DISEASE OUTBREAK

DEPARTMENT OF EPIDEMIOLOGY AND BIOSTATISTICS

2013

1
 OUTBREAK
EPIDEMIC
ENDEMIC
PANDEMIC
SEASONAL VARIATION
CHANCE

2
 EPIDEMIC/OUTBREAK
The occurrence of cases of an illness, specific health-related
behavior, or other health-related events, in a
community or region,
clearly in excess of normal expectations.

The community or region and the period in which the cases occur are
specified precisely.

3
 EPIDEMIC

The number of cases indicating the presence

of an epidemic varies according to :
the agent
size and type of population exposed
previous experience
lack of exposure to the disease
time and place of occurrence.

4
 ENDEMIC

The constant presence of a disease

or infectious agent within a given
geographic area or population group; may also
refer to the usual prevalence of a given
disease within such area or group

5
PANDEMIC
Worldwide epidemic

SEASONAL VARIATION
Change in physiological status
or in disease occurrence that conforms to a
regular seasonal pattern

6
 CHANCE

A set of cases that occur in a short period of time

BUT

do not surpass the expected number of cases for the

region

7
 Infectious Disease
(Communicable Disease)

An illness due to specific infectious agent

or its toxic product that arises through transmission
that agent or its products from an infectious person,
animal or reservoir to a susceptible host.

8
 Factors Involved in Infection
Agent

Environment Host

Agent, host and environment interrelate

and are interdependent in the production of disease
9
 Types of Transmission
Direct transmission (person to person)
Direct projection of droplet spray
(sneezes and coughs : measles)
Vertical transmission
(transplacental, from mother to child : HIV)
Mucosa to mucosa
(sexually transmitted disease)
Blood and transplants
(hepatitis)
Skin to skin
(staphylococcus)

10
 Types of Transmission

Indirect transmission
Vehicle-borne transmission
(water, food, milk, biological products,
contaminated materials or objects)

Vector-borne transmission
(mechanical, biological)

Airborne transmission
(microbial aerosols)

11
 Infectious Chain Model

Agent

Susceptible host Reservoir

Portal of entry Portal of exit

Mode of transmission
12
 Other Definitions
Vehicle
Mode of transport of an infectious agent through the environment to
a susceptible host.

Vector
A living carrier (usually an arthropod) that serves as a mode of
transport for an infectious agent from an infected host to a
susceptible host.

Reservoir
The primary habitat in which an infectious agent survives and
reproduces.

13
Carrier

A person or animal that harbors a specific infectious agent

in the absence of discernable clinical disease and serves as
a potential source of infection.
Asymptomatic carrier Subclinical
infection throughout the infectious carrier state

Incubationary carrier Infectious

carrier state occurs during the incubation period preceding clinically
recognizable disease

Convalescent carrier Infectious

carrier state continues during convalescence when clinically
recognizable disease is no longer present

14
 Periods

Exposure period
Time during which an individual or group is exposed to a source of
infection

Incubation period
Time from initial infection (entry of infection) to onset of clinical
illness.

Latent period
Time from receiving infection to onset of infectiousness.

15
 Latent period

Exposure period

Entry of infection Onset of infection Onset of clinical illness

Incubation period

16
 Periods
Infectious (or communicable) period
Period during which an infected person is able
to transmit the infectious agent.

Serial interval or generation time

Interval between the same stage of illness
in sucessive cases in a chain of transmission.

Only applicable when infection spreads from person to person e.g. the interval
between onset of rash in the primary case to onset of rash in a secondary case

17
 Use of Periods

Useful for:
Quarantine
Contact tracing
Identification of possible time of infection
Outbreak investigation
Disease modeling and forecasting

18
 Types of Outbreak
1. Common source
Transmission of an infectious agent involving a source
that is common to all outbreak-associated cases
Point source : brief common exposure. A
single source of pathogen results in exposure of persons at one point in time
Extended source :
Common source exposure present over days or weeks - intermitten :
at several points in time - continuous : over a
continuous period

Onset will still be abrupt but cases would be spread over a greater
period of time than one incubation period depending upon how long the
exposure persists.

19
 Types of Outbreak

2. Propagated or progressive (person to person)

- Caused by the spread of the pathogen from
one susceptible person to another.
- The curve tend to have a series of irregular peaks
reflecting the number of generations of infection.

