EPIDEMICS
Fessahaye Alemseged (MD, MPHE)
08/31/20 1
Objectives and Contents
Objectives
Describe the types of epidemics
Describe and apply epidemic investigation and control
measures
Contents
Patterns of disease occurrence
Types of epidemics
Ix and control of epidemics
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Reading
CDC –Principles of Epidemiology
Fletcher
Mausner
IDSR National Guideline
MOHE, Guidelines for the Prevention and Control of
Selected Epidemic Disease in Ethiopia
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Patterns of disease occurrence
Endemic-usual level of morbidity
What disease are endemic in Ethiopia?
Some of the endemic disease of public health importance
in Ethiopia include:
Tb, Malaria, Typhoid, dysentery, HIV, Malnutrition,
Meningitis, leshmaniasis, Trachoma, Scabies,
Schistosomiasis, Onchocerciasis
Patterns of endemicity
E.g. – Malaria – Holoendemic, Hyperendemic, Mesoendemic,
Hypoendemic
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Patterns of disease occurrence
Epidemic- occurrence of health related condition
in excess of its expected frequency in a given
population
Related terminologies – outbreak, cluster
What disease are known to occur in the form of
epidemics in Ethiopia?
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Patterns of disease occurrence
Some of the epidemic disease of public health
importance in Ethiopia include:
Malaria, Measles, Meningitis, Cholera ,
Shigelloses, Diarrhea with dehydration, Plague,
Typhoid fever, Relapsing fever, Epidemic typhus
Pandemic-global epidemic
E.g. - HIV/AIDS, obesity
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Epidemics
Epidemic- occurrence of health related condition in
excess of its expected frequency in a given population
Health related condition-infectious and non-infectious conditions
Expected frequency-magnitude for the given period, place and
population from previous data
In excess – more than expected frequency
Definition depends on type of disease, population affected and
time/season of occurrence
Compare with past levels
Thresholds should be developed and used for the most critical diseases
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Patterns of disease occurrence cont.
Epidemics can have the following patterns
Sporadic-irregular intervals
E.g. – Plague
Periodic/Cyclic-regular intervals
E.g. –measles, diarrhea, meningitis
Secular-slow changes over time
E.g. – lung ca
Epidemic lasting long may remain endemic
Endemic disease can turn out to be epidemic
Due to increase in susceptibles, ecological changes,
increase in no of carriers, appearance of new strains
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Types of Epidemics
Common source, Propagated and Mixed
Common source
Occur as a result of exposure to common source for the
agent
Depending on duration of exposure:
Point source Vs Common source with prolonged (continued or
intermittent) exposure
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Types of epidemics cont.
Point source epidemics
Exposure is brief and simultaneous
Cases develop within one incubation period
E.g. - food-borne outbreak
Epidemic curve-rapid rise and fall of number of cases
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Types of epidemics cont.
Common source epidemic with continuous or
intermittent exposure
Exposure continues over a period of time
Lasts for more than one incubation period
E.g. – Outbreak of hepatitis A from exposure to food
contaminated by infected food handler intermittently or
continuously
Epidemic curve-extended and irregular
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Types of epidemics cont.
Propagated/Progressive epidemics
Occur as a result of transmission from one person to
another
Lasts for more than one incubation period
E.g. – Measles, Malaria, Shigellosis
Epidemic curve-initial slow rise, succession of several
peaks and usually sharp fall
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Types of epidemics cont.
Mixed
Point source epidemic may be followed by propagated
epidemic
E.g. – Shigelloses epidemic from exposure to common
contaminated food supply followed by person-to-
person spread
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Epidemic Ix
Ix-determining the causes and population affected
so as to control the epidemic
Causes:
Agent
Source
Main mode of transmission
Contributing factors
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Epidemic Ix cont.
Activities in ix include:
1. Ix of index case and active case detection
Index case – the first case
Active case detection – to look for additional cases
2. Preparation for field work
Ix related-scientific knowledge, supplies to carry out ix,
questionnaire
Administration related- transportation, personnel
Consultation-team, local contacts
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Epidemic Ix cont.
3. Verify existence of an epidemic
Compare with past levels
Observe thresholds for the most critical diseases
alert threshold-suspected epidemic
one suspected case (as for an epidemic-prone disease or for a
disease targeted for elimination or eradication) or
For other priority diseases of public health importance -when there
is an unexplained increase over a period of time in monthly
summary reporting/ any unusual increase in the number of cases
when compared with previous time periods/
Response includes: Reporting, requesting laboratory confirmation,
being more alert to new data, alert the epidemic response team
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Epidemic Ix cont.
An action threshold-confirmed epidemic
A confirmed case -for epidemic-prone diseases, and for
disease targeted for elimination or eradication
For other priority diseases of public health importance
–confirmed epidemic
Response- a definite emergency response
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Epidemic Ix cont.
Meningococcal meningitis
alert threshold :
Population greater than 30 000, 15 cases/100 000 inhabitants/week
Population less than 30 000, 5 cases in 1 week or an increase in the number
compared to the same time in previous years
action threshold :
Population greater than 30 000, 15 cases/100 000 inhabitants/week confirms
epidemic in all situation. If no epidemic during last 3 years and vaccine
coverage against meningococcal meningitis is <80%, action threshold is 10
cases per 100 000 inhabitants per week
Population less than 30 000: 5 cases in 1 week or doubling of the number of
cases over a 3-week period
Measles- usually 5 suspected cases/month/District, if 2 are positive
epidemic confirmed
Malaria - read
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List of Priority Diseases in Ethiopia
Epidemic-Prone Diseases
Cholera
Diarrhoea with blood (Shigella)
Measles
Meningitis
Plague
Viral hemorrhagic fevers***
Yellow Fever
Typhoid Fever
Relapsing Fever
Epidemic Typhus
Malaria
Diseases Targeted for Eradication and Elimination
Acute flaccid paralysis (AFP)/polio
Dracunculiasis (Guinea Worm)
Leprosy
Neonatal tetanus
Other Diseases of Public Health Importance
Pneumonia in children less than 5 years of age
Diarrhea in children less than 5 years of age
New AIDS cases
Onchocerciasis
Sexually transmitted infections (STIs)
Tuberculosis
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Epidemic Ix cont.
