OUTBREAK

INVESTIGATIO
N
Dr.Kedar Karki
 Definition
• 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,
 Research opportunities
• Gain additional knowledge
• Opportunity to study natural history of the
disease
• Newly recognized disease
–Define natural history
–Characterize the population at risk
• Well recognized diseases
–Assess impact of control measures
–Usefulness of new epidemiology
and laboratory techniques
 Training

• Requirements of an
epidemiologist!
–Diplomacy
–Logical thinking
–Problem solving ability and
quantitative skills
–Epidemiologic know-how
–Judgment
 Public, political, or legal
concerns
• Sometimes override scientific
concerns

• Health department needs to be

responsible and responsive to public
concerns
–Even if the concern has little
scientific basis
 Program considerations
• Outbreak of disease targeted by a
public health program
–Reveal a weakness and opportunity
to change or strengthen the
program
• Identify population that may have been
overlooked
• Failure of intervention strategy
• Changes in the agent
• Events beyond scope of the program
Steps of an Outbreak
Investigation
 1. Preparation
• Investigation
–Scientific knowledge
• Review literature
• Consult experts
• Sample questionnaires
–Supplies
• Consult with laboratory
–Equipment
• 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
Establish existence of an outbreak
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
 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.
• Classification
–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 don’t 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
–Demographics
• 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
• After collection of data
characterize the outbreak by:
–Time
–Place
–Person
 Time
• Epidemic curve
– Histogram of the number of cases by
their date of onset
– Visual display of the outbreak’s
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
 Place
• Geographic extent of problem

• Clusters or patterns providing

important etiologic clues

• Spot maps
–Where cases live, work or may
have been exposed
 Person
• 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.
• Case-control
–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
• Epidemiologic
– When analytical epi unrevealing need to
reconsider your hypotheses
– Go back and gather more information
– Conduct different studies
• Laboratory
– Additional tests
• Environmental studies
 9. Implement Control
/Prevention Measures
• Implement control measures as soon
as possible

• May be aimed at agent, source, or

reservoir

• Short 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