Outbreak

Investigation
Dr. Kyaw Thu
Community Medicine
 DEFINITION OF OUTBREAK
Occurrence of more cases of
disease
than expected in a given area
among
a specific group of people over a
particular period of time.
(or)
Two or more linked cases of the
 Epidemic Curves and Types of
Outbreaks
Three types of outbreaks:
(1) Common-source
Results from exposure of a susceptible
group of people to a common agent of
disease
Further classifications:
(a) Point source outbreak
(b) Continuing source outbreak
(c) Intermittent source outbreak
(2) Propagated
(3) Mixed
 Point Source Outbreak
Duration of exposure to the common agent is
relatively brief and essentially simultaneous among
those exposed

Epidemic curve
Explosive nature
rises and fall rapidly without secondary waves

Short-lived
All cases develop disease within one incubation
period of disease
EPIDEMIC CURVE – POINT SOURCE INFECTION
NUMBER OF NEW CASES

TIME

INDEX CASE OR MEDIAN INCUBATION PERIOD

COMMON EXPOSURE
 Continuing Source Outbreak
• Exposure to the common agent of disease is
prolonged beyond a brief period
• Exposure is not always due to exposure of infectious
agent (e.g. contamination or pollution)
• Epidemic curve
– Rapid rise in # of cases
– Reach a plateau
– Followed by gradual decline
• Last longer than time range of incubation period
 Intermittent Source Outbreak
• Exposure to the common source of
disease is irregular

• Epidemic curve
– Small clusters or individual cases spread over
a relatively protracted time period
– Can see gaps
 (2) Propagated Outbreaks
• Progressive outbreak that usually is due to
direct person-to-person transmission of
disease
– Via touching, sneezing, coughing, sexual relations
• Or by indirect transmission through a vector
capable of transmitting an agent of disease to
a susceptible host
– Animal source – fly, mosquito, or rodent
 Propagated Outbreaks
Epidemic curve
– Person-to-person
• Relatively gradual rise in case #
• Tail off over a much longer period of time
– May be more than 1 peak
• Separated by distances approximately = in length to
the average incubation period
• Additional peaks represent secondary and tertiary
spread of disease
– Tend to show longer duration than those for
common-source outbreaks
– Depends on the herd immunity of population
EPIDEMIC CURVE – PROPAGATED EPIDEMIC
NUMBER OF NEW CASES

TIME

INDEX CASE OR MEDIAN INCUBATION PERIOD

COMMON EXPOSURE
 (3) Mixed Outbreaks
• Combination of common source and
propagated outbreaks
– Often begin with common source exposure
that is followed by person-to-person spread

• Epidemic curve
– Single large peak
– Subsequent smaller peaks
 Determinants of Disease
Outbreaks
• Amount of disease in a population
depends on:
– # of people in population that are susceptible
(at risk)
– # of people immune (not at risk)

• all immune (Herd immunity)⇒ no epidemic

 OBJECTIVES OF OUTBREAK
INVESTIGATIONS
To control continuing outbreaks
To prevent future outbreaks
To provide statutorily mandated
services
To strengthen surveillance at local
level
To advance knowledge about a
disease
 SPECIFIC DEMANDS WHEN
INVESTIGATING OUTBREAKS
Unexpected event
Need to act quickly
Need for rapid control
Work carried out in the
field

Systematic
approach
 STEPS OF AN OUTBREAK
INVESTIGATION
1.Confirm outbreak and diagnosis
2.Case definition and identification
3.Descriptive data collection and
analysis
4.Develop hypothesis
5.Analytical studies to test
hypothesis
6.Special studies
7.Implementation of control
measures
 Routine
surveillance
Detectio Clinical/Laborator
n y
General public
media
Is this an outbreak?
 Diagnosis verified?
 Clinical & laboratory link between
cases?
 Expected numbers?
Sequence of events in outbreak detection and confirmation(I)
Primary 1st case
Report SamplesLab: Respons
Case at HC e
to DHO takenresult
90 begins

80

70

60

50
Cases

Opportuniti
40 es
for control
30

20

10

0
1st wk 2nd wk 3rd wk 4th wk 5th wk
Days
 Sequence of events in outbreak detection and
1st
case
comfirmation (II)
Samples Respons
e
at HC taken begins
Primary Report
Lab:
Case to DHO
120 result

100

80
Cases

60
Potential
cases
prevented
40

20

0 1st wk 2nd wk 3rd wk 4th wk 5th wk

Days
 Outbreak
confirmed
Immediate control Further
measures? investigations?

