Outbreak Investigation
Dr. Abdulmohsen Alnaeem
College of Veterinary Medicine ,
King Faisal University
What is an outbreak ?
• 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
OR
• A single case of disease that has never been
occurred before (e.g. MERS-CoV in KSA)
Outbreak vs. Epidemic vs. Cluster
• Epidemic: an increase in the number of cases
of a disease above expected level in an area .
• Outbreak
• Epidemic limited to localized increase in the incidence of
disease, e.g., village, town, or farm
• Cluster
• Cluster: an aggregation of cases grouped in place
and time that are suspected to be greater than the
number expected
Why investigate outbreaks?
• Identify the cause
• Control the outbreak
• Prevent future outbreaks
• Minimize economic and social impact
Steps of an outbreak investigation
• Confirm outbreak and diagnosis
• Define a case
• Case finding
• Descriptive epidemiology of collected data
(place, time, animal)
• Develop hypothesis
• Test hypothesis: analytical studies
• Communicate results,
• Implement control measures
Confirm outbreak and Diagnosis
• Confirm Outbreak (is there an outbreak ?)
• What is the baseline level ?
• Differentiate outbreak from cluster cases
• Differentiate outbreak from seasonal variation
• Verify Diagnosis
– Clinical symptoms
– Epidemiology (person, place, time)
– Laboratory and diagnostic tests
At this stage if the disease and mode of transmission are known
start control measures
Case Definition
• The following criteria must be satisfied before
person classified as a case:
– Epidemiology criteria
• Person
• Time
• place
– Clinical criteria
– Laboratory criteria (serology, culture, PCR)
– Case classification (suspect, confirmed)
Case Definition: Outbreak of
Salmonellosis
Confirmed case Probable case
• Diarrhoea or fever • Diarrhoea
and and
• Isolate of S. typhimurium • Contact with confirmed case
• In (place) • In (place)
• During (time)
• During (time)
Case Finding
• Surveillance
• All laboratories in the affected area
• Major laboratories in neighbouring districts
• National reference laboratory
• Food borne outbreak notifications
• Interview of cases
– History
– Exposure
Descriptive Epidemiology
• Describe collected data by:
– Time (Epidemic curve)
– Place (location of cases)
– Person (age, sex)
Cases
Animal Time
Place
Evaluate information
Pathogen? Source? Transmission?
Time: Epidemic curve
• Graphical display of number of incident cases (Y) over
time (X)
• Provide information on:
– Pattern of spread:
• Common source: common event or location
– Point (in time)
– Continuous
• Propagated (person-to-person spread)
– Start and end of epidemic (duration)
– Peak
– Outlier cases
– Exposure or incubation period
Examples of Epidemic Curves
• Common point source
• Common source exposure
• Sharp rise and a gradual decline
• Exposure period is relatively brief
• All cases occur within one
incubation period
C
• Propagated source
a • Spread from person to person
s • Can last longer than point source
e
s
• Multiple waves of infection
• Can have several peaks with an
incubation period apart.
Weeks
Place: Distribution of Cholera Cases in London 1854
Person
• Distribution of cases by:
– Age
– Sex
Develop hypotheses
Hypothesis about :
cause sources, mode of transmission and
exposure period
By using
• Clues from clinical signs
• Clues from case interview
• Clues from descriptive epidemiology
Testing Hypothesis
• Cohort
- attack rate exposed group
- attack rate unexposed group
• Case control
- % of cases exposed
- % of controls exposed
Implement control measures
Apply specific measures based on the
findings:
1) Control the source of pathogen
2) Interrupt transmission
3) Modify host response
Outbreak report
• Regular updates during the investigation
• Detailed report at the end:
– Recommendation for control
– Preventing further occurrence
Conclusions
c
Epidemiologic investigations are essential o
to determine source of outbreaks n
• Be systematic tr
• Follow the steps! ol
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