4. Verify the disease
Clinical and laboratory evidence
5. Define and identify additional cases
5.1. Develop case definition
Criteria for classifying suspects - general and
specific descriptions
Based on lab results criteria: suspected/possible,
probable and confirmed
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Epidemic Ix cont.
Suspected/possible case: is a case with fewer
major or atypical symptoms but that responds to
treatment
Probable case: is a case with major/typical signs
and symptoms of a disease and/or suggestive but
not confirmative laboratory findings
Confirmed/definite case: is a suspected or
probable case which has been confirmed by
laboratory test
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Epidemic Ix cont.
5.2. Surveillance
Identifying and counting cases to determine the geographic
extent and population affected
Methods - enhanced passive surveillance and active
surveillance
Data to be collected - identification, demographic, clinical
and risk factor information
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Epidemic Ix cont.
6. Describe the epidemic by time, place and person
Epidemic curve
Provides time frame for identifying type of epidemic,
etiologic diagnosis and determining IP
Spot map
Shows geographic spread of the disease
Person
Gives profile of those affected
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Epidemic Ix cont.
7. Formulate and test hypothesis
Develop hypothesis regarding
the possible source and the etiologic agent
the mode of transmission and type of epidemic
the population at risk
Test hypothesis using
Retrospective cohort study-RR
Case-control study-OR
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Epidemic Ix cont.
Retrospective cohort study design exercise:
Of 75 persons who attended a wedding supper, 46 became ill within
several hours (AR = 46 / 75): AR = 61.3%
Test the hypothesis that contaminated Kitfo was the source of the GI
infection.
Exposure status No Became ill
Did not eat Kitfo 18 3
Ate Kitfo 54 43
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Epidemic Ix cont.
Case-control study design exercise:
Several college students presented with GI-related symptoms
thought to have been associated with food served in the cafeteria
Test the hypothesis that contaminated macaroni was source of the
GI infection.
Exposure status Cases Controls
Ate salad 12 4
Did not eat salad 6 14
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Epidemic Ix cont.
8. Intervention and follow-up
Intervention
Early
Aim at weak chains
Read: Prevention and control measures for epidemic
disease in Ethiopia
Follow-up
Evaluation of control measures
Continued surveillance
Sharing experience
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Epidemic Ix cont.
9. Report the Ix and control
Write report of the Ix and control
Disseminate to concerned bodies
Public
Health organization managers
Publication
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Reading assignment
Investigation and control measures for disease
known to occur as epidemics.
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Individual assignments
On 4th September 1999, the District Health Manger
(DHM) of Shola district received a report of an
epidemic of unknown disease that had affected
villages 1 and 2 in the district. He was informed
that the sick were presenting with sudden onset of
vomiting, weakness and acute watery diarrhoea.
Two people had already died from the disease. On
further investigation it was noted that the index
cases were seen two days ago.
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Q1. What would be the case definition?
Q2. what actions should be taken by the WHM?
Q3. How does the WHM verify the existence of
an epidemic of cholera?
The Woreda epidemic management committee
did a thorough investigation and collected the data
that is summarised in Table 1.
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Table 1: Case and deaths of cholera in Shola, from 1st to 14th September 1999.
Date Cases Deaths
1st 2 1
2nd 2 1
3rd 8 0
4th 4 0
5th 5 0
6th 3 0
7th 0 0
8th 1 0
9th 4 0
10th 2 0
11th 5 0
12th 5 0
13th 5 0
14th 2 0
Total 48 2
Q4. Draw a graph to show epidemic of cholera in Shola using the data
provided in Table 1.
Q5. Describe the graph since the onset of the first case? How do you explain
the multiple peaks seen in the graph?
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The Woreda epidemic management team also summarized the cases of cholera by locality and sex as seen in Table 2.
Table2: Distribution of cases by villages and sex , in Shola woreda.
Cases of cholera
*Attack rate per
Village Population at risk Total cases
100000
Male Female
1 30,000 12 7 19
2 20,000 12 3 15
3 40,000 4 9 13
4 10,000 0 1 1
Total 100,000 28 20 48
* Attack rates = total number of cases/ Total population at risk of the disease* 100,000.
Q6. Did the disease equally affect males and females (assume the male to female ratio
is 1:1)?
Q7. Calculate the Attack rate (incidence rate) for each village, in Shola woreda and
insert your answer in the blank column in Table 2.
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Table 3: Distribution of cases by age
Attack rate per
Population at risk Number of cases 100000
Age group
population
0-4 20,000 10
5-9 15,000 17
10-14 15,000 11
15-19 10,000 6
20-above 40,000 4
Q8. Refer to Table 3; what age groups were most affected by cholera?
Q9. Based on your answers to previous questions what hypothesis could you make
regarding the place and the group at risk of getting the disease in Shola?
Q10. What additional data would you like to get in order to make decisions on the
cause of the epidemic?
Q11. Outline the appropriate control measures for this epidemic.
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