3. Mixed epidemic
Involves both a common source epidemic and secondary
propagated spread to other individuals.

Many foodborne pathogens commonly exhibit this mode of

spread (hepatitis A, Shigella, E.coli).
20
 Elements of Control

Removal or elimination of the source of the

pathogen
Blockage of the transmission process
Elimination of susceptibility
(e.g. vaccination)

21
DISEASE OUTBREAK INVESTIGATION

Data sources
The public
The media
Reports of clinical cases from health care providers
Surveillance data
(laboratory reports, disease notifications)

22
 When reports of an outbreak are received,
the following information should be gathered :

The person(s) reporting the outbreak

Characteristics of the suspected outbreak
(clinical information, suspected etiologies)
Persons directly affected by the outbreak
(epidemiological information)

23
Steps in outbreak investigation

Establishing the existence of an outbreak

Verifying the diagnosis
Defining and counting cases
Determining the population at risk
Describing the epidemiology
Developing hypotheses
Evaluating the hypotheses
Undertaking additional epidemiological, environmental and
laboratory studies, as necessary
Implementing control and prevention measures
Communicating findings
24
CONFIRMATION & VERIFICATION OF
DIAGNOSIS

Check the report whether it is true or not

(see the case by yourself in the field)
Verify the sign or symptoms and the diagnosis
To proof the case is based on the history of the disease and the
sign or symptoms
Estimate the number of cases
If there is sufficient of time, a laboratory examination
should be done to make an etiological diagnosis

25
DETERMINE THE EVENT :
IS IT AN EPIDEMIC OR NOT?
How much the usual morbidity rate are?
Based on time, place, person
How are the usual pattern of the disease in the community?

Is the disease usually presence or never?

Is there an increase of the number of cases?
Is it conspicuous or not?
Make a graph of epidemic curve based on time of onset
of the sign in each case!
26
DESCRIBE THE EPIDEMIC :
TIME, PLACE, PERSON

TIME
When was the first case founded? The last?
How long the epidemic/outbreak happened?
Find the probable of the first exposed time!
Assume the type of the epidemic!
(common source? person to person?)

27
PLACE
What place is the most prominent number of cases?
What are the attack rate based on places?

PERSON
Identify the age specific and sex specific attack rate!
What group has the highest and the lowest attack rate?
Determine that the characteristic of the cases are differ
significantly compared with the whole population

28
COLLECTING DATA

To get the real data.

Can be simultaneously with the activity of diagnosis
verification :
- What are the exact number of cases ?
- Who are the population at risk ?
- Who are the contact person ?
- Think about loss of observation !
- Who are the carrier ?
Those data could be obtained by house to house visits !

29
IDENTIFICATION OF AGENT OR THE SOURCE
OF INFECTION AND TRANSMISSION

First we have to set hypothesis of :

The etiological agent
The source of infection
The exposure time
The incubation period
The transmission of infection
The population at risk

30
EPIDEMIC CONTROL (MANAGEMENT)

1. THE PATIENT
Adequate and prompt treatment
2. CONTROLLING against :
The primary source of infection
The reservoir (carrier, vector, environment)
Transmission vehicle (food, fluid, air etc.)
Susceptible contact person

3. EPIDEMIOLOGICAL SURVEILLANCE
31
 INVESTIGATION REPORT

The main objection of the report :

To describe the experience and all findings in the occurrence of
epidemic, to organize and operate a surveillance activity
and to improve the previous prevention and controlling activity.

32
 INVESTIGATION REPORT

The form of the report :

1. INTRODUCTION
It content description of the condition that stimulate to carry
out an investigation

2. BACKGROUND
A brief description about factors that cause the problem
(e.g. geographic, politic, economic, demographic and
historic)
33
3. DESCRIPTION OF INVESTIGATION
ARRANGEMENT

Include :
- the reason
- the method
- source of information
- how to explore the cases
- verification of diagnoses
- use of sample cases and control in analyzing data,etc.

34
4. THE FINDINGS
Only the fact finding should be reported; without any comment,
discussion or suggestion. The recent data could be related to the
previous data as it happened as an epidemic.

The findings will be presented in tables or graph such as :

- characteristic table of age, sex, race, occupation etc. and
their attack rate - the
onset of illness with the graph - the
result of laboratory test -
other evidence which might direct the possibility of the source of
infection or suspected source.
35
ANALYZING DATA AND CONCLUSION

Data should be interpreted to construct hypothesis of :

- agent of infection
- source of infection
- reservoir
- disease transmission, including the vehicle
or vector - the high risk group population

It is exactly useful if the characteristic of the recent

epidemic compared with the similar epidemic before.
36
DESCRIBE THE CONTROL ACTION

Clarify the objective of the action specifically

Discuss each of this action based on :
How, When, Where and by
Whom
Describe the results and the expenses of the actions.

Explain that there might be possibility of explosion of new

cases after passing one incubation period after the control
action.
37
 DESCRIBE THE OUTCOMES

a. The consequences of the epidemic to health condition

and economic status

b. The consequences of the control action to :

Population immunity status, way of life, etc.
Reservoir number and distribution
Vector number,density, distribution

c. The invention of new infectious agent, reservoir,

transmission of agent etc.

