INVESTIGATING AN

OUTBREAK ( EPIDEMIC )
 EPIDEMI..OUTBREAK..?
AnEpidemic is commonly defined as the
occurrence in community or area of cases
of a disease that are clearly in excess of
what is expected Manual of epidemiology
for district management, WHO
Anoutbreak is the occurrence of more
cases of disease than expected in a
given area or among a specific group of
people over a particular period of
time.Principles of epidemiology, WHO
 How to detect epidemic
Sources :
Review routine information
Surveillance
Clinical
cases
Community information
Report

Statistical measurement : 2 standard

deviation
 Dynamic Transmission of disease
How do infections or diseases spread?:
Reservoirs for a disease to perpetuate itself, there
must be a continual source of the infection called a
reservoir of infection. Reservoirs my be:
Humans Carriers or sick individuals during the incubation,
acute, or convalescent phases of a disease (depends upon
the particular disease)
Animals diseases found in animals are called zoonosis
Non-living entities such as soil or water
Transmission of disease The causative agents of
infection can be transmitted from the reservoir of
infection to a susceptible host via four different routes.
Susceptible host
 Routes of transmission
Contact
Direct contact the infection is spread from person to
person via touching, kissing, or sexual intercourse
Indirect contact the disease is transmitted to a
susceptible host by means of a non-living object called a
fomite (contaminated needles)
Droplet transmission agents of disease are spread by
droplets contained in saliva and mucous that are
discharged by sneezing, coughing, laughing, or talking.
The droplets travel only a short distance (< 1 meter) and
for such short distances, the spread is not considered to
be airborne.
Common vehicle transmission refers to
transmission of disease causing agents by a
common inanimate reservoir (food, water, blood,
drugs, etc.) to a large number of individuals
 Airborne transmission this refers to the
spread of agents of infection by droplet nuclei
or dust. In this instance the particles travel >
1 meter from the reservoir to the host.
Vector transmission a vector is an animal
that carries the pathogen from one host to
another. Arthropods are the most common
type of vector. Arthropods can transmit
disease by two general methods:
Direct contact transmission
Droplet transmission
Common vehicle transmission
Vector transmission
 Penyebaran penyakit
Man ---- Man ---- Man ( kontak langsung )
Hewan --- Hewan ---Hewan ( zoonosis )
Man
Man ---- Makanan ---Man ( Food born )
Man ---- Air -----Man ( Water born )
Man ---- Udara --- Man ( Air born )
Man ---Tanah ----Man ( Soil born )
Man -----Vektor ----Man ( Vektor Born )
 Tipe Epidemi
Tipe satu sumber ( Point source, Common
source )
Tipe orang ke orang ( propagated )

* Tipe campuran ( mix source )

 Tipe epidemi common source
Timbul cepat
40 Penularan cepat
35
30 Waktu singkat
25 Cepat hilang bila
20 East sumber dieliminir
15
Sumber relatip mudah
10
5 diketahui.
0 Masa inkubasi
pendek
Jan

Jul

ov
Mei
Mar

Sept

N
Tipe Propagated Epidemi

Timbulnya lambat
Penularan lambat
Waktu lama
Sumber sukar
duketahui
Hilangnya lambat
Person to person
 Tipe Mix Epidemi

16
14
12
10
8 Line 1
6
4
2
0
 Faktor penyebab epidemi
1. Herd immunity ( kekebalan kelompok )
penurunan herd immunitas ------ mudah terjadi
epidemi.
Penurunan herd imm :
- Proporsi anggota masyarakat yang immun menurun
: penambahan org yang tidak immun, pengurangan
org yang immun, perubahan antigenesity penyakit.
- Penyebaran orang yang immun tidak merata
2. Patogenesitas
3. Lingkungan
 Mengapa perlu investigasi?
Penyebab wabah biasanya tidak diketahui
dengan jelas.
Berhadapan dengan keadaan emergency,
sehingga perlu mengetahui sumbernya
dan penyebabnya dengan jelas dan cepat
Pengendalian ( kontrol )
Prevensi ( Prevention )
Kapan dilakukan kontrol atau
investigasi .. ?

epidemi

Masih Epidemi
berlangsung Sudah lewat

Kontrol dan prevensi investigasi

investigasi Kontrol dan prevensi

 Sumber / mode transmisi
Diketahui tak diketahui

Investigasi + Investigasi +++

Agent Tahu Kontrol +++ Kontrol +
Penyebab
Investigasi +++ Investigasi +++
tak tahu Kontrol +++ Kontrol +
 Steps of an outbreak
investigation
1. Prepare for field work
2. Establish evidence of outbreak
3. Verify the diagnosis
4. Define and identify cases
* establish a case definition
* identify and count cases
5. Perform descriptive epidemiology
6. Develop hypothesis
7. Evaluate hypotheses
8. Additional studies : Laboratory, environmental
9. Implement control and prevention
10 communicate finding
 1. Preparing for field work
Investigation group
- field investigator
- laboratory :
material,storage,transportation
techniques etc
- Medical staff
Administration group
Consultation group
2. Establishing the existence of
an outbreak
Outbreak or not ?
Area outbreak ?
Are cases occuring in increasing numbers
or the outbreak just about over ?
Reduce mortality
Report quickly
 3. Verifying the diagnosis
Clinical findings
Laboratory results
Visit several patients with the disease
Interview with patients
 4a. Establishing a case
definition
Standard clinical criteria or laboratory
Definite case definition
Probable case definition
Possible case definition
 4b. Identifying and counting
cases
Extent of the problem
Active case finding
Type information :
- geographic information
- demographic information
- clinical information
- risk factor information
- report information
 5. Performing Descriptive
Epidemiology
Time distribution : epidemic curve
Place distribution : Map distribution
Person distribution : High Risk group
 6. Developing hypotheses
Formulating hypotheses
Hypotheses : source of agent, mode of
transmission, exposure that caused the
disease
Descriptive epidemiology often provides
some hypotheses
 7. Evaluating hypotheses
Testing of hypotheses : cohort studies is
the best technique or case control studies
Calculate attack rate
Compute relative risk
Test of statistical significance
 8. Refining hypotheses
Laboratorystudies
Environmental studies
 9. Control and prevention
Main strategies :
- Primary prevention : interrupt transmission
- Secondary prevention : finding subclinical
cases, carriers and contacct tracing
- Tertiary prevention : Treatment of cases or
carriers so what that do not spread the
organism any further.
 Attack source :
- Treatment of cases and carriers
- Isolation of cases
- Surveillance of suspect
- control of animal reservoirs
- notification of cases
 Interrupt transmission
- environmental hygiene
- personal hygiene
- vector control
- disinfection and sterilization
- restrict population movement
 Protect susceptible people
- Immunization
- chemoprophylaxis
- personal protection
- better nutrition
10. Communicating the findings
An oral briefing
Written report