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Objectives of training




To understand clinical description and epidemiology To understand the disease case definition, lab specimens needed, labs role, and lab tests needed for confirmation To understand prevention and control procedures including available treatment and post-exposure prophylaxis, isolation and infection control procedures. To understand contact tracing and surveillance procedures

Team Roles and Responsibilities


Outbreak management staff Case Ascertainment staff/active surveillance



Face-to-face interviewers
Telephone interviewers Data base support



Employee Health

Education of risks of disease from exposure to BT agents or infectious patients Vaccination Personal protective equipment (PPE)




Prioritization Categories

Category A

High public health impact and public perception Variable dissemination potential Comprehensive PH preparedness
Less public health impact Variable dissemination potential Less comprehensive PH preparedness Addressed with current preparedness efforts (BT/EID)

Category B

Category C

Category A Agents
Variola virus - smallpox

Bacillus anthracis - anthrax

Yersinia pestis - plague Francisella tularensis - tularemia

C. botulinum toxins - botulism

Filo and Arenaviruses - VHFs

Characteristics of Category A Agents


via aerosol Organisms fairly stable in aerosol Susceptible civilian populations High morbidity and mortality Person-to-person transmission Difficult to diagnose and/or treat Previous development for BW
* Priority agents may exhibit all or some of the above characteristics

Characteristics of Category B Agents

Coxiella burnetii Q fever Brucella spp. - brucellosis Burkholderia mallei - glanders Alphaviruses (VEE, WEE, EEE) - encephalitis Ricinus communis - Ricin Epsilon toxin from clostridium perfingens Staphylococcus enterotoxin B

Category C Agents
Emerging infectious disease agents (Hantavirus, Nipah virus, etc.) Salmonella

E-coli O157:H7
Vibrio cholerae cholera

Cryptosporidium parvum cryptosporidiosis


Occurrence of more cases of disease than expected Nosocomial outbreak-any group of illnesses of common etiology occurring in patients of a medical care facility acquired by exposure of those patients to the disease agent while confined in such a facility.

Reasons to investigate
Control/prevention Research opportunities Training Public, political, or legal concerns Program considerations

Control / Prevention

Where are we in the outbreak? Goals will be different depending on answer(s) Cases continuing to occur Goal: prevent further cases Assess population at risk, implement control measures Outbreak appears to be coming to an end Goal: prevent future outbreaks Identify factors contributing to outbreak, implement measures to prevent similar events in the future

Steps of an Outbreak Investigation

1. Preparation


Scientific knowledge
Review literature Consult experts Sample questionnaires


Consult with laboratory


Laptop, camera etc.

Preparation, cont.

Administration-assure personnel resources, funding

Travel arrangements (orders) Approval Personal matters

Consultation-make sure you know your role and its parameters

Lead investigator or just lending a hand? Know who to contact when you arrive

2. Establish existence of an outbreak

Is an outbreak truly occurring?

True outbreak Sporadic and unrelated cases of same disease Unrelated cases of similar unrelated disease

Determine the expected number of cases before deciding whether the observed number exceeds the expected number

Establish outbreak existence, cont.

Comparing observed with expected

through surveillance records for notifiable diseases hospital discharge data, registries, mortality statistics data from other facilities, states, surveys of health care providers community survey

3. Verify the Diagnosis

Ensure proper diagnosis and rule out lab error as the bias for increased diagnosis

Review clinical findings, lab results

Summarize clinical findings with frequency distributions

Characterize spectrum of disease Verify diagnosis Develop case definition

Verify the Diagnosis cont.

See and talk with patients if at all possible

Better understand clinical features Mental image of disease and the patients affected Gather critical information

Source of exposure What they think caused illness Knowledge of others with similar illness Common denominators Helpful in generating ideas for hypothesis about etiology and spread

4a. Establish a case definition

Case definition Standard set of criteria for deciding whether an individual should be classified as having the health condition of interest Includes clinical criteria and restrictions by time, place and person Must be applied consistently and without bias to all persons under investigation Must not contain an exposure of risk factor you want to test

4a. Establish a case definition, cont.