38
 RECOMMENDATION

The objection is to improve the surveillance activity and

control.
These report can be useful as reference in surveillance
activity, what data should be collected, what is the source
of data, how to consolidate after an epidemic,
dissemination of the report, who will be responsible in an
epidemic, what kind of cooperation should be organized.

39
 EPIDEMIC CURVE

A graph of cases of disease plotted against time (date

or hour) of onset of illness

Mainly used in outbreak investigation

40
 EPIDEMIC CURVE
STEPS OF MAKING DIAGRAM
1. Draw the X and Y line : X for time of onset of cases
Y for the number of cases
2. Select interval of time depend on the incubation period of the disease,
e.g. hourly, daily, weekly or monthly

To estimate the first contact or exposed to source of the disease :

1. Take a line from the first case(s) backward at length of 14 days (the
minimum I.P.) and from the last case(s) at length of 21 days (maximum
I.P.). The results are fallen at the 7th and 8th days; it means that
the first contact to the source of disease was at the 7 th and 8th days.
2. It can also can be done by subtraction the last and the first time of onset
by the maximum and the minimum incubation period

41
 21 days
(max incubation
period)

Probable period
of exposure

14 days
(minimum incubation period)

42
 EPIDEMIC CURVE

Point source epidemic

43
Propagated outbreak

44
Extended source epidemic

45
 ATTACK RATE

Similar as incidence rate :

new events / cases
Incidence Rate = xk
Population at risk

It is used in a short period of an event - an outbreak -,

the population being affected is limited closely,
the duration of epidemic is short period.
46
Coordinating role of the OCT in an
outbreak investigation

clinicians epidemiology laboratory environment

authorities OCT public

reports control measures media

47
Definitions in an outbreak investigation

CLINICAL DESCRIPTION
Sign and symptoms found in the outbreak

CASE DEFINITION
Standard set of criteria for deciding whether an individual
should be classified as having the health condition of interest.

A case definition includes clinical criteria and particularly in the

setting of an outbreak investigation restrictions by time, place,
and person.

48
 Case definition
Confirmed cases
- have a positive laboratory result
- high spesificity

Probable cases
have the typical clinical features of the illness, but without laboratory
confirmation

Possible cases
- have fewer or atypical clinical features
- high sensitivity

49
DIFFERENTIAL DIAGNOSIS
List of possible diagnosis, ordered from the most
possible one

DESCRIPTIVE EPIDEMIOLOGY
Characterize the outbreak by time, place and person

50
 Place
A. The occurrence of diarrhea by source of water supply of
community A and B in January 2011

The attack rate of B was much lower than the attack rate of A.
In other case, people of B who visited A and drank the water A became sick,
the attack rate was 55.0% ;a quite high incidence.

Conclusion : water supply A was responsible for the occurrence of diarrhea. 51

B. Attack rate by class in Ganado Public School, Arizona in March 2011

The table shows that the highest risk is the special class out of the whole
population, followed by the test class, the 5th and the first class.
The lowest is the 4th class.

52
C. The occurrence of hepatitis A among restaurant worker
who work at night at May 12 and 13, 2011

The table shows that the night workers are much higher risk to get
hepatitis than non night worker.

53
PERSON
Attack rate per 100 person by age group in diarrhea
in Polyclinic A.

Group of 1 & 2 years are the highest risk of getting diarrhea,

followed by group of 3 years.

54
Outbreak Control Team (OCT)

The criteria for convening a multidisciplinary OCT will

vary according to the seriousness of the illness, its
geographical spread, local circumstances and the
available resources.

55
An OCT may be considered when :
The outbreak poses an immediate health hazard to the
local population
There are many cases
The disease is important in terms of its severity or its
propensity to spread
Cases have occured over a widespread area without
obvious point source
Cases have occured in high-risk establishments
(schools, day-care centres, hospitals, food
premises,etc.)

56
The role of the OCT :
to coordinate all the activities involved in the
investigation and control of an outbreak.

This may involve :

1. Deciding whether there is really an outbreak
2. Deciding on the type of investigations to be
conducted
3. Case-finding and interviews
4. Planning the appropriate clinical and environmental
sampling

57
5. Ensuring that all collaborators use a complementary
methodology
6. Conducting an environmental investigation of
suspected source
7. Agreeing and implementing control measures to
prevent the further spread
8. Working in concert with local medical providers to
make recommendations on treatment and/or
prophylaxis

58
 9. Organizing ongoing communications among OCT
members about the outbreak
10. Making arrangements for liaison with the media
11. Producing reports, including lessons learned, for
health authorities and other interested parties
12. Requesting external assistance
(e.g. secondment of a national investigation team)

59
60