Prophylaxis Unknown aetiology

Exclusion/isolation (pathogen/source/transmission)
Public warning Cases serious
Hygienic measures Cases still occurring
Public pressure
Training opportunity
Scientific interest

Assistance?
 Assistance?
Epidemiologist
Microbiologist Outbreak
Environmental
Investigation
specialist
Ministry/Governmen Team?
t
Press officer
Others

FIELD
Investigatio Surveillance Vector/reservoi Dead Sick
n r

Exposed
Prediction Clinicians
Epidemiolog
y

Coordination
Health Education Laboratory
personnel Clinical

Special General Diagnosti Specimen

Media
c transfer
groups population

Decisions
Infrastructure
Authorities Regulations
Vaccination,
etc.
 Assistance?
Outbreak
Epidemiologist
Investigation
Microbiologist
Environmental Team?
specialist
Ministry/Government
Press officer
Assess situation
Others
Examine available
information
Preliminary hypothesis?
Case definition
Case finding

Descriptive
epidemiology
 CASE DEFINITION
Standard set of criteria for deciding
if a
person should be classified as
suffering
from the disease under
investigation.
Clinical criteria, restrictions of time,
place, person.
 CASE DEFINITION:EXAMPLE

 Patient older than 5 years

with
severe dehydration or dying
of
acute watery diarrhoea in
town
 CASE
DEFINITION:CATEGORISATION
 Possible
 Patient with severe diarrhoea
 Probable
 Patient older than 5 years with
severe dehydration or dying of acute
watery diarrhoea in town "X" between
1st and 10th June 2008
 Confirmed
 Isolation of Vibrio cholerae from
stool of patient
 Identify &  Clearly identifiable
groups
count cases  Hospitals
 Laboratories
 Schools
 Work place, etc.
Obtain
information

Perform
descriptive
epidemiology
 Identify &
count cases

 Identifying information
Obtain  Demographic information
 Clinical details
information
 Risk factors

Perform
descriptive
epidemiology
 Identify &
count cases

Obtain
information

Orient cases in;

Perform
 time
descriptive  place
epidemiology  person
 Cases

  
Time Person
Place

Evaluate
Information

Pathogen? Source? Transmissio

n?
 Develop hypothesis

 Who is at risk of becoming ill?

 What is the disease causing the
outbreak?
 What is the source and the vehicle?
 What is the mode of transmission?

Compare hypothesis with

facts
 Test specific
hypothesis

Analytical epidemiological
studies

Cohort Case-
control
 Implement control
measures
May occur at any time during the
outbreak

Control the source of the pathogen

Interrupt transmission

Modify host response

Prevent recurrence
 CONTROL THE SOURCE OF
PATHOGEN

Remove source of contamination

Remove persons from exposure
Inactive/neutralize the pathogen
Isolate and/or treat infected
person
INTERRUPT TRANSMISSION

 Interrupt environmental
sources
 Control vector transmission
 Improve personal sanitation
MODIFY HOST RESPONSE

 Immunize susceptibles
 Use prophylactic
chemotherapy
 Source/transmission
Known Known Unknown

Investigation Investigation
Aetiology

+ +++
Control +++ Control +
Unknown

Investigation Investigation
+++ +++
Control +++ Control +
 AT THE END

 Prepare written report

 Communicate public health
messages
 Influence public health policy
 Evaluate performance
 COMMUNICABLE DISEASE CONTROL
IN MALAYSIA

• 1971 Epidemiology unit in MOH

• Fully operational in 1996
• Prevention and control of Infectious
disease act 1988 for notification of
communicable diseases
• 25 notifiable diseases (9 by phone)
and kept under surveillance
 Notification by phone
(within 24 hours)
1. Dengue Fever
2. Yellow Fever
3. Diphtheria
4. Ebola
5. Food Poisoning
6. Cholera
7. Plague
8. Poliomyelitis
9. Rabies
 Written Notification (within a
week)
1. Whooping Cough 11. Typhoid and
Paratyphoid
2. Measles 12. Typhus and other
ricketsioses
3. Dysentery 13. Tuberculosis
4. Gonococcal Infection 14. Viral Encephalitis
5. Leprosy 15. Viral Hepatitis
6. Malaria 16. HIV
7. Myocarditis 17. Other Life threatening
infections

8. Relapsing Fever
9. Syphilis
 Summary
• What is Outbreak?
• Types of outbreaks?
• Why outbreaks need to be
investigated?
• Detail steps in investigation of
outbreak?
• Notifiable diseases and diseases kept
under surveillance in Malaysia
THANK YOU