outbreak (epidemic) is the occurrence
of a specific disease more than the expected
number in a given area or among a specific group of
people over a specified period of time.
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Reasons to Investigate an Outbreak
Control or prevention of the health problem
Opportunity to learn (research opportunity)
Public, political, or legal concerns
Public health program considerations
Training
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When to Investigate??
Severity of illness
Transmissibility
Unanswered questions
Ongoing illness/exposure
Public concern
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Investigation of an Epidemic
The following question should be answered??
Cause(Etiologic agent)
Source of the cause
Mode of transmission
Practice or Environmental deficiencies
Preventive/Control measures of an epidemic
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Source of information for Outbreak
Routine surveillance data- an increase in reported
cases of a disease.
Health care providers(Clinicians).
Community(affected group or concerned
person)
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Types of Epidemic
1. Common source epidemics
a. Point source (Food)
b. Continuous common source (water source)
2. Propagated or progressive epidemics
– serial transfer of infection
3. Mixed Epidemics
• The epidemic begins with a single, common source
of an infectious agent with subsequent propagative
spread.
• Many food borne pathogens result in mixed
epidemics.
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1. Common source epidemics
Caused by exposure of a group of people to a
common source of pathogen at the same time or
within a brief time period.
a) Point source epidemic- If the exposure is brief
and immediate, all exposed will develop the
disease within one incubation period -. E.g. Food
borne
b) Continuous common sources epidemic: If the
exposure to a common source continues over
time.
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2. Propagated or progressive epidemics
• Direct person-to-person transmission or the
transmission could pass through a vector from
infected to healthy person.
• E.g malaria,
• The epidemic curve …successive series of peaks
reflecting increasing numbers of cases in each
generation.
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Diseases requiring investigations
1. Endemic diseases with epidemic potential –
malaria, cholera, measles, hepatitis,
meningococcal meningitis
2. Even a single case of diseases for which
eradication/elimination goals have been set –
polio, guinea worm and yaws
3. Rare but internationally important diseases with
high case fatality rates – yellow fever, Ebola
(hemorrhagic fever)
4. Outbreaks of unknown etiology
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Steps of an Epidemic Investigation
No rigid step to follow during investigation
Several activities could be done simultaneously.
The steps to follow are set by the individual
investigator depending on the suspected cause of
the outbreak.
Avoid “quick and dirty” methods . “Quick and
clean “methods preferable.
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10 Steps Approach of Epidemic Investigation
1. Prepare for fieldwork
2. Verify the existence of an epidemic
3. Verify the diagnosis
4. Describe the epidemic with respect to time, place, and
person
5. Formulate and Test Hypotheses
6. Search for additional cases
7. Analyze the Data.
8. Make a decision on the hypotheses tested
9. Intervention and follow-up.
10. Report of the investigation.
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2. Verify the existence of an epidemic
Does the observed number of cases exceed the
existing number ?
Literature search
Consult the experts / Government
Surveillance records
Previous reports
Is there a confirmed case ?
Are there additional cases?
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4. Describe the epidemic with respect to time,
place, and person
• Epidemic curve plots the cases by the time of onset
and provides a timeframe for the outbreak investigation.
• Spot map plots the cases by location and shows the
geographic spread of cases.
• Attack rates calculation of illness in population at risk.
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Person: who is getting sick ?
Age
Sex
Race/Ethnicity
Socio-Economic Status
Behavior related
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Place: where are the cases coming from
?
Geographic Distribution
Homes
Work
School
Orphanages
Hospitals/Clinics
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8/6/2023 Snows dot map of London
MTS 391
Time: when are they getting sick?
Onset of symptoms
Incubation Period
Infectious Period
Seasonality
Baseline vs. epidemic
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Epidemic Curve: Meningitis Epidemic in Addis Ababa,
Ethiopia, 2000
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6. Search for additional cases:
• Environmental & Laboratory tests (e.g. home
visit; left over food samples)
• Do additional epidemiologic studies;
– Case control;
– Retrospective cohort studies;
– Follow up to evaluate control measures;
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7. Analyze the Data
(Evaluate hypothesis)
Further analyze existing data
Compare ill populations with not ill populations
Compare attack rates
Conduct statistical tests
Recommend Control Measures
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Report---
• Make recommendations regarding future surveillance
and control.
• Distribute report to others in disease control programs
as well as publish by doing studies.
• A record of performance and a document for potential
legal issues.
• Reference if the health department encounters a similar
situation in the future.
• Broader purpose for contributing to the knowledge base
of epidemiology and public health.
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Managing Outbreak/epidemics
o Require an urgent and intelligent use of appropriate
measures against the spread of the disease.
o Action to be taken is dependent on the type of the
disease as well as the source of the outbreak.
1. Measures Directed Against the Reservoir
2.Measures that interrupt the transmission of organisms
3. Measures that reduce host susceptibility
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Measures that interrupt the transmission
of organisms
Prevent transmission of disease by ingestion
Purification of water
Pasteurization of milk
Inspection procedures designed to ensure
safe food supply.
Improve housing conditions.
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Interrupt transmission of diseases with an
intermediate host.
E.g. Clearing irrigation farms from snails to
control schistosomiasis.
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Exercise
For each of the following situations, identify whether it reflects:
A. Sporadic disease
B. Endemic disease
C. Hyper endemic disease
D. Pandemic disease
E. Epidemic disease
1. ____ 80 cases of measles occurred within 1 month among
residents of X region (usually 2 or 5 per year)
2. ____Average annual incidence was 364 cases of pulmonary
tuberculosis per 100,000 population in one area, compared with
national average of 134 cases per 100,000 population
3. ___Over 34 million people worldwide affected by HIV since 1981
4. ____ Single case of histoplasmosis was diagnosed in a
community
5. ____About 10 cases of gonorrhea are usually reported Assela
Hosp. per week, slightly less than the Arsi Zone average
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Exercise ….
There was unknown cause of liver diseases epidemic
in one of the village of Tigray Region , Northern
Ethiopia
List at least 4 reasons that might justify an
investigation.
Describe the following.
• EPIZOOTIC???
• EPORNITHIC???
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