Definite (confirmed) Laboratory confirmed Probable Typical clinical features without lab confirmation Possible (suspected) Fewer of the typical clinical features

4a. Establish a case definition, cont.

Early in investigation may use a loose case definition

Better to collect more than necessary so you dont need to make repeat visits Identify extent of problem and population affected Generating hypotheses

Later when hypotheses are sharpened investigator may tighten case definition

4b. Identify and count cases

Target health care facilities where diagnosis likely to be made Enhanced passive surveillance e.g. letter describing situation and asking for reports Active surveillance e.g. phone or visit facility to collect information Alerting the public Media alert to avoid contaminated food product and seek medical attention if symptoms arise

4b. Identify and count cases, cont.

OB population restricted and large proportion of cases are unlikely to be diagnosed e.g. on a cruise ship

Survey entire population

Always ask case-patients if they know of any others ill with the same symptoms

4b. Identify and count cases, cont.

Information to be collected about every case Identifying information

Re-contact if additional questions come up Notification of lab results and outcomes of investigation Check for duplicate records Map geographic extent


Provide person characteristics for defining population at risk

4b. Identify and count cases, cont.

Information to be collected about every case cont.

Clinical findings
Verify case definition met Chart time course Supplemental date e.g. deaths

Risk factor information

Tailored to specific disease in question

Reporter information

Id of person making report

4b. Identify and count cases, cont.

Collection forms Standard case report form Questionnaire Data abstraction form Line listing Abstraction of selected critical items from above forms Contains key information

5. Perform Descriptive Epidemiology


collection of data characterize the outbreak by:

Time Place Person


Epidemic curve
Histogram of the number of cases by their date of onset Visual display of the outbreaks magnitude and time trend Where you are in the time course of the outbreak Future course? Probable time period of exposure Helps in development of questionnaire focusing on that time period Common source vs. Propagated


Geographic extent of problem

Clusters or patterns providing important etiologic clues Spot maps

Where cases live, work or may have been exposed


Determine what population at risk

Usually define population by host characteristics or exposure Use rates to identify high-risk groups
Numerator = number of case Denominator = number of people at risk

Develop Hypotheses

Hypotheses should address

Source of the agent Mode of transmission

Vector or vehicle

Exposure that caused disease

Develop Hypotheses

Generating the hypothesis What do you know about the disease? Reservoir, transmission, common vehicles and known risk factors Talk to several case-patients Use open ended questions Ask lots of questions Talk to local health department staff Use descriptive epidemiology e.g. epi curve

7. Test Hypotheses

Evaluate the credibility of your hypotheses

Compare with established facts When clinical, lab, environmental and/or epi data undoubtedly support hypothesis Use analytic epidemiology to quantify relationships and explore the role of chance Cohort studies Case control studies

7. Test Hypotheses, cont.

Cohort Small, well defined population Contact each attendee and ask a series of questions Ill Vs not ill Look for source exposure

Attack rate is high among those exposed Attack rate is low among those not exposed Most of the cases were exposed, so that the exposure could explain most, if not all, of the cases Relative risk = measure of association between exposure and disease

7. Test Hypotheses, cont.


Population not well defined Case patients and comparison group (controls) questioned about exposure(s) Compute measure of association = Odds Ratio

Quantify relationship between exposure and disease

8. Refine hypotheses and do additional studies

When analytical epi unrevealing need to reconsider your hypotheses Go back and gather more information Conduct different studies


Additional tests

Environmental studies

9. Implement Control /Prevention Measures


control measures as soon as


be aimed at agent, source, or reservoir or long term


10. Communicate the Findings

Orally within facility/community

Local health authorities and persons responsible for implementation of control and prevention measures

Written reports (consider publication) for planning, record of performance, legal issues, reference, adding to knowledge base